What is the recommended treatment approach for individuals with eating disorders, including Anorexia Nervosa, Bulimia, Avoidant/Restrictive Food Intake Disorder (ARFID), and Other Specified Feeding or Eating Disorder (OSFED)?

Treatment Approaches for Eating Disorders

A multidisciplinary team approach incorporating disorder-specific psychotherapy, nutritional rehabilitation, and medical monitoring is the recommended treatment for all eating disorders, with specific evidence-based interventions tailored to each disorder type. 1

General Assessment and Treatment Planning

The initial evaluation of any patient with a suspected eating disorder should include:

• Complete weight and height history
• Assessment of restrictive eating, food avoidance, binge eating behaviors
• Evaluation of compensatory behaviors (purging, exercise, laxative use)
• Comprehensive physical examination including vital signs and orthostatic measurements
• Laboratory assessment including CBC and comprehensive metabolic panel
• ECG for patients with restrictive disorders or severe purging 1

All patients should have a comprehensive treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise via a coordinated team approach.

Disorder-Specific Treatment Approaches

Anorexia Nervosa

For adults with anorexia nervosa, treatment should include eating disorder-focused psychotherapy that normalizes eating behaviors, restores weight, and addresses psychological aspects like fear of weight gain and body image disturbance. 1

Treatment algorithm:

1. Nutritional rehabilitation with individualized weekly weight gain goals and target weight
2. Psychotherapy options:
   • Adults: Eating disorder-focused psychotherapy
   • Adolescents/emerging adults: Family-based treatment with caregiver involvement
3. Medical monitoring of vital signs, electrolytes, and cardiac function

Family-based treatment is strongly recommended for adolescents and has the best evidence base for this age group. 1

Bulimia Nervosa

Adults with bulimia nervosa should receive eating disorder-focused cognitive-behavioral therapy (CBT) combined with a serotonin reuptake inhibitor (typically fluoxetine 60mg daily). 1

Treatment algorithm:

1. First-line: Eating disorder-focused CBT
2. Medication: Fluoxetine 60mg daily, either initially or if minimal response to psychotherapy by 6 weeks
3. For adolescents/emerging adults: Family-based treatment is suggested

CBT specifically targeting the eating disorder has the strongest evidence base for bulimia nervosa. 1

Binge-Eating Disorder

Patients with binge-eating disorder should be treated with eating disorder-focused cognitive-behavioral therapy or interpersonal therapy, in either individual or group formats. 1

Treatment algorithm:

1. First-line: CBT or interpersonal therapy
2. For adults who prefer medication or haven't responded to psychotherapy: Consider antidepressant medication or lisdexamfetamine

Avoidant/Restrictive Food Intake Disorder (ARFID)

Treatment for ARFID should include graded exposure therapy within a cognitive behavioral framework, nutritional rehabilitation, and addressing any underlying anxiety or sensory issues. 2

ARFID differs from other eating disorders as it does not involve body image distortion or fear of weight gain. It typically presents in three patterns:

• Sensory-based food avoidance
• Fear-based avoidance
• Lack of interest in food/eating 2

Treatment approach:

1. Psychological interventions: Graded exposure therapy in a CBT setting
2. Nutritional rehabilitation: Avoid reinforcing restriction
3. Address comorbidities: Especially anxiety disorders and gastrointestinal conditions

Caution: Avoid reinforcing avoidance through elimination diets, as this can worsen ARFID. Parenteral nutrition should only be used in life-threatening malnutrition as a temporary bridge. 2

Other Specified Feeding or Eating Disorder (OSFED)

Treatment should be guided by the specific symptoms and most closely resembling full-threshold disorder:

• For restrictive presentations: Follow anorexia nervosa protocols
• For binge/purge presentations: Follow bulimia nervosa protocols
• For binge-eating presentations: Follow BED protocols

Treatment Setting Considerations

The level of care should be determined by:

1. Medical stability (vital signs, electrolytes, cardiac function)
2. Psychiatric stability (suicidality, self-harm risk)
3. Weight status and rate of weight loss
4. Treatment response

Hospital admission is indicated for those at risk of medical and/or psychological compromise, particularly with:

• Severe malnutrition
• Electrolyte abnormalities
• Cardiac complications
• High suicide risk 3

Common Pitfalls to Avoid

1. Failure to use a multidisciplinary approach: Treatment is most effective with coordinated medical, nutritional, and psychological care 4
2. Delayed intervention: Early treatment is associated with better outcomes; prognosis worsens with longer illness duration 5
3. Overlooking comorbidities: Eating disorders frequently co-occur with depression, anxiety, and other psychiatric disorders 5
4. For ARFID: Misdiagnosis by failing to distinguish from anorexia nervosa or overlooking comorbid anxiety or GI conditions 2

The evidence clearly supports that early intervention with appropriate disorder-specific treatment approaches significantly improves outcomes across all eating disorder diagnoses.