What is the treatment approach for a patient with suspected Anorexia Nervosa?

Treatment Approach for Anorexia Nervosa

Initial Assessment and Diagnosis

The initial evaluation must establish diagnosis, determine illness severity through comprehensive medical and nutritional assessment, and perform psychosocial evaluation before initiating treatment. 1

Physical Examination Components

• Measure vital signs including temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure 1
• Document height, weight, BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents) 1
• Assess physical appearance for signs of malnutrition or purging behaviors 1
• Quantify total weight loss, percent below ideal body weight, and types/frequency of purging behaviors (vomiting, laxatives, starvation) 1

Laboratory and Cardiac Evaluation

• Obtain complete blood count and comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests 1
• Perform electrocardiogram in all patients with restrictive eating disorder or severe purging behavior 1
• Note that normal test results do not exclude serious illness or medical instability 1

Psychosocial Assessment

• Evaluate degree of obsession with food and weight, understanding of diagnosis, and willingness to receive help 1
• Assess functioning at home, school, and with friends 1
• Screen for comorbid psychiatric diagnoses including depression, anxiety, obsessive-compulsive disorder 1
• Evaluate history of physical or sexual abuse, violence, and suicidal ideation 1
• Assess parents' reaction to illness, as denial or treatment disagreements may exacerbate the condition 1

Primary Treatment Strategy

Adults with anorexia nervosa should be treated with eating disorder-focused psychotherapy that includes normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects such as fear of weight gain and body image disturbance. 1

Adolescents and emerging adults with anorexia nervosa who have an involved caregiver should be treated with eating disorder-focused family-based treatment, which includes caregiver education aimed at normalizing eating and weight control behaviors and restoring weight. 1

Weight Restoration Goals

• Set individualized weekly weight gain targets of 0.5-1 kg per week for patients requiring nutritional rehabilitation 1
• Establish target weight based on age, height, stage of puberty, premorbid weight, and previous growth charts 1
• For growing children/adolescents, reevaluate goal weight at three- to six-month intervals based on changing age and height 1

Treatment Setting Determination

Outpatient Treatment Criteria

• Medically stable patients can be treated as outpatients even with severe or extreme anorexia nervosa 2
• Outpatient treatment is preferred for early intervention as it is less disruptive, less costly, and has shorter waiting lists than inpatient care 2

Inpatient Treatment Indications

• Severe malnutrition with cardiovascular instability 1
• Electrolyte abnormalities requiring immediate correction 1
• Complete food refusal 1
• Medical instability despite outpatient management 2

Multidisciplinary Team Coordination

All patients with anorexia nervosa require a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team. 1

• Medical stabilization and nutritional rehabilitation are the most crucial determinants of short- and intermediate-term outcomes 1
• Individual and family therapy, especially when working with younger patients, are crucial to long-term prognosis 1

Pharmacological Considerations

No medications are approved for anorexia nervosa, and current evidence does not support routine pharmacologic treatment for weight restoration. 3

• Psychotherapy combined with nutritional rehabilitation remains the cornerstone of treatment 3
• Medications may be considered for comorbid psychiatric conditions (depression, anxiety, OCD) but should not replace primary eating disorder treatment 1

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 3
• Do not rely solely on laboratory values to determine medical stability, as most patients have normal results despite serious illness 1
• Do not delay treatment while waiting for full DSM criteria to be met—more than half of children and adolescents with eating disorders do not fully meet criteria but still experience the same medical and psychological consequences requiring immediate attention 1

Monitoring Complications

Electrolyte Abnormalities

• Monitor for hypokalemia and hypochloremic alkalosis from purging behaviors 1
• Assess for hyponatremia or hypernatremia from fluid manipulation as part of weight control 1

Endocrine Disorders

• Screen for hypothyroidism, hypercortisolism, and hypogonadotropic hypogonadism 1

Emerging Treatment Modalities

• Guided computer-based interventions and videoconferencing show promise for overcoming barriers like shame, stigma, and provider shortages 1, 3
• Technology-based interventions may offer immediate access to evidence-based treatments for patients who otherwise may not access help 1