Academic journal article Journal of Eating Disorders

A Systematic Review of Cognitive Remediation Therapy for Anorexia Nervosa - Development, Current State and Implications for Future Research and Clinical Practice

Academic journal article Journal of Eating Disorders

A Systematic Review of Cognitive Remediation Therapy for Anorexia Nervosa - Development, Current State and Implications for Future Research and Clinical Practice

Article excerpt

Author(s): Camilla Lindvall Dahlgren[sup.1,2] and Oyvind Ra[sup.1,3]


Anorexia nervosa (AN) is a multifaceted mental disorder characterized by pathological eating behaviours. It is a serious condition and in some cases, even life threatening [1] with significant psychiatric and physical co-morbidity, and poor quality of life [2],[3]. Symptoms of the illness most commonly occur in early to late adolescence, and has a prevalence rate of 0.5-0.7% among adolescent females between 15 and 19 [4]. In the DSM-5 [5], AN is characterized by distorted body image and excessive dieting that leads to severe weight loss, with a pathological fear of becoming fat.

Although previous research in the field of eating disorders (EDs) has made important contributions to the understanding of AN, the evidence base for treatment efficacy in adult AN is scarce [6]. For younger patients, current research evidence suggests that a particular form of family based therapy, FBT [7], is the most efficient approach [8-10]. Despite numerous approaches currently being applied in the treatment of the disorder such as cognitive behavioural therapy (CBT), interpersonal therapy (IPT), cognitive analytic therapy (CAT), family based therapy (FBT) (for children and adolescents), nutritional counselling etc., existing randomised controlled trials (RCTs) are limited [11]. Also, those existing appear inconclusive as short vs. long-term investigations, sub group phenomena and current state of illness appear to influence treatment outcome, making it difficult to compare studies and predict long-term effects.

In recent years, there has been a substantial increase in papers investigating the impact of neuropsychology on eating disorder (ED) aetiology-, maintenance-, and recovery. Clinical neuropsychology is concerned with the applied science of brain-behaviour relationships, and in AN, the focus has been primarily to establish the extent to which weaknesses in cognitive flexibility (i.e. the inability to shift or change mental and behavioural strategies) and central coherence (i.e. the preoccupation with details at the cost of global/contextual processing) contribute to the development of the illness, its perseverance and the likelihood of recovery [12-16]. Early neuropsychological studies and clinical observations of adults with AN laid the groundwork for the development of cognitive remediation therapy (CRT), an intervention specifically tailored to remedy weaknesses in these two domains (i.e. cognitive flexibility and central coherence), and designed to encourage patients to reflect on their thinking styles. The CRT technique was originally conceptualized and developed from patients suffering from brain lesions [17], but over the last 50 years, the method and its application has been gradually adapted to suit individuals suffering from other health conditions as well. In psychiatry, CRT has been most commonly associated with the investigation of cognitive dysfunction in patients with schizophrenia, and dating back to the early 1990's, there is an extensive body of work describing positive outcomes of CRT for this patient group [18],[19]. The approach has also been successful in treating other mental health conditions such as mood disorders [20] attention deficit hyperactivity disorder (ADHD) [21], alcohol dependence [22], geriatric depression [23] and obsessive compulsive disorder (OCD) [24].

CRT for AN is a relatively new treatment approach. For this patient group, the intervention has been delivered as an addition to treatment as usual, and focuses on the process of thinking (i.e. the how) rather than the content (i.e. the what). In contrast to traditional interventions that centre on increasing food intake and on addressing ED specific symptoms such as weight and shape concerns, CRT aims neither to address nor directly treat these. The focus is primarily to decrease rigidity (i.e. increase flexibility) and achieve a balance between local (detailed) and global (the bigger picture) information processing strategies. …

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