What is the best approach for treating anorexia?

Best Approach for Treating Anorexia Nervosa

The best approach for treating anorexia nervosa is a multidisciplinary treatment program that combines eating disorder-focused psychotherapy (particularly family-based treatment for adolescents) with nutritional rehabilitation and medical monitoring, with inpatient care necessary for severely malnourished patients (BMI <16 kg/m²). 1, 2

Assessment and Diagnosis

• A comprehensive psychiatric evaluation must include quantifying eating behaviors, weighing the patient, and identifying co-occurring psychiatric disorders 1
• Physical examination should assess vital signs, height, weight, BMI, and physical appearance for signs of malnutrition 1
• Laboratory assessment should include complete blood count, comprehensive metabolic panel, electrolytes, liver enzymes, and renal function tests 1
• An electrocardiogram is essential for patients with restrictive eating behaviors 1

Treatment Approach Based on Age and Severity

For Adolescents and Young Adults

• Family-based treatment is strongly recommended as the first-line approach for adolescents and emerging adults with involved caregivers 1, 2
• This approach empowers parents to take control of the refeeding process and gradually return control to the adolescent as they demonstrate improved eating behaviors 2

For Adults

• A combination of renourishment and psychotherapy is recommended 2
• Effective psychotherapies include specialist supportive clinical management, cognitive behavioral therapy, and interpersonal psychotherapy 2
• No single psychotherapeutic approach has demonstrated clear superiority for adults 2

Treatment Intensity and Setting

• Treatment setting should be determined by illness severity and medical stability 1, 3
• Inpatient treatment is necessary when:
  • BMI is dangerously low (<16 kg/m²) 1, 3
  • Severe medical complications are present 1
  • Significant psychiatric comorbidities exist 1
• For severely malnourished patients (BMI ≤13.5 kg/m²), intensive inpatient treatment with enteral nutrition support may be required until the patient is medically stable 3
• Outpatient treatment is appropriate for medically stable patients 1

Nutritional Rehabilitation

• Individualized goals for weekly weight gain and target weight are essential 1
• For severely malnourished patients, nasogastric feeding may be temporarily necessary until the patient is no longer at life risk 3
• The target BMI should be at least 18.5 kg/m² before transitioning to less intensive care 1, 3

Emerging Treatment Approaches

• Technology-based interventions (TBIs) show promise as adjunctive treatments, particularly for delivering evidence-based treatments to patients who may not otherwise access help 4
• Videoconferencing appears to be a promising approach for delivering therapy remotely 4
• Mobile interventions show preliminary evidence of efficacy 4

Special Considerations

• Young patients with BMI <16 kg/m² should be restricted from athletic training and competition until treatment goals are met 1
• Future participation in sports should only be considered after achievement of BMI >18.5 kg/m², cessation of disordered behaviors, and with close follow-up 1
• Risk factors associated with higher mortality rates requiring more intensive intervention include longer illness duration, lower BMI, substance abuse, and poor social adjustment 1

Common Pitfalls and Caveats

• Focusing exclusively on weight restoration without addressing psychological factors is a common mistake 5
• Treatment should take a holistic approach rather than an overly narrow focus on weight restoration 5
• Overspecialization and siloing of treatment approaches can hinder effective care 5
• Older patients and those with longer illness duration before admission may be at higher risk for treatment dropout 3
• The evidence base for anorexia nervosa treatment is still developing, with many methodological challenges hindering progress in controlled research 2