Effectiveness of Inpatient and Community Treatment for Anorexia Nervosa

This pilot review focuses on the effectiveness of inpatient and community treatment for anorexia nervosa. The review analyses the identified patterns of quantitative data into different headings of health outcomes, based on which the most effective intervention approach is recognised.

Running head: PILOT REVIEW
Clinical psychology
Name of the Student
Name of the University
Author Note

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Abstract
Background- Anorexia nervosa is a type of an eating disorder that is potentially life
threatening and characterised by the failure to maintain a normal and healthy weight. The
condition is also manifested by a devastating and persistent fear of gaining weight, relentless
dietary behaviour and disturbances in perceiving body shape and weight.
Methods- The dissertation focuses on a pilot review that helps in providing answer to a well-
defined research question. The review collects and summarises all evidence that are in
accordance to the research question and analyses the identified patterns of quantitative data
into different headings of health outcomes, based on which the most effective intervention
approach is recognised.
Results- Both inpatient and outpatient treatment programs prove their effectiveness in
reducing the severity of anxiety and depression among anorexia nervosa patients. The
treatment regimen is highly successful in improving the BMI and body weight, besides
lowering concerns about shape, eating habit and weight. However, outpatient and community
programs demonstrate an increased efficiency in management of the presenting complaints.
Conclusion- Although both the programs are useful in treatment of anorexia nervosa, the
structured treatment sessions of community care, insurance coverage and feasibility to
maintain other commitments help in selecting outpatient approach as the better option.
Keywords: anorexia nervosa, inpatient, outpatient, treatment, community

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Table of Contents
Chapter 1- Introduction..............................................................................................................4
Background............................................................................................................................4
Problem statement..................................................................................................................6
Research question...................................................................................................................8
Research aim..........................................................................................................................8
Research objectives................................................................................................................8
Purpose of the study...............................................................................................................8
Chapter 2: Literature Review...................................................................................................11
Chapter 3: Methodology..........................................................................................................31
Introduction..........................................................................................................................31
Literature search...................................................................................................................31
Key words............................................................................................................................31
Bibliographic Aids...............................................................................................................32
Inclusion and Exclusion Criteria and Search Strategy.........................................................32
Justification behind the selection of the inclusion and exclusion criteria............................33
Search Strategy.....................................................................................................................34
Search Outcomes..................................................................................................................35
Snowball Technique.............................................................................................................37
Quality Assessment..............................................................................................................39
Research Philosophy............................................................................................................40
Research Approach..............................................................................................................41

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Research Design.......................................................................................................................41
Conclusion................................................................................................................................41
Chapter 4: Results and Discussion...........................................................................................43
Results..................................................................................................................................43
Discussion............................................................................................................................51
Chapter 5: Conclusion..............................................................................................................57
Are inpatient interventions effective?..................................................................................59
Are community/outpatient interventions effective?.............................................................60
Limitations and future scope................................................................................................61
References................................................................................................................................63

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Chapter 1- Introduction
Background
Anorexia nervosa (AN) refers to an eating disorder that is primarily characterized by
persistent loss of weight and a lack of proper weight gain among children, in their growing
years. In other words, this is a greatly distinctive grave mental abnormality that can affect
people of all sex, race, origin, and ethnic groups. This condition is also defined as a
psychiatric disorder that is manifested in the form of an unrealistic fear of gaining weight,
self-starvation, and a subsequent conspicuous distortion of the entire body image (Gauthier et
al. 2014). Individuals diagnosed with anorexia nervosausually limit the intake of calories and
the kinds of food they consume. People suffering from the disorder are also found to show
adherence to vigorous and compulsive exercise, purging via laxatives and vomiting and/or
binge eating. The condition is most commonly related with malnutrition that occurs due to
starvation that has been self-imposed, In addition to a range of complications affecting the
different organ systems. Another characteristic feature of the psychiatric disorder is the onset
of hypokalaemia, which leads to a drop in the potassium levels in the bloodstream (Treasure
and Alexander 2013). Further symptoms associated with the disorder comprise of presence of
lower body mass index, with respect to the age and height of the person, obsession with
maintaining a count of the calories, continuous monitoring of the fat content and rigid food
restrictions (MacSween and Macsween 2013).
The criteria that helps in the diagnosis of AN comprise of the following such as, (1)
denial in maintaining body weight or restriction of energy intake; (2) extreme fright of
gaining body weight and becoming fat, despite being underweight; (3) body image related
disturbances (Fairburn and Cooper 2011). There exist two different kinds of anorexia that can
be classified as the purging/binge-eating and the restricting type. The restricting type is

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generally diagnosed when the affected person does not engage in any form of binge eating or
purging, but limits his/her food intake in place. Conversely, the purging/binge-eating type is
identified when the affected individual has had events of eliminating and bingeing between
periods of limiting food intake. The disorder commonly occurs in young women and
adolescent girls, in addition to individuals approaching puberty and women reaching
menopause (Darcy et al. 2012). The disorder encompasses a specific psychopathology
characterised by a persistent fear of flabbiness and fatness of the body contour, thereby
making the patients enforce a threshold related to establishment of low weight.
Interoception is imperative in the maintenance of homeostasis in the body and also
helps in understanding the feelings(Racine and Wildes 2015). AN has time and again been
correlated with a range of disturbances that interfere with interoception. Person diagnosed
with AN often concentrate more the misleading perceptions related to their physique, due to
the fright of appearing obese or overweight. Apart from their external appearance, these
people have also been found to report presence of abnormalities in their bodily functions such
as, inarticulate state of mind that perceives fullness. This is a direct manifestation of
miscommunication between the human brain and the body (Kaye et al. 2013). Furthermore,
individuals with AN also experience atypically strong cardio-respiratory perception,
predominantly of their breath, which is found to be utmost dominant before the consumption
of their meals. AN affected person also report their incompetence in distinguishing between
their feelings from the bodily sensations, a condition commonly termed as alexithymia.
Besides metacognition, AN patients have also provided evidences of facing trouble
with their social cognition that generally encompasses interpretation of the emotions of other
people (Strigoet al. 2013). AN alsohas a tendency to run in families, thereby suggesting the
role of certain genetic components in its incidence and prevalence (Rikaniet al. 2013). In
other words, the condition is heritable. Twin studies have been conducted that have

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demonstrated presence of a heritability rate ranging between 28-58% (Thornton, Mazzeo and
Bulik 2010). Moreover, first degree relatives of people suffering from anorexia nervosa are at
an increased likelihood of developing the psychiatric disorder by approximately 12 times
(Charneyet al. 2013). In addition, association studies have also been executed in 128
polymorphismsthat are associated to 43 genes that play a critical role in reward mechanics
and motivation, regulating eating behaviour, emotion and personality traits. The findings
have been successful in establishing consistent association between the polymorphisms
with catechol-o-methyl transferase, brain derived neurotrophic factor, agouti-related
peptide, opioid receptor delta-1 and SK3 (Rask-Andersen et al. 2010). Further evidences also
emphasise on the role of epigenetic modification namely, DNA methylation in the
onsetand/or maintenance of AN (Pjetriet al. 2012).
Problem statement
Anorexia nervosa commonly affects women and girls and show an onset at the age of
16-17 years on an average. Recent reports provide the evidence that approximately 8%
females suffer from eating disorders at some point of their lives (Anorexiabulimiacare.org.uk
2018). Furthermore, an estimated 25% people in the UK are males who have been found to
struggle with eating disorders. An estimated 1.6 million individuals residing in the UK have
been affected by this psychiatric condition and of them 11% are males (Nhs.uk 2018).
Individuals belonging to the age group of 14-25 years are most commonly affected, and 10%
of those people suffer from AN (Priorygroup.com 2018). Furthermore, anorexia nervosa most
often creates an impact on people belonging to different socio-economic condition, age
group, and cultural background. The disorder usually begins in adolescence. However, most
of the people who become extremely ill from it belong to the age group of 20 - 45 years.
There exists a lack of conclusive evidence regarding the effectiveness of somespecific
treatment for anorexia nervosa, over others. However, time and again, clinical research

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studies have confirmed the fact that early treatment and intervention measures are better
operative in treating the condition (Treasure and Russell 2011).
All forms of treatment measures for anorexia nervosa primarily focus on three
different domains namely, (a) restoration of body weight of the affected person to healthy and
acceptable levels, (b) treatment of other psychological disorders that are associated with the
illness, (c) reduction or elimination of thoughts, perceptions and behaviours that
initiallyresulted in the disordered eating habit (Hay, Touyz and Sud 2012). Although the
primary aim of the interventions is related to bringing about a restoration in the weight of the
affected person, ideal treatment options also comprise of monitoring behavioural variations as
well (Zipfelet al. 2015). Difficulty associated with treatment of AN is often related to denial,
shame and an absence of insight that is concomitant with the condition. In other words,
reestablishment of healthy eating patterns in the affected person is central for rebuilding
health of the patient.
Anorexia nervosa among older adolescents and adults frequently has a protracted and
degenerating course, in addition to different levels of disability and high rates of mortality
and associated morbidity, specifically when the patient is without treatment. Moreover,
partial syndromes such as, subsyndromal anorexia nervosa are also linked with hostile health
outcomes. This directly results in a deterioration of the quality of life and increases the
burden on the affected individual, family members, and the society(Zipfelet al. 2015).
Hospital admissions are also indicated for extremely ill patients who report AN along with
cardiac dysrhythmias and other metabolic disorders. Research evidences suggest that most
patients being admitted to the healthcare facilities for the purpose of re-feeding are generally
referred to psychiatric wards/units and counselling services (Walsh 2013). Community
treatment is usually undertaken with close vigilance that encompasses weekly measurements
of body weight. Recent years have seen an upsurge in the number of clinical studies that have

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focused on assessing the underlying factors that contribute to the onset of the illness and its
management.
Research question
Is there any difference in short and long term outcome between inpatient and
community treatment for anorexia nervosa?
Research aim
To determine the effectiveness of both inpatient and community treatment services for
anorexia nervosa, based on existing literature
Research objectives
 To identify the health outcomes of inpatient treatment
 To determine the health outcomes of community treatment
 To evaluate the treatment modality that is more effective in managing anorexia
nervosa
Purpose of the study
Patients admitted to hospital settings due to AN have a high risk of mortality. It is
extremely difficult to establish the factors that are related to good and poor health outcomes
of all forms of treatment that aim to cure and/or reduce the severity of anorexia nervosa
(Yackobovitch‐Gavan et al. 2009). The cornerstone of the community treatment method
encompass conduction of individual counselling sessions, as an effective form of
psychotherapy that are held at least one each week, depending on the disorder severity and
the individual needs of the patient. CBT-E or Enhanced Cognitive Therapy and refers to a
transdiagnostic personalised psychological technique that is used for reducing the impact od
eating disorders. The four stages of CBT-E namely, starting well, taking stock, body image,
dietary restraint and mindsets have shown their efficacy in enhancing ability of AN patients

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to deal with their condition (Fairburn et al. 2013). Diet is considered as a crucial factor to be
taken into consideration while treating people affected with AN (Schmidt et al. 2012).
Individual sessions that comprise of Specialist Supportive Clinical Management (SSCM)
have also shown their potential in treating AN, based on the two distinct components namely,
clinical management and supportive psychotherapy (Schmidtet al. 2015).The ‘Maudsley
Model of Anorexia Treatment in Adults’ or MANTRA, is another novel therapy personalised
to the precise desires and features of individuals with AN. It principally targets [a] the
thinking style that is characterised by fear of committing mistakes, [b] avoidant, in-
expressive, relational and emotional style, [c] positive opinions about helpfulness of anorexia,
and [d] a reply of others (Schmidtet al. 2013). Tailoring the diet according to the individual
needs of the people, and selecting appropriate food variety, while establishing meal plans, is
an effective step of the treatment. Furthermore, evidences have also established the efficacy
of family based therapies in treating adolescents with AN (Fisher, Hetrick and Rushford
2010).
The inpatient treatment involves regular monitoring and recording of the body weight
and laboratory results. The meals are consistent and scheduled. The patients are required to
attend sessions every week with their psychologist, dietician, medical physician, therapist and
nursing professionals. Each day begins with breakfast at 8:00 am, in addition to measurement
of weight and vital signs, shower and personal hygiene. The breakfast sessions are supervised
by a person of the facility and time is usually set aside for 45 minutes to an hour, after meals
with the supervisor (Herpertz-Dahlmannet al. 2014). The meals are usually prepared by
kitchen staff having a sound understanding of dietetic programs. In between snacks and meals
that occur after every 2-3 hours, the residents are made to attend individual or family therapy,
outings, family visits, or group therapy. Counsellors also work together with the residents for
maintain a scheduled inpatient facility.Inpatient services have thus been identified beneficial

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in assisting people to stop their eating behaviours. The purpose of this quantitative review is
to draw a comparison from already published evidences that focus on either inpatient or
community treatment methods for AN, thereby determining which of the two is more
effective in enhancing the health outcomes of the patient.

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Chapter 2: Literature Review
This chapter comprises of an evaluation and search of available literature that are
relevant to the research question and documents valid information in the topic of eating
disorder that is being discussed. The section is based on conduction of an extensive survey of
the selected area of anorexia nervosa, an eating disorder and synthesises relevant information
in the form of a summary. In other words, literature review section is an important element of
a pilot review owing to its role in providing a descriptive summary and forming the base of
critical evaluation of the retrieved articles (Hart 2018). The section will primarily focus on
extracting relevant journal articles and scholarly papers for obtaining a wide array of
methodological and theoretical information. Undertaking a literature review is imperative in
in order to ensure that adequate knowledge has been gained regarding the gaps existing in
current knowledge, thereby recognising the need of further exploring the topic.
Development of a proper research question forms the basis of a literature review. The
question was kept specific and comprehensive in order to focus the article hits to those that
were in accordance to the research aims and objectives. The research question was separated
into four elements according to the PICO framework/model. The PICO format is widely used
while conducting an evidence based practice in medicine and nursing and helps in providing
pertinent clinical answers to a set of proposed research questions (Cooke, Smith and Booth
2012). The primary objective of developing the PICO framework was to gain assistance in
the literature search. The four elements of the question encompass problem/population,
intervention, comparison and outcomes. In this literature review the population comprises of
patients affected with anorexia nervosa, the eating disorder. Intervention comprises of
inpatient or hospital treatment of those patients.This will be compared to impacts of
outpatient and/or community treatment programs. The final element, outcome focuses on
enhanced health outcomes.

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P Population Anorexia nervosa patients
I Intervention Inpatient/Hospital treatment
C Comparison Community/Outpatient
treatment
O Outcome Enhanced health outcomes
Table 1- PICO search format
Certain specific search terms were combined with the use of Boolean operators for
extracting articles from four electronic databases namely, MEDLINE, OVID, CINAHL, and
the Cochrane Library. Key terms used for the purpose were ‘anorexia nervosa’, ‘eating
disorder’, ‘inpatient’, ‘hospital’, ‘treatment’, ‘community’, ‘day-care’, and ‘health’.
A particular study took into consideration the fact that partial hospital programmes
had demonstrated their effectiveness in the treatment of eating disorders in the past. The basis
of the study was grounded on the identification of anorexia nervosa and bulimia nervosa as
chronic psychiatric illnesses that were associated with severe health complications. The study
collected its data from an estimated 243 adults individuals diagnosed with both BN and AN,
who were referred to the partial hospital programme by psychiatrists and primary care
providers (Brown et al. 2018). The primary objective of the study was to measure the
efficacy of these hospital programmes for AN binge/purge patients (n = 46), AN‐restricting
patients (n = 79), and BN patients (n=118). AN‐R patients were found to be younger and less
educational attainment, when compared to BN participants, in addition to having shorter
duration of the illness. Following completion of questionnaires during admission, discharge
and follow-up period, the partial hospital programme demonstrated a significant
improvement in weight and psychopathology of eating disorders among all patients.
Furthermore, a noteworthy reduction was also observed in the manifestation of a range of
comorbid symptoms, with few exceptions reported by the purge/binge group suffering from

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AN. Furthermore, treatment resistance was most commonly observed in the AN-BN group.
The study was therefore considered effective in improving health outcomes in ED patients.
However, there was a lack of statically significant result for the AN-BN group regarding
measurement of continuous bulimic symptoms.
A similar study was conducted with the aim of investigating the association between
recovery from a major eating disorder with mentalisation and pre-treatment attachment. The
study was based on previous findings that elaborated on the necessity of mentalisation and
attachment security for gaining an understanding and providing treatment services to eating
disorders (Kuiperset al. 2017). The researchers recruited around 38 patients diagnosed with
AN and BN, who were subjected to treatment in regards to mentalisation, comorbidity,
attachment security and recovery. Upon assessing the attachment security and mentalisation
in the patients with the use of Adult Attachment Interview at the beginning of the trial and
after a year, higher levels of mentalisation were observed between the recovered patients.
However, the results failed to show any significant difference between the unrecovered and
the recovered patients for attachment security. Noteworthy improvements were also observed
in the patients who had recovered from BN and/or AN in relation to manifestation of co-
morbid symptoms. Conversely, severity of pre-treatment symptomswas found to be similar
among allpatients, in addition to low scores of recovered patients on anxiety, personality
disorders, self-injurious behaviour and depression. Effectiveness of hospital treatment was
also demonstrated in autonomy among the recovered patients. The study was successful in
demonstrating the impact of hospital treatments that focus on enhanced mentalisation in
recovery from eating disorders.
Supporting evidences for the role of hospital treatments that focus on attachment
security and mentalisation in reducing the symptoms manifested by patients diagnosed with
eating disorders were provided by a follow-up study. The research was based on testing three

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different sets of expectations that were related to AN patients subjected to psychotherapeutic
treatment for a year. Upon recruiting 38 female participants suffering from eating disorders,
the researchers attempted to measure their symptoms, co-morbid conditions, mentalisation
and attachment security. Findings from the statistical analysis suggested that there were no
major changes in recovery from eating disorders due to mentalisation in one year. Moreover,
a negative correlation was established with pre-treatment mentalisation and the severity of
AN or BN symptoms in the affected persons, in addition to anxiety, trait, psycho-neuroticism,
and self-harm inflicting behaviour (Kuiperset al. 2018).
Another study was conducted to investigate the effectiveness of day hospital based
treatment measures for reducing the emotional disturbances faced by anorexia nervosa
patients. The authors recognised the importance of day hospitals in the implementation of
therapeutic approaches for treating AN. Furthermore, the study was based on previous
evidences that day hospitals are imperative in allowing AN affected patients for maintaining
their social relationship by providing assistance to avoid isolation entailed by frequent
hospitalisation. The researchers recruited an estimated 56 adult patients diagnose with severe
AN, with the help of clinical directors (Abbate‐Dagaet al. 2015). Upon admission, these
patients were then evaluated, followed by their examination at end of treatment (EOT).
Measurements were also made during a 12-month long follow-up period. The outcomes were
primarily measured with the use of the Beck Depression Inventory, Eating Disorders
Inventory-2, Brief Social Phobia Scale, and the Hamilton Rating Scale for Anxiety. Hence,
all the patients were subjected to a multidisciplinary treatment programme, which was
grounded on psychodynamic psychotherapy. Upon analysis, 78% participants were found to
report positive health outcomes at the end of their treatment and 68% of the patients during
the follow-up evaluation period(T18). Moreover, estimated 65.4% and 82.1% long-standing
patients were found to report positive health outcomes during T18and EOT, respectively.

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Furthermore, significant improvements were also observed in the psychopathology related
measures during end of the day hospital treatment, which in turn was also maintained at
follow-up. Thus, findings of the study emphasised on the effectiveness of day hospital based
treatment in caring for patients suffering from severe AN.
The impacts of hospital outpatient programs that focused on the use of dialectical
behavioural therapy and CBT for treating binge eating disorders was assessed in another
study. The researchers identified the efficacy of guided and self-help CBT as cost-effective
protocols that were commonly utilised for treating BN and binge-eating disorder (Chen et al.
2017). The study was conducted over a period of four years and the participants were
subjected to the outpatient services. Following recruitment of 109 female participants aged
more than 18 years, who had met the DSM-IV criteria for eating disorder, they were
subjected to 4 weeks of guided self-help CBT. Depending on their response, the patients were
categorised into three groups namely, (a) early and strong responders continuing GSH, (b)
dialectical behaviour therapy, and/or (c) individual or group CBT+.Similarity was observed
in the frequency of objective binge-eating-day (OBD) at baseline betweenCBT+, DBT and
cGSH. Furthermore, OBD frequency showed a significant slower reduction in DBT and
CBT+, during treatment, compared to cGSH. In comparison to cGSH, OBD frequency was
meaningfullylargerat CBT+ (d = 0.31) and DBT end (d = 0.27).
A randomised clinical trial was also conducted with the aim of drawing a comparison
between adolescent-focused individual therapy (AFT) with family-based treatment (FBT)
among adults with AN. The RCT was primarily based on previous findings that there is a
lack of systematic investigation on the impacts of family therapy in different individuals
suffering from AN. Furthermore, the RCT also took into consideration the fact that lack of
evidence provides little guidance regarding the appropriate evidence based interventions that
can be implemented for treating patients with AN (Lock et al. 2010). Upon recruiting 121

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participants with age between 12-18 years, and diagnosed with anorexia nervosa according to
the DSM-IVcriteria, they were subjected to 24 hours of outpatient treatment services. These
were conducted over a period of 12 months of AFT or FBT. Furthermore, the participants
were evaluated at baseline; end of treatment and during a follow-up period of 6 and 12
months, respectively. No significant differences were observed in the rates of full remission
between the treatment types at end of treatment. However, FBT showed significant
improvement and gave greater results when compared to AFT, with respect to remission
rates, during both 6 and 12 months of follow-up. Significant superior measures were
observed in FBT, for partial remission during end of treatment. However, these outcomes
were not maintained during follow-up period. In addition, the patients also demonstrated a
noteworthy percentile of body mass index for FBT, in addition to manifesting larger changes
in their scores of the Eating Disorder Examination, than those who were subjected to AFT.
Thus, the findings of the study were able to explain benefits of both forms of treatment that
led to considerable improvement in AN symptoms among patients.
The role of community care services in the treatment of AN was assessed in another
study that elaborated on the benefits of a new service model. Some of the gaps identified
were related to the presence of little or no evidence regarding the effectiveness of service
models for reducing severity of the eating disorder, in addition to high costs associated with
inpatient care services (Munro et al. 2014). Furthermore, the study also tried to determine
whether community based treatment models could minimise or eliminate use of inpatient
services. The researchers built the intervention in the form of a tiered matched-care service
model, referred to as Anorexia Nervosa Intensive Treatment Team (ANITT) for reducing the
health complications associated with eating disorders in the Lothian region, comprising of
more than 800,000 individuals. Although the service was multidisciplinary in its nature, it
primarily driven focused on psychological formulation. Dietetic and psychological

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interventions were grounded on the basis of active risk management, for a time period of 2-12
weeks. Furthermore, the treatment model also elaborated and explained the evaluations of
cost-effectiveness, safety, and acceptability. The model aimed to treat severity of AN
symptoms on the basis of twice-weekly therapies that lasted for 18 months. These were
implemented along with a progress review of 6 months, and made all patient show
adherences to regular risk monitoring of their medications. Findings were recorded on the
basis of a patient satisfaction questionnaire that was distributed to 46 present or discharged
patients and suggested that all patients perceived the care provided to them as supportive and
genuine. Furthermore, withdrawal of only two patients from the treatment provided evidence
for high level of patient engagement and improved patient safety. In addition, a total savings
of an estimated £391 656 in the year 2011, determined the cost-effectiveness of the procedure
as well. Thus, the researchers could successfully establish the acceptability and benefits of
community care services for AN patients.
The effectiveness of inpatient treatment services were determined in another study
that tried to address the lack of existing evidence on effectiveness of inpatient treatment.
Owing to the fact that only 50% patients suffering from this eating disorder have been found
to recover from the condition, the researchers attempted to evaluate the benefits of the
intention-to-treat analysis. 90 admissions to inpatient eating disorder units for adults were
enrolled for the study, following their diagnosis according to the DSM-IV criteria (Collin et
al. 2010). They were subjected to the inpatient treatment program that comprised of group
and individual therapies such as, problem solving, relaxation, anxiety, social skills, dietetic
management and assertiveness training. The average length of the treatment was found to
extend over a period of 135.1 days. Results of the study showed that longer length of
hospitalisation was related with a larger degree of variation in the BMI. However, the
researchers failed to detect any other predictors of inpatient treatment outcomes. In addition,

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the participants subjected to the inpatient treatment were also found to report greater degree
of satisfaction. Thus, the findings established significant improvement of AN symptoms on
the implementation of an inpatient treatment programme.
However, the findings of another study were in contrast to those that elucidated the
positive impacts of inpatient treatment in AN. The researchers attempted to evaluate the
changes occurring in core thoughts and perception during the phase of weight restoration in
adolescents with AN. 44 adolescents who were admitted to inpatient units due to presence of
eating disorders were subjected to inpatient treatment interventions. These interventions
focused on weight reduction with the use of CBT, supervised meals, and educational
activities (Fenniget al. 2017). Upon evaluating the outcomes, the inpatient treatment services
failed to induce any significant effect on anorexic perceptions and thoughts related to drive
for thinness, body dissatisfaction, and concern over weight and shape. However, the inpatient
treatment was successful in inducing an improvement in the severity of AN symptoms.
Although a reduction was also observed in the levels of depression among the adolescent
patients, the depressive symptoms remained within the pathological range. Hence, the
research indicated that inpatient treatment services do not always help in modifying the
negative thoughts and perceptions held by AN patients.
A prospective cohort study was conducted to observe the treatment outcomes among
patients suffering from anorexia nervosa and bulimia nervosa, who were admitted to
residential treatment programs (Brewerton and Costin 2011). The researchers analysedresults
of patient surveys during admission and discharge time, from the Monte Nido Residential
Treatment Program. Out of the 287 consecutive patient admissions, only 80% (231 patients)
“graduated” or were able to successfully complete≥ 30 treatmentdays. For AN patients,
statistically significant improvements were observed in their mean BMI. Furthermore,
statistically substantial enhancements were also observed in BDI scores for both AN and BN

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patients, in addition to EDI-2 subscales, and frequencies of vomiting, bingeing, chewing and
spitting, stimulant abuse, laxative abuse, and restricting behaviour. Owing to the fact that
majority of the patients who had completed treatment manifested noteworthy enhancement
due to the intensive residential treatment, the intervention was determined as effective for
reducing severity of eating disorders.
The safety and efficacy of outpatient treatment services on patients suffering from
anorexia nervosa were assessed in an ANTOP study, where the primary focus of treatment
was on CBT and focal psychodynamic therapy, in comparison to normal optimised treatment
services (Zipfelet al. 2014). Patients were recruited from ten university hospitals and
randomly allocated to the two treatment groups for 10 months. Significant increase was
observed in the BMI of all study groups (enhanced CBT 0·93 kg/m², focal psychodynamic
therapy 0·73 kg/m², treatment as usual 0·69 kg/m²). However, no differences were observed
between the group measures. Mean BMI gain showed further increase during the follow-up
period (1·30 kg/m², 1·64 kg/m², and 1·22 kg/m²). No serious adverse events attributable to
weight loss or trial participation were recorded. Thus, outpatient treatment services proved
their efficacy in treating patients with AN.
Follow-up results of a multi-centred RCT helped in determining the value of
Specialist Supportive Clinical Management (SSCM) and Maudsley Model of Anorexia
Nervosa Treatment for Adults (MANTRA) treatment services for outpatients with anorexia
nervosa. The study was based on the fact that not much research had been conducted to
evaluate the impact of outpatient treatment services on AN patients (Schmidt et al. 2016).
The study was conducted over a period of 24 months and evaluated the cost-effectiveness and
efficacy of SSCM versus MANTRA among the participants. Findings from the study
suggested that there existed fewer differences between patients recruited to the two
intervention groups. Both the treatment groups showed a maintenance or further increase in

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ED symptomatology, BMI, clinical impairment and distress levels. Estimated changes in
mean BMI from baseline till the 24 month time period was around 2.25 kg/m2 for MANTRA
and 2.16 kg/m2 for SSCM with an effect size of 1.83 and 1.75, respectively. Although most of
the recruited participants were not in need of additional intensive treatment such as,
hospitalisation, two patients subjected to SSCM had become overweight by binge-eating.
Thus, findings of the study suggested that both MANTRA and SSCM treatment services
could have values as major types of outpatient intervention for patients suffering from AN.
Another study formally attempted to define sudden gains in anorexia nervosa and also
tried to explore the major characteristics, baseline and demographic clinical predictors and
impact on AN patients (Cartwright et al. 2017). The study was conducted in the form of a
secondary analysis with data gathered from 89 AN outpatients, having received any one of
two different psychotherapeutic interventions, which in turn were encompassed by the
MOSAIC trial. Sudden gains were reported by an estimated 61.8% patients and primarily
occurred during the middle and early treatment phases. Furthermore, larger SG proportions
predicted greater increases in the BMI, between baseline measures and the follow-up period.
Patients with at least one episode of sudden gain reported less number of days between the
first SG and baseline, in addition to an increase in BMI. Furthermore, outpatient services
failed to predict outcome changes, based on the timing and proportion of SGs. Thus,
outpatient SG was recognised clinically beneficial predictors of long-term outcomes.
The effectiveness of day treatment programs were also assessed by another systematic
review that conducted an exhaustive analysis of pre and post-treatment measures that were
collected from 15 different studies (Hepburn and Wilson 2014). Findings of the review
suggested that day hospital treatments were able to include an increase in the body mass
index of patients suffering from eating disorders, in addition to reducing their purging or
vomiting symptoms and binge eating habits. Further improvements of the day treatment

21PILOT REVIEW
programs were related to an enhancement in the psychological functioning of the affected
individuals and reduction in the severity of eating disorder related psychopathology. Thus,
the review provided strong evidence for the positive impacts of day treatment interventions in
bringing about an improvement in the major variables related to anorexia nervosa.
Owing to the presence of limited evidence regarding treatment of adults suffering
from anorexia nervosa, and their poor treatment outcomes, researchers aimed to evaluate the
acceptability and efficacy of novel psychological therapies that focused on MANTRA, in
combination with SSCM in an RCT (Schmidt et al. 2012). The researchers recruited 72 adult
individuals receiving outpatient services, with AN or eating disorder, from a UK based eating
disorder service. This was followed by random allocation of the participants to 20 one weekly
sessions of SSCM or MANTRA and additional optional sessions, based on their clinical
needs and severity of symptoms. At baseline, patients who were randomised to the
MANTRA group were found to be significantly less likely to form a partner relationship,
when compared to patients receiving SSCM (3/34 compared to 10/36; p< 0.05). Furthermore,
patients allocated to both the treatment groups showed momentous improvements with
respect to their eating disorders and other treatment outcomes. Furthermore, recovery rates
that were strictly defined were also found to be low. However, patients in the MANTRA
group showed an increased likelihood of the need for additional day-care or inpatient
treatment, when compared to those in theSSCM group (7/34 v. 0/37; P=0.004). Thus, the
findings confirmed the use of SSCM as a beneficial treatment option for anorexia nervosa
outpatients.
The long-term benefits of three different psychotherapeutic interventions were also
reported by another randomised controlled trial that recruited women diagnosed with AN,
and randomised them to treatment groups namely, CBT, IPT, and a control in the form of
SSCM (Carter et al. 2011). Findings from the study suggested that 43 patients from the

22PILOT REVIEW
original patient population of 56 women successfully participated in the follow-up
assessment of the outcome measures. No major differences could be observed in the pre-
determined secondary, primary of tertiary outcomes among the three intervention groups.
Moreover, recovery patterns were significant for the psychotherapeutic interventions on the
primary outcomes. SSCM was found to be related with rapid responses among patients, when
compared to IPT. However, outcomes of the three different treatment forms were not
distinguishable during the follow-up period.
Citation Patients Diagnosis Outcomes Results
Brown et al.
2018
243 (AN‐
restricting
subtype= 79),
(AN binge/purge
subtype = 46),
and (bulimia
nervosa= 118)
Adult patients
with BN and AN
admitted to
UCSD and
completed
surveys
BMI, Eating
Disorder
Examination
Questionnaire,
Remission,
Anxiety,
Depression
Significant
improvements found
in ED
psychopathology,
weight, and
comorbid
symptoms. 49%
patients met the
criteria for
remission at
discharge
Kuipers et al.
2017
38 AN and BN
patients
Eating disorder
patients enrolled
in clinical
treatment
program
Recovery,
relapse,
attachment
security,
mentalisation, co-
morbid
symptoms.
High levels of
mentalisation,
improved co-morbid
symptoms, no
differences in
attachment
Kuipers et al. 38 female 71% AN Attachment Attachment security

23PILOT REVIEW
2018 patients security,
mentalisation,
ED
symptoms
showed
improvement in 1
year; no significant
change in
mentalisation;
Attachment security
was not related to
improvement of ED
and/or co-morbid
symptoms
Abbate‐Daga et
al. 2015
56 adult patients AN BMI, eating
psychopathology,
Depressive and
anxious
symptomatology
Positive symptoms
reported by 68%
patients at T18 and
78% participants at
EOT. Significant
improvements
observed in all
psychopathology
measures at EOT
and follow-up
period
Chen et al. 2017 109 females Diagnosed with
bulimia nervosa
(BN) or binge-
eating disorder
(BED) according
to DSM-IV-TR
criteria
OBD frequency,
OBD abstinence,
EDE scores,
BMI, vomiting
episode
frequencies,
assessment of
Similarity found in
Baseline objective
binge-eating-day
(OBD) frequencies
between CBT+,
DBT and cGSH.
Reduction in OBD

24PILOT REVIEW
functioning frequency was
noteworthy slower
in CBT+ and DBT
group, when
compared to cGSH.
OBD frequencies
were significantly
larger at end of
CBT+ (d = 0.31),
DBT (d = 0.27)
Lock et al. 2010 121 patients DSM-IV
diagnosis of
anorexia nervosa
Remission status,
BMI percentile,
Eating Disorder
Examination
No major
differences were
observed in full
remission between
the patients
subjected to
treatments at EOT;
FBT was found to
be significantly
greater than AFT for
remission. Family-
based treatment was
meaningfully larger
for partial remission
during EOT, but not
during follow-up.
Munro et al.
2014
Approximately
800 000 people in
Suffering from Engagement,
Service costs,
Patients were found
to be greatly

25PILOT REVIEW
the Lothian
region
eating disorders patient safety satisfied with the
treatment provided
by the Anorexia
Nervosa Intensive
Treatment Team. A
relatively reduced
mortality rate was
observed for the
high-risk
population.
Treatment costs and
in-patient bed use
were substantially
cheap.
Collin et al. 2010 90 of the 208
patients
consecutively
admitted to
Priory Hospital
Glasgow
Diagnosis
according to
DSM-IV criteria
Eating Disorders
Examination,
Symptom
Checklist-90,
Parental Bonding
Instrument
Both the completers
and those subjected
to the intention-to-
treat analysis
program reported
the effectiveness of
treatment regimen.
Longer length of
hospital stays are
related with a
superior degree of
changes in BMI. No
other predictors
related to the

26PILOT REVIEW
treatment outcomes
were noticed.
Participants also
reported increased
degrees of
satisfaction, in
association with the
programme.
Fennig et al.
2017
44 adolescents Admitted to
inpatient wards,
after being
diagnosed with
anorexia nervosa,
based on referrals
by community
psychiatrists
and/or family
physicians
Eating Disorder
Inventory, Eating
Disorder
Examination
Questionnaire,
Depression,
Anxiety-Related
Emotional
Disorders,
Suicide Ideation
No major changes
observed in the core
anorexic perceptions
and thoughts as
drive for thinness,
body dissatisfaction,
weight concern, and
shape concern.
However,
reductions found in
general severity of
symptoms related to
eating disorder
(such as, eating
concern and
restraint), mostly
connected to the
structure of the
treatment. Severity
of depression were

27PILOT REVIEW
significantly
reduced but stayed
within the
pathological range.
Concerning increase
in the thoughts and
suicidal ideations
were not related to a
subsequent
elevation in
depressive
symptoms.
Brewerton and
Costin 2011
287 patients
consecutively
admitted to
Monte Nido
Residential
Treatment
Program
Diagnosed with
eating disorders
according to the
‘Practice
Guidelines for
the Treatment
of Eating
Disorders of the
American
Psychiatric
Association’
Patient survey
results
AN patients showed
statistically
significant
improvements in the
mean BMI. BDI
scores, frequencies
of bingeing, 11
EDI-2 subscales,
laxative abuse,
vomiting, stimulant
abuse, chewing and
spitting, and
restricting behavior
improved for both
BN and AN

28PILOT REVIEW
patients.
Zipfel et al. 2014 727 adults
screened and 242
randomised
Diagnosed with
AN by DSM-IV
BMI BMI showed an
increase in all the
groups, no between
the group
differences
observed, mean gain
in BMI showed
further increase in
follow-up period of
12 months
Schmidt et al.
2016
142 patients AN diagnosed BMI, eating
disorder
symptomatology,
weight, restraint,
depression,
anxiety, concerns
over eating,
shape and weight
Few differences
observed between
groups.
Improvements in
ED
symptomatology,
BMI, clinical
impairment, and
distress levels were
either maintained or
showed an increase
Cartwright et al.
2017
89 outpatients AN diagnosed BMI, stress,
eating disorder
symptomatology,
restraint, weight,
anxiety,
Sudden gains were
experienced by
61.8% patients
during middle or
early treatment

29PILOT REVIEW
depression,
concerns over
shape, eating, and
weight
phases. Large
increase in BMI
observed.
Hepburn and
Wilson 2014
15 different
studies
Studies that
focused on
patients with
eating disorders
BMI, purge
eating habits,
vomiting,
cognitive status
Enhanced
psychological
functioning, BMI
increase, reducing
vomiting and
purging habits
Schmidt et al.
2012
72 adults AN diagnosed Recovery rate,
BMI, depression,
weight, anxiety,
EDE score
Patients randomised
to the MANTRA
group showed
reduced likelihood
of being in partner
relationship,
compared to those
in SSCM group.
Significant
improvement
observed in eating
disorder and other
outcomes.
Carter et al. 2011 56 women AN diagnosed by
DSM-IV
Global outcome,
weight, BMI,
body fat, EDE
examination,
No significant
differences observed
in the outcome
measures during

30PILOT REVIEW
Eating disorders
inventory
follow-up.
Table 2 – Summary of literature review

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Chapter 3: Methodology
Introduction
Methodology is an important chapter of dissertation, it helps the researcher to choose
or select the steps that will be followed while addressing the aim of the research. The chapter
aims to illustrate the steps and approach used by the research while conducting the pilot
research with a quantitative approach. The approaches and the steps used will be evaluated
critically along with the detailed analysis of their strengths and limitations.
Literature search
A pilot review of literature on the said topic will start with searching of the research
article in an organised and methodical way. The approach will help the researcher to
highlight authentic yet relevant studies. In order to initiate the research, identification of the
keywords are stated first that have been used in the search of the literary articles (Mcintosh-
Scott et al. 2014).
Key words
According to Polit and Beck (2014), before starting to conduct a research with pilot
literature review approach, it is mandatory to identify proper keywords. The key words
should be selected in such a way that it covers key concepts of the research. The below
mentioned table highlights the keywords used along with the proper thesaurus terms that
were employed to ensure relevant flow of the data. These keywords were used to search
literature from the electronic databases.
Keywords
Keywords Thesaurus terms
Anorexia Nervosa Food aversion
Eating disorder Anorexia nervosa, bingeing, hypheragia,

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Inpatient Hospital care
Out-patients Out of hospital care
Hospital Clinic, nursing home
Treatment Medication, interventions, care plan
Community care Out of hospital care
Day-care Day-care
Table 3: Keywords Used
(Source: Created by author)
Bibliographic Aids
The search of literature is important to avail access in-depth source of information
which is available online. According to Parahoo (2014), online database helps to access
gamut information from the recently published literature. The online databases which are
used for the search for the literacy articles include MEDLINE, OVID, CINAHL, Cochrane,
among others. Parahoo (2014) stated that before conducting the pilot review of literature, it is
important to conduct a thorough search of the available reviews which are already been
published online. This helps to reduce the chance of getting duplicated work while avoiding
the observance of the same research aim which are already been published online. With this
concept of Parahoo (2014) in mind, the researcher conducted a literature search in Cochrane
Database of Systematic Review with the keywords highlighted in table one. The search
provided negative results and further identification of the gaps in the literature helped the
research to reinforce the requirement of an extended pilot review over the stated research
topic (Holloway and Wheeler 2010).
Inclusion and Exclusion Criteria and Search Strategy
Aveyard (2014) highlighted that having a clear plan of conducting a search of literary
articles mean that search protocol have a stringent focus on the highlighted aim of the

33PILOT REVIEW
research and no extra time was wasted on irrelevant information. The formulation of the
inclusion and exclusion criteria for the literature search helps to avoid wastage of time in
searching between irrelevant articles (Coughlan et al. 2013). Polit and Beck (2014) stated that
inclusion and exclusion criteria are important in order to set specific boundaries for the
review of literature. The approach helps to shorten down the available online bibliographic
resources. However, Parahoo (2014) is of the opinion that selection of the inclusion and
exclusion criteria must be justified. For example exclusion criteria which are too specific may
side-pass important information which is relevant for the search.
Initial Inclusion and Exclusion Criteria
Inclusion Exclusion
Primary research (Randomised control trials, case
control trails) and secondary search(systematic
review)
Case studies, clinical guidelines
Language: English Other than English
Country: NA
Year of publication: 2008 to 2018 Older than 2008
Peer reviewed journal article
Research methods: Qualitative and Quantitative
Table 4: Inclusion and Exclusion Criteria for the Literature Search
(Source: Created by author)
Justification behind the selection of the inclusion and exclusion criteria
Mainly primary research were selected for the review because, Parahoo (2014)
highlighted that the results of the primary research are of high validity in comparison to the
secondary search where reviewer bias can tamper the results. However, secondary data were
also included in the research because it helps to increase the provision of getting a

34PILOT REVIEW
summarised overview of the prevailing trend in a particular research area (Coughlan et al.
2013). Randomised control trials (RCTs) and case control studies are selected under primary
research. This is because, RCTs and case control studies are few of the most rigorous
approach of determining the cause-effect relationship between the treatment and
outcomes.Articles which are published before 2008 were exclude from the research in order
to highlight the evolution of the care process in anorexia nervosa during the past 10 years
only. According to Parahoo (2014), while conducting pilot review, selecting studies within
the time-limit of 10 years help to analyse recent data on the elected topic.In relation to this,
Grol et al. (2013) highlighted that the pathway of in-patient and out-patient care or
community based care approach is not constant over time. As new inventions in the disease
prognosis are discovered, the care plans changes. Moreover, the advancement in the
healthcare technology also promotes change in the overall approach of the basic care plan.
Hence it is wise to focus on the care plan for the last 10 years in order to get a detailed
overview of the effective recovery process. Moreover, Polit and Beck (2014) highlighted that
selection of the research paper in the last 10 years help to fetch authentic and relevant
information. In order to increase the scope of the research further, both qualitative and
quantitative studies were included in the research, these helped to gain additional insight
about the research topic. Only peered reviewed journals were selected for the research.
Selection of the peered reviewed journals helps to increase the overall strength of the
systematic research (Polit and Beck 2014). English is selected as the main language of the
article selection because it the official language of Australia and mostly all the scientific
articles are published in English (Polit and Beck 2014).
Search Strategy
Research questions: Is there any difference in short and long term outcome between
in-patient and community treatment for Anorexia Nervosa.

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Search Outcomes
Initially Google Scholar was used to obtain a detailed insight about the total number
of research papers available online. After adding a filter with the year of publishing (2008 to
2018) the total number of hits obtained are 16, 200 (for community care) and 17,700 (in-
patient care).
1In-patientORDayCareANDOut-patientORCommunitycaresetting/Communitycare2AnorexiaNervosaOREatingdisorderORHyperphagia3TreatmentORInterventionORCareplan

36PILOT REVIEW
Figure: Screenshot form Google Scholar
Figure: Screenshot form Google Scholar
This huge search number indicated that there is gamut of available literature in order
to answer the research question. In order to access adequate literature for performing

37PILOT REVIEW
extended literature review, it is important to define the literature search through electronic
database. According to Betanny-Saltikiv (2012) stated that this kind of approach help in
further refinement of the search results. Further limiters were then applied through the use of
the Boolean operators.
Boolean operators are used to draw relationship with the keywords used (Robb and
Shellenbarger 2014). In this study, the researcher used two types of Boolean Operators
namely AND / OR in order to obtained numerous permutation and combination of keywords.
The use of Boolean operator helped to refine the search of the articles through electronic
database (Polit and Beck 2014). Moreover, use of the Boolean operators helped the
researcher to save significant amount of time via decreasing the overall number of hits. The
numbers of search results obtained via the use of the Boolean operators are limited and this
helped to research the check the relevancy of the obtained search results through scanning the
article titles and then article abstracts. The search of the research articles mainly highlighted
studies over community care and in-patient care patients separately. We searched for separate
articles that addressed either inpatient or outpatient/community treatment outcomes among
patients diagnosed with anorexia nervosa (eating disorder).
Snowball Technique
The obtained electronic resources are comprehensive as they are updated regularly.
However, while conducting pilot review of literature, it is important to employ alternative
methods for the search of the literary articles. According to Aveyard (2014), the search of the
literary articles through electronic database is not always exhaustive as few important
literatures can be skipped while abiding this process. Taking this reference into consideration,
after the selection of the research articles from the electronic database, the selected articles
were read and reviewed. As the part of the overall process of reviewing the literatures, the
reference list of the selected articles were scanned. Any additional articles which seemed to

38PILOT REVIEW
be coinciding with the scope of the research and other inclusion criteria selected for the
literature search were included. This approach is popularly known as Snowball Technique
(Greenhalgh and Peacock 2005). This process helps the research to spot the unidentified
research. Betanny-Saltikov (2012) stated that this approach helps to avoid the database and
keyword bias.
The search of the literature was stopped when the literatures arising from the research
were found to be duplicate and no new literature was highlighted. Saumure and Given (2008)
stated that this process of obtaining redundant search results in known as “data saturation”.
At this point the literature search must be ceased to obtain rounded perspective. The overall
articles highlight 50 main articles which were selected for the further analysis.
Search Results
Resource Search Terms Number of articles
returned
Number of relevant
articles
Cochrane Database of
Systematic Review
As per table 5 20 5
Google Scholar Anorexia Nervosa, in-
patient/therapy plan
Anorexia
Nervosa/community
care/therapy plan
16, 200 (for
community care) and
17,700 (in-patient care)
Time consuming to
reduce the article
numbers
Ovid Full Text Nursing
Plus
As per table 5 10 5
Medline As per table 5 44 25
Cinhal As per table 5 30 10
Snowballing 10

39PILOT REVIEW
Quality Assessment
The quality assessment was done is an ordered manner. First the selected 50 articles
were reviewed on the basis of their tile. According to Parahoo (2014), the title of the
literature is considered to be good when the aim of the study, and the study approach are
clearly mentioned within the title. The articles which failed to satisfy this criterion was
excluded from the research. The number of excluded articles after the title scrutiny is 20 and
the remaining number of articles includes 30. The remaining number of articles was scanned
for their abstract. The abstract analysis leads to the exclusion of another 15 articles. The rest
15 articles were analysed in full-text. The literatures where the sample size was extremely
poor (below 10) were excluded from the research. According to Parahoo (2014) low sample
size in both qualitative and quantitative research increases the probability of obtaining biased
results. The full-text analysis of the data finalised 10 research articles for the conducting the
pilot literature review.

40PILOT REVIEW
Figure- PRISMA flowchart
Research Philosophy
According to Bergh and Ketchen (2011), there are three different types of research
philosophies namely positivism, interpretivism and realism. The author has chosen positivism
philosophy while conducting this research. Positivism research philosophy is suitable for
quantitative research (Bergh and Ketchen 2011). It shows adherence to factual knowledge
that is gained by observation and measurement, in a trustworthy manner. In this research due
to the restriction of the word count and as per the inclusion criteria, the researcher had
selected only 10 research papers. The positivism philosophy of research will depend on
quantifiable observations related to the major outcomes of both inpatient and outpatient

41PILOT REVIEW
treatment that led to statistical analysis of data in the retrieved articles. Thus, the role of the
researcher was restricted to collection and explanation of data in an objective manner.
Research Approach
According to Crowther and Lancaster (2012), there are two research approaches
namely deductive and inductive. The author has opted for inductive research approach.
Inductive research approach aims to generate new theory from the emerging information
while deductive research approach is test the existing theory. The inductive research
approach will help the researcher to compare the effective outcomes of the community based
approach and in-patient approach in handling anorexia nervosa patient. This will help to
emerge on best-suited therapy plan for managing anorexia nervosa.
Research Design
According to Ellis and Levy (2012), there are different types of research design
namely exploratory, explanatory and descriptive type research design. The researcher has
used descriptive type research design. The descriptive type research design will help the
researcher to describe the relationships between inpatient and/or community treatment with
the different categories of primary and secondary health outcomes among patients with
anorexia nervosa. The procedure will help the researcher to generalize the overall
presentation of the research. The quantitative descriptive style research design will help to
perform a comparative analysis between the community health approach and in-patient
approach of treating anorexia nervosa in a succinct manner.
Conclusion
Thus from the above discussion it can be concluded that the researcher will follow
quantitative research approach with deductive research approach, positivism research
philosophy and descriptive style research design. The research will use 10 quantitative

42PILOT REVIEW
research articles in order to conduct the quantitative pilot literature review, which is obtained
via electronic database search.

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Chapter 4: Results and Discussion
Results
10 articles discussed in the previous section have been divided into different
categories based on the impact that both inpatient and community/outpatient treatment
exerted on major health outcomes and eating disorder symptomatology. These provided a
detailed information on the effectiveness of both inpatient/hospital and outpatient/community
care services used for the treatment of anorexia nervosa. This chapter comprises of the data
analysis and elaborates on the contrasting features between the two different treatment
approaches, in terms of the identified categories namely, weight, BMI, eating disorder
symptomatology, concerns over shape, weight and eating habit, depression, and anxiety.
Most of the articles discussed in the literature review focused on determining the immediate
impacts of interventions on the BMI, body image disturbances, remission rates, purging or
vomiting habits and binge eating behaviours. The effects of the inpatient and community
interventions were classified into different groups, depending on the way they showed a
modification, upon the implementation of the interventions, and are given below:
Impact of inpatient and outpatient treatment on BMI
While mild anorexia nervosa is closely associated with a body mass index or BMI
larger than 17, moderate forms of AN are related to BMI ranging from 16-17. Conversely,
people suffering from severe AN report BMI ranging from 15-16. Thus, treatment of
anorexia nervosa greatly focuses on the importance of restoring healthy weight among
individuals suffering from the psychological disorder. BMI was considered as a major
outcome in a study that determine the effectiveness of partial hospital programs on AN
severity. Upon calculating BMI at two different time periods and during follow-up, objective
BMI and that derived from self‐reports of weight were intensely associated at baseline

44PILOT REVIEW
(r(289) = .98, p < .001), and discharge (r(188) = .94, p < .001). Furthermore, baseline BMI
for the AN-R groups and AN-BP groups were found to be 17.44 and 18.65, respectively.
Significant improvements that were observed in BMI due to implementation of the partial
hospital programs were 17.41 (0.25) in AN-R and 18.66 (0.34) in AN-BP, during admission.
BMI during discharge time were 20.42 (0.29) and 20.41 (0.44), respectively for the two
groups. Further improvements were also observed in the follow-up period namely 20.18 and
21.45, respectively. Thus, the partial hospital programme was effective in increasing BMI
among all affected individuals, and values ranging between 20-22 signified an improvement
in the body weight of the AN affected patients, who were usually considered underweight
(Brown et al. 2018). BMI was one of the primary outcomes of another study that evaluated
the efficacy of day hospital treatments of anorexia nervosa patients. Owing to the fact that
participants suffering from severe AN, with BMI less than 13.5 were recruited for the study,
the day-care treatment was highly effective in enhancing BMI of all patients. While the mean
BMI was an estimated 16.32 during admission, BMI at the end of the treatmentwas
approximately 17.30 (95% CI), and 17.28 at T18 (group-by-time interaction: F = 3.29, df = 2,
p = 0.08). This modest increase in BMI showed that day hospital treatment is a feasible
option for reducing the symptoms of AN (Abbate‐Dagaet al. 2015).
BMI was assessed in another study that focused on determining the effects of CBT
and dialectical behavioural therapy. The failure of the interventions in bringing any
significant changes in BMI during follow-up period elaborated on the inefficacy of the
interventions (Chen et al. 2017). Total baseline measures of BMI were 5.2 and 7.2 for AFT
and FBT among patients recruited in an RCT that compared the effects of the two
interventions. Significant improvements in BMI were observed in the FBT group, when
compared to the AFT group (31.4 compared to 23.4) at end of treatment. Furthermore, FBT
also increased the BMI during the 6- and 12-months follow-up period that was 31.4 and 32.2,

45PILOT REVIEW
respectively. AFT also increased BMI levels, among patients to 29.1 and 29.0 during the two
follow-up period. Thus, FBT approach was better effective in improving anorexia nervosa
symptoms, by increasing the body mass index (Lock et al. 2010).
Upon implementing inpatient treatment services among patients suffering from AN,
findings of another study indicated that mean BMI of 14.9 during admission of the patients
significantly increased to 17.3 after a time period of 6 weeks and 19.8, immediately before
discharge of the patients from the hospital. Greater changes in BMI score suggested presence
of an improvement in weight and elaborated on the fact that inpatient treatment were able to
improve the weight of the patients (Collin et al. 2010). Major improvements in BMI between
two time periods (p< 0.000) were observed such as, 16.19 during admission and 19.49 during
discharge, upon implementation of inpatient treatment (Fenniget al. 2017).
Admit BMI were found to be in the range of 15.9 ± 1.8 and 20.8 ± 3.4, for AN and
BN graduates, respectively, in another study that determined the impacts of a residential
treatment program. Furthermore, discharge BMI were 18.2 ± 1.4, and 21.6 ± 4.0 for the two
groups, thereby establishing the usefulness of the treatment program for AN patients
(Brewerton and Costin 2011). Statistically significant improvements in BMI were also
observed between MANTRA and SSCM treatment groups in another study with an increase
by 2.25 in the mean BMI of the MANTRA group, during 24th month. Estimated mean of
18.77 BMI determined the efficacy of the treatment forms on the mean outcomes of AN
patients (Schmidt et al. 2016). Estimated treatment effects of SSCM and MANTRA at month
12 were 17.62 and 17.77, respectively in other trials that assessed the role of outpatient
psychological therapies (Schmidt et al. 2012). BMI were found to be 21.3, 20.2, and 20.9 for
SSCM, CBT and IPT interventions on AN patients in another trial (Carter et al. 2011). Thus,
most of the interventions were able in enhancing BMI of the patients.

46PILOT REVIEW
Impact of inpatient and outpatient treatment on weight
SSCM, CBT and IPT psychotherapies demonstrated significant increase in weight
among patients with AN in a range of 57.5 kg, 54.9 kg, and 56.5 kg, respectively (Carter et
al. 2011). Mean increase in weight by 2.49kg and 3.55kg was also observed among AN
participants from baseline to 6 months and 12 months follow-up period, respectively, in a
study that elaborated on the implementation of outpatient psychological therapies (Schmidt et
al. 2012). MANTRA and SSCM therapies have also proved their effectiveness in enhancing
weight of participants who were recruited in a multicentre red RCT. Estimated weight means
were 51.00 kg for SSCM intervention and 51.09 kg for the MANTRA therapy, thereby
indicating the efficacy of these community care or outpatient treatment approaches in
restoring normal weight among the affected individuals (Schmidt et al. 2016).
Owing to the fact that AN affected people show sudden reductions in weight, over a
small period of time, 39% of AN graduates had reportd a recovery in their weight (with BMI
≥ 18) in an article that assessed the treatment results. However, approximately 25%
participants reported a poor outcome in their body weight that was elucidated by no
restoration in weight values (Brewerton and Costin 2011). 100% ultimate body weight was
achieved by an estimated 70% of patients and 90% of ideal body weight by 25% patients,
who were subjected to rigorous inpatient treatment services for management of reduction of
severity of anorexia nervosa in patients affected by the psychiatric disorder (Fenniget al.
2017). Patients subjected to family-based treatment and adolescent-focused individual
sessions showed considerable weight gain, thereby indicating usefulness of FBT and AFT as
major interventions that can be implemented for reducing the impacts of anorexia nervosa
(Lock et al. 2010). Similar findings were presented in another study where the patients
suffering from AN were subjected to day hospital treatment. Restored weight was found

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among 12 patients (N = 9 AN-BP, N = 3 AN-R, and Fisher’s exact test p = 0.007) (Abbate‐
Dagaet al. 2015).
Impact of inpatient and outpatient treatment on Depression
Studies have already established the fact that people suffering from anorexia nervosa
are at an increased likelihood of suffering from major depressive disorder. These findings
were confirmed by those of a trial where use of the Beck Depression Inventory suggested that
although the BDI scores of AN patients were much beyond the clinical cut-off values,
significant reduction of symptoms were observed at discharge (t = 2.57, P < 0.05), thereby
establishing the effects of inpatient treatment (Fenniget al. 2017). Use of the Hamilton
Depression Rating Scale helped in identifying scores of 6.4, 7.2, and 6.3, for SSCM, CBT,
and IPT treatments on AN patients. Thus, use of this scale helped to determine the reduction
in severity of depressive symptoms among the patients, owing to the fact that 0-7 scores fall
in the normal range. Hence, the different psychotherapeutic approaches were successful in
reducing depression among the affected individuals (Carter et al. 2011).
Findings presented by Schmidt et al. (2012) were also consistent with the previous
results in that MANTRA helped in reducing severity of depressive disorder from a score of
8.00 at month 6 to 6.86 at month 12, based on the HADS rating system. Similar
improvements were also observed for SSCM from an estimated 8.16 at month 6 to 7.39,
thereby approving clear correlation between depressive disorders and eating order, in addition
to determining the effectiveness of psychotherapies for the condition. Hepburn and Wilson
(2014) also provided evidence that established the success of day-care programs in reducing
severity of depression among AN patients, thereby facilitating an enhancement in their
overall self-esteem and self-worth. Following 24 months after randomisation of eating
disorder patients, DASS depression scores were 19.58 for MANTRA, and 18.68 for SSCM.

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Both of these scores indicated that patients who were randomised to either of these
psychotherapies showed moderate symptoms of depressive disorder after the treatment was
implemented, with SSCM being more effective treatment method (Schmidt et al. 2016).
Significant reductions in depression symptoms were also published in another study
with a change from 22.34 to 15.59 from admission to follow-up period among AN-R. Those
suffering from BN also demonstrated better depression outcomes by 26.39 at admission and
15.67 during follow-up. This helped to establish worth of partial hospital programs in
ANtreatment (Brown et al. 2018). Substantial decrease in depression was also found among
patients in another trial with BDI scores of 17.09 at admission (T0), 12.55 during end of
treatment and 12.31 during follow-up period (T18), upon making the patients adhere to a day
hospital program for management of anorexia nervosa (Abbate‐Dagaet al. 2015).
Impact of inpatient and outpatient treatment on Concerns
People suffering from anorexia nervosa usually become concerned over their eating
habits and weight gain, thereby limiting or restricting the food intake. Upon conducting an
eating disorder examination, SSCM showed mean of 1.9 and 2.0 for eating concern and
weight concern, respectively, which were approximately 1.2 and 1.8 for CBT, and 1.2 and 1.7
for IPT (Carter et al. 2011). This was in accordance with another study where SSCM showed
scores of 2.43, 2.13, and 2.14 for eating, shape and weight concerns, which were in contrast
to 2.57, 2.33, and 2.02 scores for their MANTRA counterparts. This again confirmed the
advantage of SSCM over MANTRA intervention (Schmidt et al. 2016). Similar results were
also obtained in a research by Collin et al. (2010) where inpatient treatment modalities were
able to put down the eating concern rates from 4.2 at time O to 2.4 and 1.9 after 6 weeks, and
before discharge, respectively. Scores for the same variables for shape concern were 4.8, 4.0
and 3.6, and that for weight concern as 4.4, 3.3, and 3.0. Hence, major impacts were observed

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in modulating the worries of patients over their eating habits. Significant reductions were also
noted in eating concerns among patients suffering from AN in another trial (t = 2.96, P <
0.01).
However, failure of any major statistical variations in anxiety over shape and eating
habits failed to provide enough evidence for inpatient treatment services (Fenniget al. 2017).
However, partial hospital treatments also proved operative in lowering eating concern scores
from 2.76 at admission to 1.56 during follow-up for AN-R, and 3.74 to 1.94 for their BN
counterparts. Similar results were also obtained for shape and weight concerns for AN-R that
reduced from 3.35 to 2.60, thereby confirming the value of the intervention (Brown et al.
2018). Analysis of the effectiveness of day treatment programs also illustrated medium to
large effect sizes for shape, eating and weight concerns among affected individuals (Hepburn
and Wilson 2014). Thus, a majority of the studies discussed in the literature review could
address worry of the patients over these three variables.
Impact of inpatient and outpatient treatment on Eating/Dietary restraint
Dietary restraint refers to the intention where a person deliberately restricts the intake
of food, with the aim of preventing weight gain. Significant reduction in dietary restraint was
observed upon implementation of inpatient treatment on patients suffering from AN. While
mean restraint was 4.5 at time 0, it showed a gradual decrease to 1.9 and 1.7 after 6 weeks
and prior to discharge, respectively, thereby establishing inpatient treatment as effective
approaches (Collin et al. 2010). While SSCM implementation resulted in an EDE mean
restraint score of 1.63 among patients suffering from eating disorder, those who has been
administered the MANTRA therapy demonstrated a score of 1.66, both of which were
successful in illustrating that psychotherapies implemented upon AN patients in outpatient
services can be considered as effective treatment methods (Schmidt et al. 2016).

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Similar findings were also presented in another trial that tried to compare the impacts
of three different psychotherapeutic treatments for AN management. While SSCM showed a
mean restraint value of 2.5, it was 1.3 for CBT, and 1.4 for IPT, in the long-run, thereby
confirming that all the treatment modalities were highly successful in bringing about an
improvement in the patients over time (Carter et al. 2011). This finding was consistent with
the results obtained in the study conducted by Fenniget al. (2017) where inpatient treatment
showed a major success in significantly decreasing the severity of restraint among the
patients diagnosed with AN (t = 2.71, P < 0.01). This was also in accordance to results of
another trial that investigated the effects of a partial hospital program on adults with ED.
While restraint scores were 2.53 in adults with AN-R, there was a noteworthy decrease to
1.31, during follow-up period. Hence, most of the inpatient programs were better effective in
reducing the habit among AN diagnosed individuals that primarily focused on diet restriction.
Impact of inpatient and outpatient treatment on Anxiety
Eating disorders have most commonly been associated with onset of anxiety
symptoms related to body image and self-worth, which in turn aggravates the mental state of
the affected person. Most articles discussed in the literature review were able to demonstrate
the impacts that inpatient and/or community/outpatient services had on the prevalence and
severity of anxiety disorder among the recruited participants. Partial hospital program was
highly useful in reducing the scores of STAI Trait from 52.45 during admission to 45.99
during follow-up period among AN-R. Owing to the fact that higher scores obtained in this
inventory signifies presence of greater anxiety in the patient being evaluated, this reduction
was successful in illustrating the efficacy of the partial hospital program (Brown et al. 2018).
Hepburn and Wilson (2014) also postulated similar results by stating that nine of the studies
included in the systematic review were able to show a decrease in symptoms of anxiety
disorder post-treatment where the patients were admitted to day treatment services for AN

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management. MANTRA was less effective than SSCM therapy in reducing anxiety
symptoms among patients suffering from eating disorder. This in turn can be established by
the fact that while MANTRA score for DASS was 19.58, those for the SSCM counterpart
was 18.68, thereby confirming SSCM as a better treatment approach (Schmidt et al. 2016).
However, these findings were in contrast to another study where inpatient treatment
programs failed to improve the anxiety disorder and made the patients demonstrate more
symptoms related to this psychological illness, with a progress towards discharge time. While
21 patients (31.8%) said that the inpatient program was slightly or not at all helpful in anxiety
management, 50 patients (68.2%) considered it moderately helpful, thereby elucidating on the
drawbacks of the administered inpatient treatment regimen (Collin et al. 2010). Hence, it
cannot be stated that inpatient programs are always effective in reducing severity of anxiety
that is concomitant with prevalence of eating disorders. However, day hospital treatments
were successful in improving the scores of HAMA-A at end of the treatment (paired-sample
t-test: t = 8.16, p < 0.001), besides showing a substantial drop in social anxiety over time, in
both AN-BP and AN-R patient groups (Abbate‐Dagaet al. 2015).
Discussion
This review inspected published trials and studies on the efficacy of both
inpatient/hospital and outpatient/community programs aimed at lowering the symptoms of
anorexia nervosa and managing the risks associated with this psychiatric disorder. The review
also assessed the impacts of both of these treatment modalities on different comorbid
conditions that are generally found among patients suffering from eating disorder, especially
anorexia nervosa. All the ten trials included in the pilot review assessed the impacts of
treatment approaches on the BMI of the affected people, of which nine studies could illustrate
the fact that both inpatient and community and/or outpatient services were highly successful

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in showing great improvements in the BMI of the recruited patients, thereby helping in
restoration of their body weight.
This is in conformity with a study protocol that compared the effects of non-
pharmacological and pharmacological interventions on adult AN patients. The protocol gave
priority to the analysis of changes in BMI that was considered as a major outcome variable.
Owing to the fact that the protocol elucidated on the fact that presence of BMI>18.5 among
patients is a major prerequisite in order to determine the impacts of both AN non-
pharmacological and pharmacological treatment approaches, it can be suggested that all trials
included in the review correctly addressed changes in this variable (BMI) as an important
outcome measure, to determine success of the implemented intervention (Wade et al. 2017).
Brown, Mountford and Waller (2013) also conducted a study where participants who had
completed CBT for anorexia nervosa showed an improvement in their BMI from 16.3 at the
beginning to the treatment to 16.7 and 18.9 at session 6 and end of treatment, respectively.
These findings were also consistent with that of a longitudinal outcome study where the
impacts of enhanced CBT were determined upon patients suffering from ensuing and severe
AN. Upon recruiting AN patients through referrals to eating disorder clinics that were
community based, CBT implementation showed similar rates of increase in ‘good BMI
outcome’ in both SE-AN and NSE-An groups (BM ≥ 18.5; 40.7% and 44.0%, respectively).
Further improvements were also observed in ‘full response’ outcomes during a 12 months
follow-up period among the patients (Negligible eating-disorder psychopathology, and
BMI ≥ 18.5; 33.3% and 32.0%, respectively), thereby providing enough evidence for the
efficiency and acceptability of CBT community treatment for management of the psychiatric
disorder (Calugi, El Ghoch and Dalle Grave 2017).
Similar findings were also presented in another trial that elaborated on the impacts of
enhanced CBT (CBT-E) on adults suffering from anorexia nervosa, in the UK and Italy.

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Implementation of CBT-E substantially improved body mass index from 16.5 in the UK to
18.1 after treatment, and 15.7 at admission to 17.7 post-treatment in Italy. Hence, the study
could accurately establish the role of cognitive behavioural therapy in bringing about a
marked increase in body weight of AN patients during follow-up period (Fairburn et al.
2013). With the aim of determining effectiveness of interpersonal psychotherapy and CBT-E,
130 patients diagnosed with eating disorder were randomised to the two treatment groups and
subjected to treatment sessions that lasted over a time period of 20 weeks. Upon assessing
their outcome measures during a follow-up period of 60 weeks, it was found that while IPT
restored the mean BMI among patients to 22.8, CBT-E treatment regimen were able to
improve them to values of 22.9, thereby establishing the effectiveness of both the approaches
in helping AN patients regain a normal body weight (Fairburn et al. 2015). BMI centile also
showed an enhancement from 2.7 prior to treatment to 34.2 after treatment, thus providing
enough evidence for the effects of inpatient CBT (Dalle Grave et al. 2014). Therefore, it can
be suggested that community based or outpatient treatment services that focused more on
non-pharmacological therapies are better effective in managing eating disorder.
Four studies assessed in the pilot review were able to demonstrate the attainment of
reduction in anxiety disorder symptoms among patients subjected to treatment regimen.
These findings are in accordance with a trial that determined the outcome and feasibility of
an inpatient program involving dialectical behavioural therapy in anorexia nervosa adult
patients. While the scores for psychological conditions were 3.15 at the time of admission,
they showed a marked reduction to values of 2.12 at discharge, thus proving the worth of
dialectical behavioural therapy in reducing the severity of comorbid psychiatric symptoms
such as, those of anxiety disorders in AN patients (Lynch et al. 2013). The association
between prevalence of anxiety symptoms and eating disorders was also postulated in another
study that aimed to evaluate the influence of emotional acceptance behaviour therapy for

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treatment of anorexia nervosa. Upon implementing the treatment regimen, notable changes
were observed in BAI scores for anxiety from 20.4 during pre-treatment to 7.6 during post-
treatment. Slight increase was observed in the scores that ranged from 11.1 at 3 months
follow-up to 8.1 at six months follow-up, all of which were successful in founding the value
of emotional acceptance behaviour therapy program as an outpatient treatment method
(Wildeset al. 2014).
Like anxiety, depression is another presenting complaint of most people suffering
from eating disorders that makes them isolated and subsequently results in the development
of poor self-esteem. Seven studies in the review were able to show the impacts that either
inpatient or community based treatment services had on the severity of depression scores,
measured with the use of certain psychological scales. Wildeset al. (2014) not only evaluated
the role of emotional acceptance behaviour therapy on anxiety, but also measured the effects
of depression scores that showed a large reduction from 21.8 during pre-treatment to 8.8 at
post-treatment. However, although symptoms of depressive disorder were found to slightly
increase to scores of 9.9 and 10.5 during three months and six months follow-up period,
respectively, they indicated almost normal or mild disturbances in mood, and not any extreme
severity. Fairburn et al. (2015) showed that CBT was also effective in lowering depressive
features among eating disorder affected patients and reduced them from 21.2 to 11.8. Similar
impacts of IPT intervention were also explained by the reduction in BDI scores from 22.8 to
14.0. Thus, CBT proved more effective in depression management among patients with
eating disorders.
Although six studies analysed in the review could successfully confirm an increase in
body weight among the patients who had been subjected to inpatient or outpatient treatment
services, one could not show any enhanced outcome. Upon assessing the correlation between
therapeutic alliance and weight gain among AN affected individuals, all participants

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subjected to CBT program demonstrated weight values of 43.6 kg, 44.5 kg, and 49.1 kg at the
beginning, session six, and end of treatment. Comparable outcomes were also observed
among the completers who reported weight of 45.0 kg, 46.1 kg, and 51.6 kg during the three
time periods, thereby demonstrating the fact that therapeutic interventions were successful in
making the AN affected people regain their lost body weight, thereby improving the overall
health and quality of life (Brown, Mountford and Waller 2013). Upon assessing the changes
in body weight of substantially underweight adolescent patients diagnosed with AN, inpatient
treatment showed a marked elevation in weight. 38.5 kg weight increased to 49.7 kg after
treatment and 48.31 after a 12 month follow-up, thereby proving the effectiveness of
inpatient facilities (Dalle Grave et al. 2014).
Four studies could validate the impacts of treatment modalities over eating or dietary
restraint in review. These can be authenticated by the reduction in dietary restraint from 4.1 at
admission to 1.1 after treatment, and 1.2 at a follow-up period of 12 months in patients
subjected to inpatient CBT (Dalle Grave et al. 2014). Similar outcomes were observed for
CBT-E and interpersonal therapy as well where the effect estimates for CBT-E versus IPT
after treatment were -1.39 and that during a 60 week follow-up was -0.42 (Fairburn et al.
2015). Comparable changes were also observed by Turner et al. (2015) upon assessing the
impacts of outpatient CBT programs on adults suffering from eating disorder that showed a
mean value of 3.87 and 2.33 at session one and six, respectively, thus validating the positive
impact of CBT on modifying restraint behaviour in terms of food consumption. While five
studies included in the review suggested that inpatient and outpatient treatment services were
successful in lowering the concern of the affected person over their eating habits, weight and
body shape, only one study did not show any significant variations in this particular outcome
measure. Eating concern scores of 3.09 before treatment reduced to 1.07 post-treatment in a
trial conducted in the UK and Italy that determined the role of CBT-E. Parallel results were

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also found for shape and weight concern that changed from 3.40 to 1.83, and 2.95 to 1.22,
respectively for the two different time periods (Fairburn et al. 2015).
Calugiet al. (2018) also evaluated the impact of intensive CBT-E on patients suffering
from severe and enduring AN and found that SE-AN showed a marked improvement in
scores related to concerns over eating, weight and shape that changed from 3.6 to 0.9, 3.7 to
1.7, and 3.8 to 2.3, respectively for the three variables. However, major reductions were also
observed among NSE-AN patients as well, although on a smaller scale when compared to the
former group. Thus, the findings presented in the pilot review were in accordance to the
results offered in other recently conducted trials.

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Chapter 5: Conclusion
The term anorexia nervosa is commonly used to refer to a psychiatric illness that most
commonly manifests itself as a subtype of eating disorders. This condition is distressing and
severe, and is primarily characterised in as a chronic mental disease, which has the potential
of the development of emaciation, skinniness, a range of physical ailments such as,
osteoporosis. Furthermore, this psychiatric condition is generally manifested in the form of an
interruption to social, emotional, and scholastic development. However, several researchers
have also found evidences for the life threatening nature of the disease. The disorder has a
mean duration that lasts from approximately five to seven years. However, in most people, if
adequate implementation measures are not adopted, the condition might take the form of a
life-long illness. Remissions and partial relapses are extremely common among the affected
people. Besides, some people also get affected in a way that results in deterioration of their
health outcomes and subsequent health related quality of life. Confusion exists in the
community regarding the categorisation of anorexia as a physical illness or a mental one. In
reality, AN is a mental complaint comprising of strong anxiety and depression, and worries or
concerns about the body weight, shape, and eating habits. Fussiness and poor self-esteem are
some of the common symptoms faced by the patients. In addition, the psychiatric illness is
most commonly experienced with obsessional thinking over increased weight or poor body
image. AN has been found to affect individuals belonging to different socioeconomic
condition, age group, and cultural backgrounds. However, it is more prevalent in females,
compared to males. Although the illness begins at adolescence, patients who are diagnosed as
seriously affected usually belong to the age group of 20 – 45 years. Furthermore, AN has a
tendency to run in families, thereby suggesting the role of a major genetic component in its
incidence and prevalence. Weight loss, the common symptom of AN is caused principally
due to a decrease in food consumption. However, there exist a plethora of related behaviours,

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which result in an increase in energy expenditure such as, intake of metabolic stimulants,
exercise, and/or cold exposure, or behaviours that lessen energy intake such as, spitting,
chewing, and purging that directly contribute to onset of the disease. Although the most
shared existing explanation for this conduct is the fear of becoming bulky, other explanations
comprise of a drive for excellence. In selected patients, no motive for the unwillingness to
consume can be established, but they stereotypically fight attempts to help reinstate
nourishment and weight.
One particular theory that clarifies the propensity of AN to trail along a prolonged
time period and the prognostic feature of the duration of disease is that, the manners that
convoy the disease become customary rather than objective directed, over time. In addition,
the difficulties associated with obstinate poor nutrition are gathered, and a procedure of
adaptation ensues in the body that are served by several concerns of famishment on the body
and the brain, thereby maintaining the illness. Problems related to social cognition function to
separate and isolate the discrete, cognitive obstinacy averts modifications. The condition also
gets aggravated by poor oestrogen levels and different metabolic and hormonal consequences
of malnutrition, which in turn results in a deterioration of health and wellbeing. Some of the
most common symptoms of the condition are sadness, low mood, confused and slow
thinking, poor judgment and memory, brittle nails and hair, dizziness, blotchy and yellow
skin, and weakness in the joints and muscles.
Diagnostic assessments of anorexia nervosa have been most commonly found to
comprise of an evaluation of the current circumstances of the affected person, his/her
biographical history, presenting complaints and family history. The condition is most
commonly classified under Feeding and Eating Disorders based on the DSM-V criteria and
are principally of two main types namely, restricting type and binge eating type. While those
belonging to the restricting type are found to limit their intake of food, perform fasts,

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consume diet pills for losing weight, binge eating type is characterised by a display of
purging behaviour. Body mass index (BMI) is mainly used by the DSM-V criteria for
identifying severity of AN among affected people. While a BMI > 17 indicates mild AN,
values <15 helps to diagnose severe AN. Analysis of the articles included in the pilot review
provide the evidence for the fact that weight suppression, which is commonly defined as the
difference between maximum weight with respect to height and present body weight are
useful in predicting AN. Most treatment approaches, both inpatient hospital treatment and
community care based outpatient therapies that mainly comprised of CBT, SSCM, IPT and
MANTRA had accurately identified the need of making the patients adhere to the treatment
modalities in a way that would help them to improve their BMI, and regain normal body
weight. Calculating the BMI is a key method that helps to assess the healthy weight of a
person. Inpatient treatment techniques for AN were successful in maintaining BMI,
increasing body weight, and reducing restraint, concerns, anxiety and depression. This can be
attributed to the fact that most of the trials utilised a combined management program that
comprised of a weight restoration regimen, family involvement and individual
psychotherapy.
Are inpatient interventions effective?
Thus, although making all patients show compliance to an inpatient program might be
difficult, but the evidences analysed in the pilot review proved their usefulness and validity.
On the other hand, community treatment approaches that are commonly categorised as a part
of outpatient programs commonly encompass dietary intervention, group and individual
treatment, and different psychological therapies. Thus, community and outpatient treatment
approaches attempted to address the difficulties that are experienced by patients subjected to
hospital care. Results of outpatient and community care programs showed a marked
improvement in BMI and weight of the patients recruited for each trial, in addition to

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reducing their concerns over shape, eating habit and weight. Furthermore, they were highly
effective in improving the scores of co-morbid conditions such as, depression and anxiety, as
evident with the use of psychological scales. Owing to the fact that despite admission to a
hospital, delivery of outpatient care on the same day as that of discharge is considered as an
outpatient treatment regimen, effectiveness of the interventions were observed more in the
latter treatment approach. Inpatient treatment offers a round the clock supervision and care
from the end of trained healthcare staff who are entitled with the responsibility of assisting
during the early stages of recovery.
Are community/outpatient interventions effective?
Conversely, outpatient care approaches to which the participants in each trial were
recruited were designed in a way that enabled them to conduct their activities of daily living.
Although inpatient treatment offers a range of benefits such as, fostering a sense of
community by residing with people suffering from similar disorder, and presence of a
structured environment for reducing risks of relapse, some of the potential disadvantages are
associated with lack of insurance coverage and a loss of freedom. On the other hand, the
community and outpatient care services involve psychotherapy sessions that are often offered
in the evenings and help the patients to apply the knowledge gained in real-time settings,
thereby promoting a speedy recovery. Furthermore, most community care programs comprise
of family based therapeutic sessions that help the support network of the patients to gain a
better understanding of the challenges faced. Additionally, outpatient and community care
services implemented for the treatment of anorexia nervosa are more affordable, when
compared to inpatient care, and are covered by insurance. Thus, it can be concluded that
although both the treatment options have proved their success in reducing severity of AN and
its co-morbid conditions, the potential advantages of community care service help in
considering it as a better option for management of the psychiatric disorder.

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Limitations and future scope
A search of the aforementioned electronic databases was conducted, for enhancing the
strength of this pilot review. The strength of the review lies in the fact that all titles and
abstracts of the acknowledged papers were originally screened next to the inclusion criteria
by two reviewers, followed by the independent assessment of the full texts. One major
limitation associated with the research was keeping the time frame restricted to 10 years,
which prevented inclusion of prospective articles from the study. Furthermore, the research
design failed to incorporate adequate articles that had drawn a comparison between the two
treatment approaches. This required extensive labour to categorise the results separately from
the inpatient and outpatient approaches, in order to observe their impacts on the patient
outcome measures. Another limitation was absence of unpublished or grey literature, such as,
national guidelines and professional publications, in addition to exclusion to relevant studies
published before 2008. Therefore, it is probable that firm evaluations and interventions are
missing from the pilot review. Thirdly, the 10 studies analysed in details featured dissimilar
aims, research designs and approach, and the interventions showed major variations in terms
of their implementation and duration. The efficacy of an inpatient or outpatient intervention
was often assessed using small sample size. These differences in primary characteristics
impeded a direct contrast of their success and the separation of data. Less number of
scholarly papers that draw conclusion from a direct comparison between hospital and
community care for AN, within the pre-specified time frame made it difficult to establish the
reliability of the concluding statements. Although the community approaches proved better
effective than the inpatient treatment regimen, an extensive study and meta-analysis is
required for measuring the exact differences between the two. Thus, future aim would be
directed at conducting a meta-analysis comparing literature that directly compare between
inpatient and outpatient treatment programs, without any limits in publication time.

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