Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders

Person-centred informed decision-making

Safe and empirically supported treatment options based on available research and expert consensus should be discussed with the individual and their family. These options should be centred wherever possible on an informed decision made with the person and (where appropriate) their family. For children and adolescents the decision balance will be age appropriate and will involve their parents or legally appointed guardian.

Involving family and significant others

Unless there are contraindications or the individual is opposed, family or significant others should be enlisted as partners in the assessment and treatment process. Given the considerable burden on family members it is important that the family is provided with appropriate support and information.

Recovery-oriented practice

Care for people with eating disorders should be provided within a framework that supports the values of recovery-oriented care (Australian Health Ministers Advisory Council, 2013). Recovery-oriented practice encapsulates mental health care that:

Least restrictive treatment context

Where possible, treatment should be offered in the setting that is least restrictive and best suited to the individual’s needs and preferences. Many people with eating disorders are difficult to engage as they are ambivalent, or fear giving up their eating disorder behaviours, or deny the illness or the seriousness of their symptoms. Offering options and control can help with therapeutic engagement. Legislation in both New Zealand and Australia allows for involuntary assessment or treatment if a person with anorexia nervosa has impaired decision-making capacity, and is unable or unwilling to consent to interventions required to preserve life. Although involuntary treatment may provide the opportunity to prevent fatal complications, the potential adverse effects on therapeutic alliance needs to be considered (Carney et al., 2007). The short-term weight gain response of involuntary patients with anorexia nervosa has been shown to be comparable to those admitted voluntarily (Watson et al., 2000). Many of those who are treated on an involuntary basis later agree that treatment was necessary and remain therapeutically engaged (Guarda et al., 2007; Tan et al., 2010; Watson et al., 2000).

Multidisciplinary approach

Expert consensus and clinical cohort studies (e.g. NICE, 2004b) support a multidisciplinary approach to ensure that the individual gets access to the combined medical, dietetic (Dietitians Association of Australia, 2012) and psychological interventions required to maximise the chances of a full recovery. Ideally, team members will have specialist knowledge, skills and experience in the area of eating disorders, and be situated in the same location or at least in places easily accessible for those being treated and their families. Although team members may have differing perspectives, a united approach in delivering treatment is critical. The general practitioner is often in the best position to be the key coordinating clinician, especially if the treating specialists are not co-located.

Stepped and seamless care

Ideally, a range of options including outpatient, intensive outpatient with meal support, day program, and inpatient treatment should be available. As many people will not be seen by a specialist service, specialists should build strong links with primary care, general hospital and community providers in order to facilitate access and smooth transitions of care between general practice, emergency departments, medical wards, mental health settings, private clinicians and specialist services (House et al., 2012).

A dimensional and culturally informed approach to diagnosis and treatment

Establishing the presence of the core syndrome of an eating disorder is crucial in terms of informing treatment, but significant symptom variability occurs within and between individual experiences of anorexia nervosa, bulimia nervosa and binge eating disorder and other eating disorders. A rigid approach to diagnosis should be avoided (Pike, 2013). Empirically supported definitions of severity are still in development (Maguire et al., 2008) and although physical measures (e.g. BMI and more specific indicators of malnutrition such as amenorrhoea, hypotension, bradycardia, hypothermia and neutropaenia) are commonly used as markers of severity, psychological symptoms and clinical history should also inform severity formulations (Maguire et al., 2012). Comparative studies (EBR III) highlight possible cultural and ethnic variability in the presentation of anorexia nervosa or other eating disorders (Soh et al., 2006). There are insufficient studies on gender differences to inform the need for major differences in assessment approaches or treatment delivery for males (Murray and Touyz, 2013).

Indigenous care

Clinicians must demonstrate the appropriate knowledge, skills, awareness, and attitudes (‘cultural competence’) when working with people with eating disorders from indigenous and other cultural backgrounds. Assessment and treatment of eating disorders in Aboriginal and Torres Strait Islander and Māori and Pacific peoples should ascribe to the broader principles of mental health care as recommended in the RANZCP online training guide (RANZCP, 2012).

Approaches to care of people of Aboriginal and Torres Strait Islander background should be informed by an understanding of their history and culture even though there is little written about specific approaches to treatment for those who suffer from an eating disorder. However, epidemiologic evidence indicates that Aboriginal and Torres Strait Islander people are no less likely, and may be more likely, to experience an eating disorder as non-indigenous Australians (Hay and Carriage, 2012). In particular, poor nutrition and health-related consequences such as Type II diabetes are well recognised problems in this population. The reasons for this are complex, but the loss of traditional values and practices in food choices and replacement with foods of less nutritional value may be part of a broader process of cultural dispossession combined with social disadvantage. In addition, Aboriginal and Torres Strait Islander adolescents do have body image concerns which appear to focus around a desired ‘muscular’ shape (Cinelli and O’Dea, 2009) and may be less concerned about being slim or losing weight (McCabe et al., 2005; Ricciardelli et al., 2004).

Epidemiological data are scarce in Māori and Pacific peoples, with older data suggesting a lifetime prevalence of 3.1% (0.7% anorexia nervosa; 2.4% bulimia nervosa) and 3.9% respectively (Baxter et al., 2006). However, there are high levels of obesity in both Māori and Pacific peoples compared with the New Zealand adult population overall (Ministry of Health, 2012a, 2012b). Thus, whilst the prevalence of binge eating disorder is unknown, because of an associated risk with obesity it is possible that Māori and Pacific peoples are at increased risk of binge eating disorder.

In New Zealand ‘cultural competence’ explicitly includes application of te Tiriti o Waitangi (the Treaty of Waitangi) principles of partnership, participation and protection. This may require different assessment practices, for example the presence of wider whānau (family) at consultations, styles of treatment engagement and the communication of treatment information. These competencies are further outlined by the Medical Council of New Zealand and the New Zealand Psychologists Board (MCNZ, 2006a, 2006b, 2010; NZPB, 2011). In every aspect, working with different cultural groups requires respect for different world views, values and meanings. Clinicians should seek cultural advice and leadership from cultural support staff/whānau advisers to maximise engagement and therapeutic alliance.

Setting priorities

Thorough assessment should lead to a working diagnosis or diagnoses, risk assessment and case formulation setting immediate treatment priorities. The case formulation should include preliminary hypotheses about predisposing, precipitating and maintaining factors, as well as noting the individual’s strengths and protective factors. Given the typically prolonged time between onset and presentation, and the diverse pathways into anorexia nervosa, early firm statements about causal factors pertaining to an individual should be avoided. It is generally agreed that treatment priorities should be set as follows: engagement, medical stabilisation, reversal of the cognitive effects of starvation, and provision of structured psychological treatment. These are discussed in more detail below.

Engagement

Engaging with the individual with anorexia nervosa and their family at the first appointment can be challenging as there is typically extreme anxiety at the prospect of increased nutrition and weight gain, which are essential for recovery. To enable therapeutic engagement it is crucial that the clinician take a non-judgemental, inclusive, empathetic and non-threatening stance. Although lacking level I empirical evidence, sensible practices for improving engagement have included psychoeducation, enlisting the support of the family (Treasure et al., 2007), motivational interviewing around what the individual themselves reports as important, and appealing to the ‘healthy’ part of the person (Nordbø et al., 2008; Vitousek et al., 1998).

Medical stabilisation

Admission to hospital is indicated if the person is at imminent risk of serious medical complications, or if outpatient treatment is not working (Beumont et al., 2003). Indicators of high medical risk requiring consideration for admission (see Table 3) include any one of the following: heart rate <40 bpm or tachycardia on standing due to cardiac deconditioning with >20 bpm increase in heart rate, blood pressure <90/60 mm Hg or with >20 mm Hg drop on standing, hypokalaemia, hypoglycaemia, hypophosphataemia, temperature <35.5°C, or BMI < 14 kg/m². It is important to note that patients can report feeling well even when the risk of cardiac arrest is high. Admission is also indicated if there is rapid weight loss, several days of no oral intake, supervision required for every meal, uncontrolled purging or exercise, or suicidality.

Ideally, whenever possible and practicable, people with anorexia nervosa requiring admission should be admitted to a specialist eating disorders unit. There is debate about rates of weight gain in inpatient settings with recommended rates ranging from 500–1,400g/week (NICE, 2004b; Yager et al., 2006). There is evidence that where weight gain is the key prioritised treatment goal, inpatient treatment is superior to less intense forms of treatment due to the faster weight gain in those settings (Hartmann et al., 2011). However, inpatient beds are unfortunately scarce and can be difficult to access. In such situations, another model that has been effective in managing acute problems is admission to general medical or psychiatric beds, with support provided to generalist clinicians by a specialist eating disorder consultation-liaison service (EDOS, 2011). Where patients are at very high medical risk (e.g. with BMI < 12 or significant medical complications), they will need to be admitted to a medical setting with input from psychiatry consultation-liaison services until medically stabilised, before being transferred to a psychiatric or eating disorders specialist unit for ongoing nutritional rehabilitation and psychiatric treatment. Discharge from hospital should only occur when the person is medically stabilised, has had enough nutrition to reverse any cognitive effects of starvation so that she or he can benefit from outpatient or day patient psychotherapy (often several weeks of nutrition are required to achieve this), has had trials of leave to demonstrate that she or he can eat outside hospital, and has a direct link in with appropriate outpatient monitoring, support and treatment (EDOS, 2011).

Following discharge to less intense treatment settings, there is insufficient evidence to point to the best means of maintaining weight (Hartmann et al., 2011). One small randomised control trial found a manualised cognitive behavioural therapy for anorexia nervosa (CBT-AN) was superior to nutritional counselling and usual care (all treatment including nutritional counselling delivered by psychologists) in preventing relapse (Pike et al., 2003). Nutritional counselling alone should not be the sole treatment for people with anorexia nervosa; a multidisciplinary approach is more supported (Dietitians Association Australia, 2003) and there is strong clinical consensus that continuity of treatment should be provided. For people with severe and enduring eating disorders, a more flexible and patient-centred approach may need to be taken when considering criteria for admission and discharge (see separate section on severe and enduring eating disorders in this clinical practice guideline).

Medical complications and their treatment

Table 4 lists the common medical complications and their management. If the medical complication is secondary to malnutrition, effective treatments must always include regular and adequate nutrition. It is important to ensure that prescribed nutrition is being consumed by the individual, either through supervision and support during mealtimes by staff in hospital or family/carers out of hospital; or if the person is well enough, through self-recording of oral intake discussed at outpatient treatment sessions. Similarly, if medical complications are due to purging or other behaviours, measures need to be taken to address these.

OPEN IN VIEWER

Table 4.

Physical and laboratory findings and their management.

System	Physical/lab findings	Action/investigation
Cardiac	• Bradycardia and/or hypotension and/or tachycardia and/or prolonged QT interval and/or arrhythmias a	• ECG• Cardiac monitoring• Cardiology consultation• Nutritional assessment/resuscitation• Re-hydration: preferential use of oral fluids because of risk of cardiac failure, note glucose based solutions may increase risk of refeeding syndrome
Core body temperature	• Hypothermia (may mask serious infection)	• Monitor; warm with external heat, nutrition
Endocrine	• Hypoglycaemia b • Poor metabolic control in co-existent Type I diabetes• Amenorrhoea• Secondary hyperaldosteronism c	• If in first week of refeeding, give thiamine; ensure adequate, steady carbohydrate supply and monitor blood glucose levels• Specialist management of diabetes• Nutritional restoration until menstruation returns g • Provision of very slow IV fluids
Fluid and electrolyte changes	• Hypokalaemia, hypochloraemia, metabolic alkalosis c • Hypophosphataemia (frequently emerges during refeeding)• Hypomagnesaemia c • Hyponatraemia	• Suspect purging, careful K+ replacement: best orally and correct alkalosis first, monitor closely• Phosphate Sandoz 500mg bd then recheck phosphate level, keep replacing until normal e • Replace magnesium• Suspect fluid loading, or over drinking as part of weight loss behaviours. 1.5 litre/day fluid restriction. Monitor in all patients
Haemato-logical	• Anaemia d • Neutropaenia	• Monitor in all patients. Consider iron level and stores of B12 and folate. Replace as necessary, f • Improve nutrition
Gastro-intestinal	• Severe acute pancreatitisc,i• Parotid and salivary gland hypertrophy c • Reduced gastric motility (and early satiety)• Mallory-Weiss tears, ruptures c • Oesophagitis• Constipation• Raised liver enzymes and low albumin	• Bowel rest, nasogastric suction and IV fluid replacement• Nil specific• Smaller but more frequent meals may be preferred• Urgent surgical referral• Consider proton pump inhibitor for severe symptoms – symptomatic relief for mild symptoms• Reassure, increase nutrition, stool softeners (do not use stimulant laxatives such as senna)• Monitor/improve nutrition
Skin/bone	• Osteopaenia, stress fractures• Brittle hair, hair loss, lanugo hair• Dorsal hand abrasions, facial purpura, conjunctival haemorrhage c	• Monitor bone density, nutritional restoration until menstruation returns, calcium h and Vitamin D, specialist referral• No specific treatment• No specific treatment
Dental	• Erosions and perimylolysis	• Dental referral

a

Cardiac arrhythmia is a common cause of death.

b

Hypoglycaemia in the first weeks is generally post prandial and occurs several hours after refeeding, hence some units preferentially use nasogastric feeding (Hart et al., 2011a).

c

Complications caused by purging behaviours as well as starvation (Bahia et al., 2012).

d

May be normocytic and normochronic, as characteristic of nutritional deficiency, but microcytic (iron-deficiency) is increasing as more people choose vegetarianism. Copper deficiency may also play a role.

e

For patients at risk of refeeding syndrome (e.g. first 7–10 days of inpatient refeeding) prophylactic phosphate is recommended.

f

Iron injections should not be given to the medically compromised patient as it is potentially hepatotoxic. Oral replacement is preferred.

g

Oral contraceptives are not effective in restoring bone health.

h

Phosphate required to prevent or treat refeeding syndrome should take precedence over calcium. Calcium should not be given at the same time as phosphate.

i

Mild acute pancreatitis is almost universal and not an indication for the proposed intervention.

Sources: Eating Disorders Outreach Service, Queensland (EDOS, 2011) Royal Australian and New Zealand College of Psychiatrists (RANZCP, 2004).

Refeeding syndrome

Refeeding syndrome is a serious and potentially fatal medical complication of aggressive refeeding of an individual who has been malnourished for a lengthy period. Refeeding syndrome is understood to be due to the switch from fasting gluconeogenesis to carbohydrate-induced insulin release triggering rapid intracellular uptake of potassium, phosphate and magnesium into cells to metabolise carbohydrates (Kohn et al., 2011). This, on top of already low body stores of such electrolytes due to starvation, can lead to rapid onset of hypophosphataemia, hypomagnesia and hypokalaemia. In addition, insulin-triggered rebound hypoglycaemia can occur, exacerbated by the fact that such patients have depleted glycogen stores. The risk factors for refeeding syndrome include the degree of malnutrition and adaptation to this state, the levels of serum minerals and electrolytes such as phosphate and potassium and the rate of provision of carbohydrate in relation to other nutrients (Gentile et al., 2010; Kohn et al., 2011; Mehler et al., 2010; O’Connor and Goldin, 2011; Ornstein et al., 2003).

There is a wide range of opinion as to ideal starting doses of nutrition for adults with anorexia nervosa, with often little evidence to support the varied opinions (Gaudiani et al., 2012; Katzman, 2012; Kohn et al., 2011). Traditionally, it has been thought that the risk of refeeding syndrome can be reduced by ‘starting low’ and ‘going slow’ with nutrition, and monitoring serum phosphate, potassium and magnesium daily for the first 1–2 weeks of refeeding, and replacing these electrolytes immediately if they fall below normal range (Beumont et al., 2003; NICE, 2004b; Yager et al., 2006).

All authors agree on the importance of regularly monitoring and replacing phosphate, potassium and magnesium. However, traditional recommendations for refeeding designed to prevent refeeding syndrome are now seen by many to be too conservative, and unnecessarily put the severely malnourished person at risk of ‘underfeeding syndrome’ and further medical deterioration. Findings from case series studies range from those reporting large numbers of adolescents being fed on relatively high initial rates of up to 8400kJ of low-carbohydrate continuous nasogastric feeds with supplemental phosphate without causing refeeding syndrome (Kohn et al., 2011; Whitelaw et al., 2010), to those of severely malnourished adults reporting that 45% of participants developed significant refeeding-induced hypophosphataemia with much lower mean initial refeeding doses of 4000kJ/day (Gaudiani et al., 2012). Thus, refeeding syndrome has been observed even with very low initial feeding doses, and initial dose has not been shown to be a predictor of refeeding hypophosphataemia or refeeding syndrome (Gaudiani et al., 2012; O’Connor and Goldin, 2011). It is unclear whether the recent literature supporting safe use of higher refeeding doses in adolescents (for more information, see the section in these guidelines on treating anorexia nervosa in children and adolescents) is applicable to adults who may have been more severely malnourished for much longer periods, theoretically putting them at higher risk of refeeding syndrome.

In light of the conflicting and inadequate literature, the CPG group recommend taking a ‘middle path’ with adults, commencing refeeding at 6000kJ/day. This should be increased by 2000kJ/day every 2–3 days until an adequate intake to meet the person’s needs for weight restoration is reached. This diet should be supplemented by phosphate at 500mg twice daily and thiamine at least 100mg daily for the first week, and thereafter as clinically indicated for people at high risk of refeeding syndrome (e.g. BMI <13). For people at high risk of refeeding syndrome, commencing with continuous nasogastric feeding with low-carbohydrate preparations (i.e. 40–50% of energy from carbohydrates) seems prudent to avoid triggering postprandial rebound hypoglycaemia due to insulin secretion in people with inadequate glycogen stores. The most important aspects of preventing refeeding syndrome are a heightened physician awareness of the syndrome, and regular monitoring of the person’s clinical status, including physical observations and biochemical monitoring, especially to guide phosphate prophylaxis or supplementation.

Refeeding protocols should, however, be individualised where necessary to minimise both the risk of refeeding syndrome and complications due to underfeeding, and involve the input of a dietician experienced in the treatment of eating disorders. Methods of nutritional provision include supervised meals, high energy high protein oral liquid supplements and nasogastric feeding. On very rare occasions where the above methods are unable to be utilised, parenteral nutrition may be indicated. The least intrusive and most normal method of nutrition that can be reliably provided should be used.

Monitoring progress and reviewing priorities

In assessing whether an individual’s nutritional heath has been adequately restored, weight is only an approximate indicator. Other indicators of normal physiological functioning should be considered, including normal blood glucose levels, reversal of hypotension and bradycardia, normal blood cell counts with bone marrow suppression reversed, return of menstruation and normal cognitive functioning.

Assessing psychological progress is more difficult given that many features of anorexia nervosa involve internalised symptoms and behavioural deficits. However, such assessment should include monitoring dietary intake, compensatory behaviours and body image disturbance and dissatisfaction. Absence of progress in treatment after reasonable trial periods should prompt a treatment review and consideration for changing interventions and/or increasing treatment intensity.

Specific treatments

Providing psychoeducation, support and building a therapeutic relationship are all crucial activities at all stages of treatment. The more intense structured psychological therapies should generally be initiated only after the individual is sufficiently stabilised and cognitively improved from the acute effects of starvation. It is important that the treatment plan is individualised and addresses any comorbid conditions.

Psychological treatment

Paradigm of management for severe and long-standing eating disorders

Adapted from approaches discussed by Strober et al. (2010), Williams et al. (2010), and Wonderlich et al. (2012).

It is important to collaboratively agree and articulate goals with the patient and (where appropriate) significant others, so as to create an environment of support and comfort. The individual is best served by a safe and secure treatment strategy that allows them to feel contained but yet allows for very gradual change. Elements of this framework include the following:

Hospitalisation and partial hospitalisation

Many people with long-standing disorders have multiple previous negative experiences of inpatient care (La Puma et al., 2009). Hospitalisation should be in order to achieve realistic, collaboratively agreed goals of care or for achievement of medical rescue based on achieving well defined medical parameters such as systolic BP above 90mmHg, pulse rate above 50 bpm, normal white cell count or albumin, etc. General inpatient psychiatric hospitals tend to be ill suited for this type of patient. Refeeding, if required, should be undertaken by a medical team with both the knowledge and experience of treating such patients (George et al., 2004). George et al. have reported a pilot day hospital program designed specifically for those with severe and enduring anorexia nervosa. Such programs that cater specifically for the needs of people with severe and enduring symptomatology are not only able to retain them in longer-term treatment but result in clinically significant changes, for example unexpected but encouraging requests to be transferred to a traditional day program as greater changes in weight and lifestyle are desired.

Countertransference

Treating someone with severe and enduring anorexia nervosa is an entirely different experience to more conventional treatment and the work can be long-term and not immediately rewarding. However, clinicians who work with people who have long-standing eating disorders consistently report in the literature the importance of never giving up hope or expectation of improvement (Theander, 1985).

In the view of the authors of this CPG, no therapist should ever be placed in a position to take on people who have long-standing eating disorders unless there is a clear will to want to do so, as this often turns into a formidable task with the therapist’s patience, anxieties and energies challenged, especially when the individual may be close to death. Outpatient teams usually comprise a psychiatrist and/or clinical psychologist, physician and dietitian. It is an absolute imperative that there is regular communication amongst team members and any medical and/or non-medical decisions are negotiated carefully with the individual. Therapists are reminded that the words of Tom Main in ‘The ailment’ (1957) remain relevant today: ‘The sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment’ (Main, 1957: 9).

Psychological therapies

First-line treatment for bulimia nervosa and binge eating disorder in adults is an individual psychological therapy. The best evidence for such therapy is for CBT. CBT has been found to be superior consistently to wait-list control and most other psychological therapies for bulimia nervosa (NICE, 2004b). The evidence is weaker due to fewer trials in binge eating disorder where behavioural weight loss management is also effective in the short (Hay, 2013b; Hay et al., 2009) but not longer-term (Wilson et al., 2010).

A specific transdiagnostic enhanced therapy (CBT-E) developed by Fairburn (Fairburn, 2008) has been found more efficacious than other psychological approaches (Fairburn et al., 2009), although the specificity of CBT-E requires more evidence (Spielmans et al., 2013). As CBT-E is a well delineated and manualised form of CBT it is described here in detail. However, in accordance with evidence based practice, clinicians may apply variations of CBT and/or use other evidence based psychological therapies according to their expertise and individual preference. CBT/CBT-E has four well defined stages over 20 weeks. It begins with psychoeducation and a CBT informed formulation of the processes maintaining the person’s disorder, and uses it to identify problems to be targeted in therapy. This is followed by the introduction of monitoring of key behaviours, establishment of regular meals and snacks, and within session weighing (sessions 1–7 over one month). The second stage (sessions 8 and 9, weeks 5 and 6) is a ‘taking stock’, or reflection and review phase with revisiting and modification of the formulation as appropriate. The third stage (sessions 10–17, weeks 7–14) is a personalised program where the main mechanisms maintaining the eating disorder are addressed. This includes the utilisation of behavioural experiments to reduce problematic behaviours, particularly those associated with weight/shape overvaluation such as body checking, and an additional module addressing a core maintaining factor, namely mood intolerance. Stage 4 (sessions 18–20, weeks 15–20) looks to the future, ensuring improvements are maintained and includes relapse prevention. A broad version (CBT-Eb) has been developed to address additional core maintaining factors with three optional modules addressing interpersonal deficits, clinical perfectionism and low self-esteem if applicable. CBT-Eb has been found to have an advantage over the original ‘focused’ CBT-Ef for people with comorbid personality disorder or other complex psychopathology (Fairburn et al., 2009).

Self-help and scalability of CBT

Where access to a therapist is delayed or there are costs or other barriers, CBT can be provided as a first-step, or stand-alone therapy in guided self-help form. An example of such an evidence based self-help book that has been evaluated for delivery within 10 half-hour session times by Australian general practitioners (Banasiak et al., 2005) is Bulimia Nervosa and Binge Eating: A Guide to Recovery (Cooper, 1995). Pure or unguided self-help may be effective in binge eating disorder; however, it has poorer outcomes compared to guided self-help CBT or specialist provided CBT in bulimia nervosa (Hay, 2013b).

Wilson and Zandberg’s (2012) systematic review similarly supported self-help CBT as an effective, accessible and time and cost-efficient alternative to specialist delivery of CBT. Furthermore, it has been translated into delivery via telemedicine and the internet. They noted, however, that most CBT-guided self-help books have not kept up to date with developments in CBT such as CBT-Eb (see above).

Other psychological therapies

There is a small and weak evidence base for interpersonal psychotherapy and dialectical behaviour therapy in both bulimia nervosa and binge eating disorder, and mindfulness in binge eating disorder (Kristeller and Wolever, 2011). Where therapists have expertise in these therapies and not in CBT and a CBT-trained therapist is not accessible then it may be appropriate to use either of these for adults. Findings are mixed for FBT in older adolescents or adults and, unlike in anorexia nervosa, FBT would not be first-line in bulimia nervosa or binge eating disorder (le Grange et al., 2007; Schmidt et al., 2007).

Pharmacotherapy

RCTs and meta-analysis have found that tricyclic antidepressants may be efficacious for people with bulimia nervosa (Flament et al., 2012; Hay and Claudino, 2012) but adverse effects limit clinical utility. In contrast, high dose fluoxetine (60mg/day) is effective for people with bulimia nervosa and this or other SSRI antidepressants are effective for both bulimia nervosa and binge eating disorder. The antiepileptic topiramate also is effective in both conditions and is associated with weight loss. However, topiramate may cause problematic side effects such as paresthesias and taste perversion (Arbaizar et al., 2008; Hay and Claudino, 2012).

Where psychological therapy is not available, antidepressants or antiepileptic medication such as topiramate ⁵ may be used (Flament et al., 2012; Hay and Claudino, 2012). However, trials of drug alone treatments have seldom followed participants up in the long-term, and therefore how long the medication should be continued for is unclear. High attrition rates and binge eating abstinence rates have consistently been found to be lower for drug alone treatments than when combined with CBT (Flament et al., 2012; Hay and Claudino, 2012). Trials in bulimia nervosa and binge eating disorder (Flament et al., 2012; Hay and Claudino, 2012) find an additive benefit for combined psychological and pharmacological treatment, but findings are inconsistent. Thus, when people have limited response to psychotherapy alone, or they have a comorbid mood disorder such as depression, pharmacotherapy may have a role as an adjunctive treatment.

Indicators for admission

The majority of people with bulimia nervosa may be treated as outpatients. Although evidence is lacking, people who are not responding to outpatient care or otherwise have an increased risk (e.g. because of suicidality or pregnancy) may benefit from the increased intensity of therapy and eating supervision available in an inpatient or day patient unit.

Medical assessment

Most medical problems in people with bulimia nervosa occur as a result of purging behaviours. Table 4 (above) lists these and their management. A dental evaluation should be considered if self-induced vomiting has been a prominent symptom. An increasing problem is comorbid weight disorder and metabolic syndrome, both of which may require further medical assessment and treatment (see below).