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The American Psychiatric Association (APA) has released new guidelines for the assessment and treatment of eating disorders. The guidelines aim to improve the quality of care and outcomes for those with eating disorders by enhancing both assessment and treatment approaches.¹
The new guideline, released in February 2023, replaces the last-issued 2006 version.
Catherine Crone, MD, chair of the guideline writing group, said in a press statement, “Eating disorders often are unrecognized and untreated. This guideline and supplementary resources are intended to serve as a practical tool for clinicians, to help with screening, diagnosis, and providing evidence-based treatment for eating disorders.”¹
The guideline provides updated recommendations for assessing eating disorders as well as evidence-based pharmacological, psychotherapeutic, and other treatments. Recommendations primarily focus on anorexia nervosa, bulimia nervosa, and binge eating disorder. While the guideline does include some detail on the assessment of avoidant/restrictive food intake disorder (ARFID), treatment recommendations for ARFID are not incorporated due to the paucity of available data on managing this condition.
Updated Guideline Recommendations for Eating Disorders
Overall, the American Psychiatric Association provides 16 clinical recommendations for eating disorder care. Fourteen of the sixteen guidelines are “recommendations,” which “denotes confidence that the benefits of the intervention clearly outweigh the harms” while two are “suggestions,” which “denotes benefits that are viewed as outweighing harms, but the balance is more difficult to judge.” Guidelines are also rated as having high confidence (A), moderate confidence (B), or low confidence (C). With the exception of the recommendations for eating-disorder-focused psychotherapy and family-based treatment in patients with anorexia nervosa (which are rated as “B” for moderate confidence), all of the recommendations are rated as “low confidence.” These ratings suggest that further research is likely to change the recommendation or the level of confidence in the recommendations.
The 2023 APA guideline recommendations and suggestions include:
Screen for eating disorders as part of initial psychiatric evaluation
Components of an initial evaluation of a patient with a possible eating disorder should include:
patient’s height and weight history
presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors
patterns and changes in food repertoire
presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors
percentage of time preoccupied with food, weight, and body shape
prior treatment and response to treatment
psychosocial impairment secondary to eating or body image concerns or behaviors
family history of eating disorders, other psychiatric illnesses, and other medical conditions
Initial evaluation should also include:
weighing the patient and quantifying eating and weight control behaviors
comprehensive review of organ systems
identification of any co-occurring health conditions and psychiatric disorders
Vital signs should be part of the initial physical examination, and include:
Certain lab tests should be included as part of the initial physical examination for all patients with a possible eating disorder (including CBC and comprehensive metabolic panel)
Indications for use of an electrocardiogram
Use of a comprehensive treatment plan that is ideally coordinated by a multidisciplinary team
Patients with anorexia nervosa should have individualized goals set for weekly weight gain and target weight
Adults with anorexia nervosa should be treated with eating-disorder focused psychotherapy
Adolescents and emerging adults with anorexia nervosa should be treated with eating disorder-focused family-based treatment
Adults with bulimia nervosa should be treated with eating disorder-focused cognitive behavioral therapy and that a serotonin reuptake inhibitor can be prescribed as well
Suggestion (lower grade level recommendation) that adolescents and emerging adults with bulimia nervosa be treated with eating disorder-focused family-based treatment
Individuals with binge eating disorder be treated with eating disorder-focused cognitive behavioral therapy or interpersonal therapy (either individual or group)
Suggestion (lower grade level recommendation) that adults with binge eating disorder additionally be treated with either an antidepressant medication or lisdexamfetamine
Clinical Considerations for Assessing and Treating Disorders
Long-Term Impact of Eating Disorders
Additionally, the guideline warns clinicians of suicide, mortality, and long-term impacts of eating disorders:
Lifetime burdens and associated psychosocial impairments of eating disorders can be substantial because these illnesses typically have an onset in adolescence and can persist for decades
Eating disorders are associated with increases in all-cause mortality and deaths due to suicide
Morbidity and mortality among individuals with an eating disorder are heightened by the common co-occurrence of health conditions and other psychiatric disorders
Initial Screening
The updated guideline may be most relevant to practitioners who specialize in eating disorder assessment and treatment. For generalists, the most relevant recommendations may be those related to initial assessment.
Here, the APA emphasizes the importance of screening for eating disorders as part of every initial psychiatric assessment/evaluation, noting that the presence of an eating disorder cannot be predicted simply by assessing weight or BMI. The guideline offers recommendations for the use of specific screening tools, including the SCOFF questionnaire, Screen for Disordered Eating, and the Eating Disorder Screen for Primary Care.
Monitoring Level of Care
The guideline also includes extensive guidance regarding medical evaluation of eating disorders, including signs and symptoms by organ system and a comprehensive list of laboratory abnormalities related to nutritional restriction or purging behavior. These resources are helpful not only in guiding the assessing/treating clinician but may also be helpful to share with a patient’s medical team.
The APA further outlines clinical considerations for determining appropriate level of care for individuals with an eating disorder as well as characteristics of different levels of care. These determinants can help to guide clinicians in making appropriate referrals for specialized treatment and/or guiding a patient’s future care.
See our special report on eating disorders in the US and how to apply the new guideline.
As an additional resource, APA released a pocket guide for clinicians, which distills the most salient points of each recommendation, as well as quick reference charts and tables.
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