Cognitive Remediation Therapy for Eating Disorders: Development, Refinement and Future Directions

  • Kate TchanturiaEmail author
  • James Lock
Part of the Current Topics in Behavioral Neurosciences book series (CTBN, volume 6)


In this chapter, we aim to address some basic conceptual and practical questions about cognitive remediation therapy (CRT) for eating disorders. We begin by providing an overall historical, conceptual, and theoretical framework for CRT. Next, we discuss the specific indications for how and why CRT might be useful for eating disorders based on existing neuropsychological research evidence. We also provide an overview of the types of tasks and stimuli used in CRT and a general protocol for a manualized version of CRT. In addition, modifications of the adult CRT manual for use with adolescents as well as preliminary acceptability of the approach with this younger age group are described. We also propose various ways to integrate CRT in a variety of inpatient and outpatient programmes. Finally, a discussion of potential future directions in research using the tools of neurocognitive assessment, imaging and treatment research is provided.


Anorexia nervosa Attention to detail Cognitive exercises Neuropsychology Set shifting Treatment 


  1. Almasy L, Gur R et al (2008) A genome screen for quantitative trait loci influencing schizophrenia and neurocognitive phenotypes. Am J Psychiatry 165:1185–1192CrossRefPubMedGoogle Scholar
  2. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders. American Psychiatric Association, Washington, DCGoogle Scholar
  3. Arnsten A, Shansky R (2004) Adolescence: vulnerable period for stress-induced prefrontal cortical function? Introduction to part IV. Ann NY Acad Sci 1021:143–147CrossRefPubMedGoogle Scholar
  4. Baldock E, Tchanturia K (2007) Translating laboratory research into practice: foundations, functions, and future of cognitive remediation therapy for anorexia nervosa. Therapy 4:1–8CrossRefGoogle Scholar
  5. Buyske S, Bates M et al (2006) Cognitive traits link to human chromosomal regions. Behav Genet 36:65–76CrossRefPubMedGoogle Scholar
  6. Carter C, Stewart D et al (2001) Eating disorder examinatin questionnaire: norms for young adolescent girls. Behav Res Ther 39:625–632CrossRefPubMedGoogle Scholar
  7. Casey B, Jones R et al (2008) The adolescent brain. Ann NY Acad Sci 1124:111–126CrossRefPubMedGoogle Scholar
  8. Cavedini P, Bassi T, Ubbiali A, Casolari A, Giordani S, Zorzi C, Bellodi L (2004) Neuropsychological investigation of decision-making in anorexia nervosa. Psychiatry Research 127:259–266CrossRefPubMedGoogle Scholar
  9. Chamberlain S, FIneberg N et al (2007) Impaired cognitive flexibility and motor inhibition in unaffected first-degree relatives of patients with obsessive-compulsive disorder. Am J Psychiatry 164:335–338CrossRefPubMedGoogle Scholar
  10. Chan R, Shum D, Toulopoulou T, Chen E (2008) Assessment of executive functions: review of instruments and identification of critical issues. Arch Clin Neurospychol 23:201–216CrossRefGoogle Scholar
  11. Chui H, Christensen B et al (2008) Cognitive function and brain structure in females with a history of adolescent-onset anorexia nervosa. Pediatrics 122:e426–e437CrossRefPubMedGoogle Scholar
  12. Cooper Z, Fairburn CG (1987) The eating disorder examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. Int J Eat Disord 6:1–8CrossRefGoogle Scholar
  13. Cooper Z, Cooper PJ et al (1989) The validity of the eating disorder examination and its subscales. Br J Psychiatry 154:807–812CrossRefPubMedGoogle Scholar
  14. Das J (1999) A neo-Lurian approach to assessment and remediation. Neuropsychol Rev 9(2):107–116CrossRefPubMedGoogle Scholar
  15. Davies M, Tchanturia K (2005) Cognitive remediation therapy as an intervention for acute anorexia nervosa: a case report. Eur Eat Disord Rev 13:311–316CrossRefGoogle Scholar
  16. Delis D, Kaplan E et al (2001) Examiner’s manual: Delis-Kaplan executive functioning systems (D-KEFS). Psychological Corporation, San Antonio, TXGoogle Scholar
  17. Eack SM, Hogarty GE, Cho RY, Prasad KM, Greenwald DP, Hogarty SS, Keshavan MS (2010) Neuroprotective Effects of Cognitive Enhancement Therapy Against Gray Matter Loss in Early Schizophrenia Results From a 2-Year Randomized Controlled Trial. Arch Gen Psychiatry 67(7):674–82CrossRefPubMedGoogle Scholar
  18. Eslinger P, Oliveri M (2002) Approaching interventions clinically and scientifically. In: Eslinger PJ (ed) Neuropsychological interventions – clinical research and practice. Guildford University Press, New YorkGoogle Scholar
  19. Fairburn CG, Cooper I (1993) The eating disorder examination. In: Fairburn CG, Wilson GT (eds) Binge eating: nature, assessment, and treatment, 12th edn. Guilford Press, New YorkGoogle Scholar
  20. Fossella J, Bishop S et al (2003) Exploring genetic influences on cognition: emerging strategies for target validation and treatment optimization. Curr Drug Targets CNS Neurol Disord 2:357–362CrossRefPubMedGoogle Scholar
  21. Friedman N, Miyake A et al (2008) Individual differences in executive functions are almost entirely genetic in origin. J Exp Psychol Gen 137:201–225CrossRefPubMedGoogle Scholar
  22. Genders R, Tchanturia K (2010) Cogntitive remediation in group format: a pilot study. J Weight Eat Disord (in press)Google Scholar
  23. Genders R, Davies H, StLouis L, Kyriacou O, Hambrook D, Tchanturia K (2008) Long-term benefits of CRT for anorexia. British Journal of Healthcare Management 14(12):15–19Google Scholar
  24. Gilbert S, Bird G et al (2008) Atypical recruitment of medical prefrontal cortex in autism spectrum disorders: an fMRI study of two executive function tasks. Neuropsychologia 46:2281–2291CrossRefPubMedGoogle Scholar
  25. Gillberg I, Råstam M, Wentz E, Gillberg C (2007) Cognitive and executive functions in anorexia nervosa ten years after onset of eating disorder. J Clin Exp Neuropsychol 29(2):170–178CrossRefPubMedGoogle Scholar
  26. Goldberg T, Weinberger D (2004) Genes and parsing of cognitive processes. Trends Cogn Sci 8:325–335CrossRefPubMedGoogle Scholar
  27. Gosso MF, de Geus EJ, van Belzen MJ et al (2006) The SNAP-25 gene is associated with cognitive ability: evidence from a family-based study in two independent Dutch cohorts. Mol Psychiatry 11:878–886CrossRefPubMedGoogle Scholar
  28. Halmi KA, Agras WS et al (2005) Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Arch Gen Psychiatry 62:776–781CrossRefPubMedGoogle Scholar
  29. Hoek HW, van Hoeken D (2003) Review of prevalence and incidence of eating disorders. Int J Eat Disord 34:383–396CrossRefPubMedGoogle Scholar
  30. Holliday J, Tchanturia K et al (2005) Is impaired set-shifting an endophenotype of anorexia nervosa? Am J Psychiatry 162:2269–2275CrossRefPubMedGoogle Scholar
  31. Kaye W, Fudge J, Paulus M (2009) New insights into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci 10:573–584CrossRefPubMedGoogle Scholar
  32. Keski-Rahkonen A, Hoek H et al (2007) Epidemiology and course of anorexia nervosa in the community. Am J Psychiatry 164:1259–165CrossRefPubMedGoogle Scholar
  33. Lauer CJ (2002) Neuropsychological findings in eating disorders. In: D'haenen H, den Boer JA, Westenberg H, Willner P (eds) Biological psychiatry. Wiley, Swansey, UK, pp 1167–1172CrossRefGoogle Scholar
  34. Lock JD, Fitzpatrick KK (2009) Anorexia nervosa. Br Med J Clin Evid 01(1011):1–19Google Scholar
  35. Lopez C, Tchanturia K, Stahl D, Treasure J (2008) Central coherence in eating disorders: a systematic review. Psychol Med 38(10):1393–1404CrossRefPubMedGoogle Scholar
  36. Losh M, Adolphs R et al (2009) Neuropsychological profile of autism and the broad phenotype. Arch Gen Psychiatry 66:518–526CrossRefPubMedGoogle Scholar
  37. Lucas AR, Beard CM et al (1991) 50-year trends in the incidence of anorexia nervosa in Rochester, Minn: a population-based study. Am J Psychiatry 148:917–929PubMedGoogle Scholar
  38. Lucas AR, Crowson C et al (1999) The ups and downs of anorexia nervosa. Int J Eat Disord 26:397–405CrossRefPubMedGoogle Scholar
  39. Luna B, Sweeney J (2004) The emergence of collaborative brain function. Ann NY Acad Sci 1021:296–309CrossRefPubMedGoogle Scholar
  40. Marsh R, Maia T et al (2009a) Functional disturbances within frontostriatal circuits across multiple childhood psychopathologies. Am J Psychiatry 166:664–674CrossRefPubMedGoogle Scholar
  41. Marsh R, Steinglass J et al (2009b) Deficient activity in the neural systems that mediate self-regulatory control in bulimia nervosa. Arch Gen Psychiatry 66:51–63CrossRefPubMedGoogle Scholar
  42. McGurk S, Twamley E, Sitzer D, McHugo G, Mueser K (2007) A meta analysis of cognitive remediation in schizophrenia. Am J Psychiatry 164:179–1802CrossRefGoogle Scholar
  43. Mcintosh VW, Jordan J et al (2005) Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry 162:741–747CrossRefPubMedGoogle Scholar
  44. Medalia A, Choi J (2009) Cognitive remediation in schizophrenia. Neuropsychol Rev 19:353–364CrossRefPubMedGoogle Scholar
  45. NICE (2004) National clinical practice guideline: eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders. National Institute for Clinical Excellence, LondonGoogle Scholar
  46. Osterrieth P (1944) Test of copying a complex figures: contribution to the study of perception and memory. Arch Psychol 20:206–356Google Scholar
  47. Pike K, Walsh BT et al (2000) Cognitive-behavioral therapy in the relapse prevention of anorexia nervosa. Third International Congress of Neuropsychology, KyotoGoogle Scholar
  48. Pike K, Walsh BT et al (2004) Cognitive-behavioral therapy in the posthospitalization treatment of anorexia nervosa. Am J Psychiatry 160:2046–2049CrossRefGoogle Scholar
  49. Resources PA (2003) Computerized Wisconsin Card Sort Task, (WCST), version 4Google Scholar
  50. Roberts M, Tchanturia K, Stahl D, Southgate L, Treasure J (2007) A systematic review and meta-analysis of set shifting ability in eating disorders. Psychol Med 37(8):1075–1084CrossRefPubMedGoogle Scholar
  51. Roberts M, Tchanturia K, Treasure J (2010) Exploring the neurocognitive signature of poor set-shifting in anorexia and bulimia nervosa. J Psychiatr Res PMID:20398910Google Scholar
  52. Robinson I, Thompson J et al (2006) A meta-analysis of cognitive deficits in euthumic patients with bipolar disorder. J Affect Disord 93:105–115CrossRefPubMedGoogle Scholar
  53. Rohling M, Faust M, Beverly B, Demakis G (2009) Effectiveness of cognitive rehabilitation following acquired brain injury: a meta – analytic re-examination of Cicerone et al. (2000–2005) systematic reviews. Neuropsychology 23:20–39CrossRefPubMedGoogle Scholar
  54. Russell T, Schmidt U, Tchanturia K (2009) Aspects of social cognition in anorexia nervosa: Affective and cognitive theory of mind. Psychiatry Research 15; 168(3):181–5Google Scholar
  55. Sanders J, Johnson K et al (2008) A review of neuropsychological and neuroimagin research in autism spectrum disorders: attention, inhibition, and cognitive flexibility. Res Autism Spectr Disord 2:1–16CrossRefGoogle Scholar
  56. Schmidt U, Treasure J (2006) Anorexia nervosa: valued and visible. A cognitive interpersonal maintenance model and its implications for research and practice. Br J Clin Psychol 45:343–366CrossRefPubMedGoogle Scholar
  57. Serfaty M (1999) Cognitive therapy versus dietary counselling in the outpatient treatment of anorexia nervosa. Eur Eat Disord Rev 7:334–350CrossRefGoogle Scholar
  58. Siegle GJ, Ghinassi F, Thase ME (2007) Neurobehavioral therapies in the 21st century: summary of an emerging field and an extended example of cognitive control training for depression. Cognit Ther Res 31:235–262CrossRefGoogle Scholar
  59. Southgate L, Tchanturia K, Treasure J (2005) Building a model of the aetiology of eating disorders by translating experimental neuroscience into clinical practice. J Ment Health 14:553–566CrossRefGoogle Scholar
  60. Southgate L, Tchanturia K, Treasure J (2008) Information processing bias in anorexia nervosa. Psychiatry Res 160:221–227CrossRefPubMedGoogle Scholar
  61. Southgate L, Tchanturia K et al (2009) Neuropsychology in eating disorders. In: Wood S, Allen N, Pantelis C (eds) Handbook of neuropsychology of mental illness. Cambridge University Press, Cambridge, pp 316–325Google Scholar
  62. Stevenson C, Whitmont S, Bornholt L, Livesey D, Stevenson R (2002) A cognitive remediation programme for adults with attention deficit hyperactivity disorder. Aust NZ J Psychiatry 36(5):610–616CrossRefGoogle Scholar
  63. Tchanturia K, Hambrook D (2009) Cognitive remediation. In: Grilo C, Mitchell J (eds) The treatment of eating disorders; Clinical handbook. Guilford Press, New York, pp 130–150Google Scholar
  64. Tchanturia K, Morris R, Surguladze S, Treasure J (2002) An examination of Perceptual and Cognitive Set Shifting Tasks in Acute Anorexia Nervosa and Following Recovery. Weight and Eating Disorders 7(4): 312–316Google Scholar
  65. Tchanturia K, Campbell I, Morris R, Treasure J (2005) Neuropsychological studies in AN. Int J Eat Disord, Special Issue Anorexia Nervosa 37:572–576Google Scholar
  66. Tchanturia K, Whitney J, Treasure J (2006) Can cognitive exercises help treat anorexia nervosa? A case report. Eat Weight Disord 11(4):112–117Google Scholar
  67. Tchanturia K, Davies H, Campbell I (2007) Cognitive Remediation for patients with anorexia nervosa: preliminary findings. Ann Gen Psychiatry 14:6–14Google Scholar
  68. Tchanturia K, Davies H, Lopez C, Schmidt U, Treasure J, Wykes T (2008) Neuropsychological task performance before and after cognitive remediation in anorexia nervosa: a pilot case series. Psychol Med 38(9):1371–1373CrossRefPubMedGoogle Scholar
  69. Tokley M, Kemps E (2007) Preoccupation with detail contributes to poor abstraction in women with anorexia nervosa. J Clin Exp Neuropsychol 29:734–741CrossRefPubMedGoogle Scholar
  70. Treasure JL, Todd G et al (1995) A pilot study of a randomized trial of cognitive-behavioral analytical therapy vs educational behavioral therapy for adult anorexia nervosa. Behav Res Ther 33:363–367CrossRefPubMedGoogle Scholar
  71. Treasure J, Claudino A, Zucker N (2010) Eating disorders. Lancet 375:583–593CrossRefPubMedGoogle Scholar
  72. Uher R, Treasure J (2005) Brain lesions and eating disorders. J Neurol Neurosurg Psychiatry 76(6):852–857, ReviewCrossRefPubMedGoogle Scholar
  73. Van Son G, van Hoeken D et al (2006) Time trends in the incidence of eating disorders: a primary care study in the Netherlands. Int J Eat Disord 39:565–569CrossRefPubMedGoogle Scholar
  74. Wechsler D (1997) WAIS-III Weschler adult intelligence scale, 3rd edn. Psychological Corporation, San Antonio, TXGoogle Scholar
  75. Whitney J, Easter A, Tchanturia K (2008) The patients experiences in cognitive exercise intervention for anorexia nervosa: Qualitative findings. International Journal of Eating Disorders 41(6):542–50CrossRefPubMedGoogle Scholar
  76. Zastrow A, Kaiser S, Stippich C, Walther S, Herzog W, Tchanturia K, Belger A, Weisbrod M, Treasure J, Friederich H (2009) Neural correlates of impaired cognitive-behavioral flexibility in anorexia nervosa. Am J Psychiatry 166(5):608–616CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2010

Authors and Affiliations

  1. 1.Department of Psychological MedicineKing’s College LondonLondonUK
  2. 2.Department of Psychiatry and Behavioral SciencesStanford University School of MedicineStanfordUSA

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