Katie Lang

Central coherence in eating disorders: an updated systematic review and meta-analysis.

Abstract Objectives. A bias towards local information over the global “gist” (weak central coherence, WCC), has been identified as a possible contributing and maintaining factor in eating disorders (ED). The present study aimed to provide an updated review of the WCC literature and examine the hypothesis that individuals with ED have WCC. Methods. The new search found 12 eligible studies. Meta-analyses were performed on nine of these 12 studies, the remaining three were commented on individually. Data were combined with data from the previous 2008 review, and meta- analyses were performed on 16 studies (nine studies from the new search and seven studies from 2008 review). Results. Meta-analysis of the Group Embedded Figures Task provided evidence of superior local processing across all ED subtypes (pooled effect size of d = −0.62 (95% CI = −0.94, −0.31), P < 0.001). Evidence of poorer global processing in ED groups was found from meta-analyses of the Rey-Osterrieth Complex Figures task (d = −0.63 (95% CI = −0.77, −0.49, P < 0.001), and the Object Assembly Task (d = −0.65 (95% CI = −0.94, −0.37), P < 0.0001). Conclusions. As well as supporting the results of previous studies by providing evidence of inefficient global processing, this review has provided evidence of superior local processing, which supports the WCC hypothesis in ED.

Cognitive Remediation Therapy for Anorexia Nervosa: Current Evidence and Future Research Directions

The effective treatment of anorexia nervosa (AN) remains a significant challenge. This had prompted new research into ways of engaging and keeping patients in treatment, and ultimately achieving better outcomes, not only on a symptomatic level but also in broader aspects of life. 1 In an attempt to improve treatment outcomes for AN, there has been a move toward approaches that target the core maintaining factors of the disorder. Impaired cognition has been implicated in the maintenance of AN, contributing to individuals’ difficulties in processing and in engaging with psychological therapy. An established body of existing research (including both systematic reviews and large sample studies) currently highlights two main areas of difficulty—cognitive flexibility (particularly setshifting difficulties) and an extreme attention to detail (or weak central coherence). 2 Both inflexibility and an overly detail-focused way of thinking are prevalent in adults with AN, and appear to be exaggerated in the acute stage of the illness. 3

Set shifting in children and adolescents with anorexia nervosa: An exploratory systematic review and meta‐analysis

OBJECTIVE Set shifting inefficiencies in adults with anorexia nervosa (AN) are established, however the neurocognitive profile of children and adolescents with AN is less clear. This study aimed to provide a review of the literature. METHOD Electronic databases were used to search for manuscripts. RESULTS Meta-analysis was performed on seven studies using two neuropsychological tests (Trail Making Task, TMT; Wisconsin Card Sorting Task, WCST). The mean difference in outcome between AN and healthy control (HC) groups was standardized by calculating Cohens d. Meta-analysis of TMT studies showed a nonsignificant negative, pooled standardized mean difference of -0.005 (95% C.I. -0.416 to 0.406, z = 0.02, p = .98). WCST studies revealed a nonsignificant pooled effect size of d = 0.196 (95% C.I. -0.091-0.483, z = 1.34, p = .18). Studies which did not allow for a calculation of effect size typically showed a nonsignificant, worse performance by the AN groups. DISCUSSION The inefficiencies in set shifting that are apparent in the adult AN literature do not appear to be as pronounced in children. This may suggest that set shifting difficulties in adult AN are the result of starvation or indicative of longer duration of illness. Larger studies are needed to confirm these impressions.

Telephone cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a randomized controlled non-inferiority trial.

Objective Many adolescents with obsessive-compulsive disorder (OCD) do not have access to evidence-based treatment. A randomized controlled non-inferiority trial was conducted in a specialist OCD clinic to evaluate the effectiveness of telephone cognitive-behavioral therapy (TCBT) for adolescents with OCD compared to standard clinic-based, face-to-face CBT. Method Seventy-two adolescents, aged 11 through 18 years with primary OCD, and their parents were randomized to receive specialist TCBT or CBT. The intervention provided differed only in the method of treatment delivery. All participants received up to 14 sessions of CBT, incorporating exposure with response prevention (E/RP), provided by experienced therapists. The primary outcome measure was the Children’s Yale–Brown Obsessive-Compulsive Scale (CY-BOCS). Blind assessor ratings were obtained at midtreatment, posttreatment, 3-month, 6-month, and 12-month follow-up. Results Intent-to-treat analyses indicated that TCBT was not inferior to face-to-face CBT at posttreatment, 3-month, and 6-month follow-up. At 12-month follow-up, there were no significant between-group differences on the CY-BOCS, but the confidence intervals exceeded the non-inferiority threshold. All secondary measures confirmed non-inferiority at all assessment points. Improvements made during treatment were maintained through to 12-month follow-up. Participants in each condition reported high levels of satisfaction with the intervention received. Conclusion TCBT is an effective treatment and is not inferior to standard clinic-based CBT, at least in the midterm. This approach provides a means of making a specialized treatment more accessible to many adolescents with OCD. Clinical trial registration information–Evaluation of telephone-administered cognitive-behaviour therapy (CBT) for young people with obsessive-compulsive disorder (OCD); http://www.controlled-trials.com; ISRCTN27070832.

Do Children and Adolescents with Anorexia Nervosa Display an Inefficient Cognitive Processing Style

Objective This study aimed to examine neuropsychological processing in children and adolescents with Anorexia Nervosa (AN). The relationship of clinical and demographic variables to neuropsychological functioning within the AN group was also explored. Method The performance of 41 children and adolescents with a diagnosis of AN were compared to 43 healthy control (HC) participants on a number of neuropsychological measures. Results There were no differences in IQ between AN and HC groups. However, children and adolescents with AN displayed significantly more perseverative errors on the Wisconsin Card Sorting Test, and lower Style and Central Coherence scores on the Rey Osterrieth Complex Figure Test relative to HCs. Conclusion Inefficient cognitive processing in the AN group was independent of clinical and demographic variables, suggesting it might represent an underlying trait for AN. The implications of these findings are discussed.

Central Coherence in Eating Disorders:: A Synthesis of Studies Using the Rey Osterrieth Complex Figure Test

Background Large variability in tests and differences in scoring systems used to study central coherence in eating disorders may lead to different interpretations, inconsistent findings and between study discrepancies. This study aimed to address inconsistencies by collating data from several studies from the same research group that used the Rey Osterrieth Complex Figure Test (Rey Figure) in order to produce norms to provide benchmark data for future studies. Method Data was collated from 984 participants in total. Anorexia Nervosa, Bulimia Nervosa, recovered Anorexia Nervosa, unaffected family members and healthy controls were compared using the Rey Figure. Results Poor global processing was observed across all current eating disorder sub-groups and in unaffected relatives. There was no difference in performance between recovered AN and HC groups. Conclusions This is the largest dataset reported in the literature and supports previous studies implicating poor global processing across eating disorders using the Rey Figure. It provides robust normative data useful for future studies.

A Systematic Review of Central Coherence in Young People with AnorexiaNervosa

Objectives: It is hypothesised that Weak Central Coherence (superior attention to detail with poorer bigger picture thinking) is a possible endophenotype for Anorexia Nervosa (AN). Currently the neuropsychological profile of children and adolescents with AN in unclear. The present review aimed to summarise the available literature with regards to the central coherence abilities of children and adolescents with AN, and clarify their neuropsychological profile. Method: The search found seven eligible studies. Meta-analyses were not possible due the variation in tasks used. Results: Evidence of less efficient global processing in children with AN was observed in a number of studies. The strongest evidence was observed from studies using the Rey Osterrieth Complex Figures Test (ROCFT). A visual comparison of ROCFT from child and adult AN studies highlighted similarities in global processing profiles. Conclusions: Evidence of inefficient global processing was observed across a number of studies. However methodological flaws in the current literature were highlighted and made interpretation difficult. These are discussed and recommendations for future research are made.

Exploring Emotion Recognition in Adults and Adolescents with Anorexia Nervosa Using a Body Motion Paradigm

OBJECTIVE There is consistent evidence of difficulties in social cognition in adults with anorexia nervosa (AN), but less is known about adolescents. The aim of this study was to investigate the ability to recognise emotion expressed in body movement in adults and adolescents with AN. METHOD One hundred and ninety-three females participated in the study (AN = 97: 61 adults and 36 adolescents). The performance of participants with AN on a body emotion recognition task was compared to age-matched healthy controls (HC = 96). RESULTS AN participants were significantly worse than HC recognising sadness, with adolescent AN participants showing worse performance overall. There were no difficulties in the recognition of other emotions. DISCUSSION The results partially support previous studies and the literature on facial emotion recognition, showing poorer recognition of sadness in AN. The results also suggest that difficulties in emotion recognition through body movements may be more subtle than other socio-emotional difficulties observed in AN.

Is inefficient cognitive processing in anorexia nervosa a familial trait? A neuropsychological pilot study of mothers of offspring with a diagnosis of anorexia nervosa

Abstract Objectives: Inefficient set shifting and poor global processing are thought to be possible traits in anorexia nervosa (AN). This study aimed to investigate the neuropsychological processing style of unaffected mothers of offspring with AN (unaffected AN mothers). Methods: The performance of 21 unaffected AN mothers were compared to 20 mothers of healthy control offspring on neuropsychological measures of set shifting (Wisconsin Card Sorting Test, WCST) and central coherence (Fragmented Pictures Task, FPT, and Rey Osterrieth Complex Figures Task, ROCFT). Associations between neuropsychological performance and clinical measures were examined in the unaffected AN mothers group. Results: There were significant differences in perseverative errors on the WCST (P≤0.01), with the unaffected mothers displaying a more inflexible thinking style compared to the control group. There were also significant differences on the FPT (P ≤ 0.01) and the ROCFT (P ≤ 0.01), whereby unaffected AN mothers showed lower levels of global processing. Conclusions. The results of this study support the idea of the familial nature of cognitive styles in AN. The implications of these findings are discussed.

How resistant is ‘treatment-resistant’ obsessive-compulsive disorder in youth?

OBJECTIVES Obsessive-compulsive disorder (OCD) is often perceived as being difficult to treat. This study aimed to test the hypothesis that treatment non-response in routine clinical practice is often due to failures in the delivery of treatment, and that most patients who are apparently treatment-resistant will respond to treatment if adequately delivered. DESIGN Retrospective cohort data analysis. METHODS Forty-three young people with severe, treatment-resistant OCD (defined as Childrens Yale-Brown Obsessive-Compulsive Scale [CY-BOCS] scores ≥ 30 and non-response to previous cognitive behaviour therapy [CBT] and selective serotonin reuptake inhibitors) were referred to a specialist clinic and completed a course of manualized CBT, with (N = 21) or without (N = 22) optimization of medication. A sub-sample (N = 15) completed a semi-structured interview to determine characteristics of their previous CBT; quality was assessed according to pre-determined criteria. RESULTS Specialist treatment was associated with significant reductions in OCD symptoms at post-treatment with gains maintained at 3-month follow-up. At the 3-month follow-up, 58% of patients showed a meaningful clinical response (≥ 35% drop on the CY-BOCS) and 22% were in remission (≤ 12 on the CY-BOCS). Patients whose medication was optimized tended (non-significantly) to have better responses. The quality of previous CBT was assessed in a sub-group of participants and rated as inadequate in 95.5% of cases. The most common inadequacy was insufficient focus on exposure techniques. CONCLUSIONS These findings provide support for the notion that treatment non-response in routine practice may be due to technical treatment failures and highlight the need to disseminate good quality evidence-based treatment among this population. Research is also needed to understand factors that impede outcome to further improve response and remission rates. PRACTITIONER POINTS Among young people with OCD, failure to respond to treatment in routine clinical practice may often reflect the nature of the treatment received. Exposure techniques may often be overlooked in CBT for OCD, potentially resulting in poor therapeutic response. Most young people with severe and apparent treatment-resistant OCD respond to outpatient CBT incorporating E/RP. Further research is needed to establish effective methods for disseminating good quality CBT for OCD.