Cognitive Remediation Therapy

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.

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,^[1][2][3][4], and in Poland among adolescents with anorexia nervosa,^[5] in the United States clinical trials are still being conducted by the National Institute of Mental Health^[6] on adolescents age 10-17 and Stanford University in subjects over 16 as a conjunctive therapy with Cognitive behavioral therapy.^[7]. 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 eatting disorders via Cognitive Remediation Therapy simultaneously with dietary modification and therapy. ^[8]

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^{[9][10][11][12][13]} 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.^[14] 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.^[15]

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

Neuropsychological tasks

Cognitive flexibility

• 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.^[16]
• 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.^[17]
• 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.^[18]

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.^[19]
• 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

• 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.

References

1. ^ 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
2. ^ 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
3. ^ 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
4. ^ 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
5. ^ 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
6. ^ National Institute of Mental Health
7. ^ Stanford School of Medicine
8. ^ Arnold, C. (2011, July). Play games, Treat Anorexia. Psychology Today, 44, 20.
9. ^ 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
10. ^ Wykes T. Cognitive remediation therapy in schizophrenia: randomised controlled trial. Br J Psychiatry. 2007 May;190:421-7.PMID 17470957
11. ^ 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
12. ^ 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
13. ^ 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
14. ^ 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
15. ^ Cognitive Remediation Approaches to Improve Drug Abuse Treatment Outcomes (R21)[1]
16. ^ 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
17. ^ Sumerall SW. et al.Expanded norms for the Controlled Oral Word Association Test.J Clin Psychol. 1997 Aug;53(5):517-21.PMID 9257231
18. ^ 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
19. ^ 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