Overall, eating disorders present an unusual challenge for clinicians. Much of the denial, resistance, and anger of the patient and occasionally the family may now be directed at the physician. However, awareness that patients with these disorders are frequently ambivalent, desiring but often afraid of recovery and making the physician the target of their emotions and of the inner conflict, serves to facilitate the building of a trusting relationship, the foundation of effective therapy.
A. Early-Stage Eating Disorders
A developmental perspective cannot be overemphasized for the early detection, and possible prevention, of eating disorders. The only factor consistently associated with more promising treatment outcomes for AN and other eating disorders is early detection and shorter duration of illness. Although many cases of early eating disturbance do not progress to full-syndrome eating disorders, the number of girls and boys in elementary, middle, and high schools engaging in extreme dieting (eg, fasting, excessive exercise) and disordered eating behaviors (eg, binge eating, purging behaviors) is alarmingly high. In fact, many of these individuals fall into the DSM-5 categories of other specified feeding or eating disorders, or unspecified feeding or eating disorders. Such behaviors should be monitored. Many cases of eating disorders are characterized by a prodromal period of dieting and excessive weight and eating concern that place vulnerable individuals at risk for full-syndrome eating disorders.
Management of the early or mild stages of an eating disorder diagnosis begins with the assessment of weight loss or weight control and establishment of a working relationship and rapport with the patient and family. Next, the physician focuses on the patient’s methods of weight loss or weight control. This opens the door to educating the patient on the importance of maintaining good health—including a discussion of normal eating, nutrition, and exercise—and assisting the patient in establishing a goal weight that will serve as a boundary for excessive weight loss.
In addition to the institution of an appropriate diet and weight goal, patients may also be instructed on beginning and maintaining a food diary. This assists the physician in identifying patterns and triggers for dysfunctional habits and gives patients a way to exert some control over their eating behavior.
Another important component of treatment is to acknowledge the possibility of relapse and have a plan in place. Discussing some of the potential triggers of relapse—relationship problems, family issues (eg, divorce, separation), academic and peer pressure—and the strategies to cope with them can help patients avoid feelings of hopelessness when they are experienced. The patient who relapses should be reevaluated within 3–6 weeks. Information obtained on the follow-up visit is helpful in determining whether weight is changing precipitously, if there are changes in physical examination findings, or, most importantly, if the dysfunctional eating habits are more entrenched. These markers help determine whether the patient will require referral.
B. Established Eating Disorders
Patients who clearly meet the criteria for an established eating disorder typically require management by a multidisciplinary team that includes a physician (family physician, pediatrician, or internist), nutritionist or dietician, nurse, mental health professional, and other support staff.
The role of any family physician who is not an integral part of an established eating disorder treatment team is to coordinate and facilitate transfer. This role is critical because the trust in the primary care physician may not be readily transferred to the team of specialists. It is essential that the family physician remain involved in the patient’s treatment by providing regular medical assessments, supporting the patient and family, clarifying the tasks performed by each of the team members, reinforcing the importance of the referral, and preventing premature discontinuation of treatment.
Among the various approaches to the management of eating disorders are family therapy, short-term psychotherapies such as cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT), behavior modification, and psychoactive medications. According to the condition of the patient (Table 11-3), they may be applied in the inpatient or outpatient setting.
Few empirically validated treatments have shown substantial efficacy for AN. Some patients, through medical management and nutritional change, along with psychotherapy, are able to maintain a requisite weight for medical stability; however, many patients retain subthreshold eating pathology and underweight status.
The primary treatment goals for AN are medical stability and weight stabilization. In the female patient, this means a weight at which ovulation and menses can occur; in the male patient, it entails return to normal hormone levels and sex drive; and in adolescents and children, return to normal physical and sexual maturation. Other goals include treating medical and physical complications; motivating patients to cooperate and participate in treatment education regarding healthy nutrition and eating patterns; treating underlying eating disordered psychopathology and fear of weight gain that accompanies AN, as well as comorbid psychiatric conditions; encouraging and supporting family participation; and, ultimately, preventing relapse. Because of the variation and severity of symptoms presented, a comprehensive approach to available services and their clinical dimensions must be considered by the multidisciplinary team. Treatment approach will also vary with the age of the patient. Younger patients are often more successfully treated by utilizing family therapy that involves the parent in refeeding and using the family for balancing food intake, exercise, bedrest, and privileges.
The cornerstone of the multidisciplinary approach to treatment is inpatient or outpatient psychiatric management. While physicians manage the medical comorbidities and nutritionists help reestablish normal eating patterns, mental health professionals target treatment of the underlying psychological causes and symptoms of eating disorders, including distorted cognitions, body image issues, self-image and ego strength problems, and comorbid conditions (ie, mood and anxiety disorders). They use various behavioral or psychological therapies. The chronic and complex characteristics of AN are also inherent problems in the use of psychosocial modalities for treatment. Although behavior modification and family therapy are often effective during the acute refeeding program, psychodynamic therapies and short-term therapies are not. However, psychotherapy is deemed very helpful once malnutrition is corrected. Clinicians use the CBT approach to restructure or modify distorted beliefs and attitudes regarding strict food rituals and dichotomous thinking (viewing the world as “black or “white” or “all or none”). Individual psychodynamic and group therapy are also used by many therapists to address underlying personality disturbances after the acute phase of weight restoration has occurred.
The treatment services available range from intensive inpatient settings, through partial hospital and residential programs, to varying levels of outpatient care. The pretreatment patient evaluation (weight, cardiac, and metabolic status) is essential in determining where treatment will occur. For example, patients who are significantly malnourished, weighing <75% of their individually estimated ideal body weight, are likely to require a 24-hour hospital program. For these patients, hospitalization should occur before the onset of medical instability (ie, marked orthostatic hypotension, bradycardia of <40 bpm, tachycardia >110 bpm, hypothermia, seizures, cardiac dysrhythmia, or failure), which could otherwise result in greater risks when refeeding and a more problematic prognosis overall. In such patients, hospitalization is based on psychiatric and behavioral grounds such as acute food refusal, uncontrollable binge eating and purging, failure of outpatient management, and comorbid psychiatric diagnosis (Table 11-5).
Table 11–5.Criteriaa for hospitalization. ||Download (.pdf) Table 11–5.Criteriaa for hospitalization.
Severe malnutrition (weight, 75% ideal body weight)
Physiologic instability (eg, severe bradycardia, hypotension, hypothermia, orthostatic changes)
Arrested growth and development
Failure of outpatient treatment
Acute food refusal
Uncontrollable binge eating and purging
Acute medical complications of malnutrition, such as syncope, seizures, cardiac failure
Acute psychiatric emergencies, such as suicidal ideation or acute psychosis, and any comorbid diagnosis that interferes with treatment, such as severe depression, obsessive-compulsive disorder, or severe family dysfunction
For milder cases of AN, successful alternatives to intensive inpatient programs have been partial hospitalization and day treatment programs. These programs typically involve a high level of parental participation and are indicative of the patient’s motivation to participate in treatment. Initially, these programs require the patient’s presence and participation for 14 hours a day. However, as patients approach their target weights, they can be seen in outpatient sessions 3 times per week. Once the target weight is reached, follow-up is less frequent.
Patients selected for outpatient treatment are highly motivated and have brief symptom duration; cooperative, supportive families; no serious medical complications; and BMI > 17.5. Their management should also be orchestrated by a multidisciplinary team that includes a primary care physician (family practitioner, pediatrician), nutritionist, psychotherapist, family therapist, and support staff, because success is highly dependent on careful monitoring of weight obtained in a hospital gown and after voiding, orthostatic vital signs, temperature, urine-specific gravity, and the patients’ eating disorder symptoms and behaviors. As an initial step, a clearly and concisely written behavioral contract with the patient and family (if appropriate) can be established. The contract serves as an agreement to maintain an acceptable minimum weight and vital signs or be hospitalized. Criteria for treatment failure and hospitalization are also included. However, it should be noted that although behavioral contracts are encouraged, they may not be as effective in the outpatient setting because they are more difficult to monitor. Nonetheless, they are helpful in achieving the goal of outpatient management, which is to prompt the patient to self-monitor and assume responsibility for appropriate eating.
For the patient with AN, daily structure is key and should include three meals and several snacks each day. Parents should ensure that healthy foods are readily available and that mealtimes are planned. Although this results in a gradual increase in caloric intake, it may still be necessary to limit physical activity to facilitate weight gain of ≤1 lb per week. This incremental weight increase prevents the gastric dilation, edema, and congestive heart failure experienced by patients who have restricted their eating for a prolonged period of time.
Psychotropic medications are not useful in treatment of AN when patients are in a malnourished state. However, they are frequently used after sufficient weight restoration has occurred for maintenance and the treatment of other associated psychiatric symptoms. Psychotropic medications other than selective serotonin reuptake inhibitors (SSRIs) are most often used. They include neuroleptics for obsessive-compulsive symptoms and anxiety disorders, and acute anxiety agents to reduce anticipatory anxiety associated with eating.
Few patients with uncomplicated BN require hospitalization. Indications for the few patients (<5%) who require inpatient care include severe disabling symptoms that have not responded to outpatient management, binge-purge behavior causing severe physiologic or cardiac disturbances (eg, dysrhythmias, dehydration, metabolic abnormalities), and psychiatric disturbances (eg, suicidal ideation or attempts, substance abuse, major depression). If hospitalization is warranted, the treatment focus is on metabolic restoration, nutritional rehabilitation, and mood stabilization. These patients may also require assistance with laxative, diuretic, and illicit drug withdrawal. Hospitalization is usually brief, and management then transfers to partial hospitalization programs or outpatient treatment facilities. Partial hospitalization programs usually require the patient to be present 10 hours per day, 5 days a week. Support is usually provided in a group format and family participation is often required. Many of the treatment modalities for BN resemble those for AN. However, the primary focus differs significantly. Although some bulimia patients may be slightly underweight, most are of normal weight; hence nutritional rehabilitation targets the patient’s pattern of binging and purging in weight restoration. Therefore, nutritional counseling serves as an adjuvant to other treatment modalities and has been noted to enhance the effectiveness of the overall treatment program.
Interventions targeting the psychosocial aspects surrounding BN address the issues of binging and purging, food restriction, attitudes related to eating patterns, body image and developmental concerns, self-esteem and sexual difficulties, family dysfunction, and comorbid conditions (eg, depression). The most efficacious psychosocial approach is CBT, a relatively short-term approach specifically focused on the eating disorder symptoms and underlying cognitions (eg, low self-esteem, body image concerns) of BN. Patients managed with CBT demonstrate profound decrements in three very characteristic behaviors: binge eating, vomiting, and laxative abuse. However, the percentage of patients who can achieve total abstinence from binge-purge behavior is invariably small. IPT, also a short-term treatment, is considered a second line of treatment.
Other types of individual psychotherapy that are used in clinical practice include psychodynamic approaches that may be helpful in treating some of the underlying causes of BN. Group psychotherapy is moderately successful. The efficacy of this approach is increased when it is combined with nutritional counseling and frequent clinic visits. Family or marital therapy should also be considered in conjunction with other treatment modalities for adolescents living at home, older patients from dysfunctional homes, and patients experiencing marital discord.
Another important aspect of eating disorder management is pharmacotherapy with antidepressants (eg, SSRIs). These agents were first used in the acute phase of treatment for BN because of its well-established comorbid association with clinical depression. It was later reported that nondepressed patients also responded to these medications. Multiple clinical studies have shown the SSRIs to have an antibulimic (reduction in binge eating and vomiting rates) effect independent of their antidepressant effect. Therapists have also noted improvement in mood and anxiety symptoms. Other antidepressant medications used in the treatment of BN include the tricyclic antidepressants (imipramine/desipramine), the monoamine oxidase inhibitors (MAOIs; phenelzine and isocarboxazid). The MAOIs should be used with great caution and only in patients with severe BN. At this time, fluoxetine is the only SSRI approved by the Food and Drug Administration for the treatment of BN. A 20-mg per day dose is used to initiate treatment, with doses of 40–60 mg/d required for maintenance.
Although most individuals with BED are obese, normal-weight people are also affected. Therefore, treatment usually focuses on the distress experienced by individuals rather than on their weight problem. CBT, IPT, and group approaches are effective. CBT, which teaches techniques to monitor eating habits and alternative responses to difficult situations, appears to be the most efficacious. For patients with greater eating-related and psychosocial distress, IPT appears to be a particularly potent treatment. The great majority of those affected can be treated as outpatients and hospitalization is rarely needed.
Similar to BN, pharmacotherapy has demonstrated effectiveness for the treatment of BED. SSRIs appear to foster reductions in binge eating, psychiatric symptoms, and the severity of the illness. Medications aiming to reduce weight among overweight and obese BED patients, including topiramate, have also shown promising results for weight reduction. There is mixed support for whether combining psychotherapy (CBT) with pharmacologic interventions enhances remission rates. However, specific medications (orlistat, topiramate) have been shown to enhance weight loss achieved with CBT and behavioral weight loss.
M Treatment of eating disorders in children, adolescents, and young adults. Pediatr Rev.
[PubMed: [PMID: 16387924]]
CM Review and meta-analysis of pharmacotherapy for binge-eating disorder. Obesity.
[PubMed: [PMID: 19186327]]