.

1. Current Therapeutic Approaches
in Anorexia Nervosa
Residents: Dr.Prachi & Dr.Neha
Chairperson: Dr.Ahkilesh Sharma

2. Overview of Part 1
Introduction to Eating Disorders and Historical Context
Diagnostic criteria for Anorexia Nervosa and Subtypes
Epidemiology
Clinical description
Etiopathogenesis
Differential Diagnosis
Current Therapeutic approaches

3. Introduction to Eating Disorders &
Historical context

4. Introduction to Eating Disorders
Treasure, Janet; Duarte, Tiago Antunes; Schmidt, Ulrike (2020). Eating disorders. The Lancet, 395(10227), 899–911.
• Disturbed attitudes towards weight, body shape, and eating
• Six main feeding and eating disorders are :
1. anorexia nervosa
2. bulimia nervosa
3. binge eating disorder
4. avoidant-restrictive food intake disorder
5. pica
6. rumination disorder

5. Important Terminologies
Hay P. Current approach to eating disorders: a clinical update. Internal medicine journal. 2020 Jan;50(1):24-9.

6. What is Anorexia Nervosa?
“An intense fear of weight gain and a
disturbed body image, which motivate
severe dietary restriction or other
weight loss behaviors such as purging
or excessive physical activity”
Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U. Anorexia nervosa: aetiology, assessment, and treatment. The lancet
psychiatry. 2015 Dec 1;2(12):1099-111.

7. Historical context
It has been recognized for many centuries, in all societies, even where cultural preference is for a
well-fed appearance.
Some of the medieval Christian female saints, such as St Catherine of Sienna, suffered from
anorexia nervosa.
By the late 19th century there was competition between the English physician William Gull (1874)
and the French Lasègue, both claiming to have been the first to describe the condition.
Lasègue (1873) who gave the condition its enduring name “anorexia” in his paper De L’Anorexie
Hystèrique.
20th century, when German-American psychoanalyst Hilde Bruch published her popular work The
Golden Cage: the Enigma of Anorexia Nervosa in 1978.

8. Cultural Context
Rationale for food avoidance varies across cultures, with religious explanations for fasting and self-denial
prevalent.
Blake Woodside (2003) has described Indian patients who endorse gastro-intestinal symptoms as their reason
for not eating. Interestingly, if these individuals are treated in groups with sufferers from Western anorexia,
they often develop fear of becoming fat and body image concerns that replace their earlier somatic concerns.
Even in Western settings, some patients start out with somatic or ascetic preoccupations but go on to re-
ascribe their behavior to the media-endorsed value of thinness.
Over all data summarises that affluent societies with demands of physical aesthetics and achievement are held
in a higher position along with Individualistic ideals irrespective of countries have increased tendency to
exhibit ED.
Blake Woodside D (2003) Culture as a defining aspect of the epidemiology and aetiology of eating disorders. In Maj M, Halmi K,
Lopez-Ibor JJ et al (eds) Eating Disorders. Chichester: Wiley, pp114-116

9. Diagnostic criteria for Anorexia
Nervosa and Subtypes

10. ICD-10 Diagnostic Criteria
Body weight is maintained at least 15% below that expected (either lost or never achieved) or body-mass index is 17.5 or less. Prepubertal patients may fail
to gain the expected amount of weight during the prepubertal growth spurt
Weight loss is self induced by avoiding "fattening foods" together with self induced vomiting, purging, excessive exercising, or using appetite suppressants
or diuretics (or both)
Body image is distorted in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient
imposes a low weight threshold on himself or herself
A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhea and in men as a loss of sexual
interest and potency (except for the persistence of vaginal bleeds in women who are taking replacement hormonal therapy, usually the contraceptive pill).
Concentrations of growth hormone and cortisol may be raised, and changes in the peripheral metabolism of thyroid hormone and abnormalities of insulin
secretion may also be seen
If onset is before puberty, the sequence of pubertal events will be delayed or even arrested (growth will cease; in girls the breasts will not develop and
primary amenorrhea will be present; in boys the genitals will remain juvenile). After recovery, puberty will often complete normally, but the menarche will
be late
All 5 criteria should meet.

11. Anorexia Nervosa: DSM 5
• Restriction of energy intake relative to requirements, leading to significantly
low body weight for the patient’s age, sex, developmental trajectory, and
physical health. Significantly low weight is defined as a weight that is less
than the minimal normal weight or, in children and adolescents, less than
the minimal expected weight.
• Intense fear of gaining weight or of becoming fat, or persistent behavior
that interferes with weight gain, even though the patient has a significantly
low weight.
• Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or persistent
lack of recognition of the seriousness of the current low body weight.
Diagnostic Criteria

12. ICD-11 Diagnosis
Significantly low body weight
for the individual’s height, age
and developmental stage ( With
significantly low Body weight-
BMI under 5th percentile; With
dangerously Low Body Weight –
BMI less 0.3 percentile ).

13. Anorexia Nervosa: Subtype
Restricting
type
During the past 3 months, the patient has not engaged in recurrent episodes
of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse
of laxatives, diuretics, or enemas)
Weight loss is accomplished primarily through dieting, fasting, excessive
exercise, or all of these methods
Binge-
eating and
purging
type
During the past 3 months, the patient has engaged in recurrent episodes of
binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of
laxatives, diuretics, or enemas)

14. Epidemiology

15. Epidemiology
Prevalence in the general population : around 1% in women and less than 0·5% in men (DSM-IV-defined AN)
The point prevalence: 0·3–0·5% (If the broader DSM-5 criteria defined AN)
Incidence: an increase in anorexia nervosa in adolescents in the past two to three decades
Onset : begins in early-to mid-adolescence (although can emerge at any age)
M to F ratio in adults: 1:8 (In children, the sex distribution is less skewed)
Outcomes: mean mortality 2% vs 5% (higher rates of full recovery and lower mortality in adolescents than in adults)
Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Curr Psychiatry
Rep 2012; 14: 406–14

16. Epidemiology-Asia & India
The pooled prevalence in Asia obtained from studies using semi-structured interviews for
anorexia nervosa (n = 118190) was 1.59%,
ED appears to be increasing in Arab and Asian countries in conjunction with increasing
industrialization, urbanization, and globalization.
In the Indian settings, there are no cases reported of BED and only five cases have been
reported of BN. The frequency of disordered eating/probable ED ranged from 4% to 45.4%.
It is possible that subsyndromal ED cases may not be captured by a self‐rated assessment. Two
studies reported the prevalence of eating distress syndrome (EDS) to be 11% and 14.8%.
Alfalahi, M., Mahadevan, S., Balushi, R. A., Chan, M. F., Saadon, M. A., Al-Adawi, S., & Qoronfleh, M. W. (2022).
Prevalence of eating disorders and disordered eating in Western Asia: a systematic review and meta-
Analysis. Eating Disorders, 30(5), 556-585. Motwani, S., Karia, S., Mandalia, B., & Desousa, A. (2021). Eating
disorders in India: An overview. Annals of Indian Psychiatry, 5(1), 12

17. Etiopathogenesis

18. Risk Factors For Anorexia Nervosa
Genetic and Biological
•No specific gene
•Risk is up to 11 X greater in
individuals with a first-degree
relative with AN
•Risk increased if a relative has a
different eating disorder
•Concordance rates of AN:
substantially higher in
monozygotic (identical) twins
as compared to dizygotic
(fraternal) twins
Developmental
•Adolescent: age of change
•Biological: experiencing
changes to body shape and
weight : stressor
•Psychological: weight-related
teasing and bullying, self
esteem
•Hormonal changes: estrogen
•Social : identity and role
formation, increasing
independence from parents,
and the initiation of romantic
relationship
Psychological
•High levels of perfectionism,
self-discipline, harm-avoidance,
and self-criticism
•the restricting subtype: exhibit
low impulsivity and delay
rewards
•Cognitive inflexibility
•mood and anxiety symptoms
precede the development of
AN
•Obsessive compulsive disorder
(OCD) and obsessive
compulsive personality traits
Environmental and Social
•Nonspecific vulnerability
factors
•Dysfunctional family types

21. Etiopathogenesis

22. Etiopathogenesis
Walter, K., Fudge, J., and Paulus, M. The time course and phenomenology of Anorexia Nervosa, Nature Review Neuroscience
2009;10:573-84

23. Clinical description

24. Clinical description
Two hallmark characteristics of patients with AN are-
• denial of the seriousness of their illness and
• resistance to treatment
both of which make obtaining an accurate history and
producing an effective treatment result a challenge

25. From History

26. Screening Questionnaire

27. Psychological Testing
1. The Eating Disorders Examination, self-report version (EDE-Q; Fairburn & Beglin,
1994). This instrument is freely available and one of the most widely used self-
report questionnaires; suitable for adolescents but not for younger children.
2. Eating Disorders Inventory-3 (Garner, 2004). Self-rated questionnaire covering
12 domains of eating cognitions, behaviours and social function; validated for
younger patients and sensitive to change.
3. The Children’s Eating Attitudes Test (ChEAT; Maloney et al, 1988). Version of the
adult EAT, also self-report questionnaire
4. Morgan-Russell Average Outcome Scale (MRAOS; Morgan & Hayward, 1988).
Interviewer-based measure of global outcome in anorexia nervosa.

28. Common Laboratory Findings

29. Diagnostic Markers
Complete blood count : leukopenia with a relative lymphocytosis in emaciated anorexia nervosa patients
Serum electrolytes : In Binge-eating and purging- hypokalemic alkalosis
Fasting serum glucose concentrations : low during the emaciated phase
Serum salivary amylase : elevated if the patient is vomiting
ECG : S-T segment and T-wave changes, which are usually secondary to electrolyte disturbances
Emaciated patients will have hypotension and bradycardia
Serum cholesterol : elevated
All these values revert to normal with nutritional rehabilitation and cessation of purging behaviors
Endocrine changes, such as amenorrhea, mild hypothyroidism, and hypersecretion of corticotrophin-releasing hormone are due to the underweight condition and revert to normal
with weight gain

30. Psychiatric Comorbidities
• Psychiatric comorbidity is very prevalent in AN
1. Lifetime mood disorder (especially depressive disorder) : 75% of patients with
AN
2. Anxiety disorder: 5% -75% of patients with AN
3. Obsessive compulsive disorder: 15–29% of patients with AN
4. Alcohol misuse or dependence: 9% and 25% of patients with AN

31. Physical Comorbidities
• In the acute state: complaints such as dizziness, fatigue, or even a syncope
• In the chronic course: almost every organ system can be affected because of
malnutrition (changes in multiple endocrine axes present to optimise energy
expenditure)
1. Osteoporosis: up to 21% of patients with AN
2. Osteopenia of the lumbar spine : 54% of patients with AN
3. Autoimmune disease: increased lifetime prevalence
4. (type 1 diabetes often precedes the onset of anorexia nervosa, is associated
with insulin purging, poor glycemic control, diabetic complications, and very
high mortality)
5. Pediatric acute-onset neuropsychiatric syndrome (PANS) :has been deemed to
be a variant of childhood onset anorexia nervosa
Toufexis MD, Hommer R, Gerardi DM, et al. Disordered eating and food restrictions in children with PANDAS/PANS. J Child Adolesc
Psychopharmacol 2015; 25: 48–56.

32. Physical Comorbidities
• a display a broad variety of somatic
complications in several organ
systems across various stages of
illness

33. Risk Factors For Serious Illness
Neale J, Hudson LD. Anorexia nervosa in adolescents. British Journal of Hospital Medicine. 2020 Jun 2;81(6):1-8.

34. Course and Prevention
Early follow up studies found that a shocking 20% of anorexic patients died of causes related to the
disorder.
Mortality in anorexia is ten times that in the general population and is among the top three or four
causes of death in teenagers in Western countries.
Treatment for fully established anorexia nervosa is slow and difficult: the average time to recovery is
six to seven years though treatment is likely to be episodic rather than continuous over this period.
Younger, intensively-treated patients often show a more rapid improvement, and it is likely that
some cases will have resolved even without treatment.
Stice E, Marti CN and Rohde P (2013) Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder
diagnoses in an 8-year prospective community study of young women. Journal of Abnormal Psychology 122: 445–457.

35. Course and Prevention
The most efficacious interventions focus on improving self-esteem, media
literacy training and a specific approach, cognitive dissonance training
individually or in groups.
Some countries have introduced legislation to require a minimum BMI for
fashion models and already some schools of dance require minimum as well as
maximum BMI bands.
It is too soon as yet to evaluate the preventative effects of such policies, but
they give a sound message to the public.

36. Prognosis
59·6% of patients with AN showed a weight normalization
57·0% normalization of menstrual status
46·8% normalization of eating behavior
an illness onset before their 17th birthday >better outcome
whereas prepubertal onset confers a worse course
0 Herpertz-Dahlmann B. Adolescent eating disorders: update on definitions, symptomatology, epidemiology, and comorbidity.
Child Adolesc Psychiatr Clin N Am 2015; 24: 177–96. 41 Harris EC, Barraclough B. Excess mortality of mental disorder. Br J
Psychiatry 1998; 173: 11–53. 42 Raevuori A, Keski-Rahkonen A, Hoek HW. A review of eating disorders in males. CurrOpin
Psychiatry 2014; 27: 426–30

37. Prognosis
adult patients with AN: complete remission is between 5 and 6 years
5·1 deaths per 1000 person-years and the standardized mortality rate of 5·9
with a mean follow-up period of 14·2 years
(most deaths due to anorexia nervosa are a direct consequence of starvation-
related medical complications, particularly cardiac complications and severe
infections, one in five deaths in patients with this disorder results from suicide)

38. Differential Diagnosis

39. Differential Diagnosis
In making a diagnosis of AN it is important to be certain the patient has no medical illness that can
account for weight loss.
Occasionally, a patient may have both AN and a medical illness contributing to weight loss.
In this situation the diagnosis of AN is made by the positive criteria for the disorder, and both the
underlying medical condition and the AN are diagnosed and treated as such.
Weight loss frequently occurs in depressive disorders.
Delusions about food in schizophrenia are rarely concerned with the calorie content of food.

40. Physical Differential Diagnosis

41. Current Therapeutic
Approaches

42. General principles and management
Establish and maintain a therapeutic alliance
Many patients with anorexia nervosa are initially reluctant to enter treatment and may remain preoccupied with their
symptoms
Many are secretive and may withhold information about their behavior because of shame
Encouraging patients to gain weight could generate extreme anxiety in them
Addressing patients’ resistance to treatment and enhancing their motivation for change is an important aspect of
management of eating disorders
Management of eating disorders should be a multidisciplinary approach involving psychiatrists, psychologists,
endocrinologists, dentists, gastro enterologists, internists so on and so forth.
All personnel must work closely together and maintain open communication and mutual respect

43. General principles and management
Setting
• Patients should be managed on an outpatient basis whenever possible with psychological
treatment given by an experienced and competent service that also assesses physical risks.
• If warranted, Inpatient treatment should be in an experienced setting that can implement
refeeding with careful physical monitoring and give psychosocial intervention.
Evidence Based Treatments
• Meeting the criteria for the highest level of “well established” is family therapy with a
behavioral focus often referred to as family-based treatment. This approach which has a
manualized published version promotes parental management of weight restoration through
education and support by focusing on eating disorder symptoms in the early phase of
treatment and emphasizing general family interactions after weight gain is wellunderway.

44. General principles and management
A family analysis should be done on all anorectic patients living with their families.
clinical judgement should be made what type of family therapy or counseling is clinically advisable.
some cases in which family therapy is not possible, and in those instances family relationships can be addressed in individual therapy.
Probably efficacious are Family systems therapy and Insight-oriented individual psychotherapy referred to as adolescent-focused therapy or
ego-oriented individual therapy.
Motivational Interviewing in resistant cases. Medications may be considered for only resistant cases or cases with comorbid conditions and
when physical condition permits.
A growing body of evidence supports low doses (2.5-10mg) of olanzapine or other antipsychotic reduce rumination and improve tolerance of
weight gain
benzodiazepines in promoting relief from anxiety and, if necessary, tranquillization to allow insertion of nasogastric tubes
UK, N. G. A. (2017). Eating disorders: recognition and treatment.
Hornberger, L. L., Lane, M. A., Lane, M., Breuner, C. C., Alderman, E. M., Grubb, L. K., ... & Baumberger, J. (2021). Identification
and management of eating disorders in children and adolescents. Pediatrics, 147(1).

45. Initial Evaluation
Patient’s height and weight history Maximum and minimum weight
Recent weight changes
Presence of, patterns in, changes in Restrictive eating
Food avoidance
Binge eating
Other eating-related behaviors (rumination,
regurgitation, chewing and spitting)
Patterns and changes in food repertoire Breadth of food variety
Narrowing or elimination of food groups
Presence of, patterns in, changes in Compensatory
Other weight control behaviors (dietary restriction,
compulsive or driven exercise)
Purging behaviors (laxative use, self-induced vomiting)
Use of medication to manipulate weight

46. Initial Evaluation
Percentage of time preoccupied With food, weight, and body shape
Prior treatment and response For an eating disorder
Psychosocial impairment Secondary to
Eating
Body image concerns or behaviors
Family history Eating disorders
Other psychiatric illnesses
Other medical conditions (obesity, inflammatory
bowel disease)

47. Practice Guideline for the Treatment of Patients
with Eating Disorders
• Restoring fluid and electrolyte balance
• Improving nutritional status, monitoring and enforcing any prescribed physical activity,
• Monitoring vital signs and weight, and monitoring intake of food and fluid and output of
urine and bowel movements.
• The guideline lists additional goals for treating AN, including:
• restoring patients to a healthy weight
• treating any physical complications
• enhancing patient motivation to cooperate and participate in treatment to restore healthy eating
patterns
• providing education regarding nutrition and healthy eating habits
• helping patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts,
and feelings
• treating any associated psychiatric comorbidities, including deficits in mood, impulse regulation,
self-esteem, and behavioral issues
• enlisting family support and providing appropriate counseling and therapy
• preventing relapse
Peterson, Kathleen PhD, RN, PCPNP-BC; Fuller, Rebecca RN-BC. Anorexia nervosa in adolescents: An overview. Nursing 49(10):p 24-
30

48. Maudsley Model of Family Therapy

49. Family Based Therapy– Structure and Phases
• Can be delivered as single-family therapy or a combination of single- and multi-
family therapy. Give children and young people the option to have some single-
family sessions: separately from their family members or carers and together
with their family members or caregivers.
• Typically 18-20 sessions over a year. Establish a calorie target with adequate
paediatrician and dietician liaison.
• First Phase – Psychoeducation. Rapport establishment. Early in treatment, support
the parents or carers to take a central role in helping the person manage their
eating, and emphasize that this is a temporary role in the first phase, aim to
establish a good therapeutic alliance with the person, their parents or carers and
other family members.
• Second Phase - support the person (with help from their parents or carers) to
establish a level of independence appropriate for their level of development .
• Final Phase – Relapse Prevention.

50. Criteria for hospitalization
American Psychiatric Association suggest hospitalization for adults, adolescents,
and children who meet one or more of the following criteria :
• Medical instability (eg, bradycardia near 40 beats per minute; blood pressure
<80/50 mmHg; dehydration; or compromised cardiac, hepatic, or renal
functioning)
• Weight <85 percent normal body weight, or rapid weight decline with food
refusal despite outpatient treatment or partial hospitalization
• Suicidal ideation with high lethality plan or suicide attempt
• Poor motivation that necessitates supervision with meals, or cooperation with
treatment that is contingent upon a highly structured environment Comorbid
psychiatric conditions (eg, depressive, substance use, or anxiety disorders) that
require hospitalization

51. Criteria for hospitalization
• Vital signs unstable
• Severe bradycardia (e.g., heart rate < 50 beats per minute during the day or < 45
at night)
• Hypotension (e.g., blood pressure < 90/50 mmHg
• Hypothermia (e.g., < 96°F)
• Orthostatic changes in pulse (> 20 beats per minute) or blood pressure (> 10
mmHg)
• Electrolyte disturbances (hypokalemia, hyponatremia, or hypophosphatemia)

52. Comparative treatment for anorexia nervosa

53. Overview of part - 2
1) Nutritional rehabilitation
2) Psychosocial intervention
A) Family based treatment
B) CBT
C) CAT (Cognitive Analytic Therapy)
D) Third wave treatments
3) Pharmacotherapy
4) Neuromodulation
5) Cochrane review of therapies
6) Critique and future direction

54. Medical stabilization, nutritional rehabilitation
and weight restoration
Restore medical
stability
Restore weight
Correct biological
and psychological
sequele of
malnutrition
Normalize eating
patterns
Achieve normal
perceptions of
hunger and satiety
GOALS FOR SERIOUSLY UNDERWEIGHT,
MALNOURISHED AND MEDICALLY UNSTABLE
PATIENTS

55. Medical stabilization, nutritional rehabilitation
and weight restoration
Outpatient – adolescents and
emerging adults under
supervision of
parents/caregivers
Day treatment program
Residential and Hospital –
markedly underweight
Supervised meals
Group therapies
Behavioral contingency
management
Settings - Vary according to
age, severity of illness,
available psychosocial support
networks and available
treatment options

56. NUTRITIONAL REHABILITATION AND WEIGHT
RESTORATION
Positive reinforcements Negative consequences
Pro-recovery behaviors
eating 100 % of food on meal plan
Abstaining from compensatory behaviors
Meeting weight gain goals
Restricting food intake
Purging or exercising
Failing to gain weight gain expectations
Gaining access to different group activities
Receiving less monitoring and supervision
Taking a more active role in meal planning
Reduction in privileges
Increase in supervision
Exercise restriction
Requiring bed rest
As target weights and goals are achieved – negative consequences are decreased or terminated and positive
reinforcements are accelerated

57. NUTRITIONAL REHABILITATION AND WEIGHT
RESTORATION
• Individuals who have not achieved weight gain in outpatient
settings
• Severe symptoms and behaviors
• Serious medical complications
• Suicidal ideation and behavior
INDICATIONS FOR
STRUCTURED TREATMENTS
• Normalizing weight through
• Calorie prescriptions
• Meal plans
• Structured and supportive meals
• Disruption of compensatory behaviors and expectations of regular
weight gain
AIMS OF BEHAVIORAL
TREATMENTS

58. NUTRITIONAL REHABILITATION AND WEIGHT
RESTORATION
• Implemented in nurturing emotional settings
• Nursing supervised oral refeeding of normal food in appropriate
amounts and composition is preferred
Renourishment
• Individually determined target weights
• Weight at which reproductive physiology normalizes
• Reassessed every 3-6 months
Target weights
• clinical consensus suggests
• 2-4 lb/week for hospitalized patients, 1-2 lb/week for outpatients
Realistic targets

59. NUTRITIONAL REHABILITATION AND WEIGHT
RESTORATION
• Starts between 1500 and 1800 kcal/day
• 3 to 4 supervised meals and snacks
• With macronutrients
Calorie
prescription
• Close monitoring of medical status
• Maintain calories around 1500 to 1800 until patient is medically stable
• Calories are increased in a predetermined sequence uptil 3500 to 4000
kcal/day
Calorie
prescription
• To prevent relapse
• Continue to focus on disordered thoughts and behaviors
Additional
therapy

60. Refeeding syndrome
Lab abnormalities ECG abnormalities Physical symptoms
Hypophosphatemia Dysrhythmias Edema
Hypokalemia Torsades de pointes Respiratory difficulty
Hypomagnesemia Muscle pain and weakness
Thiamine deficiency GI disturbances (constipation,
diarrhea)
Glucose intolerance
A rare but potentially fatal medical complication that involves fluid, electrolyte and
mineral shifts in body

61. NUTRITIONAL REHABILITATION AND WEIGHT
RESTORATION-NGT FEEDING
• When patients do not consume sufficient number of calories for
weight gain
• Short-term intervention with goal of transitioning to oral intake
INDICATIONS
• Continuously
• Overnight
• Several boluses during the day
CAN BE
DELIVERED
• Nasal irritation, epistaxis, electrolyte imbalance, patient distress
and patient initiated NGT removal
COMPLICATIONS

62. CBT-E (COGNITIVE BEHAVIOURAL THERAPY-
ENHANCED)
Based on transdiagnostic theory
Derived from CBT-BN
Designed to treat eating disorder psychopathology
Depending on individualized formulation of processes
maintaining the disorder

63. CBT-E (COGNITIVE BEHAVIOURAL THERAPY-
ENHANCED)
CBT-E
Focused Form (CBT-
Ef)
Addresses eating
disorder
psychopathology
Optimal for most
patients
Broad form (CBT-Eb)
Addresses external
obstacles

64. CBT-E (COGNITIVE BEHAVIOURAL THERAPY-
ENHANCED)
Intensities
BMI above 17.5
20 sessions over 20
weeks
BMI below 17.5
40 sessions over 40
weeks

65. CBT-E (COGNITIVE BEHAVIOURAL THERAPY-
ENHANCED)
Use of strategic changes in behavior to modify thinking
Evaluation interview assessing nature and extent of patient’s psychiatric
problems
Put the patient at ease and begin to engage patient in treatment and in
change
Main aspects of therapy described and patients encouraged to make
most of opportunity to overcome their eating disorder

66. CBT-E (Stage one)
8 sessions twice weekly over 4 weeks
Engaging patient in treatment and change
Jointly creating the formulation
Provide education about treatment and the disorder
To introduce and implement “weekly weighing” and “regular eating”

67. CBT-E (Stage two)
2 weekly appointments
Joint review of progress by therapist and patient
Identify existing problems and emerging barriers to change
Design the stage three

68. CBT-E (Stage three)
8 weekly appointments
Addressing dietary rules
Addressing the Overevaluation of Shape and Weight
Addressing event-related changes in eating
Addressing Clinical Perfectionism, Low Self-esteem, and Interpersonal Problems

70. CBT-E (Stage four)
Concerned with ending treatment well
Focus is on maintaining the progress that has already been made and reducing
the risk of relapse
Patients discontinue self monitoring and begin weekly weighing at home
3 appointments about 2 weeks apart

71. INTERPERSONAL PSYCHOTHERAPY (IPT)
Focuses on dysfunctions in
• Interpersonal relationships
• Social role
• Communication

72. Family based treatment-Maudsley method
Therapist acts as knowledge expert and facilitator
Therapist helps parents arrive at strategies that would be most optimal
for child within their family context
Parents who come up with solutions on how best to nourish their child
Facilitated by in-session family meal to which parents bring a meal that
they would feed their child

73. Family based treatment
Focus is to enlist parents as experts on parenting their child
caregiver education aimed at normalizing eating and weight
control behaviors and restoring weight
Not limited to family members but could involve other non-family
caregivers
Manual -based approach that focuses on effects of severe weight loss

74. Family based treatment
Therapist weighs patient and discusses patient’s current concerns,
emotions and thoughts
Presented to the family for use in discussion about strategies at home
that are working or need to be enhanced
Providing information about nutrition and addressing eating-related
cognitions and body image normalization
As treatment progresses to Phase 2, more responsibility for independent
eating is given to adolescent
In phase 3, the transition to typical adolescent development is
discussed

75. THIRD WAVE TREATMENTS
Includes acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT)
Emphasize importance of acceptance and mindfulness in tolerating distress and reducing
maladaptive behaviors
Case and pilot studies of ACT for AN report improvements in weight and eating disorder symptoms
Addition of ACT to TAU may result in lower rates of rehospitalization for 6 months after discharge
The empirical basis of DBT for AN is less studied
Preliminary research on DBT-based treatments for AN reports improvements in BMI and reductions
in eating disorder symptoms

76. PHARMACOTHERAPY
Limited evidence for benefits of medication to support weight gain during nutritional rehabilitation
Decision to use medications based on patient’s age and clinical presentation
Many patients are extremely reluctant to take medications
These issues must be discussed empathetically and comprehensively with patients
For children and adolescents, with their families as part of shared decision-making

77. PHARMACOTHERAPY
• Limited empirical data do not show any advantage in terms of weight gain
• may be considered for those with persistent depressive, anxiety or OC
symptoms
SSRI
• Olanzapine may be useful in selected patients to assist with weight gain
• Potential adverse effects (glucose dyscontrol, metabolic syndrome, akathisia,
extrapyramidal effects)
ANTIPSYCHOTICS
• Transdermal estradiol, human growth hormone
• Do not appear to confer any advantages, but studies have been limited
HORMONAL
THERAPIES

78. MEDICATION
• Anti depressants
• Selective serotonin reuptake inhibitors

79. NEUROMODULATION
Allow clinicians to target and probe specific brain regions or circuits
Numerous studies have investigated role of different types of
neuromodulation, as a therapeutic approach for treatment-refractory AN
These approaches are currently being researched as therapies for chronic,
treatment-refractory individuals

80. Repetitive Transcranial Magnetic Stimulation
(rTMS)
Based on electromagnetic principles
A coil capable of generating an electrical current is placed near scalp
Used to suppress (via low-frequency rTMS) or excite (via high-frequency
rTMS) neural activity within a targeted brain region
Recent findings from case studies and sham controlled trials suggest that rTMS
targeting left DLPFC may have clinical benefit for AN

81. Transcranial Direct Current Stimulation (Tdcs)
Delivers a fixed, weak current, generating subthreshold changes to targeted neurons
Increase or decrease neuronal activity using anodal or cathodal electrodes respectively
In first open-label pilot study in AN, 7 patients received 10 sessions of excitatory tDCS over the left DLPFC
At posttreatment, 5 of 7 patients reported decreases in eating disorder and depression

82. Deep brain stimulation (DBS)
Reversible procedure by which electrodes are surgically implanted and
deliver electrical pulses to target brain regions
Initial case studies of DBS in patients with concomitant AN and depression
found improvements in weight and eating disorder pathology
Substantial research is needed to evaluate its relative risks and benefits