Group cognitive remediation therapy for children and adolescents in intensive day-patient treatment for anorexia nervosa: a feasibility study

A Systematic Review to Explore a Neuropsychological Profile that Predates Anorexia Nervosa

OBJECTIVE

Research demonstrates reduced cognitive flexibility and weak central coherence during acute illness and following recovery from anorexia nervosa (AN). This systematic review investigated if these impairments are present in first-degree relatives of individuals with AN, representing a possible neuropsychological risk profile.

METHODS

A systematic review of electronic databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search ended on July 14, 2023. Established search terms and inclusion criteria identified relevant research. Risk of bias was assessed using the Critical Appraisal Skills Program. The review was registered with Prospero international prospective register of systematic reviews (No. CRD42023401268). Study selection, descriptive data, critical appraisal, and risk of bias are presented in tables and figures.

RESULTS

The search yielded 10 studies. The included studies conducted neuropsychological assessments of discordant AN relatives and lifetime longitudinal study participants. Most studies found cognitive flexibility and central coherence to be significantly reduced in participants with AN and their relatives compared with controls. One study found decision making to be significantly impaired in AN participants and relatives. Effect sizes were moderate to large.

DISCUSSION

Reduced cognitive flexibility and weak central coherence appear to be endophenotypes of AN. Further research is required with relatives concordant for AN to establish whether these biomarkers co-segregate with AN within families. These findings suggest a possibility of developing screeners to identify individuals at risk of AN allowing for early intervention.

Effect of cognitive remediation therapy in anorexia nervosa: a systematic review and meta-analysis

Background

Anorexia nervosa (AN) can significantly affect cognitive well-being. Cognitive remediation therapy (CRT) is regarded as one of the effective treatments for cognitive impairment in some mental illnesses such as schizophrenia, bipolar disorder, and attention deficit. For this reason, this systematic review and meta-analysis aim to assess the effectiveness of CRT in patients with AN.

Methods

We conducted a search of Medline, ClinicalTrials.gov, and the Cochrane Database of Systematic Reviews from the inception of each database through April 8, 2023. Randomized clinical trials evaluating the effectiveness of CRT in comparison to placebo or other psychological treatments in patients with AN were included. The quality of the studies was assessed using the revised Cochrane risk-of-bias tool. For meta-analysis, effect sizes were measured using mean difference (MD) utilizing the random-effects model and inverse variance (IV) technique. To evaluate the certainty of the evidence, we applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. The study was registered in PROSPERO, ID: CRD42023411784.

Results

In the systematic review, six studies were included, of which four underwent meta-analysis. Among these, three trials encompassing 413 participants showed that CRT was associated with improved cognitive flexibility compared to control at the end of treatment (MD = -0.21, 95% CI [-0.44, 0.02], P=0.81, I2 = 0%). In two trials with 143 patients, those who received CRT showed similar effects on the severity of AN symptoms compared to the control group in the self-reporting questionnaires: EDE-Q (MD = -0.25, 95% CI [-0.76, 0.27], P=0.77, I2 = 0%) and EDEQOL (MD = -0.19, 95% CI [-0.41, 0.03], P=0.84, I2 = 0%).

Conclusion

CRT did not show a statistically significant difference compared to the control group in improving abstract thinking skills and quality of life in individuals with AN. That indicates that CRT's efficacy remains inconclusive. Further research with larger, more diverse samples is needed to determine its long-term effects and potential benefits.

Systematic review registration

PROSPERO, identifier CRD42023411784.

Group cognitive remediation therapy for adolescents with anorexia nervosa: Outcomes before, after, and during follow-up in a real-world setting in Japan

Objective: Cognitive remediation therapy (CRT) can be used as an adjunct treatment for adolescents with severe and complex anorexia nervosa (AN) requiring inpatient treatment. However, there has been only one study on CRT for adolescents with AN in Japan. This study explored group CRT as an adjunct to inpatient treatment for Japanese adolescents with severe and complex AN requiring inpatient care. Methods: Thirty-one adolescents with AN underwent group CRT. Neuropsychological (set-shifting and central coherence) and psychological assessments (motivation, self-esteem, and depressive symptoms) were measured before and after the intervention. Weight and AN symptoms were measured before and after the intervention and at follow-up, and the adolescents completed post-intervention and follow-up questionnaires. Results: Set-shifting led to medium to large effect size improvements. Medium effect size improvements in central coherence and depressive symptoms were also observed. The feedback from the adolescents was mainly positive, and the treatment completion rate was high. The patients also reported that the skills learned through group CRT could be applied in daily life. Conclusion: Group CRT may be beneficial for adolescents with severe and complex AN who require inpatient care.

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.