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Treatment Guideline for Eating Disorders

 


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Am Fam Physician. 2000 Jul 1;62(1):185-188.

The American Psychiatric Association (APA) has revised a practice guideline on the treatment of eating disorders. The APA states that patients with eating disorders display a broad range of symptoms that occur along a continuum between those of anorexia nervosa and those of bulimia nervosa. The care of these patients requires a comprehensive array of approaches to provide them with the best chance of treatment success.

The clinical features of anorexia and bulimia are varied, but criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) may be used to establish the diagnosis (see the accompanying tables). There is a significant amount of overlap in the symptoms of these two eating disorders. The primary symptoms of anorexia and bulimia are preoccupation with weight and excessive self-evaluation of weight and shape.

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TABLE 1

DSM-IV Criteria for Anorexia Nervosa

CriterionDescription

A

Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B

Intense fear of gaining weight or becoming fat, even though underweight.

C

Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D

In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify type:

Restricting type

During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas).

Binge-eating/purging type

During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas).


DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

Reprinted with permission from American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry 2000;157(suppl):4.

TABLE 1

DSM-IV Criteria for Anorexia Nervosa

CriterionDescription

A

Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B

Intense fear of gaining weight or becoming fat, even though underweight.

C

Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D

In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify type:

Restricting type

During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas).

Binge-eating/purging type

During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics or enemas).


DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

Reprinted with permission from American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry 2000;157(suppl):4.

View/Print Table

TABLE 2

DSM-IV Criteria for Bulimia Nervosa

CriterionDescription

A

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

  1. Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

  2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting; or excessive exercise.

C

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.

D

Self-evaluation is unduly influenced by body shape and weight.

E

The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify type:

Purging type

During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.

Nonpurging type

During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.


DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

Reprinted with permission from American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry 2000;157(suppl):4.

TABLE 2

DSM-IV Criteria for Bulimia Nervosa

CriterionDescription

A

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

  1. Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

  2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting; or excessive exercise.

C

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.

D

Self-evaluation is unduly influenced by body shape and weight.

E

The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify type:

Purging type

During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.

Nonpurging type

During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.


DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

Reprinted with permission from American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry 2000;157(suppl):4.

Among women, the lifetime prevalence of anorexia nervosa is 0.5 to 3.7 percent, and the lifetime prevalence of bulimia is 1.1 to 4.2 percent. The male-to-female prevalence ratio ranges from 1:6 to 1:10.

The percentage of patients with anorexia nervosa who fully recover is modest. Although some improve over time, many continue to suffer from a distorted body image, disordered eating habits and psychiatric difficulties. Little is known about the long-term prognosis of patients with untreated bulimia. In a long-term study of patients with bulimia who were treated in an intensive program, 60 percent had a good outcome six years after successful treatment.

The goals of treatment for anorexia nervosa are to restore patients to a healthy weight, treat the physical complications, enhance the patient's motivation to cooperate with treatment and provide education about healthy nutrition and eating habits. Other goals of treatment include correcting maladaptive thoughts, attitudes and feelings related to the eating disorder; treating associated psychiatric conditions; enlisting family support; and attempting to prevent relapse. Medication should be considered in the treatment of anorexia but should not be the sole or primary treatment.

Patients with bulimia require specific nutritional counseling and psychosocial intervention. Antidepressants are an effective component of the initial treatment of this eating disorder. This is particularly true if the patient has significant symptoms of depression, anxiety, obsessions or impulse disorders. Selective serotonin reuptake inhibitors are considered to be the safest medication option in these patients, especially if they have the potential to commit suicide.

According to the APA, this guideline contains clinical factors that must be considered when treating patients with eating disorders. The ultimate treatment plan depends on the individual patients who have these disorders.

American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders (revision). Am J Psychiatry. January 2000;157(suppl):1–39.



 

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