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Services available for the treatment of eating disorders can
range from intensive inpatient settings (in which subspecialty general
medical consultation is readily available) to residential and partial
hospitalization programs to varying levels of outpatient care (in which
the patient can receive general medical treatment, nutritional counseling,
and/or individual, group, and family psychotherapy). Because
specialized programs are not available in all geographic areas and
financial considerations are often significant, access to these
programs may be difficult. The resources listed in Table 1 may provide
guidance to patients and families for accessing suitable programs.
Pretreatment evaluation of the patient is essential for determining
the appropriate treatment setting. Patient weight, rate of weight
loss, cardiac function, and metabolic status are the most important
physical parameters for making this choice. Eating disorders should
be recognized and early treatment implemented as soon as possible
after the onset of symptoms. This is especially true in children,
adolescents, and young adults, to avoid the disorder becoming chronic.
As a general rule, patients who weigh less than approximately
85% of their individually estimated healthy weights have
considerable difficulty gaining weight outside of a highly structured program
that includes inpatient care; such a program may be medically and
psychiatrically necessary even for patients above that weight level.
It is important to underscore that these are individually estimated
healthy weights, not weights simply listed in a standard insurance
table. Healthy weight estimates for a given individual must be determined
by that person's physicians on the basis of historical
data (e.g., growth charts) (3) and, for women, the weight at which
healthy menstruation and ovulation resume, which may be higher than
the weight at which menstruation and ovulation became impaired (94–96).
It is equally important that the decision to hospitalize a
patient be based on psychiatric and behavioral factors, including
a rapid or persistent decline in oral intake; a decline in weight
despite maximally intensive outpatient or partial hospitalization
intervention; the presence of additional stressors, such as dental
procedures, that may interfere with the patient's ability
to eat; the weight at which the patient was medically unstable in
the past; and co-occurring psychiatric problems that merit hospitalization.
The degree of a patient's denial and resistance to participate
in his or her own care in less supervised settings is critical in deciding
whether to hospitalize the patient. Once weight loss is
severe enough to indicate the need for immediate hospitalization,
treatment may be less effective, refeeding may entail greater risks,
and prognosis may be more problematic than if intervention had been
provided earlier. Because cortical gray matter deficits result from
malnutrition and persist after refeeding (97–99), earlier
(rather than later) interventions may be important to minimize the
persistent effects of these physiological impairments. Therefore,
hospitalization should occur before the onset of medical instability
as manifested by vital signs, physical findings, or laboratory test
results outside of the normal range.
Vital sign changes that indicate a need for immediate medical
hospitalization include marked orthostatic hypotension, with an
increase in pulse of 20 bpm or a drop in blood pressure of 20 mmHg
standing; bradycardia, with a heart rate <40 bpm; tachycardia,
with a heart rate >110 bpm; or the patient's inability
to sustain his or her body core temperature (e.g., body temperatures
<97.0°F) (3). Most severely underweight
patients, particularly those with physiological instability, require
inpatient medical management and comprehensive treatment to support
their weight-gaining efforts. To avert potentially irreversible
effects on physical growth and development, many children and adolescents
require inpatient medical treatment, even when weight loss, although
rapid, has not been as severe as that suggesting a need for hospitalization
in adult patients (3). If children refuse fluids or food out of
concern about gaining weight, they may become dehydrated quickly.
Also, a child's small size may mean that relatively smaller
reductions in weight will result in greater physiological danger.
In determining a patient's initial level of care
or suitability for change to a different level of care, expert consensus
indicates that it is important to consider a patient's
overall clinical and social picture rather than simply rely on weight
criteria. Furthermore, weight level per se should never be used
as the sole criterion for discharge from inpatient care. Patients
need to both gain healthy body weight and learn to maintain that
weight prior to discharge; patients who reach a healthy body weight
but are discharged before this learning occurs are likely to immediately
decrease their caloric intake to excessively low levels that are
often insufficient to sustain their healthy body weight. Assisting
patients in determining and practicing appropriate food intake at
a healthy body weight is likely to decrease the chances of their
relapsing. Patients who are medically stabilized on acute medical
units will still require inpatient treatment for eating disorders
if they do not meet biopsychosocial criteria for partial hospitalization
programs or if no suitable partial hospitalization program for eating
disorders treatment is accessible because of geographic or other
reasons. Patients with inadequate motivation or support who are
discharged from inpatient to partial hospitalization programs before
they are clinically ready often have high rates of early relapse,
greater struggles with recovery, and slower rates of progress, necessitating
longer future inpatient stays.
In shifting between levels of care, it is important to establish
continuity of care. Stepping down from one level of care to a less
intensive level may be destabilizing for a patient and can be even
more so when this involves a change in physician, therapist, or
treatment team. At times, patients may erroneously conclude that
moving to a less restrictive treatment setting means that they are
suddenly fully improved. The patient's ability to continue
treatment with familiar and trusted staff in a partial hospitalization
or outpatient setting may contribute to the success of aftercare
planning. Consequently, if the patient is moving from one treatment
setting or locale to another, transition planning requires that
the care team in the new setting or locale be identified and that
specific patient appointments be made. It is preferable that a specific
clinician on the team be designated as the primary coordinator of
care to ensure continuity and attention to important aspects of
treatment. Guidelines for treatment settings are provided in Table 8.
Level 1: Outpatient
Level 2: Intensive Outpatient
Level 3: Partial Hospitalization (Full-Day Outpatient
Level 4: Residential Treatment Center
Level 5: Inpatient Hospitalization
Medical status
Medically stable to the
extent that more extensive medical monitoring, as defined in levels
4 and 5, is not required
Medically stable to the extent that intravenous fluids,
nasogastric tube feedings, or multiple daily laboratory tests are not
For adults: Heart
rate <40 bpm; blood pressure <90/60 mmHg; glucose
< 60 mg/dl; potassium < 3 mEq/L;
electrolyte imbalance; temperature < 97.0°F; dehydration; hepatic,
renal, or cardiovascular organ compromise requiring acute treatment;
poorly controlled diabetes
For children and adolescents: Heart
rate near 40 bpm, orthostatic blood pressure changes (> 20 bpm
increase in heart rate or >10 mmHg to 20 mmHg drop), blood pressure
<80/50 mmHg, hypokalemia,b hypophosphatemia,
or hypomagnesemia
If suicidality is present,
inpatient monitoring and treatment may be needed depending on the
estimated level of risk
Specific plan with high lethality or intent; admission
may also be indicated in patient with suicidal ideas or after a
suicide attempt or aborted attempt, depending on the presence or
absence of other factors modulating suicide risk
Weight as percentage of healthy body weightd
Generally >85%
Generally >80%
Generally <85%
Generally <85%; acute weight decline with
food refusal even if not <85% of healthy body weight
Motivation to recover, including cooperativeness, insight,
and ability to control obsessive thoughts
Fair-to-good motivation
Fair motivation
Partial motivation; cooperative; patient preoccupied
with intrusive, repetitive thoughtse >3
Poor-to-fair motivation; patient preoccupied with intrusive
repetitive thoughtse 4–6 hours
a day; patient cooperative with highly structured treatment
Very poor to poor motivation; patient preoccupied with
intrusive repetitive thoughtse; patient
uncooperative with treatment or cooperative only in highly structured
Co-occurring disorders (substance use, depression,
Presence of comorbid condition
may influence choice of level of care
Any existing psychiatric disorder that would require
Structure needed for eating/gaining weight
Needs some structure to gain weight
Needs supervision at all meals or will restrict eating
Needs supervision during and after all meals or nasogastric/special
feeding modality
Ability to control compulsive exercising
Can manage compulsive exercising through self-control
Some degree of external
structure beyond self-control required to prevent patient from compulsive
exercising; rarely a sole indication for increasing the level of
Purging behavior (laxatives and diuretics)
Can greatly reduce incidents
of purging in an unstructured setting; no significant medical complications,
such as electrocardiographic or other abnormalities, suggesting
the need for hospitalization
Can ask for and use support from others or use cognitive
and behavioral skills to inhibit purging
Needs supervision during and after all meals and in bathrooms;
unable to control multiple daily episodes of purging that are severe,
persistent, and disabling, despite appropriate trials of outpatient
care, even if routine laboratory test results reveal no obvious
metabolic abnormalities
Environmental stress
Others able to provide adequate emotional
and practical support and structure
Others able to provide at least limited support and
Severe family conflict or
problems or absence of family so patient is unable to receive structured
treatment in home; patient lives alone without adequate support
Geographic availability of treatment program
Patient lives near treatment
Treatment program is too
distant for patient to participate from home
Source. Adapted
and modified from La Via et al. (100100).
Note. In
general, a given level of care should be considered for patients
who meet one or more criteria under a particular level. These guidelines
are not absolutes, however, and their application requires physician
aThis level of care is most effective
if administered for at least 8 hours/day, 5 days/week;
less intensive care is demonstrably less effective (101101).
bIf the patient is dehydrated,
whole-body potassium values may be low even if the serum potassium
value is in the normal range; determine concurrent urine specific
gravity to assess for dehydration.
cDetermining suicide risk is a
complex clinical judgment, as is determining the most appropriate
treatment setting for patients at risk for suicide. Relevant factors
to consider are the patient's concurrent medical conditions,
psychosis, substance use, other psychiatric symptoms or syndromes,
psychosocial supports, past suicidal behaviors, and treatment adherence
and the quality of existing physician-patient relationships. These
factors are described in greater detail in the APA's
Guideline for the Assessment and Treatment of Patients With Suicidal
dAlthough this table lists percentages
of expected healthy body weight in relation to suggested levels
of care, these are only approximations and do not correspond to
percentages based on standardized values for the population as a
whole. For any given individual, differences in body build, body
composition, and other physiological variables may result in considerable
differences as to what constitutes a healthy body weight in relation
to "norms." For example, for some patients, a
healthy body weight may be 110% of the standardized value
for the population, whereas for other individuals it may be 98%. Each
individual's physiological differences must be assessed
and appreciated. For children, also consider the rate of weight
loss. Finally, weight level per se should never be used as the sole
criterion for discharge from inpatient care. Many patients require
inpatient admission at higher weights and should not be automatically
discharged just because they have achieved a certain weight level
unless all other factors are appropriately considered. See text
for further discussion regarding weight.
eIndividuals may experience these
thoughts as consistent with their own deeply held beliefs (in which
case they seem to be ego-syntonic and "overvalued")
or as unwanted and ego-alien repetitive thoughts, consistent with
classic obsessive-compulsive disorder phenomenology.
Although most patients with uncomplicated bulimia nervosa
do not require hospitalization, indications for hospitalization
can include severe disabling symptoms that have not responded to
adequate trials of outpatient treatment, serious concurrent general
medical problems (e.g., metabolic abnormalities, hematemesis, vital
sign changes, uncontrolled vomiting), suicidality, psychiatric disturbances
that would warrant patients' hospitalization independent
of the eating disorder diagnosis, or severe concurrent substance
Legal interventions, including involuntary hospitalization
and legal guardianship, may be necessary to address the safety of
patients who are reluctant to receive treatment but whose general
medical conditions are life threatening (102). On a short-term basis
at least, outcomes for those patients who are hospitalized involuntarily
are comparable with outcomes of those hospitalized voluntarily with
respect to rates of weight restoration (103). The decision to hospitalize
on a psychiatric versus a general medical or adolescent/pediatric
unit depends on the patient's general medical status, the
skills and abilities of local psychiatric and general medical staff,
and the availability of suitable programs to care for the patient's
general medical and psychiatric problems (104). There is evidence
to suggest that patients treated in specialized inpatient eating
disorder units have better outcomes than patients treated in general
inpatient settings where staff lack expertise and experience in
treating patients with eating disorders (105).
Partial hospitalization and day hospital programs are being
increasingly used in attempts to decrease the length of inpatient
stays or even in lieu of hospitalization for individuals with milder
symptoms. However, such programs may not be appropriate for patients
with lower initial weights. The failure of outpatient treatment
is one of the most frequent indications for the more intensive treatment
provided in a day, partial hospitalization, or inpatient program.
In deciding whether a patient requires a partial hospitalization
program, the patient's motivation to participate in treatment
and ability to work in a group setting should be considered (106, 107). A growing body of evidence suggests that partial hospitalization outcomes
are highly correlated with treatment intensity and that more successful
programs involve patients at least 5 days/week for 8 hours/day
Patients who are considerably below their healthy body weight
but who are highly motivated to adhere to treatment, have cooperative
families, and have brief symptom duration may benefit
from treatment in outpatient settings, but only if they are carefully
monitored and if they and their families understand that a more
restrictive setting may be necessary if persistent progress
is not evident within a few weeks (108, 109). Careful monitoring
includes at least weekly (and often twice or thrice weekly) weight
determinations done immediately after the patient voids and while
the patient is wearing the same class of garment (e.g., hospital
gown, standard exercise clothing). Measurement of urine specific
gravity, orthostatic vital signs, oral body temperature, and, in
purging patients, electrolytes may also need to be monitored on
a regular basis. Although child and adolescent patients treated
in the outpatient setting can remain with their families and continue
to attend school or work, these advantages must be balanced against
the risks of failure to progress in recovery.
Anorexia nervosa is a complex, serious, and often chronic
condition that may require a variety of treatment modalities at
different stages of illness and recovery. Specific treatments include
nutritional rehabilitation, psychosocial interventions, and medications.
The aims of treatment are to 1) restore the patient to a healthy
weight (associated with the return of menses and normal ovulation
in female patients, normal sexual drive and hormone levels in male
patients, and normal physical and sexual development in children
and adolescents); 2) treat the patient's physical complications;
3) enhance the patient's motivation to cooperate in the
restoration of healthy eating patterns and participate in treatment;
4) educate the patient regarding healthy nutrition and eating patterns;
5) help the patient reassess and change core dysfunctional cognitions,
attitudes, motives, conflicts, and feelings related to the eating
disorder; 6) treat the patient's associated psychiatric
conditions, including deficits in mood and impulse regulation, self-esteem,
and behavior; 7) enlist family support and provide family counseling
and therapy where appropriate; and 8) prevent the patient from relapsing.
The goals of nutritional rehabilitation for seriously underweight
patients are to restore weight, normalize eating patterns, achieve
normal perceptions of hunger and satiety, and correct biological
and psychological sequelae of malnutrition (110, 111).
Healthy target weights should be established as part of the
initial treatment plan and discussed explicitly with the patient,
but with considerable sensitivity to how generally fearful patients
are of gaining weight. On occasion it may be judicious to delay
this discussion until the patient is less likely to be terrified
of his or her ultimate weight goal. In general, a healthy goal weight
for female patients is the weight at which normal menstruation and ovulation
are restored and, for male patients, the weight at which normal
testicular function is resumed. For female patients who previously
had a healthy menses and ovulation, the clinician can estimate their
healthy weight as approximately the same weight at which full physical
and psychological vigor were present. In one study of 100 adolescent
patients with anorexia nervosa (94), the resumption of menses occurred
at a weight approximately 4.5 pounds greater than the weight at
which menses was lost; at 90% of healthy weight, 86% of
patients resumed menses. In children and adolescents, growth curves
should be followed and are most useful when longitudinal data are
available, given that extrapolations from cross-sectional data at
one point in time can be misleading. Therefore, for most clinical work,
it is reasonable to simply weigh patients and gauge how far they
are from their individually estimated healthy body weight (112).
Bone age may be accurately estimated from wrist X-rays and nomograms.
In conjunction with bone measurements, menstrual history in adolescents
with secondary amenorrhea, mid-parental heights, and assessments
of skeletal frame, CDC growth charts (available at http://www.cdc.gov/growthcharts/) may be used to accurately estimate
individually appropriate ranges for "expected" weights
for current age and to set individually realistic expectations and
goals for weight and height for patients up to age 20 years.
For individuals who are markedly underweight and for children
and adolescents whose growth is substantially less than that predicted
by growth curves, hospital-based programs for nutritional rehabilitation
should be considered. For those in inpatient or residential settings,
the weight at which it is appropriate to discharge a patient may
vary in relation to the patient's healthy target weight
and will depend on the patient's ability to feed him- or
herself, the patient's motivation and ability to participate
in aftercare programs, and the adequacy of aftercare, including
partial hospitalization. In general, the closer a patient is to
his or her healthy body weight before discharge, the less the risk
he or she has of relapsing and being readmitted. Having patients
maintain their weight for a period of time before they are discharged
from inpatient treatment probably decreases the risk of their relapsing
as well.
Refeeding programs should be implemented in nurturing emotional
contexts. Staff should convey to patients their intention to take
care of them and not let them die even when the illness prevents
the patients from taking care of themselves. Staff should clearly
communicate that they are not seeking to engage in control battles
and have no punitive intentions when using interventions that the
patient may experience as aversive. Some positive reinforcements
(e.g., privileges) and negative reinforcements (e.g., required bed
rest, exercise restrictions, restrictions of off-unit privileges)
should be built into the program; negative reinforcements can then
be reduced or terminated and positive reinforcements accelerated
as target weights and other goals are achieved.
As patients work to achieve their target weights, their treatment
plan should also establish expected rates of controlled weight gain.
Clinical consensus suggests that realistic targets are 2–3
lb/week for hospitalized patients and 0.5–1 lb/week
for individuals in outpatient programs, although an intensive partial
hospitalization, stepped-down program has reported gains of up to
2 lb/week (113). Occasionally some patients may gain as
much as 4–5 lb/week, but these individuals must
be carefully monitored for refeeding syndrome and fluid retention.
Dietitians can help patients choose their own meals and provide
a structured meal plan that ensures nutritional adequacy and inclusion
of all the major food groups. Formula feeding may have to be added
to achieve large caloric intake. Some authorities advocate that
the amount of solid food eaten should not exceed the amount that patients
would ordinarily be eating at their target weight. Expanding cuisine
options is important to avoid the severely restricted food choices frequently
seen in eating disorder patients. Legitimate food allergies and
patients' religious and cultural practices must be considered
and discussed to limit patient rationalizations for restricted eating.
Intake levels should usually start at 30–40 kcal/kg
per day (approximately 1,000–1,600 kcal/day).
During the weight gain phase, intake may have to be advanced progressively
to as high as 70–100 kcal/kg per day for some
patients; many male patients require a very large number of calories
to gain weight. Patients who require significantly higher caloric
intakes may be discarding food, vomiting, or exercising frequently
or they may engage in more nonexercise motor activity such as fidgeting;
others may have a truly elevated metabolic rate. Patients requiring
much lower caloric intakes or those suspected of artificially increasing
their weight by fluid loading should be weighed in the morning after
voiding while they are wearing only a gown; their fluid intake also
should be carefully monitored. Assessing urine specimens obtained
at the time of weigh-in for specific gravity may help ascertain
the extent to which the measured weight reflects excessive water
Particularly in residential or hospital treatment programs,
it may initially be difficult to obtain the cooperation of patients
who do not wish to be there. In addition, many patients have delayed
gastric emptying that initially impairs their ability to tolerate
1,000 calories/day. Under such circumstances, it is often
more effective to begin with 200–300 calories above the
patient's usual caloric intake (e.g., a patient consuming
400 calories/day may need to start at 600–700 calories/day).
During hospitalization, giving patients a liquid feeding formula
in the early stages of weight gain and then gradually exposing them
to food and slowly increasing their activity level can be a very
effective strategy for inducing weight gain (114). As patients are
able and as their cooperation improves, a 2–3 lb/week
gain in residential or hospital programs can be expected without
compromising the patients' safety.
In addition to an increased caloric intake, patients also
benefit from vitamin and mineral supplements. Serum potassium levels
should be regularly monitored in patients who are persistent vomiters.
Hypokalemia should be treated with oral or intravenous potassium
supplementation and rehydration.
Physical activity should be adapted to the food intake and
energy expenditure of the patient, taking into account bone mineral
density and cardiac function. For the severely underweight patient,
exercise should be restricted and always carefully supervised and monitored.
Once a safe weight is achieved, the focus of an exercise program
should be on physical fitness as opposed to expending calories.
The focus on fitness should be balanced with restoring patients' positive
relationship with their bodieshelping them to take back control
and get pleasure from physical activities rather than being compulsively
enslaved to them. An exercise program should involve exercises that
are not solitary, are enjoyable, and have endpoints that are not
determined by time spent expending calories or changing weight and
shape. Sports such as soccer, basketball, volleyball, or tennis
are examples (115).
Staff should help patients deal with their concerns about
weight gain and body image changes, given that these are particularly
difficult adjustments for patients to make. In fact, there is general
agreement among clinicians that distorted attitudes about weight
and shape are the least likely to change and that excessive and
compulsive exercise may be one of the last of the behaviors associated
with an eating disorder to abate. Although it is by no means certain
that patients' abnormal eating habits will improve simply
as a function of weight gain (116), there is considerable evidence
to suggest that other eating disorder symptoms diminish as weight
is restored with nutritional rehabilitation. For example, clinical
experience indicates that with weight restoration, food choices
increase, food hoarding decreases, and obsessions about food decrease
in frequency and intensity, although they do not necessarily disappear.
Providing anorexia nervosa patients who have associated binge
eating and purging behaviors with regular structured meal plans
may also enable them to improve. For some patients, however, giving
up severe dietary restrictions and restraints appears to increase binge-eating
behavior, which is often accompanied by compensatory purging.
As weight is regained, changes in associated mood and anxiety
symptoms as well as in physical status can be expected (117). Clinicians
should advise patients of what changes they can anticipate as they
start to regain weight. In the initial stages, the apathy and lethargy
associated with malnourishment may abate. However, as patients start
to recover and feel their bodies becoming larger, and especially
as they approach frightening magical numbers on the scale that represent
phobic weights, they may experience a resurgence of anxious and
depressive symptoms, irritability, and sometimes suicidal thoughts.
These mood symptoms, non-food-related obsessional thoughts, and
compulsive behaviors, although often not eradicated, usually decrease with
sustained weight gain.
Weight gains result in improvement in most of the physiological
complications of semistarvation, including improvement
in electrolyte levels, heart and kidney function, and attention
and concentration. Initial refeeding may be associated with mild
transient fluid retention, and patients who abruptly stop taking
laxatives or diuretics may experience marked rebound fluid retention
for several weeks, presumably from salt and water retention caused
by elevated aldosterone levels associated with chronic
dehydration. Refeeding edema and bloating occur frequently.
Patients may experience abdominal pain and bloating with meals
from the delayed gastric emptying that accompanies malnutrition.
Constipation, which may be ameliorated with stool softeners, can
progress to obstipation and, rarely, acute bowel obstruction. As
weight gain progresses, many patients also develop acne
and breast tenderness. Many patients become unhappy and demoralized
about resulting changes in body shape. Management strategies for
dealing with these milder adverse effects include careful refeeding,
frequent physical examinations, and forewarnings to patients about
mild refeeding edema.
A severe refeeding syndrome may occur when severely malnourished
patients (generally those weighing <70% of their healthy
body weight) are re-fed too rapidly, particularly in the context
of enteral or parenteral feedings but also with vigorous oral refeeding
regimens. This syndrome consists of hypophosphatemia, hypomagnesemia,
hypocalcemia, and fluid retention. Thiamine deficiency may also
be seen as a feature of this syndrome. In some case series, the
refeeding syndrome has been reported to occur in roughly 6% of
hospitalized adolescents (118). Excessively rapid refeeding and
nasogastric or parenteral feeding may be particularly dangerous because
of their potential for inducing severe fluid retention, cardiac arrhythmias,
cardiac failure, respiratory insufficiency, delirium, seizures,
rhabdomyolysis, red cell dysfunction, and even sudden death, especially
in the lowest-weight patients (118, 119). In such cases, phosphorus,
magnesium, and/or potassium supplementation will be necessary
(118, 120). In one series of hospitalized adolescents, moderate
hypophosphatemia occurred in 5.8% and mild hypophosphatemia
in 21.7% of patients, requiring some degree of phosphorus
replacement in 27.5% of these patients (120).
Besides monitoring of mineral and electrolyte levels, general
medical monitoring during refeeding should include assessment of
vital signs, monitoring of food and fluid intake and output (if
indicated), and observation for edema, rapid weight gain (associated
primarily with fluid overload), congestive heart failure, and gastrointestinal
symptoms. For children and adolescents who are severely malnourished
(weigh <70% of their standard body weight), cardiac
monitoring, especially at night, may be advisable (120).
Some patients are completely unable to recognize their illness,
accept the need for treatment, or tolerate the guilt that would
accompany eating, even when performed to sustain their lives. On
the rare occasions when staff have to take over the responsibilities
for providing life-preserving care, nasogastric feedings
are preferable to intravenous feedings. In some programs, supplemental
overnight pediatric nasogastric tube feedings have been used to
facilitate weight gain in cooperative patients. This practice is
not routinely recommended at present, although it appears to be
well tolerated, may slightly decrease hospital stays in children,
and may be experienced positively by some patients, particularly
younger patients, who may feel relieved to know that they are being
cared for and who, while they cannot bring themselves to eat, are
willing to allow physicians to feed them (121). If used, such interventions
should never supplant expectations that the patient will resume
normal eating patterns on his or her own. Total parenteral feeding
is required only rarely and for brief periods in life-threatening
Forced nasogastric or parenteral feeding can each be accompanied
by substantial dangers. When nasogastric feeding is necessary, clinical
experience suggests that continuous feeding (i.e., over 24 hours)
may be less likely than three to four bolus feedings a day to result
in metabolic abnormalities or patient discomfort and may be better
tolerated by patients. As an alternative to nasogastric feedings,
in very difficult situations where patients physically resist and
constantly remove their nasogastric tubes, gastrostomy or jejunostomy tubes
may be surgically inserted. As described above, rapid refeeding
can be associated with the severe refeeding syndrome, and infection
is always a risk with parenteral feedings in emaciated and potentially immunocompromised
patients with anorexia nervosa. Consequently, these interventions
should not be used routinely but should be considered only when patients
are unwilling or unable to cooperate with oral feedings or when
the patients' health, physical safety, and recovery are
being threatened. In situations where involuntary forced feeding
is considered, careful thought should be given to clinical circumstances,
family opinion, and relevant legal and ethical dimensions of the
patient's treatment.
If using interventions that patients with anorexia nervosa
may experience as coercive, the clinician should consider the potential
impact on the therapeutic relationship, especially since maintaining
a sense of control is often a key dynamic in these patients. The
setting of limits is developmentally appropriate in the management
of children and adolescents and may help shape the patient's
behavior in a healthy direction. It is essential for caregivers
to be clear about their own intentions and empathic capacities regarding
the patient's impression of being coerced. Caregivers should
not be seen as using techniques intended to be coercive. Rather, caregivers' interventions
should always be clearly seen as components of a general medical
treatment required for the patient's health and survival.
During the last few years, there has been considerable debate
about the ethics of involuntarily feeding patients with anorexia
nervosa (122, 123). There is general agreement that children and
adolescents who are severely malnourished and in grave medical danger should
be re-fed, involuntarily if necessary, but that every effort should
be made to gain their cooperation as cognitive function improves.
Ethical as well as clinical dilemmas often confront clinicians
dealing with adult patients with chronic anorexia nervosa and their
families. The general principles to be followed are those directing
good, humane care; respecting the wishes of competent patients;
and intervening respectfully with patients whose judgment is severely
impaired by their psychiatric disorders when such interventions
are likely to have beneficial results (124, 125).
The goals of psychosocial interventions in patients with anorexia
nervosa are to help them 1) understand and cooperate with their
nutritional and physical rehabilitation, 2) understand and change
the behaviors and dysfunctional attitudes related to their eating
disorder, 3) improve their interpersonal and social functioning,
and 4) address comorbid psychopathology and psychological conflicts
that reinforce or cause them to maintain eating disorder behaviors.
Efforts to achieve these goals often benefit from an initial enhancement
of a patient's motivation to change along with ongoing
efforts to sustain this motivation.
Few controlled studies offer guidance for the psychosocial
treatment of anorexia nervosa. Clinical consensus suggests that
during the acute refeeding and weight gain stages, it is beneficial
to provide patients with individual psychotherapeutic management
that is psychodynamically informed and that provides empathic understanding,
explanations, praise for positive efforts, coaching, support, encouragement,
and other positive behavioral reinforcement. During all phases of
treatment, seeing patients' families is also helpful, particularly
for children and adolescents, for whom controlled trials suggest
that family treatment is the most effective intervention (86, 126).
For patients who initially lack motivation, their awareness and
desire for recovery may be increased by psychotherapeutic techniques
based on motivational enhancement, although solid evidence for this
contention is lacking.
At the same time, clinical consensus suggests that psychotherapy
alone is generally not sufficient to treat severely malnourished
patients with anorexia nervosa. Although the value of establishing
and maintaining a psychotherapeutically informed relationship is
clearly beneficial and psychotherapeutic sessions to enhance patient
motivation and further patient weight gain are likely to be helpful,
the value of formal psychotherapy during the acute refeeding stage
is uncertain (127). Attempts to conduct formal psychotherapy may
be ineffective with starving patients, who are often negativistic,
obsessional, or mildly cognitively impaired, presumably in relation
to the known cortical atrophy seen in nutritionally compromised
patients. One study documented the difficulty researchers have had
in initiating and sustaining cognitive-behavioral therapies for
patients with anorexia nervosa (128).
Most nutritional rehabilitation programs incorporate emotional
nurturance and one of a variety of behavioral interventions that
link exercise, bed rest, and privileges with target weights, desired
behaviors, and informational feedback. Several studies of individual
therapy have shown modest success, sometimes in only a small percentage
of patients (7, 85). In one controlled trial, nonspecific supportive
clinical management appeared to be at least as effective as CBT
or IPT in some patients. However, 70% of patients either
did not complete or made only small gains from the active psychotherapies
they received (7). In this study, clinical management included education,
care, support, and the fostering of a therapeutic relationship designed
to promote adherence to treatment through the use of praise, reassurance,
and advice.
The accumulated evidence strongly supports the value of family
therapy for the acute treatment of children and adolescents in outpatient
settings. Studies show that whether patients and parents are seen
together or are treated separately in ongoing treatment, the results
are better than when families are not involved at all (86, 126).
This approach begins with the therapist's attempting to
unite the parents in developing a consistent approach to refeeding,
sympathizing with their plight, and explicitly disclaiming the notion
that the parents have caused the eating problem. When families are
involved in treatment, sibling subsystems can be engaged to support
the affected sibling. Parents can determine for themselves how best
to refeed their child with anorexia nervosa with the therapist's
ongoing support and consultation. For some outpatients, a short-term
course of family therapy may be as effective as a long-term course;
however, a shorter course of therapy may not be adequate for patients
with severe obsessive-compulsive features or nonintact families
(129). In these studies (129), inpatient care was used briefly for medical
stabilization. For adolescents treated in inpatient settings, participation
in family group psychoeducation may help promote weight gain and
may be as effective as more intensive forms of family therapy (130).
Clinical consensus suggests that psychotherapy can be helpful
for patients with anorexia nervosa once their malnutrition has been
corrected and they have begun gaining weight (131). Because of the
enduring nature of many of the psychopathological features of anorexia
nervosa and the patient's need for support during recovery,
ongoing individual psychotherapeutic treatment is frequently required
for at least 1 year and may take many years (132, 133).
Although there have been few formal studies of its effectiveness
(134, 135), psychotherapy is generally thought to help patients
understand 1) what they have been through; 2) developmental, familial,
and cultural antecedents of their illness; 3) how their illness
may have been a maladaptive attempt to cope and emotionally self-regulate;
4) how to avoid or minimize the risk of relapse; and 5) how to better
deal with salient developmental and other important life issues
in the future. At present there is no absolute weight or percentage
of body fat that indicates when a patient is actually ready to begin
formal psychotherapy. In addition, patients often display improved
mood, enhanced cognitive functioning, and clearer thought processes
once their nutritional status has significantly improved and even
before they make substantial weight gains.
Little evidence from controlled studies exists to guide clinicians
in the use of specific therapies for adults with anorexia nervosa.
Nonetheless, some data are emerging in support of individual CBT
(136–138) for helping patients maintain healthy eating
behaviors and CBT or IPT for inducing cognitive restructuring and
promoting more effective coping (139, 140). After a patient has
begun to gain weight, CBT may be helpful in reducing the risk of relapse
and improving outcome, as demonstrated in a small randomized controlled
trial (136). In that study, patients who received CBT were more
likely to remain in treatment (78%) and have a good outcome after
a year (44%) than those assigned to nutritional counseling
Many clinicians also use psychodynamically oriented individual
or group psychotherapy to address underlying personality disorders
that may hamper treatment and help sustain the illness and to foster
psychological insight and maturation in patients who have made strides
toward weight restoration (141–148). Clinical consensus
suggests that psychosocial interventions should incorporate an understanding
of the patient's developmental traumas, cognitive development,
psychodynamic conflict and defense styles, disorders of self-esteem,
self-regulation, and "sense of self," as well
as other psychological deficits, the presence of other psychiatric
disorders, and the complexity of family relationships (149–152). Although
studies of psychotherapies focus on different interventions as distinctly
separate treatments, in practice there is frequent overlap among
treatments. Indeed, most experienced clinicians report using interventions
that cross theoretical boundaries when treating patients with eating
disorders (153).
In adolescents, controlled studies have shown that for patients
who are younger than age 19 years, have been ill for 3 years or
less, and have restored their weight, family therapy is more beneficial
than individual therapy, whereas individual therapy is more beneficial
for patients with later-onset disorders (154). At 5-year follow-up
of patients who received these therapies, much of the improvement
could be attributed to the natural outcome of the illness, but it
was still possible to detect long-term benefits of the psychological
therapies (155).
Regardless of the clinical or theoretical approach used in
treatment, some patients with eating disorders challenge clinicians' understanding
and in some instances provoke countertransference reactions, particularly
in response to patients' communications of aggression and defiance
(140, 147, 156–162). Clinical consensus suggests that eating
disorders are often difficult to ameliorate with short-term interventions,
at least in older adolescents and adults; for this reason, clinicians
often feel they have not done enough to change the patient's
plight. Countertransference feelings often include beleaguerment,
demoralization, and excessive need to change patients with a chronic eating
disorder. At the same time, when treating patients with chronic
illnesses, clinicians need to understand the longitudinal course
of the disorder and that patients can recover even after many years
of symptoms. Such awareness may help clinicians maintain a degree
of therapeutic optimism and deal with the feelings of pessimistic
demoralization that may arise (13, 163).
Some observations suggest that the gender of the clinician
may play a role in the particular kind of countertransference reactions
that come into play (156, 157). A patient's concerns about
the gender of a clinician may be tied to concerns about potential
boundary violations and should be attended to when selecting clinicians,
including psychiatrists (164, 165). In addition, cultural differences
between patients and clinicians or patients and other aspects of
the care system may also influence the course and conduct of treatment
and require attention. Ongoing processing of one's countertransference
reactions, sometimes with the help of a supervisor or
consultant, can be useful in helping the clinician persevere and reconcile
intense, troublesome countertransference reactions.
When a patient with an eating disorder has been sexually abused
or has felt helpless in other situations of boundary violations,
this may stir up needs in the clinician to rescue the patient, which
can occasionally result in a loosening of the therapeutic structure,
the loss of therapeutic boundary keeping, and a sexualized countertransference
reaction. In some cases, these countertransference responses have
led to overt sexual acting out and unethical treatment on the part
of the clinician that have not only compromised treatment but also
severely harmed the patient (166). The maintenance of clear boundaries
is critical in treating all patients with eating disorders, not
only those who have been sexually abused but also those who may
have experienced other types of boundary intrusions regarding their
bodies, eating behaviors, and other aspects of the self by family
members or others. Regular meetings with other team members and/or
formal supervision can also help clinicians avoid boundary violations
with eating disorder patients. Particularly with some adolescents,
a clinician's obvious warmth and direct educational approach
may facilitate initiating and sustaining the patient's
trust. However, the license to be informal may create a climate
in which a clinician is at a greater risk to violate therapeutic
boundaries; such an occurrence must be consistently and carefully
prevented. At the same time, according to some clinicians, a clinician's
excessively rigid, cold manner and formal distancing behaviors (e.g.,
avoiding even benign pats on the shoulder that a patient might seek
for reassurance) may be disconcerting to some patients and inhibit
them from fully engaging in treatment.
Some clinicians use group psychotherapy as an adjunctive treatment
for anorexia nervosa; in such cases, however, caution must be taken
that patients do not compete to be the thinnest or sickest patient
in the group or become excessively demoralized by observing the ongoing
struggles of other patients in the group. For that reason, clinicians
sometimes prefer heterogeneous groups that combine patients with
bulimia nervosa and those with anorexia nervosa. Although there
has been little formal study of group psychotherapy in the treatment
of anorexia nervosa, one naturalistic study suggests that CBT may
have promise (137).
Some clinicians consider that eating disorders may be usefully
treated through addiction models, but no data from short- or long-term
outcome studies using these methods have been reported. Literature
from Anorexics and Bulimics Anonymous and Overeaters Anonymous emphasizes
that these programs are not substitutes for professional treatment.
These organizations specifically recommend that members seek appropriate
medical and nutritional guidance. Nevertheless, there are concerns
about zealous and narrow application of the 12-step philosophy in
addiction-oriented programs for eating disorders. Programs that focus
exclusively on abstaining from binge eating, purging, restrictive
eating, and exercise (e.g., 12-step programs) without attending
to nutritional considerations or cognitive and behavioral deficits
have not been studied and therefore cannot be recommended as the
sole treatment for anorexia nervosa. Clinicians frequently report
encountering patients who, while attempting to resolve anorexia
nervosa by means of a 12-step program alone, might have been greatly
helped by concurrent conventional treatment approaches such as nutritional
counseling and rehabilitation, medications, and psychodynamic or
cognitive-behavioral approaches. By limiting their attempts to recover
to their participation in a 12-step program alone, patients not
only deprive themselves of the potential benefits of conventional
treatments but also may expose themselves to misinformation
about nutrition and eating disorders offered by well-intended nonprofessionals
participating in and sometimes running these groups. Attempts have
been made to integrate traditional and 12-step approaches into treatment;
such approaches can offer a strong sense of community, but the effectiveness
and potential adverse effects of these combined interventions have
not been systematically studied (167). It is important for programs
using a 12-step model to be equipped to care for patients with the
substantial psychiatric and general medical problems often associated
with eating disorders.
Selective support groups led by professionals and advocacy
organizations may be beneficial as adjuncts to other psychosocial
treatment modalities. However, clinicians should remain cognizant
of the idiosyncratic recommendations made in some self-help groups. Sometimes,
participants or leaders will eschew clinician-recommended treatments
such as psychotropic medication or insist that a participant follow
a particular kind of meal structure. These recommendations may conflict
with other treatment recommendations and potentially increase the
patient's resistance to treatment.
Patients and their families are increasingly using online
web sites, news groups, and chat rooms as resources. Although substantial
amounts of worthwhile information and support are available in this
fashion, the lack of professional supervision of these sources may
sometimes lead to misinformation and unhealthy dynamics among users.
Clinicians should ask patients about their use of electronic support
and other alternative and complementary approaches and be prepared
to openly and sympathetically discuss the information and ideas
they and their families have gathered from these sources.
As with any form of intervention, various psychosocial interventions
may generate adverse effects; however, these have not been systematically
studied with regard to treating anorexia nervosa. Some that have
been observed by clinicians, patients, and families include 1) fostering
negative attitudes in patients and/or families toward health
care professionals without adequate discussion and reflection, thereby
increasing the risk that patients will drop out of treatment and
become less willing to seek or engage in professional treatment;
2) delaying referral to more appropriate interventions; and 3) generating
burdensome costs without reasonable or expected benefits (13, 168).
Patients often have difficulty with certain elements of psychotherapy.
For example, among patients receiving CBT, some are quite resistant
to self-monitoring, whereas others have difficulty mastering cognitive
restructuring. Most patients are initially resistant to changing
their eating behaviors, particularly when it comes to increasing
their caloric intake or reducing exercise. However, the complete
lack of acceptance of a psychotherapeutic approach appears to be
rare, although this has not been systematically studied.
Management strategies to deal with potential negative effects
of psychotherapeutic interventions include 1) conducting a careful
pretreatment evaluation, during which the therapist must assess and
enhance the patient's level of motivation for change and
determine the most appropriate therapeutic approach and format (e.g.,
individual versus group); 2) being alert to a patient's
reactions to and attitudes about the proposed treatment and listening to
and discussing the patient's concerns in a supportive fashion;
3) ongoing monitoring of the quality of the therapeutic relationship;
and 4) identifying patients for whom another treatment should be
co-administered or given before psychotherapy begins (e.g.,
substance use disorder treatment for those actively abusing alcohol
or other drugs, antidepressant treatment for patients whose depression
makes them unable to become actively involved, more intensive psychotherapy
for those with severe personality disorders, group therapy for those
not previously participating). Alternative strategies may be necessary
to facilitate the therapeutic process and prevent the abrupt termination
of therapy (13). As with all therapeutic interventions, it is essential
that the therapist be alert to potential countertransference phenomena
toward these often difficult-to-treat patients. If unresolved, these
reactions have a high potential for disrupting or hastening the
termination of treatment.
Available studies of patients with chronic anorexia nervosa
typically show a lack of substantial clinical response to psychotherapy.
For example, in the study of Dare et al. (85), 84 patients, ill
for an average of 6.3 years and with an initial average BMI of 15.4
were assigned to one of three individual psychotherapies or a control
group. The results after 1 year of psychotherapy were modest in
all groups, although the psychoanalytic psychotherapy and family
therapy groups fared better than those in the low-contact, routine-care
control group. Nevertheless, many clinicians report seeing patients
with chronic anorexia nervosa who, after many years of struggling
with their disorder, experience substantial remission; thus clinicians
are justified in maintaining and extending some degree of hope to
patients and families.
For patients whose anorexia nervosa continues to be resistant
to treatment despite substantial trials of nutritional rehabilitation,
medications, and hospitalizations, more extensive psychotherapeutic
measures may be undertaken in a further effort to engage and help motivate
them or, failing that, as compassionate care. This difficult-to-treat
subgroup may represent an as-yet poorly understood group of patients
with malignant, chronic anorexia nervosa. Efforts to understand
the unique plight of such patients may sometimes lead to engagement
in the therapeutic alliance, thereby allowing the nutritional protocol
to be initiated (125, 141, 142, 169, 170). With patients who have
difficulty talking about their problems, clinicians have reported
a variety of nonverbal therapeutic methods, such as creative arts
and movement therapy programs, to be useful (171), but these methods
have not been formally studied. At various stages of recovery, occupational
therapy programs may also enhance self-concept and self-efficacy
(172, 173), but again these programs have not been formally studied.
Although psychotropic medications should not be used as the
sole or primary treatment for anorexia nervosa, they have been used
as an adjunct treatment when nutritional rehabilitation programs
alone are ineffective in restoring patients' normal weight
or when patients demonstrate significant comorbid psychopathology
such as disabling obsessive-compulsive, depressive, or anxiety symptoms. However,
because anorexia nervosa symptoms and associated features such as
depression may remit with weight gain, decisions concerning the
use of medications should be deferred if possible until patients' weight
has been restored. The decisions about whether to use psychotropic
medications and which medications to choose will be determined by
the remaining symptom picture (e.g., antidepressants are usually considered
for those with persistent depression, anxiety, or obsessive-compulsive
symptoms and for bulimic symptoms in weight-restored patients; second-generation
antipsychotics are usually considered for those with severe, unremitting
resistance to gaining weight, severe obsessional thinking, and denial
that assumes delusional proportions). Many patients with anorexia
nervosa are extremely reluctant to take medications and often refuse those
that they know to specifically affect weight. These issues must be
discussed sympathetically and comprehensively with patients and,
for children and adolescents, with their families.
The efficacy of SSRI antidepressants for anorexia nervosa
appears to vary with the phase of treatment. On the basis of several
studies, fluoxetine does not appear to confer significant benefits
during weight restoration (174, 175), nor did citalopram increase
the rate of weight gain in a small study (176). In contrast, in
weight-restored patients, fluoxetine in dosages of up to 60 mg/day
may decrease relapse episodes and has been associated with better maintenance
of weight and fewer symptoms of depression (177). However, for weight-restored
patients with anorexia nervosa who are receiving CBT to help prevent
relapse, adding fluoxetine to their treatment does not further decrease
the risk of relapse (138).
Although higher dosages of fluoxetine have been found to
impair appetite and cause weight loss in normal-weight and obese
patients, this effect has not been reported in anorexia nervosa
patients treated with lower dosages. Many clinicians report that
malnourished depressed patients are less responsive to the beneficial
effects of tricyclics, SSRIs, and other antidepressant medications
than normal-weight depressed patients. These findings are consistent
with those showing that SSRIs are not as effective for depression,
when patients without an eating disorder undergo dietary restrictions
(178, 179).
Malnourished patients are also much more prone to the side
effects of medications. For example, the use of tricyclic
antidepressants may be associated with greater risk of hypotension,
increased cardiac conduction times, and arrhythmia, particularly
in purging patients whose hydration may be inadequate and whose
cardiac status may be nutritionally compromised. Given the availability
of other antidepressant treatments, tricyclic antidepressants should
be avoided, particularly in underweight patients and in patients
who are at risk for suicide. In patients for whom there is a concern
regarding potential cardiovascular effects of medication, medical
specialty consultation can help evaluate the patient's
status and advise on the use of medication. With all antidepressants,
strategies to manage side effects include limiting the use of medications
to patients with persistent depression, anxiety, or obsessive-compulsive
symptoms; using low initial doses in underweight patients; and remaining
vigilant about early manifestations of side effects.
Several other antidepressants have also been associated with
significant side effects that are of relevance to the treatment
of anorexia nervosa patients. Bupropion has been associated with
an increased likelihood of seizures in patients with bulimia nervosa
(180, 181); although the reason for this is unknown, it is suspected
that patients with anorexia nervosa, binge-purge type, may also
be at increased risk for seizures. Thus, this medication is not recommended
for patients with anorexia nervosa, particularly those who purge.
Mirtazapine, an antidepressant associated with weight gain, has
also been associated with neutropenia. In addition, the only published
case report of using mirtazapine to treat anorexia nervosa described
a patient also taking fluvoxamine who developed the serotonin syndrome
(182). Thus, mirtazapine may not be suitable for use in underweight
anorexia nervosa patients.
Clinicians must attend to the black box warnings concerning
antidepressants and conduct appropriate informed consent with patients
and families if antidepressants are to be prescribed (183–189).
It has been suggested that antipsychotic medications, particularly
second-generation antipsychotics, can be potentially useful during
the weight-restoration phase or in treatment of other associated
symptoms of anorexia nervosa, such as marked obsessionality, anxiety, limited
insight, and psychotic-like thinking. Although no controlled studies
have been reported in patients with anorexia nervosa, controlled
trials of olanzapine and risperidone are under way. Evidence from
case reports, case series, and open-label uncontrolled trials suggests
that the second-generation antipsychotic olanzapine may
promote weight gain in adults and in adolescent patients (190–193)
and that olanzapine (190–194) and quetiapine may improve
other associated symptoms (195–197). A small open-label
study of low-dose haloperidol also showed improved insight and weight
gain in severely ill patients (198). The quality of the available
evidence on using antipsychotic medications is also limited by the
fact that studies rarely include male patients and have included
only small numbers of adolescents; in addition, only case reports
are available regarding prepubertal children. If antipsychotic medications
are used, the possibility of extrapyramidal symptoms, especially in
debilitated patients, should be considered and routinely assessed.
Also, appropriate attention must be given to the potential adverse
impact of these medications on insulin sensitivity, lipid metabolism,
and length of QTc interval.
Other somatic treatments, ranging from vitamin and hormone
treatments to ECT, have been tried in uncontrolled studies. None
has been shown to have specific value in the treatment of anorexia
nervosa symptoms (199).
Other medications have been used to address associated features
of anorexia nervosa. For example, antianxiety agents have been used
selectively before meals to reduce anticipatory anxiety concerning
eating (200, 201), and pro-motility agents, such as metoclopramide,
are commonly offered for the bloating and abdominal pains that result
from gastroparesis and that contribute to the premature satiety
seen in some patients. However, before prescribing metoclopramide,
clinicians should consider the fact that extrapyramidal symptoms
are more likely to be seen in underweight anorexia nervosa patients.
anorexia nervosa patients with prolonged amenorrhea, hormone replacement
therapy (HRT) is frequently prescribed to improve patients' bone
mineral density. However, no good supporting evidence exists to
demonstrate the efficacy of this treatment (202, 203). In women with
anorexia nervosa, the evidence supporting the use of HRT is marginal
at best. HRT has not been demonstrated to increase bone mineral
density over and above standard treatment in adults (204) or in
adolescents (203). Only in a subset of very-low-weight women (<70% average
body weight) did it prevent further bone loss (204). Estrogen can
cause the fusion of the epiphyses and should not be administered
to girls before their growth is completed (3). HRT usually induces
monthly menstrual bleeding, obscuring the major sign that indicates weight
normalization in women. This, in turn, may cause the patient to
misunderstand that her body is functioning normally and
therefore contribute to denial of the need to gain more weight.
Clinicians stress that efforts should be made to allow patients
to increase their weight and achieve resumption of normal menses
before they are offered estrogen (205). There is no indication for
the use of biphosphonates such as alendronate in patients with anorexia
nervosa. In fact, long-term use of alendronate may oversuppress
bone turnover (206). Thus, the recommended treatment for low bone
mineral density includes weight gain and calcium with vitamin D
supplementation (207).
The aims of treatment for patients with bulimia nervosa are
to 1) reduce and, where possible, eliminate binge eating and purging;
2) treat physical complications of bulimia nervosa; 3) enhance the
patient's motivation to cooperate in the restoration of
healthy eating patterns and participate in treatment; 4) provide
education regarding healthy nutrition and eating patterns; 5) help
the patient reassess and change core dysfunctional thoughts, attitudes,
motives, conflicts, and feelings related to the eating disorder;
6) treat associated psychiatric conditions, including deficits in
mood and impulse regulation, self-esteem, and behavior; 7) enlist
family support and provide family counseling and therapy where appropriate;
and 8) prevent relapse.
Bulimia nervosa is associated with nutritional chaos characterized
by alternating cycles of dietary restriction, bingeing, and purging.
A primary focus for nutritional rehabilitation is to help patients
develop a structured meal plan that will allow them to reduce the
episodes of dietary restriction and the urge to binge and purge.
Nutritional intake should be sufficient to promote satiety. Because
most bulimia nervosa patients who have been studied are of normal
weight, nutritional restoration will not be a central focus of treatment.
However, normal body weight (or normal BMI) does not ensure normal
body composition, nor does it ensure that nutritional intake is
appropriate. In addition, even if their weight is within statistically
normal ranges, many patients with bulimia nervosa weigh less than
their appropriate biologically determined set points (or ranges)
and may have to gain some weight to achieve physiological and emotional
stability. Although many patients with bulimia nervosa report irregular
menses, improvement in menstrual function has not been systematically
assessed in the available outcome studies. Thus, even among patients
of normal weight, nutritional counseling may be a useful adjunct
to other treatment modalities in reducing behaviors related to the
eating disorder, minimizing food restrictions, increasing the variety
of foods eaten, and encouraging healthy but not compulsive exercise
patterns (208). Those patients for whom some weight gain is indicated
similarly require the establishment of a pattern of regular, non-binge
meals, with attention on increasing their caloric intake and expanding
macronutrient selection. Patients with bulimia nervosa who are overweight or
obese have not been well studied.
The goals of psychosocial interventions for patients with
bulimia nervosa vary and can include the following: reducing or
eliminating binge eating and purging behaviors; improving attitudes
related to the eating disorder; minimizing food restriction; increasing
the variety of foods eaten; encouraging healthy but not compulsive
exercise patterns; treating co-occurring conditions and clinical
features associated with eating disorders; and addressing themes
that may underlie eating disorder behaviors such as developmental
issues, identity formation, body image concerns, self-esteem in
areas outside of those related to weight and shape, sexual and aggressive
difficulties, affect regulation, sex role expectations, family dysfunction,
coping styles, and problem solving. Consequently, psychosocial interventions should
be chosen on the basis of a comprehensive evaluation of the individual
patient and take into consideration the patient's cognitive and
psychological development, psychodynamic issues, cognitive style,
comorbid psychopathology, and preferences as well as age and family situation.
With respect to short-term interventions for treating acute
episodes of bulimia nervosa in adults, the available evidence indicates
that CBT is the most efficacious. CBT may effect improvements in
psychological functioning of bulimia nervosa patients as well as
ameliorate binge eating and purging symptoms. For example, studies
have shown that bulimia nervosa patients who improved with CBT also
showed improvements in self-directedness and harm avoidance (209, 210). Among patients who do not initially respond to CBT, a small number
do respond to IPT or fluoxetine (211) or other modes of treatment
such as family and group psychotherapies. Some controlled trials
(212) have also shown the effectiveness of IPT as an initial therapy.
Behavioral techniques, such as planned meals and self-monitoring,
may also be helpful for managing initial symptoms and interrupting
binge-purge behaviors (213, 214). It should be pointed out that
these study results may not be generalizable to typical clinical
situations. For example, to maximize the "clean" experimental
nature of some of the CBT/IPT controlled studies mentioned
above, the CBT intentionally avoided dealing with interpersonal
issues and the IPT intentionally avoided talking about eating issues,
which is quite different than how these therapies are conducted
in clinical practice (215). It is also possible that the narrow
inclusion criteria of some studies limit the generalizability of
the study results (216).
Some clinical reports indicate that psychodynamic and psychoanalytic
approaches in individual or group format are useful once bingeing
and purging symptoms improve (217–219). These approaches
address developmental issues; identity formation; body image concerns;
self-esteem; conflicts surrounding sexuality, anger, or aggression;
affect regulation; gender role expectations; interpersonal conflicts;
family dysfunction; coping styles; and problem solving. In a recent
naturalistic study of treatment as practiced by experienced clinicians
in the community, both CBT and psychodynamic psychotherapy
led to decreased rates of bingeing and purging similar to those
seen in controlled trials (roughly 50%). However, although
CBT has been reported to be associated with a more rapid remission
of eating symptoms, some therapists note that more integrative treatments
that include psychodynamic approaches are useful in targeting both
eating symptoms and broader personality, comorbidity, and quality-of-life
issues (153).
Some bulimia nervosa patients, particularly those with concurrent
personality pathology or other co-occurring disorders, may require
substantially longer treatment. In one study, the clinicians reported
that their average CBT treatment for bulimia nervosa lasted 69 sessions (81).
However, just how closely these clinicians adhered to formal CBT
methods is unknown. Also unknown is how the length and characteristics
of the treatments varied according to other clinical dimensions
of these patients. Exactly what is required over the long run to
best help patients resolve lingering preoccupations with body image
and the more subtle but impairing psychological dimensions that
may be associated with eating disorders requires additional study.
These concerns are often approached in practice through a variety
of longer-term psychotherapies.
Family therapy should be considered whenever possible, especially
for adolescents still living with parents or for older patients
with ongoing conflicted interactions with parents. Patients with
marital discord may benefit from couples therapy.
A variety of self-help and professionally guided self-help
programs have been effective for a small number of patients with
bulimia nervosa (220–222) and have been piloted in some
stepped-care approaches. Several innovative online programs are
currently being studied (5). Support groups and 12-step programs
such as Overeaters Anonymous may be helpful as adjuncts to initial
treatment of bulimia nervosa and for subsequent relapse prevention
but are not recommended as the sole initial treatment approach for
bulimia nervosa (168, 223). As noted above, these support organizations
emphasize in their literature that their programs are not substitutes
for professional treatment and specifically recommend that members
seek appropriate medical and nutritional guidance. However, clinicians should
remain cognizant of the idiosyncratic recommendations made in some
self-help groups.
Patients with bulimia nervosa occasionally have difficulties
with certain elements of psychotherapy similar to what was discussed
above for patients with anorexia nervosa. Possible adverse effects
of psychotherapeutic and psychosocial interventions, steps that
clinicians might take to minimize negative therapeutic reactions,
and issues concerning countertransference (as discussed in
) apply to the treatment of patients with bulimia nervosa.
Antidepressants are effective as one component of an initial
treatment program for most bulimia nervosa patients. Although various
classes of antidepressant medications can reduce symptoms of binge
eating and purging, SSRIs have the most evidence for efficacy and
the fewest difficulties with adverse effects (224–226).
To date, the only medication approved by the FDA for the treatment
of bulimia nervosa is fluoxetine. The only other SSRI shown to be effective
is sertraline, which was studied in a small randomized controlled
trial (227). Available studies also suggest that antidepressants
may be helpful for patients with substantial symptoms of depression
or anxiety, obsessions, or certain impulse disorder symptoms or
for patients who have not responded or had a suboptimal response
to previous attempts at appropriate psychosocial therapy (228, 229).
Dosages of SSRIs that are higher than those used for depression
(e.g., fluoxetine 60 mg/day) are more effective in treating
bulimic symptoms (224, 226, 230), but high dropout rates may also
be seen in patients using these drugs (226). A small open trial
demonstrated the safety and effectiveness of 60 mg/day
of fluoxetine for treating bulimia nervosa in adolescents (225).
Thus, many clinicians initiate fluoxetine treatment for bulimia
nervosa at the higher dosage, titrating downward if necessary to
manage side effects. Tricyclic and MAOI antidepressants are rarely
used to treat bulimia nervosa, but if they are used, the dosages
are similar to those used to treat depression (231).
Often, several different antidepressants may have to be tried
sequentially to identify the specific medication with the optimum
effect in a particular patient. In the bulimia nervosa patient whose
symptoms do not respond to medication, it is important to assess
whether the patient has taken the medication shortly before vomiting.
Correlations between serum levels and response have not been identified;
however, if serum levels of the medication are available, they may
help determine whether presumably effective levels of the drug have
actually been achieved. Treatment adherence will also enhance the
patient's response to treatment, and subtle interpersonal
and psychodynamic factors in the physician-patient relationship
may contribute to treatment resistance if left unaddressed (232).
As in most clinical situations, careful education of the patient
regarding possible side effects of medications and their symptomatic
management (e.g., stool softeners for constipation) is important.
Side effects vary widely across studies depending on the type of antidepressant
medication used. In the multicenter fluoxetine trials (224, 230),
sexual side effects were common, and at the dosage of 60 mg/day,
insomnia, nausea, and asthenia were seen in 25%–33% of
patients. For the tricyclic antidepressants, common side effects
include sedation, constipation, dry mouth, and, with amitriptyline,
weight gain (233–238).
The toxicity and potential lethality of tricyclic antidepressant
overdosage also dictate caution in prescribing this class of drug
for patients who are at risk for suicide. Practitioners should also
avoid prescribing MAOIs to patients with chaotic binge eating and
purging behaviors. The risk of spontaneous hypertensive crises in
patients with bulimia nervosa taking MAOIs is not insignificant
(239). This risk and the importance of eating a tyramine-free diet
while taking MAOIs should be discussed with patients
for whom this type of medication is contemplated.
There are few reports on the use of antidepressant medications
in the maintenance phase of treating bulimia nervosa patients. Although
there are data indicating that fluoxetine can be effective in preventing
relapse in these patients (226), other data suggest that high rates of
relapse occur while antidepressants are being taken and possibly
higher rates are seen when the medication is withdrawn (240). In
the absence of more systematic data, most clinicians recommend continuing
antidepressant therapy for a minimum of 9 months and probably for
1 year in most patients with bulimia nervosa.
Clinicians must attend to the black box warnings concerning
antidepressants and conduct appropriate informed consent with patients
and families if these medications are to be prescribed (183–189).
For patients with bulimia nervosa who require mood stabilizers,
the use of lithium carbonate is problematic, because lithium levels
may shift markedly with rapid volume changes. Lithium is not effective
in the treatment of bulimia nervosa (241). Both lithium carbonate and
valproic acid frequently lead to undesirable weight gains that may
limit their acceptability to bulimia nervosa patients. Selecting
a mood stabilizer that avoids these problems may result in better
patient adherence and medication effectiveness. Topiramate is not
an effective mood stabilizer but may be potentially useful for bulimia
nervosa and binge eating disorder (242, 243). However, in contrast
to the low rates of adverse effects observed in clinical trials
with topiramate, practitioners have reported several patients experiencing
adverse effects with the drug, such as word-finding difficulties
and paresthesias in a sizable minority of patients, although these
may have been related to excessively rapid rates of dosage increases
(242, 243). Also of note, patients receiving topiramate for bulimia
nervosa lost an average of 1.8 kilograms, so this medication may
be problematic for normal- to lower-weight individuals (243). No
data are available regarding the use of these medications for treating
bulimia nervosa or binge eating in children or adolescents, but
safety and tolerability data have been reported for children and
adolescents with other disorders for which lithium (244), valproic
acid (245), and topiramate (246) have been prescribed.
Several case reports indicate that methylphenidate may be
helpful for bulimia nervosa patients with concurrent ADHD (247–249).
In these situations, particular attention should be given to a range
of potential adverse effects, including abuse.
Although not all psychotherapies have been well studied, there
is general consensus among clinicians regarding the efficacy of
a combined psychotherapeutic/medication approach; such
an approach is worth considering when initiating treatment. In some
research, the combination of antidepressant therapy and CBT has
resulted in the highest remission rates of bulimia nervosa (250–252).
Other studies suggest that target symptoms such as binge eating
and purging and attitudes related to the eating disorder generally
respond better to CBT than to pharmacotherapy (253–255),
with at least two studies (251, 254) showing that the combination
of CBT and medication is superior to either alone. Two of the studies
suggested a greater improvement in mood and anxiety variables when
antidepressant therapy is added to CBT (251, 253, 256). Of note,
some experienced clinicians do not find rigidly defined and doctrinally
practiced CBT to be as useful as methods that integrate CBT with
other psychotherapeutic techniques. This may be due to several factors,
including clinician inexperience or discomfort with the methods
of CBT or differences among patients seen in the community and those
who have participated as research subjects in these studies (81, 153).
Bright light therapy has been shown to reduce binge frequency
in several controlled trials (257–259). Case reports suggest
that repeated transcranial magnetic stimulation may be effective
in treating patients with major depression and bulimia nervosa (260, 261). One controlled trial (719) showed odansetron, a peripheral
5-hydroxytryptamine type-3 (5-HT3) receptor
antagonist that reduces vagus nerve activity, to be effective in
decreasing symptoms of bulimia nervosa, and its use may be considered
in unusual circumstances.
The eating disorder not otherwise specified (EDNOS) category
is a conceptually problematic one and comprises a clinically heterogeneous
group of diagnoses (262, 263). This "everything else" category
currently consists largely of individuals with subsyndromal anorexia
nervosa or bulimia nervosa who do not meet DSM-IV-TR criteria of
being 15% below expected weight or who binge and purge
slightly less than twice per week. Such individuals merit treatment
similar to that of full-syndrome patients. In addition, the EDNOS category
lumps together normal-weight patients who purge, individuals who
chew and spit out their food without swallowing it to prevent weight
gain, and patients with binge eating disorder. Also perhaps suitable
for this "other" category are individuals who
experience psychiatric impairment related to the abuse of diet pills
and diuretics (264), individuals who are obsessively preoccupied
with liposuction (265) to deal with issues of shape and
weight, and certain new-onset postgastrectomy eating disorder patients
(266). The EDNOS diagnosis covers a wide spectrum, so no easily
generalizable comments can be made for the entire group regarding
course or prognosis (267). In addition, over time, considerable
movement occurs from one eating disorder diagnostic category to
another, including EDNOS (263).
Binge eating disorder is the most discrete and well-studied
EDNOS subgroup. Although binge eating disorder is currently not
an approved DSM-IV-TR diagnosis, research criteria listed in
DSM-IV-TR consist of disturbances in one or more of the following
spheres: behavioral (e.g., binge eating), somatic (obesity is common,
although not required), and psychological (e.g., body image dissatisfaction,
low self-esteem, depression). Empirically supported strategies for
the treatment of binge eating disorder include nutritional counseling and
dietary management; individual or group behavioral, cognitive behavioral,
dialectical behavioral, psychodynamic, or interpersonal psychotherapy;
and medications. In reviewing the available information on treating
binge eating disorder, it is important to consider the focus of
treatment. Most programs using nutritional rehabilitation and counseling
focus on weight loss as the primary outcome, whereas studies of
psychotherapy and medication generally consider reduction of binge
eating as the primary outcome measure, with weight loss as a secondary
outcome. Clinical consensus suggests that psychodynamic psychotherapy may
also be helpful to reduce binge eating in some patients.
The literature on treating binge eating disorder suggests
that 1) behavioral weight control programs incorporating low- or
very-low-calorie diets may help patients lose weight and usually reduce
symptoms of binge eating; 2) at least some degree of weight gain
often follows weight loss; 3) weight gain after weight loss may
be accompanied by a return of binge eating patterns; and 4) various
combinations of diets, behavior therapies, non-weight-directed psychosocial
treatments, and even some "nondiet/health at every
size" psychotherapy approaches may be of benefit in reducing
binge eating and promoting weight loss or stabilization in various
circumstances (268).
Some believe that patients with a history of repeated weight
loss followed by weight gain ("yo-yo" dieting)
or patients with an early onset of binge eating might benefit from following
programs that focus on decreasing binge eating rather than losing
weight (269, 270). However, at this point, there is little empirical
evidence to suggest that obese binge eaters who are primarily
seeking weight loss should receive different treatment than obese individuals
who do not binge eat.
CBT is the most widely studied treatment for binge eating
disorder, and there is substantial evidence supporting its efficacy
for behavioral and psychological symptoms, whether it is delivered
in the individual or group format. IPT and dialectical behavior
therapy have also been shown to be effective for behavioral and
psychological symptoms and can be considered as alternative therapies.
There is less consensus regarding the long-term effects of treatment;
however, some studies suggest that most patients continue to show
behavioral and psychological improvement at 1-year follow-up (271, 272). There is a substantial body of evidence supporting the efficacy
of self-help and guided self-help CBT treatment programs (273–277)
and their use as an initial low-burden step in a sequenced treatment
Because severe dieting may disinhibit eating and lead to
compensatory overeating and binge eating (278), and because chronic
calorie restriction can also increase symptoms of depression, anxiety,
and irritability (279), alternative therapies have been developed
that use a "nondiet" approach and focus on self-acceptance,
improved body image, better nutrition and health, and increased
physical movement (280–282). Addiction-based 12-step approaches,
self-help organizations, and treatment programs based on the Alcoholics Anonymous
model have been tried, but no systematic outcome studies of these
programs are available.
In sum, there appear to be several good psychotherapeutic
options for treating binge eating disorder when a reduction in binge
eating is the primary goal. Weight loss, particularly in the long
term, is a much more elusive goal, not only for obese patients with
binge eating disorder but for obese patients in general. However,
several studies suggest that at least for some patients at certain
stages of recovery, behavioral weight control may be a useful treatment
component. Also, because studies have found that binge eating may
begin before obesity or dieting (283), specific approaches are needed
for nonobese patients struggling with binge eating symptoms. The
optimal sequencing of treatmentsthat is, whether the treatment
of binge eating should precede or occur concurrently with weight
control treatmenthas yet to be definitively determined.
There is substantial evidence to suggest that treatment with
antidepressant medications, particularly SSRI antidepressants, is
associated with at least a short-term reduction in binge eating,
in most cases without substantial weight loss. The dosage of medication
is typically at the high end of the recommended range. The appetite-suppressant
medication sibutramine also appears to be effective in suppressing
binge eating, at least in the short term, and is additionally associated
with significant weight loss (284). Heart rate and blood pressure need
to be monitored closely in patients taking sibutramine, and the
medication should be discontinued if there are significant elevations
in these parameters, although these side effects seem to be uncommon
(285). Finally, the anticonvulsant medication topiramate appears
to be effective in reducing binge eating and promoting weight loss
in the short (286) and long (287) term, although side effects such
as cognitive problems, paresthesias, and somnolence may limit its
clinical utility for some individuals. The anticonvulsant zonisamide may
produce similar effects (288). Dexfenfluramine, although effective
for reducing binge eating (289), has been removed from the market
because of increased risk of primary pulmonary hypertension and
heart valve abnormalities. Patients who report having used fenfluramine
and phentermine in the past should be screened for potential cardiac
and pulmonary complications.
It is important to note that in several studies, the placebo
response rate has been reported to be quite high. The clinical implications
of this finding are that controlled studies are extremely important,
as a positive response in an open study may be nonspecific, and
short-term beneficial responses to treatment should be viewed cautiously,
given that a transient "honeymoon" effect of initiating
treatment is common.
There have been few studies of combined treatment for binge
eating disorder, so the clinical recommendations are preliminary.
Overall, it appears that for most patients, the addition of antidepressant
medication to behavioral weight control and/or CBT does
not significantly augment binge suppression but may confer additional
benefits in weight reduction (290–294). One study reported
that the addition of the weight-loss medication orlistat to a guided
self-help CBT program yielded additional weight loss (295). Another study
found that fluoxetine in the setting of group behavioral treatment
did not augment binge cessation or weight loss but did reduce depressive
symptoms (294). Thus, the addition of medication to psychotherapy
for binge eating disorder is not, in most cases, associated with
additional benefit on the core symptom of binge eating, perhaps
because psychosocial treatments are quite effective for this symptom.
However, medication augmentation may have additional benefits.
The phenomenon of wakeful nighttime eating, variously characterized
as night eating syndrome, nocturnal eating/drinking syndrome,
or nocturnal sleep-related eating disorders, is currently an area
of active research (296). Although formal agreed-upon definitions
for these syndromes do not yet exist, the construct of night eating
syndrome, first described by Stunkard et al. (297), generally includes
morning anorexia, evening hyperphagia, and insomnia. In contrast,
the construct of nocturnal eating/drinking syndrome emphasizes
a sleep disorder with recurrent awakenings often accompanied by
eating or drinking, and the construct of nocturnal sleep-related
eating disorders adds to this a reduced level of awareness or recall
of nocturnal eating episodes. Sleep-related eating disorders, including
somnambulism, have reportedly been induced by risperidone, olanzapine,
and bupropion, among other medications (298–300). The literature
does not, at this point, support the recommendation of particular
treatments for these disorders. However, there is preliminary evidence
supporting the utility of progressive muscle relaxation (301) and
sertraline (302, 303). Further studies of the phenomenology and
treatment of these disorders are needed.


text:
I created this to express out what I think and feel. Words I can't seem to tell, when the lights are out, people sleeping, stars watching over you and you'll just sit there with millions of thoughts in your head.
If a picture paints a thousand words, I shall not say more.MySpace Twitter

subset: commoncrawl


text:
Silver Trinklets
by Poppy & Red
Stationery Cards
Set of folded stationery cards printed on bright white, smooth card stock to bring your personal artistic style to everyday correspondence. Each card is blank on the inside and includes a soft white, European fold envelope for mailing.
Penguin and Trinklets pattern for the Christmas Bauble collection.
- 241Promote


text: The HP NC373F PCI Express Multifunction Gigabit server adapter is a high performance PCI Express multifunction network adapter that supports standard or low profile slots in ProLiant servers running over a fiber-optic network environment. The NC373F is a four lane (x4) serial device with 92KB of onboard memory. In addition to delivering Gigabit Ethernet networking, the NC373F supports TOE (TCP/IP Offload Engine), iSCSI (Internet Small Computer System Interface), and RDMA (Remote Direct Memory Access) over a single network connection.