Treatment Approach for Anorexia Nervosa
Adults with anorexia nervosa should receive eating disorder-focused psychotherapy as the primary treatment, combined with individualized nutritional rehabilitation and weight restoration goals, while adolescents and emerging adults with involved caregivers should receive family-based treatment. 1
Primary Treatment Framework
For Adults
- Eating disorder-focused psychotherapy is the cornerstone of treatment, which must include three core components: normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects such as fear of weight gain and body image disturbance 1
- No medications are FDA-approved or recommended for anorexia nervosa, as current evidence does not support routine pharmacologic treatment for weight restoration 2, 3
- Set individualized weekly weight gain goals and target weight for patients requiring nutritional rehabilitation 1
For Adolescents and Emerging Adults
- Family-based treatment with caregiver involvement is strongly recommended when an involved caregiver is available 1, 2
- This approach includes caregiver education specifically aimed at normalizing eating behaviors and restoring weight 1
- Family therapy or counseling should be systematically provided to support parents, provide psychoeducational guidance, and help families acquire new behaviors 4
Mandatory Initial Assessment
Before initiating treatment, complete the following evaluations:
Vital Signs and Physical Examination
- Temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure 1
- Height, weight, and BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents) 1
- Physical appearance assessment for signs of malnutrition or purging behaviors 1
Laboratory Assessment
- Complete blood count 1, 2
- Comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests 1, 2
- Electrocardiogram is mandatory in patients with restrictive eating disorders, as QTc prolongation is a critical risk 1, 2
Psychiatric Evaluation
- Weigh the patient and quantify eating and weight control behaviors (frequency, intensity, time spent on dietary restriction, binge eating, purging, exercise, and other compensatory behaviors) 1
- Identify co-occurring psychiatric disorders 1
- Conduct comprehensive review of systems 1
Multidisciplinary Team Coordination
- All patients require a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise through a coordinated multidisciplinary team 1, 2
- Most patients can be treated on an outpatient basis, but inpatient care is indicated for severe medical conditions or severe comorbid psychiatric illness 4, 5
Treatment Setting Escalation
When outpatient treatment fails, consider escalating through the following settings:
- Specialized eating disorder outpatient service 5
- Highly intensive eating disorder outpatient or home treatment program 5
- Eating disorder daycare 5
- Inpatient eating disorder service 5
- For patients with several years of futile treatment, deep brain stimulation should be considered to prevent chronic course 5
Nutritional Intervention Escalation
Progress through these interventions as clinically indicated:
- Nutritional counseling as first-line approach 5
- Nasogastric tube feeding for patients unable to achieve adequate oral intake 5
- Percutaneous endoscopic gastrostomy (PEG) for patients who rely on long-term nasogastric tube feeding 5
- Nasojejunal tube feeding for patients who vomit despite nasogastric tube 5
Critical Pitfalls to Avoid
- Do not use oral contraceptives to "treat" amenorrhea in anorexia nervosa, as they create false reassurance with withdrawal bleeding but do not restore spontaneous menses and may compromise bone health 2
- Do not separate young patients systematically from their families during treatment, as family involvement is therapeutic 4
- Avoid prolonged unsuccessful treatment without escalation, as this increases risk of chronic disease course 5