Learning Objective

After reading this article, you should be able to…

1. Determine when to refer your client to medical or psychiatric stabilization.
2. Describe and differentiate psychotherapeutic approaches to anorexia nervosa, including Family Based Treatment (FBT) and Enhanced Cognitive Behavioral Therapy (CBT-E)
3. Recognize how to adapt treatment for diverse populations.

Although anorexia nervosa (AN) is a well-known and relatively common disorder, treating it can feel daunting for many clinicians. They may consider AN to be beyond their scope, which limits patients' access to care. While specialized treatment is sometimes necessary, many patients with AN can be effectively supported with therapeutic techniques that most clinicians already know or can easily learn. In this article, I'll break down the complex topic of anorexia nervosa and emphasize the crucial role of psychotherapy, making it more approachable for everyday practice.

The Basics

What is anorexia nervosa?

The DSM-5 defines anorexia nervosa (AN) as an intense fear of gaining weight, energy intake restriction, and significantly low body weight. AN is categorized as either restricting type or binge-purge type and is rated on a scale from mild to extreme based on BMI.

It’s crucial to recognize that many individuals may fall under “atypical anorexia.” These individuals engage in severe disordered eating behaviors and face similar medical and psychiatric risks as those with low body weight but do not meet the low body weight criterion for AN. Instead, they are diagnosed with Other Specified Feeding or Eating Disorder (OSFED).

AN is often considered the psychiatric disorder with the highest mortality rate, carrying substantial financial costs for both individuals and society. The burden on caregivers is also significant, surpassing that of schizophrenia or dementia (Harvard T.H. Chan School of Public Health. Economic Costs of Eating Disorders Report, 2020). Pharmacological treatments for AN have limited evidence, so I always emphasize to my patients that treatment will primarily involve nourishment to support weight restoration, followed by psychotherapy.

What is the prevalence?

In the US, the lifetime prevalence of AN in adults is estimated to be between 0.3% and 0.9%, with some studies suggesting rates as high as 3.6% in women (Eeden A et al, Curr Opin Psychiatry 2021;34(6):515-524). This figure would be significantly higher if we included those diagnosed with OSFED, or "atypical anorexia." Rates of AN are rapidly increasing in children, with hospitalizations for eating disorders nearly doubling during the COVID-19 pandemic (Herpertz-Dahlmann B et al, Eur Psychiatry 2024;15;67(1):e77).

Risk and Development of Anorexia Nervosa

The risk for development of AN is related to a complex combination of biological, psychological, and social factors.

Biological factors

•    There is a strong genetic component to AN with relatives of individuals with AN being 11 times more likely to develop the disorder than others (Thornton L et al. Current Top Behave Neurosci 2011;6:141-156). 

•    Twin studies support heritability as the cause of this increased risk (Pinheiro AP et al. Int J Child Adolesc Health 2009 2(2):153-164). 

Psychological factors

•    About 70% of individuals diagnosed with anorexia have another psychiatric condition. 

•    There is an especially high correlation between AN and anxiety disorders and OCD, depression, substance use disorders, and personality disorders (Juli R et al, Psychiatr Danub 2023;35(2):217-220). 

Social factors

•    Societal fixation on thinness (muscularity in men) and moralization of diet culture perpetuates AN in individuals at risk for the disorder. 

•    The rise of the internet and globalization has resulted in the spread of the “thin ideal” across cultures. 

•    Though anorexia is often thought of as a disease of white middle- and upper-class women, it is prevalent in men, people of color, and across socioeconomic statuses. 

•    There has also been recent focus on increased risk for AN in gender diverse youth. Restriction and weight loss may be used to combat body dysphoria and prevent the development of secondary sex characteristics. 

Assessment and when to refer for psychiatric/medical stabilization

While psychotherapeutic approaches are the mainstay of treatment for AN, it is not appropriate to start here if a patient has signs of imminent lethality, medical instability, or is significantly low weight: 

•    Individuals with AN are at high risk of mortality due to an elevated risk of suicide. If there is imminent risk for suicidality, patients should be referred for psychiatric stabilization. 

•    Individuals with AN are at high risk of mortality due to the disorder’s impact on the cardiovascular system. Patients with daytime heart rates <50 or nighttime heart rates <45, systolic BP below 90 or diastolic BP below 45, and/or significant orthostasis or syncopal episodes should be referred for medical monitoring. 

•    Individuals with rapid and excessive weight loss and/or prolonged periods without food are at risk of developing refeeding syndrome and must be monitored in a medical environment when they begin to eat again. I refer to the American Society for Parenteral and Enteral Nutrition (ASPEN) Consensus Criteria for Identifying Patients at Risk for Refeeding Syndrome for specific guidelines on who requires medical monitoring for refeeding syndrome (DeSilva JSV et al, Nutr Clin Pract. 2020;35(2):178-195). 

•    Low-weight patients (<80% estimated body weight, EBW) will struggle with cognitive processing and fully engaging in therapy, making progress limited.

For these reasons, the first thing I do when I am evaluating a new patient with AN is determine the most appropriate level of care. I have found working on an interdisciplinary team which includes access to a medical provider who can check vital signs, EKG, and labs to be the most effective way to ensure clients are stable for outpatient treatment. In general, patients with AN do best when supported by well-rounded teams with support from psychiatry, medicine, nutrition, and their therapist. In my experience, once individuals reach around 80-85% of their EBW, they are more ready to engage in therapy. 

Therapy Options for Anorexia Nervosa

Family Based Treatment (FBT)

In adolescents, Family Based Treatment (FBT, also known as the Maudsley approach) is the gold standard for treatment of AN:

•    Manualized treatment that centers around empowering parent(s) or guardian(s) to take back autonomy overeating in their household (Lock J and Le Grange D. Treatment Manual for Anorexia Nervosa: A Family-Based Approach (2nd ed.). Guilford Press; 2012)

•    Significant family involvement, often with all family members attending and actively participating in sessions. 

FBT is broken down into three phases:

Phase I: 

Focuses on: 

•    Raising the alarm bell on the seriousness of AN 

•    Caregivers taking control of food intake (making all food selections and completing all food preparation without input from the adolescent)

•    Weight restoration

Once an adolescent reaches at least 90% of their EBW, we transition to phase II. 

Phase II:

•    Gradually moves autonomy of eating back to the adolescent with significant oversight from guardians.

•    Typically, the longest part of treatment.

•    Progress will wax and wane. There will be times that an adolescent might struggle, and guardians must take back control, that is OK! 

•    Gradually a family will be able to return to eating practices typical of their child’s age.

Phase III:

•    All about returning to normal life, allowing an adolescent to establish their identity outside of their eating disorder, and restoring relationships with their family. 

•    We also make sure to discuss relapse prevention and warning signs that disordered eating is returning. 

Outcomes:

FBT is associated with high rates of weight restoration and notable improvement in the psychological symptoms of AN at end of treatment. It has superior rates of remission 12 months after end of treatment compared to other therapy modalities (Muratore A and Attia E, Clin Ther 2021;43(1):85-94). When families are able to participate, FBT is always my first recommendation for adolescents. 

Enhanced cognitive behavioral therapy 

For adults and adolescents whose families are unable to participate in FBT, “enhanced” cognitive behavioral therapy (CBT-E) is an accessible and effective treatment for AN. CBT-E typically occurs over 40 weeks and broken down into four stages:

Stage one:

•    Begins with psychoeducation and building an understanding of an individual's eating patterns/problems with eating. 

•    Clients explore feelings about weight gain and motivation for changing eating habits. 

Stage two: 

•    A brief planning stage in which a therapist and client work together to establish goals. 

Stage three:

•    Therapists directly address day-to-day issues coming up in an individual's life; how these are impacting their eating. 

•    Eating patterns are regularized and clients develop skills to manage stressors that typically lead to restriction and compensatory behaviors. 

•    Body image issues and overvaluation of shape/weight are addressed. 

Stage four:

•    Focuses on how new eating habits can be maintained in the future 

•    Addresses any setbacks that come up. 

•    Relapse prevention is also discussed. 

(Source: Murphy R et al. Psychiatric Clin North Am 2010; 33(3): 611-627)

Outcomes:

Research in adults demonstrates high rates of weight gain and reduction in disordered eating behaviors that are maintained well past end of treatment (12 mo+). Studies have demonstrated similar outcomes in adolescents (Muratore A and Attia E, 2021). CBT-E has been shown to be as effective, though not superior, to specialized eating disorder therapy modalities (Muratore A and Attia E, 2021). It is, however, more accessible, with many more clinicians being familiar with the CBT model.

Other modalities

Other therapy modalities that may be used to treat AN include:

•    Supportive psychotherapy

•    Exposure response prevention (ERP)

•    Interpersonal therapy (IPT)

At this time further research is needed to determine the efficacy of these modalities compared to the most used therapy types. Current research is also looking into outcomes of the virtual psychotherapy that was provided for individuals with AN throughout the pandemic and continues to be used regularly. Another exciting area of research is assessing the use of neurostimulation and neuromodulation interventions as well as psychedelic substances in treating AN. 

Challenges and Considerations

Many challenges may arise when identifying and treating AN. 

Cultural and gender identity challenges

Multiple studies have shown people of color, men, and individuals in larger bodies are less likely to be screened for eating disorders and referred for appropriate care even when screening occurs (Becker A. et al, Int J Eat Disord 2003; 33(2), 205–212; Sweeting H et al. Int J Men’s Health 2015; 14(2); National Eating Disorders Collaboration. Eating disorders and people with higher weight). I am careful to screen for eating disorders in all patients I speak with, even when it is not their presenting issue and whether or not they “fit the mold.” To screen, I ask simple and straight forward questions such as “do you ever worry about your weight or body shape?” If someone answers affirmatively, I ask if they currently do anything or if have ever done anything to change their weight/shape and follow up with more specific questions about diet techniques, exercise habits, purging behaviors, and laxative or diet pill use. 

Once patients have been successfully identified, we must create individualized treatment plans that acknowledge and are respectful of our patient’s identities. This may mean:

•    Modifying FBT for families with nontraditional structures or considering religious practices and customs in treatment. We must ensure individuals are receiving appropriate nutrition while also being sensitive to these factors. 

•    Providing gender affirming care that recognizes the distress of gender dysphoria while also confronting disordered eating habits. We must work to establish healthy eating patterns while providing validation and support to such patients. 

Resistance to treatment

Another challenging aspect of working with individuals with AN is addressing resistance to treatment. The often ego-syntonic nature of AN can make change extremely difficult. In the beginning of treatment, many of my patients describe their eating disorder as a friend and protector. We cannot coerce patients into treatment as minimal progress can be made this way and must work to identify an individual’s own motivations for change and buy into treatment. For individuals who have struggled with AN for decades, this may seem impossible. In these cases of severe and enduring AN, I will typically transition to a harm reduction approach, acknowledging that remission may never come and focusing instead on maximizing a client's quality of life. 

Carlat Verdict

Anorexia nervosa is a detrimental and highly prevalent disorder that is unfortunately only becoming more common. This increase has been noted across many groups so we must screen diligently even when clients who do not fall within what is considered the “typical” population. Appropriate nutrition and weight stabilization are the first treatments for AN but once we have achieved this, psychotherapy is the mainstay of treatment. FBT (Family Based Therapy) and CBT-E (Enhanced cognitive behavioral therapy) have been shown to be highly effective for increasing weight and reducing overall symptoms of AN and can be utilized by most clinicians in the outpatient setting. We can also support patients with AN by working on interdisciplinary teams that address disordered eating from multiple perspectives.