Clinical Practice Guideline For Eating Disorders

External Review of Patient InformationAssociation in Defense of Anorexia Nerviosa and Bulimia Management (ADANER)Spanish Federation of Support Associations for Anorexia y Bulimia(FEACAB).gtinCollaborating societies, associations or federationsThis CPG is endorsed by the following organizations:adLuis Beato, Spanish Association for the Study of Eating Disorders (AEETCA)uptoAEETCA is the only scientific society specifically dedicated to eating disorderstcjeRosa Calvo, General Council of the Spanish PsychologistbusAssociationstiJavier García Campayo, Spanish Society of iPsychosomaticsdLourdes Carrillo, Spanish Society of Familyan and CommunityeMedicinein (SemFYC) (Barcelona)ldeCouncil of Social WorkersDolors Colom, GeneraliuG Neuropsychiatry AssociationMaría Diéguez, Spanishe Social Educator AssociationsAlberto Fernández de Sanmamed, General Council of tSpanishicacSociety of Dietetics and Food SciencesCarlos Iglesias, Spanishrl P Society of Endocrinology and NutritionPilar Matía, SpanishaicniAlbertol Miján, Spanish Society of Internal MedicineCshiJosé Manuel Moreno, Spanish Pediatrics AssociationtofRosa Morros, Spanish Society of Clinical Pharmacologynio Vicente Oros, Spanish Society of Primary Care Physicianstaic Núria Parera, Spanish Society of Gynaecology and ObstetricslubBelénp Sanz-Aránguez, Spanish Society of Psychiatry and Spanish Society ofeBiological PsychiatrytheIngrid Thelen, National Association of Mental Health NursingncsiM. Alfonso Villa, Spanish Odontologist and Stomatologist AssociationrsayeDeclaration of Interests:5neIashtbedevelopmentAll members of the working group, as well as the individuals who have collaborated in theof this guide (experts on eating disorders, representatives from differentassociations, scientific societies, federations and external reviewers), have carried out thedeclaration of conflict of interests by completing a form designed to this end.None of the participants have declared having a conflict of interest related with eatingdisorders.This guide is editorially independent from the funding organisation.11CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS

Key QuestionsDefinition and Classification of Eating Disorders.1. How are eating disorders defined and classified? What are the shared and specific clinicalfeatures of each type?2. Ethiopathogeny of eating disorders: What are the main risk factors?ttcjebu3. What are the most frequent co morbidities of eating disorders?Prevention of Eating Disordersstiiaodpus4. What is the efficacy of primary care interventions in avoiding eating disorders?d Are there anynegative effects?aneinledDetection of Eating DisordersuiG disorders?5. What screening instruments are useful to identify cases of eatingeicctaDiagnosis of Eating DisordersrlPa6. What clinical criteria are useful to diagnose eatingic disorders?7. How are eating disorders diagnosed?tshilinC8. What is the differential diagnosis ooff eating disorders?IashtonitInterventions at the Differenta Levels of Care in the Management of EatingciDisordersblupe9. What are the primaryh care (PC) and specialised care interventions for eating disorders?Other resources? e tcins10. In eatings disorders, what clinical criteria may be useful to assess referral amongst the healthrcarearesources available in the NHS?ye511.n In eating disorders, what clinical criteria may be useful to assess inpatient care (completeehospitalisation) in the healthcare resources available in the NHS?be12. In eating disorders, what clinical criteria may be useful to assess discharge in the healthcareresources available in the NHS?Treatment of Eating Disorders13. What is the efficacy and safety of re-nutrition in patients with eating disorders?12CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERSgtin

14. What is the efficacy and safety of nutritional counselling in patients with eating disorders?15. What is the efficacy and safety of cognitive-behavioural therapy in patients with eatingdisorders?.16. What is the efficacy and safety of self-help and guided self-help in patients with eatingdisorders?a17. What is the efficacy and safety of interpersonal therapy in patients with eating disorders?to18. What is the efficacy and safety of family therapy (systemic or not) in patients with eatingtcedisorders?jdpubsu19. What is the efficacy and safety of psychodynamic therapy in patients with eatingis disorders?Iashtitd20. What is the efficacy and safety of behavioural therapy in patients with eatingan disorders?ein disorders?21. What is the efficacy and safety of antidepressants in patients with leatingdeiu22. What is the efficacy and safety of antipsychotic drugs in patientsG with eating disorders?eict23. What is the efficacy and safety of appetite stimulants cin patients with anorexia nervosara(AN)?Palci24. What is the efficacy and safety of opioid antagonistsin patients with eating disorders?linCs psychoactive drugs in patients with eating25. What is the efficacy and safety of otherithdisorders?fon26. What is the efficacy and safetytio of combined interventions in patients with eating disorders?alicb27. What is the treatmentufor eating disorders that occur with comorbidities?pe28. How are chronicthcases of eating disorders treated?enc29. What is thesi treatment for eating disorders in special situations such as pregnancy and delivery?rsaye5Assessment of Eating Disorderseneb30. What tools are useful to assess the symptoms and behaviour of eating disorders?31. What tools are useful for the psychopathological assessment of eating disorders?Prognosis of Eating Disorders32. What is the prognosis of eating disorders?13CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERSgtin

33. Are there prognostic factors for eating disorders?Legal Aspects Concerning Patients with Eating Disorders in Spain34. What legal procedure must be followed when a patient with an eating disorder refuses toreceive treatment?.a35. Is the informed consent of a minor with an eating disorder legally valid?dpu36. In the case of a minor with an eating disorder, what is the legal solution to the dilemmatostemming from the responsibility of confidentiality, respect of autonomy and obligationstctowards the minor’s parents or legal einledanicarsenasht5yeceniethblupsbeI14CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERSgtin

15CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS

CPG RecommendationsIn this section recommendations are presented following the guide’s structure. Chapters 1,2 and3 of the CPG include an introduction, scope and objectives, and methodology, respectively.Chapter 4 covers eating disorders and Chapter 11 addresses prognosis. All these chapters aredescriptive and thus no recommendations have been formulated for clinical practice. Chapter 5,which covers prevention, is the first to provide recommendations. This section’s abbreviationscan be found at the end.toGrade of recommendation: A, B, C o D, depending on whether evidence quality is very high,ctehigh, moderate or low.bjis Good clinical practice: recommendation based on the working group’s consensuses.ti(Please refer to Annex 1).d 5.1. 5.2. 5.3.rsceniseinleaniduSample, format and design characteristics ofG eating disorder preventionprogrammes that have shown greater efficacyshould be considered theeictmodel for future programmes.craPIn the design of universal eatingl disorder prevention strategies, it must beataken into account that expectedbehavioural changes in children andicnli types of problems might differ from those ofadolescents without theseChigh-risk populations.isthfoMessages ononmeasures that indirectly protect individuals from eatingti be passed on to the family and adolescent: following adisorders ashouldchealthyli diet and eating at least one meal at home with the family,b communication and improving self-esteem, avoiding familyfacilitatingpuconversationsfrom compulsively turning to eating and image andethavoiding jokes and disapproval regarding the body, weight or eatingmanner of children and adolescents.6. Detectionea of Eating Disorders (Question 6.1.)IashtenDeb5y6.1.Target groups for screening should include young people with low bodymass index (BMI) compared to age-based reference values, patientsconsulting with weight concerns without being overweight or people whoare overweight, women with menstrual disorders or amenorrhoea, patientswith gastrointestinal symptoms, patients with signs of starvation orrepeated vomiting, and children with delayed or stunted growth, children,adolescents and young adults who perform sports that entail a risk ofdeveloping an eating disorder (athletics, dance, synchronised swimming,etc.).16CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERSadpusu5. Primary Prevention of Eating Disorders (Question 5.1.).gtin

D6.2.In anorexia nervosa (AN), weight and BMI are not considered the onlyindicators of physical risk.D6.3.Early detection and intervention in individuals presenting weight loss areimportant to prevent severe emaciation.D6.4. 6.5. 6.6. 6.7. 6.8.Iashten ebIn the case of suspected AN, attention should be paid to overall clinicalassessment (repeated over time), including rate of weight loss, growthdapcurve in children, objective physical signs and appropriate laboratory uotests.ttcjebIt is recommended to use questionnaires adapted and validated inuthesSpanish population for the detection of eating disorder cases (screening).siitdThe use of the following tools is recommended:an 11 years andEating disorders in general: SCOFF (for individualseagedover)lineAN: EAT-40, EAT-26 and ChEAT (the latter iford individuals aged betweenu8 and 12 years)GBulimia nervosa (BN): BULIT, BULIT-Rand BITE (the three foreciindividuals aged 12-13 years and over)tacrl P is considered essential for earlyAdequate training of PC physiciansaic disorders to ensure prompt treatment ordetection and diagnosis ofineatinglreferral, when deemed necessary.CshitDue to the low frequencyof visits during childhood and adolescence, it isofrecommendedn to take advantage of any opportunity to providetio management and to detect eating disorder risk habits andcomprehensiveaic disorder risk behaviour, such as repeated vomiting, can becases. lEatingbdetectedpu at dental check-ups.ethWhen interviewing a patient with a suspected eating disorder, especiallysif the suspected disorder is AN, it is important to take into account thepatient’s lack of awareness of the disease, the tendency to deny thedisorder and the scarce motivation to change, these reactions being morepronounced in earlier stages of the disease.6.9.It is recommended that different groups of professionals (teachers, schoolpsychologists, chemists, nutritionists and dieticians, social workers, etc.)who may be in contact with at-risk population have adequate training andbe able to act as eating disorder detection agents.s5cenireay.gtin17CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS

7. Diagnosis of Eating Disorders (Questions 7.1.-7.3.) 7.1.It is recommended to follow the WHO’s (ICD-10) and the APA’s (DSMIV o DSM-IV-TR) diagnostic criteria.D7.2.1.Health care professionals should acknowledge that many patients witheating disorders are ambivalent regarding treatment due to the demandsand challenges it entails.DD asht7.2.2.7.2.3.7.2.4.aPatients and, when deemed necessary, carers should be provided withinformation and education regarding the nature, course and treatment oftoteating disorders.ecdpubjusFamilies and carers may be informed of existing eating disorderisitassociations and support groups.danIt is recommended that the diagnosis of eating disordersne includeilanamnesis, physical and psychopathological examinationsandedicomplementary explorations.uGe 7.2.5.Diagnostic confirmation and therapeutictic implications should be in thechands of psychiatrists and clinical psychologists.raPalciin Care (Questions 8.1.-8.4.)8. Interventions at the Different Levels lofCsiD8.1.Individuals with eatingth disorders should be treated in the appropriate careflevel based on clinicalo criteria: outpatient care, day care (day hospital) andninpatient care(generalor psychiatric hospital).iotaiclD8.2.Healthub care professionals without specialist experience in eatingpdisordersor who are faced with uncertain situations should seek theeht advice of a trained specialist when emergency inpatient care is deemedenc the most appropriate option for a patient with an eating disorder.issDThe majority of patients with BN can be treated on an outpatient basis.ar8.3.eInpatient care is indicated when there is risk of suicide, self-inflictedy5injuries and serious physical complications.nebe D8.4.Health care professionals should assess patients with eating disorders andosteoporosis and advise them to refrain from performing physicalactivities that may significantly increase the risk of fracture.ID8.5.The paediatrician and the family physician must be in charge of themanagement of eating disorders in children and adolescents. Growth anddevelopment must be closely monitored.18CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERSgtin

D8.6.Primary care centres should offer monitoring and management ofphysical complications to patients with chronic AN and repeatedtherapeutic failures who do not wish to be treated by mental healthservices.D8.7.Family members, especially siblings, should be included in theindividualized treatment plan (ITP) of children and adolescents withg.eating disorders. The most common interventions involve sharing ofniinformation, advice on behavioural management of eating disorders andatdimproving communication skills. The patient’s motivation to change pushould be promoted by means of family shteneb eayssr8.13.8.14.ttcje aWhere inpatient care is required, it should be carried out withinbreasonable distance to the patient’s home to enable the involvementofsusirelatives and carers in treatment, to enable the patient to maintainsocialit care levels.and occupational links and to prevent difficulties betweendThis is particularly important in the treatment of childrenan and adolescentseinlPatients with AN whose disorder has not improvedwith outpatientde or inpatientitreatment must be referred to day patient treatmenttreatment.uGFor those who present a high risk of suicide or serious self-inflictedeicinjuries, inpatient management is indicated.tacrPInpatient treatment should be l consideredfor patients with AN whoseadisorder is associated with highormoderateriskdue to common disease orciniphysical complications of lAN.Cs require inpatient treatment should be admitted to aiPatients with AN whoth adequate re-nutrition, avoiding the re-feedingcentre that ensuresfoclose physical monitoring (especially in the first fewsyndrome, withnodays), alongti with the appropriate psychological intervention.alicbuThep family physician and paediatrician should take charge of theethassessment and initial intervention of patients with eating disorders whoattend primary care.When management is shared between primary and specialised care, thereshould be close collaboration between health care professionals, patientsand relatives and carers.Patients with confirmed diagnosis or clear suspicion of an eating disorderwill be referred to different health care resources based on clinical andage criteria.19CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS

Iasht 8.15.Referral to adult or children mental health centres (CSMA/CSMIJ) by thefamily physician or paediatrician should consist of integrated care withshared responsibilities. 8.16.Cases referred to adult or children mental health centres (CSMA/CSMIJ)g.still require different levels to work together and short- and mid-termnimonitoring of patients, to avoid complications, recurrences and the onsetatdof emotional disorders, and to detect changes in the patient’s puenvironment that could influence the disease.to 8.17.tcThe need to prescribe oestrogen treatment to prevent osteoporosis injegirlsband adolescents with AN should be carefully assessed, given uthat thissmedication can hide the presence of amenorrhoea.isitd 8.18.n designed forIn childhood, specific eating disorder treatment programmesathese ages will be required.einldei9. Treatment of Eating Disorders (Questions 9.1.-9.20.)uGeMedical Measures (Re-nutrition and Nutritional Counselling)ticcRe-nutrition (Question 9.1.)raPAnorexia nervosaalcniilD9.1.1.1.A physical explorationC and in some cases oral multivitamin and/ormineral supplementsisare recommended, both in outpatient and inpatientthwith AN who are in the stage of body weightcare, for patientsfrestoration. n otioaD9.1.1.2.Total parenteralnutrition should not be used in patients with AN unlesslicbthe upatient refuses nasogastric feeding and/or when there ispgastrointestinaldysfunction.eht 9.1.1.3.ce Enteral or parenteral re-nutrition must be applied using strict medicaln criteria and its duration will depend on when the patient is able to resumesioral feeding.rsaye5GeneralRecommendations on Medical Measures (GM) for Eating Disorderseneb (Questions 9.1.-9.2.)Eating Disorders 9.GM.01.Nutritional support for patients with eating disorders will be selectedbased on the patient’s degree of malnutrition and collaboration, andalways with the psychiatrist’s approval.20CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS

9.GM.02.Before initiating artificial nutrition the patient’s degree of collaborationmust be assessed and an attempt must always be made to convincehim/her of the benefits of natural feeding. 9.GM.03.In day hospitals, nutritional support for low-weight patients, where anoral diet is insufficient, can be supplemented with artificial nutrition (oralenteral nutrition). To ensure its intake, it must be administered during theday hospital’s hours, providing supplementary energy ranging from 300to 1,000 kcal/day. Iasht9.GM.04.atoOral nutritional support in eating disorder inpatients is deemed adequatecte(favourable progress) when a ponderal gain greater than 0.5 kg perbj weekuis produced, with up to 1

6. Detection of Eating Disorders 63 7. Diagnosis of Eating Disorders 73 8. Interventions at the Different Levels of Care in the Management of Eating Disorders 81 9. Treatment of Eating Disorders 91 10. Assessment of Eating Disorders 179 11. Prognosis of Eating Disorders 191 12. Legal Aspects Concerning Individuals with Eating Disorders in Spain 195