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February 13, 2023

The practice guideline for the treatment of patients with eating disorders has been updated by the American Psychiatric Association since the publication of the last version in 2006. The burden of eating disorders is pervasive, leading to psychosocial impairment, large economic costs, health problems, and increased mortality. Thus, the objective of this guideline is to improve the assessment and treatment of eating disorders, thereby reducing the burden of these disorders. The current evidence was reviewed to provide evidence-based recommendations regarding assessment and treatment planning (Table 1), as well as pharmacological, psychotherapeutic, and other nonpharmacological treatments for eating disorders in adolescents, emerging adults, and adults (Table 2).

Table 1. Recommendations for Eating Disorders Assessment and Determination of Treatment Plan*
Screen for the presence of an eating disorder as part of an initial psychiatric evaluation Initial evaluation of a patient with a possible eating disorder should include assessment of: the patient’s height and weight history presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors patterns and changes in food repertoire presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors, 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 family history of eating disorders, other psychiatric illnesses, and other medical conditions Initial psychiatric evaluation of a patient with a possible eating disorder should include weighing the patient and quantifying eating and weight control behaviors Initial psychiatric evaluation of a patient with a possible eating disorder should identify co-occurring health conditions, including co-occurring psychiatric disorders Initial psychiatric evaluation of a patient with a possible eating disorder should include a comprehensive review of systems Initial physical examination of a patient with a possible eating disorder should include assessment of vital signs, including temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure; height, weight, and body mass index; and physical appearance, including signs of malnutrition or purging behaviors Laboratory assessment of a patient with a possible eating disorder should include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests Electrocardiogram should 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 Patients with an eating disorder should 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
*All recommendations have a rating of 1C, indicating confidence that the benefits of the intervention clearly outweigh harms (1) with low strength of supporting research (C).

Table 1. Recommendations for Eating Disorders Assessment and Determination of Treatment Plan*

Screen for the presence of an eating disorder as part of an initial psychiatric evaluation
Initial evaluation of a patient with a possible eating disorder should include assessment of:
- the patient’s height and weight history
- presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors
- patterns and changes in food repertoire
- presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors, 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
- family history of eating disorders, other psychiatric illnesses, and other medical conditions
Initial psychiatric evaluation of a patient with a possible eating disorder should include weighing the patient and quantifying eating and weight control behaviors
Initial psychiatric evaluation of a patient with a possible eating disorder should identify co-occurring health conditions, including co-occurring psychiatric disorders
Initial psychiatric evaluation of a patient with a possible eating disorder should include a comprehensive review of systems
Initial physical examination of a patient with a possible eating disorder should include assessment of vital signs, including temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure; height, weight, and body mass index; and physical appearance, including signs of malnutrition or purging behaviors
Laboratory assessment of a patient with a possible eating disorder should include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests
Electrocardiogram should 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
Patients with an eating disorder should 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

*All recommendations have a rating of 1C, indicating confidence that the benefits of the intervention clearly outweigh harms (1) with low strength of supporting research (C).

Table 2. Recommendations for Eating Disorders Treatment
Recommendation					Evidence Level*
*Anorexia Nervosa (AN)*
Patients with AN who require nutritional rehabilitation and weight restoration should have individualized goals set for weekly weight gain and target weight					1C
Adults with AN should be treated with an eating disorder-focused psychotherapy, which should include normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects of AN					1B
Adolescents and emerging adults with AN who have an involved caregiver should 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					1B
*Bulimia Nervosa (BN)*
Adults with BN should be treated with eating disorder-focused cognitive-behavioral therapy; a serotonin reuptake inhibitor (e.g., 60 mg fluoxetine daily) should also be prescribed, either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment					1C
Adolescents and emerging adults with BN who have an involved caregiver should be treated with eating disorder-focused family based treatment					2C
*Binge-Eating Disorder (BED)*
Patients with BED should be treated with eating disorder-focused cognitive behavioral therapy or interpersonal therapy, in either individual or group formats					1C
Adults with BED who prefer medication or have not responded to psychotherapy alone should be treated with either an antidepressant medication or lisdexamfetamine					2C
*Recommendations with a rating of 1 indicates confidence that the benefits of the intervention clearly outweigh harms, while a rating of 2 indicates greater uncertainty; the strength of supporting research evidence was either moderate (B) or low (C).

Reference:

Crone C et al. Am J Psychiatry 2023;180(2):167-71. Abstract.

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