CASE REPORT

Instabilitatea emoţională şi anorexia nervoasă – o abordare dietetică

Emotionally unstable personality disorder and anorexia nervosa – a dietetic approach and therapeutic progress

Data publicării: 20 Decembrie 2023
Editorial Group: MEDICHUB MEDIA
10.26416/Diet.4.4.2023.9093

Abstract

Objectives. This study aimed to comprehensively evaluate the impact of a multifaceted treatment approach, combining nutritional intervention, antipsychotic medication and psychotherapy, to the recovery of a female patient diagnosed with an eating disorder. The objective was to delineate how these integrated modalities contribute to improvements in both physical health and psychological well-being. Materials and method. A mixed-methods research design was employed. Quantitative data were gathered through weekly monitoring the patient’s body weight and weekly assessments of vital blood parameters, to objectively measure physical health progress. Qualitative data were collected using semi-structured interviews with the patient and her multidisciplinary healthcare team, including dietitians, psychologists and medical staff, providing insights into the psychological impact and patient’s experience of the treatment. Advanced data processing and visualization techniques were used, employing Microsoft Excel for the creation of comprehensive charts and graphs to analyze and present the data. Results. The results indicated a notable improvement in the patient’s overall health status, with significant gains in body weight and the stabilization of blood parameters. Psychologically, the patient demonstrated enhanced coping mechanisms and emotional well-being, as evidenced by her responses to RO-DBT and EMDR therapies. The nutritional intervention, tailored to her specific needs, along with the judicious use of antipsychotic medication played a key role in supporting her recovery. Conclusions. The study underscores the efficacy of an integrated treatment approach in managing eating disorders. The synergy between nutritional intervention, antipsychotic treatment and psychotherapy emerged as a crucial factor in addressing the complex interplay of physical and psychological aspects of the disorder. These findings contribute with valuable insights into the holistic management of eating disorders, highlighting the importance of personalized and comprehensive treatment strategies. This research adds to the existing body of knowledge, suggesting directions for future studies and clinical practices in the field of eating disorder treatment.
 

Keywords
eating disordersnutritional plan carepsychotherapy

Rezumat

Obiective. Acest articol prezintă un studiu de caz detaliat al unei paciente care a fost în tratament pentru o tulburare de alimentaţie începând cu octombrie 2020. Studiul se concentrează pe abordarea multidisciplinară a tratamentului şi pe eficacitatea acestuia, observată până în iulie 2021, când a fost scris acest articol. Tratamentul pacientei a inclus o combinaţie de intervenţie nutriţională, medicaţie antipsihotică şi psihoterapie, incluzând modalităţi specifice, precum Radically Open – Dialectical Behavioural Therapy (RO-DBT) şi Reprocesarea şi Desensibilizarea prin Mişcare Oculară (EMDR). Materiale şi metodă. Am folosit o abordare cu metode mixte pentru o imagine completă a evoluţiei tratamentului. Datele cantitative au fost colectate prin urmărirea săptămânală a greutăţii corporale a pacientei şi prin evaluări săptămânale ale anumitor parametri sanguini, oferind o imagine clară privind progresul sănătăţii fizice. De asemenea, au fost obţinute informaţii calitative prin interviuri aprofundate cu pacienta şi echipa multidisciplinară, oferind perspective asupra stării ei psihologice şi a răspunsului la diversele strategii de tratament. Rezultate. Printre constatările semnificative ale acestui studiu de caz, se numără îmbunătăţirile marcante atât privind sănătatea fizică a pacientei, evidenţiate prin creşterea în greutate şi stabilizarea parametrilor biochimici, cât şi privind starea ei psihologică, evaluată prin angajamentul şi răspunsurile ei la tratament, ca urmare a abordării psihoterapeutice. Concluzii. Aceste îmbunătăţiri subliniază eficacitatea abordării integrate a tratamentului. În iulie 2021, deşi era încă în îngrijirea noastră, pacienta a progresat până la un punct în care a fost implementată o cale structurată de externare, reflectând recuperarea ei substanţială. Acest articol nu numai că documentează evoluţia pacientei, dar serveşte şi ca o referinţă importantă privind complexitatea tratării tulburărilor de alimentaţie. Lucrarea evidenţiază nevoia unei abordări personalizate, holistice, a tratamentului, care să ţină cont atât de aspectele fizice, cât şi psihologice ale acestor tulburări.
 
Cuvinte Cheie
tulburări de alimentaţieplan alimentarpsihoterapie

Anorexia nervosa – background

Anorexia nervosa (AN) and emotionally unstable personality disorder (EUPD), also known as borderline personality disorder (BPD), are distinct yet interrelated mental health disorders that can have severe consequences on an individual’s overall well-being(1,2). Anorexia nervosa is an eating disorder (ED) marked by a relentless pursuit of thinness, an intense fear of weight gain, associated with a low Body Mass Index (BMI), usually below 18.5 kg/m2, and a distorted body image, often resulting in life-threatening malnutrition(3). On the other hand, EUPD is characterized by emotional instability, impulsive behavior and turbulent interpersonal relationships, leading to significant distress and dysfunction in daily life(4).

While these disorders are diagnostically separated, they share a number of common risk factors, such as genetic predispositions, environmental influences and neurobiological abnormalities(5,6). Moreover, research has demonstrated a higher prevalence of EUPD among individuals with AN, suggesting a potential comorbidity between the two conditions(7). This comorbidity can exacerbate the severity of both disorders and complicate treatment efforts, necessitating a multidisciplinary approach that addresses the unique challenges posed by each condition(8).

This article describes the progress of a patient transitioning from a Children and Adolescent Mental Health Services (CAMHS) unit to a High Dependency Rehab (HDR) unit. Important issues and different therapeutic approaches are raised in order to highlight the importance of understanding the coexistence of eating disorders and treatment implications.

The aim of this study was to highlight the impact of nutritional intervention in association with antipsychotic treatment and psychotherapy in the recovery process of a patient with an eating disorder. The study focused on understanding how these combined approaches influence treatment outcomes and patient’s well-being

The patient consented to information being shared; however, for safety and confidentiality reasons, the patient will be referred to as N.K.

Materials and method

The data for this case study was systematically collected from multiple sources. This included comprehensive medical records, detailing N.K.’s clinical history and treatment progress, therapy session notes reflecting psychological interventions, and detailed nutritional intake logs.

N.K.’s body weight was monitored weekly, and the Body Mass Index (BMI) was calculated at each interval. Blood parameters, including complete blood count, electrolyte levels, and liver and renal function tests were assessed weekly to track physiological health indicators.

Semi-structured interviews were conducted with N.K. and the members of her healthcare team, including dietitians, clinical psychologists and medical professionals. These interviews focused on gathering insights into N.K.’s treatment experience and the effectiveness of the care provided.

All collected data were entered and processed using advanced data management tools. Quantitative data, including weight, BMI and blood parameters, were analyzed and visualized using Microsoft Excel. This allowed for the creation of detailed charts and graphs, facilitating a comprehensive and clear presentation of NK’s clinical progress over time.

The study was conducted in accordance with ethical standards, ensuring the confidentiality and the informed consent of the patient throughout the research process. This objective methodology was employed to ensure a rigorous and systematic analysis of N.K.’s treatment and recovery process, providing a clear and unbiased view of the outcomes and efficacy of the interventions used.

The patient has been under our care since October 2020, and as of the writing of this article in July 2021, she remained in our facility but was on a structured discharge pathway.

Pre-admission history

N.K. and her twin sister were adopted at the age of 2 years old. It is noted that, prior to the adoption, both girls experienced neglect and malnutrition. There was noted to be a certain level of speech and language delays in their development. Records indicate that N.K.’s biological mother experienced depression and had a history of self-harm and substance misuse. N.K. has also reported that her biological mother was officially diagnosed with bipolar personality disorder (BPD). There are reports of relationship difficulties between N.K. and her adoptive parents, as it is noted that her adoptive mother presented high levels of stress, anxiety and depression. Also, N.K. states that her relationship with her sister is problematic, as her sister calls her an “attention seeker” due to reoccurring self-harming behaviors. There are reports from NK’s adoptive father that he is acting with extra caution when N.K. is at home, due to high-risk behaviors and the risk of self-harming. There is no evidence of psychosexual abuse, however, N.K. has made reference to an incident where she states that she was abused by a person that her sister knew.

N.K. was previously under Children and Adolescent Mental Health Services (CAMHS), from June 2014 until September 2016. During this period, N.K. had several hospital admissions to different specialty units for anorexia nervosa, self-harm, suicidal ideation and depression. During this period, she was treated as both inpatient and outpatient.

In July 2016, N.K. turned 18, and she was referred by Children and Adolescent Mental Health Services (CAMHS) to the Adult Community Mental Health Team (ACMHT). She was accepted on the Structured Clinical Management (SCM) Pathway, a pathway specially designed for people with emotionally unstable personality disorder (EUPD). During this whole period, N.K. was still being followed-up by eating disorder community services.

N.K.’s first admission to an adult ward was on 12 May 2017. She was in the hospital for four weeks, and she was readmitted within 24 hours of discharge. At that time, their parents had taken her to Accident & Emergency Unit (A&E) following a ligature incident.

Whilst on the ward, N.K. continued to purge (self-induced vomiting) after eating, and there had been frequent ligatures, which usually increased in frequency when she was returning from leave from outside of the unit (Section 17 Leave according to the Mental Health Act Legislation in The United Kingdom).

On the evening of 6 October 2017, N.K. went to her room and tied a ligature around her neck, which caused her to become cyanotic and lose consciousness. She was found by her mother in an unconscious state, with a ligature around her neck. The ligature was cut by her family, who noted bruising around her neck. A suicide note was found by her side. Her family felt that they were unable to maintain her safety at home. She underwent a mental health act assessment, as she refused informal admission. She was detained on Section 2 of the Mental Health Act (MHA) and admitted as an inpatient in a psychiatric unit. Following the deliberate self-harm episodes, N.K. stated that they come as a coping mechanism for the guilt she feels after she eats. Also, the self-harm represented a coping mechanism for gaining weight.

On 3 April 2020, N.K. was detained under Section 2 of the MHA and admitted to an acute psychiatric ward, in a National Health System (NHS) hospital. At the time, she was tying ligatures regularly as well as restricting her food. N.K. was constantly expressing suicidal ideations at that time and she was looked after using enhanced levels of observations, having a member of the staff by her side all the time. This is known as one-to-one observations. It was therefore felt that N.K. could not be safely supported without specialty intervention.

She was then placed on the Section 3 of the Mental Health Act on 29 April 2020.

On 12 October 2020, N.K. was admitted into our service, a specialized private mental health unit dealing with individuals struggling with emotional unstable personality disorder and eating disorders, mixed (dual) diagnoses.

Results

Current admission – dietetic treatment

Anthropometrical data obtained at admission displayed the following values:

Weight – 45 kg.

Height – 161 cm (1.61 m).

BMI – 17.4, classified as “underweight” according to the National Institute for Health and Care Excellence (NICE) guidelines.

The biochemical data obtained at admission displayed no nutritional deficiencies or abnormalities, however decision to increase the physical health observations monitoring frequency has been taken by the medical and dietetic team.

N.K.’s physical health was observed a minimum of four times per day, using the National Early Warning Score 2 (NEWS-2). The NEWS-2 system is based on a combination of vital indicators, such as oxygen saturation, temperature, respiratory rate, heart rate and blood pressure. Each parameter is given a point value by the scoring system, which is then added up to create an overall score. With the use of this score, healthcare workers can quickly identify patients who might need more intensive monitoring or intervention, allowing for the proper escalation of care and possibly improving patients’ outcomes.

The early days of admission show N.K. in a low mood, and psychology sessions revealing that the abuse experienced during childhood has been self-replicated in adulthood. Therefore, instead of being physically assaulted and deprived of food, N.K. assaulted herself, through self-harm and restricting her dietary intake.

From a dietetic perspective, during the first three months of admission, N.K. displayed a fluctuating presentation, her engagement with meals being sporadic and the number of meals consumed remained low. Fluid intake did not represent a concern at this moment in time.

As a standard practice, the new admissions in our unit receive a generic meal plan tailored according to their needs and preferences, meant to aid them in meeting their requirements. 

In this case, the meal plan consisted of three meals and one snack, all in normal serving sizes. The average meal plan has between 1600 and 1800 kcal/24 h and 1.8 L of fluids. N.K. was handed a meal plan consisting of the same caloric and fluid values, which she described as “difficult” and “overwhelming”.

N.K.’s main consumed fluid was Pepsi Max, consuming between 0.5 and 2 L/day. Water was consumed in quantities between 0.8 and 1.5 L/day. Other consumed fluids were teas and coffees, between 0.3 and 0.5 L/day. The average fluid consumption was around 1.7 L fluids/24 h.

The patient displayed a limited calorie intake during the first stages, consuming 500 to 1000 calories daily. The clinical expression of the eating disorder was evident in her recurrent intrusive thoughts about her own body. She was forcing herself to eat in small quantities, which resulted in an inadequate intake of nutrients. N.K. had poor adherence to the recommended meal plan, eating only one or two meals a day and forgoing all recommended snacks or any prompts coming from staff members. To address the distorted body image perception and enable a steady increase in the patient’s nutritional intake in accordance with the treatment plan, this pattern of disordered eating required constant monitoring and tailored interventions.
 

Patient’s guidance meal plan implemented on admission
Patient’s guidance meal plan implemented on admission
Fortisip Compact® Macronutrients(9)
Fortisip Compact® Macronutrients(9)
Caloric distribution for N.K. for the first 14 days of NG administration of ONS
Caloric distribution for N.K. for the first 14 days of NG administration of ONS
ONS used for the nasogastric approach
ONS used for the nasogastric approach

Please note that the nutrient content outlined in the meal plan is based on a menu developed by the dietetics department in collaboration with the catering staff. While every effort has been made to ensure the accuracy of the nutritional information provided, there may be an error margin due to variations in food preparation and portion sizes.

It is important to note that the patient received continuous support from the staff during each mealtime. The staff assisted her in selecting appropriate foods from the indicated food groups and provided guidance and encouragement throughout the meal process. Despite these efforts, the patient often demonstrated reluctance to engage in the meal plan and resisted the support provided.

Following a prolonged display of minimal intake, after three months of admission, N.K. presented with complete restrictive caloric intake for five days, and the decision of commencing nasogastric (NG) administration of oral nutritional supplements (ONS) was taken. This was in accordance with the Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) Guidance.

At this moment in time, N.K.’s weight dropped to a value of 43 kg, placing her in a category of increased risk for developing malnutrition-related issues, as well as potentially compromising her cognitive function. BMI was placed at a value of 16.6 kg/m2.

N.K. scored higher than 2 on the Malnutrition Universal Screening Tool (MUST). The protocol was initiated with 600 kcal/24 h for the first 48 hours and continuing to 900 and 1200 in the following 96 hours. N.K. was every time being offered the possibility of oral intake, consisting of either food or supplements, as the least restrictive practice was always considered in the care process. Due to constant refusal, the decision to gradually increase the calories up to a value of 2100 kcal/24 h has been taken by the dietetic team. The 2100 kcal would represent the amount of calories the patient would need to consume throughout the day in order to meet her requirements and facilitate a weight gain of 0.5-1 kg/week.

  

The chosen supplements used were Fortisip Compact® 2.4 kcal/ml, with an average of 12 g protein/100 ml. Additional Fortisip Compact Fibre® and Fortisip CompactmProtein® were used to meet the patient’s energy requirements.

For the Fortisip Compact Protein®, the protein quantity/100 ml is 18 g, whereas for the normal one, it is 12 g. In terms of fiber intake, the Fortisip Compact® 2.4 kcal has 0.1 g of fibers/100 ml, whereas the Fortisip Compact Fibre® 2.4 kcal has 3.6 g/100 ml.

 

 

Following the NG administration, the decision to remove the nasogastric tube in situ was taken by the medical team, in order to give her the chance to commence oral intake. For that to be facilitated, N.K. had a meal plan designed according to her needs and preferences. However, following the removal of NG protocol, N.K. presented with another restrictive intake episode, and the decision to recommence NG was taken by the MDT in order to address the patient’s physical health needs. At this moment in time, N.K.’s admission weight has been restored, and a BMI of 17.4 was recorded.

Nasogastric administration of ONS was carried out under restraint (i.e., the usage of safety intervention holds), as the patient was uncompliant with the regimen. However, de-escalation and distraction techniques were successfully used during the feeds.

Over the following three months, N.K. has been recording small weight fluctuations, with intermittent NG administration episodes of oral nutritional supplements, her behavior being addressed in one-to-one sessions with the dietitian where an informal dietetic approach was taken in order to reveal the N.K.’s cibophobic symptoms’ cause. During these sessions, it has been revealed that N.K. was driven by a wish to become thinner, as her sister has always represented a benchmark in terms of appearance; even though they are twins, the physical resemblance was not as protruding for N.K. as she wanted it to be.

Despite the fact that N.K.’s BMI was above 15 at that moment in time, the medical and dietetic team agreed that dietary behavioral pattern should be prioritized over numerological guidelines.

The commencement of nasogastric feeding was associated with an increase in the deliberate self-harm (DSH) episodes, as N.K. was describing feelings of guilt and shame following nasogastric administration of supplements. Gaining weight was associated with a distorted body image for her, thus making the behavioral approach even more difficult.

Even though the incidents were diverse, their escalation was not always following a pattern, as de-escalation techniques, such as verbal de-escalation or distraction, were working with N.K. She was easy to distract, and restraints were only used as a safety intervention to stop the head-banging or for nasogastric administration of ONS.

Alongside the dietetic intervention, N.K.’s treatment journey consisted of a comprehensive psychological therapy plan, which was essential in addressing the underlying issues contributing to her condition. She engaged in Radically Open Dialectical Behavior Therapy (RO-DBT), a specialized form of therapy designed to help individuals who struggle with overcontrol, often manifested in rigid behavior patterns and difficulty in adapting to changing situations. RO-DBT was instrumental in aiding N.K. to develop more flexible coping mechanisms, enhance social connectivity, and foster emotional expression. Alongside RO-DBT, N.K. also participated in Eye Movement Desensitization and Reprocessing (EMDR) therapy. EMDR is a unique psychotherapy approach known for its effectiveness in treating trauma and post-traumatic stress disorder (PTSD). Through this therapy, our patient. was able to process and integrate difficult memories and experiences that were contributing factors to her eating disorder. The combination of RO-DBT and EMDR therapies provided a holistic approach, addressing both the behavioral and emotional aspects of N.K.’s condition.

Figure 1. Weight fluctuations of our patient
Figure 1. Weight fluctuations of our patient
Figure 2. Incidents by category for our patient
Figure 2. Incidents by category for our patient


In terms of medication, our patient was following a treatment scheme that consisted of:

  • Zopiclone 7.5 mg nocte P.O. – insomnia.
  • Vortioxetine 10mg daily P.O. – antidepressant, SSRI (selective serotonin reuptake inhibitor).
  • Mirtazapine 45mg nocte P.O. – antidepressant, SSRI (selective serotonin reuptake inhibitor).
  • Clozapine 450 mg daily P.O. – antipsychotic.
  • Procyclidine 5 mg daily P.O. – extrapyramidal side effects.
  • Thiamine 50 mg daily P.O. – prophylaxis.
  • Multivitamins (Forceval®) 1 capsule daily P.O. – prophylaxis (restriction of oral intake leading to vitaminic deficiency).

Following the second episode of nasogastric administration, N.K. exhibited a significant improvement in her eating behaviors. With the dedicated support of the MDT, she successfully engaged with her personalized meal plan, which was carefully tailored to meet both her nutritional requirements and personal preferences. This positive development was a pivotal moment in our patient’s recovery journey.

As N.K.’s confidence in managing her oral intake grew, the medical team observed a notable stabilization in her dietary habits. This progress allowed for a gradual reduction in the level of support provided, enabling N.K. to exercise more independence in her eating decisions. Importantly, throughout this period, she maintained her dietetic safety, a crucial aspect of her overall treatment plan.

This transition from reliance on nasogastric feeding to self-managed oral intake marked a significant milestone in her path path to recovery. Her ability to maintain a consistent intake, coupled with the appropriate support that was progressively scaled back, demonstrated her growing strength and resilience in overcoming the challenges of her condition.

N.K.’s diligent efforts and commitment to her recovery journey have led to a remarkable improvement in her physical health. Her weight has increased from 45 kg to 52 kg, as an indicator of her progress. This weight gain, in conjunction with her consistent oral intake, has resulted in an increase in her BMI from 17.4 to a healthier score of 20.1. This achievement not only signifies a significant stride in her recovery, but also underscores the effectiveness of her personalized treatment plan and the support she has received.

Asset 12

Discussion

Eating disorders are complex and challenging mental illnesses, often with coexisting psychiatric conditions. The multidisciplinary management of patients with eating disorder and emotionally unstable personality disorder is essential to achieve optimal outcomes. Dietetic therapy is an essential component of eating disorder management, and its use in combination with psychotropic medication has been shown to be effective in treating these patients. Dietetic intervention managed to address a nutritional correction in a combined oral and nasogastric manner, which lead to a weight correction that aided the usage of psychotropic intervention(10,11).

The findings from this case study contribute with valuable insights into the treatment of patients with coexisting EUPD and eating disorder, particularly highlighting the efficacy of integrating dietetic therapy with antipsychotic medication.

This approach not only addresses the psychological symptoms but also tackles the often-overlooked nutritional imbalances that can exacerbate the patient’s overall condition. The success observed in this case, where dietetic intervention significantly enhanced the effectiveness of psychotropic medications, suggests a synergistic relationship between nutritional management and psychiatric treatment.

In a recent study, the implementation of dietetic therapy, combined with psychotropic medication, such as antidepressants and antipsychotics, significantly benefited patients with eating disorder and EUPD. This approach was shown to be effective in addressing the nutritional and mental health needs of these patients, leading to better outcomes and a more sustainable discharge pathway(12).

Furthermore, pharmacological and dietary interventions have been shown to be effective in treating anorexic patients, highlighting the need for a comprehensive treatment plan that addresses both nutritional and mental health needs(13,14).

NICE recommends the use of dietetic therapy as part of a comprehensive management plan for patients with eating disorder, highlighting the importance of addressing the nutritional needs of these patients. This recommendation is supported by the evidence, which suggests that dietary intervention can have a significant impact on the nutritional status of these patients and, as a result, can improve their overall health outcomes(15).

It is important to recognize that this case study represents a single instance, and there is a need for broader research to validate these findings. Future studies should aim to explore this integrated approach in a larger, more diverse patient population. This would help in understanding the generalizability of these findings and in identifying any variations in outcomes, based on different demographic or clinical characteristics.

Conclusions

For a patient with a complicated medical history, a dietetic intervention was created to manage a nutritional correction using a combination of oral and nasogastric methods. The intervention was specifically designed to meet the patient’s unique nutritional requirements, taking into account all of her current medical conditions, oral intake and gastrointestinal function. The intervention’s objective was to deal with the patient’s nutritional situation, which had been harmed by their medical condition and medications.

To maximize the patient’s nutritional intake and promote the physical rehabilitation, a combination of oral and nasogastric feeding strategies was used. The intervention was successful in making the patient gain the necessary amount of weight, which made it easier to incorporate psychotropic therapies into a larger treatment plan for the patient.

This dietary intervention played an important role in stabilizing her physical health, enabling the effective incorporation of psychotropic medications. These medications, including antidepressants and antipsychotics, were crucial in managing symptoms such as irritability, anxiety and distorted self-perception related to body weight and image, which are characteristic of eating disorder. The success of this combined treatment approach was evident in the patient’s improved mood and stability, enhancing the receptiveness to further physical and mental health therapies.

This case study highlights the significant impact of a combined approach involving antipsychotic therapy, intense psychological treatment, and a tailored dietetic intervention in the management of a patient with a complex presentation of emotionally unstable personality disorder and eating disorder. This approach underscores the importance of addressing both the psychological and physiological aspects of such disorders in tandem.

Also, the dietary correction significantly contributed to the patient’s overall treatment progress, leading to a more structured and safer discharge plan from the hospital. This case study demonstrates that, in complex cases of emotionally unstable personality disorder and eating disorder, a holistic treatment plan that synergistically combines dietetic and psychotropic interventions can be highly effective, paving the way for a more comprehensive and successful patient management strategy.


 

Conflict de interese: niciunul declarat.

suport financiar: niciunul declarat.

Acest articol este accesibil online, fără taxă, fiind publicat sub licenţa CC-BY.

 

Bibliografie


  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th Ed.). Arlington, VA: American Psychiatric Publishing, 2013.
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  3. Treasure J, Claudino AM, Zucker N. Eating disorders. The Lancet. 2010;375(9714):583-593.
  4. Gunderson JG, Links PS. Handbook of good psychiatric management for borderline personality disorder. Arlington, VA: American Psychiatric Publishing, 2014.
  5. Frank GK, Kaye WH. Current status of functional imaging in eating disorders. International Journal of Eating Disorders. 2012;45(6):723-736.
  6. Lis S, Bohus M. Social interaction in borderline personality disorder. Curr Psychiatry Rep. 2013;15(2):338.
  7. Sansone RA, Sansone LA. Eating disorders and borderline personality: Common bedfellows. Innovations in Clinical Neuroscience. 2011;8(9):10-13.
  8. Oldershaw A, Lavender T, Sallis H, Stahl D, Schmidt U. Emotion generation and regulation in anorexia nervosa: a systematic review and meta-analysis of self-report data. Clin Psychol Rev. 2015;39:83-95.
  9. Fortisip Compact Nutritional Fact Sheet. https://www.nutricia.co.uk/hcp/pim-products/fortisip-compact.html 
  10. Musolino C, Warin M, Wade TD, Gilchrist P. Integrating dietetic therapy for patients with eating disorders and borderline personality disorder: A qualitative study. Clin Psychol Psychother. 2021;28(2):310-323.
  11. Musolino C, Warin M, Wade TD. Integrating dietetic therapy for patients with eating disorders and Emotional instability: A scoping review. Clin Psychol Rev. 2020;82:101904.
  12. Walsh BT, Kaplan AS, Attia E, et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA. 2006;296(7):694-701.
  13. Attia E, Walsh BT. Behavioral management for anorexia nervosa. N Engl J Med. 2009;361(1):74-81.
  14. National Institute for Health and Care Excellence (NICE). Eating disorders: recognition and treatment. 2017 [cited 2023 Mar 28]. https://www.nice.org.uk/guidance/ng69 
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