Map of the workshop

HOW

Psychoeducation materials

Assessments/outcomes

Exercises

Future developments

What we will cover?

• Ideas –research behind the CRT in anorexia

• CRT in other psychiatric conditions

• Exercises, case studies, preliminary evidence

• How to generate evidence further (assessments/audit measures)

• Where we are now in terms of developing CRT

• Where we would like to go next?

Recent feedback from patients:

• “it's nice to have a change from talking about food and eating. I enjoy challenging my brain, I haven't used it much since school. My brain does still work and I'm interested in what it's doing. I find I'm less anxious when my brain works harder”.

• 'I found the games too simple. I couldn't understand the point of doing them. I just remember watching the clock and thinking about when I could go'. We than had the discussion on the relevance of the tasks to everyday life experiences now I see why and how it can be relevant for me….”

Cognitive Remediation Therapy

www.katetchanturia.com http://www.national.slam.nhs.uk/wp-content/uploads/2014/03/Cognitive-remediation-therapy-for-Anorexia-Nervosa-

Kate-Tchantura.pdf

Tchanturia,Davies,Reeder,Wykes

2006, 2010 London 2 version Routledge 2014 London

Cognitive training- ecological example

Animal research

• The mice from the enriched environment (filled with toys, wheels, tunnels) against mice left to their own devices showed significant advantages on various IQ tests.

Kempermann, Kuhn, Gage (1997) “Nature”

WHAT?

Cognitive Remediation Therapy

CRT

Writing exercise: Why we are doing what we are doing?

Brain aging

Evidence demonstrates that cognitive remediation training is effective

in improving neuropsychological abilities in older adults (Vance et al 2010)

What format?

• Individual

• Group

• Computerised

with or without therapist

How AN CRT is different for ED?

Flexibility module

was modified

and tailored

4 tasks were added 4 modified

for our purposes

4 are the same

but the emphasis is

different

Reflect

Practice

Change

Maintain

Generalise

Being a CRT therapist

• Who can deliver CRT? Nurses, social workers, researchers – do not need to be qualified clinical psychologist

• What training is required? Equipped with manual and training from somebody who has delivered CRT

• Is supervision necessary? Our team has weekly group supervision.

• What’s it like being a CRT therapist? Structured. Manualised = straightforward to deliver. Supervision very useful. Feedback from patients encouraging.

Thinking

Memories and feelings Vision

Seeing and

Feeling where

our bits are

Frontal Lobes/executive functions

There are special parts of our brain that are responsible for what we call “executive functioning”

(like a big boss organising their workers!)

-Planning, organizing, problem-solving and self-control

(if you find this difficult, may find that you’re late for lessons, find it hard to get homework done on time, often act before thinking, forget to do things, etc).

-We mainly use our frontal lobes (at the top/front of the brain) when we’re doing these things.

Next part

What we target in

ANOREXIA and

WHY?

Weak Central Coherence

Characterized by an overly detailed-focused

cognitive style

Focus on details obscures the bigger picture

Leads to poorer recall of both “big picture”

and details

Impairs integration and organization of

information

May limit more abstract reasoning

Rey-Osterrieth Figure most reported (Lang et al 2014 systematic rev)

(Please copy this figure)

Rey-Osterrieth Figure

Wood and trees

Dear Thank you for the recent opportunity of serving you in our Installment Loan Department. The coupon book enclosed is provided for your convenience in making payments on your note. It will furnish you with a record of payments. We are certain that you will appreciate the convenience afforded by this book. Please make all payments directly to us. They may be made at any teller's window, including the drive in, or payments may be made by mail. Checks or money orders should be made payable to (name of bank) Please let us know if we can be of assistance to you in any of the other numerous banking services that we offer including checking accounts, savings accounts, trust department and investment counseling. Please feel free to drop in anytime at your convenience to discuss your further needs with our staff.

Text message

Bullet points

BIGGER PICTURE

Bigger Picture Task

Bigger Picture Task

Bigger Picture Task

Reflections & Everyday Examples

• Main Idea Task

– describing a film/book

– Watch episode before next session and describe

– Use face-book to summarise your day in 1 line

– Giving directions

– Write the letter

What did you learn from these tasks?

What they show you about your thinking style?

How they relate to real life?

How might you apply this in the future? (sessions 9-10)

Exploratory questions

How vs What Ability to “think about thinking” or “learning to learn”

for skill development in: • Thinking globally • Thinking flexibly

– Gain practice with non-threatening tasks and stimuli to address areas of difficulty

• Explore how the participant approached the task, try

out different strategies, and draw parallels to the tasks

of everyday life.

• Tasks challenging, but fun

• No focus on eating disorder pathology

Switching and multitasking FLAXIBILITY

• Refers to the ability to think flexibly – To move between thoughts, ideas, concepts

– Related to complex problem-solving

– Related to aspects of future planning and managing ambiguity

• Difficulties in set-shifting can lead to – Behavioral and cognitive rigidity (“black and white” thinking)

– Perseverative and perfectionistic behaviors

– Difficulties in managing fluid/dynamic situations, such as social communication

Brixton Test Burgess & Shallice, 1997

1

6 7 8 9 10

52 3 4

Flexibility in HC and ED groups Brixton task-example

(Tchanturia et al 2011,2012 Plos One)

0

2

4

6

8

10

12

14

16

HC AN tot AN IP AN OP Rec BN

HC

AN tot

AN IP

AN OP

Rec

BN

N=217 N=215

N=96

N=119

N=72 N=69

BUS

Example Maudsley CRT manual – Tchanturia et al 2010

Illusions Ability to switch between two images

present in the same picture

Cognitive Remediation Therapy: ‘The how rather what of thinking’

(Tchanturia et al 2008, Whitney et al 2007, Davies et al 2006)

• Manual based 10-session intervention, twice a week, for adult AN admitted to a specialist ED Unit

• Include exercises to: (1) See the ‘bigger picture’ (2) Increase cognitive flexibility (3) Relate to real life

Reflections & Everyday Examples

• Shifting – Hard to do something against the rules

– Not make your bed

– Wearing odd socks

– Not brushing hair

– Write draft letter and send it

– Write about subject you don’t know about

– Change order of washing

– Find alternative ways to do things

Patient’s feedback

Ending letter (excerpts):

• ‘[...] changing picture exercises. These have taught me to try and see other people’s perspectives on things, and reminded me to take on board the options and ideas of others even when I have difficulty seeing it myself.

• [...] perhaps there is more than one way to view myself, and that maybe I can be seen as not all bad

• I have tried to use what I have learnt to be more flexible in how I spend

my spare time. I have tried to allow myself to ‘enjoy the moment’ more and take time to relax and not feel as though I should be being productive.

• [I feeI I] have benefited from starting to gain a new perspective and approach, which I help will allow me to be more relaxed and flexible both with my weight and eating and in my life in general.

• ‘I hope I can apply what I’ve learnt to my life’.

Flexibility Tasks Illusions

– Strategy: able to see both images quickly • e.g. at work, has to multi-task a lot, enjoys it, likes being

busy and multi-tasking • e.g. argument with someone in the dining room: seeing

other perspective/alternative

– Patient was very quick at this task: could see both images very quickly but couldn’t focus on just one image, as she would become aware of details from the other image

details can be distracting – important to see the bigger picture to avoid getting stuck on one detail at the expense of the rest of the image

Tasks (cont.)

‘Embedded words’ task

example

1. Circle ‘hot’ words while at the same time crossing

out ‘animal’ words

2. Underline ‘musical’ words, while at the same time

crossing out ‘place-name’ words

fire violin Rome stickytape rock bear zebra sun

tissue one cat glue brimstone super mouse

american flag diamond York switch mole witch dance

velcro three kitchen burn computer holiday ice-cream

note barcode pen grass blue four granite rabbit

pillow ruler hen scald Roman road swerve tennis

wolf flame glass Canada toffee lamb mountain

barber’s pole sun Africa sea drum paperclip treacle

lava cola month triangle five blanket bed

molten mental cloud paper France pie maths subway

pomp music fur piano keyboard pills cow wallet

glue wrist tiger clown jam milk watch sand lake

chilli pepper stone kitten map quaver baboon stick

phone French flag guitar goat wallpaper paste square

bag carrot flipper horizon swimming Brazil deer

brick hot tarmac hamster antelope balloon conductor

kangaroo nice radio Cuba underwear honey alphabet

car keys clipboard

Behavioural tasks

• mixed foods in the dining room – (Patient’s own idea, i.e. not discussed in the CRT session)

• relax more in the relaxation group

• has tried to be more open in the reflection group at the end of the day

• has tried to allow mistakes in her sketches and drawings

• accepting chips/imperfections in her nail varnish

Patient’s feedback

• Bigger picture: ‘[...] useful strategy in helping me manage my anxieties about eating’. ‘I’ve

tried to remind myself that in the content of my life as a whole, weight is only one part of who I am and should not be the most important thing’. ‘It’s also helped me to start to think about the bigger picture of my recovery and to see that eating and gaining weight is only one aspect of ensuring I become well and happy’.

• I’ve also taken the idea of being of relaxed and flexible in my thinking and approach to life from tasks such as the line bisecting. This has taught me that I should be more relaxed and less perfectionistic and governed by rules or ‘shoulds’ because there is very little negative impact from doing so.

Example of group format sharing research findings and how

it relates to clinical practice

Most of the group members identified with detailed and focused thinking style:

As AN gets more severe:

Perfectionism, control, black and white thinking is more noticeable…..

Getting the bigger picture of the

sessions…

Key Points about mindmaps

Mind Mapping is an extremely effective method of taking notes.

Mind Maps show not only facts, but also the overall structure of a subject and

the relative importance of individual parts of it.

They help you to associate ideas and make connections that you might not

otherwise make.

If you do planning, thinking:

try experimenting with Mind Maps.

http://upload.wikimedia.org/wikipedia/commons/7/7f/Guru_Mindmap.jpg

Most common comments from Therapists

• Non eating focus

• Good interaction

• “Fun”

• Materialised reflection

• Deal with “other” non exercise related issues (emotions, relationships)

• More homework?

• More challenging tasks

Patients feedback

• “My experience of CRT has been very positive and I can really see the benefits of using this approach as an introduction to other types of therapy”

• “I also identified my predisposition to relate to things rationally and practically in a very action orientated way“

• Without CRT it would have taken me a much longer time to accept these tendencies, but now I feel confident to explore these issues further in psychology”

Findings in the Context of Clinical Practice

• Indicate the need for cognitive and emotion based therapy

• Cognitive Remediation Therapy (CRT) for anorexia

• Helps to improve flexibility and global integration (Tchanturia et al, 2013, 2008, 2007;Daga 2012; Daga 2012; Lock 2013)

• Acceptable to patients (Whitney et al, 2008)

• Case study for an adolescent patient

(Cwojdzińska et al, 2009)

• Maudsley model of treatment (Schmidt and Treasure, 2006) involves work addressing cognition and emotions

Take home messages: Mottos

• A picture is a worth a thousand words

• Action speaks louder than words

• All work on no play makes Jack a dull boy

• Habit is second nature

• Difficulties mastered are opportunities won

• You will never get to the end of journey if you stop to shy a stone at every dog that barks.

What we would like to achieve

• Make inflexible style of thinking and behaviour more flexible

• Help people to reflect on their thinking style

• See wood and trees

• Acknowledge own strengths

This can hopefully make a difference

This will hopefully reduce the missing gap in treatment of AN

Tasks Sessions 1-2 Sessions 3-6 Sessions 9-10

Drawing complex Figures

Visual Illusion

Stroop task x 2

Token Towers x 2/snap

Maps

Switching Attention

Main Idea

Behavioural task

Sessions