Group cognitive remediation therapy for adult anorexia nervosa inpatients: first experiences

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

PURPOSE

Anorexia nervosa (AN) is a mental disorder for which hospitalization is frequently needed in case of severe medical and psychiatric consequences. We aim to describe the state-of-the-art inpatient treatment of AN in real-world reports.

METHODS

A systematic review of the literature on the major medical databases, spanning from January 2011 to October 2023, was performed, using the keywords: "inpatient", "hospitalization" and "anorexia nervosa". Studies on pediatric populations and inpatients in residential facilities were excluded.

RESULTS

Twenty-seven studies (3501 subjects) were included, and nine themes related to the primary challenges faced in hospitalization settings were selected. About 81.48% of the studies detailed the clinical team, 51.85% cited the use of a psychotherapeutic model, 25.93% addressed motivation, 100% specified the treatment setting, 66.67% detailed nutrition and refeeding, 22.22% cited pharmacological therapy, 40.74% described admission or discharge criteria and 14.81% follow-up, and 51.85% used tests for assessment of the AN or psychopathology. Despite the factors defined by international guidelines, the data were not homogeneous and not adequately defined on admission/discharge criteria, pharmacological therapy, and motivation, while more comprehensive details were available for treatment settings, refeeding protocols, and psychometric assessments.

CONCLUSION

Though the heterogeneity among the included studies was considered, the existence of sparse criteria, objectives, and treatment modalities emerged, outlining a sometimes ambiguous report of hospitalization practices. Future studies must aim for a more comprehensive description of treatment approaches. This will enable uniform depictions of inpatient treatment, facilitating comparisons across different studies and establishing guidelines more grounded in scientific evidence.

LEVEL OF EVIDENCE

Level I, systematic review.

The Efficacy of Cognitive Remediation Therapy for Anorexia Nervosa: A Systematic Review of Systematic Reviews

BACKGROUND

Cognitive remediation therapy (CRT) for anorexia nervosa (AN) is an intervention specifically focused on addressing cognitive difficulties associated with the eating disorder. This systematic review of systematic reviews and meta-analysis aimed to provide a summary of the existing literature examining the efficacy of CRT in improving the neuropsychological, psychological, and clinical parameters of patients with AN.

METHODS

Systematic reviews and meta-analyses were sought in electronic databases, encompassing studies that explored the impact of CRT on AN. Three eligible reviews were identified based on the inclusion criteria. The Revised Assessment of Multiple SysTemAtic Reviews (R-AMSTAR) was employed to evaluate the methodological quality of the reviews, and all included reviews demonstrated satisfactory methodological quality with an R-AMSTAR score of ≥22. Relevant information was extracted from each review and qualitatively compiled.

RESULTS

Findings suggest that CRT can help people increase their awareness of cognitive styles and information processing and have a positive effect on patients' responses to treatment.

CONCLUSIONS

Further research is required to better understand its impact on other relevant outcomes, including psychological variables, to optimize the treatment's benefits.

A benchmark study of a combined individual and group anorexia nervosa therapy program

OBJECTIVE

Anorexia nervosa (AN) is a treatment-resistant illness. Up to half of the patients show limited or no significant treatment response. First, we aimed to describe a new stepped-care outpatient treatment combining group and individual therapy (CIGAN) with a strong focus on normalizing eating and weight and in vivo meal support for adults with moderate to severe AN. Second, we aimed to compare CIGAN with specialized treatments of Specialized Supportive Clinical Management (SSCM) and the Maudsley model of AN (MANTRA).

METHOD

The study includes 137 adults with moderate to severe AN and the primary outcome (BMI) at six and twelve months was compared with the outcomes published for SSCM and MANTRA using the Chi-squared test and Student's t-test. The paired t-test and Cohen's d were used to compare the within-group follow-up data with the baseline data.

RESULTS

CIGAN patients changed significantly on all outcome measures at 6 and 12 months, with effect sizes on BMI of 1.37 and 1.51 and on the weight of 1.36 and 1.60, respectively. Except for the 12-month comparison with MANTRA, patients had a higher BMI and larger BMI increase at both 6 and 12 months than SSCM (BMI p = 0.002 and 0.023, BMI increase p < 0.001 and 0.003) and MANTRA (BMI p = 0.031 and 0.168, BMI increase p < 0.001 and 0.037).

DISCUSSION

CIGAN, including a stepped care approach, is a promising treatment, and further research on the effective elements is warranted.

Adolescents With Autism Spectrum Disorder and Anorexia Nervosa Comorbidity: Common Features and Treatment Possibilities With Cognitive Remediation Therapy and Oxytocin

Autistic traits or autism spectrum disorder (ASD) can be found in 4% to 52% of anorexic patients, which makes the treatment of these patients very challenging. In this review, possible ways to treat ASD and anorexia nervosa (AN) comorbidity in children and adolescents are summarized. Over recent years, the focus has shifted from searching for the evidence of connections between these two disorders, which have started with Gillberg's study in 1983, to searching for more effective and holistic treatment of this comorbidity. The latter is known to contribute to more severe courses and worse prognosis, which is probably related to the obstacles in both diagnosing and treating. Since AN usually starts in early adolescence and high-functioning ASD children seem to begin struggling with increased pressure in adolescence, while various comorbidities can occur, it is important to improve the treatment of this comorbidity in young patients and to tailor it specifically in terms of diagnosing. In this paper, a literature review is conducted on common features and promising treatment possibilities. We describe cognitive remediation therapy and the promising pharmacotherapeutic candidate oxytocin with a special focus on adolescents.

Neurocognitive Treatments for Eating Disorders and Obesity

PURPOSE OF REVIEW

Recent research has highlighted executive function and neurocognitive deficits among individuals with eating and weight disorders, identifying a potential target for treatment. Treatments targeting executive function for eating and weight disorders are emerging. This review aims to summarize the recent literature evaluating neurocognitive/executive function-oriented treatments for eating and weight disorders and highlights additional work needed in this area.

RECENT FINDINGS

Cognitive remediation therapy (CRT) for anorexia nervosa has been the most extensively studied neurocognitive treatment for eating disorders. Results demonstrate that CRT improves executive function and may aid in the reduction of eating disorder symptomatology. Computer training programs targeting modifying attention and increasing inhibition are targeting reduction of binge eating and weight loss with modest success. Neurocognitive treatments are emerging and show initial promise for eating and weight disorders. Further research is necessary to determine whether these treatments can be used as stand-alone treatments or whether they need to be used as an adjunct to or in conjunction with other evidence-based treatments to improve outcomes.

Applying neurobiology to the treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a severe, biologically based brain disorder with significant medical complications. It is critical that new, effective treatments are developed to interrupt the persistent course of the illness due to the medical and psychological sequelae. Several psychosocial, behavioral and pharmacologic interventions have been investigated in adult anorexia nervosa; however, evidence shows that their impact is weak and treatment effects are generally small.

METHOD

This paper describes a new neurobiological anorexia nervosa model that shifts focus from solely external influences, such as social and family, to include internal influences that integrate genetic and neurobiological contributions, across the age span. The model serves as a theoretical structure for a new, five-day treatment, outlined in this paper, targeting anorexia nervosa temperament, which integrates neurobiological dimensions into evidence-based treatment interventions. The treatment is in two phases. Phase I is a five day, 40 hour treatment for anorexia nervosa adults. Phase II is the follow-up and is currently being developed.

RESULTS

Preliminary qualitative acceptability data on 37 adults with anorexia nervosa and 60 supports (e.g., spouses, parents, aunts, friends, partners, children of anorexia nervosa adults) are promising from Phase I. Clients with anorexia nervosa and their supports report that learning neurobiological facts improved their understanding of the illness and helped equip them with better tools to manage anorexia nervosa traits and symptoms. In addition, nutritional knowledge changed significantly.

CONCLUSIONS

This is the first neurobiologically based, five-day treatment for adults with anorexia nervosa and their supports. It is a new model that outlines underlying genetic and neurobiological contributions to anorexia nervosa that serves as a foundation to treat both traits and symptoms. Preliminary qualitative findings are promising, with both clients and supports reporting that the neurobiological treatment approach helped them better understand the illness, while better conceptualizing how to respond to their traits and manage their symptoms. Data in Phase I shows promise as a neurobiologically based intervention for anorexia nervosa, and it serves as a foundation for the development of Phase II. Evidence of ongoing program efficacy will be described as data are reported on Phase II.

TRIAL REGISTRATION

NCT NCT02852538 Registered 1 August 2016.

How anorexia nervosa patients with high and low autistic traits respond to group Cognitive Remediation Therapy

BACKGROUND

The current study aimed to evaluate group Cognitive remediation therapy (CRT) inpatients with Anorexia Nervosa (AN). We aimed to examine the treatment response of group CRT in AN patients with high or low levels of autistic traits.

METHODS

Thirty-five in patients with an AN diagnosis received group CRT intervention for 6 sessions in a national eating disorder unit. All participants completed self-report questionnaires on thinking styles and motivation before and after the intervention.

RESULTS

Patients with low autistic traits had statistically significant medium size effect improvements in self-reported thinking style scales as well as confidence (ability) to change. Patients with high autistic traits showed no statistically significant improvements in any outcome measure.

CONCLUSIONS

The brief group format CRT intervention improves self-reported cognitive and motivational aspects in people with AN without autistic traits. For patients with higher autistic traits brief group CRT does not improve self-reported cognitive style or motivation. This finding suggests that brief group format CRT might not be the best suited format for individuals with elevated autistic traits and individual or more tailored CRT should be explored.

Neurobiologically informed treatment for adults with anorexia nervosa: a novel approach to a chronic disorder

Anorexia nervosa (AN) is a severe and debilitating disorder with significant medical and psychological sequelae. To date, there are no effective treatments for adults, resulting in high rates of chronicity, morbidity, and mortality. Recent advances in brain imaging research have led to an improved understanding of etiology and specific neurobiological mechanisms underlying symptoms. Despite this, there are no treatments focused on targeting symptoms using this empirically supported mechanistic understanding of the illness. Updated treatment approaches focused on targeting neurobiological mechanisms underlying core AN symptomatology are necessary to improve treatment out-comes for this population. Neurobiologically Enhanced With Family Eating Disorder Trait Response Treatment (NEW FED TR) is a neurobiologically informed treatment targeting key temperament constructs associated with the illness through the delivery of psychoeducation and skills training to patients and nominated carers.

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.

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.

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

Research evidence for cognitive remediation therapy's (CRT) effectiveness for anorexia nervosa (AN) has been gathering. This approach is also increasingly being implemented in other disorders including major depressive disorder, obsessive-compulsive disorder and autistic spectrum disorder that share commonalities with AN in neuropsychological profiles and clinical presentations. This systematic literature review identified and appraised the current evidence base to see whether evidence from related conditions could be integrated into the theoretical understanding of CRT for AN as well as future AN treatment developments and research. Overall, CRT studies in AN report promising findings, and CRT appears to be associated with improvements in set-shifting and in central coherence. Cognitive remediation approaches in other conditions also show promising evidence in associated improvements in areas of executive functioning and information processing; links are made between AN treatment and what future treatment developments could consider.

A systematic review of cognitive remediation therapy for anorexia nervosa - development, current state and implications for future research and clinical practice

OBJECTIVE

To systematically review studies of cognitive remediation therapy (CRT) for anorexia nervosa (AN), and to discuss findings with references to clinical practice and future research.

METHOD

The literature was reviewed using the PubMed, Web of Science and PsycINFO search terms "cognitive remediation therapy" AND "anorexia nervosa". Papers published online between 2005 and 2013 were selected on the basis of three inclusion criteria: 1) studies of any design focusing on CRT for AN, 2) papers that were written in English or had an available published English translation, and 3) papers published in peer reviewed journals.

RESULTS

A total of 45 papers were identified of which 21 were recognized as being relevant for the review. Relevant papers were divided into three different categories 1) single case reports, 2) case series and 3) randomised controlled trials (RCTs). Single case studies and case series yielded strong evidence of feasibility and acceptability of CRT for AN despite great variety in sample compositions. Four RCTs demonstrate that CRT has the potential of enhancing the effectiveness of current treatments, reduce attrition, increase cognitive set-shifting abilities and quality of life, as well as reduce eating disorder psychopathology.

DISCUSSION

The number of CRT studies published is growing rapidly, in particular RCTs. Further research is needed to define the primary aim of delivering CRT to patients with eating disorders, and to establish how to best measure the effect of the intervention. Moreover, researchers and clinicians should focus on identifying and assessing specific versus non-specific CRT contributions, and explore long-term effects of the intervention. It is imperative that adolescent RCTs are conducted to evaluate how CRT may be effective as a treatment for this young patient group.

Neuropsychological variables and clinical status in anorexia nervosa: relationship between visuospatial memory and central coherence and eating disorder symptom severity

AIM

To explore the relationship between visuospatial memory, weak central coherence, and eating disorder (ED) symptoms in anorexia nervosa (AN) inpatients.

SAMPLE

31 female AN inpatients.

METHODS

Rey complex figure test (RCFT) was used to assess both visuospatial memory and central coherence. RCFT consisted of copy and recall trials. ED symptoms were assessed by The Eating Disorder Examination-Questionnaire (EDE-Q) and The Clinical and Research Inventory for Eating Disorders (CR-EAT).

RESULTS

We found a statistically significant negative correlation between recall accuracy and the total EDE-Q score. Furthermore, recall accuracy and recall central coherence significantly negatively correlate with several EDE-Q and CR-EAT scales.

CONCLUSIONS

These findings may contribute to a better understanding of cognitive impairments specifically in ED, and to refining interventions aiming at their improvement.