Anorexia nervosa: a therapist's manual

1. The programme at a glance

Indication. Anorexia nervosa in adults, restricting type or binge-eating/purging type, as outpatients or following on from a hospital admission, in a person whose physical state has been assessed by a doctor and remains followed by them. Section 46 describes the approach with adolescents, for whom family-based treatment is the first-line treatment.

Reference model. Cognitive behavioural therapy (CBT) for eating disorders in its enhanced version — personal formulation, open weighing, regular eating resumed, work on the overevaluation of weight and shape — enriched by two contributions that have their own data: the Maudsley cognitive-interpersonal model, for thinking style, emotions, pro-anorectic beliefs and the responses of those close to the person; and the stance of specialist supportive clinical management, for regularity, warmth and the constant place given to refeeding. These three approaches are presented in sections 6 and 16; open weighing, in which the person sees their weight in session, is presented in section 42.

Format. Twenty 50-minute sessions, the first six at a rhythm of two a week if possible, followed by four monthly appointments. This format is condensed. It corresponds to the core of the protocols evaluated for the Maudsley model and for specialist supportive clinical management, which add sessions for severe forms; CBT-E provides for around forty in people who are undernourished, and many patients need this long format. The points at which it can be extended are indicated.

Mechanism targeted. Bringing the person out of undernutrition, which maintains a large part of the disorder, by making ambivalence an object of work rather than a prerequisite. Then reducing what keeps the system going once the body has been renourished: the disproportionate place of weight, shape and control in self-esteem, dietary rules and avoidance, checking, clinical perfectionism (section 5), the avoidance of emotions, and the responses of those around the person that maintain it without meaning to.

Session	Focus	Session output
1	Welcome and assess	Picture situated, risks assessed, record handed over
2	Medical follow-up, the team and weighing	Shared follow-up, level of care decided, first open weighing
3	Understanding what maintains it	Personal formulation drawn
4	Ambivalence	What the disorder gives and costs, written down; two letters begun
5	Deciding	Decision to begin, first goals written down
6	Eating regularly	Meals and snacks at times written down
7	Increasing	First step of the eating plan under way
8	Getting through the first weeks	Compensatory behaviours looked for, written plan for difficult meals
9	Those close to the person, and meals	Role of one close person defined, one accommodation reduced
10	Progress review	Written decision: continue, intensify, change level of care
11	Avoided foods and rules	Rated lists, one food reintroduced, one rule broken
12	Physical activity and other forms of control	Activity plan approved by the doctor
13	The place of weight and shape	Pie chart drawn, two developments dated
14	Checking and "I feel huge"	Two checking behaviours dropped
15	Perfectionism and rigidity	One "good enough" experiment
16	Emotions	One written response per avoided emotion
17	Relationships	One conversation prepared, one social contact dated
18	A life not organised by the disorder	Three plans dated
19	Preventing relapse	Warning signs and a three-level plan written down
20	Review and what comes next	Measures repeated, follow-up organised

A few terms used in the table. "Picture situated" means that the clinical picture has been linked to one of the four presentations in section 3. The record is the real-time food record that the person keeps between sessions (section 14). An accommodation is a gesture through which those around the person follow the disorder's rules (section 5). The pie chart represents the place that weight, shape and control occupy in self-esteem, and the developments are the activities, relationships or projects that are made to grow so that they compete with it (session 13).

What the person takes away. Nine printable worksheets, listed in section 51: my record, before and after weighing, my two letters, my meals, my foods and my rules, my diagram, my standards and my emotions, my plan for what comes next, and the corner for loved ones and parents.

What distinguishes this programme from the other manuals on this site. Three things. It is never conducted alone: a doctor follows the somatic risk, and the programme changes level of care on their advice. It makes motivation an object of work and not an entry condition, because the disorder is valued by the person who suffers from it. And it devotes a whole section to adolescents, with whom the approach is partly reversed: it is the parents, and not the adolescent alone, who carry refeeding at the start.

2. Before you begin

The five preliminary decisions

Is a doctor following the person's physical state? If not, that is the first thing to organise, before the second session. Section 10.

Is the level of care the right one? Outpatient treatment is possible only if the physical state allows it and if the trajectory is not one of rapid decline. The doctor decides this with you, on the basis of the dedicated guidelines. Section 12.

Is there a current suicide risk? It is high in this indication, it is looked for explicitly, and it is treated at the same time as everything else. Section 11.

Is this an adult, or an adolescent living with their parents? The approach is not the same. With adolescents, it is section 46 that applies first.

And exactly which presentation is it? Restricting anorexia, the binge-eating/purging form, so-called atypical anorexia, or avoidant/restrictive food intake disorder. Section 3.

What this programme does not treat

It does not treat a medical emergency. Fainting, confusion, chest pain, refusal to drink, heart rhythm disturbances, severe or rapidly progressing undernutrition: these are medical emergencies, and they are treated in hospital.

It does not conduct refeeding on its own. Refeeding is conducted with a doctor, and often with a dietitian. The psychologist carries its meaning, the decision and the obstacles; they set neither the intake nor the pace.

It does not replace a hospital admission when one is indicated, and it does not serve to delay it.

It does not treat bulimia or binge-eating disorder at usual or high weight, which fall under Bulimia and binge-eating disorder: a therapist's manual.

And it does not treat avoidant/restrictive food intake disorder, where the difficulty is about the food itself and not about weight. Section 3.

How to use it

Read the whole text before the first session, in particular sections 4, 10, 12, 41 and 42: undernutrition, medical risk, levels of care, ambivalence and weighing. With adolescents, read section 46 before anything else.

Each session is described using the same framework: the aim, the steps, what you say, frequent mistakes, and the criterion for moving on.

Three warnings specific to this reason for consultation.

The disorder is valued. Unlike almost everything else you treat, the person does not come to get rid of their symptom: they often come because they have been pushed into it, and part of them holds on to what you want to take away from them. This is not a lack of motivation; it is a characteristic of the disorder. Section 41.

Undernutrition changes what you observe. Rigidity, obsession with food, mood, isolation, sometimes traits reminiscent of autism or of obsessive-compulsive disorder (OCD): part of all this is produced by the deprivation, and diminishes with refeeding. No personality diagnosis is made in an undernourished person.

And the risk is real. A person can appear calm, coherent and engaged, and be in physical danger. What you see in session is not enough to assess that risk; that is why it is shared.

3. Four presentations not to be confused

1. Anorexia nervosa, restricting type

What you observe. Food restriction leading to a weight that is clearly low for the person's age, height and history, an intense fear of gaining weight or behaviours that prevent weight gain, and a perception of the body, or a value placed on weight, that is profoundly altered. Physical activity is often excessive. There are no regular binges or purges.

What it implies. This is the programme described here.

2. Anorexia nervosa with binges or purges

What you observe. The same picture, with binge-eating episodes, self-induced vomiting, or the use of laxatives or diuretics.

What is different. The somatic risk is higher, in particular for electrolytes — the mineral salts in the blood, including potassium — and the heart, and so is the suicide risk. Impulsivity and emotion regulation take up more room.

What it implies. The same programme, with closer medical monitoring, and the techniques for stopping compensatory behaviours described in Bulimia and binge-eating disorder: a therapist's manual, applied once regular eating has been resumed.

3. So-called atypical anorexia

What you observe. The whole picture — the restriction, the fear, the overevaluation, sometimes serious physical complications — in a person whose weight remains within the usual range or above it, after a significant loss.

What misleads. The weight. These people are often congratulated on their weight loss, rarely diagnosed, and they can present the same complications as in the typical form.

What it implies. The same programme and the same medical vigilance. The target is not a figure: it is the end of restriction and the return of the functions that undernutrition had switched off.

4. Avoidant/restrictive food intake disorder

What you observe. Very limited eating, sometimes significant weight loss, but with no concern about weight or shape. What is at issue is the food itself: its texture, its smell, the risk of choking or vomiting, or simply a lack of interest in eating.

What decides it. The question "what would happen if you ate more?". In anorexia, the answer is about weight or the body. Here, it is about the food.

What it implies. Different work, often based on exposure to foods, with the same somatic vigilance. Applying work on the overevaluation of weight to this presentation would be beside the point.

The three other things to have ruled out

A physical cause of weight loss. Inflammatory bowel disease, coeliac disease, hyperthyroidism, diabetes, cancer, chronic infection. The doctor must have looked for these: check with them.

Depression with loss of appetite. The person no longer eats because they are no longer hungry and have no desire to, not because they fear weight gain. Section 8.

And substance use that suppresses appetite, whether prescribed or not.

The three sorting questions

"If your weight went up a little, what would that change for you?" The question that isolates the fear of weight and its place in self-esteem.

"What do you do to control your weight?" Asked broadly, then behaviour by behaviour: restriction, physical activity, vomiting, laxatives, diuretics, appetite suppressants and, in a person with diabetes, insulin.

"What do the people around you say about your weight?" It opens up how the person perceives their condition, and the worry of others, which is often the reason for the consultation.

4. What undernutrition does

What you need to know before anything else

A large part of what is attributed to anorexia nervosa is produced by undernutrition itself. This is what was shown by the early studies of semi-starvation carried out with volunteers who had no disorder at all (Keys et al., 1950): an all-pervasive preoccupation with food, rituals around meals, eating slowly, depressed and irritable mood, loss of interest in everything else, isolation, rigidity, difficulty concentrating and, during refeeding, episodes of hunger that were hard to control. These manifestations appeared in people who had no disorder beforehand, and they largely receded with refeeding.

What this changes

Part of the psychopathology is an effect, not a cause. The obsession with food, the rigidity, the isolation and some of the depression diminish with weight restoration. You need to know this so as not to treat them as stable traits.

Cognitive work has limits in an undernourished person. A starved brain thinks more rigidly, more focused on detail, and more occupied by food. That is not a reason to wait; it is a reason not to ask psychological work to do what it cannot do while undernutrition lasts.

Refeeding is therefore part of the psychological treatment, not a separate medical prerequisite. It is one of the principles of this manual.

And it is therapeutic information. Explaining to the person what undernutrition does is one of the most useful interventions of the first sessions: it gives meaning to what they are going through, it separates part of the suffering from their identity, and it makes refeeding less arbitrary.

What undernutrition does to the body, in qualitative terms

The detail is a matter for the doctor and the dedicated guidelines. What you need to know to talk about it accurately:

The heart slows and weakens, blood pressure falls, and rhythm disturbances can occur, particularly when there are purges or electrolyte disturbances.

Body temperature falls, the extremities are cold, fine body hair may appear.

Hormonal functions shut down: periods stop, sexual desire decreases and, in adolescents, growth and puberty come to a halt.

Bone becomes fragile, sometimes permanently, and all the more so when undernutrition begins early and lasts a long time.

Muscles waste away, including the heart muscle, and strength decreases.

Transit slows, and so does stomach emptying, hence a feeling of early fullness that makes resuming eating arduous at first.

And the brain changes, in ways that are largely reversible with refeeding.

What undernutrition does to the person's judgement about themselves

This is the hardest point to say, and it is said early: undernutrition alters the ability to perceive the danger of undernutrition. The person may feel energetic, clear-headed and in control while they are in danger. This is neither a lie nor wilful denial; it is one of the effects of the disorder. It is also why risk is measured by examinations and tests, and not by how the person feels.

5. What maintains the disorder

The disorder gives something

This is the particularity of anorexia nervosa, and recent models have placed it at the centre: the disorder is valued. It gives a sense of mastery, of achievement, of being special, sometimes of safety; it numbs painful emotions; it simplifies a life that had become too complex; it sometimes attracts an attention and a concern that could not be obtained otherwise. Schmidt and Treasure (2006) described these pro-anorectic beliefs as one of the factors that maintain it.

What this changes. You are not treating a symptom the person wants to get rid of. You are treating a behaviour that part of them defends. Ignoring this produces a treatment in which the therapist wants and the patient resists. Section 41.

Restriction that maintains itself

Restriction is experienced as an achievement, and each achievement strengthens the value placed on control. Hunger is reinterpreted as a victory. Undernutrition in turn produces a preoccupation with food, a rigidity and an isolation that make restriction easier to maintain.

The overevaluation of weight, shape and control

As in bulimia and related presentations, self-worth is judged overwhelmingly on weight, shape and the ability to control eating (Fairburn et al., 2003). This is the central piece of the model on which CBT-E is based (section 6), called transdiagnostic because it describes the same maintaining mechanisms in all eating disorders; clinically, its persistence after weight restoration is a signal of relapse risk.

What is specific to anorexia. Control itself is often valued more than weight. The person does not judge only their body: they judge their ability not to give in.

Checking and avoidance

Weighing several times a day, feeling one's bones, measuring, pinching, comparing, trying on test garments, which serve as a size reference; or, the other way round, avoiding mirrors and close-fitting clothes. Both keep the preoccupation going, and checking always finds something. Section 44.

The four factors of the cognitive-interpersonal model

Schmidt and Treasure (2006), then Treasure and Schmidt (2013), described four factors that predispose to the disorder and maintain it once it is established. The model is called cognitive-interpersonal because it combines thinking factors and relational factors; it underpins the Maudsley model of treatment (section 6), and it guides part of this programme.

A thinking style. Attention strongly focused on detail at the expense of the overall picture, difficulty changing rule or strategy, perfectionism and a fear of making mistakes.

A socio-emotional style. A marked sensitivity to threat and criticism, a tendency to avoid or mask emotions, and difficulty expressing them, particularly anger and sadness.

Pro-anorectic beliefs. What the disorder gives, or seems to give.

The responses of those around the person. Intense emotional reactions — fear, anger, criticism — and accommodating reactions, through which the family organises itself around the disorder's rules. Both are understandable, and both maintain it. Section 47.

Clinical perfectionism

Self-esteem that depends excessively on the determined pursuit of demanding, self-imposed standards, despite their consequences (Shafran et al., 2002). It goes beyond eating: studies, work, sport, order. And it feeds on itself, because a standard that has been reached is immediately raised. This programme works on it in session 15, once the resumption of eating is under way (section 45). Perfectionism: a therapist's manual describes a ten-session protocol devoted to this process: it can enrich that work at the point where this programme plans it, or take over when perfectionism remains high once the disorder has improved, but it never replaces the treatment of anorexia, which comes first.

The complete circle

Self-worth depends on control and weight, so restriction is experienced as an achievement. It produces undernutrition, which increases the preoccupation with food, rigidity and isolation. Painful emotions are avoided, and restriction numbs them. Those around the person, worried, watch, criticise or accommodate. The person then feels misunderstood, and withdraws further into the only thing they master, which strengthens even more the place of control in their self-worth.

This is the diagram you draw in session 3, with the person's own elements.

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