New Eating Disorder Guidelines Released
Medscape Medical News
December 05, 2014
The first eating disorder guidelines to incorporate the latest recommendations from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), including the new disorder of avoidant restrictive food intake disorder (ARFID), have been released.
Produced by the Royal Australian and New Zealand College of Psychiatrists, the guidelines are evidence-based, multidisciplinary, and include consideration of recovery-oriented practice, with a special focus on anorexia nervosa (AN).
"One thing that is new and quite distinctive about these guidelines is that we have approached anorexia nervosa from the perspective of child and adolescent anorexia nervosa, anorexia nervosa in adults, and also severe and enduring anorexia nervosa, because the treatment approaches and the outcomes differ by clinically important ways," lead author Phillipa Hay, MD, told Medscape Medical News.
"People realize that...there are really quite important differences both in terms of approaches in child or adolescent and adults and also the small proportion who go on to have severe and enduring illness," she added.
Another major change has been the expansion of the guidelines to include bulimia nervosa and binge eating disorder, as well other related disorders.
"The other thing, of course, was the DSM-5 and the way eating disorders are conceptualized and the broadening of the diagnostic criteria. That?s an important aspect that's needed to be reflected in the guidelines and updated for clinicians."
The guidelines are published in the November issue of the Australian and New Zealand Journal of Psychiatry.
Anorexia Management
According to the guidelines, the management of AN should depend on the severity of the disorder and the age of the patient.
These latest recommendations update previous guidelines published in 2009, which were developed specifically for AN.
Expanding the reach of the current guidelines to include other eating disorders, Dr Hay, who is foundation chair of mental health, School of Medicine and Centre for Health Research, University of Western Sydney, Australia, and colleagues conducted a systematic review of the literature, identifying 21 articles for inclusion.
A multidisciplinary working group then wrote draft clinical practice guidelines, which underwent community, expert, and stakeholder consultation, allowing the identification of additional evidence for best practice.
Emphasizing the need for a wide-ranging approach to the management of patients with eating disorders, the authors note that there are several principles guiding treatment. These are as follows:
New Disorder
The guidelines also incorporate ARFID, a new disorder in the DSM-5. Although there is not a great deal of literature on ARFID, Dr Hay and colleagues felt that it was important to include it in the new guidelines.
"We needed to have it there so that clinicians are aware of it as a disorder ― what it is and how to conceptualize it ― so that they can start seeing, identifying it, and start learning about its epidemiology and treatment," said Dr Hay.
Finally, Dr Hay touched on the principle of least restrictive care, which is another notable change to the guidelines since their previous iteration.
"Currently, the model for practice in Australia and New Zealand psychiatry is to treat people with the least intrusive and least restrictive environment," she explained.
"We are really moving to try to do that as much as possible with anorexia nervosa, supporting people in the community with intensive outpatients or day patients treatment approaches, and reserving hospital only for those who are medically compromised and will sometimes need more intensive care."
Looking more broadly at the growing body of literature on AN, Dr Hay believes that patient outcomes can be good.
"Particularly in child and adolescent anorexia nervosa, we can be really quite optimistic and quite positive about treatment outcomes and about the efficacy of treatment," she said.
"We have some good evidence-based treatments, particularly in child and adolescence anorexia nervosa, particularly with family-based approaches.... We do know that treatments work and that specialist treatments work."
"We don't quite have that to the same degree in adult anorexia nervosa, but we do know that individual psychological therapies provided by specialists with specialist expertise are effective, and are certainly better than doing nothing or doing very little," she added.
Need for More Research
As well as clinical practice recommendations, the new guidelines stress the importance of further research into eating disorders, particularly for ARFID. Nevertheless, Dr Hay is hopeful that a number of randomized controlled trials that are currently under way, many of which are comparing psychological therapies, will prove enlightening.
"I suspect over the next few years, we'll start to work out that specialist supportive clinical management is a very good initial psychological therapy and maybe sufficient for many people with anorexia nervosa, but not for all."
"Some will require perhaps more intensive therapies, such as with cognitive-behavior therapy or with Maudsley adult therapy or focal psychodynamic therapy," she added.
Further down the line, Dr Hay is working with Steven Childs at the University of Sydney on the concept of staging AN.
Noting that the DSM-5 does not specify a clear upper weight cutoff for the disorder, Dr. Hay said: "People who may be not so very underweight, with body mass indices closer to the normal range, around 18, for example, would have quite different treatment needs and treatment approaches than people who have a body mass index right down at the level of about 13."
"I think we are realizing that anorexia nervosa does have these different stages, these different clinical syndromes...and that has an impact upon treatment needs [in terms of] what you do and how quickly you may act, or not."
The authors have disclosed no relevant financial relationships.
Aust N Z J Psychiatry. 2014;48:977-1008. Full text
Medscape Medical News
December 05, 2014
The first eating disorder guidelines to incorporate the latest recommendations from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), including the new disorder of avoidant restrictive food intake disorder (ARFID), have been released.
Produced by the Royal Australian and New Zealand College of Psychiatrists, the guidelines are evidence-based, multidisciplinary, and include consideration of recovery-oriented practice, with a special focus on anorexia nervosa (AN).
"One thing that is new and quite distinctive about these guidelines is that we have approached anorexia nervosa from the perspective of child and adolescent anorexia nervosa, anorexia nervosa in adults, and also severe and enduring anorexia nervosa, because the treatment approaches and the outcomes differ by clinically important ways," lead author Phillipa Hay, MD, told Medscape Medical News.
"People realize that...there are really quite important differences both in terms of approaches in child or adolescent and adults and also the small proportion who go on to have severe and enduring illness," she added.
Another major change has been the expansion of the guidelines to include bulimia nervosa and binge eating disorder, as well other related disorders.
"The other thing, of course, was the DSM-5 and the way eating disorders are conceptualized and the broadening of the diagnostic criteria. That?s an important aspect that's needed to be reflected in the guidelines and updated for clinicians."
The guidelines are published in the November issue of the Australian and New Zealand Journal of Psychiatry.
Anorexia Management
According to the guidelines, the management of AN should depend on the severity of the disorder and the age of the patient.
These latest recommendations update previous guidelines published in 2009, which were developed specifically for AN.
Expanding the reach of the current guidelines to include other eating disorders, Dr Hay, who is foundation chair of mental health, School of Medicine and Centre for Health Research, University of Western Sydney, Australia, and colleagues conducted a systematic review of the literature, identifying 21 articles for inclusion.
A multidisciplinary working group then wrote draft clinical practice guidelines, which underwent community, expert, and stakeholder consultation, allowing the identification of additional evidence for best practice.
Emphasizing the need for a wide-ranging approach to the management of patients with eating disorders, the authors note that there are several principles guiding treatment. These are as follows:
- Person-centered informed decision-making
- The involvement of family and significant others
- Recovery-oriented practice, maximizing self-determination and self-management
- Least restrictive treatment, best suited to an individual's needs
- A multidisciplinary approach
- Stepped and seamless care, building on strong links with primary care as well as general hospital and community care providers
- A culturally informed approach to diagnosis and treatment
- Indigenous care, demonstrating "cultural competence" when working with people from different backgrounds
New Disorder
The guidelines also incorporate ARFID, a new disorder in the DSM-5. Although there is not a great deal of literature on ARFID, Dr Hay and colleagues felt that it was important to include it in the new guidelines.
"We needed to have it there so that clinicians are aware of it as a disorder ― what it is and how to conceptualize it ― so that they can start seeing, identifying it, and start learning about its epidemiology and treatment," said Dr Hay.
Finally, Dr Hay touched on the principle of least restrictive care, which is another notable change to the guidelines since their previous iteration.
"Currently, the model for practice in Australia and New Zealand psychiatry is to treat people with the least intrusive and least restrictive environment," she explained.
"We are really moving to try to do that as much as possible with anorexia nervosa, supporting people in the community with intensive outpatients or day patients treatment approaches, and reserving hospital only for those who are medically compromised and will sometimes need more intensive care."
Looking more broadly at the growing body of literature on AN, Dr Hay believes that patient outcomes can be good.
"Particularly in child and adolescent anorexia nervosa, we can be really quite optimistic and quite positive about treatment outcomes and about the efficacy of treatment," she said.
"We have some good evidence-based treatments, particularly in child and adolescence anorexia nervosa, particularly with family-based approaches.... We do know that treatments work and that specialist treatments work."
"We don't quite have that to the same degree in adult anorexia nervosa, but we do know that individual psychological therapies provided by specialists with specialist expertise are effective, and are certainly better than doing nothing or doing very little," she added.
Need for More Research
As well as clinical practice recommendations, the new guidelines stress the importance of further research into eating disorders, particularly for ARFID. Nevertheless, Dr Hay is hopeful that a number of randomized controlled trials that are currently under way, many of which are comparing psychological therapies, will prove enlightening.
"I suspect over the next few years, we'll start to work out that specialist supportive clinical management is a very good initial psychological therapy and maybe sufficient for many people with anorexia nervosa, but not for all."
"Some will require perhaps more intensive therapies, such as with cognitive-behavior therapy or with Maudsley adult therapy or focal psychodynamic therapy," she added.
Further down the line, Dr Hay is working with Steven Childs at the University of Sydney on the concept of staging AN.
Noting that the DSM-5 does not specify a clear upper weight cutoff for the disorder, Dr. Hay said: "People who may be not so very underweight, with body mass indices closer to the normal range, around 18, for example, would have quite different treatment needs and treatment approaches than people who have a body mass index right down at the level of about 13."
"I think we are realizing that anorexia nervosa does have these different stages, these different clinical syndromes...and that has an impact upon treatment needs [in terms of] what you do and how quickly you may act, or not."
The authors have disclosed no relevant financial relationships.
Aust N Z J Psychiatry. 2014;48:977-1008. Full text
