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.

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## 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)

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## 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

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## 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.

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## 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.

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## 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).

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## 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)

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## 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?

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## 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

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## 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.