13.3 Treatment for Eating Disorders

Early treatment is important for individuals with eating disorders because of increased risk for suicide, self-injury behaviors, and medical complications. People with eating disorders may also have other mental health disorders, such as depression, anxiety, personality disorders, or problems with substance use. There are a variety of treatments that have been shown to be effective in treating eating disorders. Generally, treatment is more effective before the disorder becomes chronic, but even people with long-standing eating disorders can recover.^[1]

Treatment plans are tailored to individual needs and may include one or more of the following:

• Individual, group, and/or family psychotherapy
• Medications
• Nutritional counseling
• Medical care and monitoring

Psychotherapy

Cognitive behavioral therapy (CBT) is a first-line treatment and is used to reduce or eliminate binge eating and purging behaviors. Individuals learn how to identify distorted or unhelpful thinking patterns and recognize and change inaccurate beliefs. Anorexia nervosa generally requires a longer duration of treatment than bulimia nervosa^[2]. Because mood and personality disorders are often comorbid with eating disorders, CBT may address these conditions as well.

Family-based therapy (FBT) is an outpatient treatment for anorexia nervosa for children and adolescents who are medically stable, and consists of three phases: (1) parents take charge of the process of nutritional rehabilitation and weight restoration with the help of the therapist; (2) control over eating is returned to the adolescent in an age appropriate fashion; (3) issues of psychosocial development in the absence of an eating disorder are addressed. FBT also aims to correct misperceptions and misattributions of blame for the patient’s illness. That is, neither the parents nor the adolescent is responsible for the eating disorder. Therefore, FBT takes a theoretically agnostic approach to the etiology of this disorder. This therapy has been found to be very effective in helping adolescents gain weight and improve eating habits and moods.^[3]

Medications

Evidence also suggests that medications such as antidepressants, antipsychotics, or mood stabilizers may be helpful for treating eating disorders and other co-occurring mental illnesses such as anxiety or depression. Fluoxetine (Prozac) is the only FDA approved medication for bulimia nervosa and binge eating disorder. If fluoxetine is not tolerated, other SSRIs may be used. However, bupropion is contraindicated in clients with bulimia because of increased risk of seizures.^[4]  Lisdexamfetamine (Vyvanse) has some value in the treatment of binge eating disorder.^[5]

Antidepressants have little role in the treatment of anorexia nervosa. Standard treatment for clients with anorexia nervosa includes nutritional rehabilitation and psychotherapy. Acutely ill patients who do not gain weight despite this standard treatment may be prescribed olanzapine, a second-generation antipsychotic, or antidepressants for concurrent depressive disorders. Nurses should keep in mind that low-weight clients are at increased risk for side effects. Additionally, medications such as antidepressants and antipsychotics can impact cardiac function. Bupropion (Wellbutrin) is contraindicated in clients with eating disorders because of increased risk for seizures, and tricyclic antidepressants should not be used because of their cardiotoxicity.^[6]

Nutritional Counseling

Nutritional counseling by a dietician with specialized training is necessary for individuals with eating disorders. The counseling should incorporate education about nutritional needs, as well as planning and monitoring healthy food choices.^[7]

Medical Care and Monitoring

Medical treatments for eating disorders can be delivered in a variety of settings. The following characteristics apply to the setting selected for an individual’s treatment^[8]:

• Intensive Outpatient: The patient is medically and psychiatrically stable and does not need daily medical monitoring. Symptoms are under sufficient control for the individual to be able to function in normal social, educational, or vocational situations and continue to make progress in recovery.
• Partial Hospitalization:
  • The patient is medically stable. The eating disorder impairs functioning but is without immediate risk. The patient requires daily assessment of physiologic and mental status.
  • The patient is psychiatrically stable but is unable to function in normal social, educational, or vocational situations. They engage in daily binge eating, purging, fasting, restricted food intake, or other pathogenic weight control techniques.
• Residential: The patient is medically stable and requires no intensive medical intervention. They are psychiatrically impaired and unable to respond to partial hospital or outpatient treatment.
• Inpatient:
  • The patient is medically unstable as determined by:
    • Unstable or depressed vital signs
    • Laboratory findings presenting acute health risk
    • Complications due to coexisting medical problems such as diabetes

• • The patient is psychiatrically unstable as determined by:
    • Rapidly worsening symptoms
    • Suicidal ideation with a plan and unable to contract for safety