cognitive remediation therapy as an intervention for acute anorexia nervosa: a case report

European Eating Disorders ReviewEur. Eat. Disorders Rev. 13, 311–316 (2005)

Cognitive Remediation Therapy asan Intervention for Acute AnorexiaNervosa: A Case Report

Helen Davies and Kate Tchanturia*Institute of Psychiatry, King’s College, University of London, UK

The aim of this case report is to illustrate how cognitiveremediation therapy (CRT) can be used as part of the treatmentprogramme in acute anorexia nervosa (AN) to stimulate mentalactivities and improve thinking skills and information-processingsystems when other therapies, for example cognitive behaviouraltherapy (CBT), may be too complex and intense for the patient toengage in. Furthermore, we hypothesize that CRT may be aneffective tool in improving flexibility of thinking in AN, asprevious neuropsychological findings have proved that rigidity isone of the maintaining factors in AN. Copyright # 2005 JohnWiley & Sons, Ltd and Eating Disorders Association.

Keywords: cognitive remediation therapy; anorexia nervosa; set-shifting

INTRODUCTION

There is no established first-choice treatment for AN(National Institute of Clinical Excellence (Guide-lines, NICE, 2004). The major focus of therapeuticwork currently for AN is cognitive behavioural ther-apy, cognitive analytical therapy (CAT), interperso-nal therapy, dynamic therapy, motivationalenhancement therapy (MET) and family therapy.Unfortunately, people at the severely underweightstage of AN can have difficulties engaging in thesetherapeutic interventions. This can be due to oneor a number of reasons: the inability to confront oradmit to an eating disorder (ED), thus the belief thatpsychological treatment is not required; anxietiesabout confronting deeply personal and emotionalissues; and, low weight and malnutrition may alter

cognitive processes and stamina, making engage-ment in one of these therapeutic processes difficult.

Thus, as a prelude to commencing one of the morecomplex therapies, CRT could be one of the possibleinterventions for the acute AN population, as it doesnot directly address thought, belief or emotions(Wykes & van der Gaag, 2001). CRT helps the patientto engage in stimulating and positive mental activ-ities without the burden or complexity of confront-ing issues or emotions that relate to their eatingdisorder. By building on and improving thinkingskills and information-processing systems, theseskills can then be used to facilitate more complexbehaviours and everyday living skills, as well asbeing utilized in future therapy (when the patientis ready and able to engage in one) which doesaddress thought, belief and emotion.

As well as being an effective means to help thepatient engage in a basic form of therapeutic process,CRT also addresses the problem of rigidity that isso prevalent in acute AN sufferers. Neuropsycho-logical studies (Tchanturia, Campbell, Morris, &Treasure, 2005) have demonstrated that AN patientsshow impaired performance in set-shifting tasks.Set-shifting is an important executive functionwhich concerns shifting back and forth between

Copyright # 2005 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.655

* Correspondence to: Dr Kate Tchanturia, Eating DisordersUnit, Box 059, Institute of Psychiatry, De Crespigny Park,London SE5 8AF, UK. Tel: þ44 (0)20 78480134. Fax: þ44 (0)207848 0182.E-mail: [email protected]

Contract/grant sponsor: BIAL Foundation; contract/grantnumbers: 88/02, 61/04.

multiple tasks, operations or mental sets. ANsufferers also display impaired performance inreversal learning and decision-making (Tchanturiaet al., 2004a). Such impairments in executive func-tioning, especially in terms of set-shifting tasks,could represent a vulnerability factor for those peo-ple with AN (Tchanturia, Morris, Surguladze, &Treasure, 2002; Tchanturia et al., 2004a), as well asthe maintenance of the disorder. From our longitu-dinal study we know that with weight gain only,set-shifting performance does not improve (Tchan-turia et al., 2004b; Green, Elliman, Wakeling, &Rogers, 1996). This particular study involved asses-sing 22 patients at the beginning of the inpatient pro-gramme (mean BMI¼ 13.5) and after inpatienttreatment (mean BMI¼ 18.5). The weight of thesepatients had increased but no changes in neuropsy-chological profile were observed.

The CRT model we are using in this case study wasdeveloped by Delahunty and Morice (1993) and wasdesigned to improve executive functioning, in parti-cular cognitive flexibility, working memory andplanning skills. Previously, it has been used as away of engaging patients with schizophrenia inmental activities, and to date, this intervention hashad a successful outcome in this population (Wykeset al., 2003). We have focused on the shifting moduleof the Delahunty and Morice programme, as ourfindings have demonstrated set-shifting deficits.Thus, the tasks involve engagement, disengagementand reengagement of a cognitive set or switchingbetween two cognitive sets.

The programme comes in the form of a booklet(thus extremely portable) and is made up of 15 dif-ferent test batteries. In each session, one task fromeach test battery is presented to the participant. Inthe main, the tasks involve using a pencil and paper.In these tasks there are five versions of each task,each of varying complexity. So, for example, one ofthe tasks which involves shifting between recogniz-ing odd or even numbers increases in difficultyslightly in each version as the font of the numbersreduces in size while the numbers on the pageincrease.

The remainder of the tasks, i.e. playing cards,coin sorts, token sorts, token towers and hand exer-cises, require some sort of interaction other thanpencil and paper. For example in token towers,which uses 36 tokens, big and small of three differ-ent shapes, each in six different colours, the parti-cipant plays with the therapist using differentsorting principles to build a tower from the tokens.The objective of the task is to switch between differ-ent sorting principles (e.g. colour, shape, size). The

task involves shifting between different cognitivesets and abstraction.

Each task has information for the therapist aboutthe skills required by the participant. So, for exam-ple, referring again to the odds and evens task, theskills involved are (a) shifting between two differentcognitive sets, (b) maintenance of a single cognitiveset, (c) sustained attention, (d) self-monitoring, (e)verbal mediation.

Positive reinforcement and scaffolding (Young &Freyslinger, 1995) are learning techniques employedby the therapist as these have shown to be particu-larly beneficial in a laboratory setting (Wykes et al.,2003). Scaffolding can extend the learner’s ability byproviding support in tasks that the learner cannotaccomplish but removing assistance where compe-tence has been achieved, thus, encouraging feelingsof self-achievement, self-esteem and confidence.

Our participant is a 21-year-old lady (we havecalled her Louise for confidentiality reasons). Louisehas a history of depression, obsessive-compulsivedisorder and AN over 8 years. This was her first hos-pital admission onto the eating disorders pro-gramme and when the CRT intervention began herBMI was 14.7 and she had been on the ward for 3weeks. CRT was offered to her as an alternative toother core treatment approaches in the inpatientward such as motivational and family work, CBTand CAT, which she did not wish to participate in.However, she was participating in communitygroups which are compulsory including occupa-tional therapy of self-catering and cooking andreflexology. Her main expectation from inpatienttreatment was to improve her ‘nutritional health’.

METHOD

Baseline tests were undertaken including self-reportinstruments such as the Maudsley Obsessive-Com-pulsive Inventory (MOCI) (Hodgson & Rachman,1977) and the Hospital Anxiety and DepressionScale (HADS) (Zigmond & Snaith, 1983). The neu-ropsychological tests were selected to cover variousfacets of set-shifting and executive function. Allselected tasks require shifting between mental sets,although the specific operations that may beinvolved are rather different across the tasks, includ-ing perceptual haptic, verbal, contextual or atten-tional patterns to the processing. A computerizedversion of the Trail Making Test (Kravarity, Morris,Rabe-Hesketh, Murray, & Frangou, 2003) was usedto measure rapid simple alternation between mentalsets; the Brixton Test (Burgess & Shallice, 1997) and

312 H. Davies and K. Tchanturia

Copyright # 2005 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 13, 311–316 (2005)

Cat Bat Tests (Tchanturia et al., 2002) measured pro-blem-solving and set-shifting. The Uznadze IllusionTask (Tchanturia et al., 2001; Uznadze, 1966) waschosen to measure perceptual rigidity. The sameassessment was conducted after the intervention,at 2 months, and at a 6-month follow-up.

Ten face-to-face sessions were conducted over a 4-week period, with two 3-weekly sessions and twotwice-weekly sessions. Each session lasted approxi-mately 25 minutes. Fifteen tasks were undertaken ineach session. The tasks were carried out using penciland paper and were graded so that they couldbecome more complex over the course of the ses-sions—the complexity of the task was determinedby Louise’s progress.

At the end each task, Louise was asked how thetask could relate to everyday living experiences.This part of the intervention is important to makesure that the participant links their ‘laboratory’experience of the intervention to ecologically valideveryday situations.

In order to measure Louise’s progress, three tasksin each session were timed; these were line-bisec-tion, odds and evens, and number shift. A descrip-tion of these three tasks is outlined below. (For adescription of all of the tasks see Delahunty andMorice (1993).

In the line bisection task, Louise was asked to markthe middle point of varying length lines on a page.Louise wanted to be as accurate as possible, butone aim of this task is to help a participant withAN, whose life is governed by controls and rigidperfectionism, to understand that approximation,when applicable, is quite acceptable.

In order to achieve flexibility of thinking, a varietyof motor and cognitive tasks are introduced in themodule, e.g. the odds and evens task involvedLouise shifting between saying, when asked, eitherthe odd or even number on a page of numbers, thusencouraging her to shift between recognizing twodifferent sets of information. The number shift taskincluded rows of different-shaped clusters made upof varying numbers of dots. Louise had to articulatehow many dots were in each cluster, thus encoura-ging her to shift between different sets.

RESULTS

As can be seen from the graphs (Figures 1, 2 and 3),Louise’s performance speed in the odds/evens andnumber manipulation tasks improved; thisimprovement is even more significant as the tasksincreased in difficulty over the 10 sessions. Louise’s

speed remained relatively constant in the line-bisec-tion task; however, paradoxically, she reported thatshe found this task most rewarding at the end of the10 sessions.

Baseline Measures on Neuropsychological Tests

Based on our previous research findings, we pre-dicted that after receiving 10 sessions of CRT at leastsome of the baseline measures of set-shifting wouldimprove. We compared Louise’s first, second andfollow-up assessment after 6 months to our datapublished in 2004 on clinical measures (Table 1)and neuropsychological assessment (Table 2). As

Odds / Evens

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Session

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Figure 1. Louise’s speed in the odds/evens task in eachof the 10 sessions (the task in Figure 1 is longer comparedto the tasks in Figures 2 and 3, hence the time difference incompleting them)

Number Shift

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Figure 2. Louise’s speed in the number shift task in eachof the 10 sessions

Cognitive Remediation Therapy as an Intervention for AN 313


can be seen from the graphs on baseline measures,not all, but some task performance improved.

In the Brixton task, Louise made 16 errors in thefirst assessment. On the second assessment, 12 errorswere made and her scores became close to the no eat-ing disorder (NED) group. From our previous find-ings, weight restoration only does not helpimprovement in this particular task. In previous stu-dies, Gillberg, Rastam and Gillberg (1994) reportedthat dysdiadokinesis is impaired in AN; this findingwas replicated in our studies (Tchanturia et al., 2004a, b). After the intervention we observed improve-ment in this task. Louise did more movements dur-ing 10 seconds than in the previous assessment. Inthe attentional shift task (trail-making B), Louiseperformed quicker but accuracy was compromised.

Line Bisection

0

10

20

30

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Sec

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Figure 3. Louise’s speed in the line-bisection task ineach of the 10 sessions

Table 1. Demographic and clinical measures for non-eating disorder controls (NED) and anorexia nervosa patientsin inpatient ward (published data Tchanturia et al., 2004a, b) and Louise’s first, second and follow -up assessments

NED AN total Louise 1 Louise 2 Louise 0 no changesN¼ 35 N¼ 34 2-month 6-month þ improved

Mean (SD) Mean (SD) follow-up follow-up � got worse

BMI (kg/m2) 21.8 (1.7)a 13.7 (1.4)b 14.7 18.1 16.5Age (yr) 24.8 (4.7) 26.7 (7.9) 20 21 21 NAMOCI 3.6 (2.8)a 12.3 (5.8)b 10 13 13 �HADS anxiety 5.6 (3.1)a 15.0 (4.4)b 15 15 16 0HADS depression 1.7 (1.5)a 11.2 (5.1)b 14 16 15 �Dysdiadochokinesis R 19.4 (3.8)a 15.9 (4.1)b 10 12 12 þDysdiadochokinesis L 18.9 (3.2)a 15.2 (3.3)b 10 12 12 þ

Note: Means and (standard deviations) one-way ANOVA. N, number of participants; non-eating disorders (NED), comparison group;AN, anorexia nervosa; R, right hand; L, left hand. Superscript letters denote significant differences between NED and AN; astatistically significant difference is indicated if the two letters differ between the respective groups.

Table 2. Comparison of Louise’s first, second and follow-up neuropsychological data with published data obtainedwith the same tests

NED AN Louise 1 Louise 2 Louise 0 no changesN¼ 35 N¼ 34 2-month 6-month þ improved

Mean (SD) Mean (SD) follow-up follow-up � got worse

Trail motor time 18.7 (6.9)a 23.5 (7.9)b 22 25 22 0Trail motor errors 0.8 (1.0) 1.0 (1.2) 0 0 0 0Trail alphabet time 21.1 (8.0)a 29.8 (10.0)b 32.0 38 21.9 þTrail alphabet errors 0.6 (1.5) 0.6 (1.0) 2 0 0 þTrail shifting time 27.9 (9.1)a 41.9 (21.7)b 39.9 39 29.0 þTrail shifting errors 0.8 (1.4) 1.6 (2.9) 1 2 0 þBrixton—total 11.7 (4.2)a 17.2 (9.5)b 16 13 12 þIllusions 7.9 (7.7)a 15.1 (11.7)b 12 12 12 0CATBAT time 50.7 (20.7)a 59.5 (23.7)a 49.9 60 52.6 �BAT time (shift time on 20.7 (12.0)a 28.2 (11.5)ab 23.9 30 23.2 þcognitive paragraph)CATBAT errors 0.8 (1.3) 1.3 (1.6) 1 2 1 0

Notes1Standard deviations are given in brackets. Abbreviations as in Table 1. Superscript letters denote significant differences betweenNED and AN; a difference is indicated if the two letters differ between the respective groups.2In the last column, 0 means no changes after the intervention in comparison to baseline results, þ improved after intervention,�worse performance after the first assessment.



This demonstrates a similar pattern of performanceto the long-term recovered group shown in ourprevious studies; however, the short-term weight-restored group did not improve in speed in this par-ticular task. There was no change in the perceptualillusion task. This is not a surprising finding, sincewe have previously reported in a series of studies(for summary, Tchanturia et al., 2005) that the per-ceptual illusion task was related to trait markerand even non-affected sisters were impaired in thistask (Holliday, Tchanturia, Landau, Collier, &Treasure, 2005).

DISCUSSION

Our results show that there is a marked improve-ment in cognitive set-shifting skills after 10 sessionsof CRT. CRT was one of the additional componentsof the inpatient programme and we believe it made asignificant difference to the participant’s neuropsy-chological profile. Our previous longitudinal study(Tchanturia, 2004b) was obtained from the sameinpatient programme; however, although the popu-lation in this study gained weight, their neuropsy-chological profile remained the same.

So far the intervention is limited to one case study,but the encouraging results from this study meritfurther investigation. We plan on undertaking a ser-ies of case studies which can determine whetherflexibility training on a basic level could contributeto global treatment outcome in AN. Further case stu-dies will also provide us with a comprehensivesource of CRT data from which we can reliably tailorthe current remediation programme to suit the exactneeds of acute AN sufferers. CRT could be a viablepart of the therapeutic programme in the treatmentof AN, especially as there is currently not a specificpsychological regime that is exclusive in the treat-ment of AN. Exercising cognitively with severecases of anorexia can serve as a first step and build-ing block before introducing more complicatedapproaches, as it is easier to engage patients withCRT than other approaches and furthermore itprovides training of the weak neuropsychologicalfunction.

Personal Comment from LouiseSpeaking as a participant in this case study, I feel thatthere are many positive short- and long-term bene-fits to CRT which could benefit patients sufferingfrom anorexia nervosa. I think that sufferers of anor-exia nervosa should have the opportunity to receivethis. The short-term benefits made apparent throughthe sessions were:

� Given a sense of achievement through positiveencouragement from Helen

� Increase in the ability to be more flexible

The long-term benefits which are still beingenforced even 6 months on from leaving the wardare:

� An improvement of being able to multi-task,therefore enabling quicker and more flexible deci-sion-making in everyday life

� Accepting that it is OK to make less than accuratedecisions, therefore reducing perfectionism ineveryday life

I feel very lucky to have been a part of the study as Ifeel it did improve my psychological health throughchallenging the characteristics of the illness, whichare mainly rigidity and perfectionism. I also feel ithelped me to be less obsessional and wonder if thistreatment could also help those suffering fromobsessional compulsive disorders. I would liketo thank both Helen and Kate for their continuedsupport.

ACKNOWLEDGEMENTS

We would like to thank our anonymous patient whoparticipated in this study and who gave her consentto the intervention, her permission to publish thereport and her helpful comments.

We would like to acknowledge the BIAL Founda-tion, grant numbers 88/02 and 61/04.

REFERENCES

Burgess, P. W., & Shallice, T. (1997). The Haylingand Brixton Tests. UK: Thames Valley Test CompanyLtd.

Delahunty, A., & Morice, R. (1993). A training programmefor the remediation of cognitive deficits in schizophrenia.Albury, NSW: Department of Health.

Gillberg, C., Rastam, M., & Gillberg, I. C. (1994). Anorexianervosa: Physical health and neurodevelopment at 16and 21 years. Developmental Medicine & Child Neurol-ogy, 36, 567–575.

Green, M. W., Elliman, N. A., Wakeling A., & Rogers P. J.(1996). Cognitive functioning, weight change andtherapy in anorexia nervosa. Journal of PsychiatricResearch, 30, 401–410.

Hodgson, R. J., & Rachman, S. (1977). Obsessional-compulsive complaints. Behaviour Research andTherapy, 15, 389–395.

Holliday, J., Tchanturia, K., Landau, S., Collier, D., &Treasure, J. L. (2005). Is impaired set-shifting anendophenotype of anorexia nervosa. American Journalof Psychiatry.

Cognitive Remediation Therapy as an Intervention for AN 315


Kravarity, E., Morris, R. G., Rabe-Hesketh, S., Murray, R.M., & Frangou, S. (2003). The Maudsley early onsetschizophrenia study: Cognitive function in adoles-cents with recent onset schizophrenia. SchizophreniaResearch, 61, 137–148.

NICE–National Institute of Clinical Excellence. (2004).Core interventions for the treatment and management ofanorexia nervosa, bulimia nervosa and related eatingdisorders. http://www.nice.org.uk/pdf/cg009nicegui\hboxdance.pdf

Tchanturia, K., Serpell, L., Troop, N., & Treasure, J. L.(2001). Perceptual illusions in eating disorders rigidand fluctuating styles. Journal of Behavior Therapy andExperimental Psychiatry, 32, 107–115.

Tchanturia, K., Morris, R., Surguladze, S., & Treasure, J. L.(2002). An examination of perceptual and cognitive setshifting tasks in acute anorexia nervosa and followingrecovery. Eating & Weight Disorders, 7, 312–315.

Tchanturia, K., Anderluh, M. B., Morris, R. G., Rabe-Hesketh, S., Collier, D. A., Sanchez, P., & Treasure, J. L.(2004a). Cognitive flexibility in anorexia nervosa andbulimia nervosa. Journal of International Neuropsychol-ogy Society, 10, 513–520.

Tchanturia, K., Morris, R. G., Anderluh, M. B., Collier, D.A., Nikolaou, V., & Treasure, J. L. (2004b). Set shifting

in anorexia nervosa: An examination before and afterweight gain, in full recovery and relationship tochildhood and adult OCPD traits. Journal of PsychiatricResearch, 38, 545–552.

Tchanturia, K., Campbell, I., Morris, R., & Treasure, J. L.(2005). Neuropsychological studies in anorexia ner-vosa. International Journal of Eating Disorders, 37, 1–5.

Uznadze, D. N. (1966). The psychology of set. New York:Consultants Bureau.

Wykes, T., & van der Gaag, M. (2001). Is it time to developa new cognitive therapy for psychosis—cognitiveremediation therapy? Clinical Psychology Review, 21,1227–1256.

Wykes, T., Reeder, C., Williams, C., Corner, J., Rice, C., &Everitt, B. (2003). Are the effects of cognitive remedia-tion therapy (CRT) durable? Results from an explora-tory trial in schizophrenia. Schizophrenia Research, 61,163–174.

Young, D. A., & Freyslinger, M. G. (1995). Scaffoldedinstruction and the remediation of Wisconsin cardsorting test deficits in chronic schizophrenia. Schizo-phrenia Research, 16, 199–207.

Zigmond, A. S., & Snaith, R. P. (1983). The hospitalanxiety and depression scale. Acta Psychiatrica Scandi-navica, 67, 361–370.



cognitive remediation therapy as an intervention for acute anorexia nervosa: a case report

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