Salient components of a comprehensive service for eating disorders
Authors: KATHERINE A. HALMI
Journal: World Psychiatry (2009)

In the past decade, eating disorders have received a fair amount of dramatic attention in the public media. However, the true incidence and prevalence of these disorders have been difficult to ascertain for several reasons. Most studies of incidence and prevalence of eating disorders have been conducted on limited populations and in various different countries. Many persons with eating disorders are reluctant to admit to their disorder and thus it is likely that a large number of persons with these problems go undiagnosed and untreated. Eating disorders may be transient or recurrent and thus point prevalence rates may not fully reflect the extent of eating disorder pathology in the population. Many persons suffering from eating disorders do not meet full criteria for anorexia nervosa or bulimia nervosa and thus fall into a less well-defined category of eating disorders not otherwise specified. Carefully defining this area in epidemiological studies is a problem. A study of patients recruited from primary care practices in England showed that the prevalence of anorexia nervosa was 20.2 cases for 100,000 population (0.02% of the total population). The prevalence among female patients aged 15–29 years was 115.4 cases per 100,000 population (0.1%) 1. Another more recent study in the United States showed that the lifetime prevalence of anorexia nervosa was 0.6% 2. In a community sample in which a structured interview was used, the prevalence rate for bulimia nervosa was 1% 3. With a standardized mortality rate of 23.14 4, eating disorders have the highest mortality rate of any psychiatric disorder. Mortality can be due to suicide, medical complications of malnutrition or complicating comorbid medical disorders. Anorexia nervosa is one of the most difficult psychiatric disorders to treat. There are few controlled treatment trials for this disorder for several reasons: a) the disorder is relatively rare, so it is difficult to obtain an adequate sample size in any one center; b) patients with anorexia nervosa have a strong resistance to treatment and c) medical complications often require withdrawal from treatment protocols. The resistance to treatment compliance often present in anorexia nervosa patients may be due to the fact that this disorder serves a strong positive function in the patient's life, providing an escape from aversive developmental issues or distressing life events. The disorder becomes highly reinforcing and the prospect of relinquishing the anorectic behavior pattern is terrifying to the patient. Another possibility is the egosyntonic nature of the disorder, which is demonstrated by the patient's denial and refusal to except the seriousness of the medical consequences of the disorder. Thus, difficulties incur in recruiting sufficient numbers for treatment trials, in inducing compliance with treatments and in retaining patients to the completion of treatment. In a recent study of 122 randomized cases, the overall dropout rate of anorexia nervosa patients was 46% 5. Involuntary admission may be necessary to manage a life-threatening emergency or a serious medical deterioration when the patient is unwilling to cooperate in treatment. Nasal gastric tube feeding may be necessary for involuntary feeding. Follow-up studies have shown that involuntary admission and feeding do not have a detrimental influence on outcome 6. Professional training for the diagnosis and treatment of eating disorders is best obtained in a well-established eating disorder program that provides outpatient, day program and inpatient treatment facilities for these disorders, with a multidisciplinary team of professionals including psychiatrists, primary care physicians, nutritionists, psychologists, as well as family therapists who may be psychologists or specifically trained social workers. The components for an ideal treatment and training center for eating disorders are summarized in this paper. The initial assessment and evaluation of an eating disorder patient usually occurs in the context of an outpatient clinic. The assessment must take into account several unique features. First, eating disorder patients are often reluctant to give a complete informative history. Therefore the participation of family members or other collateral informants is desired and necessary in the case of adolescents and younger patients. Second, the evaluation must be comprehensive: a psychiatric assessment, a medical history and examination, and social history. Third, the assessment usually requires several hours. Interview information necessary for the diagnosis of an eating disorder according to the DSM-IV 7 is summarized in Table 1. Most eating disorder patients have other common comorbid behaviors and psychiatric diagnoses: these need to be investigated and are listed in Table 2. The common abnormalities found on physical examination and laboratory findings are listed in Tables 3 and 4. Evidence should be obtained of eating disorders and other psychiatric disorders, alcoholism, substance use disorders and obesity in the first-degree relatives and extended family members who are involved with the patient. Inquiry should be made into a family history of physical or sexual abuse, family communication styles and family structural patterns. It is important to identify family stressors that may aggravate the eating disorder and to determine the family's attitude towards the patient; for example, are they resentful and critical, burned out, or devoted and encouraging. This information is helpful for the clinician to determine the extent of the family's involvement in the treatment plan. A comprehensive eating disorder treatment team means a collaborative team of specialists. It is recommended the psychiatrist assume the coordinating or leadership role within the team and program. For the management of acute and ongoing medical and dental complications, other physician specialists and dentists may need to be consulted. The initial complete physical examination is usually conducted by a primary care physician. A nutrition specialist is helpful for nutritional rehabilitation counseling and giving advice for adequate and appropriate nutritional intake. Psychotherapy may be conducted by the psychiatrist or a psychologist and family therapy by a psychiatrist, psychologist or specifically trained social worker 8. An outpatient eating disorder clinic should have available a comprehensive treatment team consisting of psychiatrists, psychologists, nutritionists, primary care physicians and social workers. Eating disorder patients admitted to outpatient treatment should be in a medically stable condition. This means that their weight should be above 75% of a normal weight for age, height and bone structure, with normal serum electrolytes, normal electrocardiogram and no evidence of suicidal ideation or incapacitating behaviors that result in non-functioning at work, school or family responsibilities. Because the eating disorders require treatment of a variety of conditions, including psychological and medical, with needs of psycho-therapy, pharmacological treatment and medical treatment, is it is advisable that a psychiatrist be in charge of the treatment plan for the individual eating disorder patient. Eating disorder clinics should be able to provide individual psychotherapy, including cognitive behavioral therapy specifically designed for eating disorders, interpersonal therapy and dialectical behavior therapy. Pharmacotherapy may be needed for treatment of depression, anxiety disorders and extreme agitation. Family therapy must be available for all adolescents with eating disorders. Nutritional counseling and education is a useful component to all treatment plans for eating disorders. A comprehensive assessment is necessary for organizing a treatment plan for the individual eating disorder patient. There will always be patients for whom evidence based treatments will not be effective and other innovative approaches may be needed. With a treatment team of experienced psychotherapists, psychopharmacologists, nutritionists and physicians, the possibilities of putting together creative and effective treatment plans are likely to be higher. Evidence-based trials are particularly scarce for this disorder, due to unwillingness of the patients to participate in the trials and high dropout rate. For outpatient individual psychotherapy in adults with anorexia nervosa, the NICE guidelines 9 recommend a cognitive behavioral therapy. This type of therapy has been described in detail by Pike et al 10 and Kleifield et al 11. The most robust evidence-based trials for anorexia nervosa are those of family therapy with adolescents. Eisler et al 12 and Lock et al 13 have shown that a cognitive behavioral style family therapy is effective for these adolescents 14. It is recommended in most medical guidelines that medication be only considered as an adjunct treatment for anorexia nervosa. Randomized controlled trials have indicated that cyproheptadine 14 in large doses of up to 24 mg per day may marginally facilitate weight gain and decrease depression. There is also a suggestion that fluoxetine 15 may in some cases help prevent relapse. A more recent study showed olanzapine to be effective in facilitating weight gain and reducing anxiety and obsessive thoughts in anorexia nervosa patients 16. A large number of randomized controlled trials have shown cognitive behavioral therapy to be a most effective treatment for bulimia nervosa. Many studies are summarized in a review article by Shapiro et al 17. These studies often give a detailed description of their technique or references to the manuals they used. Evidence for a medication treatment for bulimia nervosa is not as strong as that of cognitive behavioral therapy. Numerous randomized medication trials indicate that all serotonin reuptake inhibitors are effective in reducing bingepurge behavior 17. Selective serotonin reuptake inhibitors (SSRIs) are preferred medications, because they have fewer side effects than the other medications that have been shown to also reduce bingepurge behavior. Evidence for the effectiveness of self help is weak and for other interventions either weak or non-existent in the treatment of bulimia nervosa. The few randomized controlled psychotherapy trials for binge eating disorder (BED) indicate that cognitive behavioral therapy is the treatment of choice 18. Medication trials for BED indicate that serotonin reuptake inhibitors are moderately effective in reducing binge frequency and illness severity 19,20. Randomized controlled trials with topirimate 21 and sibutramine 22 have also shown a moderate effect for reducing bingeing behavior in BED. The majority of eating disorder patients requiring inpatient hospitalization have anorexia nervosa. The most frequent and compelling reasons for hospitalization of an anorexia nervosa patient are the medical indications listed in Table 5. Comorbid psychiatric conditions may also require the patient to be hospitalized and are listed in Table 6. A cognitive behavioral framework is useful for the overall ward milieu. Exposure and response prevention techniques can be used to prevent patients from purging and exercising. Group therapy can be used for interpersonal conflicts, psychoeducation about nutrition, medical complications and relapse prevention, assertiveness training, self control strategies, maturing and autonomy issues, and limit setting problems. In the group format the patients can discuss their symptoms and have an increased awareness of symptom triggers and coping strategies. An ideal eating disorder inpatient unit will have an adequate dining room space, so that patients can be directly monitored during meals. Day room areas must also plan for onsite monitoring of patients by nursing staff. Some programs have employed closed circuit television monitoring to reduce surreptitious exercise. The latter requires informed consent and permission of the patients. Bathrooms on this unit need to be locked, to prevent engaging in purging behaviors. One novel program has utilized electronic key-controlled flush switch on toilets so that patients may have privacy in the bathroom but must wait for a nurse to check the content of the toilet before it is flushed. Medical management involves weight restoration, nutritional rehabilitation, rehydration and correction of serum electrolytes. This requires daily monitoring of weight and urine output, and frequent assessment of electrolytes. Physicians experienced in the medical management of severely emaciated anorexia nervosa patients are necessary for adequate care. The total number of calories in emaciated patients should begin with an intake of 30–40 kcal/kg/day and can be increased gradually if there is no evidence of peripheral edema or heart failure. Liquid formulas are an advantage because they contain the necessary amount of vitamins and minerals and can be given in small amounts such as 6 equal feedings throughout the day. A randomly controlled study actually showed that this approach in early hospitalization was more effective than requiring the patient to eat food 23. At this stage of treatment, serum hypophosphatemia may develop during refeeding, requiring phosphate supplements. Bed rest may be necessary with escorted assisted walks and special observation for the development of bedsores. Medications known to prolong QTc intervals should be avoided. Occasionally, electrolyte abnormalities may have to be corrected by intravenous solutions. As patients improve, they should receive nutritional counseling with devising meal plans to practice after they are discharged from the hospital. Ideal discharge criteria from the inpatient setting are presented in Table 7. Patients who are bingeing and purging and within a normal weight range usually require only a short hospitalization for stabilization. They often have comorbid diagnoses of borderline personality disorder or substance and alcohol abuse. Addiction withdrawal is usually better accomplished on a specialized unit, with transfer to the eating disorder unit at a later date. Dialectical behavior therapy groups can be useful for managing emotional dysregulation in borderline bingeing and purging patients. There is evidence that patients who are discharged from an inpatient setting with a body mass index of 19 or greater are less likely to relapse 24. Treatment programs with a variety of different titles have developed for patients transitioning from an inpatient program who are too incapacitated for outpatient treatment. These programs also apply to patients who have been outpatients and become more severely impaired, but not to a degree requiring inpatient hospitalization. A multifaceted program with a cognitive behavioral focus on symptom change is recommended. Such programs have reported weight gain in anorexia nervosa patients and improvements in eating disorder attitude and depressive symptoms 25–27. Programs of varying intensity have been described, but no randomized controlled trials have been conducted. At least one structured meal is advisable in these programs, and nutritional counseling and meal planning can occur in the context of group therapy or in specific individual counseling sessions. Multiple group therapies addressing issues such as social skills training, social anxiety, body image distortion, or maturity fears are effective ways of continuing themes developed during inpatient treatment. These intermediate treatment settings need to have physicians available for medical monitoring, nutritionists for nutritional counseling, psychotherapists for both individual and group therapy and psychopharmacologists for those patients who need medication. There are no studies to provide evidence-based criteria for discharge in these intermediate programs. Generally it is advisable that patients be above 90% of a normal weight and have demonstrated improved functional behavior with a significant decrease of their core eating disorder symptoms. Evidence of intent to continue cognitive behavioral skills learned to reduce the core eating disorder behaviors is also a valuable criterion for transitioning a patient to outpatient treatment alone. There is a paucity of evidence based randomized controlled trials to recommend the salient components of a comprehensive service for eating disorders. Established and experienced clinical eating disorder treatment centers have come to the conclusion that a multidisciplinary team approach provides the most effective treatment service for patients with these disorders. A comprehensive service would include a diagnostic and evaluation clinic, an outpatient clinic, an inpatient service and a day program with a residential treatment component. A psychiatrist should be the captain of this multidisciplinary team, which includes psychotherapists, psychopharmacologists, nutritionists, and family therapists. Mental health support and coverage will determine the specifics of these salient features in the individual countries.