Group cognitive remediation therapy for adolescents with anorexia nervosa: Outcomes before,after,and during follow-up in a real-world setting in Japan

Abstract

Objective: Cognitive remediation therapy (CRT) can be used as an adjunct treatment for adolescents with severe and complex anorexia nervosa (AN) requiring inpatient treatment. However, there has been only one study on CRT for adolescents with AN in Japan. This study explored group CRT as an adjunct to inpatient treatment for Japanese adolescents with severe and complex AN requiring inpatient care. Methods: Thirty-one adolescents with AN underwent group CRT. Neuropsychological (set-shifting and central coherence) and psychological assessments (motivation, self-esteem, and depressive symptoms) were measured before and after the intervention. Weight and AN symptoms were measured before and after the intervention and at follow-up, and the adolescents completed post-intervention and follow-up questionnaires. Results: Set-shifting led to medium to large effect size improvements. Medium effect size improvements in central coherence and depressive symptoms were also observed. The feedback from the adolescents was mainly positive, and the treatment completion rate was high. The patients also reported that the skills learned through group CRT could be applied in daily life. Conclusion: Group CRT may be beneficial for adolescents with severe and complex AN who require inpatient care.

Plain language summary

Why was this study done? Cognitive remediation therapy (CRT) can be used as an adjunct treatment for adolescents with severe and complex anorexia nervosa (AN) requiring inpatient treatment. However, there has been only one study on CRT for adolescents with AN in Japan. This study explored group CRT as an additional inpatient treatment for adolescents with severe and complex AN requiring inpatient care in Japan. What did the researchers do? A total of 31 adolescents with AN underwent group CRT. Cognitive function and psychological parameters (motivation, self-efficacy, and depressive symptoms) were measured before and after group CRT. Body mass index and AN symptoms were evaluated before and after group CRT and at follow-up. The adolescents completed post-therapy and follow-up questionnaires. What did the researchers find? Cognitive function and depressive symptoms improved after group CRT. The feedback from the adolescents was mostly positive, and 29 of the 31 adolescents completed group CRT. Many adolescents also reported that they used the skills learned through group CRT in their daily lives. What do the findings mean? Group CRT may be beneficial for adolescents with severe and complex AN who require inpatient care.

Keywords

Adolescents anorexia nervosa cognitive remediation therapy group therapy inpatient treatment

Introduction

Anorexia nervosa (AN) is an eating disorder characterized by persistent restriction of calorie intake, fear of weight gain, and disturbances in body perception (American Psychiatric Association, DSM-5 Task Force, 2013). The lifetime prevalence of AN among women can be as high as 4% (Smink et al., 2013). For medically stable patients, outpatient AN-focused family therapy is the first-line treatment for children and adolescents (National Guideline Alliance, 2017). However, the physical and psychopathological severity of AN has increased over the past 30 years in Japan (Harada et al., 2021). Little is known about how to enhance the treatment of adolescents with severe and complex forms of this illness, which can necessitate inpatient treatment (Harrison et al., 2018).

Cognitive remediation therapy (CRT) aims to increase the cognitive flexibility of patients by practicing new ways of thinking, facilitating bigger-picture thinking, supporting patients with cognitive training exercises, and making them aware of their own thinking styles (Lindvall Dahlgren & Rø, 2014; Tchanturia et al., 2014). A systematic review suggested improvements in cognitive performance after CRT, with small effect sizes, positive feedback from adolescents, and low dropout rates (Tchanturia et al., 2017). CRT can be used as an adjunct treatment for adolescents with severe and complex AN requiring inpatient treatment (Harrison et al., 2018). However, there has been only one study on CRT for adolescents with AN in Japan, which had a small sample size (Kuge et al., 2017).

This study explored the use of group CRT for adolescents with severe and complex AN requiring inpatient care in a real-world inpatient setting in Japan by assessing 1) post-group CRT and follow-up changes using physical, psychological, and neuropsychological measures and 2) qualitative feedback regarding group CRT post-intervention and at follow-up.

Methods

Study design

This single-arm study was conducted at the Department of Children and Adolescent Psychiatry, Tokyo Metropolitan Children’s Medical Center (TMCMC) in Tokyo, Japan, which comprises seven units including three units for the admission of female adolescents. All procedures were performed in accordance with the Declaration of Helsinki and the ethical guidelines for medical and health research involving human subjects. The study was approved by the TMCMC Ethics Board (H28b-166). Enrollment began in April 2017; however, participant registration was suspended from March to August 2020 owing to the coronavirus disease (COVID-19) pandemic. Parental consent was obtained, and all participants signed consent forms.

Participants

A total of 31 adolescent girls aged 13–18 (mean 14.6, standard deviation [SD] 1.3) years were recruited at the Department of Children and Adolescent Psychiatry TMCMC during hospitalization. All participants were clinically diagnosed with AN according to the Diagnostic and Statistical Manual of Mental Disorders, fifth Edition criteria. The exclusion criteria were intellectual disabilities, history of brain injury, psychosis, drug abuse/dependence, critical physical disease, and active suicidality. Two participants did not undergo the intelligence quotient test, although they understood the CRT processes and did not have a diagnosis of intellectual disability; therefore, they were included in this study.

Interventions

The participants received the usual inpatient treatment, including physical monitoring, individual and family sessions, behavioral therapy, dietary advice, and psychoeducation. The individual and family sessions primarily consisted of supportive counseling. Upon discharge, the participants continued to receive the usual outpatient treatment, which included physical monitoring to ensure weight maintenance, individual and family sessions, and dietary advice, but in a less intensive manner than inpatient care. Although different doctors provided the standard treatment, they had learned the core treatment principles by participating in psychoeducation groups for adolescents with AN and their families, as well as case study conferences. Participants also underwent four sessions of group CRT per week, with each session lasting 40 minute. Two participants received two sessions per week and were included in the analysis because the program content was the same as that of the programs that other participants underwent.

All session plans were followed and had a similar format: ice breaker and homework review (the first session explained group CRT), today’s task, reflective discussions, and homework setting. Based on negative feedback related to public speaking from a previous study (Kuge et al., 2017), the program in this study included more paired work to help participants feel relaxed and comfortable. Participants were given homework between sessions to practice what they had learned and relate their skills to daily life scenarios. Based on the participant feedback from a previous study (Kuge et al., 2017), homework sheets were used to make the program easy and approachable. Homework also included working with doctors, nurses, or families to help facilitate and aid in applying what was learned from the sessions to everyday life.

The group CRT tasks were adapted from CRT for AN (Tchanturia et al., 2010) and the flexibility group materials (Maiden et al., 2014). The program consisted of four sessions: an illusions task (Session 1), geometric figures (Session 2), a switching attention task (Session 3), and a summary and discussion of daily life applications of the skills learned and occupational tasks (Session 4).

The therapist was a child and adolescent psychiatrist who participated in a 2-day CRT training workshop. Each group consisted of a closed group of 2–4 adolescents.

Measures

Demographic information

Data regarding age, sex, and illness duration were obtained from patient medical records.

Clinical characteristics

Body mass index (BMI) and standard body weight ratio were assessed at admission, pre- and post-group CRT, and at follow-up. Nurses recorded weight and height.

Autistic traits were measured at pre-group CRT and follow-up using the autism-spectrum quotient (AQ), which is a 50-question scale (Baron-Cohen et al., 2001). The validated Japanese version of the AQ (AQ-J) (Wakabayashi et al., 2004) was used in this study. AQ-J total scores range from 0 to 50 points, with higher scores indicating stronger autistic traits.

AN symptoms were measured using the Children’s Eating Attitude Test with 26 items (ChEAT-26) or the Eating Attitude Test with 26 items (EAT-26) pre- and post-group CRT and at follow-up. The ChEAT-26 and EAT-26 are self-reporting instruments that assess the characteristic psychopathology of AN (Maloney et al., 1989). The validated Japanese versions of the ChEAT-26 and EAT-26 were used in this study (Chiba et al., 2016; Nakai, 2003). Each scale yields a total score between 0 and 78, with higher scores indicating poorer eating attitudes. If the participants were junior high school students, ChEAT-26 was used. If the participants were high school students, EAT-26 was used.

Neuropsychological assessment

Wechsler adult intelligence scale (WAIS)-III and wechsler intelligence scale for children (WISC)-IV

WAIS-III and WISC-IV measurements were obtained during admission. If these measurements had already been assessed within 2 years, previous data were adopted.

Rey–osterrieth complex figure test (ROCFT)

ROCFT is a complex figure test used to evaluate central coherence (Lopez et al., 2008a, 2008b; Rose et al., 2011). Participants were asked to copy a complex figure design. The drawing process was video-recorded. The ROCFT was scored according to Booth’s scoring method (Booth, 2006), which incorporates the order in which the participant chooses to draw the elements (whether preference is shown for global or detailed elements) and the style in which they are drawn (fragmented or coherently). The order index (OI) and style index (SI) were computed and added to obtain the central coherence index (CCI). The ROCFT was performed before and after group CRT.

Brixton spatial anticipation test (brixton)

Brixton (Burgess & Shallice, 1997) was used to evaluate set-shifting. Brixton is a concept-attainment task that incorporates switching between mental representations. The test consists of 55 trials, each with the same array of 10 circles in a 2 × 5 matrix. In each trial, one circle was filled with a blue color. The position of this circle changes in each trial, with the participant having to determine the rule that governs the sequence of changes and predict the location of the filled circle for the next trial. As the test progresses, the rule changes, requiring the detection of new rules. No time limit was set for test completion; however, the test requires approximately 5–10 minute for administration. The total number of errors in the test was used to construct a scale score. The Brixton score was measured before and after group CRT.

Psychological assessment

Motivational ruler (MR)

MR determined the self-reported importance and ability to change (Miller, 2002). The MR consists of two questions: (1) “How important is it for you to change and recover from your AN?” and (2) “How confident are you in your ability to change and recover from your AN?” Each question was rated using a 10-point Likert scale (1 = not at all to 10 = very much). This ruler was used in a previous study on group CRT in adolescents with AN (Pretorius et al., 2012).

Beck’s depression inventory (BDI)-II

BDI-II is a 21-question scale, with each answer rated 0–3. The Japanese version of the BDI-II has been validated (Beck et al., 1996), used in numerous studies of adolescent depression, and was used in this study. The scale yields a total score between 0 and 63, with higher scores indicating higher severity of depressive symptoms.

Rosenberg self-esteem scale (RSES)

RSES is a self-reporting instrument with 10 items that measure the overall self-esteem of an individual (Rosenberg, 1986). The validated Japanese version of RSES (Yamamoto et al., 1982) was used in this study. The scale yields a total score between 10 and 50, with higher scores indicating greater self-esteem.

The MR, BDI-II, and RSES were assessed before and after CRT.

Qualitative assessment

Satisfaction questionnaire (post-final session)

This questionnaire consisted of three questions rated using a 10-point Likert scale (1 = not at all to 10 = very much). The three questions, in accordance with a previous study (Pretorius et al., 2012), were as follows: “How much did you enjoy the group CRT?” “How useful was the group CRT?” and “Did you feel that you have learned a new skill through the group CRT?” This questionnaire also included three open-ended questions about the participants’ group CRT experiences. The three open-ended questions, in accordance with previous studies (Kuge et al., 2017; Pretorius et al., 2012), were: “What are the good things that you learned from the group CRT?” “How has group CRT helped you in daily life?” and “What did you dislike or find difficult about the group CRT?”

Follow-up questionnaire

This questionnaire consisted of three open-ended questions about the group CRT experiences of the participants. The three questions were: “What did you learn from the group CRT?” “What was the most impressive thing you learned from the group CRT?” and “How would you describe any specific situations in which you have applied things you have learned from group CRT in daily life?”

Statistical methods

Quantitative analysis

Descriptive statistics of demographic variables and outcomes were reported as means and SD or medians (with ranges). The Shapiro–Wilk test was used to analyze the data distribution. Spearman’s correlation coefficients were calculated for non-normally distributed samples. Differences between pre-group and post-group CRT results of normal distribution samples were tested using paired t-tests, and effect sizes were calculated as Cohen’s d. Differences between pre-group and post-group CRT results of samples without normal distribution were tested using the Wilcoxon test, and effect sizes were calculated as r. Differences between post-group CRT and follow-up results of normal distribution samples were tested using analysis of variance, and effect sizes were calculated as η2. Differences between post-group CRT and follow-up results of samples without normal distribution were tested using the Friedman test. All statistical analyses were conducted using IBM SPSS Statistics Version 29 for Windows (IBM Corp, Armonk, NY, USA). Statistical significance was set at p < .05.

Qualitative analysis

Regarding responses to the open-ended satisfaction questionnaire (post-final session) and follow-up questionnaire, a qualitative analysis was conducted using content analysis. Comments were read several times, and elements of similar semantic content were searched for and replaced with appropriate expressions. They were categorized into subsequent headings, followed by themes defined by two authors.

Results

Baseline characteristics

The characteristics of the 31 participants upon admission are presented in Table 1. Group CRT sessions commenced at an average of 92.6 (SD 45.2, range 23–187) days after admission. Participants received adequate nutrition to ensure physical stability before initiating the CRT sessions. The average duration of admission was 166.6 (SD 69.4, range 65–396) days. Two participants (in the fourth and eighth groups) were discharged after the second session of group CRT; however, they continued the CRT sessions. Twenty-nine of the 31 participants (94%) completed four sessions of group CRT (Figure 1). Two participants dropped out: one participant (third group) could not attend the sessions because of other treatments, and the other (10th group) could not because of hospital rules concerning COVID-19.

Table 1.

Baseline characteristics.

Characteristics	Mean (SD); range
Age (years)	14.6 (1.3); 13–18
Sex	31 girls (100%)
Duration of illness (months)	16.5 (7.9); 5–36
BMI (kg/m2)	13.9 (2.0); 11.3–19.8
Standard weight ratio (%)	68.7 (8.9); 54–94
IQ (n = 29)	102.1 (16.4); 71–131

BMI: body mass index; IQ: intelligence quotient; SD: standard deviation.

Figure 1.

Flowchart of study participants, enrollment, and dropouts.

Clinical assessment

Data were collected from 12 CRT groups. Twenty-eight of 29 (97%) patients who completed group CRT underwent follow-up clinical physical assessments (BMI and standard body weight ratio) after 2–3 months (range 54–120 days after group CRT). At follow-up, 5 participants remained in inpatient care, whereas 23 received outpatient care. Twenty-five (86%) and 26 (90%) patients who completed group CRT underwent follow-up clinical psychological assessments (AN symptoms and AQ traits, respectively) (Figure 1). Table 2 presents the clinical, physical, and psychological assessments of the participants before and after the intervention and during follow-up. A significant increase in weight and a small effect size from pre-intervention to follow-up was observed. No significant changes in AN symptoms were observed from pre-intervention to follow-up. No significant change in autistic traits from pre-intervention to follow-up was observed.

Table 2.

Clinical assessment.

	Pre CRT (a)	Post CRT (b)	Follow-up (c)
Physical assessment (N = 28)	Mean (SD)	Mean (SD)	Mean (SD)	F	p-value	Effect size η²	Pairwise comparisons
BMI (kg/m²)	16.1 (1.4)	17.1 (1.4)	17.9 (1.5)	24.970	<.001*	0.23	a < b < c
Standard weight ratio (%)	79.3 (7.0)	84.1 (7.3)	87.6 (7.4)	22.262	<.001*	0.21	a < b < c

Psychologial assesment	Median (range)	Median (range)	Median (range)	Friedman	p-value
ChEAT-26/EAT-26 (N = 25)	17 (2–67)	12 (2–66)	15 (0–50)		.099

	Median (range)		Median (range)	Wilcoxon test		Effect size r
AQ (N = 26)	17 (10–34)	—	19 (7–34)	1.332	0.183	0.26

CRT: cognitive remediation therapy; BMI: body mass index; SD: standard deviation; AQ: autism-spectrum quotient; ChEAT-26: children’s version of eating attitude test with 26 items; EAT-26: eating attitude test with 26 items.

*p < .05.

Neuropsychological and psychological assessment

AN symptoms pre-group CRT significantly correlated with the BDI-Ⅱ (Spearman r = .71, p < .001) and RSES (Spearman r = −.54, p = .002). AN symptoms post-group CRT also significantly correlated with the BDI-Ⅱ (Spearman’s r = .57, p = .001) and RSES (Spearman’s r = −.55, p = .002).

Table 3 presents neuropsychological and psychological assessments of participants before and after the intervention. The effect size for the difference between pre- and post-intervention Brixton (number of errors) was large. The effect sizes for the difference between pre- and post-intervention SI, Brixton (score), and BDI were medium. The effect sizes for the difference between pre- and post-intervention OI, CCI, and MR (ability to change) were small. The effect sizes for the difference between pre- and post-intervention MR (importance to change) and RSES were negligible. The paired t-test revealed significant changes in Brixton (number of errors and score) post-group CRT. The Wilcoxon test revealed significant changes in SI and BDI post-group CRT.

Table 3.

Cognitive and psychological assessment between pre- and post-group CRT.

	Pre CRT	Post CRT	t-test	p-value	Effect size d
	Mean (SD)	Mean (SD)	t-test	p-value	Effect size d
Cognitive assessment
Central coherence (N = 26)
ROCFT order index	2.36 (0.58)	2.58 (0.48)	−1.779	.087	0.35
Set-shifting (N = 28)
Brixton (number of errors)	16.9 (6.9)	13.6 (6.2)	4.437	<.001*	0.84
Brixton (score)	5.7 (2.2)	6.7 (2.2)	−3.576	.001*	0.68
Psychologial assesment (N = 29)
RSES	27.7 (10.1)	28.2 (9.7)	−0.576	.569	0.11

	Median (range)	Median (range)	Wilcoxon test	p-value	Effect size r
Cognitive assessment
Central coherence (N = 26)
ROCFT style index	1.67 (1.00–2.00)	1.83 (1.00–2.00)	2.011	.044*	0.40
ROCFT central coherence index	1.57 (1.00–2.00)	1.70 (1.00–2.00)	1.772	.076	0.35
Psychologial assesment (N = 29)
BDI	17 (0–39)	10 (0–49)	2.399	.016*	0.45
MR-importance to change	10 (2–10)	10 (2–10)	0.345	.730	0.07
MR-ability to change	8 (1–10)	9 (1–10)	0.810	.418	0.15

CRT: cognitive remediation therapy; SD: standard deviation; ROCFT: Rey-Osterrieth complex figure test; RSES: Rosenberg self-esteem scale; MR: motivational ruler; BDI: Beck’s depression inventory.

*p < .05.

There were no significant correlations between BMI and ROCFT (OI, SI, and CCI) and Brixton (number of errors and score) at pre- and post-intervention assessments.

Qualitative assessment

Satisfaction questionnaire (post-final session)

The mean scores in the satisfaction questionnaire are shown in Figure 2.

Figure 2.

Mean scores on the feedback questionnaire given after the final session.

Group CRT advantages

Concerning the open-ended feedback questionnaire, an analysis of the free text responses about group CRT advantages (N = 29) (“What are the good things that you learned from the group CRT?”) revealed three main themes: 1) to understand myself (my thinking style/trait), 2) to determine others’ thinking styles, and 3) to find and experience a new thinking style (Table 4).

1. To understand myself (my thinking style/trait): Fourteen participants (48%) could understand themselves, including their thinking styles and traits.

2. To determine others’ thinking styles: Nine participants (31%) felt they could identify others’ thinking styles.

3. To find and experience a new thinking style: Eight participants (28%) felt that they could find and experience a new thinking style.

Table 4.

Satisfaction questionnaire feedback.

	Themes	Frequencies N (%)	Examples of actual comments
Group CRT advantages	To understand myself (my thinking style/trait)	14 (48)	“I was able to find my thinking style”
	To understand myself (my thinking style/trait)	14 (48)	“I was able to understand my trait”
	To determine others’ thinking styles	9 (31)	“I was able to know other’s thinking style”
	To determine others’ thinking styles	9 (31)	“I was able to hear thoughts of other adolescents with the same disease”
	To find and experience a new thinking style	8 (28)	“I was able to find a new thinking style”
	To find and experience a new thinking style	8 (28)	“I was able to think about something from the different perspective”
Benefits of CRT skills in daily life	To be able to think flexibly and adopt new thinking styles	21 (72)	“I became to be able to think flexibly”
Benefits of CRT skills in daily life	To be able to think flexibly and adopt new thinking styles	21 (72)	“I became to be able to choose the different thinking style than before”
Group CRT disadvantages	Difficult tasks	9 (31)	“Homework was difficult”
	Difficulty and fatigue due to unfamiliar thinking styles	6 (21)	“It was difficult for me to think flexibly”
	Difficulty in thinking and verbalizing one's thinking style	5 (17)	“It was difficult for me to verbalize my thoughts”
	Difficulty in understanding, low interest, and low effectiveness of the tasks	5 (17)	“I wasn’t interested in the content of CRT”
	Difficulty in generalizing to daily to life	2 (7)	“It was difficult for me to relate my thinking style to everyday life”

CRT: cognitive remediation therapy.

Benefits of CRT skills in daily life

An analysis of the free-text responses about the group CRT benefits (“How has the CRT group helped you in daily life?”) revealed one main theme: the ability to think flexibly and adopt new thinking styles (Table 4).

1. To be able to think flexibly and adopt new thinking styles: Twenty-one (72%) participants felt that they could think flexibly and adopt new thinking styles.

Group CRT disadvantages

An analysis of the free text responses about the group CRT disadvantages (“What did you dislike about the group CRT or find difficult?”) revealed five main themes: 1) difficult tasks, 2) difficulty and fatigue due to unfamiliar thinking styles, 3) difficulty in thinking and verbalizing one’s thinking style, 4) difficulty in understanding, low interest, and low effectiveness of the tasks, and 5) difficulty in generalizing to daily life (Table 4).

1. Difficult tasks: Nine participants (31%) experienced difficulty in the tasks.

2. Difficulty and fatigue due to unfamiliar thinking styles: Six participants (21%) experienced difficulty and fatigue due to unfamiliar thinking styles.

3. Difficulty in thinking and verbalizing one’s thinking style: Five participants (17%) felt it was difficult to think and verbalize their thinking styles.

4. Difficulty in understanding, low interest, and low effectiveness of the tasks: Five participants (17%) experienced difficulty in understanding, low interest, and low effectiveness of the task.

5. Difficulty in generalizing to daily life: Two participants (7%) experienced difficulty generalizing to daily life.

Follow-up questionnaire

For the open-ended follow-up questionnaire (Table 5), an analysis of the free-text responses about skills gained through CRT (N = 25) (“What did you learn from the group CRT?” and “What was the most impressive thing you learned from the group CRT?”) revealed three main themes: 1) to obtain various thinking styles and think more flexibly, 2) to understand myself (my thinking style), and 3) to identify the differences between one’s and others’ thinking styles.

1. To obtain various thinking styles and think more flexibly: Fifteen participants (60%) felt they could obtain various thinking styles and think more flexibly.

2. To understand myself (my thinking style): Five participants (20%) felt they could understand their thinking styles.

3. To identify the differences between one’s and other’s thinking styles: Four participants (16%) felt they could find the difference between one’s and others’ thinking styles.

Table 5.

Follow-up questionnaire feedback (skills gained through CRT).

	Themes	Frequencies N (%)	Examples of actual comments
Skills gained through CRT	To obtain various thinking styles and think more flexibly	15 (60)	“I was able to obtain various perspectives”
	To obtain various thinking styles and think more flexibly	15 (60)	“I became to be able to think more flexibly”
	To understand myself (my thinking style)	5 (20)	“I was able to find my thinking style”
	To identify the differences between one’s and other’s thinking styles	4 (16)	“I was able to find other people had different thinking styles”

CRT: cognitive remediation therapy.

For the open-ended follow-up questionnaire, an analysis of the free text responses about using thinking styles in daily life situations (N = 19) (“How would you describe any specific situations in which you have applied things you have learned from group CRT in daily life?”) revealed four main situations: 1) when things go wrong or something unplanned happens (N = 11, 44%), 2) studying (N = 5, 26%), 3) weight and mealtime (N = 4, 21%), 4) personal relationships (N = 3, 16%) (Table 6). Table 6 presents the thinking styles of participants in daily life situations, related sessions, and the participants’ examples.

Table 6.

Follow-up questionnaire feedback (using thinking styles in daily life situations).

Daily life situation	Using thinking style	Frequencies N (%)	Related sessions	Examples of actual comments
When things go wrong, or something unplanned happens	Flexible thinking style	11 (44)	All sessions	“When something unplanned happens in my daily life, I try to change my feeling”
When things go wrong, or something unplanned happens	Bigger picture	11 (44)	All sessions	“When one thing goes wrong, I try to get the bigger picture”
Studying	Flexible thinking style	5 (26)	Illusions, switching attention task	“When I can’t solve a problem, I try to find another style of thinking”
Weight, mealtime	Flexible thinking style	4 (21)		“When I regretted eating it, I became to be able to think of it with a different perspective”
Personal relationships	Switching perspective	3 (16)	All sessions	“I try to consider the feelings of others in other positions”

Discussion

This study explored the impact of group CRT on adolescents with severe and complex AN requiring inpatient care in a real-world inpatient setting in Japan by assessing 1) post-CRT changes in clinical, psychological, and neuropsychological measures; 2) follow-up changes in clinical measures; and 3) qualitative feedback post-group CRT and at follow-up.

The results of this study indicated that group CRT was acceptable for adolescents with AN who required inpatient care, with a high completion rate of 94%. This is consistent with the results of four previous studies on group CRT for adolescent inpatients or day program patients with AN (67% [Wood et al., 2011], 80% [Pretorius et al., 2012], 86% [Kuge et al., 2017], and 91% [Harrison et al., 2018]. Moreover, the reasons for dropout were not negative reactions to group CRT. The treatment completion rate of CRT was higher than that of other treatments (60%–80%) (Dejong et al., 2012). The higher treatment completion rate (94%) compared with that reported in the previous study (86%) by Kuge et al. (2017), could be because of the following two improvements made on the basis of negative feedback in that study: inclusion of more paired work to help the participants to feel relaxed and comfortable, and use of homework sheets to make the program easy and approachable. Thus, participant feedback was mainly positive. Most participants found group CRT to be fun, useful, and helpful.

This study showed that adolescents with AN demonstrated partial improvement in cognitive functioning, as measured using neuropsychological tasks, which is in agreement with the results of previous studies (Tchanturia et al., 2017). The adolescents showed significant medium to large improvements in the SI of ROCFT and Brixton scores. However, there were small effect sizes and no significant improvements in OI and CCI of ROCFT. Less consistency was observed in set-shifting tasks across different studies, with studies using fewer CRT sessions showing greater improvement (Tchanturia et al., 2017). This finding is likely because of the small number of studies, small sample sizes in each study, test-retest (learning) effects, or improvements in the mental and physiological status of patients. Therefore, further research is required to clarify these effects.

The results of this study also demonstrated a medium effect size and significant improvements in depressive symptoms as measured using a self-reported scale. Small and negligible effect sizes were observed between pre- and post-group CRT MR (importance and ability to change) and RSES. Less consistency has been observed regarding self-reported depressive symptoms, motivation, and self-esteem across studies (Dahlgren et al., 2013; Harrison et al., 2018; Kuge et al., 2017; Pretorius et al., 2012). The results of the self-reported motivation in this study showed high pre-group CRT scores; however, pre-group CRT changes could not be assessed. Future studies should include measures for depressive symptoms, motivation, and self-efficacy.

The adolescent feedback indicated that group CRT may be useful for adolescents with AN. They reported that they could understand their own thinking styles, discover other people’s thinking styles, and obtain new thinking styles, which were the purposes of CRT. Moreover, adolescents reported applying the skills they learned through CRT to daily life.

Thus, it was observed via the follow-up feedback that participants could generalize their skills learned through CRT to meals and weight, even though CRT asks patients to consider thinking rather than facing AN symptoms. Most adolescents with severe AN struggle to establish a therapeutic relationship with their therapists and articulate their AN symptoms. This may stem from adolescents’ nervousness around therapists and their ongoing development of metacognition and verbalization skills. Additionally, adolescents undergoing inpatient care for AN often exhibit reluctance to engage in treatment and may deny their condition. CRT could help foster a therapeutic relationship as it offers enjoyable sessions (the mean score for the question “How much did you enjoy the group CRT?” in the satisfaction questionnaire was 8.13 [SD 2.72]) instead of directly addressing meal and weight management issues. Some adolescents also perceived being able to understand the thoughts of others with similar difficulties as an advantage of group CRT (nine participants felt they could identify others’ thinking styles). It may be easier for them to accept their thoughts when the same thoughts are shared by peers rather than being told by their therapists. Group CRT could represent the first step in assisting adolescents with AN who struggle to change their thinking styles and behaviors. Consequently, it may be possible to motivate them to apply the coping skills learned during CRT sessions to mealtimes (four participants reported that the skills learned during CRT sessions were useful for managing weight and mealtimes).

This study has several strengths. First, the sample size was larger than that of the previous study in Japan (Kuge et al., 2017). Second, a follow-up was conducted to assess how the participants used the learned skills in their daily lives.

This study has certain limitations. First, we used an uncontrolled study design. Second, all participants received other treatments. Thus, it is difficult to attribute the extent of improvement in weight, cognitive functioning, and depressive symptoms to group CRT. In a previous study involving children and adolescents participating in group CRT, improvements in set-shifting using the Brixton and improvements in central coherence using ROCFT were moderately associated with weight restoration. However, this association was insignificant in this study, possibly due to the small sample size (Rhind et al., 2022). Although weight status would be expected to impact cognitive functions to some extent (Keys et al., 1950), another previous study showed that weight and weight gain alone are not predictors of significantly improved cognitive functions in adolescents with AN (Kjærsdam Telléus et al., 2016). We found no significant correlations between BMI and cognitive functions in this study, which may also be attributed to the small sample size; however, it is possible that CRT may have contributed to their improvement.

Furthermore, group CRT was performed in a real-world inpatient setting in Japan, indicating that performing it in an inpatient setting is feasible. Future research should compare group CRT with other types of therapies. Third, the follow-up period exhibited variation, ranging from 54 to 120 days, due to participant discharge and differing visit frequencies among the participants. Consequently, research with a more standardized and rigorous follow-up duration is warranted.

Conclusion

Group CRT may be beneficial for adolescents with severe and complex AN who require inpatient care.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.*

Footnotes

Acknowledgements

The authors would like to thank the participants of this study and Editage () for English language editing. This work was supported by the staff of the Department of Child and Adolescent Psychiatry (Drs. Ebishima, Oka, and Nishiki), Department of Psychology and Welfare, and Department of Clinical Study, Tokyo Metropolitan Children’s Medical Center.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rie Kuge

Author biographies

Dr. Rie Kuge is a senior assistant professor in the Mental Health Clinic for Children, Shinshu University Hospital. Her current research is mostly focused on children and adolescents with anorexia nervosa.

Ayano Hasegawa is a clinical psychologist at Tokyo Metropolitan Matsuzawa Hospital. Her current research interests include cognitive function in adolescents with eating disorders and ways to improve it.

Dr. Yuriko Morino is a clinical director, a Child and Adolescent Psychiatrist at Narimasu Centre for Child and Adolescent Mental Health. Her interests include family therapy for patients with eating disorders and their families.

Dr. Michiko Nakazato is a professor in the Department of Psychiatry, International University of Health and Welfare. Her current research is mostly focused on patients with eating disorders.

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