Keywords

1 What Is CRT and How Can It Be Useful in Psychiatric Disorders?

Cognitive remediation (CR) is an intervention that targets cognitive strengths and weaknesses. The focus is on encouraging patients to become more confident in using new cognitive strategies to solve problems more efficiently. In most of the cognitive remediation modules, patients are asked to do cognitive tasks that utilize a particular cognitive skill, as well as practice and reflect on their own cognitive strategies to improve this skill. There is evidence that improving cognition helps patients to improve their daily functioning. For example, six meta-analytic studies in schizophrenic populations showed that cognition/neuropsychological performance after cognitive remediation therapy (CRT) improved with moderate to large effect size. Furthermore, although the magnitude of change is less with daily activities, these are still consistent and encouraging results (Medalia and Choi 2009). Several forms of the CRT have been developed over the years. These developments include individual, group, computerized and pen and paper version approaches.

Historically, work in CRT in general started from the 1950s. Immanent Russian neuropsychologist A. Luria’s experimental and clinical work into neurological disorders and rehabilitation after brain injury highly influenced the development of cognitive remediation (Das 1999). Most of the initial work in cognitive remediation was conducted in the acquired brain injury field (for review, see Rohling et al. 2009); a recent meta-analysis based on 967 articles, after careful screening and the application of meta-analytical methods, concluded that there is sufficient evidence for CR training for brain-injured patients.

Gradually CRT became a part of the treatment for older age groups, and in the late 1970s it was developed into a new treatment for schizophrenia (the paper by McGurk et al. 2007 includes 26 studies for meta-analysis). Cognitive remediation was also effectively applied to learning disabilities, mainly focusing on skills in learning and adaptation strategies (Stevenson et al. 2002). Over the last decade, several studies have made attempts to examine the efficacy of CRT in attention-deficit hyperactivity disorder (ADHD), the aim of which is to help patients with attention by focusing various attention training programmes.

In summary, to date CRT has been broadly used in the treatment of various psychiatric disorders. The field of CRT is rapidly growing and researchers and clinicians with expertise in this approach are facing more challenges with deciding what forms, which aspects and what portion of CRT to use, as well as reviewing what CRT can and cannot do. There are several forms of CRT which include computerized, individual, group and with or without a therapist. On the other hand, there are also a number of core principles that vary from programme to programme. For example, some programmes are based on the principal of “drill and practice”, whereas some put more focus on motivational mechanisms, strategies and some are focused on developing meta-cognition. Before testing CRT in any particular disorder, from our point of view there are two factors that need to be considered: (1) what is the plausible research evidence and logic to bring CRT into a treatment package? (2) what focus should CRT have for specific disorders and what ingredients should be used: practice, strategies, behavioural and ecological strategies, reflection and the form of delivery? All these questions will tailor the application of CRT in any particular area.

2 Why Might CRT Be Useful in Eating Disorders?

Neuropsychology, in a broad sense, involves studying executive functions (planning, set-shifting, problem solving and decision making). Over the last three decades, the focus of neuropsychological research in eating disorders (EDs) has visibly shifted from the assessment of broad executive function to a hypothesis-driven approach targeting areas of clinical interest to understand more effectively what neuropsychological assessments/experiments can tell us about information processes. In fact, more recently these research findings are being translated into clinical practice (Tchanturia et al. 2005, 2008).

Two parallel processes can be observed in the current literature: on the one hand, interest is rapidly growing in examining the eating disorder field from a neuroscience perspective to broaden out understanding of the disorder (Kaye et al. 2009). On the other hand, there are attempts made to clarify assessments of executive function (Chan et al. 2008) and the integration of neuropsychological and cognitive theories in rehabilitation Hill et al (2001). There are a number of studies and a few systematic reviews on executive functions in ED reviewing: planning, cognitive flexibility, sustained attention, central coherence (extreme attention to detail) and working memory (Southgate et al. 2005, 2009; Lopez et al. 2008). Most of the available experimental literature sheds light on the so-called cold cognition (for neuropsychological assessment review, see Chan et al. 2008). Executive functions also involve “hot” emotional components in the processes like decision making where regulation of reward and punishment are involved (in ED, Cavedini et al. 2004; Tchanturia et al. 2007; Russell et al. 2009 provided some experimental work in this area). To date, findings from studies on “cold” executive functions in AN were translated into the treatment intervention of the CRT module. Therefore, we will focus on the findings in cognitive flexibility and central coherence which inspired the work in cognitive remediation for AN.

The most robust findings are supported with systematic reviews (Roberts et al. 2007; Lopez et al. 2008) which found that set-shifting (the ability to quickly change and adapt strategies when environmental demands change) and central coherence (extreme attention to details) are the areas where people with ED show suboptimal performance, compared to controls. It is worth noting that neuropsychological assessment tools were predominantly developed in brain-injured populations, and when it comes to ED in most cases we do not see a “deficit”: it is a more suboptimal performance as a group in a range of one standard deviation below the norms (Lauer 2002). Extreme attention to detail (weak central coherence) in laboratory research was first reported from Gillberg and colleagues (for the update Gillberg et al. 2007); later several groups have also found an “eye for detail” at the expense of the bigger picture, using different experimental measures. For example, Southgate et al. (2008) reported that people with eating disorders (particularly AN) tend to spot details faster and more efficiently than people without an eating disorder (a matching familiar test was used to assess this). Lopez et al. (2008) reported a detailed strategy when completing the Rey figure in a cross-sectional study comparing people with and without ED. Tokley and Kemps (2007) concluded from their study that there is also poor abstraction in people with AN (using Object Assembly test WAIS, embedded figure test).

Poor flexibility in set-shifting was also reported across the studies (Tchanturia et al. 2003, 2004; Holliday et al. 2005; Roberts et al. 2007) using a variety of set-shifting tasks (all based on the idea to change and shift strategies with rule changes), but tapping different domains: cognition [catbat, Brixton, Wisconsin card sorting task (WCST), attention (Trail making task), and perception (perceptual illusion task)].

This cognitive profile of inefficient set-shifting and weak central coherence fits well with what clinical and personality research reports have highlighted, e.g. patients with AN having high perfectionism, obsessive-compulsive personality traits, harm avoidance, and low novelty seeking. All these characteristics are associated with poor flexibility.

In psychological treatments, the main focus of learning (therapy is learning) is on the content of the symptoms alongside a cognitive formulation of the illness and possible ways to change the beliefs and behaviours of the patients. In behavioural therapy, for example, the content of thoughts is highly important.

If cognitive characteristics such as inflexibility and an over attention to detail are addressed in therapy, this may increase the effectiveness of the therapy as patients become more aware of their thinking styles and are in a better position to work towards change. Thus, the idea of the CRT is to help patients to make their thinking process more flexible (to help patients be aware of their own inflexible thinking styles using symptom-free cognitive games and then apply this knowledge to areas of rigid behaviours they struggle with the most, e.g. eating, food shopping and exercising), to make patients “think outside the box” and see the bigger picture (e.g. how ED affects their own life, what impact it has on work, private life, relationships, and quality of life in general).

Of course, there is a big variation within AN patients as to what degree each of the cognitive characteristics are present (e.g. someone can be very flexible and yet stuck with details, or the other way round, someone may be very rigid but able to develop a bigger picture approach). In intensive studies of patient groups with eating disorders, it becomes clear that patients with the most severe clinical symptoms (e.g. very low lifetime BMI and long duration of the illness) have these cognitive style characteristics that are represented more strongly than in mild cases, adolescents or people who have recovered from the illness.

CRT for AN was developed with the aim of addressing these cognitive and information processing characteristics.

The original study of CRT for AN consisted of ten sessions of cognitive exercises and behavioural experiments specifically designed to allow patients to practise skills in cognitive flexibility and global processing (bigger picture thinking).

Case studies and exploratory case series in CRT have found improvements in participant’s body mass index (BMI), performance on neuropsychological tasks and self-reported cognitive flexibility (Davies and Tchanturia 2005; Tchanturia et al. 2006, 2007). These gains have been sustained at a 6-month follow-up (Genders et al. 2008).

CRT was developed out of the continual requirement for novel treatments for AN. The National Institute of Clinical Excellence (NICE 2004) recognizes the lack of evidence-based treatments for adults with AN, and current guidelines cannot endorse a first line treatment for the disorder in this age group (for recent reviews, see Lock and Fitzpatrick 2009; Treasure et al. 2010). With current pressures for resources placed on clinicians, there is a need for cost-effective interventions. CRT, because of its motivational delivering style, has no symptom-related material, and with a relatively low intensity training requirement for the therapists, it is worth exploring as a starting point intervention. By this, we mean that CRT offers psychological input but not to the degree that cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) or other complex psychological interventions do; in other words, CRT for ED is not a stand-alone psychological intervention: we see it as a complimentary addition which is worth researching further.

3 Why Might CRT Be Useful for Adolescent Anorexia Nervosa?

Epidemiological, biological, cognitive developmental process and treatment response data all suggest that adolescence is the critical period for onset and treatment of AN. Epidemiological studies show that AN is not randomly distributed among all populations. Young females are the most vulnerable group, with only 5–10% of clinical samples being male (Hoek and van Hoeken 2003; Van Son et al. 2006; Keski-Rahkonen et al. 2007). Studies suggest that incidence rates are increasing among 15–24-year-old females, while rates in adult women are stable (Lucas et al. 1991, 1999). Onset of AN after age 25 is relatively uncommon. Thus, adolescents with AN are the key population for whom treatments, including CRT, should be targeted.

Amenorrhea is a clinical indication of malnutrition associated with AN in females and a current diagnostic criteria for the disorder (American Psychiatric Association 1994; Arnsten and Shansky 2004). However, the importance of amenorrhea may be greater in adolescent females’ developing cognitive functioning. Rising oestradiol levels during this critical period are thought to increase susceptibility to impaired judgment, prefrontal dysfunction and neuropsychiatric disease (Arnsten and Shansky 2004). While there are only scant studies on sex hormone changes and cognitive function in adolescents, recent work has shown a link between amenorrhea or irregular menses and deficits in cognition, including recall, verbal memory, working memory, visual reproduction, reading, math and oral language (Chui et al. 2008). It is possible that suppression of normal circulating oestradiol levels may have a much greater impact on cognition during puberty in patients with AN than in chronically ill adults.

In addition, adolescence is a critical period of brain development associated with synaptic pruning, elaboration of dendritic arborisation and increased myelination (Luna and Sweeney 2004). These developmental processes support the integration of brain circuitry associated with the prefrontal cortex (PFC) and sub-cortical structures (basal ganglia and thalamus) supportive of the executive functioning area of the brain. This maturation serves to improve inhibitory and reflective processes, making them more efficient and consistent. For some adolescents, difficulties in this maturational process lead to a range of externalizing behavioural difficulties (Casey et al. 2008); while in others, difficulties may arise because of excessive inhibitory processes (Marsh et al. 2009a).

In summary, the age of onset of AN, biological and cognitive developmental processes, and common behavioural manifestations of these processes including particularly avoidance of risk taking in inhibited individuals support the idea that adolescents with AN might benefit from an intervention such as CRT aimed at making their cognitive processes more flexible and less perseverative on detail to the neglect of the whole. It might be anticipated that such an intervention has the potential for greater impact on these processes in developing adolescents with less “fixed” cognitive processing styles.

In addition to these developmental reasons for considering CRT for adolescents with AN, we have recently conducted a study examining set-shifting and central coherence in adolescents with AN (Fitzpatrick et al. submitted) to assess the utility of targeting these processes in a younger group of non-chronic patients.

Neuropsychological data on 26 adolescent females between the ages of 12 and 18 (mean age 14.9 SD = 1.92) were collected. Participants were at a per cent ideal body weight of 82.13% (SD = 8.97), with 59% of the sample having secondary amenorrhea, 14% having primary amenorrhea, 18% currently menstruating and the remainder did not report menstrual status. Eating Disorder Examination Questionnaire (Cooper and Fairburn 1987; Cooper et al. 1989; Fairburn and Cooper 1993; Carter et al. 2001): scores on the EDE-Q were greater than two standard deviations above published mean norm scores (Fairburn and Cooper 1993) on all four subscales. Subjects were within the average range on the Weschsler assessment scales (Wechsler 1997). We examined cognitive flexibility or set-shifting using the Wisconsin Card Sort Task (WCST) (Resources 2003). Overall, adolescents with AN performed within expectations for their age and IQ in terms of total performance, but their performance was characterized by a high number of perseverative errors, a finding consistent with set-shifting difficulties. We also explored set-shifting using the Trails on the Delis–Kaplin Executive Functioning Scale (DKEFS) (Delis et al. 2001). Compared to a normative sample on this subscale, participants performed within expectations for their age, but those with AN performed significantly more slowly than adults with AN on the simple letter sequencing task and the shift task.

Central coherence was assessed using the Rey Osterrieth Complex Figure (ROCF; Osterrieth 1944). On this measure, adolescents with AN closely resembled the adults with AN with no significant differences between them. However, adolescents with AN demonstrated greater weakness in central coherence compared to adolescent healthy controls. Taken together, these findings suggest that adolescents with AN demonstrate neurocognitive inefficiencies in set-shifting and central coherence compared to adolescent norms. In addition, the neuropsychological profile suggested by these findings were similar to those found in adults with chronic AN, though set-shifting, appears to less severe than in adults with AN.

4 What Is CRT in Detail for Adults?

Neuropsychological interventions have been developed, which mainly concentrate on (1) restoration of function, to improve specific skill deficits and (2) compensatory training to adapt the presence of certain behavioural or cognitive problems (from Eslinger and Oliveri 2002). In brain injury rehabilitation, the targets are individuals with (a) impairments – loss/abnormalities in psychological structure and function; (b) disabilities – restriction or lack of ability to perform activities in the range considered normal, or (c) handicaps – disadvantages that prevent fulfilment of a role that is normal.

For psychiatric conditions, neuropsychological interventions can be used in the context of the clinical picture and the research evidence drawn from experimental studies. Brain injured, ADHD, schizophrenia and ED patient groups are very diverse and have very different needs. This presents a big challenge for researchers and clinicians who have to tailor and use the principals of cognitive remediation in a clinically meaningful way for the targeted population.

In the context of ED, first of all we focused on anorexia. Our choice was determined from the fact that:

  1. 1.

    There is relatively wealthy research data on neuropsychology in AN (e.g. flexibility and extreme attention to detail as problematic areas).

  2. 2.

    Treatment in AN to date has very poor outcomes and needs further investigation.

  3. 3.

    Bringing a brain hypothesis to the treatment intervention could be plausible (by brain hypothesis we mean factors like childhood preterm birth, low BMI at birth, brain synaptic pruning affected by starvation and a high association between brain lesions and ED symptoms (Uher and Treasure 2005).

There are several CRT programmes (individual, group, computerized) which can be adapted for the ED cohort. The first step for such developments is to adapt materials for the ED population, test acceptability and effectiveness as well as improvements in cognitive style and treatment engagement.

For ED, much research lies ahead to explore the benefits of CRT and adjust various approaches in remediation to eating disorders. One of the first studies making an attempt to do this adapted a model developed in schizophrenia (in-house manual by Delahunty A, Reeder C, Wykes T, Morice R, Newton E). In schizophrenia, the modules for working memory, flexibility and planning are core components presented in five workbooks. Because of the research evidence (cognitive flexibility, eye for detail), we were interested in only the flexibility module for anorexia, where we have added a number of cognitive exercises (e.g. therapist and patient come up with names of countries in alphabetical order taking turns).

Letter

Name

A

 

B

 

C

 

It could be more challenging, if it feels appropriate, to increase the difficulty of the task, e.g. switch to boys and girls names. Several exercises are based on the Stroop effect – patients are asked to name animal pictures and then switch to reading aloud the labels of the pictures.

In addition to the flexibility tasks such as the visual illusion task and the Stroop effect tasks, we have developed simple cognitive exercises which tap into the bigger picture approach, e.g. giving patient a page of meaningless or meaningful information to come up with a catchy (relevant) title; the therapist letter or assessment page can be used in later sessions to bullet point the information. After doing the exercise, the therapist further explores what the patient’s observations are on cognitive style and how this relates to everyday life behaviours. The next step is to explore alternative ways to do the same cognitive task and apply this to real-life behavioural strategies.

Pilot work has been published in several papers (Davies and Tchanturia 2005; first case report, finalizing manual for pilot case series; Tchanturia et al. 2007, case series including work conducted in 23 patients with CRT manual for AN; qualitative evaluation of patients views on intervention; Whitney et al. 2008).

5 Can CRT Modified for Use in Adolescents with AN?

In order to address the cognitive inefficiencies in AN, the basic strategies of CRT similarly target cognitive flexibility and weak central coherence. However, a range of modifications are needed to make CRT more appropriate and useful for adolescents with AN. It was not initially clear, however, how best to amend the adult version of CRT; so a case series using the adult manual was undertaken to identify areas that needed to be modified. In general, adolescents with AN found the CRT tasks interesting to do, but more range and variety of tasks seemed to be needed to keep them engaged in the therapy. In addition, some adolescents felt the tasks to be not challenging enough, while at the same time some struggled with using the reflective “thinking about thinking” aspects of CRT after the tasks were completed. It is not too surprising that some of the cognitive flexibility tasks were not as challenging to adolescents because they are less compromised in this area than severely malnourished chronically ill AN adults. It is also not unexpected that metacognitive tasks were experienced as difficult in a subject pool where the mean age was a little over 14 years since self-reflection and abstract thinking are still developing skills in this age group.

In order to address these challenges, several new and modified tasks were added to the protocol. Specifically, more challenging complex geometric figures, complex line bisection tasks and modification of letters were added. In addition, the Main Idea task is a task designed to improve central coherence through summarizing key points in a written document. Feedback from pilot adolescents suggested that the language in the adult version was confusing to them and the content not interesting. To address these issues with the Main Idea task, adolescents were asked to identify the main points and themes contained in letters and short articles that were likely to be of interest to this age group. This letters varied in length, degree of detail and contained content designed to evoke feelings – including humour, anger and frustration.

Because pilot work and preliminary information related to cognitive processing suggest that adolescents are less compromised in terms of set-shifting than adults with chronic AN, it was important to make sure that the tasks used were pitched at the correct level, taking into account by age, ability and cognitive inefficiency. Participants in pilot study provided feedback on all the tasks as well as those that remained unchanged from the adult manual to help rank them in order of difficulty. In this way, the manual was arranged so that the CRT therapist could present tasks in a sequence that provided increasing cognitive processing challenges within each session and over the course of CRT. In practice, feedback from participants in terms of their reports of difficulty, interest, as well as therapist assessments of these factors, leads to an individualized course of CRT treatment for each participant.

The initial pilot study refining the treatment manual involved 20 adolescents with AN. The feasibility of the refined manual was examined in an additional 20 adolescents with AN. Of a total of 42 adolescents approached for CRT, only two refused after the treatment was described to them (i.e. 95% acceptance rate). This is noteworthy because many adolescents (as adults) with AN are highly resistant to psychotherapy and commonly actively reject individual therapy. These pilot treatments took place on an inpatient service (see below for details); so many of the patients were particularly unhappy about being in hospital making their acceptance of CRT even more surprising. Participants appeared to like the therapy because it was similar to tasks familiar to them (e.g. homework, school work) and most of them felt competent in taking on the tasks. This was the case despite the fact that the tasks in CRT are designed to become increasingly challenging. The adolescents were not usually frustrated increasing the level of difficulty in the tasks. Therapists noted that most patients appeared to proceed well through the assigned tasks. No participants asked for stopping CRT to be discontinued. The only reason for why CRT stopping was patient discharge. The patients reported liking the therapy and their therapists – not a common report for adolescents with AN in the early stages of treatment.

Parents also appeared to feel that CRT was useful, and none objected to the treatment during the hospital stay while several requested that the treatment continue in an outpatient setting.

Comparing these preliminary results with those of CRT with adults, there is much commonality. First, CRT was acceptable and feasible, perhaps even more so than with an adult population of chronically ill adults on an inpatient service. There are several possible reasons for this. The adolescents were not as underweight as those in studies of adults with AN. As some authors have noted, extremely low weight may exacerbate cognitive inefficiencies, especially set-shifting, which might also make taking on the task of CRT more difficult, thereby possibly increasing resistance. At the same time, both adolescents and adults seemed to agree that working on their thinking styles was potentially worth while, and that having a treatment that did not focus on eating and weight was helpful in some ways by distracting them from these more challenging problems, while also being beneficial. Most thought that working with the CRT therapists was a good experience. Thus, the experience of CRT for both adolescents and adults has the potential for being a good model for later work with therapists, even therapy targeting eating, shape and weight. Some therapists thought that adolescents may have had a harder time with tasks related to meta-cognition than adults. If this was the case, it would not be too surprising since such perspective taking is more challenging for adolescents in this age group even without AN. This is a potential area for further refinement of the CR intervention.

6 How Can CRT Be Integrated into Focused Treatments for Eating Disorders?

CRT is a flexible treatment that can likely be used in conjunction with a range of other more focused treatments for eating disorders. In this section, we provide examples of how CRT might be integrated into common programmes including inpatient treatment and cognitive behavioural therapy for outpatients.

6.1 The New Maudsley Model

Anorexia is one of the most difficult conditions to treat. Treatment guidelines for AN rely on expert recommendations. These recommendations emphasize the importance of a multidisciplinary approach including medical, nutritional, social and psychological components (Lock and Fitzpatrick 2009; Treasure et al. 2010). In relation to CRT, we have offered some reflections on similarities and differences from CBT (Baldock and Tchanturia 2007; Tchanturia and Hambrook 2009). Below we will focus on CRT in the context of the new Maudsley model. Schmidt and Treasure (2006) proposed the Maudsley Model for the treatment of AN, which is based on the following four maintenance factors:

  1. 1.

    Obsessive-compulsive personality traits (OCPD)

  2. 2.

    Avoidance of emotion

  3. 3.

    Pro-anorexic beliefs

  4. 4.

    Responses to close others

This model promotes specifically tailored interventions to address these factors.

It is highlighted in the model that the core active ingredient of the therapeutic approach is the empathic, reflective style of motivational interviewing. Engagement of AN patients in any treatment is problematic, and therefore therapists’ curiosity and collaborative style are highly important. CRT is based on the same principal of working “together” with the patient and taking a journey in the exploration of cognitive styles and finding alternative approaches in doing cognitive tasks.

In the Maudsley Model, therapeutic writing is proposed to help patients with taking perspectives and develop a bigger picture approach instead of an attention to detail. In CRT, direct cognitive tasks are introduced and completed during the session, and later there is a reflection on their own thinking style. In the new model, some cognitive exercises are included in the manual and in addition to the writing tasks (e.g. estimation task, illusion task, getting the gist from the bigger chunks of information). Thus the Maudsley model addresses the maintenance factors broadly, whereas CRT focuses on cognitive styles. The delivery of the modules is highly motivational, as was proposed in the Schmidt and Treasure (2006) paper.

6.2 Use of CRT on Short-Term Medical Unit for Adolescent AN

CRT has also been used with adolescents with AN on an inpatient service for medical stabilization. Admissions to this service are specifically for bradycardia, hypothermia, orthostasis or severe underweight (below 75% of expected weight for height by age and gender). Lengths of stay are brief, lasting on average about 12 days. The mean age of patients on the service is between 14 and 15 years, though the range is between 11 and 21 years. Participants using CRT in preliminary studies were between the ages of 12 and 18 years, with a mean age of about 14.5 years. Although the main goal of the inpatient admission is resolution of medical problems due to malnutrition, the programme has an active psychiatric consultation service that provides individual, family and group therapy aimed at diagnosis, crisis management and outpatient referral processes.

Most of the patients in the service are resistant to typical therapies, while some are cognitively impaired due to malnutrition. All patients are restricted to their beds to insure their medical safety for a large portion of their brief stays. In this context, the potential utility of CRT was considered to address the following dilemmas that this kind of inpatient context brings about:

  1. 1.

    Patients have limited motivation for changing eating-related behaviours.

  2. 2.

    There is limited time to conduct individual therapy because of other required activities (e.g. psycho-educational groups, meals and snacks, family therapy, in hospital school and medical treatments).

  3. 3.

    There is limited amount of time to conduct a course of therapy because of short hospital stays.

  4. 4.

    Patients have limited ability to focus or use insight-oriented therapy.

  5. 5.

    Patients have limited ability, given the constraints of the hospital setting to use behavioural therapies likely to generalize to the outpatient setting (e.g. eating with families, managing exercise without supervision, eating with friends without eating disorders).

The use of CRT appears to be overall a good match for many of the processes of the brief medical hospitalization service. Most sessions were brief (25–40 min) and could be flexibly administered. Patients are often confined to their beds, but the therapy could easily be conducted at the bedside. Materials to conduct CRT were easily condensed and portable for therapists. For this reason, nursing staff on the unit were supportive of participants using CRT and did not feel it interfered with the routines associated with medical assessment, meal times and other milieu-based activities. In addition, while the therapeutic relationship in CRT appears to be valued, the material is not emotionally charged or intimate as is the case with some other forms of in-depth therapy making the termination process less fraught with concerns about losing a confidant. In this same vein, although CRT is warm and collaborative, it does not require the participant to develop a deep interpersonal connection to use the therapy. Treatments in hospital or other intensive setting that encourage this type of relationship run the risk that the patients will feel loss when discharged and perhaps experience challenges in taking up therapy with another provider in the outpatient setting.

There were also some limitations to using CRT in an inpatient setting such as the one described above. For example, severely underweight adolescent subjects became confused and too easily distracted to conduct CRT. Lengths of stay for medical stabilization are often very short and discharge can be precipitous; thus, on average only about five sessions of CRT could be conducted. If implemented as a regular programme feature, CRT, a specific protocol with more predictable treatment length and frequency, would be helpful. The use of trained nursing staff to conduct CRT might make the intervention easier to deliver on an inpatient medical stabilization service. Evaluation of the usefulness of the approach in an inpatient setting is needed to determine the costs and benefits of CRT in medically unstable adolescents with AN.

6.3 Fitting CRT to CBT in an Outpatient Setting for Older Adolescents and Adults with AN

We have argued that CRT might be a good “preparatory” or adjunctive treatment for other outpatient therapies for AN. This might be the case because typically focused treatments for AN often do not match well with the initial motivational state of the patient, treatment collaborations are difficult to develop when therapists and patients aims are divergent in terms of focus and goals, and capacities for using specific interventions require efficient cognitive process, particularly flexibility in thinking and an ability to see the big picture. Consideration of how CRT might particularly serve as a pre-treatment or adjunctive treatment for CBT for AN deserves particular attention. CBT is a useful therapy for many psychiatric disorders and eating disorders; but to date, it has demonstrated only limited utility for AN. Small-scale studies suggested CBT might be helpful (Treasure et al. 1995; Pike et al. 2000), but two somewhat larger treatment studies were more equivocal (Pike et al. 2004; Mcintosh et al. 2005). In one of these studies (Mcintosh et al. 2005), specialist non-specific care outperformed CBT and IPT based on treatment completers. There are likely a variety of reasons why CBT for AN is less successful than it is with adult BN, including motivation, ego-syntonic nature of AN and perhaps cognitive style.

Despite limited data, CBT is a reasonable candidate for treating AN, and it appears that those who stay in treatment may achieve benefit, treatments that complement CBT may be a useful first step to address the issue of treatment retention and ultimately treatment response (Serfaty 1999; Pike et al. 2004; Mcintosh et al. 2005). As noted above, cognitive impairments potentially make it challenging to make use of the specific treatments such as CBT. A pre-treatment to improve brain and cognitive functioning is a novel way to address this dilemma. A possible solution is to use a different therapy before beginning CBT that targets related core psychopathology, though not eating-specific psychopathology, while also providing a model of a productive therapeutic relationship and practice with relevant skills (perspective taking, practice with behavioural experiments, etc.). CRT, it can be argued, may accomplish just these goals (Davies and Tchanturia 2005; Tchanturia et al. 2006; Baldock and Tchanturia 2007).

There are several reasons to consider CRT as a likely complementary and compatible treatment with CBT. A key benefit of CRT identified by clinical reports is that it is more understandable and appealing to patients with AN than other approaches, even for those at extremely low weight (Davies and Tchanturia 2005; Whitney et al. 2008). This is the case because unlike CBT, CRT does not address weight and shape or other eating disorder symptoms directly. Instead, it examines and targets neutral material effectively, i.e. cognitive styles. In addition, patients with AN are typically emotionally avoidant; so CRT’s focus is comparatively non-threatening. At the same time, even emotionally laden topics would be managed in CRT by focusing on the cognitive aspects rather than elaborating the emotional context.

Furthermore, CRT is an engaging therapy that uses activities and tasks that while aimed at changing thinking styles are also a distraction from the obsessive preoccupation with weight, food and exercise associated with AN. The treatment sessions in CRT are not a strain on concentration, while nonetheless improving concentration. Completion of CRT-related tasks provide the patient with a sense of accomplishment thereby improving self-esteem (a factor associated with higher completion rates in one study (Halmi et al. 2005) and self-efficacy (Halmi et al. 2005).

The therapeutic gains from CRT lead to improvement in concentration, cognitive flexibility and central coherence processing (Tchanturia et al. 2008). Relatively high levels of these skills are needed in CBT. The ability to take differing perspectives as well as to take a more global view of problems are necessary to be able to identify and challenge contributing factors for symptom maintenance.

CRT also encourages the practice of a thinking style that precipitates the kind of self-reflection required when evaluating the impact of eating disorder-specific preoccupations and behaviours targeted in CBT. Behavioural tasks are also a part of CRT and may also provide a kind of template for the more demanding tasks of CBT. Although the behavioural tasks in CRT are not directly challenging to eating disorder behaviours, generalizing from these tasks to the more difficult ones required in CBT may be supported by success in CRT.

Taken together, CRT, though targeting core cognitive impairments, is a treatment that complements CBT by providing opportunities for practice in developing a positive therapeutic relationship, enhanced cognitive abilities related to concentration, flexibility in thinking, and perspective taking, practice in self-reflection and behavioural experiments, all of which may better prepare the patient to agree to take up CBT, to stick with the approach, and perhaps respond more quickly and better to this more specific treatment for the cognitions and behaviours associated with AN.

7 What Are the Future Research Directions in Using CRT?

CRT is not a stand-alone treatment for eating disorders; therefore, the next step in examining CRT for eating disorders is to examine any specific benefit CRT may add to existing effective treatments for eating disorders. In the area of BN, CRT appears to be compatible with CBT, which remains the first line of treatment. CBT for BN achieves about a 40% abstinence rate; so there is room for improvement. In the area of CBT for AN, it is possible that adding CRT may improve treatment retention and improve outcomes, but that possibility needs to be tested. A pilot randomized clinical study examining this possibility is underway. It is possible that CRT may be useful in inpatient treatment programmes as the preliminary study described in this chapter suggests. In adolescent treatment, the possible benefit of CRT in improving outcomes, preventing relapse and improving general prognosis in conjunction with family therapy could also be examined. CRT used in this way might help support the adolescent in tolerating weight restoration and perhaps improve the rate of psychological recovery which tends to be delayed in family-based treatment (FBT) for adolescent AN.

A first attempt to offer CRT work in group format is also in progress (Genders and Tchanturia 2010). The sessions followed the aim of practising global and flexible thinking with the support of a peer group and group facilitators. This may have secondary benefits of increasing motivation, self-esteem and reducing social isolation, all areas known to be a problem in AN. Four sessions were designed to include the following elements: psycho-education, practical exercises, reflection and discussion within the session and inter-session tasks. As with individual CRT, continual discussion relating the exercises and inter-session work to real-life thoughts and behaviours is an essential part of the learning and reflection process. Evaluation of this intervention programme may allow for an efficient strategy for delivery of CRT.

In addition to treatment studies, a better understanding for whom and how best CRT might be used in the treatment of eating disorders is needed. As the data related to neurocognitive processes in eating disorders remain quite limited, it will first be necessary to conduct more comprehensive and larger studies of these processes in the range of eating disorders. The relationship between neurocognitive process and severity of eating-related psychopathology needs to be better understood. There is a need to examine the “hot” neurocognitive processes in addition to the “cold” ones so far examined. Although preliminary data examining the relationship between age and chronicity of disorder suggest that similar cognitive inefficiencies are present early in the disorder, it is unknown whether they are a modifiable risk factor. Refinement of CRT for specific disorders, different cognitive profiles and ages is needed if CRT is likely to be a useful treatment for eating disorders.

It has been suggested that set-shifting and weak central coherence may be an endophenotype for AN (Holliday et al. 2005; Lopez et al. 2008; Roberts et al. 2010). Cognitive functioning is highly genetic (Fossella et al. 2003; Goldberg and Weinberger 2004; Buyske et al. 2006; Gosso et al. 2006; Friedman et al. 2008; Koten, Wood et al. 2009). In AN, specific executive functioning inefficiencies in the area of cognitive flexibility (set-shifting) and central coherence have been identified that appear to meet some of the criteria for an endophenotype (e.g. found in acute and recovered states, and in unaffected family members) (Tchanturia et al. 2004; Holliday et al. 2005; Lopez et al. 2008; Roberts et al. 2010). Other psychiatric disorders share some of these inefficiencies; e.g. set-shifting difficulties have been found in schizophrenia (Almasy et al. 2008), bipolar disorder (Robinson et al. 2006), OCD (Chamberlain et al. 2007) and autism (Losh et al. 2009).

Studies have identified a number of functional neural correlates of cognitive functioning in a range of disorders, e.g. autism, OCD and eating disorders (Gilbert et al. 2008; Sanders et al. 2008; Marsh et al. 2009a). Recent neuroimaging data specific to eating disorders are more limited, but support the involvement of fronto-striatal brain circuitry (Marsh et al. 2009b; Zastrow et al. 2009). Furthermore, other recent studies have identified neural correlates of cognitive inflexibility in a sample of adults with AN (Zastrow et al. 2009), suggesting that examining such correlates is reasonable and timely. If anatomical and functional neural correlates are better understood, both the pathophysiology and, ultimately, the ethiology of these deficits can be described on a biological level.

In summary, as Siegle et al. (2007) suggest, cognitive remediation techniques are those that aim to target neurobiological and neurocognitive mechanisms thought to underlie psychological disorders. While there is solid neuropsychological evidence demonstrating neurocognitive dysfunction in AN, and preliminary evidence suggesting that CRT may improve functionality to some extent, we still know very little about the links between CRT and changes in neurobiological parameters. It is clear that more basic science research is necessary before we can fully understand the specific brain mechanisms underlying AN, and the number of neuroimaging studies involving eating disordered patients is growing. However, we still know less than researchers in other mental health fields (e.g. schizophrenia) about the neurobiological correlates of AN, and even less about the specific neural processes underlying the cognitive impairments seen in this population, and how these might be affected by the treatment. In the psychosis field, for example, several well-designed studies have already documented cognitive and functional brain changes as a result of CRT (Eack et al 2010; Vinogradow et al. 2009). Ideally, future studies in AN will follow this lead and combine neuropsychology with neuroimaging methods to help elucidate and delineate the neural mechanisms that are susceptible to intervention and bring about clinically significant improvement. Thus, there are a number of questions we would like to explore in future studies, which are as follows:

Is CRT a beneficial intervention for AN? (replication studies of Tchanturia et al. 2002; pilot work is required).

Is CRT helping to engage patients in treatment?

Does CRT help improve cognition? Daily functioning?