What Keeps Anorexia Going: PDF Worksheet, Tools and Exercises

When working with anorexia nervosa, clinicians frequently find that a formulation discussion runs well in session, then loses traction between appointments. The patient leaves having understood the argument, returns having lived the loop again, and cannot quite explain why restriction still felt like relief. Explaining the maintenance cycle verbally is rarely sufficient. This PDF worksheet on what keeps anorexia going functions as an in-session visual support that makes the self-sustaining logic concrete enough to examine together.

Why the Maintenance Model Is Difficult to Communicate in Session

The central clinical difficulty is not explaining the aetiology of anorexia. It is demonstrating, persuasively, that what started the disorder matters less than what keeps it running. Patients in the early and middle phases of treatment tend to hold an aetiological narrative tightly: a specific trigger, a period of upheaval, a comment about their body. Dislodging this narrative with words alone is slow work, partly because the loops that sustain anorexia feel, from the inside, like evidence of who the person is rather than features of a learned pattern.

A second friction point is the starvation syndrome. The cognitive and affective sequelae of semi-starvation, documented in the work of Keys and colleagues, are routinely misattributed by patients to character or pre-existing pathology. Without something to point at, the clinician explaining that food preoccupation, emotional flatness, and irritability are physiologically driven outcomes of restriction will be met with "yes, but I've always been this way." A written label changes what can be disputed. The Starvation Syndrome PDF worksheet addresses this component directly and pairs well here.

A third layer: overvalued beliefs about shape, weight, and control are ego-syntonic. The Cognitive Behavioral Model of Anorexia Nervosa worksheet and the Transdiagnostic CBT Model of Eating Disorders both map these mechanisms formally. This fiche gives you a simpler, more patient-accessible version you can open on the table.

What the Fiche Contains: A Four-Petal Loop Diagram

The printable is built around a single central diagram described in the fiche itself as a "flower." Four petals point inward: beliefs (shape, weight, control tied to worth), strategies (restriction, food rules, compulsive exercise, body-checking), starvation (the physiological and psychological effects of insufficient fuel), and self-worth on one narrow axis. Each petal feeds the next in a closed loop: "Read the flower like this. Each petal feeds the next, and all four point inward to keep anorexia alive."

The visual does something verbal formulation typically cannot: it shows the circularity at a glance. The patient does not need to track a spoken argument across four steps; they can see that breaking any one petal weakens the whole structure.

The second panel unpacks each petal with brief clinical descriptions. The starvation panel lists specific mind, mood, and body effects. The strategies panel names six concrete behaviours (skipping meals, tiny portions, calorie-counting, food rules, compulsive exercise, body-checking). The self-worth panel includes a direct example: "Ate little today → I'm okay. Ate more → I'm bad." The All-or-Nothing Thinking worksheet and the work on low self-esteem connect naturally here.

The third panel traces a concrete morning through the loop, each step labelled with its petal: belief → strategy → starvation → self-worth tightening. This is useful for patients who can see the diagram intellectually but struggle to locate themselves in it.

The closing section offers four short reminders, including "Anorexia is the loop, not your identity" and "Loosen any petal, the loop weakens." These are formulated as take-home anchors, not homework tasks.

> Key point: This fiche is a visual support that facilitates in-session explanation, not a self-directed questionnaire. Its value is in being open on the table while you speak, giving the patient something to look at, point to, and take away.

When and How to Introduce It in Session

This worksheet is best placed in early psychoeducation work, typically once the therapeutic alliance is established and the patient has agreed to some form of engagement with the maintenance formulation. For patients who are still highly ambivalent about change, introducing it too early risks a defensive response; the loop can feel like an accusation. A brief framing that works: "I'd like to show you a diagram I find useful for understanding what keeps this pattern going, not how it started, just what feeds it right now."

Profiles for whom this tool is particularly well suited:

• Patients with sufficient cognitive access to engage with a formulation (mild to moderate clinical presentations, or partially weight-restored patients)
• Patients who report that restriction "makes sense" or feels protective, where naming the loop externalises the logic without challenging identity directly
• Carers attending a session, for whom the circular maintenance model explains why "just eating more" is not the mechanism that breaks the pattern

For patients where the starvation effects on cognition are severe, defer the fiche and prioritise the Eating and Your Energy Levels worksheet as a simpler first step. The Anorexia Nervosa overview and the Recognizing Anorexia Nervosa worksheet are useful preparatory or parallel tools. If the clinical picture involves bulimic features, the CBT Model of Bulimia Nervosa extends the framework.

After handing over the fiche, debrief using the question the fiche itself proposes: which petal feels most active right now? That answer frequently opens the most clinically useful part of the session. The fiche does not replace the therapeutic frame; it makes the explanation clearer and leaves the patient with something concrete to return to.

Sources

• Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. Guilford Press.
• Treasure, J., & Schmidt, U. (2013). The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders, 1, 13.
• Keys, A., Brozek, J., Henschel, A., Mickelsen, O., & Taylor, H. L. (1950). The Biology of Human Starvation. University of Minnesota Press.
• National Institute for Health and Care Excellence (NICE) (2017). Eating disorders: recognition and treatment (NG69).