Emotion regulation, emotion recognition, and empathy in adolescents with anorexia nervosa

Emotional Dysregulation in Anorexia Nervosa: Scoping Review of Psychological Treatments

Eating disorders are complex psychiatric disorders characterized by compensatory and restrictive behavior and a preoccupation with one's body. Eating and purging behaviors are considered dysfunctional emotional regulation strategies. Therefore, psychological treatment is essential. The most common psychological interventions are dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), family therapy (FBT), multi-family group therapy (MFTG) and mentalization-based treatment (MBT). The aim of this study was to summarize the current evidence on the impact of psychological treatments on emotional regulation difficulties and psychological symptoms in patients with eating disorders, especially anorexia nervosa. A search was conducted on PubMed and Web of Science using the terms "anorexia nervosa" and "emotion dysregulation". Of the 278 initial articles, we included 15 publications. The results indicate that the acquisition of coping strategies, through DBT, leads to an improvement in anxiety and alexithymia. DBT, CBT and MBT lead to a reduction in the use of dysfunctional emotional regulation strategies too. Eating disorders involve both physical and mental health; therefore, it is desirable for future research to focus on the mutual synergy between the mental and physical components by evaluating various factors, such as biomarkers and the most appropriate therapeutic approach, with respect to the treatment setting.

Cognitive and emotional empathy in acute and remitted anorexia nervosa: a systematic review

Background

Impairments in empathy are well established in anorexia nervosa (AN). It is unclear, however, whether these deficits only occur in the acute phases of AN due to neurocognitive impacts of starvation (often referred to as context-dependent, or state-like), or if deficits remain once remission has been achieved (trait-like). This debate is commonly referred to as the 'state vs trait' debate.

Objective

This systematic review aims to summarise existing literature regarding empathy in AN, and to investigate whether empathy deficits in AN are state- or trait-based.

Method

A total of 1014 articles were identified, and seven articles remained after the screening process. These seven articles, comparing empathy across three groups (acute AN, remission of AN, and non-clinical controls), were evaluated and summarised in accordance with PRISMA guidelines. Articles were required to have included all three groups and report on either cognitive empathy and/or emotional empathy.

Results

The majority of studies were of satisfactory quality. The results identified were inconsistent, with few articles lending some support to the 'state' hypothesis and others producing nonsignificant results.

Conclusions

There is minimal literature comparing empathy in acute and remission phases of AN. While there were some inconsistencies in included articles, some data indicate that there may be slight improvements to emotional and cognitive empathy following recovery of AN. Further research is needed to better enrich knowledge regarding the role of state vs trait with regard to neurocognitive difficulties experienced by individuals with AN.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=335669, identifier CRD42022335669.

Emotional reactivity and prosocial behaviour in response to witnessing social exclusion in adolescents with eating disorders and healthy controls

BACKGROUND

Prosocial behaviour can promote positive social interactions and it is a key skill in adolescence. People with emotional problems or psychiatric disorders, such as people with eating disorders might have impairments in prosocial behaviour, due to broader documented difficulties in underlying processes (e.g., mentalizing).

METHODS

The aim of this study was to examine prosocial behaviour in adolescents with eating disorders compared to healthy controls, using a computerised behavioural task. Adolescents (N = 123) including patients with eating disorders (n = 61) and healthy adolescents (n = 62) played a four-player computerised Prosocial Cyberball Game with three pre-programmed avatar players. During the task, participants witnessed the exclusion of one of the players, and subsequently had the opportunity to compensate for this by throwing the ball more often to the excluded player. Throughout the game, participants rated the level of negative emotion in themselves and in the excluded player.

RESULTS

Patients made significantly fewer ball tosses towards the excluded player during the compensation round compared to healthy controls (large effect size). Patients reported a significantly smaller increase in negative emotion after witnessing the exclusion and a significantly smaller decrease in negative emotion following the compensation round (large effect sizes). Patients also estimated a smaller decrease in negative emotion in the excluded player following the compensation round (medium effect size). There were no significant associations between these outcomes and eating disorder psychopathology in patients.

CONCLUSIONS

Compared to healthy adolescents, adolescent patients with eating disorders demonstrated less prosocial compensatory behaviour towards a computerised victim of social exclusion. In addition, they reported flatter negative emotion in themselves in response to witnessing and compensating for exclusion, and in the excluded player following compensation. If these findings are replicated, interventions to target these difficulties might contribute to improvements in social functioning in this patient group.

Emotion Regulation Deficits in Adolescent Girls with Major Depression, Anorexia Nervosa and Comorbid Major Depression and Anorexia Nervosa

In adolescence, both major depression (MD) and anorexia nervosa (AN) are associated with deficits in emotion regulation (ER). However, studies have yet to compare ER profiles within the disorders and the effect of comorbid MD+AN is unclear. This study examined the habitual use of ER in 229 girls, aged 12-18 years, with MD (n = 84), AN (n = 37), comorbid MD+AN (n = 25), and healthy girls (n = 83). Girls with MD, AN and MD+AN reported more maladaptive and less adaptive ER strategies than healthy girls. MD and MD+AN groups showed more frequent use of maladaptive ER compared to only AN, with no differences between only MD and MD+AN. This suggests that MD+AN is not necessarily associated with higher ER deficits, rather, an additional diagnosis of MD exacerbates impairments in AN. Identifying specific ER profiles can provide important targets in prevention and treatment for AN, MD and AN+MD.

The Mandarin Chinese auditory emotions stimulus database: A validated set of Chinese pseudo-sentences

Emotional prosody is fully embedded in language and can be influenced by the linguistic properties of a specific language. Considering the limitations of existing Chinese auditory stimulus database studies, we developed and validated an emotional auditory stimuli database composed of Chinese pseudo-sentences, recorded by six professional actors in Mandarin Chinese. Emotional expressions included happiness, sadness, anger, fear, disgust, pleasant surprise, and neutrality. All emotional categories were vocalized into two types of sentence patterns, declarative and interrogative. In addition, all emotional pseudo-sentences, except for neutral, were vocalized at two levels of emotional intensity: normal and strong. Each recording was validated with 40 native Chinese listeners in terms of the recognition accuracy of the intended emotion portrayal; finally, 4361 pseudo-sentence stimuli were included in the database. Validation of the database using a forced-choice recognition paradigm revealed high rates of emotional recognition accuracy. The detailed acoustic attributes of vocalization were provided and connected to the emotion recognition rates. This corpus could be a valuable resource for researchers and clinicians to explore the behavioral and neural mechanisms underlying emotion processing of the general population and emotional disturbances in neurological, psychiatric, and developmental disorders. The Mandarin Chinese auditory emotion stimulus database is available at the Open Science Framework ( https://osf.io/sfbm6/?view_only=e22a521e2a7d44c6b3343e11b88f39e3 ).

Novel ketamine and zinc treatment for anorexia nervosa and the potential beneficial interactions with the gut microbiome

Anorexia nervosa (AN) is a severe illness with diverse aetiological and maintaining contributors including neurobiological, metabolic, psychological, and social determining factors. In addition to nutritional recovery, multiple psychological and pharmacological therapies and brain-based stimulations have been explored; however, existing treatments have limited efficacy. This paper outlines a neurobiological model of glutamatergic and γ-aminobutyric acid (GABA)-ergic dysfunction, exacerbated by chronic gut microbiome dysbiosis and zinc depletion at a brain and gut level. The gut microbiome is established early in development, and early exposure to stress and adversity contribute to gut microbial disturbance in AN, early dysregulation to glutamatergic and GABAergic networks, interoceptive impairment, and inhibited caloric harvest from food (e.g., zinc malabsorption, competition for zinc ions between gut bacteria and host). Zinc is a key part of glutamatergic and GABAergic networks, and also affects leptin and gut microbial function; systems dysregulated in AN. Low doses of ketamine in conjunction with zinc, could provide an efficacious combination to act on NMDA receptors and normalise glutamatergic, GABAergic and gut function in AN.

Heart Rate as a Correlate for the Emotional Processing of Body Stimuli in Anorexia Nervosa

In anorexia nervosa, aberrant emotional reactions toward body stimuli have been discussed. We investigated heart rate as a physiological marker when viewing body stimuli and hypothesized altered HR reactions toward those highly significant and emotional stimuli in anorexia nervosa. In total, 37 anorexia nervosa patients and 43 control participants viewed pictures of women of five different weight categories, while their cardiac activity was recorded. R-R intervals following picture onset were determined, and means were calculated for three distinct time periods. The overall change in HR relative to baseline across all picture categories was greater in the patient group than in the control group (significant effect of “group”, p = 0.002, partial η2 = 0.120). A significant decrease in HR 2 to 8 s after picture presentation was found for pictures of women of extreme weight in both participant groups (significant “category ∗ time segment interaction”, p = 0.01, partial η2 = 0.037) and correlated with scores of sociocultural attitudes toward the appearance for the extremely underweight category (r = −0.33, p = 0.005). Therefore, differential HR reactions for anorexia nervosa patients and control participants were found for body stimuli in general. The highest HR decelerations in response to pictures of strongly underweight and overweight women may reflect emotional processes such as anxiety due to social comparison.

Affective cognition in eating disorders: a systematic review and meta-analysis of the performance on the "Reading the Mind in the Eyes" Test

BACKGROUND

The Reading the Mind in the Eyes Test (RMET) is listed in the National Institute of Mental Health's Research Domain Criteria as a tool apt to measure the understanding of others' mental states. People diagnosed with anorexia nervosa (AN) showed poorer performances on the RMET than healthy controls. Less data are available concerning other eating disorders.

METHODS

Systematic review of four major databases from inception to July 15, 2021 following the PRISMA guidelines. Meta-analysis of cross-sectional observational studies comparing the scores of the RMET between patients with eating disorders and age- and-gender matched control groups.

RESULTS

Out of 21 studies, we retrieved 29 independent samples of patients diagnosed with an eating disorder. Patients with active AN (n = 580) showed worse performances on the RMET than controls (n = 1019). Year of publication accounted for 61% of the (substantial: I² = 81%) heterogeneity in the meta-analysis. Earlier studies were more likely to find worse performances on the RMET of patients with active AN than later studies. Patients with bulimia nervosa (n = 185) performed poorly as compared to controls (n = 249), but the results were not statistically significant on the random-effect model. Obese patients with binge-eating disorder (n = 54) did not differ on the RMET from obese controls (n = 52). Patients with eating disorder not otherwise specified (n = 57) showed minimal differences compared to controls (n = 96). Study quality was good in six studies only.

CONCLUSIONS

Patients with eating disorders do not suffer from an impaired understanding of others' mental states, except for a still-to-be-identified subgroup of patients with active AN.

LEVEL OF EVIDENCE

I, systematic review and meta-analysis.

Family, friends, and feelings: the role of relationships to parents and peers and alexithymia in adolescents with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with impairments in socio-emotional functioning, including difficulties in interpersonal relationships as well as alexithymia (difficulties identifying and describing one's emotions). Although the onset of the disorder is mostly in adolescence, a developmental period in which interpersonal relationships to parents as well as peers undergo major changes, only few studies have investigated the quality of interpersonal relationships in adolescent AN patients. Furthermore, the mechanisms linking poor relationship quality to eating disorder psychopathology are not yet clarified, albeit some research suggests that alexithymia might play a pivotal role. The aims of the present study were investigating the quality of interpersonal relationships to parents and peers in adolescents with AN compared to healthy adolescents as well as exploring the mediating role of alexithymia in the association between relationship quality and eating disorder symptoms.

METHODS

Self-report questionnaires were used to assess relationship quality (Inventory of Parent and Peer Attachment) and alexithymia (Toronto Alexithymia Scale) in 12-18 year old female adolescents with AN (n = 35) in comparison to healthy adolescents (n = 40).

RESULTS

Adolescents with AN reported lower relationship quality to both of their parents and to peers compared to healthy controls. Relationship quality scores were negatively correlated to alexithymia as well as eating disorder symptoms. Alexithymia fully meditated the association between eating disorder symptoms and relationship quality to parents and partially mediated the association between eating disorder symptoms and relationship quality to peers.

CONCLUSION

The results indicate difficulties in interpersonal relationships among adolescents with AN and emphasize the role of peer relationships for adolescents' eating disorder psychopathology. Alexithymia seems to play an important role in explaining the link between quality of relationships and eating disorder psychopathology. Results suggest that treatment should not only focus on family relationships but also address relationships to peers as well as adolescents' competence in identifying and dealing with their emotions.

Experiences of parents and patients hospitalised in a child psychiatric unit for anorexia nervosa after reorganisation of care imposed by the COVID-19 Pandemic in France: a qualitative study-The QUALICOVID study

BACKGROUND

Anorexia nervosa is a serious, albeit common mental illness that generally occurs during adolescence. Although outpatient care is recommended, hospitalisation is sometimes required. There is a dedicated hospitalisation unit caring for children and adolescents presenting with anorexia nervosa in Nancy, France. However, on 16 March 2020, a national lockdown was declared by the French government as the COVID-19 pandemic escalated in France. This resulted in the adjustment of hospital admissions accompanied by premature discharge and an intensive outpatient care programme. In the light of such changes, consideration should be given to the potential impact of changes in the care pattern for anorexic patients and their parents. The purpose of our study was to explore the experiences of anorexia nervosa patients hospitalised in the unit, and their parents, following changes in the care strategy.

METHODS

The study was conducted between weeks four and eight after lockdown was announced. The study cohort included all the patients treated for anorexia nervosa and hospitalised in the treatment unit before 16 March 2020 and their parents. A qualitative method was used and every subject was offered a semi-structured interview. Data were analysed by means of inductive thematic analysis.

RESULTS

Seven superordinate themes were identified: positive aspects, concerns, preparation, loss of landmarks and hospital security, gradual return to a "normal" life, relational aspects and the likelihood of disease progression. Moreover, all the parents and patients were satisfied with the intensive outpatient care offered on discharge.

CONCLUSION

Despite initial ambivalence, all patients and their parents viewed this unexpected hospital discharge positively in these exceptional conditions. This suggests that restructuring the care programme could prove beneficial with increasing use of outpatient management, thereby reducing the length of the hospital stay and adjusting the return to school.

TRIAL REGISTRATION

ID-RCB 2020-A01101-38-This project was approved by the Comité de Protection des Personnes (CPP) Sud Méditerranée IV [South Mediterranean IV Ethics Committee (EC)] on 5 May 2020.

Disturbed families or families disturbed: a reconsideration

BACKGROUND

The relationship between anorexia nervosa (AN) and family disturbance has been a subject of debate since its first description. What began as a clear view of the pathologically disturbed family causing AN has become ever more complex over the decades.

OBJECTIVE

The aim of this review is to explore the literature to examine the changes and evolution of clinical opinion around family dysfunction and AN over the last 20 years.

METHODS

A narrative review of heterogeneous studies in peer-reviewed publications sourced from the major databases, including PubMed and ScienceDirect, to illuminate the topic of family distress and AN by highlighting the conflicting and complementary ways it has been studied.

RESULTS

This review has highlighted the complexity of the relationship between anorectic sufferers and their families. It has explored the literature about parental burden, emotions and cognitive mechanisms together with parental attitudes about weight and shape. It is clear that there is no consistent psycho-social pathology in families which has been shown to be causative. However, over the last twenty years, research has highlighted the distress and family dysfunction caused by having to look after an anoretic child with poor mentalisation skills, insecure attachment and emotion dysregulation.

CONCLUSION

The area has become clearer over the last 20 years; research suggests a bi-directional relationship between AN and family dysfunction, with difficult dynamics becoming entrenched within the family. This is best addressed, the consensus suggests, by specialist family therapy and carer skills interventions. Longitudinal research is needed to definitively answer the question with rigorous scientific certainty.

EMB RATING

Level V.

LEVEL OF EVIDENCE

Level I: Evidence obtained from: at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies. Level II: Evidence obtained from well-designed controlled trials without randomization. Level III: Evidence obtained from well-designed cohort or case-control analytic studies. Level IV: Evidence obtained from with multiple time series analysis such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Risk factors for binge eating severity among adolescent girls and boys. A structural equation modeling approach

OBJECTIVE

Parental bonding, low self-esteem, emotion dysregulation, and eating style are correlated with each other and are associated with binge eating among adolescents. However, no studies have yet examined all these variables simultaneously. In the current study, the independent and combined influences of such constructs on binge eating were tested with structural equation modeling.

METHOD

A sample of 973 students aged between 12 and 16 (M = 14.17, SD = 1.25) years was screened by means of self-report measures assessing parental bonding, self-esteem, emotion dysregulation, eating styles and binge eating severity.

RESULTS

Self-esteem (β = -0.205) and eating styles (emotional β = 0.313, external β = 0.133, and restrained β = 0.178) had a direct effect on binge eating severity. The model (χ²₍₂₂₎ = 57.679; RMSEA = 0.041; CFI = 0.987; TLI = 0.949; SRMR = 0.024) revealed that the paths from both maternal and paternal care and maternal overprotection to binge eating were mediated through low self-esteem, emotion dysregulation and each eating style, explaining 35% of the variance.

DISCUSSION

Findings provide support for a comprehensive theoretical-based model of risk factors for binge eating and suggest the possible mechanisms through which the quality of early parental relationships contribute to developing dysfunctional eating patterns. Treatment and prevention efforts should improve self-esteem and emphasize emotion regulation capabilities.

Xiaoyao Pill improves the Affective Dysregulation of Sleep-deprived Female Mice by inhibiting Brain Injury and regulating the Content of Monoamine Neurotransmitter

BACKGROUND

Sleep curtailment is a serious problem in many societies. Clinical evidence has shown that sleep deprivation is associated with mood dysregulation, formation of false memory, cardio-metabolic risk factors and outcomes, inflammatory disease risk, and all-cause mortality. The affective disorder dysregulation caused by insufficient sleep has become an increasingly serious health problem. However, to date, not much attention has been paid to the mild affective dysregulation caused by insufficient sleep, and there is no clear and standard therapeutic method to treat it. The Xiaoyao Pill is a classic Chinese medicinal formula, with the effect of dispersing stagnated hepatoqi, invigorating the spleen, and nourishing the blood. Therefore, it is most commonly used to treat gynecological diseases in China. In the present study, the effects of the Xiaoyao Pill on affective dysregulation of sleep-deprived mice and its underlying molecular mechanisms were investigated.

METHODS

Forty adult female mice were used in the present study. The sleep deprivation model was established by improving the multi-platform water environment method. After 7 consecutive days of sleep deprivation, the mice were administrated low (LXYP, 0.32mg/kg) and high (HXYP, 0.64 mg/kg) doses of the Xiaoyao Pill for two weeks. Then, the body weight, behavioral deficits, and histopathology were evaluated. Meanwhile, the expression of c-fos protein and the concentrations of monoamine neurotransmitters in the hippocampus and prefrontal cortex were determined after two weeks of treatment.

RESULTS

Xiaoyao Pill treatment significantly increased body weight and sucrose consumption and decreased the irritability scores of the sleep-deprived mice. Meanwhile, Xiaoyao Pill treatment prevented brain injury and inhibited the expression of c-fos protein in the hippocampus and prefrontal cortex. In addition, HXYP treatment significantly upregulated the levels of NE in the hippocampus and prefrontal cortex (p < 0.01). LXYP treatment significantly up-regulated the levels of 5-HT in the prefrontal cortex. Meanwhile, both HXYP and LXYP treatment significantly up-regulated the levels of DA in the prefrontal cortex (p < 0.05 or p < 0.01) of sleep-deprived mice.

CONCLUSIONS

The present study demonstrates that Xiaoyao Pill treatment prevented the behavioral deficits of mice induced by sleep deprivation by promoting the recovery of brain tissue injury and up-regulating the levels of NE, 5-HT, and DA in the brain tissue.

Construct validity of the Levels of Emotional Awareness Scale among women high in eating disorder symptoms: a cross-sectional study

PURPOSE

The Levels of Emotional Awareness Scale (LEAS), a measure of the ability to identify and describe one's own and others' emotions, may complement work with women with disordered eating symptoms. The study purpose was to (a) examine differences in hand (LEAS) versus computerized (e-LEAS) scoring methods and (b) examine the e-LEAS' psychometric properties, including convergent and discriminant validity, among women endorsing eating disorder symptoms.

METHODS

Forty women (ages 18-21) scoring high on a self-report measure of disordered eating symptoms completed the LEAS and measures of convergent validity including a self-report measure of alexithymia (the perceived ability to identify and describe one's own emotions) and a measure of facial affect recognition as well as discriminant validity, including affect and facial memory. Inter-rater reliability was assessed via a two-way mixed effects model and correlations between the LEAS and the study constructs were examined.

RESULTS

Computerized scoring (e-LEAS) offered benefits over hand scoring and correlations between LEAS and e-LEAS were statistically significant. Better total emotional awareness scores on the e-LEAS were significantly associated with more perceived difficulty identifying and describing emotions. Better total emotional awareness scores were also significantly associated with better facial memory and greater depression scores. The e-LEAS showed weak associations with facial affect recognition.

CONCLUSION

The e-LEAS offers practical advantages over the LEAS in the assessment of emotional awareness among women endorsing eating disorder symptoms. Results suggest that the e-LEAS measures the ability to describe emotional experiences in oneself and others, but not facial affect recognition.

LEVEL OF EVIDENCE

Level V: Evidence obtained from a cross-sectional descriptive study.

Characteristics of autism spectrum disorders are associated with longer duration of anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

Anorexia nervosa (AN) is associated with neuropsychological characteristics such as impairments in central coherence, cognitive flexibility, and emotion recognition. The same features also manifest in autism spectrum disorders (ASD) and have been suggested to be associated with illness prolongation in AN. The purpose of this meta-analysis was to examine whether pronounced neuropsychological characteristics related to ASD are associated with illness duration in AN.

METHOD

Four databases (Medline, PsycINFO, Scopus, PubMed) were searched for eligible studies. Search terms were (a) "anorexia nervosa" and (b) "cognitive flexibility" or "set-shifting" or "central coherence" or "emotion recognition" or "theory of mind". The final sample consisted of 53 studies. Duration of AN was divided into three categories in order to investigate differences between the groups with varying illness duration. The meta-analysis was performed with Review Manager using a random-effects model.

RESULTS

Deficits in central coherence, cognitive flexibility, and emotion recognition were pronounced among individuals with prolonged AN compared to those with shorter illness duration.

DISCUSSION

A prolonged course of AN appears to be associated with underlying neuropsychological characteristics that are also distinctive to ASD. Neuropsychological impairments may lead to prolonged AN, and prolonged illness may contribute to the subsequent "neurological scar effect," further strengthening these impairments.

Improving emotion recognition in anorexia nervosa: An experimental proof-of-concept study

OBJECTIVE

Previous research has found increasing evidence for difficulties in emotion recognition ability (ERA) and social cognition in anorexia nervosa (AN), and recent models consider these factors to contribute to the development and maintenance of the disorder. However, there is a lack of experimental studies testing this hypothesis. Therefore, the present proof-of-concept study examined whether ERA can be improved by a single session of a computerized training in AN, and whether this has short-term effects on eating disorder symptoms.

METHOD

Forty inpatients (22.20 ± 7.15 years) with AN were randomly assigned to receive a single session of computerized training of ERA (TERA) or a sham training (training the recognition of different types of clouds). ERA, self-reported eating disorder symptoms, and body mass index (BMI) were assessed within 3 days before and after training.

RESULTS

After training, both groups showed improved ERA, reduced self-reported eating disorder symptoms, and an increased BMI. As compared to patients in the control group, patients who received TERA showed greater improvements in ERA and self-reported eating disorder symptoms.

DISCUSSION

ERA can be effectively trained in patients with AN. Moreover, short-term improvements in self-reported eating disorder symptoms provide tentative support for the hypothesis that difficulties in ERA contribute to the maintenance of AN, and that specific trainings of ERA hold promise as an additional component in AN treatment. Future studies are needed to replicate these findings in larger samples, and to investigate long-term effects and transfer into real-world settings.

Adapted emotion skills training group for young people with anorexia nervosa : A mixed-methods evaluation

BACKGROUND

Brief interventions focused on emotion processing are needed to support young people (YP) in inpatient treatment programmes to manage emotions. Cognitive Remediation and Emotion Skills Training (CREST) has been found beneficial in adult anorexia nervosa (AN) groups. An initial case series found that CREST is a feasible intervention for YP with AN. Further age-appropriate adaptations were needed to improve YP's engagement. Following qualitative feedback on the original CREST manual, a second case series was conducted in an inpatient unit with age-appropriate adaptations to evaluate its feasibility in a YP inpatient setting.

METHODS

A mixed-methods methodology was used to evaluate the intervention. A total of 30 YP were asked to write a feedback letter about their experience of the group and to complete the Emotion Skills Scale (ESS), an ad hoc 12-item self-report Likert scale assessing emotional functioning. The ESS was also completed by a member of the multidisciplinary team for an external assessment.

RESULTS

Quantitative results showed no statistically significant changes in YP's emotional functioning, while qualitative results 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. Four high-order themes were identified: Helpfulness of CREST Group for Young People (CREST-GYP), Perception of contents, Challenges of group therapy, Suggestions for improvement.

CONCLUSIONS

Pilot findings suggest that CREST-GYP is an acceptable intervention for YP with AN. Clinical and research studies are needed to clarify whether CREST-GYP can produce more beneficial treatment results than treatment as usual.