Outpatient ED Tx - First Steps
- Context: First-line for many EDs if criteria met.
- Goals: Medical stability, weight restoration (if needed), nutritional rehab, psychoeducation, relapse prevention.
- Initial Assessment:
- Comprehensive: medical, psychiatric, nutritional, social support.
- Determine suitability for outpatient level of care.
- Core Team: Physician, registered dietitian, mental health professional.
- First Actions: Establish therapeutic alliance, collaborative goal-setting, psychoeducation for patient/family.
⭐ Outpatient suitability: BMI > 15 kg/m² (adult AN), medically stable, motivated, adequate support. Not actively suicidal or engaging in severe, frequent purging requiring medical management.
Psychotherapies - Talk Power
Key evidence-based psychotherapies form the cornerstone of outpatient ED management. Each targets specific aspects of the disorder:
| Psychotherapy | Key Target ED(s) | Primary Age Group | Core Therapeutic Focus | Typical Duration / Sessions |
|---|---|---|---|---|
| CBT-E | AN, BN, BED (all severities) | Adolescents, Adults | Modifying dysfunctional cognitions & behaviours maintaining ED; psychoeducation, self-monitoring, cognitive restructuring | 20 sessions (BN/BED) to 40 (AN outpatient) |
| FBT | AN (esp. <18 yrs, moderate-severe) | Children, Adolescents | Phase 1: Parental control of re-feeding. Phase 2: Gradual return of control to adolescent. Phase 3: Normal development. | 15-20 sessions over ~12 months |
| IPT | BN, BED (if interpersonal issues prominent) | Adults | Identifying & resolving current interpersonal problems in specific areas (e.g., grief, role transitions, disputes) that trigger ED. | 16-20 sessions over ~4-5 months |
Meds & Meals - Fuel & Fix
- Nutritional Rehabilitation:
- Primary goal: Restore healthy weight (AN), normalize eating patterns (BN, BED).
- AN target: Outpatient weight gain 0.5-1 kg/week.
- Initial calories (AN): Start 1200-1500 kcal/day, increase by 300-500 kcal every few days.
- Structured eating: 3 meals, 2-3 planned snacks. Psychoeducation & meal support crucial.
- Key Pharmacotherapy:
| Drug | ED Indication | Key Dose/Notes |
|---|---|---|
| Fluoxetine | Bulimia Nervosa (BN) | 60mg/day (often higher than for depression) |
| Olanzapine | Anorexia Nervosa (AN) | 2.5-10mg/day (adjunct for weight gain, ↓ anxiety) |
| Lisdexamfetamine | Binge Eating Disorder (BED) - Mod/Sev | 30-70mg/day (reduces binge frequency) |
Monitoring & MDT - Safety Net
- Medical Monitoring (Regular):
- Vitals (HR, BP, Temp), Weight (weekly), BMI
- Key Electrolytes ($K^+$, $PO_4^{3-}$, $Mg^{2+}$), esp. pre-feeding
- ECG (QTc, bradycardia), Hydration status
- Menstrual cycle restoration
- Multidisciplinary Team (MDT) Roles:
- Psychiatrist: Diagnosis, pharmacotherapy, team lead
- Psychologist: Evidence-based psychotherapy (e.g., CBT-E)
- Dietitian: Nutritional rehabilitation, meal planning
- Physician (GP/Internist): Monitor medical stability
⭐ Closely monitor for refeeding syndrome (hypophosphatemia, fluid shifts, cardiac compromise) in severely malnourished patients initiating nutritional therapy.
High‑Yield Points - ⚡ Biggest Takeaways
- CBT-E (Enhanced Cognitive Behavioral Therapy) is primary for adult Bulimia Nervosa (BN) & Binge Eating Disorder (BED).
- Family-Based Treatment (FBT), or Maudsley method, is first-line for adolescent Anorexia Nervosa (AN).
- Fluoxetine (SSRI) is FDA-approved for BN; can aid BED. Limited role in AN weight gain.
- Nutritional rehabilitation & medical monitoring are crucial foundational elements for all eating disorders.
- A multidisciplinary team approach (therapist, dietitian, physician) is optimal for comprehensive care.
- Relapse prevention strategies are essential for achieving and maintaining long-term recovery outcomes.
- Outpatient settings are for medically stable patients with adequate motivation and support systems.
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