The Cognitive Behaviour Therapist (2019), vol.

12, e32, page 1 of 8

doi:10.1017/S1754470X19000187

CASE STUDY

Who am I without anorexia? Identity exploration in the

treatment of early stage anorexia nervosa during
emerging adulthood: a case study
A. Koskina1,* and U. Schmidt1,2
1
Maudsley Eating Disorders Service, Maudsley Hospital, London, UK and 2Institute of Psychiatry, Psychology &
Neuroscience, King’s College London, London, UK
*Corresponding author. Email: antonia.koskina@huttvalleydhb.org.nz

(Received 16 January 2019; revised 22 April 2019; accepted 23 April 2019)

Abstract
Emerging adulthood (age 18–25 years) is a distinct developmental phase, characterized by multiple life
changes, transitions and uncertainties, associated with significant risk of mental ill health in vulnerable
individuals. Identity exploration and development is key during this phase, and the development of an
eating disorder during this time can significantly impact on this process. This single-case study details
the treatment of an 18-year-old female outpatient with first episode, recent onset anorexia nervosa.
Using the Maudsley Model of Anorexia Nervosa Treatment in Adults (MANTRA), focus was placed
on identity exploration and development as a tool to reduce the dominance of anorexia nervosa and
increase recovery focus. Outcome measures at end of treatment and 6-month follow-up showed significant
sustained improvement in BMI and EDE-Q scores. The patient gave detailed positive feedback suggesting
that this was a highly acceptable and effective intervention. The case study is discussed with reference to
limitations and some reflections on the utility of incorporating identity work in the treatment of anorexia
nervosa in emerging adulthood.

Key learning aims

(1) This case study is thought to have important clinical implications for tailoring the treatment of
early stage AN to the emerging adult population.
(2) Identity exploration is a key feature of this developmental stage, and incorporating this work into
therapy allows for experimentation and formation of an alternative, healthy set of values, beliefs
and behaviours.
(3) This case also highlights the value of using role models in the construction of a non-illness driven
identity, to support with behavioural change.

Key words: anorexia nervosa; case study; identity; emerging adulthood; MANTRA

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, 2002). Converging data support the idea that
neurobiological changes alter the trajectory of illness (Gama et al., 2013; Moylan et al., 2013;
O’Hara et al., 2015; Steinglass and Walsh, 2016). 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., 2015).
© British Association for Behavioural and Cognitive Psychotherapies 2019

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 2 A. Koskina and U. Schmidt

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, 2016). This is a developmental stage characterized by risk
taking, identity exploration and self-focus, just like adolescence (Arnett, 2000; Taber-Thomas
and Perez-Edgar, 2016). However, in contrast to adolescents, emerging adults face multiple
uncertainties and transitions (Schwartz et al., 2013; Arnett et al., 2014), 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., 2014).
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., 2013). 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, 2006; Gregertsen et al., 2017). 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., 2006; Weigel et al., 2014).
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.,
2014) 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., 2014). 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., 2014). 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.
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 The Cognitive Behaviour Therapist 3

Table 1. Summary of scores on self-report outcome measures at initial assessment and final
follow-up

Measure Initial assessment Final follow-up

EDE-Q global score 4.5 0.5

Restraint 5.4 0.4
Eating concern 2.8 0.4
Weight concern 4.6 0.2
Shape concern 4.9 0.9
CORE-10 19 4

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, 1994), and Clinical Outcomes in Routine Evaluation –
Outcome Measure 10 (CORE-10; Connell and Barkham, 2007). 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. (2006) and Connell and
Barkham (2007), respectively]. A summary of these scores is provided in Table 1.

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., 2014) was developed collaboratively during
sessions 4–6. Key maintaining factors of Becky’s eating difficulties were identified as pro-AN
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 4 A. Koskina and U. Schmidt

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.
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 The Cognitive Behaviour Therapist 5

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., 2006). 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, 2007). 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.’
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 6 A. Koskina and U. Schmidt

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.,
2013; Arnett et al., 2014), 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., 2004; Wallier et al., 2009). 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., 2017), 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, 1977). 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., 2015). 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

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 The Cognitive Behaviour Therapist 7

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.

Further reading
Arnett, J. J., Zukauskiene, R., & Sugimura, K. (2014). The new life stage of emerging adulthood at ages 18–29 years:
implications for mental health. Lancet Psychiatry, 1, 569–576.
Schmidt, U., Wade, T. D., & Treasure, J. (2014). The Maudsley model of anorexia nervosa treatment for adults (MANTRA):
development, key features, and preliminary evidence. Journal of Cognitive Psychotherapy, 28, 48–71.

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Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ, USA: Prentice Hall.

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Cite this article: Koskina A and Schmidt U. Who am I without anorexia? Identity exploration in the treatment of early stage
anorexia nervosa during emerging adulthood: a case study. The Cognitive Behaviour Therapist. https://doi.org/10.1017/
S1754470X19000187

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