By Joel Yager, M.D., Editor-in-Chief
Reprinted from Eating Disorders Review
March/April 2000 Volume 11, Number 2
©2000 Gürze Books
After several years of work, the revised American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders has been published as a supplement to the January 2000 issue of the American Journal of Psychiatry (volume 157 no.1).
This revision represents substantial rethinking and updating, and reflects major input by many members of the Eating Disorders Review editorial board. The core work group of Drs. Arnold Andersen, Michael Devlin, Helen Egger, David Herzog, James Mitchell, Pauline Powers, Alayne Yates, Kathryn Zerbe, and myself have all been seriously involved with the eating disorders field for quite a while. Initial drafts of the guideline drew hundreds of instructive comments from dozens of national and international consultants and from many professional and advocacy organizations.
While the Guideline is in theory authored by and for psychiatrists, it is actually very broadly written and will be useful for clinicians of many backgrounds. Psychologists, adolescent medicine specialists, other primary care physicians, registered dieticians, social workers, and other caregivers have all had substantial input into and influence upon this document.
The Guideline fills 30 large two-columned journal pages, has 7 instructional tables, and contains 356 references. Here are some of the more important highlights:
Choosing the treatment site. The most significant new feature of the revised guidelines deals with choosing the site for treatment. Table 5, “Level of Care Criteria for Patients with Eating Disorders,” offers guidelines for selecting outpatient, intensive outpatient, partial hospitalization/full day programming, residential or inpatient care based on the types and levels of medical complications, suicidality, weight concerns, motivation, co-morbid disorders, need for structure, ability to care for oneself, environmental stressors, availability of treatment facilities, and living situations associated with each setting. These recommendations are much more specific and should be more helpful to patients, families and providers than the broad recommendations of the original 1993 guideline.
Diagnoses. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM IV) is closely followed, but several controversies in current diagnostic schemes are highlighted, and may merit additional attention in the future. For example, since many clinicians see extremely “anorectic” patients who continue to have some menstrual function, should amenorrhea continue to be a requirement for the diagnosis of AN? How does culture influence the appearance and clinical features of eating disorders, and how do these disorders differ across cultures? What is “atypical” anorexia nervosa, in which patients acknowledge that they are too thin and seem not to have much distortion about their body image? The revised Guideline recognizes how important eating disorders not otherwise specified (ED-NOS) are in most practices, and provides an expanded discussion of the clinical features and treatment of binge eating disorder, not addressed in the 1993 version.
Recent epidemiologic data and clinical features. Several new tables outline the major physical complications and abnormal laboratory test results clinicians are likely to encounter in anorexia nervosa and bulimia nervosa and offer guidelines for routine laboratory workups as well as indications for additional tests.
Standardized assessment. The guidelines also discuss the value of standardized eating disorders assessment instruments for clinicians. Major features of representative assessment instruments clinicians might wish to select for use in their practices are reviewed.
Treatment strategies for anorexia nervosa and bulimia nervosa. Strategies for anorexia nervosa and for bulimia nervosa are each discussed by major therapeutic domains, i.e., nutritional rehabilitation, psychosocial treatments, and psychopharmacological interventions. These domains are then addressed with respect to selecting and establishing specific goals, considerations of how effective these approaches have been in research studies and other professional literature, side effects and toxicities that may arise and strategies for managing them (especially regarding medications), and how to implement these various treatment strategies. For example, nutritional rehabilitation issues that are discussed include determining goal weights, calculating initial and subsequent caloric intake, and how to progress after initial implementation. Other issues include dealing with patient reluctance and resistance, as well as side effects, consideration of nasogastric feeding, and what constitutes medical monitoring.
Psychosocial treatment approaches for anorexia nervosa include structured inpatient and partial/day programs, one-on-one psychotherapies, family counseling and therapy, addiction model interventions, and the role of support groups. The medication review stresses recent studies showing that selective serotonin reuptake inhibitors (SSRIs) add little to programs based on good experienced nursing care during hospital-based weight restoration. However, after weight has been regained, some studies suggest that SSRIs (fluoxetine was used in these studies) may be useful in helping patients maintain weight and decease the risks of depression and the likelihood of rehospitalization. (The guidelines also alert clinicians to the fact that the SSRI citalopram has been associated with weight loss in the treatment of outpatient anorexia nervosa relative to psychotherapy alone. See EDR January/February 2000, page 8).
Cognitive behavioral therapy and interpersonal psychotherapy. Cognitive-behavioral therapy remains the strongest psychosocial intervention. For persons with bulimia nervosa and for patients receiving psychotherapy and psychopharmaco-therapy, SSRIs may be preferred.
Interpersonal psychotherapy also has considerable value. Professionally written guided “self-help” manuals may benefit many patients, those in formal treatment as well as those who are attempting to deal with the symptoms on their own.
Collaborative models of care. Collaborative models of care are discussed in greater detail.
Special considerations. Special consideration is given to such issues as the chronicity of eating disorders, co-morbid conditions and/or concurrent medical conditions in relation to assessment and management, and special considerations related to demographic/setting features related to male gender, age, culture, athletics, high schools and colleges.
Copies of the Guideline may be purchased from the American Journal of Psychiatry Circulation Department (202-682-6158). The January issue of the Journal, including the supplement, is priced at $17.25 for the single issue. If they have all been sold, other copies of the revised guideline (fancier edition, bigger print) are now available from the American Psychiatric Press, Inc. (1-800-368-5777).