Community Treatment of Eating Disorders

The book is intended as a practical guide to setting up, staffing and running eating disorders services. The guidance and advice given is based.
Table of contents

This is either for physical reasons — usually for someone who is undernourished to the point that it is a risk to their physical health or their life — or to enable more intensive psychiatric or psychological treatment. Inpatient clinics are provided in hospitals and in some private treatment centres. Patients are admitted to the treatment centre and receive hour care. The location of the inpatient care varies from hospital to hospital — there may be a specialist unit with beds for eating disorder patients; more commonly eating disorder patients are treated in beds within psychiatric wards, or other in-patient wards in hospitals.

Patients who are admitted as inpatients are generally acutely medically unwell and have severe symptoms.

Treatment generally focuses first on medical stabilisation, re-feeding and weight restoration. Ideally, once the patient is medically stable ie their life is out of danger , some sort of psychotherapy is usually given as well. However, whether this happens depends on the hospital treatment regime. When the patient is considered well enough, they are normally moved to a day patient or an outpatient program.

Support and Services

Intravenous drips or a naso-gastric tube may be used a tube inserted through the nose to the stomach. Many people with eating disorders do not need hour care, but they do need ongoing treatment.

Assessment and Treatment for Eating Disorders

This training provides relevant professional development in the area of Eating Disorders suitable for Medical Practitioners, Nurses, Dietitians, Psychologists and other allied health professionals. This training can be completed at your own pace and both the eLearning training and webinar will take approximately 1 hour each to complete. The eLearning training is a highly interactive online course that includes expert videos, role-plays, interactive exercises, quizzes, assessment tools and resources.

The webinar and eLearning training will provide you with a basic understanding of current thinking on identifying, screening and assessing people with eating disorders; effective strategies to support the needs of people with eating disorders; identifying challenges in treatment and understanding care planning and coordinating services for people with eating disorders. To find out if you are eligible for subsidised access please link in with your local eating disorder coordinator click here. Broadcasted live on the 9 th May For webinar recordings and resources click here. To view these trainings ensure that you have Adobe Flash Player, enable pop-ups and if you are having difficulty viewing the content go to the settings in your Internet browser to zoom in.

The high overall satisfaction rating and open text themes from our survey reflect a largely engaged patient population. Only two patients during dropped out of the service and only five patients required detention under the Mental Health Act. Three patients were detained due to starvation-related risks. One patient was detained due to suicide risk following a significant overdose.

All four patients detained for admission had comorbid personality disorder diagnoses and required prolonged periods of in-patient care. Service cost is an important outcome for a service providing intensive treatment for a severely ill patient group usually treated in an in-patient setting. During , in-patient care reduced due to increased capacity to deliver intensive treatment in the community Fig. Patient safety is the most important outcome. A significant mortality rate would be expected in a service selecting patients with severe anorexia nervosa.

All four had a duration of illness of over 10 years. One patient died of starvation-related causes while an in-patient; one died of an overdose after weight restoration; the third patient died of post-operative septicaemia following acute bowel obstruction having dropped out of ANITT care; and the fourth patient died of pneumonia and heart failure with comorbid insulin-dependent diabetes, in the context of a starvation state. There is very little reliable evidence for the efficacy of in-patient care for adults with anorexia nervosa. A recent randomised controlled trial has shown the potential for managing patients with chronic anorexia nervosa in the community 15 and one other community-based treatment programme has described promising preliminary outcomes.

We aim to publish data on quality of life and symptomatic outcomes for a cohort of ANITT patients in the near future. Our crude mortality rate of 4. Tanaka et al 20 report a crude mortality rate of A year follow-up of a Swedish cohort with severe eating disorder analysed standardised mortality ratios SMRs according to lowest BMI around admission.


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The Swedish data and our experience would suggest that managed and stabilised low weight may allow for adequate physiological adaptation, substantially reducing the risk of serious medical complications or death. We are firmly of the belief that developing trusting, long-term relationships is key to risk management. The transparent sharing of the risk assessment with patients leads to fewer surprises and less opposition from patients when admission is necessary.

Given the expense of in-patient care and the lack of evidence for its efficacy, 2 unless patients are ready to change, 22 we argue that in-patient care should be used sparingly for brief admissions wherever possible. Our experience is that treating patients at home produces a wealth of contextual information that enriches the dietetic treatment and psychotherapy, in an environment where the patient feels safer.

We believe this leads to more sustainable change, more often, than in an in-patient ward. A small number of studies have explored cognitive, perceptual and socioemotional deficits in patients with anorexia nervosa in a starved state and in patients who have recovered. However, of the two studies that specifically tested patients who had recently restored weight after in-patient treatment, 24 , 25 neither showed an association between weight gain and improved deficits. This may suggest that starvation is not the central cause of these deficits and that what evidence exists of improved cognitive, perceptual or socioemotional deficits in recovered patients may be more to do with the psychological than the physical recovery.

In our opinion therefore, there is insufficient evidence of a causal relationship between starvation, cognitive abnormalities and a failure to engage in psychotherapy and therefore this in itself is not a rationale for admission and re-feeding. Our clinical experience is that emotionally engaged, trusting therapeutic relationships can be established with the majority of patients with severe anorexia nervosa, even at very low BMIs.

This takes persistence and patience. Re-feeding resistant patients within an in-patient programme, however sensitively achieved, necessitates the removal of their core coping strategy and their sense of autonomy and control. For many patients, this results in fear, resistance, defensiveness and a loss of trust in professionals. We therefore argue that in-patient care is overused because of fears about physical safety rather than objective evidence of acute risk and because of beliefs about starvation-related cognitive deficits preventing engagement in therapy.

There is a case for intensive community care for patients with severe anorexia nervosa as it can be acceptable to patients, relatively safe and cost less than admission. We would like to acknowledge the dedication and contribution of all staff who have worked within the ANITT in developing the service model and delivering high-quality care.

In particular Diane Matheson, without whose organisational skills the team would grind to a halt. We would also like to acknowledge the continued support of NHS Lothian in maintaining the service, in particular Linda Irvine and Tim Montgomery who supported the development and expansion of the service. Declaration of interest None.

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National Center for Biotechnology Information , U. Journal List Psychiatr Bull v. Correspondence to Calum Munro ku. This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License http: Abstract Aims and method A community intensive treatment service for severe anorexia nervosa is described.


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ANITT staffing, capacity and organisation The multidisciplinary team all work within a psychological framework, focusing on engagement. Open in a separate window. Assessment, engagement and stabilisation period This is a physical, dietetic and psychological assessment process carried out over weeks.

Assertive Community Treatment for Patients with Eating Disorders

Intensive therapy service An month course of twice-weekly therapy is offered with 6-monthly progress reviews. Supportive treatment service For patients who are unwilling or deemed currently unable to benefit from intensive therapy, a period of supportive treatment is offered. Psychological treatment All multidisciplinary work is driven by an individual psychological formulation for that patient.

Dietetic treatment The focus is on supporting the patient to make their own decisions about nutritional change. Risk management Safe management of risk is essential in a patient group with a relatively high mortality rate. Patient risk management We have a system for defining a physical state reflecting acute risk in anorexia nervosa, to guide when in-patient care is necessary online Appendix DS1. Staff risk management Burnout is a much acknowledged problem for clinicians working with eating disorders.

Staff perceived as supportive, caring and genuine: SO much effort is made with me from everyone. I feel genuinely supported.

IMPORTANT NEWS!

Patients valued a holistic psychological approach based on emotional and physical needs and not just weight: Patients valued individualised care: Engagement Evidence of engagement in treatment was gathered from the patient satisfaction survey, treatment drop-out and Mental Health Act use, for this notoriously hard to engage patient population. Service costs Service cost is an important outcome for a service providing intensive treatment for a severely ill patient group usually treated in an in-patient setting.


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    8. Anorexia Nervosa Intensive Treatment Team in-patient usage and costs Patient safety Patient safety is the most important outcome. Discussion There is very little reliable evidence for the efficacy of in-patient care for adults with anorexia nervosa. Acknowledgments We would like to acknowledge the dedication and contribution of all staff who have worked within the ANITT in developing the service model and delivering high-quality care.

    Footnotes Declaration of interest None.