As an outpatient provider or a loved one of someone with an eating disorder, it can be difficult to know when this person needs a higher level of care. Some weeks outpatient treatment may seem to be working well, while the next week you can feel like you’re back at ground zero. Let’s discuss first the symptoms of an eating disorder, and then the signs that a higher level of care may be necessary.

Eating Disorder Signs and Symptoms

Below is a list of some warning signs and symptoms associated with eating disorders.  If the following symptoms do not lessen or if they worsen during the course of outpatient treatment, the client may need a higher level of care:

• Worry about body shape/weight more than others; talk about feeling fat
• Significant fear/distress about weight gain (even a few pounds)
• Continual dieting behavior and talk
• Fasting
• Binge eating or eating uncontrollably
• Hiding or hoarding food
• Abusing diuretics and/or laxatives
• Excessively exercising or becoming distressed if unable to exercise
• Throwing up food
• Restricting food or fluids (avoiding certain foods or food groups)
• Low self-esteem
• Insomnia and/or fatigue
• Feeling dizzy, nauseous, and/or lightheaded
• Having difficulty making decisions and/or being slow to respond in conversation
• Gastrointestinal pain or related problems
• Hair loss

Signs That the Client Needs a Higher Level of Care

Because eating disorder symptoms present differently from person to person, it can be difficult to definitively state when someone isn’t responding to outpatient treatment and/or needs a higher level of care.  This decision may be more complicated if a person is experiencing comorbid psychiatric, psychosocial, or medical problems.  The following list is not exhaustive, but it can serve as a general guide for clinicians and parents who are making decisions about treatment needs.

An adolescent may need a higher level of care…

• If the client is medically unstable as a result of eating disorder symptoms
• If the client is suicidal and is unable to identify or follow a safety plan
• If the client has difficulty reducing eating disorder symptoms without significant support/structure from parents or treatment providers
• If the client needs structure and support to restore weight
• If the client’s family needs emotion coaching, family therapy, intensive family-based treatment strategies, and/or psychoeducation about eating disorders and supporting their loved one’s recovery
• If the client presents with significant comorbid symptoms (such as depression, anxiety, PTSD, etc.) that may be exacerbating symptoms and need to be addressed concurrently
• When eating disorder symptoms interfere with activities of daily living, including socializing, self-care, and extra-curricular activities
• When the client is presenting as cognitively impaired due to malnutrition and/or dehydration. Note: this may manifest in poor (or lower than average) school performance
• If the client is not attending scheduled outpatient appointments with the therapist, psychiatrist, dietitian, or other treatment providers
• If the client would benefit from supportive, psychoeducational, exposure-based, and/or expressive group therapy experiences (which may be especially helpful for clients who isolate from others or avoid activities)