What is the treatment for anorexia nervosa?

Treatment for Anorexia Nervosa

Adults with anorexia nervosa should be treated with eating disorder-focused psychotherapy combined with individualized nutritional rehabilitation and weight restoration goals, while adolescents and emerging adults with involved caregivers should receive family-based treatment. 1

Treatment Algorithm by Age and Caregiver Involvement

For Adolescents and Emerging Adults with Involved Caregivers

• Family-based treatment is the recommended first-line approach, focusing on caregiver education to normalize eating behaviors and restore weight 1, 2
• This approach shows superior long-term outcomes in patients with early onset and short illness duration, with benefits persisting 5 years after treatment completion 3

For Adults

• Eating disorder-focused psychotherapy is the cornerstone of treatment, specifically addressing normalization of eating patterns, weight restoration, fear of weight gain, and body image disturbance 1, 4
• Cognitive-behavioral therapy (CBT) demonstrates the strongest evidence for post-hospitalization care, with a 22% relapse rate compared to 73% treatment failure with nutritional counseling alone 5
• Individual supportive therapy may be preferred for patients with late-onset anorexia nervosa 3

Pharmacologic Considerations

• No medications are FDA-approved or recommended for anorexia nervosa, as current evidence does not support routine pharmacologic treatment for weight restoration 4, 6
• Psychotherapy remains the primary treatment modality, with medications reserved only for managing co-occurring psychiatric disorders 4

Essential Initial Assessment Components

Physical Examination Requirements

• Vital signs including 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 signs of malnutrition or purging behaviors 1

Laboratory Assessment

• Complete blood count and comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests 1, 2
• Electrocardiogram for all patients with restrictive eating disorders, as cardiac complications are common 1, 4

Behavioral Quantification

• Document frequency, intensity, and time spent on dietary restriction, binge eating, purging, exercise, and other compensatory behaviors 1
• Identify all co-occurring psychiatric disorders, which are highly prevalent in this population 1, 7

Multidisciplinary Team Structure

Treatment requires coordination among multiple specialists 1, 2:

• Primary care or sports medicine physician for medical monitoring, physical examinations, and care coordination 2
• Mental health practitioner delivering specialized eating disorder-focused psychotherapy 2
• Registered dietitian/nutritionist providing nutritional rehabilitation, meal planning, and education 2
• Psychiatrist for medication management of psychiatric comorbidities 2
• Additional specialists as needed: endocrinologist for hormonal complications, cardiologist for cardiac issues, exercise physiologist for activity guidance 2

Nutritional Rehabilitation Specifics

• Set individualized weekly weight gain goals and target weight for each patient requiring weight restoration 1
• Progress from nutritional counseling to more intensive interventions if needed 8
• In severe cases requiring escalation: nasogastric tube feeding, percutaneous endoscopic gastrostomy (PEG) for those dependent on tube feeding, or nasojejunal tube feeding for patients who vomit despite nasogastric tubes 8

Treatment Escalation for Non-Responders

When outpatient treatment fails, escalate systematically 8:

• Highly intensive outpatient or home treatment programs 8
• Eating disorder daycare programs 8
• Inpatient eating disorder services or residential treatment 8
• For patients with several years of futile treatment, consider deep brain stimulation (DBS) to prevent chronic disease course 8

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 4
• Avoid relying solely on nutritional counseling without psychotherapy, which has a 73% treatment failure rate 5
• Do not continue the same unsuccessful treatment without escalation—regularly review and modify the treatment plan 8
• Recognize that many patients, particularly adults, do not derive sufficient benefit from existing treatments, requiring adaptive treatment approaches 6

Emerging Treatment Options

• Technology-based interventions including guided computer-based programs and videoconferencing show promise for overcoming barriers like shame, stigma, and provider shortages 4, 2
• These approaches may be particularly useful for patients in areas with limited access to specialized eating disorder services 2