Managing Eating Disorders

Managing Eating Disorders

Guides eating disorder assessment with medical stability criteria, APA Practice Guidelines for Treatment of Eating Disorders, and level-of-care determination using APA and AACAP placement criteria.

Why This Skill Exists

Eating disorders have the highest mortality rate of any psychiatric illness, with anorexia nervosa carrying a standardized mortality ratio of 5.86 — six times the expected death rate. Medical complications including cardiac arrhythmias, electrolyte derangements, refeeding syndrome, and organ failure require coordinated psychiatric-medical management. The APA Practice Guidelines for the Treatment of Patients with Eating Disorders (Third Edition) establish evidence-based standards for assessment, medical stabilization, nutritional rehabilitation, psychotherapy, and pharmacotherapy.

Underrecognition remains a critical problem — average time from symptom onset to treatment is 5-7 years. Males, older adults, ethnic minorities, and individuals with atypical presentations (normal or higher weight) are systematically underdiagnosed. Level-of-care decisions must integrate psychiatric severity, medical instability, and nutritional status using validated criteria, not clinical impression alone.

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the suspected or confirmed eating disorder diagnosis? (anorexia nervosa restricting type, AN binge-purge type, bulimia nervosa, binge eating disorder, ARFID, other specified/unspecified) — default: assess at intake
2. What is the patient's current weight, height, and BMI? — default: obtain vital signs
3. What is the patient's weight history? (highest, lowest, premorbid) — default: obtain
4. Are there signs of medical instability? (bradycardia, orthostatic hypotension, electrolyte abnormalities, hypothermia) — default: assess immediately
5. What is the purging method and frequency, if applicable? (vomiting, laxatives, diuretics, exercise, insulin omission) — default: assess
6. Is the patient currently in treatment? If so, what level of care? — default: assess
7. Does the patient have co-occurring psychiatric conditions? (depression, anxiety, OCD, PTSD, SUD, personality disorder) — default: screen
8. Is the patient medically cleared or is medical clearance needed? — default: obtain labs and ECG

Documents to Request

• Complete metabolic panel (Na, K, Cl, CO2, BUN, Cr, glucose, Ca, Mg, Phos)
• CBC with differential
• Hepatic function panel
• Thyroid panel (TSH, free T4)
• ECG (12-lead)
• Vital signs including orthostatic blood pressure and heart rate
• Amylase and lipase (elevated amylase suggests purging)
• Urinalysis (specific gravity for hydration status, laxative screen)
• DEXA scan if amenorrhea >6 months or low BMI >6 months
• Prior treatment records including weight charts, meal plans, treatment summaries
• Nutritional assessment from registered dietitian
• Dental records if purging (enamel erosion documentation)

Step 1: Diagnostic Assessment

DSM-5-TR Eating Disorder Diagnoses

Anorexia Nervosa (F50.0x):

• Criterion A: Restriction of energy intake leading to significantly low body weight (BMI <18.5 in adults; in children, failure to make expected weight gain)
• Criterion B: Intense fear of gaining weight or persistent behavior interfering with weight gain
• Criterion C: Disturbance in body weight/shape experience, undue influence on self-evaluation, or persistent lack of recognition of seriousness
• Subtypes: Restricting (F50.01) vs. Binge-eating/purging (F50.02)
• Severity by BMI: Mild ≥17, Moderate 16-16.99, Severe 15-15.99, Extreme <15

Bulimia Nervosa (F50.2):

• Recurrent binge eating episodes (large amount in discrete period with sense of loss of control)
• Recurrent compensatory behaviors (vomiting, laxatives, diuretics, fasting, excessive exercise)
• Binge eating and compensatory behaviors occur at least once per week for 3 months
• Self-evaluation unduly influenced by body shape and weight
• Severity: Mild 1-3/week, Moderate 4-7, Severe 8-13, Extreme ≥14 compensatory episodes/week

Binge Eating Disorder (F50.81):

• Recurrent binge episodes (at least once/week for 3 months)
• Marked distress regarding binge eating
• Three or more of: eating rapidly, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty after
• NOT associated with regular compensatory behaviors

Avoidant/Restrictive Food Intake Disorder (ARFID, F50.82):

• Eating disturbance leading to persistent failure to meet nutritional/energy needs
• NOT better explained by lack of food, cultural practice, concurrent medical condition, or another mental disorder
• NOT associated with body image disturbance

Step 2: Medical Stability Assessment

Assess for medical emergencies requiring immediate stabilization:

Criteria for Medical Hospitalization (APA/AACAP):

• Heart rate <50 bpm (adults) or <40 bpm
• Blood pressure <90/60 mmHg
• Orthostatic changes: HR increase >20 bpm or BP drop >20/10 mmHg on standing
• Temperature <97.0°F (36.1°C)
• Potassium <3.2 mEq/L or other dangerous electrolyte abnormality
• Glucose <60 mg/dL
• BMI <15 (adults) or <75% median BMI (adolescents)
• Dehydration
• ECG abnormalities: prolonged QTc >450ms, arrhythmia, ST changes
• Acute medical complications of purging (Mallory-Weiss tear, esophageal rupture, aspiration)
• Syncope
• Seizures
• Organ failure markers

Refeeding Syndrome Risk Assessment: Refeeding syndrome is the most dangerous medical complication of nutritional rehabilitation and can be fatal. High-risk patients include:

• BMI <16 or weight loss >15% in 3-6 months
• Little or no nutritional intake for >10 days
• Low pre-feeding phosphate, potassium, or magnesium
• History of alcohol misuse, chemotherapy, or insulin use

Monitor: Phosphate, potassium, magnesium, calcium daily during first 7-10 days of refeeding. Start caloric intake conservatively (1,200-1,500 kcal/day in severe cases) and advance slowly with electrolyte supplementation.

Step 3: Level-of-Care Determination

Inpatient Medical: Medical instability meeting any criteria above. Primary focus: medical stabilization, electrolyte correction, cardiac monitoring, refeeding initiation.

Inpatient Psychiatric: Medically stable but: suicidal ideation with plan/intent, severe malnutrition requiring structured refeeding, failure of lower levels of care, inability to maintain nutritional intake in less structured settings, severe co-occurring psychiatric symptoms.

Residential Treatment: Medically stable, BMI typically ≥15, able to participate in programming, requires 24-hour structure for meals and symptom management, failure of PHP/IOP.

Partial Hospitalization (PHP): Medically stable, BMI typically >16, can be safe overnight, needs structured eating during the day (typically 3 meals + 2-3 snacks supervised).

Intensive Outpatient (IOP): Medically stable, weight restoration progressing, needs support but can manage most meals independently.

Outpatient: Medically stable, weight stable or progressing, can manage meals with minimal professional support, working on relapse prevention and body image issues.

Step 4: Treatment Interventions

Nutritional Rehabilitation:

• Target weight restoration of 1-2 lbs/week for inpatient, 0.5-1 lb/week for outpatient
• Registered dietitian to develop individualized meal plan
• Monitor weight (gown weight, after voiding, before meals — consistent conditions)
• Supervise meals and post-meal periods (minimum 30-60 minutes post-meal to prevent purging)
• Address refeeding syndrome risk with electrolyte monitoring and supplementation

Psychotherapy (Evidence-Based):

• Anorexia Nervosa Adults: CBT-E (Enhanced CBT), SSCM (Specialist Supportive Clinical Management), or psychodynamic therapy. No single therapy has strong evidence superiority for AN.
• Anorexia Nervosa Adolescents: FBT (Family-Based Treatment / Maudsley Approach) is the gold-standard first-line treatment
• Bulimia Nervosa: CBT-BN (first-line), IPT (interpersonal therapy) as alternative
• Binge Eating Disorder: CBT-BN adapted for BED, IPT, DBT

Pharmacotherapy:

• AN: No medication has FDA approval. SSRIs NOT effective for acute weight restoration. Consider fluoxetine for relapse prevention AFTER weight restoration.
• BN: Fluoxetine 60mg/day (only FDA-approved medication for BN). Topiramate off-label (caution: appetite suppression).
• BED: Lisdexamfetamine (Vyvanse) 50-70mg/day (FDA approved). Topiramate off-label. SSRIs may reduce binge frequency.
• Do NOT prescribe bupropion in patients with purging behaviors (seizure risk).

Step 5: Ongoing Monitoring and Relapse Prevention

• Weekly weight monitoring (outpatient), daily (inpatient/residential)
• Monthly labs (CMP, phosphate, magnesium) during active treatment
• ECG monitoring if cardiac symptoms, electrolyte abnormalities, or medication changes
• DEXA scan annually if amenorrhea persists or BMI <18.5
• Dental referral for patients with purging history
• Monitor for exercise compulsion (which may replace other compensatory behaviors)
• Develop relapse prevention plan identifying triggers, early warning signs, and intervention strategies
• Family involvement in treatment planning (essential for adolescents, strongly recommended for adults)

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the DSM-5-TR diagnosis documented with specific criteria met and severity specifier?
2. Is the medical stability assessment documented with all relevant vital signs and lab values?
3. Is the level-of-care recommendation supported by specific clinical criteria (not just clinical impression)?
4. Are evidence-based treatments selected for the specific diagnosis?
5. Is the refeeding risk assessment documented for patients requiring nutritional rehabilitation?

Quality Audit

• DSM-5-TR eating disorder diagnosis with severity specifier documented
• Weight, BMI, and weight history documented
• Vital signs including orthostatics obtained and documented
• Laboratory panel including electrolytes, CBC, and metabolic panel reviewed
• ECG obtained and interpreted
• Medical stability criteria assessed systematically
• Refeeding syndrome risk assessment completed
• Level-of-care determination documented with supporting criteria
• Purging behaviors assessed with specific method, frequency, and duration
• Co-occurring psychiatric diagnoses screened and documented
• Suicide risk assessment completed (elevated risk in AN)
• Evidence-based psychotherapy selected for specific diagnosis
• Medication decisions documented with rationale (including decision NOT to medicate in AN)
• Nutritional rehabilitation goals documented with target weight and rate
• Family involvement plan documented

Guidelines

1. Never prescribe bupropion to patients with active purging behaviors — seizure risk is significantly elevated and this is a contraindication per FDA labeling.
2. Always obtain orthostatic vital signs in eating disorder assessments — bradycardia and orthostatic hypotension are the most common indicators of medical instability.
3. Monitor phosphate levels during refeeding — hypophosphatemia is the hallmark of refeeding syndrome and can cause cardiac arrest, respiratory failure, and death if untreated.
4. Do not rely on BMI alone for severity assessment — patients with significant weight loss from a higher baseline may be medically unstable at a "normal" BMI (atypical anorexia nervosa).
5. For adolescents with anorexia nervosa, FBT (Family-Based Treatment) is the first-line intervention — individual therapy alone is less effective than family-based approaches in this population.
6. Screen all eating disorder patients for suicide risk — anorexia nervosa has one of the highest suicide rates of any psychiatric diagnosis, and completed suicide accounts for approximately 20% of AN deaths.
7. Involve a registered dietitian as part of the multidisciplinary team — medication management alone is insufficient for eating disorders.