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psych.eating-disorders.core.v1PRODUCTION
psych.eating-disorders.core.v1

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)

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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DSM-5-TR 2022 eating-disorder criteria — AN (energy restriction + low body weight + fear of weight gain + body-image disturbance); BN (recurrent binge + compensatory ≥ 1×/wk × 3 mo + body-image disturbance); BED (recurrent binge ≥ 1×/wk × 3 mo + distress + no compensation); ARFID (avoidant/restrictive without body-image disturbance); OSFED (atypical AN with normal weight; subthreshold BN/BED; purging disorder; night-eating); functional impairment; not better explained by medical or other psychiatric condition (DSM-5-TR 2022; APA 2023)

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DSM-5-TR ED subtype criteria met + medical / psychiatric mimics ruled out

Patient inputs (28)

Drug + therapy selection; pediatric < 12 rare + medical workup; adolescent 12-17 FBT first-line (Lock & Le Grange 2013); adult CBT-E / MANTRA / SSCM; geriatric ≥ 65 rare + medical-mimic workup mandatory (APA 2023)

SSRI choice (sertraline preferred for lactation; paroxetine AVOIDED FDA Cat D); bupropion CONTRAINDICATED in active purging (seizure); MFM coordination if severe (APA reproductive psychiatry; APA 2023)

BMI percentile-for-age (adolescents) + % IBW (adults); weight-loss velocity; medical-instability marker if < 75% IBW or BMI < 14 (AED 2016 Garber; APA 2023)

BMI calculation; adolescent BMI percentile-for-age (CDC 2-20 yr growth charts)

PHQ-9 — comorbid MDD ~50-70% in AN, ~50% in BN (APA 2023); Q9 flags suicidality; informs SSRI choice (Kroenke 2001 PMID 11556941)

Prior FBT / CBT-E / IOP / PHP / residential / inpatient response determines next step in ladder (APA 2023; NICE NG69 2023)

Rule out bipolar — MDQ screen — antidepressant alone may precipitate manic switch (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2023)

Comorbid SUD ~50% in BN (especially AUD + stimulants); bupropion CONTRAINDICATED in active purging; AVOID benzo in active SUD (APA 2023)

CV / GI / renal / endocrine (T1DM diabulimia, T2DM in BED) / osteoporosis / dental erosion (BN) affect drug + workup choice (APA 2023; AED 2016 Garber)

MAOI washout; serotonergic load; bupropion + purging contraindication (seizure); olanzapine metabolic baseline; lisdexamfetamine Schedule II + cardiovascular warning; QTc-prolonging drugs in low-K patient (APA 2023; FDA)

Baseline electrolytes — K / Phos / Mg critical for refeeding-syndrome + purging-related hypokalemia; AED 2016 Garber admission criteria

Baseline — anemia + leukopenia + thrombocytopenia common in severe AN; rule out occult illness (APA 2023; AED 2016 Garber)

Hypothyroidism + hyperthyroidism mimics; sick-euthyroid in severe AN; baseline before SSRI (APA 2023)

Refeeding-syndrome flag if Phos < 2.5; daily monitoring during refeeding (AED 2016 Garber)

Refeeding-syndrome flag if Mg < 1.5; daily monitoring during refeeding (AED 2016 Garber)

QTc > 470 = AED 2016 Garber admission criterion; correct K / Mg / Phos before declaring electrocardiographic abnormality; cardiac monitoring during refeeding

Bradycardia HR < 40 = telemetry-indicated; AED 2016 Garber inpatient admission criterion

Hypothermia < 36.0°C = AED 2016 Garber inpatient admission criterion

Orthostatic SBP drop > 20 mm Hg or pulse rise > 20 = AED 2016 Garber inpatient admission criterion

C-SSRS — AN has 4-5× completed-suicide rate per population; AN-BP + BN highest SI rates among EDs; mandatory at intake + first 4 wk of any new antidepressant (Posner 2011 PMID 22193671; APA 2023)

SCOFF stratifies pre-test probability for any ED in primary care (Morgan BMJ 1999 PMID 10688783; LR+ ~4-7 at ≥ 2; LR+ ~10 at ≥ 3)

DSM-5-TR severity bands for BN / BED (mild 1-3/wk, moderate 4-7, severe 8-13, extreme ≥ 14)

GAD-7 — comorbid anxiety ~50% in ED patients; OCD-spectrum ~35% in AN-R; social anxiety ~35% (Spitzer 2006 PMID 16717171; APA 2023)

Early < 3 yr high recovery rate; SE-AN ≥ 7 yr with ≥ 2 evidence-based treatments failed (Hay BMC Psychiatry 2012 NEEDS_SOURCE_REVIEW)

Hepatic dysfunction in severe AN (starvation hepatitis); hepatic-cleared agents (APA 2023; AED 2016 Garber)

Hypoglycemia in severe AN; A1c baseline for olanzapine / lisdexamfetamine + BED metabolic comorbidity (APA/ADA 2004; APA 2023)

Olanzapine / atypical antipsychotic metabolic baseline; BED metabolic comorbidity (APA/ADA 2004)

EDE-Q global score tracks ED severity + treatment response (Fairburn & Beglin 1994); ≥ 4 = clinical severity

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Severity triggers (10)

10 need judgement
  • informationallife_threateningsevere_an_with_medical_instability (AED 2016 Garber; APA 2023)
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefeeding_syndrome_risk_at_admit (AED 2016 Garber)
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningeating_disorder_with_acute_suicidality (Posner 2011 PMID 22193671; APA 2023)
    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%)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_bn_with_electrolyte_disturbance (APA 2023; AED 2016 Garber)
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_adolescent_an_with_weight_loss_velocity (AED 2016 Garber; APA 2023; Lock & Le Grange 2013)
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_eating_disorder_history (APA reproductive psychiatry; APA 2023; NICE NG69 2023)
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_resistant_an_chronic_severe (Hay BMC Psychiatry 2012 NEEDS_SOURCE_REVIEW; APA 2023)
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedental_erosion_and_parotid_in_bn (APA 2023)
    BN with dental enamel erosion + parotid hypertrophy + Russell's sign (knuckle calluses from self-induced vomiting) — chronic active purging with dental + ENT complications
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateosteoporosis_from_an_chronic (Misra Bone 2017 NEEDS_SOURCE_REVIEW; APA 2023)
    Chronic AN with osteoporosis — DEXA T-score < -2.5 (postmenopausal / men ≥ 50) OR Z-score < -2.0 (premenopausal / men < 50 / adolescents) + amenorrhea ≥ 6 mo OR significant low estradiol + low IGF-1 from energy deficiency
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebed_with_metabolic_comorbidity (McElroy JAMA Psychiatry 2015 PMID 25587642; APA 2023)
    BED with metabolic comorbidity — obesity (BMI ≥ 30) OR T2DM OR metabolic syndrome OR pre-diabetes + moderate-severe BED (≥ 4 binge episodes/wk × 3 mo)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: eating_disorders_pharmacotherapy_by_subtypestep 1 - Step 1 — BN: fluoxetine 60 mg/d first-line (Walsh JAMA 1997 PMID 9215413 FDA-approved)
Selected step "Step 1 — BN: fluoxetine 60 mg/d first-line (Walsh JAMA 1997 PMID 9215413 FDA-approved)" — BN moderate-severe (≥ 1 binge-purge episode/wk × 3 mo) + medically stable + no prior fluoxetine failure
  • fluoxetine
    first line
    SSRI
    20 mg PO daily × 1 wk → 40 mg × 1 wk → 60 mg • PO • once daily (mornings) (max: 60 mg/day for BN (per FDA label and Walsh JAMA 1997))
    triggers: BN_moderate_to_severe, BN_with_comorbid_MDD, adolescent_BN_off_label
    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)
    rxcui 4493

outpatient playbook — drug actions (5)

  1. 1. FBT (Maudsley) for adolescent AN OR CBT-E for adult AN/BN/BED — first-line psychotherapy
    Per Lock & Le Grange 2013 FBT manual (phase 1 refeeding + parental control × 10-15 sessions; phase 2 gradual return of adolescent autonomy × 5-10 sessions; phase 3 identity development × 5-10 sessions) OR Fairburn 2008 CBT-E manual (focused 20 sessions / broad 40 sessions) • psychotherapy • weekly
    trigger: DSM-5-TR ED diagnosis + medically stable for outpatient
    APA 2023 + NICE NG69 2023 first-line; psychotherapy + pharmacotherapy combination superior to either alone in moderate-severe disease (Walsh JAMA 1997 PMID 9215413 BN; McElroy JAMA Psychiatry 2015 PMID 25587642 BED)
  2. 2. BN: fluoxetine 60 mg/d (FDA-approved)
    Fluoxetine 20 mg × 1 wk → 40 mg × 1 wk → 60 mg • PO • daily mornings
    trigger: BN moderate-severe + medically stable (APA 2023)
    Walsh JAMA 1997 PMID 9215413 — FDA-approved for BN at 60 mg/d; higher than typical MDD dose; combination with CBT-E superior
  3. 3. BED: lisdexamfetamine 30-70 mg/d (FDA-approved Schedule II)
    Lisdexamfetamine 30 mg → 50 mg → 70 mg titrated weekly • PO • daily mornings
    trigger: BED moderate-severe + medically stable + no CV / hyperthyroidism / glaucoma / MAOI / pregnancy contraindication (APA 2023)
    McElroy JAMA Psychiatry 2015 PMID 25587642 — FDA-approved for moderate-severe BED; Schedule II — informed consent on abuse / dependence / cardiovascular risks; BP / HR monitoring
  4. 4. AN: olanzapine 2.5-10 mg QHS (off-label adjunct)
    Olanzapine 2.5 mg × 1-2 wk → 5 mg → 10 mg QHS • PO • QHS
    trigger: AN with stalled weight restoration despite adequate FBT or CBT-E × 8-12 wk + severe restrictive cognitions / pre-meal anxiety
    Attia Am J Psych 2019 PMID 30958539 — off-label for AN weight restoration; modest BMI gain (~0.3 units) over 16 wk; metabolic burden REAL — informed consent + A1c + lipids + weight baseline + Q3-6 mo (APA/ADA 2004)
  5. 5. SSRI for comorbid MDD/anxiety POST-weight-restoration
    Sertraline 25 → 200 OR escitalopram 5-10 → 20 • PO • daily
    trigger: PHQ-9 ≥ 10 or GAD-7 ≥ 10 + weight restoration to ~85% IBW (Walsh JAMA 2006 NEEDS_SOURCE_REVIEW — SSRI NOT effective in low-weight AN)
    APA 2023 — comorbid MDD ~50-70% in AN; SSRI initiation deferred until weight restoration in AN; can initiate anytime for BN/BED

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Restrictive eating pattern + significant weight loss OR failure to gain expected weight (DSM-5-TR 2022 AN criterion A; F50.0x); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**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)** (psych.eating-disorders.core.v1).
Phenotype framing: AN-R vs AN-BP vs BN vs BED vs ARFID vs OSFED vs atypical AN vs pica F50.83 vs rumination F50.84 vs MDD with weight loss vs hyperthyroidism vs malignancy vs malabsorption (celiac, IBD) vs T1DM with insulin omission (diabulimia — cross-routes to endo) vs OCD with food avoidance vs psychosis with food-refusal (DSM-5-TR 2022; APA 2023)
Scope: Confirm DSM-5-TR 2022 eating-disorder criteria — AN (energy restriction + low body weight + fear of weight gain + body-image disturbance); BN (recurrent binge + compensatory ≥ 1×/wk × 3 mo + body-image disturbance); BED (recurrent binge ≥ 1×/wk × 3 mo + distress + no compensation); ARFID (avoidant/restrictive without body-image disturbance); OSFED (atypical AN with normal weight; subthreshold BN/BED; purging disorder; night-eating); functional impairment; not better explained by medical or other psychiatric condition (DSM-5-TR 2022; APA 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — BN: fluoxetine 60 mg/d first-line (Walsh JAMA 1997 PMID 9215413 FDA-approved)".
1. fluoxetine 20 mg PO daily × 1 wk → 40 mg × 1 wk → 60 mg PO once daily (mornings) (SSRI, first line) — 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)

Setting playbook (outpatient) — ED-specific psychotherapy first-line (FBT for adolescents per Lock & Le Grange 2013; CBT-E for adults per Fairburn 2008) + pharmacotherapy adjunct (fluoxetine BN / lisdexamfetamine BED / olanzapine AN off-label) + weekly weight + serial PHQ-9 + GAD-7 + EDE-Q + C-SSRS surveillance to remission and ≥ 12-month maintenance (APA 2023; NICE NG69 2023; AED 2016 Garber)
2. FBT (Maudsley) for adolescent AN OR CBT-E for adult AN/BN/BED — first-line psychotherapy Per Lock & Le Grange 2013 FBT manual (phase 1 refeeding + parental control × 10-15 sessions; phase 2 gradual return of adolescent autonomy × 5-10 sessions; phase 3 identity development × 5-10 sessions) OR Fairburn 2008 CBT-E manual (focused 20 sessions / broad 40 sessions) psychotherapy weekly — DSM-5-TR ED diagnosis + medically stable for outpatient (APA 2023 + NICE NG69 2023 first-line; psychotherapy + pharmacotherapy combination superior to either alone in moderate-severe disease (Walsh JAMA 1997 PMID 9215413 BN; McElroy JAMA Psychiatry 2015 PMID 25587642 BED))
3. BN: fluoxetine 60 mg/d (FDA-approved) Fluoxetine 20 mg × 1 wk → 40 mg × 1 wk → 60 mg PO daily mornings — BN moderate-severe + medically stable (APA 2023) (Walsh JAMA 1997 PMID 9215413 — FDA-approved for BN at 60 mg/d; higher than typical MDD dose; combination with CBT-E superior)
4. BED: lisdexamfetamine 30-70 mg/d (FDA-approved Schedule II) Lisdexamfetamine 30 mg → 50 mg → 70 mg titrated weekly PO daily mornings — BED moderate-severe + medically stable + no CV / hyperthyroidism / glaucoma / MAOI / pregnancy contraindication (APA 2023) (McElroy JAMA Psychiatry 2015 PMID 25587642 — FDA-approved for moderate-severe BED; Schedule II — informed consent on abuse / dependence / cardiovascular risks; BP / HR monitoring)
5. AN: olanzapine 2.5-10 mg QHS (off-label adjunct) Olanzapine 2.5 mg × 1-2 wk → 5 mg → 10 mg QHS PO QHS — AN with stalled weight restoration despite adequate FBT or CBT-E × 8-12 wk + severe restrictive cognitions / pre-meal anxiety (Attia Am J Psych 2019 PMID 30958539 — off-label for AN weight restoration; modest BMI gain (~0.3 units) over 16 wk; metabolic burden REAL — informed consent + A1c + lipids + weight baseline + Q3-6 mo (APA/ADA 2004))
6. SSRI for comorbid MDD/anxiety POST-weight-restoration Sertraline 25 → 200 OR escitalopram 5-10 → 20 PO daily — PHQ-9 ≥ 10 or GAD-7 ≥ 10 + weight restoration to ~85% IBW (Walsh JAMA 2006 NEEDS_SOURCE_REVIEW — SSRI NOT effective in low-weight AN) (APA 2023 — comorbid MDD ~50-70% in AN; SSRI initiation deferred until weight restoration in AN; can initiate anytime for BN/BED)

Non-pharmacologic actions:
- FBT (Maudsley) first-line for adolescent AN — phase 1 refeeding + parental control; phase 2 gradual return of adolescent autonomy; phase 3 identity development (Lock & Le Grange 2013 manual; Lock Arch Gen Psych 2010 RCT NEEDS_SOURCE_REVIEW superiority over AFT)
- CBT-E (Fairburn 2008 manual) first-line for adult AN/BN/BED — focused (20 sessions) or broad (40 sessions); trans-diagnostic
- MANTRA (Maudsley Anorexia Nervosa Treatment for Adults) OR SSCM (Specialist Supportive Clinical Management) — alternatives for adult AN per APA 2023
- IPT-ED (Interpersonal Psychotherapy for ED) — alternative for BN/BED per APA 2023
- DBT-ED — for ED with personality / emotion-dysregulation features (off-label adaptation)
- Registered dietitian / nutrition counseling MANDATORY — meal-plan structuring; energy needs estimation; tracking; psychoeducation on macros + micronutrients (APA 2023; AED 2016 Garber)
- Family / caregiver involvement with consent — MANDATORY for adolescent FBT; recommended for adults (APA 2023; Lock & Le Grange 2013)
- Psychoeducation on medical risks — refeeding-syndrome; bradycardia; QTc; osteoporosis; dental erosion (APA 2023)
- Horowitz hyperbolic taper plan documented at the moment any SSRI / SNRI discontinuation is considered — receptor-occupancy-anchored 50% step-downs to minimise discontinuation syndrome (Horowitz Lancet Psych 2019 NEEDS_SOURCE_REVIEW)
- Lethal-means counseling for any patient with current or historical SI — firearm + large-quantity-medication restriction (Mann JAMA 2005 NEEDS_SOURCE_REVIEW; Stanley-Brown 2012; APA 2023)
- MDQ administered before every SSRI initiation in patient with no prior antidepressant trial history (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2023) — avoids antidepressant-induced manic switch
- Stanley-Brown 2012 safety-plan documented for any patient with current or historical SI — 6 steps
- Social-determinants-of-health screen + referral (housing, food security, transportation, employment, social isolation, IPV / abuse, financial stress) — all are ED prognostic factors and modifiable via care-navigator / social-work referral
- BN-specific oral-health counseling — DO NOT brush teeth immediately after purging (worsens enamel erosion); rinse with water or fluoride first; brush > 30 min later; dental Q6 mo (APA 2023)
- AN-specific bone-health counseling — weight restoration is PRIMARY treatment for AN osteoporosis (Misra Bone 2017 NEEDS_SOURCE_REVIEW); estrogen does NOT prevent bone loss in AN; calcium 1200 mg + vitamin D 1000-2000 IU daily; DEXA Q1-2 yr if amenorrhea ≥ 6 mo
- Exercise prescription / restriction — restrict if medically unstable (HR < 50, K < 3.5, weight < 80% IBW); gradual return when stable + cleared by team; not always recommended in AN early treatment due to weight-loss risk
- Relapse-prevention plan documented at remission — continuation phase ≥ 12 mo after remission for first episode, ≥ 2-3 yr or indefinite for recurrent; CBT-E or FBT relapse-prevention reduces relapse (APA 2023; NICE NG69 2023)

AVOID / contraindication checks:
- Fluoxetine_NOT_effective_low_weight_AN_reserve_for_post_weight_restoration (Walsh JAMA 2006 NEEDS_SOURCE_REVIEW; APA 2023)
- Bupropion_avoid_seizure_disorder_eating_disorder_active_purging (FDA; APA 2023)
- Lisdexamfetamine_NEVER_in_AN_only_BED (FDA label; APA 2023)
- Lisdexamfetamine_Schedule_II_pre_screen_CV_history_BP_HR_baseline (FDA label; McElroy JAMA Psychiatry 2015 PMID 25587642)
- Lisdexamfetamine_NEVER_with_current_or_recent_MAOI_within_14d (FDA)
- Olanzapine_metabolic_baseline_A1c_lipids_weight_BMI_Q3_6mo (APA/ADA 2004; APA 2023)
- Olanzapine_off_label_for_AN_informed_consent (Attia 2019 PMID 30958539)
- Topiramate_FDA_Cat_D_pregnancy_test_first (FDA)
- Topiramate_metabolic_acidosis_monitor_bicarb (FDA)
- Paroxetine_avoid_pregnancy_first_trimester (FDA Category D; APA reproductive psychiatry)
- Citalopram_QTc_dose_cap_20mg_elderly_correct_K_Mg_first_in_ED_patient (FDA 2012; AED 2016 Garber)
- Horowitz_hyperbolic_taper_mandatory_for_any_SSRI_SNRI_discontinuation (Horowitz Lancet Psych 2019 NEEDS_SOURCE_REVIEW)
- Serotonin_syndrome_avoid_combo_serotonergic_SSRI_stimulant_MAOI_tramadol (Boyer NEJM 2005 NEEDS_SOURCE_REVIEW; APA 2023)
- MDQ_screen_before_initiating_SSRI_in_suspected_bipolar (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2023)
- C_SSRS_at_intake_and_first_4_weeks_of_any_new_antidepressant (FDA 2004 black box adolescent reassessment)
- Estrogen_DOES_NOT_prevent_bone_loss_AN_weight_restoration_primary (Misra Bone 2017 NEEDS_SOURCE_REVIEW; APA 2023)

Monitoring

Regimen monitoring:
- Weekly weight and vitals outpatient (APA 2023; AED 2016 Garber)
- BMP Phos Mg K Q1 2 weeks outpatient until stable (AED 2016 Garber)
- ECG QTc at baseline and with QTc prolonging drugs or K lt 3 (AED 2016 Garber; APA 2023)
- PHQ 9 GAD 7 EDE Q Q2 4 weeks during treatment (APA 2023)
- C SSRS at intake and first 4 weeks of new antidepressant (FDA 2004 black-box; APA 2023)
- Olanzapine A1c lipids weight BMI baseline 3mo 6mo annual (APA/ADA 2004)
- Lisdexamfetamine BP HR Q1 3 months and growth velocity pediatric (FDA label)
- Fluoxetine BN response assessment at 4 8 wk (Walsh JAMA 1997 PMID 9215413)
- DEXA Q1 2yr in chronic AN with amenorrhea geq 6mo (Misra 2017 NEEDS SOURCE REVIEW; APA 2023)
- Dental Q6mo in BN (APA 2023)
- Continue treatment geq 12mo after remission first episode (APA 2023; NICE NG69 2023)
- Continue geq 2 3yr or indefinite if recurrent (APA 2023; NICE NG69 2023)

Setting (outpatient) monitoring:
- Weekly weight + vitals + orthostatics × 4 wk then Q1-2 wk (APA 2023; AED 2016 Garber)
- BMP + Phos + Mg + K Q1-2 wk outpatient until stable (AED 2016 Garber)
- ECG (QTc) at baseline + Q3-6 mo or with QTc-prolonging Rx (AED 2016 Garber; FDA 2012)
- PHQ-9 + GAD-7 + EDE-Q Q 2-4 weeks (APA 2023)
- C-SSRS at every visit for first 4 weeks of any new antidepressant (FDA 2004 black-box; APA 2023)
- Olanzapine A1c + lipids + weight + BMI baseline / 3 mo / 6 mo / annual (APA/ADA 2004)
- Lisdexamfetamine BP + HR Q1-3 mo + growth velocity in pediatric (FDA label)
- DEXA Q1-2 yr in chronic AN with amenorrhea ≥ 6 mo (Misra 2017 NEEDS_SOURCE_REVIEW)
- Dental + ENT Q6 mo in BN with active purging (APA 2023)

Follow-up plan: 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)
- Close-out criterion: Maintenance plan in place

Monitoring phase: Outpatient: weekly weight + vitals + BMP × 4 wk then Q1-2 wk; PHQ-9 + GAD-7 + EDE-Q q 2-4 wk; C-SSRS at every visit during induction (FDA 2004 black-box); inpatient refeeding: daily Phos + Mg + K + ECG + weight × 5-7 d then Q1-2 d as stable; DEXA Q1-2 yr in chronic AN; dental Q6 mo in BN; response = sustained weight gain on schedule + EDE-Q reduction ≥ 50% + binge-purge cessation; remission = weight restoration ~85-90% IBW + EDE-Q < 1.5 + cessation of binge-purge (APA 2023; AED 2016 Garber)

Disposition

Current setting: outpatient — ED-specific psychotherapy first-line (FBT for adolescents per Lock & Le Grange 2013; CBT-E for adults per Fairburn 2008) + pharmacotherapy adjunct (fluoxetine BN / lisdexamfetamine BED / olanzapine AN off-label) + weekly weight + serial PHQ-9 + GAD-7 + EDE-Q + C-SSRS surveillance to remission and ≥ 12-month maintenance (APA 2023; NICE NG69 2023; AED 2016 Garber)

Disposition criteria:
- Continue current step if responding — sustained weight gain on schedule + EDE-Q reduction ≥ 50% + binge-purge cessation (APA 2023)
- Step up if inadequate response at adequate dose / duration (APA 2023; NICE NG69 2023)
- Refer to specialty ED program if at Step 3 augmentation or beyond, complex comorbidity, pregnancy, or treatment-resistance (APA 2023)
- IOP / PHP / residential if outpatient stalled + medically stable (APA 2023)
- Inpatient medical if instability per AED 2016 Garber criteria

Escalation triggers (move to higher acuity):
- Medical instability (HR < 40, QTc > 470, K < 3.0, Phos < 2.5, Mg < 1.5, weight < 75% IBW or BMI < 14, hypothermia < 36.0°C, severe orthostatic) → inpatient medical / ED-medical-stabilization unit (AED 2016 Garber)
- Refeeding-syndrome risk at admission → severity_trigger refeeding_syndrome_risk_at_admit (AED 2016 Garber)
- Active SI with intent / plan / means → ED + cross-route to psych.suicidality.ed.core.v1 (Posner 2011; APA 2023)
- Outpatient stalled + not responding to ≥ 8-12 wk → IOP / PHP / residential ED program (APA 2023)
- Severe SE-AN with multiple prior treatments failed → SE-AN framework + specialty psychiatry referral (Hay 2012 NEEDS_SOURCE_REVIEW)
- Pregnancy with active ED → MFM + reproductive psychiatry (APA 2023)
- Antidepressant-induced manic switch → cross-route to psych.bipolar-disorder.core.v1 (APA 2023; CANMAT 2016)
- Serotonin syndrome features → ED + workup.hyperthermic_toxidromes (Boyer NEJM 2005 NEEDS_SOURCE_REVIEW)
- Comorbid SUD with active substance use → cross-route to psych.alcohol_withdrawal.core.v1 OR psych.opioid_use_disorder.core.v1 (APA 2023)

Patient Action Plan

**Eating disorder action plan + Stanley-Brown 2012 safety plan + medical-instability red-flags (APA 2023; AED 2016 Garber; NICE NG69 2023)**
Personalised values: baseline_weight, baseline_PHQ9, baseline_EDE_Q, current_medication_list, identified_supports, crisis_line_numbers, reasons_for_living, means_restriction_steps, meal_plan, identified_triggers.

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

**Caution — weight declining or stalled, increased binge/purge frequency, EDE-Q rising, passive SI without plan (APA 2023; NICE NG69 2023)** (yellow):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- 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)

**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)** (red):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- Any red zone trigger — emergency department immediately, do not wait (APA 2023; AED 2016 Garber)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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%)

Citations

- 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) [PMID:9215413](https://pubmed.ncbi.nlm.nih.gov/9215413/)
- Cited evidence (PMID 25587642) [PMID:25587642](https://pubmed.ncbi.nlm.nih.gov/25587642/)
- Cited evidence (PMID 30958539) [PMID:30958539](https://pubmed.ncbi.nlm.nih.gov/30958539/)
- Cited evidence (PMID 10688783) [PMID:10688783](https://pubmed.ncbi.nlm.nih.gov/10688783/)
- Cited evidence (PMID 11556941) [PMID:11556941](https://pubmed.ncbi.nlm.nih.gov/11556941/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:9215413
  • Cited evidence (PMID 25587642) — PMID:25587642
  • Cited evidence (PMID 30958539) — PMID:30958539
  • Cited evidence (PMID 10688783) — PMID:10688783
  • Cited evidence (PMID 11556941) — PMID:11556941