Clinical Practice Guideline for Eating Disorders.

  1. Introduction
  2. Scope and Objectives
  3. Methodology
  4. Definition and Classification of Eating Disorders
  5. Prevention of Eating Disorders
  6. Detection of Eating Disorders
  7. Diagnosis of Eating Disorders
  8. Interventions at the Different Levels of Care in the Management of Eating Disorders
  9. Treatment of Eating Disorders
  10. Assessment of Eating Disorders
  11. Prognosis of Eating Disorders
  12. Legal Aspects Concerning Individuals with Eating Disorders in Spain
  13. Detection, Diagnosis and Treatment Strategies for Eating Disorders
  14. Dissemination and Implementation
  15. Recommendations for Future Research
  16. Annexes
  17. Bibliography
  18. Full list of tables and figures


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8. Interventions at the Different Levels of Care in the Management of Eating Disorders

Key Questions

8.1. What are the primary care (PC) and specialised care interventions for eating disorders? Other resources?

8.2. In eating disorders, what clinical criteria may be useful to assess referral amongst the health care resources available in the NHS?

8.3. In eating disorders, what clinical criteria may be useful to assess complete hospitalisation (inpatient care) in healthcare resources available in the NHS?

8.4. In eating disorders, what clinical criteria may be useful to assess discharge in health care resources available in the NHS?

8.1. What are the primary care (PC) and specialised care interventions for eating disorders? Other resources?

The management model proposed, in which patients are referred from one management resource to another, is bound by protocols, recommendations and guidelines elaborated with clinical criteria for which there is little evidence that guides decisions regarding where to perform the intervention (See question 8.2. in this chapter).

8.1.1. Primary Care (PC) interventions

Primary care is carried out in primary care centres, the first level of access to health care. At this level interventions are focused on:

  1. Identifying individuals at risk of developing an eating disorder (See chapter 6, “Detection”) and establishing an early diagnosis (See chapter 7, “Diagnosis”).
  2. Deciding whether the disorder can be treated in the primary care centre or whether it must be referred to specialised care. In order to make this decision, the patient’s type of eating disorder, age, level of risk, physical and psychological complications and preferences must be taken into account.
  3. Initiating nutritional treatment that includes the following objectives: restoring normal weight in the patient, correcting malnutrition, avoiding the refeeding syndrome, managing or curing medical complications, carrying out nutritional education with the objective of normalising altered dietary behaviour, both in the patient and in his/her family, and preventing and managing recurrences.

Initiating nutritional restoration by means of adequate renutrition or refeeding (See question 9.1. chapter 9, “Treatment”) and performing nutritional education (nutritional counselling) (See question 9.2. chapter 9, “Treatment”).

  1. Monitoring cases that are managed in primary care centres (in AN: the patient will be requested to record daily consumption, hyperactivity, laxative abuse and use of diuretics; he/she will be not be allowed to weigh him or herself and weight will be recorded weekly at the practice, results to which the patient will not have access; in BN: binge-eating episodes and self-induced vomiting, substance abuse and other behaviour disorders (impulse, etc.) will be recorded, as well as recurrence prevention.
  2. Conveying clear and true information regarding eating disorders to patients and relatives (See Annex 3.1.). Also detecting and correcting maladaptive ideas about weight and health (See Annex 2.9.).
  3. Carrying out interventions with affected families (See chapter 7, “Diagnosis”).
  4. Managing physical complications (See chapter 9, “Treatment”).

8.1.2. Specialised care interventions

Eating disorder patients are provided with specialised care, the second and third levels of access to health care, in the form of inpatient care resources (psychiatric and general hospital), specialised outpatient practices (mental health centres for adults and children), day hospitals for day care (centres specialised in eating disorders and general mental health centres), emergency services, medical services pertaining to general hospitals and specific units (for eating disorders, borderline personality disorder and toxicology).

  1. Assessment and diagnosis visits are performed at an outpatient level (CSMA and CSMIJ) after referral from PC. In the case of vital emergencies or autolytic risk that stand in the way of this assessment, the patient must be referred to internal medicine and psychiatry services and will be admitted if indicated by the physicians on-duty.
  2. The clinical history must update and complete what has been established in PC.
  3. After establishing a diagnosis, the mental health team will design an ITP which includes: a) definition of the problem based on the diagnosis and altered areas, b) formulation of psychotherapeutic objectives, c) election of treatment (psychological therapies, pharmacological treatments, medical measures and social interventions) (See the “treatment” section), and d) time-frame for therapeutic assessment. Following the therapeutic decision, the ITP will be presented to the patient and family, informing them on: a) health care professionals who will be involved in treatment, b) techniques that will be employed, c) duration, and d) time-frame for assessment.

The degree of nutritional deterioration, along with the presence or absence of complications, determine the selection of access and feeding route, as well as the location where nutritional follow-up must be performed.

The day care treatment programme includes meal monitoring, and patients must complete a survey on the foods they ingest in 24 hours, including on weekends when they are away from the centre. Each patient must be medically and nutritionally assessed at least once a week, weight and related medical symptoms must be monitored, requested blood work must be assessed if necessary, and the dietary survey and objectives must be reviewed. In inpatient care, nutritional support with artificial nutrition must be strictly monitored to avoid or manage the onset of the refeeding syndrome.

8.1.3. Other resources

Mutual help groups (MHG) are groups of people who meet voluntarily with the aim of helping each other. They are generally comprised of individuals who share the same problem or who find themselves in a similar difficult situation. The MHG emphasises personal interaction and each member’s capacity to assume responsibilities. It tends to provide emotional help and promote values that help members strengthen their own sense of self. These groups provide assistance and emotional support to families and patients, facilitating the success of the corresponding therapy. Groups are guided by facilitators (people who have experienced the same problem or situation as the participants) and are periodically aided by a professional who supervises the intervention and provides instruments to improve group dynamics (See Annex 3.2. Support associations for patients with eating disorders and their families).

Counselling consists of performing a series of personal interviews with patients and relatives to inform and educate on the disease and its main health, family and social consequences, as well as to provide guidance on the current situation of health care, legal, economic and social resources, with the objective of reassuring and assisting the patient and/or family.

Day centres are public sociosanitary resources that accommodate patients with different long-term disorders, including cases of chronic eating disorders and cases with psychiatric comorbidity. These centres provide, amongst other activities and interventions, rehabilitation (tertiary prevention). In our setting there are no public day centres aimed exclusively at patients with eating disorders.

Therapeutic apartments (assisted or not) constitute another public network resource that enables social reinsertion of patients suffering from different disorders. In our public network there are no apartments specifically for eating disorder patients.


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8.2. In eating disorders, what clinical criteria may be useful to assess referral amongst the health care resources available in the NHS?


8.2.1. Referral to mental health services

Criteria for referral from primary care to mental health services (CSMA and CSMIJ) are as follows:

  1. When there is an established diagnosis of eating disorder.
  2. Weight loss equal to or higher than 10%-25% of weight, without a cause to account for it.
  3. Presence of regular bulimic episodes, meaning over-eating and/or persistent purging behaviour (self-induced vomiting, laxative abuse and use of diuretics).
  4. Presence of associated psychopathological disturbances.
  5. Lack of disease awareness.
  6. If, despite following PC indications, weight and bulimic behaviour do not improve.

8.2.2. Referral to emergency hospitalisation

Criteria for referral from primary care to emergency hospitalisation (Emergency service of a general hospital) to receive emergency medical treatment are as follows:

  1. Weight loss >50% in the last 6 months (30% in the last 3 months).
  2. Consciousness disturbances.
  3. Convulsions.
  4. Dehydration.
  5. Severe liver or kidney disturbances.
  6. Pancreatitis.
  7. Decreased potassium <3 mEq/l or sodium (<130 o >145).
  8. Serious arrhythmia or conduction disorder.
  9. Bradycardia of <40 bpm.
  10. Other ECG disorders.
  11. Syncopes or hypotension with SBP <70 mm Hg.
  12. HDH: hematemesis, rectal bleeding.
  13. Acute gastric dilation.

8.2.3. Referral to emergency psychiatric assessment

Criteria for referral from primary care to emergency psychiatric assessment (at a hospital’s Psychiatry Service) are as follows:

  1. Absolute refusal to eat or drink.
  2. Depressive symptomatology, with autolytic risk.
  3. Significant self-injurious behaviour.

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8.3. In eating disorders, what clinical criteria may be useful to assess inpatient care (complete hospitalisation) in one of the health care resources available in the NHS?


8.3.1. Inpatient care (complete hospitalisation) criteria

  1. Biological state that entails a risk of serious complications (no food intake, especially liquids, BMI<16, ionic disturbances, repeated self-induced vomiting, laxative abuse and use of diuretics, hemametesis and rectal bleeding).
  2. There are significant depressive symptoms with autolytic risk.
  3. Serious self-injurious behaviour.

These are not absolute criteria and, depending on their intensity, day care may be indicated (partial hospitalisation).

There are other psychopathological disorders that prevent outpatient treatment:

  1. Due to the psychopathology presented, the patient is unable to follow guidelines in the outpatient programme: frequency of visits, limitation of physical activity, recommended diet, etc.
  2. The patient’s difficult behaviour at home, the existence of conflict in family relationships and/or family psychopathology are excessive and impossible to manage at an outpatient level.
  3. Weight evolution does not follow the rate indicated in the weight restoration programme.

In order to pursue complete hospitalisation, the judge’s authorisation is required. In the case of minors, it is advisable though not indispensable to have the parents’ authorisation as well as the judge’s, and in the case of over-age patients, to have judicial authorisation (see chapter 12, “Legal Aspects”).

Inpatient management (complete hospitalisation) can be carried out in a general hospital (or one specialised in eating disorders), the psychiatric hospital being the most recommended resource in special cases such as chronicity and severe mental disorders (delirium, repeated self-aggression, cognitive deterioration, etc.).

Specific eating disorder units are found in general hospitals and depend on the psychiatry service (although in some alienated cases they depend on the endocrinology service). Amongst other functions, they tackle especially resistant cases. These specific units are in contact with other hospital services such as Internal Medicine, Gynaecology, etc. and perform interventions on complications derived from eating disorders.

8.3.2. Criteria for admission to day patient care (day hospital)

  1. From the adult or children MHC. If the patient does not meet emergency medical care or emergency psychiatric admission criteria and does meet any of the following criteria:
  2. — The patient is unable due to the psychopathology presented to follow the guidelines in the outpatient programme: frequency of visits, limitation of physical activity, recommended diet, etc.
  3. — There are serious behavioural problems at home, conflicts in family relationships and/or family psychopathology that cannot be modified at an outpatient level.
  4. — Weight evolution does not follow the rate indicated in the outpatient programme for weight restoration.
  5. From complete hospitalisation (once discharge criteria have been fulfilled). If additional eating and behaviour management is necessary, but can be carried out on an outpatient basis. Also in those cases in which psychopathological intensity requires psychological treatment to modify the patient’s image, beliefs, assertiveness and other aspects related with eating disorders.

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8.4. In eating disorders, what clinical criteria may be useful to assess discharge from health care resources available in the NHS?


8.4.1. Criteria for discharge from inpatient care (complete hospitalisation)

  1. Normalisation of biological disturbances that have led to complete hospitalisation.
  2. Weight restoration as is established in an individualised programme.
  3. Improved psychopathological state.
  4. Elimination of self-injurious behaviour.
  5. Remission of abnormal eating behaviour and compensatory behaviour.
  6. Improved family conflicts.
  7. Improved general functioning.

8.4.2. Criteria for discharge from day patient care (day hospital)

In order to refer to outpatient care (adult or children MHCs):

  1. Weight restoration and/or maintenance as established in the ITP.
  2. Completion of group programmes that had been initiated.
  3. Improved eating pattern and compensatory behaviour (if any).
  4. Improved family conflicts and general functioning that enable outpatient treatment.

For hospital admission:

  1. Weight does not increase as is established in the weight restoration programme.
  2. Does not comply with rules established in the day hospital in terms of meals, physical activity restriction and general functioning.
  3. Presence of significant psychopathology.
  4. The patient’s biological state entails a risk of serious complications (heart rate less than 45, potassium less than 3.5 mEq/l, hemametesis and rectal bleeding).
  5. At any moment during the patient’s stay at the day hospital, referral to the Internal Medicine Service may be indicated.

8.4.3. Criteria for discharge from the outpatient treatment programme

Discharge criteria will depend on the ITP.

  1. Maintenance of non-altered eating behaviour (diets, over-eating and purging) throughout a period of one year.
  2. Maintenance of stable weight that is within normal values throughout a period of one year.
  3. Absence of menstrual irregularities secondary to eating disorders.
  4. Decreased recurrence risk.
  5. Absence of other psychopathological disturbances that require treatment.

8.4.4. Discharge criteria for eating disorders

The process will end when clinical improvement is evident and enables the patient to resume normal daily life, verifying that during a period of time greater than two years the following criteria are being fulfilled:

  1. Maintenance of weight and absence of nutritional imbalances.
  2. Absence of eating peculiarities that are harmful to health.
  3. Adequate relational life.
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Recommendations

D 8.1. Individuals with eating disorders should be treated in the appropriate care level based on clinical criteria: outpatient care, day care (day hospital) and inpatient care (general or psychiatric hospital).
D 8.2. Health care professionals without specialist experience in eating disorders or who are faced with uncertain situations should seek the advice of a trained specialist when emergency inpatient care is deemed the most appropriate option for a patient with an eating disorder.
D 8.3. The majority of patients with BN can be treated on an outpatient basis. Inpatient care is indicated when there is risk of suicide, self-inflicted injuries and serious physical complications.
D 8.4. Health care professionals should assess patients with eating disorders and osteoporosis and advise them to refrain from performing physical activities that may significantly increase the risk of fracture.
D 8.5. The paediatrician and the family physician must be in charge of the management of eating disorders in children and adolescents. Growth and development must be closely monitored.
D 8.6. Primary care centres should offer monitoring and management of physical complications to patients with chronic AN and repeated therapeutic failures who do not wish to be treated by mental health services.
D 8.7. Family members, especially siblings, should be included in the individualized treatment plan (ITP) of children and adolescents with eating disorders. The most common interventions involve sharing of information, advice on behavioural management of eating disorders and improving communication skills. The patient’s motivation to change should be promoted by means of family intervention.
D 8.8. Where inpatient care is required, it should be carried out within a reasonable distance to the patient’s home to enable the involvement of relatives and carers in treatment, to enable the patient to maintain social and occupational links and to prevent difficulties between care levels. This is particularly important in the treatment of children and adolescents
D 8.9. Patients with AN whose disorder has not improved with outpatient treatment must be referred to day patient treatment or inpatient treatment. For those who present a high risk of suicide or serious self-inflicted injuries, inpatient management is indicated.
D 8.10. Inpatient treatment should be considered for patients with AN whose disorder is associated with high or moderate risk due to common disease or physical complications of AN.
D 8.11. Patients with AN who require inpatient treatment should be admitted to a centre that ensures adequate re-nutrition, avoiding the re-feeding syndrome, with close physical monitoring (especially in the first few days), along with the appropriate psychological intervention.
D 8.12. The family physician and paediatrician should take charge of the assessment and initial intervention of patients with eating disorders who attend primary care.
D 8.13. When management is shared between primary and specialised care, there should be close collaboration between health care professionals, patients and relatives and carers.
8.14. Patients with confirmed diagnosis or clear suspicion of an eating disorder will be referred to different health care resources based on clinical and age criteria.
8.15. Referral to adult or children mental health centres (CSMA/CSMIJ) by the family physician or paediatrician should consist of integrated care with shared responsibilities.
8.16. Cases referred to adult or children mental health centres (CSMA/CSMIJ) still require different levels to work together and short- and mid-term monitoring of patients, to avoid complications, recurrences and the onset of emotional disorders, and to detect changes in the patient’s environment that could influence the disease.
8.17. The need to prescribe oestrogen treatment to prevent osteoporosis in girls and adolescents with AN should be carefully assessed, given that this medication can hide the presence of amenorrhoea.
8.18. In childhood, specific eating disorder treatment programmes designed for these ages will be required.

Latest update: January 2010

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