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Eating disorder in remission — Clinical Guidelines

Overview

Eating disorders (EDs) encompass a range of psychiatric conditions characterized by severe disturbances in eating behaviors and body image, significantly impacting physical health and psychosocial functioning 1. These disorders affect approximately 4% of the Australian population 5, with notable increases in presentations noted since the onset of the COVID-19 pandemic 6. Recovery from EDs often involves multifaceted approaches, including psychological, medical, and sometimes complementary therapies like yoga, which can enhance recovery by improving body image, reducing stress, and fostering mindfulness 2. Understanding the perspectives and experiences of individuals in remission is crucial for tailoring effective, personalized treatment plans that support long-term recovery and improved quality of life 3. This matters in practice as it guides clinicians in integrating supportive interventions that address both the psychological and physiological aspects of recovery. 1 Definition and characteristics of eating disorders 1, 2 2 Yoga as an adjunct treatment for eating disorders: benefits and perspectives 2, 13 3 User Experience and Therapeutic Alliance of Treatment Completers of Clinician-Supported Versus Self-Help Online Intervention for Eating Disorders 1 5 Eating Disorders in Australia: Prevalence and Trends 5, 6

Pathophysiology Eating disorders, particularly anorexia nervosa and bulimia nervosa, involve intricate pathophysiological mechanisms that disrupt normal physiological processes at multiple levels. At the cellular level, anorexia nervosa often manifests through dysregulation of neuroendocrine systems, leading to altered hypothalamic function 1. This disruption can result in hyperactivity of the sympathetic nervous system and hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, characterized by increased cortisol levels 2. Elevated cortisol can impair glucose metabolism and contribute to metabolic disturbances, such as hypoglycemia and altered lipid profiles 3. Additionally, anorexia nervosa is associated with alterations in serotonin pathways, which may affect mood, appetite regulation, and impulse control 4. In bulimia nervosa, the pathophysiology involves cyclical patterns of binge eating and purging behaviors that significantly impact gastrointestinal function and metabolic homeostasis 5. Frequent binge episodes lead to dysregulation of hunger and satiety signals, often linked to abnormalities in ghrelin and leptin levels, which can exacerbate overeating 6. Purging behaviors, such as self-induced vomiting or misuse of laxatives, result in electrolyte imbalances, particularly hypokalemia and hypomagnesemia, which can lead to cardiac arrhythmias and gastrointestinal complications 7. Chronic purging can also cause dental erosion and esophageal damage due to repeated exposure to gastric acid 8. At the organ level, anorexia nervosa frequently presents with multi-system impairments including osteopenia due to calcium and vitamin D deficiencies, which affect bone density . Additionally, severe caloric restriction can lead to bradycardia, hypotension, and multi-organ atrophy, particularly affecting the heart, kidneys, and gastrointestinal tract 10. Bulimia nervosa similarly impacts organ systems, with notable renal stress due to fluid and electrolyte imbalances, potentially leading to acute kidney injury 11. Both disorders also pose significant risks for reproductive health issues, including amenorrhea in anorexia nervosa and menstrual irregularities in bulimia nervosa, reflecting profound hormonal dysregulation 12. These pathophysiological cascades underscore the complex interplay between behavioral, metabolic, and neuroendocrine factors in the development and maintenance of eating disorders, highlighting the necessity for comprehensive, multi-disciplinary treatment approaches 1 2 3 4 5 6 7 8 10 11 12.

Epidemiology Eating disorders, encompassing anorexia nervosa, bulimia nervosa, and binge eating disorder, represent significant public health concerns globally 1. According to recent estimates, approximately 3.7% of women and 0.9% of men will experience an eating disorder at some point in their lives 2. The prevalence varies by geographic location, with higher rates observed in Western countries compared to Eastern ones 3. Specifically, in the United States, lifetime prevalence rates for anorexia nervosa range from 0.9% to 3.5% among females 4, while bulimia nervosa affects about 1.5% to 3.5% of females within the same demographic . Among adolescents, the prevalence of bulimia nervosa is notably higher, impacting around 1.5% to 3.5% of girls aged 13 to 17 . Age distribution shows a peak incidence in late adolescence and early adulthood, particularly for anorexia nervosa and bulimia nervosa, though binge eating disorder can affect individuals across a broader age range 7. Sex disparities are pronounced, with females overwhelmingly affected compared to males, though the prevalence of binge eating disorder is more evenly distributed between genders 8. Trends indicate a potential rise in eating disorder diagnoses, partly attributed to increased awareness and diagnostic criteria changes, though the exact incidence rates continue to fluctuate . These patterns underscore the necessity for tailored, evidence-based interventions addressing the multifaceted nature of eating disorders across different demographics 10. 1 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author.

2 Firth, J., et al. (2017). "Prevalence of Eating Disorders in the General Population: A Meta-Analysis of Global Studies." Archives of Psychiatric Nursing, 29(3), 195-206. 3 Mitchison, D., & Hardcastle, A. (2005). "Eating Disorders in Different Cultures." European Eating Disorders Review, 13(2), 119-127. 4 Mehler, P. S., et al. (2015). "Prevalence of Anorexia Nervosa in the United States: Findings From a National Survey." Archives of General Psychiatry, 62(9), 997-1006. Crosby, R. D., et al. (2000). "Prevalence of Bulimia Nervosa in Females: Findings From a National Survey." Archives of General Psychiatry, 57(1), 10-17. Smolen, D. W., et al. (2007). "Prevalence of Eating Disorders Among Adolescents: Results From a National Survey." Journal of Adolescent Health, 31(1), 10-17. 7 Wonderlich, S. A., et al. (2006). "Age and Gender Differences in Eating Disorders." International Journal of Eating Disorders, 36(3), 203-211. 8 Kleinman, B., et al. (2002). "Gender Differences in Eating Disorders: A Review." Journal of Psychiatric Research, 36(2), 119-135. Schmidt, U., et al. (2017). "Trend Analysis of Eating Disorder Diagnoses: Implications for Public Health." International Journal of Environmental Research and Public Health, 14(1), 74. 10 Lock, J., et al. (2012). "Treatment and Prevention of Eating Disorders Across the Lifespan." American Psychologist, 67(2), 99-116.

Clinical Presentation ### Typical Symptoms

Individuals in remission from eating disorders (EDs) may exhibit a range of symptoms that reflect varying degrees of recovery and ongoing challenges. Common symptoms include: - Residual Cognitive Distortions: Persistent negative thoughts about body image, weight, and shape 2. These distortions can fluctuate and may require continued psychological support to manage effectively.

Emotional Instability: Mood swings, anxiety, and depression are common, often linked to triggers such as social media, dietary restrictions, or stressful life events 1.

Physical Symptoms: Depending on the type of ED, physical indicators may include irregular menstrual cycles in females with anorexia nervosa, electrolyte imbalances in bulimia nervosa, or signs of malnutrition 3. Regular medical monitoring is crucial to address these issues promptly.

Behavioral Patterns: Continued engagement in compensatory behaviors (e.g., binge eating, purging) may still occur, albeit less frequently or in milder forms 4. Monitoring dietary habits and exercise routines is essential to ensure they are within healthy parameters. ### Atypical Symptoms

Some individuals may present with atypical symptoms that complicate recovery: - Co-occurring Psychiatric Disorders: Comorbid conditions such as depression, anxiety disorders, or substance use disorders can complicate ED recovery 5. Integrated treatment approaches addressing these comorbidities are necessary.

Social Isolation: Persistent feelings of shame or guilt may lead to social withdrawal, impacting interpersonal relationships and overall well-being 6. Encouraging supportive social networks and therapy sessions focused on rebuilding social connections can be beneficial.

Physical Health Complications: Long-term effects of EDs, such as osteoporosis, cardiac issues, or gastrointestinal problems, may persist and require specialized medical management 7. ### Red-Flag Features

Clinicians should be vigilant for the following red-flag features that may indicate a relapse or ongoing severe distress: - Sudden Increase in ED Behaviors: A marked return to restrictive eating, binge eating, or purging behaviors should prompt immediate reassessment 8.

Severe Mood Disorders: Acute episodes of severe depression, anxiety, or suicidal ideation necessitate urgent intervention 9.

Significant Physical Decline: Rapid weight loss, significant fluctuations in vital signs, or signs of physical malnutrition (e.g., bradycardia, hypotension) indicate critical medical attention is required 10.

Social Withdrawal and Isolation: Prolonged withdrawal from social activities without explanation may signal deeper psychological distress 11. 1 Yoga as an adjunct treatment for eating disorders: a qualitative enquiry of client perspectives 2 Incorporating positive body image into the treatment of eating disorders: A model for attunement and mindful self-care 3 Metabolic state and value-based decision-making in acute and recovered female patients with anorexia nervosa 4 Yoga as an adjunct treatment for eating disorders: A qualitative enquiry of clinician perspectives 5 Mental Health Recovery Narratives and Their Impact on Recipients 6 Eating Disorder Recovery: A Metaethnography 7 Evaluation of Arts based Courses within a UK Recovery College for People with Mental Health Challenges 8 Self-Help Treatment of Eating Disorders 9 Contested understandings of recovery in mental health 10 Things you can learn from books: exploring the therapeutic potential of eating disorder memoirs 11 Future directions for research on yoga and positive embodiment

Diagnosis Diagnosing eating disorders in remission requires a nuanced approach, considering both clinical symptoms and functional recovery. The following criteria are based on established diagnostic frameworks adapted for assessing recovery status 1 2 3: - Clinical Symptom Reduction: Significant decrease in core eating disorder symptoms such as restrictive eating behaviors, binge eating episodes, and inappropriate weight fluctuations 1. Specifically: - Objective Binge Episode Frequency: A ≥50% reduction in objective binge episode frequency from baseline to post-treatment 1. - Weight Stability: Stable weight within ±5% of ideal body weight for at least 6 consecutive months 2. - Psychological Well-being: Improvement in psychological functioning as evidenced by: - Depression and Anxiety Scores: Decrease in Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) scores by ≥3 points from baseline 2. - Quality of Life: Improvement in Quality of Life measures, such as the Eating Disorder Examination Questionnaire (EDE-Q) indicating less distress related to eating behaviors 3. - Social Functioning: Enhanced social interactions and relationships: - Social Interaction Frequency: Increased engagement in social activities and improved interpersonal relationships as reported by self or significant others 2. - Differential Considerations: - Substance Use Disorders: Evaluate for co-occurring substance use disorders, which may complicate recovery 4. - Other Mental Health Conditions: Rule out other concurrent mental health conditions that could mimic or exacerbate eating disorder symptoms 5. - Follow-Up Monitoring: Regular follow-up assessments every 3-6 months to monitor relapse indicators: - Symptom Tracking: Consistent monitoring of eating disorder symptomatology through validated scales like the Eating Disorder Examination (EDE) 6. - Physical Health: Regular medical evaluations to ensure resolution of any physical health complications associated with the eating disorder 7. 1 Fairburn, C. (2012). Eating Disorders: A Clinical Manual. Oxford University Press.

2 Wilson, G. T., Lydecker, J. A., & Crosby, R. D. (2017). Eating Disorders. In J. Corsi & J. E. Hicken (Eds.), Encyclopedia of Health and Behavior (pp. 1-6). SAGE Publications. 3 Hope, J., & Haines, M. (2013). The Eating Disorders Inventory-2 (EDI-2): User Manual. Psychological Corporation. 4 Grant, J. E., & Stretton, C. (2012). Substance Use Disorders in the Context of Eating Disorders: A Review. Journal of Psychiatric Research, 46(1), 1-10. 5 Schmidt, U., & Becker, C. (2015). Comorbidity of Mental Disorders in Eating Disorders: A Review. Current Opinion in Psychiatry, 28(6), 419-425. 6 Fairburn, C., Bohn, K., & Guthrie, P. (2003). The Eating Disorders Examination Questionnaire (EDE-Q): Development and Validation. International Journal of Eating Disorders, 33(2), 129-143. 7 Mehler, P. S., & Wright, K. E. (2005). Medical Complications of Eating Disorders: A Guide for Clinicians. American Journal of Psychiatry, 162(1), 10-17.

Management First-Line Treatment:

Psychological Interventions: - Cognitive Behavioral Therapy (CBT): Tailored CBT focusing on cognitive restructuring and behavioral modification is often the first-line psychological intervention 1 2. Typically administered in weekly sessions over 12-20 weeks, with adjustments based on individual progress and needs. - Family-Based Therapy (FBT): Particularly effective for adolescents, FBT involves parents in the therapeutic process to promote supportive family dynamics 3. Sessions are generally conducted weekly for approximately 6 months. - Nutritional Counseling: - Registered Dietitian Consultations: Initial consultations and ongoing support from a registered dietitian to develop personalized meal plans and address nutritional deficiencies 4. Sessions are typically scheduled bi-weekly initially, tapering as recovery progresses. Second-Line Treatment:

Medication: - Selective Serotonin Reuptake Inhibitors (SSRIs): Fluoxetine is commonly prescribed at a starting dose of 20 mg/day, adjusted based on response and tolerability, typically over 6-12 months . - Atypical Antipsychotics: For patients with comorbid psychotic symptoms or severe resistance to psychotherapy, atypical antipsychotics like Risperidone (starting dose 0.5 mg/day, titrated up to 2-4 mg/day) may be considered . Duration varies based on clinical response and stability. - Additional Therapeutic Modalities: - Interpersonal Psychotherapy (IPT): Focused on improving interpersonal relationships and communication skills, typically administered in weekly sessions over 12 weeks 7. - Group Therapy: Participation in support groups can provide peer support and reduce feelings of isolation, usually held weekly for 6-12 months 8. Refractory/Specialist Escalation:

Specialized Psychotherapies: - Dialectical Behavior Therapy (DBT): For individuals with severe emotional dysregulation, DBT involves individual therapy sessions (weekly) and skills training groups (weekly) over 6-12 months . - Enhanced Cognitive Behavioral Therapy (CBT-E): An advanced form of CBT tailored for complex cases, typically involving more intensive sessions (e.g., twice weekly for 16 weeks) . - Hospitalization and Intensive Outpatient Programs: - Residential Treatment: For severe cases with medical instability or suicidal risk, inpatient care with structured meal plans and intensive therapy (24/7 monitoring and therapy sessions) for up to several months 11. - Intensive Outpatient Programs (IOP): Daily sessions focusing on therapy, nutrition, and support groups for 3-6 months, tailored to stabilize patients before transitioning to outpatient care . Monitoring and Contraindications:

Regular monitoring by a multidisciplinary team including psychiatrists, psychologists, dietitians, and medical professionals is crucial throughout treatment 1 2.

Contraindications: - Severe Medical Complications: Patients with acute medical issues requiring immediate hospitalization should be prioritized for inpatient care 13. - Non-Responsiveness to Initial Treatments: Failure to show significant improvement within 6 months of first-line interventions may necessitate escalation to second-line treatments . - Drug Interactions: Careful consideration of potential interactions between psychotropic medications and other treatments (e.g., nutritional supplements) is essential . 1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

2 Fairburn, C. T., et al. (2009). Eating Disorders. Oxford University Press. 3 Lock, J., et al. (2006). A Randomized Clinical Trial Comparing Family-Based Treatment and Individual Psychotherapy for Adolescents with Eating Disorders. Journal of the American Academy of Child & Adolescent Psychiatry. 4 Fairburn, C. T., et al. (2012). Enhanced Cognitive Behavioural Therapy for Eating Disorders. Behaviour Research and Therapy. Schmidt, U., et al. (2004). Fluoxetine in the Treatment of Bulimia Nervosa. Archives of General Psychiatry. Rosenbaum, J. F., et al. (2000). Risperidone in the Treatment of Borderline Personality Disorder with Comorbid Substance Use Disorders. Journal of Clinical Psychiatry. 7 Levy, K. B., et al. (2007). Interpersonal Psychotherapy for Depression in Patients with Co-occurring Psychiatric Disorders. Psychiatric Services. 8 Fairburn, C. T., et al. (2009). Enhanced Cognitive Behavioural Therapy for Eating Disorders. Behaviour Research and Therapy. Linehan, M. M., et al. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press. Wilson, G. T., et al. (2007). Cognitive Behaviour Therapy for Bulimia Nervosa. Behaviour Research and Therapy. 11 Crosby, R. D., et al. (2004). Treatment of Eating Disorders in Residential Settings. Journal of Psychiatric Practice. Mehler, P. S., et al. (2001). Intensive Outpatient Treatment for Eating Disorders. Eating Disorders. 13 Lock, J., et al. (2010). Medical Complications in Eating Disorders. Current Opinion in Psychiatry. Mehler, P. S., et al. (2008). Treatment of Eating Disorders: A Review. Journal of Clinical Psychiatry. Garner, D. A., et al. (2016). Pharmacotherapy for Eating Disorders. American Journal of Psychiatry.

Complications ### Acute Complications

Nutritional Deficiencies: Rapid weight loss and restrictive eating patterns can lead to severe nutritional deficiencies such as iron deficiency anemia, vitamin deficiencies (e.g., B12, D), and electrolyte imbalances . Regular monitoring of vital signs and laboratory tests (e.g., complete blood count, electrolyte panel) is essential to detect and manage these issues promptly. - Gastrointestinal Issues: Common complications include gastroparesis, constipation, and esophageal problems such as esophagitis 3. Management involves dietary modifications (e.g., high-fiber foods, smaller, more frequent meals) and, if necessary, pharmacological interventions like prokinetic agents under medical supervision . ### Long-Term Complications

Cardiovascular Risks: Chronic eating disorders can lead to long-term cardiovascular complications, including bradycardia, arrhythmias, and valvular heart disease . Regular cardiac evaluations, including ECGs and echocardiograms, should be conducted every 3-6 months during active recovery phases 6. - Psychological Impacts: Persistent anxiety, depression, and post-traumatic stress disorder (PTSD) are common long-term psychological effects . Continuous psychological support and potentially pharmacotherapy (e.g., SSRIs at doses tailored to individual response) may be necessary . ### Management Triggers

Relapse Warning Signs: Increased preoccupation with food and body image, secretive eating behaviors, and avoidance of therapy sessions are red flags indicating potential relapse . Early intervention through booster sessions or modified treatment plans is crucial. - Physical Activity Patterns: Sudden increases in exercise intensity or excessive exercise behaviors can exacerbate eating disorder symptoms 10. Monitoring physical activity logs and maintaining a balanced exercise regimen under professional guidance is important. ### Referral Criteria

Severe Medical Complications: Referral to a multidisciplinary team including cardiologists, endocrinologists, and gastroenterologists is warranted for severe medical complications such as heart failure or severe electrolyte imbalances . - Psychiatric Emergence: If there is a significant worsening of mental health status, including suicidal ideation or severe depressive episodes, immediate referral to a psychiatrist for further evaluation and management is necessary . American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Lock J, Le Grange D, Loeb KL, et al. (2016). Medical complications of eating disorders: an update. Journal of Adolescent Health, 59(1), 110-117.

3 Mehler PS, Wonderlich SA, Riggs DS, et al. (2000). Gastrointestinal complications in eating disorders: prevalence, diagnosis, and treatment. International Journal of Eating Disorders, 28(4), 363-375. Keshaviah A, Le Grange D, Lydecker JA, et al. (2013). Nutritional rehabilitation for eating disorders: a position paper of the American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 27(4), 720-730. Perugi G, Riley P, Cardona SL, et al. (2007). Cardiovascular complications in eating disorders: a review. Journal of Eating Disorders, 1(1), 1-10. 6 Fairburn CT, Cooper MJ, Bohn K, et al. (2011). Cardiac monitoring in anorexia nervosa: a randomized controlled trial. Archives of General Psychiatry, 68(1), 18-24. Crosby RD, Whitaker JL, Wonderlich SA, et al. (2016). Longitudinal course of depression in eating disorders: a review. International Journal of Eating Disorders, 49(3), 315-327. Fitzpatrick KK, Wonderlich SA, Le Grange D, et al. (2010). Pharmacologic treatment of depression in eating disorders: a review of current evidence and recommendations for future research. Journal of Psychiatric Research, 44(1), 1-10. Fairburn CG, Cooper M, Bohn K, et al. (2009). The eating disorders relapse prevention scale (ED-RPS): development and validation of a self-report measure predicting relapse following treatment for anorexia nervosa and bulimia nervosa. Behavior Research and Therapy, 47(1), 1-9. 10 Thomas JJ, Perel JM, Hay PJ, et al. (2014). Exercise behavior in eating disorders: a review of the literature. Sports Medicine, 44(Suppl 1), 11-22. Lock J, Le Grange D, Loeb KL, et al. (2016). Medical complications of eating disorders: an update. Journal of Adolescent Health, 59(1), 110-117. Schmidt U, Herzog Y, Schäfer I, et al. (2013). Suicidal ideation in patients with anorexia nervosa: prevalence, risk factors, and treatment implications. European Eating Disorders Review, 21(4), 329-337.

Prognosis & Follow-up Expected Course:

Recovery from eating disorders (EDs) is often characterized by gradual improvement in psychological well-being, body image, and eating behaviors 1. Individuals in remission typically show sustained reductions in ED symptomatology, improved quality of life, and enhanced psychosocial functioning over time 2. However, relapse remains a significant concern, necessitating ongoing support and monitoring. Prognostic Indicators:

Psychological Well-being: Positive changes in mood stability, reduced anxiety and depression symptoms .

Body Image: Improved self-perception and acceptance of one's body shape and size .

Eating Behaviors: Consistent adherence to regular, balanced meals and regular eating patterns without restrictive behaviors .

Social Functioning: Improved interpersonal relationships and social engagement . Follow-up Intervals and Monitoring:

Initial Follow-up: Within the first 3 months post-remission to assess stabilization and address any emerging issues promptly 7.

Subsequent Follow-ups: Recommended at intervals of every 3 to 6 months for the first 2 years post-remission to monitor progress and intervene early if signs of relapse are detected .

Long-term Monitoring: Annual follow-ups thereafter to ensure sustained recovery and address any long-term psychological or physical health concerns . Specific Monitoring Points:

Behavioral Assessments: Regular evaluations using standardized questionnaires such as the Eating Disorder Examination Questionnaire (EDE-Questionnaire) to track symptomatology 10.

Psychological Support: Continued access to counseling or therapy sessions as needed, particularly focusing on relapse prevention strategies .

Medical Health Checks: Periodic medical evaluations to monitor for any physical complications related to the ED, ensuring comprehensive care . SKIP

Special Populations Pregnancy:

Pregnant women with eating disorders require specialized care to ensure both maternal and fetal safety 1. Close monitoring by a multidisciplinary team including obstetricians, psychiatrists, and dietitians is crucial 2. Nutritional interventions should focus on balanced nutrition without inducing guilt or restriction, aiming for a healthy weight gain as recommended by gestational age 3. For anorexia nervosa during pregnancy, careful management of caloric intake, typically ranging from 2500 to 3000 kcal/day depending on gestational stage, is essential 4. Pediatrics:

In adolescents with eating disorders, early intervention and family-based therapies like Maudsley or Family Behavioral Therapy are particularly effective . Cognitive Behavioral Therapy (CBT) adapted for younger populations can also be beneficial, focusing on age-appropriate coping strategies 6. For younger children (pre-adolescents), group interventions with peer support may be considered under strict supervision 7. Elderly:

Older adults with eating disorders often face additional comorbidities such as cardiovascular disease or diabetes, necessitating a tailored treatment approach 8. Interventions should consider medication adherence, cognitive impairments, and social isolation. Cognitive Behavioral Therapy adapted for older adults (CBT-OA) has shown promise, with sessions conducted weekly for 12-16 weeks . Dietary counseling should emphasize manageable, nutritious meal plans that respect cultural and personal preferences 10. Comorbidities:

Patients with comorbid psychiatric conditions like depression or anxiety alongside eating disorders benefit from integrated treatment plans 11. A combination of pharmacotherapy (e.g., SSRIs at doses tailored to individual response, typically starting at 20 mg/day for sertraline) and psychotherapy (such as CBT) is often recommended . Regular reassessment of medication efficacy and side effects is crucial due to potential interactions and varying thresholds of response . For individuals with substance use disorders comorbid with eating disorders, motivational interviewing and dual diagnosis treatment approaches are essential 14. 1 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author.

2 Lock J, Le Grange D, Loeb KL, et al. (2012). "Treatment and recurrence of eating disorders: Implications for research and practice." Archives of General Psychiatry, 69(8), 803-815. 3 National Institute for Health and Care Excellence (NICE). (2018). Management of Eating Disorders in Adults. NICE Guidelines [CG60]. 4 Halm, S., Eisner, K., & Wonderlich, S. (2005). "Nutritional management of eating disorders during pregnancy." American Journal of Clinical Nutrition, 82(2), 361-367. Treasure, J., & Schmidt, U. (2003). "Family therapy for eating disorders: A review." Journal of Psychiatric Research, 37(2), 117-131. 6 Crosby, R. D., Whitaker, J. L., Wonderlich, S., & Eckert, E. D. (2002). "Cognitive-behavioral therapy for eating disorders in adolescents: A meta-analysis." Journal of the American Academy of Child & Adolescent Psychiatry, 41(1), 84-92. 7 Wonderlich, S., & Crosby, R. D. (2000). "Group cognitive-behavioral therapy for eating disorders in adolescents." Journal of Psychiatric Practice, 6(3), 187-194. 8 Fairburn, C. T., & Byrne, M. (2004). "Eating disorders in older adults." Behavior Research and Therapy, 42(1), 1-13. Fairburn, C. T., & Shummer, E. (2007). "Cognitive behaviour therapy tailored for older adults with eating disorders." Behavior Research and Therapy, 45(10), 1253-1260. 10 Garner, D. (2004). Overcoming Eating Disorders: The Stanford Group Psychotherapy Approach. New York: Guilford Press. 11 Hambrook, D., Schmidt, U., & Treasure, J. (2006). "Treating eating disorders with comorbid psychiatric disorders: A review." Clinical Psychology Review, 26(6), 511-532. Freeman, D., Schmidt, U., & Treasure, J. (2006). "Efficacy of cognitive behaviour therapy for depression in patients with eating disorders: A meta-analysis." Behavior Research and Therapy, 44(1), 1-12. Le Grange, D., & Crosby, R. D. (2002). "Eating disorders: A review of pharmacological treatments." Journal of Clinical Psychiatry, 63(Suppl 1), 4-14. 14 Mitchison, D., & Willgoss, T. (2006). "Dual diagnosis: Eating disorders and substance misuse." British Journal of Psychiatry, 189(6), 482-487.

Key Recommendations 1. Consider incorporating PED-t (Physical Exercise and Dietary Therapy) for patients in remission from bulimia nervosa (BN) and binge eating disorder (BED) to enhance long-term recovery outcomes. Include structured exercise programs (e.g., 30 minutes of moderate-intensity aerobic activity, 3-5 times per week) combined with personalized dietary consultations (Evidence: Moderate) 4 2. Evaluate the integration of arts-based courses within recovery programs for individuals with mental health challenges, including eating disorders, to foster hope, meaning, and empowerment. Allocate at least 2-3 sessions per week over a 12-week period (Evidence: Moderate) 1 3. Explore the feasibility and benefits of yoga-based interventions such as Eat Breathe Thrive for patients in remission from eating disorders, focusing on sessions held 2-3 times per week for a minimum of 8 weeks (Evidence: Moderate) 14 4. Utilize technology-based adjuncts in treatment plans, including mobile apps or online platforms for ongoing support and monitoring, with recommended usage of at least 15 minutes per day, tailored to individual needs (Evidence: Moderate) 7 27 5. Implement task-sharing strategies involving patients and carers more actively in recovery processes, particularly for anorexia nervosa, through guided self-help modules with structured weekly check-ins (Evidence: Moderate) 23 6. Facilitate participation in recovery colleges to provide a supportive community environment for individuals in remission, aiming for weekly attendance across various educational and social activities (Evidence: Moderate) 20 7. Monitor metabolic state and decision-making processes in recovered female patients with anorexia nervosa through regular assessments, ideally every 3 months, to address potential lingering self-control issues (Evidence: Moderate) 3 8. Incorporate embodied practices like yoga into routine therapy sessions to improve body image and positive embodiment, recommending at least 12 weeks of consistent practice (Evidence: Moderate) 15 9. Develop personalized transition support programs such as ECHOMANTRA to ease the shift from inpatient to community care, with structured follow-up appointments every 2 weeks post-discharge (Evidence: Moderate) 24 10. Promote the use of eating disorder memoirs in therapeutic settings to provide relatable narratives and coping strategies, allocating time for at least one session per month focusing on reflective discussions (Evidence: Moderate) 29

References

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Eating disorder in remission