Eating Disorders, including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) are serious disorders affecting 2-5% of the population, and are associated with high rates of medical as well as psychiatric morbidity. Notably, suicide is responsible for one in five deaths among individuals who die with AN (Smink 2012).
Treatments for eating disorders are complex, and often include a team of multi-disciplinary clinicians such as pediatricians or internists, psychiatrists, psychologists or other mental health professionals, and nutritionists. Effective treatments emphasize improved eating behaviors, and, for AN, include nutritional rehabilitation and weight restoration. Treatments may occur both in an inpatient and outpatient setting depending on the clinical presentation and illness severity.
Patients and clinicians alike are understandably interested in identifying effective treatments that use the least restrictive settings. Nevertheless, higher levels of care, including inpatient treatment, are sometimes necessary for the management of the serious medical and psychiatric manifestations of these complicated illnesses. Inpatient treatment is appropriate for more severely affected individuals with eating disorders, especially those in need of medical or nutritional stabilization or those who present with significant psychiatric co-morbidity. Hospital settings are used for individuals with eating disorders who require 24-hour attention for medical, psychiatric and behavioral disturbances associated with their illnesses. Most commonly, seriously underweight individuals with AN who demonstrate the medical features of starvation, including significant bradycardia, hypotension, or the metabolic disarray that may result from disordered eating behaviors are treated in a hospital. Most patients with BN and BED receive intensive treatment in less restrictive settings. However, when severe concurrent medical or psychiatric problems persist or patients fail to respond to outpatient treatment, even individuals with BN or BED may need inpatient care.
When practitioners consider whether inpatient treatment is indicated, a variety of factors should be taken into account, such as the patient’s weight, rate of recent weight loss, cardiac function, metabolic status, eating disorder behaviors, psychiatric co-morbidities, available social supports, and response to previous treatments. Should a patient require inpatient care, the hospital program should be expected to include the following elements: a multi-disciplinary team to offer close supervision; consistently applied policies and procedures aimed to manage eating and associated behaviors; careful medical monitoring; nutritional planning and re-feeding; individual, group and family treatment components; and post-hospitalization planning to help patients move significantly toward recovery. By having a full array of services and support, the program will be able to address the patient multi-faceted needs.
A Clinical Example
The Outlook at New York-Presbyterian Hospital/Westchester Division, part of The Center for Eating Disorders at Weill Cornell Medical College and Columbia University Medical Center, is a psychiatric inpatient unit specializing in eating disorders treatment. The program illustrates the elements of behavioral management that may be used to assist individuals with eating disorders. When first arriving at The Outlook, patients receive information about unit expectations and unit policies. Patients are asked to consume 100% of prescribed foods and supplements and, if diagnosed with AN, fully normalize weight. For individuals with binge eating or purging behaviors, goals for normal eating and post-eating practices are reviewed. Weight recommendations are discussed with patients. The unit is highly structured, with supervised meals and snacks, group-based therapeutic activities, and individual and family psychotherapy sessions.
Upon admission to The Outlook, patients receive a comprehensive medical and psychiatric evaluation. The patient’s height and weight are measured at the time of admission, and patients are weighed daily in order to observe trends in weight. Medical stabilization includes addressing any acute medical complications that may result from either the eating disorder itself (e.g. hypokalemia from vomiting) or from the initiation of treatment (i.e. re-feeding syndrome). Every day, the patient’s medical status is assessed, initially multiple times a day, until the patient’s status stabilizes.
The treatment for AN includes medical stabilization, weight gain and weight maintenance. The hospital setting is commonly used for the first of these phases and as much of the second phase as can be arranged. Ever shortening hospital stays have made it less common for patients to complete weight restoration on an inpatient unit. Weight maintenance and treatments focusing on preventing relapse following successful weight restoration are essential for ultimate treatment success but are generally conducted using outpatient settings.
The treatment for BN and BED includes structuring patients’ mealtime eating and interrupting patterns of vomiting and other compensatory behaviors. Patients with BN and BED whose illnesses are serious enough to require inpatient treatment may require medical stabilization for fluid or electrolyte imbalance, or may need medication adjustment, either for their significant eating disorder symptoms or for the mood and anxiety symptoms that commonly co-occur with BN and BED.
Patients with AN are initially provided with a daily diet of food in the form of three meals and one snack totaling 1800 kcal. All patients are supervised during and for one hour following each meal and snack. In addition, all patients are prescribed a multivitamin with therapeutic minerals, thiamine, and folic acid as a preventive measure given their malnourished state. Once patients are tolerating their initial diet without developing re-feeding syndrome, the diet is advanced in a stepwise fashion. Daily caloric prescription is increased by approximately 400 kcal/day every 48-72 hours using food to a maximum of 3000 kcal/day and nutritional supplement, generally to the level of 800 kcal/day, although additional increases may be necessary to achieve adequate weight gain. Patients with BN or BED are generally provided with a regular diet, as the unit’s nutritional plan targets normal eating, not weight change. All patients are expected to eat and drink 100% of the food and nutritional supplement prescribed. Meal and post-meal times are highly structured and supervised. Thirty minutes are allotted for each meal, and prescribed foods may not be saved or exchanged.
During the weight gain phase for individuals with AN, patients are expected to increase 1-2 kg/week. If the rate of weight gain is not adequate, additional doses of nutritional supplement may be added or the duration of close observation may be increased. In addition, unit privileges and activity level may be also adjusted if weight does not increase expectedly.
Therapeutic activities are informed by principles of cognitive behavioral therapy (CBT) and emphasize the expectation that additional treatment will be necessary following the hospital stay. For patients with anorexia nervosa, post-hospitalization treatments will likely include additional weight gain and weight maintenance goals. For patients with bulimia nervosa and binge eating disorder, post-hospitalization treatments will aim to maintain and enhance behavioral changes achieved during the hospital stay such as eating three meals daily and cessation of purging.
The unit’s behaviorally focused protocol provides structure and guidance to aid patients and providers through the challenges associated with achieving significant behavioral change for individuals with eating disorders, leading to improved eating, weight and general emotional health. The treatment relies on reinforcement of healthy changes and interruption of patterns of illness. (Attia 2009) Patients with eating disorders are commonly ambivalent about treatment and benefit from the support and clarity that accompany structured treatment programs. While not always possible, it is optimal to review the behavioral program with patients prior to admission, but even in the setting of prior review and agreement, patients may experience the plan as harsh or punitive and staff must be well versed in approaching questions and confrontations about program principles in a compassionate and clear manner. Finally, it is essential for staff to be mindful that clinical protocols are imperfect and may require adjustment in practice. Clinical treatment teams will need to decide together whether and how a protocol adjustment may be important for a particular patient.
In addition to the behavioral treatment and nutritional rehabilitation described above, individual and family psychoeducation and support are part of an intensive comprehensive treatment plan.
Several clinical challenges are commonly encountered in the delivery of inpatient treatment for eating disorders. Ambivalence regarding treatment goals and, relatedly, the management of persistent eating disordered behaviors, including restriction of dietary intake and post-meal purging may be difficult for staff to negotiate. Therapeutic sessions should include discussion of motivations for behavioral change with particular focus on the factors that contributed to decision to seek treatment. Clinical programs generally have policies and procedures to help patients resist engaging in behaviors of illness. For example, supervision during and following meals aims to support and redirect patients around urges to engage in symptoms. Peer supervision and frank clinical discussions with all team members may be helpful to maintain consistency and avoid undue rigidity around clinical management decisions.
Patients with particularly limited insight into their illness may require involuntary commitment for some or all of their eating disorders treatment. Physician-certified or court-ordered treatment poses challenges for patients and for specialized staff. Staff may find it useful to consider the medical urgency of the clinical presentation and the life-sustaining elements of the treatment in their treatment planning. Sometimes, patients describe a sense of relief or acceptance that accompanies intensive treatment because of the perception that they “have to” eat or “have no choice” about the treatment components. Further, a study of hospitalized patients with eating disorders found at 2-week follow up, that 41% of patients with AN and 50% of patients with BN who did not endorse the need for hospitalization at the time of their admission converted to believing they did need admission (Guarda 2007). The challenge to staff includes helping patients connect with their motivations for improvement, however limited they may be.
Intensive treatment for eating disorders is a potentially useful program of care for individuals struggling with weight and eating disorder behaviors who need more structured treatment than what traditional outpatient interventions provide. Offered across a range of settings, intensive treatment may be an effective way to manage the serious psychiatric and medical features that may be associated with AN, BN or BED.
Evelyn Attia, MD, is Director of the Center for Eating Disorders at New York-Presbyterian Hospital. Dr. Attia is Professor of Clinical Psychiatry, Columbia University College of Physicians & Surgeons, Weill Cornell Medical College.
Attia E, Walsh BT. Behavioral Management for Anorexia Nervosa. N Engl J Med. 2009 Jan 29;360(5):500-6.
Guarda AS, Pinto AM, Coughlin JW, Hussain S, Haug NA, Heinberg LJ. Perceived coercion and change in perceived need for admission in patients hospitalized for eating disorders.Am J Psychiatry. 2007 Jan;164(1):108-14.
Smink FR, van Hoeken D, Hoek HW., Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry Rep. 2012 Aug;14(4):406-14.