OFFICIAL ABP TOPIC:

The American Psychiatric Association Practice Guideline For The Treatment Of Patients With Eating Disorders

BACKGROUND

This guideline focuses on the treatment of the eating disorders anorexia nervosa, bulimia nervosa, binge-eating disorder, and avoidant/restrictive food intake disorder. Eating disorders typically have an onset in adolescence or early adulthood and frequently co-occur with other psychiatric disorders and medical conditions.

SCREENING AND EVALUATION

The APA recommends screening for eating disorders as part of routine evaluations, particularly in high-risk populations (e.g., adolescents, LGBTQ+ individuals, athletes). The SCOFF questionnaire is a useful screening tool, supplemented by questions about binge eating and compensatory behaviors.

Key Recommendation: A comprehensive initial evaluation of a patient with a possible eating disorder should assess:

• Eating disorder symptoms and behaviors:
  • Restrictive eating patterns, binge eating, purging, and other eating-related behaviors
  • Changes in weight, food choices, and physical activity
  • Body image concerns and preoccupation with weight/shape
  • Psychosocial impairments and motivation for change
• Medical status:
  • Vital signs, including orthostatic changes
  • Growth curves and sexual development in youth
  • Signs of malnutrition (e.g., lanugo, brittle hair, dry skin)
  • Signs of purging (e.g., dental erosion, calluses, electrolyte abnormalities)
  • Comprehensive review of systems

• Psychiatric comorbidities:
  • Depression, anxiety, obsessive-compulsive symptoms
  • Substance use, self-harm, and suicidality
  • Neurodevelopmental disorders (e.g., autism spectrum disorder, ADHD)
• Psychosocial history:
  • Psychosocial impairment secondary to eating or body image concerns
  • Bullying, trauma, and adverse childhood experiences
  • Family structure, dynamics, and psychiatric history
  • Cultural attitudes and beliefs about food and appearance
• Diagnostic studies:
  • Laboratory testing (CBC, comprehensive metabolic panel)
  • ECG in patients with a restrictive eating disorder, severe purging behavior, or medications that prolong QTc intervals
  • DEXA scan if prolonged amenorrhea or malnutrition

Specific considerations for avoidant/restrictive food intake disorder include assessing for sensory sensitivities, fear of aversive consequences (e.g., choking, vomiting), and lack of interest in food, as well as evaluating for autism spectrum disorder and anxiety disorders.

DIAGNOSIS

Diagnoses should be made using DSM-5 criteria. Some key diagnostic features include:

• Anorexia Nervosa: Restriction of energy intake leading to low body weight, intense fear of gaining weight, and disturbance in the way body weight/shape is experienced.
• Bulimia Nervosa: Recurrent episodes of binge eating and inappropriate compensatory behaviors (e.g., self-induced vomiting, misuse of laxatives/diuretics, excessive exercise) at least once a week for 3 months.
• Binge-eating Disorder: Recurrent binge-eating episodes (at least once a week for 3 months) associated with marked distress, but without regular compensatory behaviors.
• Avoidant/Restrictive Food Intake Disorder: An eating disturbance leading to persistent failure to meet appropriate nutritional/energy needs, but without body image disturbance or fear of weight gain.

DETERMINING TREATMENT PLAN AND LEVEL OF CARE

Key Recommendation: Patients should have a documented, comprehensive, person-centered treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise from a coordinated multidisciplinary team.

Treatment settings range from outpatient (for medically stable patients with adequate support) to intensive outpatient, partial hospitalization, residential, or inpatient programs. Even after initial symptom improvement, ongoing care is important for continued progress and relapse prevention. This may involve:

• A gradual decrease in intensity of services
• Continuation of psychotherapy to address residual symptoms, body image, self-esteem, and interpersonal functioning
• Encouragement of family involvement, including psychoeducation, support, and guidance
• Link to peer and community support services

TREATMENT OF ANOREXIA NERVOSA (AN)

Key Recommendation: Nutritional Rehabilitation for AN

• Establish individualized target weights based on age, height, pubertal stage, premorbid weight, and physiological functioning.
• Set expected rates of weight gain (e.g., 2-4 lbs/week for inpatient or residential, 0.5-2 lbs/week for outpatient).
• Start with 1500-2000 kcal/day and increase by 250-500 kcal every 2-3 days; most patients require 3000-4000+ kcal/day to achieve weight goals.
• Monitor weight gain, vital signs, electrolytes, and cardiac function closely.
• Monitor for refeeding syndrome, especially in severely malnourished patients.
• Use behavioral contracts, meal supervision, and supplemental feedings (liquid supplements or NG tube) if needed to ensure intake.

Key Recommendation: Psychotherapy for AN

• For adolescents with AN, family-based treatment (FBT) is first-line:
  • FBT works to empower parents to take charge of nutrition and interrupt disordered behaviors.
  • It is typically provided over 6-12 months in 3 phases (weight restoration, returning control to patient, establishing healthy identity).
  • For refractory cases, intensified FBT or parent-focused FBT may be considered.
• Other approaches (e.g., adolescent-focused therapy) may be used if FBT is declined or ineffective.

Medication has a limited role in AN. Olanzapine may have some benefits for weight gain, but psychotherapy remains the foundation of treatment.

TREATMENT OF BULIMIA NERVOSA (BN)

Key Recommendation: Family-Based Treatment for Youth with BN

• For adolescents and young adults with BN, family-based treatment (FBT) is a suggested approach.
• FBT for BN is similar to that for AN, with a focus on interrupting binge-purge cycles, normalizing eating, and addressing body image in a developmentally appropriate way.
• Use of fluoxetine or other SSRIs has not been well studied to treat BN in adolescents, although it is recommended for adults with BN. It could be considered after discussion with patients and families about the risks and benefits of SSRIs.

Self-help approaches based on CBT principles may be used as an initial step for patients with less severe BN symptoms or difficulty accessing specialty care. Nutrition counseling is also beneficial in promoting structured, balanced eating to reduce binge triggers.

TREATMENT OF BINGE-EATING DISORDER

Key Recommendation: Psychotherapy for Binge-Eating Disorder

• Offer CBT or interpersonal therapy in individual or group formats as first-line treatment for binge-eating disorder:
  • Treatment typically involves 12-20 weekly sessions over 3-6 months.
  • Key elements include regular eating, self-monitoring, problem-solving, cognitive restructuring, and improving interpersonal functioning.
• Guided self-help based on CBT principles is an alternative approach.
• Behavioral weight loss may be considered for patients with comorbid obesity, but does not sufficiently address binge eating.

TREATMENT OF AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER

Goals of treatment are to increase dietary variety, volume, and nutritional adequacy. Treatment approaches include:

• Family-based interventions to reduce accommodating behaviors and encourage exposure to new foods.
• Cognitive-behavioral approaches to address underlying anxiety, sensory sensitivities, and maladaptive beliefs.
• Occupational therapy and speech therapy to improve oral-motor skills and tolerance of food textures.
• Psychoeducation for patients and families about nutritional needs and consequences of dietary restriction.
• Supplemental feedings (liquid supplements, NG tube) for nutritional rehabilitation if unable to meet needs orally.

REFERENCES

https://psychiatryonline.org/doi/epdf/10.1176/appi.books.9780890424865