JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY

2012, 34 (10), 10091015

Effectiveness of cognitive remediation therapy (CRT)

in anorexia nervosa: A case series
Giovanni Abbate-Daga, Sara Buzzichelli, Enrica Marzola, Federico Amianto,
and Secondo Fassino
Department of Neuroscience, Section of Psychiatry, Eating Disorders Program, University of Turin,
Turin, Italy

We investigated whether cognitive remediation therapy (CRT) is effective in improving cognitive flexibility in
anorexia nervosa (AN). Twenty AN outpatients were consecutively recruited at the Eating Disorders Center of
the Turin University. All participants completed 10 sessions of CRT. Neuropsychological performances improved
with CRT. Data showed also a significant improvement of impulse regulation and interoceptive awareness (subscales of the Eating Disorders Inventory2). CRT was also associated with improvement of reflexive skills and
awareness. These preliminary findings are promising, but further work is necessary to find ways of enhancing the
effects of this treatment.
Keywords: Anorexia nervosa; Cognitive remediation therapy; Cognitive flexibility; Verbal domains; Awareness.

Background
Anorexia nervosa (AN) is a complex and difficultto-treat illness with unknown etiology; it is characterized by restricted eating, pursuit of thinness,
obsessive fears of becoming fat, and dysphoric
mood (American Psychiatric Association, APA,
2000). Treatment is complex, and prognosis is poor,
as widely reported in literature; long duration of illness and obsessive personality symptoms are unfavorable prognostic characteristics (Halmi, 2005).
According to the National Institute for Clinical
Excellence (NICE, 2004) guidelines, there is no
proven treatment for AN (Treasure, Claudino, &
Zucker, 2010); therefore, it has the highest death
rate of any psychiatric illness (Sullivan, 1995).
In spite of the lack of specific guidelines, previous studies provided evidence that addressing
patients psychological difficulties can be relevant
from a long-term prognosis standpoint (Zipfel,
Lwe, Reas, Deter, & Herzog, 2000).

Neuropsychological research showed AN individuals to be impaired in some cognitive domains

(Tchanturia et al., 2012; Tchanturia et al., 2011;
Tchanturia & Lock, 2011). In particular, studies
conducted by several research groups showed that
AN individuals have problems in set-shifting abilities (for review see Roberts, Tchanturia, Stahl,
Southgate, & Treasure, 2007; Tchanturia et al.,
2011; Tchanturia & Lock, 2011). A recent study
conducted by our group (Abbate-Daga et al.,
2011) demonstrated that AN restricting-type (ANR) patients were rigid not only in verbal but also in
nonverbal domain. Recently, neuroimaging studies
provided support to poor set shifting in AN individuals (Zastrow et al., 2009), showing lower activation
of the ventral anterior cingulated striatothalamic
network and greater activation of the frontoparietal circuits in these patients. These data raise
the hypothesis that people with AN recruit more
top down, effortful control in this task (Roberts,
Tchanturia, & Treasure, 2010).

We state that we do not have any financial supports or other relationships that could be interpreted as a conflict of interest affecting
this manuscript.
Address correspondence to Giovanni Abbate-Daga, Department of Neuroscience, University of Turin, Via Cherasco 11, 10126 Turin,
Italy (E-mail: [email protected]).

2012 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/jcen
http://dx.doi.org/10.1080/13803395.2012.704900

1010

ABBATE-DAGA ET AL.

In other psychiatric disorders like schizophrenia,

neuropsychological processes and thinking skills
have already been investigated, and it has been
demonstrated that cognitive remediation therapy
(CRT) helps to improve working memory, planning skills, and flexibility (Wykes & Reeder, 2005).
One of the aims of CRT is to improve thinking
processes rather than content, and targeting and
improving set-shifting skills represent an important
strategy in AN. Tchanturia et al. (2008, 2011) developed a CRT manual for AN (based on the original
CRT workbook by Delahunty & Morice, 1993),
which uses cognitive exercises to strengthen thinking skills and improves cognitive flexibility in these
patients (Davies & Tchanturia, 2005; Tchanturia
et al., 2008). CRT is not considered as a standalone therapy but it is thought to be useful as pretreatment or alongside other therapies (Tchanturia
et al., 2008). Through increasing flexibility in
thinking and making small, manageable changes,
CRT has the potential to increase the success of
other psychological therapies for AN (Pretorius
& Tchanturia, 2007; Davies, & Campbell, 2007).
A preliminary study on a small sample of AN inpatients showed that CRT is not only acceptable but
also a positive experience for patients (Tchanturia
et al., 2007, 2008; Whitney, Easter, & Tchanturia,
2008). A pilot study conducted by Tchanturia and
collaborators (2008) showed an improved cognitive profile (set shifting and central coherence) of
AN patients after CRT sessions. A group format
has been recently proposed for CRT (Genders &
Tchanturia, 2010) with results showing that CRT
can be effective on patients perfectionism (Pitt,
Lewis, Morgan, & Woodward, 2010).
These are all preliminary studies, and it is important to further investigate this intervention in other
eating disorders (ED) settings (e.g. outpatients, different countries). Hence, with this study we aimed
to investigate whether CRT is effective in improving
cognitive flexibility both in verbal and in nonverbal
domains in AN outpatients. We also aimed to evaluate whether CRT can be associated with weight
and eating psychopathology improvements.

METHOD
Participants
Twenty patients with anorexia nervosa restrictingtype (AN-R) were consecutively recruited at the
Eating Disorders Center of the University of Turin,
Italy, from October 1, 2009, to October 1, 2010.
Patients were included in this study who met the
Structured Clinical Interview for DSM Disorders

(SCID-I; First, Spitzer, Gibbon, & Williams, 1997)

diagnostic criteria for AN-R. SCID-I was administered by an experienced psychiatrist. Inclusion criteria were: (a) no severe medical comorbidity (e.g.,
epilepsy or diabetes); (b) no drug dependence; (c)
no need of acute hospitalizations; (d) female gender; and (e) normal IQ range. A male patient and
4 patients requiring hospitalization were excluded
from this study. Patients were all Caucasian. After
a first psychiatric assessment, all participants were
consecutively recruited accordingly to the order of
the waiting list of our outpatient program.
None of the patients refused being part of the
study. All participants provided written informed
consent for this ethical committee approved study.

Psychiatric assessment measures

All sociodemographical and clinical data have been
collected during the first clinical evaluation.
We assessed eating characteristics of the sample using both Eating Disorder Inventory2 (EDI
2; Garner, 1991) and body mass index (BMI).
Depression severity was evaluated with the Beck
Depression Inventory (BDI; Beck, Brown, & Steer,
1987). Overall functioning was evaluated with the
Global Assessment of Functioning scale (GAF;
American Psychiatric Association, 2000).

Neuropsychological assessment
We used a comprehensive neuropsychological battery comprising Wisconsin Card Sorting Test
(WCST), Iowa Gambling Task (IGT), Trail Making
Test (TMT) Parts A and B, and the Hayling
Sentence Completion Task (HSCT). We employed
the WCST (penpaper version; Bergh, 1948;
Heaton, 1981) to assess abstraction ability and cognitive strategies in response to changing environmental contingencies. We examined, according to
Laiacona, Inzaghi, De Tanti, and Capitani (2000),
the following quantitative measures of the WCST:
(a) global score that represents an overall index
of WCST performance and estimates how many
cards the subject actually used in excess of the minimum necessary to achieve the six categories; global
score = n of trials (n of achieved categories 10);
(b) perseverative errors; (c) nonperseverative errors;
and (d) failure to maintain set. The IGT (Bechara,
Damasio, Damasio, & Anderson, 1994) measures
decision-making ability as the subject is required
to select advantageous or disadvantageous cards
from four decks with the goal of maximizing profit.
On the TMT Parts A and B (Reitan, 1958), the

COGNITIVE REMEDIATION THERAPY IN ANOREXIA NERVOSA

subject connects numbers in ascending order and

numbers and letters in ascending order, respectively,
to provide information regarding attention and cognitive flexibility. The HSCT (Burgess & Shallice,
1997) requires the subject to complete 15 sentences
by filling in the correct missing word (Part 1) and an
unconnected word (Part 2) and provides an index of
response initiation and suppression.
These data were then used as baseline to measure change over time (before and after CRT). CRT
module for anorexia nervosa (Tchanturia, Davies,
Reeder, & Wykes, 2010) comprises relevant shifting exercises. It is an intervention that consists of
pen and paper exercises aimed at improving cognitive strategies, thinking skills, and informationprocessing systems. The module included 10 weekly
sessions, with each session lasting approximately
45 minutes. Tasks included geometric figures, illusions, Stroop materials, manipulations, infinity
signs, line bisection, token towers, hand tasks,
maps, the main idea, switching attention, and
embedded words. After pen and paper exercises
the psychologist may investigate patients perspective, asking them whether the cognitive strategies
used in the task could be useful also in everyday situations, aiming to help them reflecting on
their thinking style in general rather than only on
eating-related issues. CRT operates on the foundation that practice will improve performance and
increase confidence in using the skill. This module
emphasizes ecological validity by encouraging participants to reflect on strategies and thinking styles
at the end of sessions and introducing behavioral
tasks to complete as homework. All sessions activities were registered in the observation form. At the
end of the therapy, patients were asked to report
their impressions and thoughts on CRT; all patients
reported CRT to be interesting and useful.

Procedure
Neuropsychological, EDI2, GAF, and BMI
assessments were conducted before and after CRT
intervention. Clinical and neuropsychological
assessments were performed by a trained investigator (E.M.). All sessions were administered by
a clinical psychologist specifically trained in CRT
(S.B.), following the clinical protocol described in
the manual (Tchanturia et al., 2010). We used the
Italian version of the CRT manual, and all therapies
were monitored by a supervisor (G.A.-D.).
Ten face-to-face sessions were conducted
once a week, lasting approximately 45 minutes.
In line with the recommendations of Whitney and
collaborators discussion (Whitney et al., 2008), at

1011

the end of therapy the clinical psychologist asked

the patients to write a feedback letter describing
their experience of taking part in CRT.
Statistical analysis
For statistical analysis, we used the Statistical
Package for Social Sciences (SPSS 13.0 Application
Guide, Chicago; SPSS, Inc., 2004). A paired-sample
statistic was used to determine whether cognitive
flexibility, decision-making strategies, and clinical
conditions differed before and after the intervention. An level <.05 was considered to be statistically significant.
Cohens d, (Mean 1 Mean 2)/pooled standard
deviation, was calculated to provide effect sizes for
normally distributed data, with an effect size of
0.2 defined as small, 0.5 defined as medium, and
0.8 defined as large.
RESULTS
Sample characteristics
All recruited participants completed the CRT protocol. Patients characteristics were: mean age
22.5 years (SD = 3.9), median age of onset
16.65 years (SD = 2.21), duration of illness
5.85 years (SD = 3.87), mean years of education
12.15 (SD = 2.23). At the time of the first assessment, mean BMI was 16.24 (SD = 1.09), and mean
weight was 43.41 kg (SD = 3.51).
Neuropsychological performances before
and after CRT
Statistical analyses showed that neuropsychological
performances changed after CRT, in particular
on the WCST. Improvements were also found on
the other neuropsychological tests. Effect size has
been calculated for all neuropsychological scores
(Table 1).
As regards clinical characteristics, BMI, weight,
GAF, and several EDI2 subscales significantly
improved after CRT whilst perfectionism score did
not improve. We did not find a significant improvement in depressive symptomatology (Tables 2
and 3).
DISCUSSION
With this study, we aimed to evaluate the effectiveness of a CRT intervention in reducing cognitive
rigidity.

1012

ABBATE-DAGA ET AL.
TABLE 1
Neuropsychological performances of the sample

Test
TMT

Trail A
Trail B
Errors

HSCT

Net score

WCST

Global score
Perseverations
Errors
Failures

IGT

Net score

Before CRT (n = 20)

After CRT (n = 20)

Effect size

44.99 22.79
67.87 28.04
0.25 0.55

34.91 11.77
63.64 19.81
0.00 0.00

2.335
0.947
2.032

.031
.355
.056

0.6 medium
0.2 negligible
0.7 medium

4.14 2.96

3.40 2.45

1.68

.109

0.3 small

22.80 23.56
7.50 7.49
7.90 7.81
0.35 0.58

11.35 2.39
4.30 0.571
3.65 1.66
0.05 0.22

2.177
1.885
2.329
2.349

.042
.075
.031
.030

0.7 medium
0.6 medium
0.8 large
0.7 medium

1.30 19.33

0.70 29.58

0.113

.109

0.1 negligible

Note. Mean and standard deviation are reported for all neuropsychological scores. Raw scores are provided for all neuropsychological
tests. CRT = cognitive remediation therapy; TMT = Trail Making Task; WCST = Wisconsin Card Sorting Test; HSCT = Hayling
Sentence Completion Task; IGT = Iowa Gambling Task. Cohens d effect size has been calculated: negligible effect (0.15 and <0.15);
small effect (0.15 and <0.40); medium effect (0.40 and <0.75); large effect (0.75 and <1.10); very large effect (1.10 and <1.45).
TABLE 2
Clinical characteristics of the sample
Before CRT (n = 20)

Characteristic
EDI2

DT
B
BD
I
P
ID
IA
MF
A
IR
SI

11.05 6.16
2.10 1.35
10.80 6.24
9.40 6.27
4.15 2.96
5.35 3.48
8.30 6.32
6.65 4.64
5.90 4.19
4.40 4.19
7.50 4.72

After CRT (n = 20)

9.85 7.27
1.35 2.43
9.75 5.80
7.95 7.79
4.10 2.65
4.90 4.17
5.10 4.96
6.90 4.27
5.05 4.26
2.65 3.26
7.00 5.12

1.506
2.073
0.964
1.248
0.105
0.856
3.643
0.348
1.473
2.451
0.759

.148
.052
.347
.227
.918
.403
.002
.731
.157
.024
.457

BDI

9.98 6.82

8.98 6.50

1.117

.278

BMI

16.24 1.09

17.01 1.07

3.606

.002

GAF

55.80 4.23

58.15 5.21

3.979

.001

Note. Means and standard deviations are reported for all assessments. CRT = cognitive remediation therapy; EDI2 = Eating Disorder
Inventory2; DT = drive for thinness; B = bulimia; BD = body dissatisfaction; I = ineffectiveness; P = perfectionism; ID = interpersonal
distrust; IA = interoceptive awareness; MF = maturity fears; A = asceticism; IR = impulse regulation; SI = social insecurity; BDI =
Beck Depression Inventory; BMI = body mass index; GAF = Global Assessment of Functioning scale.

This case series shows some strengths: (a) None

of the patients dropped out/failed to complete the
full course of CRT; (b) we evaluated patients in the
verbal domain, which goes beyond the assessment
measures employed in previous studies; (c) it should
be considered that it is important to test that CRT
effectiveness was investigated in an eating disorder
center other than the Maudsley Hospital, in which
the first studies in this field were conducted. In our
case series, set-shifting abilities were found to have
significantly improved after CRT. On the WCST
in particular, we found a significant improvement
in global score and a significant decrease of errors
and failures in maintenance of the criterion. Large
and medium effect sizes were found for the error
subscales of the WCST. In previous literature, CRT

was effective in improving cognitive flexibility and

bigger picture thinking (Tchanturia et al., 2007,
2008) when assessed by the TMT rather than the
WCST. Our data provide converging evidence for
the effectiveness of CRT (Tchanturia et al., 2007,
2008).
The complex improvement of patients performances that we found on both TMT (medium
effect size) and WCST seems to confirm the role
of CRT in improving cognitive flexibility. It should
be noted that impairments of neuropsychological
performances are frequently reported in literature (Abbate-Daga et al., 2011; Tchanturia et al.,
2012), even on large samples (Roberts et al.,
2010; Tchanturia et al., 2012; Tchanturia et al.,
2011). Due to the case series design of the current

COGNITIVE REMEDIATION THERAPY IN ANOREXIA NERVOSA

TABLE 3
Weights of the sample before and after cognitive remediation
therapy
Weight
difference
(kg)

Patient

Weight before
CRT (kg)

Weight after
CRT (kg)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

52
43.03
46
49.99
44
40
38
46.5
41.6
41.9
42.5
39
44
47
41
43
44
40
42
42.7

52
43.35
46.92
52
47.4
48
42
47.5
43.1
42.7
42.5
40
45.2
48
46
43
44.6
42.6
42
44

0
0.29
0.92
2.01
3.4
8
4
1
1.5
0.8
0
1
1.2
1
5
0
0.6
2.6
0
1.3

Averagea

43.41 3.51

45.14 3.27

1.73

.001

Note. CRT = cognitive remediation therapy.

a Mean standard deviation.

study, it should not be excluded that the improvement could be related to eating psychopathology
and nutritional aspects. However, previous works
highlighted that treatment-as-usual cannot significantly modify AN patients neuropsychological
task performances (Tchanturia et al., 2004) and
that its effectiveness is not even comparable with
CRT (Tchanturia et al., 2007, 2008). Moreover,
weight gain alone is not effective in improving neuropsychological performances (Kingston,
Szmukler, Andrewes, Tress, & Desmond, 1996;
Tchanturia et al., 2004), and this raises the
hypothesis of a direct effect of treatment on
neuropsychological flexibility and attention to
detail, even if further studies are needed to clarify
this issue.
We did not find changes in verbal domain performances (small effect size found for HSCT), and
this finding could be explained by two different
hypotheses. First, the CRT protocol has not been
designed to improve verbal domains, given its focus
on thinking processes and not on thinking contents (Tchanturia et al., 2007; Tchanturia & Lock,
2011). Second, we could speculate that verbal rigidity may be more resistant that the nonverbal; to
be more effective on this issue therefore, such an
intervention could require more than 10 sessions.

1013

Data concerning BMI, GAF, and EDI2 are

interesting; it is noteworthy indeed that CRT is currently considered as a pretreatment or adjunctive
treatment and not an AN treatment per se.
However, it is nevertheless true that this intervention showed positive effects on interoceptive
awareness and impulsive regulation (two EDI
2 subscales). First, CRT seemed to be useful in
involving patients in treatment and in motivating
them, as demonstrated in this study by the absence
of dropouts. This is an uncommon finding, given
the high rates of dropout in both AN treatmentas-usual (Fassino, Pier, Tomba, & Abbate-Daga,
2009) and treatment protocols (Halmi, 2005).
Patients indeed showed good compliance to such
a treatment in spite of initial confusion or skepticism (Genders & Tchanturia, 2010; Pitt et al.,
2010; Tchanturia et al., 2008) with positive effects
on self-esteem derived from their sense of achievement when completing the task (Pitt et al., 2010):
all patients reported CRT to be interesting and
useful. Second, the improvement of cognitive performances could help AN individuals to better
recognize and manage distorted thoughts of illness.
In general, the EDI2 scores were found to be
improved, mostly regarding impulsive regulation
and interoceptive awareness subscales. Although
these data could be due to nonspecific effects, it
could also be that CRT improved patients reflexivity and awareness. In support of this hypothesis,
CRT primarily aims to train patients in reflecting,
and in developing more global and flexible thinking strategies. The exercises in CRT could encourage the skills required to behave more reflectively
and to think accurately about complex situations.
This is an important element because impulsivity is typical of acute phase of illness and represents also a maintaining factor of this disorder
(Lilenfeld, 2011). Also the improvement of interoceptive awareness scores can be relevant. Improved
reflexivity could indeed facilitate a more careful
recognition of inner states through the development
of complex thought-processing abilities focused not
only on details but also on the global perception.
Moreover, paying more attention to the thinking
style acquired with CRT could lead to higher attention to ones own perception style. It is noteworthy that interoceptive awareness is a core psychological aspect both as a trait and as a state feature
of AN (Fassino et al., 2005; Wagner et al., 2006),
and it plays an important role in AN pathogenesis: its improvement can be relevant in patients
therapeutic framework (Skrderud, 2007).
In contrast to the previous literature, we did not
report a significant improvement in the perfectionism scale (Pitt et al., 2010); this could be due to

1014

ABBATE-DAGA ET AL.

different samples and measures or to the fact that

we applied a quantitative method to a small sample. However, it has been highlighted in a case
series study (Pitt et al., 2010) that when a specific
instrument to measure perfectionism is used, only
some patients improve on tests, whereas some maintain their scores, and others perform even worse.
Therefore, it has been proposed that the effect on
perfectionism is only a part of treatment and is
valid only for those patients highly perfectionist
before treatment. We did not recruit patients using
this criterion, so we included also patients with low
scores on perfectionism at baseline; it is well known
indeed that not all AN patients are pathologically
perfectionist (Westen & Harnden-Fischer, 2001).
In spite of several strengths, the study shows
also some limitations: the sample is not very large,
and we did not recruit a control group; therefore,
it could not be excluded that the aforementioned
improvements could depend on less specific elements. Finally, the testretest procedure could have
biased the results, and we did not perform a specific neuropsychological assessment of attention to
details. Nevertheless, we found a significant increase
of BMI after CRT, suggesting that CRT might play
a role in weight gain: CRT studies should investigate whether the BMI increase is CRT-related or
it rather represents an effect of the beginning of
treatment. In general, future studies on CRT are
warranted to distinguish better between unspecific
and specific effects of this intervention.

CONCLUSIONS
This study replicates and extends previous reports
providing evidence of the efficacy of CRT in
improving cognitive flexibility (Tchanturia et al.,
2007, 2008). According to the results after CRT:
(a) neuropsychological performance improved; (b)
motivation increased; (c) impulsivity and interoceptive awareness of the EDI2 improved. Given the
body of evidence currently available on this topic,
this should be considered a promising research field
for multicenter studies.
Original manuscript received 27 January 2012
Revised manuscript accepted 11 June 2012
First published online 10 August 2012

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