Levels of Eating Disorder Care

Eating Disorder Treatment

Eating disorder treatment can be delivered in a variety of settings, depending on a patient’s needs. Understanding the differences between the various levels of care and methodologies used in eating disorder treatment can be helpful when selecting a provider, treatment program or facility.

Levels of Eating Disorder Care

There are eight levels of eating disorder care as outlined in the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders, Fourth Edition, six of which are eating disorder-specific and two that are not.¹

Treatment should be offered in the least restrictive setting possible that will still effectively address the condition. There is no algorithmic approach that can determine the optimal care setting with certainty, and patients will differ in what factors influence what level of care is most appropriate. There are a number of factors that can suggest a higher level of care is needed:¹

• Low weight in relation to estimated individually determined target weight
• Rate of recent weight loss
• Medical complications of purging
• Evidence of medical instability
• Approaching a weight at which instability previously occurred in the patient
• Additional stressors that affect the patient’s eating disorder behaviors
• The degree of the patient’s difficulties in collaborating in their care
• Co-occurring psychiatric symptoms or diagnoses
• Insufficient weight gain or worsening eating disorder symptoms despite treatment¹

Age, duration of eating disorder as well as financial, occupational and social stressors may also make a higher level of care more appropriate. While the goal is for patients to slowly move from higher to lower levels of care, individuals will not necessarily move in a sequential fashion from one level on the care to another.¹

When possible, it is best to refer patients to specialized eating disorder programs, as they are specifically designed to improve eating disorder symptomatology and restore weight in the majority of underweight patients using a multidisciplinary approach.¹

Inpatient Medical Hospitalization for Eating Disorders

Inpatient medical hospitalization is the highest level of eating disorder care. Inpatient medical hospitalization is necessary to treat the severe medical complications that can accompany an eating disorder. Patients are monitored 24/7, including when they use the bathroom or eat, although there usually isn’t an expectation to eat around other patients. Unlike other levels of care, inpatient medical hospitalization is most often a short-term measure, and most patients only stay at this level of care until they have been medically stabilized and can be discharged to a lower level of care. Patients typically have private rooms and spend most of their time in their room.

Another differentiator between inpatient medical hospitalization and other levels of care is the level of medical management available. Patients at an inpatient medical hospitalization level require monitoring of vitals, intravenous fluids, daily lab monitoring, tube feeding and medication that isn’t available at a lower level of care.

Inpatient medical hospitalization can also offer a wider breadth of medical services, including things like occupational and physical therapy. Because inpatient medical hospitalization programs are often affiliated with hospitals, they also have access to a network of different medical specialties, including cardiology, neurology, gastroenterology, etc. Even though the primary focus is medical stabilization, psychiatric, psychological and social work services are typically available to ensure patients have the tools to manage during their stay and after discharge.

Because patients are medically compromised, physical activities, including walking or standing unassisted, are limited to prevent injury and facilitate weight gain. Patients are usually transported via wheelchair. Activities that are not physically taxing, like knitting, reading or web browsing are encouraged during down time.

Who is Inpatient Medical Hospitalization For?

The recommended admissions criteria for inpatient medical hospitalization is as follows:

• Weigh less than 70% of ideal body weight or have a BMI <15, even without the current presence of medical complications
• Drastic weight loss (>10% in six months or >20% in one year)
• Heart, kidney or liver failure or compromise requiring acute treatment
• Electrolyte imbalance or dehydration
• Acute medical complications of malnutrition (seizures, syncope, cardiac failure, pancreatitis)
• In adults:
  • Heart rate of <40 bpm
  • Blood pressure <90/60 mmHg
  • Glucose <60 mg/dl
  • Potassium <3 mEq/L
  • Temperature <97°F
• In adolescents and children:
  • Heart rate near 40 bpm
  • Blood pressure <80/50
  • Blood pressure changes (>20 bpm increase in heart rate or >10 mmHg to 20 mmHg drop)
• Requiring an NG tube or special feeding modality^1,2

Inpatient Psychiatric Hospitalization

Inpatient psychiatric care happens in a psychiatric hospital or a psychiatric unit care setting. Patients in this treatment setting are medically stable, but still require acute psychiatric care. The goal of inpatient treatment is to stabilize the patient and ensure they are not a danger to themselves or others, with stays usually lasting up to 30 days.

Inpatient psychiatric hospitalization is ideal for patients who need psychiatric treatment and continuous support. This level of care may be necessary after a suicide attempt or another mental health crisis. Inpatient psychiatric hospitals and units are able to offer crisis intervention experts that people at this level of care need, which aren’t usually available at lower levels. Inpatient psychiatric care can also be an opportunity to identify, diagnose and/or begin medication therapy for any co-occurring psychiatric disorders that may be exacerbating or exacerbated by an eating disorder.

An inpatient psychiatric unit may offer:

• Crisis intervention and stabilization
• Medication management
• Psychotherapy and/or Psychoeducation
• Case management
• Recreational therapies
• Group therapy

Like inpatient medical hospitalization, inpatient psychiatric care is in a hospital setting, while some units may offer private rooms, it’s more common for two patients to share a room. While group therapy may be offered, care is more isolated than in a residential treatment environment and there aren't usually outings or activities outside of planned therapies.

Who is Inpatient Psychiatric Hospitalization For?

The recommended admissions criteria for inpatient psychiatric hospitalization are as follows:

• The presence of a specific suicide plan with high lethality or intent
• Very poor-to-poor motivation to recover and preoccupation with intrusive and repetitive thoughts
• Requiring a highly structured environment to eat and gain weight
• An existing psychiatric disorder that would require hospitalization
• Needing supervision during and after all meals
• Needing supervision in bathrooms and unable to control daily episodes of purging
• Absence of family, severe family conflict or problems or lives alone³

Residential Treatment

Unlike inpatient psychiatric care, the goal of residential treatment is primarily toward long-term healing and not acute care. Residential treatment programs can last up to 90 days. The residential treatment center usually looks less clinical and more homelike, with bedrooms and shared living spaces. In a residential treatment program, patients stay on premises 24/7, with the sole purpose of recovery. Patients in this treatment setting are stable but still require a highly structured environment.

Specific programming can vary a lot between programs, but most programs include:

• Psychotherapeutic counseling
• Nutritional counseling
• Group therapy
• Family-based therapy
• Medication therapy
• Holistic therapy options (like yoga, meditation or art therapy)

Residential treatment is usually a more social environment. Patients typically share a bedroom and bathrooms. Meals often occur in a group setting with clinician supervision. All snacks and meals are eaten in the residential treatment facility. Meal preparation, grocery shopping outings and restaurant outings are frequently included in residential treatment programs to help patients develop practical skills and decrease food-related anxiety.

Because the program is 24/7, there are moments of downtime. Unlike with inpatient medical or inpatient psychiatric hospitalization programs, patients can move freely and without assistance. Patients are encouraged to engage in hobbies in their downtime. The facility may schedule recreational or community activities on the weekends to keep patients occupied.

Who is Residential Treatment For?

• Medically stable enough that IV fluids, NG tube feeding and daily lab monitoring are not necessary

• Poor-to-fair motivation to recover and preoccupation with intrusive, repetitive thoughts
• Need supervision at all meals to eat and gain weight
• Need some degree of external structure beyond self-control to prevent compulsive exercising
• Can ask for and use support from others or use cognitive and behavioral skills to inhibit purging
• Absence of family, severe family conflict or problems or lives alone³

Partial Hospitalization Programs

Partial Hospitalization Programs (PHP), also known as Full-Day Outpatient Care or Day Treatment Programs, are structured treatment programs that occur five to seven days a week, up to 12 hours per day. The number of days and hours per day depend on the patient’s needs. While patients in this treatment setting are medically and psychiatrically stable, they still require daily assessment and struggle to function without structure or support.

Partial hospitalization is a step down from 24-hour residential care. It provides more structure than outpatient care, but less support than inpatient care. Patients receive psychotherapeutic counseling, nutrition counseling, group therapy, practice skills of daily living and other treatment modalities during the day and return home at night. Depending on the hours spent in the program daily, some programs have patients eat all meals and snacks during the day, while others encourage patients to eat one meal or snack when they return home.

Who is Partial Hospitalization For?

PHP are best for patients who are:

• Medically stable
• Partially motivated to recover but preoccupied with intrusive, repetitive thoughts
• Need some structure and support to eat and gain weight
• Need some degree of external structure beyond self-control to prevent compulsive exercising
• Can greatly reduce incidents of purging in an unstructured setting
• Has others able to provide at least limited support and structure³

Intensive Outpatient Care

A step down from partial hospitalization, intensive outpatient treatment (IOP) is an eating disorder treatment setting that runs between three to five days a week for three to five hours per day.

IOP maintains many of the same treatment components as partial hospitalization, except it includes fewer days and fewer hours per day. Intensive outpatient care includes the same interventions, including psychotherapeutic counseling, nutrition counseling and group therapy. All these treatment components are delivered as a program at a single location. IOP programs may include short group outings and opportunities to practice skills of daily living.

IOP allows individuals to still spend part of their day with family, go to school (depending on schedule) or work a part-time job. Patients in this treatment setting are largely self-sufficient but need a small amount of support to maintain recovery and gain weight.

Who is Intensive Outpatient Eating Disorder Care For?

IOP eating disorder care is best for patients:

• Medically stable
• Fair motivation to recover
• Self-sufficient in eating and gaining weight
• Need some degree of external structure beyond self-control to prevent compulsive exercising
• Can greatly reduce incidents of purging in an unstructured setting
• Has others who are able to provide adequate emotional support, practice support and structure³

Outpatient Care

Outpatient care is the most flexible and least restrictive level of care for eating disorders, and one of the main benefits of this treatment setting is that it takes place in one’s real-life environment. In this treatment setting patients can remain fully engaged in their daily lives, able to fully attend work and school and be involved in family and social life.

The main component of outpatient treatment is typically individual counseling sessions. Typically, psychotherapy occurs at least once a week for an hour. As treatment progresses, a therapist will likely recommend spacing sessions out in longer intervals, recommending every other week, then once a month, working up to an as-needed basis.

Nutrition counseling is also frequently utilized, with sessions lasting 30 minutes to an hour, and may occur as frequently as weekly. Sessions usually include nutrition education and meal planning, as well as assisting patients become more accountable for sticking to their nutrition goals.

There are other components therapists may recommend as part of ongoing eating disorder care. Some people may attend family therapy as part of their eating disorder, either with their primary therapist or a specialized family therapist. Group therapy or support groups may also be recommended.

Who is Outpatient Eating Disorder Care For?

Outpatient eating disorder care is best for patients:

• Medically stable
• Fair-to-good motivation to recover
• Self-sufficient in eating and gaining weight
• Can manage compulsive exercising through self-control
• Can greatly reduce incidents of purging in an unstructured setting
• Has others who are able to provide adequate emotional support, practice support and structure³

References

1. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders. Fourth Edition. (2023). https://doi.org/10.1176/appi.books.9780890424865
2. Medical stabilization for eating disorders. (2021, February 26). ACUTE. https://www.acute.org/resource/medical-stabilization-eating-disorders
3. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders. Third Edition. (2010).