Cognitive Remediation Therapy for Anorexia Nervosa

What is Cognitive Remediation Therapy?

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Cognitive Remediation Therapy (CRT) for anorexia nervosa is a relatively new treatment. The technique was originally developed for patients suffering brain injuries and has more recently been adapted for patients with schizophrenia and other mental health conditions including anorexia nervosa. It consists of mental exercises aimed at improving cognitive strategies and thinking skills through practice.

Research on patients with anorexia nervosa shows cognitive deficits. To date two primary cognitive deficits have been identified and targeted as a part of CRT:

  • A lack of cognitive flexibility (the ability to shift or change mental and behavioral strategies).  Anorexia sufferers commonly exhibit rigid thinking both during the acute phase of the illness and after weight restoration. It may manifest as rigid rules about which foods they can eat, routinized behaviors, and difficulty multi-tasking. When habits are interrupted, they may become extremely upset.
  • Problems with central coherence (a preoccupation with details and relative lack of attention to the bigger picture).  Patients with anorexia are usually good at focusing on details, but to the exclusion of seeing the bigger picture. For example, they may become preoccupied with details such as calorie content or fat content of a particular food item and be unable to consider the larger context of overall nutritional intake.

    CRT interventions address these two deficits by focusing on the patient’s process of thinking, rather than the content of their thoughts. In contrast to traditional interventions, CRT does not directly address symptoms specific to eating disorders such as weight and shape concerns or dietary restriction.

    It is always delivered as an adjunct to traditional treatments and is not designed to be a standalone treatment for anorexia nervosa.

    In CRT, the therapist introduces the patient to neuropsychological tasks, puzzles, games, and other real life activities that address cognitive flexibility and/or central coherence. Examples of neutral activities that may be used to develop cognitive flexibility include:

    • Changing the order of a routine behavior (i.e. when getting ready for bed brush your teeth before changing instead of after)
    • Choosing a different brand of the same product (e.g., a cleaning supply)
    • Sitting at a different place at mealtimes

    Through brain training and activities, new skills and strategies are learned. The therapist also provides psychoeducation to help the patient understand their process of thinking, encouraging the patient to reflect on their performance in cognitive exercises and drawing parallels to behaviors in real life.

    The hope is that by practicing cognitive flexibility and central coherence in these more neutral domains, the patient will be able to apply the new cognitive skills to eating-related tasks.

    For example, with training, they may be more willing to try new foods or to focus on balance in their entire meal plan and not get bogged down in the nutrient makeup of a single food.

    There have been clinical trials of CRT with child, adolescent, and adult patients with anorexia nervosa.  Preliminary research shows that CRT is acceptable to the majority of patients. Because it does not target emotionally laden content, CRT may be less threatening for patients who are very ill and unprepared to tackle emotional issues or make behavioral changes related to eating. CRT seems to have the potential to enhance the effectiveness of traditional treatments, reduce treatment dropout, improve cognitive abilities, improve quality of life, and reduce eating disorder symptoms.

    Activities you can try at home

    Although they do not represent formal CRT, many fun games and puzzles may help increase cognitive flexibility and central coherence. Here are some ideas for activities you can do at home:

    • Q-bitz is a set of patterned blocks that are assembled in different ways to match designs on a set of cards. It focuses on integration of elements.
    • Set game is a card game that focuses on matching elements according to different criteria (e.g. shading, color, figure, and number of elements). It addresses set shifting. It is also available as an app for iPhones and tablets.
    • Alternate uses is a verbal set-shifting game that challenges the participant to come up with uncommon alternative uses for common items. For example, instead of eating an apple, it could be cut in half and used to stamp color on fabric. The point of the game is to brainstorm the uses (you don’t have to perform the alternate use!)
    • Rush hour is a logic and problem-solving puzzle that is also available in tablet form. It addresses abstract thinking and does not specifically fall under set shifting or central coherence.
    • Word searches. The focus of this task is to focus on relevant versus irrelevant information, an aspect of central coherence.

    Playing these games does not constitute Cognitive Remediation Therapy. Anorexia nervosa is a serious mental illness and usually requires treatment from a team of professionals. For more information on traditional treatments for anorexia, see here. If you or a loved one is suffering from anorexia nervosa or another eating disorder, please seek treatment from a qualified treatment provider.

    References

    Dahlgren CL, Rø Ø. (2014). A systematic review of cognitive remediation therapy for anorexia nervosa–development, current state and implications for future research and clinical practice.  Journal of Eating Disorders. 2(1):1–12. 

    Fitzpatrick, K.K. and Lock, J.D. (2014). Cognitive Remediation Therapy with Children and Adolescents in Tchanturia, K., Cognitive Remediation Therapy (CRT) for Eating and Weight Disorders.

    Tchanturia, K., Davies, H., Reeder, C., Wykes, T. (2010).  Cognitive Remediation Therapy for Anorexia Nervosa

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