Approach
The goals of treatment for AN include helping the individual return to a healthy weight range, normalizing eating patterns and behaviors, and establishing a healthy relationship with food and with their body weight, shape, and size.[70]
Treatment includes helping the person with anorexia nervosa to identify strategies to prevent relapse following weight restoration. Treatment settings may vary given the severity of illness presentation and issues such as availability of specialized clinical services to the patient. Treatment may additionally vary based on the person's willingness to participate in recommended treatment, and in social supports available to them.
Effective treatments for AN, across a range of available settings, include behavioral management and supervised meals. Evidence-based therapies such as cognitive behavioral therapy (CBT), focal psychodynamic psychotherapy, or for adolescents, family-based therapy may be included in treatment plans.[65][66][84] Treatment for AN may include telehealth delivery of services, if appropriate. Various psychotherapeutic approaches have been adapted for remote delivery.
It is important to note that starting nutritional rehabilitation may be associated with intensely distressing feelings for patients; psychosocial support for the individual receiving treatment with conveyance of empathy and compassion is a cornerstone of effective treatment.[67]
Urgent and acute considerations
Any patient with a severe eating disorder can deteriorate rapidly, and should be referred without delay to secondary care.[67] Many patients will require acute inpatient medical stabilization and management of medical complications associated with the presenting illness.
Use clinical judgment, but note that inpatient care is generally recommended for patients with:[66][67][85]
Life-threatening weight loss (e.g., BMI <15 in adults or <75 % of median BMI for age and sex in children and adolescents)
Precipitous loss of weight (e.g., recent loss of >1 kg for two consecutive weeks)
Evidence of medical complications of illness, including significant bradycardia (e.g., pulse <50 bpm), hypotension or postural drop (e.g., >20 mmHg) with dizziness, hypothermia (e.g., core temperature <96.8°F, abnormal ECG results (e.g., prolonged QTc >450 or other significant ECG abnormalities) or with evidence of cardiac failure
Laboratory abnormalities (e.g., low sodium, potassium, phosphate, magnesium, or glucose)
Evidence of refeeding syndrome, or at high risk for refeeding syndrome
An indication for compulsory treatment under mental health legislation due to refusal of life-threatening treatment
Psychiatric instability including suicidality or psychosis
Guidelines are available that provide a comprehensive list of parameters supporting the need for medical or psychiatric inpatient hospitalization, according to whether the person with anorexia is a child or adult. Clinicians should be familiar with the applicable local guidance based on their practice location.[66][67]
Hospital care may be either within medical or psychiatric facilities depending on the degree and severity of physical symptoms, and the experience of the unit in managing malnutrition.[83]
Care setting
Treatment for AN may be carried out in settings of various intensity (i.e., levels of care).[86] Patients may receive care across a continuum of treatment settings, either stepping up from less restrictive settings (e.g., outpatient) to those that are more structured if needed, or stepping down from hospital or residential treatment to settings that are less intensive.
Clinicians should determine whether outpatient, day patient, residential, or inpatient treatment is appropriate for the clinical needs of a patient with AN. In determining the patient’s initial level of care, or whether to change to a different level of care, consider a number of factors including their:[66]
Overall physical condition
Behaviors and cognitions
Affective state
Social circumstances
When shifts are made in the care setting and location of care, continuity of care is essential.[66] Consultation with a psychiatrist and/or eating disorder specialist is important for general clinical guidance, and to establish team leadership and primary clinical responsibility for the patient's care.
Individuals with AN may require structured treatment settings to help them achieve improved weight and eating behavior. Hospital-based care is the most intensive, whether offered on a psychiatric unit for behavioral health management, or on a medical unit for medical stabilization. Patients treated in a medical facility should ideally have ongoing support from a consultant psychiatrist with experience and training in the management of severe eating disorders, to work in partnership with the physician responsible for their medical care. While voluntary admission to hospital is always preferred, involuntary treatment may be necessary for the treatment-refusing patient who is medically or psychiatrically unstable.[65][85]
If available, residential treatment programs (e.g., specialist eating disorder units) may serve as an alternative to hospitalization. Like hospitals, residential programs offer 24 × 7 care, but with less intensive medical monitoring. Some medical treatments (e.g., intravenous infusions) may not be available in residential programs. Residential treatment is generally recommended for patients with low weight without marked medical instability.
It should be noted that for adolescents, hospitalization, and residential treatment may pose challenges to emerging autonomy; health professionals working within these settings should be cognisant of the potential need to assist the young person in coping with a loss of independence by adapting existing hospital facilities and services to better meet adolescent developmental needs, for example, by ensuring confidentiality, offering private spaces, and providing the young person with developmentally appropriate psychological support and reassurance.[87]
When a patient is not in need of hospital-based care, and when a good patient-clinician relationship exists with family support, the patient may be monitored as an outpatient.[85] Structured outpatient programs may include full-day or part-day treatment on several or most days of the week. Structured outpatient programs are appropriate for outpatients who require some meal supervision and other supports, whose weight and health status is not severe enough to require residential or hospital care.
Weight restoration and nutrition
Nutritional rehabilitation for individuals with AN requires a nutritionally balanced meal plan with adequate calories for weight restoration, with the aim of restoring weight, normalizing eating patterns, and achieving normal perceptions of hunger and satiety. Furthermore, in those who are seriously underweight, malnourished, or medically unstable, goals of nutritional treatment are to restore medical stability (e.g., normalizing vital signs, electrolytes, and fluid balance), and to correct biological and psychological sequelae of malnutrition. Once weight restoration has been achieved, maintenance of healthy weight range is key.[66]
Oral feeding is preferred, but some patients may not gain weight when fed orally, or may express a preference for nasogastric feeding.[67] Use of nasogastric feeding can be associated with complications such as nasal irritation, epistaxis, electrolyte disturbance, patient distress, and patient-initiated nasogastric tube removal. Consequently, it is recommended that nasogastric tube feeding is viewed as a short-term intervention with the goal of transitioning to oral intake.[66]
Caloric prescription can commonly begin at significantly higher levels than the patient had been consuming prior to treatment.[88] Guidelines on initiation of caloric prescription vary significantly, and international practices vary; note that patients with risk factors for refeeding syndrome may require slower rates of caloric increase (see below). Many clinics now use higher initial caloric prescriptions than have been used historically (e.g., 1500-2000 kcal/day) and faster rates of renourishment because the literature has not shown an association between higher caloric intake during nutritional rehabilitation and the development of refeeding syndrome when patients are under close medical monitoring with electrolyte correction (e.g., for hypophosphatemia) as needed.[66]
Caloric prescriptions may increase by 400 kcal/day every 48-72 hours if patients tolerate prior caloric level. Peak caloric requirements in treatment programs that aim to help patients achieve full weight restoration typically reach between 3000 and 4000 kcal/day. Meal plans may include liquid supplements as snacks in addition to solid foods.[89][90]
Patients with risk factors for refeeding syndrome (e.g., those with very low weight <70% average body weight, preexisting electrolyte or renal abnormalities, infection, or other medical complications) may require lower initial caloric intake, with caloric increases over a longer period of time, in combination with careful monitoring of electrolytes and clinical state, in order to mitigate this risk.[67][88]
Dietary assessment and guidance by registered dietitian or nutritionist with specific expertise in AN is beneficial to identify specific deficiencies and to develop an optimal plan.[66]
Vitamins and minerals (e.g., multivitamin, phosphorus, magnesium, and calcium) should be given until the patient's diet contains enough to meet their dietary reference values.[65] No specific nutritional regimen is considered most optimal, as the calorie intake per day is the most important goal.[91] Thiamine supplementation should be specifically considered. Additionally, patients should normalize fluid intake, given the tendency in AN to consume excessive fluids to assuage hunger or to inflate measured weight. Monitoring and restriction may be necessary. Limitation of caffeine intake should also be considered, as caffeine may be used by people with AN to suppress appetite.[92]
Setting weight targets
It is recommended that an individually determined target for weight is established as part of the initial treatment plan.[66] Factors to guide this target include body mass index (BMI) guidelines (e.g., BMI >20 kg/m²), commonly available weight-for-height tables (e.g., Metropolitan Life Actuarial Tables), the individual's pre-illness weights, or, for younger patients, their growth charts.[80] In adolescents, target weight will need to be adjusted upward to correspond to increases in the patient’s height, and it can be helpful to discuss this with them from the initiation of treatment. During a period of growth, it is recommended that the target weight be reassessed every 3-6 months.[66]
Typically the target weight will be discussed explicitly with the patient, but this can require considerable sensitivity; it may be sensible to delay this discussion in some circumstances, until the person with AN is less fearful of their ultimate weight.[66]
Clinical consensus suggests that realistic targets are 2-4 lb/week for patients in residential or inpatient programs, at least 1-3 lb/week for patients in partial hospital programs, and at least 1-2 lb/week for individuals in outpatient programs.[66] Outpatients should be weighed weekly and inpatients at least several times each week. Patients should be weighed using consistent procedures. For example, patients should be weighed at a consistent time of day (e.g., early morning postvoiding, prebreakfast), in such a manner as to minimize manipulation of weight data (e.g., wearing a hospital gown or light clothing). People with AN require support and sensitivity during weighing procedures as these are frequently associated with anxiety and distress. Note that patients differ in the extent to which they wish to be informed of their weight, with some wanting to know specific values and others wanting only to know whether they have met their weekly weight targets.[66]
Difficulties with adherence
If a person with AN strongly resists renourishment, initial recommended steps include offering choices about the type of foods/supplements. Additional support, for example from a dietitian, with or without a nurse experienced in eating disorder management, may be beneficial, and can help with providing explanations of the need for refeeding and in alleviating concerns relating to fear of weight restoration.[67] It is recommended that healthcare staff aim to convey to the individual their intention to take care of them and not let them die even when the illness prevents the person with AN from taking care of themselves.[66]
If a patient with AN declines treatment when their physical health is seriously compromised by their illness, involuntary treatment may become necessary.[65][85] This is ethically and clinically justified only when a patient’s decision-making capacity regarding appropriate treatment for their eating disorder is impaired, the risk of death or serious morbidity is high, and the likelihood of benefit from involuntary treatment outweighs the risk of harm.[66]
In this scenario, clinicians should utilize the legal frameworks for compulsory treatment appropriate to their country of practice. If a child or young person with AN refuses treatment in the context of serious medical compromise, parents or caregivers will usually serve as guardians for such minors, consenting on behalf of their children, and if necessary, using an appropriate legal framework for compulsory treatment. Feeding people without their consent should only be performed within appropriate legal constructs, and should only be carried out by multidisciplinary teams who are competent to do so and who are trained in safe control and restraint techniques.[65][67]
Involuntary feeding commonly relies on the use of a nasogastric tube, usually as a short-term measure. Some patients may have fewer gastrointestinal symptoms with tube feeding via the small intestine and use of a Dobhoff or "duo" tube. In rare situations, for example, where longer-term parenteral feeding is required and the patient attempts to remove the tubing, surgically placed tubing, such as a gastrostomy or jejunostomy tube, may be considered, although the use of such an approach is not preferred.[66] Total parenteral nutrition is recommended only as a treatment of last resort when all other options for nutritional supplementation have been attempted; it requires intensive medical monitoring and is associated with an increased risk of serious adverse effects including hepatic injury, sepsis, disseminated intravascular coagulation, and refeeding syndrome.[66] Degree of voluntariness regarding treatment, competency for clinical decision-making, and legal construct for involuntary treatment are common considerations for individuals who require feeding by surgically placed tubes.
Physical health considerations during refeeding
The risk of adverse medical effects from nutritional rehabilitation in malnourished people with AN is highest during the first week of renourishment. Refeeding syndrome is the most serious complication.[66]
It is recommended that, during the refeeding process, laboratory values (including phosphate and glucose) and vital signs (including weight and other evidence of excessive fluid accumulation) should be closely monitored; consultation with internal medicine is typically necessary.
For inpatients, laboratory values should typically be monitored daily initially (twice daily in the presence of risk factors for refeeding syndrome).[67] Patients with nasogastric or intravenous methods are at higher risk for refeeding syndrome and need to be carefully monitored.
Refeeding syndrome is uncommon, but potentially dangerous. It is characterized by rapid reductions in phosphate, potassium, and magnesium, water dysregulation, and altered glucose metabolism, and can lead to fatal cardiac complications. Other risk factors for refeeding syndrome include very low weight (<70% average body weight), pre-existing electrolyte or renal abnormalities, infection, or other medical complications.[67][88] For patients with risk factors for refeeding syndrome, a slower rate of caloric increase may be required, and it is advisable to restrict calories from carbohydrate and increase dietary phosphate.[67][83][88]
Oral supplementation of phosphate and magnesium is recommended when serum electrolyte levels of these minerals are low, and also in the presence of other risk factors for refeeding syndrome, together with regular assessment of cardiac function (auscultation of lungs, blood test for B-type natriuretic peptide).
Signs of refeeding syndrome include hypophosphatemia (which is the hallmark biomarker), congestive heart failure, and mental status change.[93] Patients may also develop edema; although mild and transient edema may develop during refeeding in the absence of refeeding syndrome, significant edema indicates a need for careful monitoring for signs and symptoms of refeeding syndrome. Immediate attention is necessary if there are changes in mental status, tachycardia, congestive heart failure, abdominal pain, prolonged QT interval, serum potassium levels <3 mEq/L (<3 mmol/L), and serum phosphate levels <2.5 mg/dL (<0.8 mol/L).[93] If refeeding syndrome develops, referral to emergency medical care is required, with continuous cardiac monitoring. A patient with refeeding syndrome will typically need to be managed by a physician experienced in managing this life-threatening complication and may need to be in the intensive care unit.
It is important to monitor electrolytes with specific attention to potassium in patients who induce vomiting or misuse laxative medications. Repletion for those with potassium levels >3.2 mEq/L can usually be achieved with foods alone if purging behaviors are interrupted. If purging behavior is interrupted as proper nutrition is established, potassium levels generally correct in several days. For lower levels, or for patients who are still purging, oral supplementation is generally helpful, and may be required for several days. Intravenous potassium chloride may be given together with fluids for significant hypokalemia (e.g., <2.8 mEq/L) when patients present to intensive medical settings. Simple replacement may provide adequate correction, but if refractory, may be due to concomitant hypomagnesemia or hypocalcemia. These deficits must be corrected first, and consultation with internal medicine is recommended.[92][94]
Constipation is a frequent complaint, and patients will need a great deal of encouragement, and often some nonstimulant laxative medications (such as fiber-containing, and osmotically active agents) during the refeeding process.[66]
Correction of fluid intake
Monitor fluid intake during the renourishment process. Initially the patient may not have adequate fluid intake, especially if symptoms include fluid loss from purging behaviors. During treatment, patients may consume large quantities of water in order to falsely elevate weights being monitored as part of a behavioral plan. Additional supervision and/or urinalysis for specific gravity determination may be necessary for successful refeeding with appropriate levels of fluid consumption.
Electrolyte disturbances during refeeding
Abnormal levels of serum electrolytes and glucose may result from deficient nutrient intake, nutrient loss secondary to purging behavior, or increased catabolic needs as refeeding commences. The initiation of nutritional rehabilitation should help normalize electrolyte levels in days to weeks if purging behavior discontinues, and if frank refeeding syndrome does not develop.[92][94] Complete blood count abnormalities, including leukopenia and low levels of red blood cells and platelets, may be present on presentation and should improve over several weeks during refeeding. If hepatic transaminitis is present, it too is expected to resolve within several weeks of refeeding. Frequent laboratory assessment for electrolytes and any other laboratory abnormalities is recommended during the first week or two of refeeding. In highly structured settings (e.g., hospital), assessments are commonly done daily at the start of treatment (twice daily in the presence of risk factors for refeeding syndrome).[67] Thereafter, assessment frequency may be slowed to weekly or less frequently.
Psychological treatments for adults with AN
It is recommended that all adults with AN are treated with an eating disorder-focused psychotherapy. Timing of this should be individualized based on the individual’s level of medical stability and willingness to engage with psychological treatment; for example, for people who are severely malnourished, attempts to conduct formal psychotherapy may be ineffective.[66]
While several psychological treatments have been examined in adult patients, no single approach has demonstrated clear superiority.[95] Behavioral management is commonly recommended and effective in structured treatment settings.[96] Outpatient strategies that have a modest evidence base for improving outcome (associated with moderate weight increases, although not to fully normalized weight ranges) include CBT and specialist supportive clinical management (SSCM), and are commonly offered as part of structured treatment approaches for AN, or as outpatient treatments, with or without additional interventions offered by a multidisciplinary treatment team.[97][98][99] The Maudsley Anorexia Treatment for Adults (MANTRA) is designed to address psychological factors (e.g., personality traits and thinking styles) known to maintain anorexia, and takes a collaborative approach with the patient. It was shown in one randomized controlled trial looking at outpatient treatment to be equally effective to SSCM, and more acceptable to patients, at 12 months.[100]
Based on the available evidence, UK-based guidance from the National Institute for Health and Care Excellence (NICE) recommends that first-line psychological treatment options are:[65]
Individual eating disorder-focused cognitive behavioral therapy (CBT-ED)
MANTRA
SSCM
The American Psychiatric Association recommends psychotherapy as an initial intervention in all age groups.[66] Features of specific psychotherapies are often shared but those with efficacy in treating AN include:
CBT (eating focused and broadly focused)
Focal psychodynamic psychotherapy (FPT)
Interpersonal therapy (IPT)
MANTRA
SSCM
Psychological treatments for children and adolescents with AN
For children and adolescents, family-based treatment (FBT) is often an effective intervention, and is recommended as a first-line option for all those with AN who have an involved caregiver.[65][66][70] Multiple studies have demonstrated that a family-based outpatient approach to refeeding adolescents with AN is associated with high rates of full remission of symptoms at the end of treatment and at 1 year following presentation, and is modestly better than individual outpatient psychotherapy focused on general adolescent issues.[101][102][103][104] The salient feature of FBT is the empowerment of parents to refeed their starving child. Additionally, the approach includes establishing that parents are not to blame for the development of the illness, and that parents are uniquely positioned to create a refeeding plan tailored to the needs of their particular child. The treatment offers some education about the severe mortality and morbidity associated with AN, creating a sense of urgency for the need for treatment. Once the parents have had success with initial refeeding, FBT includes the transition to having the adolescent resume responsibility for his or her own refeeding, self-care, and attention. Dissemination and training in FBT are occurring at a relatively rapid rate, and there is also interest from the patient community.[105][106] Maudsley Parents: a site for parents of eating disordered children Opens in new window
If AN-focused family therapy is unacceptable, contraindicated, or ineffective, the second-line recommendations are CBT-ED or adolescent-focused psychotherapy for AN (AFP-AN).[65]
Relapse prevention
Management of acute AN should be followed by an extended period of treatment aimed at relapse prevention. Following weight restoration, relapse prevention treatment should commonly include regular outpatient meetings with 1 or more clinicians for 1 year or more. Treatment should include weight monitoring and general monitoring of nutritional plan. Discussion may focus on strategies for maintaining healthy eating and weight, and avoiding situations that renew vulnerability to weight loss.
Ongoing behaviorally focused treatment aimed at maintaining normal weight and eating behaviors is generally accepted as useful during the year following acute weight normalization.[107][108] There is a small amount of evidence to suggest that CBT may be helpful for relapse prevention.[98] Successful treatment generally includes a transition from discussion of food, eating, and weight to other life issues that become possible and relevant for the patient as the eating disorder stabilizes. For some patients this outpatient treatment continues for several years.
Pharmacotherapy
No medications are currently approved for the treatment of AN. In recent years, several controlled studies have found that add-on pharmacotherapy with low-dose olanzapine may help acutely ill patients increase weight modestly.[109][110][111][112][113] However, olanzapine treatment does not significantly impact anxiety or obsession with shape and weight. It is important to carefully decrease and discontinue treatment when the patient is near ideal body weight. Atypical antipsychotic medications can be associated with prolonged QTc interval.[114] Thus, prior to use of olanzapine, an ECG should be performed and repeated periodically during treatment. Patients typically require significant support and reassurance before they are willing to accept treatment with olanzapine because of fears of excessive weight gain.[111]
Although individuals with AN commonly present with symptoms of anxiety and depression, there is no evidence that antidepressants ameliorate symptoms. Several antidepressants have been examined in comparison with placebo and none has been shown to improve eating, weight, mood, or anxiety symptoms.[113][115][116][117] Despite these data, clinicians often prescribe selective serotonin-reuptake inhibitors (SSRIs) to patients with AN, likely because of lack of awareness of the evidence base, frustration with the limited treatment options for this clinical population, and the relatively low risk profile of these medications.[118]
Other classes of medication, including those that stimulate appetite in other clinical populations, have been examined in small trials for AN without any significant benefit.
The malnourished state present in individuals with AN is presumed to contribute to the consistently poor response to medications that achieve symptom relief in other clinical groups. In addition to psychiatric medications being ineffective, orally administered exogenous hormone medications are notably ineffective at improving bone health in underweight individuals with AN.[119]
Comorbidities
Suicidal ideation is common in AN; 20% of deaths amongst adults with AN are attributable to suicide.[69] Suicidality or evidence of self harm indicate a need for urgent psychosocial evaluation.[67] Mood, anxiety disorders, and obsessive compulsive disorder are the most common comorbidities in patients with AN.[67] These conditions may be difficult to diagnose because of the symptom overlap between AN and these conditions. Consequently, when AN is present, it is preferable to help individuals normalize weight prior to confirming mood and/or anxiety disorder diagnoses. While SSRIs and other antidepressant medications are effective for treating mood and anxiety disorders in healthy weighted individuals, these medications are not as effective when low weight is present.[120] Whenever possible, the use of medication to treat comorbid conditions should be avoided in patients with AN until they are renourished, as weight gain is typically associated with significant improvement in comorbid symptoms, including depression and obsessionality. If significant comorbid symptoms persist following full weight restoration and suggest the existence of a comorbid condition, psychological and pharmacologic treatment should be based on evidence-based interventions for the condition.
As patients with AN typically exhibit cardiovascular disturbances when low in weight, such as orthostatic hypotension, bradycardia, and prolonged QT interval, medications with known adverse cardiac effects should be avoided until cardiovascular abnormalities have resolved. Medications with potentially adverse effects include SSRIs (e.g., citalopram, escitalopram), atypical antipsychotics (e.g., olanzapine), and tricyclic antidepressants (e.g., clomipramine).[121][122]
Substance use disorders may also be comorbid with AN. Substance use is more prevalent in individuals with the binge-eating/purging subtype than in those with the restricting subtype.
Physical activity
Increased physical activity is commonly observed in individuals with AN and may reach excessive levels. Activity may include formal exercise behaviors such as running, sit-ups, or other calisthenic activities, or spending time in a gym. Activity among individuals with AN may also include walking long distances instead of taking other methods of transportation, or climbing stairs instead of taking elevators. Patients may not inform clinicians about these activities when asked about "exercise," and may need to be specifically asked about different types of physical activity. Additionally, patients may be observed to shake their legs or move their muscles while sitting, eating, or having conversations. Limitations to physical activity are frequently recommended during weight restoration treatment, and reintroduction of activity warrants careful consideration. For people with AN who are severely underweight, exercise should always be carefully supervised and monitored. Even at a restored weight, it is recommended to redirect goals toward fitness and not solely weight loss.[66]
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