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Clinical Case Studies 2020, Vol. 19(2) 115 –132

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Cognitive Remediation Therapy as a Feasible Treatment for a Young Person With Anorexia Nervosa and Autism Spectrum Disorder Comorbidity: A Case Study

Yasemin Dandil1,2, Claire Baillie1, and Kate Tchanturia1,2

Abstract Anorexia nervosa (AN) is a challenging illness to treat with inefficiencies in central coherence and set-shifting known to be cognitive maintaining factors for the eating disorder. AN is further complicated by comorbidities such as autism spectrum disorder (ASD). Cognitive remediation therapy (CRT) aims to address problems with cognitive style and meta-cognition by stimulating the neural connections involved in cognitive processing through cognitive tasks, reflection, and behavioral experiments. However, to date, no reported studies are supporting individual CRT for patients with AN and ASD comorbidity. This single complex case study provides preliminary evidence to support the efficacy of individual CRT in the treatment of a 21-year-old female patient with AN and ASD comorbidity. Clinical and self-report data collected before and after CRT indicate improvements in cognitive flexibility and central coherence, alongside an increase in body mass index (BMI). This case study reflects the possible ways to adapt and calibrate treatment to individual needs and the efficacy of CRT, before proceeding to more complex individual psychological work, such as cognitive behavioral therapy.

Keywords anorexia nervosa, autism spectrum disorder, cognitive remediation, treatment, cognitive flexibility, case formulation

1 Theoretical and Research Basis for Treatment

Anorexia nervosa (AN) is a severe and enduring mental illness and has the highest mortality rate of any psychiatric disorder (Arcelus et al., 2011; Schmidt et al., 2016; Treasure et al., 2010). AN is often associated with poor treatment outcomes due to problems in cognitive flexibility and cen- tral coherence (Lang et al., 2016; Tchanturia et al., 2012). Moreover, AN is further complicated by neurodevelopmental comorbidities such as autism spectrum disorder (ASD) characterized by

1South London and Maudsley NHS Foundation Trust, UK 2King’s College London, UK

Corresponding Author: Kate Tchanturia, London Institute of Psychiatry, Psychology and Neuroscience, King’s College London, P.O. 59, 16 De Crespigny Park, London SE5 8AF, UK. Email: [email protected]

890425CCSXXX10.1177/1534650119890425Clinical Case StudiesDandil et al. review-article2019

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difficulties with set-shifting/high rigidity of thinking (Westwood, Stahl, Mandy & Tchanturia, 2016). Research has suggested that the overrepresentation of symptoms of ASD among inpatients in eating disorder services is associated with more severe eating disorders and poorer everyday functioning (Tchanturia et al., 2019).

Preliminary suggestions of the increased prevalence of ASD in AN have since highlighted that around 23% of adults have this comorbidity (Gillberg & Råstam, 1992; Westwood & Tchanturia, 2017). In support, a systematic review found that, potentially, one in four females with AN is autistic, compared with a prevalence rate of ~1% in the general population (Scott et al., 2002). Consequently, researchers are now having a specific focus on the hypothesis that ASD places females at high risk of developing AN (Oldershaw et al., 2011).

The exact prevalence of ASD and AN is complicated. One of the rationales for the overlap between AN and ASD could be that the acute, starved state associated with AN may exacerbate the characteristics of ASD, including problems in theory of mind, reduced cognitive flexibility, and poor social function (Mandy & Tchanturia, 2015). Furthermore, females with ASD are underrepresented in ASD services and require more severe symptomatology than males to meet the ASD diagnostic criteria (Dworzynski et al., 2012). This diagnostic bias can lead to females not being diagnosed with ASD until they access eating disorder services.

Emerging evidence also suggests that there may be a “female phenotype” of ASD character- istics, with females displaying less repetitive and restricted behaviors than males and more likely to “camouflage” their social difficulties, leading to underrecognition or missed diagnoses (Westwood et al., 2017). Consequently, qualitative research findings have reported the signifi- cant barriers to treatment experienced among this population (Kinnaird et al., 2019). Significantly, heightened ASD traits in people with AN are associated with poorer treatment outcomes suggest- ing traditional treatment approaches may need to be adapted for this population (Tchanturia et al., 2019). Potential contributors behind these poorer outcomes could reflect the heightened rigidity and difficulties with introspection seen in ASD, making it difficult for patients to engage in treat- ment (Dudova et al., 2015).

However, the current National Institute for Health and Care Excellence (NICE; 2017) guidelines has no mention or highlighted recommended treatment for AN and ASD comorbid- ity. The similarities in cognitive profiles among AN and ASD (Kinnaird et al., 2019) support the notion of exploring the practicability of cognitive remediation therapy (CRT), a treatment adjunct showing positive outcomes in AN (Tchanturia et al., 2014, 2017; Westwood & Tchanturia, 2017). CRT aims to target inefficiencies in central coherence and cognitive flexi- bility known to be cognitive maintaining factors for AN. Randomized treatment trials have consistently shown cognitive improvements followed by cognitive exercises, reflection, and behavioral changes in patients receiving CRT as well as better quality of life (Tchanturia et al., 2014, 2017)

Although there have been several case studies implementing CRT for patients with AN, which has demonstrated significant improvements in neuropsychological tests of set-shifting and with positive patient feedback (Davies & Tchanturia, 2005; Pretorius & Tchanturia, 2007; Tchanturia et al., 2006, 2010), or case studies on cognitive remediation and emotional skills training (CREST) or third-generation behavior therapies for patients with AN (Martin-Murcia et al., 2011; Money et al., 2011), there has only been one small pilot study in Japan that supported the feasibility of individual CRT sessions for adults with ASD (Okuda et al., 2017). Therefore, to the authors’ knowledge, this was the first study with the aim to describe a complex single case study of the treatment of a 21-year-old female with both AN and ASD using the individual CRT format. It is hoped that the findings from this case will enhance the understanding of the feasibility of CRT in individual format among people with complex AN and ASD comorbidities.

Dandil et al. 117

2 Case Introduction

A 21-year-old female (referred to as Milly for anonymity) provided consent to having her case published. Milly met the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM- 5; American Psychiatric Association, 2013) diagnostic criteria for AN (restricting type). She was also diagnosed with ASD at age 11 in a specialist ASD clinical service. Milly’s eating problems were first associated with weight gain as a result of chemotherapy (aged 12 Milly was diagnosed with Hodgkin’s Lymphoma, from which she is currently in remission). This was further exacer- bated by her father leaving the family home. On admission to the inpatient ward, Milly’s weight was 41.9 kg, with a body mass index (BMI) of 14.1 (normal range for BMI is between 19 and 25). Milly previously had three inpatient admissions, of between 3- and 4-month duration, within the past 16 months. Upon each discharge, she had lost weight and required readmission.

3 Presenting Complaints

Milly was admitted to the inpatient treatment program in the specialist national eating disorder service after struggling to manage and maintain her weight in the community and during her previous inpatient admissions. Milly’s early life experiences contributed to the development of negative core beliefs of low self-worth and, consequently, Milly had an overfocus on weight and shape as signifiers of happiness and personal worth. She had low self-esteem, a confused sense of identity, and high levels of anxiety. Milly held her ASD accountable for her fixation and rigidity of ritualized patterns, such as doing certain exercises every day and restriction of the amount of food she was consuming. Consequently, Milly was inclined to panic if there were changes in her routine due to unexpected and novel experiences. Milly described being with others as difficult and struggled to make friends. She was often observed sitting on her own covered with a blanket. Furthermore, Milly has expressed her scare of the possibility off her cancer reoccurring.

4 History

Personal

Milly reported a difficult upbringing as at aged 11 she was diagnosed with ASD and as described above had a serious physical illness. She had lived a socially isolated adolescence as she expressed her ASD made it difficult for her to make friends and described herself as a shy teenager. Milly described her ASD meant that she will get nervous talking to people she does not know. Milly recalls that following her weight gain from chemotherapy she overcompensated with comfort eating for the feelings of abandonment and sadness she experienced after her father left the fam- ily home. However, she then recalls being “obsessed” with being healthy and relates this to her ASD and obsessive-compulsive disorder (OCD) traits for “driving me the wrong way” by over- exercising and abusing laxatives. Milly expressed that she thought losing weight will make her “happy,” she said, “I never had a target weight I just wanted my weight to get lower and lower.” She expressed that she holds her ASD accountable for her fixation and rigidity for doing certain exercises every day and restricting her food intake.

Family

Milly lived with her mother and younger brother aged 18. Milly described having a good and close relationship with her mother and recalled that she would witness the verbal arguments between her parents. She reported feeling “distressed” at the time her parents divorced.

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Milly reports that she has an “okay” relationship with her brother and described having a “bet- ter” relationship with her older sister who is aged 23 and lives with her boyfriend and that she speaks to her more often.

Milly’s father left the family home when she was aged 17. This was a particularly challenging time for Milly as she reported to have a “normal fine relationship” with her father before he left. Milly has had no contact with her father since he left the family home and, at present, she does not want to be in contact with him as she reported she will find this “stressful due to his drink- ing.” Milly also mentioned that her father would message her at midnight and “say that I should be seeing him and question why I am not but I blocked him so he cannot contact me.” There are reports of Milly’s father suffering from depression.

5 Assessment

Milly was assessed by a psychiatrist on admission to the inpatient ward and met the DSM-5 cri- teria for AN restricting type. These symptoms include a BMI of <17.5, and behaviors such as restriction of food. Milly also completed the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), a measure based on the observation of characteristics associated with autism during a series of tasks and interview questions. Milly’s assessment was carried out using Module 4 of the ADOS-2, which is designed for use with verbally fluent adolescents and adults. The assessment was scored according to the revised algorithm, which has improved specificity and sensitivity compared to the original measure (Hus & Lord, 2014). The algorithm scores individu- als in the following domains: communication, reciprocal social interaction, and the presence of repetitive or restrictive behaviors. Available scores range from 0 (no observed characteristics) to a maximum of 30 (high levels of characteristics associated with autism). A score above 8 indi- cates clinically significant levels of autistic traits.

Milly’s assessment was administered by a trained researcher. Milly scored a total of 11 on the ADOS-2, placing her above the clinical cut-off. Milly’s score was primarily driven by observed traits in the areas of communication and reciprocal social interaction, rather than the presence of repetitive or restrictive behaviors. During the assessment, conversation with the examiner did not flow: Milly typically gave single word responses to questions. She rarely used gestures to facilitate communication, instead of keeping her hands still in her lap and exhibited minimal facial expres- siveness. Milly also showed limited insight into typical social situations and relationships.

6 Case Conceptualization

The cognitive behavioral model informs the following case formulation. We present a brief description of the formulation alongside a diagrammatic snapshot (Figure 1). The following is taken from direct information provided from Milly, as well as her assessment data. The predis- posing factors related to Milly’s eating difficulties began to emerge following weight gain associ- ated with chemotherapy, Milly was diagnosed with Hodgkin’s Lymphoma at age 12. In line with this, her father left the family home at age 17 and her maternal grandfather passed away a few months later. Milly reported that her father leaving home was “hard” for her as she had a “normal fine relationship” with him and named feeling “sad, upset, and angry” when he left, and then after a couple of months “the feelings got numb.”

Milly was diagnosed with ASD at age 11 which she did not like, she cited “I felt I was not normal growing up and I always felt like an outcast as I found it hard to make friends.” Reports have noted the deficits in Milly’s theory of mind, weak central coherence, and executive func- tion, which may have increased her vulnerability. Furthermore, Milly reported that she had traits of OCD which began in primary school and she named being a “perfectionist” with straightening her hair. Milly was also diagnosed with anxiety and depression at age 13.

Dandil et al. 119

Figure 1. (continued)

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Figure 1. Case formulation (formulation snapshot).

These early childhood stressors subsequently informed Milly’s perceptions about herself, relationships, and her future (i.e., core beliefs). Hers were characterized by overarching low self- worth that over time manifested as an overfocus on weight and shape as signifiers of happiness and personal worth.

A significant precipitant to the onset of eating disorder behavior was the weight gain with the steroids associated with chemotherapy, then Milly’s father leaving, and her grandfather whom she saw as a father figure passing away a few months later. Milly also reported her worry and “scare” of the idea of her cancer reoccurring. In the context of these stressors, she recalls eating for comfort, leading to weight gain up to a BMI of 30.1, and reports that this was the biggest she has been. Following her weight gain, Milly cited that she tried to lose weight “healthily” by eat- ing healthy and exercising. She then reports becoming “obsessed” with being healthy and related this to her ASD and OCD features for “driving me the wrong way” by overexercising and abus- ing laxatives. Milly views laxatives as an “easy way to eat but not keep the food in my body.” Milly reported, “I never had a target weight I just wanted my weight to get lower and lower.” She reported that she holds her ASD accountable for her fixation and rigidity for doing certain exer- cises every day and restriction of the amount of food she was consuming.

Maintaining factors for the AN for Milly included the “safety” of AN which she reported as part of her and hard to let go and the fear of change of getting bigger and, in consequence, feeling sad. Milly reported comparing herself to other people on the unit and felt “big” in the inpatient environ- ment. Milly expressed AN becoming a way of being able to “control and avoid feelings of hurt” and cited “everything else feels out of control in my life such as my family life and I want something to control so at least I can control the eating disorder.” Furthermore, Milly reported a “sense of achievement and feeling good when the scale goes down.” Milly saw her ASD and AN as inter- linked. She then processed this information with her cognitive and behavioral rigidity, with her insistence on sameness and ritualized patterns of behavior impacted by starvation. This same rigid- ity associated with her ASD made it difficult for Milly to change her eating disorder behaviors.

Protective factors for Milly include her stepfather wanting to adopt her and the feelings of joy this provoked in Milly as she has longed to have a father figure in her life. Milly described that the news had her feeling “really happy” and gave her a feeling of “safety, happiness, and excitement”

Dandil et al. 121

and has also given her some motivation to work toward. Other protective factors include Milly’s motivation to engage with psychological work and challenge her AN and focused and detailed thinking. Milly’s supportive family is a significant protective factor for her. Milly identified longer term goals of going to the residential placement and then later completing a child care course and having her own family. Milly also reported that she is now able to make friends in the hospital and also enjoys occupational therapy activities which include art and textiles.

Treatment Recommendations

The clinical team tried to engage Milly collaboratively in her care planning. For example, we explored what was most difficult for Milly in terms of the inpatient environment. Milly expressed that her rigidity is making the inpatient environment most difficult for her. This was due to her insistence on sameness, inflexible adherence to routines on the ward, and ASD rituals which included having to go out at specific times for her walks. Subsequently, Milly was first offered CRT for AN manualized therapy (Tchanturia et al., 2010) from the psychological therapies team.

1. It is known that acutely ill AN inpatients are difficult to engage in psychological work. CRT aimed to offer a simple, nonthreatening and collaborative treatment that would moti- vate further engagement later on in treatment.

2. People with AN often struggle with being overly detail-focused, prefer familiar routines, and find it hard to be flexible or think about the bigger picture. It was established that this was the case for Milly, as highlighted in her case conceptualization Milly reported her ASD was accountable for her fixation and rigidity for doing specific exercises and restric- tion of food. Therefore, Milly would benefit from CRT to help her increase flexibility, bigger picture thinking, and spontaneity.

7 Course of Treatment and Assessment of Progress

CRT was offered consecutively to patients on the ward before they moved on to more complex psychological work, such as cognitive behavioral therapy (CBT). The assessments described below were administered as outcome measures for CRT. They included clinical questionnaires relating to eating pathology and mood, and calculation of BMI throughout treatment. Although eating pathology, mood, and weight was not being directly targeted in CRT, it was important to see if these clinical symptoms changed after CRT. The main focus of CRT was to target thinking processes by using cognitive exercises.

Milly’s BMI was calculated before, during, and after CRT intervention (see Figure 2). The following self-report measures were administered before and after individual CRT.

However, it is important to note that given the short timeframe of the intervention the validity of pre–post assessments can be questionable. Therefore, it would be beneficial to do a 6-month follow-up to measure the outcome:

The Detail and Flexibility Questionnaire (DFlex; Roberts et al., 2011) is a 24-item self-report scale measuring two aspects of neurocognitive functioning: cognitive rigidity which looks at (difficulty with set-shifting/flexibility) and attention to detail (weak coherence). The Rey–Osterrieth Complex Figure (ROCF) is one of the most widely used neuropsychologi- cal assessments (Osterrieth, 1944). The measure assesses whether a person is adopting a detailed information processing style or a global information processing style when copying a complex figure (Lang et al., 2016). The Brixton Spatial Anticipation Test (Burgess & Shallice, 1997) is a visuospatial sequencing task with rule changes. This test measures the ability to detect rules in sequences of stimuli by switching between mental representations (Tchanturia et al., 2011).

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Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994): The EDE-Q is a measure of psychopathological and behavioral indicators of disordered eating. The EDE-Q provides a global score and has four subscales measuring dietary restraint, eating concern, weight concern, and shape concern. Subscale and global scores range from 0 to 6, with higher scores representing greater pathology. For this assessment, we report only the global score, which is calculated as the mean of the four subscales. Motivational ruler: These explore beliefs about the importance to change and perceived abil- ity to change. They are visual analogue scales which are scored from 1 to 10.

As already discussed, Milly’s AN in part developed to assist with her maintaining control over affect. Individual CRT sessions were completed in 13 often twice-weekly face-to-face sessions (30 min each). CRT usually consists of eight or 10 sessions; however, Milly requested more ses- sions as she reported she needed further help with flexibility. Therefore, three additional sessions were agreed upon. From the start of the sessions, Milly was often tearful during initial check-ins, however, when she was given the space to openly express herself, she was able to compose her- self and move on with the CRT session content. The therapeutic safe space also helped with building rapport and Milly appeared to be more open in sessions when expressing her thoughts and feelings to her therapist.

A protocol of treatment and examples from the individual CRT sessions can be found in Table A1.

Introducing CRT and Building Rapport

The first session started with an introduction of CRT, so Milly was able to get an idea of what to expect from the sessions. We explored the importance of training the brain through cognitive tasks and the research evidence concerning people with anorexia often struggling with being overly detail-focused and challenges with being flexible. CRT consists of mental exercises aimed at improving cognitive strategies, thinking skills, and information processing through practice. Hence, CRT aims to increase mental flexibility, raise awareness of current thinking styles, and explore new thinking strategies in everyday life (Tchanturia et al., 2010). Milly reported she was “happy” to engage in sessions and learn more.

Figure 2. BMI chart. Note. BMI = body mass index; CRT = cognitive remediation therapy.

Dandil et al. 123

To address the ASD, the therapist made sure to keep the introduction very simple by using a more didactic style and ensuring written and visual means were being used to augment conversa- tions. Milly reported that she benefited from this and therefore the therapist implemented this process in the subsequent sessions.

It was also significant to clarify sensory sensitivity from the start of the sessions in terms of turning the light off in the therapy room.

In terms of building rapport, the therapist ensured that the sessions were always patient-driven, where Milly was specifically asked what she would find helpful and checking in whether she thought she was getting stuck with ASD routines or if it was more her eating disorder that was in play. It was also important to accommodate certain routines and special interests Milly had, such as ensuring session times were not in the way of Milly’s occupational therapy activities which she enjoyed. This also helped role model flexibility from the therapist.

Following each task, Milly was encouraged to reflect on her thinking style and how she pro- cessed the information was explored.

Thinking About Thinking

The first two session’s focus on “thinking about thinking” which aimed to explore thinking styles and promote switching between the bigger picture alongside smaller details. Milly was asked to plot herself on a continuum (big picture vs. detail thinking and flexible vs. focused). Milly described her usual thinking pattern as “detailed and focused” and cited “I have to do one thing at a time and I have to do certain walks every day and I cannot deviate, otherwise I will panic.” During the “complex picture task” targeting central coherence, Milly demonstrated detailed thinking by focusing on the components of the pictures as separate entities instead of in terms of the bigger picture; therefore, we discussed that it may be more difficult for someone else to draw a shape if the inner details of the shape were described. This task also demonstrated the weak central coherence in the overlap between AN and ASD. Milly reflected that she likes being detailed, however, being flexible will be “less stressful.” Milly appeared to find the tasks easier when she was given concrete examples.

Milly was particularly good at the “main idea task” where she had to synthesize detail to a summative main point, targeting central coherence. Milly reported being drawn to the main points and summarized the letter in bullet points then into a short paragraph. Milly related this task to when she is planning her day and said that she focuses on the main things she wants to get done. Milly benefited from frequent repetitions and inquiring about her understanding of the directions during tasks. In addition, Milly was competent in the “Big-Picture Task” where she had to extract succinct pieces of information from detailed stimuli. Milly was able to start to use bigger picture thinking and was able to relate it to real life by citing “I need to think about the whole day instead of small routines.”

Switching Attention

Themes of subsequent sessions included practicing switching between different pieces of infor- mation. Milly was competent in the “illusions task,” intending to practice holding two ideas— seeing the bigger picture as well as the details. Milly reported that she was almost immediately able to see more than one image and interchange between the two, without pushing herself and using any particular techniques. We discussed what Milly learned from this task where she cited, “that there is more than one view-point and there is more to something than it seems,” Milly was encouraged to think of examples and elaborate further, she then reported “being in a hospital as it is not as simple as it seems.” During the discussions around what the task showed about her thinking style, Milly cited “that I can see the big picture sometimes and I am also quite detailed.”

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During the “Switching Attention Task” which aims to practice switching between two differ- ent pieces of information (going through the alphabet and switching between male and female names). Milly reported that she found the task “quite tricky” as she got stuck on letters X and U; however, she was able to “just move on.” She was then able to identify how this task relates to day-to-day life and reported: “when I am in the dining room and different conversations are going on, but I feel okay with it.” Milly recognized that when she has many things to keep track of it is easier to follow one than others and gave the example “it’s easier to just stick to one con- versation at a time”; however, she will feel “fine” if this was to change. We discussed what Milly learned about this task and she cited “that I can concentrate, and I can think quickly, and my thinking style is focused.” She related this to real life by citing that she is focused when she goes on her walks.

Goal Setting/Behavioral Changes and Flexibility

Milly was continually prompted throughout the sessions to reflect on her thinking styles and to relate these styles to her daily life. Her confidence in cognitive abilities increased, and she responded well to praise and encouragement. Once Milly appeared to reflect more on her think- ing styles the idea of Specific Measurable Achievable Realistic Timely (SMART) goals were introduced. The aim was to enhance Milly’s flexibility by implementing small behavioral changes in her daily life to reinforce strategies that have been discussed during exercises. Milly and her therapist collaboratively identified goals which included, Milly wearing her hair differently every other day, to walk her dog slowly as an alternative to walking at a fast pace, and to explain CRT to her mother and come up with another goal together.

A particular theme that was identified in the sessions was Milly’s distress over her rigid walk- ing patterns where she would walk for a specific time, specific pace, and a specific route. She related her rigid walks to her ASD and reported the anxiety she experienced if routines are removed.

Therefore, one of the goals collaboratively identified was for Milly to take a different route during her walks to help with flexibility and, therefore, to start with going on a mindfulness walk with her therapist. The walk was a difficult and challenging experience for Milly as she talked about her difficulties to change. After the walk, Milly appeared upset and reported “that was the slowest walk ever and I never want to do a mindfulness walk again.

However, in subsequent sessions, Milly completed a mindfulness walk on her own where she changed her route slightly. She then later disclosed that she has changed her walking patterns and is also going on walks with her peers which keep her distracted and is helping her build friend- ships. It was clear that undertaking these small behavioral tasks gave Milly a sense of achieve- ment and helped to mentalize and internalize different cognitive styles.

Ending the Therapy

At the end of Session 12, the idea of ending letters was introduced. The therapist asked Milly to write her perceptions and experiences of CRT, focusing on what she felt she learned, what was helpful, and anything that she felt could be improved about the treatment. By the completion of CRT, Milly was able to demonstrate bigger picture thinking and flexibility and cited “I need to view my weight in terms of moving on and going to residential care.” Milly expressed in her ending letter

“The sessions have helped me open up which I normally have trouble doing. I am now able to be detailed when needed but also able to switch up my thinking skills when needed. I found CRT helpful and I would recommend it to others”.

Dandil et al. 125

Milly described in her ending letter that the one thing she would have improved on was her abil- ity to put the strategies from the sessions into practice more often. Milly described feeling moti- vated to continue with therapy and therefore continued with further individual work.

8 Complicating Factors

Several factors complicated Milly’s case. Milly’s tearful presentation at the start of nearly all her sessions was a challenge as it had an impact on her level of engagement with CRT during the allocated time. Milly found it difficult to concentrate for more than 30 min at a time. Therefore, to still give her a space to have a check-in and express her feelings but continue with the sched- uled CRT sessions, we agreed that we will have a 5-min check-in at the beginning and then move on with CRT tasks. However, there were instances when Milly required longer check-ins. Milly was also particular and rigid around her session times, as it had to be around Milly’s scheduled walks and occupational therapy activities. Therefore, the therapist accommodated for this, to assist with the therapeutic relationship and demonstration of flexibility.

Furthermore, Milly found it difficult to provide examples of thinking styles toward the begin- ning of the sessions and was unable to see how tasks can relate to real life. However, on reflection with Milly it, was apparent she required concrete examples that were simple and visual to assist her to understand the material. In addition, although Milly was competent in completing the tasks in sessions with CRT emphasizing the importance of acknowledging strengths, Milly was strug- gling to implement the strategies in her day-to-day life. Therefore, it may have been useful for CRT to balance identifying the strengths with uncovering the challenges too.

9 Access and Barriers to Care

There were no barriers to care in this case. Milly’s care was not in any way inhibited or limited by managed care. She also had the support of her family throughout treatment.

10 Follow-Up

Following CRT, Milly remained on the ward and engaged in further individual psychological work with her therapist. Themes included working on a collaborative formulation to come up with a shared understanding of the AN. We then agreed to start more complex individual psycho- logical work, such as CBT. This was to identify and change unhelpful patterns of thinking and behaviors using different strategies and techniques, to explore the accuracy of the beliefs of weight gain as signifiers of happiness.

Furthermore, individual CRT has assisted with Milly’s confidence in attending psychology groups and she has attended the Flexibility Group (group version of CRT). Milly seems more likely to attend groups and to stay longer in the sessions when she is partially familiar with the materials and has a therapeutic relationship with a facilitator for instance if her therapist is pres- ent. In groups, Milly seems to work well in pairs with a peer and will reflect on tasks but strug- gles more with group discussions.

Following individual CRT, Milly was admitted to hospital with Clostridium infection. Unfortunately, during this period, she lost weight and had great difficulty eating. Over this time Milly also noticed some swelling of some lymph nodes in her groin and neck. This has led to heightened anxiety for Milly as she has disclosed “I am scared my cancer may come back.”

11 Treatment Implications of the Case

Milly’s clinical symptoms improved following CRT in her inpatient treatment with her BMI increasing from 13.5 during her first individual CRT session to 14.5 on her last CRT session

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(Table 1) and her willingness to eat increasing during this period. Table 1 illustrates Milly’s scores on the self-report measures described above pre- and post-CRT. It also provides the healthy control normative scores for each of these measures to put Milly’s scores into context. During the early sessions of CRT Milly discovered that she can work and intentionally change her rigid habits.

Illness related symptoms improved with the global score of the EDE-Q decreasing from 5.15 to 4.80. To put this into context, the global score from a community sample of women is 1.5 (Fairburn & Beglin, 1994). Furthermore, Milly’s scores on the DFlex suggest that her cognitive rigidity and attention to detail have improved. However, interestingly, Milly’s scores on the ROCF had demonstrated that her central coherence scores had slightly decreased, possibly sug- gesting that after CRT how she processed the figure had become slightly less global. In addition, on the Brixton Spatial Anticipation Test, Milly’s scores had slightly increased which suggests less cognitive flexibility.

12 Recommendations to Clinicians and Students

This case study provides preliminary support for the acceptability and effectiveness of individual CRT in an inpatient eating disorder unit when comorbidity with ASD is taken into account. Considering patients with AN are often difficult to engage and retain in treatment, ASD can make it more difficult, due to heightened rigidity, difficulties with introspection, and deficits in social- emotional reciprocity. CRT enabled Milly to engage in a simple, collaborative, and reflective psycho-educational and cognitive training intervention (Tchanturia et al., 2014, 2017, for sys- tematic reviews).

After completing CRT, patients may be more aware of their thinking style and how this can impact on their daily functioning. It is possible that after receiving this intervention patients will be more equipped with strategies to adapt to the environment and make better use of treatment if they choose to. One of the strengths highlighted in the literature is the average to high IQ in the AN population (Lopez, Stahl & Tchanturia, 2010).

CRT also provides an opportunity to establish a therapeutic relationship in the acute stage of AN/ASD, which may positively influence engagement in further comprehensive psychological therapy. In Milly’s case, for example, she was able to attend the group treatment program, where patients have a safe space and support to be with the other people and develop social skills.

Table 1. Changes After CRT.

Outcome Measures Time 1

Before CRT Time 2

After CRT Healthy control

norms

+ (improved)/= (no change)/−

(worse)

BMI 13.5 14.5 19–25 + EDE-Q (global score) 5.1 4.8 1.5 + DFlex Cognitive rigidity 63 55 31 + Attention to detail 53 42 31 + ROCF 0.7 0.4 1.6 − The Brixton Spatial Anticipation Test 10 11 9.8 − Motivational ruler Importance to change 10 10 NA = Ability 6 9 NA +

Note. CRT = cognitive remediation therapy; BMI = body mass index; EDE-Q = Eating Disorder Examination Questionnaire; DFlex = Detail and Flexibility Questionnaire; ROCF = Rey–Osterrieth Complex Figure.

Dandil et al. 127

Before individual CRT Milly declined to attend groups. She was then able to attend the group format of CRT and attributed this to being familiar with the materials and having a therapeutic relationship with the facilitator. After this group, she was able to attend further groups. She was also able to continue with individual psychological work.

Undoubtedly further work needs to be carried out to assess the therapeutic value of CRT and diagnostic tools for sensory sensitivities and female ASD diagnostic tools (Leppanen et al., 2018). Ideally, large-scale studies would be beneficial to conduct across multiple sites to evaluate the intervention and its generalizability.

In summary, this case study highlights the feasibility of individual CRT treatment for support- ing adults with complex comorbidity of AN and ASD address thinking styles. This case study reflects the possible ways to adapt and calibrate treatment to individual needs and the efficacy of CRT before proceeding to more complex individual psychological work, such as CBT.

128

A p

p e n

d ix

T a b

le A

1 .

Pr o to

co l o

f T

re at

m en

t an

d Ex

am pl

es F

ro m

I nd

iv id

ua l C

R T

S es

si o ns

.

Se ss

io n

nu m

be r

Ex am

pl e

o f co

nt en

t A

im o

f in

te rv

en ti o n

Ex am

pl es

f ro

m M

ill y’

s C

R T

s es

si o ns

Se ss

io n

1 T

hi nk

in g

st yl

es “C

o nt

in uu

m a

nd C

o m

pl ex

pi

ct ur

e ta

sk ”

T o h

ig hl

ig ht

a nd

p ro

m o te

s w

it ch

in g

be tw

ee n

th e

bi gg

er p

ic tu

re a

lo ng

si de

s m

al le

r de

ta ils

. In

tr o du

ct io

n o f C

R T

. M ill

y w

as a

ls o a

sk ed

t o p

lo t

he rs

el f o n

a co

nt in

uu m

( bi

g pi

ct ur

e vs

. d et

ai l t

hi nk

in g

an d

fle xi

bl e

vs . f

o cu

se d)

. M ill

y de

sc ri

be d

a de

ta ile

d fo

cu se

d th

in ki

ng s

ty le

a nd

r ig

id b

eh av

io rs

, pa

rt ic

ul ar

ly a

ro un

d w

al ki

ng p

at te

rn s.

D ur

in g

th e

“c o m

pl ex

p ic

tu re

t as

k, ”

M ill

y de

m o ns

tr at

ed d

et ai

le d

th in

ki ng

b y

fo cu

si ng

o n

th e

co m

po ne

nt s

o f th

e pi

ct ur

es a

s se

pa ra

te e

nt it ie

s in

st ea

d o f in

t er

m s

o f th

e bi

gg er

p ic

tu re

, M ill

y al

so a

pp ea

re d

to f in

d th

e ta

sk e

as ie

r w

he n

sh e

w as

g iv

en c

o nc

re te

e xa

m pl

es .

Se ss

io n

2 T

hi nk

in g

st yl

es “M

ai n

Id ea

T as

k” T

o e

nc o ur

ag e

bi gg

er p

ic tu

re t

hi nk

in g

ra th

er

th an

d et

ai le

d, f o cu

se d

th in

ki ng

M ill

y w

as p

ar ti cu

la rl

y go

o d

at t

he “

m ai

n id

ea t

as k,

” w

he re

s he

h ad

t o s

yn th

es iz

e de

ta il

to a

s um

m at

iv e

m ai

n po

in t, t

ar ge

ti ng

c en

tr al

c o he

re nc

e. S

he d

is cu

ss ed

b ei

ng d

ra w

n to

t he

m ai

n po

in ts

a nd

su

m m

ar iz

ed t

he le

tt er

in b

ul le

t po

in ts

t he

n in

to a

s ho

rt p

ar ag

ra ph

. M ill

y re

la te

d th

is t

as k

to w

he n

sh e

is p

la nn

in g

he r

da y

an d

sa id

t ha

t sh

e fo

cu se

s o n

th e

m ai

n th

in gs

s he

w an

ts t

o g

et d

o ne

. M ill

y w

as a

bl e

to s

ta rt

t o u

se b

ig ge

r pi

ct ur

e th

in ki

ng a

nd a

bl e

to r

el at

e it t

o r

ea l l

ife b

y ci

ti ng

“ I ne

ed t

o t

hi nk

a bo

ut

th e

w ho

le d

ay in

st ea

d o f sm

al l r

o ut

in es

.” Se

ss io

n 3

Ill us

io ns

a nd

S tr

o o p

ta sk

A im

s to

p ra

ct ic

e ho

ld in

g tw

o id

ea s

an d

pr ac

ti ce

s w

it ch

in g

be tw

ee n

di ffe

re nt

pi

ec es

o f in

fo rm

at io

n

M ill

y re

po rt

ed t

ha t

th e

ill us

io ns

t as

k sh

e le

ar ne

d, “

th at

t he

re is

m o re

t ha

n o ne

v ie

w -p

o in

t an

d th

er e

is

m o re

t o s

o m

et hi

ng t

ha n

it s

ee m

s, ”

M ill

y w

as e

nc o ur

ag ed

t o t

hi nk

o f ex

am pl

es a

nd e

la bo

ra te

f ur

th er

, sh

e th

en r

ep o rt

ed “

be in

g in

a h

o sp

it al

a s

it is

n o t

as s

im pl

e as

it s

ee m

s. ”

D ur

in g

th e

di sc

us si

o ns

ar

o un

d w

ha t

th e

ta sk

s ho

w ed

a bo

ut h

er t

hi nk

in g

st yl

e, M

ill y

ci te

d “t

ha t

I ca

n se

e th

e bi

g pi

ct ur

e so

m et

im es

a nd

I a

m a

ls o q

ui te

d et

ai le

d. ”

Se ss

io n

4 Sw

it ch

in g

at te

nt io

n an

d em

be dd

ed w

o rd

s ta

sk Pr

ac ti ce

s w

it ch

in g

be tw

ee n

tw o d

iff er

en t

pi ec

es o

f in

fo rm

at io

n (g

o in

g th

ro ug

h th

e al

ph ab

et a

nd s

w it ch

in g

be tw

ee n

m al

e an

d fe

m al

e na

m es

).

M ill

y re

po rt

ed t

ha t

sh e

fo un

d th

e ta

sk “

qu it e

tr ic

ky .”

S he

w as

t he

n ab

le t

o id

en ti fy

h o w

t hi

s ta

sk r

el at

es

to d

ay -t

o -d

ay li

fe a

nd r

ep o rt

ed : “

w he

n I am

in t

he d

in in

g ro

o m

a nd

d iff

er en

t co

nv er

sa ti o ns

a re

g o in

g o n,

b ut

I f ee

l o ka

y w

it h

it .”

M ill

y re

co gn

iz ed

t ha

t w

he n

sh e

ha s

m an

y th

in gs

t o k

ee p

tr ac

k o f it is

ea

si er

t o f o llo

w o

ne t

ha n

o th

er s

an d

ga ve

t he

e xa

m pl

e “i

t’ s

ea si

er t

o ju

st s

ti ck

t o o

ne c

o nv

er sa

ti o n

at

a ti m

e, ”

W e

di sc

us se

d w

ha t

M ill

y le

ar ne

d ab

o ut

t hi

s ta

sk a

nd s

he c

it ed

“ th

at I c

an c

o nc

en tr

at e,

a nd

I ca

n th

in k

qu ic

kl y,

a nd

m y

th in

ki ng

s ty

le is

f o cu

se d.

” Sh

e re

la te

d th

is t

o r

ea l l

ife b

y ci

ti ng

t ha

t sh

e is

fo

cu se

d w

he n

sh e

go es

o n

he r

w al

ks .

Se ss

io n

5 W

o rd

s ea

rc h

an d

es ti m

at in

g Fo

cu s

o n

re le

va nt

in fo

rm at

io n

am o ng

ir

re le

va nt

in fo

rm at

io n/

en co

ur ag

es

es ti m

at in

g an

d co

ns id

er s

th in

gs a

s be

in g

“g o o d

en o ug

h” r

at he

r th

an p

er fe

ct

W it h

re ga

rd t

o t

he e

st im

at in

g ta

sk , M

ill y

re ca

lle d

ap pr

o ac

hi ng

t he

t as

k “o

ne b

it a

t a

ti m

e an

d I di

d no

t us

e an

y te

ch ni

qu e

I ju

st w

en t

fo r

th e

m id

dl e.

” M

ill y

th en

r ep

o rt

ed t

ha t

sh e

do es

n o t

lik e

gu es

si ng

a nd

lik

es t

o b

e “a

cc ur

at e.

” W

e ex

pl o re

d th

e ad

va nt

ag es

a nd

d is

ad va

nt ag

es o

f gu

es si

ng . O

n ex

pl o ra

ti o n

w it h

re ga

rd t

o h

er t

hi nk

in g

st yl

e, s

he r

ep o rt

ed “

th e

ta sk

s ho

w ed

m e

I w

as d

et ai

le d

to m

ak e

su re

it

w as

in t

he c

en te

r” a

nd r

el at

ed t

hi s

to r

ea l l

ife b

y ex

pr es

si ng

“ I am

d et

ai le

d w

it h

ho w

lo ng

it t

ak es

m e

to w

al k.

I h

av e

to w

al k

a ce

rt ai

n am

o un

t o f ti m

e an

d If

I do

n’ t, I w

ill p

an ic

.”

( co

nt in

ue d)

129

Se ss

io n

nu m

be r

Ex am

pl e

o f co

nt en

t A

im o

f in

te rv

en ti o n

Ex am

pl es

f ro

m M

ill y’

s C

R T

s es

si o ns

Se ss

io n

6 G

o al

s et

ti ng

T o in

tr o du

ce s

m al

l b eh

av io

ra l c

ha ng

es

o ut

si de

o f se

ss io

ns t

o r

ei nf

o rc

e st

ra te

gi es

th

at h

av e

be en

d is

cu ss

ed d

ur in

g ex

er ci

se s.

M ill

y w

as c

o m

pe te

nt in

id en

ti fy

in g

SM A

R T

g o al

s to

e nh

an ce

h er

f le

xi bi

lit y.

O ne

o f th

e go

al s

id en

ti fie

d by

M ill

y w

as t

o t

ak e

a di

ffe re

nt r

o ut

e du

ri ng

h er

w al

ks t

o h

el p

w it h

fle xi

bi lit

y an

d, t

he re

fo re

, t o s

ta rt

w

it h

go in

g o n

a m

in df

ul ne

ss w

al k

w it h

he r

th er

ap is

t. A

f ur

th er

g o al

w as

f o r

M ill

y to

e xp

la in

C R

T t

o

he r

m o th

er a

nd c

o m

e up

w it h

a sh

ar ed

g o al

. Se

ss io

n 7

R ev

ie w

g o al

s T

o in

tr o du

ce s

m al

l b eh

av io

ra l c

ha ng

es

o ut

si de

o f se

ss io

ns t

o r

ei nf

o rc

e st

ra te

gi es

th

at h

av e

be en

d is

cu ss

ed d

ur in

g ex

er ci

se s.

Lo ng

er c

he ck

-i n

du e

to M

ill y’

s di

st re

ss ed

p re

se nt

at io

n as

a r

es ul

t o f ch

an ge

s in

h er

A SD

r it ua

ls a

nd

ch an

ge s

in h

er m

ed ic

at io

n. T

he s

es si

o n

th en

r ev

ie w

ed M

ill y’

s go

al s

an d

en co

ur ag

ed h

er .

Se ss

io n

8 R

ev ie

w g

o al

s an

d bi

g- pi

ct ur

e di

sc us

si o ns

T o in

tr o du

ce s

m al

l b eh

av io

ra l c

ha ng

es

o ut

si de

o f se

ss io

ns t

o r

ei nf

o rc

e st

ra te

gi es

th

at h

av e

be en

d is

cu ss

ed d

ur in

g ex

er ci

se s.

C o nt

in ue

d to

r ev

ie w

M ill

y’ s

go al

s an

d ag

re ed

t o g

o o

n a

m in

df ul

ne ss

w al

k.

Se ss

io ns

9 M

in df

ul ne

ss W

al k/

fle xi

bi lit

y “a

rm f o ld

in g

ta sk

a nd

m in

d m

ap t

as k”

T o r

ei nf

o rc

e st

ra te

gi es

t ha

t ha

ve b

ee n

di sc

us se

d in

s es

si o ns

a nd

t o e

nh an

ce

fle xi

bi lit

y.

M ill

y w

as v

er y

br av

e to

g o o

n a

m in

df ul

ne ss

w al

k w

it h

he r

th er

ap is

t w

hi ch

in cl

ud ed

a d

iff er

en t

ro ut

e fr

o m

h er

u su

al w

al ki

ng p

at te

rn . H

o w

ev er

, a ft

er t

he w

al k,

M ill

y ap

pe ar

ed u

ps et

a nd

r ep

o rt

ed “

th at

w

as t

he s

lo w

es t

w al

k ev

er a

nd I n

ev er

w an

t to

d o a

m in

df ul

ne ss

w al

k ag

ai n.

” N

ev er

th el

es s,

in

su bs

eq ue

nt s

es si

o ns

, M ill

y co

m pl

et ed

a m

in df

ul ne

ss w

al k

o n

he r

o w

n w

he re

s he

c ha

ng ed

h er

r o ut

e sl

ig ht

ly . S

he t

he n

la te

r re

po rt

ed t

ha t

sh e

ch an

ge d

he r

w al

ki ng

p at

te rn

s an

d is

a ls

o g

o in

g o n

w al

ks

w it h

he r

pe er

s w

hi ch

k ee

p he

r di

st ra

ct ed

a nd

is h

el pi

ng h

er b

ui ld

f ri

en ds

hi ps

. Se

ss io

n 10

“A rm

f o ld

in g

ta sk

a nd

m ap

s ta

sk ”

En co

ur ag

in g

to t

hi nk

in d

iff er

en t

w ay

s.

R eq

ui re

s th

in ki

ng in

t er

m s

o f th

e bi

gg er

pi

ct ur

e an

d th

in ki

ng f le

xi bl

y.

M ill

y w

as p

ri nt

ed a

m ap

o f th

e ho

sp it al

g ro

un ds

a nd

f o r

he r

to m

ap o

ut h

er w

al ks

a nd

t he

n m

ap o

ut

al te

rn at

iv e

ro ut

es s

he c

an t

ak e,

w hi

ch s

he e

ng ag

ed w

el l i

n.

Se ss

io n

11 T

he “

Pr o fe

ss o r’

s Le

ss o n”

En co

ur ag

es p

eo pl

e to

t hi

nk a

bo ut

w ha

t th

ey

sp en

d th

ei r

ti m

e do

in g

an d

w he

th er

it

su pp

o rt

s w

ha t

m at

te rs

t o t

he m

in li

fe .

M ill

y id

en ti fie

d “f

am ily

, f ri

en ds

, I zz

y (d

o g)

, c o o ki

ng a

nd b

ak in

g” a

s th

e m

o st

im po

rt an

t th

in gs

in h

er li

fe .

Sh e

al so

r ep

o rt

ed t

ha t

sh e

en jo

ye d

ba ki

ng in

t he

p as

t an

d he

r fu

tu re

a sp

ir at

io ns

o f st

ud yi

ng c

hi ld

c ar

e an

d w

o rk

in g

w it h

ch ild

re n.

M ill

y w

as a

bl e

to d

em o ns

tr at

e bi

gg er

p ic

tu re

t hi

nk in

g an

d fle

xi bi

lit y

an d

ci te

d “I

n ee

d to

v ie

w m

y w

ei gh

t in

t er

m s

o f m

o vi

ng o

n an

d go

in g

to t

he d

ay u

ni t. ”

Se ss

io n

12 M

in d

m ap

Su m

m ar

iz e

an d

co ns

o lid

at e

w ha

t ha

s be

en

co ve

re d

in t

he p

re vi

o us

s es

si o ns

M ill

y en

ga ge

d w

el l i

n th

e ta

sk . M

ill y

w as

a ls

o e

nc o ur

ag ed

t o t

hi nk

a bo

ut h

o w

f le

xi bi

lit y

is r

el at

ed t

o h

er

ge ne

ra l p

la n

fo r

re co

ve ry

, a nd

h o w

it h

el ps

t o t

ak e

th e

ne xt

s te

ps in

t re

at m

en t

an d

to t

he f ut

ur e

in

ge ne

ra l.

M ill

y id

en ti fie

d ph

ra se

s su

ch a

s “b

ig ge

r pi

ct ur

e, d

et ai

le d

an d

w al

ki ng

r o ut

e” a

nd r

el at

ed t

hi s

to h

er p

la n

fo r

re co

ve ry

b y

ch an

gi ng

h er

w al

ki ng

r o ut

e an

d im

pl em

en ti ng

b ig

ge r

pi ct

ur e

an d

fle xi

bi lit

y in

to h

er d

ay -t

o -d

ay li

fe .

Se ss

io n

13 “C

R T

e nd

in g

le tt

er s”

T he

e nd

in g

le tt

er h

el ps

t o r

ef le

ct a

nd

su m

m ar

iz e

w ha

t w

as le

ar ne

d. M

ill y

ci te

d in

h er

e nd

in g

le tt

er “

th e

se ss

io ns

h av

e he

lp ed

m e

o pe

n up

w hi

ch I n

o rm

al ly

h av

e tr

o ub

le

do in

g. I a

m n

o w

a bl

e to

b e

de ta

ile d

w he

n ne

ed ed

b ut

a ls

o a

bl e

to s

w it ch

u p

m y

th in

ki ng

s ki

lls w

he n

ne ed

ed . I

f o un

d C

R T

r ea

lly h

el pf

ul a

nd I w

o ul

d re

co m

m en

d it t

o o

th er

s. ”

N ot

e. C

R T

= c

o gn

it iv

e re

m ed

ia ti o n

th er

ap y;

S M

A R

T =

S pe

ci fic

M ea

su ra

bl e

A ch

ie va

bl e

R ea

lis ti c

T im

el y;

A SD

= a

ut is

m s

pe ct

ru m

d is

o rd

er .

T a b

le A

1 . (c

o n

ti n

u e d

)

130 Clinical Case Studies 19(2)

Acknowledgments

The authors would like to sincerely thank the anonymous patient for allowing us to publish her case, and Tyson West Inpatient team for supporting this work.

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) disclosed receipt of the following financial support for the research, authorship, and/or publi- cation of this article: This work was supported by the Health foundation, an independent charity committed to bringing better health care for people in the United Kingdom (Ref: AIMS ID: 1115447). Authors would like to sincerely thank the Health foundation for funding this project.

ORCID iD

Kate Tchanturia https://orcid.org/0000-0001-8988-3265

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Author Biographies

Yasemin Dandil is an assistant psychologist in the inpatient Eating Disorder Service for the South London and Maudsley NHS Foundation Trust. Her work has involved the delivery of cognitive remediation therapy (CRT) and other interventions in the inpatient setting in both individual and group format. She is also actively involved in research, clinical audits, and organizing well-being workshops for staff and service users.

Claire Baillie is a chartered counseling psychologist who has worked in the eating disorders field for more than 20 years. She is the senior psychologist on the Inpatient Eating Disorder Unit of the South London and Maudsley NHS Foundation Trust. Her work includes delivering individual and group evidence-based psy- chological interventions including CRT and cognitive remediation and emotional skills training (CREST).

Kate Tchanturia is a lead clinical psychologist in the Eating Disorder Service of the South London and Maudsley NHS Foundation Trust and professor for psychology of eating disorders at the King’s College London, Psychological Medicine. She is actively involved in research on cognition and emotion in eating disorder and the translation of research findings into clinical practice.