Guidelines for hospitalizing patients with eating disorders are based on the severity of symptomatology. In the United States, length of hospitalization is primarily determined by managed care companies and health maintenance organizations. No randomized controlled studies have been done to determine the criteria for either hospitalization or discharge from the hospital. In this chapter, I discuss hospital treatment programs for anorexia nervosa and bulimia nervosa. Although the number of patients falling into the eating disorder not otherwise specified category has been increasing, the treatment of this eating disorder is similar to the treatment of anorexia nervosa or bulimia nervosa, depending on the specific problems these patients have. For example, an underweight patient who is vomiting but not bingeing and is menstruating would be given the same treatment program as a patient with anorexia nervosa. A person of normal weight who binges only once a week but is severely depressed would be treated as a bulimia nervosa patient and, of course, receive treatment for her depression.
Anorexia Nervosa
It has been extraordinarily difficult to subject severely medically ill patients with anorexia nervosa to controlled treatment studies in the very emaciated state of their illness. However, open studies have shown that a multifaceted treatment approach is most effective. The treatment should include medical management, psychoeducation, and individual therapy that involves both cognitive and behavior therapy principles. Depending on the individual case, the treatment plan also might include family therapy, nutritional counseling, and pharmacological intervention. Hospitalization depends on 1) weight status of the patient, 2) cooperativeness of the patient and family, 3) whether medical complications are present, and 4) related psychiatric comorbidities, such as depression, suicidal behavior, and obsessive-compulsive disorder.
Other practical factors the clinician has to consider are insurance coverage and the availability of appropriate management facilities. Currently, managed care companies determine both the type and the duration of treatment patients may receive. However, clinical criteria for hospitalization have been established and can guide the practitioner in determining the appropriate level of care based on the changing demands of the health care system. The guidelines for hospitalizing anorexia nervosa patients developed at the Cornell Eating Disorders Program are as follows.
Inpatient Brief Hospitalization
Inpatient brief hospitalization (7-14 days) is for patients who have 1) relapsed from previous treatment or been ill for less than 6 months; 2) weight loss of 10%-15% from normal weight if relapsed, 16%-20% if first episode; 3) hypokalemic alkalosis with serum potassium less than 2.5 mEq/L; and 4) cardiac arrhythmias.
These patients are placed on a liquid formula for 5-7 days to promote rapid weight gain. After this, they are given regular meals on trays, which can be monitored for calories ingested for 3-5 days. This allows the patient to eat food for a few days before the required discharge. All patients are monitored for the bathroom; however, about 3 days before discharge, they are given bathroom privileges. The patients participate in multiple group therapy sessions, which include groups for body image and specific eating disorder problems; self-esteem, self-confidence, and self-expression groups; female issues groups; and a movement-controlled exercise group. If the patient is younger than 18, she or he participates in intensive family counseling.
The ideal discharge criteria, if permitted by managed care, are as follows: 1) normal weight range, if this is a patient who has relapsed, or within 10% of normal weight, if this is the patient’s first episode; 2) ability to maintain weight gain with unsupervised bathroom use and to select foods in family-style servings; 3) medical stability (e.g., a normal electrocardiogram and serum electrolytes); and 4) no suicide risk.
Discharge planning should consider transition to a partial hospitalization program if the patient has had repeated relapses and an outpatient program would not provide sufficient structure for the patient’s current needs. Extensive consultation with the outpatient therapist is very useful for an easier transition for the patient and for more effective outpatient therapy.
Extended Hospital Treatment
Extended hospital treatment (14-60 days) is for patients who have 1) weight loss greater than 20% of normal weight for age, height, and bone structure; 2) a history of repeated hospitalizations for anorexia nervosa or being underweight for more than 6 months; 3) psychotic depression or serious suicide attempt; 4) incapacitating obsessions and compulsions related or not related to eating disorder; and 5) serious comorbid medical conditions such as edema, hypoproteinemia, and severe anemia.
Treatment consists of 1) a liquid formula until within 5%-10% of a normal weight range; 2) appropriate medical treatment, with highly monitored 24-hour surveillance necessary to prevent purging, exercising, and other damaging behavior; 3) multiple group therapy sessions (see above); 4) individual therapy; 5) family counseling, especially intensive for those younger than 18; and 6) cognitive-behavioral ward milieu to prevent bingeing/purging and to ensure normal ingestive behavior.
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The ideal discharge criteria are as follows: 1) ability to maintain or gain weight with unsupervised bathroom use and to select foods in family-style servings, 2) medical stability (e.g., a normal electrocardiogram and serum electrolytes), 3) no suicide risk, 4) no incapacitating impairment from comorbid conditions such as psychosis or severe obsessions and compulsions.
Because of the complexities and special knowledge required to promote effective treatment of anorexia nervosa, hospitalized patients are best in a specialized inpatient treatment setting, which provides a team of individuals highly skilled in the multidisciplinary management of anorectic patients. Medical management involves weight restoration, nutritional rehabilitation, rehydration, and correction of serum electrolytes. Inpatient hospitalization should include daily monitoring of weight, food and calorie intake, and urine output. In the patient who is vomiting, frequent assessment of serum electrolytes is necessary. Patients must be monitored closely for attempts to vomit. An appropriate weight range must be established for the patient and should consider the patient’s height, bone structure, and weight at the time of onset of menses.
Cognitive and behavior therapy principles can be applied in both inpatient and outpatient settings. For example, in controlled inpatient studies of anorexia nervosa, behavior therapy was effective in inducing weight gain (Wulliemier et al. 1975). Contingency contracting involves earning rewards (e.g., visiting privileges, increased physical activity, and social activity) when weight gain is achieved. Behavior therapy is used primarily to restore weight. This is necessary for several reasons. First, the state of emaciation causes irritability, depression, preoccupation with food, and sleep disturbance. Second, cognitive impairment is a common byproduct of emaciation. It is exceedingly difficult to achieve behavioral change with psychotherapy in a patient who is enduring the psychological and emotional effects of emaciation. For a review of behavioral techniques in the management of anorexia nervosa, see Halmi (1985a).
Anorexia nervosa patients have a rigid and extreme thinking style, as demonstrated by dichotomous, or “all-or-nothing,” thinking. These distorted thoughts are present in relation to food (e.g., “If I eat any food that contains fat, I will gain weight”) and weight (e.g., “Feeling fat means I am fat”). These distorted thoughts are also present around issues of self-esteem and self-concept with pervasive feelings of ineffectiveness and a drive for perfectionism. These cognitive distortions are best dealt with in individual cognitive therapy. Cognitive therapy techniques for anorexia nervosa were first developed by Garner and Bemis (1982). More recent refinement of these techniques is well described and summarized by Kleifield et al. (1996).
Two techniques used in cognitive therapy are cognitive restructuring and problem solving. Cognitive restructuring is a method in which patients are taught to identify autonomic thoughts and challenge their core beliefs. They become aware of specific negative thoughts and first present arguments and evidence to support the validity of these thoughts and then present arguments and evidence that cast doubt on the validity of the thoughts. Finally, the patients form a reasoned conclusion based on the evidence. Problem solving is a method in which patients learn to reason through or problem-solve difficult food-related and/or interpersonal situations. This is especially relevant to events that are likely to trigger anorectic or bulimic behaviors. When the patient learns to use these techniques effectively, they reduce her or his vulnerability to rely on anorectic behaviors as a means of coping.
A family analysis should be done on all anorectic patients who are living with their families. On the basis of this analysis, a clinical judgment can be made as to what type of family therapy or counseling is advisable. In some cases, family therapy is not possible. However, in those cases, issues of family relationships can be addressed in individual therapy or in brief counseling sessions with immediate family members. The family counseling can begin during the hospitalization phase and continue through partial hospitalization and outpatient treatment. A controlled family therapy study by Russell et al. (1987) showed that anorectic patients younger than 18 benefited from family therapy, whereas patients older than 18 did worse in family therapy compared with the controlled therapy. No controlled studies of the combination of individual and family therapy have been done; however, in actual practice, most clinicians provide individual therapy and some sort of family counseling in managing anorexia nervosa.
Medications may be useful adjuncts in the treatment of anorexia nervosa. Cyproheptadine in high doses (up to 28 mg/day) can facilitate weight gain in anorectic restrictors and also provide an antidepressant effect (Halmi et al. 1986). The first drug used to treat anorexia was chlorpromazine. This medication is especially helpful in the severely obsessive-compulsive, agitated anorectic patient. It is surprising that no double-blind controlled studies are available to show the efficacy of chlorpromazine for inducing weight gain and reducing agitation in anorectic patients. It may be necessary to start at a low dosage of 10 mg three times a day and gradually increase the dosage. Newer antipsychotics such as olanzapine are also useful for the severely obsessive-compulsive and very disturbed anorectic patient. The tricyclic antidepressants and the serotonin reuptake inhibitors are not effective in treating emaciated anorectic patients.
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In summary, a multifaceted treatment approach is necessary for the effective care of hospitalized anorexia nervosa patients. Behavioral contingencies are very useful for inducing weight gain and changing the medical condition of the patient. As medical rehabilitation proceeds, an associated improvement in psychological state occurs. All patients need cognitive individual psychotherapy, and patients younger than 18 benefit most from additional family therapy. Severely obsessive-compulsive, anxious, and agitated anorectic patients are likely to require additional chlorpromazine or olanzapine. Anorectic restrictor patients who are extremely emaciated may benefit from cyproheptadine.
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Katherine A. Halmi, M.D.
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References
Braun DL, Sunday SR, Halmi KA: Psychiatric comorbidity in patients with eating disorders. Psychol Med 24:859-867, 1994
Fairburn CG, Kirk J, O’Connor M, et al: A comparison of two psychological treatments for bulimia nervosa. Behav Res Ther 24:629-643, 1986
Garner DM, Bemis K: A cognitive-behavioral approach to anorexia nervosa. Cognitive Therapy and Research 6:123-150, 1982
Halmi KA: Behavioral management of anorexia nervosa, in Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. Edited by Garner DM, Garfinkel PE. New York, Guilford, 1985a, pp 147-159
Halmi KA: Medical aberrations in bulimia nervosa, in A Comprehensive Approach to the Treatment of Normal Weight Bulimia. Edited by Kaye WH, Gwirtsman HE. Washington, DC, American Psychiatric Press, 1985b, pp 37-46
Halmi KA, Eckert E, LaDu TJ, et al: Anorexia nervosa: treatment efficacy of cyproheptadine and amitriptyline. Arch Gen Psychiatry 43:177-181, 1986
Kleifield EI, Wagner S, Halmi KA: Cognitive-behavioral treatment of anorexia nervosa. Psychiatr Clin North Am 19:715-735, 1996
Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
Mitchell JE, Pyle RL, Miner RA: Gastric dilatation as a complication of bulimia. Psychosomatics 23:96-98, 1982
Mitikainen N: Spontaneous rupture of the stomach. Am J Surg 138:451-452, 1979
Russell GFM, Szmukler GI, Dare C, et al: An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 44:1047-1056, 1987
Walsh BT, Delvin MJ: The pharmacological treatment of eating disorders. Psychiatr Clin North Am 15:149-160, 1992
Wulliemier F, Rossel F, Sinclair K: La therapie comportementale de l’anorexie nerveuse [Behavior therapy in anorexia nervosa]. J Psychosom Res 19:267-272, 1975
check also Bulimia Nervosa