Cognitive Behavioral Therapy for Anorexia Nervosa
For adults with anorexia nervosa, eating disorder-focused CBT is the recommended first-line psychotherapy, with the primary goals of normalizing eating behaviors, achieving weight restoration, and addressing core psychological features including fear of weight gain and body image disturbance. 1
Treatment Framework
Adults with Anorexia Nervosa
Eating disorder-focused psychotherapy, specifically CBT-based approaches, should be the cornerstone of treatment for adults with anorexia nervosa. 1 This represents a Level 1B recommendation from the American Psychiatric Association, indicating strong confidence with moderate research support. 1
The therapy must simultaneously address three core components: normalizing eating and weight control behaviors, restoring weight to healthy levels, and targeting the psychological drivers of the disorder (particularly fear of weight gain and body image disturbance). 1
Enhanced CBT (CBT-E) has shown effectiveness in both outpatient and intensive settings, with studies demonstrating significant improvements in BMI and eating disorder psychopathology. 2, 3, 4
Adolescents and Emerging Adults
Family-based treatment is the preferred approach for adolescents and emerging adults with anorexia nervosa when an involved caregiver is available, rather than individual CBT. 1 This treatment emphasizes caregiver education to normalize eating behaviors and restore weight. 1
Individual CBT-E can be effective for adolescents when delivered intensively, with no significant outcome differences compared to adults in treatment acceptance, dropout rates, or clinical improvements. 3
Evidence Quality and Real-World Implementation
Effectiveness Data
Intensive CBT-E programs (combining inpatient and day-hospital treatment) show strong completion rates exceeding 85% and significant improvements in weight, eating disorder psychopathology, and general psychiatric symptoms. 3, 4
In standard outpatient settings at public hospitals, CBT-E faces substantial challenges with dropout rates ranging from 50-69%. 5, 2 However, patients who complete treatment achieve meaningful outcomes, with 77% reaching target BMI >18.5 kg/m² by 12 months. 2
The simpler, eating disorder-focused version of CBT-E appears equally effective as the more complex version that additionally targets mood intolerance, perfectionism, and interpersonal difficulties, suggesting no benefit from the broader approach. 4
Critical Implementation Considerations
The high dropout rate in routine clinical practice (50-69%) represents the most significant challenge to CBT effectiveness for anorexia nervosa. 5, 2 This contrasts sharply with the >85% completion rates seen in intensive programs, suggesting that treatment intensity and structure significantly impact engagement. 3
Weight gains achieved during treatment can deteriorate after discharge, particularly in the first 6 months, though this decline is typically not severe if patients complete the full treatment course. 3, 4
Treatment should be delivered within a coordinated multidisciplinary team incorporating medical monitoring, psychiatric care, psychological therapy, and nutritional expertise to optimize outcomes. 1, 6
Technology-Based CBT Delivery
Technology-based CBT interventions currently have insufficient evidence for treating anorexia nervosa and cannot be recommended as primary treatment. 6 This stands in contrast to bulimia nervosa, where guided internet-based CBT shows established efficacy. 6, 7
Internet-based relapse prevention for anorexia nervosa patients transitioning from inpatient to outpatient care may help stabilize treatment gains, though evidence remains preliminary. 6
Unguided computer-based interventions are explicitly not recommended for anorexia nervosa treatment. 6
Treatment Structure
Standard outpatient CBT-E typically involves at least 40 sessions delivered over 12 months. 2
Intensive programs combine 13 weeks of inpatient treatment with 7 weeks of day-hospital care (20 weeks total), which may be necessary for severely ill patients who have not responded to outpatient treatment. 3, 4
Individualized goals for weekly weight gain and target weight must be established as part of nutritional rehabilitation. 1