Training the Brain to Think Flexibly in Adolescent Anorexia

By Jillian Rose Lim

Whether it’s a road closure on the morning commute or new responsibilities at work, we’re constantly faced with opportunities to use our cognitive flexibility, the ability to shift gears and think up new solutions. But for those who struggle with serious conditions such as eating disorders or depression, improving this executive function could have a major impact on treatment outcomes.

With support from a recent National Institutes of Health grant, C. Alix Timko, PhD, a psychologist in the Department of Child and Adolescent Psychiatry at CHOP, is leading an innovative study that investigates whether training adolescents and their parents in cognitive flexibility (also known as set-shifting) could benefit current treatments for anorexia nervosa.

“One thing that individuals with anorexia have is a tendency to be less flexible in their behaviors,” said Dr. Timko, who is also an assistant professor of Psychiatry at the University of Pennsylvania. “For example, they have very specific rules they follow in relationship to food. There’s a lot of inflexibility in their everyday life. So, if we can identify this as a difficulty, we can potentially develop treatments to improve set-shifting and foster flexibility that can hopefully translate to flexible behavior.”

Effective treatments for anorexia are limited, despite the condition having the highest mortality rate of all psychiatric illness. Family-based treatment (FBT), the therapy with the strongest evidence base, has a modest success rate of 50 percent of adolescents reaching remission after treatment. After looking at adult studies of anorexia and drawing on existing research into cognitive flexibility, Dr. Timko wondered if incorporating a type of treatment called cognitive remediation therapy (CRT) in addition to FBT would improve FBT’s effectiveness.

Why Cognitive Remediation Therapy?

CRT involves a series of tasks similar to today’s “brain-training” games, and clinicians have used the rehabilitation therapy in a variety of conditions, from traumatic brain injury to depression, since World War I. Several years ago, researchers at King’s College in London began to develop CRT for anorexia, finding that women who received CRT demonstrated increased flexibility in their thinking styles, and that CRT increased the likelihood they would stay in treatment and helped to improve quality of life.

Though robust research already shows adults with anorexia have inefficiencies in their set-shifting abilities, limited research exists about how CRT might be helpful for adolescents and their flexible thinking. Taking into account one other intriguing fact — that some studies show parents or siblings of adults with anorexia also struggle with flexible thinking — Dr. Timko’s new study will test whether offering CRT to both parents andtheir adolescents with anorexia could make FBT more effective.

It’s important to note that researchers still don’t know whether impaired cognitive flexibility in anorexia is an endophenotype — an inherited gene trait, or a state-based quality — or a result of the condition itself. Starvation on an adolescent’s part, and stress on both parents and the adolescent, can both lead to reductions in cognitive flexibility. But Dr. Timko points out that training the brain to become more flexible, especially for adolescents who are still developing the executive function as they age, can only help, not hurt, efforts to improve treatments.

As for parents, Dr. Timko explains that “helping parents with cognitive flexibility may actually help them to implement FBT more easily, or adapt more quickly to changes they need to do with their child with anorexia.”

How Cognitive Remediation Therapy Works

CRT can look different for individual people and conditions, since it can be adapted to target different types of executive functioning, such as memory or attention or problem-solving. In anorexia, CRT focuses on both cognitive flexibility and central coherence, or the idea of “big picture” thinking.

“What we see in individuals with anorexia is that they tend to focus on the small details,” Dr. Timko said. “They tend to see the little pieces of the picture. They see the trees and not the forest. What CRT does is foster the ability to take a step back and see the forest.”

This involves a combination of tasks, none of which talks about the eating disorder itself.

“We don’t talk about weight, or the body, or food,” explained Dr. Timko, adding that the therapy creates a non-emotional setting where it’s much easier to build skills. In fact, CRT employs a handful of games, puzzles, and tasks on seemingly unrelated scenarios.

These can be as simple as illusion games — think the old lady/young lady optical illusion — followed by a discussion about the patient’s thinking process. How easy or difficult was it to see the second face? Can you switch back and forth between seeing one or the other? Can you approach this in a different way, and what does that feel like? When you solve problems in the real world, do you tend to approach them always in the same way? Do you try something different?

“We take these fairly benign and innocuous tasks, and we’re able to gain some insight into thinking processes and practice training new skills,” Dr. Timko said. “You get used to the discomfort of thinking a different way. But it often feels like playing games, so it feels very different than other forms of treatment. Adolescents tend to really enjoy it, and we’re just getting started with parents to see how they like it.”

Flexible Thinking for Parents

Dr. Timko believes improved cognitive flexibility could help parents better handle family-based treatment, which can at times be stressful and demanding. For example, in FBT, the first and often most difficult phase involves restoring an adolescent with anorexia to physical health as quickly as possible. Parents take over complete responsibility for renourishing their child: They plan, prepare, and plate all meals for their child, ensure their child eats, and turn to alternatives such as milkshakes or nutritional supplements if their child doesn’t reach their caloric requirements.

“In this phase, what parents are basically asking their child to do is face their biggest fear over and over and over again, multiple times a day,” Dr. Timko said. “It’s hard. It’s difficult, and sometimes parents can feel like what they are doing is hurting their child because they are asking their child to do such a scary and difficult thing.”

Therefore, strengthening a parent’s ability to cope with the stress is equally as important for an adolescent’s recovery as strengthening the adolescent themselves.

“Parents are our best and strongest allies, and anything that we can do to provide more support to parents is good,” Dr. Timko said. “From my perspective, if we can do something that supports parents, and help parents get through FBT, which can be really tough some days, we can get more children better faster. My ultimate goal is to eliminate adult anorexia. I don’t want adolescents to go on and struggle with this into adulthood.”

For more information about the “Shifting Perspectives” study and to find out how to participate, visit CHOP’s Clinical Trial Finder.