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New APA Eating Disorder Guidelines Advise Patient-Centered Care
In early 2023, The American Psychiatric Association (APA) released a new guideline for treating patients with eating disorders (ED), approved by the APA Board of Trustees in April 2021. The last guideline for eating disorders was released in 2006.
The guideline’s goal, according to its authors, is “to improve the quality of care and treatment outcomes for patients with eating disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)” and “help clinicians enhance care for their patients by reviewing current evidence and providing evidence-based statements that are intended to increase knowledge, improve assessment, and optimize treatment of eating disorders.”
Guidelines were shaped by the diagnostic criteria for eating disorders as well as a systematic review of literature going through September 2021 and focuses on anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).
“Eating disorders often are unrecognized and untreated,” noted Catherine Crone, MD, chair of the guideline writing group and acting medical director of Inova Women's Behavioral Health Services, Virginia. “This guideline and supplementary resources are intended to serve as a practical tool for clinicians, to help with screening, diagnosis, and providing evidence-based treatment for eating disorders.”
The guidelines include evidence-based nutritional support, therapeutic interventions, and psychiatric medications.
The APA remarked that there is little information in the new guideline on avoidant/restrictive food intake disorder (ARFID) due to the unavailability of clinical trial data and the relative recency of the diagnosis. There is also limited information on comorbidities in patients with eating disorders, though the APA recommends, “in the absence of more robust evidence, the statements in this guideline should generally be applicable to individuals with co-occurring conditions.”
When initially assessing a patient for care, the APA recommends taking weight and family history, looking for signs of restrictive/binge eating or weight control behaviors, previous ED treatment, taking vitals, and determining how much food, eating, and body appearance affects daily life and social interactions.
“As a person’s eating disorder begins to take up less brain space, we want to see them begin to re-engage with other elements in their life, such as building relationships with friends and family,” noted Dr Nicole Garber, chief medical officer of Alsana, a treatment program and recovery community with locations in California, Alabama, and Missouri. “Their illness often keeps their focus on eating and body image, causing them to miss out on other important parts of life.”
The guideline then suggests doing patient evaluations such as lab tests and electrocardiograms and identifying existing comorbidities before formulating a person-centered treatment plan.
For patients with AN, the new guidelines recommend weekly target weight goals, eating disorder-focused psychotherapy, and family-focused treatment for younger patients.
Dr Garber emphasized that weight-focused goals are vital for patients who need nutritional rehabilitation. “This is because we know that other interventions don’t work when a patient is under-nourished. For example, patients don’t retain therapy concepts and medications are not effective. That being said, weight goals are just one of many that should be set during treatment,” Dr Garber noted. “We also want to set goals that focus on normalized and varied eating, changing food and body image thought patterns, reducing obsessional thoughts with more cognitive space to start to put in the work and effort into an individual’s true values, including body acceptance.”
For adults with BN, eating disorder-focused cognitive behavioral therapy (CBT) and the prescription of a serotonin reuptake inhibitor (SSRI) are recommended in the 2006 guideline. Family-focused treatment is also beneficial for younger patients.
Board members recommend individual or group-based CBT or interpersonal therapy for patients with BED as well as prescription of antidepressant medication who don’t respond to therapy alone.
