Throughout the process of assessment, diagnosis, and formulation and implementation of a treatment plan, the following principles of psychiatric management should be kept in mind:

• Establish and maintain a therapeutic alliance.
  • Enhance development of the alliance through empathic comments and behaviors, positive regard, reassurance, and support.
  • Recognize and acknowledge anxieties that patients with anorexia nervosa have about gaining weight.
  • Be aware that many patients may withhold information about their behaviors because of shame.
  • Set clear boundaries.
  • Be aware of countertransference reactions.
  • Adapt and modify therapeutic strategies as the disorder and the therapeutic alliance change over time.
• Collaborate with other clinicians.
  • Provide and/or coordinate care.
  • Collaborate with other individuals who are involved in the patient’s treatment, including other physicians, registered dietitians, mental health professionals, and school personnel.
  • Consult with other physician specialists and dentists.
  • Educate and supervise inexperienced staff.
• Assess and monitor eating disorder symptoms and behaviors.
  • Use DSM-IV-TR criteria to guide diagnosis and identification of target symptoms and behaviors.
  • Obtain history of previous episodes of eating disorder, including previous treatment response.
  • Assess specific eating-related behaviors by
    • obtaining a detailed report of food intake during a single day,
    • observing the patient during a meal, and
    • recording food and/or fluid intake and output as part of nutritional management.
  • Consider the use of formal measures (e.g., semistructured interviews, rating scales, self-report questionnaires).
  • Assess related psychological symptoms (e.g., obsessional thoughts related to weight, shape, and eating).
  • Explore the patient’s understanding of how the illness developed and the effects of interpersonal issues on onset, including aspects of sexual history and psychological, physical, or sexual abuse.
  • Identify stressors that exacerbate the symptoms of the eating disorder.
  • Identify relevant psychodynamic and interpersonal conflicts.
  • Determine the patient’s insight into the presence of the disorder and the patient’s motivation for change.
• Ensure that the patient’s general medical status is assessed and monitored.
  • Ensure that a physical examination is conducted by a physician knowledgeable about eating disorders:
    • Vital signs
    • Weight and height, including calculation of BMI
    • Physical and sexual growth and development
    • Cardiovascular system, including evidence of dehydration, cardiac arrhythmias, or congestive heart failure
    • Lanugo
    • Salivary gland enlargement
    • Russell’s sign (scarring on dorsum of hand)
    • Muscular irritability or weakness
    • Evidence of self-injurious behaviors
  • Review dental examination results.
  • Conduct laboratory analyses, as indicated. For laboratory assessments and their patient indications, see Table 1.
  • For commonly found signs, symptoms, and associated laboratory abnormalities, see Table 2.

• Assess and monitor the patient’s psychiatric status, including co-occurring conditions and safety.
  • Determine whether the patient is at potential risk of self-harm.
    • Assess current suicidal ideation, plan, or intent, including access to means for suicide.
    • Obtain history of suicidal ideation, suicide attempts, and self-injurious behavior.
  • Identify the presence of co-occurring psychiatric signs, symptoms, or conditions, including
    • mood symptoms and disorders,
    • anxiety symptoms and disorders,
    • obsessions/compulsions,
    • substance abuse,
    • impulsive behaviors (including shoplifting), and
    • personality disturbances.
• Assess family issues and enlist family support.
  • Identify any family history of eating disorders, other psychiatric disorders, and obesity.
  • Assess family dynamics (e.g., guilt, blame) and attitudes toward eating, exercise, and appearance.
  • Identify family reactions to the patient’s disorder and the burden of illness for the family.
• Provide education about the patient’s eating disorder and its treatment.
  • Give direct advice and information to the patient and to involved family members.
  • Suggest resources such as self-help workbooks and community- and Internet-based information.
  • Caution about potentially detrimental Internet sites that encourage eating-disordered lifestyles.

After establishing initial treatment goals, reassess and adjust them during the course of treatment.

• Restore or maintain healthy weight.
  • Estimate healthy weight for each individual patient.
  • Base estimate on historical considerations (e.g., growth charts; for women, weight at which healthy menstruation and ovulation resume) and patient’s individual characteristics (e.g., body build, body composition, other physiological variables).
• Minimize food restrictions.
• Reduce binge eating and purging behaviors, if present.
• Provide education regarding healthy nutrition and eating patterns.
• Encourage healthy but not excessive exercise.
• Enhance the patient’s motivation to cooperate and participate in treatment.
• Address underlying themes and correct core maladaptive thoughts and attitudes:
  • Developmental issues
  • Identity formation
  • Body image concerns
  • Self-esteem in areas outside weight and shape
  • Difficulties with sexual issues and aggression
  • Affect regulation
  • Gender role expectations
  • Family dysfunction
  • Coping styles
• Treat physical complications.
• Treat associated psychiatric conditions, including defects in mood regulation, self-esteem, and behavior.
• Provide family counseling and therapy where appropriate.
• Prevent relapse.

1. Treatment Setting

• Determine an initial level of care or change to a different level of care based on an overall assessment of the patient.
  • Consider the patient’s physical condition (particularly weight and cardiac status), psychology, behaviors, and social circumstances. Also consider the availability of the appropriate level of care (e.g., consider constraints of geography or insurance).
  • Avoid basing level of care determinations on a single or limited number of physical parameters, such as weight alone.
  • Hospitalize before a patient becomes medically unstable. Use the patient’s general medical status to determine whether psychiatric or medical hospitalization is indicated.
• Consider inpatient hospitalization for patients with the following indications:Medical Indications

• Other Factors
  • Suicidal intent and suicide plan or other factors suggesting a high level of suicide risk
  • Poor motivation to recover
  • Preoccupation with ego-syntonic or -dystonic maladaptive thoughts
  • Lack of cooperation with treatment or cooperation only in highly structured settings
  • Any existing psychiatric disorder that would require hospitalization
  • Severe co-occurring substance use disorder
  • Need for supervision during and after all meals and in bathrooms
  • Uncontrolled vomiting or hematemesis
  • Presence of additional stressors interfering with the patient’s ability to eat (e.g., intercurrent viral illnesses, significant psychosocial stressors or inadequate social supports)
  • Weight near that at which medical instability occurred in the past
  • Severe disabling symptoms of bulimia that have not responded to outpatient treatment
• Consider a residential treatment center for patients with the following indications:
  • Medical stability to the extent that intravenous fluids, nasogastric tube feedings, or multiple daily laboratory tests are not needed
  • Generally, weight <85% of individually estimated healthy body weight
  • Poor to fair motivation to recover
  • Preoccupation with ego-syntonic or -dystonic maladaptive thoughts
  • Cannot eat and gain weight by self; needs supervision at all meals to prevent restrictive eating
  • Need for structure to prevent compulsive exercising
  • Pronounced role impairment
  • Severe family conflict or problems; absence of family, adequate support system, or both
• Consider partial hospitalization (full-day outpatient care) for patients with the following indications:
  • Partial motivation to recover
  • Preoccupation with ego-syntonic or -dystonic maladaptive thoughts
  • Need for structure to gain weight
  • Need for structure to prevent compulsive exercising
  • Presence of comorbid psychiatric conditions requiring intensive treatment
• Consider intensive outpatient care for patients who are medically stable but who require the additional structure afforded by more frequent contact and involvement in groups.
• Consider outpatient care for patients who are medically stable and do not require a more structured setting to address their eating disorder symptoms.

2. Anorexia Nervosa

a. Nutritional Rehabilitation

• Establish goals for seriously underweight patients:
  • Restore weight.
  • Normalize eating patterns.
  • Achieve normal perceptions of hunger and satiety.
  • Correct biological and psychological sequelae of malnutrition.
• Help the patient to resume eating and to gain weight.
  • Establish a target weight and rates of weight gain: a healthy goal weight is the weight at which normal menstruation and ovulation are restored or, in premenarchal girls, the weight at which normal physical and sexual development resumes.
  • Usually begin intake at 30–40 kcal/kg per day (approximately 1,000–1,600 kcal/day); intake may be increased to as high as 70–100 kcal/kg per day.
  • Reserve nasogastric feeding for rare patients with extreme difficulty recognizing their illness, accepting the need for treatment, or tolerating guilt accompanying active eating even when done to sustain life.
  • Help the patient limit physical activity and caloric expenditure according to food intake and fitness requirements.
  • Monitor vital signs; food and fluid intake/output; electrolytes; signs of fluid overload (e.g., presence of edema, rapid weight gain, congestive heart failure); or other evidence of a serious refeeding syndrome.
  • Address gastrointestinal symptoms, particularly constipation, bloating, and abdominal pain.
  • Provide cardiac monitoring, especially at night, for children and adolescents who are severely malnourished.
  • Add vitamin and mineral supplements; for example, phosphorus supplementation may be particularly useful to prevent serum hypophosphatemia.
  • Create a milieu that incorporates emotional nurturance and a combination of reinforcers that link exercise, bed rest, and privileges to target weights, desired behaviors, and feedback concerning changes in weight and other observable parameters.
• Help the patient to maintain weight.
  • Once desired weight is achieved, calculate ongoing caloric intake based on weight and activity. For children and adolescents, intake levels at 40–60 kcal/kg per day are often needed for growth and maturation.
  • Help the patient cope with concerns about weight gain and body image changes.
  • Educate about the risks of eating disorders.
  • Provide ongoing support to the patient and the family.

b. Psychosocial Treatments

• Establish goals, including to help the patient
  • understand and cooperate with nutritional and physical rehabilitation,
  • understand and change the behaviors and dysfunctional attitudes related to the eating disorder,
  • improve interpersonal and social functioning, and
  • address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors.
• Establish and maintain a psychotherapeutically informed relationship with the patient.This includes understanding the following:
  • Psychodynamic issues, including deficits in sense of self and interpersonal and intrapsychic conflicts
  • Cognitive development
  • Psychological defenses
  • Complexity of family relationships
  • Influence of other psychiatric disorders that may be present
  • Patient preferences
• Provide formal psychotherapy once weight gain has started.

c. Medications

• Use psychotropic medications in conjunction with psychosocial interventions, not as a sole or primary treatment for patients with anorexia nervosa.
• Whenever possible, defer making decisions about medications until after weight has been restored.
• Be aware of and manage general side effects.
  • Malnourished, depressed patients are more prone to side effects.
  • Cardiovascular consultation may be helpful if there is concern about potential cardiovascular effects of a medication.
• Consider antidepressants to treat persistent depression or anxiety following weight restoration.
  • Selective serotonin reuptake inhibitors (SSRIs) have the most evidence for efficacy and the fewest difficulties with adverse effects.
  • SSRIs may also be useful in patients with bulimic or obsessive-compulsive symptoms.
  • Bupropion should be avoided in patients with eating disorders because of increased risk of seizures.
  • Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) should be avoided in underweight patients; their potential lethality and toxicity in overdose should be taken into consideration.
  • Clinicians should attend to the black box warnings in the package inserts relating to antidepressants and discuss the potential benefits and risks of treatment with patients and families if such medications are to be prescribed.
• Consider second-generation and low-potency antipsychotics for selected patients with severe symptoms.
  • Evidence from controlled trials is limited. Clinical impression suggests these agents may be useful for patients with severe unremitting resistance to gaining weight, severe obsessional thinking, and denial that approaches delusional proportions.
  • If these agents are used, monitor for side effects, including laboratory abnormalities.
• Consider approaches to restore lost bone mineral density.
  • Calcium supplementation should be considered when dietary calcium intake is inadequate for growth and maintenance.
  • Vitamin D supplementation can be added in patients without daily sunlight exposure, but excessive doses should be avoided.
  • Hormone replacement therapy is sometimes given, but there is no good evidence for efficacy and its use can enhance patient denial of illness by creating regularly occurring "pseudomenses" (pharmacologically induced menses).
  • Biphosphonates such as alendronate are generally not indicated.

3. Bulimia Nervosa

a. Nutritional Rehabilitation

• Optimal weights should be determined and restored for all patients, since deviance from optimal weight may contribute to sustaining bulimia symptoms.
• Provide nutritional counseling to help the patient
  • establish a pattern of eating regular, nonbinge meals,
  • increase the variety of foods eaten,
  • correct nutritional deficiencies,
  • minimize food restriction, and
  • encourage healthy but not excessive exercise patterns.

b. Psychosocial Treatments

• Establish goals that include helping the patient to
  • reduce and, when possible, eliminate binge eating and purging,
  • understand and cooperate with nutritional and physical rehabilitation,
  • enhance motivation to cooperate in the restoration of healthy eating patterns and to participate in treatment,
  • learn about healthy nutrition and eating patterns,
  • reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder, and
  • improve interpersonal and social functioning.
• Other goals may include
  • enlisting family support and providing family counseling and therapy, when appropriate, and
  • treating associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior.
• Establish and maintain a psychotherapeutically informed relationship with the patient.This includes understanding the following:
  • Psychodynamic issues that address conflicts, core sense of self, affect regulation
  • Cognitive and psychological development
  • Cognitive style and psychological defenses
  • Complexity of family situation and relationships
  • Influence of other psychiatric disorders that may be present
  • Influence of transference and countertransference
  • Patient preferences
• Provide psychotherapeutic interventions appropriate to the individual patient’s development history, psychodynamic issues, cognitive style, comorbid psychopathology, preferences, age, and family situation.Psychotherapy may be needed on a long-term basis, particularly for patients with concurrent anorexia nervosa or severe personality disorders, although controlled studies have been short-term.

c. Medications

• Consider an antidepressant to reduce the frequency of binge eating and vomiting, reduce associated symptoms (e.g., depression, anxiety, obsessions, impulsivity), and prevent relapse.
  • For relapse prevention, most clinicians recommend continuation of the antidepressant for at least 9 months.
  • The combination of psychotherapy and medication may be superior to either modality alone.
  • Various antidepressants may have to be tried sequentially to achieve optimum effect. If no response, the clinician should assess whether the patient has taken medication shortly before vomiting; serum levels may be helpful.
  • Clinicians should attend to the black box warnings in the package inserts relating to antidepressants and discuss the potential benefits and risks of treatment with patients and families if such medications are to be prescribed.

• For patients who require a mood-stabilizing medication (e.g., for co-occurring bipolar disorder), choose an agent that is most compatible with the patient’s preferences and disordered behaviors.
  • Weight gain associated with lithium and valproic acid can distress patients with eating disorders and result in nonadherence.
  • Levels of lithium carbonate can shift markedly with rapid volume changes that accompany bingeing and purging.

4. Eating Disorders Not Otherwise Specified

a. Subsyndromal Eating Disorders

• For patients with subsyndromal anorexia nervosa or bulimia nervosa, who meet most but not all of the DSM-IV-TR criteria, provide treatment similar to that provided for patients who fulfill all criteria.

b. Binge Eating Disorder

• Provide nutritional rehabilitation.
  • Behavioral weight control programs incorporating low- or very-low-calorie diets may help with weight loss and usually reduce symptoms of binge eating.
  • Weight loss is often difficult to maintain, and binge eating can recur with weight gain.
  • Obese binge eaters who primarily wish to lose weight should be treated with the same approaches as other obese individuals.
• Provide psychosocial treatment.
  • Cognitive-behavioral therapy has evidence for efficacy in individual and group formats as well as in self-help and guided self-help sequenced treatment programs.
  • Interpersonal therapy and dialectical behavior therapy also have efficacy in treating behavioral and psychological symptoms.
  • Other diets, behavior therapies, psychodynamic psychotherapy, and non-weight-directed psychosocial treatments are less well studied but may be of benefit for binge eating, weight loss, or stabilization in some patients.
  • Self-help organizations and 12-step-based approaches have been tried, but no systematic outcome studies are available.
• Consider if the patient would benefit from an antidepressant or other medication.
  • Antidepressant treatment is associated with short-term reductions in binge eating but generally does not result in substantial weight loss.
  • SSRIs have the fewest difficulties with adverse effects and the most evidence for efficacy when used at the high end of the recommended dosage range.
  • Sibutramine, an appetite suppressant medication, is effective for binge suppression in the short-term and can produce significant weight loss.
  • Topiramate, an anticonvulsant, can reduce bingeing and decrease weight, but its use may be limited by side effects.
• Consider if the patient would benefit from the combination of psychotherapy and pharmacotherapy.Although limited evidence is available, combined treatment is frequently used in clinical practice.