Patient handout

Eating Disorders (AN-R / AN-BP / BN / BED / ARFID / OSFED) — chronic stepwise + acute medical instability (APA 2023; AED 2016 Garber; NICE NG69 2023; Maudsley FBT Lock & Le Grange 2013; CBT-E Fairburn 2008)

PRODUCTION

1. Your condition

This handout is for eating disorders (an-r / an-bp / bn / bed / arfid / osfed) — chronic stepwise + acute medical instability (apa 2023; aed 2016 garber; nice ng69 2023; maudsley fbt lock & le grange 2013; cbt-e fairburn 2008). Your care team identified this based on: restrictive eating pattern + significant weight loss or failure to gain expected weight (dsm-5-tr 2022 an criterion a; f50.0x).

Other reasons your team may use this plan: recurrent binge-eating episodes (dsm-5-tr 2022 bn criterion a.1 / bed criterion a; f50.2 / f50.81); self-induced vomiting / laxative / diuretic / fasting / excessive exercise to compensate for binge (dsm-5-tr 2022 bn criterion a.2; f50.2); avoidant / restrictive food intake without body-image disturbance — sensory, fear of consequences, lack of interest (dsm-5-tr 2022 arfid; f50.82).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
fluoxetine	20 mg PO daily × 1 wk → 40 mg × 1 wk → 60 mg	PO	once daily (mornings)	FDA-approved for BN at 60 mg/d per Walsh JAMA 1997 PMID 9215413; higher than typical MDD dose; long half-life buffers missed doses; mornings to avoid insomnia; combination with CBT-E superior to either alone (APA 2023)

Plan: ED-specific pharmacotherapy by subtype — BN fluoxetine 60 mg/d FDA-approved; BED lisdexamfetamine 30-70 mg/d FDA-approved; AN olanzapine off-label adjunct; SSRI for comorbid MDD post-weight-restoration (APA 2023; Walsh JAMA 1997 PMID 9215413; McElroy JAMA Psychiatry 2015 PMID 25587642; Attia Am J Psych 2019 PMID 30958539)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — weight stable / restoring on schedule, EDE-Q low, no SI, functioning at baseline (APA 2023; NICE NG69 2023)

If you have:

Weight stable or gaining on schedule (APA 2023; AED 2016 Garber)
Eating regularly with meal plan in place (Lock & Le Grange 2013; Fairburn 2008)
No active binge or purge (DSM-5-TR 2022)
PHQ-9 + GAD-7 + EDE-Q low (APA 2023)
No suicidal thoughts (C-SSRS; Posner 2011 PMID 22193671)
Engaging with usual activities and relationships (APA 2023)

Do this:

Take medications as prescribed every day — do not stop suddenly (APA 2023)
Continue therapy / coping practices — FBT or CBT-E homework, nutrition plan, supportive routines (APA 2023; Lock & Le Grange 2013; Fairburn 2008)
Keep follow-up appointments — weekly weight + therapy + nutrition (APA 2023)
Keep crisis line numbers (988 US) available even when feeling well (APA 2023; VA/DoD 2022)
Maintain consistent sleep-wake schedule; minimise alcohol and recreational drugs

YELLOW — Caution — weight declining or stalled, increased binge/purge frequency, EDE-Q rising, passive SI without plan (APA 2023; NICE NG69 2023)

If you have:

Weight loss > 2-3 lb in 1 wk OR weight gain plateau against plan (AED 2016 Garber)
Increased restriction OR binge frequency OR purge frequency (DSM-5-TR 2022)
Compensatory behaviors returning — excessive exercise, laxative / diuretic use, fasting (DSM-5-TR 2022)
EDE-Q rising by ≥ 1 point or PHQ-9 rising by ≥ 5 points (Fairburn & Beglin 1994; Kroenke 2001)
Passing thoughts that life is not worth living without intent or plan (C-SSRS; Posner 2011)
Withdrawal from supports OR avoidance of meals with family (APA 2023; Lock & Le Grange 2013)

Do this:

Use coping strategies from your safety plan — call a support person, attend scheduled meals, use distraction or grounding for binge/purge urges (Stanley-Brown 2012; APA 2023)
Contact your provider for an early appointment — within 1 week (APA 2023)
Review medication adherence with provider — consider dose adjustment if appropriate (APA 2023)
Avoid means of self-harm — lock or remove firearms; secure or limit medications to short supply (VA/DoD 2022)
Do NOT use diet pills, laxatives, or diuretics — these worsen the eating disorder + electrolyte derangement (APA 2023)
Engage family / supports — let them know what is happening (APA 2023)

Call your provider if:

Weight changes outside expected range (APA 2023; AED 2016 Garber)
Binge / purge frequency rising (APA 2023)
Any thoughts of suicide become more frequent (VA/DoD 2022)
Functioning at school / work / home declines (APA 2023)
Symptoms not improving after 2 weeks of self-care (APA 2023)

RED — Medical alert — fainting / severe weakness / chest pain / palpitations / severe abdominal pain / blood in vomit / active SI with intent or plan (AED 2016 Garber; APA 2023)

If you have:

Fainting, dizziness, severe weakness, or palpitations (AED 2016 Garber medical-instability criteria)
Chest pain or arrhythmia — possible cardiac complication from electrolyte derangement (AED 2016 Garber)
Severe abdominal pain or blood in vomit / blood in stool — possible GI complication from purging (APA 2023)
Severe shaking / confusion / hallucinations — possible electrolyte / refeeding-syndrome / starvation complication (AED 2016 Garber)
Specific thoughts of how to end your life (C-SSRS; Posner 2011 PMID 22193671)
Access to means — firearms, large-quantity meds (APA 2023; VA/DoD 2022)
Recent self-harm or attempt (APA 2023)
Inability to keep yourself safe (APA 2023)

Do this:

Call 988 (US) / your local crisis line / emergency services NOW for any SI (APA 2023; VA/DoD 2022)
Go to the nearest emergency department for any medical symptom; bring medication list (APA 2023)
Do not be alone — call a trusted person to come with you (APA 2023)
Hand any means (firearms, pills) to a trusted person before going (VA/DoD 2022; Mann JAMA 2005 NEEDS_SOURCE_REVIEW)
Tell someone you trust what is happening (Stanley-Brown 2012 NEEDS_SOURCE_REVIEW)
Do not use alcohol or non-prescribed substances (APA 2023)

Call your provider if:

Any red zone trigger — emergency department immediately, do not wait (APA 2023; AED 2016 Garber)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Severe AN with medical instability — HR < 40 OR QTc > 470 OR K < 3.0 OR Phos < 2.5 OR Mg < 1.5 OR weight < 75% IBW or BMI < 14 OR hypothermia < 36.0°C OR severe orthostatic SBP drop > 20 mm Hg or pulse rise > 20 (AED 2016 Garber Medical Management of Severely Restrictive Eating Disorders admission criteria)(life-threatening)
Refeeding-syndrome risk at admission — severe restriction past 1-2 wk OR weight < 70% IBW or BMI < 13 OR existing electrolyte derangement (K < 3.0, Phos < 2.5, Mg < 1.5) OR rapid weight-loss velocity prior to admission(life-threatening)
Severe BN with active purging + electrolyte derangement — K < 3.0 OR HCO3 > 30 (metabolic alkalosis from vomiting) OR Phos < 2.5 OR QTc > 470 in BN patient with active vomiting / laxative / diuretic abuse
C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in ED patient — AN has 4-5× completed-suicide rate per population; AN-BP and BN carry highest SI rates among EDs (especially with comorbid MDD ~50-70%)(life-threatening)
Pediatric / adolescent AN with significant weight-loss velocity — > 5% weight loss in 3 mo OR > 10% in 6 mo OR < 5th BMI percentile-for-age OR rapid weight loss in adolescent (any weight starting point)
Pregnancy with active or historical eating disorder — high-risk obstetric pregnancy due to preterm + low birth weight + preeclampsia + postpartum-depression risk; medication decisions complicated by FDA categories + breastfeeding plans
Severe-Enduring AN (SE-AN) — duration ≥ 7 yr with persistent ED behaviors despite ≥ 2 evidence-based treatments (FBT / CBT-E / MANTRA / SSCM / inpatient medical stabilization / PHP / residential); harm-reduction + quality-of-life framework per Hay 2012

5. Follow-up

Continue ED-specific treatment ≥ 12 mo after remission for first episode (APA 2023; NICE NG69 2023); ≥ 2-3 yr or indefinite if recurrent; relapse-prevention CBT-E or FBT continuation reduces relapse; lifestyle (regular meal pattern, exercise prescription if cleared, social engagement); long-term outpatient continuity for SE-AN ≥ 7 yr (Hay 2012 NEEDS_SOURCE_REVIEW)

6. Sources

Guideline: APA Practice Guideline for the Treatment of Patients with Eating Disorders, 4th Edition 2023 + AED Medical Management of Severely Restrictive Eating Disorders (Garber 2016 + 2022 update) + NICE NG69 Eating Disorders 2017 (last updated 2023) + Maudsley FBT manual (Lock & Le Grange 2013) + CBT-E manual (Fairburn 2008)