Cognitive-Remediation Therapy
"We know that cognitive process is very involved in anorexia," Dr. Brandt noted. This includes learning, reasoning, problem solving, perception, judgment, and concentration. Cognition provides the ability for people to analyze, discriminate, organize, categorize, memorize, and perform other functions that are influenced by emotions and social feelings.
A cognitive deficit is any impairment in the thought process. Cognitive remediation is working on "techniques to develop skills and strategies that maximize the cognitive abilities and compensate deficits with the idea of developing alternative strategies for impaired functioning," he said. The technique has been used successfully in schizophrenia, brain lesions, attention-deficit/hyperactivity disorder, and obsessive-compulsive disorder.
"Can the brain change? We know the brain is a plastic organ, so of course, it can change. ... Can we get our patients practicing skills that might help them with the kinds of distortions that we see in anorexia nervosa," he asked.
CRT has an objective of exercising connections in the brain that hopefully include functioning. "This seemed to have applicability to eating disorders," Dr. Brandt said. The technique also is used to encourage patients to reflect on the exercises, as a way of raising awareness of thinking styles. By using practice, reflection, and guided discovery, a patient’s thinking style can be improved.
CRT is attractive for several reasons. It’s relatively simple, and there’s a very clear specificity of the material. The therapist’s delivery of this treatment should be very motivational. "The therapist really gets involved in this, and our patients love it. The therapist basically plays games with the patient," Dr. Brandt said. "The therapist is open about what his or her thought processes are as he plays these games and the patients play along. "The patient hopefully learns something about their own cognitive style."
Dr. Brandt observed that CRT is different from cognitive-behavioral therapy, or CBT, because the latter focuses on symptoms of illness rather than on the structure of the thinking. CRT uses effectively neutral material targeting the thought processes with the goal of developing new types of thinking. There isn’t a focus on bingeing/purging or weight restoration."
However, "CRT is not meant to be a stand-alone treatment for eating disorders but as a supplement to more traditional therapies such as CBT and dialectical behavior therapy," he said in an interview. In CRT, cognitive processing skills are the target of treatment, while these skills are required for CBT. CBT requires being able to think, while CRT really focuses on improving the quality of the thinking.
"The application of CRT has little to do with a patient’s intelligence level and much to do with a patient’s thinking style. In fact, the goals of CRT are to help individuals learn about how their brains work so that they can develop new problem-solving skills and enhanced cognitive flexibility."
He added, "Patients with anorexia often struggle with rigid thought patterns and an over focus on details that serve to maintain the symptoms of the disorder. These patients are also commonly very resistant to treatment, and CRT’s nontraditional focus also helps provide opportunities to enhance the therapeutic alliance and increase the patient’s motivation to change."
It’s long been known that anorexia involves detail focus or weak central coherence. Patients with anorexia have an excessively detailed information processing style with a neglect of holistic thinking. "They can’t really see the big picture." They are very good at tasks that involve piecemeal information processing.
In addition, these patients tend to be inflexible and poor at set shifting. They are also very rule-bound. Set shifting is the ability to hold two different cognitive frameworks. Anorexia patients have rigid thinking, and applications of rules and habits. It’s important to talk with patients about their thought processes during exercises that attempt to improve flexible thinking.
Flexible thinking exercises are used to encourage switching between different stimuli. These exercises include illusions (seeing two different pictures in the same image), switching attention tasks, embedded word tasks, estimating tasks, and ecological tasks.
The aim of switching attention tasks is to practice switching between two difference pieces of information swiftly and accurately, while also holding in mind a rule that requires remembering the previous answer. Embedded word tasks are designed to practice identifying particular categories of information among irrelevant information. This requires seeing the bigger picture and the detail, increasing flexibility of thinking.
Exercises like these help patient recognize strengths and weaknesses of thinking styles, challenge anxieties related to those styles, build confidence, and acknowledge and appreciate their strengths.
Dr. Brandt reported that he has no relevant financial relationships.