Even among advanced eating disorder specialists, there is confusion about what an appropriate level of care is for a given patient. This article aims to help elucidate the referral process with information from the American Psychiatric Association’s Practice Guidelines (Yager, et al., 2006) as well as my own clinical experience.
- Tara Deliberto, PhD
The Importance of Medical Clearance for All Eating Disorders
When working with people who do not have eating disorders, making a judgment call regarding which level of care is required can be made with a thorough verbal and/or self-report assessment by a licensed therapist. This is not the case with eating disorders! Because eating disorder behaviors impact the physical health of a patient, you cannot determine the level of care – whether it be medical hospitalization, psychiatric inpatient, residential, partial hospitalization program (PHP), day treatment, intensive outpatient program (IOP), or outpatient – simply by talking to or looking at a patient with an eating disorder. Self-report measures don’t cut it either. We therapists need to collaborate with colleagues in other disciplines, specifically medicine. As a therapist, think of yourself as a project manager: your job is to help keep a patient and their carers accountable for health, but it is not your job to determine how often a patient needs medical examination, nor to interpret the results of one. A medical doctor needs to collect information such as lab work, an EKG, and a physical exam before a determination regarding level of care is made. Often a brief chat asking the doc to interpret the results is required before treatment at any level of care can commence.
Although it is not a therapist’s responsibility to determine if a person is medically at risk or not, therapist input about appropriate levels of psychiatric care (e.g. partial hospitalization program) is needed. As such, you must communicate with the doctor to determine whether or not a given patient is appropriate for your practice. If a given patient’s medical doctor is not familiar with the treatment of eating disorders, quickly send them practice guidelines for your country (e.g. the American Psychiatric Association’s [APA] Practice Guidelines; Yager, Devlin, Halmi, Herzog, Mitchell, Power, et al., 2006). It may also be helpful to provide the patient’s medical doctor with a copy of the AED’s Medical Care Standards Guide (available at www.AEDweb.org). With an ability to communicate about the specifics of the practice guidelines as they relate to the results of the patient’s tests, appropriate decisions can be made.
Prior to scheduling an evaluation to be considered for our program, we require that a potential patient send us the results of the following:
- A medical examination
- An EKG
- The following laboratory tests conducted:
o CBC
o CMP
o Amylase
o Magnesium
o B12
o TSH
o HCG
o Cholesterol (not fasting)
Although you may not be trained to read the results of these tests, you should facilitate a discussion with the medical doctor in which they are reviewed in relation to the level of care guidelines. For instance, although you may not know what all of the medical implications are if potassium, phosphorous, and magnesium are low, you do know that these are criteria for medical hospitalization from reading the guidelines. This should be discussed with the medical doctor and a treatment recommendation made with their input.
Tip: Facilitate Investigation of Potential Medical Symptoms Rather than Avoiding
There is an easy way to know if a patient is at medical risk or not: send them to a medical doctor! It is a tragedy for patients with eating disorders that fearful therapists turn them away due to blanket concerns about medical illness. Rather than turning away from treating people who may be medically ill, encourage investigation of potential medical illness.
Referring to an Appropriate Level of Care
In the United States, we use the APA’s Practice Guidelines (Yager, et al., 2006), parts of which are included below to inform level of care. Although excerpts of these guidelines are quoted below, it is highly recommended that the entire guidelines are downloaded from www.psych.org and reviewed. Please note that the numbers listed below are for children/adolescents and numbers are different for adults.
Inpatient Hospitalization Level of Care
Child or adolescent patients who meet any of the criteria that will be listed below should be referred to an inpatient of care. Please note that adult patients have a different set of medical criteria than children and adolescents. Relatively, adults have a greater number of medical issues that are cause for inpatient hospitalization (e.g. glucose <60 mg/dl, poorly controlled diabetes, temperature <97.0 degrees Fahrenheit, dehydration, organ compromise, etc.) than children and adolescents.
Below are some of the criteria listed in the APA Practice Guidelines for the inpatient hospitalization of children and adolescents, regarding eating disorders:
Medically:
Heart rate near 40 bpm
Blood pressure <80/50 mmHg
Electrolyte imbalances, specifically:
Low potassium (i.e. Hypokalemia)
Low phosphorous (i.e. hypophosphatemia)
Low magnesium (i.e. hypomagnesemia)
Orthostatic blood pressure changes
(>20 bpm increase in heart rate or >10 mmHg to 22 mmHg drop)
Weight Percentage:
Generally <85% of healthy body weight
Notes:
This translates to a BMi of around 16.7
This only applies diagnoses specifically of either AN and ARFID
Acute weight decline with food refusal, even if not <85% of healthy body weight
e.g. as in AAN
If the person has BN, BED, AAN, or OSFED body weight criteria do not apply
Behaviorally:
“Unable to control multiple daily episodes of purging that are severe, persistent, and disabling”
“despite appropriate trials of outpatient care, even if routine laboratory test results reveal no obvious metabolic abnormalities”
“Needs supervision during and after all meals” as well as snacks
Needs supervision in the bathroom
Please note that if one does not have personal experience working with people who have extremely severe eating disorders this may seem an invasion of privacy; however, having working in inpatient settings it is perhaps the number one behavioral intervention that can reduce the dangerous behavior of purging. In the context of reduced purging behaviors, this ultimately helps to restore a person’s autonomy.
“Needs supervision during and after all meals”
Requires nasogastric feeding (e.g. feeding through a tube)
“Motivation to recover”
“Very poor motivation”
“Patient uncooperative with treatment”
Patient is compliant with treatment only in a “highly structured environment”
Tip: Hospitalization on a Psychiatric vs Medical Unit Depends on the Local Resources
Whether a patient requiring hospitalization goes to a psychiatric or medical inpatient unit can largely depend on the resources available in your area. Each individual unit is able to accommodate different medical needs. For instance, a particularly psychiatric inpatient unit specializing in eating disorders may not be able to address low potassium (i.e. hypophosphatemia) through an intravenous potassium infusion. As such, a patient with hypophosphatemia may require treatment on an inpatient unit at a medical hospital prior to being discharged to a relatively lower level of care such as an inpatient psychiatric unit or residential treatment setting. The hospitals should know if they can accommodate the patient or not based on the patient’s medical records. This determination is made by having the results of a patient’s medical examination (e.g. lab work, EKG, doctor’s report, etc.) sent to a given psychiatric setting for review. Someone there should be able to provide information about whether or not that psychiatric setting has the resources and capacity to treat the patient. If not, the patient may require medical care.
Residential Level of Care
For patients that do not have medical and psychiatric symptoms severe enough for inpatient hospitalization but who still have eating disorders on the severe end of the spectrum, residential treatment may be required. Unlike inpatient hospitalization which occurs in the context of a medical or psychiatric hospital, residential treatment is often conducted by professionals in a house where patients stay for a period of time (e.g. 6-8 weeks). Residential treatment for eating disorders is conceptually similar to “going to rehab” for a drug or alcohol addiction.
Below are some of the criteria listed in the APA Practice Guidelines for referring children and adolescents with eating disorders to a residential level of care:
Medically
Deemed medically stable for residential and does not require an inpatient setting
According to the APA Guidelines: “Intravenous fluid, nasogastric tube feedings, or multiple laboratory daily tests are not needed.”
Weight Percentage
Generally <85% of healthy weight
Note: this only applies diagnoses specifically of either AN and ARFID
If the person has BN, BED, AAN, or OSFED body weight criteria do not apply
Behaviorally:
Can implement the skill of asking for help from others in the environment
Can implement skills to inhibit purging behaviors
Patient requires supervision at meal and snack times
“Motivation to Recover”
“poor-to-fair” motivation
In the context of treatment in a structured environment, patient is compliant
Partial Hospitalization Program (PHP) or Day Treatment Level of Care
If inpatient or residential treatment is not necessary, a patient may require treatment at a “partial hospitalization program” (i.e. PHP) or “day treatment” level of care. Although some programs are run through hospitals while others are run through private treatment centers, they share the commonalities of: multiple hours per day of treatment with a multidisciplinary team. At this level of care, patients go in for treatment during the day and sleep elsewhere (e.g. at home) at night. Each program will have different hours. For example, the specific PHP program at NewYork-Presbyterian Hospital that Dr. Deliberto established in 2016 for adults currently runs from 8:15am until 3:00pm, Monday through Friday. PHPs and day treatment programs for eating disorders have multidisciplinary teams with members from the disciplines of social work, psychiatry, as well as nutrition, and oftentimes psychology, pastoral care, art therapy, rehabilitation counseling, etc. Within the context of working together in concert to stabilize acute eating disorder behaviors at this level of care, professionals from each discipline contributes a tremendous amount to holistically treating the patient during each treatment day.
Below are some of the criteria listed in the APA Practice Guidelines for referring children and adolescents with eating disorders to a PHP or day treatment level of care:
Medically
“Patient must be medically stable to the extent that more extensive medical monitoring as defined for [inpatient and residential treatment] is not required”
Weight Percentage
Generally >80% of healthy body weight
Note: this only applies diagnoses specifically of either AN and ARFID
If the person has BN, BED, AAN, or OSFED body weight criteria do not apply
Behaviorally:
Needs some structure
“Motivation to recover”
“Partial motivation”
Cooperative
Intensive Outpatient Program (IOP) Level of Care
An intensive outpatient program (IOP) can be run through a hospital or private treatment setting. At an IOP level of care, patients attend program for relatively fewer hours per week than at the PHP or day treatment level of care. Some programs may offer IOP for a small number of hours a day (e.g. 2-3 hours) several days per week (e.g. 3-5) or a relatively greater number of hours per day (e.g. 5-6 hours) on fewer days per week (e.g. 2-3 days).
Below are some of the criteria listed in the APA Practice Guidelines for referring children and adolescents with eating disorders to a PHP or day treatment level of care:
Medically
“Patient must be medically stable to the extent that more extensive medical monitoring as defined for [inpatient and residential treatment] is not required”
Weight Percentage
Generally >80% of healthy body weight
Note: this only applies diagnoses specifically of either AN and ARFID
If the person has BN, BED, AAN, or OSFED body weight criteria do not apply
Behaviorally:
“Can greatly reduce incidents of purging in an unstructured setting”
“Some degree of structure is needed beyond self-control to prevent patient from compulsive exercising”
“Motivation to recover”
“Fair motivation”
Outpatient Level of Care
If you are going to be treating a patient at an outpatient level of care, it is important that they do not meet the medical and behavioral criteria for treatment at a higher level of care previously outlined. Because only partial information was included from the APA Practice Guidelines here, it is important to obtain a copy yourself for reference.
Below are criteria listed in the APA Practice Guidelines for treating children and adolescents with eating disorders at an outpatient level of care:
Medically
“Patient must be medically stable to the extent that more extensive medical monitoring as defined for [inpatient and residential treatment] is not required”
Weight Percentage
Generally >85% of healthy body weight
Note: this only applies diagnoses specifically of either AN and ARFID
If the person has BN, BED, AAN, or OSFED body weight criteria do not apply
Behaviorally:
“Can greatly reduce incidents of purging in an unstructured setting”
“Can manage compulsive exercising through self-control”
This criterion likely references outpatient individual therapy for youth
In our clinical experience, outpatient treatment is also acceptable for medically stable children and adolescents who have behaviors that can be managed by willing and able carers at home
“Motivation to recover”
“Fair-to-good” motivation
In our clinical experience, child and adolescent patients with poor motivation can still sometimes be treated in an outpatient setting with family interventions if carers are highly motivated, willing, and able to participate in treatment
Tip: Do Not See Potentially Ill Patients Who Refuse Medical Investigation
If, for whatever reason, your patient refuses to be medically evaluated or their carers do not bring them to appointments, the implications must be directly discussed in session. If you do not have information about medical risk and the ability to discuss this with a medical doctor, it is likely wise not to continue with treatment. As such, treatment may need to be terminated or put on hold until the appropriate information is obtained. The exception to this is when treating BED in which there is currently no evidence for the presence of intolerance behaviors (e.g. the patient is motivated, forthcoming, etc.). As will be discussed below, however, intolerance behaviors covertly occurring can be identified upon medical examination in cases that present as BED, but are more accurately either BN or OSFED. <end tip>
Ongoing Medical Management in Treatment
Once the appropriate level of care is ascertained, the frequency of ongoing medical assessment will need to be determined by the medical doctor’s a given patient’s treatment team. If the patient is cleared for outpatient treatment, the patient’s pediatrician is part of the treatment team with you. The same goes for any psychiatrists or dietitians the patient with whom the patient may be working. As such, each individual patient may have a unique treatment team. Regarding the frequency of medical assessment, the medical doctor on the patient’s treatment team will determine this.
Although deferring to the medical doctor for frequency of visits is always recommended, it is often necessary to introduce the idea of ongoing medical management throughout the course of eating disorder therapy to the patient/family. If the medical doctor is not familiar with the treatment of eating disorders, this concept may need to be introduced to them before they determine the frequency of the visits. Again, we must develop a level of trust in medical doctors and their ability to contribute to the team.
Because it is the medical doctor’s job to make recommendations regarding the frequency of medical visits needed for each individual patient, only examples of the types of medical management that may recommended for various disorders are provided here:
Binge Eating Disorder (BED): On intake, a medical examination with lab work is often necessary to rule out purging (e.g. based on amylase levels). Ongoing medical management of BED can be required relatively infrequently in comparison to other eating disorders, unless physical symptoms (e.g. acid reflux, diabetes, etc.) are present.
Bulimia Nervosa (BN) and OSFEDx (OSFED without Atypical Anorexia Nervosa [AAN]): The frequency of medical examinations and lab work varies depending on symptom severity. A general rule of thumb – as an example – is every several weeks. Patients with BN or OSFEDx may also be required to see specialists (e.g. gastroenterologists).
Anorexia Nervosa (AN) and Atypical AN (AAN): In the treatment of AN and many cases of AAN, patients often are required to have medical examinations and lab work taken at a higher frequency of about once per week or biweekly. Patients with AN or AAN may also be required to see specialists (e.g. cardiologists, endocrinologists, etc.).
Dangerous Behaviors to Note
In addition to common eating disorder behaviors (e.g. purging, compulsive exercise while dehydrated, etc.) being quite dangerous, there are some behaviors that may be particularly perilous worth mentioning here.
Although this is by no means a comprehensive list, note the following may be particularly perilous:
If a patient is purging right after taking psychiatric medications, the medication might be coming up and not getting absorbed in consistent doses.
Patients can be drinking alcohol and/or using drugs in addition to purging, which can result in electrolyte imbalances.
Patients at any weight can be restricting water and fluid intakes, which can be particularly dangerous.
Patients who are engaging in various combinations of the following behaviors may be particularly at risk of dehydration: restricting fluid intake, purging, abusing laxatives, engaging in compulsive exercise, and abusing alcohol.
Patients who are underweight can have any number of electrolyte imbalances at any time.
Patients who are not underweight but who are engaging in behaviors are also at risk for electrolyte imbalances.
For patients who have severely restricted – especially those who have not eaten for many days in a row – there is a risk for refeeding syndrome. A non-medical way of describing this is the body “going into shock” after eating for the first time after a period of starvation. Refeeding syndrome could lead to a heart attack, stroke, coma, or death. As such, it is required that a patient be medically cleared before starting treatment and continued to be monitored.
Why Lab Work Is Helpful in Therapy
If a patient is purging, getting lab work can be very useful. It is always best to consult with a medical professional regarding the interpretation of lab results. At the same time, a non-medical therapist can learn the basics. For instance, amylase levels can be in the elevated when the patient is purging. Sometimes, however, the patient can be purging and the level is not elevated or the patient is not purging and it is elevated. This is why it is best to consult with a licensed medical professional! Regardless of occasional ambiguity, results can still be clinically helpful. For instance, if your patient denies ever having intentionally purged, however, lab results are starting to come back week after week with increased amylase levels, you might suspect purging. Confronting the patient on this issue may bring about disclosure of the behaviors. On occasion, we have had patients at higher levels of care with a co-morbid BPD who reported purging but amylase levels were not elevated. Having lab reports to objectively back up the team’s assessments that eating disorder behaviors were not being engaged in has also been clinically useful.