Cognitive Remediation Therapy for Anorexia Nervosa:Current Evidence and Future Research Directions

Kate Tchanturia, PhD*Samantha Lloyd, MScKatie Lang, MSc

VVC 2013 by Wiley Periodicals, Inc.

(Int J Eat Disord 2013; 46:492–495)

The Need for New Ideas in theTreatment of Anorexia Nervosa

The effective treatment of anorexia nervosa (AN)remains a significant challenge. This had promptednew research into ways of engaging and keepingpatients in treatment, and ultimately achieving bet-ter outcomes, not only on a symptomatic level butalso in broader aspects of life.1 In an attempt toimprove treatment outcomes for AN, there hasbeen a move toward approaches that target thecore maintaining factors of the disorder. Impairedcognition has been implicated in the maintenanceof AN, contributing to individuals’ difficulties inprocessing and in engaging with psychologicaltherapy. An established body of existing research(including both systematic reviews and large sam-ple studies) currently highlights two main areasof difficulty—cognitive flexibility (particularly set-shifting difficulties) and an extreme attention todetail (or weak central coherence).2 Both inflexibil-ity and an overly detail-focused way of thinkingare prevalent in adults with AN, and appear to beexaggerated in the acute stage of the illness.3

Translation of NeurocognitiveResearch into Treatment: CognitiveRemediation Therapy

Behavioral correlates of cognitive inflexibility canbe seen clinically in patients’ fixation with cer-tain behaviors or routines (e.g., specific rulesand ritualized eating behaviors at meal times).Furthermore, a rigid thinking style can havenegative consequences on patients’ interactionswith the outside world and their ability toorganize information. Unsurprisingly, this cogni-tive style poses challenges for the treatment ofadults with AN. Extreme focus on detail andrelated behaviors (e.g., calorie counting, exercise,and obsessional rituals) and resistance to changeeach negatively impact upon engagement.

The way an individual processes information iscrucially important to how they make sense of sit-uations in their environment. Both an extremefocus upon detail and limited flexibility can impairsocial interactions. Therefore, before attempting tochange strategies and behaviors, it is important toencourage patients to develop an awareness oftheir thinking style. Research findings relating toextreme attention to detail and cognitive inflexibil-ity have led to the adaptation and development ofcognitive remediation therapy (CRT) for AN.4 Ini-tially developed for use with patients with brainlesions and acquired brain injury, cognitive reme-diation has since been used effectively in a range ofdisorders including psychosis and attention deficithyperactivity disorder, with the format and focusadapted depending upon the nature of the illnessand context. Thus, the development of a CRTapproach for AN involved tailoring the treatmenttoward set-shifting, cognitive exercises for holisticthinking, and the development of behavioralexercises.

Accepted 4 December 2012

Department of Psychological Medicine, Institute of Psychiatry,

King’s College London, United Kingdom

*Correspondence to: Kate Tchanturia, PO59, King’s College Lon-

don, Department of Psychological Medicine, Institute of Psychia-

try, De Crespigny Park, London SE5 8AF, UK.

E-mail: kate.tchanturia@kcl.ac.uk

Supported by Swiss Anorexia Foundation, the National Institute

for Health Research, the Biomedical Research Centre for Mental

Health at South London, Maudsley NHS Foundation Trust and

King’s College London, Institute of Psychiatry.

Published online in Wiley Online Library

(wileyonlinelibrary.com). DOI: 10.1002/eat.22106

VVC 2013 Wiley Periodicals, Inc.

492 International Journal of Eating Disorders 46:5 492–495 2013

AN IDEA WORTH RESEARCHING

Cognitive Remediation Therapy forAnorexia Nervosa: A Snapshot

CRT for AN targets cognitive style broadly, ratherthan directly focusing on issues with eating, weight,or shape. The intervention consists of simple exer-cises designed to develop and encourage a moreflexible and holistic thinking style. These includefocusing on the ‘‘bigger picture’’ rather than details,prioritizing information, and estimating (whichchallenges maladaptive perfectionist tendencies).The simple cognitive exercises provide specific andnon-threatening material (at the level of ‘‘doing’’tasks) to encourage curiosity, reflectiveness andinsightfulness about one’s own thinking process(the metacognitive level). There is emphasis uponpracticing such skills first in everyday behaviors(e.g., changing one’s hairstyle or accessories) beforetargeting illness-specific rules and thinking.

CRT is a brief individual intervention (8–10sessions), which provides a good introduction tofurther psychological treatment. It encouragespatients to discover the ways in which they thinkand decide what they would like to change andhow. CRT also encourages the use of intra-sessionexperimentation with different ways of thinkingand behaving, which can then be reflected uponduring the next session. The style of delivery ismotivational, and the therapist is able to modelinefficiencies and imperfect performance. CRT canbe delivered by therapists from across a range ofdisciplines (psychology, nursing, occupational ther-apy, and social work). Training and supervision areessential, as with any other form of psychologicaltreatment.

The Evidence So Far: Published andForthcoming Cognitive RemediationTherapy Studies

Following a small case series and production of atreatment manual, a further early case series wascarried out.4 Existing studies demonstrate improve-ments in neuro-cognitive performance (medium tolarge effect sizes in flexibility and central coherencetasks) and low drop-out rates from treatment(around 10–15%). The approach has a high level ofacceptability to both patients and therapists.5

Whilst a detailed discussion of study findings isbeyond the scope of this article, readers arereferred to Table 1 for a summary of the existingpublished studies, including both quantitative andqualitative analyses. We are also aware of three

large randomized controlled trials of CRT that arein progress.

In Table 2, we also report on recent findings fromour own service in the form of previously unpub-lished data from 46 individual cases and from 25patients who took part in a short group format ofCRT in an adult inpatient ward. For those in individ-ual treatment, Table 2 shows improvements of mod-erate size in flexibility of task performance, andsmall effect sizes in both global processing and self-reported flexibility. In the group format, four to fivesessions of the intervention in an adult inpatient set-ting was associated with improvements in confi-dence to change (measured using a motivationalruler), and small-sized effects in self-reported cogni-tive flexibility. Further work is needed to test theeffectiveness of group CRT and to define the opti-mum number of sessions. For example, feedbackfrom both patients and clinicians suggests anincrease in the number of group sessions.

Summary and Future Directions

In summary, the role of CRT in the treatment of ANis an idea worth researching, given its clearhypothesized links between brain function, psy-chological function, and treatment. Findings fromour own published studies and current data, alongwith other replications and extensions demonstratea relatively consistent picture—CRT is associatedwith cognitive improvements in this population. Itis also associated with low drop-out rates and highlevels of acceptability among both patients andtherapists. Such findings will be of interest to clini-cians given the difficulty of engaging patients withAN in therapy and the role of early engagement asa strong predictor of treatment outcome.

There are a number of promising avenues forfuture research. These include:

1. Developing our understanding of cognitivecharacteristics in the adolescent populationby synthesizing the literature on young cases.

2. Direct comparison with the effects of othertherapies, to determine whether the benefitsreported here are specific to CRT or representbroader changes (e.g., refeeding).

3. Exploring how cognitive improvements mayinfluence AN symptomatology and broaderoutcomes (e.g., work and social aspects).

4. Examining the length of CRT intervention, toclarify which patients benefit from short- and

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long forms of the intervention. Furtherresearch is also needed regarding whetherindividual or group formats of CRT are mostbeneficial for patients with AN.

5. Research has also highlighted the importanceof involving family members and carers in thetreatment of AN. Future research aims tofocus on the development of a ‘‘user-friendly’’

module of CRT, which could be delivered bycarers. Further work is needed to evaluate theeffectiveness and acceptability of CRT deliv-ered in this way.

6. Further work is needed to explore the brainmechanisms implicated in cognitive impair-ment in AN. Whilst there is strong evidencefor such impairments, little is known regard-

TABLE 1. Summary of published studies reporting CRT in AN

PublicationDescription of patients and studydesign Main findings

Tchanturia K, Davies H, Campbell IC. Cognitiveremediation for patients with Anorexia Nervosa:preliminary findings. Ann Gen Psychiatry 2007;6:14.

N5 4; Inpatient adults; age range 521–42; illness duration range 5 7–24 years.

Improvements in neuropsychological taskperformance (set-shifting measured indifferent domains) post treatment(medium to large effect sizes).

Pretorius N, Tchanturia K. Anorexia nervosa how peoplethink and how we address it in psychologicaltreatment. Therapy 2007;4(4):423–433.

Case study; inpatient adult (31 years);illness duration 5 1 year

Patient’s clinical improvements and feedbackon the tasks reported.

Tchanturia K, Davies H, Lopez C, Schmidt U, Treasure J,Wykes T. Neuropsychological task performance beforeand after cognitive remediation in anorexia nervosa:A pilot case series. Psychol Med 2008;38(9):1371–1373.

N5 23; inpatient adults; M age 528.8 (SD 5 9.6); illness duration M5 13.1 (9.6)

Medium to large effect size improvements inset-shifting and global processingcognitive style.

Low drop-out rate (4/27)

Cwojdzinska A, Markowska-Regulska K, Rybakowski F.Cognitive remediation therapy in adolescent anorexianervosa—Case report. Psychiatr Pol 2009;43(1);115–124. [Article in Polish].

Case study, adolescent The paper is in Polish; The abstract reportsgeneral improvements in clinicalsymptoms and set-shifting.

No information available on age orillness duration.

Genders R, Tchanturia K. Cognitive remediation therapy(CRT) for anorexia in group format: a pilot study. EatWeight Disord, 2010;15(4),e234–239.

N5 18; inpatients, group format Short group format found to be acceptablefor patients. Statistically significantchanges on the ‘ability to change’ scale.No significant changes in self-reportedcognitive flexibility.

Pitt S, Lewis R, Morgan S, Woodward, D. Cognitiveremediation therapy in an outpatient setting: a caseseries. Eat Weight Disord 2010;15(4),e281–286.

N5 7; outpatient adults; M age 529; illness duration range 5 3–22years

Improvements in self-reported flexibility ofthinking after individual CRT. Mixedresults for self-reported perfectionism.

Wood L, Al-Khairulla H, Lask B. Group cognitiveremediation therapy for adolescents with anorexianervosa. Clin Child Psychol Psychiatry 2011;16(2):225–231.

N5 9; Inpatient adolescents; agerange 5 9–13.

Positive observations from group membersand clinicians were reported.

Abbate-Daga G, Buzzichelli S, Marzola E, Amianto F,Fassino S. Effectiveness of cognitive remediationtherapy (CRT) in anorexia nervosa: A case series. J ClinExp Neuropsychol 2012.

N5 20; outpatient adults; M age 522.5 (SD 5 3.9); illness duration 5

5.8 years

Medium to large effect sizes reported onmost neuropsychological tasks, e.g. TMT,WCST (Cohen’s d5 0.6) and positiveimprovement in clinical characteristics.

Pretorius N, Dimmer M, Power E, Eisler I, Simic M,Tchanturia K. Evaluation of a Cognitive RemediationTherapy group for adolescents with Anorexia Nervosa:pilot study. Eur Eat Dis Rev 2012;20(4):321–325.

N5 30 (7 groups); daypatientadolescents; M age 5 15.6 (1.4) ;Illness duration M 5 2 years

Small effect size for self-reported cognitiveflexibility post group. Adolescents foundthe group interesting and useful; however,some wanted more support withapplication to real life.

M: mean; SD: standard deviation.

TABLE 2. Updated evaluation of the case series (n5 46) presented: cognitive task performance before and after CRTin individual format

Before CRT(n5 46)

After CRT(n5 46)

Significance(p-value)

Effect size(Cohen’s d)

Brixton (set shifting task)—Total (n5 46)

13.3 (6.2) 9.5 (6.1) \ .001 0.62

RCFT Style index (N5 45)Central coherence task

1.14 (0.4) 1.26 (0.5) .01 0.25

Cognitive Flexibility Scale CFS (n 5 36)Self-report measure

43.05 (10.1) 46.19 (10.0) .03 0.32

In Tchanturia et al. (2008), data for 23 cases was presented; this table contains an additional 23 cases.

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ing the specific neural mechanisms involved.Neuroimaging studies are needed in order toexplore this, and would also enable investiga-tion of the cognitive and functional brainchanges associated with clinical improve-ments following CRT. This would bothstrengthen the support for neuropsychologi-cal inefficiencies in AN and the evidence basefor CRT.

A further, more ambitious direction for futureresearch is to investigate how socio-emotionalfocused interventions can be integrated with thisline of treatment. There is support for such anapproach, given strong evidence for socio-emo-tional impairments in AN and for the superioreffectiveness of interventions that focus upon asso-ciations between cognitions, emotions, and behav-iors in treating eating disorders. Initial research inthis area has already started.6

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