Selecting Treatment for Eating Disorders
Adapted from the following article: Garner, D. M. (2008). Treatment centers for eating disorders. In K. Keller (Ed.), Encyclopedia of obesity (pp. 752-756). Thousand Oaks, CA: Sage Publications.
Services for treating eating disorders range on a continuum of intensity from inpatient hospitalization to residential care to partial hospitalization programs to varying levels of outpatient treatment. Decisions about the best treatment setting in which to manage a person with an eating disorder depend on the nature of the disorder, the level of risk, physical and psychological complications, and patient preference. There is evidence that those with eating disorders have better outcomes when treated in specialized eating disorder facilities where staff has experience and expertise in treating eating disorders. Major deterrents in selecting the most appropriate treatment include geographic proximity to specialist centers that limit access, lack of data for comparing cost and effectiveness of different settings, inadequate insurance coverage, and managed care decisions that limit access to effective care.
Anorexia nervosa occurs in about 1 in 250 females and 1 in 2,000 males and is estimated to be the third most common chronic medical illness in girls 15-19 years of age. Bulimia nervosa is about five times more common than anorexia nervosa. The mortality rates for anorexia nervosa are more than 12-fold the number of deaths expected from all causes among women 15-24 years of age and two to three times as high as any other psychiatric disorder. Mortality rates for bulimia nervosa are lower but still not insignificant. Medical complications are typical during the acute phase of an eating disorder and persist among those not successfully treated, leading to a wide range of physical and emotional disorders into early adulthood.
An even larger diagnostic category consists of patients with “atypical eating disorders;’ or “eating disorders not otherwise specified:’ These are conditions of clinical severity that do not conform to the diagnostic criteria for anorexia nervosa or bulimia nervosa, but nevertheless closely resemble these disorders. An example would be someone who possesses all of the features of bulimia nervosa but purges only after consuming small amounts of food (does not have objectively large binge-eating episodes). Another example is an individual at low weight with the features of anorexia nervosa who is still menstruating. Yet another example would be a person who maintains a low normal weight by engaging in extreme restrictive dieting, compulsive exercise and vomits only one time a week on average.
Many people with atypical eating disorders have suffered with anorexia nervosa or bulimia nervosa in the past. Binge eating disorder (BED) has been more recently identified and refers to individuals who engage in uncontrollable episodes of binge eating but do not use compensatory behaviors. Many BED patients are obese and mayor may not be accepted into treatment facilities that routinely accept those with anorexia and bulimia nervosa.
Current systems of diagnosing eating disorders into mutually exclusive categories based largely on body weight, bingeing, and purging fail to emphasize the overlap between these conditions in terms of core psychological features, behavioral symptoms, medical symptoms, motivation for change, and social supports. Moreover, there is extraordinary variability within each of the diagnostic subgroups on these key variables. It is well known that individuals with eating disorders can move between the diagnostic categories at different points in time based only on variations in body weight and symptoms such as binge eating and vomiting. Therefore, it is important to avoid generalizations based only upon diagnosis.
Selecting a treatment site
Eating disorders treatment facilities can be distinguished in terms of treatment philosophy, types of clients served, levels of care provided, program structure, staff training, cost, and documented effectiveness. In determining the optimal initial treatment or whether a change to a different type or level of treatment, it is important to consider the patient’s age, the nature of the eating disorder, level of risk, physical and psychological complications, motivation, social circumstances, and patient preference.
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.
Factors to consider in the choice of a treatment site
A comprehensive clinical assessment is the first step in deciding what is the most appropriate form of treatment. A proper clinical assessment is a careful assessment of the patient’s history and current circumstances and usually, if done thoroughly, requires several hours. It includes a thorough review of the patient’s height and weight history; current and past symptoms, restrictive eating behaviors, binge eating, exercise patterns, purging and other compensatory behaviors; attitudes regarding weight, shape, and eating as well as the presence of other psychological disorders.
A full physical examination of the patient is strongly recommended and may be performed by a physician familiar with common findings in patients with eating disorders physical health and associated risks. For children and adolescents, family involvement in the assessment is considered essential. It is desirable for older patients. An assessment should include a family history of eating disorders or other psychiatric and medical disorders, family stressors, and family attitudes toward eating, exercise, and appearance. Family members usually approach treatment with considerable guilt about their role in the development of the eating disorder, and theories that imply blame of family members can alienate family members and interfere with the patient’s care and recovery. Therefore, it is important to take the focus off of these theories when interacting with patients’ families. Standardized and empirically validated measures of eating disorder symptoms and associated psychological features should be part of the initial assessment and discharge.
Specialized eating disorder program
Specialized eating disorder programs are not available in all geographic areas, and their financial requirements may limit access. However, there is evidence to suggest that patients with eating disorders have better outcomes when treated in settings specializing in the treatment of these disorders than when treated in general settings where staff lack expertise and experience in treating eating disorders.
Optimal treatment requires a highly skilled interdisciplinary team, whose members are specifically trained in the management of the full spectrum of disorders. Ideally, staff should include experienced psychiatrists, psychologists, social workers, registered nurses, dietitians, mental health workers, and school personnel to coordinate ongoing education with schools as well as provide tutoring. Medical consults should be readily available from cardiology, endocrinology, gynecology, and internal medicine.
Ongoing assessment of eating disorder symptoms and medical condition
There is considerable variability across treatment centers in the frequency with which body eating disorder symptoms (weight, body, medical status) are part of the ongoing assessment. The treatment team must be continually vigilant regarding shifts in weight, blood pressure, pulse, other cardiovascular indices, and behaviors that are likely to precipitate physiological decline and collapse. Patients should be continually monitored for safety with particular attention given to suicidal thoughts, plans, and intentions, as well as to impulsive behavior including self-harm behaviors.
Do programs meet needs across the continuum of care?
Not all specialized eating disorders programs provide all available levels of care-inpatient hospitalization, partial hospitalization, intensive outpatient, and outpatient treatment. However, providing a range of services can facilitate continuity of care. Programs must give consideration to the age continuum (from adolescents to adults) and disorder severity (from mild to severe and chronic). It is important for the setting to be age appropriate to the educational and social needs of children and adolescents.
Stepping down from one level of care to a less intensive level may be destabilizing for a patient and can lead to resistance to change. Patients may erroneously interpret moving to a less restrictive level of care as meaning they should be expected to be fully improved. Programs that encourage continuation of treatment with familiar and trusted staff across different levels of care are optimal, because they may contribute to the success of aftercare planning. If this is not possible, there must be careful coordination between clinicians planning a move from one treatment setting to another to ensure continuity and attention to important aspects of treatment.
Eating disorder programs vary considerably in the degree to which services are tailored to meet the individual needs of patients. Specific treatment protocols are followed but are adapted to meet the unique needs of individual patients. An individualized treatment plan should be developed for each patient based on a comprehensive assessment, and it should be grounded in evidence-based treatment principles. This plan should also be continually revised, with active input from patients and families based on changes that occur during treatment. Programs of fixed duration or those identified too closely to one philosophical orientation (e.g., faith-based) or exclusive treatment model (e.g., addiction model) are obviously limited in their ability to adapt to individual patient needs.
Evidence-based treatment recommendations
One of the most important advancements in the treatment of eating disorders has been the dissemination of evidence-based practice guidelines from the American Psychiatric Association (APA) in 2006, the National Institute for Clinical Excellence (NICE) in 2004, and the Evidence Based Practice Center in 2006. These clinical practice guidelines provide clinicians with specific treatment recommendations based on the best available empirical evidence. Where evidence is lacking, they provide recommendations based on the consensus view of experts in the field. Treatment centers should endeavor to follow these guidelines where possible. They should also be dedicated to improving clinical practice by evaluating therapeutic outcomes using well-established measures of change. Data should be collected prospectively using standardized measures that can be used as a benchmark for progress and to determine the outcomes and effectiveness of current practices. Patient evaluations of treatment are also part of routine assessment, and are used to assess the effective components of treatment, as well as to evaluate therapists for the purpose of remedying deficits and adding new skills.
Involvement of the family and carers
There are ethical, financial, and practical grounds for including parents in treatment of younger patients. There are also benefits in involving the family in the treatment of adult patients to the degree that the patient is at risk and the degree to which parental involvement is likely to reduce that risk. Many adult patients live with parents or other caregivers and, depending on the extent to which they require nutritional and behavioral management, family members need to be involved if management is to be effective. In some cases, the involvement is limited to information about the disorder and management principles.
On one hand, involvement in therapy can lead to recommendations for parents to be less involved in practical day-to-day management of food and symptom control. On the other hand, caregivers may assume a significant role in shopping for food, meal planning, and managing meal times. In most cases, families benefit from education and support to deal with the stress they experience. Although clear parameters need to be established related to confidentiality, it is also important to consider the health and safety concerns that may take priority.
In general, those with bulimia nervosa and binge-eating disorder can be effectively treated with outpatient therapy. Some patients with anorexia nervosa can begin effectively treated in an outpatient setting; however, if progress is not made, they should be referred to specialized partial hospitalization or inpatient programs. Similar recommendations are appropriate for bulimia nervosa patients who fail outpatient treatment or who develop serious medical complications. Failure to refer patients who remain highly symptomatic (low weight, high frequency ofbingeing and purging) is not recommended by current practice guidelines.
Inpatient hospitalization should be considered for individuals who are markedly underweight and for children and adolescents whose weight has deviated below their expected growth curves. Generally, adult patients with anorexia nervosa have difficulty gaining weight without the structure provided by inpatient treatment. Hospitalization may also be appropriate for some eating disorder patients who are not at a low body weight. Factors suggesting hospitalization may be appropriate include rapid or persistent decline in food intake, medical instability manifested in abnormalities in vital signs or abnormal laboratory tests, continuing weight loss while in a lower level of care, uncontrolled bingeing and purging, the presence of family or social stressors leading to psychological instability, or other psychiatric problems that merit hospitalization. Ideally, hospitalization should occur before the onset of medical instability.
An economical alternative to inpatient and residential treatment
Anorexia nervosa can be particularly costly to treat because the duration of inpatient treatment required for complete weight restoration can be between two to three months and relapses are common during the first year after discharge. The costs of inpatient treatment have increased dramatically in the past two decades, placing an onerous burden on insurers and those individuals who must pay for treatment privately. One approach to cost containment has been shorter lengths of inpatient treatment emphasizing medical stabilization of acute medical symptoms. However, shorter lengths of stay result in lower discharge weights and low discharge weights are one of the most reliable predictors of relapse and poor long-term outcome.
Partial hospitalization programs (PHPs) that specialize in eating disorders are more economical than inpatient treatment and have produced encouraging outcomes with adults. Patients participating in a PHP generally participate in treatment at least five days a week for seven hours a day. Higher quality programs are able to achieve about the same rate of weight gain as inpatient hospitalization. The cost savings can be considerable with some PHPs being able to provide as much as three months of treatment for the same cost as 10-14 days of inpatient hospitalization. An added advantage of the PHP level of care is that the time outside of the program on evenings and weekends permits patients to practice eating, socialization, and relapse prevention, while participating in treatment that is relatively intense and structured.
Geographic proximity to treatment centers
There has been a proliferation in specialized treatment centers in recent years and some have invested heavily in aggressively marketing their programs. Some of these programs provide quality care; however, it is important for the consumer not to confuse marketing skills with treatment effectiveness. In general, seeking treatment at specialized centers, with closer geographic proximity to home, makes ongoing family involvement during treatment more practical. Moreover, the recovery process can be fraught with advancements followed by backslides and brief periods of readmission can be a valuable option. Treatment centers should work closely with patients to develop a realistic plan after discharge and this usually will involve making referrals to therapists in the patients’ communities. Nevertheless, if complications or a relapse should occur, being relatively near the center providing care can be reassuring and lead to better aftercare.
There have been major advancements in the treatment of both anorexia nervosa and bulimia nervosa in recent years. Although there are large variations across outcome studies, approximately 70 percent of adolescents with anorexia nervosa recover from their eating disorder. The course can be difficult for these patients, and a significant proportion remain impaired in terms of psychological adjustment and social functioning. Long-term follow-up studies of adults with anorexia nervosa indicate a less favorable outcome with approximately 50 percent recovery rates; however, again, there are significant variations in outcome across follow-up studies. Despite these promising results, there is tremendous variability in treatment outcome from different centers, suggesting that the components for effective treatment exist but are not well established or consistently applied.
There is more evidence of effective treatment for bulimia nervosa, with as many as 70 percent recovering within three months of an empirically validated outpatient cognitive-behavior therapy. However, recent studies have emphasized the fluctuating nature of symptoms over the follow-up period with many patients who have pervasive psychological and interpersonal problems. This cannot be attributed simply to selective bias associated with treatment seeking, because prospective studies of representative community-based cases indicate that poor psychosocial functioning and psychological maladjustment affect a significant subgroup of patients with anorexia and bulimia nervosa. Even among those who recover from anorexia nervosa, there is evidence of elevated rates of persistent perfectionism, obsessionality, and poor social functioning, as well as an increased risk for a range of health problems during early adulthood.
BIBLIOGRAPHY. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Eating Disorders, 3rd ed. (American Psychiatric Association, 2006); N. D. Berkman, et aI., Management of Eating Disorders. Evidence Report/Technology Assessment No. 135 (Agency for Healthcare Research and Quality, 2006); Eating Disorder Referral and Information Center, www.edreferral.com; Something Fishy Website on Eating Disorders, www.something-fishy.org.
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