Family cognitive remediation therapy for anorexia nervosa

The importance of improving cognitive flexibility in adolescents with anorexia nervosa: The case for cognitive remediation therapy

OBJECTIVE

Inefficiencies in executive functioning (EF), more specifically cognitive flexibility and an overly detailed processing style, are frequently observed in individuals with Anorexia Nervosa (AN) and have been identified as potential targets in treatment. Cognitive Remediation Therapy (CRT) is an adjunctive treatment approach specifically designed to have a positive impact on EF. Mainly evaluated in adults, CRT has been criticized for its perceived ineffectiveness in promoting weight restoration or directly reducing eating disorder symptoms.

METHOD

We argue that we need to refocus our conceptual framework for using CRT as an adjunctive treatment and specifically explore its potential benefit in adolescents.

RESULTS

Adolescence is a critical window for EF development during which CRT has the potential to have the most impact. While it may not specifically ameliorate eating disorder symptoms and directly improve weight gain, CRT may mitigate the impact of malnutrition on adolescent brain development, reduce attrition rates in treatment, and improve cognitive flexibility and (indirectly) other maintaining factors, thereby improving global functioning.

DISCUSSION

More research needs to be done to understand the development of EF in adolescents with AN and how best to employ CRT as an adjunctive treatment to support development and target maintaining factors. The current article broadly reviews findings on executive functioning inefficiencies in adolescents with AN and discusses the purpose and role of CRT in treating AN. Finally, we highlight key critiques of using CRT and pose questions for future research.

PUBLIC SIGNIFICANCE

Treatments targeting executive functioning in adolescents with AN are limited. We need to better understand how CRT can benefit adolescents in treatment. Increasing treatment options, including adjunctive treatments, is necessary to reduce the long-term impact of AN.

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.

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.

The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family based treatment for adolescents with anorexia nervosa

BACKGROUND

Adolescents with anorexia nervosa have set-shifting inefficiencies that can be exacerbated by starvation and that may interfere with outcomes of treatment interventions. Cognitive Remediation Therapy (CRT), an adjunctive treatment focused on improving set-shifting, can target inefficiencies and may augment treatment effectiveness. The best way to add CRT to the standard of care (Family Based Treatment, FBT) for adolescents with anorexia remains understudied.

METHODS/DESIGN

This is a randomized controlled trial designed to determine if CRT is effective in increasing flexibility in adolescents with anorexia and/or their parents. Participants are adolescents 12-18 years old with anorexia and their parents. 54 family groups will be randomized into one of three groups: FBT only, FBT plus Parent-focused CRT, or FBT plus Adolescent-focused CRT. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study.

DISCUSSION

This is the first study of its kind to apply CRT to parents. All forms of CRT in the context of anorexia have targeted the individual with anorexia's thinking style. We propose that it may be impactful to target the parent of the adolescent with anorexia as parents carry the burden of treatment and re-nourishment of their child during FBT and may have similar thinking styles.

CONCLUSION

This study takes an experimental therapeutics approach to further our understanding of the mechanisms of treatment for adolescents with anorexia. It focuses on increasing cognitive flexibility in patients or their parents and determining the appropriate dose of CRT needed to achieve positive change.

TRIAL REGISTRATION

ClinicalTrails.gov Identifier NCT03928028.

A randomized controlled trial of group cognitive remediation therapy for anorexia nervosa: Effects on set-shifting tasks for inpatient adults and adolescents

OBJECTIVE

The aim of this randomized controlled trial with a parallel design was to evaluate the effect of brief, cognitive remediation therapy (CRT) for anorexia nervosa (AN) on set-shifting.

METHOD

Two hundred seventy-five inpatient adults and adolescents with AN (mean age = 23.1; SD = 12.7) were randomly assigned (using simple randomization procedures) to either a CRT or control condition. All participants received treatment as usual; however, the CRT condition completed five CRT group sessions in lieu of other group therapies provided on the unit. Set-shifting abilities were evaluated by: (a) neuropsychological measures and (b) experimental cognitive behavior therapy thought records. Blinding of group assignment occurred during baseline assessment and ended following group commencement.

RESULTS

Data from 135 CRT and 140 control condition participants were analyzed. On all neuropsychological measures, results revealed no between group condition effects, but did show statistically significant time effects, with medium to large effect sizes. Thought record analysis revealed a significant condition by age interaction effect where adults in the CRT condition generated significantly more alternative thoughts and had stronger believability of alternative thoughts than children, a trend that was not found in the control condition. This yielded moderate to large effect sizes of.0.56 and 0.72, respectively.

DISCUSSION

Based on traditional neuropsychological measures, these findings do not suggest a differential effect of CRT for AN in the format applied. However, results suggest that CRT may have some increased beneficial cognitive effect for adults, as compared to children, based on thought record analysis.

Cognitive remediation therapy (CRT) as a pretreatment intervention for adolescents with anorexia nervosa during medical hospitalization: a pilot randomized controlled trial protocol

BACKGROUND

Anorexia nervosa (AN) is a severe psychiatric condition characterized by low body weight, fear of weight gain/becoming fat and/or behavior that interferes with weight gain, and body disturbance. Though there have been recent advances in the treatment of AN, there continues to be an urgent need to increase treatment options. Cognitive remediation therapy (CRT) has been successfully used as an adjunctive treatment for individuals with AN. In this study, we pilot the use of CRT plus an innovative parent involvement component as a pre-treatment intervention on a medical unit. We hypothesize that adding CRT with parent involvement to a standard hospital stay is feasible, acceptable by patients and staff, and may improve treatment outcomes post-hospitalization.

METHODS/DESIGN

This is a pilot randomized controlled trial with three arms. Participants are adolescents aged 12-18 with AN; 60 participants will be included. They are randomized into one of three groups: treatment as usual (TAU, standard care at Children's Hospital of Philadelphia), CRT + contact control (known as "Family Fun Time"), and CRT + Teach the Parent. Intervention will occur on an inpatient basis. Follow-up will be outpatient and will continue until 6 months post-discharge. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study, and group differences will be evaluated at 4 weeks, 3 months, and 6 months post-discharge. The study will take place at The Children's Hospital of Philadelphia.

DISCUSSION

This pilot randomized controlled trial will inform feasibility of the integration of a pre-treatment intervention into a medical hospital stay for AN. We will assess recruitment procedures, treatment administration, and participant retention. Finally, a comprehensive assessment battery will be evaluated. Secondary goals are to conduct a preliminary evaluation of whether or not CRT with parent involvement increases rate of weight gain and treatment engagement and decreases parental accommodation of symptoms post-discharge. If successful, this pilot study will inform a larger controlled trial fully powered to examine the secondary goals.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02883413.

Cognitive Remediation Therapy for Adolescents with Anorexia Nervosa-Treatment Satisfaction and the Perception of Change

Cognitive remediation therapy (CRT) has recently been developed for children and adolescents with anorexia nervosa (AN). It focuses on decreasing rigid cognitions and behaviors, as well as increasing central coherence. Overall, CRT has been proven feasible for young individuals with AN, but little is known regarding the specifics of its feasibility, and the perception of change associated with the intervention. Consequently, the aim of the current study was to explore service users’ perspective on CRT with a specific focus on treatment delivery, treatment content, and perceived change. Twenty adolescents (age 13–18) with AN participated in a 10-session course of CRT. A 20-item treatment evaluation questionnaire was administered at the end of treatment, focusing on four aspects of the intervention: (1) general attitudes towards treatment, (2) treatment specifics, (3) the perception of change and (4) the patient-therapist relation. The main findings suggest high levels of treatment satisfaction, but somewhat limited perceptions of change. The current study is one of the most detailed accounts of adolescents’ perspective on CRT published on eating disorders, and highlights several important aspects of the treatment viewed through the eye of the receiver.

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.