I. Introduction: Anorexia Nervosa
Anorexia nervosa (AN) is a serious, potentially life-threatening eating disorder characterized
by self-starvation and excessive weight loss. Anorexia is one of the most common psychiatric
diagnoses in young women, affecting about 1%, and has the highest mortality rate of any mental
illness. Between 5-20 percent of individuals struggling with AN will die from the disorder2. The
probability of death increases with increased duration of the illness. The following is the DSM-V
diagnostic criteria for Anorexia Nervosa3:
A. Restriction of energy intake relative to requirements leading to a significantly low body
weight in the context of age, sex, developmental trajectory, and physical health.
Significantly low weight is defined as a weight that is less than minimally normal, or, for
children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with
weight gain, even though at a significantly low weight.
C. 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.
The DSM-V also divides AN into two diagnostic categories, restrictive anorexia and binge/purge
anorexia. The restricting type is characterized by self-starvation without engagement in recurrent
episodes of binge eating or purging behavior (i.e., self induced vomiting or the misuse of
laxatives, diuretics, or enemas). The binge/purge subtype is characterized by self-starvation with
engagement in recurrent episodes of these binge eating or purging behaviors3.
The level of care needed for the treatment of an AN patient depends on the severity of the
constant monitoring of weight, vital signs and/or laboratory test values, are malnourished and/or
refuse oral intake, possibly require nutrition support, and weigh less than 75% of ideal body
weight (IBW). Those requiring partial hospitalization treatment and day treatment are medically
stable but have difficulty following a meal plan without supervision. Treatment typically lasts
two to three months and consists of a structured behavioral program aimed at normalizing weight
and eating behavior. Patients are prescribed meal plans with sufficient caloric content to gain at
least one kilogram per week and additional calories in the form of supplements, such as Ensure,
Boost, etc are often added. These supplements are used when patients do not consume 100% of
their meal in order to assure that patients are still meeting their caloric needs even if restriction
and other ED behaviors are being used. Patients are seen in individual therapy as well as group
and family therapy multiple times per week.
Weight-restoration continues until the patient reaches at least 90% of IBW. After
weight-restoration, patients remain in treatment between two to four weeks for practice with “normal”
eating behaviors such as buffet portioning and ordering at restaurants, continued support with
meals and redirection of eating disorder behaviors, and discharge planning. Once patients
suffering from anorexia are weight restored, they usually require more calories than the general
population to maintain their weight, needing approximately 50-60 kilocalories/kg/day, as
compared with 30-40 kilocalories/kg/day6. By the end of their hospital stay, patients’ daily food intake routinely exceeds 3000 kcals. It is estimated that these increased metabolic requirements
in weight-restored AN patients may last up to a year6. Unfortunately, the rate of relapse
following treatment is very high. Reported relapse rates range from 30% to 50%, with the
greatest risk of relapse occurring in the first year following treatment1. These high relapse rates
that weight restoration is only the first step in an extensive recovery process for patients with
AN.
II. Eating Behaviors in AN Patients Before and After Treatment
In addition to weight loss, disturbance in eating behavior is a hallmark clinical feature of
anorexia. Before treatment, AN patients typically avoid high-calorie foods and eat a limited
variety of foods both across and within food groups8. Hadigan et al. documented that, when
allowed to choose their own meals, AN patients consumed far fewer calories than controls,
especially by reducing calories from fat16. Most patients regularly skip meals and maintain very strict diets such as vegetarianism, low-carb, or low-fat diets. Structured treatment programs, like
day hospitals and in patient facilities are generally successful at helping patients to gain weight
and provide varied diets and sufficient calories; however, abnormal eating behaviors typically
persist after treatment16. Steinglass et al. reported that weight-restored patients ate significantly
less than healthy controls at a single-item (i.e., macaroni and cheese) meal than healthy
controls15. Another study reported that weight-restored AN individuals who had completed
inpatient treatment chose diets after treatment that were significantly lower in energy,
carbohydrate, and fat content than healthy individuals16. Mayer et al., replicated these findings in a study in which patients were asked to consume lunch meals near the beginning and end of their
hospital stays. While the kilocalories in the end-of-stay meal increased from the
beginning-of-stay meal, intake at both meals was less than controls by more than 200 kilocalories and was
lower in percent of calories derived from fat7. These behaviors may persist for many years
following treatment. In a 20-year follow-up study of previously hospitalized patients, Eckert et
al., found abnormal eating behaviors that included eating low calorie foods (71%), eating small
treatment, such as avoiding fat or skipping meals, often return rather quickly after he/she leaves
treatment.
Research reveals that decreased dietary energy density and decreased diet variety may
play a significant role in increasing the rate of relapse among weight restored AN patients after
treatment. Schebendach et al. conducted two separate studies that examined the relationship
between eating behavior immediately prior to hospital discharge and outcome over the next year
among weight restored AN patients. Eating behavior was assessed from four-day food records
obtained after participants had maintained >90% IBW for 2 to 4 weeks. Dietary energy density
scores and diet variety scores were calculated from the four-day food record. Weight-restored
patients consuming a diet of lower energy density or of a limited variety of foods were more
likely to relapse in the year following hospital discharge compared to those individuals with
more varied diets and higher overall density10. Studies suggest that in normal weight,
overweight, and obese individuals, increased diet variety is associated with increased energy
intake, while limited dietary variety is associated with decreased energy intake and weight loss9. The decreased diet variety of AN patients after treatment may possibly contribute to weight loss
and successive relapse. Weight maintenance in AN patients has been shown to be a crucial factor
in recovery1. Once a weight-restored patient begins to lose even a small amount of weight, it is a
slippery slope and many patients will return back to their very low IBW reached prior to
treatment.
It is evident that current treatment strategies are able to promote weight restoration in AN
patients but are not as successful in normalizing eating behavior. Without addressing the factors
responsible for abnormal eating behaviors, AN patients may return back to their restrictive,
variety is correlated with increased overall calorie intake and weight gain, the outcome of AN
may be improved through increased focus on improving patients’ narrow range of food choices.
III. Overlap Between Anxiety Disorders and AN
Research suggests that many of the abnormal eating behaviors seen in AN, described
above, may be anxiety-reducing coping mechanisms14. There are clear similarities between the
clinical phenomena seen in AN and those described in anxiety disorders and
obsessive-compulsive disorders (OCD). Patients with AN commonly describe feeling nervous and unable
to relax and often report physical symptoms of anxiety, such as muscle tension, shortness of
breath, and fidgeting. There is also a high degree of comorbidity diagnosis between anxiety
disorders and AN. In a study of lifetime diagnoses, 55-62% of patients with current or past AN
had at least one DSM-IV anxiety disorder diagnosis. Studies have consistently found that in the
majority of patients with comorbid diagnoses, anxiety disorders preceded the onset and diagnosis
of AN. In addition, those with comorbid diagnoses manifested more severe symptoms of AN14.
The primary characteristic of AN is an avoidance of food due to the belief that it will
produce weight gain. Three core features of anxiety- fear, avoidance, and rituals- may play a
significant role in this disturbance. “Fear of fat” is central to the diagnosis of AN and this fear
often drives avoidance behavior, such as avoiding high calorie or high fat foods. Individuals with
AN also often demonstrate rigidly controlled, rule-bound eating patterns as well as abnormal,
ritualized eating behaviors that are meant to decrease their anxiety around food, such as cutting
food into tiny pieces, taking very small bites, refusing to touch silverware, etc. Individuals with
AN may also develop “safe” and “unsafe” foods that leads to a narrow, restricted diet that lacks
variety and is often low in fat14. Steinglass et al., also found that for patients with AN, greater
suggests that there is a direct association between anxiety and the restrictive eating behavior seen
in AN15.
Steinglass et al., created a model of AN in which traits of anxiety and obessionality result
in a combination of fearful avoidance of calorie dense foods and irrational beliefs surrounding
eating. This combination ultimately results in a diet with limited variety that promotes weight
In this model, if the anxiety-related components of AN are not addressed- specifically
those of avoidance, rigidity, and rituals- even after successful weight gain, patients are highly
susceptible to losing weight and becoming vulnerable to relapse. While anxiety decreases in
some patients after weight-restoration, many patients experience the same level, if not increased
anxiety after weight restoration. Addressing these “food fears” and avoidance behaviors may be
a useful approach to treating the dysfunctional beliefs and behaviors that serve to perpetuate AN.
Currently, the most widely used treatment for all eating disorders is Cognitive Behavioral
Therapy (CBT), which emphasizes changing beliefs that lead to maladaptive behaviors. CBT has
been demonstrated to be successful in treating bulimia nervosa; however, its success with AN is
not as clear4. While CBT may help patients to manage the stress of gaining weight during
treatment, it does not necessarily repair the dysfunctional eating behaviors that prompted the
weight loss. If AN and anxiety share characteristic traits, and if these traits are at the core of
these abnormal eating behaviors, it is reasonable to suggest that treatment approaches aimed at
reducing anxiety could potentially be successful treatment strategies for AN. A number of
studies have applied Exposure and Response Prevention therapy, a common treatment strategy
for anxiety disorders, to the treatment of AN. To date, there is limited research on the effect of
exposure therapy to improve food intake in AN. The following section reviews the available
evidence on the use of exposure therapy for treating AN.
IV. Exposure Therapy to Improve Eating Behaviors in AN Patients: A Review of the Evidence
Exposure and Response Prevention therapy is one of the primary treatment methods for
anxiety disorders such as generalized anxiety, OCD, and phobias5. This treatment is predicated
designed to elicit a patient’s emotional experience in the moment and to, in the process, identify
and address feared consequences. While in the presence of a trained professional, the patient is to
stay in contact with the trigger without engaging in ritual (escape) behaviors. The goal is to
habituate the patient to the anxiety and therefore decrease the psychological and physical
responses to the phobia over time14.
Research demonstrates that AN patients have high anxiety towards high calorie and high
fat foods. This has been shown in Cynthia Bulik’s work in which she studied the psychological
affect (i.e., feelings, attitudes) towards food and weight stimuli in three groups: patients with
acute AN, patients recovered from AN, and healthy controls with no AN history. In this study, participants from each group were shown a variety of high-calorie, low-calorie, thinness-related,
and fat-related images, amongst others. They found that AN patients displayed significantly
greater negative implicit affect toward images of high- but not low-calorie food, indicating that
they do not display negative implicit affect toward all foods: only high-calorie foods. Bulik et al., recommend that treatment should help patients reduce negative reactions to high-calorie (junk, hyper-palatable, etc.) food through exposure therapy11.
Recently Joanna Steinglass and colleagues have published a few papers developing a
treatment intervention to target eating-related fear and anxiety, known as Exposure and Response
Prevention for AN (AN-EXRP). AN-EXRP is a manualized treatment that adapts exposure and
response prevention techniques to address eating disorder behaviors. They argue that, given the
fact that “eating patterns prior to discharge are related to such individuals’ ability to maintain
longer-term health” it is important to engage “patients in the task of confronting, rather than avoiding, fears” so that they can “experience decreasing anxiety over time”. During individual
holding a sandwich and eating it without the use of anxiety-reducing rituals, such as breaking it
into pieces or taking tiny bites. Interventions aim to enhance the patient’s awareness of the
physical symptoms of anxiety (ex. nausea, sensations of fullness, tension, etc), help him/her
articulate the feared consequences (ex. immediate obesity), and recognize that the feared
outcome (ex. weight gain) did not occur. A patient may begin the exposure treatment by simply
holding, smelling, and tasting the food and over several sessions work up to eating the food in its
entirety in one sitting. According to the literature that describes AN-EXRP, the ultimate goal of
AN-EXRP is to specifically encourage increased dietary variety, increased intake of high fat
foods or high calorie foods, and increased caloric intake overall12.
Two studies conducted by Steinglass et al., evaluated the use of AN-EXRP and its effect
on the eating behavior of weight-restored AN patients, specifically its effect on overall caloric
intake. In the first study, 9 participants were recruited between the ages of 16 and 45 who met the
DSM-IV criteria for AN. The intervention consisted of 12 individual 90-minute sessions for four
weeks. Each session included an exposure to a feared eating situation, beginning with the least
feared exposure at the first session and progressively moving up to the most feared exposure.
Eating behavior and anxiety were assessed before and after the study treatment using test meals,
self-report four-day food records, and three standardized anxiety measurement tests (STAI-S,
STUDS, FAH). The primary outcome measure was caloric intake and meal-related anxiety in a
laboratory meal in which patients were provided with a tray consisting of a sandwich, a large
bowl of potato chips, and a small bottle of water. Participants were instructed to eat an
appropriate lunch and intake was calculated by measuring the weight of the food. Pre-meal
anxiety, as measured by STAI-S before entering the test meal room decreased from 58.4±6.4
before AN-EXRP was 429±169 kcal and after AN-EXRP mean intake was 434±242 kcal. These
results suggest that over the course of AN-EXRP treatment, mean meal-related anxiety decreased
and caloric intake increased12. Limitations of this study include the small sample size, lack of a control group, and relatively short treatment period.
Steinglass et al., replicated the study above in a 4-week randomized controlled trial to
again evaluate the effects of AN-EXRP on caloric intake in a laboratory setting. Cognitive
remediation therapy (CRT) was selected as a control for the experiment as there is no evidence,
to date, that CRT is associated with an increase in caloric intake in AN patients. All participants
were receiving in patient treatment for AN at the same treatment center and were randomly
assigned to receive either AN-EXRP or CRT. There were 30 individuals in each group that
completed the study. The intervention is similar to the intervention described above and the
primary outcome was change in caloric intake between the baseline and post-treatment
laboratory lunch meal. The meal consisted of a large sandwich, a bottle of mayonnaise, a bowl of
potato chips and a bottle of water. Participants were instructed to eat an appropriate lunch and
intake was calculated by measuring the weight of the food. The average test meal caloric intake
of participants who received AN-EXRP increased from 352±263 kcal at baseline to 401±215
kcal post-treatment, while that of participants who received CRT decreased from 501±232 kcal
at baseline to 424±221 kcal post-treatment. These results indicate that those randomized to
AN-EXRP had significantly better change in food intake in a test meal than the control group13. Levinson and Byrne created a Fear of Food Measure (FOFM) to assess the improvements
in patients undergoing AN-EXRP treatment. They conducted four separate studies to first assess
the validity of the FOFM and then to assess the anxiety about eating, food anxiety behavior, and
recruited from an eating disorder facility (n=41) were matched to healthy controls (n=23)
recruited from the local community. Participants completed four sessions of a 45-minute
mealtime exposure intervention focusing on mealtime anxiety. Food percentage was measured at
the end of the meal to calculate percent consumed. As expected, participants with an eating
disorder had significantly higher levels of anxiety about eating than the matched controls, both
before and after the study. However, across the AN-EXRP intervention, anxiety about eating,
food avoidance behaviors, and feared concerns all significantly decreased in the eating disorder
participants. As described previously, pre-meal anxiety has been shown to be associated with
food intake. By decreasing pre-meal anxiety, AN-EXRP could potentially increase caloric intake
and decrease the fear of food among AN patients. It is important to note that this study did not
exclude other eating disorder diagnoses and some participants were diagnosed with bulimia
nervosa5.
V. Research Translated into Practice
While the research demonstrates that exposure therapy can be a useful tool in the
treatment of AN, its implementation in practice is not typically the scientific, manualized
treatment that is described in the studies above. There is a gap that exists between how exposure
therapy has been utilized in research and how it is currently being utilized in practice. Current
practice includes strategies that could also could be considered exposure therapy, however, these
strategies are mostly done in group settings rather than individually and take place outside the
walls of a therapy room. In most current eating disorder treatment centers, these strategies
include group restaurant outings, cooking groups, and buffet portioning. Once patients get to a
certain level in treatment (i.e. greater than 85% IBW and 100% completion at most meals), they
themselves or in small groups. Restaurant outings expose patients to “fear foods” that they would
face in their normal, everyday lives such as when they are at school or when they are eating out
with family and friends. Another strategy is cooking groups in which patients cook meals for
themselves in small groups at the treatment center facility. Cooking groups give patients the
opportunity to be exposed to ingredients that they would not normally cook with (i.e. pasta, red
meat, butter, etc) and mimic the “normal” experience of cooking with family and friends at
home. In addition, patients become more familiar with the kitchen and more comfortable with
cooking a wider variety of foods in the hopes that they will continue to cook a wider variety of
foods upon their return home after treatment. Patients also practice buffet portioning at the
treatment center. With the help of a Registered Dietitian, patients serve themselves and plate
their own meals from a buffet that is set up by the kitchen. At first, most patients will greatly
under portion themselves when plating their own meals; buffet portioning helps them practice
meeting their exchanges at meals while they still have the help and support of an RD present.
These activities are typically done at least 2-3 times per week and serve to help patients confront
the anxiety that undoubtedly comes with eating meals that are viewed as “scary” such as
restaurant foods and desserts.
While all three of these strategies are successful at utilizing exposure therapy, they do not
have specific, measurable outcomes that show that their use in treatment is effective at increasing
diet variety and decreasing food avoidance once patients return home. In typical treatment, these
strategies are mostly successful at decreasing patients’ anxiety surrounding fear foods, but it is
difficult to follow patients after leaving treatment. Do these strategies continue to reduce a
patient’s anxiety around food once he/she returns home? Would they have the same outcome as
manualized exposure therapy sessions into AN patients’ treatment may improve AN treatment
outcomes, there are barriers to incorporating AN-EXRP into treatment. These barriers include
available training to practitioners, reimbursement, lack of measurable outcomes, and lack of
knowledge related to frequency of treatment (i.e. once per week, twice per week, etc.). It is
therefore easier, cheaper, and more pragmatic to instead incorporate the three strategies
described above.
VI. Discussion
While current treatment strategies for AN are generally successful at promoting
weight-restoration among the AN patient population, the rate of relapse following treatment is
substantial, indicating that current treatments are not completely adequate. Although the research
on Exposure and Response Prevention therapy in the treatment of AN is very limited, the studies
described above demonstrate that this approach may be a novel strategy to address the abnormal
eating behaviors that still plague many patients after treatment. While there are no studies that
directly measure changes or improvements in diet variety as an outcome, these studies do
suggest that overall energy intake increases after AN-EXRP treatment. As described previously,
studies suggest that in normal weight, overweight, and obese individuals, increased diet variety is
associated with increased energy intake and limited dietary variety is associated with decreased
energy intake and weight loss9. Therefore producing an increase in these patients’ caloric intake will most likely also produce an increase in diet variety. It is also reasonable to assume that by
overcoming anxiety related to “fear foods”, patients will be able to leave treatment with a less
restrictive diet by being willing and open to incorporate more of these fear foods into their daily
diet. For example, if a patient is vegetarian due to the belief that eating meat will make him/her
the feared outcome of instantly gaining weight when consuming meat will not occur. The patient
is then more likely to return home with a diet that incorporates meat. In addition, while treatment
programs often incorporate “food challenges” in which patients are encouraged to add fear foods
into their diet, few treatment programs structure meals to ensure that the foods that are presented
are those that the patient actually fears. A critical component of AN is that all patients have
slightly different fears/avoidances/behaviors. One patient may have severe anxiety when asked to
eat a turkey sandwich, while another may have very little anxiety when faced with the sandwich
but really struggle when presented with dessert. If the second patient is only challenged once
during treatment with a dessert, he/she will most likely leave treatment continuing to avoid most
dessert foods.
Despite the advantages described above, incorporating AN-EXRP treatment into practice
is not necessarily realistic or practical. Few treatment centers have the resources to actually
provide the one-on-one time that is required for implementation of AN-EXRP therapy.
Restaurant outings, cooking groups, and other food exposure activities are typically done in
group settings because this is more efficient and ultimately requires fewer staff members to
participate. Conducting at least 12 one-on-one sessions throughout a patient’s treatment stay
would require an excessive amount of paid RD staffing time. More than likely treatment centers
would have to hire additional RDs and additional primary therapists to accommodate this large
increase in patient sessions. In addition, very few RDs and therapists are actually trained to
conduct the manualized treatment of Exposure and Response Prevention Therapy. Treatment
centers would need to provide additional training for their employees, which is costly and time
consuming. Treatment centers are also typically not reimbursed by insurance for each patient
a larger number of one-on-one patient sessions during a patient’s stay does not necessarily equate
to a larger financial return.
While the research suggests that AN-EXRP may be a successful strategy, more questions
need to be answered in the research in order to determine if the benefits gained from its
implementation into practice support the increase in cost and staffing. How often should
exposure therapy sessions be conducted? Does exposure therapy need to be conducted in
therapeutic sessions or does exposing a particular food to a patient everyday have a similar
outcome? For example, if a patient fears chocolate cake, does including chocolate cake in their
dinner every night have the same outcome on their anxiety levels as exposing the patient to
chocolate cake in weekly sessions with a therapist? If exposures do not necessarily need to be
conducted in one-on-one patient sessions and can rather be implemented during meals,
implementation of AN-EXRP is significantly more practical. Another question that needs to be
answered is whether or not there is certain criteria that AN patients need to meet in order to be
“eligible” for AN-EXRP sessions. It is unlikely that AN-EXRP is applicable to all AN patients
because the root cause, severity, and willingness of AN patients is going to be somewhat
different. Some patients may be very opposed to weekly one-one-one exposure sessions, and
their lack of willingness will definitely influence the effectiveness of the treatment. AN patients
are extremely complex, and one treatment strategy will not work for all patients.
Finally, it is important for additional research to determine a best practice when
measuring the change in a patient’s anxiety levels and food behaviors both before and after
exposure therapy sessions. Should the outcome measured be the presence of specific eating
disorder behaviors (i.e. hiding food, taking tiny bites, etc.) that are serving as a coping
patient’s anxiety level itself using standardized anxiety measurement tests (ex. STAI-S, STUDS,
FAH)? Having a measurable outcome that can confirm the effectiveness of AN-EXRP treatment
is essential in order to provide motive for its implementation. Answering these questions will
help shape the best practices for the implementation of AN-EXRP therapy, as well as solidify the
evidence for its use in treatment.
The one factor that has not yet been addressed but that is critical to the success of
AN-EXRP therapy is the importance of patients completing the entire treatment program.
Unfortunately some patients, due to both cost and to willingness/motivation, leave treatment
before the clinical staff recommends it. Although patients may be weight-restored at the time that
they leave, many of their eating disorder behaviors, food fears, and food avoidances may not
have been addressed. If this is the case there is a very high probability for relapse, and this
patient will most likely end up back in treatment. In order for AN-EXRP therapy to be
successful, patients need to be in treatment long enough to be exposed to most or all of their food
avoidances and food fears. This will ultimately increase their diet variety upon completion of
treatment.
VII. Conclusion
As described previously, most AN patients that leave treatment require a significant
number of calories in order to maintain their weight. AN patients are at a high risk for relapse
after weight-restoration, indicating that abnormal eating behaviors, such as food avoidance and
food fears, are not always addressed during treatment. The diet variety of AN patients tends to be
narrow and limited both before and after treatment, which is likely due to the continued presence
of these abnormal eating behaviors. AN and anxiety share core features, namely fear, avoidance,
Prevention Therapy, has been suggested as a possible treatment approach for addressing these
abnormal AN eating behaviors. AN-EXRP could alter patients’ experiences around eating and
increase their flexibility of food choice and caloric consumption, thus improving their ability to
maintain weight and prevent relapse. While studies utilizing this approach suggest that this may
be an effective treatment tool, the current research is very limited and describes only short-term
results. Future longitudinal research will be needed to test the long-term effects of AN-EXRP in
the treatment of AN.
One of the biggest barriers in implementation of AN-EXRP treatment is a lack of
proficient providers. I would recommend that all dietetic (RD) education programs offer students
the opportunity to receive training in exposure therapy. In addition, the Academy of Nutrition
and Dietetics should offer continuing education credits for this training on a consistent basis to
current and future RDs. I would also like to see an increase in “on the job” training for those RDs
currently working in the ED field that would like to implement this training into their practice.
Simply put, I would like to see an increase in general knowledge and awareness surrounding
exposure therapy and its use in AN treatment. In addition, I would like to see research that
addresses how often this therapy needs to be conducted in order for it to be effective, who
qualifies for the treatment, and how changes in anxiety or food behaviors can be accurately
measured in order to confirm that the treatment has been successful for a particular patient. If
these questions are not answered, implementation of AN-EXRP treatment may simply be too
costly and impractical.
To date, there are few studies and a lack of evidence-based interventions for eating
disorders in general and there are large gaps in research identifying successful treatment
currently there is no “gold standard” treatment strategy. AN is an extremely complex disorder
with many factors contributing to the development and progression of the disorder. Therefore
exposure interventions should be integrated into a broader treatment program. CBT and
family-based therapy are useful in reducing cognitive rigidity, changing negative self-image beliefs, and
improving family relationships. Together, these various therapeutic strategies can form the base
of a comprehensive treatment program that can hopefully decrease AN patients’ anxiety,
improve abnormal eating behaviors, and ultimately improve the outcome of this devastating
illness.
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