What is the best course of treatment for a 17-year-old female with severe anxiety who has stopped eating?

Treatment of a 17-Year-Old Female with Severe Anxiety Who Has Stopped Eating

This patient requires immediate hospitalization for medical stabilization before any psychiatric intervention can be effective, as refusal to eat constitutes a life-threatening emergency regardless of whether the underlying cause is anxiety, an eating disorder, or another psychiatric condition. 1

Immediate Medical Assessment and Stabilization

The first priority is determining medical stability, not psychiatric diagnosis. This patient needs:

• Vital signs measured immediately: temperature, resting heart rate, blood pressure, and orthostatic changes (pulse and blood pressure) to assess for imminent risk of sudden cardiac death from malnutrition-induced cardiac complications 2, 1

• Weight, height, and BMI documentation to establish severity of malnutrition 2, 1

• ECG obtained urgently to assess for QTc prolongation and bradycardia, which predict sudden cardiac death risk in malnourished patients 2, 1, 3

• Laboratory tests ordered stat: comprehensive metabolic panel (electrolytes, liver enzymes, renal function) and complete blood count to identify life-threatening abnormalities like hypokalemia, hypophosphatemia, or metabolic alkalosis 2, 1, 3

Critical caveat: Approximately 60% of severely malnourished patients show normal routine laboratory values despite life-threatening malnutrition, so normal labs do not exclude serious illness. 3

Life-Threatening Complications Requiring Hospital Management

If the patient is medically unstable (bradycardia, hypotension, orthostatic changes, QTc prolongation, or significant weight loss):

• Initiate slow, cautious refeeding with phosphorus supplementation to prevent fatal refeeding syndrome 1, 3

• Provide nutrition via nasogastric tube or intravenously if oral intake is insufficient due to refusal 1, 3

• Monitor cardiac status continuously with serial ECGs, as up to one-third of deaths in severe malnutrition are cardiac-related, and QTc intervals can worsen during early refeeding 1, 3

• Do not attempt rapid nutritional rehabilitation, as this increases risk of fatal refeeding syndrome characterized by electrolyte shifts and cardiac arrhythmias 1, 3

Psychiatric Assessment After Medical Stabilization

Once medically stable, determine the primary psychiatric diagnosis:

If This Is an Eating Disorder (Anorexia Nervosa):

Family-based treatment (FBT) is the first-line psychotherapy for this 17-year-old with an involved caregiver, which includes caregiver education aimed at normalizing eating behaviors and restoring weight. 2, 3, 4

• Set individualized goals for weekly weight gain and target weight 2, 3
• Address psychological aspects including fear of weight gain and body image disturbance 2
• Continue medications for 6-12 months after remission 5

If This Is Primary Severe Anxiety Causing Food Refusal:

Cognitive-behavioral therapy (CBT) is the first-line psychotherapy with the highest level of evidence for anxiety disorders in adolescents, combined with an SSRI if there is minimal response to psychotherapy alone by 6 weeks. 2, 6, 5

• Start sertraline or another SSRI as first-line pharmacotherapy (SSRIs show standardized mean difference of -0.55 for generalized anxiety disorder compared to placebo) 6, 5
• Alternatively, use an SNRI like venlafaxine extended-release 6, 5
• Do not use benzodiazepines for routine treatment 5

Coordinated Multidisciplinary Care Plan

A documented, comprehensive treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise is required, commonly via a coordinated multidisciplinary team. 2, 3

• Medical monitoring by primary care or adolescent medicine physician 3
• Psychiatric management of anxiety and/or eating disorder 2
• Registered dietitian for nutritional rehabilitation and meal planning 7, 3
• Individual psychotherapy (CBT or FBT depending on diagnosis) 2

Critical Management Principles

The principle "in dubio pro vita" (when in doubt, favor life) applies when the patient lacks capacity to make informed decisions, which may be the case with severe anxiety or eating disorder psychopathology. 1

• Do not delay hospitalization based on patient or family denial of illness severity 1, 3
• Assess suicidality regularly, as both eating disorders and anxiety disorders carry elevated mortality risk 1, 3
• Screen for co-occurring psychiatric disorders (depression, other anxiety disorders) as these are highly comorbid and affect treatment planning 2
• Address the patient's medical instability first before transfer to a psychiatric eating disorder program 1, 3

Common pitfall to avoid: Treating this as a purely psychiatric problem without addressing medical instability can be fatal. The cardiac complications (bradycardia, QTc prolongation) are directly related to starvation and are completely reversible with appropriate nutritional rehabilitation, but require careful medical monitoring during refeeding. 3