managing-eating-disorders

# Managing Eating Disorders Guides eating disorder assessment with medical stability criteria, APA Practice Guidelines for Treatment of Eating Disorders, and level-of-care determination using APA and AACAP placement criteria. ## Why This Skill Exists Eating disorders have the highest mortality rate of any psychiatric illness, with anorexia nervosa carrying a standardized mortality ratio of 5.86 — six times the expected death rate. Medical complications including cardiac arrhythmias, electrolyte derangements, refeeding syndrome, and organ failure require coordinated psychiatric-medical management. The APA Practice Guidelines for the Treatment of Patients with Eating Disorders (Third Edition) establish evidence-based standards for assessment, medical stabilization, nutritional rehabilitation, psychotherapy, and pharmacotherapy. Underrecognition remains a critical problem — average time from symptom onset to treatment is 5-7 years. Males, older adults, ethnic minorities, and individuals with atypical presentations (normal or higher weight) are systematically underdiagnosed. Level-of-care decisions must integrate psychiatric severity, medical instability, and nutritional status using validated criteria, not clinical impression alone. --- ## Checkpoint A: Pre-Draft Intake (Mandatory) 1. What is the suspected or confirmed eating disorder diagnosis? (anorexia nervosa restricting type, AN binge-purge type, bulimia nervosa, binge eating disorder, ARFID, other specified/unspecified) — default: assess at intake 2. What is the patient's current weight, height, and BMI? — default: obtain vital signs 3. What is the patient's weight history? (highest, lowest, premorbid) — default: obtain 4. Are there signs of medical instability? (bradycardia, orthostatic hypotension, electrolyte abnormalities, hypothermia) — default: assess immediately 5. What is the purging method and frequency, if applicable? (vomiting, laxatives, diuretics, exercise, insulin omission) — default: assess 6. Is the patient currently in treatment? If so, what level of care? — default: assess 7. Does the patient have co-occurring psychiatric conditions? (depression, anxiety, OCD, PTSD, SUD, personality disorder) — default: screen 8. Is the patient medically cleared or is medical clearance needed? — default: obtain labs and ECG ### Documents to Request - Complete metabolic panel (Na, K, Cl, CO2, BUN, Cr, glucose, Ca, Mg, Phos) - CBC with differential - Hepatic function panel - Thyroid panel (TSH, free T4) - ECG (12-lead) - Vital signs including orthostatic blood pressure and heart rate - Amylase and lipase (elevated amylase suggests purging) - Urinalysis (specific gravity for hydration status, laxative screen) - DEXA scan if amenorrhea >6 months or low BMI >6 months - Prior treatment records including weight charts, meal plans, treatment summaries - Nutritional assessment from registered dietitian - Dental records if purging (enamel erosion documentation) --- ## Step 1: Diagnostic Assessment ### DSM-5-TR Eating Disorder Diagnoses **Anorexia Nervosa (F50.0x):** - Criterion A: Restriction of energy intake leading to significantly low body weight (BMI <18.5 in adults; in children, failure to make expected weight gain) - Criterion B: Intense fear of gaining weight or persistent behavior interfering with weight gain - Criterion C: Disturbance in body weight/shape experience, undue influence on self-evaluation, or persistent lack of recognition of seriousness - Subtypes: Restricting (F50.01) vs. Binge-eating/purging (F50.02) - Severity by BMI: Mild ≥17, Moderate 16-16.99, Severe 15-15.99, Extreme <15 **Bulimia Nervosa (F50.2):** - Recurrent binge eating episodes (large amount in discrete period with sense of loss of control) - Recurrent compensatory behaviors (vomiting, laxatives, diuretics, fasting, excessive exercise) - Binge eating and compensatory behaviors occur at least once per week for 3 months - Self-evaluation unduly influenced by body shape and weight - Severity: Mild 1-3/week, Moderate 4-7, Severe 8-13, Extreme ≥14 compensatory episodes/week **Binge Eating Disorder (F50.81):** - Recurrent binge episodes (at least once/week for 3 months) - Marked distress regarding binge eating - Three or more of: eating rapidly, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty after - NOT associated with regular compensatory behaviors **Avoidant/Restrictive Food Intake Disorder (ARFID, F50.82):** - Eating disturbance leading to persistent failure to meet nutritional/energy needs - NOT better explained by lack of food, cultural practice, concurrent medical condition, or another mental disorder - NOT associated with body image disturbance --- ## Step 2: Medical Stability Assessment Assess for medical emergencies requiring immediate stabilization: **Criteria for Medical Hospitalization (APA/AACAP):** - Heart rate <50 bpm (adults) or <40 bpm - Blood pressure <90/60 mmHg - Orthostatic changes: HR increase >20 bpm or BP drop >20/10 mmHg on standing - Temperature <97.0°F (36.1°C) - Potassium <3.2 mEq/L or other dangerous electrolyte abnormality - Glucose <60 mg/dL - BMI <15 (adults) or <75% median BMI (adolescents) - Dehydration - ECG abnormalities: prolonged QTc >450ms, arrhythmia, ST changes - Acute medical complications of purging (Mallory-Weiss tear, esophageal rupture, aspiration) - Syncope - Seizures - Organ failure markers **Refeeding Syndrome Risk Assessment:** Refeeding syndrome is the most dangerous medical complication of nutritional rehabilitation and can be fatal. High-risk patients include: - BMI <16 or weight loss >15% in 3-6 months - Little or no nutritional intake for >10 days - Low pre-feeding phosphate, potassium, or magnesium - History of alcohol misuse, chemotherapy, or insulin use Monitor: Phosphate, potassium, magnesium, calcium daily during first 7-10 days of refeeding. Start caloric intake conservatively (1,200-1,500 kcal/day in severe cases) and advance slowly with electrolyte supplementation. --- ## Step 3: Level-of-Care Determination **Inpatient Medical:** Medical instability meeting any criteria above. Primary focus: medical stabilization, electrolyte correction, cardiac monitoring, refeeding initiation. **Inpatient Psychiatric:** Medically stable but: suicidal ideation with plan/intent, severe malnutrition requiring structured refeeding, failure of lower levels of care, inability to maintain nutritional intake in less structured settings, severe co-occurring psychiatric symptoms. **Residential Treatment:** Medically stable, BMI typically ≥15, able to participate in programming, requires 24-hour structure for meals and symptom management, failure of PHP/IOP. **Partial Hospitalization (PHP):** Medically stable, BMI typically >16, can be safe overnight, needs structured eating during the day (typically 3 meals + 2-3 snacks supervised). **Intensive Outpatient (IOP):** Medically stable, weight restoration progressing, needs support but can manage most meals independently. **Outpatient:** Medically stable, weight stable or progressing, can manage meals with minimal professional support, working on relapse prevention and body image issues. --- ## Step 4: Treatment Interventions **Nutritional Rehabilitation:** - Target weight restoration of 1-2 lbs/week for inpatient, 0.5-1 lb/week for outpatient - Registered dietitian to develop individualized meal plan - Monitor weight (gown weight, after voiding, before meals — consistent conditions) - Supervise meals and post-meal periods (minimum 30-60 minutes post-meal to prevent purging) - Address refeeding syndrome risk with electrolyte monitoring and supplementation **Psychotherapy (Evidence-Based):** - Anorexia Nervosa Adults: CBT-E (Enhanced CBT), SSCM (Specialist Supportive Clinical Management), or psychodynamic therapy. No single therapy has strong evidence superiority for AN. - Anorexia Nervosa Adolescents: FBT (Family-Based Treatment / Maudsley Approach) is the gold-standard first-line treatment - Bulimia Nervosa: CBT-BN (first-line), IPT (interpersonal therapy) as alternative - Binge Eating Disorder: CBT-BN adapted for BED, IPT, DBT **Pharmacotherapy:** - AN: No medication has FDA approval. SSRIs NOT effective for acute weight restoration. Consider fluoxetine for relapse prevention AFTER weight restoration. - BN: Fluoxetine 60mg/day (only FDA-approved medication for BN). Topiramate off-label (caution: appetite suppression). - BED: Lisdexamfetamine (Vyvanse) 50-70mg/day (FDA approved). Topiramate off-label. SSRIs may reduce binge frequency. - Do NOT prescribe bupropion in patients with purging behaviors (seizure risk). --- ## Step 5: Ongoing Monitoring and Relapse Prevention - Weekly weight monitoring (outpatient), daily (inpatient/residential) - Monthly labs (CMP, phosphate, magnesium) during active treatment - ECG monitoring if cardiac symptoms, electrolyte abnormalities, or medication changes - DEXA scan annually if amenorrhea persists or BMI <18.5 - Dental referral for patients with purging history - Monitor for exercise compulsion (which may replace other compensatory behaviors) - Develop relapse prevention plan identifying triggers, early warning signs, and intervention strategies - Family involvement in treatment planning (essential for adolescents, strongly recommended for adults) --- ## Checkpoint B: Post-Draft Alignment (Mandatory) 1. Is the DSM-5-TR diagnosis documented with specific criteria met and severity specifier? 2. Is the medical stability assessment documented with all relevant vital signs and lab values? 3. Is the level-of-care recommendation supported by specific clinical criteria (not just clinical impression)? 4. Are evidence-based treatments selected for the specific diagnosis? 5. Is the refeeding risk assessment documented for patients requiring nutritional rehabilitation? --- ## Quality Audit - [ ] DSM-5-TR eating disorder diagnosis with severity specifier documented - [ ] Weight, BMI, and weight history documented - [ ] Vital signs including orthostatics obtained and documented - [ ] Laboratory panel including electrolytes, CBC, and metabolic panel reviewed - [ ] ECG obtained and interpreted - [ ] Medical stability criteria assessed systematically - [ ] Refeeding syndrome risk assessment completed - [ ] Level-of-care determination documented with supporting criteria - [ ] Purging behaviors assessed with specific method, frequency, and duration - [ ] Co-occurring psychiatric diagnoses screened and documented - [ ] Suicide risk assessment completed (elevated risk in AN) - [ ] Evidence-based psychotherapy selected for specific diagnosis - [ ] Medication decisions documented with rationale (including decision NOT to medicate in AN) - [ ] Nutritional rehabilitation goals documented with target weight and rate - [ ] Family involvement plan documented --- ## Guidelines 1. Never prescribe bupropion to patients with active purging behaviors — seizure risk is significantly elevated and this is a contraindication per FDA labeling. 2. Always obtain orthostatic vital signs in eating disorder assessments — bradycardia and orthostatic hypotension are the most common indicators of medical instability. 3. Monitor phosphate levels during refeeding — hypophosphatemia is the hallmark of refeeding syndrome and can cause cardiac arrest, respiratory failure, and death if untreated. 4. Do not rely on BMI alone for severity assessment — patients with significant weight loss from a higher baseline may be medically unstable at a "normal" BMI (atypical anorexia nervosa). 5. For adolescents with anorexia nervosa, FBT (Family-Based Treatment) is the first-line intervention — individual therapy alone is less effective than family-based approaches in this population. 6. Screen all eating disorder patients for suicide risk — anorexia nervosa has one of the highest suicide rates of any psychiatric diagnosis, and completed suicide accounts for approximately 20% of AN deaths. 7. Involve a registered dietitian as part of the multidisciplinary team — medication management alone is insufficient for eating disorders.