Introduction
Anorexia nervosa (AN) is a severe mental disorder with high levels of disability and mortality. Peak onset occurs during the ages of 15–25, i.e. onset spans adolescence into adulthood. Illness duration is a key predictor of poor outcome (Steinhausen, Reference Steinhausen2002). Converging data support the idea that neurobiological changes alter the trajectory of illness (Gama et al., Reference Gama, Kunz, Magalhaes and Kapczinski2013; Moylan et al., Reference Moylan, Maes, Wray and Berk2013; O’Hara et al., Reference O’Hara, Campbell and Schmidt2015; Steinglass and Walsh, Reference Steinglass and Walsh2016). Evidence suggests that early stage AN can be defined as <3 years illness duration, beyond which the treatment response is significantly poorer (Treasure et al., Reference Treasure, Stein and Maguire2015).
Early stage AN typically presents during emerging adulthood, i.e. age 18–25 years. Neurodevelopmental changes include a frontolimbic fine tuning, promoting adult functions through balancing pre-frontal sub-regions involved in modulating approach and avoidance (Taber-Thomas and Perez-Edgar, Reference Taber-Thomas, Perez-Edgar and Arnett2016). This is a developmental stage characterized by risk taking, identity exploration and self-focus, just like adolescence (Arnett, Reference Arnett2000; Taber-Thomas and Perez-Edgar, Reference Taber-Thomas, Perez-Edgar and Arnett2016). However, in contrast to adolescents, emerging adults face multiple uncertainties and transitions (Schwartz et al., Reference Schwartz, Zamboanga, Luyckx, Meca and Ritchie2013; Arnett et al., Reference Arnett, Zukauskiene and Sugimura2014), e.g. within relationships and friendship groups, ending school, starting further education and developing a career. Whilst some individuals with a severe eating disorder (ED) may be impeded in making these transitions due to the illness, many others leave home for the first time and are thus separated from established supports. Of key significance to AN, this has implications for nutrition, help-seeking, and who is involved in treatment. For example, one recent study found that emerging adults with an ED have a duration of untreated illness which is on average 30% longer than that of adolescents below age 18, as they have less parental support (Weigel et al., Reference Weigel, Rossi, Wendt, Nebauer, von Rad, Daubmann, Romer, Löwe and Gumz2014).
In terms of identity development emerging adults for the first time have the legal independence and financial means to explore this. Questions such as ‘who am I’, ‘what do I value?’ and ‘who do I want to become?’ are often at the forefront (Schwartz et al., Reference Schwartz, Zamboanga, Luyckx, Meca and Ritchie2013). Whilst such challenges likely makes this life stage a vulnerable time for all young people with mental health problems, these struggles may be particularly salient in anorexia given the ego-syntonic nature of the illness (Schmidt and Treasure, Reference Schmidt and Treasure2006; Gregertsen et al., Reference Gregertsen, Mandy and Serpell2017). As aspects of AN are often highly valued by sufferers, during early adulthood there is a risk that healthy identity formation may be undermined in favour of illness-driven values and beliefs, which can later impact relationships, interests and career choices. Indeed, research has shown that AN erodes and alters patients’ values, with utmost importance placed on thinness and other aspects of life diminishing in importance and ultimately becoming valueless (Tan et al., Reference Tan, Hope, Stewart and Fitzpatrick2006; Weigel et al., Reference Weigel, Rossi, Wendt, Nebauer, von Rad, Daubmann, Romer, Löwe and Gumz2014).
Together, these features make emerging adults with early stage AN particularly vulnerable. Thus, any treatment for adults with early stage illness needs to be tailored to this developmental stage.
The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) (Schmidt et al., Reference Schmidt, Wade and Treasure2014) is a National Institute for Health and Care Excellence (NICE, 2017) recommended outpatient therapy for adults with AN. It is formulation-based, aims to tackle a range of intra- and interpersonal maintaining factors, and is centred on a patient manual (Schmidt et al., Reference Schmidt, Wade and Treasure2014). MANTRA lends itself well to addressing these issues with emerging adults, as the approach considers valued aspects of the illness and pro-anorexia beliefs to be a key maintenance factor. In the early stages of treatment this is addressed via motivational interviewing techniques, exercises that externalize anorexia as separate from the person’s identity, and exploration of the values that guide illness behaviour and how these may conflict with values of the healthy self. Towards the latter half of therapy and during follow-up, sessions focus on helping the individual build up a new identity separate from anorexia (Schmidt et al., Reference Schmidt, Wade and Treasure2014). Aspects include discussion of the impact of anorexia on identity, exploration of a ‘best possible’ self, including the qualities, values, struggles and coping skills of admired others, and using role models and behavioural experiments to practise living a new identity.
This paper aims to describe a single case study of the treatment of an 18-year-old female with recent onset anorexia nervosa. Using MANTRA, an early focus was placed on the role of healthy identity development in order to shift illness-driven values and pro-anorexia beliefs.
Presenting problem
Becky was an 18-year-old female who was referred to an adult Eating Disorders Service for difficulties with restrictive eating, weight loss and excessive exercise. Becky had a pre-existing diagnosis of anorexia nervosa (restrictive subtype) and had previously been seen within Child and Adolescent Mental Health Services (CAMHS), where she had received a 6-month course of family therapy.
When Becky was referred to the adult eating disorder service she had made some good progress with weight restoration in CAMHS, from a body mass index (BMI) of 15.5 at initial presentation in December 2015, to a BMI of 17 in July 2016. With the support of her parents she had been adhering to a re-feeding meal plan and weight gain had been steady over the course of treatment with some reduction in excessive exercise. At time of referral Becky was largely taking full responsibility for the planning and preparation of her meals with significantly less parental involvement. Despite her progress in these domains however, Becky continued to experience perfectionistic thinking in many areas of her life, significant rigidity around her eating routines, and impaired social relationships. She also described a narrowing of interests and struggled to identify any enjoyable activities that were not related to exercise.
Becky reported that her AN onset at age 16 when she was studying for her end of school exams. In the year previously she reported several stressors including feeling ostracized from her peer group due to bullying, and familial difficulties after her sister was diagnosed with obsessive compulsive disorder. During the period leading up to exams Becky described following an increasingly rigid and restrictive eating pattern, spending excessive amounts of time studying, and filling any free time with walking. She reported feeling increasingly isolated and low in mood, and following results day when she did not obtain the grades hoped for, described a strong sense that the only thing important in her life was AN. Becky identified strong valued aspects of AN including beliefs such as ‘AN makes me a better person’, and ‘AN prevents me from making mistakes’.
Assessment measures
Alongside clinical interview, Becky completed the Eating Disorder Examination questionnaire (EDE-Q; Fairburn and Beglin, Reference Fairburn and Beglin1994), and Clinical Outcomes in Routine Evaluation – Outcome Measure 10 (CORE-10; Connell and Barkham, Reference Connell and Barkham2007). The results suggested that she was experiencing significant symptoms of an ED together with a moderate level of psychological distress [above the suggested clinical cut-off for caseness; see Mond et al. (Reference Mond, Hay, Rodgers and Owen2006) and Connell and Barkham (Reference Connell and Barkham2007), respectively]. A summary of these scores is provided in Table 1.
Table 1. Summary of scores on self-report outcome measures at initial assessment and final follow-up
Treatment goals
Becky identified her primary treatment goal as building up a bigger life than the one AN had allowed for, with the ultimate aim of being well enough to go to university. This was a strong motivator for Becky, along with the desire to improve her physical health, e.g. protect bone density and have menstruation resume. Becky identified that to be able to make the most of university life she would like to be more flexible with her eating and able to be spontaneous with decision making. She also identified a desire to be less self-critical and fearful of making mistakes.
Case conceptualization
A MANTRA informed formulation (Schmidt et al., Reference Schmidt, Wade and Treasure2014) was developed collaboratively during sessions 4–6. Key maintaining factors of Becky’s eating difficulties were identified as pro-AN beliefs (e.g. ‘AN makes me a better person’), a detail focus and inflexible thinking style, fear of making mistakes, high self-criticism and unrelenting standards, and difficulties with anxiety and tolerating uncertainty. Becky engaged well with the MANTRA model, spending lots of time completing sections of the formulation in further detail for homework. Becky described finding it a helpful exercise to gain clarity over areas in which she continued to feel stuck, as well as supporting a bigger picture perspective of her eating difficulties. A reformulation letter was also written and presented to Becky at session 6.
Course of therapy
Becky completed 30 individual sessions of MANTRA plus three dietician sessions. The follow-up period was extended for 5 months to support transition to university.
Initial sessions (1–3) focused on motivational exercises that externalized AN and developed the idea of a ‘healthy me’, narrative letters considering what life might be like in the future without AN present, and exploration of valued aspects of the illness. Content of these exercises was used to gather information for Becky’s formulation and this was developed collaboratively during sessions 4–6. Throughout sessions 1–6, psychoeducation was used where appropriate alongside the weekly setting of small dietetic goals.
After taking stock at session 6 to design the rest of Becky’s treatment, she elected to begin working on the Thinking Styles chapter of MANTRA first due to prominent difficulties in this domain. Becky’s formulation revealed a highly detail-focused and inflexible cognitive style that impacted negatively on various life domains, including a rigid eating pattern focused on numbers (e.g. calorie counting, weighing and measuring foods), compulsive exercise (step counting), high levels of anxiety if plans were changed at the last minute, and excessive amounts of time spent on menial day-to-day tasks. This often led to her feeling overwhelmed and ‘unable to see the forest for the trees’, a difficulty that she also described as impairing socially and academically, e.g. Becky felt she achieved lower grades than expected as during one exam she felt unable to move on to the next question for repeatedly checking and correcting answers for small grammatical errors. Sessions 7–10 focused on a series of behavioural experiments to increase flexibility and bigger picture thinking, initially in the domains of work and social life, with support to apply this learning to eating and exercise-related behaviours.
At this time Becky’s weight began to plateau and she described struggling to make behavioural changes. Although she continued to attend sessions at this time and therapeutic alliance was considered positive, the therapist began to feel that Becky was ‘going through the motions’ with regard to completion of homework tasks (perhaps in part to be perceived as a ‘good student’), and struggled to use exercises within the Thinking Styles chapter to move forwards. On reflection of this with Becky, the main difficulties she described were feeling highly fused to valued aspects of anorexia and unable to imagine how change might lead to a better life. Questions such as, ‘who will I be without anorexia?’ were also raised, leading her to feel increasingly ambivalent about continuing with treatment.
Given that difficulties with identity formation and pro-AN beliefs were considered to be a primary barrier to further progress, following a further review at session 10 it was agreed that a change in focus towards identity exploration may be beneficial. This next phase of treatment encouraged discussion about the current emphasis Becky placed on eating-disordered behaviours at the expense of other areas of life, and a series of exercises designed to help explore her best self were completed during sessions 11–16. Becky described finding it particularly useful to centre discussions on the idea of role models, to bring to life abstract ideas and concepts, allowing them to feel more tangible. She was encouraged to choose individuals she knew personally and/or famous figures and identify the personal qualities, strengths and values of those she admired. Also considered were the real or imagined struggles and unique coping strategies of her role model, an exercise which she cited as particularly powerful in shifting the idea that only an eating disorder could be relied upon in times of adversity.
To complete these exercises Becky chose to elect Nadiya Hussain, winner of the 2015 TV show The Great British Bake Off, as her role model. Nadiya was regarded positively by Becky for her optimism and humour in the face of mistakes and adversity, her eye for detail, and concurrent ability to re-focus on things that were of bigger picture importance. Becky also admired Nadiya’s compassionate responses towards others when they were struggling, her emotional openness, and her family-orientated values; and, importantly, her passion for delicious food and unapologetic enjoyment of a slice of cake.
This piece of work was considered to be a turning point for Becky, and paved the way to a lived experiment of embodying a different self. In the following sessions, identity exploration was encouraged more actively, with Becky partaking in a series of small behavioural experiments to begin ‘road testing’ these new ways of being, whilst holding in mind her role model to guide her. Experiments were initially conducted at work and in social situations, and after building confidence, were expanded to eating and exercise behaviours. Sessions 20 onwards prompted a return to previous work on thinking styles, this time with continued use of Becky’s chosen role model to provide guidance. For example, when planning to experiment with being spontaneous or reducing perfectionism, she found that asking ‘what would Nadiya do in this situation?’ helped to support behavioural change. Towards the latter part of therapy (sessions 25–30), this framework was also applied to work on emotional expression and enhancing self-compassion. Follow-up sessions were used to work on developing a staying well and relapse prevention plan, together with a ‘healthy me’ recovery-orientated formulation. Continued reflection on Becky’s experiences of road testing her ‘best self’ was encouraged during the transition to university, with focus on consolidating new skills and behaviours.
Outcomes
The results of key outcome measures at initial assessment and follow-up are outlined in Table 1. Unfortunately mid- and end-of treatment EDE-Q or CORE-10 scores were not obtained. Becky’s Global EDE-Q scores reduced from 4.5 at initial assessment, to 0.5 at 5-month follow-up. In context, community norms for young adult women (aged 18–22 years) are reported to be 1.52, with a suggested clinical cut-off of 2.3 (Mond et al., Reference Mond, Hay, Rodgers and Owen2006). This suggests that Becky experienced significant reduction in ED symptoms with low scores relative to individuals in her age group post-treatment. Improvements on the CORE-10 were also seen, with a reduction from 19 at assessment, to 4 at follow-up. By comparison, a score of 10 or above denotes clinical range, <10 ‘low level’ distress, and <5 as ‘healthy’ (Connell and Barkham, Reference Connell and Barkham2007). In addition, Becky’s BMI increased from 17 at assessment, to 20.5 at 1-month follow-up, which was consistently maintained through to 5-month follow-up.
Becky gave the following written feedback of her treatment:
‘The Identity chapter was the most helpful chapter for me. This is because it helped me to finally make up my mind that recovery was what I truly wanted and life became “good” again. I started by reflecting on who I wanted to be by listing all the features that my “best possible self” would have … I then thought about some inspirational individuals and explored why one in particular inspired me, Nadiya Hussain from The Great British Bake off … with the support of my therapist, I conducted a “Nadiya experiment” – living like Nadiya for a week. That week, I stopped letting my anxieties and perceptions of criticism worm away at me. I stayed confident in that I was helping others to the best of my abilities and embraced that it was okay to be different. I dared to try out new activities. In stressful situations, I remained calm, was able to practise bigger picture thinking more easily and laughed off the worries. All in all, I stayed smiling and found myself enjoying life more and getting so much more out of it. Letting go of some of my rigid safety behaviours and viewing things with a different perspective had made me happier and had also had a positive influence in my relationships with others. These experiments taught me the important lesson that there is more than one way to live life and I could choose what kind of life that would be.’
Discussion
This case study offers an illustration of how to incorporate identity exploration and development in the treatment of early stage AN, as a tool to reduce the dominance of illness-driven values and beliefs and increase recovery focus. There was significant improvement in ED symptoms, BMI and psychological distress over the course of treatment, which were sustained during extended follow-up throughout Becky’s transition to university, suggesting an enduring treatment effect. Furthermore, Becky provided detailed positive feedback of her treatment experience, suggesting that this was a highly acceptable and effective intervention.
Becky’s eating disorder developed during late adolescence following a series of stressors. At 18, she was navigating many of the challenges characterized by emerging adulthood (Schwartz et al., Reference Schwartz, Zamboanga, Luyckx, Meca and Ritchie2013; Arnett et al., Reference Arnett, Zukauskiene and Sugimura2014), with uncertainties within friendship groups, ending school, deciding upon a career path and starting further education. As described, Becky engaged well with the initial phase of treatment before progress began to plateau, motivation to change diminished, and she began to feel increasingly stuck. This is not an uncommon experience in the treatment of AN, and many individuals struggle to achieve full recovery, drop out of treatment prematurely, or relapse (Carter et al., Reference Carter, Blackmore, Sutandar-Pinnock and Woodside2004; Wallier et al., Reference Wallier, Vibert, Berthoz, Huas, Hubert and Godart2009). Whilst the ego-syntonic nature of AN and reluctance to let go of perceived valued aspects of the disorder may present as a key barrier for individuals at any stage of illness (Gregertsen et al., Reference Gregertsen, Mandy and Serpell2017), it is possible that this issue is particularly relevant during emerging adulthood when issues related to identity and the sense of self are at the forefront. In this case, Becky clearly cited pro-anorexia values and beliefs as a key barrier to making further behavioural changes, and she struggled to connect to the work on shifting thinking styles for fear of the person she may become should she change.
The shift towards work on identity, specifically the use of role models in constructing an alternative, non-illness-driven set of values, beliefs and coping styles, was considered pivotal in addressing these difficulties. In the process of asking, ‘who am I and what can I be?’ young adults not only analyse themselves but also frequently look to others for guidance. This process of observation and behavioural modelling occurs from a young age, and was originally conceptualized by Social Learning Theory (Bandura, Reference Bandura1977). However, in later life too, role models are thought to contribute significantly to identity formation by way of modelling desired skills and behaviours, representing what is possible or achievable, and providing inspiration and motivation for change (Morgenroth et al., Reference Morgenroth, Ryan and Peters2015). Use of role models in this way within therapy appeared to challenge some of Becky’s rigid thinking and behaviour patterns by providing a real-life alternative way of operating in the world and overcoming problems, which she was later able to begin emulating and testing out for herself. The exercises used also seemed to make concrete some of the more abstract ideas and concepts from the Thinking Styles chapter of the MANTRA manual, allowing them to feel more personally meaningful to her, which in turn also facilitated engagement.
It is worthwhile acknowledging that in this case Becky’s chosen role model was a well-known TV celebrity, therefore making it easier for the therapist to also generate a sense of the individual’s character. This may not always be the case when undertaking identity work, and therapists should encourage patients to consider in as much detail as is possible the positive qualities, strengths and other admired characteristics of chosen role models, as well as their (real or imagined) values and struggles. It is also important that the therapist is cautious of role models chosen for solely illness-related reasons (e.g. appearance or eating behaviours), and that the tasks support the development of healthy, non-illness-driven values. Furthermore, where a role model is chosen for only one specific characteristic this may only have limited usefulness. In these cases, consideration of multiple role models should be encouraged.
With regard to limitations, as with other case studies it is difficult to determine specific causation. It may be an oversimplification to attribute change in this case to a single aspect of treatment targeting identity development and exploration. The MANTRA approach is also based on motivational principles and theory, and a motivational clinician stance underlies the treatment ethos. It may be that Becky’s readiness to change status shifted throughout the course of treatment due to external factors (e.g. her upcoming transition to university). Unfortunately, outcome measures other than BMI were not obtained during the course of treatment, which could have provided further details about the process of change; however, Becky clearly attributed the work on identity exploration as being most helpful in her written feedback.
Other considerations may include the fact that Becky was also prescribed an anti-depressant medication, which may have contributed to her improvement. However, this is unlikely to be attributable to the total effect as her prescribed dosage remained constant throughout therapy, and there is little evidence that medication alone is effective in the treatment of AN (NICE, 2017). The input of other members of the multidisciplinary team is also important – Becky met with a specialist dietitian within the service for three sessions over the course of her therapy, who reinforced messages about the importance of continuing with treatment and did not contradict what was covered in therapy sessions. Similarly, Becky lived at home and her family were also significant in supporting her recovery, although she reported they had taken a less active role since ending family therapy in CAMHS and being transferred to adult services.
Acknowledgements
The authors would like to sincerely thank Becky for her consent to publish her treatment journey.
Financial support
Ulrike Schmidt is supported by a National Institute of Health Research (NIHR) Senior Investigator Award and receives salary support from the NIHR Mental Health Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Conflicts of interest
Antonia Koskina has no conflicts of interest with respect to this publication. Ulrike Schmidt is a developer of MANTRA.
Ethical statement
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the APA. Ethical approval was not sought as this is a single case study. However, the patient gave her written consent to the publication of this case study.
Key practice points
(1) To gain knowledge of the unique challenges faced by individuals with early stage anorexia during the period of emerging adulthood.
(2) To demonstrate how the treatment of anorexia nervosa can be tailored to meet the needs of this unique developmental stage.
(3) To illustrate the use of identity exploration and development to increase recovery focus in young adults with early stage anorexia nervosa.
(4) To support clinicians working in eating disorders in gaining insight as to the practical applications of using MANTRA, a relatively new NICE recommended treatment for anorexia nervosa.
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