CPG for Eating Disorders

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Aspects includedThe CPG includes the following aspects of eating disorders: prevention, detection, diagnosis,interventions at the different levels of care, treatment, assessment, prognosis and legal aspects.InterventionsThe CPG includes the following interventions for primary prevention of eating disorders:psychoeducational interventions, media literacy, social and political mobilization and activism(advocacy), dissonance-induction techniques, interventions focused on eliminating or reducingthe risk factors of eating disorders or interventions to make the patient stronger (by developingstress coping skills).Some of the outcome variables of primary prevention interventions are: incidence of eatingdisorders, BMI, internalisation of the thin-ideal, body dissatisfaction, anomalous diet, negativeaffects and eating disorders.The CPG includes the following treatments:• Medical measures: oral nutritional support, nutritional support with artificial nutrition (enteraloral [nasogastric tube] and parenteral intravenous) and nutritional counselling (NC). NCincludes dietary counselling, nutritional counselling and/or nutritional therapy.• Psychological therapies: cognitive-behavioural therapy (CBT), self-help (SH), guided self-help(GSH), interpersonal therapy (IPT), family therapy (systemic [SFT] or unspecified [FT]),psychodynamic therapy (PDT) and behavioural therapy (BT).• Pharmacological treatments: antidepressants, antipsychotics, appetite stimulants, opioidantagonists and other psychoactive drugs (topiramate, lithium and atomoxetine).• Combined interventions (psychological and pharmacological or more than one psychologicalintervention).Clinically important treatment outcome variables according to the working group are: BMI,menstruation, pubertal development, reduction/elimination of binge-eating and purging,restoration of a healthy diet, absence of depression and psychosocial and interpersonalfunctioning. The latter two aspects are described in the questions regarding safety ofinterventions.In some cases, recurrence or relapse results are described in the safety section, along withtreatment withdrawls.CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS40
Aspects not included in the CPGThe CPG does not include the following diagnoses related with eating disorders for severalreasons:• Orthorexia. A poorly defined and insufficiently studied syndromic spectrum that consists ofextreme focus on eating healthy and contaminant-free foods. This disorder can be related toobsessive concerns about health, hypochondriac fears of diseases, and, in a certain way, tocultural attitudes linked to diet and food. Though it is true that people with orthorexia maypresent restrictive anomalies in their diets and ponderal losses, they cannot be consideredatypical or incomplete cases of AN.• Vigorexia (muscle dysmorphia). This disorder is characterized by excessive concern aboutobtaining body perfection by performing specific exercises. This extreme preoccupationentails significant dissatisfaction with one’s own body image, excessive exercise, special dietsand foods, to the point of generating dependence, as well as substance abuse 35 . At the momentit remains a vaguely defined disorder related with obsessiveness, perfectionism anddysmorphophobia 36-40 .• Night eating syndrome (nocturnal eaters). People with this disorder experience recurrentepisodes of binge-eating during sleep. It is not defined whether these clinical pictures are dueto an eating disorder or to a primary sleep disorder 41-44 .The CPG does not include patients under the age of 8 and, thus, diagnoses relating to eatingdisorders most common during those ages, such as swallowing phobia, selective eating andrefusal to eat are not included. However, these disorders are not included either when they areobserved in patients aged 8 and older for the following reasons:• Food phobia (simple phobias). In some cases it may be an anxiety-related disorder, while inothers it may be linked to hypochondria (fear of choking, swallowing phobia and death).Therefore, it does not seem to belong to the spectrum of eating disorders.• Selective eating and refusal to eat. Both are eating disorders but lack the complete andcharacteristic symptomatology associated with AN and BN (cognitive disturbances, distortedbody image, purging behaviours, etc).This does not mean that when deciding on primary prevention policies no interventions shouldbe carried out to address these behaviours, which could indeed be precursors of an eatingdisorder.The CPG does not include exclusive interventions for comorbid conditions that may occurwith eating disorders.CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS41
Page 1 and 2: Clinical Practice Guidelinefor Eati
Page 3: This clinical practice guideline (C
Page 6 and 7: Annex 2.7. Diagnostic Criteria for
Page 8 and 9: This CPG aims to provide the popula
Page 11 and 12: External Review of Patient Informat
Page 13 and 14: 14. What is the efficacy and safety
Page 15 and 16: CLINICAL PRACTICE GUIDELINE FOR EAT
Page 17 and 18: D 6.2. In anorexia nervosa (AN), we
Page 19 and 20: D 8.6. Primary care centres should
Page 21 and 22: 9.GM.02. Before initiating artifici
Page 23 and 24: Binge-Eating DisorderA 9.3.3.1. A s
Page 25 and 26: D 9.GP.11. In children and adolesce
Page 27 and 28: Binge-Eating DisorderD 9.GPH.6. In
Page 29 and 30: 11. Prognosis of Eating Disorders (
Page 31 and 32: ED: Eating disorderEDNOS: Eating di
Page 33 and 34: 1. IntroductionBackgroundThe develo
Page 35 and 36: However, there is a need for a guid
Page 37 and 38: Table 2. Studies on the prevalence
Page 39: 2. Scope and ObjectivesTarget Popul
Page 43 and 44: 3. MethodologyThe methodology emplo
Page 45 and 46: - Synthesis and analysis of the sci
Page 47 and 48: 4. Definition and Classification of
Page 49 and 50: - Other psychopathological disturba
Page 51 and 52: Sociocultural factorsThe studies id
Page 53 and 54: accompany eating disorders. However
Page 55 and 56: 5. Prevention of Eating DisordersKe
Page 57 and 58: (causal factors). Participants in t
Page 59 and 60: is a programme that promotes a heal
Page 61 and 62: MA 1341++MA 1341++No definitive con
Page 63 and 64: Of all the proposed criteria and re
Page 65 and 66: Spanish version of the EAT-40In Spa
Page 67 and 68: of the five dimension results in th
Page 69 and 70: 6.5. It is recommended to use quest
Page 71 and 72: 7.2. How are eating disorders class
Page 73 and 74: to help them cope with the situatio
Page 75 and 76: Other examinationsTo ascertain whet
Page 77 and 78: CLINICAL PRACTICE GUIDELINE FOR EAT
Page 79 and 80: - Initiating nutritional treatment
Page 81 and 82: 8.2. In eating disorders, what clin
Page 83 and 84: 8.3.2. Criteria for admission to da
Page 85 and 86: RecommendationsD 8.1. Individuals w
Page 87 and 88: 9. Treatment of Eating DisordersThe
Page 89 and 90: An RCT (Rigaud, 2007; France) 203 c
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9.2. Nutritional Counselling (NC)9.
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Recommendations(See recommendations
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Anorexia nervosaRecommendationsD 9.
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PSYCHOLOGICAL THERAPIESIn this sect
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Summary of the Evidence(See also th
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There is limited evidence to sugges
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In an RCT (Wilson, 2002; USA) 234 C
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SRSE 2401++SRSE 2401++CBT treatment
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In an RCT (Bulik, 1998) 236 the ove
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Evidence indicates that it is unlik
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A 9.3.3.1. Adult patients with BED
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In an RCT (Carter, 2003; Canada) 24
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Variable: reduction / remission of
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In yet another RCT (Carter, 1998 26
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Scientific EvidenceThere is insuffi
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Recommendations(See also recommenda
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Summary of the Evidence(See summary
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In an RCT (Lock, 2005) 271 , 20% of
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elaborated by the AHRQ of the US (2
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SUMMARY OF THE EVIDENCE FORPSYCHOLO
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D 9.GP.6. For patients with AN who
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PHARMACOLOGICAL TREATMENTIn this se
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9.9.1.2. What is the safety of anti
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There is strong evidence that antid
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Summary of the EvidenceSRSE 311++SR
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There is insufficient evidence sugg
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An RCT (Appolinario, 2003; Brazil)
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9.10. AntipsychoticsEvidence in AN
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9.11.2. What is the safety of cypro
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9.13.1.2. What is the safety of top
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Recommendations(See recommendations
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SUMMARY OF THE EVIDENCE FORPHARMACO
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COMBINED INTERVENTIONSThis section
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Antidepressants vs. antidepressants
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There is insufficient evidence to s
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Summary of the EvidenceSRSE 311++SR
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9.16.3. Binge-eating disorder9.16.3
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TREATMENT OF EATING DISORDERS THATO
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TREATMENT OF CHRONIC EATING DISORDE
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10. Assessment of Eating DisordersK
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EDI-2 (Version 2 of the EDI-1)Later
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BIABody Image Assessment. Collins,
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10.1.5. The use of questionnaires a
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has been widely used. It consists o
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out as the most adequate, given its
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abuse/dependency, low sensation see
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the freedom of articles 17 of the S
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12.2. Is the informed consent of an
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RecommendationAccording to current
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CLINICAL PRACTICE GUIDELINE FOR EAT
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Algorithm 2. Intervention if there
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9) Day care admission criteria:- Fr
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- Oral nutritional support in eatin
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Algorithm 4. Treatment of BN and BE
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14.Dissemination and implementation
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IntegralcareOutcomeSatisfaction ind
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15. Future research recommendations
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Annex 1. Levels of Evidence and Gra
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Annex 2. Clinical chaptersAnnex 2.1
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30. I eat diet food.31. I feel food
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Annex 2.4. Spanish version of the C
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6. Do you feel you have control ove
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20. I feel sad after eating more th
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33. APPLICABLE ONLY TO WOMEN. My la
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12. Do you eat reasonable amounts o
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Annex 2.7. Diagnostic Criteria for
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Within each guideline some variatio
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Bulimia nervosa (307.51)Diagnostic
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Annex 2.8. Spanish version of the E
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Formula:Patients with eating disord
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Annex 3. Information for patients w
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Alert SignsWhat signs can alert us
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members can seek support and guidan
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therapist who guides the sessions a
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negative attitudes towards weight a
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PizotifenThis drug belongs to the g
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TopiramateAnticonvulsant psychoacti
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BULIT Bulimia TestBULIT-R Revised v
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ISCIII Carlos III Health InstituteI
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General Directorate for Public Heal
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2) We identified 20 documents elabo
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estimator, establishing the followi
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17. Detecció i orientacions terap
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59. Lo importante es tu vida. No la
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98. Garner DM. Pathogenesis of anor
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141. Wilksch SM, Tiggemann M, Wade
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181. Rivas T, Jiménez M, Bersabé
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224. Fairburn CG, Jones R, Peveler
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262. McCann UD, Agras WS. Successfu
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302. McElroy SL, Casuto LS, Nelson
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341. Hodes M, Timimi S, Robinson P.
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388. Steinhausen HC. The outcome of
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427. Finnish Medical Society Duodec
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