Cognitive Remediation Therapy in the Treatment of Anorexia Nervosa PDF

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Cognitive Remediation Therapy in the Treatment of Anorexia Nervosa

Anorexia nervosa (AN) is an eating disorder with two main types: the restrictive subtype, and the binge-purge subtype. Of interest within this report is the restrictive subtype. Despite the unknown aetiology of this female-prevalent eating disorder (ED), twin studies have shown that 50-80% of AN variance can be accounted for by genetics (Bulik et al., 2006; Walters & Kendler, 1995). Personality also seems to be implicated, particularly neuroticism (Bulik et al., 2006). This suggests that individuals may be predisposed to developing AN. Symptoms include a fear of fat, restricted eating, preoccupation with weight loss, and emaciation (Kaye, Fudge, & Paulus, 2009). Despite AN’s high prevalence within the Western world (0.1-5.7%; Makino, Tsuboi, & Dennerstein, 2004), the prognosis outlook for AN patients is poor (Steinhausen, 2002), and there is no established first-choice treatment for AN (National Institute for Health and Clinical Excellence, 2004). As a result, AN’s mortality rate is approximately 10%, cited by many as the highest mortality rate of all mental disorders (Wilsom, Grilo, & Vitousek, 2007; Sullivan, 1995).

AN patients display deficits in cold processing, particularly in set-shifting and central coherence. Set-shifting is the ability to move flexibly between tasks according to situational demands, an ability key to self-regulating behaviour (Lezak, 1995). AN individuals perform poorly on tests of set-shifting(0) indicating cognitive inflexibility (Westwood, Stahl, Mandy & Tchanturia, 2016; Roberts, Tchanturia, Stahl, Southgate, & Treasure, 2007; Southgate, Tchanturia, & Treasure, 2009). Poor set-shifting may lead to the rigid, compulsive behaviours seen in AN. This cognitive rigidity may stem from an impaired ability to switch behaviours or overcome inhibition(01). The restrictive subtype of AN is associated with a high capacity

for delayed discounting, which can, in pathological cases, be interpreted as excessive self-control (Steinglass et al., 2012). This ability to delay rewards allows individuals with AN to override the fundamental biological drive to eat and thus maintain dangerously low body weights (Steinglass et al., 2012).

Another cognitive deficit in AN is weak central coherence. This particular deficit results in excessive preoccupation with details and order, and may account for the pathological fixation on calories and weight loss seen in AN (Lopez et al., 2008). This intense focus can leave individuals with an inability to see the forest for the trees, and may arguably be linked to the difficulties with set-shifting. If an individual with AN zones in on details, this may explain their decreased ability to withdraw their attention and cast it upon another task. Weak central coherence and cognitive inflexibility are the two main cognitive markers of AN, and thus, a cold processing focused intervention may facilitate recovery.

One such treatment is cognitive remediation therapy (CRT). Originally developed as a rehabilitation intervention for patients with brain lesions (e.g., Goldberg, 2001), CRT identifies impaired cognitive functions through testing and employs repetitive cognitive exercises to strengthen the weakened domains. CRT operates on the assumption that practice within a safe environment will improve performance in other contexts, and aims to improve thought processes rather than thought content, while also encouraging metacognition. As cognitive rigidity and weak central coherence are the fundamental cognitive deficits of AN (Schmidt & Treasure, 2006), these faculties in particular are targeted in CRT, with the aim of training the patient to think more flexibly. CRT typically consists of 10 sessions, with

clinician and patient working together to complete cognitive tasks(1) and reflecting on them (Tchanturia & Hambrook, 2010).

Cognitive flexibility is often trained through the Stroop task, which involves reading aloud the colour of a written word while ignoring its meaning, or reading aloud the word and ignoring its colour. Switching back and forth between these two aims improves cognitive flexibility (Tchanturia & Hambrook, 2010). Another exercise targeting this faculty is the use of illusions(2) which encourages patients to explore the multiple ways of perceiving an image (Tchanturia, Davies, & Campbell, 2007). Holistic processing tasks are used also in CRT to train central coherence, allowing AN individuals to practice seeing ‘the bigger picture.’ These tasks involve using global strategies rather than paying intense attention to details(3). Other elements of CRT include reflection, relating learnings to real life, and applying such strategies to real life. CRT, therefore, trains these attentional control and executive function faculties directly, attempting to intercept the mechanisms of the pathology.

As for its effectiveness, CRT appears to bring about improvements in many neuropsychological domains (Tchanturia et al., 2008; Abbate-Daga, Buzzichelli, Marzola, Amianto, & Fassino, 2012). Both cognitive flexibility and global information processing, the two main cognitive deficits of AN, show significant improvements following CRT (Genders et al., 2008). The primary questions, therefore, in assessing CRT’s effectiveness in treating AN, are whether these cognitive improvements alleviate real life difficulties. Several studies based on qualitative feedback have shown CRT to be both enjoyable to patients and useful in their daily life (Tchanturia, Davies, & Campbell, 2007; Whitney, Easter & Tchanturia, 2008). Group-based CRT seems to also be well-received by adolescents with AN (Wood,

Al-Khairulla, & Lask, 2011). Apart from increasing quality of life and reducing ED symptomatology, CRT may also have the potential to enhance the effectiveness of other concurrent treatments of AN. (Dahlgren  & Rø, 2014). Clinicians also appear to find CRT feasible and easy to deliver, thus, it appears to be a welcome addition to the suite of treatments of AN (Easter & Tchanturia, as cited in Tchanturia & Hambrook, 2010; Dahlgren, Lask, Landrø, & Rø, 2014). 

One major limitation of this intervention, however, is its failure to address the distorted self-image problems which underpin EDs. CRT focuses solely on the underlying cognitive processes, taking a reductionist’s approach to psychological health. Several studies, however, have found individuals’ recovery from AN to be attributable to continued and  repeated self-image confrontations (G  ottheil, Backup, & Cornelison, 1969; Birgegård, Björck, Norring, Sohlberg, & Clinton, 2009). Thus, self-image reformation may be an important aspect of recovery and it may be unwise to focus solely on attentional and self-control processes.

Cognitive remediation therapy is a useful, effective, and enjoyable intervention for anorexia nervosa, training directly the central cognitive deficits of the disorder: cognitive inflexibility and weak central coherence. This intervention addresses the most singular aspects of this eating disorder, excessive self-control and over-inhibition. However, due to the narrow lens through which this intervention views AN, coupled with its capabilities for supporting other treatments, CRT could potentially be put to best use in combination with other therapies. While there have been few attempts to date to assess the financial feasibility of this CRT, and no large-scale quantitative studies determining the proportion of AN

patients this intervention could help, it is clear that any new promising intervention such as this is one worth exploring given the ineptitude of most treatments and the high mortality rates of AN. Group interventions seem to be effective also, meaning this intervention could be widely available and less costly. Its success among adolescent and adult populations alike also furthers its potential impact. Thus, cognitive remediation therapy may facilitate positive change and recovery from anorexia nervosa and warrants further exploration.

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