food in a particular order, chews gum or ice excessively, and has excessive intake of fluids, helps the provider make a presumptive diagnosis of an ED.
If the practitioner suspects that the patient has an ED, then the patient should be screened for risk of suicide (Rome et al.,2003).
Patients who present with ED symptoms, such as appetite loss, weight loss, men- strual irregularities, or unexplained vomiting, could actually be suffering from a variety of medical disorders (Rome et al.,2003). Providers should consider medical and psychiatric diagnoses when they suspect that the patient has an ED, but common aspects of the disorder are not present. At the same time, clinicians should con- sider the possibility that the patient is in denial or is intentionally deceiving them.
Sometimes, clinicians will mistakenly diagnose an ED when the patient actually has such conditions as inflammatory bowel disease, cancer, thyroid disease, dia- betes mellitus, and diseases of the central nervous system. Moreover, practitioners may mistakenly diagnose an ED when the patient is actually suffering from psychi- atric conditions. For example, clinicians may mistakenly diagnose an ED when the patient’s loss of appetite and subsequent weight loss is actually due to major depres- sion. In addition, symptoms of an ED may mimic OCD, alcohol and drug abuse, and psychosis.
Afflicted individuals will rarely admit to having an ED (Rome et al., 2003).
A parent, teacher, coach, or school nurse may become suspicious and then refer the child. It is more frequent that the child will seek medical attention for symptoms, such as dizziness, constipation, heartburn, headaches, or menstrual irregularities, which are due to weight loss or disordered eating.
Health-care providers should work with the patient and family. If parents have concerns about their child’s eating problems, the clinician should ascertain parental concerns in the patient’s presence (Rome et al.,2003). The patient should then be interviewed alone. The clinician should conduct the patient interview with empathy and should be nonjudgmental to find out whether the patient has an ED. The physical examination may be inconclusive. However, a number of clues may indicate that the patient is suffering from an ED. For example, the patient with ED may exhibit the following symptoms: emaciation, sunken eyes, loss of shine or brittle hair, atrophy of the breasts, the loss of tooth enamel, edema of the extremities, and diminished deep tendon reflexes.
Treatment
If possible, the primary care provider should assemble a team consisting of a registered dietitian and therapist who have experience working with children and adolescents with EDs (Rome et al.,2003). Parents should be involved early in the treatment and management plans. In addition, a psychiatric consultation is some- times important to assess the ED and comorbid conditions, such as depression, suicidal risks, OCD, anxiety disorder, and psychiatric medications.
In some cases, clinicians should discuss the patient’s calorie and fat gram needs, while for other patients, it is not useful. Parents with younger children may be taught
Treatment 181 to prepare and plate their child’s food and oversee their food consumption to ensure that the child is eating sufficient food portions.
Rome et al. (2003) suggest that the treatment should vary depending on the sever- ity of the condition. For patients with mild or early ED (85–95% of ideal body weight and stable vital signs), the clinician should begin a food plan consisting of three meals and three snacks with a minimum of 1,200–1,500 calories per day, depending on the patient’s recent caloric intake. The food plan should be increased once or two times per week. The clinician should refer the patient to a dietitian and therapist.
For patients with mild or early ED, the provider should establish a patient con- tract for expected rate of weight gain, target weight goal, hospitalization weight goal, and what will happen if the patient fails to reach her/his weight. The clinician can draw a target weight line, and this graph can be shown to the patient to pro- vide feedback on treatment progress. The patient should see the health-care provider every 2 weeks until she/he is gaining weight on a consistent basis. Once consistent weight gain has been achieved, the patient should be seen at least once a month until the patient achieves target the weight range. For patients with mild or early ED, the clinician should communicate weight, vital signs, and other issues to the therapist and dietitian every few weeks.
For children and adolescents with mild or early ED who do not gain weight adequately, the provider should add liquid supplements and/or restrict the patient’s activity. If the patient is bradycardic, the patient’s activity should be restricted. In addition, if the patient does not gain weight, parental supervision of patient food consumption should be added to the treatment plan.
Patients with moderate or established ED are 75–85% of ideal body weight (Rome et al.,2003). Their vital signs may be going downhill or they may have minor laboratory abnormalities. For these patients, referral to a dietitian and therapist should be required.
These patients should have their physical activity restricted until they have a weight gaining trend and their vital signs continue to be stable (Rome et al.,2003).
A short-term goal for these patients is to achieve a weight at which they can exercise safely.
The provider should establish a contract with the patient, specifying expected rate of weight gain, the patient’s target weight, hospitalization weight, and what will happen if the patient fails to gain her/his target weight. A target line also should be drawn. The clinician should see the patient weekly until the patient is gaining weight on a consistent basis. Afterward, the provider should see the patient every 2 weeks until the target weight range is reached. On a regular basis, the provider should communicate weight, vital signs, and other relevant information to other members of the team. In addition, the clinician should consider liquid supplements to increase caloric intake. The provider should discuss the need for hospitalization if the patient cannot reach her/his weight goals.
Patients with a severe ED are less than 75% of ideal body weight, are medically unstable, have a pulse less than 50, and may be dehydrated (Rome et al., 2003).
These patients should be hospitalized immediately. The hospital nursing staff should
participate in the treatment plan. They should be both firm and supportive. They should not bargain with the patient and should keep other members of health team updated on all relevant information.
In the hospital setting, the goal is to restore nutrition, which is planned by a dietitian (Rome et al.,2003). The dietitian plans the patient’s food trays with the expectation that the patient will follow the prescribed nutritional plan. The patient will be given an oral or nasogastric supplement which is equivalent to any uneaten food portion. Over the course of the day, the patient will receive three meals and three snacks. The provider should set the minimum calorie level range at 1,200–
1,500 per day and increase it by 200 kcal per day until the patient is gaining weight.
Once the patient is gaining weight, the provider should increase it by 200 kcal per day every 2–3 days until the patient is consuming the recommended calories.
Patients should be monitored for acute medical complications, such as the re-feeding syndrome, shifts in fluid, and cardiac arrhythmias.
To ensure patient compliance and support, the patient should be monitored closely while eating and 1 h afterward (Rome et al., 2003). To prevent purging or exercise and prevent injuries associated with orthostatic hypotension, the staff should supervise bathroom time.
Another important component of hospital treatment is to provide the patient with psychological support several times per week (Rome et al.,2003). The patient’s cog- nitive functioning is frequently impaired at this time. As a result, supportive therapy is recommended until the patient’s nutritional and cognitive functioning improves.
Once this is accomplished, the therapist can begin to offer therapy. During therapy, one strategy is to ask the patient to write a list of positive messages that she/he can rely on when she is having difficulty overcoming the ED. Moreover, the patient can learn to use relaxation methods before and after meals to help reduce the stress associated with these time periods.
How long should the hospitalization last? The patient should be hospitalized for a long enough period so that the patient stops losing weight, is able to develop a weight-gaining trend, and has normal vital signs and laboratory values (Rome et al., 2003). In addition, the hospitalization should be long enough to enable the patient to eat independently so that she/he continues to gain weight on an outpatient basis.
Clinicians set higher weight goals for patients who have been hospitalized more than once (Rome et al.,2003). With improved health status, providers should give the patient more autonomy in selecting their meals. Patients can choose meals from the hospital menu in collaboration with her/his family. Moreover, the patient can have some unsupervised meals.
The treatment plan should be evaluated and, modified, if necessary, on a contin- uous basis by the primary care provider, other members of the treatment team, and the patient’s parents to ensure that progress is being made.
Patients frequently drop out of inpatient treatment for AN, and dropout from inpatient treatment is associated with worse outcomes. Using a French sample of 601 consecutive female patients with AN, restrictive (AN-R) or AN, binge/purging (AN-B/P) subtypes, Huas et al. (2011) evaluated dropout rates and predictors of dropout. They showed that 50.0% of the AN-R patients and 56.2% of the AN-B/P
Treatment 183 patients dropped out of AN inpatient treatment between 1988 and 2004. Factors that predicted dropout were as follows: having one or more children, low desired BMI, a low minimum BMI, paranoid ideation, pathological eating behaviors, and low edu- cational attainment. Patients who dropped out early were more likely to have lower desired BMI, paranoid ideation, and more impulsive behaviors, e.g., use alcohol and have suicide attempts. The authors suggest that certain factors reflect illness severity and should be warning signs for clinicians, e.g., pathological eating behaviors and low minimum BMI, while other factors could be targeted before hospitalization, such as patients who have one or more children and low desired BMI.
Treatment guidelines and clinical pathways for treating AN in adolescents have become popular (Rome et al., 2003). The American Psychiatric Association and the Society for Adolescent Medicine have published guidelines for AN treatment.
Health-care providers at Stanford developed the first clinical pathway for treating AN in adolescents.
Investigators have evaluated the effectiveness of psychological treatments for individuals with different EDs (Eisler et al.,2007; Lock et al.,2006; Loeb et al., 2007). Family-based therapy (FBT) can be effective in treating adolescent AN.
Based on 86 persons who had been previously treated in a randomized clinical trial using FBT, Lock et al. (2006) discovered that short-term FBT was just as effective as longer term FBT in improving the participants’ ideal body weight. Eighty-nine percent of the research subjects were above 90% ideal body weight at follow-up.
Seventy-four percent had eating disorder examination scores in the normal range.
In addition, 91% of the postmenarcheal females who were not on birth control had normal menstruation.
Clinicians have developed a manual-based form of cognitive behavior therapy to treat BN (CBT-BN). In a review of the literature, Hay et al. (2009) evaluated the effectiveness of cognitive behavior therapy (CBT), CBT-BN, and other psychothera- pies. Based on a review of 48 studies involving 3,054 participants, the authors found that CBT is effective, especially CBT-BN in treating persons with BN and associated ED conditions. The literature review also showed that other psychotherapies were effective, especially interpersonal psychotherapy (IPT) in treating persons with BN and related syndromes in the long term. The trials revealed that self-help therapies that used very structured CBT models had potential. However, the literature showed that exposure and response prevention approaches did not improve the effectiveness of CBT.
CBT has been shown to be effective in treating individuals who have core symp- toms of BED (Striegel-Moore et al.,2010; Wilson et al.,2010). Based on a sample of 123 persons, including 10% with BN, 48% with BED, and 41.4% with recurrent BE without BN or BED, Striegel-Moore et al. (2010) tested whether a manual- based guided self-help type of CBT (CBT-GSH) that was given in 8 sessions at a health maintenance organization over a 12-week period was more effective than usual care. The authors discovered that CBT-GSH produced greater avoidance of BE than usual care at 12-month follow-up. Participation in CBT-GSH also was associated with improvements in dietary restraint, eating, concerns about shape and weight, depression symptoms, and social adjustment. However, CBT-GSH did not
lead to significant weight change. The authors suggest that CBT-GSH is useful as a first-line therapy for most patients with recurrent BE without BN or AN.
Wilson et al. (2010) report that behavioral weight loss treatment (BWL) and CBT-GSH have produced short-term reductions in BE in obese patients with BED.
The authors compared both BWL and CBT-GSH with IPT using a sample of 205 women and men with BMI between 27 and 45 who met the DSM-IV criteria for BED. At 2-year follow-up, IPT and CBT-GSH were more effective than BWL in curing BE. The investigators conclude that CBT-GSH should be the first-line therapy for a majority of patients with BED. IPT or a complete form of CBT should be undertaken to treat patients with low self-esteem and severe ED symptoms.