Cognitive remediation in anorexia nervosa and related conditions: a systematic review

The set-shifting profiles of anorexia nervosa and autism spectrum disorder using the Wisconsin Card Sorting Test: a systematic review and meta-analysis

Difficulties in set-shifting are commonly reported in both autism spectrum disorder (ASD) and anorexia nervosa (AN) populations. Despite this, it is not known whether this cognitive profile persists across different ages, or whether the profiles seen in ASD and AN are comparable. This systematic review and meta-analyses aimed to compare the set-shifting profiles, as measured by the Wisconsin Card Sorting Test (WCST) in adults and younger people with either ASD or AN, relative to healthy controls (HCs) and to statistically compare performance on the WCST between ASD and AN. In all, 24 studies on ASD and 22 studies on AN were identified. In ASD, there were significant differences between the clinical group and HCs, with the ASD group making significantly more perseverative errors, indicating greater difficulty in set-shifting [pooled effect size of d = 0.67, 95% confidence interval (CI) 0.53-0.81, p ⩽ 0.001]. This effect was consistent across the age span. For AN studies, there was a significant difference between adults with AN and HCs (d = 0.52, 95% CI 0.36-0.68, p ⩽ 0.001) but a non-significant effect in child studies (d = 0.25, 95% CI -0.05 to 0.55, z = 1.66, p = 0.096). Meta-regression indicated no effect of diagnosis (AN or ASD) on performance in adult studies but there was a non-significant trend (p = 0.053) towards children with ASD performing worse than children with AN. While difficulties with set-shifting appear to be stable in ASD, there may be differences between children and adults with AN, which warrant further investigation.

Recent advances in psychological therapies for eating disorders

Recent years have seen substantial consolidation and development of the evidence base for psychological therapies for eating disorders. This review summarises the key changes over that time period. Specific forms of cognitive behavioural therapy and family-based treatment have consolidated and extended their positions as treatments of choice despite the development of novel approaches. However, there is still a significant need for further development and testing to improve recovery rates, particularly in anorexia nervosa.

Are Weight Status and Cognition Associated? An Examination of Cognitive Development in Children and Adolescents with Anorexia Nervosa 1 Year after First Hospitalisation

Objective

The aim of this study was to characterise the association between the cognitive profile and weight restoration in children and adolescents with anorexia nervosa.

Methods

The study was a longitudinal, matched case–control, multicentre study. An assessment of cognitive functions was conducted by using the Wechsler Intelligence Scale for Children–III/the Wechsler Adult Intelligence Scale–III, the Test of Memory and Learning–second edition, Trail Making Tests A and B, the Rey–Osterrieth Complex Figure Test and the Cambridge Neuropsychological Test Automated Battery.

Results

One hundred twenty individuals, 60 patients with anorexia nervosa with mean age of 14.65 (SD 1.820) years and 60 healthy controls with mean age of 14.76 (SD 1.704) years, participated. No association was found between weight recovery and cognitive functions. However, a significant increase in motor speed was found in Trail Making Test A (p = 0.004), Reaction Time (RTI) five‐choice movement time (p = 0.002) and RTI simple movement time (p = 0.011), resulting in a normalisation corresponding to that found in healthy controls. Furthermore, a significantly lower score in the perceptual organization index (p = 0.029) was found at follow‐up.

Conclusions

Weight recovery appears not to be associated with cognition. Copyright © 2016 The Authors European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd

Contributions of cognitive inflexibility to eating disorder and social anxiety symptoms

Eating disorders and social anxiety are highly co-occurring. These disorders share fears of social evaluation, possibly maintained by similar cognitive content and styles, including an inability to adapt or flexibly respond to unexpected conditions. However, the role of cognitive inflexibility in eating disorders in relation to social anxiety has not been explored.

OBJECTIVE

In this study, the link between eating disorder symptoms and cognitive inflexibility, while accounting for social anxiety, is examined.

METHOD

Participants (N=461) were undergraduates who completed the Detail and Flexibility Questionnaire 12-item Cognitive Rigidity subscale, the Eating Disorders Diagnostic Scale, and the Social Interaction Anxiety Scale.

RESULTS

Eating disorder symptoms and social anxiety were both positively correlated with cognitive inflexibility. After controlling for social anxiety, the relationship between eating disorder symptoms and cognitive inflexibility remained robust.

DISCUSSION

Further examination of cognitive inflexibility in eating disorders and comorbid social anxiety in clinical samples is warranted. We suggest future directions for examining cognitive inflexibility as a trans-diagnostic construct important to eating disorders and frequently comorbid disorders, consistent with NIMH Research Domain Criteria.

Brain effects of computer-assisted cognitive remediation therapy in anorexia nervosa: A pilot fMRI study

Poor cognitive-behavioral flexibility is considered a trait marker in anorexia nervosa (AN) that can be improved by cognitive remediation therapy (CRT). The present pilot study aimed at identifying changes in brain function potentially associated with CRT in AN. Data was obtained from a randomized, controlled trial. Twenty-four patients were assessed before and after 30 sessions of either CRT or a non-specific neurocognitive therapy. Voxel-wise analysis of whole brain functional magnetic resonance imaging was applied. Brain activation was measured during response inhibition and task switching. Although results did not reach significance, we found tentative support for CRT-related increases in brain activation in the dorsal putamen during task switching and in the dorsolateral prefrontal, sensorimotor and temporal cortex during response inhibition. These pilot findings provide viable pathways for future research on brain changes underlying CRT in AN.

Benefits of group cognitive remediation therapy in anorexia nervosa: case series

Background

Cognitive remediation therapy (CRT) is a treatment targeting cognitive difficulties in psychiatric disorders. CRT has been used with patients with severe anorexia nervosa (AN) in individual and group formats. Research of group CRT in AN is limited.

Methods

Evaluation of a series of CRT groups delivered in inpatient and intensive daycare services was performed. Participants’ self-reported cognitive flexibility and central coherence, as well as motivation to change were assessed pre- and post-group. Additionally, patients’ evaluative feedback was collected after completion of the group.

Results

There was a significant improvement in the patients’ self-reported cognitive flexibility and bigger picture thinking, as well as in their self-efficacy to change. The feedback questionnaires highlighted that patients found the sessions useful and reported confidence in using some of the skills and strategies they learnt in the group.

Conclusion

In line with evidence from small-scale reports, this larger scale case series study indicates that group CRT leads to increased flexibility and bigger picture thinking, as well as improved confidence in the ability to change for participants. CRT in a group format seems to be a practical and helpful intervention for patients with AN in intensive treatment programmes.

Applying evidence-based management to anorexia nervosa

AIM

This paper considers how the three principles of evidence based practice (clinical expertise, scientific evidence, and patient preference) can be applied to the complexity of treatment for anorexia nervosa AN.

METHOD

A narrative review of the evidence of these three domains is presented. Clinical cases are used to illustrate how the formulation and management can be put into practice at different stages of illness.

RESULTS

The management of anorexia nervosa is complex. First, individuals with the illness do not regard the manifestations of the illness as a source of concern rather they are embraced and integrated into their identity. This contrasts to the reaction of other people who are terrified by the overt signs of ill health. Thus engagement into treatment is problematic. Second, the core symptom restricted eating, produces malnutrition which impacts on brain, body, and the social network. Thus a mixture of psychological and physical problems gradually accumulates over the course of the illness. This means that the treatment targets increase over time.

CONCLUSION

Thus treatment has to work with motivation and readiness to change and tackle the various domains of ill health.

Normative body dissatisfaction and eating psychopathology in teenage girls: the impact of inflexible eating rules

PURPOSE

Adolescence has been considered a critical time for the development of body image-related difficulties and disordered eating behaviours, especially in females. Although adherence to eating rules has been linked to disordered eating, literature has not yet explored how the inflexible subscription to those rules impacts on eating psychopathology. Therefore, the aim of the current study was to explore whether inflexible eating impacts on the relationships between weight and body image-related variables, and disordered eating.

METHODS

Participated in this study are 497 female adolescents from the community, aged between 14 and 18 years old, who completed self-report measures.

RESULTS

Results revealed that the majority of the participants were dissatisfied with their weight and body shape. Moreover, 6.64 % of the participants demonstrated severe eating psychopathology. A path analysis revealed that BMI, body dissatisfaction and social comparisons based on physical appearance impact on disordered eating behaviours, through the mechanism of inflexible adherence to eating rules. This model explained 52 % of eating psychopathology's variance.

CONCLUSIONS

Findings highlight the relevance of body image-related difficulties in adolescence and additionally they emphasise the importance of promoting more flexible attitudes towards eating in prevention and intervention programmes with female adolescents.

Functional connectivity correlates of response inhibition impairment in anorexia nervosa

Anorexia nervosa (AN) is a disorder characterized by high levels of cognitive control and behavioral perseveration. The present study aims at exploring inhibitory control abilities and their functional connectivity correlates in patients with AN. Inhibitory control - an executive function that allows the realization of adaptive behavior according to environmental contingencies - has been assessed by means of the Stop-Signal paradigm. The study involved 155 patients with lifetime AN and 102 healthy women. A subsample underwent resting-state functional magnetic resonance imaging and was genotyped for COMT and 5-HTTLPR polymorphisms. AN patients showed an impaired response inhibition and a disruption of the functional connectivity of the ventral attention circuit, a neural network implicated in behavioral response when a stimulus occurs unexpected. The 5-HTTLPR genotype appears to significantly interact with the functional connectivity of ventral attention network in explaining task performance in both patients and controls, suggesting a role of the serotoninergic system in mechanisms of response selection. The disruption of the ventral attention network in patients with AN suggests lower efficiency of bottom-up signal filtering, which might be involved in difficulties to adapt behavioral responses to environmental needs. Our findings deserve further research to confirm their scientific and therapeutic implications.

Anorexia nervosa: aetiology, assessment, and treatment

Anorexia nervosa is an important cause of physical and psychosocial morbidity. Recent years have brought advances in understanding of the underlying psychobiology that contributes to illness onset and maintenance. Genetic factors influence risk, psychosocial and interpersonal factors can trigger onset, and changes in neural networks can sustain the illness. Substantial advances in treatment, particularly for adolescent patients with anorexia nervosa, point to the benefits of specialised family-based interventions. Adults with anorexia nervosa too have a realistic chance of achieving recovery or at least substantial improvement, but no specific approach has shown clear superiority, suggesting a combination of re-nourishment and anorexia nervosa-specific psychotherapy is most effective. To successfully fight this enigmatic illness, we have to enhance understanding of the underlying biological and psychosocial mechanisms, improve strategies for prevention and early intervention, and better target our treatments through improved understanding of specific disease mechanisms.

Anorexia nervosa

Anorexia nervosa (AN) is a psychiatric condition characterized by severe weight loss and secondary problems associated with malnutrition. AN predominantly develops in adolescence in the peripubertal period. Without early effective treatment, the course is protracted with physical, psychological and social morbidity and high mortality. Despite these effects, patients are noted to value the beliefs and behaviours that contribute to their illness rather than regarding them as problematic, which interferes with screening, prevention and early intervention. Involving the family to support interventions early in the course of the illness can produce sustained changes; however, those with a severe and/or protracted illness might require inpatient nursing support and/or outpatient psychotherapy. Prevention programmes aim to moderate the overvaluation of 'thinness' and body dissatisfaction as one of the proximal risk factors. The low prevalence of AN limits the ability to identify risk factors and to study the timing and sex distribution of the condition. However, genetic profiles, premorbid features, and brain structures and functions of patients with AN show similarities with other psychiatric disorders and contrast with obesity and metabolic disorders. Such studies are informing approaches to address the neuroadaptation to starvation and the other various physical and psychosocial deficits associated with AN. This Primer describes the epidemiology, diagnosis, screening and prevention, aetiology, treatment and quality of life of patients with AN.

Cognitive remediation therapy for eating disorders

PURPOSE OF REVIEW

This review compares the literature on cognitive remediation therapy (CRT) for eating disorders with findings in the field of schizophrenia, and discusses future directions for CRT for eating disorders.

RECENT FINDINGS

First studies using a randomized controlled trial design show the added value of CRT for eating disorders. Patients reported lessened symptoms and further improvements in quality of life and cognitive flexibility. Furthermore, the acceptability of the intervention was good and attrition rates for CRT itself were low. Research into the use of cognitive remediation for schizophrenia is extensive and the results on global cognition appeared to be robust at post-treatment and durable at follow-up, with small to medium effect sizes. Recent articles within the field of schizophrenia emphasize the necessity of intrinsic motivation to translate cognitive gains into actual changes in everyday life.

SUMMARY

A next step is to examine the impact of CRT for eating disorders on motivation. It is also important to focus on the transdiagnostic use of CRT, considering the overlap in cognitive inefficiencies between eating disorders. Another important step may be to develop effective personalized methods of CRT by taking into account individual differences in cognitive processes most relevant to improvement in outcome.

Are There Differences in Central Coherence and Set Shifting Across the Subtypes of Anorexia Nervosa?: A Systematic Review

Anorexia nervosa (AN) has been associated with weaknesses in central coherence and set shifting. In this line, it has been proposed to directly address these neuropsychological features in treatment (e.g., cognitive remediation therapy). It is not clear, however, whether the 2 subtypes of AN, the restricting (AN-R) and bingeing/purging (AN-BP) type, have the same amount of problems in these domains. A systematic search of the literature was conducted, using the databases Web of Science and PubMed, looking for studies on the comparison of AN-R and AN-BP in performing central coherence/set-shifting tasks. Notably, very few authors describe the results of a direct comparison of the performance of patients with AN-R and AN-BP. In summary, the available indications for possible group differences are not strong enough to draw definitive conclusions.

Striatal dopamine type 2 receptor availability in anorexia nervosa

The neurobiology of anorexia nervosa remains incompletely understood. Here we utilized PET imaging with the radiotracer [(11)C]raclopride to measure striatal dopamine type 2 (D2) receptor availability in patients with anorexia nervosa. 25 women with anorexia nervosa who were receiving treatment in an inpatient program participated, as well as 25 control subjects. Patients were scanned up to two times with the PET tracer [(11)C]raclopride: once while underweight, and once upon weight restoration. Control subjects underwent one PET scan. In the primary analyses, there were no significant differences between underweight patients (n=21) and control subjects (n=25) in striatal D2 receptor binding potential. Analysis of subregions (sensorimotor striatum, associative striatum, limbic striatum) did not reveal differences between groups. In patients completing both scans (n=15), there were no detectable changes in striatal D2 receptor binding potential after weight restoration. In this sample, there were no differences in striatal D2 receptor binding potential between patients with anorexia nervosa and control subjects. Weight restoration was not associated with a change in striatal D2 receptor binding. These findings suggest that disturbances in reward processing in this disorder are not attributable to abnormal D2 receptor characteristics, and that other reward-related neural targets may be of greater relevance.

Gyrification brain abnormalities as predictors of outcome in anorexia nervosa

Gyrification brain abnormalities are considered a marker of early deviations from normal developmental trajectories and a putative predictor of poor outcome in psychiatric disorders. The aim of this study was to explore cortical folding morphology in patients with anorexia nervosa (AN). A MRI brain study was conducted on 38 patients with AN, 20 fully recovered patients, and 38 healthy women. Local gyrification was measured with procedures implemented in FreeSurfer. Vertex-wise comparisons were carried out to compare: (1) AN patients and healthy women; (2) patients with a full remission at a 3-year longitudinal follow-up assessment and patients who did not recover. AN patients exhibited significantly lower gyrification when compared with healthy controls. Patients with a poor 3-year outcome had significantly lower baseline gyrification when compared to both healthy women and patients with full recovery at follow-up, even after controlling for the effects of duration of illness and gray matter volume. No significant correlation has been found between gyrification, body mass index, amount of weight loss, onset age, and duration of illness. Brain gyrification significantly predicted outcome at follow-up even after controlling for the effects of duration of illness and other clinical prognostic factors. Although the role of starvation in determining our findings cannot be excluded, our study showed that brain gyrification might be a predictor of outcome in AN. Further studies are needed to understand if brain gyrification abnormalities are indices of early neurodevelopmental alterations, the consequence of starvation, or the interaction between both factors.

Cognitive Remediation Therapy for Children with Anorexia Nervosa

Abstract. Objective: Evidence-based treatment programs for children with anorexia nervosa (AN) are scarce, while their prognosis is negative and the incidence rate rises. A new therapeutic approach recently received positive attention: cognitive remediation therapy (CRT). This intervention targets inflexibility and the inability to perceive the bigger picture in persons with AN. So far, studies and case reports have focused on either adolescent or adult patients and less on young children with AN. This case report therefore describes and evaluates the implementation of CRT with a child with AN. Method: A 12-year-old girl with severe chronic AN was treated with 10 sessions of CRT. Her clinical and neuropsychological evaluations before, directly after and 7 months after CRT are reported. Additionally, the patient’s written and verbal feedbacks are reviewed. Results: At the 7-month follow-up the patient showed a stable healthy weight and reported a reduced presence of psychopathology. Her neuropsychological performance directly after CRT and after 7 months did not improve. Conclusions: The clinical evaluation of our case report suggests that CRT may be a promising add-on therapy in the clinical treatment of young girls with AN.

Verbal Versus Figural Fluency Tests in Currently Ill and Weight Restored Anorexia Nervosa Patients

Fluency tests allow domain-specific assessment of verbal and non-verbal executive functions (EF) comparison and also enable utilizing of both quantitative and qualitative scoring methods. Thirty-five currently ill anorexia nervosa patients (PANs), 33 weight-restored patients (WRAN) and 47 healthy controls (HCs) were administered the word fluency test and the five-point test. Results show that WRANs tended to perseverate more than HCs in the verbal-fluency test. In addition, PANs produced significantly less correct figures and perseverated more than HCs and WRANs; HCs used more strategy methods than PANs and WRANs. Additionally, a positive correlation was found in the HC group between the total number of words in the verbal phonemic test and the number of designs produced and the number of correct designs. No such correlations were found in both anorexia groups. In conclusion, there is a differentiation between verbal and non-verbal EF in PANs and WRANs, showing a deficiency in the non-verbal domain. These findings may contribute to our understanding of the cognitive nature of the disorder.

Do Children and Adolescents with Anorexia Nervosa Display an Inefficient Cognitive Processing Style?

OBJECTIVE

This study aimed to examine neuropsychological processing in children and adolescents with Anorexia Nervosa (AN). The relationship of clinical and demographic variables to neuropsychological functioning within the AN group was also explored.

METHOD

The performance of 41 children and adolescents with a diagnosis of AN were compared to 43 healthy control (HC) participants on a number of neuropsychological measures.

RESULTS

There were no differences in IQ between AN and HC groups. However, children and adolescents with AN displayed significantly more perseverative errors on the Wisconsin Card Sorting Test, and lower Style and Central Coherence scores on the Rey Osterrieth Complex Figure Test relative to HCs.

CONCLUSION

Inefficient cognitive processing in the AN group was independent of clinical and demographic variables, suggesting it might represent an underlying trait for AN. The implications of these findings are discussed.

Could training executive function improve treatment outcomes for eating disorders?

Current gold standard treatments for eating disorders (EDs) lack satisfactory efficacy, and traditional psychological treatments do not directly address executive functioning deficits underpinning ED pathology. The goal of this paper is to explore the potential for enhancing ED treatment outcomes by improving executive functioning deficits that have been demonstrated to underlie eating pathology. To achieve our objective, we (1) review existing evidence for executive functioning deficits that underpin EDs and consider the extent to which these deficits could be targeted in neurocognitive training programs, (2) present the evidence for the one ED neurocognitive training program well-studied to date (Cognitive Remediation Therapy), (3) discuss the utility of neurocognitive training programs that have been developed for other psychiatric disorders with similar deficits, and (4) provide suggestions for the future development and research of neurocognitive training programs for EDs. Despite the fact that the body of empirical work on neurocognitive training programs for eating disorders is very small, we conclude that their potential is high given the combined evidence for the role of deficits in executive functioning in EDs, the initial promise of Cognitive Remediation Training, and the success in treating related conditions with neurocognitive training. Based on the evidence to date, it appears that the development and empirical evaluation of neurocognitive training programs for EDs is warranted.

Cognitive Remediation and Emotion Skills Training (CREST) for anorexia nervosa in individual format: self-reported outcomes

BACKGROUND

To evaluate self-reported outcomes after a brief course of skills-based individual therapy for inpatients with anorexia nervosa (AN).

METHODS

In this case series study 37 adults with AN participated in cognitive remediation and emotion skills training (CREST) sessions, and completed social anhedonia, alexithymia and motivational measures before and after the intervention.

RESULTS

The CREST primary outcome measures were total scores on the Revised Social Anhedonia Scale (RSAS), which decreased significantly (p = 0.03) with an effect size of 0.31, and the Toronto Alexithymia Scale (TAS), which also decreased significantly (p = 0.05) with an effect size of 0.35. The secondary outcome measures focused on motivation: perceived 'importance to change' and 'ability to change'; the second of which increased significantly (p < 0.001) with a medium effect size (d = 0.71).

CONCLUSIONS

The individual format of CREST led to a decrease in patients' self-reported social anhedonia, an improvement in the ability to label their emotions, and increased confidence in their ability to change. Considering the limited number of individual sessions, this is a promising preliminary finding which warrants further research.

Acceptability and feasibility of self-help Cognitive Remediation Therapy for anorexia nervosa delivered in collaboration with carers: a qualitative preliminary evaluation study

Anorexia nervosa (AN) is an eating disorder without a recommended first-line treatment. Cognitive Remediation Therapy (CRT) is showing great promise in helping patients reduce cognitive inflexibility and excessive detail focus, thinking styles that could make engaging in psychological therapies difficult. CRT has shown to be effective, feasible and acceptable in both individual and group formats, and positive qualitative data has been gathered from both service users and clinicians. The aim of the current study was to assess the use of CRT as a self-help treatment for individuals with AN delivered in collaboration with carers. Six families underwent a six-week self-help CRT intervention. Feedback was gathered from qualitative interviews and analysed using thematic analysis. Neuropsychological outcomes were also collected. Participant feedback regarding the intervention was generally positive, with participants describing a number of benefits such as it creating a space for families to spend time together outside of the eating disorder, acting as a 'gateway' for more emotional work and helping participants to gain insight into their cognitive profiles. These preliminary findings suggest that self-help CRT delivered in collaboration with carers is an acceptable form of treatment, and adds to the growing literature supporting CRT for AN.