Level of Care Considerations for Severe and Extreme Eating Disorders

Vol. 30 / No. 1 — Eating Disorders Review

by Jeana J. Cost, MS, LPC, CEDS, and Philip S. Mehler, MD, FACP, FAED, CEDSEating Recovery Center, Denver, Colorado

Determining what level of care a patient with an eating disorder needs can be one of the most challenging aspects of referring to treatment. Between client resistance and the body’s ability to feign stability, it can be easy to accept the least intensive route.

The eating disorder industry has an ongoing need for even more definitive level of care guidelines, supported by empirical evidence and embraced by the eating disorder community. Historically, there has been reliance on the guidelines published by the American Psychiatric Association (APA), but there remains some degree of deficient integration of changing diagnostic criteria, as well as definition of what each level of care means. Additionally, the APA guidelines outline the five levels of care between outpatient and inpatient, but fail to completely outline a sixth level of care – medical treatment.  The provision of additional information for the eating disorder community about all levels of care, appropriate admission guidelines, as well as appropriate treatment options, is critically important to optimize a successful outcome for the patient suffering with an eating disorder.

Using the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5)

Positive strides towards appropriate diagnosis and referrals were made in 2013, when theDSM-5was updated and released. It included several clinically relevant criterions. One of the most important changes was adding the severity index for evaluating one’s body mass index (BMI, kg/m2), which primarily impacts the diagnosis of anorexia nervosa (AN). The index is as follows: Mild(BMI > or = 17.0), Moderate(16.0-16.99), Severe(15.0-15.99), and Extreme(< 15.0). This not only helps clinicians to diagnose Anorexia Nervosa in someone above 85% of ideal body weight (previous marker), but it also highlights the concerning fact that there are also a number of patients with extremely low BMIs. We often think about eating disorder treatment as singularly behavioral in nature, but the “extreme” category should compel families and clinicians to consider a patient’s needs beyond that.

Severe and extreme eating disorders can cause life threatening medical complications including dangerous electrolyte imbalances, re-feeding syndrome, severe dehydration, edema, gastrointestinal complications, superior mesenteric artery syndrome (SMA), bradycardia and organ failure, to name but a few. It is important that there is appreciation and consideration that these potential complications exist not infrequently, especially at lower BMIs, and thus the need to intervene in a timely fashion.

Intervention should include medical stabilization in a highly sophisticated and specialized medical unit, prior to a patient starting traditional eating disorder treatment. Many experts espouse that this should happen when a BMI is < 14.0, or when that patient’s weight is < 70% ideal body weight (IBW). Thus, in general, patients with AN or Avoidant/Restrictive Food Intake Disorder (ARFID) who are below 70% IBW, should first be treated in a specialized medical unit for the medical stabilization of those patients.

In general, if the patients’ weight is between 70-84% of IBW, they are best served in an inpatient or residential treatment center, and if they are 85% to 95% of IBW, a partial hospitalization program (PHP) will generally suffice.  But nothing is absolute, and thus the frequency of purging behaviors and other physical or psychiatric considerations can further qualify the level of care that may be needed.

Considerations with Normal to Higher BMIs

More recently it has been being recognized that harm may occur by assuming that those with a “normal” or “higher” BMI are stable enough to access lower levels of care. Not only can these patients be presenting with a falsely elevated weight, but they can also be at risk for dangerous complications due to excessive purging behaviors followed by abrupt cessation or significant and rapid “weight disruption” from weight loss. Thus, the need to consider the severity of purging behaviors (also outlined in theDSM-5) and the severity of absolute weight loss when choosing an appropriate level of care. Again, consider medical stabilization first for those showing severe weight disruption as well as those needing to safely “detox” from severe substance, laxative or diuretic abuse.  Starting in the appropriate level of care can have a significant impact on the patient’s health, success in recovery, and satisfaction with treatment.

Suggested Reading

1. Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition(DSM-5).
2. Garber, A. K. (2018). Moving beyond “skinniness”: presentation weight is not sufficient to assess malnutrition in patients with restrictive eating disorders across a range of body weights. Journal of Adolescent Health, 63(6), 669-670. https://doi.org/10.1016/j.jadohealth.2018.09.010

3. Academy for Eating Disorders (2016). Critical points for early recognition & medical risk management in the care of individuals with eating disorders (3rd ed.). Reston, VA: Academy for Eating Disorders. https://community.aedweb.org/learn/publications/medical-care-standards

4. American Psychiatric Association (2006). Practice guideline for the treatment of patients with eating disorders (3rd ed). Washington, DC: American Psychiatric Association. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/eatingdisorders.pdf