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Cognitive remediation therapy

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The effects of Cognitive Remediation Therapy can be visibly assessed via fMRI.

Cognitive Remediation Therapy (CRT) is a cognitive rehabilitation therapy developed at King's College in London designed to improve neurocognitive abilities such as attention, working memory, cognitive flexibility and planning, and executive functioning which leads to improved social functioning.

Also Cognitive Enhancement Therapy (CET): an approach to the enhancement of neuro and social cognitive abilities based on the concept of neuroplasticity and the positive effect of enriched cognitive experiences.[1] CET is recommended for patients with schizophrenia who are in a stable with low risk of relapse. Atypical antipsychotic medications have increased the effectiveness of symptom management, but patients may remain socially or cognitively disabled.[2]

CRT has been used in the treatment of schizophrenia with positive results. In studies conducted at Kings College London with adults with anorexia nervosa CRT was shown to be beneficial in treatment,[3][4][5][6] and in Poland among adolescents with anorexia nervosa,[7] in the United States clinical trials are still being conducted by the National Institute of Mental Health[8] on adolescents age 10-17 and Stanford University in subjects over 16 as a conjunctive therapy with Cognitive behavioral therapy.[9] Research at King's College London further explains that people with eating disorders such as anorexia nervosa, are considered to be cognitively inflexible with their perspectives of food. Psychologist, Kate Tchanturia aims to correct the thinking of patients with eating disorders via Cognitive Remediation Therapy simultaneously with dietary modification and therapy.[10]

For individuals with AN, CRT is an interactive treatment which combines practical exercises with discussions about their relevance to the patient’s everyday life. It addresses the process rather than the content of thinking, thus helping patients to develop a metacognitive awareness of their own thinking style (ref mitt bokkapitel).The treatment is hypothesized to work by strengthening and refining neural circuits, and by learning and transferring new cognitive strategies to appropriate situations. The aim is to identify and target the cognitive impairments specific to each patient, and to motivate the patient to engage in meta-cognitive processes i.e. to consider their cognitive/thinking styles and to explore alternative strategies, which in turn might lead to behavioral changes. By becoming aware of problematic cognitive styles, the patient can reflect on how these affect everyday life and learn to develop new strategies. The intervention was originally developed for adults with chronic AN [11] but during the last decade, there has been a substantial increase in studies exploring CRT for younger patients as well. Much of this work has been conducted at Oslo University Hospital, where a feasibility trial of CRT for adolescents with AN has been performed [12][13][14] and novel materials targeting young individuals with AN has been developed – the CRT Resource Pack (available free of charge at www.rasp.no).

CRT has also been shown to be useful in both children and adults with ADHD., as well as for cognitive deficits associated with Major depressive disorder[15][16][17][18][19] CRT has also been used in a subset of pediatric cancer survivors who experienced cognitive impairment due to the effects of cancer or cancer treatment on cognitive functioning.[20] Clinical trials are slated to begin in 2010 in the United States by the National Institute of Health and the National Institute of Drug Abuse on the efficacy of cognitive remediation upon the cognitive deficits associated with drug abuse.[21]

CRT is usually administered via use of a computer, with the tasks appearing on the monitor.

Neuropsychological tasks

Cognitive flexibility

Green Red Blue
Purple Blue Purple

Blue Purple Red
Green Purple Green

Naming the color of the first set of words is easier and quicker than the second.
  • Hayling Sentence Completion Task (Burgess & Shallice, 1996):is a measure of response initiation and response suppression. It consists of two sets of 15 sentences each having the last word missing. In the first section the examiner reads each sentence aloud and the participant has to simply complete the sentences, yielding a simple measure of response initiation speed.The second part of the Hayling requires subjects to complete a sentence with a nonsense ending word (and suppress a sensible one), giving measures of response suppression ability and thinking time.[22]
  • Controlled Oral Word Fluency Test (Spreen & Benton, 1977).Used for assessing verbal fluency and how easily a person can think of words that begin with a specific letter.[23]
  • Stroop Neuropsychological Screening Test (Trenerry et al., 1989). Used to test for neurological deficits, ages 18–79. Consists of two parts. The Color Task, consists of a list of 112 color names, printed in a different color, the subject repeats the color name. In the Color-Word Task, the subject names the color of ink in which the color names are printed.[24]

Memory

  • Visual span: subjects are required to reproduce increasingly complex figures presented on a grid from memory. The key measure is the highest level at which two out of four figures are correctly recalled.
  • Sentence span: based on the Daneman & Carpenter (1980) Sentence Span task. Groups of sentences are read to the subject, who then must recall the last word of each sentence . With each subsequent group the number of sentences is increased.[25]
  • Digit span: from the Wechsler Adult Intelligence Scale — Revised (Wechsler, 1981). Digit span is the longest list of numbers that a person can repeat back in correct order immediately after presentation on 50% of all trials.
  • Dual Span (Della Sala et al., 1995): measures Baddeley's (1986) conception of working memory as the ability to process two tasks simultaneously ( tracking and remembering numbers).

Cognitive activation tasks

Two back n-back task
A Q R Q Z V Z D X D L P L
A Q R Q Z V Z D X D L P L
  • Working memory condition (task) using the "Two back n-back task" The subject is presented with a sequence of letters on a computer screen; the task consists of indicating when the current letter matches the one from 2 steps earlier in the sequence this requires subjects to keep a current record of the previous two letters and to compare the present letter on the screen with that occurring two before. Example:the red letters correspond to the blue letters, which are "two back".
  • Vigilance condition (look for X): subjects view a series of letters presented in alphabetical order and indicate when the letter X appears out of sequence (e.g. A—B—X).
  • Baseline condition: for this, subjects simply view a blank screen.
  • A message on the screen (‘Look for X’ or ‘Task’) appears and subjects are asked to say each letter (subvocally) as it appears on the screen in both the vigilance and working memory conditions. The letters appear at the rate of (one every 1.2 s) and the frequency of target responses (two or three in each 15-letter epoch) are the same in the vigilance and working memory conditions. Both of these tasks require the subject to pay attention to the screen.

See also

Alice Medalia

References

  1. ^ Hogarty GE. Cognitive Enhancement Therapy. Arch Gen Psychiatry. 2004;61:866-876.
  2. ^ Keshavan MS, Hogarty GE. Brain maturational processes and delayed onset in schizophrenia. Dev Psychopathol. 1999;11:525-543.
  3. ^ Tchanturia K, Davies H, Campbell IC.Cognitive remediation therapy for patients with anorexia nervosa: preliminary findings.Ann Gen Psychiatry. 5 June 2007;6:14.doi:10.1186/1744-859X-6-14 PMID 17550611
  4. ^ Davies H, Tchanturia K. (2005) Cognitive Remediation Therapy as an intervention for acute Anorexia Nervosa: A Case Report. European Review of Eating Disorders. 13, 311-316
  5. ^ 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 Psychological Medicine 38(9):1371-3
  6. ^ 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):542-50
  7. ^ Cwojdzińska A, Markowska-Regulska K, Rybakowski F.Cognitive remediation therapy in adolescent anorexia nervosa--case reportPsychiatr Pol. 2009 Jan-Feb;43(1):115-24.PMID 19694406
  8. ^ National Institute of Mental Health
  9. ^ Stanford School of Medicine
  10. ^ Arnold, C. (2011, July). Play games, Treat Anorexia. Psychology Today, 44, 20.
  11. ^ Tchanturia, Campbell, I. C., Morris, R., & Treasure, J. (2005). Neuropsychological Studies in Anorexia Nervosa. International Journal of Eating Disorders, 37Supp, S72-S76
  12. ^ Dahlgren, C. L., Lask, B., Landrø, N. I., & Rø, Ø. (2013). Developing and evaluating cognitive remediation therapy (CRT) for adolescents with anorexia nervosa: A feasibility study. Clinical Child Psychology and Psychiatry. DOI: 10.1177/1359104513489980
  13. ^ Dahlgren, C. L., Lask, B., Landrø, N. I., & Rø, Ø. (2013). Neuropsychological functioning in adolescents with anorexia nervosa before and after cognitive remediation therapy: A feasibility trial. International Journal of Eating Disorders. DOI:10.1002/eat.22155
  14. ^ Dahlgren, C. L., Lask, B., Landro, N. I., & Ro, O. (2013). Patient and Parental Self-reports of Executive Functioning in a Sample of Young Female Adolescents with Anorexia Nervosa Before and After Cognitive Remediation Therapy. European Eating Disorders Review. DOI: 10.1002/erv.2265
  15. ^ Elgamal S, McKinnon MC, Ramakrishnan K, Joffe RT, MacQueen G.Successful computer-assisted cognitive remediation therapy in patients with unipolar depression: a proof of principle study. Psychol Med. 2007 Sep;37(9):1229-38. Epub 5 July 2007. doi:10.1017/S0033291707001110 PMID 17610766
  16. ^ Wykes T. Cognitive remediation therapy in schizophrenia: randomised controlled trial. Br J Psychiatry. 2007 May;190:421-7.PMID 17470957
  17. ^ Wykes T. Cognitive remediation therapy (CRT) for young early onset patients with schizophrenia: an exploratory randomized controlled trial.Schizophr Res. 2007 Aug;94(1-3):221-30. Epub 2007 May 2PMID 17524620
  18. ^ O'Connell RG, Bellgrove MA, Dockree PM, Robertson IH. Cognitive remediation in ADHD: effects of periodic non-contingent alerts on sustained attention to response. Neuropsychol Rehabil. 2006 Dec;16(6):653-65.PMID 17127571
  19. ^ Stevenson CS. et al.A cognitive remediation programme for adults with Attention Deficit Hyperactivity Disorder.Aust N Z J Psychiatry. 2002 Oct;36(5):610-6.PMID 12225443
  20. ^ Spencer J.The role of cognitive remediation in childhood cancer survivors experiencing neurocognitive late effects. J Pediatr Oncol Nurs. 2006 Nov-Dec;23(6):321-5.PMID 17035622
  21. ^ Cognitive Remediation Approaches to Improve Drug Abuse Treatment Outcomes (R21)[1]
  22. ^ Joshua N, Gogos A, Rossell S.Executive functioning in schizophrenia: a thorough examination of performance on the Hayling Sentence Completion Test compared to psychiatric and non-psychiatric controlsSchizophr Res. 2009 Oct;114(1-3):84-90. Epub 21 June 2009.PMID 19541454
  23. ^ Sumerall SW. et al.Expanded norms for the Controlled Oral Word Association Test.J Clin Psychol. 1997 Aug;53(5):517-21.PMID 9257231
  24. ^ Floden D, Vallesi A, Stuss DT.Task Context and Frontal Lobe Activation in the Stroop Task.J Cogn Neurosci. 29 March 2010. [Epub ahead of print] PMID 20350183
  25. ^ Friedman NP, Miyake A.Comparison of four scoring methods for the reading span test. Behav Res Methods. 2005 Nov;37(4):581-90.PMID 16629290
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