Clinical Practice Guideline for Eating Disorders.

Full Version

  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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13. Detection, diagnosis and treatment strategies for eating disorders

Algorithm 1. Detection of potential cases of eating disorders


Detección de potenciales casos de TCA


Algorithm 2. Intervention if there is suspicion of an eating disorder


Detección de potenciales casos de TCA

Algorithm 3. Treatment of AN


Tratamiento en la AN


Algorithm 4. Treatment of BN and BED


Tratamiento en la BN y TA

arriba Algorithm Notes

Algorithm 1. Detection of potential cases of eating disorders

  1. Visits of healthy children/adolescents and visits prior to participating in sports, for example, would be a good opportunity to carry out integrated prevention (primary) and screening of different disorders, including eating disorders.
  2. Screening instruments are useful for a quick, first assessment aimed at ruling out the existence of suspicious symptoms in the first phase of the two-phase screening process, in which individuals who obtain high scores are re-assessed to determine if they fulfil formal diagnostic criteria.
  3. Screening instruments are inefficient at establishing the diagnosis of an eating disorder.
  4. In order to identify potential cases of eating disorders, several different screening self-reported questionnaires have been designed that enable systematic assessment of eating behaviour.
  5. It is recommended to use questionnaires that have been adapted and validated in the pulation to detect cases (screening) of eating disorders. The following instruments are recommended (√ Good clinical practice). Recommendation 6.5.:
    • - Eating disorders in general: SCOFF (for individuals aged 11 years and over).
    • – AN: EAT-40, EAT-26 and ChEAT (the latter for individuals aged between 8 and 12 years).
    • – BN: BULIT, BULIT-R y BITE (the three for individuals aged 12-13 years and over).

Algorithm 1 abbreviations

PC = Primary Care
BITE = Bulimic Investigatory Test, Edinburgh
BULIT = Bulimia Test
BULIT-R = revised version of the
BULIT ChEAT = Children’s version of the EAT-26
EAT-40 = Eating Attitudes Test
EAT-26 = Abbreviated version of the EAT-40
SCOFF = Sick, Control, One, Fat, Food questionnaire
EDs = Eating Disorders


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Algorithm 2. Intervention if there is suspicion of an eating disorder

  1. If a person attends the primary care practice presenting symptoms of a suspected eating disorder, the clinician must assess whether he/she is in a borderline biological or mental situation after performing basic examinations and blood work.
  2. If the person seeking help is aware of the problem, the standard diagnostic procedure must be carried out, including anamnesis, physical and psychopathological examinations and complementary examinations (√ Good clinical practice). Recommendation 7.2.4.
  3. Although communication must always be established with the family, the health care practitioner must study the patient’s family environment and generate a climate of trust and confidentiality. When it is the family that seeks help, it becomes a key piece in the physician-patient relationship.
  4. It is recommended to follow the WHO’s (ICD-10) and the APA’s (DSM-IV or DSM-IV-TR) diagnostic criteria. (√ Good clinical practice). Recommendation 7.1.
  5. NC is provided with the aim of modifying what the patient eats, as well as maladaptive eating habits and attitudes. The advice given includes the description of a healthy diet, the benefits of maintaining a regular eating schedule, eating three meals a day, eating normal rations according to age, eating with the family, in a relaxed environment without distractions, without being the one to prepare the meal or staying in the kitchen and resting after meals, amongst others. Weight restoration requires a normocaloric and healthy diet except in cases where it is contraindicated due to the patient’s condition.
  6. Criteria for referral from PC to the hospital (emergency service of a general hospital) depend on whether the emergency is medical or psychiatric.

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

  1. – Weigh 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 or >145)
  8. – Serious arrhythmia or conduction disorder
  9. – Bradycardia <40 bpm
  10. – Other ECG disorders
  11. – Syncopes or hypotension with SBP <70 mmHg
  12. – HDH: hematemesis, rectal bleeding
  13. – Acute gastric dilation

Criteria for referral from PC to emergency psychiatric assessment (psychiatric service of a hospital) are as follows:

  1. – Absolute refusal to eat or drink.
    – Depressive symptomatology, with autolytic risk.
    – Significant self-inflicted injury behaviour.
  1. Criteria for referral from PC to adult or child/adolescent mental health centres/units are as follows:
    • – When there is an established diagnosis of eating disorder.
    • – Weight loss equal to or higher than 10%-25% of weight, without a justifiable cause.
    • – Presence of regular bulimic episodes, meaning binge-eating behaviour and/or persistent purging practices (self-induced vomiting, laxative abuse and use of diuretics).
    • – Presence of associated psychopathological disturbances.
    • – Lack of disease awareness.
    • – If neither weight nor bulimic behaviour improve after following PC guidelines.
  1. Complete hospitalisation (inpatient care) criteria:
    • – The biological state entails serious risk of complications (no consumption of food or liquids, BMI <16, ionic alterations, repeated self-induced vomiting, laxative abuse, use of diuretics, hematemesis and rectal bleeding).
    • – There are significant depressive symptoms and autolytic risk.
    • – Significant self-inflicted injury behaviour.

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

There are other psychopathological disorders that prevent outpatient treatment:

  1. – The patient is unable due to her psychopathological state to follow the guidelines of the outpatient treatment programme: frequency of visits, limitation of physical activity, recommended diet, etc.
  2. – The patient’s problematic behaviour at home, the existence of family conflicts and/or family psychopathology is excessive and impossible to manage on an outpatient basis.
  3. – Weight progress does not follow the rate established in the weight restoration programme.

If the patient refuses to undergo inpatient treatment, the parents’ and judge’s authorisation in the case of minors, and judicial authorisation in the case of over-age patients, will be required.

Inpatient treatment can be performed in a general hospital (or one specialised in eating disorders), the psychiatric hospital being the most recommended resource in special cases such as those involving chronicity and serious mental disorders (delirium, repeated self-aggression, cognitive deterioration, etc.)

  1. Day care admission criteria:
    • - From the adult or children’s mental health centre. If the patient does not meet emergency medical care or emergency inpatient treatment in a psychiatric hospital criteria and does fulfil one of the following criteria:
      • – The patient is unable due to her psychopathological state to follow the guidelines of the outpatient treatment programme: frequency of visits, limitation of physical activity, recommended diet, etc.
      • – There are serious behavioural problems in the patient’s home, family conflicts and/or family psychopathology that are not modified on an outpatient basis.
      • – Weight progress does not follow the rate established in the outpatient weight restoration programme.
    • – From inpatient care (complete hospitalisation) (once discharge criteria have been fulfilled). More control must be exercised on eating and diet and disordered behaviour and though it can also be performed on an outpatient basis, it is not indicated if there are serious behavioural problems in the patient’s home, family conflicts and/or history of family psychopathology that cannot be modified by outpatient management.

Algorithm 2 abbreviations

PC = Primary care
MHC = Mental health centre
NC=Nutritional counselling
DH = Day hospital
NC = Nutrional counselling
EDs = Eatind Disorders


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Algorithm 3. Treatment of AN

  1. It is recommended to follow the WHO’s (ICD-10) and the APA’s (DSM-IV or DSM-IV-TR) diagnostic criteria to establish the diagnosis of AN. (√ Good clinical practice). Recommendation 7.1.
  2. Nutritional or dietary counselling. This type of intervention aims mainly to modify what the patient eats, as well as maladaptive eating habits and attitudes, providing a model to follow (description of a healthy diet, the benefits of maintaining a regular eating schedule, eating three meals a day, eating normal rations according to age, eating with the family, in a relaxed environment without distractions, without being the one to prepare the meal or and resting after meals, amongst others.). A normocaloric and healthy diet is required for weight restoration, except in cases where it is contraindicated due to the patient’s condition.
  1. – In feeding guidelines for children and adolescents with anorexia nervosa, carers should be included in any dietary information, education and meal planning. (Grade D). Recommendation 9.GM.1.
  1. Renutrition
  1. - Performance of standard treatments to resolve the situation acknowledging individual needs, especially in the case of children and adolescents. (Grade D). Recommendation 9.GM.1.
  2. – A physical exploration and in some cases oral multivitamin and/or mineral supplements are recommended, both in outpatient and inpatient care, for patients with AN who are in the stage of body weight restoration. (Grade D). Recommendation 9.1.1.1.
  3. – Feeding against the will of the patient should be used as a last resort in the management of AN. It is an intervention that must be performed by experts in the management of eating disorders and related clinical complications. Legal requirements must be taken into account and complied with when deciding whether to feed a patient against his/her will. (Grade D). Recommendations 9.GM.2, 9.GM.3 and 9.GM.4.

Total parenteral nutrition should not be used in patients with AN unless the patient refuses nasogastric feeding and/or when there is gastrointestinal dysfunction. (Grade D). Recommendation 9.1.1.2.

  1. - Nutritional support for patients with eating disorders will be selected based on the patient’s degree of malnutrition and collaboration, and always with the psychiatrist’s approval. (√ Good clinical practice). Recommendation 9.GM.01.
  2. – Before initiating artificial nutrition the patient’s degree of collaboration must be assessed and an attempt must always be made to convince him/her of the benefits of natural feeding. (√ Good clinical practice). Recommendation 9.GM.02.
  3. – In day hospitals, nutritional support for low-weight patients, where an oral diet is insufficient, can be supplemented with artificial nutrition (oral enteral nutrition). To ensure its intake, it must be administered during the day hospital’s hours, providing supplementary energy ranging from 300 to 1,000 kcal/day. (√ Good clinical practice). Recommendation 9.GM.03.
  4. – Oral nutritional support in eating disorder inpatients is deemed adequate (favourable progress) when a ponderal gain greater than 0.5 kg per week is produced, with up to 1 kg increments being the usual during that period. Sometimes, when the patient with moderate malnutrition resists resuming normal feeding, the diet can be reduced by 500-700 kcal and be supplemented by complementary oral enteral nutrition in the same amount, which must be administered after meals and not instead of meals (√ Good clinical practice). Recommendation 9.GM.04.
  5. – In the case of severe malnutrition, extreme starvation, poor progress or lack of cooperation of the patient in terms of eating, artificial nutrition treatment is indicated. If possible, an oral diet with or without oral enteral nutrition is always the first step, followed by a 3 to 6 day period to assess the degree of collaboration and medical-nutritional evolution. (√ Good clinical practice). Recommendation 9.GM.05.
  6. – Regarding estimated energetic requirements, it is recommended that caloric needs at the beginning always be below the usual, that real weight, as opposed to ideal weight, is used to make the estimation and that in cases of severe malnutrition energetic requirements be 25 to 30 kcal/kg real weight or total kcal not higher than 1,000/day. (√ Good clinical practice). Recommendation 9.GM.06.
  1. Pharmacological interventions
    • – Pharmacological treatment is not recommended as the only primary treatment of AN. (Grade D). Recommendation 9.GPH.1.
    • – Caution should be exercised when prescribing pharmacological treatment for patients with AN who have associated comorbidities such as obsessive-compulsive disorder (OCD) or depression. (Grade D). Recommendation 9.GPH.2.
    • – If drugs with adverse cardiovascular effects are administered, ECG monitoring of patients should be carried out. All patients with AN must be warned of the side effects of pharmacological treatments. (Grade D). Recommendations 9.GPH.4 and 9. GPH.5.
  1. Psychological therapies

The objective of psychological treatment is to reduce risk, to encourage weight gain by means of a healthy diet, to reduce other symptoms related with eating disorders and to facilitate physical and psychological recovery. (Grade D). Recommendation 9.GP.3.

The psychological therapies that should be considered for AN are: CBT, SFT, IPT, PDT and BT. (Grade D). Recommendation 9.GP.1.

  1. – The duration of psychological treatment should be of at least 6 months when performed on an outpatient basis (with physical monitoring) and 12 months for individuals who have been under inpatient management. (Grade D). Recommendation 9.GP.5.
  2. – For patients with AN who have undergone outpatient psychological therapy but have not improved or have deteriorated, the indication of more intensive treatments (combined individual and family therapy, day or inpatient care) must be considered. (Grade D). Recommendation 9.GP.6.
  3. – Following hospital discharge, patients with AN should be offered outpatient care that includes monitoring of normal weight restoration and psychological intervention that focuses on eating behaviour, attitudes to weight and shape and the fear of social response regarding weight gain, along with regular physical and psychological follow-up. Follow-up duration must be of at least 12 months. (Grade D). Recommendation 9.GP.10.
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Algorithm 4. Treatment of BN and BED

  1. It is recommended to follow the WHO’s (ICD-10) and the APA’s (DSM-IV or DSM-IV-TR) diagnostic criteria to establish the diagnosis of BN and BED. (√ Good clinical practice). Recommendation 7.1.
  2. Nutritional counselling and dental hygiene advice

This type of intervention aims mainly to modify what the patient eats, as well as maladaptive eating habits and attitudes, providing a model to follow (healthy diet, maintenance of a fixed eating schedule, eating three meals a day, eating normal rations according to age, eating with the family in a relaxed environment without distractions, without being the one to prepare the meal and resting after eating).

In the case of laxative misuse, patients with BN must be advised on how to decrease and stop abuse. This process must be carried out gradually. Patients must also be informed that the use of laxatives does not decrease nutrient absorption. (Grade D). Recommendation 9.GM.8.

When electrolyte imbalance is detected, in most cases elimination of the behaviour that caused it is sufficient to correct the problem. In a small number of cases, oral administration of electrolytes whose plasmatic levels are insufficient is necessary to restore normal levels, except in cases involving gastrointestinal absorption. (Grade D). Recommendation 9.GM.7.

Patients who vomit habitually must have regular dental check-ups and be provided with dental hygiene advice. (Grade D). Recommendation 9.GM.9.

  1. Psychological therapies
  1. - CBT-BN is a specifically adapted form of CBT and it is recommended that 16 to 20 sessions are performed over 4 or 5 months of treatment. (Grade A). Recommendation 9.3.2.1.1.

Patients with BN who do not respond to or refuse to receive CBT treatment may be offered alternative psychological treatment. (Grade B). Recommendation 9.3.2.1.2.

Adolescents with BN can be treated with CBT adapted to their age, level of development, and, if appropriate, the family’s intervention can be incorporated. (Grade D). Recommendation 9.3.2.1.3.

Adult patients with BED can be offered a specifically adapted form of CBT. (Grade A). Recommendation 9.3.3.1.

  1. – A possible first step in the treatment of BED is to encourage patients to follow a SH programme (guided or not). (Grade B). Recommendation 9.GP.13.

Health care professionals can consider providing BED patients with SH programmes (guided or not) that may yield positive results. However, this treatment is only effective in a limited number of patients with BED (Grade B). Recommendation 9.GP.14.

  1. – If there is a lack of evidence to guide the care of patients with EDNOS or BED, health care professionals are recommended to follow the eating disorder treatment that most resembles the eating disorder the patient presents. (Grade D). Recommendation 9.GP.15.
  2. – IPT should be considered an alternative to CBT although patients should be informed that it requires 8 to 12 months to achieve results similar to those obtained with CBT. (Grade B). Recommendation 9.5.2.1.

IPT-BED can be offered to patients with persistent BED. (Grade B). Recommendation 9.5.3.1.

  1. Pharmacological interventions
  1. – In the treatment of BN pharmacological treatments other than antidepressants are not recommended (Grade B). Recommendation 9.9.2.1.2.

Patients should be informed that antidepressant treatment can reduce the frequency of binge-eating and purging but effects are not immediate. (Grade B) Recommendation 9.9.2.1.1.

The dose of fluoxetine used in patients with BN is greater than the dose used for treating depression (60 mg/day). (Grade D). Recommendation 9.9.2.1.3.

Amongst SSRI antidepressants, fluoxetine is the first-choice drug for treatment of BN, in terms of acceptability, tolerability and symptom reduction. (Grade D). Recommendation 9.9.2.1.4.

  1. – SSRI antidepressant treatment can be offered to a patient with BED, regardless of whether he/she follows a guided SH programme or not. (Grade B). Recommendation 9.9.3.1.1.

Patients must be informed that SSRI antidepressant treatment can reduce the frequency of binge-eating, but the duration of long-term effects is unknown. Antidepressant treatment may be beneficial for a small number of patients. (Grade B). Recommendation 9.9.3.1.2.

Figures and Tables

Algorithm 1. Detection of potential cases of eating disorders Abrir nueva ventana (pdf, 401 Kb.)

Algorithm 2. Intervention if there is suspicion of an eating disorder Abrir nueva ventana (pdf, 549 Kb.)

Algorithm 3. Treatment of AN Abrir nueva ventana (pdf, 570 Kb.)

Algorithm 4. Treatment of BN and BED Abrir nueva ventana (pdf, 581 Kb.)


Latest update: January 2010

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