Clinicians aim first to evaluate whether or not a person with anorexia nervosa is in medical danger as a result of food restriction. A general goal is to help the person achieve a minimum healthy weight, but there is not one most recommended way to accomplish this goal. A priority is to correct any problems with body fluids and salts. Doctors evaluate the person's heart, liver and kidney functioning and provide necessary medical support. Hospitalization may be necessary in the most severe cases (for example, when weight loss is more than 20-25% of body weight), but most treatment is done in an outpatient setting.
Treatment often requires coordinating help from a number of professionals, especially in the most serious cases. Comprehensive eating disorders programs are efficient because they bring all the treatment elements together.
One major task is helping the person with anorexia nervosa recognize the illness and participate in treatment. Education is key, with an emphasis on addressing the distorted beliefs about body image that are central to the disorder. But it should be noted that patients with anorexia nervosa are – in many ways – already experts in their illness. Therefore, the people providing treatment have to try not to behave in a way that could be perceived as patronizing or scolding.
Anorexia nervosa is best treated with a combination of psychotherapy, support, education, medication, and medical and nutritional supervision.
Although a number of specialized psychotherapy approaches have been studied, there is some evidence that supportive psychotherapy and sympathetic clinical management are just as – if not more – helpful. Elements include education, care and support. Praise, reassurance and advice can help sustain a positive therapeutic relationship that encourages adherence to treatment.
Behavior treatments that solely provide rewards and punishments to change eating behavior are probably not effective if they don't also deal with the patient's distorted thinking. They may help in the short run, but patients can easily learn how to comply with the program to gain discharge (i.e., "eat their way out of the hospital"). Then, since they have not given up their distorted body image and beliefs about food, they soon resume abnormal eating.
Health care professionals try to define the problem in a way the person can accept, then work with the person toward common goals.
No single psychotherapy approach has proven to be better than any other. Therefore, once the person acknowledges the problem, a variety of therapy techniques may be tried. A nutritionist can plan a healthy eating program that promotes slow weight gain. Cognitive therapy encourages the person to recognize flawed thoughts about body image, food and dieting, and helps to control anxiety about eating. Family therapy may be important, both to support and educate family members and to examine negative interactions in the family. For example, family members can be taught to avoid unproductive power struggles about food. In families where there is a great deal of open conflict, educational programs designed for parents may be more useful than therapy meetings that include the patient.
Later, when symptoms are under better control, the person with anorexia nervosa may want to understand the meaning of the symptoms, including how they may have affected important relationships, limited emotional growth and altered self-concept. It may also be possible to look at what problems may have set off the eating disorder in the first place.
As with psychotherapy, there is no single medication that has been proven best for anorexia nervosa. Low weight also can make a person more susceptible to drug side effects. Antidepressant medications can improve associated mood problems, but they usually do not hasten weight gain (unless depression is in part causing the weight loss). No medication is known to make a person with this disorder want to eat or gain weight. Nonetheless, antidepressants and other medications may provide relief for people who have symptoms of depression, anxiety or obsessive-compulsive disorder. There is also some evidence that selective serotonin reuptake inhibitors like fluoxetine can help reduce relapse.
A person's thinking about food can become distorted enough that it is considered psychotic, and in those cases, treatment may include an antipsychotic medication. Some of the newer antipsychotic drugs, such as olanzapine (Zyprexa), have weight gain as a side effect. In this case, the side effect may be a benefit, but a person with anorexia nervosa may also not tolerate it.