Target Population

Target Population The CPG is focused on patients aged 8 years and older with the following diagnoses: AN, BN and eating disorders not otherwise specified (EDNOS). EDNOS include: binge-eating disorder (BED) and non-specific, incomplete or partial forms that do not satisfy all criteria for AN, BN and BED.

Although binge-eating disorder is the standard name, the truth is that several recurrent binge-eating episodes must take place to establish this diagnosis (amongst other manifestations). This guide refers to this disorder as binge-eating disorder.

The CPG also includes treatment of chronic eating disorder patients, refractory to treatment, who can be provided with tertiary prevention of the most serious symptoms and severe complications.

Comorbilidades

The most frequent comorbidities which may require a different type of care have been included in the CPG:

1. Mental: substance abuse, anxiety, obsessive-compulsive, personality, mood and impulse control disorders.
2. Organic: diabetes mellitus, obesity, malabsorbtion syndromes and thyroid diseases.

Special situations

The approach to be employed in special situations such as pregnancy and delivery is also included.

Clinical setting

The CPG includes management provided in PC and specialised care. PC services are performed in primary care centres (PCC), the first level of access to health care. Patients with eating disorders receive specialised care, the second and third levels of access to health care, by means of inpatient management resources (psychiatric and general hospital), specialised outpatient consultations (adult and child/adolescent mental health centres/units, day hospitals for day care (partial hospitalisation) (specialised in eating disorders and for other general mental health disorders), emergency services and medical services of general hospitals. In general hospitals there are specific units specialised in eating disorders that include the three care levels. Other types of specific units are included: borderline personality disorder and toxicology units.

Aspects included

The CPG includes the following aspects of eating disorders: prevention, detection, diagnosis, interventions at the different levels of care, treatment, assessment, prognosis and legal aspects.

Interventions

The CPG includes the following interventions for primary prevention of eating disorders: psychoeducational interventions, media literacy, social and political mobilization and activism (advocacy), dissonance-induction techniques, interventions focused on eliminating or reducing the risk factors of eating disorders or interventions to make the patient stronger (by developing stress coping skills).

Some of the outcome variables of primary prevention interventions are: incidence of eating disorders, BMI, internalisation of the thin-ideal, body dissatisfaction, anomalous diet, negative affects and eating disorders.

The CPG includes the following treatments:

1. Medical measures: oral nutritional support, nutritional support with artificial nutrition (enteral oral [nasogastric tube] and parenteral intravenous) and nutritional counselling (NC). NC includes dietary counselling, nutritional counselling and/or nutritional therapy.
2. Psychological therapies: cognitive-behavioural therapy (CBT), self-help (SH), guided self-help (GSH), interpersonal therapy (IPT), family therapy (systemic [SFT] or unspecified [FT]), psychodynamic therapy (PDT) and behavioural therapy (BT).
3. Pharmacological treatments: antidepressants, antipsychotics, appetite stimulants, opioid antagonists and other psychoactive drugs (topiramate, lithium and atomoxetine).
4. Combined interventions (psychological and pharmacological or more than one psychological intervention).

Clinically important treatment outcome variables according to the working group are: BMI, menstruation, pubertal development, reduction/elimination of binge-eating and purging, restoration of a healthy diet, absence of depression and psychosocial and interpersonal functioning. The latter two aspects are described in the questions regarding safety of interventions.

In some cases, recurrence or relapse results are described in the safety section, along with treatment withdrawls.

Aspects not included in the CPG

The CPG does not include the following diagnoses related with eating disorders for several reasons:

1. Orthorexia. A poorly defined and insufficiently studied syndromic spectrum that consists of extreme focus on eating healthy and contaminant-free foods. This disorder can be related to obsessive concerns about health, hypochondriac fears of diseases, and, in a certain way, to cultural attitudes linked to diet and food. Though it is true that people with orthorexia may present restrictive anomalies in their diets and ponderal losses, they cannot be considered atypical or incomplete cases of AN.
2. Vigorexia (muscle dysmorphia). This disorder is characterized by excessive concern about obtaining body perfection by performing specific exercises. This extreme preoccupation entails significant dissatisfaction with one’s own body image, excessive exercise, special diets and foods, to the point of generating dependence, as well as substance abuse³⁵. At the moment it remains a vaguely defined disorder related with obsessiveness, perfectionism and dysmorphophobia^36-40.
3. Night eating syndrome (nocturnal eaters). People with this disorder experience recurrent episodes of binge-eating during sleep. It is not defined whether these clinical pictures are due to an eating disorder or to a primary sleep disorder^41-44.

The CPG does not include patients under the age of 8 and, thus, diagnoses relating to eating disorders most common during those ages, such as swallowing phobia, selective eating and refusal to eat are not included. However, these disorders are not included either when they are observed in patients aged 8 and older for the following reasons:

1. Food phobia (simple phobias). In some cases it may be an anxiety-related disorder, while in others it may be linked to hypochondria (fear of choking, swallowing phobia and death). Therefore, it does not seem to belong to the spectrum of eating disorders.
2. Selective eating and refusal to eat. Both are eating disorders but lack the complete and characteristic symptomatology associated with AN and BN (cognitive disturbances, distorted body image, purging behaviours, etc).

This does not mean that when deciding on primary prevention policies no interventions should be carried out to address these behaviours, which could indeed be precursors of an eating disorder.

The CPG does not include exclusive interventions for comorbid conditions that may occur with eating disorders.

Objectives

Main objective

To provide health care professionals responsible for the management of patients with eating disorders with a tool that enables them to make the best decisions to address the problems their care entails.

Secondary objectives

1. a) To help patients with eating disorders by providing them with useful information that will aid them in making decisions concerning their disease.
2. b) ) To inform families and carer on eating disorders and provide them with counselling and advice so they become actively involved in treatment.
3. c) To implement and develop health care quality indicators that enable the assessment of the clinical practice of recommendations presented in this CPG.
4. d) To establish recommendations for research on eating disorders that enable knowledge to grow.
5. e) To address confidentiality and informed consent issues of patients, especially in the case of minors under the age of 18, and to include legal procedures in the cases of complete hospitalisation (inpatient care) and involuntary treatment.

Main users

This CPG is aimed at professionals who are in direct contact with patients with eating disorders or who make decisions regarding the care of these patients (family physicians, paediatricians, psychiatrists, psychologists, nurses, dieticians, endocrinologists, pharmacists, gynaecologists, internal medicine physicians, odontologists, occupational therapists and social workers). It is also aimed at professionals pertaining to other fields who are in direct contact with patients with eating disorders (education, social services, media, justice).

The CPG’s purpose is to serve as a tool for planning the integrated care of patients with eating disorders.

The CPG provides eating disorder patients with information that can also be used by family members and friends, as well as by the general population.