Treatment of Patients With Eating Disorders

Publication Date: July 18, 2022
Last Updated: February 28, 2023

Key Points

Key Points

  • The goal of this guideline 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; American Psychiatric Association 2013).
  • We focus primarily on anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) rather than other feeding and eating disorders.
  • The lifetime prevalence of eating disorders in the United States is approximately 0.80% for AN, 0.28% for BN, and 0.85% for BED.
  • The lifetime burdens and psychosocial impairments associated with an eating disorder can be substantial because these illnesses typically have an onset in adolescence or early adulthood and can persist for decades.
  • Eating disorders are associated with increases in all-cause mortality and deaths due to suicide.
  • Morbidity and mortality among individuals with an eating disorder are heightened by the common co-occurrence of health conditions, such as diabetes, and other psychiatric disorders, particularly depression, anxiety, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and substance use disorders.
  • This guideline is intended to enhance the assessment and treatment of eating disorders, thereby reducing the mortality, morbidity, and significant psychosocial and health consequences of these important psychiatric conditions.

Assessment

Assessment

Screening for Presence of an Eating Disorder

Statement 1

APA recommends screening for the presence of an eating disorder as part of an initial psychiatric evaluation. (1, C)
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Table 2. Screening Questionnaires for Eating Disorders

(Instructions: circle "Y" for "yes" and "N" for "no")
SCOFF Questionnaire (Morgan et al. 1999)
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Y / N Do you make yourself Sick because you feel uncomfortably full?
Y / N Do you worry you have lost Control over how much you eat?
Y / N Have you recently lost >14 lbs (One stone) in a 3-month period?
Y / N Do you believe yourself to be Fat when others say you are too thin?
Y / N Would you say that Food dominates your life?
Y / N To assess for binge eating disorder, add: During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)?
Screen for Disordered Eating (Maguen et al. 2018)
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Y / N Do you often feel the desire to eat when you are emotionally upset or stressed?
Y / N Do you often feel that you can’t control what or how much you eat?
Y / N Do you sometimes make yourself throw up (vomit) to control your weight?
Y / N Are you often preoccupied with a desire to be thinner?
Y / N Do you believe yourself to be fat when others say you are too thin?
Eating Disorder Screen for Primary Care (Cotton et al. 2003)
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Y / N Are you satisfied with your eating patterns? Answering “no” to this question is classified as an abnormal response.
Y / N Do you ever eat in secret? Answering “yes” to this and all other questions is classified as an abnormal response.
Y / N Does your weight affect the way you feel about yourself?
Y / N Have any members of your family suffered with an eating disorder?
Y / N Do you make yourself sick because you feel uncomfortably full?

Initial Evaluation of Eating History

Statement 2

APA recommends that the initial evaluation of a patient with a possible eating disorder include assessment of:
  • the patient’s height and weight history (e.g., maximum and minimum weight, recent weight changes);
  • presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors (e.g., rumination, regurgitation, chewing and spitting);
  • patterns and changes in food repertoire (e.g., breadth of food variety, narrowing or elimination of food groups);
  • presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (e.g., laxative use, self-induced vomiting), and use of medication to manipulate weight;
  • percentage of time preoccupied with food, weight, and body shape;
  • prior treatment and response to treatment for an eating disorder;
  • psychosocial impairment secondary to eating or body image concerns or behaviors; and
  • family history of eating disorders, other psychiatric illnesses, and other medical conditions (e.g., obesity, inflammatory bowel disease, diabetes mellitus).
(1, C)
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Quantitative Measures

Statement 3

APA recommends that the initial psychiatric evaluation of a patient with a possible eating disorder include weighing the patient and quantifying eating and weight control behaviors (e.g., frequency, intensity, or time spent on dietary restriction, binge eating, purging, exercise, and other compensatory behaviors). (1, C)
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Identification of Co-Occurring Conditions

Statement 4

APA recommends that the initial psychiatric evaluation of a patient with a possible eating disorder identify co-occurring health conditions, including co-occurring psychiatric disorders. (1, C)
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Initial Review of Systems

Statement 5

APA recommends that the initial psychiatric evaluation of a patient with a possible eating disorder include a comprehensive review of systems. (1, C)
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Table 3. Signs and Symptoms of Eating Disorders - General1

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Related to nutritional restriction Related to purging
Low weight, cachexia
Fatigue
Weakness Weakness
Dehydration
Cold intolerance, low body temperature
Hot flashes, sweating
1 Symptoms are in regular font; signs are in italic font.

Table 3. Signs and Symptoms of Eating Disorders - Nervous System1

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Related to nutritional restriction Related to purging
Anxiety, depression, or irritability Anxiety, depression, or irritability
Apathy Apathy
Poor concentration Poor concentration
Headache Headache
Seizures (in severe cases) Seizures (in severe cases)
Paresthesia (due to electrolyte abnormalities)
Peripheral polyneuropathy (in severe cases)
1 Symptoms are in regular font; signs are in italic font.

Table 3. Signs and Symptoms of Eating Disorders - Oropharyngeal1

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Related to nutritional restriction Related to purging
Dysphagia
Dental enamel erosion and decay
Enlarged salivary glands
Pharyngeal pain
Palatal scratches, erythema, or petechiae
1 Symptoms are in regular font; signs are in italic font.

Table 3. Signs and Symptoms of Eating Disorders - Gastrointestinal1

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Related to nutritional restriction Related to purging
Abdominal discomfort Abdominal discomfort
Constipation Constipation
Diarrhea (due to laxative use)
Nausea
Early satiety
Abdominal distention, bloating Abdominal distention, bloating
Heartburn, gastroesophageal erosions or inflammation
Vomiting, possibly bloodstreaked
Rectal prolapse
1 Symptoms are in regular font; signs are in italic font.

Table 3. Signs and Symptoms of Eating Disorders - Cardiovascular1

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Related to nutritional restriction Related to purging
Dizziness, faintness, orthostatic hypotension Dizziness, faintness, orthostatic hypotension
Palpitations, arrhythmias Palpitations, arrhythmias
Bradycardia
Weak irregular pulse
Cold extremities, acrocyanosis
Chest pain
Dyspnea
1 Symptoms are in regular font; signs are in italic font.

Table 3. Signs and Symptoms of Eating Disorders - Reproductive/Endocrine1

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Related to nutritional restriction Related to purging
Slowing of growth (in children or adolescents) Slowing of growth (in children or adolescents)
Arrested development of secondary sex characteristics Arrested development of secondary sex characteristics
Low libido Low libido
Fertility problems
Oligomenorrhea Oligomenorrhea
Primary or secondary amenorrhea
1 Symptoms are in regular font; signs are in italic font.

Table 3. Signs and Symptoms of Eating Disorders - Musculoskeletal1

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Related to nutritional restriction Related to purging
Proximal muscle weakness, wasting, or atrophy
Muscle cramping
Bone pain2 Bone pain2
Stress fractures2 Stress fractures2
Slowed growth (relative to expected)2 Slowed growth (relative to expected)2
1 Symptoms are in regular font; signs are in italic font.
2 Risk of skeletal effects is in individuals with previous low weight and menstrual irregularity or amenorrhea.

Table 3. Signs and Symptoms of Eating Disorders - Dermatological1

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Related to nutritional restriction Related to purging
Dry, yellow skin
Change in hair including hair loss and dry and brittle hair
Lanugo
Scarring on dorsum of hand (Russell's sign)
Poor skin turgor Poor skin turgor
Pitting edema (with refeeding) Pitting edema
1 Symptoms are in regular font; signs are in italic font.

Initial Physical Examination

Statement 6

APA recommends that the initial physical examination of a patient with a possible eating disorder include assessment of vital signs, including temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure; height, weight, and body mass index (BMI) (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents); and physical appearance, including signs of malnutrition or purging behaviors. (1, C)
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Initial Laboratory Assessment

Statement 7

APA recommends that the laboratory assessment of a patient with a possible eating disorder include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests. (1, C)
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Initial Electrocardiogram

Statement 8

APA recommends that an electrocardiogram be done in patients with a restrictive eating disorder, patients with severe purging behavior, and patients who are taking medications that are known to prolong QTc intervals. (1, C)
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Table 4. Laboratory Abnormalities Related to Nutritional Restriction or Purging Behaviors

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Recommendation Organ system Test Related to nutritional restriction Related to purging
Recommended Cardiovascular ECG Bradycardia or arrhythmias, QTc prolongation Increased P-wave amplitude and duration, increased PR interval, widened QRS complex, QTc prolongation, ST depression, T-wave inversion or flattening, U waves, supraventricular or ventricular tachyarrhythmias
Recommended Metabolic Serum electrolytes Hypokalemia, hyponatremia, hypomagnesemia, hypophosphatemia (especially on refeeding) Hypokalemia, hyponatremia, hypochloremia, hypomagnesemia, hypophosphatemia, metabolic acidosis
Recommended Metabolic Lipid panel Hypercholesterolemia
Recommended Metabolic Serum glucose Low blood sugar
Recommended Gastrointestinal Liver function and associated tests Elevated liver function tests
Recommended Genitourinary Renal function tests Increased BUN, decreased GFR, decreased Cr because of low lean body mass (normal Cr may indicate azotemia), renal failure (rare) Increased BUN and Cr, renal failure (rare)
Based on history or exam Genitourinary Urinalysis Urinary specific gravity abnormalities Urinary specific gravity abnormalities, high pH
Based on history or exam Reproductive Serum gonadotropins and sex hormones Decreased serum estrogen or serum testosterone; prepubertal patterns of luteinizing hormone, follicle stimulating hormone secretion May be hypoestrogenemic if menstrual irregularities are present
Based on history or exam Skeletal Bone densitometry (DXA scan) Reduced BMD, osteopenia, or osteoporosis in individuals with previous low weight and menstrual irregularity or amenorrhea Reduced BMD, osteopenia or osteoporosis in individuals with previous low weight and menstrual irregularity or amenorrhea
Incidental Oropharyngeal Dental radiography Erosion of dental enamel

Treatment Plan, Including Level of Care

Statement 9
APA recommends that patients with an eating disorder have a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team. (1, C)
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Table 5. Considerations in Determining an Appropriate Level of Care

  • Factors that suggest significant medical instability, which may require hospitalization for acute medical stabilization, including need for monitoring, fluid management (including intravenous fluids), electrolyte replacement, or nutritional supplementation via nasogastric tube feeding (see Table 6)
  • Factors that suggest a need for inpatient psychiatric treatment (e.g., significant suicide risk, aggressive behaviors, impaired safety due to psychosis/self-harm, need for treatment over objection or involuntary treatment)
  • Co-occurring conditions (e.g., diabetes, substance use disorders) that would significantly affect treatment needs and require a higher level of care.
  • Lack of response or deterioration in patient’s condition in individuals receiving outpatient treatment
  • Extent to which the patient is able to decrease or stop eating disorder and weight control behaviors (e.g., dietary restriction, binge eating, purging, excessive exercise) without meal support or monitoring
  • Level of motivation to recover, including insight, cooperation with treatment, and willingness to engage in behavior change
  • Psychosocial context, including level of environmental and psychosocial stress and ability to access support systems
  • Extent to which a patient’s access to a level of care is influenced by logistical factors (e.g., geographical considerations; financial or insurance considerations; access to transportation or housing; school, work, or childcare needs)

Table 6. Factors Supporting Medical Hospitalization or Hospitalization on a Specialized Eating Disorder Unit

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Factor Adults Adolescents (12–19 years)
Heart rate <50 bpm <50 bpm
Orthostatic change in heart rate Sustained increase of >30 bpm Sustained increase of >40 bpm
Blood pressure <90/60 mmHg <90/45 mmHg
Orthostatic blood pressure >20 mmHg drop in sBP >20 mmHg drop in sBP
Glucose <60 mg/dL <60 mg/dL
Potassium Hypokalemia1 Hypokalemia1
Sodium Hyponatremia1 Hyponatremia1
Phosphate Hypophosphatemia1 Hypophosphatemia1
Magnesium Hypomagnesemia1 Hypomagnesemia1
Temperature <36° C (<96.8° F) <36° C (<96.8° F)
BMI <15 <75% of median BMI for age and sex
Rapidity of weight change >10% weight loss in 6 months or
>20% weight loss in 1 year
>10% weight loss in 6 months or
>20% weight loss in 1 year
Compensatory behaviors Occur frequently and have either caused serious physiological consequences or not responded to treatment at a lower level of care Occur frequently and have either caused serious physiological consequences or not responded to treatment at a lower level of care
ECG Prolonged QTc >450 or other significant ECG abnormalities Prolonged QTc >450 or other significant ECG abnormalities
Other conditions Acute medical complications of malnutrition (e.g., seizures, syncope, cardiac failure, pancreatitis) Acute medical complications of malnutrition (e.g., seizures, syncope, cardiac failure, pancreatitis), arrested growth and development
1 Reference ranges for potassium, sodium, phosphate, and magnesium and numerical thresholds for values that determine hypokalemia, hyponatremia, hypophosphatemia, and hypomagnesemia depend upon the clinical laboratory.

Table 7. Characteristics of Levels of Care - Unit Security and Patient Legal Status

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Level of care Unit security Patient legal status
Specialized pediatric/ medical inpatient eating disorders program Unlocked Voluntary or involuntary
General pediatric/ medical inpatient program Unlocked Voluntary
Specialized psychiatric inpatient eating disorders program Typically locked Voluntary or involuntary
General psychiatric inpatient program Typically locked Voluntary or involuntary
Residential program Unlocked Voluntary
Partial hospital Unlocked Voluntary
Intensive outpatient Unlocked Voluntary
Outpatient Unlocked Voluntary

Table 7. Characteristics of Levels of Care - Physician/Nursing On-Site and Medical Monitoring

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Level of care Physician on-site 24/7 Nursing on-site 24/7 Medical monitoring
Specialized pediatric/ medical inpatient eating disorders program On-site 24/7 On-site 24/7 Frequent
General pediatric/ medical inpatient program On-site 24/7 On-site 24/7 Frequent
Specialized psychiatric inpatient eating disorders program On-call or on-site 24/7 On-site 24/7 Frequent
General psychiatric inpatient program On-call or on-site 24/7 On-site 24/7 Frequent
Residential program On-call 24/7 Typically on-site 24/7 Limited
Partial hospital Typically not on-site full-time Typically not on-site full-time Limited
Intensive outpatient Not on-site full-time Typically not on-site Limited
Outpatient No No As indicated

Table 7. Characteristics of Levels of Care - Hours of Operation and Ability to Maintain Work/School

Having trouble viewing table?
Level of care Hours of operation Able to maintain work/school
Specialized pediatric/ medical inpatient eating disorders program 24/7 School, in some instances
General pediatric/ medical inpatient program 24/7 School, in some instances
Specialized psychiatric inpatient eating disorders program 24/7 School, in some instances
General psychiatric inpatient program 24/7 School, in some instances
Residential program 24/7 School, in some instances
Partial hospital Variable hours per day (5–12 hours) and days per week (5–7) School, in some instances
Intensive outpatient 3–4 hours per day,
3–7 days per week
Often
Outpatient 1–2 psychotherapy sessions per week with additional visits with other clinicians as indicated Yes

Table 7. Characteristics of Levels of Care - Nutritional Interventions

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Level of care Option for IV hydration Option for nasogastric tube feedings Meal supervision and support Nutritional management
Specialized pediatric/ medical inpatient eating disorders program Yes Yes All meals/day Yes
General pediatric/ medical inpatient program Yes Yes In some instances Consultation
Specialized psychiatric inpatient eating disorders program On some units On some units All meals/day Yes
General psychiatric inpatient program On some units On some units Not eating disorder-specific Consultation
Residential program No Typically not All meals/day Yes
Partial hospital No No 2–3 meals/day Yes
Intensive outpatient No No ~1 meal/day Variable
Outpatient No No Provided by family or care partners As indicated

Table 7. Characteristics of Levels of Care - Management Interventions

Having trouble viewing table?
Level of care Option for treatment over objection Medical management Psychiatric management Psychological management Multi-disciplinary team-based management
Specialized pediatric/ medical inpatient eating disorders program Yes Yes Yes Yes Yes
General pediatric/ medical inpatient program Yes Yes Consultation In some instances In some instances, not eating disorder specific
Specialized psychiatric inpatient eating disorders program Yes Consultation Yes Yes Yes
General psychiatric inpatient program Yes Consultation Not eating disorder specific On some units, not eating disorder specific Not eating disorder specific
Residential program No Limited consultation Yes Yes Yes
Partial hospital No Limited consultation Yes Yes Yes
Intensive outpatient No No Variable Yes Yes
Outpatient No Outpatient, as indicated As indicated Yes As indicated

Table 7. Characteristics of Levels of Care - Therapy Interventions

Having trouble viewing table?
Level of care Group-based therapies Individual psychotherapies Family psychotherapies Milieu therapy
Specialized pediatric/ medical inpatient eating disorders program Yes Yes Yes Yes
General pediatric/ medical inpatient program No Generally not available Generally not available No
Specialized psychiatric inpatient eating disorders program Yes Yes On some units Yes
General psychiatric inpatient program Not eating disorder specific Not eating disorder specific Not eating disorder specific Not eating disorder specific
Residential program Yes Yes Yes Yes
Partial hospital Yes Yes Yes Yes
Intensive outpatient Yes Yes Yes Yes
Outpatient As indicated Yes Yes No

Treatment

Treatment

ANOREXIA NERVOSA

Medical Stabilization, Nutritional Rehabilitation, and Weight Restoration

Statement 10
APA recommends that patients with anorexia nervosa who require nutritional rehabilitation and weight restoration have individualized goals set for weekly weight gain and target weight. (1, C)
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Psychotherapy in Adults

Statement 11
APA recommends that adults with anorexia nervosa be treated with an eating disorder-focused psychotherapy, which should include normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects of the disorder (e.g., fear of weight gain, body image disturbance). (1, B)
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Family-Based Treatment in Adolescents and Emerging Adults

Statement 12
APA recommends that adolescents and emerging adults with anorexia nervosa who have an involved caregiver be treated with eating disorder-focused family-based treatment, which should include caregiver education aimed at normalizing eating and weight control behaviors and restoring weight. (1, B)
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Table 8. Components of Psychotherapies for the Treatment of Anorexia Nervosa

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Component CBT-AN CBT-E FPT SSCM MANTRA ECHO AFT FBT
In-session weighing × × × × ×
Individualized case formulation × × × × × ×
Motivational phase of treatment × × × × × ×
Focus on interpersonal issues/emotional expression × × × × × × × (indirectly)
Monitoring of symptoms, including eating × × × × × × × ×
Examining association of symptoms/eating with cognitions × ×
Focus on building activities/passions to minimize overconcern with weight/body shape × × If raised
by patient
× ×
Use of an experimental mindset to change attitudes and behaviors × × × ×
Parent-facilitated meal supervision × ×

BULIMIA NERVOSA

Cognitive-Behavioral Therapy and Serotonin Reuptake Inhibitor Treatment for Adults

Statement 13
APA recommends that adults with bulimia nervosa be treated with eating disorder-focused cognitive-behavioral therapy and that a serotonin reuptake inhibitor (e.g., 60 mg fluoxetine daily) also be prescribed, either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment. (1, C)
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Family-Based Treatment in Adolescents and Emerging Adults

Statement 14
APA suggests that adolescents and emerging adults with bulimia nervosa who have an involved caregiver be treated with eating disorder-focused family-based treatment. (2, C)
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BINGE-EATING DISORDER

Psychotherapy

Statement 15
APA recommends that patients with binge-eating disorder be treated with eating disorder-focused cognitive-behavioral therapy or interpersonal therapy, in either individual or group formats. (1, C)
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Medications in Adults

Statement 16
APA suggests that adults with binge-eating disorder who prefer medication or have not responded to psychotherapy alone be treated with either an antidepressant medication or lisdexamfetamine. (2, C)
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Recommendation Grading

Abbreviations

  • ADHD: Attention-deficit/hyperactivity Disorder
  • AFT: Adolescent Focused Individual Therapy
  • AN: Anorexia Nervosa
  • APA: American Psychiatric Association
  • BED: Binge-eating Disorder
  • BMD: Bone Mineral Density
  • BMI: Body Mass Index
  • BN: Bulimia Nervosa
  • BUN: Blood Urea Nitrogen
  • CBT: Cognitive-behavioral Therapy
  • CBT-AN: Cognitive-behavioral Therapy For Anorexia Nervosa
  • CBT-E: Enhanced Cognitive-behavioral Therapy
  • Cr: Creatinine
  • DSM: Diagnostic And Statistical Manual Of Mental Disorders
  • DSM-5: Diagnostic And Statistical Manual Of Mental Disorders, 5th Edition
  • DXA: Dual Energy X-ray Absorptiometry
  • ECG: Electrocardiogram
  • ECHO: Experienced Carers Helping Others
  • FBT: Family-based Therapy/treatment
  • FPT: Focal Psychodynamic Psychotherapy
  • GFR: Glomerular Filtration Rate
  • MANTRA: Maudsley Model Of Anorexia Nervosa Treatment For Adults
  • OCD: Obsessive-compulsive Disorder
  • PTSD: Posttraumatic Stress Disorder
  • QTc: Corrected QT Interval
  • SD: Standard Deviation
  • SPT: Supportive Psychotherapy
  • SSCM: Specialist Supportive Clinical Management
  • SSRI: Selective Serotonin Reuptake Inhibitor
  • TAU: Treatment As Usual
  • bpm: Beats Per Minute
  • mmHg: Mm Mercury
  • sBP: Systolic Blood Pressure

Source Citation

American Psychiatric Association: Practice Guideline for the Treatment of Patients with Eating Disorders, Fourth Edition. Washington, DC, American Psychiatric Publishing 2023.

Disclaimer

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