Treating Eating Disorders - Psychiatry Online (PDF)

Based on Practice Guideline for the Treatment of Patients With Eating Disorders, Third Edition, originally published in July 2006. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org. TREATING EATING DISORDERS A Quick Reference Guide  American Psychiatric Association Steering Committee on Practice Guidelines John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D. Area and Component Liaisons Robert Pyles, M.D. (Area I) C. Deborah Cross, M.D. (Area II) Roger Peele, M.D. (Area III) Daniel J. Anzia, M.D. (Area IV) John P. D. Shemo, M.D. (Area V) Lawrence Lurie, M.D. (Area VI) R. Dale Walker, M.D. (Area VII) Mary Ann Barnovitz, M.D. Sheila Hafter Gray, M.D. Sunil Saxena, M.D. Tina Tonnu, M.D. Medical Editors, Quick Reference Guides Michael B. First, M.D. Laura J. Fochtmann, M.D. Staff Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Assistant Project Manager Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research  Statement of Intent The Practice Guidelines and the Quick Reference Guides are not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judg- ment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diag- nostic and treatment options available. The development of the APA Practice Guidelines and Quick Reference Guides has not been financially supported by any commercial organization. For more detail, see APA’s “Practice Guideline Development Process,” available as an appen- dix to the compendium of APA practice guidelines, published by APPI, and online at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm.  B. Treatment Goals................237 C.Treatment 1. Treatment Setting...239 2. Anorexia Nervosa...............242 a. Nutritional Rehabilitation....242 b. Psychosocial treatments.........243 c. Medications ......245 3. Bulimia Nervosa...............247 a. Nutritional Rehabilitation....247 b. Psychosocial treatments .........247 c. Medications ......250 4. Eating Disorders Not Otherwise Specified ..............251 a. Subsyndromal Eating Disorders...251 b. Binge-Eating Disorder ...........252 • TREATING EATING DISORDERS 224 OUTLINE A. Psychiatric Management • Establish and maintain a therapeutic alliance. .................225 • Collaborate with other clinicians. ...............225 • Assess and monitor eating disorder symptoms and behaviors................226 •. Ensure that the patient’s general medical status is assessed and monitored ...............227 • Assess and monitor the patient’s psychiatric status, including co- occurring conditions and safety...............236 • Assess family issues and enlist family support...................236 • Provide education about the patient’s eating disorder and its treatment ............236  TREATING EATING DISORDERS • 225 A. Psychiatric Management Establish and maintain a therapeutic alliance. • Enhance development of the alliance through empathic comments and behaviors, positive regard, reassurance, and support. • Recognize and acknowledge anxieties that patients with anorexia nervosa have about gaining weight. • Be aware that many patients may withhold information about their behaviors because of shame. • Set clear boundaries. • Be aware of countertransference reactions. • Adapt and modify therapeutic strategies as the disorder and the therapeutic alliance change over time. Collaborate with other clinicians. • Provide and/or coordinate care. • Collaborate with other individuals who are involved in the patient’s treatment, including other physicians, registered dietitians, mental health professionals, and school personnel. • Consult with other physician specialists and dentists. • Educate and supervise inexperienced staff. Throughout the process of assessment, diagnosis, and formulation and implementation of a treatment plan, the following principles of psychiatric management should be kept in mind:  • TREATING EATING DISORDERS 226 A. Psychiatric Management (continued) Assess and monitor eating disorder symptoms and behaviors. • Use DSM-IV-TR criteria to guide diagnosis and identification of target symptoms and behaviors. • Obtain history of previous episodes of eating disorder, including previous treatment response. • Assess specific eating-related behaviors by • obtaining a detailed report of food intake during a single day, • observing the patient during a meal, and • recording food and/or fluid intake and output as part of nutritional management. • Consider the use of formal measures (e.g., semistructured interviews, rating scales, self-report questionnaires). • Assess related psychological symptoms (e.g., obsessional thoughts related to weight, shape, and eating). • Explore the patient’s understanding of how the illness developed and the effects of interpersonal issues on onset, including aspects of sexual history and psychological, physical, or sexual abuse. • Identify stressors that exacerbate the symptoms of the eating disorder. • Identify relevant psychodynamic and interpersonal conflicts. • Determine the patient’s insight into the presence of the disorder and the patient’s motivation for change.  TREATING EATING DISORDERS • 227 Ensure that the patient’s general medical status is assessed and monitored. • Ensure that a physical examination is conducted by a physician knowledgeable about eating disorders: • Vital signs • Weight and height, including calculation of BMI • Physical and sexual growth and development • Cardiovascular system, including evidence of dehydration, cardiac arrhythmias, or congestive heart failure • Lanugo • Salivary gland enlargement • Russell’s sign (scarring on dorsum of hand) • Muscular irritability or weakness • Evidence of self-injurious behaviors • Review dental examination results. • Conduct laboratory analyses, as indicated. For laboratory assessments and their patient indications, see Table 1, p. 228. • For commonly found signs, symptoms, and associated laboratory abnormalities, see Table 2, p. 230.  • TREATING EATING DISORDERS 228 TABLE 1. Laboratory Assessments for Patients With Eating Disorders Assessment Patient Indication Basic analyses All patients with eating disorders Blood chemistry studies Serum electrolytes Blood urea nitrogen Serum creatinine (interpretations must incorporate assessments of weight) Thyroid-stimulating hormone test; if indicated, free T4, T3 Complete blood count including differential Erythrocyte sedimentation rate Aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase Urinalysis Additional analyses Malnourished and severely symptomatic Complement component 3a patients (Serum magnesium should be Blood chemistry studies obtained prior to administering certain Serum calcium medications if QTc is prolonged.)b Serum magnesium Serum phosphorus Serum ferritin Electrocardiogram 24-hour urine for creatinine clearancec Osteopenia and osteoporosis Patients amenorrheic for >6 months assessments Dual-energy X-ray absorptiometry Serum estradiol in female patients Serum testosterone in male patients  TREATING EATING DISORDERS • 229 TABLE 1. Laboratory Assessments for Patients With Eating Disorders (continued) Assessment Patient Indication Nonroutine assessments Toxicology screen Patients with suspected substance use, particularly those with anorexia nervosa, binge/purge subtype, or for patients with bulimia nervosa Serum amylase (fractionated for Patients with suspected surreptitious salivary gland isoenzyme if vomiting available to rule out pancreatic involvement) Serum luteinizing hormone, follicle- Patients with persistent amenorrhea but stimulating hormone, β-human who are normal weight chorionic gonadotropin, prolactin Brain magnetic resonance imaging, Patients with significant cognitive deficits, computed tomography other neurological soft signs, unremitting course, or other atypical features Stool for guaiac Patients with suspected gastrointestinal bleeding Stool or urine for bisacodyl, emodin, Patients with suspected laxative abuse aloe-emodin, rhein aSome experts recommend the routine use of complement component 3 as a sensitive marker that may indicate nutritional deficiencies even when other laboratory test results are apparently in the normal range. bDuring hospital refeeding, it is recommended that serum potassium, magnesium, and phosphorus levels be determined daily for 5 days and thereafter at least three times/week for 3 weeks. cCreatinine clearance should be calculated with equations that involve body surface using assessments of height and weight.  • TREATING EATING DISORDERS 230 TABLE 2. Physical Complications of Eating Disorders Organ System Signs and Symptoms Associated Laboratory Abnormalities Whole body Low body weight, dehydration, Weight: Low weight and BMI hypothermia, cachexia, weakness and Anthropometrics: Low body fat percentage by lassitude increase with degree of malnutrition anthropometrics or underwater weighinga Cardiovascular and Weakness; faintness; dizziness; orthostatic ECG: Bradycardia in AN; ST-T wave peripheral vascular hypotension; shortness of breath; chest pain; abnormalities in AN and with hypokalemia; palpitations; arrhythmias; bradycardia; increased PR interval and first-degree heart weak irregular pulse; cold extremities; block in AN; QTc prolongationb in AN and acrocyanosis with hypokalemia; QT dispersion correlated with weight loss. In severe cases of BN, hypokalemia- widened QRS complex, increased P-wave amplitude, increased PR interval, increased supraventricular and ventricular ectopic rhythms; torsade de pointes correlated with hypokalemia; autonomic dysfunction on spectral analysis Echocardiogram: Mitral valve prolapse and pericardial effusion in AN; cardiomyopathy in ipecac abusers Chest X-ray: Small heart Central nervous Apathy; poor concentration; in AN and CT scan: Cortical atrophy, ventricular system severe cases of BN cognitive impairment; enlargement anxious, depressed, irritable mood and, less PET, fMRI: Abnormal cerebral blood flow and often, seizures, peripheral neuropathy metabolism MRI: Decreased gray and white matter EEG: Nonspecific abnormalities; seizures (rare)  TREATING EATING DISORDERS • 231 TABLE 2. Physical Complications of Eating Disorders (continued) Organ System Signs and Symptoms Associated Laboratory Abnormalities Endocrine, metabolic Fatigue, diuresis, cold intolerance and low Complete metabolic panel: Electrolyte body temperature in AN; weight fluctuation, abnormalities, including hypokalemia (with poor skin turgor and pitting edema in BN; hypokalemic hypochloremic alkalosis in rarely, proximal weakness, irritability, muscle vomiters); hypomagnesemia (in vomiters, cramping, Chvostek’s and Trousseau’s signs laxative abusers, and AN); hypophosphatemia (in vomiters and laxative abusers and especially on refeeding in AN); hypercholesterolemia in AN; hypoglycemia (rare) Urinalysis: Dehydration (increased urine specific gravity, osmolality) with purging or diuretic use Thyroid testing: Decreased T3 with increase in reverse T3 in AN Serum cortisol: Increased serum cortisol in AN Vitamin assays: In severe cases, folate, B12, niacin, and thiamine deficiencies in AN Gastrointestinal In AN, abdominal pain, bloating, Liver function tests: Occasionally abnormal liver obstipation, constipation, vomiting, function test results abdominal distension with meals, abnormal Serum amylase: Increased serum amylase in bowel sounds; acute gastric distension (rare) purging patients (if fractionation is available, In vomiters, benign parotid hyperplasia, usually salivary gland isoenzymes); increased caries, gingivitis, occasional blood-streaked pancreatic amylase (rare), possibly indicating vomitus; possibly gastritis, esophagitis, laxative abuse or other causes for pancreatic gastroesophageal erosions, heartburn, inflammation or pancreatitis esophageal dysmotility patterns (including Gastric motility testing: In AN, delayed gastric gastroesophageal reflux) and, rarely, Mallory- emptying, increased whole bowel and colonic Weiss (esophageal) or gastric tears, transit time, anorectal dysfunction  • TREATING EATING DISORDERS 232 TABLE 2. Physical Complications of Eating Disorders (continued) Organ System Signs and Symptoms Associated Laboratory Abnormalities Gastrointestinal perforation, or necrosis; increased rates of Endoscopy: Occasional inflammation or Barrett’s (continued) pancreatitis; abdominal pain and discomfort; esophagus involuntary vomiting, obstipation, constipation Radiography: Rarely, superior mesenteric artery In chronic laxative abusers, possibly bloating, syndrome, pancreatitis colonic dysmotility or melanosis coli Stool for guaiac: Occasionally positive because In patients with vitamin deficiencies, angular of purging or laxative abuse stomatitis, glossitis, diarrhea Genitourinary In AN, decreased or increased urinary Renal function tests: In AN, increased blood urea volumec nitrogen, decreased glomerular filtration rate, decreased serum creatinine because of low lean body mass (normal creatinine may indicate azotemia), renal failure (rare) Other renal findings: In AN, greater formation of renal calculi, hypovolemic nephropathy, hypokalemic nephropathy Hematologic In AN, fatigue, cold intolerance, bruising/ Complete blood count: In AN, anemia (may be clotting abnormalities (rare) normocytic, microcytic, or macrocytic); leukopenia with relative lymphocytosis; low erythrocyte sedimentation rate; thrombocytopenia; clotting factor abnormalities (rare) Other hematologic abnormalities: In AN, decreased serum ferritin, B12, folate  TREATING EATING DISORDERS • 233 TABLE 2. Physical Complications of Eating Disorders (continued) Organ System Signs and Symptoms Associated Laboratory Abnormalities Immune system Fewer than expected viral infections in Multiple unexplained immune system AN but may develop viral infections during abnormalities; abnormalities in tumor necrosis weight restoration, reduced febrile response factor–α and interleukin subtypes to bacterial infection Integument In AN, change in hair, including lanugo; Vitamin assays: In AN, increased serum hair loss and dry and brittle hair; self-injury carotene; in severe cases, vitamin deficiencies marks; numerous integumentary abnormalities, (e.g., niacin) including xerosis, carotenoderma (yellowing of skin), and acne In vomiters, scarring on dorsum of hand (Russell’s sign); petechia; conjunctival hemorrhages shortly after vomiting Muscular With severe malnutrition or ipecac- Enzyme tests: With severe malnutrition, creatine associated peripheral myopathy, muscle kinase and other muscle enzyme abnormalities; weakness, muscle aches, cramps; in severe creatine kinase isoenzymes for skeletal vs. cases, muscle wasting cardiac source Oropharyngeal In vomiters, dental caries with erosion of Radiography: Erosion of dental enamel dental enamel, particularly the lingular surface Serum amylase: Increased serum amylase of incisors; pain and erythema of pharynx; associated with benign parotid hyperplasia palatal scratches; swollen cheeks and neck (usually painless); enlarged salivary glands Pulmonary With severe malnutrition, reduced aerobic Pulmonary function tests: With severe capacity and wasting of respiratory muscles malnutrition, decreased pulmonary capacity  • TREATING EATING DISORDERS 234 TABLE 2. Physical Complications of Eating Disorders (continued) Organ System Signs and Symptoms Associated Laboratory Abnormalities Reproductive In AN, loss of menses or primary Serum gonadotropins: Decreased serum estrogen amenorrhea; arrested sexual development in female patients with AN or BN; decreased or regression of secondary sex characteristics serum testosterone in male patients; prepubertal and psychosexual maturation or interest; patterns of luteinizing hormone, follicle- loss of libido, fertility problems; higher rates stimulating hormone secretion with amenorrhea of pregnancy complications and neonatal Pelvic ultrasound: Lack of follicular development complications. Deficiencies in the mother and/or lack of dominant follicle with can result in deficiencies in the fetus. amenorrhea In BN, fertility problems and oligomenorrhea or amenorrhea  TREATING EATING DISORDERS • 235 TABLE 2. Physical Complications of Eating Disorders (continued) Organ System Signs and Symptoms Associated Laboratory Abnormalities Skeletal Bone pain with exercise; point tenderness; Radiography and bone scans: Increased rate of in severe cases, short stature and arrested pathological stress fractures (more likely in AN skeletal growth (more likely in AN than in BN) than BN)d; delayed bone age in some patients with AN DEXA: Osteopenia or osteoporosis, especially in hip and lumbar spine (more likely in AN than BN)d Note. More information on the physical complications of anorexia nervosa is available in Birmingham CL, Beumont PJV: Medical Management of Eating Disorders. Cambridge, UK, Cambridge University Press, 2004. AN = anorexia nervosa; BN = bulimia nervosa; CT = computed tomography; DEXA = dual energy X-ray absorptiometry; ECG = electrocardiogram; EEG = electroencephalogram; EMG = electromyogram; fMRI = functional magnetic resonance imaging; MRI = magnetic resonance imaging; PET = positron emission tomography. aAnthropometrics estimate only peripheral fat. Underwater weighing assesses total body fat. bBecause QTc prolongation may be associated with sudden death, other medications known to prolong QTc intervals should generally be avoided and any electrolyte abnormalities (e.g., hypokalemia) and hypomagnesemia should be corrected if QTc prolongation is present. In anorexia nervosa, QTc intervals typically normalize with refeeding. cSome chronically ill patients have renal abnormalities associated with decreased urinary volume. Some drink excessive amounts of fluids to assuage hunger, producing increased urinary volume. dAlthough patients with bulimia nervosa who are of normal weight may not need extensive evaluation for osteopenia or osteoporosis, those who have had previous episodes of anorexia nervosa may be at higher risk for these abnormalities and require a similar assessment to that recommended for patients with anorexia nervosa.