Cognitive Remediation Therapy: Improving Thinking Skills for Patients with Anorexia Nervosa

People with anorexia nervosa (AN) often have difficulty switching from strategy to strategy, from one stimulus to another, and with multitasking as well. These set-shifting difficulties go along with the persistently rigid, conforming, and obsessional behaviors brought on by the disorder. A team at King’s College, London, recently developed a clinical intervention based on cognitive remediation therapy (CRT), an approach that uses cognitive exercises to help patients strengthen their thinking skills (Ann Gen Psychiatry 2007;6:14).

CRT has improved memory, planning skills, and flexibility in patients with other types of psychiatric disorders, such as schizophrenia, according to the authors. It is hypothesized that CRT trains basic brain processes by proliferating and refining neural connections and by teaching adaptive strategies. Thus, the main function of CRT is to improve the thinking process rather than the content. According to the authors, an important and helpful streatment strategy is targeting and improving set-shifting skills among patients with chronic AN.

A small pilot study

In their small pilot project, Dr. Kate Tchanturia and colleagues used ten 45-minute sessions of CRT with four female patients with chronic AN. All four had body mass indexes (BMIs) lower than 17.5, and all had prior inpatient treatment. They represented a wide age range (21 to 42 years of age) and had AN for 7 to 24 years. They had previously been admitted from one to three times for treatment.

The CRT intervention

The intervention included a number of tasks, including viewing geometric figures, which were selected and described for the patient to draw; illusions, to encourage patients to explore the multiple illusion in one picture; Stroop task material to switch between attending to different parts of a stimulus (word or color); line bisections; and hand movement tasks. The patients were assessed before and after the 10 sessions using five set-shifting tests and clinical assessments. At the end of the 10 sessions, each patient wrote a letter giving her feedback about the intervention and offering suggestions for future tests.

What follow-up showed

Eighteen months after receiving CRT, each patient was contacted and interviewed. The authors were particularly interested in the patient’s current BMI, whether she had been readmitted for treatment, and whether she was using skills and strategies gained during the CRT sessions. All patients had maintained stable BMIs, although these were lower than the normal range of 18.5-24.9; none had been readmitted for treatment; and all were either working or in school.

Patient feedback

Patient feedback was particularly helpful. For example, at first the researchers used a monitoring form to report the patient’s performance on a task, and the exercises were timed as well. However, this approach was found to be ineffective without a good baseline.

In the future, in larger studies, the tester will ask the patient questions and record the answers throughout the session. In future tests the interviewer will ask such questions as, “What did you learn from these tasks?” and “What do the tasks show you about your thinking style?” These types of questions should help the patient to internalize the strategy she has used, as well as to help her reflect on the tasks in terms of thinking style.

Patients also felt that during the tasks the therapist should encourage them to make connections between thinking styles and real-life situations. Some of the patients’ suggestions included reading a newspaper in a different order, taking a different route to school or work, changing their cell phone ring-tones, or changing their nighttime routine. All four patients found the geometric figures task problematic and had difficulty following the instructions about drawing the geometric shapes—this tied in with research showing that people with AN pay extensive attention to small details. The next test will add tasks that will help with global thinking and priotizing information.