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

Impact of virtual adjunctive cognitive remediation therapy on cognitive flexibility and treatment outcomes in comorbid anorexia nervosa and exercise dependence as quantified using novel biomarkers: A stage 1 registered report

OBJECTIVE

Anorexia nervosa (AN) is associated with significant individual mental and physical suffering and public health burden and fewer than half of patients recover fully with current treatments. Comorbid exercise dependence (ExD) is common in AN and associated with significantly worse symptom severity and treatment outcomes. Research points to cognitive inflexibility as a prominent executive function inefficiency and transdiagnostic etiologic and maintaining mechanism linking AN and ExD. This study will evaluate the initial efficacy of adjunctive Cognitive Remediation Therapy (CRT), which has been shown to produce cognitive improvements in adults with AN, in targeting cognitive inflexibility in individuals with comorbid AN and ExD. As an exploratory aim, this study also addresses the current lack of quick and cost-effective assessments of cognitive flexibility by establishing the utility of two proposed biomarkers, heart rate variability and salivary oxytocin.

METHOD

We will conduct a single-group, within-subjects trial of an established CRT protocol delivered remotely as an adjunct to inpatient or intensive outpatient treatment as usual (TAU) to adult patients (n = 42) with comorbid AN and ExD. Assessments, including self-report, neuropsychological, and biomarker measurements, will occur at three time points.

RESULTS

We expect CRT to increase cognitive flexibility transdiagnostically and consequently, along with TAU, positively impact AN and ExD compulsivity and symptom severity, including weight gain.

DISCUSSION

Findings will inform the development of more effective integrative interventions for AN and ExD targeting shared mechanisms and facilitate the routine assessment of cognitive flexibility as a transdiagnostic risk and maintaining factor across psychopathologies in clinical and research settings.

PUBLIC SIGNIFICANCE

Patients with anorexia nervosa often engage in excessive exercise, leading to harmful outcomes, including increased suicidal behavior. This study examines the preliminary efficacy of an intervention that fosters flexible and holistic thinking in patients with problematic eating and exercise to, along with routine treatment, decrease harmful exercise symptoms. This study also examines new biological markers of the inflexible thinking style thought to be characteristic of anorexia nervosa and exercise dependence.

Adaptations of cognitive remediation therapy for adolescents with anorexia nervosa for delivery via telehealth

OBJECTIVE

The COVID-19 pandemic hastened a transition to treatment delivery via telehealth. While barriers still exist, the increased uptake of telehealth has the potential to increase access to mental health treatment for all diagnoses, including eating disorders. Delivery of evidence-based treatment as well as adjunctive treatments, including those that are hard to find in-person, have been modified to virtual format to increase accessibility and allow for continuity of care for adolescents with anorexia nervosa.

METHOD

We describe how to modify and deliver Cognitive Remediation Therapy for youth with anorexia nervosa (CRT-AN) via a telehealth platform. Preliminary and practical guidance for best practice for both group and individual delivery is established.

RESULTS

With minimal modifications, CRT-AN can be delivered via telehealth for both individual and group delivery. More disengagement in group delivery was noted; however, overall application of the treatment via a remote platform was observed.

DISCUSSION

As more treatment moves to a telehealth format, highlighting how an adjunctive treatment like CRT-AN can combined with other treatments in a telehealth format has the potential to increase research in its implementation and furthermore increase its dissemination.

PUBLIC SIGNIFICANCE

Cognitive Remediation Therapy for Anorexia Nervosa (CRT-AN) requires significant manipulation of materials and supplementary human guidance. Suggestions for how to modify CRT-AN for remote delivery via telehealth are provided. Modifications grew out of immediate changes made during the beginning of the COVID-19 pandemic and can be used to inform changes therapists and programs can make to continue to or begin to use CRT-AN in a remote fashion.

Post-traumatic stress symptoms in parents of adolescents hospitalized with Anorexia nervosa

The current study was a planned secondary analysis to examine post-traumatic stress symptoms (PTSS) in parents of youth hospitalized for medical stabilization due to anorexia nervosa (AN). Questionnaires were administered to 47 parents (34 mothers, 13 fathers; 10 parental dyads) after admission; follow-up occurred at discharge and 4 weeks, 3 months, and 6 months post-discharge. PTSS were present in the majority of mothers (55.9%) and fathers (61.5%). PTSS were not associated with illness severity, but were associated with parental report of mood symptoms, avoidance, inflexibility, and symptom accommodation. Parental PTSS may negatively impact the adolescent rate of weight gain post-discharge. As hospitalization of a child for medical management of AN can be a traumatizing experience for parents, astute attention should be paid by medical staff to their needs. More work needs to be done to understand the impact of PTSS on parents of adolescents with AN.

Young people and parents' views towards individual cognitive remediation therapy-qualitative findings from a feasibility randomised controlled trial

PURPOSE

Cognitive Remediation Therapy (CRT) has been used mostly in adults. Randomised Controlled Trials (RCTs) in anorexia nervosa (AN) have shown that CRT enhances cognitive flexibility, abstract thinking and is associated with quality-of-life improvement. More research is needed in younger populations.

METHODS

A single-centre feasibility RCT with young people (YP) with AN was conducted in an inpatient setting. A secondary aim of this study was to explore patient satisfaction and parents' views towards CRT to inform further development and implementation of CRT in YP. YP were asked to complete a therapy feedback questionnaire and write a letter with their views on CRT. Parents were asked to complete a questionnaire exploring their perceptions of CRT. Data were analysed using inductive thematic and deductive content analysis.

RESULTS

Both YP and parents valued CRT. Its engaging and pragmatic nature and its focus on thinking styles were perceived as a novel aspect. Parents expressed the need to be involved in the sessions to be able to continue to support their children at home.

CONCLUSIONS

This study confirms previous qualitative findings. Should a fully powered RCT be conducted, it would be important to take into account these findings to further adapt the content of the CRT sessions to the YP needs and to consider their parents' involvement in the sessions, which could also increase the likelihood of parents' engagement in providing their feedback.

LEVEL OF EVIDENCE

Level I: Evidence obtained from one randomized controlled trial.

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.

Cognitive remediation therapy for anorexia nervosa as a rolling group intervention: Data from a longitudinal study in an eating disorders specialized inpatient unit

Objective

Cognitive remediation therapy (CRT) has been proposed as an add‐on treatment approach that could increase the engagement in treatment of anorexia nervosa (AN) patients and reduce maintaining factors, but prior studies have evaluated CRT in individual and group settings, difficult protocols for rehabilitation settings. Our aim is to evaluate the CRT rolling protocol implementation in an inpatient specialised unit.

Methods

A historical longitudinal controlled study was designed to include 31 AN patients for the CRT program, and 28 AN patients treated as usual. The CRT rolling group was implemented in a multidisciplinary inpatient rehabilitation ward with both adolescent and adult patients and an 8‐weeks protocol. To evaluate the treatment implementation effect, different self‐administered questionnaires were used.

Results

The study found greater improvements of the CRT group in clinical symptomatology (p = 0.039), flexibility (p = 0.003), self‐confidence about the ability to change (p < 0.001), and less short‐term focus (p < 0.001), with no differences between restrictive and binge‐purging patients.

Conclusion

This study demonstrates that CRT rolling group protocol is feasible in an inpatient treatment setting and may improve a rehabilitation program's outcome. Our results have shown how CRT can influence cognitive styles considered AN maintenance factors, positively affecting both restrictive and binge‐purge type.

Cognitive remediation therapy (CRT) could be implemented in an inpatient setting with a rolling protocol

CRT improves flexibility, drive to change, and therapy engagement

No differences between restrictive or binge/purge subgroups

Both adolescent and adult patients improved their cognitive styles

Conducting a Pilot Randomized Controlled Trial on a Medical Inpatient Unit Utilizing Cognitive Remediation Therapy for Adolescents with Restrictive Eating Disorders: Protocol Updates and Reflections on Feasibility

We conducted a pilot randomized control trial (RCT) to simultaneously examine the feasibility of effectively implementing Cognitive Remediation Therapy (CRT) for adolescents with anorexia nervosa (AN) during medical hospitalization at a single-site hospital center. Employment of this protocol occurred on a general medical unit with diverse medical admitting diagnoses, not an eating disorder floor of a hospital and not part of a structured inpatient anorexia nervosa treatment program. This was the first time an RCT for a psychosocial intervention was implemented on this unit with patients with eating disorders. Here, we describe the process of piloting the study, including modifications that needed to be made to the original protocol. We also describe the feedback from major stakeholders regarding the process of conducting the pilot study. We summarize lessons learned and steps to take for smooth integration of an RCT of a therapeutic intervention on medical unit.Trial registration: ClinicalTrials.gov Identifier NCT02883413.

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 preliminary systematic review and meta-analysis of randomized-controlled trials of cognitive remediation therapy for anorexia nervosa

Cognitive remediation therapy (CRT) for anorexia nervosa (AN) was developed as an adjuvant treatment to target set-shifting and central coherence inefficiencies important in AN and to ultimately improve clinical outcomes of those with AN. The primary aim of this preliminary systematic review and meta-analysis was to determine the effect of CRT for AN relative to control treatments in randomized-controlled trials (RCTs) on neuropsychological inefficiencies at end-of-treatment. Secondary aims were to assess the effect of CRT for AN on dropout, eating-disorder-related, and other psychological outcomes at end-of-treatment. Systematic review and meta-analytic procedures were conducted in accordance with PRISMA Guidelines. RCTs evaluating CRT for AN compared to a control treatment were identified via ProQuest, PsycINFO, PubMed, and SCOPUS. Seven RCTs and one quasi-RCT of CRT for AN were included. RCT quality ratings ranged from fair (n = 3) to good (n = 4). Random-effects meta-analysis was conducted using Hedge's g. Study heterogeneity was assessed using I2 and publication bias was assessed with Begg's adjusted-rank correlation and the trim-and-fill method. CRT was not associated with improvement in central coherence compared to control treatments at end-of-treatment (g = 0.25, 95% CI = -0.35, 0.85, k = 3). Set-shifting outcomes were mixed due to heterogeneity of set-shifting measures across studies. CRT may prevent dropout; yet, more studies are needed to draw conclusions. CRT did not confer advantage over control treatments for eating-disorder-related and other psychological outcomes at end-of-treatment. Future RCTs of CRT for AN should use precise measures to assess constructs (particularly for set shifting), increase sample size, and implement longitudinal follow-up. (Word Count: 247 words).

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.