Cognitive Remediation Therapy (CRT) for Anorexia Nervosa

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Cognitive remediation therapy (CRT) helps people develop cognitive strategies and improve their thinking skills by practicing mental exercises. It was originally developed for people with brain injuries but has been adapted to help individuals with schizophrenia and, more recently, anorexia nervosa.

People with eating disorders often experience certain cognitive deficits that can contribute to their condition. There's some evidence that shows CRT might be able to help teach thinking cognitive skills that improve social, emotional, and cognitive functioning in order to better help manage daily life.

What Is Anorexia Nervosa?

Anorexia nervosa is a mental health condition classified as a feeding and eating disorder in the DSM-5. A person with anorexia nervosa has a distorted perception of their body size and shape and is afraid to gain weight.

Anorexia nervosa is characterized by a certain set of behaviors, including a preoccupation with food, caloric restriction (which can be extreme), fear of weight gain or being fat, refusal to eat certain foods or entire groups of foods, and in some cases, overexercising or bingeing and purging. These behaviors can have life-threatening consequences.

Cognitive Deficits in Anorexia Nervosa

Research on anorexia nervosa has demonstrated that people with the condition often have specific cognitive deficits. Such deficits in neurocognitive functioning not only contribute to the development of the condition, but they also maintain the behaviors and can interfere with recovery.

The two primary cognitive deficits that have been identified and are targeted in CRT therapy for anorexia are a lack of cognitive flexibility and problems with central coherence.

  • A lack of cognitive flexibility (the ability to shift or change mental and behavioral strategies): People with anorexia commonly exhibit rigid thinking both during the acute phase of the illness and after weight restoration. It can manifest as rigid rules about which foods they will eat, routinized behaviors, and difficulty multitasking. A person typically becomes highly distressed if their habits and routines are disrupted.
  • Problems with central coherence (a preoccupation with details and relative lack of attention to the bigger picture): People with anorexia may focus on details to the exclusion of seeing the bigger picture. For example, a person might be preoccupied with the calorie count and macronutrient profile of a particular food yet be unable to consider that information within the larger context of their overall nutritional intake.

How Does CRT Work?

In CRT, a therapist introduces an individual to neuropsychological tasks, puzzles, games, and other real-life activities that target cognitive flexibility and/or central coherence. People will then repeat these tasks with the therapist as well as on their own to strengthen their skills.

The Goals of CRT

CRT addresses cognitive deficits in anorexia nervosa by helping people understand their process of thinking rather than focusing on the content of their thoughts. Once a person becomes aware of and understands their thinking process, practicing CRT exercises can help them change it.

For people with anorexia nervosa, improving cognitive flexibility is often a core component of recovery. Neutral activities that can be used to develop cognitive flexibility and improve central coherence include:

  • Changing the order of a routine behavior (such as brushing your teeth before you change into your pajamas instead of after)
  • Choosing a different brand of a product you buy routinely (like laundry detergent)
  • Sitting in a different place at mealtimes
  • Using the dominant and non-dominant hands and fingers to complete repetitive, motor skills
  • Switching your attention back and forth between two categories like movie titles and spices

People who have anorexia learn these new skills and strategies through brain training exercises and are encouraged to reflect on their performance and draw parallels to their behaviors in the rest of their life.

CRT is designed to be a relatively short-term treatment. It usually lasts for between three and six months. One review found that most courses of CRT treatment lasted for 16 weeks. However, treatment duration depends on a variety of factors, including the individual's needs and their progress. People with more severe illness or co-occurring conditions may require longer treatment.

CRT does not directly address symptoms specific to eating disorders, such as weight and shape concerns or dietary restrictions. To be used to treat anorexia nervosa, CRT needs to be paired with other traditional treatments.

CRT is always delivered as an adjunct to eating disorder treatment; it is not designed to be a standalone treatment for anorexia nervosa.

How Effective Is It?

CRT allows people with anorexia nervosa to gain new cognitive skills through practicing cognitive flexibility and central coherence in neutral situations that are not directly related to eating or nutrition. After practicing these skills, people can then apply them to eating-related tasks. For example, the skills acquired through CRT training might help a person with anorexia nervosa balance a full meal plan instead of becoming preoccupied with the nutrition content of a single food.

Research on the use and effectiveness of cognitive remediation for anorexia is still relatively new. Of the studies that have been done so far, it appears that CRT can be useful for helping people improve their cognitive skills.

Preliminary research exploring the effectiveness of CRT in children, adolescents, and adults with anorexia nervosa has demonstrated that most find CRT acceptable and that the technique can be used in traditional treatment settings (such as hospitals).

CRT is not focused on emotionally laden content, which might make it less threatening to people who are seriously ill and unprepared to tackle emotional topics or make major behavioral changes related to eating.

Larger reviews of studies have indicated that CRT could have a number of potential benefits. It may:

  • Enhance the effectiveness of traditional treatments
  • Improve cognitive abilities
  • Improve the quality of life
  • Reduce eating disorder symptoms
  • Reduce treatment dropout

Activities You Can Try at Home

There are many games, puzzles, and "brain teasers" that are fun and may help you improve your cognitive flexibility and central coherence. You might recognize a few classic board and card games on the list, but you'll also find many available as apps for your phone or tablet. Here are a few you can play at home:

  • Last Word Response: Last Word Response is a game often used as an improv exercise in theater arts that calls on players' cognitive flexibility and the ability to listen fully before responding. The first player can start by making a statement or asking a question, such as "Where is the library?" The second player must respond starting with the last word of the first person's question, "Library? Uh, let me think…" The first player could then pick up the conversation by saying, "Think as long as you need to." The second player could respond, "To get to the library, you need to through the quad." The game gets tricky and the conversations tend to take strange turns.
  • Set: Set is a card game that focuses on matching elements according to different criteria (e.g., shading, color, figure, and a number of elements). It addresses set-shifting, a type of executive function that involves the ability to unconsciously shift your attention between tasks.
  • Unusual Uses: Unusual Uses is a verbal set-shifting game that challenges you to come up with uncommon alternative uses for common items. For example, instead of eating an apple, you could cut it in half and use it to stamp color on fabric. The point of the game is to brainstorm uses—you don’t have to actually perform them.
  • Word searches: Word searches require you to focus on relevant vs. irrelevant information—an aspect of central coherence.

It's important to note, however, that playing these games does not constitute cognitive remediation therapy. If you are interested in trying CRT as an adjunct treatment for anorexia or another mental health condition, make sure to work with a trained therapist.

A Word From Verywell

CRT is a relatively recent development that has been adapted to help treat anorexia nervosa. Because it addresses some of the underlying cognitions that contribute to the development and maintenance of the disorder, it has the potential to serve as an effective adjunctive treatment. If you decide to try CRT, you will be able to learn skills that will help you overcome rigid thinking and better see the big picture as you progress toward recovery.

If you or a loved one are coping with an eating disorder, contact the National Eating Disorders Association (NEDA) Helpline for support at 1-800-931-2237

For more mental health resources, see our National Helpline Database.

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