Guideline sources The following summarized guidelines for the evaluation and management of anorexia nervosa are prepared by our editorial team based on guidelines from the American Psychiatric Association (APA 2023), the The Scottish Intercollegiate Guidelines Network (SIGN 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the Canadian Practice Guidelines (CPG 2021; 2020), the German Society for Psychiatry, Psychotherapy and Psychosomatics (DGPPN 2019), the American Academy of Child and Adolescent Psychiatry (AACAP 2015), the American Association of Family Physicians (AAFP 2015), the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2014), and the American College of Gastroenterology (ACG 2013). 1 2 3 4 5 6 7 8 9 10 Calculator DSM 5 diagnostic criteria for an Guidelines https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 1/8 6/23/23, 2:38 AM Anorexia nervosa Pathway 1. Screening and diagnosis Indications for screening: As per APA 2023 guidelines, screen for the presence of an eating disorder as part of an initial psychiatric evaluation. B As per SIGN 2022 guidelines: Consider screening for the presence of eating disorders as part of the routine review of patients with T1DM. C Elicit history of current or past history of eating disorders in females during pregnancy and postnatal period, recognizing the potential barriers for disclosure. A As per USPSTF 2022 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. I As per AACAP 2015 guidelines, screen all pediatric and adolescent patients for eating disorders seen by a mental health clinician, followed by a comprehensive diagnostic evaluation (including laboratory tests and imaging studies as indicated) if positive. B As per ACG 2013 guidelines, consider assessing for the presence of eating disorders (including anorexia nervosa) when evaluating a patient for gastroparesis. B 2. Diagnostic investigations Initial evaluation: As per APA 2023 guidelines, assess the following during the initial evaluation of patients with a possible eating disorder: height and weight history (maximum and minimum weight, recent weight changes) presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and 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, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (laxative use, self-induced vomiting), and use of medication to manipulate weight percentage of time preoccupied with food, weight, and body shape prior treatment and response to treatment for an eating disorder psychosocial impairment secondary to eating or body image concerns or behaviors family history of eating disorders, other psychiatric illnesses, and other medical conditions (obesity, IBD, diabetes mellitus). B Show 2 more As per RANZCP 2014 guidelines: Obtain a detailed assessment of core symptoms including restriction methods, psychological symptoms related to fear of weight gain, weight loss, drive for thinness, and body image https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 2/8 6/23/23, 2:38 AM Anorexia nervosa Pathway disturbance/dissatisfaction, establishing both severity and (where possible) duration of illness. B Perform a detailed physical examination and obtain medical and laboratory evaluations, thereby setting priorities for any specific medical interventions. B Laboratory tests: obtain a CBC and a comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests in the laboratory assessment of patients with a possible eating disorder. B Electrocardiogram: obtain an ECG in patients with a restrictive eating disorder, severe purging behavior, or taking medications known to prolong the QTc interval. B Screening for comobidities: As per APA 2023 guidelines, assess for co-occurring health conditions, including psychiatric disorders, in the initial psychiatric evaluation of patients with a possible eating disorder. B As per DGPPN 2019 guidelines, assess for comorbid conditions in patients with anorexia nervosa, and take these into consideration when making treatment decisions. B As per AAFP 2015 guidelines, assess for psychiatric comorbidities, including depression and suicide risk, anxiety disorders, and substance use disorders, in patients with an eating disorder. B As per RANZCP 2014 guidelines, obtain detailed evaluations for any comorbid psychiatric diagnoses. B 3. Medical management Multidisciplinary care: As per APA 2023 guidelines, provide a documented, comprehensive, culturally appropriate, and person-centered treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team, in patients with an eating disorder. B As per AACAP 2015 guidelines, ensure a multidisciplinary team approach (developmentally aware, sensitive, and skilled in the care of pediatric and adolescent patients with eating disorders) for the treatment of eating disorders in young patients. B As per AAFP 2015 guidelines, ensure an interdisciplinary team approach, often including a family physician, a psychotherapist or psychiatrist, a dietitian, an eating disorder specialist, and school personnel, for the treatment of patients with anorexia nervosa. B Pharmacotherapy, general principles: As per SIGN 2022 guidelines: Monitor all low-weight patients, particularly closely when psychotropic drugs are prescribed. Consider obtaining a baseline ECG and further monitoring to alert about avoidable dangers. B https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 3/8 6/23/23, 2:38 AM Anorexia nervosa Pathway Obtain careful monitoring of any medication selected for the symptomatic treatment of anorexia nervosa and comorbid conditions. B As per AACAP 2015 guidelines, reserve medications, including complementary and alternative medications, for comorbid conditions and refractory cases. B Pharmacotherapy, antipsychotics: As per SIGN 2022 guidelines, consider offering olanzapine to support recovery, but not as the sole treatment, in adult patients with anorexia nervosa. B As per CPG 2020 guidelines, consider offering olanzapine or aripiprazole with careful monitoring in certain pediatric and adolescent patients with anorexia nervosa. C As per DGPPN 2019 guidelines, do not use neuroleptics for the sole purpose of achieving weight gain in patients with anorexia nervosa. D Show 2 more As per AAFP 2015 guidelines, avoid using antipsychotics for the treatment of patients with anorexia nervosa. D As per RANZCP 2014 guidelines: Consider offering low-dose antipsychotics, such as olanzapine, to reduce anxiety and obsessive thinking. B Be cautious when prescribing psychotropic medications for severe comorbid conditions/symptoms until it is clear that such symptoms are not secondary to starvation. B Pharmacotherapy, antidepressants: As per DGPPN 2019 guidelines, do not use antidepressants for the sole purpose of achieving weight gain, both in the initial treatment and relapse prevention, in patients with anorexia nervosa. D As per RANZCP 2014 guidelines, be cautious when using antidepressants B Do not use SSRIs in the acute or maintenance stages of anorexia nervosa. A 4. Inpatient care Indications for hospitalization: As per CPG 2020 guidelines, provide the least intensive treatment environment (such as family- based treatment or day treatment versus lengthy hospitalizations) especially in pediatric and adolescent patients with anorexia nervosa requiring a first admission to hospital and/or with a duration of illness < 3 years. A As per DGPPN 2019 guidelines, ensure that inpatient treatment facilities used for anorexia nervosa are able to offer specialized multimodal treatment programs. B Show 2 more As per AACAP 2015 guidelines, consider offering psychiatric hospitalization, day programs, partial hospitalization programs, and residential programs for eating disorders in pediatric and https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 4/8 6/23/23, 2:38 AM Anorexia nervosa Pathway adolescent patients only when outpatient interventions have been unsuccessful or are unavailable. C As per AAFP 2015 guidelines, assess medical stability and the need for hospitalization in the initial evaluation of patients with eating disorders. B As per RANZCP 2014 guidelines: Provide treatment in the least restrictive environment possible, usually in an outpatient setting. B Provide outpatient treatment as first-line therapy in adolescent patients withanorexia nervosa. A Reserve hospitalization for medical rescue and management of psychiatric risk. B Admit patients at high risk of life-threatening medical complications, extremely low weights, and other uncontrolled symptoms to the hospital. B 5. Nonpharmacologic interventions Psychotherapy: As per APA 2023 guidelines: Offer eating disorder-focused psychotherapy including normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects of the disorder (such as fear of weight gain and body image disturbance) in adult patients with anorexia nervosa. B Offer eating disorder-focused family-based treatment including caregiver education aimed at normalizing eating and weight control behaviors and restoring weight in adolescent and emerging adult patients with anorexia nervosa having an involved caregiver. B As per SIGN 2022 guidelines, offer enhanced CBT in patients with eating disorders. Offer other forms of CBT as first-line therapy in adult patients with anorexia nervosa. A Consider offering other therapeutic approaches, such as interpersonal psychotherapy, the Maudsley model, Specialist Supportive Clinical Management, or focal psychodynamic therapy, if CBT is ineffective, unsuitable, or unacceptable. B Show 3 more As per CPG 2020 guidelines: Offer family-based treatment in all pediatric and adolescent patients with anorexia nervosa, especially with a duration of illness < 3 years. A Consider offering multi-family therapy or CBT in pediatric and adolescent patients and adolescent-focused psychotherapy in adolescent patients with anorexia nervosa. C As per DGPPN 2019 guidelines: Address ambivalence and motivation to change as a central task in the treatment of patients with anorexia nervosa, as they are highly ambivalent towards change, and maintain it throughout the whole treatment process. B Offer the following evidence-based psychotherapies, administered by practitioners experienced with eating disorders, as first-line therapy for the outpatient treatment of patients with anorexia nervosa: https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 5/8 6/23/23, 2:38 AM Anorexia nervosa Pathway family-based treatment in pediatric and adolescent patients focal psychodynamic therapy in adult patients enhanced CBT in adult patients Maudsley model in adult patients specialist supportive clinical management in adult patients. B As per AACAP 2015 guidelines, offer outpatient psychosocial interventions as the initial treatment of choice in pediatric and adolescent patients with an eating disorder. B As per AAFP 2015 guidelines, offer Maudsley model family-based treatment in adolescent patients with anorexia nervosa. B As per RANZCP 2014 guidelines, offer psychotherapy as the mainstay of treatment in patients with anorexia nervosa. Offer family-based therapies in younger (< 18 years old) patients living with families. Offer family-based therapy or alternate family therapy as the treatment of choice in most pediatric and adolescent patients with anorexia nervosa. (EBR I). A Show 2 more Technology-based interventions: As per SIGN 2022 guidelines, consider offering psychological assessments and treatment via videoconferencing as an adjunct or alternative to in-person sessions when there are barriers to accessing in-person sessions. C As per CPG 2021 guidelines, consider offering telehealth family-based treatment in pediatric and adolescent patients with anorexia nervosa. C Show 12 more Nutritional management: As per APA 2023 guidelines, set an individualized goal for weekly weight gain and target weight in patients with anorexia nervosa requiring nutritional rehabilitation and weight restoration. B As per SIGN 2022 guidelines: Provide refeeding to an optimized healthy weight (taking the patient's ethnicity and sex into consideration), both as a life-saving measure and also as an adjunct to achieve an optimized weight and reduce relapse, in patients with anorexia nervosa. A Set nutritional goals on a case-by-case basis after a holistic assessment of the patient's general physical and psychological condition, taking into account the patient's ethnicity, biological sex, genetics, personal dietary requirements, sensory sensitivities, and cultural beliefs, and guided by an experienced specialist eating disorder dietitian or suitably qualified alternative healthcare professional. B As per DGPPN 2019 guidelines: Do not provide an initial low caloric energy supply with a gradual increase for the sole purpose of safe weight gain (avoidance of refeeding syndrome) in patients with mild-to-moderate anorexia nervosa, provided that medical monitoring is ensured. D Individualize and obtain continuous monitoring of the energy supply for the expected weight gain, tailored to the treatment phase. B https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 6/8 6/23/23, 2:38 AM Anorexia nervosa Pathway As per AAFP 2015 guidelines, set a minimum weight restoration target of 90% of the average weight expected for the patient's age, height, and sex in patients with anorexia nervosa. B As per RANZCP 2014 guidelines, provide refeeding and weight gain regimes to minimize the risk of refeeding syndrome, underfeeding, and other medical complications arising from increased nutritional intake. B Exercise programs: offer specialist-supervised exercise programs as part of a comprehensive management program including a psychoeducation component in patients with anorexia nervosa. A Show 3 more Yoga: advise practicing, yoga in addition to standard treatments, in medically stable young patients with anorexia nervosa. B 6. Specific circumstances Pregnant patients: elicit history of current or past history of eating disorders in females during pregnancy and postnatal period, recognizing the potential barriers for disclosure. A Show 13 more Patients with diabetes mellitus type 1: consider assessing for the presence of eating disorders as part of the routine review of patients with T1DM. C Show 3 more Patients with osteopenia/osteoporosis: offer weight restoration as part of a holistic program of treatment to improve bone mineral density in patients with low-weight anorexia, regardless of gender identity and age. A Show 4 more References 1. Phillipa Hay, David Chinn, David Forbes et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014 Nov;48 11 977 1008. Open 2. Catherine Crone, Laura J Fochtmann, Evelyn Attia et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders. Am J Psychiatry. 2023 Feb 1;180 2 167 171. Open 3. James Lock, Maria C La Via, American Academy of Child and Adolescent Psychiatry AACAP Committee on Quality Issues CQI . Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015 May;54 5 412 25. Open 4. Scottish Intercollegiate Guidelines Network. SIGN 164 Eating disorders. SIGN. 2022 Aug. Open 5. Gaby Resmark, Stephan Herpertz, Beate Herpertz-Dahlmann et al. Treatment of Anorexia Nervosa-New Evidence-Based Guidelines. J Clin Med. 2019 Jan 29;8 2 153. Open https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 7/8 6/23/23, 2:38 AM Anorexia nervosa Pathway 6. US Preventive Services Task Force, Karina W Davidson, Michael J Barry et al. Screening for Eating Disorders in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Mar 15;327 11 1061 1067. Open 7. Camilleri M, Parkman HP, Shafi MA et al. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013 Jan;108 1 18 37. Open 8. Brian C Harrington, Michelle Jimerson, Christina Haxton et al. Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa. Am Fam Physician. 2015 Jan 1;91 1 46 52. Open 9. Jennifer Couturier, Leanna Isserlin, Mark Norris et al. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord. 2020 Feb 1;8 4. Open 10. Jennifer Couturier, Danielle Pellegrini, Catherine Miller et al. The COVID 19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID 19 and beyond. J Eat Disord. 2021 Apr 16;9 1 46. Open 11. American Geriatrics Society. Choosing Wisely AGS recommendations. Choosing Wisely. 2015. Open 12. Brian C Harrington, Michelle Jimerson, Christina Haxton et al. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. Am Fam Physician. 2015 Jan 1;91 1 46 52. Open 13. Jennifer Couzin-Frankel. Rethinking anorexia. Science. 2020 Apr 10;368 6487 124 127. Open 14. American Psychiatric Association. Treatment of patients with eating disorders,third edition. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163 7 Suppl):4 54. Open 15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision DSM 5 TR ). APA. 2022. Open https://web.pathway.md/diseases/recRtaTMHhaVTKJg8 8/8