FINAL PAPER_Comparison of Treatment Methods for Anorexia Nervosa

Running Head: TREAMENT FOR ANOREXIA NERVOSA 1
Comparison of Treatment Methods for Anorexia Nervosa
Brooke Harrison
The Pennsylvania State University

TREATMENT FOR ANOREXIA NERVOSA 2
Abstract
The aims of this study is to determine if a Maudsley model of family-based care or in-patient
care results in a better outcome for participants with anorexia nervosa, and to determine if anti-
depression medication also results in a better outcome. Fifty participants clinically diagnosed
with anorexia nervosa will be randomly placed in a Maudsley model of family-based care or in-
patient care, as well as on anti-depressants or not. They will receive four months of therapeutic
treatment with weekly weigh-ins and monthly questionnaires assessing their mental state. Their
improvement will be measured by the Global Assessment of Functioning (GAF). Participants
receiving family-based care plus medication scored sixty, participants receiving family-based
care minus medication scored fifty-five, participants receiving in-patient care plus medication
received fifty, and participants receiving in-patient care minus medication received forty. These
findings show that the Maudsley model of family-based therapy plus anti-depression medication
results in the best outcome for participants with anorexia nervosa.

Comparison of Treatment Methods for Anorexia Nervosa
The research topic of interest is comparing different treatment methods for anorexia
nervosa and determining their effectiveness. The DSM-IV-TR has diagnostic criteria for
anorexia nervosa including refusal to maintain body weight at or above a minimally normal
weight for age and height, intense fear of gaining weight or becoming fat even though
underweight, disturbance in the way in which one’s body weight or shape is experienced, undue
influence of body weight or shape on self-evaluation, or denial of the seriousness of the current
low body weight, and in postmenarcheal females, amenorrhea i.e. the absence of three
consecutive menstrual cycles. There are also two different types including restricting and binge-
eating/purging type. Treatment methods for anorexia nervosa have not been very successful and
there have not been many research studies to evaluate the effectiveness of them. The relapse rate
for anorexia nervosa is still high and the average length of the disorder is 5-6 years, some cases
becoming chronic. Many people who suffer get stuck going in and out of hospitals and in-
patient units.
For this current study I would like to learn from previous experiments on how other
methods have succeeded, or not, and build upon that. Due to this pervious research I have
learned that family-based therapy seems to be the most successful. I believe that family-based
treatment with veteran Maudsley model parents and patients as mentors will be more effective in
recovery of anorexia nervosa, including weight restoration and rate of depression, than in-patient
treatment. The Maudsley model of therapy is a form of family-based care created, originally, for
adolescents with anorexia nervosa by Christopher Dare. This treatment will be compared to in-
patient care where the participant will stay in a rehab facility surrounded by other eating disorder
patients and their care will be in control of professionals. The three articles I will highlight here
describe how I came to the experiment I will conduct.

The first article aimed to determine the most effective treatment for anorexia nervosa.
Gowers et al. (2007) hypothesized that the more intensive in-patient treatment would be more
effective than out-patient treatment; and specialist out-patient treatment would be more effective
than general child and adolescent mental health service (CAMHS) treatment. During in-patient
treatment each individual received supportive individual or cognitive therapies as well as family
therapy. Specialist out-patient care consisted of multiple therapies including, an initial
motivational interview, individual cognitive therapy (CBT) plus parental feedback, parental
counseling with the participant, dietary therapy, multi-modal feedback. The last treatment
method called General Child and Adolescent Mental Health Service (CAMHS) took more of a
family-based approach with variable dietetic, individual supportive therapy and a medical
liaison. The independent variables (IV) for this study are the three common treatment methods
for anorexia including intensive in-patient and two out-patient options (specialist out-patient and
CAMHS). The dependent variables (DV) are based upon the improvement from the baseline to a
1 and 2 year follow up. This is measured by interviews and participant ratings; including,
Morgan Russell Average Outcome Scale (MRAOS), clinical diagnosis based on the DSM-IV,
Eating Disorder Inventory and more.
After conducting the study Gowers et al. (2007) concluded that there is no statistical
significance between intention-to-treat analyses across different treatments, as well as finding the
Morgan Russell Average Outcome Scale (MRAOS) being remarkable similar across treatments.
There is a much better outcome for those who completed the out-patient treatments compared to
those who resigned, for example those who completed CAMHS were less likely to have anorexia
after 1 year. Gowers et al. (2007) discovered that in-patient admissions appears to have little or
no impact on core cognitions such as body dissatisfaction or drive for thinness, where as those

who declined admission made improvements in these areas. After two years twenty-seven
percent of all participants still had anorexia nervosa and there was still no statistically
significance between the groups by intention to treat. In the end, fewer than one in five fully
recovered in one year and one-third recovered in two years leaving one-quarter still experiencing
anorexia nervosa. Gowers et al. (2007) decided contrary to hypothesis there is no advantage for
specialist over general CAMHS treatment or in-patient over out-patient management.
The second article attempted to shed light on the Maudsley Method of treatment for
anorexic patients and if the addition of a parent-to-parent consultation would be effective for the
overall improvement of the anorexia nervosa. Rhodes, Baillee, Brown, and Madden (2010)
hypothesized that parent-to-parent consultations would be associated with some improvement in
parental efficacy, relative to standard treatment, which, in turn, would be associated with a
relative increase in the rate of weight restoration. The IV for this experiment was the type of
treatment the participants underwent, either the Maudsley model with a Maudsley veteran or just
regular family-based therapy. The DVs for Rhodes et al.’s (2010) study was Parental Efficacy or
the ability of a parent to adopt a primary role in taking charge of the anorexia in the home setting
for the purpose of bringing about recover of this child, patient distress including depression,
anxiety, and stress scales, and body weight done by percentage of ideal body weight according to
metropolitan life tables.
Rhodes et al. (2010) discovered that, as far as the measure of weight, nine out of twenty
received a good outcome, or they no longer met the DSM-IV-TR weight criteria. Six out of
twenty were in the intermediate outcome and five out of twenty were in the poor outcome. The
relationship between parent-to-parent consultations was found to not be significant. Rhodes et
al. (2010) concluded that because there was no significant difference after the parent-to-parent

consultations, the consultations may be used more as an additional tool when treatment is
slowing instead of a requirement. The consultations seemed to have a more emotional and
reflective quality rather than the active role displayed in the standard treatment, it would possibly
be more effective if the veteran was a mentor throughout the whole process instead of only one
appointment.
The third article focused on the potential benefits of adding an anti-depressant after
weight restoration in anorexic patients. Walsh et al.’s (2006) primary aim of the study is to
determine, in a large sample, whether fluoxetine, compared with a placebo, reduced the rate of
relapse and enhanced psychological and behavioral recovery following initial treatment for
anorexia nervosa. The IVs for this study is the drug dosage, the participant was either given
fluoxetine or a placebo. The DVs were assessments collected every four weeks including, Eating
Disorders Inventory (EDI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI)
and the Rosenberg Self-Esteem Scale (RSE). Obsessions and quality of life were measured with
the Yale Brown Cornell Obsessive Compulsive Scale for Eating Disorders (YBC-EDS) and the
Quality of Life Enjoyment and Satisfaction Questionnaire (QlesQ). Participants were also
weighed weekly and the primary outcome measure was the time-to-relapse.
Walsh et al. (2006) discovered that forty of the ninety-three initial participants completed
the study and fifty-three were terminated prematurely either due to relapse, did not attend
minimum number of therapy sessions, or patient dissatisfaction with treatment. Also there were
no significant differences between the fluoxetine and placebo groups in BMI or in measures of
psychological state at the time of termination or the participants who completed the full study.
Walsh et al. (2006) concluded there was no significant relationship between the average total
fluoxetine plus nor-fluoxetine plasma concentration and time-to-relapse.

These three articles aided me substantially in deciding and developing my research study.
Due to Walsh et al.’s (2006) article I decided to have half the participants on medication and half
not on medication; however, I will not be using placebos. I also decided not to just pull
depressed participants because of Walsh et al. (2010) showing that the participants do not have to
be clinically diagnosed with depression. Gowers et al. (2007) and Rhodes et al. (2010) articles
helped me to decide what treatments I will use, how I will manipulate my IVs and what DVs I
will use. My participants will be fifty clinically diagnosed anorexic nervosa patients, all
currently meeting diagnostic criteria according to DSM-IV. My IVs will be the different
treatments (in-patient vs. family-based care) and anti-depressant medication (drug vs. no drug).
Half will be randomly allocated to in-patient treatment facilities and half receiving Maudsley
model family-based therapy with veteran Maudsley method mentor throughout the process. I
chose in-patient treatment due to Gowers et al. (2007) and a Maudsley model treatment due to
Rhodes et al. (2010). Rhodes et al. (2010) made me choose to have the Maudsley model veteran
as a mentor throughout the whole process, since they discovered nothing significant in just one
parent-to-parent consultation. Half of each treatment group will be randomly treated with anti-
depressants and half not.
Walsh et al. (2010) helped me to decide which scales and questionnaires I will use to
operationalize my dependent variable. My dependent variable will be the Global Assessment of
Functioning (GAF) which is also Axis V according to the DSM axes. This number will be
measured by the Morgan-Russell Average Outcome Scale, Eating Disorder Inventory, and
weekly weighins in order to measure the participant’s weight restoration. I will also measure the
participants depression, quality of life and self-esteem using Beck Depression Inventory (BDI),
Rosenberg Self-Esteem Scale (RSE), and the Quality of Life Enjoyment and Satisfaction

Questionnaire (QlesQ). I believe there will be a main effect for both IVs so that being on
medication will improve the participants GAF more than not being on medication, and
undergoing family-based care will improve the participants GAF more than in-patient. There
should also be an interaction displaying that the effectiveness of the medication depends upon
the treatment. My hypotheses is that participants (1) receiving Mausdley model of family-based
care will improve more than those undergoing in-patient care and (2) those on anti-depression
medication will improve more than those not on medications.
Method
Participants
In order to conduct my experiment I need fifty currently clinically diagnosed anorexia
nervosa participants. The participants do not need to have any previous treatment; if they are
currently in treatment they will be pulled from it and just be given our treatment. The
participant’s gender and subtype (restricting or bingeing-purging) will not be discriminated
against. The age of the participants will need to be between thirteen and eighteen in order to
correctly conduct the Maudsley model, which calls for adolescents. The participants will be
recruited through a website I will set up advertising towards parents who want help for their
teenage daughter or son; as well as, teenagers looking for help for their anorexia. They will also
be recruited through letting local high school guidance counselors, therapists, and hospitals
aware of our experiment.
Materials and Procedure
For this experiment I will need to obtain a facility that the in-patient participants can go
to. This facility will ideally already be an eating disorder facility so therapists, cooks,

psychiatrists, etc. will be readily available. I will also recruit therapists, nutritionists, and
psychiatrists for the Maudsley model participants. Lastly, I will need to find a Maudsley model
veteran family. The family must include the patient and at least one parent, or guardian, who
went through the therapy with the patient. This will be done by posting it on our website as well
as informing local therapists and facilities of our experiment and need for a Maudsley model
veteran family.
This experiment is a 2 treatment type (Maudsley model of family-based care or in-
patient) X 2 anti depressant medication (on drug or not of drug) factorial design. In order to
conduct my experiment I will need to divide my participants. The first divide will be randomly
allocating the fifty participants into either the Maudsley model of treatment or in-patient care
(twenty-five in each group). Then these groups will be randomly split into two halves, one given
anti-depressant medication and the other half no medication. The level of medication that the
participant is on will be decided by their psychiatrist, for their own safety. Both treatments will
continue for four months, this will be accurate time for the medication and treatment to start
working. At the end of each week the participants will be weighed, and their weight will be
tracked. At the end of each month the participants will fill out the Morgan-Russell Average
Outcome Scale, Eating Disorder Inventory, Beck Depression Inventory (BDI), Rosenberg Self-
Esteem Scale (RSE), and the Quality of Life Enjoyment and Satisfaction Questionnaire (QlesQ).
This will help to determine the participants Global Assessment of Functioning scale for 1-100, 1
being the least functional and 100 being the most functional.
The Maudsley participants will attend one fifty minute meeting with a therapist, one
twenty minute meeting with a nutritionist, and one thirty minute meeting with a psychiatrist (if
on medication) per week, as well as, one fifty minute meeting per month with a Maudsley model

veteran family. The fifty minute weekly meeting with the therapist will include twenty minutes
with the family and thirty minutes alone with the therapist. The meals for the participant must be
prepared and monitored by their parents. The participant will be kicked out of the experiment if
they miss more than three meetings without rescheduling, after three meetings they have the
possibility of regressing. They will also be eliminated if it is found out that the parents are not
preparing the meals or monitoring. This study will be conducted primarily during the summer,
so that the parents will be able to monitor the participant’s entire food intake. However, if there
is an overlap with school the participant, their parents, and the therapist must decide between
allowing a friend at school to monitor them or come home for lunch. In-patient care will include
individual therapy meetings, nutritionist meetings, psychiatry meetings (if on medication), and
group therapy meetings weekly. Their meals will be prepared by the cooks at the facility. The
participant will be eliminated if they decide to leave the facility for more than three days for any
reason.
Results
When the participant first enters the experiment they will be assessed by a therapist,
weighed, and fill out the Morgan-Russell Average Outcome Scale, Eating Disorder Inventory,
Beck Depression Inventory (BDI), Rosenberg Self-Esteem Scale (RSE), and the Quality of Life
Enjoyment and Satisfaction Questionnaire (QlesQ). Their Global Assessment of Functioning
will be determined at this point, so I will be able to track their improvement. I predict that the
average GAF for all the participants will be thirty-five. Once the participants are divided into
groups I predict the beginning averages for family-based plus medication will be twenty-nine,
family-based without medication will be thirty-three, in-patient plus medication will be thirty-
five, and in-patient without medication will be thirty-five.

My predicted results are that participants receiving a Maudsley-model of family based
therapy and on anti-depressant medication scored an average of sixty on the Global Assessment
of Functioning after the three months. Participants receiving a Maudsley-model of family-based
therapy and not on medication scored an average of fifty-five, participants receiving in-patient
care and on medication scored an average of fifty, and participants receiving in-patient care and
not on medication scored an average of forty. This makes the post-treatment average GAF to be
51.25. The studies I read seemed to indicate that there was slight more improvement in patients
on medication and undergoing the Maudsley Method, which is why that number is the highest.
The studies also showed that participants on medication undergoing in-patient tended to do better
than those not on medication as well. I also predict that at least four participants will be
eliminated from the study due to either missing meetings or being dissatisfied with the treatment.
The overall averages across both IVs are; on medication has an average GAF of fifty-
five, not on medication has an average GAF of 47.5, undergoing in-patient care has an average
GAF of forty-five, and undergoing family-based therapy has an average GAF of 57.5. These
numbers are displayed on Table 1. When compared to the beginning GAFs family-based plus
medication improved by thirty-one, family-based without medication improved by twenty-two,
in-patient with medication improved by fifteen, and in-patient without medication improved by
five. According to my predicted results, there will be overall improvement, with the average
GAFs for all participants increasing by 18.5.
Discussion
According to my predicted results the experiment will have both main effects and an
interaction. There will be an interaction, showing that the effect of the medication depends on
the type of treatment the participant underwent. The anti-depressant medication is clearly more

effective when the patient undergoes the Maudsley-model of family-based therapy as opposed to
in-patient care, which can be seen on Figure 2. I did predict a main effect across the independent
variables, showing that family-based therapy improves the participant’s GAF more than in-
patient care and anti-depressants improve the participant’s GAF more than no medication.
Looking at the overall averages on medication and undergoing family-based care have the
highest overall GAFs. Whether or not someone is on medication effected how they performed in
treatment, and the type of treatment they underwent effected the medication they were on. The
results are also positively correlated, so that as the participant’s GAF when on medication
increases, so does their GAF while undergoing family-based care. All of these factors prove my
hypothesis to be true; participants (1) receiving Maudsley-model of family-based care will
improve more than those undergoing in-patient care and (2) those on anti-depressant medication
will improve more than those not on medications.
If my results were to come out as what I did not predict, the highest GAF would be a
participant undergoing in-patient care with no medication. A participant undergoing family-
based care and on medication would receive an average forty GAF, while a participant
undergoing in-patient care without medication would receive an average sixty GAF, and so on
and so forth. The main difference between my predicted results and alternative results are that
the alternative results are negatively correlated, so that as participants GAF on no medication
increase, those on medication GAF’s will decrease. There would still be two main effects but it
would prove that in-patient care and no medication would improve the participant’s GAF more.
This study has both its strengths and limitations and still has room to improve upon. A
strength of this experiment is that both treatment methods will have a support system. The
Maudsley model of family-based care will have the support of a veteran Maudsley family that

understands what the participant is going through. The in-patient care has the support of other
peers that are currently struggling with the same dilemmas they are. I also believe having half
the patients taking anti-depressants in conjunction with therapy is a good idea. I do not believe
that anti-depressants alone could significantly help improve anorexia nervosa symptoms, but
with therapy they could. This is an area, however, that could be expanded. I did not just pull
depressed participants, in a follow up study the participants could be suffering from anorexia
nervosa with, clinically diagnosed, comorbid depression. This current study in comparison with
this idea of a follow up study could show if anti-depressants are more helpful if the participant
has depression or not. Another suggestion for a follow up study would be to focus on the
different subtypes of anorexia nervosa. I did not discriminate against either subtype, but
separating restricting from bingeing/purging could result in different outcomes.
Anorexia nervosa is a mental disorder that still has a low recovery rate, and the more
studies conducted the closer we get to an answer. With the four studies I have highlighted in this
research proposal, some questions have already been answered. Gowers et al. (2007) concluded
that there is no advantage for specialist over general CAMHS treatment or in-patient over out-
patient management. Rhodes et al. (2010) concluded that a veteran Maudsley model family
could be used more as an additional tool or mentor when treatment is slowing. Walsh et al.
(2006) discovered that there were no significant differences between the fluoxetine and placebo
groups in BMI or in measures of psychological state at the time of termination or the participants
who completed the full study. My experiment could finally conclude whether a Maudsley-model
of care or in-patient results in a better outcome. There are thousands of people in the world
suffering from anorexia nervosa and we are responsible for finding them happiness.

References
Gowers, S. G., Clark, A., Roberts, C., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N.,
Byford, S., & Barrett, B. (2007). Clinical effectiveness of treatments for anorexia
nervosa in adolescents: Randomised controlled trial. The British Journal of Psychiatry,
191(5), 427-435. doi: 10.1192/bjp.bp.107.036764
Rhodes, P., Baillee, A., Brown, J., & Madden, S. (2010). Can parent-to-parent consultation
improve the effectiveness of the Maudsley model of family-based treatment for anorexia
nervosa? A randomized control trial. Journal of Family Therapy, 30 (1), 96-108. doi:
10.1111/j.1467-6427.2008.00418.x
Walsh, B. T., Kaplan, A. S., Attia, E., Olmstead, M., Parides, M., Carter, J. D., Pike, K. M.,
Devlin, M. J., Woodside, B., Roberto, C. A., & Rockert, W. (2006, Jun 14). Fluoxetine
After Weight Restoration in Anorexia Nervosa: A Randomized Controlled Trial. JAMA:
Journal of the American Medical Association, 295 (22), 2605-2612. doi:
10.1001/jama.295.22.2605

Table 1
Participant Results
IV #1: Treatment Type
Lvl 1 Family-Based Lvl 2 In-Patient Overall
IV #2:
Anti-Depressant
Medication
Lvl 1 Drug 60 50 55
Lvl 2 No Drug 55 40 47.5
Overall 57.5 45

Figure 1. Global Assessment of Functioning (GAF) scores of all participants, separated into
treatment type and anti-depression medication dosage.
0
20
40
60
80
100
Family-Based In-Patient
Drug
No Drug
GAF
Treatment Type

FINAL PAPER_Comparison of Treatment Methods for Anorexia Nervosa

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