What is the recommended treatment approach for anorexia nervosa?

Treatment of Anorexia Nervosa

For adolescents and emerging adults with anorexia nervosa who have an involved caregiver, family-based treatment (FBT) is the first-line psychotherapy; for adults, eating disorder-focused psychotherapy combined with nutritional rehabilitation to restore weight and normalize eating behaviors is the recommended approach. 1

Treatment Algorithm by Age Group

Adolescents and Emerging Adults

• Initiate family-based treatment (FBT) as first-line psychotherapy when an involved caregiver is available, as this approach has demonstrated consistent efficacy in randomized clinical trials for this age group 1, 2
• FBT empowers parents to take control of refeeding, addresses family dynamics, and provides psychoeducational guidance without systematically separating the patient from family 3

Adults

• Provide eating disorder-focused psychotherapy that simultaneously normalizes eating behaviors, restores weight, and addresses psychological aspects including fear of weight gain and body image disturbance 1
• Specialist supportive clinical management, cognitive-behavioral therapy, or interpersonal psychotherapy are all acceptable modalities, as no single approach has shown superiority in adults 4

Essential Multidisciplinary Components

All patients require coordinated care incorporating medical, psychiatric, psychological, and nutritional expertise 1:

Medical Management

• Measure temperature, resting heart rate, blood pressure, and orthostatic vital signs at initial evaluation to assess cardiovascular stability 1
• Document height, weight, and BMI (or percent median BMI for children/adolescents) 1
• Assess for physical signs of malnutrition including Russell's sign, parotid enlargement, and dental erosion 1
• Perform electrocardiogram in all patients with restrictive eating disorders to evaluate for QTc prolongation and cardiac complications, as up to one-third of deaths are cardiac-related 1

Laboratory Assessment

• Obtain complete blood count to detect anemia and leukopenia 1
• Order comprehensive metabolic panel including electrolytes (sodium, potassium, chloride, bicarbonate), liver enzymes, and renal function tests 1
• Approximately 60% of anorexia nervosa patients show normal laboratory values despite severe malnutrition, so normal results do not exclude serious illness 1
• Measure TSH and free T4 in patients with oligomenorrhea or amenorrhea 1

Nutritional Rehabilitation

• Set individualized goals for weekly weight gain and target weight for all patients requiring nutritional rehabilitation 1
• Most cardiac manifestations including bradycardia, QTc prolongation, and cardiac muscle atrophy are completely reversible with appropriate nutritional rehabilitation 1

Critical Management Considerations

Refeeding Syndrome Prevention

• Initiate slow, cautious refeeding with phosphorus supplementation to prevent refeeding syndrome, which can be fatal in severely malnourished patients 1
• Do not attempt rapid nutritional rehabilitation, as overzealous refeeding can trigger life-threatening ventricular arrhythmias and sudden cardiac death 1
• Nutrition may need to be provided via nasogastric tube or intravenously if oral intake is insufficient 1

Cardiac Monitoring

• Monitor QTc intervals in patients with restrictive eating, as prolonged starvation results in electrical cardiac abnormalities and sudden cardiac death is a frequent cause of mortality 1
• Low weight, low BMI, and rapid weight loss are the most important independent predictors of QTc interval prolongation 1

Hospitalization Criteria

• Patients with severe eating disorder complications must be medically stabilized in an acute care hospital setting before transfer to a specialized eating disorder program 1
• Do not delay hospitalization based on patient or family denial of illness severity, as eating disorders are life-threatening conditions requiring aggressive early intervention 1
• Assess and stabilize suicidality, as 25% of anorexia nervosa deaths are from suicide 1

Hormonal Abnormalities

• Assess for hypothyroidism, hypercortisolism, and hypogonadotropic hypogonadism, which are common in severe malnutrition 1
• These hormonal abnormalities typically resolve with nutritional rehabilitation and do not require specific treatment 1
• If true hypothyroidism is confirmed, initiate levothyroxine while carefully monitoring response 5

Common Pitfalls to Avoid

• Never rely on normal laboratory values to rule out medical instability, as most severely malnourished patients have normal routine testing 1
• Never delay hospitalization waiting for laboratory abnormalities to develop, as clinical assessment of vital signs and weight loss severity takes precedence 1
• Avoid prolonged, unbalanced, very low-calorie diets, as they may provoke life-threatening ventricular arrhythmias 1