Innovations Psychother Psychosom 2014;83:29–36 DOI: 10.1159/000355240
Received: December 4, 2012 Accepted after revision: August 24, 2013 Published online: November 19, 2013
The Effectiveness of Cognitive Remediation Therapy in Patients with a Severe or Enduring Eating Disorder: A Randomized Controlled Trial Alexandra E. Dingemans a Unna N. Danner b Judith M. Donker a Jiska J. Aardoom a Floor van Meer b Karin Tobias b Annemarie A. van Elburg b, c Eric F. van Furth a, d a
Center for Eating Disorders Ursula, Leidschendam, b Altrecht Eating Disorders Rintveld, Zeist, c Department of Child and Adolescent Psychiatry, University Medical Center, Utrecht, and d Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
Abstract Background: Individuals with eating disorders show deficits in neuropsychological functioning which might preexist and underlie the etiology of the eating disorders and influence relapse. Deficits in cognitive flexibility, i.e. set-shifting and central coherence, might perpetuate the symptoms. Cognitive remediation therapy (CRT) was developed to improve cognitive flexibility, thereby increasing the likelihood of improved outcome. The focus of CRT is on how patients think, rather than on what patients think. The present study investigated the effectiveness of CRT for patients with a severe or enduring eating disorder by means of a randomized controlled trial comparing intensive treatment as usual (TAU) to CRT plus TAU. Methods: Eighty-two patients were randomly assigned to CRT plus TAU (n = 41) or TAU alone (n = 41). Outcome measures were set-shifting, central coherence, eating disorder and general psychopathology, motivation, quality of life and self-esteem. Assessments were performed at baseline (n = 82) and after 6 weeks (T1; n = 75) and 6 months (T2; n = 67). Data were analyzed by means of linear mixed
© 2013 S. Karger AG, Basel 0033–3190/14/0831–0029$39.50/0 E-Mail
[email protected] www.karger.com/pps
model analyses. Results: Patients who received CRT in addition to TAU improved significantly more with regard to eating disorder-related quality of life at the end of treatment (T1) and eating disorder psychopathology at follow-up (T2), compared to those who received TAU only. Moreover, moderator analyses revealed that patients with poor baseline setshifting abilities benefited more from CRT than patients with no deficits in set-shifting abilities at baseline; the quality of life of the former group was higher than that of the latter at follow-up. Conclusions: CRT seems to be promising in enhancing the effectiveness of concurrent treatment. © 2013 S. Karger AG, Basel
Introduction
Studies have shown that individuals with eating disorders have deficits in neuropsychological functioning [1– 8]. These deficits may decrease both treatment motivation and the efficacy of psychological interventions and may even perpetuate the illness [9, 10]. Both anorexia nervosa (AN) and bulimia nervosa (BN) are chronic disorders with periods of symptom exacerbation and symptom remission [11]. It has been proposed that neuropsychological deficits preexist and underlie the etiology of the development and relapse of eating disorders [10]. ImDr. A. Dingemans Center for Eating Disorders Ursula PO Box 422 NL–2260 AK Leidschendam (The Netherlands) E-Mail a.dingemans @ centrumeetstoornissen.nl
Downloaded by: Rivierduinen 82.139.64.183 - 11/19/2013 10:50:15 AM
Key Words Cognitive remediation therapy · Eating disorder · Randomized controlled trial · Set-shifting · Central coherence
30
Psychother Psychosom 2014;83:29–36 DOI: 10.1159/000355240
group) to TAU plus CRT (CRT group) and to answer the following research questions: (1) Is CRT plus TAU more effective in reducing eating disorder psychopathology than TAU alone? (2) Is CRT plus TAU more effective in changing body mass index (BMI), quality of life, depressive and anxiety symptoms, self-esteem, perfectionism, motivation to change and neuropsychological functioning than TAU alone? (3) Can moderators of the treatment response be identified? Methods Participants Participants were 82 female patients ranging in age from 17 to 53 years with an eating disorder according to the DSM-IV-TR. Participants who were marked down prior to admission to receive less than 6 weeks of TAU (i.e. booster admission) were not approached for the study. Exclusion criteria were (1) psychotic disorder, (2) use of medication (including psychotropic medication), unless receiving a stable dose, (3) developmental mental disorder or known brain damage or (4) substance abuse. All consecutive patients were approached for participation if they did not fulfill the exclusion criteria (n = 16; fig. 1). Study Design and Procedure This was a parallel-group study, stratified by treatment unit and by site, conducted in two treatment sites. All eligible participants received information about the study in the first week of their admission. In the second week, one of the researchers made an appointment with each eligible participant to explain the written information in person. After a complete description of the study was provided to the subjects and written informed consent was obtained, an appointment was made for the first baseline assessment (T0). All participants were reassessed after 6 weeks (T1) and 6 months after T1 (T2). All assessments were done on a computer except for the Rey Complex Figure Test (RCFT; see below). Researchers who were not involved in conducting CRT did the assessments and were blind for condition. Participants in the CRT group received 10 individual sessions of CRT as an adjunction to TAU. CRT and TAU could take place on the same day. No sessions of TAU were missed. Ethics approval was obtained from the Medical Ethics Committee for Mental Health Institutions in The Netherlands. Randomization A randomization sequence was created using SPSS version 19 and was stratified by center and treatment unit with a 1:1 allocation using random block sizes of 4. An individual not involved in the study performed the randomization. After the baseline assessment, a neutral person not involved in the study informed the patients to which condition they were assigned. Given the nature of the treatment, participants and therapists were naturally fully aware of the treatment condition. Interventions Cognitive Remediation Therapy We used the CRT manual adapted for eating disorders by Tchanturia and Davies [18]. The manual was translated into Dutch
Dingemans/Danner/Donker/Aardoom/ van Meer/Tobias/van Elburg/van Furth
Downloaded by: Rivierduinen 82.139.64.183 - 11/19/2013 10:50:15 AM
portant neuropsychological deficits in eating disorders involve set-shifting and weak central coherence. Setshifting concerns the ability to move back and forth between multiple tasks, operations or mental sets; it represents cognitive flexibility. Difficulties in set-shifting have been found in women with current and past AN and BN [7] in a variety of neuropsychological tests [2–6, 8]. Weak central coherence refers to superior detail processing and weak global integration, which is present in individuals with current AN and BN [12, 13]. Cognitive remediation therapy (CRT) was developed with the aim of improving cognitive flexibility and thereby increasing the likelihood of improved functioning [14]. A recent meta-analysis demonstrated that CRT has a small to moderate effect on cognitive functioning following treatment and at follow-up assessments in individuals with schizophrenia [15]. Similar neurocognitive training modules have been developed in other areas, such as bipolar disorder [16] and obsessive-compulsive disorder [17]. Tchanturia and Davies [18] adapted and tailored CRT for eating disorders. Using exercises, reflection and behavioral tasks, patients are encouraged to develop more flexible styles of thinking. The focus of CRT is thus on how patients think, rather than on what patients think. Metacognition refers to one’s knowledge about one’s own cognitive processes. It is hypothesized that CRT training works by proliferating and refining neural connections and by teaching new, adaptive strategies, thus making individuals more flexible in the way they think and behave [19]. Case reports of severely ill adult patients with AN [9, 19, 20] and one randomized controlled trial [21] which compared 8 sessions of outpatient CRT to 8 sessions of cognitive-behavioral therapy showed that CRT improved performance on cognitive tasks and that it is an acceptable and feasible therapy [22]. It has been suggested that CRT might be most effective as an adjunctive treatment in the context of other therapies to enhance treatment success [21]. Because of the transdiagnostic nature of eating disorders [11, 23], the instability of eating disorder symptoms [24] and the fact that neuropsychological deficits are present across eating disorders [25], it could be hypothesized that CRT might be suitable for all types of eating disorders, in particular for patients with a severe or enduring eating disorder, since neuropsychological deficits might play a role in the maintenance of the eating disorder [10]. The present study aimed to explore the treatment-enhancing effectiveness of CRT for patients with a severe or enduring eating disorder in a randomized controlled trial, comparing intensive treatment as usual (TAU; control
Assessed for eligibility (n = 159)
Enrolment
Excluded (total, n = 77) No interest (n = 57) Booster admission too short (TAU
