Helping you become all that you are capable of becoming!



Chapter 11 Anorexia 

Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T



After reading this section, you will learn the answers to the following questions:

  1. What are the ICD-10-CM Codes for Anorexia?
  2. What are the clinical descriptors for Anorexia?
  3. What are the common symptoms for Anorexia?
  4. What are some common medical comorbidities of Anorexia?
  5. What are the common populations which are treated for Anorexia?
  6. What are the common treatment settings for Anorexia?
  7. What are the Evidence Based Practices for treating Anorexia?
  8. What are the common psychopharmacological treatments for Anorexia?
  9. What are some common manuals, guideline books and client workbooks for treating Anorexia?
  10. What are some good references you can use to learn more in-depth information about Anorexia?

ICD-10-CM Codes for Anorexia in DSM-5  

F50.01 Anorexia Nervosa Restricting type

F50.02 Anorexia Nervosa Binge-eating/purging type

F50.8 Other Specified Feeding or Eating Disorder

F50.9 Unspecified Feeding or Eating Disorder


American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed) (DSM-5). Washington, DC: Author.

Alissa: Anorexia Nervosa

You get a call from Dr. Graham who has frequently referred clients and he sounds very concerned and frustrated. “I have a patient named Alissa who has anorexia nervosa and at this point in time weighs only 85 pounds and her acceptable weight is 125 pounds. She is in denial and unwilling to work on any psychological reasons for her irrational need to limit her food intake. However she said she would be willing to meet with you if you could see her today.” You agree to see Alissa in hopes you can motivate her to get on the road to recovery for her eating disorder.

You welcome Alissa in to your office and she immediately lets you know she is there only to please Dr. Graham. She then begins to tell you why she has been seeing Dr. Graham.

Two years ago she began to feel “fat” looking into the mirror she saw a young lady who had to be 180 or more pounds but in reality she weighed 135 pounds and needed to lose 10 pounds according to Dr. Graham. She immediately worked at losing those 10 pounds but everytime she looked in the mirror she still saw that fat young lady. So she continued to diet and the next time she went in to see the doctor she weighed 115. The doctor said she was fine so she could stop restricting her food intake doing her excessive exercising of 2 hours a day. She agreed with him but on getting home and looking at herself in the mirror she still was unhappy with her body and how fat it looked, so despite her promise to Dr. Graham she went back to her rigid food restriction and excessive exercising. On her next visit with Dr. Graham she was wearing bulk clothes to hide her body. She was at that point 105 pounds and the doctor was emphatic she must stop trying to lose weight because she was “Just fine” in fact she now was 10 pounds below her desired weight. She again ignored Dr. Graham’s prodding to go to a counselor and continued to spend time each day in front of the mirror convincing herself that she needed to lose more weight so her body would look good to her. She went back two more times to Dr. Graham and on this last visit was when she reached 85 pounds and Dr. Graham called me.

You tell Alissa you would be willing to work with her if she would be willing to do some work You give her to do which has proven successful in helping people like herself fall in love with themselves and accept their body as acceptable. She looked at you in shock and said how did you know I don’t love myself? She began to cry saying this and you let her cry it out. When she stopped you let her know that poor body image often leads to an eating disorder which is often due to the self-hatred of the person with the eating disorder.. She crumbled and then asked you about these self-hatred and Body issues which you explain and then she said. “OK let’s get started.” You explain to her that the Cognitive Behavioral Therapy approach you are going to train her in has been well researched and documented as an effective treatment for her condition. You tell her she will be given at least 12 sessions over the next six months. You give her first homework assignment which is to be brought back to our next session.

Anorexia nervosa (AN) is an eating disorder where no single psychotherapy or single medication alone has been proven truly effective in treating it (Fairburn, 2005). AN is characterized by people refusing to maintain normal body weight in fear of becoming fat or because they have faulty or distorted perceptions of their body size and shape (Resnick, 2005). Depression or anxiety are often co-occurring conditions with AN. For that reason clinicians have widely used medications with anorexia clients to treat secondary conditions (Bowers and Anderson, 2007). Researchers have shown that adolescents tend to have AN little more than a year (Fairburn, 2005). Adults with AN have the disorder in the range of one to eight years and an average of five years with premature mortality being associated with AN (Fedyszyn and Sullivan, 2007). 

Because people with AN are fearful of losing control and becoming overweight, they stop eating at a healthy level and their semi-starvation results in changes in mood, behavior and physical health resulting in comorbid conditions which include food preoccupation; depression; social withdrawal; altered hormone secretion; amenorea; and decreased metabolic rate (Wilson, Grilo, Vitousek, 2007).

Clients with anorexia nervosa are unique and present a wide array of symptamotology, comorbid disorders and variations in their behaviors. Because of this reality it is not easy to classify or categorize them. This makes it challenging, if not impossible, for the clinician to identify strong EBPs (Shaffner and Buchanan, 2010).

Populations with anorexia nervosa include:

1) Children and Adolescents/College age (Resnick, 2005; Gowers, 2006; Lock and Fitzpatrick, 2007; Keel and Haedt, 2008; Jones, Volker, Lock, Taylor and Jacobi, 2012; Goddard et al., 2013; Bezance and Holliday, 2013).

2) Adults (Chakraborty and Basu, 2010)

3) Families of individuals with AN (Lock and Fitzpatrick, 2007; Keel and Haedt, 2008; Jones, Volker, Lock, Taylor and Jacobi, 2012; Goddard et al., 2013).

Recognized treatments for anorexia nervosa include:

1) Cognitive Behavior Therapy or Behavioral Therapy (Gowers, 2006; Bulik, Berkman, Brownley, Sedway and Lohr, 2007; Wilson, Grilo, Vitousek, 2007).

2) Inpatient/outpatient treatment program for weight restoration with combination of CBT, medication and weight restoration and nutritional counseling and psychoeducation (Bowers and Anderson, 2007; Lock and Fitzpatrick, 2007; Keel and Haedt, 2008; Chakraborty and Basu. 2010; Shaffner and Buchanan, 2010; Bezance and Holliday, 2013; Goddard et al., 2013; Schmidt et al., 2013).

Assignment for Alissa after her first visit

A Look at Body Image

The cavepeople used to draw images and pictures of themselves on the walls of their caves to keep a running narrative history of their lives. The cavepeople did not seem to be bothered by body image problems since they drew their bodies just as they were. Cavepeople were not irrational about body size since they were happy to have bodies which were alive and surviving the hardness of their lives. They were accepting of their bodies in an unconditional way by saying: "My body is fine and acceptable as long as it keeps me alive and well."


How well do you compare with the cavepeople when it comes to your body image? Answer the following questions:

  1. Do you have a problem in being able to unconditionally accept your body as OK as long as it is alive and well?
  2. Are you concerned about looking at images of yourself?
  3. Do you have a problem accepting your body just the way it is?
  4. Do you have a problem with your body being seen in public?
  5. Are you bothered about being seen or looked at when you are trying on clothes in a clothing store?
  6. Do you have a problem looking at your naked body in the mirror?
  7. Do you hate having your picture or a home video taken of you?
  8. Do you hate seeing your body's image in a shadow?
  9. Do you avoid looking into large street side windows to avoid seeing your body's reflection?
  10. Do you avoid being captured on the camera in a store window so that you do not see your body on the TV monitor?
  11. Do you hate looking at pictures or home videos of you?

If the answer is yes to all or most of these questions, then most probably you have poor body image and are in need of extensive work to get more rational, realistic, healthy and reality based concerning your body image.

Where does poor body image come from?

Poor body image comes from a variety of irrational, unrealistic and unhealthy causes.

  1. It can be based on the conditional acceptance of your body only if it meets certain criteria for such acceptance or approval.
  2. Poor body image can be based in denial over what your body really looks like and a refusal to see your body the way it is rather than how you fantasize it to be.
  3. It can also come from self-rejection and self-non-acceptance. This is the refusal of self-acceptance of yourself as a good person. This refusal is because your body does not meet the "standard" which you believe it has to reach. This body standard must be reached before you can believe that you are a "good enough" person to be accepted by yourself.
  4. Poor body image can come from self-hatred over what your body has become.
  5. It can come from the fear of your body being seen by others the way it is rather than how you would like it to be.
  6. It can come from the need to be invisible and not seen by others and yet it is seen by others and commented on by them.
  7. Poor body image can come from the guilt over the fact that: "I have done this to my body."
  8. It can come from perfectionism over the fact that: "My body is not good enough the way it is."

Now that you have looked at if you have a body image problem and now that you have identified what are the irrational thoughts that cause body image problems are you now willing to take steps to overcome your body image problem? If yes sign this form and bring it back to your next counseling session.

Signed:                                                                 Date:

Adapted from: Chapter 5: A New Look at Body Image in: Messina, J.J. (2013), Tools for a Balanced Lifestyle: A Manual for a Guilt Free System of Healthy Living, retrieved from

Medications used for treating Anorexia 


Drug Name (Generic Name)


Zofran (Ondansetron)

Potassium chloride

K-Dur,K-Lor,K-Tab,Micro-K (Potassium chloride)

Calcium gluconate

Calcium gluconate (Calcium gluconate)

Atypical Antipsychotic

Risperdal (Risperdone)
Zyprexa (Olanzapine) 

Seroquel (Quetiapine fumarate)

Geodon (Ziprasidone) 
Abilify (Aripiprazole)   

Invega (Paliperidone palmitrate) 


Recently, researchers have utilized new intervention models.  For example, one utilized a structured Internet meeting with parents of adolescents with AN (Jones, Volker, Lock, Taylor and Jacobi, 2012). Another utilized two specific multimodal interventions of psychoeducation, groups, counseling, nutritional education and social support (Schmidt et al., 2013). Both had promising results, but require further study before the clinical community can consider the models as EBPs.

Handouts for Alissa to better explain the elements involved in her treatment

  1. TEA System
  2. ALERT System
  3. ANGER System
  4. LET GO System
  5. CHILD System
  6. RELAPSE System

All available online at: www. at:

Workbook for Treating Anorexia Related Disorders

Albers, S. (2006) Mindful eating 101: A guide to healthy eating in college and beyond. New York: Routledge.


Grilo, C.M. and Mitchell, J.E. (2010). The treatment of eating disorders: A clinical handbook. New York: The Guildford Press.


Kramer, G.F., Golden, R.N. and Peterson, F. (2009). The truth about eating disorders, second edition. New York: Facts on File, Inc.


Levitt, J.L., Sansone, R.A. and Cohn, L. (2004). Self-Harm Behavior and Eating Disorders-Dynamics, Assessment, and Treatment. New York: Brunner-Routledge.


Maj, M., Halmi, K., Lopez-Ibor, J.J. and Sartorius, N. (2003). Eating disorders. Chichester, West Sussex, England: John Wiley & Sons, LTD.


Messina, J.J. (2013). Tools for coping series: (1) Self-esteem seekers anonymous-The SEA’s program manual; (2) Laying the foundation: Personality traits of low self-esteem; (3) Tools for handling loss; (4) Tools for personal growth; (5) Tools for relationships; (6) Tools for communications; (7) Tools for anger work-out; (8) Tools for handling control issue; (9) Growing down:Tools for healing the inner child; (11) Tools for a balanced lifestyle, retrieved at


Ogden, J. (2010). The Psychology of eating: From health to disordered behavior, Second Edition. Chichester, West Sussex: Wiley-Blackwell.


Treasure, J., Schmidt, U. and Van Furth, E. (2003). Handbook of eating disorders, second edition. Chichester, West Sussex, England: John Wiley & Sons, LTD.


Yager, J. and Powers, P (2007). Clinical manual of eating disorders. Washington, DC: American Psychiatric Publishing, Inc.

References for Anorexia

Bezance, J. and Holliday, J. (2013). Adolescents with anorexia nervosa have their say: A review

of qualitative studies on treatment and recovery from anorexia nervosa. European Eating Disorders Review, 21, 352-360. DOI: 10.1002/erv.2239


Bowers, W. A. and Andersen, A. E. (2007). Cognitive-behavior therapy with eating disorders:

The role of medications in treatment. Journal of Cognitive Psychotherapy, 21, 16-27. 


Bulik, C. M., Berkman, N. D., Brownley, K. A., Sedway, J. A. and Lohr, K. N. (2007). Anorexia

nervosa treatment: A systematic review of randomized controlled trials. International Journal of Eating Disorders, 40, 310-320. doi: 10.1002/eat.20367


Chakraborty, K. and Basu, D. (2010). Management of anorexia and bulimia nervosa: An

evidence-based review. Indian Journal of Psychiatry, 52, 174-186. doi:10.4103/0019-5545.64596 


Fairburn, C. (2005). Evidence-based treatment of anorexia nervosa. International Journal of

Eating Disorders, 37, 26-30. doi: 10.1002/eat.20112 


Fedyszyn, I.E. and Sullivan, G.B. (2007). Ethical re-evaluation of contemporary treatments for

anorexia nervosa: Is an aspirational stance possible in practice? Australian Psychologist, 42(3), 198-211. doi: 10.1080/00050060701326962 


Goddard, E., Raenker, S., Macdonald, P., Todd, G., Beecham, J., Naumann, U., Bonin, E.,

Schmidt, U., Landau, S. and Treasure, J. (2013). Carers’ assessment, skills, and information sharing: Theoretical framework and trial protocol for a randomized controlled trial evaluating the efficacy of a complex intervention for carers of inpatients with anorexia nervosa. European Eating Disorders Reviewm 21 , 60-17. DOI: 10.1002/erv.2193


Gowers, S. (2006). Evidence based research in CBT with adolescent eating disorders. Child and

Adolescent Mental Health11, 9-12. doi: 10.1111/j.1475-3588.2005.00348.x 


Jones, M., Volker, U., Lock, J., Taylor, C.B. and Jacobi, C (2012). Family-based early

intervention for anorexia nervosa. European Eating Disorders Review, 20, e143. DOI: 10.1002/erv.2167


Keel, P.K. and Haedt, A. (2008). Evidence-based psychosocial treatments for eating problems

and eating disorders. Journal of Clinical Child and Adolescent Psychology, 37(1), 39-61. doi: 10.1080/15374410701817832 


Lock, J. and Fitzpatrick, K.K. (2007). Evidenced-based treatments for children and adolescents

with eating disorders: Family therapy and family-facilitated cognitive-behavioral

therapy. Journal of Contemporary Psychotherapy, 37. 145-155. doi:10.1007/s10879-007-9049-x 


Resnick, J. L. (2005). Evidence-based practice for treatment of eating disorders. Journal of

College Student Psychotherapy, 20(1), 49-65. doi:10.1300/J035v20n01_05 


Schaffner, A.D. and Buchanan, L.P. (2010). Evidence-based practices for outpatient treatment of

eating disorders. International Journal of Behavioral Consultation and Therapy, 6(1), 35-44. 


Schmidt, U., Renwick, B., Lose, A., Kenyon, M., DeJong, H., Broadbent, H., Loomes, R.,

Watson, C., Ghelani, S., Serpell, L., Richards, L., Johnson Sabin, E., Boughton, N., Whitehead, L., Beecham, J., Treasure, J. and Landau, S. (2013). The MOSAIC study-comarison of the maudsley model for treatment of adults with anorexia nervosa (MANTRA) with specialist supportive clinical management (SSCM) in outpatients with anorexia nervosa type: Study protocol for a randomized controlled trial. Trials, 14, 160. doi:10.1186/1745-6215-14-160


Wilson, G., Grilo, C., Vitousek, K. (2007). Psychological treatment of eating disorders.American

Psychologist, 62(3), 199-216. doi: 10.1037/0003-066X.62.3.199  



Now that you have read this section, in “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practices concerning Anorexia in my clinical practice?
  3. Why is it important that I learn more about Anorexia?
  4. What more do I need to know about Anorexia?
  5. Where can I go to obtain more information about Anorexia?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on Anorexia?