Management of Anorexia Nervosa
The management of anorexia nervosa requires a comprehensive multidisciplinary team approach that includes medical, psychiatric, psychological, and nutritional expertise to address the serious physical and psychological aspects of this potentially fatal eating disorder.
Initial Assessment
Medical Evaluation
- Vital signs assessment: temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure 1
- Physical examination: height, weight, BMI calculation (or percent median BMI/BMI percentile/Z-score for children), signs of malnutrition or purging behaviors 1
- Laboratory tests:
Psychiatric Evaluation
- Quantify eating and weight control behaviors (frequency, intensity, time spent on restriction, purging, exercise) 1
- Identify co-occurring psychiatric conditions (depression, anxiety, OCD) 1
- Comprehensive review of systems 1
Treatment Approach
1. Level of Care Determination
Categorical restriction from activities for:
- BMI <16 kg/m²
- Moderate-to-severe bulimia nervosa (purging >4 times/week) 1
Inpatient hospitalization indications:
- Medical instability
- Severe malnutrition
- Failed outpatient treatment
- Suicidal risk
- Lack of awareness of illness severity 2
2. Nutritional Rehabilitation
- Set individualized goals for weekly weight gain and target weight 1
- Target BMI >18.5 kg/m² for return to activities 1
- Monitor for refeeding syndrome in severely malnourished patients 2
- Gradual refeeding with careful monitoring 3
3. Psychotherapeutic Interventions
For adults: Eating disorder-focused psychotherapy that addresses:
- Normalizing eating behaviors
- Weight restoration
- Psychological aspects (fear of weight gain, body image disturbance) 1
For adolescents and emerging adults: Family-based treatment with:
- Caregiver education
- Focus on normalizing eating behaviors
- Weight restoration 1
4. Pharmacological Management
- Limited evidence for medications to restore weight or prevent relapse in anorexia nervosa 1
- Selective serotonin reuptake inhibitors may be helpful for co-occurring conditions (anxiety, depression, obsessive-compulsive behavior) 1
- Unlike bulimia nervosa, there is no specific medication recommendation for anorexia nervosa 1
Return to Activities Considerations
Return to physical activities or sports should be contingent on:
- BMI ≥18.5 kg/m²
- Cessation of disordered eating behaviors
- Close follow-up with the treatment team 1
Team physician has ultimate authority on return-to-play decisions 1
Long-term Management
- Prolonged monitoring to prevent relapse 3
- Recognition of risk factors for higher mortality:
- Illness duration >10 years
- BMI <16 kg/m²
- Alcohol abuse
- Poor social adjustment 1
Common Pitfalls to Avoid
- Underestimating severity: Anorexia nervosa has the highest mortality rate among psychiatric disorders
- Premature return to activities: Can worsen physical condition and reinforce eating disorder behaviors
- Inadequate follow-up: Long-term monitoring is essential as relapse is common
- Isolated treatment approaches: Success requires coordinated multidisciplinary care
- Overlooking co-occurring conditions: Depression, anxiety, and other psychiatric disorders often accompany anorexia and require treatment
Special Considerations
- Pregnancy, vegetarianism, and type 1 diabetes mellitus require specialized approaches 2
- Transition from pediatric to adult care requires careful planning 2
- Physical activity must be carefully managed and monitored 2
The most recent evidence emphasizes that anorexia nervosa treatment requires a holistic approach that addresses both psychological and physical aspects of the disorder, with treatment decisions guided by a multidisciplinary team with expertise in eating disorders 4.