Treatment for Anorexia
Anorexia is a complex, often chronic condition, which is challenging to treat. It can cause severe medical complications and has the highest mortality rate of any mental illness. It also often co-occurs with other disorders, including major depressive disorder and obsessive-compulsive disorder.
Some individuals with anorexia don’t even realize they’re sick, which naturally complicates treatment and recovery.
Even though anorexia is difficult and devastating, individuals can get better and fully recover. The key is to get comprehensive, collaborative treatment, which includes a team of practitioners, such as a psychologist, primary care physician, and dietitian. It’s important to work with professionals who specialize in treating anorexia. It’s also critical to have a thorough physical exam—including bloodwork and EKG—since anorexia is associated with anemia, osteoporosis, electrolyte imbalances, heart damage, kidney problems, and other complications.
For most people with anorexia, treatment will be provided on an outpatient basis. However, for some individuals—for instance, with severe symptoms—hospitalization or an inpatient facility may be necessary.
Psychotherapy is essential for effectively treating anorexia. In kids and adolescents, the treatment of choice is family-based therapy (FBT), also known as the Maudsley approach or Maudsley method, where parents play a positive and vital role. As one article noted, “FBT therapists serve as expert consultants to the families, supporting parents to assume ultimate responsibility for guiding their child through recovery.”
Specifically, the Maudsley approach consists of three phases. In phase 1, parents assume responsibility for feeding their teen so they can gain weight. In phase 2, parents help their child have more control over their eating. In phase 3, parents encourage their child’s normal adolescent development. (You can learn more at this website.)
Individual therapy also might be helpful for adolescents with anorexia. One example is enhanced cognitive behavioral therapy, which some research suggests is effective in teens (more on what this therapy looks like below).
For adults with anorexia, research hasn’t identified one superior treatment. Several treatment guidelines, such as the UK’s National Institute for Health and Care Excellence, recommend these evidence-based treatments as first-line options: Maudsley model of anorexia for adults (MANTRA); enhanced cognitive behavioral therapy (CBT-E); and specialist supportive clinical management (SSCM).
MANTRA is a cognitive-interpersonal treatment that focuses on four factors that maintain anorexia: a rigid, excessively detailed, perfectionistic thinking style; emotional impairment (e.g., avoiding emotions); a belief that anorexia positively affects one’s life; and unhelpful responses from loved ones (e.g., criticism, enabling symptoms).
CBT-E is a “transdiagnostic” treatment for eating disorders, which means that it assumes that most of the mechanisms that maintain eating disorders are similar. The primary factor is a self-worth that’s based on shape and weight. CBT-E consists of three phases. In phase 1, the therapist helps the person with anorexia increase their motivation to change. In phase 2, the focus is on regaining weight and tackling symptoms such as appearance-based concerns. In phase 3, clients learn how to maintain their positive changes along with identifying and instantly resolving setbacks.
SSCM focuses on developing a positive relationship between the person and practitioner; helping individuals see the link between their symptoms and unhealthy eating behavior; restoring the person to a healthy weight; providing education about anorexia and nutrition; and asking the person to decide other things to explore in therapy.
Another empirically-supported therapy that might be helpful is focal psychodynamic psychotherapy (FPT). According to guidelines from UK’s National Institute for Health and Care Excellence, if one or all of the above treatments doesn’t work, a person can try FPT. Guidelines from Germany recommend FPT as a first-line intervention. Other treatment guidelines, however, disagree over using psychodynamic psychotherapy. While the evidence is limited, it’s generally found that FPT is effective.
FPT is divided roughly into three phases. Phase 1 focuses on cultivating the therapeutic alliance between therapist and client, building self-esteem, and examining pro-anorexic beliefs and behaviors. Phase 2 addresses the association between relationships and eating behavior. Phase 3 focuses on navigating situations in daily life and addressing concerns after treatment concludes.
In addition, various emerging therapies appear to be promising in treating anorexia. For instance, temperament-based therapy with supports (TBT-S) is a 5-day neurobiologically-informed intervention for adults. TBT-S teaches individuals with anorexia, along with their supportive loved ones, about the traits that contribute to anorexia and the skills and strategies to constructively manage these traits. You can learn more in this interview with an eating disorder expert; this journal article; and this list of research.
There are no specific medications that treat anorexia, and research shows that medication has limited use. Several guidelines advised against using selective serotonin reuptake inhibitors (SSRIs), especially in kids and teens. Trials exploring the efficacy of fluoxetine (Prozac) for anorexia haven’t shown any benefit.
Some evidence suggests that the atypical antipsychotic olanzapine (Zyprexa) may reduce obsessional thinking and anxiety during the refeeding process. But most guidelines call for careful use of these medications in anorexia.
Because anorexia often co-occurs with other disorders, including major depression and anxiety disorders, medication may be prescribed to treat those conditions. However, it’s critical to first restore a person to their healthy weight because those symptoms could be due to starvation. Also, research has shown that people respond much better to medication after gaining weight.
Most eating disorder treatment guidelines recommend outpatient treatment as the first choice. However, more intensive interventions may be necessary if outpatient treatment hasn’t worked, or there’s a high risk for medical complications due to low weight, increased suicide risk, unstable vital signs, or behavioral or environmental factors (e.g., decline in eating, lack of support).
There are various options for intense interventions, and the decision should be made on an individual basis. In general, the specific intervention depends on severity, medical status, treatment motivation, treatment history, and insurance coverage.
For some individuals with anorexia, staying at an eating disorder residential treatment center might be the right choice. Such facilities usually include a wide range of specialists—psychologists, medical doctors, and nutritionists—and treatments—individual therapy, group therapy, and family therapy. Individuals stay at the center 24/7, and eat supervised meals.
When a person with anorexia is severely ill and has a relapse from baseline weight, or has other serious medical problems, inpatient hospitalization may be necessary, which is the highest level of care. If possible, it’s best to stay at a unit that specializes in treating eating disorders. During hospitalization, people with anorexia are closely monitored. They’re encouraged to eat regular meals with liquid supplements. If individuals are unable to eat enough to regain or maintain their weight, they’re fed through a nasogastric tube. This is known as medical refeeding, and carries food through the nose, past the throat, to the stomach.
At one time, inpatient treatment lasted many weeks, if not months, but today, the goals of hospitalization are weight gain and medical stabilization. When it’s considered safe to do so, the person starts attending outpatient treatment.
This might be partial hospitalization (PHP) or intensive outpatient treatment (IOP). PHP may be appropriate for individuals who are medically stable but still need structure and support in gaining weight or not engaging in eating disorder behavior. Typically, this means going to an eating disorder center for about 6 to 10 hours a day, 3 to 7 days a week; attending various therapies, such as individual and group therapy; and eating most of their meals there, but sleeping at home. IOP involves attending a treatment program, which also includes various therapies, for several hours a day, 3 to 5 days a week, and eating one meal there.
Getting professional, evidence-based treatment for anorexia is vital. In addition, whether you or your child has anorexia, there are some things you can do on your own to bolster recovery.
Consider support groups. Support groups are a great way of getting emotional support while trying to stop engaging in eating disorder behavior and working toward recovery. You could join an in-person or online group. For instance, the UK-based eating disorder charity Beat offers a variety of online support groups for individuals with eating disorders and their loved ones. The National Eating Disorders Association (NEDA) offers online forums.
Try self-help books. A Cognitive-Interpersonal Therapy Workbook for Treating Anorexia Nervous is based on MANTRA (the Maudsley model of anorexia for adults). Another resource is The Anorexia Recovery Skills Workbook. Science writer Carrie Arnold, who struggled with anorexia for 15 years, wrote Decoding Anorexia, which delves into the neurochemistry of the illness.
Seek out reputable resources. For instance, if your child has anorexia, F.E.A.S.T. is an excellent international nonprofit organization made up of parents, caregivers, and psychologists that offers reliable information and support to families, including videos, family guides, stories of recovery, and an online forum.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Anderson, L.K., Reilly, E.E., Berner, L., Wierenga, C.E., Jones, M.D., Brown, T.A., … Cusack, A. (2017). Treating eating disorders at higher levels of care: Overview and challenges. Current Psychiatry Reports, 19, 48, 1-9. DOI: 10.1007/s11920-017-0796-4.
Byrne, S., Wade, T., Hay, P., Touyz, S., Fairburn, C. G., Treasure, J., … Crosby, R. D. (2017). A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychological Medicine, 47, 16, 2823-2833. DOI: 10.1017/S0033291717001349.
Crow, S.J. (2019). Pharmacologic treatment of eating disorders. Psychiatric Clinics of North America, 42, 253-262. DOI: 10.1016/j.psc.2019.01.007.
Dalle Grave R., Calugi S., Doll H.A., Fairburn C.G. (2013). Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: an alternative to family therapy? Behavior Research and Therapy, 51, 1, R9–R12. DOI: 10.1016/j.brat.2012.09.008.
de Jong, M., Schoorl, M., Hoek, H.W. (2018). Enhanced cognitive behavioural therapy for patients with eating disorders: A systematic review. Current Opinion in Psychiatry, 31, 6, 436-444. DOI: 10.1097/YCO.0000000000000452.
Gorrell, S., Loeb, K.L., Le Grange, D. (2019). Family-based treatment of eating disorders: A narrative review. Psychiatric Clinics of North America, 42, 193-204. DOI: 10.1016/j.psc.2019.01.004.
Hilbert, A., Hoek, H.W., Schmidt, R. (2017). Evidence-based clinical guidelines for eating disorders: international comparison. Current Opinion in Psychiatry, 30, 423-437. DOI: DOI:10.1097/YCO.0000000000000360.
Kaye, W.H., Wierenga, C.E., Knatz, S., Liang, Boutelle, K., Hill, L., Eisler, I. (2014). Temperament-based treatment for anorexia nervosa. European Eating Disorders Review, 23, 1, 12-18. DOI: 10.1002/erv.2330.
National Institute for Health and Care Excellence (NICE). (2017). Eating disorders: recognition and treatment. Retrieved from nice.org.uk/guidance/ng69.
Resmark, G., Herpertz, S., Herpertz-Dahlmann, B., Zeeck, A. (2019). Treatment of anorexia nervosa—new evidence-based guidelines. Journal of Clinical Medicine, 8(2) 153, 1-16. DOI: 10.3390/jcm8020153.
Wierenga, C.E., Hill, L., Knatz Peck, S., McCray, J., Greathouse, L., Peterson, D., … Kaye, W.H. (2017). The acceptability, feasibility, and possible benefits of a neurobiologically-informed 5 day multifamily treatment for adults with anorexia nervoa. International Journal of Eating Disorders, 51, 863-869. DOI: 10.1002/eat.22876.
Zipfel, S., Giel, K.E., Bulik, C.M., Hay, P., Schmidt, U. (2015). Anorexia nervosa: aetiology, assessment, and treatment. The Lancet, 2, 1099-1111. DOI: 10.1016/S2215-0366(15)00356-9.
Tartakovsky, M. (2020). Treatment for Anorexia. Psych Central. Retrieved on October 27, 2020, from https://psychcentral.com/eating-disorders/treatment-for-anorexia/