52 Psychosomatic Medicine C LINICAL P SYCHIATRY N EWS • November 2006

ment, clinicians may have to assess the priate portions for weight maintenance by Use a ‘Multidisciplinary Stance’ family’s mealtime behavior and parenting eyeballing portions, not measuring them. Eating Disorders from page 1 skills and assist them in setting firm but When patients transition to partial hos- supportive limits on disordered behavior pitalization and earn time off the unit, they help parents become part of a unified Many patients with eating disorders and in carrying out the roles assigned to are asked to keep a record of any meal they team in assisting their child to change her have problems with preparing meals and them by the treatment team. This may in- eat outside the hospital, bingeing/purging behavior,” she explained. eating in social settings, which can be iso- volve having the family practice designing behaviors, urges, and exercising. “The important point to make to both lating and result in occupational and edu- menus, going to the grocery store, and Patients initially go on outings to restau- patients and families is that, unless you cational limitations. Social activities in eating at a restaurant together. Family rants in the partial hospital setting with change your behavior, you won’t be able which patients do participate may be mal- members must show a united front in set- staff so that they can practice and prepare in the long run to correct your eating dis- adaptive, such as exercising excessively. ting limits on the patient’s behavior and in for real-life social eating. ordered thoughts and feelings,” Dr. Eating disorders can “freeze” a person’s following through with consequences, Ms. Because many patients have lost or not Guarda said. “Treatment is a process of developmental progress, resulting in im- Bodenstein said. developed skills that are appropriate for conversion—from seeing dieting as the paired formation of identity and intimate “When lines get blurred, roles become their age, Fiona Scott, an occupational answer to recognizing it as the problem.” relationships, and difficulty in separating unclear, and progress stalls or regresses; it therapist with the eating disorders pro- Discussions with patients include mak- from parents, according to Dr. Guarda. can be helpful to use a behavior contract gram, works with patients on money man- ing patients realize that it is normal to have “It’s very important to educate parents ... to reset the treatment frame and to re- agement, coping strategies, work/study ambivalent feelings toward change, to re- about grocery shopping,” because eating delineate and make explicit what every- skills, and body image. lapse on the road to recovery, and to be ini- disorder patients “often want to be inti- body’s role is,” said Dr. Graham Redgrave, Daily and weekly schedules are impor- tially dissatisfied with the changes to their mately involved in planning family meals, assistant director of the eating disorder tant for planning social activities, meals, bodies. Body dissatisfaction typically lags the grocery shopping list, and anything program at Johns Hopkins. and filling in free time to stave off bore- behind behavioral change by several that has to do with food,” said Sandra During hospitalization, clinicians at Johns dom, which is a trigger for eating disorder months, Dr. Guarda said. Kirckhoff, a nurse on the inpatient unit in Hopkins consistently try to “take the emo- behavior, Ms. Scott said. Despite the reluctance of some thera- the eating disorders program. Adolescent tion out of the meals” and do not allow any Clothes shopping “is probably one of pists to weigh patients for fear of encour- patients can request some nondiet foods, arguments over whether something should the most important things that a patient aging focus on weight, it is critical to but they should not be in charge of doing be eaten or not, Ms. Kirckhoff said. has to do, especially after they’ve gotten up weigh patients at weekly office visits, be- the shopping or making menus or lists. The nursing staff supervises meals and to normal weight,” Ms. Scott said. She in- cause it is very difficult to know how Families should try to eat balanced encourages patients to eat all of their structs patients to get rid of all of their old things are going without doing so. “We are meals together at a table, with no one eat- food. Each patient is expected to eat like clothes, especially ones that were associ- very explicit with patients that we require ing diet food, such as having only a light a “normal weight, nondieter,” to consume ated with the illness. Sick clothes can in- [weigh-ins] in order to treat them,” she salad for dinner, or excessively discussing a wide food repertoire, and to stop all ex- clude overly large sweatpants or overly said. “You don’t treat hypertension with- how foods are prepared. After-meal activ- ercise if on weight gain. Team sports and small child sizes. New clothes should be out checking a patient’s blood pressure; ities can help to prevent purging, strenu- weight training are introduced when pa- appropriate for their age and size, and rea- why would we treat anorexia nervosa ous exercise, or guilt from feeling full. tients reach their target weight. The staff sonably tailored, neither baggy nor exces- without checking weight?” At various points in a patient’s treat- also teaches patients to determine appro- sively tight fitting. ■ Sparse Data on Eating Disorders Prompt Call for Research

BY JEFF EVANS department of psychiatry at the try 2006;163[suppl.]:1-54). For dif- Other tests may be necessary evidence suggesting some bene- Senior Writer University of South Florida, ferent organ systems, the guide- in certain circumstances, such as fit of cognitive-behavioral thera- Tampa. The total NIMH/NIH lines list symptoms and signs to dual-energy x-ray absorptiome- py (CBT) on purging, little data B ETHESDA, MD. — The re- funding for schizophrenia, which look for and particular laborato- try in anorexic patients who were available to support its ef- lease this year of American Psy- affects 3 million Americans, is es- ry tests that may help to diagnose haven’t had a menstrual period fectiveness on bingeing and anx- chiatric Association guidelines on timated to be $291 million, while the problem. for more than 6 months, Dr. iety or depression. treating eating disorders and two about $30 million is spent on eat- “Almost everyone seeing pa- Powers said. At her center, clini- Weak evidence suggests that analyses of the available evidence ing disorders research, Dr. tients with eating disorders cians also routinely order an elec- CBT may be more effective than to support such treatments have Powers said. should at least know the symp- trocardiogram, a 24-hour urine medications for purging behav- highlighted the dearth of effec- Efforts aimed at spreading the toms and then be able to choose creatinine clearance test, and a iors, but no other distinction be- tive, evidence-based interven- word about the high prevalence, how they’re going to work with test for level of complement 3, tween the two interventions tions for the disorders. morbidity, and mortality of eat- which is an immune system pro- could be made. The lack of such data and the ing disorders to legislators may be The APA guidelines stress tein that often drops to low lev- Virtually no evidence exists to funding to support eating disor- the best bet for greater funding of the assessment of els early in anorexic patients. suggest that CBT is better than ders research show that much re- eating disorders, which in turn It also may be easier to make a other forms of psychotherapy. mains to be accomplished before may attract greater interest from physical complications case for insurance coverage with There was no evidence on the disorders get the recognition researchers to submit research and lab tests that may be reviewers if you have baseline val- whether the interventions im- they deserve from the medical grant proposals, said Dr. Thomas ues for laboratory tests, she noted. proved quality of life. community and insurers, said R. Insel, director of the NIMH. relevant in patients with The guidelines recommend Fluoxetine is already Food and speakers and attendees at the an- While the lack of research anorexia nervosa or placing patients at different levels Drug Administration–approved nual conference of the National funding has made it difficult to of care (outpatient, intensive out- at 60 mg per day for the treat- Eating Disorders Association. At discern which treatments are best bulimia nervosa. patient, partial hospitalization, res- ment of bulimia nervosa, based least 5 million Americans have for particular eating disorders, idential treatment center, inpa- on 6- to 18-week trials showing the disorders, and anorexia ner- the APA’s new guidelines will still those particular problems—ei- tient hospitalization) according to that it reduced binge eating, vosa has the highest premature be helpful for clinicians who “are ther by themselves, or [by] con- categories that are used to assess purging, and associated psycho- mortality of any mental illness. not real familiar with the kinds of sult with a primary care doctor or the severity of their illness, even logical features, even though the The National Institute of Men- things that you see as complica- a specialist,” Dr. Powers advised. though there is little evidence to results were “pretty weak be- tal Health is funding 10 extra- tions in patients with eating dis- Bulimia nervosa patients may substantiate such placements. cause of the high dropout rates,” mural studies on eating disorders orders,” said Dr. Powers, who have many of the same symp- The independent, nonprofit said Dr. Russell Marx, medical di- at outside locations (seven of was a member of the APA work toms as anorexia nervosa patients health services research agency rector of the eating disorders pro- which are in New York), but group on eating disorders that because they have a past history ECRI (formerly the Emergency gram at the University Medical none of the institutes within the wrote the guidelines. of anorexia. Care Research Institute) con- Center at Princeton (N.J.). National Institutes of Health are For providers to make the best According to the guidelines, ducted a meta-analysis of 48 Dialectical behavior therapy conducting any intramural stud- judgment of the level of care and basic laboratory tests for bulim- unique randomized clinical trials has shown preliminary evidence ies on the disorders. In compari- specific type of treatment that a ia and anorexia patients should on bulimia nervosa. of being effective for bulimia. son, the NIMH and other NIH in- patient needs, the APA guidelines include urinalysis for ketones and The report found weak to In binge eating disorder, short- stitutes are funding 12 intramural stress the assessment of physical blood tests for electrolytes, urea moderate evidence supporting term trials of selective serotonin studies on schizophrenia and 14 complications and laboratory nitrogen, creatinine, thyroid- the effectiveness of medications reuptake inhibitors have reduced on bipolar disorder, in addition to tests that may be relevant in pa- stimulating hormone, a complete in reducing bingeing and purging the severity of illness as well as eat- many more extramural studies, tients with anorexia nervosa or blood count, liver enzymes, and behaviors, as well as anxiety and ing, psychiatric, and weight symp- said Dr. Pauline S. Powers of the bulimia nervosa (Am. J. Psychia- erythrocyte sedimentation rate. depression. Except for moderate toms, compared with placebo. ■