APA guidelines suggest structured weight gain, behavioral therapy for eating disorders

In 2012, the American Psychiatric Association issued an update to its Practice Guideline for the Treatment of Patients with Eating Disorders, 3rd Edition. The updated version is largely consistent with the previous version, which was issued in 2006.

The most significant change to this guideline is the retraction of the 2006 recommendation of sibutramine (Meridia, Abbott) for the treatment of binge eating disorder. In 2010, the FDA withdrew its approval of sibutramine due to clinical trial findings suggesting the drug increased the risk for heart attack and stroke. As a result, the drug’s manufacturer, Abbott Laboratories, removed the medication from the US market, and the drug is no longer recommended in the guidelines.

Anorexia nervosa

According to the APA guidelines, the choice of treatment setting for a patient with anorexia nervosa should take into account various factors, including overall physical condition, psychology, behaviors and social circumstances. In patients who are underweight, the guideline advises considering hospital-based programs for nutritional rehabilitation. The guidelines state that adult patients weighing less than roughly 85% of their estimated healthy weights are often unable to regain weight outside of a highly structured program.

In a hospital setting, nutrition can be reintroduced while monitoring the patients for serious complications such as refeeding syndrome, which can lead to cardiac arrhythmias, coma or death. When implementing a refeeding program to anorexic patients, it is important that practitioners employ sensitivity and compassion, and to emphasize that they do not wish to punish the patient with refeeding, but rather to save their lives. When executing a weight gain plan, health care providers should set goals for controlled weight gain at a rate of two to three pounds per week for hospitalized patients and 0.5 to one pound per week for those in an outpatient setting. The guidelines advise working with registered dieticians to help patients choose meals that are nutritionally sound and palatable.

Patients who require live-saving sustenance but refuse to eat should be given nasogastric feeding, according to the guidelines. In very severe situations, such as when patients physically fight and remove nasogastric tubes, feeding may be initiated through surgically implanted gastrostomy or jejunostomy tubes. When deciding whether to undertake involuntary feeding, it is imperative that the practitioner carefully consider the patient’s clinical circumstances, the wishes of the family, and the soundness of the patient’s own judgment. Overriding a patient’s wishes in such situations should be done with respect and with only the patient’s well-being and health in mind.

Once proper nutrition has been restored and the patient has begun to gain weight, psychotherapy may be helpful for an anorexic patient to understand the cognitive distortions implicit in their illness. The guidelines recommend cognitive-behavioral therapy for adults; for children and adolescents, family therapy is also advised. Group therapy is often beneficial for patients with eating disorders, according to the guidelines.

Bulimia nervosa/binge eating disorder

Patients with bulimia nervosa require treatment addressing both somatic symptoms and the sequence of binging and purging behavior that is central to this illness. According to the guidelines, treatment of these patients should include a structured diet in order to avoid the binge/purge cycle, and to encourage satiety. Nutritional counseling should be a central part of this treatment, and should offer balanced, healthy meals that interrupt the pattern of craving, overindulgence and purging. A diet plan and individualized nutritional counseling should be implemented even for patients at a normal weight.
Psychotherapy is also recommended by the guidelines for these patients, in order to understand the dysfunctional thoughts and distortions in body image that may have driven the disease.

For patients with both anorexia nervosa and bulimia nervosa, the use of selective serotonin reuptake inhibitors (SSRIs) are widely used, and the guidelines particularly recommend these medications for patients with accompanying depression, anxiety or obsessive-compulsive symptoms. The use of tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) should generally be avoided in anorexic patients, as reactions to these medications are usually amplified in malnourished patients.

For more information:

Yager J. Guideline Watch (August 2012): Practice guideline for the treatment of patients with eating disorders, 3rd edition. Psychiatry Online. http://www.psychiatryonline.org. Accessed on Sept. 29, 2014.