NEDA TOOLKIT for Parents
Table of Contents
Common myths about eating disorders………………………………………………………………………….6
Eating disorder signs, symptoms and behaviors………………………………………………………….9
Ways to start a discussion with a loved one…………………….………………….………………………13
Advice from other parents: What to expect and how to respond………………………….17
Why parent-school communications may be difficult…………………………………………….20
Useful online resources for eating disorders……………………………………………………………. 21
Treatments available for eating disorders………………………………………………………………….24
The evidence on what treatment works………………………………………………………………………30
How to find a suitable treatment setting…………………………………………………………………….56
Treatment settings and levels of care………………………………………………………………………….59
Questions to ask the care team at a facility……………………………………………………………….61
Questions to ask when interviewing a therapist……………………………………………………….62
Questions parents may want to ask treatment providers privately…………………….63
Online databases to find suitable treatment………………………………………………………………64
How to take care of yourself while caring for a loved one…………………………………….65
Navigating and understanding insurance issues……………………………………………………….68
Sample letters to use with insurance companies………………………………………………………75
How to manage an appeals process…………………………………………………………………………….83
NEDA TOOLKIT for Parents
The NEDA Educational Toolkits Story
The background
Parents and Educators.the starting point
In September 2007 the Board of Directors of NEDA
Using the core questions we decided the Parent and
officially approved the organization's new strategic
Educators Toolkits would be created first. Additional
priorities, listing educational toolkits as a new NEDA
target audiences will include Coaches and Trainers,
priority fitting the new mission
Health Care Providers, and Individual Patients. We then
hired ECRI Institute, a recognized expert in providing
"To support those affected by eating disorders and be a
publications, information and consulting services
catalyst for prevention, cures, and access to quality
internationally for healthcare assessments. Their ability
care." Educational Toolkits were created to strengthen
to translate work on behalf of the eating disorders
existing materials and provide vital information to
community into useful, real world tools established an
targeted audiences. A list of audiences was prioritized
excellent partnership for creating the content of the
by the board and acts as a reference for ongoing
materials and toolkit development.
Parents and Educators.the process
The toolkit concept
ECRI initially created two separate toolsets with a
The initial concept of the toolkits was to tie together
consistent tone. We brought together two focus groups
existing information along with the development of
to guide us in the types of information to be included
new materials to create complete packages that would
for each of the audiences – parents and educators.
help targeted audiences during critical moments in
ECRI conducted additional interviews with interested
their search for help, hope and healing. They are
elementary and high school teachers and families.
intended for guidance, not for standards of care and
Next, ECRI researched and revised existing NEDA
would be based on information available at the time of
educational materials and handouts (as needed) and
created new materials as appropriate for each kit. The
result was a draft set of "tools" for each toolkit. Some
Creation of the toolkits took thoughtful consideration.
basic information is common to each; other tools are
We identified several key questions as we began
unique to each toolkit. As with all our materials, we
working on this project. First: "What is a NEDA
want to increase the outreach and support to our
Educational Toolkit?" led us to ask ourselves these
constituents while providing reliable information to the
general public about the unique and complex nature of
eating disorders.
Who is the audience we are trying to reach?
All focus groups agreed that an electronic toolkit,
How many different toolkits will we develop?
accessible via the NEDA website, would be the easiest,
What should a toolkit contain?
most up-to-date way to make the toolkits available.
How do we include our stakeholders in the
NEDA researched and reviewed several online toolkits,
development of the toolkits?
looking for the best elements of each that could be
How does our audience want to receive the toolkit
used to inform the design concept. The final design
once it's developed?
plan for the organization of each kit was created by
How do we market the toolkits?
designer, David Owens Hastings. ECRI then produced
What is the plan to revise and enhance the toolkits
the final documents that are the body of each of the
first toolkits. The focus groups reviewed materials one
more time and made suggestions for revisions. Their
excellent edits and useful comments were integrated
into the drafts. Joel Yager, MD, and additional clinical
advisors were final reviewers on all documents. ECRI
then submitted the Toolkit documents to NEDA.
NEDA TOOLKIT for Parents
Beyond parent and educators toolkits
We fully recognize that not all the information within
each toolkit will be able to address the diversity and
the nuances of each person's and/or families unique
circumstances. Our intent is to provide a one-stop
place for a comprehensive overview relating to eating
disorders for each audience. We have included
resources for further information and will be going
deeper as funding permits with each audience. We are
imagining at this point in the project Parent and
Educator toolkits version 1.0, then version 2.0 and so
on. The lifecycle of the toolkits is an important aspect
in managing this strategic priority for the organization.
Our goal is to maintain the usefulness of the toolkits by
reviewing and revising each at two-year intervals and
including the most up-to-date research and
information. NEDA's clinical advisors will be primary
reviewers, along with others invited by NEDA, including
members of professional organizations that will be
disseminating the toolkits.
We are currently seeking funding for the ongoing
development of toolkits, as well as distribution and
marketing. If you or anyone you know may be
interested in contributing to, sponsoring or providing a
grant to support these efforts, please be sure to contact
our Development Office at 212-575-6200, ext. 307;
We hope you'll find these toolkits useful and will share
this resource with others.
NEDA TOOLKIT for Parents
Basic Information
for Parents
NEDA TOOLKIT for Parents
Common myths about eating disorders
This information is intended to help dispel all-too-common misunderstandings about eating disorders and those
affected by them. If your family member has an eating disorder, you may wish to share this information with others (i.e., other family members, friends, teachers, coaches, family physician).
Eating disorders are not an illness
because females are more likely to seek help, and
health practitioners are more likely to consider an
Eating disorders are a complex medical/psychiatric
eating disorder diagnosis in females. Differences in
illness. Eating disorders are classified as a mental
symptoms exist between males and females: females
illness in the American Psychiatric Association's
are more likely to focus on weight loss; males are more
Diagnostic and Statistical Manual of Mental Health
likely to focus on muscle mass. Although issues such as
Disorders (DSM-IV), are considered to often have a
altering diet to increase muscle mass, over-exercise, or
biologic basis, and co-occur with other mental illness
steroid misuse are not yet criteria for eating disorders,
such as major depression, anxiety, or obsessive-
a growing body of research indicates that these factors
compulsive disorder
are associated with many, but not all, males with eating
Eating disorders are uncommon
Men who suffer from eating disorders tend to
They are common. Anorexia nervosa, bulimia nervosa,
and binge-eating disorder are on the rise in the United
States and worldwide. Among U.S. females in their
Sexual preference has no correlation with developing
teens and 20s, the prevalence of clinical and
an eating disorder.
subclinical anorexia may be as high as 15%. Anorexia
nervosa ranks as the 3rd most common chronic illness
Anorexia nervosa is the only serious eating
among adolescent U.S. females. Recent studies suggest
disorder
that up to 7% of U.S. females have had bulimia at some
time in their lives. At any given time an estimated 5% of
All eating disorders can have damaging physical and
the U.S. population has undiagnosed bulimia. Current
psychological consequences. Although excess weight
findings suggest that binge-eating disorder affects 0.7%
loss is a feature of anorexia nervosa, effects of other
to 4% of the general population.
eating disorders can also be serious or life threatening,
such as the electrolyte imbalance associated with
Eating disorders are a choice
People do not choose to have eating disorders. They
A person cannot die from bulimia
develop over time and require appropriate treatment
to address the complex medical/psychiatric symptoms
While the rate of death from bulimia nervosa is much
and underlying issues.
lower than that seen with anorexia nervosa, a person
with bulimia can be at high risk for death and sudden
Eating disorders occur only in females
death because of purging and its impact on the heart
and electrolyte imbalances. Laxative use and excessive
Eating disorders occur in males. Few solid statistics are
exercise can increase risk of death in individuals who
available on the prevalence of eating disorders in
are actively bulimic.
males, but the disorders are believed to be more
common than currently reflected in statistics because
Subclinical eating disorders are not serious
of under-diagnosis. An estimated one-fourth of
anorexia diagnoses in children are in males. The
Although a person may not fulfill the diagnostic criteria
National Collegiate Athletic Association carried out
for an eating disorder, the consequences associated
studies on the incidence of eating-disordered behavior
with disordered eating (e.g., frequent vomiting,
among athletes in the 1990s, and reported that of those
excessive exercise, anxiety) can have long-term
athletes who reported having an eating disorder, 7%
consequences and requires intervention. Early
were male. For binge-eating disorder, preliminary
intervention may also prevent progression to a full-
research suggests equal prevalence among males and
blown clinical eating disorder.
females. Incidence in males may be underreported
NEDA TOOLKIT for Parents
Dieting is normal adolescent behavior
Eating disorders are about appearance and
While fad dieting or body image concerns have
become "normal" features of adolescent life in Western
Eating disorders are a mental illness and have little to
cultures, dieting or frequent and/or extreme dieting
do with food, eating, appearance, or beauty. This is
can be a risk factor for developing an eating disorder. It
indicated by the continuation of the illness long after a
is especially a risk factor for young people with family
person has reached his or her initial ‘target' weight.
histories of eating disorders and depression, anxiety, or
Eating disorders are usually related to emotional issues
obsessive-compulsive disorder. A focus on health,
such as control and low self-esteem and often exist as
wellbeing, and healthy body image and acceptance is
part of a "dual" diagnosis of major depression, anxiety,
preferable. Any dieting should be monitored.
or obsessive-compulsive disorder.
Anorexia is "dieting gone bad"
Eating disorders are caused by unhealthy and
unrealistic images in the media
Anorexia has nothing to do with dieting. It is a life-
threatening medical/psychiatric disorder.
While sociocultural factors (such as the ‘thin ideal') can
contribute or trigger development of eating disorders,
A person with anorexia never eats at all
research has shown that the causes are multifactorial
and include biologic, social, and environmental
Most anorexics do eat; however, they tend to eat
contributors. Not everyone who is exposed to media
smaller portions, low-calorie foods, or strange food
images of thin "ideal" body images develops an eating
combinations. Some may eat candy bars in the morning
disorder. Eating disorders such as anorexia nervosa
and nothing else all day. Others may eat lettuce and
have been documented in the medical literature since
mustard every 2 hours or only condiments. The
the 1800s, when social concepts of an ideal body shape
disordered eating behaviors are very individualized.
for women and men differed significantly from today—
Total cessation of all food intakes is rare and would
long before mass media promoted thin body images for
result in death from malnutrition in a matter of weeks.
women or lean muscular body images for men.
Only people of high socioeconomic status get
Recovery from eating disorders is rare
eating disorders
Recovery can take months or years, but many people
People in all socioeconomic levels have eating
eventually recover after treatment. Recovery rates vary
disorders. The disorders have been identified across all
widely among individuals and the different eating
socioeconomic groups, age groups,
disorders. Early intervention with appropriate care can
improve the outcome regardless of the eating disorder.
Although anorexia nervosa is associated with the
You can tell if a person has an eating disorder
highest death rate of all psychiatric disorders, research
simply by appearance
suggests that about half of people with anorexia
nervosa recover, about 20% continue to experience
You can't. Anorexia may be easier to detect visually,
issues with food, and about 20% die in the longer term
although individuals may wear loose clothing to
due to medical or psychological complications.
conceal their body. Bulimia is harder to "see" because
individuals often have normal weight or may even be
overweight. Some people may have obvious signs, such
as sudden weight loss or gain; others may not. People
with an eating disorder can become very effective at
hiding the signs and symptoms. Thus, eating disorders
can be undetected for months, years, or a lifetime.
NEDA TOOLKIT for Parents
Eating disorders are an attempt to seek
You're not sick until you're emaciated
attention
Only a small percentage of people with eating
disorders reach the state of emaciation often portrayed
The causes of eating disorders are complex and
in the media. The common belief that a person is only
typically include socio economic, environmental,
truly ill if he or she becomes abnormally thin
cultural, and biologic factors. People who experience
compounds the affected individuals' perceptions of
eating disorders often go to great lengths to conceal it
body image and not being "good" at being "sick
due to feelings of shame or a desire to persist in
enough." This can interfere with seeking treatment and
behavior perceived to afford the sufferer control in life.
can trigger intensification of self-destructive eating
Eating disorders are often symptomatic of deeper
disorder behaviors.
psychological issues such as low self-esteem and the
desire to feel in control. The behaviors associated with
Kids under age 15 are too young to have an
eating disorders may sometimes be interpreted as
eating disorder
‘attention seeking"; however, they indicate that the
affected person has very serious struggles and needs
Eating disorders have been diagnosed in children as
young as seven or eight years of age. Often the
precursor behaviors are not recognized until middle to
Purging is only throwing up
late teens. The average age at onset for anorexia
nervosa is 17 years; the disorder rarely begins before
The definition of purging is to evacuate the contents of
puberty. Bulimia nervosa is usually diagnosed in mid-
the stomach or bowels by any of several means. In
to-late teens or early 20s, although some people do not
bulimia, purging is used to compensate for excessive
seek treatment until even later in life (30s or 40s).
food intake. Methods of purging include vomiting,
enemas and laxative abuse, insulin abuse, fasting, and
You can't suffer from more than one eating
excessive exercise. Any of these behaviors can be
disorder
dangerous and lead to a serious medical emergency or
death. Purging by throwing up also can affect the teeth
Individuals often suffer from more than one eating
and esophagus because of the acidity of purged
disorder at a time. Bulimarexia is a term that was
coined to describe individuals who go back and forth
between bulimia and anorexia. Bulimia and anorexia
Purging will help lose weight
can occur independently of each other, although about
half of all anorexics become bulimic. Many people
Purging does not result in ridding the body of ingested
suffer from an eating disorders not otherwise specified
food. Half of what is consumed during a binge typically
(EDNOS), which can include any combination of signs
remains in the body after self-induced vomiting.
Laxatives result in weight loss through fluids/water and
the effect is temporary. For these reasons, many people
Achieving normal weight means the anorexia
with bulimia are average or above-average weight.
Weight recovery is essential to enabling a person with
anorexia to participate meaningfully in further
treatment, such as psychological therapy. Recovering
to normal weight does not in and of itself signify a cure,
because eating disorders are complex
medical/psychiatric illnesses.
NEDA TOOLKIT for Parents
Eating Disorder Signs, Symptoms, and Behaviors
Anorexia Nervosa
Dramatic weight loss
Has intense fear of
others without eating
weight gain or being
Dresses in layers to hide
"fat," even though
Consistently makes
excuses to avoid
Is preoccupied with
weight, food, calories, fat
situations involving
experience of body
grams, and dieting
weight or shape,
undue influence of
Refuses to eat certain
weight or shape on
foods, progressing to
excessive, rigid
self-evaluation, or
restrictions against
exercise regimen –
whole categories of food
despite weather,
seriousness of low
(e.g., no carbohydrates,
fatigue, illness, or
injury, the need to
"burn off " calories
Postpuberty female
feeling "fat" or
Withdraws from usual
overweight despite
friends and activities
Feels ineffective
and becomes more
isolated, withdrawn,
Has strong need for
constipation, abdominal
pain, cold intolerance,
lethargy, and excess
Shows inflexible
about eating in public
Has limited social
Denies feeling hungry
Develops food rituals
restrained initiative
Resists maintaining
(e.g., eating foods in
body weight at or
certain orders, excessive
above a minimally
chewing, rearranging
normal weight for
food on a plate)
NEDA TOOLKIT for Parents
Bulimia Nervosa
In general, behaviors and
Steals or hoards food
Looks bloated from
attitudes indicate that
in strange places
weight loss, dieting, and
control of food are
Drinks excessive
Frequently diets
amounts of water
becoming primary concerns
Shows extreme
Evidence of binge eating,
concern with body
including disappearance of
weight and shape
large amounts of food in
mouthwash, mints, and
short periods of time or lots
Has secret recurring
of empty wrappers and
Hides body with baggy
containers indicating
binge eating (eating
consumption of large
period of time an
Maintains excessive,
amount of food that
rigid exercise regimen
Evidence of purging
is much larger than
behaviors, including
– despite weather,
most individuals
frequent trips to the
fatigue, illness, or
bathroom after meals, signs
injury, the need to
and/ or smells of vomiting,
"burn off " calories
circumstances); feels
presence of wrappers or
lack of control over
packages of laxatives or
Shows unusual
ability to stop eating
swelling of the cheeks
Purges after a binge
Appears uncomfortable
(e.g., self-induced
eating around others
Has calluses on the
vomiting, abuse of
back of the hands and
laxatives, diet pills
knuckles from self-
Develops food rituals (e.g.,
and/or diuretics,
eats only a particular food
induced vomiting
excessive exercise,
or food group [e.g.,
Teeth are discolored,
condiments], excessive
chewing, doesn't allow
Body weight is
foods to touch)
Creates lifestyle
typically within the
schedules or rituals to
normal weight range;
Skips meals or takes small
make time for binge-
may be overweight
portions of food at regular
and-purge sessions
Withdraws from usual
friends and activities
NEDA TOOLKIT for Parents
Binge Eating Disorder (Compulsive Eating Disorder)
Evidence of binge eating,
Steals or hoards food in Has periods of
including disappearance of
large amounts of food in
short periods of time or lots
Hides body with baggy
continuous eating
of empty wrappers and
beyond the point of
containers indicating
feeling comfortably
consumption of large
Creates lifestyle
schedules or rituals to
make time for binge-
Does not purge
Develops food rituals (e.g.,
eats only a particular food or
Engages in sporadic
food group [e.g., condiments], Skips meals or takes
fasting or repetitive
excessive chewing, doesn't
small portions of food
allow foods to touch)
at regular meals
Body weight varies
from normal to mild,
moderate, or severe obesity
Other Eating Disorders
Any combination of the above
NEDA TOOLKIT for Parents
How to be supportive
Recommended Do's
Recommended Don'ts
Accuse or cause feelings of guilt
Educate yourself on eating disorders; learn the jargon
Invade privacy and contact the patient's doctors
or others to check up behind his/her back
Learn the differences between facts and myths about weight, nutrition, and exercise
Demand weight changes (even if clinically
necessary for health)
Ask what you can do to help
Insist the person eat every type of food at the
Listen openly and reflectively
Be patient and nonjudgmental
Invite the person out for social occasions where
Talk with the person in a kind way when you are
the main focus is food
calm and not angry, frustrated, or upset
Invite the person to go clothes shopping
Have compassion when the person brings up
painful issues about underlying problems
Make eating, food, clothes, or appearance the focus of conversation
Let him/her know you only want the best for
Make promises or rules you cannot or will not follow (e.g., promising not to tell anyone)
Remind the person that he/she has people who
care and support him/her
Threaten (e.g., if you do this once more I'll…)
Offer more help than you are qualified to give
Suggest professional help in a gentle way
Create guilt or place blame on the person
Offer to go along
Put timetables on recovery
Be flexible and open with your support
Take the person's actions personally
Try to change the person's attitudes about
Compliment the person's personality, successes,
eating or nag about food
and accomplishments
Try to control the person's life
Encourage all activities suggested by the treating care team, such as keeping
Use scare tactics to get the person into
appointments and medication compliance
treatment, but do call 911 if you believe the
person's condition is life-threatening
Encourage social activities that don't involve food
Encourage the person to buy foods that he/she
will want to eat (as opposed to only "healthy"
Help the person to be patient
Help with the person's household chores (e.g.,
laundry, cleaning) as needed
Remember: recovery takes time and food may
always be a difficult issue
Remember: recovery work is up to the affected
Show care, concern, and understanding
Ask how he/she is feeling
Try to be a good role model Understand that the person is not looking for
attention or pity
NEDA TOOLKIT for Parents
Ways to start a discussion with a loved one who might
have an eating disorder
The following guidance presumes that the situation is serious, that it is not immediately life threatening, and that it does not require emergency medical care or a call to 911.
Learn all you can about eating disorders
Explain the reasons for your concerns, without
mentioning eating behavior
Then, prepare yourself to listen with compassion and
no judgment. Have a list handy of the resources to offer
The person may den the situation because of
overwhelming feelings, such as shame and guilt. Avoid
expressing frustration with the person. Stay calm. Be
Remember that even though you are
gently persistent as you go on expressing your
informed about the eating disorder, only a
concerns. Ask, "Are you willing to consider the
professional trained in diagnosing eating
possibility that something is wrong?" Be prepared with
disorders can make a diagnosis
resources to offer if the person seems to be listening—or leave a list of resources behind for the person to
Avoid using your knowledge to nag or scare the person.
look at on his/her own. Expressing your concerns may
The goal of a discussion should be to express your
be awkward at first, but such efforts can provide the
concerns about what you've observed and persuade,
bridge to help the person. Even if the person does not
but not force, the person to accept help.
acknowledge a problem during your discussion, you
have raised awareness that you are paying attention,
Plan a private, uninterrupted time and place
are concerned, and want to be a support.
to start a discussion
Ask if he/she is willing to explore these
Be calm, caring, and nonjudgmental. Directly express,
concerns with a healthcare professional who
in a caring way, your observations and concerns about
understands eating disorders
the person's behavior. Use a formula like "I am concerned about you and what's going on for you when
Remember that only appropriately trained
I see you [fill in the blank]." Cite specific days/times,
professionals can offer appropriate options and guide
situations, and behaviors that have raised your concern.
treatment. Your job is to express concern and offer
Share your wonder about whether the behavior might
support. Ask if he/she will share the feelings that come
indicate an eating disorder that requires treatment.
from the behavior you've observed. Does it provide a
Share what you've observed about the person's mood,
sense of control, relief, satisfaction, or pleasure? Let
depression, health, addiction recovery, or relationships.
your loved one know there are other ways to feel
Avoid words and body language that could imply
better that don't take such a physical and emotional
blame. Avoid discussing food and eating behavior,
which can lead to power struggles. Leave those issues
for the therapist to handle. Comments like "You're
Remind your loved one that many people
putting on weight" or "You look thinner," may be
have successfully recovered from an eating
perceived as encouraging disordered eating.
disorder
Offer to help find a treatment center and offer to go along to a therapist or intake appointment. Offer
encouragement and support, but, understand that in
the long run, recovery is up to the person.
NEDA TOOLKIT for Parents
Take a break if your loved one continues to
deny the problem
Revisit the subject again soon, but not in a
confrontational way. It's frustrating and scary to see someone you love suffering and be unable to do much
about it. Remember that control is often a big issue. You cannot successfully control another person's
behavior. Many patients and families interviewed about these issues discussed "control" as a key issue
they had to come to terms with. If your child is older than 18, treatment cannot be forced or discussed with
any health professional without written permission from your child. Even if your child is younger than age
18 years of age, he/she must be willing to acknowledge the problem and want to participate in treatment. In
some cases, enlisting the support of others whom the person likes and respects may help—like a teacher,
coach, guidance counselor, or other mentor who can
share your concerns.
Lastly, being a good support means that you
also have to take good care of yourself and
attend to the stresses you feel from the
This is important not only for your wellbeing, but also to serve as a model of healthy behavior for the person
you are trying to support. Don't let your loved one's eating disorder completely rule your life.
NEDA TOOLKIT for Parents
First steps to getting help
These steps are intended for use in a nonemergency situation. If the situation is a medical or psychiatric emergency in which the patient is at risk of suicide or is medically unstable, call 911 immediately.
Early detection, initial evaluation, and ongoing
Medical assessment should include the following:
management can play a significant role in recovery and
in preventing an eating disorder from progressing to a
Physical exam including weight, height, body
more severe or chronic state. The following
mass index (BMI), cardiovascular and
assessments are recommended as first steps to
peripheral vascular function, dermatologic
diagnosis and will help determine the level of care
symptoms (e.g., health of skin, hair growth),
needed for your family member. Receiving appropriate
and evidence of self-injurious behaviors
treatment at the earliest opportunity can aid in long-
term recovery. The following assessments are
Laboratory tests (see list below)
recommended as first steps to diagnosis and will help
determine the level of care your child or family
Dental examination if a history of purging
behaviors exists
Patient assessment by a physician experienced in
Establishment of the diagnosis along with a
eating disorders should include the following:
determination of eating disorder severity
Patient history, including screening questions
about eating patterns
Laboratory Testing Used for Diagnosis of Eating
Disorders and Monitoring Response to Treatment
Medical, nutritional, and psychological and
social functioning (if possible, an eating
Standard Work-Up
disorder expert should assess the mental
health of your child)
Complete Blood Count (CBC) with differential
Attitudes toward eating, exercise, and
Complete Metabolic Profile: sodium, chloride,
potassium, glucose, blood urea nitrogen,
Family history of eating disorders or other
psychiatric disorders, including alcohol and
Creatinine, total protein, albumin, globulin,
other substance use disorders
calcium, carbon dioxide, asat, alkaline
Family history of obesity
Phosphates, total bilirubin
Assessment of how the patient interacts with
Serum magnesium
people regarding food-related feelings and
Thyroid Screen (T3, T4, TSH)
Assessment of attitudes toward eating,
Electrocardiogram (ECG)
exercise, and appearance
NEDA TOOLKIT for Parents
Special Circumstances
Level of Care
If uncertain of diagnosis:
Once a diagnosis is made, a level of care will be
recommended based on the physical, psychiatric, and
Erythrocyte sedimentation rate
laboratory findings. Pursue the level of care that is
recommended for your child. This may include
Radiographic studies (computed tomography
inpatient, outpatient, intensive outpatient, partial
or magnetic resonance imaging of the brain or
hospital, or residential treatment.
upper or lower gastrointestinal system)
If patient has been amenorrheic for 6 months:
Urine pregnancy, luteinizing and follicle-
stimulating hormone, and prolactin tests
If patient is 15% or more below ideal body weight
Complement 3 (C3)
24 Creatinine Clearance
If patient is 15% or more below IBW lasting 6 months or
longer at any time during course of eating disorder:
Dual Energy X-Ray Absorptiometry (DEXA) to
assess bone mineral density
Estradiol Level (or testosterone in male)
If patient is 20% or more below IBW or any neurologic
If patient is 20% or more below IBW or sign of mitral
Echocardiogram
If patient is 30% or more below IBW:
Skin Testing for Immune Functioning
NEDA TOOLKIT for Parents
Advice from other parents: What to expect and how to
respond
Well-meaning people who have no idea about what
Can I give you some advice?
your family is going through can sometimes say
insensitive things. Others who need to be part of the
I appreciate your thoughtfulness and desire to help,
care and communication plan—like schools, coaches,
and it's good to know I have your support. I'd really
other family members—need to know certain things.
prefer to rely on the advice of our care team right
Avoid responding to intrusive questions that are none
now. We are getting lots of input from lots of
of the asker's business. On the other hand, some
directions and it's really a little overwhelming. Thanks
questions provide an opportunity to educate and
enlighten if you feel so inclined. Some days you may
just feel too drained to respond to questions—let the
Why do you think he/she has an eating
asker know it's not a great day to be asking questions. Parents of adolescents and young adults with an
disorder?
eating disorder offer the advice below about possible
No one knows exactly what causes eating disorders.
ways to respond to questions, based on their own
Right now I'm concerned with supporting my child
through treatment and not focusing on the how and whys.
Aren't eating disorders just the new disease
fad? I hear about them all over the media.
How can he/she be sick? He/she doesn't look
Not at all. An eating disorder is not a "fad" or a
"phase." People don't just "catch" it and get over it.
Individuals with bulimia nervosa typically are within
Eating disorders are complex and devastating
the normal weight range, and some may be
conditions that can have serious consequences for
underweight or overweight. Individuals with anorexia
physical and emotional health, quality of life, and
may not look it outwardly until the disorder becomes
so severe that it is life threatening.
An eating disorder? That's not really an
illness is it? It's just dieting gone bad
Why did he/she tell a teacher [coach, nurse,
[anorexia]. It's just an excuse to get sympathy
counselor—any other adult] first?
for being overweight [bulimia; binge eating
disorder].
Kids often are hesitant to tell their parents something
they feel really bad about. We're happy and relieved
It's a recognized and real illness, identified by the
that he/she at least told someone who then told us so
National Institute of Mental Health. It's also serious –
we can get him/her the care he/she needs.
anorexia is the largest cause of death among teenage
What are you doing to help your child?
He's/she's only in middle school. Isn't that too
We're listening to our child, educating ourselves about
young to have an eating disorder?
it, and getting the best, most comprehensive care
possible to address all the aspects of a really complex
No. Eating disorders are diagnosed in people as young
illness. It's exhausting.
NEDA TOOLKIT for Parents
Can't you just make her eat?
Why didn't you do anything sooner?
Like many behavioral problems, it is hard to make
The scariest thing about eating disorders is how
changes unless there is a consistent, persistent, and
secretive they are and how well a person can hide the
clinically informed way of going about it. Although
condition. Hindsight is 20/20. Had we known the signs
you can't just "make them eat," you can, as parents
and symptoms back then that we know now, we might
working with a professional who supports your efforts,
have suspected it sooner and would have sought help
find effective ways to disrupt starvation and over
right away. Even then, the person has to be willing to
exercise. In fact, studies in the UK and US suggest that
accept treatment after the initial medical crisis is
putting parents in charge of weight restoration is
over—and the nature of the illness makes that hard.
effective for most adolescents with anorexia nervosa.
What can I do to help?
Will he/she be cured after treatment?
Thanks very much for asking. Life has been very
We're hopeful for a full recovery over time. It can be a
draining lately just trying to make sure my child is
very long haul. Getting the right treatment is key and
getting the care he/she needs. It leaves little time for
that's a significant part of what I'm trying to
the mundane. I keep my "to-do" list handy. (Pull out
your list.) If you're serious, I could use help with (assign
a task with a date and time that it's needed).
Is there a chance that he/she could die?
Why aren't you letting me help you?
Eating disorders can be life-threatening. They affect a
person's physical and emotional health. Some people
Our child's illness is serious and I'm relying on
have died from them. It's very scary, but we are
professional help to treat his/her condition. The help I
hopeful and doing everything we can to make sure
need from family and friends is your continued
he/she gets care that will prevent that.
support and ongoing friendship. I appreciate your
asking. If I think of something our family needs that
Do you want us to help the child make-up
you can do for us, I'll let you know.
work (flexible schedule) or should we leave
him/her back a grade? Do you want us to
Why didn't you tell me about this earlier?
provide a tutor?
It's private and our focus initially was on educating
Let's schedule a meeting with my child's therapist and
ourselves and getting our child the best care. We
the principal, key teachers, nurse, and school
weren't even sure it would be helpful to share with
psychologist to create the education plan.
others. So when we were ready, we decided that now
is the right time for us to share this with friends and
What kind of support do you want the school
to provide?
How are you coping with this?
Have a specific list from the treatment team: Mealtime
Thanks for asking. It's very draining and very stressful
support; excuse from physical education or other
on our entire family. We really appreciate the
activities as needed; communication expected from
understanding and support coming from friends.
school and with whom.
NEDA TOOLKIT for Parents
Can I go with you to the support group?
Can't you just make him/her go to the
hospital?
The response depends on the context: If the person is
being nosy and is not close to the family or patient, it
The use of hospitalization to treat anorexia nervosa
may be inappropriate to attend a support group. In
varies from country to country. In the US,
that case, here is a response: The support group is
hospitalization for medical complications for
intended for people who are closest to the situation. If
adolescents with AN is a common intervention.
you want to learn more about eating disorders, that's
Depending on individual state law, a parent may be
terrific. Community information seminars are given
able to admit their minor children for medical
locally sometimes on eating disorders and that might
hospitalization against the minor's wishes. Laws
be a more comfortable setting—these are often
governing psychiatric hospitalization of minors also
offered through local hospital outreach programs or
vary from state to state, but in many, parents cannot
eating disorder advocacy groups.
require their minor children to stay in a psychiatric
facility if a judge determines they are not a danger to
Is he/she going to have to be hospitalized?
themselves or others, or cannot care for themselves.
That depends on the progress he/she makes as an
How long will he/she be in treatment?
outpatient. We'll just have to see how it goes.
Hospitalization is sometimes necessary with this
Everyone's treatment process and progress is different.
illness because of the serious medical consequences it
It could be months; it could be years.
Why are you going to family therapy?
Why is he/she returning to the hospital
We're hoping to better understand the problem, our
role in the recovery process, how best to encourage
Recovery is a hard and not always predictable road. A
and support our son/daughter, and how to help
few steps forward and a step back. Sometimes events
manage the symptoms.
or stresses can trigger a relapse. But keeping a
positive outlook is important and knowing that many
How long will he/she be in recovery?
people recover keeps us going.
Don't put timetables on recovery. Every patient
Why can't you stop this destructive behavior?
progresses at his/ her own speed. Be patient with
therapy, finding the right medication, and the process
Recovery is ultimately up to the patient. The care
of the entire treatment plan.
team and all of us in the family are doing everything
we can to give her/him the care and support needed
for recovery. But no one can force or speed up
Is your child on any medications that I should
treatment and recovery.
be aware of? What are the side effects I
should be looking out for?
How much school is your child going to miss?
The school and coaches and anyone your child spends
That isn't entirely clear right now, but based on the
significant time with should be given this information
treatment team's recommendation for the near term,
in case of an adverse event. Be prepared with copies
here is what we know…
of a sheet that summarizes medication names, dosing
regimen, and the prescribing physician's contact
NEDA TOOLKIT for Parents
Why parent-school communications may be difficult:
Regulatory constraints and confidentiality issues
This information is intended to help both parents and school staff understand each other's perspectives about
communication and the factors that affect their communications.
Parents of children with an eating disorder (diagnosed
Teachers explain that sometimes the student considers
or undiagnosed) sometimes express frustration about
the problem to be the parent, so contacting the parent
what they perceive as a lack of communication about
about a concern can make a student's problem worse
their child's behavior from school teachers, coaches,
in the students' eyes. Conversely, a student can also
guidance counselors, and other school administrative
prohibit a teacher from talking with parents about the
personnel. From the parents' perspective, feelings have
teachers' concerns without evidence from direct
been expressed that "my child is in school and at
observations of behavior.
school activities more waking hours a day than they are home. Why didn't the school staff notice something
The following link presents the position statement from
was wrong? Why don't they contact us about our child
the professional association of school counselors:
to tell us what they think?"
It states the professional
From a teacher's perspective, feelings have been
responsibilities of school counselors, emphasizing
expressed that "my hands are tied by laws and
rights to privacy, defining the meaning of
regulations about what and how we are allowed to
confidentiality in a school setting, and describing the
communicate concerns to parents. Also, it's often the
role of the school counselor. The position statement's
case that a given teacher sees a student less than an
summary is as follows:
hour a day in a class full of kids. So no school staff person is seeing the child for a prolonged period. Kids
"A counseling relationship requires an atmosphere of
are good at hiding things when they want to. "
trust and confidence between student and counselor. A
student has the right to privacy and confidentiality. The
While rules vary from state to state, the Position
responsibility to protect confidentiality extends to the
Statement on Confidentiality from The American
student's parent or guardian and staff in confidential
School Counselor Association may help both sides
relationships. Professional school counselors must
better understand why communications between
adhere to P.L. 93-380."
family members and school personnel may be difficult at times. The rationale behind this position is that an
atmosphere of trust is important to the counseling
relationship. In addition, schools may be bound by strict protocols generated by state regulations about
how teachers and staff are required to channel observations and concerns. For example, school
districts in a state may be required to have a "student assistance program" team to handle student
nonacademic issues. Teacher concerns are submitted
on a standard form to the team that then meets to develop a "student action plan." Privacy laws can
prohibit a teacher from discussing their concerns with a student without parent permission.
NEDA TOOLKIT for Parents
Useful online resources for eating disorders
Academy for Eating Disorders
Eating Disorders Coalition for Research,
Policy & Action
An organization for healthcare professionals in the
eating disorders field. The academy promotes
A coalition with representatives of various eating
research, treatment, and prevention of eating
disorder groups. This organization focuses on lobbying
disorders. Their Web site lists current clinical trials and
the federal government to recognize eating disorders
general information about eating disorders.
as a public health priority.
A Chance to Heal Foundation
ECRI Institute Bulimia Resource Guide for
Families
This foundation was established to provide financial
assistance to individuals with eating disorders who
might not otherwise receive treatment or reach full
ECRI Institute, an independent, nonprofit healthcare
recovery due to their financial circumstances. The
research organization, researching the best ways to
organization's mission also focuses on increasing
improve patient care. ECRI Institute produces
public awareness and education about eating
evidence-based information about healthcare for
disorders and advocating for change to improve
patients and families, including the Web site listed
access to quality care for eating disorders.
above. The Institute is designated an Evidence-based
Practice Center by the U.S. Agency for Healthcare
Anna Westin Foundation
Research and Quality and a Collaborating Center of
the World Health Organization.
Maudsley Parents
This organization was founded in memory of a child
who died from bulimia complications. It performs
advocacy, education, and speakers, and provides
resources about eating disorders, treatment, and
Maudsley Parents is an independent, nonprofit,
navigating the health insurance system. The
volunteer organization of parents. The Maudsley
Anna Westin Foundation and Methodist Hospital
approach is an evidence-based treatment for eating
Eating Disorders Institute partnered to establish a
disorders. In Maudsley treatment, parents play a key
long-term residential eating disorder treatment
role in helping their child recover.
program for women in Minnesota.
National Alliance on Mental Illness
Anorexia Nervosa and Related Eating
Disorders, Inc.
A national grassroots mental health organization
dedicated to improving the lives of people living with
serious mental illness and their families.
This organization provides information about
anorexia, bulimia, binge-eating disorder, and other lesser-known food and weight disorders, including
self-help tips and information about recovery and
NEDA TOOLKIT for Parents
National Association of Anorexia Nervosa
Something Fishy
and Associated Disorders (ANAD)
This Web site gives detailed information on most aspects of eating disorders: defining them, preventing
This organization seeks to alleviate the problems of
them, finding treatments, and paying for recovery.
eating disorders by educating the public and
Useful links to related articles and stories are
healthcare professionals, encouraging research, and
sharing resources on all aspects of these disorders.
ANAD's Web site includes information on finding support groups, referrals, treatment centers, advocacy,
Voices not Bodies
and background on eating disorders.
National Eating Disorders Association
An all-volunteer organization dedicated to eating
disorders awareness and prevention.
This organization is the largest non-profit organization in the United States dedicated to supporting those
affected by eating disorders and being a catalyst for
prevention, cures and access to quality care. NEDA
develops support programs for a wide range of
audiences, publishes and distributes educational
materials, operates a toll-free eating disorders
Information and Referral Helpline which links callers
to vital information and treatment. The searchable
database of treatment providers throughout the U.S.
and Canada is also available on the website.
Eating Disorder Referral and Information
Center
This is a sponsored site with a large archive of
information on eating disorders and referral information to treatment centers.
Perfect Illusions
These Public Broadcasting System web pages are based on a NOVA television program documentary.
The site provides information on eating disorders with personal stories and links.
NEDA TOOLKIT for Parents
Treatment
Information
NEDA TOOLKIT for Parents
Treatments available for eating disorders
Standard treatments include medications (prescription
alleviate depression, but may also play a role in
drugs), various psychotherapies, nutrition therapy,
making an individual feel full and possibly prevent
other nondrug therapies, and supportive or adjunct
binge eating in patients with bulimia or binge eating
interventions such as yoga, art, massage, and
disorder. FDA has issued a warning and labeling to
movement therapy. Some novel treatments are
prevent prescription of one particular antidepressant
currently under research, such as implantation of a
for eating disorders Wellbutrin, which is available in
device called a vagus nerve stimulator implanted at
several brand and generic formulations— because it
the base of the neck. This stimulator is currently in use
leads to higher risk of epileptic seizures in these
to treat some forms of depression, and it is under
research for treating obesity.
Psychological Therapy
The most commonly used treatments—psychotherapy
and medication—are delivered at various levels of
Several types of psychotherapy are used in individual
inpatient and outpatient care, and in various settings
and group settings and with families. Patients must be
depending on the severity of the illness and the
medically stable to be able to participate meaningfully
treatment plan that has been developed for a
in any type of psychological therapy. Thus, a patient
particular patient. Bulimia nervosa and binge eating
who has required hospitalization for refeeding and to
disorders can often be treated on an outpatient basis,
stabilize his/her medical condition will ordinarily not
although more severe cases may require inpatient or
be able to participate in therapy until after he/she has
residential treatment. The levels of care and types of
recovered sufficiently to enable cognitive function to
treatment centers are discussed in separate documents
return to normal.
in the tool kit. The treatment plan should be developed
by a multidisciplinary team in consultation with the
A given psychologist or psychiatrist may use several
patient, and family members as deemed appropriate by
different approaches tailored to the situation. The
the patient and his/her team.
types of psychotherapy used are listed here in a chart
and defined below. Cognitive behavior therapy (CBT)
Medication
and behavior therapy (BT) have been used for many
years as first-line treatment, and they are the most-
Biochemical abnormalities in the brain and body have
used types of psychotherapy for bulimia. CBT involves
been associated with eating disorders. Many types of
three overlapping phases. The first phase focuses on
prescription drugs have been used in treatment of
helping people to resist the urge to engage in the cycle
eating disorders; however, only one prescription drug
of behavior by educating them about the dangers. The
(fluoxetine) actually has a labeled indication for one
second phase introduces procedures to reduce dietary
eating disorder, bulimia nervosa. (This means that the
restraint and increase eating regularity. The last phase
manufacturer requested permission from the U.S. Food
involves teaching people relapse-prevention strategies
and Drug Administration (FDA) to market the drug
to help prepare them for possible setbacks. A course of
specifically for treatment of bulimia nervosa and that
individual CBT for bulimia nervosa usually involves 16-
FDA approved this request based on the evidence the
to 20-hour-long sessions over a period of 4 to 5 months.
manufacturer provided about the drug's efficacy for
BT uses principles of learning to increase the frequency
bulimia nervosa.)
of desired behavior and decrease the frequency of
problem behavior. When used to treat bulimia nervosa,
Most prescription drug therapy used for treatment of
BT focuses on teaching relaxation techniques and
the disorder is aimed at alleviating major depression,
coping strategies that individuals can use instead of
anxiety, or obsessive-compulsive disorder (OCD), which
binge eating and purging or excessive exercise or
often coexist with an eating disorder. Some
prescription drug therapies are intended to make
individuals feel full to try to prevent binge eating.
Self-help groups are listed here because they may be
Generic and brand names of prescription drugs that
the only option available to people who have no
have been used to treat eating disorders are listed in
insurance. However, self-help groups can also have
the chart. Some of these antidepressants also can exert
negative effects on a person with an eating disorder if
other effects. Selective serotonin reuptake inhibitors
they are not well-moderated by a trained professional.
NEDA TOOLKIT for Parents
Medication names: Generic (Brand)
Antidepressants
Opioid antagonist
Tricyclics
Naltrexone (Nalorex) (Intended to alleviate
Amitriptyline (Elavil)
addictive behaviors such as the addictive drives to
Clomipramine (Anafranil)
eat or binge eat.)
Desipramine (Norpramin, Pertofrane)
Imipramine (Janimine, Tofranil)
Antiemetic
Nortriptyline (Aventyl, Pamelor)
Modified Cyclic Antidepressants
Ondansetron (Zofran) (Used to give sensation of
Trazodone (Desyrel)
satiety and fullness.)
Selective Serotonin Reuptake Inhibitors (SSRIS)
Citalopram (Celexa)
Escitalopram (Lexapro)
Topiramate (Topamax) (May help regulate feeding
Fluoxetine (Prozac, Sarafem)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Aminoketone
Lithium carbonate (Carbolith, Cibalith-S, Duralith,
Bupropion (Wellbutrin, Zyban): Now
Eskalith, Lithane, Lithizine, Lithobid, Lithonate,
contraindicated for treatment of eating disorders
Lithotabs) (Used for patients who also have
because of several reports of drug-related
bipolar disorder, but may be contraindicated for
patients with substantial purging.)
Monoamine Oxidase Inhibitors
Brofaromine (Consonar)
Isocarboxazide (Benazide)
Moclobemide (Manerix)
Phenelzine (Nardil)
Tranylcipromine (Parnate)
Serotonin And Noradepinephrine Reuptake Inhibitor
Duloxetine (Cymbalta)
Venlafaxine (Effexor)
Mianserin (Bolvidon)
Mirtazapine (Remeron)
NEDA TOOLKIT for Parents
Psychological Therapies
Other Adjunctive and Alternative Treatments
Individual Psychotherapy
Creative Art Therapies
Behavior therapy
Exposure with response prevention
Movement Therapy
Hypnobehavior therapy
Cognitive therapy
Cognitive analytic therapy
Nutritional Counseling
Cognitive behavior therapy (all forms)
Individual, group, family, and mealtime-support
Cognitive remediation therapies
Scheme-based cognitive therapy
Self-guided cognitive behavioral therapy
Other Therapies
Dialectical behavior therapy
Although little research exists to support the use of
Guided imagery
the following interventions, individual patients have
Psychodynamic therapy
sometimes found some of these approaches to be
Self psychology
useful, particularly as adjuncts to conventional
Psychoanalysis
treatments. However, these approaches should not be
Interpersonal psychotherapy
used in place of evidence-based treatments where the
Motivational enhancement therapy
latter are available.
Psychoeducation
Supportive therapy
Emailing for support or coaching
Family therapy
Eye movement desensitization
Involving family members in psychotherapy
sessions with and without the patient
Group psychotherapy
Cognitive behavioral therapy
Psychodynamic
Relaxation training
Psychoeducational
Interpersonal
Self-Help groups
ANAD (Anorexia Nervosa and Associated
12-step approaches
Eating Disorders Anonymous
Web-based on-line programs
NEDA TOOLKIT for Parents
Treatments Defined
Antidepressants Prescription drugs used for treatment
Cognitive Remediation Therapy (CRT) Since patients
of eating disorders and aimed at alleviating major
with anorexia nervosa (AN) have a tendency to get
depression, anxiety, or obsessive-compulsive disorder,
trapped in detail rather than seeing the big picture, and
which often coexist with an eating disorder.
have difficulty shifting thinking among perspectives,
this newly investigated brief psychotherapeutic
Behavior Therapy (BT) A type of psychotherapy that
approach targets these specific thinking styles and
uses principles of learning to increase the frequency of
their role in the development and maintenance of an
desired behaviors and/or decrease the frequency of
eating disorder. Currently, it's usually conducted side
problem behaviors. Subtypes of BT include dialectical
by side with other forms of psychotherapies.
behavior therapy (DBT), exposure and response
prevention (ERP), and hypnobehavioral therapy.
Dialectical Behavior Therapy (DBT) A type of
behavioral therapy that views emotional deregulation
Cognitive Therapy (CT) A type of psychotherapeutic
as the core problem in eating disorders. It involves
treatment that attempts to change a patient's feelings
teaching people new skills to regulate negative
and behaviors by changing the way the patient thinks
emotions and replace dysfunctional behavior. (See also
about or perceives his/her significant life experiences.
Behavioral Therapy.)
Subtypes include cognitive analytic therapy and
cognitive orientation therapy.
Equine/Animal-assisted Therapy A treatment program
in which people interact with horses and become
Cognitive Analytic Therapy (CAT) A type of cognitive
aware of their own emotional states through the
therapy that focuses its attention on discovering how a
reactions of the horse to their behavior.
patient's problems have evolved and how the
procedures the patient has devised to cope with them
Exercise Therapy An individualized exercise plan that is
may be ineffective or even harmful. CAT is designed to
written by a doctor or rehabilitation specialist, such as
enable people to gain an understanding of how the
a clinical exercise physiologist, physical therapist, or
difficulties they experience may be made worse by
nurse. The plan takes into account an individual's
their habitual coping mechanisms. Problems are
current medical condition and provides advice for what
understood in the light of a person's personal history
type of exercise to perform, how hard to exercise, how
and life experiences. The focus is on recognizing how
long, and how many times per week.
these coping procedures originated and how they can
Exposure with Response Prevention (ERP) A type of
behavior therapy strategy that is based on the theory
Cognitive Behavior Therapy (CBT) CBT is a goal-
that purging serves to decrease the anxiety associated
oriented, short-term treatment that addresses the
with eating. Purging is therefore negatively reinforced
psychological, familial, and societal factors associated
via anxiety reduction. The goal of ERP is to modify the
with eating disorders. Therapy is centered on the
association between anxiety and purging by preventing
principle that there are both behavioral and attitudinal
purging following eating until the anxiety associated
disturbances regarding eating, weight, and shape.
with eating subsides.(See also Behavioral Therapy.)
Cognitive Orientation Therapy (COT) A type of
Expressive Therapy A nondrug, nonpsychotherapy form
cognitive therapy that uses a systematic procedure to
of treatment that uses the performing and/or visual
understand the meaning of a patient's behavior by
arts to help people express their thoughts and
exploring certain themes such as aggression and
emotions. Whether through dance, movement, art,
avoidance. The procedure for modifying behavior then
drama, drawing, painting, etc., expressive therapy
focuses on systematically changing the patient's beliefs
provides an opportunity for communication that might
related to the themes, not beliefs that refer directly to
otherwise remain repressed.
eating behavior.
NEDA TOOLKIT for Parents
Eye Movement Desensitization and Reprocessing
Mandometer Therapy Treatment program for eating
(EMDR) A nondrug and nonpsychotherapy form of
disorders based on the idea that psychiatric symptoms
treatment in which a therapist waves his or her fingers
of people with eating disorders emerge as a result of
back and forth in front of the patient's eyes, and the
poor nutrition and are not a cause of the eating
patient tracks the movements while also focusing on a
disorder. A mandometer is a computer that measures
traumatic event. It is thought that the act of tracking
food intake and is used to determine a course of
while concentrating allows a different level of
processing to occur in the brain so that the patient can
review the event more calmly or more completely than
Massage Therapy A generic term for any of a number of
various types of therapeutic touch in which the
practitioner massages, applies pressure to, or
Family Therapy A form of psychotherapy that involves
manipulates muscles, certain points on the body, or
members of an immediate or extended family. Some
other soft tissues to improve health and well-being.
forms of family therapy are based on behavioral or
Massage therapy is thought to relieve anxiety and
psychodynamic principles; the most common form is
depression in patients with eating disorders.
based on family systems theory. This approach regards
the family as the unit of treatment and emphasizes
Maudsley Method A family-centered treatment
factors such as relationships and communication
program with three distinct phases. During the first
patterns. With eating disorders, the focus is on the
phase parents are placed in charge of the child's eating
eating disorder and how the disorder affects family
patterns in hopes to break the cycle of not eating, or of
relationships. Family therapies may also be
binge eating and purging. The second phase begins
educational and behavioral in approach.
once the child's refeeding and eating is under control
with a goal of returning independent eating to the
Hypnobehavioral Therapy A type of behavioral therapy
child. The goal of the third and final phase is to address
that uses a combination of behavioral techniques such
the broader concerns of the child's development.
as self-monitoring to change maladaptive eating
disorders and hypnotic techniques intended to
Mealtime Support Therapy Treatment program
reinforce and encourage behavior change.
developed to help patients with eating disorders eat
healthfully and with less emotional upset.
Interpersonal Therapy (IPT) IPT (also called
interpersonal psychotherapy) is designed to help
Motivational Enhancement Therapy (MET) A treatment
people with eating disorders identify and address their
based on a model of change, with focus on the stages
interpersonal problems, specifically those involving
of change. Stages of change represent constellations of
grief, interpersonal role conflicts, role transitions, and
intentions and behaviors through which individuals
interpersonal deficits. In this therapy, no emphasis is
pass as they move from having a problem to doing
placed directly on modifying eating habits. Instead, the
something to resolve it. The stages of change move
expectation is that the therapy enables people to
from "pre-contemplation," in which individuals show no
change as their interpersonal functioning improves. IPT
intention of changing, to the "action" stage, in which
usually involves 16 to 20 hour-long, one-on-one
they are actively engaged in overcoming their problem.
treatment sessions over a period of 4 to 5 months.
Transition from one stage to the next is sequential, but
not linear. The aim of MET is to help individuals move
Light therapy (also called phototherapy) Treatment
from earlier stages into the action stage using cognitive
that involves regular use of a certain spectrum of lights
and emotional strategies.
in a light panel or light screen that bathes the person in
that light. Light therapy is also used to treat conditions
Movement/Dance Therapy
such as seasonal affective disorder (seasonal
The psychotherapeutic use of movement as a process
that furthers the emotional, cognitive, social, and
physical integration of the individual, according to the
American Dance Therapy Association.
NEDA TOOLKIT for Parents
Nutritional Therapy Therapy that provides patients
Psychotherapy The treatment of mental and emotional
with information on the effects of eating disorders,
disorders through the use of psychological techniques
techniques to avoid binge eating, and advice about
designed to encourage communication of conflicts and
making meals and eating. For example, the goals of
insight into problems, with the goal being symptom
nutrition therapy for individuals with bulimia nervosa
relief, changes in behavior leading to improved social
are to help individuals maintain blood sugar levels,
and vocational functioning, and personality growth.
help individuals maintain a diet that provides them
with enough nutrients, and help restore overall
Psychoeducational Therapy A treatment intended to
physical health.
teach people about their problem, how to treat it, and
how to recognize signs of relapse so that they can get
Opioid Antagonists A type of drug therapy that
necessary treatment before their difficulty worsens or
interferes with the brain's opioid receptors and is
recurs. Family psychoeducation includes teaching
sometimes used to treat eating disorders.
coping strategies and problem-solving skills to families,
friends, and/or caregivers to help them deal more
Pharmacotherapy Treatment of a disease or condition
effectively with the individual.
using clinician-prescribed drugs.
Self-guided Cognitive Behavior Therapy A modified
Progressive Muscle Relaxation A deep relaxation
form of cognitive behavior therapy in which a
technique based on the simple practice of tensing or
treatment manual is provided for people to proceed
tightening one muscle group at a time followed by a
with treatment on their own, or with support from a
relaxation phase with release of the tension. This
nonprofessional. Guided self-help usually implies that
technique has been purported to reduce symptoms
the support person may or may not have some
associated with night eating syndrome.
professional training, but is usually not a specialist in
eating disorders. The important characteristics of the
Psychoanalysis An intensive, nondirective form of
self-help approach are the use of a highly structured
psychodynamic therapy in which the focus of
and detailed manual-based CBT, with guidance as to
treatment is exploration of a person's mind and
the appropriateness of self-help, and advice on where
habitual thought patterns. It is insight oriented,
to seek additional help.
meaning that the goal of treatment is for the patient to
increase understanding of the sources of his/her inner
Self Psychology A type of psychoanalysis that views
conflicts and emotional problems.
anorexia and bulimia as specific cases of pathology of
the self. According to this viewpoint, people with eating
Psychodrama A method of psychotherapy in which
disorders cannot rely on human beings to fulfill their
patients enact the relevant events in their lives instead
self-object needs (e.g., regulation of self-esteem,
of simply talking about them.
calming, soothing, vitalizing). Instead, they rely on food
(its consumption or avoidance) to fulfill these needs.
Psychodynamic Therapy Psychodynamic theory views
Self psychological therapy involves helping people
the human personality as developing from interactions
with eating disorders give up their pathologic
between conscious and unconscious mental processes.
preference for food as a self-object and begin to rely
The purpose of all forms of psychodynamic treatment
on human beings as self-objects, beginning with their
is to bring unconscious thoughts, emotions and
memories into full consciousness so that the patient
can gain more control over his/her life.
Supportive Therapy Psychotherapy that focuses on the
management and resolution of current difficulties and
Psychodynamic Group Therapy Psychodynamic groups
life decisions using the patient's strengths and
are based on the same principles as individual
available resources.
psychodynamic therapy and aim to help people with
past difficulties, relationships, and trauma, as well as
Telephone Therapy A type of psychotherapy provided
current problems. The groups are typically composed
over the telephone by a trained professional.
of eight members plus one or two therapists.
NEDA TOOLKIT for Parents
The Evidence on What Treatment Works:
Clinical Guidelines and Evidence Reports
If you want access to the same documents that clinicians use to guide their treatment decisions, and if you want to
know what the available evidence says on what works for treatment of eating disorders, you want to look at
published clinical practice guidelines and medical journal articles called systematic reviews. The information in this document provides links to that information so you can look it over and take it with you to discuss the care
plan with the physicians and others who will treat your family member. This document discusses two types of evidence-based
treatments for bulimia eating disorders in general; the
information used by clinicians in determining
other systematic review did not pool data for analysis
appropriate care for eating disorders: clinical practice
from groups of studies, but rather looked at individual
guidelines and systematic reviews. We define below
studies on their own. Both systematic reviews were
what an evidence-based clinical guideline and a
performed by very reputable research organizations:
systematic review are and provide links to the
two U.S. Evidence-based Practice Centers of the U.S.
documents. If you review this information before
Agency for Healthcare Research and Quality (AHRQ).
meeting with the care team, it can help you have
Links to the Executive Summary and full Evidence
informed discussions about care plans with your loved
Reports are provided.
one's care team.
Bulimia Nervosa: Efficacy of Available
Systematic Reviews of Clinical Studies
Treatments
A systematic review is a comprehensive review and
A Systematic Review conducted by ECRI Institute
analysis of data from the available published clinical
Evidence-based Practice Center ECRI Institute's
studies on existing methods of diagnosing and treating
approach was unique in producing this evidence report
a disorder. Researchers start out with key clinical
and the bulimia nervosa resource guide. The focus of
questions that they seek to answer, and then they
the work was driven by an external advisory committee
perform a comprehensive search for published data to
of patients and family members affected by bulimia
analyze to address the questions. Thus, the data for
nervosa, clinicians and specialists from leading eating
analysis are collected from as many published clinical
disorder treatment centers that treat eating disorders,
studies as there are to address the question. The data
scientists who conduct research on eating disorders,
are then pooled together statistically where possible
health insurance representatives, and others who
and analyzed to figure out how well each treatment
affect patient care. ECRI Institute gratefully
works and for whom it works best. Sometimes sufficient
acknowledges the support of The Hilda & Preston Davis
data are not available to conclusively answer a
Foundation, which provided major funding for this
question. Knowing where the holes in the research are
evidence report and the family resource guide and
is important, because that knowledge will help in
Web site that emerged from the research. The
planning new research that hopefully will answer the
approach was unique because of the intensive
questions about "what works?" Also, it's important to
involvement of families and recovering patients in
understand that some treatments may not have
formulating the key questions and reviewing the family
evidence available about how well they work.
and patient information before publication.
Therefore, your decisions about treatment may have to
be based on considerations other than conclusive
Link to the Summary:
clinical evidence. A lot more research is needed about
what works best in the field of eating disorders. That
said, some information is available about how well
some types of treatment work. Keep in mind that a lack
Link to the Full Report:
of evidence doesn't mean that a treatment does not
work—it just means no evidence is available to be able
to conclude whether or not it works.
Following this section are links to two systematic
reviews: one pertains to bulimia nervosa and pooled
data together where possible on all the different
NEDA TOOLKIT for Parents
Management of Eating Disorders
A systematic review conducted by RTI
Clinical Practice Guidelines
International, University of North Carolina at
Chapel Hill Evidence-based Practice Center
A practice guideline is defined as a "systematically
developed statement to assist practitioner and patient
This systematic review of the literature focused on key
decisions about appropriate healthcare for specific
questions concerning anorexia nervosa, bulimia
clinical conditions." The following four clinical practice
nervosa, and eating disorders not otherwise specified
guidelines have been published by reputable medical
(i.e., especially binge eating disorder) to address
organizations and are available to the medical
questions posed by the American Psychiatric
treatment team that is providing care to your child. We
Association and Laureate Psychiatric Clinic and
also provide summaries of these guidelines below.
Hospital through AHRQ. Funding was provided by
These guidelines were identified from the National
AHRQ, the Office of Research on Women's Health at
Guideline Clearinghouse (www.guideline.gov)
the National Institutes of Health, and the Health
Resources and Services Administration. We received
Identifying and treating eating disorders. American
guidance and input from a Technical Expert Panel. This
Academy of Pediatrics.
report was also published as four separate articles in
the International Journal of Eating Disorders in 2007.
Practice guideline for the treatment of patients
Link to the Executive Summary:
with eating disorders. American Psychiatric
Link to the Full Report:
Finnish Medical Society Duodecim. Eating disorders
among children and adolescents.
Berkman, N.D., C.M. Bulik, and K.N. Lohr. (2007).
U.K. National Collaborating Centre for Mental
Outcomes of Eating Disorders: A Systematic Review of
Health (National Institute for Health and Clinical
the Literature. International Journal of Eating
Excellence [NICE]). Eating disorders. Core
Disorders, 40(4): 293-309
interventions in the treatment and management of
Brownley, K.A., N.D. Berkman, J.A. Sedway, K.N. Lohr,
anorexia nervosa, bulimia nervosa and related
and C.M. Bulik. (2007). Binge Eating Disorder Treatment:
eating disorders.
A Systematic Review of Randomized Controlled Trials.
International Journal of Eating Disorders, 40(4):337-348
Bulik, C.M., N.D. Berkman, K.A. Brownley, J.A. Sedway,
and K.N. Lohr (2007). Anorexia Nervosa Treatment: A
Systematic Review of Randomized Controlled Trials.
International Journal of Eating Disorders, 40(4): 310-
Shapiro, J.R., N.D. Berkman, K.A. Brownley, J.A. Sedway,
K.N. Lohr, and C.M. Bulik (2007). Bulimia Nervosa
Treatment: A Systematic Review of Randomized
Controlled Trials. International Journal of Eating
Disorders, 40(4): 321-336
NEDA TOOLKIT for Parents
Eating disorders among children and adolescents
From the Finnish Medical Society Duodecim
Aetiology
Brief Summary
Currently, eating disorders are considered to be
Bibliographic Source
multifarious. Genetic and sociocultural factors and
also individual dynamics all affect eating
Finnish Medical Society Duodecim. Eating
disorders among children and adolescents. In:
The typical age of onset is adolescence, when the
EBM Guidelines. Evidence- Based Medicine
body changes and grows.
[Internet]. Helsinki, Finland: Wiley Interscience.
Anorexia nervosa typically emerges between 14
John Wiley & Sons; 2007 Mar 28 [Various].
and 16 years of age or around the age of 18 years.
Bulimia appears typically at the age of 19 to 20 years.
Major Recommendations
Eating disorders are 10 to 15 times more common
among girls than boys.
The levels of evidence [A-D] supporting the
Every 150th girl between the ages of 14 and 16
recommendations are defined at the end of the "Major
years suffers from anorexia nervosa.
Recommendations" field.
There is no epidemiologic data on the occurrence
of bulimia, but it is considered to be more
Objectives
common than anorexia nervosa.
Remember that eating disorders are very common
Diagnostic Criteria for Anorexia Nervosa
among adolescent girls, and especially bulimic
disorders are encountered in boys as well.
The patient does not want to maintain his/her
One must remember to look for signs of an eating
normal body weight.
disorder; patients seldom report it themselves.
The patient's weight is at least 15% below that
The diagnosis and planning of treatment are the
expected for age and height.
responsibility of special personnel.
The patient's body image is distorted.
The patient is afraid of gaining weight.
Basic Rules
There is no other sickness that would explain the
An eating disorder refers to states in which food
and nourishment have an instrumental and
Diagnostic Criteria of Bulimia Nervosa
manipulative role: food has become a way to
regulate the appearance of the body.
Desire to be thin, phobic fear of gaining weight.
The spectrum of eating disorders is vast. The most
Persistent preoccupation with eating and an
common disorders are anorexia nervosa and
irresistible urge or compulsive need to eat.
bulimia nervosa. In addition, incomplete clinical
Episodes of binge eating (at least twice a week);
pictures and simple binge eating have become
control over eating is lost.
After the episode of binge eating, the person
Recently the international trend has been to put
attempts to eliminate the ingested food (e.g., by
more emphasis on early reaction to the symptoms.
self-induced vomiting and by abuse of purgatives
Even small children can have different kinds of
eating disorders that relate to difficulties in the
relationships between the child and his/her
NEDA TOOLKIT for Parents
Symptoms
Laboratory Findings
Anorexia nervosa generally starts gradually.
In anorexia nervosa:
Losing weight can either be very rapid or very
slow. Generally the patients continue to go to
Blood glucose levels on the lower border
school; they go on with their hobbies and feel
great about themselves. Therefore, the families
are usually surprised to find that their child
suffers from malnutrition.
Increased serum amylase
A screening questionnaire is helpful in the
assessment of patients with suspected eating
Differential Diagnosis
disorders (each positive answer gives one point;
two or more points suggest an eating disorder).
Severe somatic diseases, for example, brain
Do you try to vomit if you feel
Psychiatric diseases — severe depression,
unpleasantly satiated?
psychosis, and drug use
Are you anxious with the thought that
you cannot control the amount of food
Treatment
If the symptoms correspond to the diagnostic
Have you lost more than 6 kg of weight
criteria of anorexia nervosa, the situation should
during the last 3 months?
be discussed with the family before treatment is
Do you consider yourself obese although
others say you are underweight?
The adolescent and his/her family should be made
Does food/thinking of food dominate
aware of the seriousness of the disorder.
Sometimes it takes time to motivate the patient to
participate in the treatment.
Anorexic adolescents deny their symptoms, and it
The treatment is divided into:
takes time and patience to motivate them to
Restoring the state of nutrition
accept treatment.
Psychotherapeutic treatment
Somatic symptoms include the following:
Disappearance of menstruation
If the state of malnutrition is life threatening, the
The slowing of metabolism, constipation
patient is first treated in a somatic ward, and
Slow pulse, low blood pressure
thereafter the adolescent is guided into therapy if
Flushed and cold limbs
Reduction of subcutaneous fat
The forms of psychotherapy vary: both individual
Bulimic adolescents are aware that their eating
and family therapy have brought results; in cases
habits are not normal, but the habit causes so
of bulimia cognitive therapy and medication
much guilt and shame that seeking treatment is
(Lewandowski et al., 1997; Whittal, Agras, & Gould,
1999) [C] have been successful.
Bulimia also causes physical symptoms, including
With adolescents between the ages of 14 and 16
years, positive results have been obtained by
treating the entire family. This is because the
Disturbances of menstruation
adolescent's symptoms are often connected with
Disturbances in electrolyte and acid-alkali balances created by frequent
difficulties to "cut loose" from the family.
With older patients, individual, supportive, and
long lasting treatment has been the best way to
Damage to tooth enamel
promote recovery.
A prolonged state of malnutrition and insufficient
outpatient care are reasons to direct a patient into
forced treatment.
NEDA TOOLKIT for Parents
Medical Treatment
A specialist should start all drug treatment.
Different psychopharmaceuticals, for example,
neuroleptics and antidepressants, have been tried
in the treatment of anorexia nervosa. Controlled
studies have proved them indisputably useful only
if the disorder is linked to clear depression.
Most research on the medical treatment of
bulimia has concentrated on antidepressants
(Bacaltchuk & Hay, 2003) [A], particularly
fluoxetine, which has been found to decrease
binge eating and vomiting for about two-thirds of
bulimic patients.
Prognosis
Early intervention improves prognosis.
Eating disorders comprise a severe group of
diseases that are difficult to treat. The prognosis
for the near future of anorexic patients is good,
but for the long term the prognosis is worse. The
percentage of mortality is still 5% to 16%.
Not enough follow-up research has been carried
out on the prognosis of bulimia, but the disease is
thought to last years.
Bulimia can be associated with depression, self-
destructiveness, alcohol or drug abuse, and other
psychological problems.
Link to Full Summary:
NEDA TOOLKIT for Parents
Eating disorders: Core interventions in the treatment and
management of anorexia nervosa, bulimia nervosa, and
related eating disorders.
U.K. National Collaborating Centre for
shared with the patient and, where appropriate,
Mental Health: Brief Summary
his/her family and caregivers.
Bibliographic Source
Providing Good Information and Support
National Collaborating Centre for Mental Health.
Eating disorders. Core interventions in the treatment
C — Patients and, where appropriate, caregivers
and management of anorexia nervosa, bulimia
should be provided with education and information on
nervosa and related eating disorders. Leicester (UK):
the nature, course, and treatment of eating disorders.
British Psychological Society; 2004. 260 p. [408
C — In addition to the provision of information, family
and caregivers may be informed of self-help groups
Major Recommendations
and support groups, and offered the opportunity to
participate in such groups where they exist.
Evidence categories (I-IV) and recommendation
grades (A-C) are defined at the end of the Major
C — Healthcare professionals should acknowledge
Recommendations field.
that many people with eating disorders are
ambivalent about treatment. Healthcare professionals
Care Across All Conditions
should also recognize the consequent demands and challenges this presents.
Assessment and Coordination of Care
Getting Help Early
C — Assessment of people with eating disorders
There can be serious long-term consequences to a
should be comprehensive and include physical,
delay in obtaining treatment.
psychological, and social needs and a comprehensive
assessment of risk to self.
C — People with eating disorders seeking help should
be assessed and receive treatment at the earliest
C — The level of risk to the patient's mental and
physical health should be monitored as treatment
progresses because it may change--for example,
C — Whenever possible patients should be engaged
following weight gain or at times of transition
and treated before reaching severe emaciation. This
between services in cases of anorexia nervosa.
requires both early identification and intervention.
Effective monitoring and engagement of patients at
C — For people with eating disorders presenting in
severely low weight or with falling weight should be a
primary care, general practitioners (GPs) should take
responsibility for the initial assessment and the initial
coordination of care. This includes the determination
Management of Physical Aspects
of the need for emergency medical or psychiatric
C — Where laxative abuse is present, patients should
be advised to gradually reduce laxative use and
C — Where management is shared between primary
informed that laxative use does not significantly
and secondary care, there should be clear agreement
reduce calorie absorption.
among individual healthcare professionals on the
responsibility for monitoring patients with eating
C — Treatment of both subthreshold and clinical
disorders. This agreement should be in writing (where
cases of an eating disorder in people with diabetes is
appropriate using the Care Program Approach) and
essential because of the greatly increased physical risk in this group.
NEDA TOOLKIT for Parents
C — People with type 1 diabetes and an eating
Identification and Screening of Eating Disorders in
disorder should have intensive regular physical
Primary Care and Non-Mental Health Settings
monitoring, because they are at high risk of
retinopathy and other complications.
C — Target groups for screening should include young
women with low body mass index (BMI) compared
C — Pregnant women with eating disorders require
with age norms, patients consulting with weight
careful monitoring throughout the pregnancy and in
concerns who are not overweight, women with
the postpartum period.
menstrual disturbances or amenorrhea, patients with
gastrointestinal symptoms, patients with physical signs
C — Patients with an eating disorder who are vomiting
of starvation or repeated vomiting, and children with
should have regular dental reviews.
C — Patients who are vomiting should be given
C — When screening for eating disorders one or two
appropriate advice on dental hygiene, which should
simple questions should be considered for use with
include avoiding brushing after vomiting; rinsing with
specific target groups (for example, "Do you think you
a nonacid mouthwash after vomiting; and reducing an
have an eating problem?" and "Do you worry
acid oral environment (for example, limiting acidic
excessively about your weight?").
C — Young people with type 1 diabetes and poor
C — Healthcare professionals should advise people
treatment adherence should be screened and
with eating disorders and osteoporosis or related bone
assessed for the presence of an eating disorder.
disorders to refrain from physical activities that
significantly increase the likelihood of falls.
Management of Anorexia Nervosa in Primary
Additional Considerations for Children and
Adolescents
C —In anorexia nervosa, although weight and BMI are
C — Family members, including siblings, should
important indicators of physical risk they should not
normally be included in the treatment of children and
be considered the sole indicators (as they are
adolescents with eating disorders. Interventions may
unreliable in adults and especially in children).
include sharing of information, advice on behavioral
management, and facilitating communication.
C — In assessing whether a person has anorexia
nervosa, attention should be paid to the overall
C — In children and adolescents with eating disorders,
clinical assessment (repeated over time), including
growth and development should be closely monitored.
rate of weight loss, growth rates in children, objective
Where development is delayed or growth is stunted
physical signs, and appropriate laboratory tests.
despite adequate nutrition, pediatric advice should be
C — Patients with enduring anorexia nervosa not
under the care of a secondary care service should be
C — Healthcare professionals assessing children and
offered an annual physical and mental health review
adolescents with eating disorders should be alert to
indicators of abuse (emotional, physical and sexual)
and should remain so throughout treatment.
Psychological Interventions for Anorexia
C — The right to confidentiality of children and
adolescents with eating disorders should be respected.
The delivery of psychological interventions should be
accompanied by regular monitoring of a patient's
C — Health care professionals working with children
physical state including weight and specific indicators
and adolescents with eating disorders should
of increased physical risk.
familiarize themselves with national guidelines and
their employers' policies in the area of confidentiality.
NEDA TOOLKIT for Parents
Common Elements of the Psychological Treatment of
Psychological Aspects of Inpatient Care
Anorexia Nervosa
C — For inpatients with anorexia nervosa, a structured
C — Therapies to be considered for the psychological
symptom-focused treatment regimen with the
treatment of anorexia nervosa include cognitive
expectation of weight gain should be provided in
analytic therapy (CAT), cognitive behavior therapy
order to achieve weight restoration. It is important to
(CBT), interpersonal psychotherapy (IPT), focal
carefully monitor the patient's physical status during
psychodynamic therapy, and family interventions
focused explicitly on eating disorders.
C — Psychological treatment should be provided
C — Patient and, where appropriate, carer preference
which has a focus both on eating behavior and
should be taken into account in deciding which
attitudes to weight and shape and on wider
psychological treatment is to be offered.
psychosocial issues with the expectation of weight
C — The aims of psychological treatment should be to
reduce risk, to encourage weight gain and healthy
C — Rigid inpatient behavior modification programs
eating, to reduce other symptoms related to an eating
should not be used in the management of anorexia
disorder, and to facilitate psychological and physical
Post-Hospitalization Psychological Treatment
Outpatient Psychological Treatments in First Episode
C — Following inpatient weight restoration, people
and Later Episodes
with anorexia nervosa should be offered outpatient
psychological treatment that focuses both on eating
C — Most people with anorexia nervosa should be
behavior and attitudes to weight and shape and on
managed on an outpatient basis, with psychological
wider psychosocial issues, with regular monitoring of
treatment (with physical monitoring) provided by a
both physical and psychological risk.
health care professional competent to give it and to
assess the physical risk of people with eating
C — The length of outpatient psychological treatment
and physical monitoring following inpatient weight
restoration should typically be at least 12 months.
C — Outpatient psychological treatment and physical
monitoring for anorexia nervosa should normally be of
Additional Considerations for Children and
at least 6 months' duration.
Adolescents with Anorexia Nervosa
C — For patients with anorexia nervosa, if during
B — Family interventions that directly address the
outpatient psychological treatment there is significant
eating disorder should be offered to children and
deterioration, or the completion of an adequate
adolescents with anorexia nervosa.
course of outpatient psychological treatment does not
lead to any significant improvement, more intensive
C — Children and adolescents with anorexia nervosa
forms of treatment (for example, a move from
should be offered individual appointments with a
individual therapy to combined individual and family
health care professional separate from those with
work or day care or inpatient care) should be
their family members or carers.
C — The therapeutic involvement of siblings and other
C — Dietary counseling should not be provided as the
family members should be considered in all cases
sole treatment for anorexia nervosa.
because of the effects of anorexia nervosa on other
C — In children and adolescents with anorexia
nervosa, the need for inpatient treatment and the
need for urgent weight restoration should be balanced
alongside the educational and social needs of the
young person.
NEDA TOOLKIT for Parents
Pharmacological Interventions for Anorexia
Managing Weight Gain
C — In most patients with anorexia nervosa, an average weekly weight gain of 0.5-1 kg in inpatient
C — There is a very limited evidence base for the
settings and 0.5 kg in outpatient settings should be an
pharmacological treatment of anorexia nervosa. A
aim of treatment. This requires about 3,500 to 7,000
range of drugs may be used in the treatment of
extra calories a week.
comorbid conditions but caution should be exercised
in their use given the physical vulnerability of many
C — Regular physical monitoring, and in some cases
people with anorexia nervosa.
treatment with a multi-vitamin/multi-mineral
supplement in oral form, is recommended for people
C — Medication should not be used as the sole or
with anorexia nervosa during both inpatient and
primary treatment for anorexia nervosa.
outpatient weight restoration.
Caution should be exercised in the use of medication
for comorbid conditions such as depressive or
C — Total parenteral nutrition should not be used for
obsessive-compulsive features, as they may resolve
people with anorexia nervosa, unless there is
with weight gain alone.
significant gastrointestinal dysfunction.
C — When medication is used to treat people with
Managing Risk
anorexia nervosa, the side effects of drug treatment
(in particular, cardiac side effects) should be carefully
C — Health care professionals should monitor
considered because of the compromised
physical risk in patients with anorexia nervosa. If this
cardiovascular function of many people with anorexia
leads to the identification of increased physical risk,
the frequency of the monitoring and nature of the
investigations should be adjusted accordingly.
C — Health care professionals should be aware of the
risk of drugs that prolong the QTc interval on the
C — People with anorexia nervosa and their carers
electrocardiogram (ECG) (for example, antipsychotics,
should be informed if the risk to their physical health
tricyclic antidepressants, macrolide antibiotics, and
some antihistamines). In patients with anorexia
nervosa at risk of cardiac complications, the
C — The involvement of a physician or pediatrician
prescription of drugs with side effects that may
with expertise in the treatment of physically at-risk
compromise cardiac functioning should be avoided.
patients with anorexia nervosa should be considered
for all individuals who are physically at risk.
C — If the prescription of medication that may
compromise cardiac functioning is essential, ECG
C — Pregnant women with either current or remitted
monitoring should be undertaken.
anorexia nervosa may need more intensive prenatal
care to ensure adequate prenatal nutrition and fetal
C — All patients with a diagnosis of anorexia nervosa
should have an alert placed in their prescribing record
concerning the risk of side effects.
C — Oestrogen administration should not be used to
treat bone density problems in children and
Physical Management of Anorexia Nervosa
adolescents as this may lead to premature fusion of
Anorexia nervosa carries considerable risk of serious
physical morbidity. Awareness of the risk, careful
monitoring, and, where appropriate, close liaison with
an experienced physician are important in the
management of the physical complications of
anorexia nervosa.
NEDA TOOLKIT for Parents
Feeding Against the Will of the Patient
C — Health care professionals without specialist
experience of eating disorders, or in situations of
C — Feeding against the will of the patient should be
uncertainty, should consider seeking advice from an
an intervention of last resort in the care and
appropriate specialist when contemplating a
management of anorexia nervosa.
compulsory admission for a patient with anorexia
nervosa, regardless of the age of the patient.
C — Feeding against the will of the patient is a highly
specialized procedure requiring expertise in the care
C — Health care professionals managing patients with
and management of those with severe eating
anorexia nervosa, especially that of the binge purging
disorders and the physical complications associated
sub-type, should be aware of the increased risk of self-
with it. This should only be done in the context of the
harm and suicide, particularly at times of transition
Mental Health Act 1983 or Children Act 1989.
between services or service settings.
C — When making the decision to feed against the will
Additional Considerations for Children and
of the patient, the legal basis for any such action must
Adolescents
Service Interventions for Anorexia Nervosa
C — Health care professionals should ensure that
children and adolescents with anorexia nervosa who
have reached a healthy weight have the increased
This section considers those aspects of the service
energy and necessary nutrients available in their diet
system relevant to the treatment and management of
to support further growth and development.
anorexia nervosa.
C — In the nutritional management of children and
C — Most people with anorexia nervosa should be
adolescents with anorexia nervosa, carers should be
treated on an outpatient basis.
included in any dietary education or meal planning.
C — Where inpatient management is required, this
C — Admission of children and adolescents with
should be provided within reasonable travelling
anorexia nervosa should be to age-appropriate
distance to enable the involvement of relatives and
facilities (with the potential for separate children and
carers in treatment, to maintain social and
adolescent services), which have the capacity to
occupational links, and to avoid difficulty in transition
provide appropriate educational and related activities.
between primary and secondary care services. This is
particularly important in the treatment of children and
C — When a young person with anorexia nervosa
refuses treatment that is deemed essential,
consideration should be given to the use of the Mental
C — Inpatient treatment should be considered for
Health Act 1983 or the right of those with parental
people with anorexia nervosa whose disorder is
responsibility to override the young person's refusal.
associated with high or moderate physical risk.
C — Relying indefinitely on parental consent to
C — People with anorexia nervosa requiring inpatient
treatment should be avoided. It is recommended that
treatment should be admitted to a setting that can
the legal basis under which treatment is being carried
provide the skilled implementation of refeeding with
out should be recorded in the patient's case notes, and
careful physical monitoring (particularly in the first
this is particularly important in the case of children
few days of refeeding), in combination with
and adolescents.
psychosocial interventions.
C — For children and adolescents with anorexia
C — Inpatient treatment or day patient treatment
nervosa, where issues of consent to treatment are
should be considered for people with anorexia
highlighted, health care professionals should consider
nervosa whose disorder has not improved with
seeking a second opinion from an eating disorders
appropriate outpatient treatment, or for whom there
is a significant risk of suicide or severe self-harm.
NEDA TOOLKIT for Parents
C — If the patient with anorexia nervosa and those
C — Selective serotonin reuptake inhibitors (SSRIs)
with parental responsibility refuse treatment, and
(specifically fluoxetine) are the drugs of first choice for
treatment is deemed to be essential, legal advice
the treatment of bulimia nervosa in terms of
should be sought in order to consider proceedings
acceptability, tolerability, and reduction
under the Children Act 1989.
Psychological Interventions for Bulimia
C — For people with bulimia nervosa, the effective
dose of fluoxetine is higher than for depression (60 mg
B — As a possible first step, patients with bulimia
B — No drugs, other than antidepressants, are
nervosa should be encouraged to follow an evidence-
recommended for the treatment of bulimia nervosa.
based self-help program.
Management of Physical Aspects of Bulimia
B — Health care professionals should consider
providing direct encouragement and support to
patients undertaking an evidence based self-help
program, as this may improve outcomes. This may be
Patients with bulimia nervosa can experience
sufficient treatment for a limited subset of patients.
considerable physical problems as a result of a range
of behaviors associated with the condition. Awareness
A — Cognitive behavior therapy for bulimia nervosa
of the risks and careful monitoring should be a
(CBT-BN), a specifically adapted form of CBT, should
concern of all health care professionals working with
be offered to adults with bulimia nervosa. The course
people with this disorder.
of treatment should be for 16 to 20 sessions over 4 to 5
C — Patients with bulimia nervosa who are vomiting
frequently or taking large quantities of laxatives
C — Adolescents with bulimia nervosa may be treated
(especially if they are also underweight) should have
with CBT-BN adapted as needed to suit their age,
their fluid and electrolyte balance assessed.
circumstances, and level of development, and
including the family as appropriate.
C — When electrolyte disturbance is detected, it is
usually sufficient to focus on eliminating the behavior
B — When people with bulimia nervosa have not
responsible. In the small proportion of cases where
responded to or do not want CBT, other psychological
supplementation is required to restore electrolyte
treatments should be considered.
balance, oral rather than intravenous administration is
recommended, unless there are problems with
B — Interpersonal psychotherapy should be
gastrointestinal absorption.
considered as an alternative to CBT, but patients
should be informed it takes 8-12 months to achieve
Service Interventions for Bulimia Nervosa
results comparable with CBT.
The great majority of patients with bulimia nervosa
Pharmacological Interventions for Bulimia
can be treated as outpatients. There is a very limited
role for the inpatient treatment of bulimia nervosa.
This is primarily concerned with the management of
B — As an alternative or additional first step to using
suicide risk or severe self-harm.
an evidence-based self-help program, adults with
bulimia nervosa may be offered a trial of an
C — The great majority of patients with bulimia
antidepressant drug.
nervosa should be treated in an outpatient setting.
B — Patients should be informed that antidepressant
C — For patients with bulimia nervosa who are at risk
drugs can reduce the frequency of binge eating and
of suicide or severe self-harm, admission as an
purging, but the longterm effects are unknown. Any
inpatient or day patient, or the provision of more
beneficial effects will be rapidly apparent.
intensive outpatient care, should be considered.
NEDA TOOLKIT for Parents
C — Psychiatric admission for people with bulimia
B — Other psychological treatments (interpersonal
nervosa should normally be undertaken in a setting
psychotherapy for binge eating disorder and modified
with experience of managing this disorder.
dialectical behavior therapy) may be offered to adults
with persistent binge eating disorder.
C — Health care professionals should be aware that
patients with bulimia nervosa who have poor impulse
A — Patients should be informed that all
control, notably substance misuse, may be less likely
psychological treatments for binge eating disorder
to respond to a standard program of treatment. As a
have a limited effect on body weight.
consequence treatment should be adapted to the
problems presented.
C — When providing psychological treatments for
patients with binge eating disorder, consideration
Additional Considerations for Children and
should be given to the provision of concurrent or
Adolescents
consecutive interventions focusing on the
management of comorbid obesity.
C — Adolescents with bulimia nervosa may be treated
C — Suitably adapted psychological treatments
with CBT-BN adapted as needed to suit their age,
should be offered to adolescents with persistent binge
circumstances, and level of development, and
eating disorder.
including the family as appropriate.
General Treatment of Atypical Eating
Pharmacological Interventions for Binge
Eating Disorder
Disorders
B — As an alternative or additional first step to using
C — In the absence of evidence to guide the
an evidence based self-help program, consideration
management of atypical eating disorders (eating
should be given to offering a trial of an SSRI
disorders not otherwise specified) other than binge
antidepressant drug to patients with binge eating
eating disorder, it is recommended that the clinician
considers following the guidance on the treatment of
the eating problem that most closely resembles the
B — Patients with binge eating disorders should be
individual patient's eating disorder.
informed that SSRIs can reduce binge eating, but the
long-term effects are unknown. Antidepressant drug
Psychological Treatments for Binge Eating
treatment may be sufficient treatment for a limited
Disorder
subset of patients.
B — As a possible first step, patients with binge eating
disorder should be encouraged to follow an evidence
Evidence Categories
based self-help program.
B — Health care professionals should consider
I: Evidence obtained from a single randomized
providing direct encouragement and support to
controlled trial or a meta-analysis of randomized
patients undertaking an evidence-based self-help
controlled trials
program as this may improve outcomes. This may be
IIA: Evidence obtained from at least one well-designed
sufficient treatment for a limited subset of patients.
controlled study without randomization
IIB: Evidence obtained from at least one well-designed
A — Cognitive behavior therapy for binge eating
quasiexperimental study
disorder (CBTBED), a specifically adapted form of CBT,
III: Evidence obtained from well-designed non-
should be offered to adults with binge eating disorder.
experimental descriptive studies, such as comparative
studies, correlation studies, and case-control studies
IV: Evidence obtained from expert committee reports
or opinions and/or clinical experience of respected
NEDA TOOLKIT for Parents
Recommendation Grades
Grade A — At least one randomized controlled trial as
part of a body of literature of overall good quality and
consistency addressing the specific recommendation
(evidence level I) without extrapolation
Grade B — Well-conducted clinical studies but no
randomized clinical trials on the topic of
recommendation (evidence levels II or III); or
extrapolated from level I evidence
Grade C — Expert committee reports or opinions
and/or clinical experiences of respected authorities
(evidence level IV) or extrapolated from level I or II
evidence. This grading indicates that directly
applicable clinical studies of good quality are absent
or not readily available.
Patient Resources
The following is available:
Eating disorders: anorexia nervosa, bulimia nervosa
and related eating disorders. Understanding NICE
guidance: a guide for people with eating disorders,
their advocates and carers, and the public. London:
National Institute for Clinical Excellence. 2004 Jan. 44.
Electronic copies: Available in English and Welsh in
Portable Document Format (PDF) from the National
Institute for Clinical Excellence (NICE) Web site
Print copies: Available from the National Health
Service (NHS) Response Line 0870 1555 455. ref:
N0407. 11 Strand, London, WC2N 5HR.
NEDA TOOLKIT for Parents
Identifying and treating eating disorders
American Academy of Pediatrics
Pediatricians need to be aware of the resources in
Brief Summary
their communities so they can coordinate care of
various treating professionals, helping to create a
Bibliographic Source
seamless system between inpatient and
outpatient management in their communities.
Identifying and treating eating disorders. Pediatrics
2003 Jan;111(1):204-11. [78 references] PubMed
Pediatricians should help advocate for parity of
mental health benefits to ensure continuity of
Major Recommendations
care for the patients with eating disorders.
Pediatricians need to be knowledgeable about the
Pediatricians need to advocate for legislation and
early signs and symptoms of disordered eating
regulations that secure appropriate coverage for
and other related behaviors.
medical, nutritional, and mental health treatment
in settings appropriate to the severity of the
illness (inpatient, day hospital, intensive
Pediatricians should be aware of the careful balance that needs to be in place to decrease the
outpatient, and outpatient).
growing prevalence of eating disorders in children
and adolescents. When counseling children on risk
Pediatricians are encouraged to participate in the
of obesity and healthy eating, care needs to be
development of objective criteria for the optimal
taken not to foster overaggressive dieting and to
treatment of eating disorders, including the use of
help children and adolescents build self-esteem
specific treatment modalities and the transition
while still addressing weight concerns.
from one level of care to another.
Pediatricians should be familiar with the
screening and counseling guidelines for
disordered eating and other related behaviors.
Link to Full Summary:
Pediatricians should know when and how to
monitor and/ or refer patients with eating
disorders to best address their medical and
Link to Complete Guideline:
nutritional needs, serving as an integral part of the
multidisciplinary team.
Pediatricians should be encouraged to calculate
and plot weight, height, and body mass index
(BMI) using age and gender-appropriate graphs at
routine annual pediatric visits.
Pediatricians can play a role in primary prevention
through office visits and community- or school-
based interventions with a focus on screening,
education, and advocacy.
Pediatricians can work locally, nationally, and
internationally to help change cultural norms
conducive to eating disorders and proactively to
change media messages.
NEDA TOOLKIT for Parents
Practice guideline for the treatment of patients with
eating disorders
Brief Summary
and dental complications, it is important that
psychiatrists consult other physician specialists and
Bibliographic Sources
American Psychiatric Association (APA). Practice
guideline for the treatment of patients with eating
When a patient is managed by an interdisciplinary
disorders. 3rd ed. Washington (DC): American
team in an outpatient setting, communication among
the professionals is essential to monitoring the
Psychiatric Association (APA); 2006 Jun. 128 p. [765
patient's progress, making necessary adjustments to
references] American Psychiatric Association.
the treatment plan, and delineating the specific roles
Treatment of patients with eating disorders, third
and tasks of each team member [I].
edition. Am J Psychiatry 2006 Jul;163(7 Suppl):4-54.
b. Assessing and Monitoring Eating Disorder
Symptoms and Behaviors
Major Recommendations
Each recommendation is identified as meriting one of
A careful assessment of the patient's history,
three categories of endorsement, based on the level of
symptoms, behaviors, and mental status is the first
clinical confidence regarding the recommendation, as
step in making a diagnosis of an eating disorder [I].
indicated by a bracketed Roman numeral after the
The complete assessment usually requires at least
statement. Definitions of the categories of
several hours and includes a thorough review of the
endorsement are presented at the end of the "Major
patient's height and weight history; restrictive and
Recommendations" field.
binge eating and exercise patterns and their changes;
purging and other compensatory behaviors; core
attitudes regarding weight, shape, and eating; and
Psychiatric Management
associated psychiatric conditions [I]. A family history of
Psychiatric management begins with the
eating disorders or other psychiatric disorders,
establishment of a therapeutic alliance, which is
including alcohol and other substance use disorders; a
enhanced by empathic comments and behaviors,
family history of obesity; family interactions in relation
positive regard, reassurance, and support [I]. Basic
to the patient's disorder; and family attitudes toward
psychiatric management includes support through the
eating, exercise, and appearance are all relevant to
provision of educational materials, including self-help
the assessment [I]. A clinician's articulation of theories
workbooks; information on community-based and
that imply blame or permit family members to blame
Internet resources; and direct advice to patients and
one another or themselves can alienate family
their families (if they are involved) [I]. A team
members from involvement in the treatment and
approach is the recommended model of care [I].
therefore be detrimental to the patient's care and
recovery [I]. It is important to identify family stressors
whose amelioration may facilitate recovery [I]. In the
Coordinating Care and Collaborating with Other
Clinicians
assessment of children and adolescents, it is essential
to involve parents and, whenever appropriate, school
In treating adults with eating disorders, the
personnel and health professionals who routinely
psychiatrist may assume the leadership role within a
work with the patient [I].
program or team that includes other physicians,
psychologists, registered dietitians, and social workers
or may work collaboratively on a team led by others.
For the management of acute and ongoing medical
NEDA TOOLKIT for Parents
c. Assessing and Monitoring the Patient's General
d. Assessing and Monitoring the Patient's Safety and
Medical Condition
Psychiatric Status
A full physical examination of the patient is strongly
The patient's safety will be enhanced when particular
recommended and may be performed by a physician
attention is given to suicidal ideation, plans,
familiar with common findings in patients with eating
intentions, and attempts as well as to impulsive and
disorders. The examination should give particular
compulsive self-harm behaviors [I]. Other aspects of
attention to vital signs, physical status (including
the patient's psychiatric status that greatly influence
height and weight), cardiovascular and peripheral
clinical course and outcome and that are important to
vascular function, dermatological manifestations, and
assess include mood, anxiety, and substance use
evidence of self-injurious behaviors [I]. Calculation of
disorders, as well as motivational status, personality
the patient's body mass index (BMI) is also useful (see
traits, and personality disorders [I]. Assessment for
suicidality is of particular importance in patients with
i-tables.pdf [for ages 2-20] and
co-occurring alcohol and other substance use
i-adults.pdf [for adults]) [I]. Early recognition of eating
disorder symptoms and early intervention may
e. Providing Family Assessment and Treatment
prevent an eating disorder from becoming chronic [I].
During treatment, it is important to monitor the
For children and adolescents with anorexia nervosa,
patient for shifts in weight, blood pressure, pulse,
family involvement and treatment are essential [I]. For
other cardiovascular parameters, and behaviors likely
older patients, family assessment and involvement
to provoke physiological decline and collapse [I].
may be useful and should be considered on a case-by-
Patients with a history of purging behaviors should
case basis [II]. Involving spouses and partners in
also be referred for a dental examination [I]. Bone
treatment may be highly desirable [II].
density examinations should be obtained for patients
who have been amenorrheic for 6 months or more [I].
2. Choosing a Site of Treatment
In younger patients, examination should include
Services available for treating eating disorders can
growth pattern, sexual development (including sexual
range from intensive inpatient programs (in which
maturity rating), and general physical development [I].
general medical care is readily available) to
The need for laboratory analyses should be
residential and partial hospitalization programs to
determined on an individual basis depending on the
varying levels of outpatient care (in which the patient
patient's condition or the laboratory tests' relevance
receives general medical treatment, nutritional
to making treatment decisions [I].
counseling, and/or individual, group, and family
psychotherapy). Because specialized programs are not
available in all geographic areas and their financial
requirements are often significant, access to these
programs may be limited; petition, explanation, and
follow-up by the psychiatrist on behalf of patients and
families may help procure access to these programs.
Pretreatment evaluation of the patient is essential in
choosing the appropriate treatment setting [I].
NEDA TOOLKIT for Parents
In determining a patient's initial level of care or
Hospitalization should occur before the onset of
whether a change to a different level of care is
medical instability as manifested by abnormalities in
appropriate, it is important to consider the patient's
vital signs (e.g., marked orthostatic hypotension with
overall physical condition, psychology, behaviors, and
an increase in pulse of 20 beats per minute (bpm) or a
social circumstances rather than simply rely on one or
drop in standing blood pressure of 20 millimeters of
more physical parameters, such as weight [I]. Weight
mercury (mmHg), bradycardia <40 bpm, tachycardia
in relation to estimated individually healthy weight,
>110 bpm, or an inability to sustain core body
the rate of weight loss, cardiac function, and
temperature), physical findings, or laboratory tests [I].
metabolic status are the most important physical
To avert potentially irreversible effects on physical
parameters to be considered when choosing a
growth and development, many children and
treatment setting; other psychosocial parameters are
adolescents require inpatient medical treatment, even
also important [I]. Healthy weight estimates for a
when weight loss, although rapid, has not been as
given individual must be determined by that person's
severe as that suggesting a need for hospitalization in
physicians [I]. Such estimates may be based on
adult patients [I].
historical considerations (often including that person's
growth charts) and, for women, the weight at which
Patients who are physiologically stabilized on acute
healthy menstruation and ovulation resume, which
medical units will still require specific inpatient
may be higher than the weight at which menstruation
treatment for eating disorders if they do not meet
and ovulation became impaired. Admission to or
biopsychosocial criteria for less intensive levels of
continuation of an intensive level of care (e.g.,
care and/or if no suitable less intensive levels of care
hospitalization) may be necessary when access to a
are accessible because of geographic or other reasons
less intensive level of care (e.g., partial hospitalization)
[I]. Weight level per se should never be used as the
is absent because of geography or a lack of resources
sole criterion for discharge from inpatient care [I].
Assisting patients in determining and practicing
appropriate food intake at a healthy body weight is
Generally, adult patients who weigh less than
likely to decrease the chances of their relapsing after
approximately 85% of their individually estimated
healthy weights have considerable difficulty gaining
weight outside of a highly structured program [II].
Most patients with uncomplicated bulimia nervosa do
Such programs, including inpatient care, may be
not require hospitalization; indications for the
medically and psychiatrically necessary even for some
hospitalization of such patients include severe
patients who are above 85% of their individually
disabling symptoms that have not responded to
estimated healthy weight [I]. Factors suggesting that
adequate trials of outpatient treatment, serious
hospitalization may be appropriate include rapid or
concurrent general medical problems (e.g., metabolic
persistent decline in oral intake, a decline in weight
abnormalities, hematemesis, vital sign changes,
despite maximally intensive outpatient or partial
uncontrolled vomiting), suicidality, psychiatric
hospitalization interventions, the presence of
disturbances that would warrant the patient's
additional stressors that may interfere with the
hospitalization independent of the eating disorder
patient's ability to eat, knowledge of the weight at
diagnosis, or severe concurrent alcohol or drug
which instability previously occurred in the patient,
dependence or abuse [I].
co-occurring psychiatric problems that merit
hospitalization, and the degree of the patient's denial
Legal interventions, including involuntary
and resistance to participate in his or her own care in
hospitalization and legal guardianship, may be
less intensively supervised settings [I].
necessary to address the safety of treatment-reluctant
patients whose general medical conditions are life threatening [I].
NEDA TOOLKIT for Parents
The decision about whether a patient should be
In an outpatient setting, patients can remain with their
hospitalized on a psychiatric versus a general medical
families and continue to attend school or work.
or adolescent/ pediatric unit should be made based on
Inpatient care may interfere with family, school, and
the patient's general medical and psychiatric status,
work obligations; however, it is important to give
the skills and abilities of local psychiatric and general
priority to the safe and adequate treatment of a
medical staff, and the availability of suitable programs
rapidly progressing or otherwise unresponsive
to care for the patient's general medical and
disorder for which hospital care might be necessary [I].
psychiatric problems [I]. There is evidence to suggest
that patients with eating disorders have better
3. Choice of Specific Treatments for Anorexia
outcomes when treated on inpatient units specializing
in the treatment of these disorders than when treated
in general inpatient settings where staff lack expertise
The aims of treating anorexia nervosa are to 1) restore
and experience in treating eating disorders [II].
patients to a healthy weight (associated with the
return of menses and normal ovulation in female
Outcomes from partial hospitalization programs that
patients, normal sexual drive and hormone levels in
specialize in eating disorders are highly correlated
male patients, and normal physical and sexual growth
with treatment intensity. The more successful
and development in children and adolescents); 2) treat
programs involve patients in treatment at least 5
physical complications; 3) enhance patients'
days/week for 8 hours/day; thus, it is recommended
motivation to cooperate in the restoration of healthy
that partial hospitalization programs be structured to
eating patterns and participate in treatment; 4)
provide at least this level of care [I].
provide education regarding healthy nutrition and
eating patterns; 5) help patients reassess and change
Patients who are considerably below their healthy
core dysfunctional cognitions, attitudes, motives,
body weight and are highly motivated to adhere to
conflicts, and feelings related to the eating disorder; 6)
treatment, have cooperative families, and have a brief
treat associated psychiatric conditions, including
symptom duration may benefit from treatment in
deficits in mood and impulse regulation and self-
outpatient settings, but only if they are carefully
esteem and behavioral problems; 7) enlist family
monitored and if they and their families understand
support and provide family counseling and therapy
that a more restrictive setting may be necessary if
where appropriate; and 8) prevent relapse.
persistent progress is not evident in a few weeks [II].
Careful monitoring includes at least weekly (and often
a. Nutritional Rehabilitation
two to three times a week) weight determinations
The goals of nutritional rehabilitation for seriously
done directly after the patient voids and while the
underweight patients are to restore weight, normalize
patient is wearing the same class of garment (e.g.,
eating patterns, achieve normal perceptions of hunger
hospital gown, standard exercise clothing) [I]. In
and satiety, and correct biological and psychological
patients who purge, it is important to routinely
sequelae of malnutrition [I]. For patients age 20 years
monitor serum electrolytes [I]. Urine specific gravity,
and younger, an individually appropriate range for
orthostatic vital signs, and oral temperatures may
expected weight and goals for weight and height may
need to be measured on a regular basis [II].
be determined by considering measurements and
clinical factors, including current weight, bone age
estimated from wrist x-rays and nomograms,
menstrual history (in adolescents with secondary
amenorrhea), mid-parental heights, assessments of
skeletal frame, and benchmarks from Centers for
Disease Control and Prevention (CDC) growth charts
(available at http://www.cdc.gov/growthcharts/) [I].
NEDA TOOLKIT for Parents
For individuals who are markedly underweight and for
Patients who require much lower caloric intakes or
children and adolescents whose weight has deviated
are suspected of artificially increasing their weight by
below their growth curves, hospital-based programs
fluid loading should be weighed in the morning after
for nutritional rehabilitation should be considered [I].
they have voided and are wearing only a gown; their
For patients in inpatient or residential settings, the
fluid intake should also be carefully monitored [I].
discrepancy between healthy target weight and
Urine specimens obtained at the time of a patient's
weight at discharge may vary depending on patients'
weigh-in may need to be assessed for specific gravity
ability to feed themselves, their motivation and ability
to help ascertain the extent to which the measured
to participate in aftercare programs, and the
weight reflects excessive water intake [I]. Regular
adequacy of aftercare, including partial
monitoring of serum potassium levels is
hospitalization [I]. It is important to implement
recommended in patients who are persistent vomiters
refeeding programs in nurturing emotional contexts
[I]. Hypokalemia should be treated with oral or
[I]. For example, it is useful for staff to convey to
intravenous potassium supplementation and
patients their intention to take care of them and not
rehydration [I].
let them die even when the illness prevents the
patients from taking care of themselves [II]. It is also
Physical activity should be adapted to the food intake
useful for staff to communicate clearly that they are
and energy expenditure of the patient, taking into
not seeking to engage in control battles and have no
account the patient's bone mineral density and
punitive intentions when using interventions that the
cardiac function [I]. Once a safe weight is achieved,
patient may experience as aversive [I].
the focus of an exercise program should be on the
patient's gaining physical fitness as opposed to
In working to achieve target weights, the treatment
expending calories [I].
plan should also establish expected rates of
controlled weight gain. Clinical consensus suggests
Weight gain results in improvements in most of the
that realistic targets are 2-3 pounds (lb)/week for
physiological and psychological complications of
hospitalized patients and 0.5-1 lb/week for individuals
semistarvation [I]. It is important to warn patients
in outpatient programs [II]. Registered dietitians can
about the following aspects of early recovery [I]: As
help patients choose their own meals and can provide
they start to recover and feel their bodies getting
a structured meal plan that ensures nutritional
larger, especially as they approach frightening,
adequacy and that none of the major food groups are
magical numbers on the scale that represent phobic
avoided [I]. Formula feeding may have to be added to
weights, they may experience a resurgence of anxious
the patient's diet to achieve large caloric intake[II]. It
and depressive symptoms, irritability, and sometimes
is important to encourage patients with anorexia
suicidal thoughts. These mood symptoms, non-food-
nervosa to expand their food choices to minimize the
related obsessional thoughts, and compulsive
severely restricted range of foods initially acceptable
behaviors, although often not eradicated, usually
to them [II]. Caloric intake levels should usually start
decrease with sustained weight gain and weight
at 30-40 kilocalories/kilogram (kcal/kg) per day
maintenance. Initial refeeding may be associated with
(approximately 1,000-1,600 kcal/day). During the
mild transient fluid retention, but patients who
weight gain phase, intake may have to be advanced
abruptly stop taking laxatives or diuretics may
progressively to as high as 70-100 kcal/kg per day for
experience marked rebound fluid retention for several
some patients; many male patients require a very
weeks. As weight gain progresses, many patients also
large number of calories to gain weight [II].
develop acne and breast tenderness and become
unhappy and demoralized about resulting changes in
NEDA TOOLKIT for Parents
Patients may experience abdominal pain and bloating
Patients' serum levels of phosphorus, magnesium,
with meals from the delayed gastric emptying that
potassium, and calcium should be determined daily
accompanies malnutrition. These symptoms may
for the first 5 days of refeeding and every other day for
respond to pro-motility agents [III]. Constipation may
several weeks thereafter, and electrocardiograms
be ameliorated with stool softeners; if unaddressed, it
should be performed as indicated [II]. For children and
can progress to obstipation and, rarely, to acute bowel
adolescents who are severely malnourished (weight
<70% of healthy body weight), cardiac monitoring,
especially at night, may be desirable [II]. Phosphorus,
When life-preserving nutrition must be provided to a
magnesium, and/or potassium supplementation
patient who refuses to eat, nasogastric feeding is
should be given when indicated [I].
preferable to intravenous feeding [I]. When
nasogastric feeding is necessary, continuous feeding
b. Psychosocial Interventions
(i.e., over 24 hours) may be better tolerated by patients
and less likely to result in metabolic abnormalities
The goals of psychosocial interventions are to help
than three to four bolus feedings a day [II]. In very
patients with anorexia nervosa 1) understand and
difficult situations, where patients physically resist and
cooperate with their nutritional and physical
constantly remove their nasogastric tubes, feeding
rehabilitation, 2) understand and change the
through surgically placed gastrostomy or jejunostomy
behaviors and dysfunctional attitudes related to their
tubes may be an alternative to nasogastric feeding [II].
eating disorder, 3) improve their interpersonal and
In determining whether to begin involuntary forced
social functioning, and 4) address comorbid
feeding, the clinician should carefully think through
psychopathology and psychological conflicts that
the clinical circumstances, family opinion, and
reinforce or maintain eating disorder behaviors.
relevant legal and ethical dimensions of the patient's
treatment [I]. The general principles to be followed in
Acute Anorexia Nervosa
making the decision are those directing good, humane
care; respecting the wishes of competent patients; and
During acute refeeding and while weight gain is
intervening respectfully with patients whose judgment
occurring, it is beneficial to provide anorexia nervosa
is severely impaired by their psychiatric disorders
patients with individual psychotherapeutic
when such interventions are likely to have beneficial
management that is psychodynamically informed and
results [I]. For cooperative patients, supplemental
provides empathic understanding, explanations, praise
overnight pediatric nasogastric tube feeding has been
for positive efforts, coaching, support, encouragement,
used in some programs to facilitate weight gain [III].
and other positive behavioral reinforcement [I].
Attempts to conduct formal psychotherapy with
With severely malnourished patients (particularly
starving patients who are often negativistic,
those whose weight is <70% of their healthy body
obsessional, or mildly cognitively impaired may be
weight) who undergo aggressive oral, nasogastric, or
ineffective [II].
parenteral refeeding, a serious refeeding syndrome
can occur. Initial assessments should include vital
For children and adolescents, the evidence indicates
signs and food and fluid intake and output, if
that family treatment is the most effective
indicated, as well as monitoring for edema, rapid
intervention [I]. In methods modeled after the
weight gain (associated primarily with fluid overload),
Maudsley approach, families become actively
congestive heart failure, and gastrointestinal
involved, in a blame-free atmosphere, in helping
patients eat more and resist compulsive exercising
NEDA TOOLKIT for Parents
For some outpatients, a short-term course of family
For adolescents who have been ill <3 years, after
therapy using these methods may be as effective as a
weight has been restored, family therapy is a
long-term course; however, a shorter course of
necessary component of treatment [I]. Although
therapy may not be adequate for patients with severe
studies of different psychotherapies focus on these
obsessive-compulsive features or non-intact families
interventions as distinctly separate treatments, in
practice there is frequent overlap of interventions [II].
Most inpatient-based nutritional rehabilitation
It is important for clinicians to pay attention to
programs create a milieu that incorporates emotional
cultural attitudes, patient issues involving the gender
nurturance and a combination of reinforcers that link
of the therapist, and specific concerns about possible
exercise, bed rest, and privileges to target weights,
abuse, neglect, or other developmental traumas [II].
desired behaviors, feedback concerning changes in
Clinicians need to attend to their countertransference
weight, and other observable parameters [II]. For
reactions to patients with a chronic eating disorder,
adolescents treated in inpatient settings, participation
which often include beleaguerment, demoralization,
in family group psychoeducation may be helpful to
and excessive need to change the patient [I].
their efforts to regain weight and may be equally as
effective as more intensive forms of family therapy
At the same time, when treating patients with chronic
illnesses, clinicians need to understand the
longitudinal course of the disorder and that patients
Anorexia Nervosa after Weight Restoration
can recover even after many years of illness [I].
Because of anorexia nervosa's enduring nature,
Once malnutrition has been corrected and weight gain
psychotherapeutic treatment is frequently required for
has begun, psychotherapy can help patients with
at least 1 year and may take many years [I].
anorexia nervosa understand 1) their experience of
their illness; 2) cognitive distortions and how these
Anorexics and Bulimics Anonymous and Overeaters
have led to their symptomatic behavior; 3)
Anonymous are not substitutes for professional
developmental, familial, and cultural antecedents of
treatment [I]. Programs that focus exclusively on
their illness; 4) how their illness may have been a
abstaining from binge eating, purging, restrictive
maladaptive attempt to regulate their emotions and
eating, or excessive exercising (e.g., 12-step programs)
cope; 5) how to avoid or minimize the risk of relapse;
without attending to nutritional considerations or
and 6) how to better cope with salient developmental
cognitive and behavioral deficits have not been
and other important life issues in the future. Clinical
studied and therefore cannot be recommended as the
experience shows that patients may often display
sole treatment for anorexia nervosa [I].
improved mood, enhanced cognitive functioning, and
clearer thought processes after there is significant
It is important for programs using 12-step models to
improvement in nutritional intake, even before there is
be equipped to care for patients with the substantial
substantial weight gain [II].
psychiatric and general medical problems often
associated with eating disorders [I]. Although families
To help prevent patients from relapsing, emerging
and patients are increasingly accessing worthwhile,
data support the use of cognitive-behavioral
helpful information through online web sites,
psychotherapy for adults [II]. Many clinicians also use
newsgroups, and chat rooms, the lack of professional
interpersonal and/or psychodynamically oriented
supervision within these resources may sometimes
individual or group psychotherapy for adults after
lead to users' receiving misinformation or create
their weight has been restored [II].
unhealthy dynamics among users.
NEDA TOOLKIT for Parents
It is recommended that clinicians inquire about a
patient's or family's use of Internet-based support and
For example, these medications may be considered for
other alternative and complementary approaches and
those with persistent depressive, anxiety, or obsessive-
be prepared to openly and sympathetically discuss the
compulsive symptoms and for bulimic symptoms in
information and ideas gathered from these sources [I].
weight-restored patients [II]. A U.S. Food and Drug
Administration (FDA) black box warning concerning
Chronic Anorexia Nervosa
the use of bupropion in patients with eating disorders
has been issued because of the increased seizure risk
Patients with chronic anorexia nervosa generally show
in these patients. Adverse reactions to tricyclic
a lack of substantial clinical response to formal
antidepressants and monoamine oxidase inhibitors
psychotherapy. Nevertheless, many clinicians report
(MAOIs) are more pronounced in malnourished
seeing patients with chronic anorexia nervosa who,
individuals, and these medications should generally be
after many years of struggling with their disorder,
avoided in this patient population [I]. Second-
experience substantial remission, so clinicians are
generation antipsychotics, particularly olanzapine,
justified in maintaining and extending some degree
risperidone, and quetiapine, have been used in small
of hope to patients and families [II]. More extensive
series and individual cases for patients, but controlled
psychotherapeutic measures may be undertaken to
studies of these medications are lacking. Clinical
engage and help motivate patients whose illness is
impressions suggest that they may be useful in
resistant to treatment [II] or, failing that, as
patients with severe, unremitting resistance to gaining
compassionate care [I]. For patients who have
weight; severe obsessional thinking; and denial that
difficulty talking about their problems, clinicians have
assumes delusional proportions [III]. Small doses of
reported that a variety of nonverbal therapeutic
older antipsychotics such as chlorpromazine may be
methods, such as the creative arts, movement therapy
helpful prior to meals in very disturbed patients [III].
programs, and occupational therapy, can be useful
Although the risks of extrapyramidal side effects are
[III]. Psychosocial programs designed for patients with
less with second-generation antipsychotics than with
chronic eating disorders are being implemented at
first-generation antipsychotics, debilitated anorexia
several treatment sites and may prove useful [II].
nervosa patients may be at a higher risk for these than
c. Medications and Other Somatic Treatments
Therefore, if these medications are used, it is
i. Weight Restoration
recommended that patients be carefully monitored for
extrapyramidal symptoms and akathisia [I]. It is also
The decision about whether to use psychotropic
important to routinely monitor patients for potential
medications and, if so, which medications to choose
side effects of these medications, which can result in
will be based on the patient's clinical presentation [I].
insulin resistance, abnormal lipid metabolism, and
The limited empirical data on malnourished patients
prolongation of the QTc interval [I]. Because
indicate that selective serotonin reuptake inhibitors
ziprasidone has not been studied in individuals with
(SSRIs) do not appear to confer advantage regarding
anorexia nervosa and can prolong QTc intervals,
weight gain in patients who are concurrently receiving
careful monitoring of serial electrocardiograms and
inpatient treatment in an organized eating disorder
serum potassium measurements is needed if anorexic
program [I]. However, SSRIs in combination with
patients are treated with ziprasidone [I].
psychotherapy are widely used in treating patients
with anorexia nervosa.
NEDA TOOLKIT for Parents
Antianxiety agents used selectively before meals may
Hormone therapy usually induces monthly menstrual
be useful to reduce patients' anticipatory anxiety
bleeding, which may contribute to the patient's denial
before eating [III], but because eating disorder
of the need to gain further weight [II]. Before estrogen
patients may have a high propensity to become
is offered, it is recommended that efforts be made to
dependent on benzodiazepines, these medications
increase weight and achieve resumption of normal
should be used routinely only with considerable
menses [I]. There is no indication for the use of
caution [I]. Pro-motility agents such as
bisphosphonates such as alendronate in patients with
metoclopramide may be useful for bloating and
anorexia nervosa [II]. Although there is no evidence
abdominal pains that occur during refeeding in some
that calcium or vitamin
patients [II]. Electroconvulsive therapy (ECT) has
D supplementation reverses decreased bone mineral
generally not been useful except in treating severe co-
density, when calcium dietary intake is inadequate for
occurring disorders for which ECT is otherwise
growth and maintenance, calcium supplementation
should be considered [I], and when the individual is
not exposed to daily sunlight, vitamin D
Although no specific hormone treatments or vitamin
supplementation may be used [I]. However, large
supplements have been shown to be helpful [I],
supplemental doses of vitamin D may be hazardous [I].
supplemental calcium and vitamin D are often
recommended [III]. Zinc supplements have been
4. Choice of Specific Treatments for Bulimia Nervosa
reported to foster weight gain in some patients, and
patients may benefit from daily zinc-containing
The aims of treatment for patients with bulimia
multivitamin tablets [II].
nervosa are to 1) reduce and, where possible,
eliminate binge eating and purging; 2) treat physical
ii.
Relapse Prevention
complications of bulimia nervosa; 3) enhance patients'
motivation to cooperate in the restoration of healthy
Some data suggest that fluoxetine in dosages of up to
eating patterns and participate in treatment; 4)
60 mg/day may help prevent relapse [II]. For patients
provide education regarding healthy nutrition and
receiving cognitive-behavioral therapy (CBT) after
eating patterns; 5) help patients reassess and change
weight restoration, adding fluoxetine does not appear
core dysfunctional thoughts, attitudes, motives,
to confer additional benefits with respect to
conflicts, and feelings related to the eating disorder; 6)
preventing relapse [II]. Antidepressants and other
treat associated psychiatric conditions, including
psychiatric medications may be used to treat specific,
deficits in mood and impulse regulation, self-esteem,
ongoing psychiatric symptoms of depressive, anxiety,
and behavior; 7) enlist family support and provide
obsessive-compulsive, and other comorbid disorders
family counseling and therapy where appropriate; and
[I]. Clinicians should attend to the black box warnings
8) prevent relapse.
in the package inserts relating to antidepressants and
discuss the potential benefits and risks of
a. Nutritional Rehabilitation Counseling
antidepressant treatment with patients and families if
such medications are to be prescribed [I].
A primary focus for nutritional rehabilitation is to help
the patient develop a structured meal plan as a means
iii.
Chronic Anorexia Nervosa
of reducing the episodes of dietary restriction and the
urges to binge and purge [I]. Adequate nutritional
Although hormone replacement therapy (HRT) is
intake can prevent craving and promote satiety [I]. It is
frequently prescribed to improve bone mineral density
important to assess nutritional intake for all patients,
in female patients, no good supporting evidence exists
even those with a normal body weight (or normal
either in adults or in adolescents to demonstrate its
BMI), as normal weight does not ensure appropriate
nutritional intake or normal body composition [I].
NEDA TOOLKIT for Parents
Among patients of normal weight, nutritional
A variety of self-help and professionally guided self-
counseling is a useful part of treatment and helps
help programs have been effective for some patients
reduce food restriction, increase the variety of foods
with bulimia nervosa [I]. Several innovative online
eaten, and promote healthy but not compulsive
programs are currently under investigation and may
exercise patterns [I].
be recommended in the absence of alternative
treatments [III]. Support groups and 12-step programs
b. Psychosocial Interventions
such as Overeaters Anonymous may be helpful as
adjuncts in the initial treatment of bulimia nervosa
It is recommended that psychosocial interventions be
and for subsequent relapse prevention, but they are
chosen on the basis of a comprehensive evaluation of
not recommended as the sole initial treatment
the individual patient that takes into consideration
approach for bulimia nervosa [I].
the patient's cognitive and psychological
Issues of countertransference, discussed above with
development, psychodynamic issues, cognitive style,
respect to the treatment of patients with anorexia
comorbid psychopathology, and preferences as well
nervosa, also apply to the treatment of patients with
as patient age and family situation [I]. For treating
bulimia nervosa [I].
acute episodes of bulimia nervosa in adults, the
evidence strongly supports the value of CBT as the
c. Medications
most effective single intervention [I]. Some patients
who do not respond initially to CBT may respond when
i.
Initial Treatment
switched to either interpersonal therapy (IPT) or
Antidepressants are effective as one component of an
fluoxetine [II] or other modes of treatment such as
initial treatment program for most bulimia nervosa
family and group psychotherapies [III]. Controlled
patients [I], with SSRI treatment having the most
trials have also shown the utility of IPT in some cases
evidence for efficacy and the fewest difficulties with
adverse effects [I]. To date, fluoxetine is the best
studied of these and is the only FDA-approved
In clinical practice, many practitioners combine
medication for bulimia nervosa. Sertraline is the only
elements of CBT, IPT, and other psychotherapeutic
other SSRI that has been shown to be effective, as
techniques. Compared with psychodynamic or
demonstrated in a small, randomized controlled trial.
interpersonal therapy, CBT is associated with more
In the absence of therapists qualified to treat bulimia
rapid remission of eating symptoms [I], but using
nervosa with CBT, fluoxetine is recommended as an
psychodynamic interventions in conjunction with CBT
initial treatment [I]. Dosages of SSRIs higher than
and other psychotherapies may yield better global
those used for depression (e.g., fluoxetine 60 mg/day)
outcomes [II]. Some patients, particularly those with
are more effective in treating bulimic symptoms [I].
concurrent personality pathology or other co-
Evidence from a small open trial suggests fluoxetine
occurring disorders, require lengthy treatment [II].
may be useful for adolescents with bulimia [II].
Clinical reports suggest that psychodynamic and
psychoanalytic approaches in individual or group
Antidepressants may be helpful for patients with
format are useful once bingeing and purging improve
substantial concurrent symptoms of depression,
anxiety, obsessions, or certain impulse disorder
symptoms or for patients who have not benefited from
Family therapy should be considered whenever
or had only a suboptimal response to appropriate
possible, especially for adolescent patients still living
psychosocial therapy [I]. Tricyclic antidepressants and
with their parents [II] or older patients with ongoing
MAOIs have been rarely used with bulimic patients
conflicted interactions with parents [III]. Patients with
and are not recommended as initial treatments [I].
marital discord may benefit from couples therapy [II].
NEDA TOOLKIT for Parents
Several different antidepressants may have to be tried
iii.
Combining Psychosocial Interventions and
sequentially to identify the specific medication with
the optimum effect [I].
In some research, the combination of antidepressant
Clinicians should attend to the black box warnings
therapy and CBT results in the highest remission rates;
relating to antidepressants and discuss the potential
therefore, this combination is recommended initially
benefits and risks of antidepressant treatment with
when qualified CBT therapists are available
patients and families if such medications are to be
[II]. In addition, when CBT alone does not result in a
substantial reduction in symptoms after 10 sessions, it
is recommended that fluoxetine be added [II].
Small controlled trials have demonstrated the efficacy
of the anticonvulsant medication topiramate, but
iv.
Other Treatments
because adverse reactions to this medication are
common, it should be used only when other
Bright light therapy has been shown to reduce binge
medications have proven ineffective [III]. Also, because
frequency in several controlled trials and may be used
patients tend to lose weight on topiramate, its use is
as an adjunct when CBT and antidepressant therapy
problematic for normal or underweight individuals
have not been effective in reducing bingeing
Two drugs that are used for mood stabilization,
5. Eating Disorder Not Otherwise Specified
lithium and valproic acid, are both prone to induce
weight gain in patients [I] and may be less acceptable
Patients with subsyndromal anorexia nervosa or
to patients who are weight preoccupied. However,
bulimia nervosa who meet most but not all of the
lithium is not recommended for patients with bulimia
DSM-IV-TR criteria (e.g., weight >85% of expected
nervosa because it is ineffective [I]. In patients with co-
weight, binge and purge frequency less than twice per
occurring bulimia nervosa and bipolar disorder,
week) merit treatment similar to that of patients who
treatment with lithium is more likely to be associated
fulfill all criteria for these diagnoses [II].
with toxicity [I].
a. Binge Eating Disorder
ii.
Maintenance Phase
i. Nutritional Rehabilitation and Counseling
Limited evidence supports the use of fluoxetine for
relapse prevention [II], but substantial rates of relapse
Behavioral weight control programs incorporating
occur even with treatment. In the absence of adequate
low- or very-low-calorie diets may help with weight
data, most clinicians recommend continuing
loss and usually with reduction of symptoms of binge
antidepressant therapy for a minimum of 9 months
eating [I]. It is important to advise patients that weight
and probably for a year in most patients with bulimia
loss is often not maintained and that binge eating may
nervosa [II]. Case reports indicate that
recur when weight is gained [I]. It is also important to
methylphenidate may be helpful for bulimia nervosa
advise them that weight gain after weight loss may be
patients with concurrent attention-
accompanied by a return of binge eating patterns [I].
deficit/hyperactivity disorder (ADHD) [III], but it should
Various combinations of diets, behavior therapies,
be used only for patients who have a very clear
interpersonal therapies, psychodynamic
diagnosis of ADHD [I].
psychotherapies, non-weight-directed psychosocial
treatments, and even some "non-diet/health at every
size" psychotherapy approaches may be of benefit for
binge eating and weight loss or stabilization [III].
NEDA TOOLKIT for Parents
Patients with a history of repeated weight loss
The anticonvulsant medication topiramate is effective
followed by weight gain ("yo-yo" dieting) or patients
for binge reduction and weight loss, although adverse
with an early onset of binge eating may benefit from
effects may limit its clinical utility for some individuals
following programs that focus on decreasing binge
[II]. Zonisamide may produce similar effects regarding
eating rather than on weight loss [II].
weight loss and can also cause side effects [III].
There is little empirical evidence to suggest that obese
iv.
Combining Psychosocial and Medication
binge eaters who are primarily seeking weight loss
should receive different treatment than obese
individuals who do not binge eat [I].
For most eating disorder patients, adding
antidepressant medication to their behavioral weight
ii. Other Psychosocial Treatments
control and/or CBT regimen does not have a
significant effect on binge suppression when
Substantial evidence supports the efficacy of
compared with medication alone. However,
individual or group CBT for the behavioral and
medications may induce additional weight reduction
psychological symptoms of binge eating disorder [I].
and have associated psychological benefits [II]. Adding
IPT and dialectical behavior therapy have also been
the weight loss medication orlistat to a guided self-
shown to be effective for behavioral and
help CBT program may yield additional weight
psychological symptoms and can be considered as
reduction [II]. Fluoxetine in conjunction with group
alternatives [II]. Patients may be advised that some
behavioral treatment may not aid in binge cessation
studies suggest that most patients continue to show
or weight loss but may reduce depressive symptoms
behavioral and psychological improvement at their 1-
year follow-up [II]. Substantial evidence supports the
efficacy of self-help and guided self-help CBT
b. Night Eating Syndrome
programs and their use as an initial step in a
sequenced treatment program [I]. Other therapies that
Progressive muscle relaxation has been shown to
use a "non-diet" approach and focus on self-
reduce symptoms associated with night eating
acceptance, improved body image, better nutrition
syndrome [III]. Sertraline has also been shown to
and health, and increased physical movement have
reduce these symptoms [II].
been tried, as have addiction-based 12-step
approaches, self-help organizations, and treatment
Definitions
programs based on the Alcoholics Anonymous model,
but no systematic outcome studies of these programs
The three categories of endorsement are as follows:
are available [III].
[I] Recommended with substantial clinical confidence
[II] Recommended with moderate clinical confidence
iii. Medications
[III] May be recommended on the basis of individual
Substantial evidence suggests that treatment with
antidepressant medications, particularly SSRI
antidepressants, is associated with at least a short-term reduction in binge eating behavior but, in most
cases, not with substantial weight loss [I]. The
Link to Full Summary:
medication dosage is typically at the high end of the
recommended range [I]. The appetite-suppressant
medication sibutramine is effective for binge
Link to Information for the Public:
suppression, at least in the short term, and is also
associated with significant weight loss [II].
NEDA TOOLKIT for Parents
How to find a suitable treatment setting
Several considerations enter into finding a suitable
Determining Quality of Care
treatment setting for the patient. The patient's options
may be limited by his/her available insurance
Determining the quality of care offered by a center is
coverage, by whether or not a particular center or
difficult at this time. No organization yet exists to
therapist accepts insurance, and the ability of the
specifically accredit treatment centers for the quality
patient to pay in the absence of insurance. Primary
and standard of eating disorder-specific care. Leaders
care physicians (i.e., family doctor, gynecologist,
within the national eating disorders community
pediatrician, internal medicine doctor) may be able to
organized in mid-2006 to develop care standards and
play a valuable advisory role in referring patients for
a process for accrediting eating disorder centers. That
treatment if they have had previous experience with
effort is ongoing. One national organization, the Joint
referring to eating disorder facilities, participating as a
Commission on Accreditation of Healthcare
member of a care team for a patient with an eating
Organizations (JCAHO), provides generic accreditation
disorder, or outpatient therapists. Some primary care
for healthcare facilities, and some eating disorder
physicians, however, don't have much or any
centers advertise "JCAHO accreditation." JCAHO
experience in this area. Therefore, it's important to ask
accreditation does not link directly to quality of care
about their experience before asking for a referral.
for treatment of eating disorders. Another issue
regarding quality of care is that much care is delivered
In 2005 and again in 2007, ECRI Institute (a nonprofit
on an outpatient basis. For individual psychotherapists
health services research organization) sought to
in private practice, no special credentialing or
identify all healthcare facilities that stated that they
specialty certification exists regarding treatment of
offered treatment for eating disorders. This included
eating disorders. Thus, any mental healthcare
hospitals, psychiatric hospitals, residential centers,
professional can offer to treat an eating disorder
and outpatient-care facilities. We surveyed treatment
whether or not he/ she has experience or training in
facilities nationwide to obtain information about their
this specific area. Therefore, it is important to ask a
treatment philosophies, treatment approach, years of
prospective therapist about his/her knowledge about
experience, and the clinical and support services they
eating disorders and years of experience treating
offer. The information is available in a searchable
database, www.bulimiaguide.org. This database
focuses on facilities offering any or all levels of care
Factors Affecting Choice of Treatment Center
(see the tool explaining Treatment setting and levels
of care). It does not include a listing of individual
For insured patients, the choice of a treatment center
therapist outpatient practices. For information on
may be dictated by the beneficiary's health insurance
outpatient-only therapists, go to the "treatment
plan. Health insurers should provide a list of in-
referral" source at www.nationaleatingdisorders.org;
network (covered) treatment centers. If the treatment
www.something-fishy.org/treatmentfinder; or
center is outside of the health insurer's system (out-of-
www.edreferral.com.
network), the insurer might pay a percentage of the
treatment costs leaving the patient responsible for the
remainder. It is best to negotiate this percentage with
the insurer before starting treatment. A small number
of treatment centers offer financial assistance; but
most do not. However, inquiring about treatment
scholarships, as they are termed, may be worth investigating if the patient does not have financial
resources or insurance.
NEDA TOOLKIT for Parents
Costs aside, other factors may be important to the
Professionals in a Multi-disciplinary Care
patient in selecting a treatment center: the treatment
center's philosophy (or religious affiliation, if any),
multidisciplinary approach to care, distance from
Primary care physician (i.e., family doctor, internal
home, staff/patient ratio, professional qualifications of
medicine doctor, pediatrician, gynecologist)
staff, their experience in treating eating disorders, and
Psychiatrist
adjunct therapies offered. Some treatment centers
Nutritionist
provide therapies in addition to psychiatric counseling
Clinical psychologist
and pharmacotherapy, like equine therapy, massage,
Psychopharmacologist (psychiatrist, clinical
dance, or art therapy. These therapies may be
psychologist, or pharmacologist with special
appealing, although you may want to consider
knowledge about medications used for mental
whether they're covered by your health insurance.
Social worker
Some important questions to ask treatment centers
Claims advocate for reimbursement
are provided at the end of this document. If you are
Other professionals who administer supplemental
considering traveling some distance to a center, you
services such as massage, yoga, exercise
may want to ask these questions by phone before you
programs, and art therapy
invest the time and expense in traveling. Also, if the
patient is going to enter some type of facility, knowing
how the facility plans for discharge is important. Discharge plans can be complicated and require much
coordination of care among different healthcare
providers. That takes time. Effective discharge
planning needs to start much earlier than a day or two
before the patient is expected to be discharged from a
Also important in your considerations are the type of
care team a facility typically uses. Below is a list of the
types of professionals that are generally
recommended to be on the care team to ensure well-
rounded care. Once a treatment facility decision has been made, there is another checklist of questions in a
separate document in this toolkit—Questions to ask
the care team—that you may want to ask the care
Lastly, there are some questions a family may want to ask the treatment facility and care team separately
(i.e., not in the presence of the patient). We have
created a separate checklist in another document in
the Parent Toolkit: Questions parents may want to ask
treatment providers privately. Depending on the
patient's age, you may need written permission to speak about the patient with a treatment facility or
member of the care team.
NEDA TOOLKIT for Parents
Questions to Ask When Seeking a Treatment Center
Does the center accept the patient's insurance? If
Who will the patient have the most contact with
so, how much will it cover?
on a daily basis?
Does the center offer help in obtaining
What is the mealtime support philosophy?
reimbursement from the insurer?
Who will update key family or friends? How often?
Does the center offer financial assistance?
How is care coordinated for the patient inside the
How long has the center been in business?
center and outside if needed?
What is its treatment philosophy?
How does the center communicate with the
Does the center have any religious affiliations and
patient's family doctors and other doctors who
what role do they play in treatment philosophy?
may routinely provide care?
Does the center provide multidisciplinary care?
What are your criteria for determining whether a
Is the location convenient for the patient and
patient needs to be partially or fully hospitalized?
his/her support people who will be involved
What happens in counseling sessions? Will there
through recovery?
be individual and group sessions?
If the location is far away for in-person family
Will there be family sessions?
participation, what alternatives are there?
How does the care team measure success for the
What security does the facility have in place to
protect patients?
How do you decide when a patient is ready to
How quickly will you complete a full assessment
How is that transition managed with the patient
Prior to traveling to the treatment center: what
are your specific medical criteria for admission
What after-care plans do you have in place and at
and will you talk with my insurance company
what point do you begin planning for discharge?
before we arrive to determine eligibility for
What follow-up care after discharge is needed and
who should deliver it?
What is expected of the family during the person's
Does the patient have a follow-up appointment in
hand before being discharged? Is the follow-up
Anorexic specific: Please describe your strategy for
appointment within 7 days of the discharge date?
accomplishing refeeding and weight gain, and
When is payment due?
please include anticipated time frame.
What are the visiting guidelines for family or
Key Sources
ECRI Institute Bulimia Resource Guide
What levels of care does the center provide?
Please define criteria for each level mentioned.
ECRI Institute interviews with families and treatment
What types of professionals participate on the
care team and what is each person's role?
What are the credentials and experience of the
How many hours of treatment are provided to a
patient each day and week?
Which professional serves as team leader?
What types of therapy does the center consider
essential? Optional?
What is the patient-staff ratio?
What is the rate of turnover (staff resigning) for
How is that handled with patients?
NEDA TOOLKIT for Parents
Treatment settings and levels of care
Several types of treatment centers and levels of care are available for treating eating disorders. Knowing the
terms used to describe these is important because insurance benefits (and the duration of benefits) are tied not
only to a patient's diagnosis, but also to the type of treatment setting and level of care.
Treatment is delivered in hospitals, residential
Psychotherapy and drug therapy are available in all
treatment facilities, and private office settings. Levels
the care settings. Many settings provide additional
of care consist of acute short-term inpatient care,
care options that can be included as part of a tailored
partial inpatient care, intensive outpatient care (by
treatment plan. Support groups may help a patient to
day or evening), and outpatient care. Acute inpatient
maintain good mental health and may prevent relapse
hospitalization is necessary when a patient is
after discharge from a more intensive program.
medically or psychiatrically unstable. Once a patient is
medically stable, he/she is discharged from a hospital,
The intensity and duration of treatment depends on:
and ongoing care is typically delivered at a subacute
insurance coverage limits and ability to pay for
care residential treatment facility. The level of care in
such a facility can be full-time inpatient, partial
severity and duration of the disorder;
inpatient, intensive outpatient by day or evening, and
mental health status; and
outpatient. There are also facilities that operate only
coexisting medical or psychological disorders.
as outpatient facilities. Outpatient psychotherapy and
medical follow-up may also be delivered in a private
A health professional on the treatment team will
make treatment recommendations after examining
and consulting with the patient.
The treatment setting and level of care should
complement the general goals of treatment. Typically,
Criteria for treatment setting and levels of
to medically stabilize the patient;
help the patient to stop destructive behaviors (i.e.,
restricting foods, binge eating,
Inpatient
purging/nonpurging); and
Patient is medically unstable as determined by:
Unstable or depressed vital signs
address and resolve any coexisting mental health problems that may be triggering the behavior.
Laboratory findings presenting acute health risk
Complications due to coexisting medical problems
Patients with severe symptoms often begin treatment
such as diabetes
as inpatients and move to less intensive programs as
Patient is psychiatrically unstable as determined by:
symptoms subside. Hospitalization may be required
Rapidly worsening symptoms
for complications of the disorder, such as electrolyte
Suicidal and unable to contract for safety
imbalances, irregular heart rhythm, dehydration,
severe underweight, or acute life-threatening mental
Residential
breakdown. Partial hospitalization may be required
Patient is medically stable and requires no intensive
when the patient is medically stable, and not a threat
medical intervention.
to him/ herself or others, but still needs structure to
continue the healing process. Partial hospitalization
Patient is psychiatrically impaired and unable to
programs last between 3 and 12 hours per day,
respond to partial hospital or outpatient treatment.
depending on the patient's needs.
NEDA TOOLKIT for Parents
Partial Hospital
Patient is medically stable but:
Eating disorder impairs functioning, though
without immediate risk
Needs daily assessment of physiologic and mental
Patient is psychiatrically stable but:
Unable to function in normal social, educational,
or vocational situations
Engages in daily binge eating, purging, fasting or
very limited food intake, or other pathogenic
weight control techniques
Intensive Outpatient/Outpatient
Patient is medically stable and:
No longer needs daily medical monitoring
Patient is psychiatrically stable and has:
Symptoms under sufficient control to be able to
function in normal social, educational, or
vocational situations and continue to make
progress in recovery
These criteria summarize typical medical necessity
criteria for treatment of eating disorders used by many
healthcare facilities, eating disorder specialists, and
health plans for determining level of care needed.
Please see Questions to Ask a Treatment Center for
additional help in determining a suitable treatment
NEDA TOOLKIT for Parents
Questions to ask the care team at a facility
Some of these questions pertain to particular eating disorders; some pertain to particular treatment settings; and
some pertain to any eating disorder and all settings.
What are the names, roles, titles, and contact
When do you begin discharge planning? Do you
information of those who will treat my family
schedule and give the patient a specific follow-up
appointment date/time at discharge?
What other professionals will be involved in the
How do you follow up if the patient does not show
up for a scheduled appointment?
What treatment plan do you recommend? Do you
What are your criteria for determining whether and
use current published clinical guidelines to guide
when a patient needs to be hospitalized?
treatment? If so, which guidelines?
What happens in counseling sessions? Will there be
What's your prognosis for the patient's chance of a
individual and group sessions? Will there be family
full recovery? How long might it take? How do you
measure success?
If I become very concerned about the patient, who
What specific goals will be set for the treatment
How long does each counseling session last? How
Is there any psychiatric diagnosis in addition to the
many will there be? How often will they happen?
eating disorder? How will it be treated?
What contact can the patient have with family and
What physical/medical complications need
friends through the course of treatment?
ongoing treatment?
What are we permitted to bring when visiting?
What will the sequence of treatments be?
What are we not permitted to bring?
Are there alternative or adjunct treatments you
How will you help us prepare for the patient's
What benefits and risks are associated with the
What should we do and who should we contact in
recommended treatments and alternatives?
the event of a partial or complete relapse?
How can I best help my family member during
What books, websites, or other sources of
treatment? What is my role within the treatment?
information would you recommend?
How often will you talk to me about my family
member's progress?
What if my family member doesn't want to
participate in therapy?
What are your admissions criteria for residential,
inpatient, partial hospital, intensive, and
outpatient/inpatient care?
How much weight gain should be expected in what
time period for anorexia? What can I do to support
my family member during a time of weight gain?
Who should monitor refeeding and/or weight
status? What procedures should we follow for
How do family members determine whether purge
behavior is occurring at home? What should we do
if we notice this behavior?
If my family member is being treated as an
outpatient, how do you decide if more intensive
intervention is needed?
How often do team members communicate with
each other? (Even if the team doesn't talk to each
other, you can serve as a liaison to relay
NEDA TOOLKIT for Parents
Questions to ask when interviewing a therapist
What is your experience and how long have you
What happens in counseling sessions? If a
been treating eating disorders?
particular session is upsetting for my child, will
How are you licensed? What are your training
you advise me on how best to support my child?
credentials? Do you belong to the Academy for
How long does each counseling session last? How
Eating Disorders (AED)? AED is a professional
many will there be and how often?
group that offers its members educational
How often will you meet with me/us as parents?
trainings every year. This doesn't prove that
How do you involve key family members or
individuals are up-to-date, but it does increase the
What specific goals will be set for treatment and
How would you describe your treatment style?
how will they be communicated?
Many different treatment styles exist. Different
How and when will progress be assessed?
approaches may be more or less appropriate for
How long will the treatment process take? How
your child and family depending on your child's
do you know when recovery is happening and
situation and needs.
therapy can stop?
What kind of evaluation process do you use to
Do you charge for phone calls or emails from
recommend a treatment plan? Who all is involved
patients or family between sessions? If so, what do
in that planning?
you charge and how and to whom (insurance
What are the measurable criteria you use to assess
company or patient) is that billed?
how well treatment is working? Can you give me a
Will you send me written information, a treatment
plan, treatment price, etc.? The more information
Do you use published clinical practice guidelines
the therapist or facility is able to send in writing,
to guide your treatment planning for eating
the better informed you will be.
Do you deal directly with the insurer or do I need
What psychotherapeutic approaches and tools do
When is payment due?
How do you treat coexisting mental health
Are you reimbursable by my insurance? What if I
conditions such as depression or anxiety?
don't have insurance or mental health benefits
How do you decide which approach is best for the
under my health care plan?
patient? Do you ever use more than one
It is important for you to research your insurance
What kind of medical information do you need?
coverage policy and what treatment alternatives are
Will a medical evaluation be needed before my
available in order for you and your treatment provider
child begins treatment?
to design a treatment plan that suits your coverage.
How will you work with my child's other doctors,
such as medical doctors, who may need to provide
With a careful search, the provider you select will be
helpful. If the first time you meet is awkward, don't be
How often will you communicate with them?
Will you work with my child's school and
discouraged. The first few appointments with any
teachers? How often do you communicate with
treatment provider can be challenging. It takes time to
build trust when you are sharing highly personal
Will medication play a role in my child's
information. If you continue feeling that a different
therapeutic environment is needed, consider other
Do you work with a psychopharmacologist if
medication seems indicated or do I find one on my
What is your availability in an emergency? If you
are not available, what are my alternatives?
What are your criteria for determining whether a
patient needs to be hospitalized?
What is your appointment availability? Do you
offer after work or early morning appointments?
NEDA TOOLKIT for Parents
Questions parents may want to ask treatment providers
privately
Appropriate support from parents and family is crucial to the treatment process and recovery. Below are some questions you can ask the treatment provider (at an eating disorder facility or private practice) to assist you in providing the best support possible for your loved one. Remember you may need to be proactive to help
Is it wise for a recovering patient to have a job
ensure the communication process flows smoothly.
related to food or exercise?
And don't forget to find support for yourself! As a
How should I involve my family member in meal
parent, family member, or friend it's easy to overlook
planning, preparation, and food shopping?
the self-care you need as you focus on your loved
How much weight gain should be expected in
one's recovery. National Eating Disorders Association's
what time period with anorexia nervosa?
(NEDA's) treatment referral resource on the website
What support can I offer during a time of weight
lists family support groups, though you can ask the
treatment provider helping your loved one to make a
Is it my responsibility to monitor refeeding and/or
weight? What procedures should I follow for
How can I best support my child/family member
How do family members determine if purge
during treatment?
behavior is occurring in the home setting?
What is my role?
What action should I take if we notice this
How often can I discuss progress with you?
What should be done if my child/family member
If I become anxious or notice problems, who
does not want to participate in treatment?
Can my child/family member be admitted to a
My family member doesn't want anyone to know
facility against her/his will? If so, under what
about the illness. I do because it would help me to
share about the illness with select, carefully
How should I prepare for our family member's
chosen, discrete people in our lives. They could be
supportive, but I'm afraid that my family member
What books, websites, or other resources do you
might see them as spies. What should I do?
How can I tell if a relapse is occurring? What
If the patient is age 18, and often even younger,
parents will need written permission from the patient
If my family member receives outpatient
to discuss his/her situation with a healthcare provider
treatment, how will you decide if more intensive
(professional or facility).
treatment is needed?
If I have concerns about how it's going, who
What limits should be placed on exercise? What
distinguishes compulsive from healthy exercise?
Are there any special first-aid items such as
Gatorade® or Pedialyte® that I should keep on
hand to help with bulimia-related emergencies?
How can I encourage "safe" food choices?
What if my family member shuts me out of talking
Will my family member be in group treatment
with people of similar age/sex? What kind of food-
related supervision should I provide?
If my family member is fascinated by cooking,
nutrition, or fitness, should those interests be
NEDA TOOLKIT for Parents
Find eating disorder treatment
Online databases and telephone referral lines are available to help families find a suitable treatment setting.
Excellent resources are listed below
Treatment Center Databases to Search
Something Fishy
The database contains listings from individual
therapists, dieticians, treatment centers, and other
Treatment center listings can be accessed from the
professionals worldwide who treat eating disorders.
NEDA homepage. This database contains listings from
Open the "treatment finder" tab on the left, and search
professionals who treat eating disorders. Simply open
by category (type of treatment), country, state, area
the treatment referral tab and agree to the disclaimer.
code, name, services, description, or zip code.
Find an eating disorders treatment provider who will
serve your state, a nationwide list of
What to Consider When Searching for a
inpatient/residential treatment facilities, search for
Treatment Center
free support groups in your area or locate a national
Eating Disorders Research Study.
Several considerations enter into finding a suitable
treatment setting. Options may be limited by factors
Bulimia Guide
such as insurance coverage, location, or ability to pay
for treatment in the absence of insurance. When
contacting treatment centers, be sure to talk with
This database focuses on U.S. centers that treat all
them to find out their complete admission criteria and
types of eating disorders (not just bulimia) and offer
whether your loved one meets their criteria for
various levels of care and many types of treatment
treatment. That way, you can better ensure that your
from standard to alternative. On this website, you can
loved one will meet their criteria before traveling.
browse center listings by state, type of treatment
Arriving at a center only to find out, after they take
offered, whether or not they accept insurance, or other
sufficiently detailed patient intake information, that
characteristics by selecting from the drop-down lists.
they won't admit your loved one is a situation you'll
Some states have no eating disorder treatment
want to prevent. Primary care physicians (i.e., family
centers, and that's why no listings come up for some
doctor, gynecologist, pediatrician, internal medicine
states. This information was compiled from detailed
doctor) may be able to assist in referring patients to
questionnaires sent to every center to gather
appropriate treatment facilities, because they may
information about its treatment philosophies,
have experience with various centers or outpatient
approaches, staffing, and the clinical and support
services it offers. The amount of information centers
provided varies widely among centers. This database
Telephone Referral and Information
does not contain listings for individual outpatient
Helplines
therapists who claim to treat eating disorders.
NEDA Helpline 800.931.2237
Something Fishy 866.690.7239
Hope Line Network 800.273.TALK
National Suicide Hotline 800.784.2433
National Call Center for At-Risk Youth 800.USA.KIDS
NEDA TOOLKIT for Parents
How to take care of yourself while caring for a loved one
with an eating disorder
Take time for yourself. Keep in mind that what you
Remind yourself daily that you are doing the best
do is a much more powerful message than what
for your child or family member. Keeping a journal
you say. Being a good role model for your child or
can help— making a self-commitment to jot down
family member during the healing process means
one positive thought each day can help.
taking care of your own physical, emotional, and
spiritual needs.
Find support in what others are saying – join a
local or online support group.
If you are married or in a significant relationship,
spend time on that relationship. Talk daily to your
Say "No" when you can. Give yourself a break.
partner about your feelings and frustrations. Take
Don't take on any added responsibilities at this
time for a hug. If time allows, make a date for
something you both enjoy to have fun.
Explore your options if you think you may need to
Seek support from family, friends, and/or
leave work temporarily to provide full-time care.
professionals whom you find to be helpful. Allow
Learn about the Family and Medical Leave Act
yourself to be cared for.
(FMLA). FMLA provides job protection for
employees who must leave their job for family
Ask for help with the mundane. It makes your
medical concerns.
friends feel useful and keeps you from becoming
isolated. Make a list of things you can use help
with: laundry, errands, lawn care, housecleaning,
meals for the rest of the family. If someone says,
"Let me know if there is anything I can help with,"
show them your list of unassigned tasks. Ask what
NEDA TOOLKIT for Parents
Confidentiality issues
Parents of children of legal age or friends of a person
Other documents worth knowing about include a
with an eating disorder may want to help navigate
medical POA, which lets someone make medical
insurance issues and finding treatment facilities, or
decisions about the patient's healthcare if the patient
participate in treatment, but cannot talk with health
is incapable of making these decisions.
professionals or facilities on a patient's behalf without
The rules about medical POAs vary by state and it's
the patient's permission because of certain regulations
best to consult a lawyer to write one. Advanced
protecting medical privacy. The Health Insurance
directives are another set of documents that the
Portability and Accountability Act of 1996, or HIPAA,
patient authorizes for future treatment in case the
protects individuals' medical records from becoming
patient cannot make decisions at that time. Most
public knowledge. HIPAA states that under normal
hospitals have forms for patients to fill out to specify
circumstances, medical records are private and that
anyone with access to them, like healthcare
professionals, healthcare facilities, or insurers, cannot
In most states parents have medical POA over their
share that medical information with anyone but the
children as long as the children are younger than age
patient. HIPAA protection also extends to human
18 although the exact regulations depend on the state.
resources (HR) departments at employers. If a person
Parents do not have medical or durable POA over
discloses his/her medical condition to HR personnel
children who are older than age 18, even if the
when talking about health insurance benefits, HR is
children are covered under the parents' health
required to maintain confidentiality. If HR divulges
insurance policy. If a child is in college, is over age 18,
information without permission, the harmed party can
but is still covered by the parents' insurance, then the
file a civil rights complaint. HIPAA requires companies
parents and child must go through the usual legal
to have policies that provide for sanctions against any
process to set up POA. This can be a problem if the
HR person who releases confidential medical
child does not want treatment or is at odds with the
information. The Americans with Disabilities Act may
parents, which is sometimes the case. Parents have no
provide recourse for anyone fired from a job because
legal authority to force a legally adult child into
of a medical condition.
If a friend or family member is helping a patient
through the treatment process, the patient can give
oral permission for that person to see the patient's
records and participate when talking with healthcare
providers or insurers. That person may also make
doctors' appointments for the patient. A friend or
family member cannot see a patient's medical files or
transport the files or lab samples if the patient is
absent, even if permission has been given orally.
To grant a friend or family member access to medical
records, the patient must provide a durable power of
attorney (POA) document. This document varies by
state so it's best to have a lawyer create it. Anyone
with a POA can sign legal documents for the patient
and read or transport medical records in the patient's
NEDA TOOLKIT for Parents
Insurance Issues
NEDA TOOLKIT for Parents
Navigating and Understanding Health Insurance Issues
This guidance is intended to assist people looking for help when accessing care and when insurance denies coverage for treatment of eating disorders. The information here was compiled from research by ECRI Institute
and the experience of parents and treatment providers who have had experience obtaining coverage for eating disorders care.
In a separate document are sample letters to adapt to
Another issue is the level of benefits for mental
various insurance situations related to obtaining
healthcare. For years, many health plans provided few
appropriate care. This information has not been
or no mental health benefits. When they did, most
prepared by attorneys and is not intended as a legal
subcontracted those benefits through "mental health
document. This information does not guarantee
carve-out" plans. Such plans are administered by
success. If you have suggestions, feedback, or personal
behavioral health service companies that are separate
additions to share (e.g., submit a sample letter you've
from health plans. This approach made well-rounded
used with your insurance company with all identifying
care by a multidisciplinary team very difficult to
information removed), please email National Eating
achieve. Even when a psychotherapist and medical
Disorders Association at
doctor want to integrate services and case
[email protected] with "Insurance
management to treat the patient as a whole person,
Issues" in the subject line.
the healthcare delivery system in the United States
poses barriers that prevent that from happening.
The National Eating Disorders Association fields many
questions every day that focus on how to gain access
For example, when a service is provided by a doctor or
to care and navigate insurance issues. While there is
facility, a billing code is needed to obtain
little argument that early intervention offers the best
reimbursement for services. Certain rules and
chance for recovery, insurance and the healthcare
regulations govern how services must be coded and
system can pose barriers to accessing prompt,
who can perform those services. Different types of
comprehensive treatment.
facilities and different healthcare professionals must
use codes that apply to that type of facility and health
Accessing the full benefits a patient is entitled to
professional. Also, if codes don't exist for certain
under his/her health plan contract requires
services delivered in a particular setting, then facilities
understanding a few things about all the factors that
and health professionals have no way to bill for their
affect access to care, coverage, and reimbursement.
services. Codes used for billing purposes are set up by
Navigating the system to find out what the patient is
various entities, such as the American Medical
entitled to receive also takes a lot of energy. While
Association, U.S. Medicare program, and the World
parents can legally act on behalf of children younger
Health Organization's International Classification of
than age 18, they need permission from a child older
Diseases. Thus, even a patient with good health
than age 18 to act on his/her behalf.
insurance may face barriers to care simply because of
the way our healthcare system is set up.
Because treatment usually involves both mental
healthcare and medical care aspects, a well-rounded
The system is slowly changing. Sporadic improvements
care plan must address both types of care. The overall
have come about as a result of lawsuits and state
healthcare system has long treated medical care and
legislation prompted by individuals, legislators,
mental healthcare separately. The result of that care
clinicians, support groups, and mental health
model is that health insurer benefits plans have often
advocacy groups. The U.S. federal government and
followed suit by separating mental health benefits
most U.S. states have passed some form of mental
(also called behavioral health benefits) from medical
health parity law. Generally these laws require
benefits. This split has created great difficulty for
insurers to provide benefits for mental healthcare that
people with an eating disorder because they need an
are equivalent to benefits for medical care. These laws
integrated care plan. Ways to steer through these
do, however, vary widely in their provisions.
difficulties are offered here in an 8-step plan.
NEDA TOOLKIT for Parents
Landmark lawsuits brought by families of patients
with bulimia nervosa and/or anorexia in two states—
Wisconsin in 1991, and Minnesota in 2001—were
watershed events that set legal precedents about
what insurers should cover for eating disorders. These
lawsuits also raised public awareness of the problems
faced by people seeking coverage for treatment of
eating disorders. Nonetheless, the system today has a
long way to go to improve access to care and
adequate reimbursement for care for a sufficient
period for a patient with an eating disorder.
Given that appropriate well-integrated treatment for
eating disorders can easily cost more than $30,000 dollars per month, even with insurance, an insured
individual is usually responsible for some portion of
The first-line of decision making about health plan
benefits is typically made by a utilization review
manager or case manager. These managers review the
requests for benefits submitted by a healthcare
provider and determine whether the patient is entitled
to benefits under the patient's contract. These decision
makers may have no particular expertise in the
complex, inter-related medical/mental healthcare
needs for an eating disorder. Claims can be rejected
outright or approved for only part of the
recommended treatment plan. Advance, adequate
preparation on the part of the patient or the patients'
support people is the best way to maximize benefits.
Prepare to be persistent, assertive, and rational in
explaining the situation and care needs. Early
preparation can avert future coverage problems and
situations that leave the patient holding the lion's
NEDA TOOLKIT for Parents
Steps to maximize insurance benefits
Educate yourself
A spouse, partner, friend, or other person who wants to
act on behalf of the patient will need to have the
Read the other information in the Parent Toolkit to
patient sign appropriate authorizations. Medical
learn about eating disorders, treatment, current
confidentiality is discussed later in this section.
clinical practice guidelines, and how you can best
advocate for and support the family member who has
Read the patient's entire insurance benefits
an eating disorder. Refer to the latest evidence-based
manual carefully to understand the available
clinical practice guidelines in this toolkit and have
benefits
them in hand when speaking to your health plan
about benefits. Be prepared to ask your health plan
Obtain a copy of the full plan description from the
for the evidence-based information they use to create
health plan's member's website (i.e., the specific plan
their coverage policy for eating disorders.
that pertains to the insured), the insurer or, if the
insurance plan is through work, the employer's human
Find out if your state has a mental health parity law or
resources department. This document may be longer
mandate and what the terms of that law or mandate
than 100 pages. Do not rely on general pamphlets or
are. Mental health parity simply means that your
policy highlights. Read the detailed description of the
insurance company must not limit mental health and
benefits contract to find out what is covered and for
substance abuse healthcare by imposing lower day
how long. If you can't understand the information, try
and visit limits, higher copayments and deductibles,
talking with the human resources staff at the company
and lower annual and lifetime spending caps than
that the insurance policy comes through, with an
they do for medical care. The website
insurance plan representative (the number is on the
www.bulimiaguide.org has detailed information about
back of your insurance identification card), or with a
which states have mental health parity laws or
billing/claims staff person at facilities where you are
mandates and what those laws and mandates cover.
considering obtaining treatment. If hospital
See the Eating Disorders Coalition for Research, Policy
emergency care is not needed, make an appointment
& Action web site for how to get involved in the effort
with a physician you trust to get a referral or directly
to influence federal policy at:
contact eating disorder treatment centers to find out
how to get a full assessment and diagnosis. The
assessment should consider all related physical and
Get organized
psychological problems (other documents in this
toolkit explain the diagnostic or assessment process
If a patient's first encounter with the healthcare
and testing). The four main reasons for doing this are:
system is admission to an emergency room for a life-
threatening situation with an eating disorder, whoever
To obtain as complete a picture as possible about
is going to deal with insurance issues on the patient's
everything that is wrong
behalf will need to get organized very quickly to
To develop the best plan for treatment
figure out how to best access benefits. Patients who
To obtain cost estimates before starting treatment
are seriously medically compromised will likely be in
To obtain the benefits the patient is entitled to
the hospital for a few days before discharge to
under his/ her contract for the type of care
outpatient care or a residential eating disorder center.
needed—for example, many insurers provide
Those few days are critical to negotiating
more coverage benefits for severe mental disorder
reimbursement for the longer-term care.
diagnoses. Some insurers categorize anorexia and
If the situation is not an acute emergency and you
bulimia nervosa as severe disorders that qualify
want to find a treatment center, consider whether you
for extensive inpatient and outpatient benefits,
have authority to act on the patient's behalf or
while others may not.
whether the patient must give you written authority to
act on his/her behalf. If a child is 18 years of age or
older, parents will need the child's written permission
to act on the child's behalf. Healthcare providers have
forms that require signatures to allow free flow of
communication and decision making.
NEDA TOOLKIT for Parents
Medical benefits coverage also often comes into play
This will improve your chance of getting one contact
to treat eating disorder-associated medical conditions,
person to talk with over the longer term of treatment
so diagnosing all physical illnesses present is
who better understands the complexities of treatment.
important. Other mental conditions often coexist with
Confirm with the insurer that the patient has benefits
an eating disorder and should be considered during
for treatment. Also ask about "in-network" and "out-of-
the assessment, including depression, trauma,
network" benefits and the eating disorder facilities
obsessive compulsive disorder, anxiety, social phobias,
that have contracts with the patient's insurance
and chemical dependence. These coexisting
company, because this affects how much of the costs
conditions can affect eligibility for various benefits
the patient is responsible for. If the insurer has no
(and often can mean more benefits can be accessed)
contract with certain treatment facilities, benefits may
and eligibility for treatment centers.
still be available, but may be considered out-of-
network. In this case, the claims will be paid at a lower
Keep careful and complete records of
rate and the patient will have a larger share of the bill.
communications with the insurance company
and healthcare providers for future reference
You may also want to consider having an attorney in mind at this point in case you need to consult
as needed
someone if roadblocks appear; however, avoid an
adversarial attitude at the beginning. Remember to
From the first call you make, keep a complete record
keep complete written records of all communications
of your conversation. Treatment often occurs over a
with every person you speak with at your insurance
long period of time. Maintaining a log book—whether
company. Other things to remember:
computerized or in hard copy—can be important for
future reference if there are questions about claims.
Thank and compliment anyone who has assisted
Decide where all notes and documentation will be
kept for easy access. Create a back-up copy of
You're more likely to receive friendly service when
everything, and keep it in a safe and separate place.
you are polite while being persistent.
The record log of conversations should contain the
Send important letters via certified mail to ensure
they can be tracked and signed for at the recipient
Notes taken of each conversation with an insurer
Set a timeframe and communicate when you
or healthcare provider
would like an answer. Make follow-up phone calls
Date, time, name, and title of person with whom
if you have not received a response in that
Person's contact information
Don't assume one department knows what the
other department is doing. Copy communications
As a courtesy, you may wish to let the people you talk
to all the departments, including health, mental
with know that you are keeping careful records of
health, enrollment, and other related
your conversations to help you and the patient
remember what was discussed. If you decide to tape
Don't panic when and if you receive the first
record any conversation, you must first inform and ask
denial. Typically, a denial is an automatic
the permission of the person with whom you are
computer-generated response that requires a
"human override." Often you need to go up at least
one level, and perhaps two levels, to reach the
Call the insurer to discuss benefits options
decision maker with authority to override the
automated denial.
With documentation of the patient's diagnosis and
Your insurance company only knows what you and
proposed care plan in hand, it's a good idea to call the
the treating professionals tell them. Make sure
insurance company before the patient formally enters
they have all information necessary to make
a treatment program. Quite often, preauthorization for
decisions that will be of most benefit to you or
a treatment facility or healthcare provider is needed.
Ask for a case manager who has credentials in eating
Make no assumptions. Your insurance company is
not the enemy – but may be uninformed about
your case. Treat each person as though he/she has a tough job to do.
NEDA TOOLKIT for Parents
Be aware that if the patient is a college student who
Not all health plans will do this, but some do, so it's
had to drop out of school to seek treatment and was
worth asking. Going this route can save the behavioral
covered by school insurance or a parent's insurance
health benefits for the time when the patient is better
policy, the student may no longer be covered if not a
able to take part in the psychotherapy.
full-time student. While many people will continue
working or attending school, some cannot. If this is the
Another way to get the most out of benefits is to find
case, it's important to understand what happens with
out whether chemical dependency or substance abuse
insurance. Most insurance policies cover students as
benefits are included in the mental health day
long as they are enrolled in 12 credit hours per
allotment or if it is a separate benefit. If it is separate
semester and attend classes. Experts in handling
and the patient does not really need this benefit, find
insurance issues for patients with eating disorders
out whether the insurer will "flex" the benefit to apply
caution that patients who have dropped out of school
it for treating an eating disorder.
should avoid trying to cover up that fact to maintain
benefits, because insurance companies will usually
Find out the authorizations for care that the
find out and then expect the patient to repay any
insurer requires for the patient to access
benefits that were paid out.
If coverage has been lost, the student may be eligible
to enroll in a Consolidated Omnibus Budget
Once insurance benefits are confirmed, be sure to
Reconciliation Act (COBRA) insurance program.
obtain the health plan authorizations required for
COBRA is an Act of Congress that allows people who
reimbursement for the care the patient will receive.
have lost insurance benefits to continue those benefits
Sometimes authorizations and referrals are sent
as long as they pay the full premium and qualify for
electronically to the concerned parties. Always
the program. See www.cobrainsurance.com for more
confirm that they have been sent and received by the
information. A person eligible for COBRA has only 30
appropriate parties. Ask for the level-of-care criteria
days from the time of loss of benefits to enroll in a
the patient must meet to be eligible for the various
COBRA plan. It is critical that the sign up for COBRA be
levels of benefits. Again, keep a record of the
done or that option is lost. Be sure to get written
authorizations received.
confirmation of COBRA enrollment from the plan. If
the student is not eligible for COBRA, an insurance
Communicate with key caregivers to give any
company may offer a "conversion" plan for individual
needed input and devise a treatment plan.
Obtain the names of the people who will be providing
If the patient is in the hospital and will be discharged
care and having daily interactions with the patient
to a residential treatment center, discuss how the
(including lower-level staff such as aides). Try to meet
medical and behavioral health components of
with, or talk by phone, to each caregiver on the team.
benefits will work. Although a patient may be
Discuss the diagnosis (and whether there is more than
"medically stable" at discharge, he/she may not be
one primary diagnosis) and treatments options, and
nearly well enough to participate fully in
ask whether there is clinical evidence to support the
psychotherapy at the residential center. The patient's
recommended treatment and what that evidence is.
medical condition, though not life-threatening at this
point, affects mental health and ability to participate
in treatment. Restoring physical health may take days
or weeks. Therefore, before the patient is admitted to
a residential eating disorder center or placed in
outpatient treatment, contact the patient's health plan
or employer (if applicable and the health plan is self-
funded by the employer) and ask for the early claims
for psychotherapy to be paid under the medical
benefits instead of the behavioral health benefits. The
language to use is: "Will you intercept psychotherapy
claims and pay them under medical benefits until the
patient is stable enough to participate fully and assist
in her treatment?"
NEDA TOOLKIT for Parents
This information can be useful when talking to the
Enlist support from family members and
insurance company about benefits, because insurance
companies value evidence-based care. Also, ask how
friends you can count on.
the treatment plan will be coordinated and managed,
and who will coordinate the plan. In the case of
Make a list of people you can count on for moral
bulimia nervosa, the patient often has close to normal
support throughout the course of treatment. Keep
body weight. However, serious, but less obvious
their names, phone numbers, and email addresses
medical conditions may also be present (e.g.,
handy. For this list, identify people who can help the
osteoporosis, heart problems, kidney problems, brain
patient remain focused and provide helpful emotional
abnormalities, diarrhea, reflux, nausea, malnutrition,
support and encouragement while navigating the
heartburn). Tests that are used to diagnose medical
system to obtain care and while receiving care. Find
symptoms and criteria for levels of care are listed in
out from each of them their availability (i.e., times,
First steps to getting help in this toolkit. Ask for "letters
dates) for support and the kind of support they can
of support" from the healthcare team. See Sample
offer. Also consider distributing that list among key
letter #6 in Sample letters to use with insurers in this
people on the list so they know who is in your support
toolkit. Using language that is used by insurance
network. Also, list key healthcare provider (facilities
companies is helpful to have common ground. For
and healthcare providers) contact numbers on that list
example, it's important to point out care that is
in the event of an emergency.
considered by the doctors to be "medically necessary"
for the patient's recovery.
Documentation like this is useful to provide to the
insurer when discussing reimbursement, because it
gives both you and the insurer a framework for
discussion. With regard to the healthcare providers,
ask them how to and who can obtain copies of the
patient's medical records, who will provide progress
reports, how often they will provide them, and to
whom. Ask the healthcare provider (whether a facility
or individual therapist) for an itemization of the
estimated costs of care, which costs will likely be paid
by the insurer, and which costs will be paid by the
patient. Also ask how billing for reimbursement will be
handled—ask whether you have to submit claims or
whether the healthcare service provider submits the
claims on the patient's behalf.
NEDA TOOLKIT for Parents
COBRA rights checklist
This is a list of requirements that employers must follow to inform their group health plan beneficiaries
(employees, spouses, dependents) of their rights under the Consolidated Omnibus
Budget Reconciliation Act (COBRA).
Required notices
Payment of COBRA premiums
Model general and election notices available at
Premiums are due the first of the coverage month.
An administrative charge may be added to the
General Rights Notice (must be sent within 90
monthly premium. There is a 30-day grace period
days of enrollment into a group health plan -
to make payments. This begins on the second day
health, dental, vision, flexible spending account)
of the coverage month. For example, September's
Specific Rights Notice (Election notice - the plan
grace period expires on October 1, not September
administrator must provide the notice within 14
days after receiving notice of a qualifying event)
Conversion Rights Notice (must be sent 180 days
Reasons for terminating COBRA coverage
prior to the end of the maximum continuation
The maximum continuation period has been
Notice of Unavailability (must be sent when the
plan administrator denies coverage after receiving
The Qualified Beneficiary fails to make a timely
notice and explain why continuation coverage is
COBRA premium payment.
The Qualified Beneficiary is covered under
Notice of Termination of COBRA Rights (must be
another group health plan AFTER the election of
sent when COBRA coverage terminates before the
end of the maximum COBRA period)
The Qualified Beneficiary is no longer disabled
after the start of the 11-month extension has
Enrollment into group health plan
The Employer ceases to provide any group health
Send General COBRA notice addressed to covered
coverage to any covered employee.
employee and spouse, if applicable, to home
The Qualified Beneficiary has become entitled to
address within 90 days of enrollment into group
Medicare, part A or B (For purposes of Medicare,
ELIGIBLE means the person has attained the age
Send General COBRA notice to covered spouse if
of 65. ENTITLEMENT means the person has
added during open enrollment or qualified event
actually become enrolled under Medicare).
Types of qualifying events for COBRA
Open enrollment
eligibility
During open enrollment, the same information
Employee Termination
and enrollment options must be communicated to
Employee Reduction in Hours
COBRA Qualified Beneficiaries as to active
Employee Death
employees. This includes allowing Qualified
Entitlement to Medicare
Beneficiaries the ability to enroll under a new
Employee Divorce or Legal Separation
Loss of Dependent Child Status
Length of coverage available
18 months (Employee Events)
36 months (Dependent Events)
29 months (Disability Extension periods)
NEDA TOOLKIT for Parents
Sample letters to use with insurance companies
This section provides seven sample letters to use for various circumstances you may encounter that require you to
communicate with insurance companies. These letters were developed and used by families who encountered
these situations.
Keep in mind that a cordial, business communication tone is essential as discussed in Navigating and
understanding health insurance issues. Remember:
Follow up letters with phone calls and document whom you speak to. Don't assume one insurance department knows what the other is doing. Don't panic! Your current issue or rejection can be a computer generated "glitch." Copy letters to others relevant to the request. Also, if you are complimenting someone for the assistance
they've provided, tell them you'd love to send a copy to their boss to let him/ her know about the great service you've received.
Supply supporting documents. Get a signed delivery receipt – especially when time is of the essence. Sample letters begin on the following page.
NEDA TOOLKIT for Parents
Sample Letter #1
Request that the copay for the psychiatrist from the patient be changed to a medical copay rate instead of the higher mental health copay, because the psychiatrist was providing medication management, not psychotherapy.
Adjustments can be made so that the family is billed for the medical copay. Remember, the psychiatrist must use the proper billing code.
To: Name of Clinical Appeals Staff Person INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS Re: PATIENT'S NAME
DOB (Date of Birth) Insurance ID#
Dear [obtain and insert the name of a person to address your letter to—avoid sending to a generic title or "To Whom It May Concern"];
Thank you for assisting me with my [son's/daughter's] medical care. As you can imagine, this process is very emotionally draining on the entire family. However, the cooperation of the fine staff at [INSURANCE COMPANY
NAME] makes it a little easier.
At this time, I would like to request that [INS. CO.] review the category that [Dr. NAME's] services have been placed into. It appears that I am being charged a copay for [his/her] treatment as a mental health service when in reality
[he/she] provides [PATIENT NAME] with pharmacologic management for [his/her] neuro-bio-chemical disorder. Obviously, this is purely a medical consultation. Please review this issue and kindly make adjustments to past and
future consultations.
Thank you in advance for your cooperation and assistance.
[YOUR NAME] Cc: [list the people in the company you are sending copies to]
NEDA TOOLKIT for Parents
Sample Letter #2
The need to flex hospital days for counseling sessions. Remember, just because you are using outpatient services does not mean that you cannot take advantage of benefits for a more acute level of care if your child is eligible
for that level of care. The insurance company only knows the information you supply, so be specific and provide support from the treatment team!
10 Hospital days were converted to 40 counseling sessions.
Date: To: Name of an individual in the Ins. Co. Management Dept
INS. CO. NAME & ADDRESS From: YOUR NAME & ADDRESS
Re: PATIENT'S NAME DOB (Date of Birth)
Insurance ID# Case #
Dear [insert name]:
This letter is in response to [insurance company name's] denial of continued counseling sessions for my
[daughter/son]. I would like this decision to be reconsidered because [insert PATIENT NAME] continues to meet the American Psychiatric Association's clinical practice guidelines criteria for Residential treatment/Partial
hospitalization. [His/Her] primary care provider, [NAME], supports [his/her] need for this level of care (see attached – Sample Letter #3 below provides an example of a physician letter). Therefore, although [he/she]
chooses to receive services from an outpatient team, [he/she] requires an intensive level of support from that team, including ongoing counseling, to minimally meet [his/her] needs. I request that you correct the records re:
[PATIENT NAME's] level of care to reflect [his/her] needs and support these needs with continued counseling services, since partial hospitalization/residential treatment is a benefit [he/she] is eligible for and requires.
I am enclosing a copy of the APA guidelines and have noted [PATIENT NAME'S] current status. If you have further questions you may contact me at: [PHONE#] or [Dr. NAME] at: [PHONE#].
Thank you in advance for your cooperation and prompt attention to this matter.
[YOUR NAME] Cc: [Case manager]
[Ins. Co. Medical manager]
NEDA TOOLKIT for Parents
Sample Letter #3
Letter to a managed care plan to seek reimbursement for services that the patient received when time was
insufficient to obtain pre-authorization because of the serious nature of the illness and the need to deal with it
urgently. Remember: you need to research the professionals available through your plan and local support systems. In this case, after contacting their local association for eating disorders experts, the family that created
this letter realized that no qualified medical experts were in their area to diagnose and make recommendations for their child. Keep in mind that you need to seek a qualified expert and not a world-famous expert. Make sure
you provide very specific information from your research.
Outcome
Reimbursement was provided for the evaluating/treating psychiatrist visits and medications. Further research and
documentation was required to seek reimbursement for the treatment facility portion. DATE To: Get the name of a person to direct a letter to
INS. CO. NAME & ADDRESS From: YOUR NAME & ADDRESS
Re: PATIENT'S NAME DOB (Date of Birth)
Insurance ID# Case #
Dear [insert name]:
My [son/daughter] has been under treatment for [name the eating disorder and any applicable co-existing
condition] since [month/year]. [He/she] was first seen at the college health clinic at [UNIVERSITY NAME] and then referred for counseling that was arranged through [INS. CO.]. At the end of the semester I met with my
[son/daughter] and [his/her] therapist to make plans for treatment over the summer. At that time, residential treatment was advised, which became a serious concern for us. We then sought the opinion of a qualified expert
about this advice. I first spoke to [PATIENT NAME'S] primary physician and then contacted the local eating disorders support group. No qualified expert emerged quickly from the community of our [INS. CO.] network
providers. In my research to identify someone experienced in eating disorder evaluation and treatment, I discovered that [insert Dr.NAME at HOSPITAL in LOCATION] was the appropriate person to contact to expedite
plans for our child. Dr. [NAME] was willing to see [him/her] immediately, so we made those arrangements. As you can imagine, this was all very stressful for the entire family. Since continuity of care was imperative, we
went ahead with the process and lost sight of the preapproval needed from [INS. CO.]. I am enclosing the bills we paid for those initial visits for reimbursement. [PATIENT NAME] was consequently placed in a residential setting in
the [LOCATION] area and continues to see Dr. [NAME] through arrangements made by [INS. CO.]. Also, at the beginning of [his/her] placement, some confusion existed about medications necessary for [PATIENT NAME] during this difficult/ acute care period. At one point payment for one of [his/her] medications was denied
even though the treatment team recommended it, and it was prescribed by [his/her] primary care physician, Dr. [NAME]. I spoke to a [INS. CO.] employee [insert name] at [PHONE #] to rectify the situation; however, I felt it was a little too late to meet my timeframe for visiting [PATIENT NAME], so I paid for the Rx myself and want reimbursement at this time. If you have any questions, please speak to [employee name].
Thank you in advance for your cooperation. I'd be happy to answer any further questions and can be reached at:
[PHONE] Sincerely, [YOUR NAME]
NEDA TOOLKIT for Parents
Sample Letters #4
To continue insurance while attending college less than full-time so that student can remain at home for a
semester due the eating disorder. Note: When a student does not register on time at the primary university at
which he/she has been enrolled, insurance is automatically terminated at that time. Automatic termination can cause an enormous amount of paperwork if not rectified IMMMEDIATELY. The first letter informs the insurance
company of the student's current enrollment status in a timely fashion, and the second letter responds to the abrupt and retroactive termination. Students affected by an eating disorder may be eligible for a medical leave of
absence from college for up to one year—so you may want to inquire about that at the student's college.
Outcome
The student was immediately reinstated as a less than full-time student.
DATE To: NAME OF CONTACT PERSON INS. CO. NAME & ADDRESS
From: YOUR NAME & ADDRESS Re: PATIENT'S NAME
DOB (Date of Birth) Insurance ID#
Case # Dear [NAME]: We spoke the other day regarding my [son's/daughter's] enrollment status. I am currently following up on your instructions and appreciate your assistance in explaining what to do. [Dr. NAME] is sending you a letter that should
arrive very soon about [PATIENT NAME's] medical status that required [him/her] to reduce the number of classes [he/she] will be able to take this fall. When [he/she] completes re-enrollment at [UNIVERSITY NAME] (which is not
possible to do until the first day of classes, [DATE]), [he/she] will have the registrar's office notify you of her status. At this time, [NAME] plans to be a part-time student at [UNIVERSITY] for the [DATE] semester and plans to return to
[UNIVERSITY] in [DATE], provided [his/her] disorder stabilizes. If all goes well; [he/she] may be able to graduate with [his/her] class and complete [his/ her] coursework by the [DATE] in spite of the medical issues. Please feel
free to get answers to any questions regarding these plans from [PATIENT NAME'S academic advisor Mr./Ms. NAME], whom [PATIENT NAME] has given written permission in a signed release to speak to you. This advisor has
been assisting my [son/daughter] with [his/her] academic plans and is aware of [his/her] current medical status. The advisor's phone number and email are: [PHONE #/ email].
Please feel free to contact me at [PHONE #] if you have any questions or need any further information. Thank you
for your assistance. Sincerely, [YOUR NAME]
NEDA TOOLKIT for Parents
Sample Letter #5
Follow-up letter to enrollment department after coverage was terminated retroactively to June 1st by the
insurance company's computer.
(HEADING SAME AS PREVIOUS LETTER)
Dear [NAME]: I am sure you can imagine my shock at receiving the attached letter [copy of the letter you received] that my [son/daughter] received about termination of coverage. [NAME] has been receiving coverage from [INSURANCE
COMPANY] for treatment of serious medical issues since [DATE]. We have received wonderful assistance from [NAME], Case Manager [PHONE#]; [NAME], Mental Health Clinical Director [PHONE#]; and Dr. [NAME], [INS. CO.]
Medical Director [PHONE #]. I am writing to describe the timeline of events with copies to the people who have assisted us as noted above. In [DATE], [ PATIENT NAME] requested a temporary leave of absence from [UNIVERSITY 1 NAME] to study at [UNIVERSITY 2 NAME] for one year. [He/she] was accepted at [UNIVERSITY 2 NAME] and attended the [DATE]
semester. At the end of the spring semester [PATIENT NAME'S] medical issues intensified and [PATIENT NAME] returned home for the summer. The summer of [YEAR] has been very complicated and a drain on our entire family.
The supportive people noted earlier in this letter made our plight bearable but we were constantly dealing with one medical issue after another. At the beginning of August [PATIENT NAME] and the treatment team members began to discuss [PATIENT NAME's]
needs for the fall semester of [YEAR]. As far as our family was concerned, all options [UNIV. 1, UNIV. 2, & several local options full and part-time] needed to be up for discussion to meet [patient name's] medical needs. We hoped
that with the help of [his/her] medical team we could make appropriate plans in a timely fashion. During [PATIENT NAME's] appointments the first two weeks of August, the treatment team agreed that [PATIENT NAME] should continue to live at home and attend a local university on a part-time basis for the fall semester. This
decision was VERY difficult for [PATIENT NAME] and our family. [PATIENT NAME ]still hopes/plans to return to [UNIV. 1] in [date] as a full-time student. [He/ she] has worked with [his/her] [UNIV. 1] advisor since [date] to work
out a plan that might still allow [him/her] to graduate with [his/her] class even if [he/she] needed to complete a class or two in the summer of [YEAR]. This decision by [NAME] was difficult but also a major
breakthrough/necessity for [his/her] treatment. After a workable plan was made, I called the enrollment department at [INS. CO. NAME] to gain information about
the process of notification regarding this change in academic status due to [his/her] current medical needs. [INS. EMPLOYEE NAME] communicated to me that I needed to have my child's primary care physician write a letter
supporting these plans. This letter is forthcoming as we speak. As soon as [PATIENT NAME's] fall classes are finalized on [date]' that information will also be sent to you. In summary, [PATIENT NAME] intended to be a full-time student this fall until [his/her] treatment team suggested
otherwise in the early August. At that time I began notifying the insurance company. Please assist us in expediting this process. I ask that you immediately reinstate [him/her] as a policy member. If [his/her] status is not resolved
immediately it will generate a GREAT DEAL of unnecessary extra work for all parties involved and, quite frankly, I'm not sure that our family can tolerate the useless labor when our energy is so depleted and needed for the
medical/life issues at hand. I am attaching 1) my previous enrollment notification note; 2) [PATIENT NAME's] acceptance from [UNIV. 2]; 3) a copy of [PATIENT NAME'S] apartment lease for the year; and 4) [his/her] recent letter to [UNIV. 2] notifying them
that [he/she] will be unable to complete the year as a visiting student for medical reasons. Please call me TODAY at [PHONE #] to update me on this issue. This is very draining on our family. Thank you for your assistance. Sincerely,
[YOUR NAME] Cc: [CASE MANAGER, MENTAL HEALTH CLINICAL DIRECTOR, MEDICAL DIRECTOR]
NEDA TOOLKIT for Parents
SAMPLE LETTER #6
Letter from doctor describing any medical complications your child has had, the doctor's recommendations for
treatment, and the doctor's prediction of outcome if this treatment is not received. This is a sample physician letter that parents can bring to their child's doctor as a template to work from.
To: [Get the name of a medical director at the insurance company]: INS. CO. NAME & ADDRESS
Re: PATIENT'S NAME DOB (Date of Birth)
Insurance ID# We are writing this letter to summarize our treatment recommendations for [patient name]. We have been following [patient name] in our program since [DATE]. During these past [NUMBER years], [patient name] has had
[NUMBER] hospitalizations for medical complications of [insert conditions, e.g., malnutrition, profound bradycardia, hypothermia, orthostasis]. Each of the patient's hospital admissions are listed below [list each and
every one separately]: Admission Date – Discharge Date [condition]
In all, [patient] has spent [NUMBER] days of the past [NUMBER years] in the hospital due to complications of [his/her] malnutrition.[Patient name's] malnutrition is damaging more than [his/her] heart. [His/Her] course has
been complicated by the following medical issues: List each issue and its medical consequence [e.g., secondary amenorrhea since DATE, which has the potential
to cause irreversible bone damage leading to osteoporosis in his/her early adult life.]
Despite receiving intensive outpatient medical, nutritional and psychiatric treatment, [patient name's] medical
condition has continued to deteriorate with [describe symptoms/signs, e.g., consistent weight loss since DATE] and is currently 83% of [his/her] estimated minimal ideal body weight (the weight where the nutritionist estimates[
he/she] will regain regular menses). White blood cell count and serum protein and albumin levels have been steadily decreasing as well, because of extraordinarily poor nutritional intake.
Given this history, prior levels of outpatient care that have failed, and [his/her] current grave medical condition,
we recommend that [patient name] urgently receive more intensive psychiatric and nutritional treatment that can be delivered only in a residential treatment program specializing in eating disorders. We recommend a minimum
60- to 90-day stay in a tiered program that offers: intensive residential and transitional components focusing on adolescents and young adults with eating disorders (not older patients). [Patient] requires intensive daily
psychiatric, psychologic, and nutritional treatment by therapists well trained in the treatment of this disease. Such a tiered program could provide the intensive residential treatment that [he/she] so desperately needs so [he/she]
can show that [he/she] can maintain any progress in a transitional setting. We do not recommend treatment in a non-eating disorder-specific behavioral treatment center. [Patient]'s severe anorexia requires subspecialty-level
care. Examples of such programs would include [name facilities]. Anorexia nervosa is a deadly disease with a 10% to 15% mortality rate; 15% to 25% of patients develop a severe lifelong course. We believe that without intensive treatment in a residential program, [patient name's and
condition], and the medical complications that it causes, will continue to worsen causing [him/her] to be at significant risk of developing lifelong anorexia nervosa or dying of the disease. We understand that in the past,
your case reviewers have denied [patient] this level of care. This is the only appropriate and medically responsible care plan that we can recommend. We truly believe that to offer a lesser level of care is medically negligent. We trust that you will share our grave concern for [patient's] medical needs and approve the recommended level of care to assist in [his/her] recovery.
Thank you for your thorough consideration of this matter. Please feel free to contact us with any concerns
regarding [patient's] care. Sincerely, [PHYSICIAN NAME]
NEDA TOOLKIT for Parents
SAMPLE LETTER #7
"Discussion" with the insurance company about residential placement when the insurance company suggests that
the patient needs to fail at lower levels of care before being eligible for residential treatment. In a telephone
conversation, the parents asked the insurance company to place a note in the patient file indicating the insurance company was willing to disregard the American Psychiatric Association guidelines and recommendations of the
patient's treatment team and take responsibility for the patient's life. (SEND BY CERTIFIED MAIL!)
OUTCOME
Shortly thereafter, the parents received a letter authorizing the residential placement.
To: CEO (by name) INS. CO. NAME & ADDRESS (use the headquarters) From: YOUR NAME & ADDRESS Re: PATIENT'S NAME
DOB (Date of Birth) Insurance ID#
Case # Dear (Pres. of INS. CO.): Residential placement services for eating disorder treatment have been denied for our [son/daughter] against the recommendations of a qualified team of experts consistent with the American Psychiatric Association's evidence-
based clinical practice guidelines. Full documentation of our child's grave medical condition and history and our attempts to obtain coverage for that care is available from our case manager [name]. At this time, I would like you
to put in writing to me and to my child's case file that [INS. CO.] is taking complete responsibility for my [son's/daughter's] life.
[YOUR NAME] Cc: [CASE MANAGER
NATIONAL MEDICAL DIRECTOR (get the names for both the medical and behavioral health divisions) NATIONAL MEDICAL DIRECTOR—Behavioral Health]
NEDA TOOLKIT for Parents
How to manage an appeals process
Continue treatment during the appeals
Ask the insurer what evidence-based
process.
outcome measures it uses to assess patient
health and eligibility for benefits.
Appeals can take weeks or months to complete, and
health professionals and facilities that treat eating
Some insurance companies may use body mass index
disorders advise that it's very important for the
(BMI) as a criterion for inpatient admission or
patient's well-being to stay in treatment if at all
discharge from treatment for bulimia nervosa, for
possible to maintain progress in recovery.
example, which may not be a valid outcome measure.
This is because patients with bulimia nervosa can have
Clarify with the insurer the reasons for the
close-to-ideal BMIs, when in fact, they may be very
denial of coverage.
sick. Thus, BMI does not correlate well with good
health in a patient with bulimia nervosa. For example,
Most insurers send the denial in writing. Claims
if a patient with bulimia nervosa was previously
advocates at treatment centers advise patients and
overweight or obese and lost significant weight in a
families to make sure they understand the reasons for
short timeframe, the patient's weight might approach
the denial and ask the insurance company for the
the norm for BMI. Yet, a sudden and large weight loss
reason in writing if a written response has not been
in such a person could adversely affect his or her
blood chemistry and indicate a need for intensive
treatment or even hospitalization.
Send copies of the letter of denial to all
concerned parties with documentation of the
Ask that medical benefits, rather than mental
health benefits, be used to cover
patient's need.
hospitalization costs for bulimia nervosa-
Claims advocates at treatment centers state that
related medical problems.
sending documentation of an appeals request to the
medical director, the human resources director of the
Claims advocates advise that sometimes claims for
company where the patient works (or has insurance
physical problems such as those arising from excessive
under), if applicable can help bring attention to the
fasting or purging, for example, are filed under the
situation. Presenting a professional-looking and
wrong arm of the insurance benefit plan—they are
organized appeal with appropriate documentation,
filed under mental health instead of medical benefits.
including an evidence-based care plan makes the
They say it's worth checking with the insurance
strongest case possible. Initial denials are often
company to ensure this hasn't happened. That way,
overturned at higher appeal levels, because higher-
mental health benefits can be reserved for the
level appeals are often reviewed by a doctor who may
patient's nonmedical treatment needs like
have a better understanding than the initial claims
psychotherapy. Various diagnostic laboratory tests can
reviewer of the clinical information provided,
identify the medical conditions that need to be treated
especially well-organized, evidence-based
in a patient with eating disorders. Also, if a patient has
a diagnosis of two mental disorders (also called a dual
diagnosis), and if that diagnosis is considered by the
insurance company to be more "severe" than an eating
disorder, the patient may be eligible for more days of treatment.
NEDA TOOLKIT for Parents
Ask the insurer whether they will "flex the
Negotiate with the treatment center about
benefit."
the cost of treatment.
Flexing benefits means that the insurer applies one
Our survey of treatment centers indicates that some
type of benefit for a different use. For example,
treatment centers have a sliding fee scale and may
medical benefits might be "flexed" to cover some
adjust the treatment charges or set up a payment
aspect of mental health treatment— usually
plan for the patient's out-of pocket costs.
inpatient treatment. Also, inpatient benefits might be
flexed (traded) to substitute intensive outpatient
Discuss with the insurer how existing laws
care for inpatient care—for example, 30 inpatient
and clinical practice standards affect your
days for 60 intensive outpatient benefit days.
Substance abuse (also called chemical dependency)
situation.
benefits might be traded for additional benefits to
treat the eating disorder if the beneficiary thinks
Educate yourself about how the state's mental
he/she will never need the substance abuse benefits
health parity laws and mandates apply to the
available under his/ her coverage. There is a clinical
patient's insurance coverage. Also ask the insurer if it
rationale for doing this: if the eating disorder is not
is aware of evidence reports on treatment for eating
treated appropriately from the outset, the insurer
disorders and guidelines like the American
risks incurring additional and higher costs for patient
Psychiatric Association's clinical guidelines for
care in the future because further hospitalization
treating eating disorders: www.psych.org. Ask what
and treatment may be needed. By flexing inpatient
role the evidence plays in the decision about
medical benefits or trading inpatient days for
benefits. As a last resort, some patients or their
outpatient days to obtain more days of mental
advocates may also contact the state insurance
health treatment, future and possibly higher
commissioner, state consumer's rights commission,
healthcare expenses might be avoided. While
an attorney, the media, or legislators to bring
insurers are not obligated to do flex benefits, they
attention to the issue of access to care for patients
may respond to a sound, logical argument to do so if
with eating disorders.
it makes good sense from both a business and
patient care perspective in the longer term. If you
can support this argument with your doctors'
recommended treatment plan and clinical evidence
from practice guidelines and an evidence report, the
insurer may agree.
If the patient is employed or in a union, consider
asking the employer (or its human resources
manager) or union representative to negotiate with
the insurer about aspects of the coverage policy that
seem open to interpretation. As a client of the
insurance company, the employer is likely paying a
lot of money to provide benefits to employees (even
when employees pay part of the insurance
premiums). Because insurance companies want to
maintain good business relationships with their
clients, the employer may have more influence than
the patient alone when negotiating for
reimbursement. Many patients or families of patients
are afraid or embarrassed to discuss bulimia or
anorexia with an employer. Remember that legally, a
person cannot be fired and insurance cannot be
dropped solely because of having an eating disorder
(or any other health condition).
NEDA TOOLKIT for Parents
Additional Resources
NEDA TOOLKIT for Parents
Glossary
This eating disorders glossary defines terms you may encounter when seeking information and talking with care
providers about diagnosis and treatment of all types of eating disorders. It also contains some slang terms that may be used by individuals with an eating disorder.
Alternative Therapy In the context of treatment for
Art Therapy A form of expressive therapy that uses
eating disorders, a treatment that does not use drugs
visual art to encourage the patient's growth of self-
or bring unconscious mental material into full
awareness and self-esteem to make attitudinal and
consciousness. For example yoga, guided imagery,
behavioral changes.
expressive therapy, and massage therapy are
considered alternative therapies.
Atypical Antipsychotics A new group of medications
used to treat psychiatric conditions. These drugs may
Amenorrhea The absence of at least three
have fewer side effects than older classes of drugs
consecutive menstrual cycles.
used to treat the same psychiatric conditions.
Ana Slang for anorexia or anorexic.
B&P An abbreviation used for binge eating and
purging in the context of bulimic behavior.
ANAD (National Association of Anorexia Nervosa and
Associated Disorders) A nonprofit corporation that
Behavior Therapy (BT) A type of psychotherapy that
seeks to alleviate the problems of eating disorders,
uses principles of learning to increase the frequency
especially anorexia nervosa and bulimia nervosa.
of desired behaviors and/or decrease the frequency
of problem behaviors. When used to treat an eating
Anorexia Nervosa A disorder in which an individual
disorder, the focus is on modifying the behavioral
refuses to maintain minimally normal body weight,
abnormalities of the disorder by teaching relaxation
intensely fears gaining weight, and exhibits a
techniques and coping strategies that affected
significant disturbance in his/her perception of the
individuals can use instead of not eating, or binge
shape or size of his/her body.
eating and purging. Subtypes of BT include
dialectical behavior therapy (DBT), exposure and
Anorexia Athletica The use of excessive exercise to
response prevention (ERP), and hypnobehavioral
Anticonvulsants Drugs used to prevent or treat
Binge Eating Disorder (also Bingeing) Consuming an
amount of food that is considered much larger than
the amount that most individuals would eat under
Antiemetics Drugs used to prevent or treat nausea
similar circumstances within a discrete period of
time. Also referred to as "binge eating."
Anxiety A persistent feeling of dread, apprehension,
Beneficiary The recipient of benefits from an
and impending disaster. There are several types of
insurance policy
anxiety disorders, including: panic disorder,
agoraphobia, obsessive-compulsive disorder, social
Biofeedback A technique that measures bodily
and specific phobias, and posttraumatic stress
functions, like breathing, heart rate, blood pressure,
disorder. Anxiety is a type of mood disorder. (See
skin temperature, and muscle tension. Biofeedback is
Mood Disorders.)
used to teach people how to alter bodily functions
through relaxation or imagery. Typically, a
Arrhythmia An alteration in the normal rhythm of the
practitioner describes stressful situations and guides
a person through using relaxation techniques. The
person can see how their heart rate and blood
pressure change in response to being stressed or
relaxed. This is a type of non-drug, non-
NEDA TOOLKIT for Parents
Body Dysmorphic Disorder or Dysmorphophobia A
COBRA A federal act in 1985 that included provisions
mental condition defined in the DSM-IV in which the
to protect health insurance benefits coverage for
patient is preoccupied with a real or
workers and their families who lose their jobs. The
perceived defect in his/her appearance. (See DSM-
landmark Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) health benefit
provisions became law in 1986. The law amends the
Body Image The subjective opinion about one's
Employee Retirement Income Security Act (ERISA),
physical appearance based on self-perception of
the Internal Revenue Code, and the Public Health
body size and shape and the reactions of others.
Service Act to provide continuation of employer-
sponsored group health coverage that otherwise
Body Mass Index (BMI) A formula used to calculate
might be terminated. The U.S. Centers for Medicare &
the ratio of a person's weight to height. BMI is
Medicaid Services has advisory jurisdiction for the
expressed as a number that is used to determine
COBRA law as it applies to state and local
whether an individual's weight is within normal
government (public sector) employers and their
ranges for age and sex on a standardized BMI chart.
group health plans.
The U.S. Centers for Disease Control and Prevention
Web site offers BMI calculators and standardized
Cognitive Therapy (CT) A type of psychotherapeutic
treatment that attempts to change a patient's
feelings and behaviors by changing the way the
Bulimia Nervosa A disorder defined in the DSM-IV-R
patient thinks about or perceives his/her significant
in which a patient binges on food an average of
life experiences. Subtypes include cognitive analytic
twice weekly in a three-month time period, followed
therapy and cognitive orientation therapy.
by compensatory behavior aimed at preventing
weight gain. This behavior may include excessive
Cognitive Analytic Therapy (CAT) A type of cognitive
exercise, vomiting, or the misuse of laxatives,
therapy that focuses its attention on discovering how
diuretics, other medications, and enemas.
a patient's problems have evolved and how the
procedures the patient has devised to cope with
Bulimarexia A term used to describe individuals who
them may be ineffective or even harmful. CAT is
engage alternately in bulimic behavior and anorexic
designed to enable people to gain an understanding
of how the difficulties they experience may be made
worse by their habitual coping mechanisms.
Case Management An approach to patient care in
Problems are understood in the light of a person's
which a case manager mobilizes people to organize
personal history and life experiences. The focus is on
appropriate services and supports for a patient's
recognizing how these coping procedures originated
treatment. A case manager coordinates mental
and how they can be adapted.
health, social work, educational, health, vocational,
transportation, advocacy, respite care, and
Cognitive Behavior Therapy (CBT) A treatment that
recreational services, as needed. The case manager
involves three overlapping phases when used to
ensures that the changing needs of the patient and
treat an eating disorder. For example, with bulimia,
family members supporting that patient and family
the first phase focuses on helping people to resist
members supporting that patient are met.
the urge to binge eat and purge by educating them
about the dangers of their behavior. The second
phase introduces procedures to reduce dietary
restraint and increase the regularity of eating. The
last phase involves teaching people relapse-
prevention strategies to help them prepare for
possible setbacks. A course of individual CBT for
bulimia nervosa usually involves 16- to 20-hour-long
sessions over a period of 4 to 5 months. It is offered
on an individual, group, or self-managed basis. The
goals of CBT are designed to interrupt the proposed
bulimic cycle that is perpetuated by low self-esteem,
extreme concerns about shape and weight, and
extreme means of weight control.
NEDA TOOLKIT for Parents
Cognitive Orientation Therapy (COT) A type of
Disordered Eating Term used to describe any
cognitive therapy that uses a systematic procedure
atypical eating behavior.
to understand the meaning of a patient's behavior by
exploring certain themes such as aggression and
Drunkorexia Behaviors that include any or all of the
avoidance. The procedure for modifying behavior
following: replacing food consumption with
then focuses on systematically changing the
excessive alcohol consumption; consuming food
patient's beliefs related to the themes and not
along with sufficient amounts of alcohol to induce
directly to eating behavior
vomiting as a method of purging and numbing
Comorbid Conditions Multiple physical and/or
mental conditions existing in a person at the same
DSM-IV The fourth (and most current as of 2006)
time. (See Dual Diagnosis.)
edition of the Diagnostic and Statistical Manual for
Mental Disorders IV published by the American
Crisis Residential Treatment Services Short-term,
Psychiatric Association (APA). This manual lists
round-the-clock help provided in a nonhospital
mental diseases, conditions, and disorders, and also
setting during a crisis. The purposes of this care are
lists the criteria established by APA to diagnose
to avoid inpatient hospitalization, help stabilize the
them. Several different eating disorders are listed in
individual in crisis, and determine the next
the manual, including bulimia nervosa.
appropriate step.
DSM-IV Diagnostic Criteria A list of symptoms in the
Cure The treated condition or disorder is
Diagnostic and Statistical Manual for Mental
permanently gone, never to return in the individual
Disorders IV published by APA. The criteria describe
who received treatment. Not to be confused with
the features of the mental diseases and disorders
"remission." (See Remission.)
listed in the manual. For a particular mental disorder
to be diagnosed in an individual, the individual must
Dental Caries Tooth cavities. The teeth of people
exhibit the symptoms listed in the criteria for that
with bulimia who using vomiting as a purging
disorder. Many health plans require that a DSM-IV
method may be especially vulnerable to developing
diagnosis be made by a qualified clinician before
cavities because of the exposure of teeth to the high
approving benefits for a patient seeking treatment
acid content of vomit.
for a mental disorder such as anorexia or bulimia.
Depression (also called Major Depressive Disorder) A
DSM-IV-R Diagnostic Criteria Criteria in the revised
condition that is characterized by one or more major
edition of the DSM-IV used to diagnose mental
depressive episodes consisting of two or more weeks
during which a person experiences a depressed
mood or loss of interest or pleasure in nearly all
Dual Diagnosis Two mental health disorders in a
activities. It is one of the mood disorders listed in the
patient at the same time, as diagnosed by a clinician.
DSM-IV-R. (See Mood Disorders.)
For example, a patient may be given a diagnosis of
both bulimia nervosa and obsessive-compulsive
Diabetic Omission of Insulin A nonpurging method of
disorder or anorexia and major depressive disorder.
compensating for excess calorie intake that may be
used by a person with diabetes and bulimia.
Eating Disorders Anonymous (EDA) A fellowship of
individuals who share their experiences with each
Dialectical Behavior Therapy (DBT) A type of
other to try to solve common problems and help
behavioral therapy that views emotional
each other recover from their eating disorders.
deregulation as the core problem in bulimia nervosa.
It involves teaching people with bulimia nervosa
Eating Disorders Not Otherwise Specified (ED-NOS)
new skills to regulate negative emotions and replace
Any disorder of eating that does not meet the criteria
dysfunctional behavior. A typical course of treatment
for anorexia nervosa or bulimic nervosa.
is 20 group sessions lasting 2 hours once a week.
(See Behavioral Therapy.)
Eating Disorder Inventory (EDI) A self-report test that
clinicians use with patients to diagnose specific
eating disorders and determine the severity of a
patient's condition.
NEDA TOOLKIT for Parents
Eating Disorder Inventory-2 (EDI-2) Second edition of
Expressive Therapy A nondrug, nonpsychotherapy
form of treatment that uses the performing and/or
visual arts to help people express their thoughts and
Ed Slang Eating disorder.
emotions. Whether through dance, movement, art,
drama, drawing, painting, etc., expressive therapy
ED Acronym for eating disorder.
provides an opportunity for communication that
might otherwise remain repressed.
Electrolyte Imbalance A physical condition that
occurs when ionized salt concentrations (commonly
Eye Movement Desensitization and Reprocessing
sodium and potassium) are at abnormal levels in the
(EMDR) A nondrug and nonpsychotherapy form of
body. This condition can occur as a side effect of
treatment in which a therapist waves his/her fingers
some bulimic compensatory behaviors, such as
back and forth in front of the patient's eyes, and the
patient tracks the movements while also focusing on
a traumatic event. It is thought that the act of
Emetic A class of drugs that induces vomiting.
tracking while concentrating allows a different level
Emetics may be used as part of a bulimic
of processing to occur in the brain so that the patient
compensatory behavior to induce vomiting after a
can review the event more calmly or more
binge eating episode.
completely than before.
Enema The injection of fluid into the rectum for the
Family Therapy A form of psychotherapy that
purpose of cleansing the bowel. Enemas may be
involves members of a nuclear or extended family.
used as a bulimic compensatory behavior to purge
Some forms of family therapy are based on
after a binge eating episode.
behavioral or psychodynamic principles; the most
common form is based on family systems theory.
Equine/Animal-assisted Therapy A treatment
This approach regards the family as the unit of
program in which people interact with horses and
treatment and emphasizes factors such as
become aware of their own emotional states
relationships and communication patterns. With
through the reactions of the horse to their behavior.
eating disorders, the focus is on the eating disorder
and how the disorder affects family relationships.
Exercise Therapy An individualized exercise plan
Family therapy tends to be short-term, usually
that is written by a doctor or rehabilitation specialist,
lasting only a few months, although it can last longer
such as a clinical exercise physiologist, physical
depending on the family circumstances.
therapist, or nurse. The plan takes into account an
individual's current medical condition and provides
Guided Imagery A technique in which the patient is
advice for what type of exercise to perform, how
directed by a person (either in person or by using a
hard to exercise, how long, and how many times per
tape recording) to relax and imagine certain images
and scenes to promote relaxation, promote changes
in attitude or behavior, and encourage physical
Exposure and Response Prevention (ERP) A type of
healing. Guided imagery is sometimes called
behavior therapy strategy that is based on the theory
visualization. Sometimes music is used as
that purging serves to decrease the anxiety
background noise during the imagery session. (See
associated with eating. Purging is therefore
Alternative Therapy.)
negatively reinforced via anxiety reduction. The goal
of ERP is to modify the association between anxiety
and purging by preventing purging following eating
until the anxiety associated with eating subsides.
(See Behavioral Therapy.)
NEDA TOOLKIT for Parents
Health Insurance Portability and Accountability Act
Hypoglycemia An abnormally low concentration of
(HIPAA) A federal law enacted in 1996 with a number
glucose in the blood.
of provisions intended to ensure certain consumer
health insurance protections for working Americans
In-network benefits Health insurance benefits that a
and their families and standards for electronic
beneficiary is entitled to receive from a designated
health information and protect privacy of
group (network) of healthcare providers. The
individuals' health information. HIPAA applies to
"network" is established by the health insurer that
three types of health insurance coverage: group
contracts with certain providers to provide care for
health plans, individual health insurance, and
beneficiaries within that network.
comparable coverage through a high-risk pool.
HIPAA may lower a person's chance of losing
Indemnity Insurance A health insurance plan that
existing coverage, ease the ability to switch health
reimburses the member or healthcare provider on a
plans, and/or help a person buy coverage on his/her
fee-for-service basis, usually at a rate lower than the
own if a person loses employer coverage and has no
actual charges for services rendered, and often after
other coverage available.
a deductible has been satisfied by the insured.
Health Insurance Reform for Consumers Federal law
Independent Living Services Services for a person
has provided to consumers some valuable–though
with a medical or mental health-related problem
limited–protections when obtaining, changing, or
who is living on his/ her own. Services include
continuing health insurance. Understanding these
therapeutic group homes, supervised apartment
protections, as well as laws in the state in which one
living, monitoring the person's compliance with
resides, can help with making more informed
prescribed mental and medical treatment plans, and
choices when work situations change or when
changing health coverage or accessing care. Three
important federal laws that can affect coverage and
Intake Screening An interview conducted by health
access to care for people with eating disorders are
service providers when a patient is admitted to a
listed below. More information is available at:
hospital or treatment program.
International Classification of Diseases (ICD-10) The
World Health Organization lists international
Consolidated Omnibus Budget Reconciliation
standards used to diagnose and classify diseases.
Act of 1985 (COBRA)
The listing is used by the healthcare system so
Health Insurance Portability and Accountability
clinicians can assign an ICD code to submit claims to
Act of 1996 (HIPAA);
insurers for reimbursement for services for treating
Mental Health Parity Act of 1996 (MHPA).
various medical and mental health conditions in
patients. The code is periodically updated to reflect
Health Maintenance Organization (HMO) A health
changes in classifications of disease or to add new
plan that employs or contracts with primary care
physicians to write referrals for all care that covered
patients obtain from specialists in a network of
Interpersonal Therapy (IPT) IPT (also called
healthcare providers with whom the HMO contracts.
interpersonal psychotherapy) is designed to help
The patient's choice of treatment providers is usually
people identify and address their interpersonal
problems, specifically those involving grief,
interpersonal role conflicts, role transitions, and
Hematemesis The vomiting of blood.
interpersonal deficits. In this therapy, no emphasis is
placed directly on modifying eating habits. Instead,
Hypno-behavioral Therapy A type of behavioral
the expectation is that the therapy will enable
therapy that uses a combination of behavioral
people to change as their interpersonal functioning
techniques such as self-monitoring to change
improves. IPT usually involves 16 to 20 hour-long,
maladaptive eating disorders and hypnotic
one-on-one treatment sessions over a period of 4 to
techniques intended to reinforce and encourage
behavior change.
NEDA TOOLKIT for Parents
Ketosis A condition characterized by an abnormally
Maudsley Method A family-centered treatment
elevated concentration of ketones in the body
program with three distinct phases. The first phase
tissues and fluids, which can be caused by starvation.
for a patient who is severely underweight is to regain
It is a complication of diabetes, starvation, and
control of eating habits and break the cycle of
starvation or binge eating and purging. The second
phase begins once the patient's eating is under
Level of Care The care setting and intensity of care
control with a goal of returning independent eating
that a patient is receiving (e.g., inpatient hospital,
to the patient. The goal of the third and final phase is
outpatient hospital, outpatient residential, intensive
is to address the broader concerns of the
outpatient, residential). Health plans and insurance
patient's development.
companies correlate their payment structures to the
level of care being provided and also map a patient's
Mealtime Support Therapy Treatment program
eligibility for a particular level of care to the
developed to help patients with eating disorders eat
patient's medical/ psychological status.
healthfully and with less emotional upset.
Major Depression See Major Depressive Disorder.
Mental Health Parity Laws Federal and State laws
that require health insurers to provide the same
Major Depressive Disorder A condition that is
level of healthcare benefits for mental disorders and
characterized by one or more major depressive
conditions as they do for medical disorders and
episodes that consist of periods of two or more
conditions. For example, the federal Mental Health
weeks during which a patient has either a depressed
Parity Act of 1996 (MHPA) may prevent a group
mood of loss of interest or pleasure in nearly all
health plan from placing annual or lifetime dollar
activities. (See Depression)
limits on mental health benefits that are lower, or
less favorable, than annual or lifetime dollar limits
Mallory-Weiss Tear One or more slit-like tears in the
for medical and surgical benefits offered under the
mucosa at the lower end of the esophagus as a
result of severe vomiting.
Mia Slang. For bulimia or bulimic.
Mandometer Therapy Treatment program for eating
disorders based on the idea that psychiatric
Modified Cyclic Antidepressants A class of
symptoms of people with eating disorders emerge as
medications used to treat depression.
a result of poor nutrition and are not a cause of the
eating disorder. A Mandometer is a computer that
Monoamine Oxidase Inhibitors A class of
measures food intake and is used to determine a
medications used to treat depression.
course of therapy.
Mood Disorders Mental disorders characterized by
Mandates See State Mandates.
periods of depression, sometimes alternating with
periods of elevated mood. People with mood
Massage Therapy A generic term for any of a number
disorders suffer from severe or prolonged mood
of various types of therapeutic touch in which the
states that disrupt daily functioning. Among the
practitioner massages, applies pressure to, or
general mood disorders classified in the Diagnostic
manipulates muscles, certain points on the body, or
and Statistical Manual of Mental Disorders (DSM-IV)
other soft tissues to improve health and well-being.
are major depressive disorder, bipolar disorder, and
Massage therapy is thought to relieve anxiety and
dysthymia. (See Anxiety and Major Depressive
depression in patients with an eating disorder.
Movement/Dance Therapy The psychotherapeutic
use of movement as a process that furthers the
emotional, cognitive, social, and physical integration
of the individual, according to the American Dance
Therapy Association.
NEDA TOOLKIT for Parents
Motivational Enhancement Therapy (MET) A
Osteoporosis A condition characterized by a
treatment is based on a model of change, with focus
decrease in bone mass with decreased density and
on the stages of change. Stages of change represent
enlargement of bone spaces, thus producing porosity
constellations of intentions and behaviors through
and brittleness. This can sometimes be a
which individuals pass as they move from having a
complication of an eating disorder, including bulimia
problem to doing something to resolve it. The stages
nervosa and anorexia nervosa.
of change move from "pre-contemplation," in which
individuals show no intention of changing, to the
Out-of-network benefits Healthcare obtained by a
"action" stage, in which they are actively engaged in
beneficiary from providers (hospitals, clinicians, etc.)
overcoming their problem. Transition from one stage
that are outside the network that the insurance
to the next is sequential, but not linear. The aim of
company has assigned to that beneficiary. Benefits
MET is to help individuals move from earlier stages
obtained outside the designated network are usually
into the action stage using cognitive and emotional
reimbursed at a lower rate. In other words,
beneficiaries share more of the cost of care when
obtaining that care "out of network" unless the
Nonpurging Any of a number of behaviors engaged
insurance company has given the beneficiary special
in by a person with bulimia nervosa to offset
written authorization to go out of network.
potential weight gain from excessive calorie intake
from binge eating. Nonpurging can take the form of
Parity Equality (see Mental Health Parity Laws).
excessive exercise, misuse of insulin by people with
diabetes, or long periods of fasting.
Partial Hospitalization (Intensive Outpatient) For a
patient with an eating disorder, partial
Nutritional Therapy Therapy that provides patients
hospitalization is a time-limited, structured program
with information on the effects of their eating
of psychotherapy and other therapeutic services
disorder. For example, therapy often includes, as
provided through an outpatient hospital or
appropriate, techniques to avoid binge eating and
community mental health center. The goal is to
refeed, and advice about making meals and eating.
resolve or stabilize an acute episode of
The goals of nutrition therapy for individuals with
mental/behavioral illness.
anorexia and bulimia nervosa differ according to the
disorder. With bulimia, for example, goals are to
Peptic Esophagitis Inflammation of the esophagus
stabilize blood sugar levels, help individuals
caused by reflux of stomach contents and acid.
maintain a diet that provides them with enough
nutrients, and help restore gastrointestinal health.
Pharmacotherapy Treatment of a disease or
condition using clinician-prescribed drugs.
Obsessive-compulsive Disorder (OCD) Mental
disorder in which recurrent thoughts, impulses, or
Phenethylamine Monoamine Reuptake Inhibitors A
images cause inappropriate anxiety and distress,
class of drugs used to treat depression.
followed by acts that the sufferer feels compelled to
perform to alleviate this anxiety. Criteria for mood
Pre-existing Condition A health problem that existed
disorder diagnoses can be found in the DSMIV.
or was treated before the effective date of one's
health insurance policy.
Opioid Antagonists A type of drug therapy that
interferes with the brain's opioid receptors and is
Provider A healthcare facility (e.g., hospital,
sometimes used to treat eating disorders.
residential treatment center), doctor, nurse,
therapist, social worker, or other professional who
Orthorexia Nervosa An eating disorder in which a
provides care to a patient.
person obsesses about eating only "pure" and
healthy food to such an extent that it interferes with
Psychoanalysis An intensive, nondirective form of
the person's life. This disorder is not a diagnosis
psychodynamic therapy in which the focus of
listed in the DSM-IV.
treatment is exploration of a person's mind and
habitual thought patterns. It is insight oriented,
meaning that the goal of treatment is for the patient
to increase understanding of the sources of his/her inner conflicts and emotional problems.
NEDA TOOLKIT for Parents
Psychodrama A method of psychotherapy in which
Recovery Retreat See Residential Treatment Center.
patients enact the relevant events in their lives
instead of simply talking about them.
Relaxation Training A technique involving tightly
contracting and releasing muscles with the intent to
Psychodynamic Therapy Psychodynamic theory
release or reduce stress.
views the human personality as developing from
interactions between conscious and unconscious
Remission A period in which the symptoms of a
mental processes. The purpose of all forms of
disease are absent. Remission differs from the
psychodynamic treatment is to bring unconscious
concept of "cure" in that the disease can return. The
mental material and processes into full
term "cure" signifies that the treated condition or
consciousness so that the patient can gain more
disorder is permanently gone, never to return in the
control over his/her life.
individual who received treatment.
Psychodynamic Group Therapy Psychodynamic
Residential Services Services delivered in a
groups are based on the same principles as
structured residence other than the hospital or a
individual psychodynamic therapy and aim to help
people with past difficulties, relationships, and
trauma, as well as current problems. The groups are
Residential Treatment Center A 24-hour residential
typically composed of eight members plus one or
environment outside the home that includes 24-hour
provision or access to support personnel capable of
meeting the client's needs.
Psychoeducational Therapy A treatment intended to
teach people about their problem, how to treat it,
Selective Serotonin Reuptake Inhibitors (SSRI) A class
and how to recognize signs of relapse so that they
of antidepressants used to treat depression, anxiety
can get necessary treatment before their difficulty
disorders, and some personality disorders. These
worsens or recurs. Family psychoeducation includes
drugs are designed to elevate the level of the
teaching coping strategies and problem-solving
neurotransmitter serotonin. A low level of serotonin
skills to families, friends, and/or caregivers to help
is currently seen as one of several neurochemical
them deal more effectively with the individual.
symptoms of depression. Low levels of serotonin in
turn can be caused by an anxiety disorder, because
Psychopathological Rating Scale Self-Rating Scale
serotonin is needed to metabolize stress hormones.
for Affective Syndromes (CPRS-SA) A test used to
estimate the severity of depression, anxiety, and
Self-directedness A personality trait that comprises
obsession in an individual.
self-confidence, reliability, responsibility,
resourcefulness, and goal orientation.
Psychopharmacotherapy Use of drugs for treatment
of a mental or emotional disorder.
Self-guided Cognitive Behavior Therapy A modified
form of cognitive behavior therapy in which a
Psychotherapy The treatment of mental and
treatment manual is provided for people to proceed
emotional disorders through the use of psychologic
with treatment on their own, or with support from a
techniques (some of which are described below)
nonprofessional. Guided self-help usually implies
designed to encourage communication of conflicts
that the support person may or may not have some
and insight into problems, with the goal being relief
professional training, but is usually not a specialist in
of symptoms, changes in behavior leading to
eating disorders. The important characteristics of the
improved social and vocational functioning, and
self-help approach are the use of a highly structured
personality growth.
and detailed manual-based CBT, with guidance as to
the appropriateness of self-help, and advice on
Purging To evacuate the contents of the stomach or
where to seek additional help.
bowels by any of several means. In bulimia, purging
is used to compensate for excessive food intake.
Methods of purging include vomiting, enemas, and
excessive exercise.
NEDA TOOLKIT for Parents
Self Psychology A type of psychoanalysis that views
Telephone Therapy A type of psychotherapy
anorexia and bulimia as specific cases of pathology
provided over the telephone by a trained
of the self. According to this viewpoint, for example,
people with bulimia nervosa cannot rely on human
beings to fulfill their self-object needs (e.g.,
Tetracyclics A class of drugs used to treat depression.
regulation of self-esteem, calming, soothing,
vitalizing). Instead, they rely on food (its
Therapeutic Foster Care A foster care program in
consumption or avoidance) to fulfill these needs. Self
which youths who cannot live at home are placed in
psychological therapy involves helping people with
homes with foster parents who have been trained to
bulimia give up their pathological preference for
provide a structured environment that supports the
food as a self-object and begin to rely on human
child's learning, social, and emotional skills.
beings as selfobjects, beginning with their therapist.
Thinspiration Slang Photographs, poems, or any
Self-report Measures An itemized written test in
other stimulus that influences a person to strive to
which a person rates his/her feeling towards each
question; the test is designed to categorize the
personality or behavior of the person.
Third-party Payer An organization that provides
health insurance benefits and reimburses for care for
State Mandate A proclamation, order, or law from a
state legislature that issues specific instructions or
regulations. Many states have issued mandates
Thyroid Medication Abuse Excessive use or misuse of
pertaining to coverage of mental health benefits and
drugs used to treat thyroid conditions; a side effect
specific disorders the state requires insurers to cover.
of these drugs is weight loss.
Substance Abuse Use of a mood or behavior-altering
Treatment Plan A multidisciplinary care plan for
substance in a maladaptive pattern resulting in
each beneficiary in active case management. It
significant impairment or distress of the user.
includes specific services to be delivered, the
frequency of services, expected duration, community
Substance Use Disorders The fourth edition of the
resources, all funding options, treatment goals, and
Diagnostic and Statistical Manual of Mental
assessment of the beneficiary environment. The plan
Disorders (DSM-IV) defines a substance use disorder
is updated monthly and modified when appropriate.
as a maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
Tricyclic Antidepressants A class of drugs used to
manifested by one (or more) of the following,
treat depression.
occurring within a 12-month period: (1) Recurrent
substance use resulting in a failure to fulfill major
Trigger A stimulus that causes an involuntary reflex
role obligations at work, school, or home;
behavior. A trigger may cause a recovering person
(2) Recurrent substance use in situations in which it
with bulimia to engage in bulimic behavior again.
is physically hazardous; and (3) Recurrent substance-
related legal, social, and/ or interpersonal problems.
Usual and Customary Fee An insurance term that
indicates the amount the insurance company will
Subthreshold Eating Disorder Condition in which a
reimburse for a particular service or procedure. This
person exhibits disordered eating but not to the
amount is often less than the amount charged by the
extent that it fulfills all the criteria for diagnosis of
service provider.
an eating disorder.
Vocational Services Programs that teach skills
Supportive Residential Services See Residential
needed for self-sufficiency.
Treatment Center.
Yoga A system of physical postures, breathing
Supportive Therapy Psychotherapy that focuses on
techniques, and meditation practices to promote
the management and resolution of current
bodily or mental control and well-being.
difficulties and life decisions using the patient's
strengths and available resources.
NEDA TOOLKIT for Parents
References
Common Myths about eating disorders
Ways to start a discussion with a loved one
who might have an eating disorder
ECRI Institute Feasibility Study on Eating Disorders
Awareness and Education Needs. March 2004; 24 p.
Navigating the System: Consumer Tips for Getting Treatment for Eating Disorders, Margo Maine, PhD for
An Eating Disorders Resource for Schools, The
Victorian Centre of Excellence in Eating Disorders and
the Eating Disorders Foundation of Victoria (2004); pgs
Identifying and treating eating disorders. American
Academy of Pediatrics. Practice Guideline Pediatrics
2003 Jan; 111 (1): 204-11
Eating Disorders: A Time for Change
Practice guideline for the treatment of patients with
Russell, Michael. 2006 Myths About Eating Disorders.
eating disorders. American Psychiatric Association.
EzineArticles (December 02),
Why parent-school communications may be
U.S. Department of Health and Human Services; Office
on Women's Health; Eating Disorders
difficult: Regulatory constraints and
confidentiality issues
American School Counselor Association
American Psychiatric Association Diagnostic and
Statistical Manual for Mental disorders-IV
ECRI Institute interviews with educators and parents of children with eating disorders
Eating disorder signs, symptoms, and
behaviors
Levine, M. (1994). "A Short List of Salient Warning Signs
Treatment settings and levels of care
for Eating Disorders." Presented at the 13th National
ECRI Institute Bulimia Resource Guide
http://www.bulimiaguide.org
American Psychiatric Association (1994). Diagnostic and Statistical Manual for Mental Disorders, 4th ed.
APA: Washington D.C.
Questions to ask the care team at a facility
Zerbe, K.J. (1995). The Body Betrayed. Carlsbad, CA: Gurze Books.
ECRI Institute Bulimia Resource Guide
http://www.bulimiaguide.org
U.S. Office on Women's Health: Eating Disorders
Gidwani, G.P. and Rome, E.S. (1997). Eating Disorders. Clinical Obstetrics and Gynecology, 40(3), 601-615.
Questions parents may want to ask treatment
providers privately
ECRI Institute Bulimia Resource Guide
ECRI Institute Bulimia Resource Guide
http://www.bulimiaguide.org
ECRI Institute interviews with parents
NEDA TOOLKIT for Parents
How to take care of yourself while caring for
a loved one with an eating disorder
Canadian National Eating Disorder Information Centre
University of Florida, Institute of Food and Agricultural
Anorexia nervosa and related eating disorders, Inc.
Confidentiality Issues
ECRI Institute Bulimia Resource Guide
http://www.bulimiaguide.org
COBRA rights checklist
U.S. Department of Labor www.dol.gov
ECRI Institute Bulimia Resource Guide
http://www.bulimiaguide.org
Sample letters to use with insurance
companies
National Eating Disorders Association member
How to manage an appeals process
ECRI Institute Bulimia Resource Guide
Source: http://www.bulimie.ro/files/ParentToolkit.pdf
What is CRPS? that the ischemia that occurs Lifting the veil CRPS generally occurs after a when the blood flow to living tis- fracture, sprain or soft tissue dam- sue is stopped for a few or more on complex age to an arm or leg. "In the days hours, and the reperfusion that following the injury, the limb follows when the blood re-enters
Vehicular Based Drug Box Temperature Control Study A Research Project Presented to the Department of Occupational and Technical Studies Old Dominion University In Partial Fulfillment of the Requirement for the Degree of Master of Science in Occupational and Technical Education