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A Case Study Introducing Cognitive Remediation and Emotion Skills Training for
Anorexia Nervosa Inpatient Care
Claire Money, Helen Davies and Kate Tchanturia
Clinical Case Studies 2011 10: 110 originally published online 16 January 2011
DOI: 10.1177/1534650110396545
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A Case Study Introducing

Cognitive Remediation
and Emotion Skills Training
for Anorexia Nervosa
Inpatient Care

Clinical Case Studies

10(2) 110121
The Author(s) 2011
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534650110396545
http://ccs.sagepub.com

Claire Money1, Helen Davies2, and Kate Tchanturia1,2

Abstract
Difficulties in executive functioning and emotional processing are reported in anorexia nervosa
(AN).This case study describes the application of cognitive remediation and emotion skills training
(CREST), an intervention that has been piloted in an inpatient eating disorders (EDs) unit. CREST
is a 10-session treatment package, which primarily addresses emotion processing difficulties, one
of the maintaining features of AN. The stages of CREST are described, which includes targeting
thinking styles, recognizing emotions in the self and others, strategies to manage emotions, and
practice of emotion expression. Clinical and self-report data collected before and after CREST
indicate improvements in identifying emotions and using healthier emotion regulation strategies,
alongside an increase in body mass index (BMI) and reduction in ED symptomatology. This case
study provides preliminary evidence for the acceptability and effectiveness of CREST as a lowintensity intervention before proceeding to more comprehensive therapies, such as cognitive
behavior therapy to address the ED more fully.
Keywords
anorexia, cognition, emotion, remediation, treatment

1 Theoretical and Research Basis for Treatment

Anorexia Nervosa (AN) has the highest mortality rate of any psychiatric disorder (Lock & Fitzpatrick, 2009). AN is an illness that is complicated by comorbidity and is often associated with
low self-esteem (Fairburn, Cooper, & Shafran, 2003), difficulties with emotion regulation (Harrison, Sullivan, Tchanturia, & Treasure, 2009), and cognitive rigidity (Tchanturia et al., 2004).
Current U.K. national guidelines are unable to highlight a recommended treatment for AN
(National Institute for Health and Clinical Excellence [NICE], 2004). There is little support for
individual psychological therapies and no superiority for any particular therapy, such as
1

South London and Maudsley NHS Foundation Trust, UK

Kings College London, UK

Corresponding Author:
Kate Tchanturia, P.O. Box 59, Section of Eating Disorders, Psychological Medicine, Institute of Psychiatry, Kings College
London, De Crespigny Park, London SE58AF, UK
Email: kate.tchanturia@kcl.ac.uk

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Money et al.

cognitive behavioral therapies (CBT) or interpersonal psychotherapy (McIntosh et al., 2005).

Treatment outcomes are also poor with 20% of cases remaining chronically ill with impaired
quality of life and often requiring repeated hospital admissions (Steinhausen, 2002).
A crucial step toward generating treatment advances for AN involves targeting the core maintaining factors of the illness (Schmidt & Treasure, 2006). The cognitive-interpersonal model
proposed by Schmidt and Treasure (2006) focuses on four maintaining factors: emotion avoidance, cognitive rigidity, proanorectic beliefs, and the response of close others. This case study
evaluates a brief 10-session treatment package, which has been piloted in a specialist eating disorder (ED) inpatient ward to address two of the maintaining features of AN, namely, cognitive
rigidity and to a greater extent emotional processing difficulties.
Emotions in AN. Bruch (1962) highlighted the importance of targeting emotions in AN and
described prominent deficiencies in AN patients abilities to identify emotional states. More
recently, qualitative (Kyriacou, Easter, & Tchanturia, 2009) and quantitative studies have highlighted difficulties in AN with labeling and describing emotions, recognizing emotions in self
and others, alongside problems in recognizing internal visceral and affective states (e.g., Harrison
et al., 2009; Jansch, Harmer, & Cooper, 2009; Oldershaw et al., 2010; Russell, Schmidt, Doherty,
Young, & Tchanturia, 2009). Furthermore, it has been reported that patients with AN subjugate
their own needs in an attempt to preserve relationships (Geller, Cockell, Hewitt, Goldner, &
Flett, 2000), suppress negative feelings (Hambrook et al., 2010), and inhibit the expression of
emotions (Davies, Schmidt, Stahl, & Tchanturia, 2010). It has also been suggested that AN
becomes a means to regulate affect through down-regulating emotional experience (Waller, Kennerly, & Ohanian, 2004).
Considering the reported difficulties in emotional processing skills in AN, alongside some
evidence that these difficulties are a maintaining factor and could predict long-term outcome
(Speranza, Loas, Wallier, & Corcos, 2007), it seems appropriate to target emotional difficulties
in the comprehensive treatment of AN.
The cognitive remediation and emotion skills training (CREST) intervention. CREST is a recently
developed, 10-session individual treatment for inpatients with severe AN. It aims to target thinking styles, emotion recognition, and the management and expression of emotion. It is important
to consider that in the early stages of treatment, AN patients are often severely underweight
(body mass index [BMI] < 15 kg/m2), with low levels of concentration, and are thought to struggle to engage in complex psychological work (Tchanturia, Davies, & Campbell, 2007).
Considering these factors, brief and low-intensity interventions could be useful for patients
when they are first admitted to an inpatient ward and are in the acute stage of illness. Cognitive
remediation therapy (CRT) is commonly used as a brief intervention for AN (Davies & Tchanturia, 2005; Tchanturia et al., 2007, 2008). Patients with severe AN often present with a rigid and
detailed focused thinking style struggling to contextualize information within the bigger picture.
CRT targets this by using exercises to promote cognitive flexibility by looking at the bigger
picture and the ability to shift focus from a detailed style to a bigger picture thinking style
(Tchanturia & Hambrook, 2009). CREST incorporates some exercises from CRT to facilitate
reflection on thinking styles and encourage flexible thinking in the day to day. A recent study
reports that patients with AN found CRT useful in reducing perfectionism and rigidity (Whitney,
Easter, & Tchanturia, 2008).
CREST comprises 10 sessions of psychoeducation and skills-based strategies to encourage
patients to reflect on and develop their elementary emotion-processing skills. In Sessions 1 and
2, the focus is on thinking styles, such as bigger picture thinking and flexibility, and derives from
CRT (Tchanturia et al., 2007, 2008). This initial focus on thinking styles encourages reflection
and aims to enable the development of a therapeutic relationship before thinking about emotions.
Sessions 3 to 10 directly target emotions with basic education regarding the nature and function

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Clinical Case Studies 10(2)

of emotions alongside a focus on emotion recognition, in particular, labeling and identifying

emotion states. During sessions, specific tasks are used to encourage reflection on strategies to
identify, manage, and express emotion.
CREST was intentionally designed to broaden the patients perspective on their current situation and focus on everyday emotional skills. Therefore, the intervention is not related to eating,
shape, or weight concerns. In addition, CREST is not a complete treatment modality in its own
right but is rather a preparatory intervention to engage patients in low-intensity therapy to facilitate further psychological work. All patients admitted to our inpatient unit are routinely offered
CREST as an initial intervention to facilitate engagement in more complex psychological work.

2 Case Introduction
A 19-year-old female (referred to as Helen) met Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association [APA], 1994) diagnostic criteria for
AN (restricting type). She did not have any additional Axis I or II diagnoses. On admission to the
inpatient ward, Helens weight was 38.3 kg with a BMI of 15.2 (normal range for BMI is between
19 and 25). She previously had five inpatient admissions, of between 6 and 9 months duration,
within the past 4 years. On each discharge, she had lost weight and required readmission.

3 Presenting Complaints
Helen was admitted to the ward after struggling to manage and maintain her weight in the community. She had lived a socially isolated adolescence as she had suffered with AN since she was
14 years of age and much of her teenage years had been spent in inpatient wards. This left her
with low self-esteem, a confused sense of identity, and high levels of anxiety. Helen significantly
restricted her food intake (e.g., cut out all carbohydrates from her diet) and experienced feelings
of guilt and anxiety if she did not engage in a rigorous daily exercise regime. She said she was
frustrated because she had not been able to overcome her AN. However, she also said she was
fearful of change as this had become a way of life for her and represented something that she
could control and be perfect.

4 History
Personal. Helen reported a difficult childhood due to witnessing her fathers violence toward
her mother. Her parents separated when she was a child. Her mothers second partner was also
violent (which Helen witnessed), and they separated shortly after her first admission into an
adolescent ED unit when she was 14. Helen felt very protective toward her mother as a child and
took on a caring role.
Helen was a successful athlete and began competitive gymnastics at the age of seven. She
remembers dieting for the first time at this time because of perceived pressure from her sports
coach. She went for training four to five times a week and described this as being a way of avoiding the problems at home. In addition, she described the sports team as another family to which
she felt a sense of belonging. She was also very good at athletics and this fueled her tendency
toward perfectionism. By secondary school, she became more aware of athletic competition and
suddenly felt that she was not the best. This increased her desire to achieve further.
At the age of 14, Helen suffered an injury that resulted in her being unable to participate in
any sport for 6 weeks. During this time, she began to lose significant amounts of weight. Since
this time, she has spent the majority of the last 5 years in inpatient wards.

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Money et al.

Helen chose to end her athletics career because of her ED and the sports regime fueling her
anorectic behaviors. At the age of 18, she was due to start a sports psychology degree. As she was
unable to maintain a healthy weight, she was readmitted to hospital before she could start. At the
present time, she is uncertain about the future and what she would like to do. This leaves her with
strong feelings of anxiety and fear.
Family. Helen lives with her mother and younger sister. She has had no contact with her father
since he left the family home when she was a young child. She reports a conflicted relationship
with her mother where she feels she oscillates from being the carer to being overly cared for and
monitored by her mum. There are reports of depression on the maternal side of the family. Helens mother has been treated for depression in the past.

5 Assessment
Helen was assessed by a psychiatrist on admission to the inpatient ward and met DSM-IV criteria
(APA, 1994) for AN. These symptoms include a BMI of <17.5, amenorrhea (absence of three
consecutive menstrual cycles), and behaviors such as restriction of food, binging and/or purging
behavior, an intense fear of gaining weight, and disturbance in the way body shape is perceived.
CREST was offered consecutively to patients in the ward as a pretreatment before they moved
on to more complex psychological work such as CBT. Assessments described below were administered as outcome measures for CREST. They included clinical questionnaires relating to eating
pathology and mood, and calculation of BMI over the course of treatment. Although eating
pathology, mood, and weight were not being directly targeted in CREST, it was important to see
if these clinical symptoms changed as a consequence of CREST. As the main focus of CREST is
on emotions, three questionnaires were included to measure emotion identification, emotion
regulation, and emotion expression. In addition, to assess acceptability of CREST, a patient satisfaction measure was administered as well as a motivational ruler.
Helens BMI was calculated before, during, and after CREST (see Figure 1). The following
self-report measures were administered before and after CREST:
Eating Disorder Examination Questionnaire (EDE-Q). The EDE-Q (Fairburn & Beglin, 1994) is a
measure of psychopathological and behavioral indicators of disordered eating. The EDE-Q provides a global score and has four subscales measuring dietary restraint, eating concern, weight
concern, and shape concern. Subscale and global scores range from 0 to 6, with higher scores
representing greater pathology. For the purpose of this assessment, we report only the global
score that is calculated as the mean of the four subscales.
Depression, Anxiety, and Stress Scale (DASS). The DASS (Lovibond & Lovibond, 1995) is a
21-item self-report instrument designed to measure the three related negative emotional states of
depression, anxiety, and tension or stress. The questionnaire comprises 7 items in each of the
three subscales.1 Each subscale has a maximum score of 21.
The Toronto Alexithymia Scale (TAS-20). The TAS-20 (Bagby, Parker, & Taylor, 1994) is the most
widely used measure of alexithymia. It consists of 20 items loading onto three subscales: difficulty identifying feelings and distinguishing them from bodily sensations, difficulty describing
feelings to others, and an externally oriented style of thinking. A score of less than 51 indicates
nonalexithymia, equal to or greater than 61 indicates alexithymia, and 52 to 60 shows possible
alexithymia. Bagby et al. (1994) found the TAS-20 had good internal consistency for the total
score (a = .81) and acceptable internal consistency for the subscale scores.
Emotion Regulation Questionnaire (ERQ). The ERQ (Gross & John, 2003) measures two emotionregulation strategies: cognitive reappraisal (e.g., when I am faced with a stressful situation, I
make myself think about it in a way that helps me stay calm) and suppression (e.g., I control my
emotions by not expressing them). The maximum score on the reappraisal subscale is 42 and

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Clinical Case Studies 10(2)

19
18

BMI (kg/m2)

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Figure 1. BMI chart

Note: BMI = body mass index.

suppression subscale is 28. High internal consistency for reappraisal (a = .79) and suppression
(a = .73) has been reported (Gross & John, 2003).
The Emotion Expression Questionnaire (EES). The EES (Kring, Smith, & Neale, 1994) is a
17-item questionnaire that measures the extent to which an individual expresses positive and
negative emotions. Respondents evaluate statements such as I do not express my emotions to
other people and I think of myself as emotionally expressive on a 7-point Likert-type scale
ranging from 0 (never true) to 6 (always true). The EES has been shown to have high internal
consistency (a = .91) and good testretest reliability (Kring, Smith, & Neale, 1994).
Patient Satisfaction Questionnaire. This poses five questions: how positive, effective, and useful
the individual found the treatment; whether it met expectations and provided transferable skills.
It is rated on a 1 to 10 Likert-type scale with 1 being not at all and 10 being extremely.
Motivational ruler. These explore beliefs about the importance to change and perceived ability
to change. They are visual analogue scales that are scored from 1 to 10.

6 Case Conceptualization
The following formulation regarding Helen is based on a cognitive behavioral model. We present
a brief description of the formulation alongside a diagrammatic snapshot (Figure 2). Helens
involvement in athletics, gymnastics training, and competitions from a young age led her to
become acutely aware of her size and shape. In line with this, she felt under pressure to monitor
what she ate and engage in a rigorous exercise regime. At this time, Helen was also witnessing
domestic violence and felt the need to protect, be strong, and care for her mother. She developed
a number of core beliefs (Figure 2) and experienced strong feelings of fear, anxiety, anger, and a
sense of being out of control at home. She also felt that she had to subjugate her own needs and
emotions to meet her mothers emotional needs. Alongside this, she developed the belief that
negative emotions, particularly anger, are dangerous and must be suppressed. Helens experience

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Money et al.

Figure 2. Case formulation

Note: AN = anorexia nervosa.

of anger was that it led to violence. Helen compensated for these feelings by putting all of her
efforts into sports and this became a means of distraction and avoidance of what she was feeling.
She developed a number of rules and assumptions for living (Figure 2).
The triggering factor for the onset of AN was the sports injury, putting a temporary stop to her
training. Until this point, athletics had been Helens means of escape from home life and the difficult feelings this created, alongside giving her a sense of being in control of an aspect of her
life. Exercise had become a way of managing her feelings of anxiety. Without it, Helen needed
an alternative way to gain a sense of control in a chaotic home life. This became the function of
her AN. At the time of her first admission into hospital, her mum and partner separated, and
Helen perceived the AN as a means of gaining attention from her mum and protecting her from
further violence. As to maintaining factors, Helen associates exercise with anxiety management.
She also fears change and has an underdeveloped sense of identity. AN became a means to manage difficult feelings and ensured that she was looked after. It enabled her to move away from the
caring role she felt toward her mother. She craved stability, warmth, and guidance from her mum
and found this was more present when she became unwell.
With regard to protective factors, Helen was motivated to challenge her AN. She was also
keen to work on resolving difficulties in her relationship with her mother.
Treatment recommendations. Helen was offered CREST immediately after the admission
because

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Clinical Case Studies 10(2)

1. It is known that acutely ill AN inpatients are difficult to engage in psychological work.
CREST aimed to offer a simple, nonthreatening, and collaborative treatment that
would motivate further engagement later on in treatment.
2. Emotion processing difficulties are common in AN and serve as a maintaining factor.
It was established that this was the case for Helen and that she would benefit from
CREST to help her start thinking about how she identifies, manages, and expresses
emotion.

7 Course of Treatment and Assessment of Progress

As already discussed, Helens AN in part developed to assist in maintaining control over affect.
Prior to commencing CREST, Helen talked of feeling detached from her emotions and found it
difficult to label and tolerate her feelings. CREST was completed in 10 twice weekly face-to-face
sessions (50 min each), conducted over a 5-week period. The first two sessions focused on
thinking about thinking and identifying processes of thinking, namely, how seeing the bigger
picture and being more flexible could be beneficial in everyday life. The remaining eight sessions focused on emotion processing (Table 1). Simple exercises were used as a tool for providing basic education around emotions as well as being a platform for Helen to reflect on and
explore how she processed her own emotions. Specifically, exercises helped Helen to learn about
(a) the function of emotions; (b) how to label and identify emotions, in particular listening to her
body as an indicator of what she might be feeling; (c) the positive intention of emotions and the
needs emotions communicate to the self and others; and (d) practice accepting, tolerating, and
expressing emotions.
An illustration of some of the tasks follows:
By completion of CREST, Helen talked of starting to get to know herself as she was becoming
more aware of how she was feeling. This was a positive but difficult experience for Helen as she
talked of change being difficult. In particular, Helen worked hard to challenge her need to exercise and is learning to tolerate the emotion of anxiety. Helen talked of feeling motivated to continue with therapy and went on to see a psychologist for further individual work. CREST also
highlighted the importance of finding an identity outside of AN, which had been serving to block
her emotional growth and experience. Helen completed the self-report outcome measures on the
day following her final session of CREST.

8 Complicating Factors
Being in an inpatient ward, Helen was unable to test and put into practice the skills she was learning in a normal social environment. This would be something she would practice once discharged. However, Helen was able to start practicing these skills in the ward environment and
appeared to find this a useful first step.

9 Follow-Up
Following CREST, Helen remained on the ward and engaged in further work with a psychologist. Themes of her ongoing work included identity and self-esteem issues, alongside exploring
the relationships within the family, particularly with her mother.
Helen completed CREST in July 2009 and was discharged from the ward in September 2009.
After 12 months, she had a BMI of 18.5 kg/m2 (above the AN range). She continues to receive
treatment for her AN in an outpatient service. She is currently waiting to start a college course
and is looking for part-time work.

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Table 1. Some Examples From CREST Sessions
Session

Example of content

Aim of intervention

Intersession work and Helens feedback

Session 2

Optical illusions
task.

To highlight and
promote switching
between the
bigger picture
alongside smaller
details.

Session 3

How emotion
states impact on
physiology.

To increase emotion
awareness by
listening to the
body.

Session 5

Emotion word
lists. Switching
between emotion
states.

Identifying and
labeling emotions
in the self.
Emotions as fluid
and transient.

Session 8

The positive
intention
of negative
emotions.
Emotions signal
needs.

To encourage
Helen to
accept, tolerate,
and express
emotions by
considering the
needs emotions
communicate
and how difficult
emotions can
communicate
something useful.

Helen reports a detailed focused thinking

style and has rigid behaviors, particularly
around morning routines.
Helen went on to introduce some flexibility
in her day by changing one small aspect of
her morning routine. Helen reflected that
she was surprised she could do this as she
expected her anxiety to increase.
Helen found it difficult to listen to her
body. She kept a record of emotions
and associated physical changes. On
reflection, she could identify that when
she was anxious she became tense and
experienced an adrenalin rush and in
response to this would overexercise.
Helen was able to consider that
overexercising was maintaining her anxiety
in the long term. She reported that she
became more able to challenge her need
to exercise.
Helen found these exercises helpful as she
recognized that she did experience a
number of emotion states both positive
and negative and that emotions of
anger, anxiety, and guilt were not fixed
and permanent making them easier to
identify, acknowledge, and consider. As a
homework, Helen was asked to complete
a self-exercise. She was asked to create
one image of how she wants to appear
to the world and another of how she
feels inside. This revealed a discrepancy
between what she shows and what she
feels. Helen was able to recognize that this
discrepancy was causing her more stress
and anxiety and was open to thinking
about expressing her true emotions,
rather than suppressing them.
Helen responded well to this as it provided a
new way of thinking about emotions. This
enabled her to think about the emotion
of anger. Her own experience of anger
was that it led to conflict and violence.
This session encouraged Helen to see
that anger can be a healthy emotion and
it is how people respond to it that can be
problematic, not the emotion itself.

Note: CREST = cognitive remediation and emotion skills training.

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Table 2. Changes After CREST

Time 1 before Time 2 after Healthy control
CREST
CREST
normsa
BMI
EDE-Q (global score)
DASS anxiety
DASS depression
Emotion regulation (reappraisal)
Emotion regulation (suppression)
TAS (describing feelings)
TAS (identifying feelings)
TAS (externally oriented thinking)
TAS total
Emotional expression
Motivational ruler: Importance to change
Ability to change

15.5
2.70
0
2
20
17
18
24
27
69
49
10
7

16.2
2.10
2
5
28
20
18
21
26
65
49
8
8

19-25b
1.5
2
3
29
11.8
6.4
7
9.2
37.4
66.1
NA
NA

+ improved
= no change
worse
+
+

=
+
+
+
=

Note: CREST = cognitive remediation and emotion skills training; BMI = body mass index; EDE-Q = Eating Disorder
Examination Questionnaire; DASS = Depression, Anxiety, and Stress Scale; TAS = The Toronto Alexithymia Scale.
NA = nonapplicable.
a. Normative scores taken from in-house data of 60 controls.
b. Normative range for BMI.

10 Treatment Implications of the Case

Helens clinical symptoms improved after CREST with her BMI increasing from 15.5 to 16.2
(Figure 1). Table 2 illustrates her scores on the self-report measures described above pre- and
post CREST. It also provides the healthy control normative scores for each of these measures to
put Helens scores into context.
Illness-related symptoms improved with the global score of the EDE-Q decreasing from 2.7
to 2.1. To put this into context, the global score from a community sample of women is 1.5 (Fairburn & Beglin, 1994). Interestingly, Helens anxiety and depression worsened, moving from 0 to
2 and 2 to 5, respectively. This may reflect an underreporting at baseline. Helens baseline anxiety and depression scores were below the healthy control range, however, typically there is high
comorbidity with anxiety and depression in AN (Kaye et al., 2004). During the early sessions of
CREST, Helen discovered that she was not in touch with her emotions, using ED behaviors such
as excessive exercise to avoid emotions and food restriction to numb affect. Speculatively, identifying feelings associated with these mood states prior to CREST was more difficult for Helen
and she was better able to identify emotion states at a later stage.
Improvement in her ability to identify her emotions is supported by Helens lower TAS-20
score after CREST. Alexithymia is described as a difficulty in experiencing, describing, and
expressing emotion. At Time 2, Helen showed a small shift in being able to identify her feelings
better, albeit she had not moved into the healthy range. Our hypothesis for this improvement is
that Helen had a unique opportunity to use exercises, which helped to identify emotions with
support from her therapist. The describing feelings score on the TAS-20 remained the same after
CREST. In the reappraisal subscale of the ERQ, Helens score increased after CREST suggesting
that she was able to change her emotional responding. As well as changing the emotion itself,
reappraisal is often used to decrease an emotional response or it may be used to magnify the
emotional response. CREST has a particular focus on identifying and nurturing positive emotion
that has been shown to be attenuated in AN (Davies et al., 2010). The improved reappraisal score

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shown after CREST may reflect Helens ability to shift from negative to positive emotion as well
as enhance positive emotion.
Interestingly, the suppression score on the ERQ slightly increased after CREST. This may be
because Helen had become more aware of emotions and the methods she was using to avoid
them, such as suppression, hence the increased score post-CREST. The score on the EES
remained the same after CREST. One of the aims of CREST is to improve emotional expression
and indeed Helen describes how she had become more confident on the ward in relating her feelings to others. The same score at Time 2 on the EES may therefore be because of a sensitivity
issue pertaining to this questionnaire.
As well as demonstrating a positive change overall in the clinical and emotion processing
domains, Helen reported on the patient satisfaction questionnaire that she valued the usefulness
and positive aspect of the treatment as her score was above the average of 5. Helen also reported
an increased score in her ability to change on the motivational ruler following CREST. This may
reflect her confidence in her newfound skills and sense of achievement in completion of a course
of treatment. However, her score decreased in the importance to change category.

11 Recommendations to Clinicians and Students

This case study provides preliminary support for acceptability and effectiveness of CREST. This
treatment package appears to provide a platform for severely malnourished patients to start
thinking about and exploring emotions. Considering patients with AN are often difficult to
engage and retain in treatment, CREST has enabled Helen and many other patients to engage in
a simple, collaborative, and reflective psychoeducational intervention (Money, Genders, Treasure, Schmidt, & Tchanturia, IN PRESS).
After completing CREST, patients may be more aware of their own emotion-processing style
and how this impacts on their daily functioning. It is possible that after receiving this low-intensity intervention, patients will be more equipped and open to explore the nature and function of
the AN in ongoing psychological therapy and move toward recovery from this complex and lifethreatening illness.
CREST also provides an opportunity to establish a therapeutic relationship in the acute stage
of AN, which may positively influence engagement in further comprehensive psychological
therapy. With regards to CREST enabling engagement in psychological work, it would be interesting and important to conduct studies to explore outcomes of patients who have CREST before
more comprehensive psychological therapy in comparison with treatment as usual.
Undoubtedly, further work needs to be carried out to assess the therapeutic value of CREST.
Ideally, large-scale studies would be conducted across multiple sites to evaluate the intervention
and its generalizability.
In summary, this case study highlights support for the acceptability of CREST as an initial
intervention to facilitate engagement in emotional processing work before moving onto more
in-depth and complex psychological work.
Authors Note
The views expressed herein are those of the authors and not necessarily those of the NHS, the NIHR, or the
Department of Health.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication
of this article.

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Clinical Case Studies 10(2)

Funding
This report/article presents independent research commissioned by the National Institute for Health
Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1043). The
views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the
NIHR or the Department of Health.

Note
1. The Depression, Anxiety, and Stress Scale 21 is a short form of the 42-item measure. Therefore, when
the final score for each subscale is calculated, it is multiplied by 2.

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Bios
Claire Money is a chartered counseling psychologist working in a specialist inpatient eating disorders
service for the South London and Maudsley NHS Foundation Trust. Her work has involved delivering the
cognitive remediation and emotion skills training (CREST) intervention, and she is currently developing
and piloting a group format of CREST.
Helen Davies is a clinical researcher and PhD student at the Institute of Psychiatry, Kings College London.
The subject of her doctorate is emotion expression and regulation in eating disorders.
Kate Tchanturia is a lead clinical psychologist in the eating disorder service of the South London and
Maudsley NHS Foundation Trust and senior lecturer in eating disorders at the Institute of Psychiatry, Kings
College London. She is actively involved in research on cognition and emotion in eating disorder and the
translation of research findings into clinical practice.

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