What are the management principles of anorexia nervosa?

Management Principles of Anorexia Nervosa

A multidisciplinary team approach including medical, psychiatric, psychological, and nutritional expertise is the cornerstone of effective anorexia nervosa treatment, with Family-Based Treatment (FBT) as first-line for adolescents and Cognitive Behavioral Therapy (CBT) as a primary intervention for adults. 1

Core Treatment Components

Nutritional Rehabilitation

• Establish individualized weekly weight gain goals with a target BMI >18.5 kg/m² 1
• Implement structured meal planning with gradual increase in caloric intake 1
• Monitor carefully for refeeding syndrome, particularly in severely malnourished patients 2
  • Close monitoring of body weight, heart rate, rhythm, and serum electrolytes (especially phosphorus)
  • Begin with slow refeeding in severely malnourished patients to avoid complications

Psychological Interventions

• For adolescents and young adults with involved caregivers:

  • Family-Based Treatment (FBT) as first-line therapy 1

• For adults:

  • Cognitive Behavioral Therapy (CBT) focusing on challenging dysfunctional thoughts about food 1
  • CBT should emphasize what can be eaten rather than restrictions 1
  • Consider Interpersonal Therapy (IPT) as an alternative 1

• Delivery options:

  • Guided internet/computer-based CBT for patients with trauma history or fear of stigmatization 1
  • Videoconferencing for patients with limited access to specialists 1
  • Collaborative approach to set goals and design exposure tasks 1

Medical Management

• Regular monitoring of weight and nutritional status 1
• Ongoing evaluation of eating behaviors and trauma symptoms 1
• Careful assessment of vital signs 1
• Address medical complications through appropriate interventions 3

Activity/Exercise Restrictions

• Patients with BMI <16 kg/m² require categorical restriction from training and competition 1
• Return to sports only after achieving BMI >18.5 kg/m², cessation of bingeing/purging behaviors, and with close multidisciplinary follow-up 1

Treatment Settings and Intensity

• Treatment intensity should be matched to illness severity:
  • Outpatient care for medically stable patients
  • Residential/semi-residential for moderate cases
  • Hospitalization for medical/psychiatric emergencies 3, 4

Pharmacological Interventions

• Medications are generally not effective for primary symptoms of anorexia nervosa 4
• May be considered for comorbid conditions (depression, anxiety)

Common Pitfalls to Avoid

• Underestimating anorexia as a serious mental illness 1
• Premature return to sports before adequate weight restoration 1
• Failing to involve a multidisciplinary team 1, 5
• Inadequate monitoring for medical complications 1
• Not addressing underlying trauma 1
• Focusing solely on weight rather than normalizing eating behaviors 1

Prognosis Factors

• Worse outcomes associated with:
  • Longer illness duration
  • Lower BMI
  • Alcohol abuse
  • Poor social adaptation 1
• Early and comprehensive intervention improves prognosis 1, 5

Long-term Management

• Recognize anorexia nervosa as a chronic condition requiring long-term follow-up 1
• Periodic reevaluation to determine need for continued treatment 1
• Regular monitoring for relapse, especially during periods of stress or transition