The basic goals for the inpatient treatment of AN and bulimia nervosa are nutritional rehabilitation, psychosocial treatment, and if needed medical stabilization. Inpatient treatment is part of a continuum of care to restore healthy mental, physical, and social functioning. An inpatient program must achieve safe, prompt, and effective short-term improvement while preparing patients for transition to a less intense level of care. The conceptual model most appropriate for guiding the treatment of eating disorders emphasizes a multifactorial etiology. Because treatments logically grow out of assumptions of the nature of the disorder, the clearest possible description of known contributing factors is important for guiding effective treatment of eating disorders.

Admission to hospital for treatment of AN or bulimia nervosa remains a clinical decision based on multiple factors. Many of these factors interact with or potentiate each other. An initial goal of medical stabilization is intended to differentiate between symptoms produced by starvation or a chaotic binge and purge cycle, which will generally respond to simple nutritional rehabilitation versus those medical signs and symptoms that are either life threatening or atypical. For example, a very rapid weight loss of 25 lb may be medically more dangerous than a slower weight loss of 40 lb. Hypokalemia with an irregular but nonbradycardic heartbeat may be more medically serious than a gradually attained, very slow regular heart beat of 40. These distinctions require the clinician to thoroughly understand the adaptive responses of the body to an eating disorder. Many of the social behaviors and psychological symptoms attributed to the eating disorder may be due to the consequences of poor nutrition or chaotic eating and will normalize by restoration to a healthy body weight or a return to consistent adequate nutrition.

Medical indications for hospitalization among adult patients include an estimated healthy body weight below 85% of normal, a heart rate <40 bpm, blood pressure <90/60 mm Hg, glucose <60 mg per dL, potassium <3 mEq per L, and electrolyte imbalance. Consider hospitalization if an individual’s temperature is <36.1°C (97.0°F), there is evidence of dehydration, hepatic, renal, or cardiovascular organ compromise requiring acute treatment. Also, consider hospitalization if there is poorly controlled diabetes. Along with the reasons mentioned in preceding text consider hospitalization for children and adolescents when weight <85% of estimated healthy body weight or acute weight decline with food refusal. Inpatient care needs to be initiated when the heart rate nears 40 bpm, there is orthostatic hypotension (with an increase in pulse of >20 bpm or a drop in blood pressure of >10 to 20 mm Hg per minute from supine to standing). Additional makers for hospitalization include blood pressure <80/50 mm Hg, hypokalemia, hypophosphatemia, or hypomagnesemia.

Other factors to assess when making a decision to hospitalize include a high level of suicide risk, suicidal intent, and suicide plan. Also, assess the individual’s level of motivation to change. Hospitalization occurs when there is a need for supervision during and after all meals and in bathrooms; if there is uncontrolled vomiting or hemataemesis. Hospitalization needs to be considered if there is deterioration in any existing psychiatric disorder or severe co-occurring substance use disorder. Also, consider hospitalization if there are additional stressors interfering with the patient’s ability to eat (e.g., significant psychosocial stressors or inadequate social supports). Additionally, an inpatient setting is important when the individuals weight is near that at which medical instability occurred in the past and/or there is severe disabling symptoms of bulimia that have not responded to outpatient treatment.

Hospitalization suggests that medical or psychological instability of the patient has occurred with an increased likelihood that outpatient or partial hospitalization has failed. The decision to hospitalize on a psychiatric versus a general medical or adolescent/pediatric unit depends on the patient’s general medical
status, the skills and abilities of local psychiatric and general medical staff, and the availability of suitable programs to care for the patient’s general medical and psychiatric problems.¹² Even when admission has been primarily for medical stabilization, without changes in the psychological or environmental aspects of the disorder, there is a high probability those medical difficulties will return. The skilled management of inpatient care for patients with eating disorders is of paramount importance to the outcome of treatment. Because of the complex nature of treatment and consistency of goals and methods required to keep the focus of treatment, the best practice is inpatient care in a specialty eating disorder unit. A interdisciplinary team approach to treatment grows logically from a multifactorial concept of origin of the disorder. The interdisciplinary team provides patients with a consistent approach to a wide variety of their individual needs. The team focuses on the goal of changing illness behavior and thinking not only in the protected environment of the inpatient unit, but on an enduring basis after discharge. This interdisciplinary approach provides the patient with numerous opportunities to practice what they are learning and to receive consistent feedback in all parts of the therapeutic program. There is evidence to suggest that patients treated in specialized inpatient eating disorder units have better outcomes than patients treated in general inpatient settings where staff lacks expertise and experience in treating patients with eating disorders.¹³

The broad goals of inpatient care are weight restoration and initiation of treatment on the psychological and environmental factors that contribute to the maintenance of the disorder. Weight restoration (a vital but not exclusive goal), means restoration of a fully healthy body weight, with rebuilding of body and organ tissue as well as organ functioning. Restoration to a healthy body weight is a means, not an end, to comprehensive treatment. The conclusive work of treatment involves a fundamental and enduring change in overvalued ideas, dysfunctional family systems, and distorted beliefs concerning weight, shape, size, and appearance. Treatment is focused on decreasing the overinvestment in thinness as a means of dealing with crucial central issues in life, such as mood regulation, personal identity, or family stability.

Most patients and therapists agree that a healthy normal weight is an important condition for physical recovery. Clinicians place more importance on weight restoration and suggest it is important to psychological, emotional, and psychosocial well-being. Studies show that patients who do not attain a healthy normal weight are at a greater risk for relapse. There is no consensus on the question of what weight needs to be reached for recovery and clinicians have expressed different opinions on healthy normal, varying from a BMI of 18.5 to 19.5 or BMIs above 20. However, the establishment of a desired weight gain can be handled in different ways with the goal being a healthy normal weight. The three standards generally used are (a) the Metropolitan Life Tables¹⁴ for patients aged 18 and older, (b) the nomograms devised by Frisch and McArthur¹⁵ for achieving the weight necessary for return of periods in females and for adolescent girls, or (c) a BMI appropriate for age. A reasonable goal is the mid-range of the weight on the Metropolitan Life chart for a given height (with appropriate age correction and occasionally frame correction) or a BMI between 20 and 25. For female patients younger than age 18, with secondary amenorrhea, weights identified by Frisch and McArthur nomograms¹⁵ for a 50% chance of return of menstrual cycles are suggested. It should be noted that the weight for return of periods is approximately 10 lb higher than the weight required to begin menstrual cycles during normal development. For patients younger than 14, 100% weight for height for age is used as the definition for 100% of expected weight in children and young adolescents, as available on the Internet at http://www.cdc.gov/growthcharts/.

Picking a number from a chart is not the whole answer, however. Some attention should be given to the weight at which the patient functioned well if she or he had a time of stable weight and height before the onset of illness. Establish a target weight and rates of weight gain at which normal menstruation and ovulation are restored or, in premenarchal girls, the weight at which normal physical and sexual development resumes. The average anorexic patient often begins dieting at 5% to 10% above the matched population ideal weight at the onset of dieting. There is a rationale for setting the goal weight of these patients at 5% to 15% above the “ideal” weight. Because many of these patients may, in fact, be biologically normal only when above the “ideal” in weight. However, few patients accept this reasoning and few clinicians practice individualization of weight goals within the normal range.

Where practical considerations dictate a short inpatient treatment period, moderate weight gain to 85% of normal may have to be accepted. In this case, close follow-up is required in a partial hospitalization program or the outpatient clinic. A goal weight range, rather than a single point, should
be set so that patients can fluctuate comfortably within a 4 to 5 lb (1.4 kg) range. The weight goal is not firmly set when the patient comes into the hospital, but only after treatment has been under way for several weeks.

Nutritional rehabilitation begins with the establishment of weight restoration goals. Along with restoration of weight is a goal to normalize eating patterns and to achieve normal perceptions of hunger and satiety. In the process of restoration the biological and psychological sequelae of malnutrition are diminished. The initial nutritional intake begins with 1,200 to 1,500 calories per day, according to the patient’s admission weight, low in fat, salt, and lactose. Calories are increased by 500 every 4 to 5 days until a maximum of between 3,500 and 4,500 calories per day is achieved. The exact number will depend on the individual rate of weight gain, the height of the patient, and the presence of gastrointestinal discomfort. Once nutritional rehabilitation has been under way for several weeks, most calories can be prescribed in fairly dense form, including a moderate amount of fats and sweets. A safe continuing weight restoration averaging 3 lb a week in females, and 4 lb in males can be achieved without significant medical symptoms, except for occasional pedal edema, easily treated without diuretics by feet elevation, limitation of salt, and psychoeducation.

As restoration progresses it is important to help the patient cope with concerns about weight gain, body image changes, and to educate about the risks of eating disorders. Concurrent with restoration is helping the patient understand and cooperate with nutritional and physical rehabilitation, understanding and changing the behaviors and dysfunctional attitudes related to the eating disorder. Nutritional rehabilitation can improve interpersonal and social functioning, and lay the ground work to address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors. During this phase of treatment, providing ongoing support to the family is critical.

The use of a treatment protocol that deals with all the specifics related to the management of the patient’s weight restoration is vitally important. Members of the programs staff initially remain with patients for 24-hour support and supervision, until a normal eating pattern is established and comprehensive assessment of the patient’s psychological and physical state has been obtained. Staff sits with patients at all meals and encourages them to eat. The emphasis is on psychological support and the use of the milieu for group encouragement. An empathic supervised weight restoration program using normal food in a milieu setting with group support, results in patients’ beginning to eat three meals a day with only moderate anxiety within 24 hours. Food- and weight-related discussions are discouraged with an emphasis on self-understanding of the patient’s feelings and thoughts.

During restoration help the patient limit physical activity and caloric expenditure according to food intake and fitness requirements. Monitor their vital signs, food and fluid intake/output, electrolytes, signs of fluid overload (e.g., presence of edema, rapid weight gain, congestive heart failure), or other evidence of a serious refeeding syndrome. Also, address gastrointestinal symptoms, particularly constipation, bloating, and abdominal pain. Provide cardiac monitoring, especially at night, for children and adolescents who are severely malnourished. Add vitamin and mineral supplements; for example, phosphorus supplementation may be particularly useful to prevent serum hypophosphatemia. Nasogastric feeding is a rare occurrence and is reserved for patients with extreme difficulty recognizing their illness, accepting the need for treatment, or tolerating guilt accompanying active eating even when done to sustain life.

Restoration encourages a wide variety of foods but diet foods are not allowed. On admission the dietitian takes a complete nutritional history from the patients and leads decisions about changes in dietary programs. Dietitians also play an essential role in relating to patients, families, and staff regarding restoration. However, they do not discuss treatment directly with the patient until weight is in the maintenance range. In conjunction with the dietitian a patient can name three specific foods to delete from their menu, but other than these three specific choices (i.e., artichoke, pork chops, scrambled eggs), they do not determine their foods. Vegetarianism is permitted only if part of an established religious or philosophical practice (for example, Seventh Day Adventist) preceding the eating disorder. Vegetarianism in eating disordered patients represents an early phase of their eating disorder. Direct or daily interaction between the dietitian and the patients is discouraged to reduce the potential for endless requests to change in menus.

With patients who binge and/or purge, healthy normal weight is determined and if needed restoration is begun to achieve and maintain healthy normal weight. Weights outside of healthy normal range may be a contributing factor to the bulimia nervosa. Additionally providing nutritional counseling can help the patient establish a pattern of eating regular, nonbinge meals, and increase the variety of foods eaten. A normal eating pattern can correct nutritional deficiencies, minimize food restriction, and encourage healthy exercise patterns.

Although the initial emphasis of inpatient care is weight restoration and/or disrupting the chaotic binge-purge cycle, additional interventions especially psychoeducation and psychotherapy are provided once treatment has started. The goals of psychosocial interventions include reduction and, when possible, elimination of binge eating and purging, as well as understanding and cooperating with nutritional and physical rehabilitation. Treatment works to enhance motivation to cooperate in the restoration of healthy eating patterns and to participate in healthy nutrition. Psychotherapy of various theoretic models such as psychodynamic systems and cognitive behavioral therapies (CBTs) using individual, group, family, occupational, and recreational therapy formats can be implemented.⁶ Also, an inpatient unit can be designed to support a specific theoretic perspective (i.e., cognitive therapy).

Beginning with and maintaining a psychotherapeutically informed relationship with the patient is critical. This includes being aware of the following: understanding deficits in sense of self, interpersonal and intrapsychic conflicts, cognitive and psychological development, as well as psychological defenses, and the complexity of family relationships. Therapy also focuses on the assessment and change in core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder. Additional goals are improvement of interpersonal and social functioning as well as, treating associated conditions, including deficits in mood, impulse regulation, self-esteem, and behavior. It is important to monitor how the patient reacts to and understands the therapy and if possible create a therapeutic plan that fits the patient’s preferences. Complexity of family situation and relationships need to be assessed and if needed enlist family support and provide family counseling and therapy.

Increasing a patient’s readiness and developing motivation to change is essential for a positive outcome. Developing a treatment to match the patient’s motivation and readiness to change is critical. An empathic attitude on the part of the staff is highly valued by patients as a necessary condition for change in beliefs and behaviors related to an eating disorder. The growth process of patients is enhanced by skillful therapeutic use of the expression of empathy, creating and the understanding of psychological discrepancy, increasing individual self-efficacy, and meeting the patients where they are rather than battling with refusal to go along with treatment.

The APA guidelines¹⁶ suggest the use of CBT to engage and create change in patients with an eating disorder. Because AN and bulimia nervosa share symptoms (overemphasis on body shape and weight as sources of self-esteem and identity, relentless drive for thinness, phobic fear of normal weight, rigid dietary habits), CBT seems well suited for the treatment of a heterogeneous mix of eating disorders during inpatient treatment when specifically directed at eating disorder symptoms, underlying maladaptive cognitions and working with relationship concerns.¹⁷, ¹⁸, ¹⁹, ²⁰ CBT has been shown to be the most effective psychological method in the treatment of bulimia nervosa.¹⁷ Although CBT can be effectively applied to treatment of AN, definitive demonstration of its effectiveness in AN has not yet been shown.²¹

A CBT conceptual model for eating disorders²²,²³ proposes that an eating disorder is largely maintained by harmful beliefs that a patient holds about the self, the future, relationships, world, and the eating disorder. The self-destructive beliefs can take on a life of their own in which they develop a routine quality. The eating disorder symptoms act as precipitants and as responses to difficult life experiences, and the patient becomes consumed by negative beliefs about the self, the future, relationships, world, and the disorder. The model also posits that beliefs may be rigid and paralyzing, and prevent the patient from experimenting with different ways of thinking or behaving that could result in alternative ways of believing and interacting with the world. To change the belief system it must be tested through inquiry and experimentation. This can include looking at supporting and disconfirming evidence and setting up cognitive and behavioral experiments to determine whether
anticipated outcomes will occur. The model and approach are especially important during inpatient treatment to overcome the difficulty in developing engagement with the patient during therapy.