Treatment
Anorexia Nervosa
People with Anorexia Nervosa (AN) are often very reluctant to accept that they are ill, and have a realistic fear that the main aim of the treatment will be for them to gain weight. The first goal is therefore, the establishment of a good relationship between treating clinician and patient in order to engage the person in treatment.
People with AN should be assessed for physical, psychological, social needs and risk to the individual.
The aim of treatment is to reduce risk, to encourage weight gain and healthy eating, to reduce other symptoms and to facilitate psychological and physical recovery.
For most people with AN the aim of treatment should be an average weekly weight gain of 0.5 to 1kg in inpatient settings and 0.5kg in outpatient settings. This requires 3500 to 7000 extra calories a week.
If laxative abuse is present, advice should be given to gradually reduce laxative use and that laxative use does not significantly reduce calorie absorption.
Family members should normally be included in the treatment of adolescents with AN.
In AN, although weight and BMI are important indicators, they should not be considered the sole indicators of physical risk.
Psychological therapies employed include cognitive therapy, interpersonal psychotherapy, focal psychodynamic therapy and family interventions focused explicitly on eating disorders.
Inpatient treatment or day patient treatment should be considered for people with AN, whose disorder has not improved with appropriate outpatient treatment or for whom there is a significant risk of suicide or self harm.
Inpatient treatment should be considered for people at moderate physical risk:
- BMI < 15 kg/m2
- Weight loss per week >0.5kg for more than 2 months
- Blood pressure <90/60
- Postural drop in blood pressure of >10mm Hg on standing
- Pulse rate <50 beats per minute
- unable to get up without using arms for balance
- body temperature < 35 degrees centigrade
- blood biochemistry outside normal limits
Or high physical risk:
- BMI < 13 kg/m2
- Weight loss per week >1.0kg for more than 2 months
- Blood pressure <80/50
- Postural drop in blood pressure of >20mm Hg on standing
- Pulse rate <40 beats per minute
- unable to get up without using arms for leverage
- body temperature < 34.5 degrees centigrade
- blood biochemistry significantly deranged
Inpatients should have a structured symptom focused treatment regimen with the expectation of weight restoration.
Feeding against the will of the person should be a last resort. This should only be done in the context of the Mental Health Act 1989 or the Children Act 1989.
The length of outpatient psychological treatment and physical monitoring following inpatient weight restoration should typically be at least 12 months.
There is very limited evidence to support the use of drugs in AN. SSRI antidepressants (e.g. fluoxetine) have been tried. Generally, however, antidepressants are reserved for treatment of any associated depression. Small doses of antipsychotics or antihistamines can help the severe anxiety and overactivity associated with refeeding.
Severe medical complications, known as “refeeding syndrome” may occur, particularly in people with a BMI of less than 12 kg/m2, those who binge and purge, and those with concurrent physical problems. The clinical features of refeeding syndrome include muscle breakdown, respiratory failure, cardiac failure, cardiac arrhythmias, seizures, coma and sudden death. Close monitoring in hospital is required to manage these.
Bulimia Nervosa
The treatment follows the same general principles as for Anorexia Nervosa (AN).
The management of Bulimia Nervosa (BN) is usually easier than that of AN as the person is likely to wish to recover, and a good working relationship with treating clinicians can often be established. The starting BMI is generally above 20 so there is usually no need for weight restoration.
People with BN should be assessed for physical, psychological, social needs and risk to the individual. People who are vomiting frequently or taking large quantities of laxatives should have their blood biochemistry checked and corrected if necessary.
Some people respond well to an evidence based self help programme as a first step.
Cognitive behavioural therapy (CBT) achieves full remission in 40% of people with BN. The course of treatment should be for 16 to 20 sessions over 4 to 5 months.
When people with BN have not responded to or do not want CBT, other psychological treatments such as interpersonal psychotherapy should be offered but this takes 8 to 12 months to achieve results comparable to CBT.
As an alternative or additional first step to using evidence based self help programme, adults with BN may be offered an antidepressant drug. SSRIs (specifically fluoxetine) are the drugs of choice. The effective dose of fluoxetine is higher than that for depression (60mg daily).
The vast majority of people with BN can be treated as outpatients. There is a very limited role for inpatient treatment.
For people who are at risk of suicide or severe self harm, admission as an inpatient or the provision of more intensive outpatient care should be considered.
Other events that may precipitate an admission include a metabolic crisis secondary to electrolyte disturbance, renal failure, arrhythmia or oesophageal tears.
People with BN who have poor impulse control, especially those who have associated substance misuse may be less likely to respond to treatment.
EDNOS
Management of people with EDNOS is similar to that of people with AN or BN
Fluoxetine, other antidepressants and appetite suppressants may reduce binge eating episodes in people with binge eating disorder.
Amended June 2008
