APA Releases New Practice Guideline on Evaluating and Managing Eating Disorders

The American Psychiatric Association (APA) has published a new practice guideline on the treatment of eating disorders, which appeared in the American Journal of Psychiatry.

According to the guideline authors, the goal of the guideline is to improve the care quality and treatment outcomes of patients with eating disorders with evidence-based statements on optimal management of these conditions.

The guideline committee rated the level of confidence for each statement based on a numeric scale of 1 (confidence that the potential benefits of the intervention outweigh potential harms) or 2 (suggestion; indicative of greater uncertainty). Additionally, the guideline uses an alphabetic rating system of A, B, and C to denote the relative strength of the evidence for each statement (high, moderate, and low, respectively).

Evaluating and Determining a Treatment Plan

During the initial assessment of a patient with a possible eating disorder, the APA recommends that clinicians first assess the patient’s (1C):

• Height and weight history;
• Presence of, as well as patterns and changes in restrictive eating, binge eating, or other related behaviors;
• Presence of, as well as patterns and changes in compensatory and weight control behaviors (ie, caloric restriction, compulsive exercise, purging behaviors);
• Percentage of time preoccupied with food as well as body shape and weight;
• Previous treatment for an eating disorder and associated treatment response;
• Psychosocial impairment secondary to eating or body image concerns or behaviors;
• A family history of eating disorders, other psychiatric conditions, and other medical conditions such as diabetes mellitus, inflammatory bowel disease, and obesity.

The guideline committee recommends weighing the patient as well as quantifying eating and weight control behaviors, including frequency and intensity, during the initial psychiatric evaluation (1C).

The APA recommends identifying any co-occurring health conditions or co-occurring psychiatric disorders during the initial psychiatric evaluation of a patient with a possible eating disorder (1C).

The guideline also recommends taking a comprehensive assessment of vital signs during the initial physical examination, including (1C):

• Temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure;
• Height, weight, and body mass index;
• Physical appearance (ie, signs of malnutrition or purging behaviors).

For the laboratory assessment, the APA recommends obtaining a complete blood count and a comprehensive metabolic panel that includes electrolytes, liver enzymes, and renal function tests (1C).

An electrocardiogram is recommended for patients with a restrictive eating disorder and severe purging behavior as well as for patients who are taking medications that prolong QTc intervals (1C).

Finally, the APA places emphasis on culturally appropriate and person-centered treatment plans comprising medical, psychiatric, psychological, and nutritional expertise, ideally through a coordinated multidisciplinary team (1C).

Anorexia Nervosa

The APA guideline recommends that individualized goals for weekly weight gain and target weight be set for patients with anorexia nervosa who require nutritional rehabilitation and weight restoration (1C).

For adults with anorexia nervosa, the guideline recommends the use of eating disorder-focused psychotherapy designed to normalize eating and weight maintenance behaviors, restore weight, and address psychological factors such as fear of weight gain and body dysmorphia (1B).

Eating disorder-focused family-based treatment is recommended for adolescents and emerging adults with anorexia nervosa. The APA states that the family-based approach should incorporate caregiver education focused on normalizing eating and weight maintenance behaviors as well as weight restoration (1B).

Bulimia Nervosa

In adults with bulimia nervosa, the APA guideline recommends that the initiating treatment comprise eating disorder-focused cognitive-behavioral therapy (CBT). Additionally, the guideline authors recommend prescribing a serotonin reuptake inhibitor, such as 60 mg fluoxetine daily, either at the start of treatment or if there is little to no response to psychotherapy alone by 6 weeks (1C).

Similar to anorexia nervosa, an eating disorder-focused family-based treatment is also recommended for adolescents and emerging adults with bulimia nervosa who have an involved caregiver (2C).

Binge-Eating Disorder

The APA recommends individual or group-based eating disorder-focused CBT or interpersonal therapy in the management of patients with binge-eating disorder (1C).

Antidepressant medication or lisdexamfetamine is suggested by the guideline for adult patients with binge-eating disorder who either prefer medication or who have not responded to psychotherapy alone (12).

Potential Limitations

Guideline authors noted that there is limited available research data on patients with eating disorders with considerable physical health conditions or co-occurring psychiatric conditions. In addition, the authors stated that many of the studies on eating disorders used for guideline development did not evaluate data separately for these subgroups of patients or excluded patients with comorbidities.

Despite these research gaps, the guideline committee wrote that “in the absence of more robust evidence, the statements in this guideline should generally be applicable to individuals with co-occurring conditions.”