What is the recommended treatment approach for Anorexia Nervosa?

Treatment Approach for Anorexia Nervosa

For anorexia nervosa, the recommended treatment is a comprehensive, multidisciplinary approach centered on eating disorder-focused psychotherapy, with specific approaches differing between adults and adolescents. 1

Initial Assessment

A thorough initial evaluation should include:

• Medical assessment:

  • Vital signs (temperature, resting heart rate, blood pressure, orthostatic measurements)
  • Height, weight, BMI calculation
  • Physical examination for signs of malnutrition or purging behaviors 1
  • Laboratory tests: complete blood count, comprehensive metabolic panel 1
  • Electrocardiogram for patients with restrictive eating patterns or severe purging 1

• Psychiatric assessment:

  • Quantification of eating and weight control behaviors
  • Identification of co-occurring psychiatric conditions
  • Comprehensive review of systems 1

Treatment Algorithm for Anorexia Nervosa

For Adults:

1. Primary Treatment: Eating Disorder-Focused Psychotherapy

   • Should address three core components:
     • Normalizing eating behaviors
     • Restoring weight
     • Addressing psychological aspects (fear of weight gain, body image disturbance) 1

2. Nutritional Rehabilitation

   • Set individualized goals for weekly weight gain and target weight
   • For severely underweight patients (BMI <16 kg/m²), categorical restriction from physical activity until weight restoration 1

3. Treatment Setting Decision:

   • Outpatient: For medically stable patients without severe psychiatric comorbidity
   • Inpatient/Residential: Consider for:
     • BMI <16 kg/m²
     • Medical instability
     • Failed outpatient treatment
     • Severe psychiatric comorbidity 1

For Adolescents and Emerging Adults:

1. Primary Treatment: Family-Based Treatment (FBT)

   • Involves active caregiver participation
   • Includes caregiver education on normalizing eating behaviors and weight restoration
   • Has stronger evidence base than other approaches for this age group 1

2. Nutritional Rehabilitation

   • Similar to adults but with age-appropriate BMI targets (percentiles or Z-scores) 1

Special Considerations

• Treatment Resistance: Common in anorexia nervosa due to ego-syntonic nature of the disorder and denial of illness 2, 3

• Medical Monitoring: Regular assessment of vital signs, weight, and laboratory parameters throughout treatment 1

• Return to Activity: Athletes with anorexia nervosa should not return to training/competition until:

  • BMI >18.5 kg/m²
  • Cessation of disordered eating behaviors
  • Close follow-up with treatment team 1

• Long-term Follow-up: Essential due to high relapse rates, particularly for patients with:

  • Longer duration of illness (>10 years)
  • Lower BMI (<16 kg/m²)
  • Alcohol abuse
  • Poor social adjustment 1

Treatment Team Components

The multidisciplinary team should include:

• Psychiatrist (often coordinating care)
• Primary care physician or other medical specialists
• Nutritionist/dietitian
• Psychotherapist with eating disorder expertise 1, 4

Common Pitfalls to Avoid

• Underestimating medical severity: Anorexia has the highest mortality rate among psychiatric disorders
• Inadequate weight restoration: Correlational data suggest weight-restored patients are less likely to relapse 3
• Premature return to activity: Athletes should not return to training until medically stable and at appropriate weight 1
• Insufficient treatment duration: Treatment should continue through weight restoration into relapse prevention phase 3
• Neglecting family involvement: Particularly important for adolescents 1

The evidence strongly supports that early intervention with appropriate intensity of care improves outcomes and reduces chronicity in anorexia nervosa 1, 2, 5.