Treatment of Anorexia Nervosa
Eating disorder-focused psychotherapy combined with nutritional rehabilitation and weight restoration is the primary treatment for anorexia nervosa, with no medications approved or recommended for routine use in weight restoration. 1
Primary Treatment Framework
For adolescents and emerging adults with involved caregivers, family-based treatment is strongly recommended as the first-line psychotherapeutic approach. 1, 2 This differs from adult treatment where no single psychotherapy has shown superiority, and options include specialist supportive clinical management, cognitive-behavioral therapy, or interpersonal psychotherapy combined with renourishment. 3
Core Treatment Components
- Nutritional rehabilitation with individualized weekly weight gain targets and goal weights must be established immediately. 2, 4
- Eating disorder-focused psychotherapy should normalize eating behaviors, restore weight, and address the psychological dimensions of the disorder. 2, 4
- A multidisciplinary team coordinating medical, psychiatric, psychological, and nutritional expertise is mandatory for effective treatment. 1, 5
Pharmacologic Considerations
The American Psychiatric Association explicitly states that no medications are approved for anorexia nervosa, and current evidence does not support routine pharmacologic treatment for weight restoration. 1 However, selective serotonin reuptake inhibitors may be beneficial specifically for treating comorbid anxiety, depression, and obsessive-compulsive behaviors that present as neuropsychiatric symptoms, not for the eating disorder itself. 2
Critical Pitfall to Avoid
- Do not prescribe oral contraceptives to "treat" amenorrhea in anorexia nervosa—they create false reassurance with withdrawal bleeding but do not restore spontaneous menses and may compromise bone health. 1
Initial Assessment Requirements
Before initiating treatment, the American Psychiatric Association mandates specific evaluations:
- Vital signs assessment (heart rate, blood pressure, temperature, orthostatic measurements). 1, 2
- Complete blood count and comprehensive metabolic panel including electrolytes, liver enzymes, and renal function. 1, 2, 4
- Electrocardiogram to evaluate cardiac status, particularly important given cardiovascular complications. 1, 2, 4
- Quantification of eating behaviors, weight control behaviors, and identification of co-occurring psychiatric disorders. 1, 2
Treatment Setting Algorithm
Outpatient treatment is appropriate for most patients, but specific criteria mandate inpatient care:
- BMI <16 kg/m² requires inpatient admission. 2
- Severe medical complications (cardiac arrhythmias, severe electrolyte disturbances, hemodynamic instability) necessitate inpatient care. 2, 6
- Significant psychiatric comorbidities including suicidality require inpatient treatment. 2, 6
Specialized eating disorder inpatient units with cognitive-behavioral frameworks provide superior outcomes compared to general psychiatric units, with medical management and nutritional rehabilitation as primary goals. 5
Special Population Considerations
**For young girls with BMI <16 kg/m², categorically restrict athletic training and competition until treatment goals are met.** 2 Future sports participation should only be considered after achieving BMI >18.5 kg/m², cessation of disordered behaviors, and establishment of close follow-up. 2
Monitoring During Treatment
- Weekly weight measurements during active weight restoration phase. 4
- Regular vital signs and laboratory parameter monitoring, with particular attention to electrolytes during refeeding. 2, 4
- Risk factors associated with higher mortality—longer illness duration, lower BMI, substance abuse, and poor social adjustment—require more intensive intervention. 2
Emerging Treatment Modalities
Guided computer-based interventions and videoconferencing show promise for overcoming barriers like shame, stigma, and provider shortages, though these are better established for bulimia nervosa than anorexia nervosa. 1