Eating disorders

Treatment for eating disorders involves healthy eating together with medical care and psychological treatment.

Some people might also be prescribed medications.

Your health care team will work with you to decide which combination of treatments is right for you.

Healthy eating

For people with anorexia nervosa, effective treatment must always include regular and adequate nutrition. Your health-care team will talk this over with you in detail, but these are some key points:

• Adequate nutrition is a non-negotiable part of your treatment plan. Getting back to a healthy weight and getting the nutrients your body needs to stay healthy are essential to your treatment. Your health-care team will help you to do this yourself.
• Usually, a dietitian experienced in the treatment of eating disorders will plan a tailored diet for you to make sure you get all the essential proteins, carbohydrates, fats, vitamins and minerals your body needs. The dietitian’s role is to help you make healthy eating part of your everyday life. Habits will not change overnight, but over time you can learn to have a healthy and stress-free relationship with food.
• Your health-care team will do their best to make sure you eat enough, either by staying with you at mealtimes if you are in hospital, or by asking you to agree to family or carers being with you at mealtimes. When you are well enough, you can record what you eat at each meal and discuss this with your health-care team during your outpatient appointments.

• If you are unable to eat, or you refuse food, you will be given balanced food substitutes – drinks that are high in energy and protein. Food substitutes are generally avoided because the key goal is to get you to eat normal foods again.
• If you are seriously unwell and unable to eat food or drink food substitutes, you may need nasogastric feeding (where a feeding tube is passed through the nose and into the stomach).

When adults with severe or long-standing anorexia nervosa start to eat or be fed after a long period of not eating enough, there is a risk of a serious reaction known as ‘refeeding syndrome’. Because of this risk, the process should be supervised by a specialised team with skills and experience in working with people with severe long-term anorexia nervosa.

People with bulimia nervosa or binge eating disorder may need to lose some weight to avoid or to overcome medical problems. Your healthcare team may recommend a supervised and appropriate weight loss program in the short term. In the long term, the most effective way to manage your weight is to change your thinking and behaviour. Psychological treatment will help you do this.

For children, it is best to work on eating healthy food at the usual mealtimes, sitting at a table with their family (or in a situation that is like a family meal). Even after children and teenagers have reached a healthy weight they will still need their eating patterns checked regularly. Their doctor will also regularly measure their growth, do blood tests for hormones, and check their temperature, pulse and blood pressure.

Medical care

You may need treatment for medical complications caused by starvation, vomiting, or laxative use. You may also need general medical and dental care.

Medical complications due to starvation can include serious and even life-threatening problems such as:​

Very rarely, a person who has been starving or severely malnourished for a long time can have a serious reaction when they start eating again (known as refeeding syndrome). If you are at risk of this, your doctors will check the levels of phosphate, potassium and magnesium in your blood every day for the first one or two weeks. If they find any dangerous changes, your doctors will treat them with oral supplements or by intravenous fluids (via a drip).

Making yourself vomit too often can cause ulceration or tearing of the oesophagus (the tube that connects the mouth and the stomach) or swelling of the salivary glands. You may need to see a specialist for oesophageal problems. The stomach acid in your vomit can damage the enamel of your teeth, so you may also need regular dental visits.

Losing too much potassium by vomiting can cause an irregular heartbeat, which can be lifethreatening. Your doctor may test your blood and arrange treatment, if needed.

Over-use of laxatives can upset your normal bowel function. Sometimes this damage can be permanent. You may need specialist treatment for bowel problems.

People with bulimia nervosa or binge eating disorder who have put on a lot of weight may have (or be at risk of) cardiovascular disease because of abnormally high levels of cholesterol or triglycerides in the blood, high blood pressure or high blood glucose. They may also be at risk of developing diabetes. Your health-care team can arrange the usual tests and treatments for these conditions.

Medications

Medications (medicines) are not part of the standard treatment for anorexia nervosa because there is not strong enough evidence that they are effective.

For people with bulimia nervosa or binge eating disorder, if you also have another mental health condition such as depression, anxiety, impulse control or substance use disorder, your doctor may prescribe antidepressant or mood-stabiliser medications. These medications may also be useful alongside psychological treatment, even if you don’t have one of these conditions.Research shows that antidepressant medications can help people with bulimia nervosa reduce their uncontrolled overeating, as well as improve their mood.

Your doctors may suggest a low dose of an antipsychotic or antidepressant medication if you have symptoms of anxiety or obsessive thinking. People with a very low body weight have a higher risk of unwanted side effects from these medications, so they are prescribed only when necessary.

Tell your health-care team immediately if you think you may be having side effects from a medication.

Psychological treatment

In addition to nutrition and medical treatment, to recover and stay well you must also make changes in your thinking and behaviour. Psychological treatment is an essential part of treatment for everyone with an eating disorder. It provides a chance to find out what triggers a person’s eating problems and to work out how to deal with them.

There are many different types of psychological treatments, but all involve talking with a therapist (a psychologist or psychiatrist). These treatments are designed to help you understand your thinking, actions and relationships, so that you can make changes that will make you less distressed and make everyday living easier.

Some of the main psychological treatments used to help people with eating disorders are:

• family therapy (family members work together as a team to directly manage a child’s behaviour)
• cognitive behavioural therapy (works by teaching you to recognise your negative thoughts and beliefs and to challenge them, so that you can change your behaviour)
• interpersonal psychotherapy (focuses on the link between when and how your symptoms started and on problems you have relating to other people)
• psychodynamic psychotherapy (focuses on uncovering what’s on your mind that you are not normally aware of).

For children and teenagers with anorexia nervosa, family therapy is usually the best choice. Other types of psychological treatment are considered if family therapy is not possible or has not been successful.

If you are severely underweight, you will need to begin your physical recovery before you start psychological treatment, so you are strong enough and your brain is working properly.

Whichever therapy you and your health-care team decide on, three things will always be true:

• You will play an important role in your own treatment.
• You will need to be patient and keep persisting.
• You must be committed to the treatment.

Challenging the way you think, feel and behave is very hard work. This may be distressing as you work through issues and problems with your therapist, and begin to make changes that affect the way you live your life.

It takes time and persistence to achieve real change. Learning new ways of thinking, feeling and behaving will involve trial and error, and may be very frustrating. This process may take many months before you discover subtle changes in the way you think about yourself and the world around you. The goal for you is to be in control of your thinking and feeling – and therefore in charge of your behaviour.

It is important for everyone involved in your treatment to be committed to it. For example, family therapy would not be the best choice of treatment if a key person in your family is not supportive or is not always available.

Other practical help

Adults with long-term anorexia nervosa may need help with nutrition, housing, financial issues, and recreational and occupational activities. If substance use is a problem, your health-care team will arrange treatment.

Why should I get treatment?

If you think you might have an eating disorder, it is very important to see a health professional as soon as possible.

If eating disorders are not treated, they can result in serious medical problems. Eating disorders can become medical emergencies, so some people with an eating disorder will need to go to hospital to get life-saving treatment, or treatment for long-term problems caused by malnutrition.

Having an eating disorder can interfere with your home life, education, work and social life.

Where will I have treatment?

Whenever possible, you will be able to choose where you have your treatment, and it should restrict your life as little as possible. Usually there is a range of options, including:

• outpatient treatment (you live at home and go to a clinic or hospital for regular appointments)
• a day program (you sleep at home but go to a clinic each day)
• inpatient treatment (you stay in hospital during your treatment).

Most people with eating disorders have mainly outpatient treatment.