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Eating disorders - Management
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How should I manage someone with a confirmed eating disorder in primary care?
- Ensure there is a clear agreement between primary and secondary or tertiary care about the responsibility for monitoring someone with an eating disorder. Monitoring of general medical problems usually occurs in primary care.
- Advise people who are vomiting on the importance of regular dental review and dental hygiene, including avoiding brushing after vomiting, rinsing with a non-acidic mouthwash after vomiting, and reducing the acidity of the oral environment (for example by limiting acidic foods).
- Place an alert in the prescribing record of people with anorexia nervosa concerning the risk of adverse effects. Harmful effects of drugs, such as prolonged QT interval and cardiac dysrhythmias, are more likely in people who are malnourished with electrolyte abnormalities. Each drug prescribed to people with an eating disorder should be reviewed with this in mind.
- Monitor the level of risk to the person's mental and physical health as treatment progresses, because it may change – for example following weight change or at times of transition between services.
- If the person has enduring anorexia nervosa and is not under secondary care, review their physical and mental health at least annually in primary care.
- Manage complications depending on their type and severity. Some people will need admission to hospital, whereas others can be managed in primary care.
- For more information on managing the osteoporosis risk associated with amenorrhoea in primary care, see the CKS topic on Amenorrhoea.
- For information on what treatments may be offered in secondary care, see:
Basis for recommendation
This recommendation is based on a guideline commissioned by the National Institute for Health and Clinical Excellence (NICE), Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders [National Collaborating Centre for Mental Health, 2004; NICE, 2004].
When should I admit a person with a confirmed eating disorder to hospital?
- Consider admission to hospital if any of the following are present (discussion with a specialist may be necessary):
- Risk of suicide or severe self harm — this will require admission to an acute psychiatric ward, not a specialist eating disorders unit.
- Home environment impedes recovery.
- Severe deterioration — this may require admission to an acute medical ward.
- Very low body weight or rapid weight loss or no improvement with appropriate outpatient treatment — admission to an eating disorders unit may be most appropriate.
- Medical complications (for example pronounced oedema, severe electrolyte disturbance, hypoglycaemia, or severe intercurrent infection) — admission to an acute medical ward may be most appropriate.
- If considering compulsory admission (regardless of the person's age), consider seeking advice from an appropriate specialist.
- If a young person refuses treatment that is deemed essential, consideration should be given to the use of the Mental Health Act 1983 or the right of those with parental responsibility to override the young person's refusal.
- Discuss with a local specialist the most appropriate place to admit a person with life-threatening anorexia, as it is not always obvious and depends on local services and practice.
- An acute medical ward that specializes in endocrinology, gastroenterology, or diabetes may be preferable to an eating disorders unit or general psychiatric ward in certain circumstances.
- Admit children and adolescents to age-appropriate facilities (with the potential for separate child and adolescent services), which have the capacity to provide appropriate educational and related activities.
Basis for recommendation
What specialist treatments are recommended for anorexia nervosa?
- Most people with anorexia nervosa should be managed on an outpatient basis, with psychological treatment (with physical monitoring) provided by a healthcare professional competent to give it and to assess the physical risk associated with eating disorders. However, a substantial minority receive inpatient treatment.
- Therapies to be considered for the psychological treatment of anorexia nervosa include cognitive analytic therapy (CAT), cognitive behavioural therapy (CBT), interpersonal psychotherapy (IPT), focal psychodynamic therapy, and family interventions focused explicitly on eating disorders.
- Additional interventions which may be offered include:
- Dietary counselling (this should not be provided as the sole treatment for anorexia nervosa).
- Regular physical monitoring, and in some cases treatment with a multi-vitamin/multi-mineral supplement in oral form.
- Regular monitoring of height as well as weight (in children and adolescents with anorexia nervosa).
- Support in gradually reducing laxative use.
- Occasionally, admission is needed for re-feeding, although this itself can cause complications such as hypophosphataemia.
- Medication should not be used as the sole or primary treatment for anorexia nervosa.
Basis for recommendation
What specialist treatments are recommended for bulimia nervosa?
- Psychological treatments are usually offered first-line, for example:
- Evidence-based self-help programmes.
- Cognitive behavioural therapy (CBT) for bulimia nervosa.
- Interpersonal psychotherapy (although this takes longer to achieve results than CBT).
- For people with bulimia nervosa who have not responded to, or do not want, CBT — other psychological treatments should be considered.
- As an alternative or additional first step to using an evidence-based self-help programme, adults with bulimia nervosa may be offered a trial of an antidepressant. Selective serotonin reuptake inhibitors (specifically fluoxetine) are the only drugs recommended.
- Very few drugs are recommended for children and adolescents younger than 18 years of age; and they should not be initiated in primary care.
Basis for recommendation
This recommendation is based on a guideline commissioned by the National Institute for Health and Clinical Excellence (NICE), Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders [National Collaborating Centre for Mental Health, 2004; NICE, 2004].
What specialist treatments are recommended for atypical eating disorders?
- In the absence of evidence to guide the management of atypical eating disorders (also known as eating disorders not otherwise specified) other than binge eating disorder, treatment will be based on that for the eating problem that most closely resembles the person's eating disorder (for example treatment for bulimia nervosa in instances in which there is binge eating, and treatment for anorexia nervosa in instances in which weight is low).
Basis for recommendation
What specialist treatments are recommended for binge eating disorder?
- For people with binge eating disorder there is an apparently good short-term response to a range of psychological interventions including:
- Evidence-based self-help manuals.
- Cognitive behavioural therapy (CBT) for binge eating disorder.
- Other psychological treatments (interpersonal psychotherapy for binge eating disorder and modified dialectical behaviour therapy).
- As an alternative, or additional first step to using an evidence-based self-help programme, a trial of a selective serotonin reuptake inhibitor (SSRI) antidepressant may be given. The use of an SSRI can reduce binge eating, but the long-term effects are unknown.
Basis for recommendation
This recommendation is based on a guideline commissioned by the National Institute for Health and Clinical Excellence (NICE), Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders [National Collaborating Centre for Mental Health, 2004; NICE, 2004].
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