AF.E.A.S.T.FAMILYGUIDEFORCOMINGTOTERMSWITHALOVEDONE’SEATINGDISORDERDIAGNOSISF.E.A.S.T.FAMILYGUIDESERIESMARCH2014�

Althoughaneatingdisorderdiagnosismayfeellikeadevastatingblowtoapatientandtheirfamily,itisanopportunitytobeginatreatmentprocessthatcanallowyourlovedonetorestoretheirmentalandphysicalhealthandliveafull,successfullife.©CopyrightbyF.E.A.S.T..2014Thisbookletmaybereprintedanddistributedbyothers.Formoreinformation,pleasecontactF.E.A.S.T.atinfo@feast-ed.org�

EDITORINCHIEFWalterKaye,MDProfessorofPsychiatry,UniversityofCalifornia,SanDiegoDirector,EatingDisorderResearchandTreatmentProgram,UCSDFAMILYGUIDETASKFORCECHAIRMaryBethKrohelMember,F.E.A.S.T.AdvisoryPanel,MemberAEDAdvisoryBoardMember,LiasontoAEDMedicalCareStandardsCommitteeSENIOREDITOR&DESIGNERLeahDean,M.ArchExecutiveDirector,F.E.A.S.T.EDITORSCraigJohnson,PhD,FAED,CEDSClinicalProfessorofPsychiatryattheUniversityofOklahomaMedicalSchoolChiefClinicalOfficerofEatingRecoveryCenterinDenver,ColoradoDanielLeGrange,PhD,FAEDProfessorofPsychiatryandBehavioralNeuroscience,andDirector,EatingDisordersProgram,TheUniversityofChicagoKimMcCallum,MD,FAPA,CEDSClinicalFacultyPsychiatry,WashingtonUniversitySchoolofMedicineFounderMcCallumPlaceEatingDisordersTreatmentCenterMaryTantillo,PhDPMHCNS-BCFAEDProfessorofClinicalNursing,UniversityofRochesterSchoolofNursing,Director,WesternNYComprehensiveCareCenterforEatingDisorders,President/CEOandClinicalDirector,TheHealingConnection,Inc.EllenRome,MD,MPH,Head,CenterforAdolescentMedicine,ClevelandClinicChildren’sHospital,ProfessorofPediatrics,ClevelandClinicLernerCollegeofMedicineatCase;Chair,SubcommitteeforEatingDisordersfortheSocietyforAdolescentHealthandMedicine;Member,TaskForceonMedicalGuidelinesfortheAcademyforEatingDisordersJoelYager,MD,FAED,Chair,AmericanPsychiatricAssociationWorkgrouponPracticeGuidelinesforEatingDisorders,Chair,AmericanPsychiatricAssociationCouncilonQualityCare,PastPresident,AcademyofEatingDisorders(AED),ProfessorofPsychiatry,UniversityofColoradoSchoolofMedicineLauraCollinsLyster-Mensh,MSFounder&PolicyDirector,F.E.A.S.T.,AEDAwardJenniferMcFarlandWhismanF.E.A.S.T.BoardofDirectors,FamilyGuideTaskForce�

DOWNTHERABBITHOLE:COMINGTOTERMSWITHALOVEDONE’SEATINGDISORDERDIAGNOSISWESUSPECTTHATOURLOVEDONEHASANEATINGDISORDERANDNEEDSTREATMENT.WHATDOWEDONOW?Eatingdisordersareserious,life-threatening,braindisordersthatoftencreateturmoilwithinafamilyevenbeforeadiagnosisismade.Whilereceivinganeatingdisorderdiagnosismayofferamomentofreliefforfamilieswhofeelthattreatmentcanfinallybegin,itcanalsocompoundfeelingsofguiltfornothavingactedsooner,fearfortheirlovedone’sfuture,andanxietyaboutfacinglongtermcaregiverresponsibilitiesandexpensivemedicalbills.Theexperienceisusuallymadeworseasfamiliesaregivenconflictingoroutdatedinformation,findthereisnocleartreatmentpathtotake,andreceiveverylittlesupportorguidancetohelpthemmakegoodcaredecisions.Thisguideisintendedtohelpyoucometotermswiththediagnosisandwadethroughsomeofthemythsandfactsthatyouwillencounterwhengettingstartedontheroadtorecovery.OURFAMILYSITUATIONHASALWAYSBEENLOVINGANDSTABLE-HOWCANTHISHAVEHAPPENED?Familiesdonotcauseeatingdisorders,andpatientsdonotchoosetohavethem.Onthecontrary,parentsandcaregiverscanbeapowerfulsupportforalovedone’srecoveryfromaneatingdisorder.Whileyoumaynotbeanexpertineatingdisorders,youareanexpertwhenitcomestoyourlovedoneandyouhavevaluableinsights,intuitionsandparentingskillsthatarecriticaltotherecoveryprocess.�

CANEATINGDISORDERSBESUCCESSFULLYTREATED?Yes.Withappropriateexpertandfamilyassistance,thereisalwayshopeforsuccessfulrecovery.Treatingeatingdisordersisnoteasy,andtheearliertheintervention,thehigherthechanceofsuccess.Effectivecareusuallyrequiresamultidisciplinaryapproach,specializedcaregivingskills,andlong-termvigilance.Althoughaneatingdisorderdiagnosismayfeellikeadevastatingblowtoapatientandtheirfamily,itisanopportunitytobeginatreatmentprocessthatcanallowyourlovedonetorestoretheirmentalandphysicalhealthandliveafull,successfullife.1HOWDOWEKNOWWHATKINDOFTREATMENTWENEED?Ifyoususpectthatyourlovedonehasaneatingdisorder,itisimportanttoseekdiagnosisandtreatmentrightaway.Evidenceshowsthatearlyrecognitionofsymptomsandearlyinterventionarecorrelatedwithimprovedtreatmentoutcomes.Thetypeandlevelofcarethatyourlovedoneneedswilldependonmanyfactorsincluding:age,physicalandbehavioralsymptoms,medicalstability,psychiatricstate,andlengthofillness.Itisimportantforthepatienttoreceivecompletemedicalandpsychologicalevaluationsbyprovidersfamiliarwitheatingdisordersbeforeatreatmentplancanbeputinplace.Asdifferentprovidersmayrecommenddifferenttreatmentplans,itisessentialthatcaregiversbecomefamiliarwiththevarioustreatmentoptions,diagnosticcriteria,andcurrentclinicalguidelinessothattheycanmakeinformeddecisionsaboutthecarebeingoffered.Everypatienthasuniqueneedsandmultipletreatmentoptionsshouldbeconsidered.1SeeAPPENDIXAforDSV-5DiagnosticCategoriesofEatingDisordersPage|4www.feast-ed.org�

RELIABLERESOURCESTOSTARTWITH:???APAPracticeGuidelines:TreatmentofPatientswithEatingDisorders,ThirdEdition,2006,AmericanPsychiatricAssociation,www.psych.orgAAPClinicalReport:IdentificationandManagementofEatingDisordersinChildrenandAdolescents,2010,AcademyofPediatrics,www.aap.orgAEDCriticalPointsforEarlyRecognitionandMedicalRiskManagementintheCareofIndividualswithEatingDisorders,2ndEdition,AcademyforEatingDisorders,www.aedweb.orgDOESOURLOVEDONENEEDFULL-TIMECAREAWAYFROMHOME?Manypatientsdonotneedtobehospitalized;however,inthefaceofmedicalinstability,lackofprogressinoutpatienttreatment,oranacutepsychiatriccrisis,ahigherlevelofcaremayberequired.Needinghospitalizationorresidentialcareisnotafailureofoutpatientcareorofacaregiver’seffectiveness.Theseoptionssimplyrepresentdifferentlevelsofcarethatprovideahigherdegreeofsafetyandsupportforthepatient.Whilehospitalizationisdesignedtoensuremedicalstability,stopdestructivebehavior,andbeginnutritionalrehabilitation,residentialtreatmentprovideslong-termnutritionalandtherapeuticcareinanenvironmentwheremedicalstatecanbemonitored.Treatingeatingdisordersrequiresfulltimevigilancenomatterthecaresetting.2Althoughhigherlevelsofcareareoftennecessaryandhelpfulforpatientswhosemedicaland/orpsychiatrichealthisdeclining,DayTreatmentandIntensiveOutpatientProgram(IOP)settingscanbeeffectivealternativestoInpatient(IP)orResidentialtreatmentifavailableinyourcommunity.Anytypeoftreatmentshouldbeacollaborativeeffortinvolvingthepatient,familyandtheproviders,withplansandproceduresinplaceformakingchangesinthelevelandsettingofcareasneeded.Planningforyourchildtocomehomeshouldbeginsoonafteryourchildisadmittedtoahigherlevelofcare.Thetreatmentteamshouldbe2SeeAPPENDIXBfordescriptionsofcommoncaresettings.�

workingwithyou(andideallyyouroutpatientproviders)earlyontodeveloparealisticdischargeplanforcontinuityofcareathome.Patientswitheatingdisordersbecomeveryanxiousduringtransitionsbetweenlevelsofcare,andanill-plannedtransitioncancontributetorelapse.Yourchildwillneedcontinuedsupportathomeforanextendedperiodoftimeevenafterhospitalizationand/orresidentialcare.Ifchangesareneededathometosupportyourchild,suchasspecialarrangementswithschool,aleaveofabsencefromwork,orarrangingforextendedfamilytohelpcareforsiblings,thisworkshouldnotbedelayed.Higherlevelsofcarearenotareplacementforeventualoutpatientwork.Infact,muchoftheeffectivenessoftreatmenthastodowithworkthatisdonelateronanoutpatientbasis.WHYISSOMUCHOFTHEADVICEWE’REGETTINGCONTRADICTORY?Onereasonwhyparentshearsomuchconflictinginformationisbecauseeatingdisorder‘experts’comefrommanydifferentprofessions,includingpsychology,psychiatry,nursing,nutrition,medicine,andsocialwork.Evenwithintheseprofessions,notwoprovidersarelikelytohavethesamebackground,training,experience,andprofessionalaffiliations.Inaddition,theknowledgebaseandtreatmentmethodsforeatingdisordershavechangeddramaticallyovertime.First,clinicalpracticeismovingtowardtreatmentapproachesbasedondatashowingthataspecifictreatmentresultsinmeasurableandsignificantimprovementsinoutcome(evidence-basedtreatment).Second,recentadvancesinneuroscienceareleadingtoabetterbiologicalunderstandingofeatingdisorders,whichinturnareleadingtonewtherapies–medicalandpsychological-thattargetthespecificbrainpathwaysthathavegoneawryforthepatient.Unfortunately,somepractitionersdonotfolloworkeepupwiththiskindofresearchandsomechoosenottoprovideevidence-basedtreatments.Additionally,thereareveryfewcontinuingeducationopportunitiesthatteachaboutthesenewfindingsandideas.WECAN’TAFFORDTOPAYFORTREATMENT,TRAVEL,ORTOMISSWORK.CAN’TWEJUSTDOITOURSELVESATHOME?Veryfewfamiliesexpecttofacealife-threateninghealthcareemergencyandmostfindtheresultingfinancialburdenanadditionalcrisistocopewith.ThebesttreatmentforyourchildisnotnecessarilythemostPage|6www.feast-ed.org�

expensivetreatment;but,delayingeffectivetreatment,duetocost,lostincome,orproximity,mayturnouttobethemostexpensiveoptionovertime.Evidenceshowsthatearlyinterventioniscriticaltoeffectivetreatment.Aswithdrugandalcoholabuse,itisdifficulttostopdestructivebehaviorsandtemptingtodiscontinuetreatmentoncethecrisisispast.Inaddition,itbecomesmoreandmoredifficulttosuccessfullyachieverecoverythelongerthepatientremainsillandthemoretimestheyrelapse.Eatingdisordersareverydangerousandtryingmentalillnessesthatchallengeevenseasonedprofessionals.Mortalityratesforeatingdisordersareashighas10%andmanymorepatientsareultimatelydisabledbychronicillness.Justaswithacancerdiagnosis,eatingdisordersneedtobeaddressedquicklyandintenselywithevidencebased,specializedtreatment.OURRELIGIOUSCOUNSELORFEELSWECANDOTHISWITHOUTPROFESSIONALHELPManypeopleareskepticalaboutpsychiatryandpsychology,sometimesduetovalidpersonalexperiencesandconcerns.Certainly,recoveringfromaneatingdisorderinvolvespersonaltoolsandresourcesinadditiontoprofessionalcare.Justascancerpatientscanbenefitfromspiritualcounselingwhilereceivinglife-savingmedicalcare,patientswitheatingdisordersmaybenefitfromspiritualcounselingwhilealsoreceivingneededevidence-based,scientificallygroundedtreatments.Eatingdisordersymptomsareunlikelytorespondtoreligiousorspiritualcounselingalone.Professionalhelpshouldbeabletoworktogetherwithspiritualguidance,notagainstitOURDAUGHTERISAREADYINTREATMENTANDLIKESHERTHERAPISTHEREINTOWN.Ingeneral,likingone’streatmentproviderisabonus,butisnotnecessaryanddoesnotassureeffectivetreatmentorsuccessfuloutcomes.Infact,witheatingdisordersitisnotuncommonforapatienttofeelthemostcomfortablewithtreatmentthatisn’tworking!Successfultreatmentrequireschallengingbehaviorsthathavebecomerewardingtothepatientandthisisnotusuallycomfortableorsimple.Infact,confrontingtheillnessmayinitiallyworsenanxietyandincrease�

resistancetotreatment,andcanresultindislikingone’streatmentproviderOURSON’SINDIVIDUALTHERAPISTSAYSTHATHEISMAKINGPROGRESS,BUTNOTHINGSEEMSTOHAVECHANGEDATHOME,INFACT,HESEEMSTOBEGETTINGWORSE.Progressneedstobeevaluatedwithinweeksofbeginninganyeatingdisordertreatment.Ifnoimprovementisevident,thenthetreatmentplanshouldbere-evaluatedandsensiblechangesshouldbeimplemented.Sinceatherapistoftenhaslimitedcontactwithapatient,itisimportantthatfamiliesbeincludedinthesediscussions,evenforadultpatients,sothatbehaviorsoutsideofappointmentscanbereportedtothetherapist.Ifcaregiversareexcluded,therapistsmustrelyonpatientreportsoftheirprogress,andcaregiverscannotassessiftheproviderisdeliveringeffectivecare.Unfortunately,patientstoooftenminimizethedifficultiesthey’reexperiencinginordertoavoidthedistressoftrulyconfrontingtheillnessorupsettingtheirfamilies.Recoveryischallengingandanxietyprovokingbecauseitrequiresbehavioral,physicalandemotionalchangesateverystepofthewayinordertocreatealifewithoutillness.WHYDOESN’TMYLOVEDONEUNDERSTANDTHATWEARETRYINGTOHELP?Itissoimportantforfamiliestoknowthattheirlovedoneisinanalteredstateevenwhentheyareotherwisequitebrightandrational.Evidenceshowsthatmalnutritionandunhealthyeatingpatternsaffectthebrain.Thebrainisacomplexnetworkofsystemsandonesystemcanbemalfunctioningwithoutaffectingtheothers.Peoplewitheatingdisordersoftenachieveexcellentgradesandperformwellinjobsevenwhilegravelyill.Itisnotuncommonforpatientstoargueforcefullyabouttheirreasonsfortheirbehaviors,evenbelievingtheydonotneedtoeat.Theymaynotbeconcernedbytheirphysicaldecline,andmaynotfeeltheyneedtoengageintreatment.Inthisstate,theyoftenfailtoseethegoodintentionsbehindtheirparents’andproviders’effortstochangetheirbehaviors.Page|8www.feast-ed.org�

Recentresearchishelpingustounderstandwhatbrainregionsmayberesponsiblefordenialandresistancetotreatment.Thislackofinsightisasymptomoftheillnesscalled“anosognosia”,andoftenimproveswithrestorednutrition.Thisiswhyitisessentialthatparentsdotheirownresearchandmakedecisionsabouttreatmentonthepatient’sbehalf,asthepatientmaybeunwillingorunabletoparticipatefullyinthesedecisionsuntilalaterstageofrecovery.THETHERAPISTSAYSOURDAUGHTERWILLEATNORMALLYAGAINONCESHE‘GAINSINSIGHT’AND‘WANTSTOGETBETTER.’I’MTERRIFIEDTHATSHEWILLDIEBEFORETHATHAPPENS.Eatingdisordersareseriousmentalillnessesthatprofoundlyaffectthebrain.Whileweknowthatfullrecoveryismorethan“just”normaleating,fooditselfisthemostimportantmedicineneededtorestoreamalnourishedbodyandbraintogoodhealth.Unfortunately,takingthismedicineisharderthanmostpeoplecanimagine.Justaswithchemotherapyforcancer,thetreatmentforaneatingdisordercansometimesfeelworsethantheactualdisease.Thisiswhyinsightandimprovedemotionalstatearenotsufficientorreliablemotivatorsforthepatientto‘comeonboard’withtreatment.Trueinsightandimprovedemotionalstatecanonlyoccurasthebrainreceivesthefooditneeds.Donotexpect,orwait,foryourlovedoneto‘wanttogetbetter’beforebeginningnutritionalrestoration.HOWDOWEKNOWIFTHETREATMENTWEAREGETTINGWILLBEEFFECTIVE?Inthepastfivetotenyearsarapidincreaseinresearchoneatingdisordershaschangedthefield.Thisresearchhasinvolvedknowledgeaboutgeneticvulnerability,howthebrainworks,personalitytraitsandtemperamentalreadypresentveryearlyinlife,andclinicaltrialsthatcomparehowwelldifferenttreatmentswork.Muchofthisresearchcallsintoquestionpastassumptionsabouteatingdisordersaslifestylechoices,astheresultofdysfunctionalfamilies,andaschronicconditionsthatcanonlybemanagedbutnotcured.Newevidenceshowsthateffectivetreatmentforeatingdisordersisavailablethatcanresultinimprovementofsymptomsfairlyquickly.Infact,today’sprovidersshouldbeabletogiverealisticestimatesandtimeframesforstagesofrecovery,andrecognizefamilymembersas�

importantcollaboratorsincaringforeatingdisorderedpatientsandeffectinggoodoutcomes.WEKEEPHEARINGTHETERM‘EVIDENCE-BASED.’WHATDOESITMEAN?Evidence-basedmeansthereisvalidresearchtobackuptheuseofaspecifictreatment.Forexample,weknowfromresearchthatantibioticsareaneffectivetreatmentformostulcers,despitestrongresistancetothatideabeforethedatawascollected.Whenamedicalprofessionalprescribesacertaindoseofamedicinetoapatient,thisdecisionisgenerallybasedonsolidresearchalongwithclinicaljudgment.Inthepast,witheatingdisorders,littleresearchexistedtoestablishwhycertainapproacheswereused.Mosttreatmentwasbasedonideas,alwayschanging,aboutwhatcausedthethoughtsandbehaviors.Althoughthecurrentevidence-basecannotexplainwhat“causes”eatingdisorders,itdoesshowusthatcertaintreatmentsaremoreeffectivethanothers.Justasadoctorwillbeginwiththemosteffectivemedicineknowntotreataninfection,eatingdisordercliniciansshouldbeabletorecommendandprovide“evidence-based”careasastartingpointfortreatment.IDON’TWANTTOTELLANYONETHATMYCHILDHASTOGETTREATMENTFORAMENTALILLNESS.I’MAFRAIDSHE’LLBESTIGMATIZEDANDFEELBADABOUTHERSELF.Psychiatricillnesses,includingeatingdisorders,stillcarrystigma.Thestigmaisbasedonideasthataremostlyunfounded;forexample,thatbrainproblemscan’tbefixed,thatpatientsdon’trecover,thattheyarepermanently“broken”orstrange,orthattheysomehowcausedtheirownmentalillness.Itisimportantforparents,childrenandthegeneralpopulationtoknowthatmentalillnessisquitecommon.Aneweraofthinkingaboutthebrainandpsychiatricdisordersisunderway.Justaswecannowtalkaboutdiseaseslikebreastcancerinpublicandincommonconversation,weshouldbeabletotalkabouteatingdisordersveryopenly.Likebreastcancer,eatingdisordersneednotbeproblemsthatareonlywhisperedabout.HidinganeatingdisorderdiagnosisreinforcesstigmaandPage|10www.feast-ed.org�

outdatedideasandmayleadtopoorcaredecisionsthatcanlowerthechanceoffullrecovery.Theendofstigmabeginswithhoweachofusaddressesit.Asparentsbecomemoreopenaboutadmittingtheproblem,andmoreproactiveaboutfindingcarefortheirlovedonesandeducatingothersaboutthedisease,thedemandforeffective,evidence-basedcarewillincrease.Thiskindofadvocacyhasalreadyhelpedtode-stigmatizeandimprovecareforpatientswithautism,AttentionDeficitDisorder(ADD),depression,ObsessiveCompulsiveDisorder(OCD),alcoholismandmanyotherpsychiatricdisorders.IBLAMEMYEX-WIFEFOROURSON’SEATINGDISORDER.SHEBLAMESABULLYATSCHOOL.THELOCALTHERAPISTSAYSITISABOUT‘CONTROL.’Thetemptationtofocuson‘blame’and‘cause’iscounterproductiveineatingdisordertreatment.Researchersandprovidersdonotknowenoughaboutthesecomplexdiseasestodefinitivelystatewhatcausedanygivenpatienttobecomeill.Whilefamilymembersmayhavedifferentopinionsaboutwhatmayhavecontributedtothe‘perfectstorm’ofconditionswithinwhichtheeatingdisorderdeveloped,itisimportanttoputtheseissuesasideandinstead,tofocusonprovidingquality,effectivecareasaunifiedteam.Beingillisterriblydifficult,frightening,anddisorienting,andpatientsdeservetohaveacalm,confidentandunifiedstancefamilyandprofessionals.Patientsarebestservediftheyreceiveconsistent,factualinformationabouttheillnessandcoordinatedmessagesabouttreatment,andprognosis.Whenthereisadifferenceofopinion,itshouldbeaprioritytosortoutanydisagreementswithoutthepatientpresent.Thevalueofbeingonthesamepage,sameline,andthesameletter,sotospeak,cannotbeoverstated.WHATCANWEDOASAFAMILYTOSUPPORTTREATMENT?Takingcareofanillchildisnot“normal”parenting,andfamiliesoftenneedtolearnnewskillsandtechniquestosupportalovedonewithaneatingdisorder.Belowaresomeofthethingsthatfamiliescando:???Letyourchildknowthatyouunderstandtheseverityofthesituation.Validateyourchild’sfeelings,butdon’tpretendtounderstandthem.Acknowledge,butdonotaccommodateyourchild’sfears.�

???????????????Setasideallfeelingsofblame.Learncaregivingskillssuchasmotivationalinterviewing.Separatethechildfromtheillnessinyourmind.Makesureallcaregiversare“onthesamepage.”Requireandsupportappropriatenutritionateverymeal.Provideawarmandsupportivefamilyenvironment.WorkwithaclinicalteamwiththemostrecenttrainingandexpertiseTrustyourbravestparentalinstinctsandsharethesewithproviders.Becalm,confidentandassertiveasyouadvocateforyourlovedone.Trustthatthesymptomsyouseearenotintendedtobeamanipulation,buttendtobedrivenbypowerfulbiologicalforces.Acknowledgethepatient’sfearsoflettinggooftheillness.Seeksupportforyourselfasacaregivertopreventburnoutandtohelpyoudealwiththehighstresslevelsthatcomewithdevotedandconstant24/7caregiving.Rememberthatotherchildreninthehomemayneedsupportandreassurancethattheirsiblingisgettingappropriatetreatment.Bepatientandknowthatrecoveryisalong-termprocessShowconfidenceinyourparentingandcaregivingroles.WHERECANIGETMOREINFORMATIONABOUTEATINGDISORDERSANDHOWTOFINDEFFECTIVETREATMENTFORMYLOVED-ONE?ThisFamilyGuideisoneofaseriesofbookletspublishedbyF.E.A.S.T.Othertitlesintheseriesinclude:PUZZLINGSYMPTOMS:EatingDisordersandtheBrain,Fall2012PORTINASTORM:HowtoChooseaTreatmentTeamforaLovedOnewithanEatingDisorderintheU.S.,January2014DigitalcopiesofalloftheF.E.A.S.T.FamilyGuidescanbefoundat:www.feast-ed.orgPage|12www.feast-ed.org�

APPENDIXA:DSM-5DIAGNOSTICCATEGORIESEatingDisordersarediagnosedintheU.S.accordingtospecificcriteriaintheDiagnosticandStatisticalManualofMentalDisorders(DSM).Thelatestversionofthismanual,publishedbytheAmericanPsychiatricAssociation(APA),istheDSM-5,whichwasreleasedinMay2013.3TheDSV-5categorizesEatingandFeedingDisordersasfollows:4?AnorexiaNervosa(AN)?BulimiaNervosa(BN)?BingeEatingDisorder(BED)?Pica?RuminationDisorder?Avoidant/RestrictiveFoodIntakeDisorder(ARFID)?OtherSpecifiedFeedingorEatingDisorder(OSFED)?UnspecifiedFeedingorEatingDisorder(UFED).TheOSFEDandUFEDcategoriesapplytocaseswherebehaviorscauseclinicallysignificantdistressand/orimpairmentoffunctioning,butdonotmeetthefullcriteriaforanyoftheotherFeedingorEatingDisorders.Thesenewcategoriesarenotanindicationofalesssevereeatingdisorder,simplyadifferentconstellationofsymptoms.HealthcareprovidersintheU.S.usespecificdiagnosticcodesbasedontheDSM-5tobillprivatehealthinsurancecompaniesfortreatment.APPENDIXB:COMMONLEVELSOFCAREDEFINEDBelowaredescriptionsofthemostcommontypesoftreatmentenvironmentsintheU.S.Pleasenotethattheterminologyusedinthisguidemayhaveadifferentmeaninginothercountriesand/orhealthcaresystems.Outpatient(OP):Thepatientlivesathomeandattendsregularlyscheduled(usually45-50minute)sessionsatatherapist'soffice.Thistypicallyincludesoneormoresessionsperweek.Thepatientmaybeseenindividually,withthefamily,inagroupformatwithotherpatients,and/orsometimesinamulti-familygroupformat.Thetypeoftherapyprescribedwilldependontheageofthepatient,theprescribedtreatmentplan,andthephilosophyoftheprovider.Outpatienttreatmentdoesnotusuallyincludesupervisedmeals.3DiagnosticandStatisticalManualofMentalDisorders,FifthEdition,DSM-5,2013,AmericanPsychiatricAssociation,ISBN-13:978-08904255414SomechangesfromtheDSM-4includetheadditionofBED,thegroupingofFeedingDisorderswithEatingDisorders,andthereplacementofEDNOS(EatingDisorderNotOtherwiseSpecified)withOSFEDandUFED.�

IntensiveOutpatientProgram(IOP):Thepatientlivesathomebutspendssomeoftheirtimeataclinicfortherapysessionsandlimitedmealsupport.AcommonIOPschedulewouldbethreehoursperday,threedaysperweek,andincludesdinner.DayTreatmentProgram:Thepatientlivesprimarilyathomebutspendsfourtotwelvehoursperdayatahospitalorclinicforindividual,groupandfamilytherapysessionsandmealsupport.Typicallythepatientwilleatatleasttwomealsandasnackattheprogrameachday.Daytreatmentprogramsmayormaynotincludeweekendhousingandorsupport.PartialHospitalization(PHP):Thepatientlivesathomebutspendssixtotwelvehoursperday,fivetosevendaysperweekatahospitalorclinicforindividual,group,andfamilytherapysessions,medicaloversight,andmealsupport.Typicallythepatientwilleatatleasttwomealsandasnackattheprogrameachday.SomePHPprogramswillprovidehousingandkeepapatientovernightforpartsoftheweek.NOTE:Stateregulationandlicensingwillinfluencewhethertherearedaytreatmentand/orpartialhospitalizationprogramsinyourcommunity.Inpatient(IP):Thepatientishospitalized,usuallyformedicaland/orpsychiatricstabilization,andmayormaynotreceivetherapy.Hospitalizationcanoccuronavoluntaryorinvoluntarybasis.Somehospitalshavepsychiatricbedsforinvoluntarilyadmittedpatientsandsomedonot.OftenInpatientstaystakeplaceatageneralmedicalorpsychiatricfacilitywhichmayormaynothaveaspecializedeatingdisorderunit.Mealsupportatageneralfacilityusuallyfocusesonmedicalstabilization(notweightrestoration)andmaynotincluderegularmealsupport.Residential:Thepatientlivesfulltimeataspecializedeatingdisorderfacilitywhere24/7careisprovided.Residentialtreatmentusuallyrequiresalongertermstayrangingfromafewweekstoseveralmonthstoayearormore.Residentialcareisusuallyindicatedwhenoutpatientinterventionshavenotbeensuccessfulatinterruptingeatingdisordersymptomsandwhenthepatientneedsahighlycontrolledenvironmenttorestoreweight,stopbingeeating,purgingorotherself-destructivebehaviors.Page|14www.feast-ed.org�

FAMILIESEMPOWEREDANDSUPPORTINGTREATMENTOFEATINGDISORDERSP.O.Box11608F.E.A.S.TMilwaukee,WI53211US.F�