Practice Parameter
Eating Disorders
JAACAP 2015
Aims
• Reviews evidence-based practices for evaluation and treatment of
eating disorders in children and adolescents
• Includes adult studies
• Specifically: anorexia nervosa (AN), bulimia nervosa (BN), bingeeating disorder (BED), and avoidant-restrictive food intake disorder
(ARFID)
• Not: feeding problems in infancy, pica, rumination, purging, obesity
Methods
• Pubmed, Cochrane, and PsycINFO keyword search 1985-2011
• Book chapters and their bibliographies
• Colleague-recommended source materials
• English-only
• 91 publications from search + 19 recent (2012-13) publications
Anorexia nervosa: presentation and course
• 2 subtypes: restricting type and binge-purge type
• As of DSM-5, amenorrhea is no longer required
• Level of severity (mild to extreme) based on age and gender norms
according to BMI %iles (usually < 10 %ile)
• In children and adolescents, self-report is unreliable due to lack of
insight and underdeveloped ability to verbalize abstract thoughts
• Need to focus on observed behaviors (often from parent report)
• Restricting type more common than binge-purge
• Death is most often secondary to complications of starvation (50%) or
suicide (50%)
Anorexia nervosa: epidemiology, etiology, and
risk factors
• In US, 0.3-0.7% prevalence in teenage girls, with increasing incidence
through 20th century
• Less certainty about prevalence among males
• Peak incidence ages 14-18
• 30-75% heritability (increases post-puberty)
• Temperament and personality risks: perfectionistic, cognitive rigidity
• Ballet, gymnastics, wrestling, modeling
• “Westernization:” increasing emphasis on a thin ideal has increased
rates of AN worldwide
Anorexia nervosa: DDx and comorbidity
• DDx: ARFID, chronic infection, thyroid disease, Addison’s disease, IBD,
connective tissue disorders, CF, PUD, celiac, other GI disease, DM,
malignancy
• 55.2% comorbidity with at least one other psychiatric illness
• Lots of overlap with OCD
• Anxiety disorders usually present before and persist longer
Bulimia nervosa: presentation and course
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•
•
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Severity based on frequency of compensatory behaviors
Often normal or high normal weight for age
Accompanied by internalizing problems (secrecy, shame, guilt)
M>F: overexercise and steroid use
Lack of control may be a better marker than amount of calories consumed
Again, rely on reported behaviors rather than self-report
Fluctuating course
5-10 years after treatment, 50% are symptom-free, 50% continue to exhibit
symptoms
Bulimia nervosa: epidemiology, etiology, and
risk factors
• Increasing in urban areas and in Westernizing countries
• 1-2% adolescent females and 0.5% adolescent males
• 1:10 to 1:3 male-to-female ratio
• BN rarely diagnoses in children and adolescents, but older patients pinpoint
adolescent onset
• 60-83% heritability
• Trauma, impulsive traits, perfectionism
• Wrestling, gymnastics, diving, and long-distance running
• Homosexuality > heterosexuality
Bulimia nervosa: DDx and comorbidity
• DDx: other eating disorders, MDD, CNS tumors, Kleine-Levin
syndrome, Kluber-Bucy syndrome, and GI pathologies
• 88% psychiatric comorbidity rate: mood disorders, anxiety, substance
use disorders, and personality disorders, suicidal ideation and
behaviors
Binge eating disorder
• Episodes need to occur at least once a week for at least 3 months
• Though in children and adolescents, a lower frequency threshold can be
considered, since younger patients may not have independent access to food
• May be the most common: 2.3% female adolescents and 2.6% males
• Typical onset in late adolescence or early adulthood
• DDx: night eating syndrome, nocturnal sleep-related eating disorder,
CNS tumors, Kleine-Levin syndrome, Kluver-Bucy syndrome, PraderWilli, and GI pathology
• Comorbidities: depression, anxiety, PTSD, impulse control disorders,
substance use disorders, and personality disorders
ARFID
• Presenting concerns include highly selective eating, neophobia (fear
of new things), sensory issues, fear of swallowing or choking, specific
fear-triggering events, and general lack of interest in eating or low
appetite
• Epidemiology unknown
• Risk factors: comorbid autism, anxiety, depression, neglect, abuse,
developmental delays
• DDx: AN
Other categories
• “Other specified feeding or eating disorders”
• Atypical AN, purging disorder, night eating syndrome
• “Unspecified feeding and eating disorder” when clinician does not
specify the reason the patient fails to meet criteria for a more specific
diagnosis
• Female triad syndrome:
• Low dietary energy availability, amenorrhea, and low bone density
Practice Parameter levels of evidence
• Clinical Standard (CS). Rigorous empirical evidence
• Clinical Guideline (CG). Strong empirical evidence (fewer metaanalyses and systematic reviews)
• Clinical Option (CO). Emerging evidence lacking strong evidence or
consensus
• Not Endorsed (NE). Known to be ineffective or contraindicated.
1: Screen everyone (CS)
• Preteens and adolescents should be asked about eating patterns and
body dissatisfaction, and growth should be monitored
• Screening instruments: EDE-Q, EDI, EAT, KEDS, ChEDE-Q, EDI-C, CHEAT
2: Positive screen -> further evaluation and
workup (CS)
• Diagnostic evaluation including diet history (registered dieticians may
be helpful) and other ED behaviors (weight and label checking),
metrics (percentage of weight loss, rate of weight loss), psychiatric
and medical comorbidities, and collateral information from caretakers
• Eating Disorder Examination: valid 12 years and up; child version
available
• EDE-Q: self-reported questionnaire, reliable in adolescents
• Labs: CBC, BMP, transaminases, TSH, Ca, Mg, Phos, protein, albumin,
ESR, amylase, B12, lipids, FSH, estradiol, pregnancy test
• Other workup: EKG, DEXA (with amenorrhea lasting >6 months, and
all males with rapid weight loss)
3: Treat severe medical complications (CS)
• Most reversible over time with adequate diet and restoration
• Possible exceptions: growth impairment, decreased bone density, structural
brain changes, infertility
• Admitted patients should be monitored for refeeding syndrome
• Look out for parotid swelling, dorsal hand callouses (Russell’s sign),
dental enamel erosion, fluid and electrolyte disturbances, orthostatic
hypotension and syncope, esophageal tears, gastric rupture
• Clinical need for NG feeding not substantiated
4: Inpatient programs should be considered only
when outpatient interventions have been
unsuccessful or are unavailable (CG)
• No evidence that hospitalization is more effective than outpatient
treatment
• No comparisons between residential and partial programs
• When clinical necessity for inpatient emerges, recommendations for
short length of stay, using lowest level of care, involvement of family
in programming, and using experienced staff
5: Involve a multidisciplinary team (CS)
• Psychotherapist, pediatrician, dietician, child psychiatrist (may be dual
therapist-med provider)
• Nutritional counseling is not recommended as a sole treatment
6: Outpatient psychosocial interventions are
first-line (CS)
• AN: Family-based therapy is superior to individual therapies, though
individual therapies can be offered and are effective when FBT is
unavailable
• BN: Limited studies show mixed results comparing CBT and FBT; FBT
again superior to individual therapies
• BED: adult studies demonstrate that CBT, IPT, and DBT are effective
• Too few studies in adolescents
• ARFID: no studies; still, start with behavior plans, CBT, and family
interventions
7: Reserve medications for comorbid
conditions and refractory cases (CG)
• AN: adult studies of pharmacotherapy (SSRIs, atypical antipsychotics)
have not been encouraging
• No adolescent studies
• BN: some promise for antidepressants (fluoxetine at higher doses) in
adults in reducing binge/purge urges
• CBT superior to meds
• Combination best in the case of BN + depression
• Starved patients have lower available serotonin; SSRI effectiveness is
limited
Table 1
Fin
Thank you!