CHAPTER 13 Integrative Management of Disordered Eating

OVERVIEW

psychiatric illness with the second highest rates of mortality.

characterized by harmful eating patterns and often a preoccupation with shape and weight. Disordered eating causes great psychosocial distress and physical damage to the body.

BODY SHAPE AND WEIGHT: A NORMATIVE DISCONTENT

dissatisfied with their shape and weight.

“pursuit of thinness” and “body dissatisfaction”

cultural ideal that thinness equals attractiveness

dieting industry places heavy pressure on continuing societies’ pursuit of thinness, and on continuing the belief that thin = beautiful.

not all feeding and eating disorders are characterized by weight and shape concerns.)

Anorexia nervosa (AN) namely the presence of self-starvation or food restriction and extreme weight loss.

Normative discontent and related pursuit for thinness is one of the theories

TYPES OF FEEDING AND EATING DISORDERS

Pica

consumption of nonfood substances.

affects all age groups but is seen more frequently in children and those with intellectual disabilities or autism spectrum disorders.

mouthing of nonfood substances—a developmentally normal behavior

develops during pregnancy.

correlation to anemia levels

medical complications.

heavy metal toxicity, infection, and intestinal perforation

dramatic weight loss or failure to thrive

stomach pain, indigestion, or nausea.

Rumination Disorder

repeated regurgitation of undigested food

may contract abdominal muscles or activate the gag reflex in some way to allow for regurgitation

spontaneously. Regurgitated food is re-chewed, re-swallowed, or spat out.

infancy and affects all ages. In infants, failure to thrive and not meeting developmental milestones is common. In adolescents and adults, regurgitation may be covered up by coughing or restricting intake. In all groups, secondary malnutrition

chief complaints may be complaints of stomach pain, indigestion, nausea, weight loss, and additionally bad breath. Dentists - tooth decay

interfere with social functioning

embarrassed of the behavior and avoid social interaction as a result

Avoidant/Restrictive Food Intake Disorder (ARFID)

“feeding disorder of infancy and early childhood.”

affects all age groups

eating or feeding disturbance plus either significant weight loss, significant nutritional deficiency, dependence on nutritional supplements, or a marked interference in psychosocial functioning.

normal or high weight

sensory characteristics of the food, fear of aversive consequences of eating (choking, vomiting), and/or a lack of interest in eating or food

do not endorse body shape and weight concerns.

Anorexia Nervosa

severely restrict their intake

significantly low weight and emaciation.

intense fear of gaining weight, despite being medically underweight.

disturbance in how the individual sees and experiences their body and how others do.

overvaluing of shape and weight on identity and an inability to recognize the seriousness of such a low weight. Two forms are identified: restricting type, evidenced by low weight achieved through dieting, fasting, and/or excessive exercising; and binge-eating/purging type, characterized by low weight through fasting behaviors, episodes of self-induced vomiting, and misuses of laxatives, diuretics, and/or enemas.

psychosocial impairment and numerous medical complications. Extreme malnourishment impacts all bodily systems. Psychosocially, individuals report high levels of isolation, withdrawal, loss of friendships and relationships, and feelings of hopelessness.

Bulimia Nervosa (BN)

episodes of binge eating, inappropriate compensatory behaviors (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise) to prevent weight gain

occur at least once per week and one’s self-evaluation is mostly based on shape and weight. Binges are episodes of eating large amounts of food in a period of no longer than 2 hours coupled with feeling a loss of control. As with AN, BN greatly impairs psychosocial functioning.

dental carries and gum erosion caused by excessive exposure to stomach acid.

Binge Eating Disorder

binge eating disorder (BED) are recurrent distressing episodes of binge eating without compensatory behaviors

three of the following: eating more rapidly than considered normal; eating until feeling uncomfortably full; eating large amounts of feed when not feeling physically hungry; eating alone due to feelings of embarrassment over quantity of food; and/or feeling disgusted with oneself, or depressed or guilty afterward

have weight and shape concerns

having weight and shape concerns, individuals with BED endorse distress levels regarding their weight and shape as severe as those with AN and BN.

Other Specified Feeding and Eating Disorders

Atypical Anorexia Nervosa

meet all criteria for AN. despite losing a great deal of weight, their BMI remains in the healthy or higher range. treatment required is often similar to that of AN.

Bulimia Nervosa of Low Frequency and/or Limited Duration

full criteria for BN. occur less than once per week and/or are present fewer than 3 months.

Binge Eating Disorder of Low Frequency and/or Limited Duration

full criteria for BED. occurs less than once per week and/or are present fewer than 3 months.

Purging Disorder

recurrent purging behaviors in the absence of binge eating. self-induced vomiting. misuse of laxatives, diuretics, or other medications. behaviors to influence their shape and weight.

Night Eating Syndrome

night eating syndrome (NES) engage in recurrent episodes of excessive eating following the evening meal or, more commonly, after first being asleep for a period of time. some awareness of the eating episode, this is not always the case with some reporting finding evidence (e.g., open food containers, dirty plates). distress and often associated impairment related to sleep disturbances.

Unspecified Feeding and Eating Disorder

severity is not high enough or not yet known to warrant a diagnosis. impaired by their feeding and eating behaviors and thoughts, yet the clinician does not define why a specific eating disorder diagnosis is not listed. emergency department settings. more time is required before a specific diagnosis is made.

A Note About Diagnostic Categories: Transdiagnostic Conceptualization

Each of these disorders shares a common psychopathology, namely an overevaluation of shape and weight and their control.

Transdiagnostic means that the specific diagnostic categories are less relevant than the shared characteristics of each disorder.

Clinicians can learn one treatment for all of these disorders rather than attempting to learn and implement multiple treatments.

ASSESSMENT

determine eating disorder diagnosis and severity.

assessment can include a full medical assessment including blood work, types of eating disorder behaviors, frequency of these behaviors, and impairment (Table 13.1). Height and weight should also be obtained.

shrouded in secrecy and carries a great deal of shame. Some elements of the disordered eating may be highly valued (e.g., dietary restriction) and therefore difficult to “give up,” while other behaviors are difficult to discuss (e.g., self-induced vomiting).

ask direct questions about disordered eating.

weight and shape control methods

disordered eating behaviors are any related psychosocial or physical impairments.

full history of eating disorder behaviors. Disordered eating evolves and changes over time. Often what caused the eating disorder to begin with is not what is maintaining it.

IMPORTANT LABS AND FINDINGS RELATIVE TO EATING DISORDERS

Complete blood count - Leukopenia, anemia, or thrombocytopenia

Comprehensive panel to include electrolytes, renal function tests, and liver enzymes

- Glucose: ↓ poor nutrition

- Sodium: ↓ water loading or laxatives

- Potassium: ↓ vomiting, laxatives, diuretics,

- Chloride: ↓ vomiting, laxatives

- Blood bicarbonate: ↑ vomiting ↓ laxatives

- Blood urea nitrogen: ↑ dehydration

- Creatinine: ↑ dehydration, renal dysfunction, muscle wasting

- Calcium: slightly ↓ poor nutrition at the expense of bone

- Phosphate: ↓ poor nutrition

- Magnesium: ↓ poor nutrition, laxative use

- Total protein/albumin: ↑ in early malnutrition at the expense of muscle mass, ↓ in later malnutrition

- Prealbumin: ↓ in protein-calorie malnutrition

- Aspartate aminotransaminase (AST), alanine

- Aminotransaminase (ALT): starvation

Electrocardiogram (ECG)- Bradycardia (low heart rate), prolonged QTc (>450 msec), other arrhythmias

Special Consideration: Social Media

Social media use in general appears correlated with higher levels of depression, anxiety, and self-harm, especially in adolescents

Pro eating disorder pages often termed “proana” (pro anorexia) or “promia” (pro bulimia) explicitly discuss tips and techniques to further eating disorder behavior.

increased body dissatisfaction, negative affect

social media consumption and eating disorder risk

SIGNS

severely underweight or overweight; however, the vast majority of individuals are of normal weight.

physical side effects or complications

Pica and rumination disorders frequently involve GI distress. Disorders involving extreme dietary restriction—AN, atypical AN, and some ARFID presentations—affect all body systems.

system impairments: cardiovascular (e.g., hypotension, bradycardia, arrhythmias); dermatological (e.g., dry skin, lanugo); metabolic (e.g., hypoglycemia, electrolyte disturbance); gastrointestinal (e.g., delayed gastric emptying); skeletal (e.g., osteopenia); liver (e.g., liver failure); and reproductive (e.g., infertility).

purge. Physical findings include electrolyte disturbances; constipation and steatorrhea; ulcers; gastric perforations; leukopenia; dental erosion; and acute renal injury.

SCREENING TOOLS AND OBJECTIVE OUTCOME MEASURES

Some measures are designed to screen an individual for an eating disorder, while others serve as indicators of illness severity and treatment progress.

screening tool, such as the Sick, Control, One, Fat, and Food (SCOFF)

Eating Disorders Assessment-5 (EDA-5) or Eating Disorder Examination Questionnaire (EDE-Q)

All Feeding and Eating Disorder Measures

Eating Disorders Assessment-5 (EDA-5)

semi structured interview which diagnoses and differentiates between all eight of the DSM-5’s eating and feeding disorders.

only questions that appear relevant based on prior answers are asked.

past 3 weeks, with some inquiry to past historic behaviors. Individuals are asked to rate behaviors (i.e., purging) for the past 3 weeks and then are asked if this number of behaviors is consistent for the past 3 months.

Pica, Rumination Disorder, and Avoidant/Restrictive Food Intake Disorder Measures

Pica, Avoidant/Restrictive Food Intake Disorder, and Rumination Disorder Interview

Pica, ARFID, and Rumination Disorder Interview (PARDI) assesses all three of these disorders

completed by the individual, parent/carer, and clinician). It is designed for use across the life span

guide for treatment to assist clinical judgment.

with intellectual disability, the measure should not be used for diagnosis, but more to provide additional information.

the assessment of growth and development, a physical and mental health checklist, and current feeding and eating patterns.

asking about behaviors and related impairment

Nine-Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS)

assesses eating restriction- appetite, fear, and picky eating.

Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Other Specified Feeding or Eating Disorder Measures

The Sick, Control, One, Fat, and Food

SCOFF questionnaire - only five questions

use in primary care to allow providers to quickly and simply detect eating concerns indicative of an eating disorder

The Eating Disorders Examination

EDE is a semistructured clinician-administered questionnaire, and the EDE-Q is self-administered.

questions concerned with the past 28 days and also some with a longer time frame of 3 months to assist with diagnosis.

Topics include “dissatisfaction with weight,” “preoccupation with shape or weight,” and desire for a “flat stomach.”

The EDE-Q consists of 28 questions focusing on behaviors and cognitions in the past 28 days.

four subscales assess the cognitive features of eating disorders: restraint, eating concern, shape concern, and weight concern.

assess specific behavioral symptoms (i.e., frequency of binge eating, self-induced vomiting, laxative misuse, diuretic misuse, and excessive exercise).

The Eating Disorders 15

used session by session with individuals receiving CBT for eating disorders. It measures eating disorder cognitions (e.g., worried about losing control over my eating) and behaviors (e.g., compared my body negatively with others’).

It is best used for indicating to the clinician and individual where progress is being made and where to focus treatment.

Clinical Impairment Assessment

Clinical Impairment Assessment (CIA) measures the impact of various eating disorder behaviors and thoughts on the individual’s psychosocial functioning and life impartment.

used together with the EDE-Q. The measure assesses the past 28 days.

higher the rating the more severely impaired the individual is.

Special Consideration: Bias in Eating Disorder Diagnosis

“Golden Girls’ disease”

thought to mostly affect young, White, wealthy, cisgender females.

disorders that do not discriminate. They affect all people regardless of gender, race, socioeconomic status, sexuality, or weight.

males not tend to seek treatment, possibly related to shame in having a typically “female illness,” but when they do they are frequently misdiagnosed, often with depression. (Of note, excessive exercising is more frequently a hallmark feature of an eating disorder in males

Many private eating disorder centers do not have beds for male, transgender, or nonbinary individuals.

older adults being misdiagnosed or offered inadequate treatments.

Finally, eating disorders occur in all body weights.

ACHIEVING CONCORDANCE

behaviors frequently occur in secret.

Individuals with eating disorders often fear letting go of their eating disorder.

Ego-syntonic disorders are consistent with one's goals. Extreme dietary restriction or self-induced vomiting may have an impact on body shape and weight and, importantly, are effective at regulating mood. The eating disorder may also have been a friend in times of loneliness.

Sharing printed material on treatment effectiveness can further instill hope in the individual.)

The goal will be to form internal motivation as well, but that can take time. Moving someone out of a state of malnourishment is often needed before they are able to find internal motivation.

individual is able to name anything about the disorder they would like to change (e.g., binge eating), that is used to explain how treatment could improve this aspect of their disorder.

sessions is on identifying any motivators, highlighting any harmful physical side effects, and creating pros and cons of embarking on treatment.

keep the individual out of the hospital or to keep the individual medically safe.

EXPECTED OUTCOMES

determine treatment outcomes collaboratively with the individual.

what objectives are important to provide long-lasting recovery.

individual is the expert in their eating disorder and the clinician is the expert in the treatment.

TREATMENT

range from self-help or bibliotherapy to inpatient medical and/or behavioral units.

least intensive level of care and more up to more supportive treatment if needed.

outpatient psychological treatment with 1x to 2x weekly sessions.

Medical/Behavioral Inpatient Units

Medical Units

Behavioral Units

medically stable, yet still requires intensive treatment in a 24-hour hospital environment, inpatient psychiatric hospital stays are recommended.

dramatic loss in weight that cannot be halted, acute malnutrition, refusal to take in food and/or fluid, extreme levels of eating disorder behavior (binge eating, self-induced vomiting, excessive exercise), and/or the presence of suicidal thinking or a comorbid psychiatric illness which requires attention first.

group therapies, meetings with a registered dietician, supported meals, and medication management.

Refeeding Syndrome (RFS)

potentially fatal complication of refeeding.

extreme fluid shift which dramatically disrupts electrolyte levels. Hypophosphatemia is most often noted along with changes in glucose; protein, and fat metabolism; thiamine deficiency; hyper/hyponatremia; hypokalemia; and hypomagnesaemia. individuals with severe malnourishment receiving oral, enteral, or parenteral refeeding. Of note, malnourishment is not weight dependent and occurs at all BMIs.

Residential Treatment

residential treatment provides 24-hour care. The setting is more home-like rather than a hospital setting. Residential programs take individuals who are motivated for treatment and voluntary, unlike inpatient units where individuals are sometimes admitted involuntarily. Treatments include groups, individual treatment, shared meals with prevention of engaging in eating disorder behavior afterward, individual therapy, medication management, and nutritional guidance. They also often include a wide variety of extracurricular programs such as yoga, music, and art therapy.

Partial Hospital Program and Intensive Outpatient Treatment

“day treatment.” -8 a.m. to 4 p.m. in the program.

restoring regular meals, weight regain or stabilization, and consolidation of gains made in higher levels of care.

group therapies, shared meals with prevention of engaging in eating disorder behavior following, individual therapy, medication management, and nutritional guidance.

practice recovery–oriented behaviors at home on the evenings and weekend.

intensive outpatient treatment (IOP). meet several times per week for a few hours. They often include at least one shared meal with support to not engage in eating disorder behaviors afterward.

Outpatient Treatment

Pica

no first-line treatment recommendation

reinforcement-based treatments and response interruption techniques

Reinforcement-based techniques reward the absence of pica behaviors or replace pica behaviors with a positive alternative (e.g., parental attention). In response interruption, the individual is physically prevented from engaging in pica behavior. Punishment-based techniques (e.g., time out, verbal reprimand)

negative impact of punishment- punishment techniques if other techniques have been ineffective.

Rumination

diaphragmatic breathing as a likely treatment of choice

Diaphragmatic breathing or “belly breathing”

shown where their breathing likely currently occurs—in their chest. They are then taught to breathe more deeply through their abdomen. Individuals are advised to sit in a chair (as opposed to lying down

Sitting physically discourages regurgitation). They are instructed to place one hand on their upper chest and one hard on their “stomach” (e.g., below the ribcage and sternum) and to take a deep breath. This will highlight to the individual their breathing is likely located in their chest. Then the individual is instructed to practice breathing from their stomach and to keep their chest still.

use this breathing technique mid-way through meals and/or after meals depending on when they typically regurgitate.

Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Other Specified Feeding and Eating Disorders

EBTs exist for outpatient treatment of AN, BN, BED, and OSFED

psychological therapy. These therapies are time-limited with a beginning, middle, and end.

Children and Adolescents

Family-based treatment (FBT), also referred to as the Maudsley method, is the recommended first-line treatment for children and adolescents with AN, BN, and OSFED.

CBT for eating disorders is offered as a second-line treatment for these disorders and a first-line treatment for BED in children/adolescents.

Family-Based Therapy

In FBT, the parent or primary caregiver takes responsibility for re-feeding their child. The aim is to regain weight to a healthy BMI or in individuals with BN to stabilize weight and encourage normative eating. Once this initial phase in treatment is reached, eating control is handed back over to the individual. The final goal in treatment is to help the individual resume appropriate adolescent developmental milestones.

four phases of treatment. The first phase focuses on engagement of the individual and family and building a solid therapeutic alliance. session two, the family attends a meal in the therapist’s office. receive guidance from the therapist on how to support their child en vivo. The family meal has three aims: it allows the clinician to observe the family dynamic around mealtimes, is an opportunity to provide the family with skills in the moment, and encourages confidence in the parents to feed their child successfully.

second phase, families are helped to manage the eating disorder. Providing guidance and support for mealtimes and continuing to provide psychoeducation about the effects of starvation are highlighted. Feeding and eating responsibilities are temporarily handed over to parents and removed from the child.

monitor intake, prepare all foods, get their child’s weight, and monitor activity levels.

Phase 3 begins when weight restoration is achieved. The focus starts to shift toward the future but also with a heavy emphasis on individuation and adolescent development. The individual starts to take charge in preparing their meals and snacks. Phase 4 focuses mainly on the future, exploring life without the eating disorder and preparing for discharge.

Adults

CBT for eating disorders is the main recommended treatment for individuals with BN, OSFED, and BED.

Cognitive Behavioral Therapy

CBT for eating disorders is short-term, focused psychotherapy. It targets the primary maintaining mechanisms of the eating disorder, namely the overevaluation of eating and the overevaluation of shape and weight.

four stages. In stage 1 highlights the behaviors and cognitions that maintain the eating problem and serves as the initial blueprint for treatment. Developing a pattern of planned regular eating is another key component. adopt a pattern of eating three meals and three snacks at least every 4 hours. Another key component of stage 1 is “collaborative weighing.” Individuals are weighed each week (or twice a week if underweight), facing forward. many individuals believe that their weight changes dramatically after eating a feared food. show this on the graph challenges their belief and helps to erode it.

stage 2 (sessions 8 and 9), progress in treatment thus far is highlighted and a plan for tackling the main cognitions around shape and weight is jointly created. “focused” version and a “broad” version. The focused version focuses entirely on eating disorder behaviors and thoughts while the broad version contains modules targeting clinical perfectionism, core low self-esteem, and interpersonal difficulties.

Stage 3 (sessions 10–17) focuses on the individual's overevaluation of shape and works to improve body image. The main techniques involve stopping body checking (e.g., pinching, using a measuring tape on the body) and modifying mirror checking and body shape comparisons. Help the individual to relabel times when they “feel fat” by looking for what else is happening in their life. Time is also spent improving individuals’ problem-solving skills. This allows them to build in other coping mechanisms. A number of individuals also need support in learning to modulate their moods in ways other than the eating disorder. Additionally, time is spent on teaching individuals to effectively problem-solve life's difficulties.

In stage 4 (sessions 18–20), the focus shifts toward the future and completing treatment. A short-term maintenance plan is created jointly with the individual and potential future difficulties and newly learned coping skills are put in place.

Maudsley Anorexia Treatment for Adults

MANTRA is a short-term focused psychological treatment - uses a treatment workbook

four phases with an additional follow-up phase. At the start of treatment, individuals undergo neuropsychological testing examining set-shifting abilities and central coherence.

In the first phase (sessions 1–4), motivating the individual to embark on treatment is key.

therapist’s style is warm and understanding.

collaborative case formulation and treatment goals are jointly created. It is suggested that SMART (specific, measurable, achievable, realistic, and tangible) goals be identified.

middle sessions (9–18) concentrate on lasting change. The emphasis continues to work on the previous sessions, namely nutrition and weight improvement, as well as changing thinking style. Individuals are provided with feedback on the neuropsychological testing at the start and if there are difficulties with cognitive rigidity and perfectionistic traits. therapist and individual work toward expressing emotions and needs rather than believing doing so is “bad.”

The final sessions (19–20) focus on relapse prevention and finishing treatment. The therapist and the individual reflect on the treatment, areas that have gone well, and those that require further work.

Specialist Supportive Clinical Management

SSCM is a focused outpatient psychological therapy consisting of both behavioral change elements (e.g., improved weight and nutrition) and focused therapeutic support.

phase 1, the individual is oriented to the treatment and the therapist applies a strongly empathetic yet firm style. Clear treatment objectives are laid out including weight restoration goals and the need for a normalized eating pattern. There is also a focus on psychoeducation of the eating disorder and in particular how the eating disorder impacts one’s life.

In phase 2, focus remains on normalizing eating and sustained weight restoration. Individuals are supported in seeing the link between challenges in their life and their undereating.

third phase of treatment, focus remains on the behavioral components, and there is a clear shift to ending treatment. Change is highlighted, future obstacles are discussed, and individuals are encouraged to maintain changes

Interpersonal Psychotherapy

Interpersonal Psychotherapy for Eating Disorders (IPT-ED) is considered a second-line treatment for BN and BN-like presentations of OSFED, and a first-line treatment for BED.

Individual Interpersonal Psychotherapy

Individual IPT-ED is a short-term, focused psychological therapy.

based on the premise that interpersonal difficulties are common in those with eating disorders and contribute to their maintenance. For example, many individuals who struggle with an eating disorder withdraw and isolate themselves. This isolation may be caused by not wanting to eat out socially with friends. Avoiding the social interaction negatively impacts mood and increases feelings of loneliness. Binge eating is then used to improve or modulate these feelings and mood state.

engaging in binge eating to alleviate the distress caused by an argument with a loved one.

three phases. Phase 1 (sessions 1–4) aims to engage the individual into treatment and to orient the individual to treatment. agree on the interpersonal problem area to focus on for the duration of treatment. An interpersonal inventory aims to highlight links between impersonal events and what was happening at the time. In doing so, patterns begin to emerge indicating which interpersonal difficulties are likely to keep the eating problem going. What was happening at the time in your environment and interpersonal relationships?” five main problem areas: lack of intimacy and interpersonal deficits, interpersonal role disputes, role transitions, complicated grief, and life goals. working on the most problematic area provides improvement to the other areas.

In phase 2 (sessions 4–16), the sessions are mainly client led; active directives from the clinician are used sparingly. The therapist is strategic in keeping the individual on the problem area and a general sense of pressure for change.

final phase, phase 3 -   more time to implement changes without clinician input and prepares them for treatment ending. The goals of phase 3 are to help the individual continue to make changes and to minimize relapse.

Group Interpersonal Psychotherapy

conduct a thorough assessment privately with the client, ensure appropriateness for the group, and begin to establish a therapeutic rapport. identify the primary problem and establish treatment goals.

Bibliotherapy

The least intensive treatment for eating disorders is self-help. Guided self-help (GSH) in particular sees the greatest improvement. The guidance is in the form of support, encouragement, and checking in on between-session homework. BED appears to be especially responsive to bibliotherapy. Bibliotherapy is often the first line of treatment for those with short duration of illness, low severity of symptoms, or those who have not received treatment.

Technology-Assisted Treatment

Computer-assisted programs (apps, virtual sessions, telehealth) are likely to help. These programs increase access

remove the stigma

Telehealth

challenges and opportunities. Challenges for outpatient psychological treatment include how to get an individual’s weight and how to obtain their monitoring records. Opportunities are seen as more involvement from family and significant others who may be able to help with treatment, not missing sessions due to not having transportation to the session.

Emerging and Alternative Psychological Treatments

mindfulness-based approaches, compassion-focused therapies, schema therapies, acceptance and commitment therapies, equine therapies, and yoga-based interventions

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) was created to treat individuals with borderline personality disorder and chronic suicidality. This particular group of individuals greatly struggle with emotion dysregulation; DBT, therefore, focuses on enhancing their ability to self-regulate. Individuals with eating disorders likewise can struggle with emotional reactivity.

binge eating and/or vomiting to self-soothe.

focuses on emotion-regulation skills, balanced eating, and the DBT skill “a life worth living.”

promising for BN and BED.

Psychopharmacological Treatment

antipsychotics and antidepressants

antipsychotics (e.g., olanzapine), benzodiazepines (e.g., lorazepam), and antidepressants (e.g., mirtazapine) have shown some benefit for ARFID

antihistamine cyproheptadine is used to help stimulate an interest in eating or food

against medications as the sole treatment for these disorders.

fluoxetine is U.S. Food and Drug Administration (FDA) approved for BN and BED and lisdexamfetamine (LDX) is approved to treat BED. No medications are approved for AN.

“off-label” when used to treat eating disorder symptoms

Special Consideration: Highlighted Medications

high number of physical complications secondary to eating disorders, a number of medications that bring their own medical risks may be especially harmful in those with eating disorders.

Bupropion: BN or purging disorder are already at risk of increased seizures due to potential electrolyte disturbance. Bupropion abuse is a concern due to the medication’s appetite suppressing side effect. contraindicated in those with an eating disorder.

Lithium: greater risk of lithium toxicity due to dehydration and impaired renal functioning.

Methylphenidate: appetite suppressing effects

Mirtazapine: rare,  can cause neutropenia. monitor complete blood count.

Tricyclic antidepressants (TCAs): BN or purging disorder with electrolyte disturbance may also be at higher risk of cardiac side effects -hypotension, tachycardia

Ziprasidone: can prolong QTc

Time of administration: self-induced vomiting will interfere with the amount of medication in the body and absorbed by the body. Where possible, the best time of day is just before bed.

Antidepressants

Fluoxetine remains the only FDA-approved medication for the treatment of BN. higher than typical doses, with one study finding 60 mg effective compared to 20 mg. it reduces episodes of binge eating and related self-induced vomiting. reductions in binge eating and related self-induced vomiting (i.e., sertraline, fluvoxamine, citalopram, imipramine, desipramine, amitriptyline). Using the dosage suggestions for OCD treatment. (SSRIs) will likely be ineffective in an individual with low weight AN

related to depleted levels of plasma tryptophan caused by extreme food restriction. Low plasma tryptophan causes a hyposerotonergic state in the brain (Powers & Bruty, 2009). This hyposerotonergic state interferes with SSRIs' effectiveness.

Antipsychotics

Olanzapine shown usefulness in helping individuals with AN to regain weight. Several studies found low-dose olanzapine (2.5 mg–10 mg) superior to placebo regarding weight gain. improvement in related obsessive thinking.  low-dose aripiprazole (5 mg–15 mg) also provide preliminary evidence of efficacy in reducing eating-related preoccupation and rituals

D-Cyclosireine (NMDA Receptor Agonist)

D-cyclosireine to exposure therapy significantly increased BMI more than those receiving exposure therapy alone

Dronabinol (Cannabinoid Receptor Agonist)

Dronabinol is commonly used to treat nausea, vomiting, loss of appetite, and related weight loss in those receiving chemotherapy or who experience these symptoms secondary to HIV/AIDS. weight gain in individuals with AN

Lisdexamfetamine (Stimulant)

LDX is the only FDA-approved medication for the treatment of moderate to severe BED.

reducing binge eating and also reducing weight. started at 30 mg and titrated over 4 weeks to a maintenance dose between 50 mg and 70 mg.

Topiramate (Antiepilectic)

Topiramate is currently under investigation for FDA approval for the treatment of BN. Doses of 75 mg to 200 mg, initially started low (12.5 mg–20 mg) and increased slowly, have shown reductions in binge eating and self-induced vomiting. carries the side effect of appetite suppression.

could be harmful in exacerbating dieting and eating disorder thinking.

Neuromodulation

Neuromodulation as treatment

two primary methods are the minimally invasive repetitive transcranial magnetic stimulation (rTMS) and the more invasive deep brain stimulation (DBS).

AN show improvement in eating disorder symptoms. DBS is a surgical procedure involving the implantation of electrodes in targeted brain structures. improvement in mood and BMI

OBESITY

BMI over 30

health risks such as hypertension, type 2 diabetes mellitus, dyslipidemia, coronary heart disease, stroke, and early death.

shame, stigma, increased depression, and lower reported quality of life.

Weight bias, holding negative stereotypes (i.e., “obese people are lazy”) about individuals perceived to be overweight, leads to discrimination and poorer interactions with healthcare providers

experienced by those with BN and especially BED. weight gain, most notably antipsychotics. metabolic syndrome

Treatment

four categories: diet and lifestyle change; psychological treatment; surgery; and medication.

psychological therapies and surgery.

health risks related to obesity are greatly reduced with even modest reductions in weight. Improvement of cholesterol, blood pressure, glucose tolerance, sexual dysfunction, stress incontinence, polycystic ovarian syndrome, and infertility are seen with 5% to 10% weight loss

Special Consideration: Health at Every Size (HAES)

HAES encourages acceptance of all body shapes and sizes and aims to shift away from weight loss as a goal and over to general healthy habits of movement and nutrition (without these changes necessarily leading to weight loss).

HAES interventions improved quality of life, feelings of depression, and some associated cardiovascular improvement in reducing total and LDL cholesterol.

Psychological Treatment

CBT and behavioral weight loss. Effects  do not last in the long term

Bariatric Surgery

Bariatric surgery is the most effective treatment for severe obesity. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the two main types of gastric surgery. SG is more common and involves surgically reducing the size of the stomach pouch, effectively creating a sleeve-shaped organ. RYGB also surgically reduces the size of the stomach pouch, but also connects the new pouch to the jejunum, skipping the first part of the small intestine.

Bariatric Evaluations

bariatric evaluations to assess candidates’ psychosocial appropriateness for surgery.

full psychological diagnostic assessment

individual assessments for mood, anxiety, and other psychiatric illness.

current eating and their understanding of the changes required of their intake following surgery. Common reasons for surgery contraindication cited on evaluations are current drug misuse disorder, uncontrolled schizophrenia, severe intellectual disability, and a lack of knowledge about surgery.

episodes describing a loss of control in overeating (i.e., binge eating—subjective or objective in size), do less well following surgery. On average, they lose less weight and some gain further weight. Quality of life assessments also indicate that those who had an eating disorder find less improvement in their quality of life.

PEDIATRIC POINTERS

•Many eating disorders begin in adolescence

•obtain recent growth curves

•one maintains a weight that is too low and this negatively impacts growth—there is a limited amount of time to refeed the person before their growth plates harden, preventing future growth. - faster the eating disorder is detected and treated, the higher the likelihood of full recovery

•Parents or guardians are integral to pediatric treatment of eating disorders.

•FBT is the first-line treatment for AN in adolescents. If family cannot be involved, then CBT needs to be considered first-line treatment.

AGING ALERTS

•Eating disorders in older people are frequently overlooked or misdiagnosed

• begin in adolescence, most individuals do not seek treatment until their adult years

•eating disorders for many years are at far greater risk of health complications. dental erosion, osteoporosis, and renal failure.

•EBT treatments

•older clients with long eating disorder history may struggle more to overcome the problem.

•“severe and enduring anorexia nervosa” (SE-AN) is sometimes used to describe those with extreme AN with long duration of illness. recovery is possible. goal of treatment with a harm reduction approach would be on keeping the client out of the hospital and living the best life possible for them.

OVERVIEW

Eating disorders are psychiatric illnesses characterized by harmful eating patterns and may lead to significant psychosocial distress and physical health issues. They include factors like a strong focus on body shape and weight, which can lead to severe conditions such as anorexia nervosa, bulimia nervosa, and binge eating disorder.

BODY SHAPE AND WEIGHT: A NORMATIVE DISCONTENT

Cultural pressures promote dissatisfaction with body shape and weight, with ideals equating thinness to attractiveness, influenced by the dieting industry. Not all feeding and eating disorders focus solely on weight and shape concerns.

TYPES OF FEEDING AND EATING DISORDERS

1. Pica

   • Involves consuming nonfood substances.

   • More prevalent in children and those with intellectual disabilities.

   • Associated with health risks such as heavy metal toxicity and severe digestive issues.

2. Rumination Disorder

   • Characterized by the repetitive regurgitation of undigested food.

   • Common in infants but can affect individuals of all ages; may result in malnutrition and social embarrassment.

3. Avoidant/Restrictive Food Intake Disorder (ARFID)

   • A feeding disturbance leading to significant weight loss or nutritional deficiency without focusing on body shape.

   • Can be due to sensory aversions or fears about eating.

4. Anorexia Nervosa (AN)

   • Involves severe restriction of food intake leading to significantly low weight.

   • Characterized by an intense fear of gaining weight and distortion in body image.

   • Two subtypes: restricting and binge-eating/purging type.

5. Bulimia Nervosa (BN)

   • Features binge eating followed by inappropriate compensatory behaviors to prevent weight gain.

   • Binge episodes involve a loss of control over eating.

6. Binge Eating Disorder (BED)

   • Recurrent episodes of binge eating without compensatory behaviors.

   • Individuals experience distress regarding binge frequency and effects on their weight.

OTHER SPECIFIED DISORDERS

• Atypical Anorexia Nervosa: Meets all criteria for AN but with a normal BMI.

• Purging Disorder: Involves purging behaviors without prior binge eating.

• Night Eating Syndrome (NES): Excessive eating occurring mainly at night, often linked to sleep disturbances.

ASSESSMENT

• A thorough medical assessment is essential, including blood work and evaluation of eating disorder behaviors.

• Direct and sensitive questioning about disordered eating habits is crucial.

IMPORTANT LABS AND FINDINGS

• Complete Blood Count: Detects abnormalities such as leukopenia or anemia.

• Electrolyte Levels: Electrolyte disturbances are common in eating disorders and have significant health implications.

SPECIAL CONSIDERATION: SOCIAL MEDIA

Social media can exacerbate body dissatisfaction and promote eating disorder behaviors, particularly among adolescents.

TREATMENT

• Varies from self-help methods to intensive inpatient care.

• Psychological Treatments: Including cognitive-behavioral therapy (CBT) and family-based therapy (FBT).

• Medication: Certain medications can aid treatment but should be used cautiously.

• Bariatric Surgery may be an option for obesity but requires careful evaluation of mental health conditions.

PEDIATRIC POINTERS

Early intervention is critical for growth and health. Family involvement in treatment is vital.

This guide encapsulates the key points to understand feeding and eating disorders, including their types, assessment, treatment options, and special considerations in treatment.