Anorexia Nervosa: Gold Standard of Care

Anorexia nervosa is an eating disorder involving fear of gaining weight, food restriction, distorted body image, and a lack of insight into the severity of the condition.  According to the National Institute of Mental Health, the lifetime prevalence of anorexia in the U.S. is .6% for adults.  Only about one-third of adults with anorexia seek treatment for it.  The average age of onset is around 18 years old.

Eating disorders involve overestimating the importance of shape/weight and a need for control.  People with eating disorders base their self-worth on their weight and ability to control it.  They feel unworthy if their weight is not where they want it to be.  Over time, their goals become more unrealistic.  As a result, their self-esteem becomes lower because rather than recognizing that their goals are unattainable and unhealthy, they blame themself for not being able to meet them.  For general information on eating disorders, read this blog by Clinical Director of Gateway to Solutions’, John Carnesecchi, LCSW, CEAP.


There are two subtypes of Anorexia Nervosa:

  1. Restricting: It is the more common type of anorexia.  People with restricting anorexia will limit their food intake, have strict rules around food, cut out certain foods, and/or carefully count and track calories.  This subtype often includes excessive exercise.  Personalities of people who often fall into this subtype are often anxious and obsessive. (Merwin et al., 2019)
  2. Binge eating/Purging: The binge-eating/purging subtype includes restricting, but it also involves binge-eating episodes (eating more than most people would eat in one sitting).  It also may include purging through vomiting, laxatives, or diuretics.  The personality type that often falls into this subtype may also be anxious and obsessive but is typically more impulsive and emotionally dysregulated.  (Merwin et al., 2019)


Risks of Anorexia Nervosa

AN is a mental health condition that puts people at the highest risk of death.  The starvation associated with anorexia causes the body to try to protect itself by feeding on organs and other areas to stay alive.  It causes damage to the brain, heart, bones, kidneys, reproductive system, and muscles.  Results of AN can include low blood pressure, slowed breathing, brittle nails, yellowish skin, fine hair (lanugo) growth all over the body attempting to keep it warm, weakened bones and osteoporosis, muscle wasting, loss of menstruation, infertility, and kidney disease.  If this goes on for too long, the organs can begin to shut down.  While AN is extremely dangerous, with the proper treatment, individuals struggling with it can make a full recovery.


Gold Standard Care for Anorexia for Adults: CBT-E

The gold standard treatment of AN for adults is CBT-E (enhanced cognitive behavioral therapy), a very structured form of cognitive behavioral therapy.  It takes between 20 and 40 sessions to complete treatment, depending on the individual’s weight.  There are four stages to the treatment.

Stage one is the initial stage lasts for eight sessions over four weeks.  This stage includes engaging the client in treatment, building a rapport between the client and therapist, providing psychoeducation about diagnosis and treatment, and forming a case conceptualization.  The case conceptualization will discuss what is upholding the eating disorder and provides a focus for the treatment.  The main goals of this stage are to alter and stabilize the client’s eating habits and patterns.  This stage includes ‘regular eating,’ which provides structure to the clients eating for each day and consists of meals and snacks.  It involves monitoring food intake, thoughts, feelings, behaviors, and events along with eating.  Weekly weigh-ins will occur so they can discuss concerns about weight, the clinician can provide psychoeducation about bodies and weight, and the clinician can support clients in interpreting their weight in a healthier way. 

Stage 2 is brief and consists of two sessions one week apart, where progress is reviewed and reinforced, and barriers to success are recognized and addressed.  The case conceptualization may be updated, and planning for Stage 3 will occur.

Stage 3 is the main part of treatment and consists of 8 weekly sessions to go deeper to address what is maintaining the clients eating disorder.  It includes addressing the overvaluation of weight and shape, dietary rules, event-related eating changes, perfectionism, low self-esteem, and interpersonal problems that contribute to the eating disorder.

Stage 4 includes about three appointments, two weeks apart.  The final stage of this approach focuses on relapse prevention and the maintenance of progress made through a post-treatment plan.  This stage helps clients set realistic expectations and allows clients to recognize and cope with setbacks as early as possible.


Gold Standard Care for Anorexia for Adolescents: Family-Based Therapy

Family- Based Therapy is very effective for adolescents with anorexia.  Studies show it works more quickly and lead to a higher recovery rate than other forms of treatment.  This approach focuses on strengthening the relationship between family members rather than trying to identify the cause of the eating disorder.  The therapy includes about 20 sessions over one year.

Stage 1 is when the parents take complete control over their child’s food intake to help them regain healthy eating patterns and disrupt behavioral patterns contributing to the child’s eating disorder.  This stage includes weekly sessions, and weight gain will occur during this stage.

Stage 2 focuses on gradually returning some control to the teen.  When weight is close to being restored, and the eating behaviors are showing significant improvement, some control will start to go back to the teen.  It is normal to have some regression into previous disordered eating behaviors in this stage, and parents will have to regain control when this occurs.  This stage includes biweekly sessions.

Stage 3 focuses on the healthy development of the teen’s identity and independence.  When the teen is no longer showing disordered eating behavior, the focus of treatment shifts to helping the family reorganize and helping the teen reestablish their own identity.  It also may include working on other comorbid diagnoses the teen may have.  This stage contains monthly sessions.


Other Important Components of Quality Care for Anorexia Nervosa:

Regardless of the therapeutic approach utilized, quality care for eating disorder treatment requires collaboration amongst many professionals and support networks for the client.

Dietician: While many evidence-based manuals for treating eating disorders do not mention the role of dieticians, they are necessary and can be essential to ensuring quality care to clients.  A significant component of eating disorders is their dietary restriction level and malnutrition.  Dieticians assess the level of malnutrition a client is experiencing.  Since the most effective psychological treatments for eating disorders include changing eating habits and meals, dieticians are a crucial part of that planning process to ensure clients get proper nutrition.  Dieticians and therapists must collaborate to provide the best results for clients.

Psychiatrist: While research has not found medication to be particularly helpful for treating anorexia alone, the likelihood of someone with AN meeting criteria for another psychological disorder is 56%, and anxiety and depression are the most commonly comorbid with AN.  Taking medication to help with the symptoms of comorbid disorders can make it easier for the individual to do better in their AN treatment.

Family Involvement: Regardless of the client’s age or therapeutic approach, family/social support is critical in treating AN.  The people the client is surrounded by daily must be aware of what is going on so that they can help reinforce healthy eating behaviors and progress made.  It is important to note that there are some cases in which family involvement may not be helpful to a client’s progress on their eating disorder, and the therapist and client would collaboratively determine that.  However, even if family support is not beneficial, gaining help from friends and other close relationships in the client’s life will be necessary.

Therapist: Therapists will work with clients to create and implement the treatment plan and collaborate with the other professionals/support people needed (psychiatrists, dieticians, family) to ensure the most effective care for clients.  Therapists will also help to determine the level of care necessary for the eating disorder.  Depending on the client’s needs, treatments can vary at an inpatient level, a partial hospitalization level, an intensive outpatient level, or an outpatient level.

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