Levels of care for anorexia nervosa
There are several levels of care for those living with anorexia nervosa. The level of care often depends on the severity of the illness or where a person may be in their recovery.
Inpatient care is usually required for people with anorexia whose disordered eating behaviors have left them psychologically or medically compromised. (1)
Signs of medical instability
- Unstable or depressed vital signs
- Complications from coexisting medical conditions
- Lab test results suggesting an acute health risk
Signs of psychological instability
- Suicidal ideation and thoughts of self-harm
- Concerns for physical safety
- Rapidly worsening disordered eating behaviors
Inpatient treatment involves round-the-clock care and monitoring, which is usually provided in a hospital setting or a specialized facility for eating disorders. (2)
Patients in inpatient care may require medical management, such as tube feeding, intravenous fluids, vitals monitoring, and regular lab testing. (3) Psychotherapy, supervised meals, and nutrition counseling are also usually part of the treatment plan.
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Residential treatment also houses individuals with anorexia for 24 hours a day and provides multidisciplinary treatment. But it’s only for medically stable patients.
Those in residential treatment still require round-the-clock supervision to monitor their meals and eating disorder behaviors, which can include restriction, excessive exercise, and laxative and diuretic use. (3)
Residential treatment may also be suitable for those who:
- Struggle with intrusive, repetitive, disordered thoughts
- Require a highly-structured environment to engage in treatment
- Can’t control their compensatory behaviors without structure
- Have little motivation
- Live in a triggering or chaotic home environment
Partial hospitalization program (PHP)
Partial hospitalization programs (PHPs) are day treatment programs that still provide a level of structure for people with anorexia, but do not require overnight stays.
Patients are required to attend several days a week, for many hours. PHP treatment can include nutritional counseling, monitored eating sessions, medical care, and individual, family, and group therapy. (4)
Individuals with AN in this level of care are psychiatrically and medically stable, but have: (3,4)
- A bodyweight greater than 80% of the “normal” range
- Disordered eating patterns that impair function
- The need for structure to continue with weight regain
- Demonstrated compensatory behaviors, like restriction, purging, or other weight control techniques
- An inability to function in normal social situations
- Partial cooperation
Intensive outpatient (IOP)
Intensive outpatient care (IOP) is usually for those with anorexia nervosa who are ready to step down from residential treatment but still need some structure and support to help maintain their self-control. (5)
A multidisciplinary team of therapists, nutritionists, and mental health professionals will continue with a treatment plan, which will include supported meals, nutritional counseling, and individual and group therapy.
No overnight stays are required. Instead, treatment is delivered at a specialist clinic for a few days a week, which allows patients to maintain a job or their education if they choose.
Outpatient treatment is the lowest level of care for those with AN and usually involves one-on-one sessions with a dietician and therapist once a week to monitor their progress.
Those in outpatient treatment tend to be able to control their disordered eating and compensatory behaviors, and are self-sufficient at weight gain. (4)
Psychotherapy for anorexia nervosa
Acceptance and commitment therapy (ACT)
Acceptance and commitment therapy (ACT) helps people with AN to reduce their disordered eating behaviors, thoughts, and feelings.
By using metaphors, ACT teaches strategies to help those suffering from AN manage and cope with their maladaptive eating behaviors, like restriction and over-exercising. It helps a person move from rigid thoughts and behaviors to ones that are more flexible.
Six processes are involved in ACT for anorexia nervosa: (6)
- Defusion: As the name suggests, patients learn how to defuse their unhelpful eating disorder thoughts and behaviors. Techniques are used to reframe them, take away the power and significance of these actions, and help an individual with AN be more flexible.
- Acceptance: This step helps a person with AN to accept and tolerate their thoughts and feelings, as opposed to avoiding them, as eating disorder behaviors are often a way to escape negative emotions.
- Mindfulness: This practice teaches an individual to focus on the present moment and explore what they feel, their thoughts, sensations, emotions, and environment in that moment.
- Detaching: This therapy teaches people that they are not defined by their thoughts or disordered eating behaviors. The aim is to replace these beliefs with healthy ones.
- Clarity: ACT helps someone with AN determine who they want to be and to develop their own set of values outside of their eating disorder, as a person with AN can often get “stuck” in their eating disorder values.
- Action-Focused: The final stage of ACT helps people with AN practice what they have learned during their sessions. The ultimate goal of ACT is to work toward letting go off their eating disorder and create a purposeful life for themselves without AN.
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy (CBT) is a type of talking therapy that helps people living with anorexia nervosa understand the interaction between their thoughts, feelings, and behaviors. With a therapist’s help, CBT teaches a person to develop strategies to change their negative emotions and challenge their disordered eating behaviors. Components of CBT for AN can include: (7)
- Challenging dietary rules
- Developing strategies to reduce and prevent compensatory behaviors
- Exposure to fear foods
- Meal planning
- Psychoeducation to understand what maintains anorexia
- Food diaries
Cognitive remediation therapy (CRT)
Cognitive remediation therapy (CRT) for AN targets specific cognitive deficits that are believed to contribute to the onset of the condition and maintain disordered eating behaviors. These deficits are: (8)
- Lack of cognitive flexibility: People with anorexia exhibit tight thinking, which can manifest as rigid food rules and routines and difficulty multitasking.
- Problems with central coherence: People with anorexia are often preoccupied with the little details, without being able to see the bigger picture.
CRT introduces tasks and games that target these cognitive deficits and it encourages individuals to practice these skills on their own to strengthen their skills.
Dialectical behavior therapy (DBT)
Dialectical behavior therapy (DBT) is a type of talking therapy best suited to people with AN that feel emotions very intensely. During DBT, a therapist helps a person to accept themselves as they are, while also motivating them to change their disordered eating behaviors. (9) To achieve this goal, a therapist uses a balance of acceptance and change techniques:
- Acceptance Techniques: These place a focus on an individual understanding themself and why they engage in the disordered eating behaviors associated with anorexia nervosa.
- Change Techniques: Change techniques teach an individual with anorexia to replace their maladaptive behaviors with ones that help them.
Exposure therapy is a form of CBT that helps in the treatment of anxiety, which is often a significant psychological component of anorexia nervosa. (10) Patients are exposed to situations that cause fear and distress, which are intensified over time, to increase the level of comfort with certain anxiety triggers.
The goal of exposure therapy is for those with AN to approach situations and behaviors that cause them anxiety in ways that are controlled and manageable. By confronting their fears, people living with anorexia can dispel the irrational beliefs they have about the dangers of food and certain eating situations. (11)
During family therapy, family members of an individual with anorexia learn how to support their loved ones in their eating disorder recovery. This form of therapy is particularly useful for parents of a child or teenager with anorexia and teaches them how to restore healthy eating behaviors and achieve a healthy weight. (4)
Group therapy gives patients with anorexia nervosa the opportunity to form deep connections and a strong support network with others in a similar situation.
A psychologist or other mental health professional leads these sessions, encouraging intimate conversations that can help relieve emotional distress, provide healing, bring positive changes to a person’s thoughts, and provide the realization that they’re not alone.
Interpersonal psychotherapy (IPT)
Interpersonal psychotherapy (IPT) is based on the principle that how you relate to others impacts your mental health. Therefore, problems in relationships can result in emotional issues, such as eating disorders. The aim of ITP is to resolve relationship problems in 4 key areas: (12)
- Role disputes, which are problems relating to otters, such as conflict in a relationship.
- Role transitions, which occur when there are difficulties adjusting to a life change.
- Unresolved grief, which means that a person is negatively impacted by not processing their grief.
- Interpersonal deficits, which occur when a person struggles making and maintaining healthy relationships.
Nutrition counseling and meal support
In nutrition counseling, someone with anorexia learns about the body’s nutritional needs and how much food someone of their age, size, and sex should eat to stay healthy. Patients with anorexia are also taught how to recognize the body’s hunger cues, work on repairing their relationship with food, work on body image, and address emotional dysregulation.
The aims of nutrition counseling for anorexia are to: (13)
- Increase food intake through a personalized meal plan
- Understand that gaining fat and other tissue types is part of the weight restoration process
- Restore and maintain body weight
- Regulate phosphate levels in the blood
Meal support ensures those with AN are eating meals that meet the requirements of their individual meal plan. If a meal falls short, it can be supplemented, and the patient is advised on how to make sure their meals meet their dietary requirements going forward.
During supervised mealtimes, staff watches for disordered eating behaviors or rituals, which will be redirected. Light-hearted conversation and games during meals helps take the focus off food.
Experimental treatments for anorexia nervosa
Art therapy, such as painting, drawing, and sculpture, can help people with anorexia to express their feelings and emotions when it’s difficult to find words. This form of creative self-expression provides a way to engage with difficult feelings and externalize them visually, which can give much-needed perspective.
Psychodrama is a form of group therapy where people with anorexia can explore their issues and feelings by acting out events, with role-playing and dramatic self-presentation. It can help a person living with anorexia to gain a greater understanding of thoughts and emotions that come to the surface during the session. (14)
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Treating anorexia nervosa at Within Health
The experienced team at Within Health recognizes that no two people with anorexia nervosa are the same. Therefore, we formulate personalized treatment plans for each client with the goal of helping our clients embrace weight neutrality and flexibility around food and eating.
Our AN treatment program consists of three levels of care:
- Partial hospitalization program
- Intensive outpatient program
- Outpatient program
At Within Health, we evaluate and assess each client to determine the appropriate level of treatment, which will depend on the severity of the illness, overall health, and needs of the individual seeking treatment.
We use an intuitive eating model to counteract diet culture and rigid food rules, and to recognize internal cues of hunger and satiety.
Furthermore, we don't discuss numbers, any numbers. This includes calorie counting, weight, clothing size, and more. We believe fixating on numbers is counterproductive to treatment, and we want our clients to recognize they’re more than a number on a scale.
We know how difficult it is to seek help for anorexia nervosa and treat each patient with empathy, understanding, and compassion. We care about our clients and pride ourselves on providing a safe space where anyone of any ethnicity, gender identity, sexuality, shape, and size, can feel safe.