Evaluation of Group Emotion Skills Training and Individual Cognitive Remediation Therapy in a specialist inpatient eating disorder service for children and adolescents

Student thesis: Doctoral ThesisDoctor of Philosophy


Anorexia nervosa (AN) is a life-threatening eating disorder (ED) with a lifetime prevalence of up to 3.6 – 4 %, according to DSM-5 criteria, and is associated with high individual, familial, and healthcare costs. The incidence is highest for female adolescents and it is the third most common chronic disorder affecting this group. For young people (YP) who receive treatment, the remission rate is as high as 50–70%.

No Grade A recommendations are currently made by the National Institute of Health and Clinical Excellence guidelines (NICE, 2017). The best available evidence is for family therapy for children and adolescents with AN (Grade B recommendation), and that most people with AN should be managed on an outpatient basis in the first instance.

An increase of the number of hospital admissions and inpatient stays for both children and adolescents, as well as adults, with a diagnosis of an ED has been observed. Patients with an ED require an inpatient admission when their physical health is severely compromised and they are no longer safe within the outpatient setting. The most frequent mean age of admissions, for both males and females, is 15, with a majority of all ED admissions being between the ages of 10 and 19.

Hospital stays for those with a diagnosis of an ED were more likely to be longer than all other admissions, with 30% of those with an ED having a stay longer than a month, compared to just 1% of all other admissions.

However, as outpatient treatment is the primary recommended treatment, there is considerably limited research into psychological interventions in inpatient services. Despite some findings in support of various treatments such as Cognitive Behaviour Therapy (CBT) and Cognitive Remediation Therapy (CRT), no conclusions were able to be drawn as to the most efficacious psychological treatments due to methodological weaknesses. This highlights a major limitation in ED research: that there are few studies into inpatient treatment, and much of the current literature has significant methodological limitations, such as lack of control or comparison groups and consistent measurements. Ultimately, further research is imperative to draw conclusions as to the best psychological treatments, perhaps drawing on early findings in support of CBT and CRT.

Furthermore, as the peak age of AN onset during adolescence is between 15 and 19 years old, this age group appears to be an important population to consider. This overlaps with critical periods of brain maturation and associated plasticity, indicating that early and effective interventions are fundamental to improve the prognosis.

Identifying appropriate treatment addressing cognitive and emotion processing underlying AN is an opportunity to improve overall illness outcomes.

The thesis consists of the research evaluating Emotions Skills Training (CREST) and Cognitive Remediation Therapy (CRT) in a specialist ED inpatient service for YP. They are two brief adjunct psychological interventions addressing the cognitive and emotion processing mechanism underlying AN. They have been studied particularly in the treatment of adults with AN, and proved to be suitable and beneficial in both outpatient and inpatient settings.

CREST was evaluated in a group format. Two case series were conducted to initially evaluate the feasibility of the original CREST group , developed for the adult population, and subsequently to evaluate the adaptations made on the basis of YP’s feedback. A mixed-methods methodology was used. Results from pre and post self-report questionnaire showed no statistically significant changes in YP’s self-perceived emotional functioning. Qualitative results from interviews and questionnaires showed that YP found it helpful to learn about emotion processes, acknowledging their need to be supported to express them and understand the link with AN symptoms. Pilot findings suggest that group CREST for young people (CREST-GYP) is an acceptable intervention for children and adolescents with AN in an inpatient setting. Clinical and research studies are needed to clarify if CREST-GYP can produce more beneficial treatment results than treatment as usual.

CRT was evaluated in an individual format. An initial explorative study and then within-subjects studies were conducted to assess the feasibility of CRT through a pre and post qualitative and quantitative assessment. The findings from these studies, alongside a systematic review of the literature, led to the development and conduction of a pilot randomised controlled trial (RCT).

The first aim of the pilot RCT study was to assess whether CRT improves cognitive function, using quantitative methods. The second aim was to qualitatively examine service users' and their parents’ experiences. It also explored the effect of CRT in YP with AN and autistic spectrum condition traits (ASC).

Participants were randomly allocated to the Immediate or Delayed condition to receive CRT, in addition to standard treatment. A repeated measures design was conducted. YP and parents’ view were explored through a letter and a feedback questionnaire.

Eighty participants were recruited. Significant improvements in set-shifting and central coherence were found, with no main effect between Immediate and Delayed condition. Significant interactions were found between the condition, and ASC and No-ASC subgroups, with significant positive impact of CRT on set-shifting in the No-ASC subgroup. There was some evidence that for the No-ASC subgroup, CRT was more effective if delivered at the start of the treatment; and for the ASC subgroup, that CRT was more effective if delivered at the later stage of treatment. Both YP and parents valued CRT. Its engaging and pragmatic nature and its focus on thinking styles were perceived as a novel aspect. Parents expressed the need to be more involved in the sessions.

These findings suggest the overall positive effect of CRT in set-shifting and central coherence alongside standard treatment. They also indicate the importance of screening for the presence of ASC which could require tailored CRT. YP and parents’ experiences should be taken into account to further adapt the content of the CRT sessions. Parents’ involvement in the sessions should be considered.

The overall findings of these studies confirm that both CREST and CRT are a beneficial adjunct intervention for YP with AN. Their brevity makes them suitable for an inpatient setting. YP showed good engagement and attended all the sessions. The fact that they address the emotion and cognitive processing underlying AN, without tackling directly the ED symptoms, make the two interventions less threatening for YP with poor motivation towards therapy and treatment in the acute phase of the illness.

Future research may benefit of further RCT studies on CREST and CRT to confirm these findings, with also a specific attention to the AN with ASC traits subgroup, which require tailored treatments.

This research area is tightly related to the clinical practice, where a stronger need for early and targeted interventions, and condition-specific clinical pathways are needed to improve the illness outcomes in the young population and its prognosis.

Date of Award1 Sept 2022
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorKate Tchanturia (Supervisor) & Abigail Easter (Supervisor)

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