Tag: Criteria for hospitalization

Cognitive-behavioral therapy (CBT)

 

Eating disorders: Treatment Eating disorders: Treatment  Eating

disorders, including anorexia, bulimia nervosa, and binge

disorder may be life-threatening because of general medical

complications and suicide, and are often difficult to treat. This

topic provides an summary of treatment in patients with eating

disorders. The epidemiology, pathogenesis, clinical features,

assessment, diagnosis, course of illness, and medical

complications of eating disorders are discussed separately, as is

that the refeeding syndrome in anorexia.

GENERAL PRINCIPLES

— Treatment setting for patients with eating disorders relies

upon the severity of illness still as underlying or concurrent

psychiatric issues. As an example, patients with eating disorders

may have serious medical complications and are at increased

risk for suicide still as non-suicidal self-injurious behavior and

will thus require psychiatric hospitalization or day treatment

programs. Interdisciplinary care

— Treatment of eating disorders

generally involves an interdisciplinary team with experience in

treating these disorders; the team includes a mental state

clinician, dietitian, and a general medical clinician. Mental health

clinician — The mental state clinician typically coordinates care

among the team members, and administers the individual,

group, and family psychotherapies that are the mainstays of

treatment. In general, psychotherapy focuses primarily upon

disorder cognitions and behaviors, and secondarily addresses

affective issues, relationships, and underlying issues which will

have initiated the disorder. additionally, clinicians like an expert

in eating disorders can even provide pharmacotherapy.

Psychotherapy and pharmacotherapy for anorexia and bulimia

nervosa are discussed elsewhere during this topic. Registered

dietitian

— Dietary and nutritional support staff direct nutritional

rehabilitation, discuss available dietary options and hotel plan

requirements with patients, and supply nutritional education

regarding changes in eating behaviors. The dietitian, with the

overall medical clinician, sets appropriate weight goals. General

medical clinician

— If the diagnosis of an disorder isn’t clear, the

overall medical clinician must rule out other nonpsychiatric

medical causes of weight loss, vomiting, or menstrual

irregularity. additionally, the clinician assesses patients for

medical complications and monitors immediate medical issues

 sign stability, electrolyte abnormalities, and hydration

status) still as long term issues  bone density, menstruation,

and growth issues in younger patients). For patients with

anorexia, it’s often necessary to test their weight and vital signs

on a weekly basis to confirm weight gain and medical stability.

The evaluation of patients with eating disorders for medical

complications is discussed separately, as is that the

management of those complications: TREATMENT Anorexia

nervosa

— The treatment of anorexia generally involves

nutritional rehabilitation and psychotherapy additionally,

patients should be monitored for medical complications of

anorexia still because the refeeding syndrome. The evaluation of

patients with anorexia for medical complications, the

management of those complications, and therefore the refeeding

syndrome are discussed separately. Nutritional rehabilitation

For patients with anorexia who are underweight, we propose

nutritional rehabilitation (including supervised meals and

proscribing binge eating and purging), as a part of first line

treatment to push weight gain. this is often in keeping with

practice guidelines from the American Psychiatric Association uk

National Institute for Clinical Excellence and therefore the

Academy for Eating Disorders Weight restoration can correct

many of the physiologic consequences of anorexia Expected

rates of controlled weight gain are generally 2 to three pounds

(0.9 to 1.4 kg) per week and 0.5 to 1 pound (0.2 to 0.5 kg) per

week for outpatients. Intake levels usually begin with 30 to 40

kcal/kg (1000 to 1600 kcal/day), and are progressively

advanced. Early within the refeeding process, patients may gain

weight rapidly due to fluid retention and a baseline low rate the

amount of required calories increases considerably with weight

gain. Hospitalization

— Patients with anorexia frequently resist

refeeding and will require inpatient treatment to push weight

gain. Criteria for hospitalization of patients with eating disorders

are discussed elsewhere during this topic The treatment team

should have experience refeeding patients, and will find order

sets and treatment protocols helpful. Nurses have to be sensitive

to disorder psychopathology, and at the identical time set limits

and enforce the treatment plan. Programs differ in their use of

food, oral liquid nutrition, or nasogastric tube feedings to

gradually increase caloric intake, and clinical guidelines may

help identify which patients require gavage Parenteral nutrition

is never indicated, except within the most challenging cases.

Weight gain is central to successful outcomes for anorexia An

observational study of twenty-two women with anorexia who

were hospitalized and followed for a mean of 29 months after

discharge found higher rates of rehospitalization and more

symptoms in patients who were discharged while underweight,

compared with patients who remained within the hospital until

that they had regained their normal weight (90 to 92 percent of

ideal body weight) As a result, a extended initial hospitalization

could also be cost-effective Refeeding syndrome — Although

weight gain is that the cornerstone of treatment for patients

with anorexia, serious and potentially fatal complications can

arise when refeeding is run too rapidly and/or aggressively The

refeeding syndrome is defined because the clinical complications

that occur as a results of fluid and electrolyte shifts during

nutritional rehabilitation of malnourished patients. One case

series reported an incidence of six percent in adolescents

hospitalized for treatment of anorexia The refeeding syndrome is

discussed separately. Psychotherapy

— Standard treatment of

anorexia includes psychotherapy. Although several therapies are

adapted or developed to treat the disorder, there’s no compelling

evidence that one therapy is clearly superior to the others. Thus,

the selection relies upon availability, patient age, patient

preference, and cost. the choices include:

Cognitive-behavioral therapy (CBT)

– CBT encourages patients to alter the dysfunctional

• cognitions (thoughts and beliefs about weight and shape)

and behavioral disturbances (eg, excessive food

• restriction) that perpetuate anorexia, and places less
• emphasis upon the factors that caused the disorder The
• efficacy and administration of CBT for anorexia are
• discussed separately. • Specialist supportive clinical
• management – This therapy combines features of clinical
• and supportive psychotherapy to deal with the core
• symptoms of anorexia (including low weight, restrictive
• eating, and inappropriate compensatory behaviors) by
• providing education and advice about the illness, eating,
• and weight; facilitating normal eating and weight gain;
• praising the patient’s progress; and exploring other life
• issues identifiedby patients • Motivational interviewing –
• Motivational interviewing is employed to motivate patients
• with anorexia to realize weight by eliciting both their
• reasons to try and do so, and their ambivalence about
• change The sessions explore how the illness affects the
• patient’s life, the pros and cons of the disorder, the worth
• and meaning of anorexia within the patient’s life, the
• patient’s goals, and therefore the discrepancy between the
• current state of functioning and desired future state. •
• group therapy – Family therapy can benefit adolescents
• with anorexia A specialized style of group therapy is
• family-based treatment (also called the Maudsley method),
• which is employed for adolescents and initially places
• parents to blame of creating decisions about appropriate
• eating and related behaviors, with the support of a family
• therapist As patients begin to boost, control over eating is
• transferred back to them, and other issues associated with
• family functioning are addressed. Pharmacotherapy —
• isn’t an initial or primary treatment for anorexia However,
• adjunctive pharmacotherapy is indicated for acutely ill
• patients who don’t gain weight despite initial treatment
• with nutritional rehabilitation and psychotherapy. the
• employment of medicines to treat anorexia is discussed
• separately. Investigational approaches — Deep brain
• stimulation (DBS) is an investigational procedure for
• anorexia which will possibly be beneficial and safe. in a
• very nine month, prospective observational study in six
• patients with severe and treatment refractory anorexia
• (mean duration of illness 18 years; history of general
• medical complications), electrodes were implanted
• into the subcallosal gyrus cinguli through burr holes
• employing a stereotactic frame, resonance imaging, and
• guidance A second procedure was performed to tunnel
• wires beneath the scalp and skin of the neck to attach the
• electrodes to a generator that controlled stimulation
• and was implanted subcutaneously within the chest.
• Weight gain occurred in three patients, and improvement
• mood and anxiety symptoms occurred in four
• patients.Adverse events include seizure, air embolus,
• intraoperative scare, and pain. Bulimia nervosa — Standard
• for bulimia nervosa includes nutritional rehabilitation,
• psychotherapy, and pharmacotherapy, furthermore as
• patients for medical complications Patients are typically
• treated as outpatients or in partial hospital programs, but
• hospitalization could also be necessary for suicidal ideation
• or behavior, or uncontrolled purging Medical complications
• are discussed separately Nutritional rehabilitation — For
• patients with bulimia nervosa, nutritional counseling is
• employed with other treatment modalities to regulate
• binge eating furthermore as inappropriate compensatory
• behavior like purging Psychotherapy — For patients with
• bulimia nervosa, cognitive-behavioral therapy (CBT) is
• superior to other psychotherapies. The indications,
• evidence of efficacy, and administration of CBT for bulimia
• nervosa are discussed separately. For patients with bulimia
• nervosa preferring initial treatment with CBT alone, there’s
• evidence that a decrease in binge eating and purging of a
• minimum of 70 percent by the sixth treatment visit
• predicts abstinence However, a less robust response
• suggests that the requirement for adjunctive
• pharmacotherapy should be considered. Pharmacotherapy
• — Pharmacotherapy combined with nutritional
• rehabilitation and psychotherapy is indicated for treatmentof bulimia nervosa, furthermore as comorbid anxiety and
• depressive disorders [ However, if nutritional
• rehabilitation and psychotherapy don’t seem to beavailable, pharmacotherapy alone is affordable, in
• conjunction with self help workbooks and academicmaterial for patients and relations to read. the employmentof medicines to treat bulimia nervosa is discussedseparately Binge disorder— The treatment of bingedisorder generally involves psychotherapy; however,pharmacotherapy could be a reasonable alternative. Foroverweight or obese patients with binge disorder,behavioral weight loss therapy could also be beneficialadditionally, patients should be monitored for medicalcomplications. Psychotherapy, pharmacotherapy,behavioral weight loss therapy, and medical complications are discussed separately.
• 

Criteria for hospitalization

— Stabilization of and recovery from eating disorders may

require hospitalization on a psychiatric, medical, or combined

ward, depending upon the age and medical status of the patient

and available resources. Although no randomized trials have

evaluated criteria for inpatient treatment of eating disorders,

expert consensus practice guidelines from the American

Psychiatric Association suggest hospitalization for adults,

adolescents, and kids who meet one or more of the subsequent

criteria • Medical instability (eg, bradycardia near 40 beats per

minute; pressure <80/50 mmHg; dehydration; or compromised

cardiac, hepatic, or renal functioning) • Weight <85 percent

normal weight, or rapid weight decline with food refusal despite

outpatient treatment or partial hospitalization • Suicidal ideation

with high lethality plan or suicide attempt • Poor motivation that

necessitates supervision with meals, or cooperation with

treatment that’s contingent upon a highly structured environment • Comorbid psychiatric conditions (eg, depressive,

substance use, or anxiety disorders) that need hospitalization

Practice guidelines from the Society for Adolescent Medicine

suggest hospitalization for adolescents with eating disorders

who meet one or more of the subsequent criteria

• Failure of outpatient or partial hospital treatment

• Acute food refusal

•Uncontrollable binging and purging

• Severe malnutrition (eg, rapid weight loss and/or weight at a medically concerning level)

• Dehydration

• Cardiac dysrhythmia

• Vital signs unstable

•Severe bradycardia (eg, pulse <50 beats per minute during the

or <45 at night)

• Hypotension (eg, pressure <90/50 mmHg)

•Hypothermia (eg, <96ºF)

• Orthostatic changes in pulse (>20

beats per minute) or pressure (>10 mmHg)

• Electrolyte disturbances (hypokalemia, hyponatremia, or

hypophosphatemia)

• Acute medical complication of malnutrition

eg, syncope, seizures, cardiac failure, or pancreatitis)

• Arrested growth and development

• Acute psychiatric emergencies (eg,

ideation or behavior, or acute psychosis)

• Comorbid diagnosis that interferes with the treatment of eating disorders (eg,

moderate to severe depression, obsessive compulsive disorder,

drug abuse, or family dysfunction) Additional information about

the factors for hospitalization to manage medical complications

of anorexia is discussed separately. Referral services within the

u. s. — it’s going to be difficult for patients with eating disorders

within the u. s. (and elsewhere) to access clinicians like an

expert in these illnesses. Several national organizations provide

referral services PREVENTION — Specific varieties of

interventions could prevent eating disorders. A meta-analysis of

44 heterogeneous controlled studies (9297 participants) found

that prevention programs had beneficial effects upon

•Knowledge of eating disorders

• Idealization of thinness

• Body dissatisfaction

• Dieting

• Negative affect (dysphoria) .

• Eating disorder psychopathology

• Body mass index The effects were

clinically small but statistically significant additionally, the effectiveness of prevention programs was greater for the subsequent varieties of interventions and participants:

•Selected programs that targeted high-risk participants (eg,

dissatisfaction with body shape or weight), in contrast to

universal programs that were offered to all or any available

participants

• Interactive programs that included exercises

focusing upon risk factors (eg, body dissatisfaction) for onset of

upset psychopathology, in contrast to didactic

(psychoeducational) programs

• Multisession programs, incontrast to single session interventions

• Females instead of males

• Age ≥15 years instead of younger participants Many

prevention programs are conducted in schools. a 1 year trial

randomly assigned 12 high schools (N = 356 girls, mean age 16

years) to education plus a program focused upon weight-related

problems or to education alone . Improvement in body image,

unhealthy weight control behaviors, and eating patterns were

greater with the adjunctive intervention. INFORMATION FOR

PATIENTS — UpToDate offers two varieties of patient education

materials, “The Basics” and “Beyond the fundamentals.” the

fundamentals patient education pieces are written in plain

language, at the 5 th to six th grade reading level, and that they

answer the four or five key questions a patient may need a

couple of given condition. These articles are best for patients

who need a general overview and preferring short, easy-to-read

materials. Beyond the fundamentals patient education pieces are

longer, more sophisticated, and more detailed. These articles are

written at the ten th to 12 th grade reading level and are best for

patients who want in-depth information and are comfortable

with some medical jargon. Here are the patient education

articles that are relevant to the current topic. We encourage you

to print or e-mail these topics to your patients. (You can even

locate patient education articles on a spread of subjects by

searching on “patient info” and also the keyword(s) of interest.

• Basics topics SUMMARY and proposals

• Specific upsets include

anorexia and bulimia nervosa also as eating disorder not

otherwise specified (eg, binge eating disorder).

• Patients with

eating disorders should be monitored for medical complications.

• Patients with eating disorders are best cared for by an

interdisciplinary team consisting of a mental state clinician,

dietitian, and general medical clinician.

• The treatment of

anorexia generally involves nutritional rehabilitation and

psychotherapy. Nutritional rehabilitation for patients with

anorexia includes prescribing and supervising meals, and

proscribing binge eating and purging; hospitalization is also

necessary for treatment resistant patients. Refeeding that’s too

rapid or aggressive can result in the possibly fatal refeeding

syndrome. Psychotherapy options for anorexia include group

psychotherapy, cognitive-behavioral therapy (CBT), specialist

supportive clinical management, and motivational interviewing.

additionally, adolescent patients may have the benefit of group

psychotherapy. Adjunctive pharmacotherapy is indicated for

acutely ill patients who don’t gain weight despite initial treatment with nutritional rehabilitation and psychotherapy.

•Standard treatment for bulimia nervosa includes nutritional rehabilitation, psychotherapy, and pharmacotherapy. Cognitive-

behavioral therapy is that the psychotherapy of choice.

• Thetreatment of binge upset generally involves psychotherapy;

however, pharmacotherapy could be a reasonable alternative.

For overweight or obese patients with binge upset, behavioral weight loss therapy is also beneficial.

• Stabilization of and recovery from eating disorders may require hospitalization on a

psychiatric, medical, or combined ward. Criteria for inpatient

treatment are based upon practice guidelines