CREST for Anorexia Nervosa
CREST for Anorexia Nervosa
The aim of this exploratory study was to evaluate the efficacy and impact of a novel and brief skills-based therapy for inpatients with anorexia. Recent research findings have highlighted that abstract and flexible thinking styles seem to be less present in individuals with AN, despite other cognitive strengths such as high IQ and good working memory remaining intact. Eating disorders research has also made progress in characterising low emotional intelligence, poor positive emotional expression, difficulties with social communication, difficulties in friendships, emotionally-driven thinking as 'hot' cognition, high social anhedonia, difficulties with social interactions, and the patterns of both positive and negative emotion processing. Qualitative assessments of patients' emotional needs, along with these recent research developments, have been translated to inform treatment interventions such as cognitive and emotional remedial therapies; for example, CRT and CREST.
This study is the first of its kind in that we have explored the feasibility of delivering CREST in a short (10 sessions), individual format using self-report measures of social anhedonia and alexithymia. We found a clinically significant decrease in social anhedonia and alexithymia among the participants, and these aspects were directly targeted by CREST. BMI and motivation were not directly addressed in CREST, but were used here as secondary measures to assess improvements in other important domains. The results show that the main outcomes, such as improved use of emotional vocabulary and development of the ability to be with other people, changed in the positive direction. Small effect sizes (0.31-0.35) and statistical significance together with patients' comments on how they benefited from CREST suggest that CREST is a useful tool for this severe group of patients receiving inpatient treatment.
We are aware of several limitations within the current study and will try to improve upon these shortcomings in future research and evaluation. For example, we would like to explore in more detail exactly who benefits the most from this intervention and audit more precisely the clinical characteristics of patients who either do not respond to or do not choose to take part in this therapy. It would be desirable to explore the presence of autistic characteristics within this group of patients, since the current research findings suggest that many inpatients with AN have elevated levels of autistic traits. In summary, this study provides some evidence that our brief CREST intervention can influence social anhedonia, the ability to recognise one's own emotions, and confidence in one's ability to change. These findings are promising because from previous research we know that social anhedonia is highly correlated with chronicity of illness and the current data has been collected from adult patients with a long duration of illness (the mean duration of illness in this study is 8 years). However, further research is needed in order to corroborate these findings; to be precise, a randomised controlled design study with a larger sample size.
This is our attempt to contribute towards intervention developments targeting emotion skills in severely nutritionally compromised patients with AN. The intervention has been positively received by patients and therapists, and the manual has been informed by the latest research updates. Well-tested outcome measures which seem to tap into problematic areas for eating disorder patient groups have been selected, which also capture changes after CREST.
The absence of accurate information explaining the reasons for 'drop out' cases (e.g. early discharge, not wanting to complete questionnaires) is a clear limitation of this study.
Further improvements of this study would include addressing the limitation mentioned above and refining our assessment battery to include tests measuring emotion expression, an area into which CREST taps and which has been shown to be sub-optimal in people with AN.
Discussion
The aim of this exploratory study was to evaluate the efficacy and impact of a novel and brief skills-based therapy for inpatients with anorexia. Recent research findings have highlighted that abstract and flexible thinking styles seem to be less present in individuals with AN, despite other cognitive strengths such as high IQ and good working memory remaining intact. Eating disorders research has also made progress in characterising low emotional intelligence, poor positive emotional expression, difficulties with social communication, difficulties in friendships, emotionally-driven thinking as 'hot' cognition, high social anhedonia, difficulties with social interactions, and the patterns of both positive and negative emotion processing. Qualitative assessments of patients' emotional needs, along with these recent research developments, have been translated to inform treatment interventions such as cognitive and emotional remedial therapies; for example, CRT and CREST.
This study is the first of its kind in that we have explored the feasibility of delivering CREST in a short (10 sessions), individual format using self-report measures of social anhedonia and alexithymia. We found a clinically significant decrease in social anhedonia and alexithymia among the participants, and these aspects were directly targeted by CREST. BMI and motivation were not directly addressed in CREST, but were used here as secondary measures to assess improvements in other important domains. The results show that the main outcomes, such as improved use of emotional vocabulary and development of the ability to be with other people, changed in the positive direction. Small effect sizes (0.31-0.35) and statistical significance together with patients' comments on how they benefited from CREST suggest that CREST is a useful tool for this severe group of patients receiving inpatient treatment.
We are aware of several limitations within the current study and will try to improve upon these shortcomings in future research and evaluation. For example, we would like to explore in more detail exactly who benefits the most from this intervention and audit more precisely the clinical characteristics of patients who either do not respond to or do not choose to take part in this therapy. It would be desirable to explore the presence of autistic characteristics within this group of patients, since the current research findings suggest that many inpatients with AN have elevated levels of autistic traits. In summary, this study provides some evidence that our brief CREST intervention can influence social anhedonia, the ability to recognise one's own emotions, and confidence in one's ability to change. These findings are promising because from previous research we know that social anhedonia is highly correlated with chronicity of illness and the current data has been collected from adult patients with a long duration of illness (the mean duration of illness in this study is 8 years). However, further research is needed in order to corroborate these findings; to be precise, a randomised controlled design study with a larger sample size.
Strengths
This is our attempt to contribute towards intervention developments targeting emotion skills in severely nutritionally compromised patients with AN. The intervention has been positively received by patients and therapists, and the manual has been informed by the latest research updates. Well-tested outcome measures which seem to tap into problematic areas for eating disorder patient groups have been selected, which also capture changes after CREST.
Limitations
The absence of accurate information explaining the reasons for 'drop out' cases (e.g. early discharge, not wanting to complete questionnaires) is a clear limitation of this study.
Further improvements of this study would include addressing the limitation mentioned above and refining our assessment battery to include tests measuring emotion expression, an area into which CREST taps and which has been shown to be sub-optimal in people with AN.
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