LATAM Revista Latinoamericana de Ciencias Sociales y Humanidades, Asunción, Paraguay.
ISSN en línea: 2789-3855, abril, 2025, Volumen VI, Número 2 p 2251.

DOI: https://doi.org/10.56712/latam.v6i2.3766

Cognitive remediation therapy in eating disorders: a
systematic review

Terapia de remediación cognitiva en trastornos alimentarios: una revisión
sistemática

Jesús Adrián Figueroa Hernández1

Adrian.figueroa@iztacala@unam.mx
https://orcid.org/0000-0003-1791-5533

Estancia Posdoctoral DGAPA. Universidad Nacional Autónoma de México
Ciudad de México – México

Rosalía Vázquez Arévalo

rvamap@unam.mx
https://orcid.org/0000-0001-6491-9639

Universidad Nacional Autónoma de México
Ciudad de México – México

Karina Franco Paredes

karina.franco@cusur.udg.mx
https://orcid.org/0000-0002-5899-3071

Universidad de Guadalajara
Guadalajara – México

Rebeca María Elena Guzmán-Saldaña

rguzman@uaeh.edu.mx
https://orcid.org/0000-0003-0877-4871

Universidad Autónoma del Estado de Hidalgo
Hidalgo – México

Juan Manuel Mancilla Díaz

jmm@unam.mx
https://orcid.org/0000-0001-7259-3667

Universidad Nacional Autónoma de México
Ciudad de México – México

Felipe Santoyo Telles

santf22@yahoo.com.mx
https://orcid.org/0000-0003-3854-9405

Universidad de Guadalajara
Guadalajara – México

Artículo recibido: 30 de marzo de 2025. Aceptado para publicación: 13 de abril de 2025.

Conflictos de Interés: Ninguno que declarar.

Abstract
This study constitutes a systematic review analyzing the evidence on the effectiveness of Cognitive
Remediation Therapy (CRT) in the treatment of eating disorders in adults, with a particular focus on
anorexia nervosa (AN). Studies published between 2005 and 2025 were examined using various
databases, applying inclusion criteria that ensured relevance and methodological quality based on
PRISMA. A total of 24 articles were collected, and data related to sample characteristics, assessment
instruments (self-reports and performance-based tests), and outcomes were reported. Findings
indicate that CRT significantly improves executive functions and central coherence, which are critical

1 Beca otorgada por la Dirección General de Asuntos del Personal Académico febrero 2024-enero 2025.

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elements in counteracting the cognitive rigidity inherent to eating disorders. It was observed that CRT,
in both inpatient and outpatient settings, enhances therapeutic engagement and reduces treatment
dropout rates. Additionally, factors such as age, body mass index, illness duration, and comorbidities
influence the intervention's effectiveness, highlighting the need for personalized treatment protocols.
The implications of these results suggest that CRT stands as a promising complementary intervention.
Further research is recommended with larger samples and standardized methodologies integrating
both objective and subjective assessments to optimize the therapy's application.

Keywords: cognitive remediation therapy, eating disorder, systematic review

Resumen
Este trabajo constituye una revisión sistemática que analiza la evidencia sobre la efectividad de la
Terapia de Remediación Cognitiva (TRC) en el tratamiento de los trastornos alimentarios en adultos,
con especial énfasis en la anorexia nervosa (AN). Se investigaron estudios publicados entre 2005 y
2025 a partir de diversas bases de datos, utilizando criterios de inclusión que aseguraron la relevancia
y calidad metodológica basado en PRISMA. El estudio recopiló un total de 24 artículos y se reportaron
datos relacionados con las características de la muestra, los instrumentos de evaluación empleados
(autoinformes y pruebas de desempeño) y los resultados obtenidos. Los hallazgos muestran que la
TRC mejora significativamente las funciones ejecutivas y la coherencia central, elementos críticos
para contrarrestar la rigidez cognitiva inherente a los trastornos alimentarios. Se detectó que, tanto en
entornos hospitalarios como ambulatorios, la TRC fomenta el compromiso terapéutico y reduce el
abandono del tratamiento. Además, se evidencia que la diversidad en la edad, el índice de masa
corporal, la duración de la enfermedad y la presencia de comorbilidades modulan la efectividad de la
intervención, lo que evidencia la necesidad de personalizar los protocolos terapéuticos. Las
implicancias de estos resultados sugieren que la TRC se posiciona como una intervención
complementaria prometedora, a la vez que se recomienda continuar la investigación con muestras
más amplias y metodologías estandarizadas que integren evaluaciones objetivas y subjetivas para
optimizar la aplicación de la terapia

Palabras clave: terapia de remediación cognitiva, trastornos alimentarios, revisión sistemática

Todo el contenido de LATAM Revista Latinoamericana de Ciencias Sociales y Humanidades,
publicado en este sitio está disponibles bajo Licencia Creative Commons.

Cómo citar: Figueroa Hernández, J. A., Vázquez Arévalo, R., Franco Paredes, K., Guzmán-Saldaña, R.
M. E., Mancilla Díaz, J. M., & Santoyo Telles, F. (2025). Cognitive remediation therapy in eating
disorders: a systematic review. LATAM Revista Latinoamericana de Ciencias Sociales y Humanidades
6 (2), 2250 – 2273. https://doi.org/10.56712/latam.v6i2.3766

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INTRODUCTION

Eating and Feeding Disorders (EFD) represent a group of psychiatric conditions characterized by
persistent disturbances in eating behavior, significantly impacting the physical and psychosocial health
of those affected. In 2013, the American Psychiatric Association (APA) eliminated the classification of
childhood and adolescent eating disorders, acknowledging that pica, rumination disorder,
avoidant/restrictive food intake disorder, Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge
eating disorder (BED) can manifest at any stage of life, integrating them into a unified framework
(Vázquez et al., 2015).

Among these disorders, AN, BN, and BED have gained particular relevance due to their prevalence in
both adolescents and adults, with global estimates indicating symptomatology in approximately 5.5%
of women and 2.4% of men in Western settings, who experience an EFD during adolescence or early
adulthood (Silén & Keski, 2022). In Latin America, studies such as that by Kolar et al. (2007) have
reported a prevalence of 0.1% for AN, 1.16% for BN, and 3.53% for BED, with the latter being the most
common (Udo & Grilo, 2019).

Due to their complex symptomatology, EFDs have been widely linked to impairments in various
cognitive functions, particularly those related to executive processing (Tchanturia et al., 2016).
Difficulties have been identified in cognitive flexibility, inhibitory control, decision-making, and working
memory, which hinder the regulation of eating behavior and the adaptation to new coping strategies
(Alvarado & Silva., 2014).

These deficits may contribute to the maintenance of symptoms by perpetuating rigid thought patterns
and maladaptive automatic responses (Tchanturia et al., 2012). Scientific evidence has indicated that
these cognitive impairments not only impact clinical symptomatology but may also hinder adherence
to and effectiveness of conventional treatments (Álvarez et al., 2021; Jáuregui-Lobera, 2013; Knight et
al., 2020). In this regard, cognitive functioning plays a key role in how individuals with EFDs process
information and regulate their eating behavior, as it encompasses a set of mental activities necessary
for completing tasks that require thought monitoring, planning, and decision-making. These functions
involve processes such as sensory activation, attention, learning, and working memory, as well as
problem-solving, reasoning, introspection, and metacognition, all of which are framed within executive
functions (Álvarez et al., 2021; Muñoz-Céspedes & Tirapu-Ustárroz, 2004).

Executive functions (EF) encompass a set of cognitive tasks and strategies mediated by the brain's
prefrontal areas, including problem-solving, concept formation, impulse control, planning, and working
memory (Ardila & Surloff, 2007). These abilities enable individuals to filter out irrelevant information,
engage in goal-directed behaviors, anticipate consequences, and adjust coping strategies through
cognitive flexibility. Impairments in these functions result in cognitive deficits that can significantly
impact the prognosis and treatment of various psychiatric disorders, including EFDs (Arbel et al., 2013;
Hirst et al., 2017; Konstantakopoulos et al., 2011).

Specifically, deficits in EF can affect an individual's ability to self-regulate and organize themselves to
achieve their goals, manifesting as difficulties in controlling emotions or impulses, initiating or
completing tasks, maintaining attention, retaining short-term information, and adapting to new
circumstances. These deficits can lead to academic and occupational difficulties, interpersonal
relationship problems, mood disturbances, low self-esteem, and avoidance of complex tasks,
reinforcing the cycle of symptoms characteristic of EFDs (Álvarez et al., 2021; Jáuregui-Lobera, 2013;
Knight et al., 2020).

In this regard, EF impairments manifest differently in each of the main EFDs, directly influencing their
clinical characteristics. In AN, deficits in cognitive flexibility and inhibitory control have been reported,

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which may contribute to rigid thought patterns and the persistence of extreme restrictive behaviors
(Zipfel et al., 2015; Wykes & Reeder, 2005). In BN, difficulties in inhibitory control and impulsivity affect
the ability to regulate episodes of excessive food intake and compensatory behaviors, creating a cycle
of eating dysregulation (Lavagnino et al., 2016). Meanwhile, BED has been associated with deficits in
decision-making and emotional regulation, which increase the tendency toward compulsive eating in
response to negative emotional states (Kittel et al., 2017). Additionally, it has been proposed to
incorporate neuropsychological variables, such as cognitive flexibility, to assess the severity of EFDs,
highlighting the importance of considering these deficits in the planning of therapeutic interventions
(Seidel et al., 2022; Wykes, 2002).

Given the impact of these cognitive deficits on EDs with impaired executive functions (ED-IEF), various
intervention strategies have aimed to improve the affected executive functions in these disorders. One
of the most promising complementary interventions is Cognitive Remediation Therapy (CRT), an
approach based on structured exercises designed to encourage reflection on cognitive processes,
develop new strategies and thinking skills, and facilitate "thinking about thinking" to promote behavioral
change (Cella et al., 2015). CRT was first introduced in the treatment of eating disorders in 2005 as a
novel approach for adults with chronic and long-standing AN. Since then, it has been established as a
brief and effective intervention for different ED-IEF, showing favorable results in improving cognitive
flexibility and inhibitory control (Alserihi et al., 2024; Hagan et al., 2020; Marchesi et al., 2024).

The purpose of Cognitive Remediation Therapy (CRT) is to rehabilitate neuropsychological impairments
by stimulating neuronal connections involved in cognitive processes (Gordon & Hibbard, 1992). This
therapy has been shown to strengthen cognitive flexibility, global thinking, and, in general, the skills
necessary for solving complex problems (Tchanturia & Lock, 2010).

To date, there are a total of seven publications, including systematic reviews and meta-analyses, that
address the application of CRT in eating disorders. The first was conducted by Lindvall and Rø (2014),
who carried out a systematic review on the development, current state, and clinical implications of CRT.
Their work highlights that case studies provide strong evidence of feasibility and acceptability, while
randomized clinical trials indicate its potential to reduce treatment dropout, improve cognitive shifting
abilities, enhance quality of life, and decrease eating disorder psychopathology. In the same year,
Tchanturia et al. (2014) conducted a systematic review on CRT in Anorexia Nervosa (AN) and related
conditions. They found that the therapy was effective in improving task-switching abilities and central
coherence, as well as promoting a strong therapeutic alliance and maintaining a low dropout rate
(between 10% and 15%).

Following this, Tchanturia et al. (2017) conducted a systematic review and meta-analysis on young
individuals with AN. Their study revealed significant methodological differences among the reviewed
studies, making it difficult to compare findings. However, the meta-analysis showed small effect sizes
for improvements in central coherence, although no significant improvements were found in task-
switching abilities. The authors concluded that CRT is a suitable complementary therapy for young
individuals with AN.

Similarly, Hagan et al. (2020) conducted a systematic review and meta-analysis based on randomized
clinical trials of CRT in individuals with AN. They found that CRT was not associated with significant
improvements in central coherence compared to control groups at the end of treatment, and the results
regarding task-switching abilities were mixed. They suggested that CRT might be useful in preventing
treatment dropout, although in this study, it did not show clear advantages over conventional
treatments.

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Subsequently, Marchesi et al. (2024) conducted a systematic review of systematic reviews. Their study
emphasized that CRT can help individuals become aware of their cognitive style and information
processing, in addition to having positive effects on treatment response.

More recently, Alserihi et al. (2024) conducted a systematic review and meta-analysis on CRT in
randomized clinical trials. This study concluded that CRT did not show statistically significant
differences compared to control groups in improving abstract thinking or quality of life in individuals
with AN, indicating that the effectiveness of CRT remains inconclusive.

The available evidence on CRT in eating disorders, particularly in AN, presents mixed results. While
some reviews highlight its feasibility, acceptability, and potential for improving cognitive aspects and
reducing dropout rates, others have not found significant differences compared to conventional
treatments. This suggests that, although CRT has promising elements, its clinical efficacy is not yet
clearly established. Furthermore, the reviews do not include the still scarce studies conducted in Latin
America, making it difficult to assess its global effectiveness.

The objective of the present study is to analyze the effectiveness of Cognitive Remediation Therapy
(CRT) in improving cognitive deficits associated with eating disorders in adults with eating disorders.
The study aims to identify key findings regarding sample characteristics (country of study, type of
patient, number of participants, age, BMI, duration of illness, and comorbidities), as well as the
assessment instruments used (both self-report and performance-based measures).

METHODOLOGY

Literature Search

The article search was conducted in the following databases: PubMed, ProQuest, Scopus, SpringerLink,
Web of Science, and EBSCO. The following keywords in English were used: “Neuropsychology OR
Neuropsychology evaluation OR Neuropsychology intervention OR Neuropsychology instruments” AND
“Anorexia OR Anorexia nervosa OR Eating disorders” AND “Cognitive remediation therapy”, which had
to appear in the title, abstract, and keywords of the articles.

The evaluation period for the studies covered the years 2005 to 2025, with the initial date criterion based
on the identification of the first article addressing the main variables in that year. Article selection was
conducted in pairs following the PRISMA methodology (Hutton et al., 2016) and considering the
following inclusion and exclusion criteria.

Inclusion and Exclusion Criteria

The studies included in this review were selected following the inclusion criteria: a) Studies that present,
in the title and abstract, the defined keywords, b) Studies that focus exclusively on adult populations,
considering at least the age of 17 years, c) Publications made between 2005 and 2025, and d) Studies
published in English or Spanish.

On the other hand, the studies were excluded if: a) They were systematic reviews or meta-analyses, and
b) They were theoretical or opinion articles. This selection allows the review to focus on empirical and
relevant research for evaluating the effectiveness of CRT in eating disorders, a total of 24 articles were
selected (see Table 1).

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Figure 1

PRISMA 2020 flow diagram for new systematic reviews that included only database and registry searches
(Page et al., 2021)

Critical Assessment of Study Quality

To assess the methodological quality of each included study, predefined criteria and standardized tools
were applied. First, two evaluators independently evaluated each article, considering key aspects such
as research design, sample size, representativeness, and clarity in the description of procedures.
Discrepancies between evaluators were resolved through consensus or, if necessary, with the
intervention of a third reviewer. This process allowed for determining the internal quality of each study
and its potential impact on the overall synthesis of the evidence.

Synthesis of Results

The integration of the evidence was carried out through a systematic two-stage process. Initially,
relevant data from each study were extracted and organized, such as the country of study, sample
characteristics (type of patient, number of participants, age, BMI, duration of illness, comorbidities), and

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the assessment instruments used. An analysis of these categories was conducted, highlighting the
findings related to the efficacy of Cognitive Remediation Therapy (CRT) in improving cognitive deficits
associated with eating disorders. This analysis identified patterns and inconsistencies in the data,
allowing for a deeper understanding of the impact of CRT on cognitive functioning, treatment
adherence, and the reduction of eating disorder symptoms. The findings were then synthesized to
provide an overall assessment of the effectiveness of CRT in addressing cognitive deficits in individuals
with eating disorders, while considering the quality of the studies and potential biases.

LITERATURE REVIEW

Study Characteristics

The studies analyzed showed the inclusion of participants with BN in some works (Larsson et al., 2020;
Mac-Neil et al., 2016; Roberts, 2018) and the participation of men in others (Mac-Neil et al., 2016; Van-
Passel et al., 2020; Zuchova et al., 2013), in methodological terms, three designs were identified in the
analyzed works:

Four case studies (Alvarado-Sánchez et al., 2019, 2023; Davies & Tchanturia, 2005; Tchanturia et al.,
2006).

Sixteen between-subjects designs (Abbate-Daga et al., 2012; Brockmeyer et al., 2016; Dandil et al., 2020;
Davies et al., 2012; Fonville et al., 2014; Leppanen et al., 2018; Mac-Neil et al., 2016; Pitt et al., 2010;
Roberts, 2018; Tchanturia et al., 2007, 2008, 2015; Tchanturia, Larsson, & Brown, 2016; Zuchova et al.,
2013).

Four case-control designs (Dingemans et al., 2013; Lock et al., 2013; Tchanturia, Doris, et al., 2014;
Tchanturia, Larsson, & Adamson, 2016; van Passel et al., 2020). All studies were published between
2005 and 2024, and the information was organized systematically in the following order: country of
study, type of patient, number of participants, age, body mass index (BMI), duration of the illness,
comorbidities, and psychological and neuropsychological instruments used (see Tables 1 and 2).

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Country Where the Study Was Conducted

The analysis of the geographical distribution of the scientific production on CRT in AN and BN reveals
a marked concentration of research in the United Kingdom, particularly in London, with 13 studies
published (Davies & Tchanturia, 2005; Tchanturia et al., 2006, 2007, 2008; Genders & Tchanturia, 2010;
Pitt et al., 2010; Davies et al., 2012; Tchanturia et al., 2014, 2015, 2016; Dandil et al., 2020). This
predominance suggests not only leadership in the theoretical development and clinical application of
CRT, but also a consolidation of the approach in contexts with a long tradition in neuropsychological
and therapeutic research.

To a lesser extent, Germany (Brockmeyer et al., 2016) and the Netherlands have provided evidence
through controlled studies (Dingemans et al., 2013; Van-Passel et al., 2020), while both Mexico and the
United States present, respectively, two studies (Alvarado-Sánchez et al., 2019, 2023; Lock et al., 2013;
Fonville et al., 2014). Finally, Italy (Abbate-Daga et al., 2012), the Czech Republic (Zuchova et al., 2013),
Canada (Mac-Neil et al., 2016), and New Zealand (Roberts, 2018) are each represented by one
publication.

Overall, as shown in table 1, these findings underscore the geographical disparities in the current
literature, highlighting a dominant research presence in the United Kingdom alongside contributions
from a diverse range of other countries.

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Patient Type

Regarding the patient type, there are substantial differences in the care modality in which CRT is
employed. The majority of studies have focused on inpatients, representing 84% of the total sample,
while only 16% focus on outpatients (Brockmeyer et al., 2016; Mac-Neil et al., 2016; Lock et al., 2013;
Pitt et al., 2010). This predominance of hospital care is partly related to the severity and chronicity of
the pathology, as it has been shown that patients admitted to inpatient services tend to present with
more severe clinical conditions or with a longer duration of illness.

The differentiation in patient type not only highlights the clinical characteristics and severity of eating
disorders but also underscores the need to adapt therapeutic interventions to the specificities of the
care setting. As detailed in table 1, these findings emphasize the importance of considering the
treatment context when evaluating the efficacy of CRT.

Number of Participants and Sessions per Study

The analysis of the variable "number of participants per study" reveals considerable diversity. Some
studies have focused on single-case designs (Alvarado-Sánchez et al., 2019; 2023; Davies & Tchanturia,
2005; Tchanturia et al., 2006) with the objective of implementing and preliminarily evaluating the
feasibility and applicability of CRT in specific clinical contexts. Over time, and with the accumulation of
evidence, an increase in sample sizes has been observed, with some studies including up to 145
participants (Dingemans et al., 2013). This growth in the number of participants has allowed not only
the validation of the therapeutic effects of CRT but also the diversification of its application formats.
Accordingly, both individual and group interventions have been developed, with variations in the number
of sessions: some group-format studies have used as few as 4 sessions, while individual approaches
have required up to 10 sessions (Tchanturia et al., 2010; Lang et al., 2015; Roberts, 2018; Tchanturia et
al., 2016).

It is important to note that studies conducted in countries such as Mexico, representing Latin American
contexts, typically employ single-case designs. Overall, the trend in the number of participants indicates
that while early research often relied on single-case designs, more recent studies tend to include larger
samples, which enhances the robustness and generalizability of the findings.

Age of Participants

The age of the participants indicates that most of the studies have been conducted with adults;
however, it was noted that some studies included patients as young as 17 years old, who were
administered the protocol established for the adult population, and no differentiated analyses were
conducted (Dingemans et al., 2013; Lang et al., 2015; Lock et al., 2013; Tchanturia et al., 2016; Wu et
al., 2016).

Among the studies presented, at least 18 included individuals aged between 20 and 40 years, four
studies included participants ranging from 17 to 60 years, and at least three studies included women
aged 20 and 21. The diversity in ages not only enriches the body of evidence but also underscores the
importance of considering age as a moderating variable in the evaluation and monitoring of therapeutic
outcomes.

Overall, while the diversity in participant age enriches the body of evidence, it also highlights a critical
gap in the current literature: the necessity for a more nuanced understanding of how age influences
both the process and outcomes of CRT in the treatment of eating disorders.

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Body Mass Index (BMI)

The difference in BMI among participants can be attributed to several factors, notably the heterogeneity
of the samples in terms of gender, type of eating disorder, and clinical severity. For example, while a
marked decrease in BMI is observed in AN—as seen in a patient with a BMI of 14.3 (Roberts et al., 2018;
Dandil et al., 2020), indicating a state of severe malnutrition—in patients with BN, values are recorded
as high as 23.93 (Roberts et al., 2018), suggesting differences in clinical profile and eating behavior
patterns. Likewise, the variability in BMI could directly impact cognitive performance and treatment
adherence, as a compromised nutritional status may affect executive functions essential for the
therapeutic process. Therefore, it is relevant that research organizes the results according to BMI and
other clinical markers to broaden the application of CRT, taking this biological variable into account.

Duration of Illness

On average, patients have been living with the disorder for at least 7 years, although some studies have
included patients with trajectories as short as less than 2 years, while others have grouped cases with
over 10 years of illness duration within the same analysis (Brockmeyer et al., 2016; Leppanen et al.,
2018; Roberts, 2018; Tchanturia et al., 2016; Tchanturia et al., 2016; Zuchova et al., 2013).

However, these data should be interpreted with caution, as the wide variability in illness duration
complicates direct comparisons between subgroups. For example, positive results have been observed
with CRT in both patients with severe AN (Davies & Tchanturia, 2005) and those with chronic eating
disorders (Alvarado et al., 2019). This suggests that CRT may have beneficial effects across different
stages of illness progression. Nevertheless, it remains inconclusive which type of therapy—
psychological or complementary—proves most effective for patients with a long history of the disorder.

The variability in duration may influence treatment outcomes in several ways. Longer illness duration
could be associated with more deeply entrenched maladaptive cognitive and behavioral patterns,
potentially requiring more intensive or tailored interventions. On the other hand, patients with shorter
illness durations might display a more rapid response to therapy due to less ingrained symptomatology.
Future research should strive to disaggregate these subgroups to determine whether the length of
illness serves as a moderating factor in the effectiveness of CRT and to identify optimal therapeutic
strategies for different patient profiles.

Comorbidities

Of the studies examined, 15 (60%) did not report any information on participants’ comorbidities.
However, among those that did, the most commonly evaluated conditions were mood disorders,
anxiety, depression, and obsessive-compulsive disorder (Davies & Tchanturia, 2005; Du et al., 2020);
perfectionism (Dingemans et al., 2013; Pitt et al., 2010); alcohol or drug abuse; self-harm (Roberts,
2018); and autism spectrum disorder (Dandil et al., 2020). It should be noted, however, that the presence
of these conditions was not an exclusion criterion in the analyzed studies.

The lack of information on comorbidities in a significant percentage of studies limits a comprehensive
understanding of their impact on the response to CRT. It has been suggested that conditions such as
anxiety and depression may affect performance on executive functions, which in turn could influence
the efficacy of the therapy (Tchanturia et al., 2016). In this sense, some authors have proposed that
these psychological characteristics should be an essential part of the analysis in studies, given that
their role as moderating variables in the therapeutic response has been documented. Moreover, patient
selection criteria often excluded those with learning disabilities, psychosis, or intellectual limitations
(Davies et al., 2012).

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Measurement Instruments

Two major categories of instruments were identified: self-report measures, which assess psychological
characteristics as perceived by the patient, and performance-based tests, which objectively evaluate
cognitive performance through structured tasks that measure response times and accuracy. This
distinction is important because each type of test provides complementary information about the
patient’s neuropsychological profile and the effectiveness of CRT.

Self-report measures have been widely used to assess symptoms related to eating disorders and their
comorbidities. Common instruments include those designed to evaluate eating disorder symptoms,
such as the Eating Disorder Inventory-2 (Abbate-Daga et al., 2012), the eating disorder-Specific Health
Quality of Life (Dingemans et al., 2013; Du et al., 2020), and the Eating Disorder Examination (Alvarado-
Sánchez et al., 2019; Fonville et al., 2014). For the evaluation of obsessive-compulsive symptoms,
instruments such as the Maudsley Obsessive-Compulsive Inventory, the Obsessive-Compulsive
Inventory-Revised, and the Yale Brown Obsessive-Compulsive Scale have been employed (Davies &
Tchanturia, 2005; Fonville et al., 2014; Tchanturia et al., 2006, 2007, 2008; van Passel et al., 2020). In
assessing mood disorders, anxiety, and depression, the Hospital Anxiety and Depression Scale, Beck
Depression Inventory, Beck Anxiety Inventory-II, and Depression, Anxiety and Stress Scale-21 have been
utilized (Abbate-Daga et al., 2012; Alvarado-Sánchez et al., 2019; Davies & Tchanturia, 2005; Dingemans
et al., 2013; Fonville et al., 2014; Leppanen et al., 2018; Mac-Neil et al., 2016; Roberts, 2018; Tchanturia
et al., 2006, 2007, 2008). Specific scales for perfectionism, such as Frost’s Multi-Dimensional
Perfectionism Scale and the Multidimensional Perfectionism Scale, have also been applied (Dingemans
et al., 2013; Pitt et al., 2010). Additional instruments have measured constructs such as self-esteem,
autistic traits, motivation to change, and body image, including the Rosenberg Self-Esteem Scale,
Autism-Spectrum Quotient, Motivational Ruler, and the Body Shape Questionnaire (Lock et al., 2013;
Tchanturia et al., 2015; Leppanen et al., 2018; Roberts, 2018; Alvarado-Sánchez et al., 2019; 2023). It is
noteworthy that three studies did not report the use of self-report measures (Davies et al., 2012;
Zuchova et al., 2013), which might limit a full evaluation of the patients.

On the other hand, performance-based tests have been essential for objectively measuring cognitive
functions. To evaluate executive functions, instruments such as the Trail Making Test, Wisconsin Card
Sorting Test, Iowa Gambling Task, Hayling Sentence Completion Task, and Tower of London have been
used (Brockmeyer et al., 2016). Cognitive flexibility and central coherence have been assessed through
tests like the Brixton Test, Cued Task-Switching, Detail and Flexibility Questionnaire, Group Embedded
Figures Task, and the Reading the Mind in the Eyes Task (Leppanen et al., 2018; Roberts, 2018). For
attention and working memory, the D2 Test of Attention, Wechsler Adult Intelligence Scale-III, and the
Delis-Kaplan Executive Functioning System have been utilized (Lock et al., 2013). Furthermore, specific
evaluations of central coherence have been performed using the Rey-Osterrieth Complex Figure Test
and the Simple/Complex Embedded Figures Task (Mac-Neil et al., 2016; Pitt et al., 2010; Roberts, 2018).
However, nine studies did not incorporate performance-based tests, limiting the ability to establish
correlations between cognitive performance and clinical progression (Mac-Neil et al., 2016; Pitt et al.,
2010; Roberts, 2018; Tchanturia et al., 2016; Tchanturia et al., 2014, 2015, 2016A; 2016B; Zuchova et
al., 2013).

The combination of self-report measures and performance-based tests allows for a more
comprehensive assessment of the effects of CRT on patients with eating disorders. Yet, some
interventions do not clearly distinguish between the two, using self-report measures to evaluate
executive functions when these are better assessed through performance-based tests such as the Trail
Making Test or the Iowa Gambling Task. The inclusion of a standardized battery that encompasses
both perspectives could facilitate comparisons between studies and optimize CRT protocols. As
detailed in Table 2, integrating both types of instruments is critical for developing a robust

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understanding of the therapeutic impact of CRT, ultimately supporting more individualized treatment
approaches.

Study Results

Studies consistently show that Cognitive Remediation Therapy (CRT) has a positive impact on cognitive
flexibility, central coherence, and the ability to change in patients with eating disorders, particularly
anorexia nervosa (AN). Various investigations have reported significant improvements in these areas,
suggesting that CRT is an effective tool for addressing the cognitive difficulties associated with these
disorders.

Several studies highlight improvements in cognitive flexibility and central coherence in patients who
received CRT. Positive changes in cognitive adaptability and a reduction in mental rigidity have been
observed, which are fundamental aspects in the treatment of eating disorders. Research by Davies &
Tchanturia (2005), Tchanturia et al. (2013), and Lock et al. (2013) agree that CRT facilitates the ability
to change and improves cognitive organization, contributing to the therapeutic process of these
patients.

In addition to cognitive benefits, CRT has also shown positive effects on eating disorder
psychopathology and other psychiatric symptoms. Improvements in eating patterns and a reduction in
perfectionism—factors influencing the persistence of AN—have been reported (Pitt et al., 2010).
Similarly, studies by Tchanturia et al. (2015) indicate significant reductions in anhedonia and
alexithymia after CRT intervention. Other investigations, such as Roberts (2018), have found
improvements in mood disorders and general psychiatric symptoms, reinforcing the therapeutic
potential of this intervention.

CRT has also been well accepted by both patients and therapists. In various studies, participants have
reported that the therapy is useful and positive, indicating a high rate of adherence and satisfaction
(Genders & Tchanturia, 2010; Zuchova et al., 2013; Mac-Neil et al., 2016). This aspect is crucial in any
therapeutic intervention, as greater patient acceptance often translates into better long-term outcomes.

Despite the positive findings, some studies have shown mixed results regarding CRT's effectiveness.
While most studies highlight its benefits, others have found no significant differences between the
intervention and control groups. For example, Fonville et al. (2014) and Van-Passel et al. (2020) reported
that CRT did not produce additional improvements in certain cognitive variables. These findings
suggest that CRT’s effectiveness may depend on individual factors or the type of measures used to
assess its impact.

In terms of similarities, most studies agree that CRT improves cognitive flexibility and central
coherence, reduces some psychiatric symptoms, and is well received by patients. However, there are
differences in results concerning certain variables. For instance, some studies found no significant
changes in body mass index (BMI) following the intervention (Alvarado-Sánchez et al., 2019, 2023),
while others did not observe improvements in attention to detail (Leppanen et al., 2018). Additionally,
differences have been identified based on the presence of autism spectrum traits, suggesting that CRT
may not be equally effective across all patient subgroups (Tchanturia et al., 2016; Dandil et al., 2020).

DISCUSSION

The objective of the present study was to analyze the effectiveness of Cognitive Remediation Therapy
(CRT) in improving cognitive deficits associated with eating disorders in adults with eating disorders.
The study aims to identify key findings regarding sample characteristics (country of study, type of
patient, number of participants, age, BMI, duration of illness, and comorbidities), as well as the
assessment instruments used (both self-report and performance-based measures).

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Regarding the geographic distribution, it indicates a diversity in the application and methodological
approach of CRT, which has been explored in various cultural contexts and healthcare systems. This
panorama suggests the need to continue expanding research in underrepresented regions, which will
not only enrich the theoretical and empirical body of knowledge on CRT but also facilitate the adaptation
of the intervention to diverse clinical and cultural realities (Davies & Tchanturia, 2005; Tchanturia et al.,
2006, 2007, 2008; Genders & Tchanturia, 2010; Pitt et al., 2010; Davies et al., 2012; Tchanturia et al.,
2014, 2015, 2016; Dandil et al., 2020).

The decision to group patients into inpatient and outpatient modalities is not merely a categorization;
it also implies differences in therapeutic management. For example, inpatient care allows for more
intensive monitoring and an integrated intervention that addresses both medical and psychosocial
aspects, whereas outpatient care is aimed at patients in less acute phases who, despite exhibiting
deficits in executive functions, may benefit from a less restrictive approach that focuses more on social
and functional reintegration (Davies & Tchanturia, 2005; Tchanturia et al., 2006, 2007, 2008; Genders &
Tchanturia, 2010; Pitt et al., 2010; Davies et al., 2012; Tchanturia et al., 2014, 2015, 2016; Dandil et al.,
2020).

In hospitalized patients, where the severity and presence of comorbidities can be more pronounced,
CRT emerges as a complementary tool that, by improving executive functions and central coherence,
facilitates therapeutic engagement and helps reduce treatment dropout. On the other hand, in
outpatient settings, the application of CRT can be oriented towards strengthening autonomy and the
everyday management of the disorder, promoting adaptive strategies in a less controlled environment
(Cella et al., 2015; González de Chávez, 1999)

The heterogeneity in the sample suggests that future research could benefit from a comparative
analysis between care modalities, which would allow for the optimization of CRT protocols and the
personalization of interventions according to the patient’s clinical context. This variability in sample
size and study design not only reflects the growing maturity of CRT research but also underscores the
importance of adapting therapeutic protocols to the specific characteristics of each sample. The
evolution in the number of participants per study shows a trend toward more robust and generalizable
research, which is essential for consolidating the therapeutic impact of CRT.

In the analyzed studies, the age of participants ranges from 17 to 59 years, reflecting the heterogeneity
of the clinical population to which CRT is applied and the possible influence of age-related variables,
such as the duration of the disorder and adaptation to specific therapeutic interventions. It has been
suggested that age might be linked to the chronicity of the disorder and, consequently, to the magnitude
of deficits in executive functions—an aspect essential for managing and regulating eating behavior
(Tchanturia et al., 2016; Alvarado et al., 2019). Likewise, the inclusion of such a wide age range suggests
the need to adapt the CRT intervention, both in the selection of assessment instruments and in the
application methodology, to the particularities of each age subgroup. Some studies have differentiated
protocols for adolescents and adults, acknowledging that differences in cognitive maturity and
psychosocial demands can influence the effectiveness of the therapy (Dingemans et al., 2013).

Regarding BMI, there is a wide variability in the reported values. For example, the lowest BMI was
identified in a case study with a value of 13 (Tchanturia et al., 2006), while other studies have recorded
higher values, reaching up to 25 (Roberts, 2018). This variability is consistent with the nature of eating
disorders, where low body weight is characteristic, especially in AN. It is important to note that although
CRT focuses on improving executive functions and central coherence, BMI is often used as a
complementary variable to evaluate the evolution of nutritional status following the intervention. Some
studies have attempted to explore the possible relationship between changes in cognitive functions
and modifications in BMI, although to date no direct and consistent link has been established
(Tchanturia et al., 2010; Lang et al., 2015; Roberts, 2018; Tchanturia et al., 2016).

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The duration of the disorder is another crucial factor, as the time elapsed with the pathology may reflect
the diversity of previous therapeutic processes (psychological, nutritional, and medical) to which
patients have been subjected (Madruga et al., 2010) These antecedents can influence the degree of
cognitive rigidity and the capacity for adaptation to change, aspects that CRT seeks to improve through
structured interventions. The uncertainty regarding the influence of the disorder’s duration suggests
that a chronic course could be associated with a greater deterioration in executive functions, which in
some cases would require more intensive or adapted therapeutic strategies (Mehler & Brown, 2015).
Therefore, future studies should disaggregate the results according to the duration of the disorder,
allowing for the identification of specific patient profiles and the optimization of CRT application based
on the chronology of the disorder (Morris et al., 2015)

Regarding comorbidities, mood disorders, depression, anxiety, obsessive-compulsive disorder,
substance abuse, and autism spectrum disorder are common conditions in eating disorders (Salbach-
Andrae et al., 2008). However, many studies have not exhaustively evaluated whether these conditions
affect CRT outcomes. Given that these comorbidities can influence cognitive functioning, it is essential
to consider their impact when analyzing the efficacy of the intervention (Jagielska & Kacperska, 2017;
Raney et al., 2008)

Regarding the instruments used, two main categories were identified: self-report instruments and
performance-based tests. Self-report instruments, such as the Eating Disorder Inventory-2, the Eating
Disorder Examination, or scales to assess anxiety and depression, allow for understanding the patient’s
perception of their own psychological state. On the other hand, performance-based tests (for example,
the Trail Making Test, the Wisconsin Card Sorting Test, or the Iowa Gambling Task) provide an objective
evaluation of executive functions and central coherence. The combination of both types of instruments
is crucial for obtaining a comprehensive picture of the patients’ neuropsychological profile and for more
accurately assessing the impact of CRT. Nevertheless, it is observed that in some studies this
distinction is not clearly defined, as self-reports have been used to evaluate functions that might be
more appropriately measured through performance-based tests, which limits the ability to compare and
contrast the results (Reville et al., 2016)

Regarding study results, the majority indicate that CRT has a positive impact on cognitive flexibility,
central coherence, and, overall, on the adaptive capacity of patients with eating disorders, especially
those with AN. Significant improvements have been reported in the ability to change and cognitively
organize, as well as in the reduction of psychopathological symptoms related to eating disorders.
Furthermore, some studies highlight that CRT helps reduce treatment dropout and improves patient
engagement. However, there are studies that have reported mixed results, especially concerning
variables such as attention to detail, BMI, or certain specific executive functions, suggesting that the
efficacy of CRT may be modulated by individual factors or by the nature of the assessment instruments
used (Easter & Tchanturia 2011; Fagundo et al., 2012)

CRT appears to be a promising complementary intervention for addressing cognitive difficulties in
eating disorders. The diversity in the sample, the variability in the duration of the disorder, and the use
of different assessment instruments underscore the need for future research that refines therapeutic
protocols and personalizes interventions according to each patient’s clinical profile. Moreover, the
integration of self-report instruments and performance-based tests is fundamental for obtaining a more
complete and precise evaluation of CRT’s effects, which in turn will facilitate the identification of
strategies tailored to the specific needs of patients, thereby optimizing therapeutic outcomes
(Southgate et al., 2005).

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CONCLUSIONS

This work constitutes a systematic review that has allowed us to analyze the available evidence on the
effectiveness of CRT in the treatment of eating disorders in adults, with special emphasis on AN. The
findings extracted from the included studies demonstrate that CRT is a promising complementary
intervention, as it significantly contributes to improving executive functions and central coherence.
These improvements are essential to counteract the cognitive rigidity characteristic of eating disorders
and to facilitate the regulation of eating behavior, enabling patients to adopt more flexible and adaptive
thought and behavior patterns.

The systematic review reveals that, both in inpatient and outpatient settings, the application of CRT
promotes greater therapeutic engagement and significantly reduces treatment dropout. In the hospital
context, where the severity and presence of comorbidities tend to be more pronounced, CRT stands out
as a tool that, by enhancing cognitive capacities, helps patients comprehensively address both the
medical and psychosocial aspects of the disorder. On the other hand, in outpatient settings, the
intervention is oriented towards strengthening autonomy and the everyday management of the
disorder, offering a less restrictive approach that facilitates social and functional reintegration.

The evidence gathered in this systematic review supports the effectiveness of CRT as a complementary
intervention in the treatment of eating disorders, highlighting its potential to improve cognitive flexibility,
central coherence, and, overall, the adaptive capacity of patients. However, to consolidate these
findings and optimize the application of CRT, it is imperative to continue research through studies with
larger samples, standardized methodologies, and an approach that combines both objective and
subjective evaluations. Only in this way can the intervention be personalized, maximizing therapeutic
benefits and providing a response tailored to the specific needs of each patient.

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