Talk:Cognitive remediation therapy

Issue with relevance of AFNI screenshot
As the creator of the image used here, I just want to note that the fMRI task depicted in the screenshot is quite obviously a simple block motor paradigm (alternating left/right finger movement). Block motor tasks are often used to demonstrate very basic fMRI and these images were acquired during protocol testing. I created the image simply to showoff AFNI for the AFNI wikipedia page. As far as I know it has nothing to do with cognitive remediation therapy.

I raise this issue because I was very surprised to come across this image on a blog post showing it off as a clear demonstration of the effects of CRT at http://www.publicseminar.org/2014/04/physics-envy/. I was quite confused as to how an image of a motor task could be confused for CRT. Some googling lead me to this wikipedia article. The wording of the caption used here is misleading. It's not clear to me that this image contributes to the article at all. Jstorrs (talk) 16:13, 14 November 2014 (UTC)

new content on Cognitive Enhancement Therapy
Content below was introduced by a novice editor today in these 2 difs. First dif had edit note: "clarify difference between cognitive remediation therapy CRT and cognitive enhancement therapy CET, contact Ray Gonzalez at rgonzalez@cetcleveland.org for any questions"

Content needs to be formatted with in-line citations like the rest of the article. Also needs to be reviewed for WP:NPOV, WP:COI and WP:MEDCOI in particular, and WP:MEDRS sourcing. Jytdog (talk) 13:39, 23 July 2014 (UTC)

introduced content copy/pasted from edits
Cognitive Enhancement Therapy

Cognitive Enhancement Therapy (CET) is a SAMHSA (Substance Abuse Mental Health Services Agency) recognized Evidence Based Practice form of cognitive rehabilitation (remediation) training program for adults with chronic or early-course schizophrenia or schizoaffective disorder (per DSM-III-R or DSM-IV criteria) who are stabilized and maintained on antipsychotic medication and not abusing substances (see National Registry of Evidence-based Programs and Practices (NREPP) at http://www.nrepp.samhsa.gov). CET is designed to provide cognitive training to participants to help them improve impairments related to neurocognition (including impaired processing speed, poor memory and problem-solving abilities), cognitive style (including impoverished, disorganized, or rigid cognitive style), social cognition (including lack of perspective taking, foresight, and social context appraisal), and social adjustment (including social, vocational, and family functioning), which characterize these mental disorders and limit functional recovery and adjustment to community living. Through CET, participants learn to shift their thinking from rigid serial processing to a more generalized processing of the core essence or gist of a social situation and a spontaneous abstraction of social themes.

CET is curriculum based and delivered over a period of 12 to 18 months, beginning with approximately 1 to 3 months of weekly 1-hour sessions of computer-assisted neurocognitive attention training conducted with paired partnerships between participants. As the treatment proceeds over 12 to 15 months, participants engage in 54 to 60 hours of targeted, performance-based neurocognitive training exercises to improve their attention, memory, and problem-solving abilities.

After approximately 1 to 3 months of neurocognitive training, participants add attending structured social cognition group sessions, which last for 1.5 hours each and are held weekly; there are a total of 45 to 48 social cognition group sessions in the program. In these sessions, clinicians following a curriculum, help groups of six to twelve participants improve social-cognitive abilities (e.g., taking perspectives, abstracting the main point in social interactions, appraising social contexts, managing emotions) and achieve individualized recovery plans. Participants also use experiential learning and real-life social cognition exercises two person teams to facilitate the development of social wisdom and success in interpersonal interactions; enhance social comfort; respond to unrehearsed social exchanges; present homework and lead homework reviews; provide feedback to peers; and receive psycho-education on social cognition and schizophrenia.

Clinicians also provide active, supportive, individual weekly one-on-one coaching session to keep each participant on task and to encourage greater understanding of social cognition and greater elaboration, organization, and flexibility in thinking and communication. After social-cognitive group sessions begin, neurocognitive training and social-cognitive training proceed concurrently throughout the remainder of the program.

Both neurocognitive training and social-cognitive group sessions are facilitated by clinicians who have at least 2 years' experience in the treatment of schizophrenia and related disabilities. Social-cognitive group sessions require a minimum of two clinicians who follow a comprehensive structured curriculum. CET is designed to be implemented in agency- and center-based treatment settings.

CET was initially developed and piloted in the early 1990s. The program was successfully tested in a randomized clinical trial (RCT) conducted from 1995 to 2002 to study the use of CET with outpatients with chronic schizophrenia (Hogarty G, Flesher S, Ulrich R,Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. Archives General Psychiatry, v 61, Sep 2004, pp. 866-876 ; this study was led by Gerard Hogarty and Samuel Flesher at the University of Pittsburgh. CET was validated in an RCT conducted from 2001 to 2006 to study the use of CET with patients with early-course schizophrenia; this study was led by Gerard Hogarty, Matcheri Keshavan and Shaun Eack at the University of Pittsburgh. Both studies were funded by the National Institute of Mental Health (NIMH) and conducted at the Western Psychiatric Institute and Clinic in Pittsburgh, Pennsylvania. A total of 121 patients participated in the first CET study, and 58 patients participated in the early-course study.

CET also has been implemented in more than 31 sites in 11 states with over 1,500 graduates (see www.cetcleveland.org). NIMH has funded an expanded study of CET (in Pittsburgh and in Boston, Massachusetts) with patients with early-course schizophrenia and schizoaffective disorder. In addition, studies are being conducted in Pittsburgh on the effectiveness of CET with verbal young adults with high functioning autism spectrum disorder and with patients with schizophrenia who use cannabis and alcohol. (see Shaun Eack at Univ of Pittsburg)

See also

Autism Center, Univ. of Pittsburgh Matcheri Keshavan at Harvard Univ

www.cetcleveland.org

YouTube Videos of CET at Bridgehaven Mental Health Services, Louisville KY

Shaun Eack, Univ. of Pittsburgh

Ray Gonzalez, Center for Cognition and Recovery

REFERNCES

Hogarty G, Flesher S, Ulrich R, Carter M, Greenwald D, Pogue-Geile M, Kechavan M, Cooley S, DiBarry AL, Garrett A, Parepally H, Zoretich R. Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. Archives General Psychiatry, v 61, Sep 2004, pp. 866-876. www.archgenpsychiatry.com Hogarty G, Greenwald D, Eack. Durability and mechanism of effects of cognitive enhancement therapy. Psychiatric Services, v 57, 12, Dec 2006, pp. 1751-1757. www.psychiatryonline.org Eack S, Greenwald D, Hogarty S, Cooley S, DiBarry AL, Montrose D, Keshavan, M. Cognitive enhancement therapy for early-course schizophrenia: effects of a two-year randomized controlled trial. Psychiatric Services, v 60, 11, Nov 2009, pp. 1468-1476. www.psychiatryonline.org

Eack S, Greenwald D, Hogarty S, Keshavan M. One-year durability of the effects of cognitive enhancement therapy on functional outcome in early schizophrenia. Schizophrenia Research, 120, 2010, pp. 210-216. www.elsevier.com

Eack S, Hogarty G, Cho R, Prasad KMR, Greenwald D, Hogarty S, Keshavan M. Neuroprotective effects of cognitive enhancement therapy against gray matter loss in early schizophrenia. Archive General Psychiatry, v 67, 7, July 2010, pp. 674-682. www.archgenpsychiatry.com

Eack S, Hogarty G, Greenwald D, Hogarty S, Keshavan M. Effects of cognitive enhancement therapy on employment outcomes in early Schizophrenia: results from a 2- year randomized trial. Research on Social Work Practice, 21(1), pp. 32-42.

revisions to come
Just wanted to give a heads up to everyone that I will be initiating major revisions to this page in bulk form within the next few weeks, including removing the irrelevant AFNI image. Thanks! Arielschvarcz (talk) 23:28, 16 November 2014 (UTC)
 * you clearly put a lot of work into this but a bunch of your sources are not ok per WP:MEDRS. There should  be no WP:PRIMARY sources, much less ones that are over 10 years old.  If that stuff is not discussed in reviews it is probably not real. Also, every source should include the PMID so that one can quickly go check if it is classified as "research" (a primary source) or a review ( a secondary source).   This is going to be a shitload of work to review... you could help by taking out the bad sources.  Thanks. Jytdog (talk) 03:25, 30 November 2014 (UTC)

article as edited by Arielschvarcz
below is the work product of Arielschvarcz. This needs to be reviewed for sourcing before it can be implemented. Jytdog (talk) 03:28, 30 November 2014 (UTC)

Cognitive remediation therapy (CRT), also referred to as cognitive rehabilitation or cognitive enhancement, has been defined by the Cognitive Remediation Experts Workshop as a ″behavioral-training based intervention that aims to improve cognitive processes (attention, memory, executive function, social cognition, or metacognition) with the goal of durability and generalization″. CRT also aims to affect the domains of working memory, cognitive flexibility, and problem solving, ultimately intending to improve functioning in everyday life. Cognitive remediation is used to treat the deficits in neurocognitive abilities that may have resulted from a range of neurological and psychiatric disorders or from other brain injuries. CRT aims to take advantage of the brain’s plasticity, or its ability to change, in order to improve deficits in abilities.

History
The theory of applying methods to improve cognitive deficits has been discussed as early as 1896. However, the earliest documented examples of CRT date back to World War I, during which time soldiers returning from war evidenced brain injuries necessitating assessment and rehabilitation. Clinics treating these soldiers developed internationally in Germany, Great Britain, and Russia, with the famed Soviet neuropsychologist Alexander Luria providing much information about injury-related brain dysfunction. In particular, Luria assessed the current functioning of soldiers on a neurosurgical unit, investigated medications that could improve memory skills, and identified the functions of various brain regions.

Within the United States, the rehabilitation field was developing with psychologists such as Shepherd Franz commenting on related “reeducation” techniques. Others, such as Kurt Goldstein continued studying soldiers who had sustained brain injuries, noting their restrictions and suggesting psychotherapy treatments as remedies. Later advances in neurocognition and cognitive psychology in the 1960s led to the modern remediation methods used today, with the burgeoning field of neuropsychology and its testing tools aiding in the assessment of cognitive deficits needing intervention. For example, the earliest known study on CRT in psychotic patients dates back to 1973. The additional advances in modern technology throughout the 1980s and 1990s, in particular, the development of computers and video gaming systems (e.g., Atari) allowed for the introduction of educational and rehabilitation software that could be used with individuals who had experienced traumatic brain injuries. Although current CRT iterations were developed in the early 1990s, the accepted, formalized definition above was not ratified until 2010 by the Cognitive Remediation Experts Workshop.

CRT training techniques and assumptions
One CRT technique is to teach individuals "errorless learning," or learning to complete tasks in structured situations that minimize the number of errors that can be made. This can be accomplished by initially presenting a task very slowly and then increasing the speed, or by breaking down a task into smaller, simpler steps. Other technique are "self-monitoring," for which the individual is taught to develop routines for remembering instructions and completing the task, and "scaffolding," where assistance is provided based on the person’s level of competency and is altered as the skill grows. CRT can focus on extended practice on a single task, or can involve multiple tasks and strategies intended to improve functioning on a particular skill. Cognitive training is provided either though computer-based tasks or pencil-and-paper activities, during which either an examiner or a computer-based program will provide feedback and alter task difficulty.

In order to determine which tasks should be used to address deficits in certain cognitive abilities, researchers rely on several assumptions of CRT, which one group deemed the "higher-order assumption," the "central-deficit assumption," and the "task-purity assumption". The higher-order assumption refers to the idea that certain functions are targeted for treatment because they are thought to influence several downstream cognitive processes; therefore, improvement in this function would lead to improvement in many others. The central-deficit assumption states that the deficit targeted by CRT must be one that is centrally related to the disorder in question. Lastly, that the training exercise is known to target the impaired ability. Although these assumptions are often employed by researchers, the research highlights some theoretical weakness regarding the validity of them.

Mechanisms of change
CRT aims to improve cognition to a noticeable, long lasting extent in one of three main ways: helping to regain lost skills, aiding in the acquiring of new skills, or improving global functioning. It does so by affecting and altering existing neural pathways in the brain. In a typical brain, regions communicate with one another through connections established by neural synapses. These highly organized connections become damaged or atypical due to various psychiatric/neurological disorders, and can cause observable cognitive deficits associated with those disorders. However, due to the brain’s plasticity, or the ability of experience to modify brain structures and corresponding function, neural circuitry can be altered in many ways to restore such deficits. By providing an enriched environment, CRT has been shown to facilitate such neural plasticity and promote recovery.

For example, a recent review of the neural substrates altered by CRT in schizophrenia (SZ) patients showed significant post-CRT increases in activation within frontal brain regions such as the prefrontal cortex, as well as in changes in limbic, parietal, temporal, and parahippocampal areas using functional magnetic resonance imaging (fMRI) techniques. Other studies on SZ patients revealed increased activation in regions associated with working memory following CRT as compared to both SZ patients receiving control therapy and healthy controls. These network activation patterns appear not just to improve, but to normalize toward the patterns observed in healthy controls. Similarly, among patients with mood disorders, increased activation in lateral and medial prefrontal, lateral parietal, hippocampal, and superior temporal regions was observed on a memory task following CRT.

Structural MRI techniques have revealed changes in gray matter volume in medial temporal areas of SZ patients (e.g., amygdala, hippocampus, anterior cingulate cortex) following CRT, namely that CRT appears to have neuroprotective effects of reducing gray matter loss in those regions or even facilitating localized increases in gray matter volume. Changes to white matter organization have also been reported via diffusion tensor imaging techniques, including increased white matter integrity within the corpus callosum.

These neural changes are then measured by comparing pre-CRT performance on standardized neuropsychological tests to performance on these tests following CRT, with the goal to find improvements in the areas examined. Indeed, observed neural changes often correlate with such enhancements in neurocognitive performance.

Effects of CRT on psychiatric conditions
Overall, CRT has been reported to have small to moderate effects on global cognition, social cognition, verbal working memory, and daily functioning that at times appear relatively long-lasting. However, some differences within individual psychiatric conditions exist.

Schizophrenia
The largest CRT literature on severe mental illness exists among the schizophrenia (SZ) cohort in part due to the inability of other existing treatments to address the persistent declines in cognition often observed in psychosis-spectrum disorders. Computerized CRT has been shown to increase attention, processing speed, verbal memory and working memory with small effect sizes, with the largest (medium) effect size observed in the improvement in social cognition; results were independent of whether or not these domains were specifically targeted by CRT tasks. Treatment duration, remediation approach, and training delivery method (e.g., computerized or not) were reported not have an effect on cognitive changes, but functioning outcome appears most affected by the increased clinical stability of patients and the conjunction of CRT with other treatment options. Post-CRT increases in cognitive flexibility and working memory have also been observed among comorbid populations, such as individuals with both SZ and social behavior problems, with improvements in the working memory predicting increase social functioning. Extended studies with a 2-year training period have continued to show improved neurocognition, processing speed, social cognition, social adjustment and cognitive style.

Cognitive improvements in working memory, reasoning, problem-solving and processing speed have also led to increased self-esteem and better quality of life as endorsed by patients. CRT has also improved patients’ level of insight into their symptoms and treatment by targeting episodic autobiographical memory and metacognition. These cognitive improvements resulting from CRT appear to persist, particularly in the memory domain, as they are apparent at a 6-month follow-up evaluation; some aspects of social functioning remain improved at follow-up as well while immediate post-CRT increases in self-esteem did not.

The timing of CRT was also considered within a SZ cohort; the effects of 12 weeks of CRT were compared between early-course patients (e.g., within five years of their initial psychotic episode) and chronic patients (more than 15 years of illness). While both groups improved cognitively, the early-course cohort demonstrated greater gains in processing speed and executive functioning, as well as better post-treatment adaptive function and real-world work skills. The authors concluded that CRT is most effective on its own in SZ when it is delivered early in the intervention phase. Relatedly, the effects of CRT appear limited in older individuals diagnosed with SZ as compared to younger ones, regardless of initial intelligence. However, other work has showed significant improvements in memory, executive function, and social functioning among chronic patients below the age of 55 years that persisted at 6-month follow-up evaluations, suggesting that CRT is still feasible in this group.

The benefits of CRT have also been demonstrated in disorders related to SZ, such as schizoaffective disorder. Other variants of SZ have equally benefitted from CRT, which has also been implemented in early-onset schizophrenia (EOS) patients who develop overt psychotic symptoms prior to the age of 18. In a group of 21 adolescents who received three months of CRT, individuals showed improvements in cognitive flexibility that led to decreased symptomatology and better social functioning as compared to a group receiving standard care. When combined with treatment-as-usual, a randomized controlled trial of 50 EOS individuals receiving CRT led to increased verbal memory ability and executive functions, improved daily living and adaptive functioning, and decreased family burden that were not observed among non-CRT treatment-as-usual controls. While the cognitive gains were maintained after three months, however, the functional changes were not. Gains in visuospatial abilities from CRT have also been reported in among EOS individuals and those identified as being putatively at clinical-high risk (CHR) for psychosis, above and beyond those associated with a computer games control group. Other preliminary work with CHR individuals, who also evidence cognitive deficits, have shown trends towards improved working memory and social functioning after CRT, though the authors caution about their likely underpowered study.

CRT among individuals with SZ also appears to have positive societal outcomes; cognitive improvements have been associated with reduced depressive symptoms, which subsequently predicts a reduction in health care costs, day care costs, and special accommodations costs (e.g., costs associated with residential care or psychiatric rehabilitation wards).

Eating disorders
There is a large body of research addressing CRT as a treatment for the cognitive deficits associated with anorexia nervosa (AN), an eating disorder, such as cognitive inflexibility (e.g., the ability to switch between strategies and multitask), and extreme detail-oriented thinking that leads to restrictive eating. CRT for AN, the creation of which has been credited to Tchanturia and Davies, has been described as broadly targeting cognitive style (thought process) rather than focusing on the more specific symptoms of emotions, weight, or eating (thought content). CRT for AN has also been reported to have low drop-out rates, suggesting that this is a promising treatment approach among a cohort that usually has difficulty engaging in therapy. Participants across studies express direct interest in the treatment and have endorsed positive change in their lives following CRT. Successful implementation of CRT has occurred across the world, including in England, France, Norway,  Italy, Germany, and the United States.

In particular, CRT for AN adults has improved cognition on a range of neuropsychological tasks, particularly those assessing for set-shifting flexibility. Significant increases in weight, body mass index scores, global functioning, and eating disorder symptoms like impulse control have also been reported, though perfectionism and depressive symptoms appear unaffected. AN-specific CRT appears more advantageous for this group as compared to nonspecific neurocognitive training, as a randomized controlled trial (RCT) contrasting the two reported significantly greater improvements in cognitive set-shifting among women who received the CRT versus the nonspecific treatment. An RCT comparing outpatient CRT with cognitive behavioral therapy (CBT) also showed greater cognitive improvement and fewer drop outs in the CRT group.

CRT has been effective for AN across different ages, helping not only adults but adolescents as well. For example, CRT appears to lead to significant weight gain, decreased depressive symptoms, and improved visuospatial memory, verbal abilities, and perceptual abilities. CRT has also shown to decrease self-reported and parent-reported executive dysfunction and increase self-reported cognitive flexibility and treatment engagement, particularly when patients believe it is important to change. This treatment appears effective for both inpatient and outpatient adolescents, and can accommodate individual tailoring of the intervention based on cognitive styles, age, and developmental status to reduce boredom and other negative associations.

CRT has also demonstrated preliminary efficacy in treating AN symptoms when presented in a group format, though more recent work has suggested an individual format is preferred. For example, an inpatient unit cohort of adolescents ages 13 to 19 received 10 sessions of group CRT targeting several cognitive domains such as attention and planning; after each training session, the group discussed the pros and cons of different thinking styles. Post-treatment changes were observed in cognitive flexibility and task performance. Other work has demonstrated comparable changes in self-reported flexibility following group CRT, as well as increased self-reported motivation and confidence to change. Additionally, early work on CRT implemented with families of a young person with AN revealed post-CRT improvements in communication and cooperation among family members, increased patient engagement in the treatment process, increased family knowledge of AN-related cognitive deficits, and decreased symptomatology of patients.

Mood disorders
Mood disorders such as Major Depressive Disorder(MDD) have been associated with cognitive impairment in a wide range of executive function and neuropsychological tasks such as those assessing attention, memory, working memory, and psychomotor skills. Similar deficits in processing speed, attention, memory, and executive functioning have been reported in bipolar disorder as well. There is some effect of diagnostic variability, with greater cognitive deficits accompanying bipolar disorder(BP) than unipolar depression (MDD), and mood disorders with psychotic features showing the greatest impairments. Some of the cognitive dysfunction appears to persist even after clinical symptoms have remitted, necessitating the use of tools such as CRT to combat these effects.

A recent review of CRT for mood disorders revealed improvements in depressive symptoms and psychosocial functioning, as well as increased occupational functioning that correlated with better executive functioning, following remediation in individuals with BP. However, people with more severe cognitive functioning prior to treatment appeared to benefit less from CRT, suggesting that CRT may need to be more individualized for those with greater impairments. Given the paucity of current research addressing the benefits of CRT for BP, replication of such findings among independent samples is recommended.

Much more work has been done reviewing the effects of CRT on individuals with depression though with inconsistent findings reported; increases in executive functioning and decreases in depressive symptoms and rumination among adults with MDD have been suggested after remediation intervention. Among a relatively small group of 12 patients with recurrent MDD who received computerized CRT (versus healthy controls and a non-CRT treatment MDD group), improvements were observed across many tasks including those assessing executive function, psychomotor speed, attention, and verbal learning and memory; no changes in depressive symptoms were reported. CRT has been additionally shown as beneficial for verbal memory, attention, and processing speed in a group of 33 adults with treatment-resistant MDD for whom other treatment methods were not successful at fully alleviating symptoms. However, no improvements in executive functioning or changes in everyday functioning and behavior were found, suggesting that skills training or other remediation might be necessary for those effects. Given these inconsistencies in the literature, a recent review by Porter et al. (2013) suggested that sample sizes have been too small to be conclusive in their findings, but that additional research using more well-defined criteria is warranted to continue to assess the impact of CRT on mood disorders.

Interestingly, CRT has also been suggested as a potentially effective and beneficial tool for remedying the side effects of a more aggressive form of MDD treatment, electroconvulsive therapy (ECT). ECT can cause treatment-induced memory deficits in some individuals which has negative effects on their reported quality of life. Pilot data suggested that a modified version of CRT, Memory Training for ECT, was easy to implement in the ECT treatment community and was well-received by patients.

Substance use disorders
The negative effects of substance use on cognition and brain development have been well documented especially in the domains of memory and attention,     with particular detrimental effects observed in adolescents. CRT has recently been employed as a potential mechanism to address these issues, and has been shown to be beneficial for individuals suffering from a range of substance use disorders. In a randomized clinical trial, 160 adults with any substance use disorder received either treatment plus computer-based CRT or treatment without CRT; these individuals were followed for one year after treatment in a residential program. Those that had received the CRT showed higher scores on neuropsychological tasks during treatment, though these improvements did not persist at the 12-month follow-up evaluation. Individuals with CRT also showed significantly greater engagement in treatment, commitment to therapy, and a persistent reduction in substance use frequency and addiction severity, demonstrating that CRT has wide-reaching positive effects even above cognitive enhancement.

CRT has additionally been used in populations with one specific substance use disorder such as alcohol dependence. A study of 41 individuals with alcohol dependence revealed patients who had received treatment plus computer-based CRT had greater improvements in working memory, delayed recall memory, and attention as compared to patients who received treatment without CRT. In addition, CRT patients demonstrated endorsed fewer psychological symptoms and impairment post-treatment than non-CRT patients, particularly noting less compulsion-based craving. The effects of CRT on improving cognition in individuals with alcohol dependence has been demonstrated in several other studies using attentional retraining methods.

Although this field is reportedly in its infancy with limited data available, CRT has been proposed as a potentially effective and efficacious treatment for several other substance use disorders including stimulant abuse.

Attention-deficit/hyperactivity disorder
Cognitive deficits have long been associated with Attention-Deficit/Hyperactivity disorder (ADHD), particularly within executive function, inhibitory control, organizational skills, and divided, selective, and sustained attention. Among adults, these deficits have been successfully targeted by CRT that included coaches and homework; as compared to wait-list controls, 22 adults exhibited improved symptomatology (including reduced anger) and organizational skills that persisted to a one-year follow-up evaluation.

Although there is a large literature on CRT treatment of adults with ADHD, there is evidence of success among children as well. In fact, there appears to be more support for the transferring of improvement between the targeted ability and other cognitive areas among children as compared to adults. One review highlighted that children with ADHD had successful reductions in ADHD symptoms and improved academic skills following CRT, as well as improved working memory and attention. The use of more varied CRT approaches, such as one involving movement-based visual and auditory tasks, have led to preschool children with high-risk ADHD symptoms showing improved selective attention and executive control as compared to controls. Therefore, even diverse, sensorimotor CRT programs can successfully address impairments related to ADHD symptoms, though this study was limited by a relatively small sample.

Other disorders/conditions
CRT has shown efficacy for improving cognition among a range of other disorders and conditions, though with more limited evidence than those addressed above. Preliminary evidence via a pilot study of two adults with borderline personality disorder, showed that 40 sessions of biweekly CRT improved verbal working memory, processing speed, planning, self-esteem, and performance in everyday tasks like multi-tasking. In one study of children with language-based learning disabilities, post-CRT improvements in auditory perception were observed. Similarly, attention training reportedly decreased impulsive behaviors and the frequency of tics and improved quality of life among children with Tourette Syndrome.

Non-psychiatric medical conditions such as cancer can also result in cognitive impairment. CRT appears to improve performance on attentional tasks among cohorts of childhood cancer survivors who have attentional difficulties, but the evidence remains inconsistent regarding generalized improvement in academic achievement.

CRT has also been applied to disorders of aging, such as Alzheimer’s Disease and dementia. A review of the literature revealed several computer-based CRT programs modified for Alzheimer’s have led to a wide range of documented improvements in cognition, working memory, depressive symptoms, and executive functioning. Additionally, the combination of one-on-one CRT with motor movements had increased positive effects over and above those caused by psychosocial support alone, for example. However, other reviews were unable to find positive effects of CRT on alleviating memory deficits among those with vascular dementia or Alzheimer’s Disease due to poor quality of the randomized controlled trials, again highlighting inconsistencies in this early line of research. However, computerized CRT has been shown to be preliminarily beneficial for other aspects of aging, such as for improving gait velocity and multitasking while walking (i.e., walking and talking) among elderly individuals.

Cognitive rehabilitation, a more comprehensive cognitive enhancement program that takes place in a rehabilitation setting, has also been substantially shown (i.e., via reviews and meta-analyses) to aid in cognitive disability brought on by brain injuries such as traumatic brain injuries and strokes.

Multimodal clinical approach
CRT was not necessarily developed as a tool to be used in place of pharmacological, cognitive behavioral therapy (CBT), or other interventions, though some research has shown it to be as effective as (or more effective than) CBT, for example, in reducing schizophrenia symptoms and minimizing safety concerns. Instead, a multimodal approach may in fact be ideal, in which CRT is used in addition to those other methodologies in order to best combat cognitive decline. For example, CRT combined with trauma therapy, psychosocial and vocational rehabilitation, or CBT may be most effective for treating severe mental illness and creating lasting cognitive improvement,    while aspects of CRT incorporated into school curricula may help children with attentional or language-based difficulties. Similarly, flexible CRT-related strategies for helping with attention, memory, and problem-solving can be directly applied to skills-based work in psychosocial therapies for a range of psychiatric conditions. In particular, CRT combined with therapy (namely, when therapists are aware of the training) has been suggested to facilitate discussions of applying training exercises to daily lives, increasing the day-to-day relevance of this treatment.

Limitations
Researchers caution that assessing salient cognitive changes from a research framework (e.g., using statistical significance) does not always translate into clinical significance. Specifically, the use of neuropsychological tests that examine larger cognitive indices may make it difficult to assess subtle changes in cognition. This often leads to modest group-wide treatment effect sizes reported in meta-analyses that may underestimate the important and practical changes that may have taken place within the individual’s daily life. Additionally, the variation in outcome measures used by each study makes comparisons between them challenging, limiting the generalizability of results. However, multisite studies are also beginning to take form to help establish uniformity, and confirm neurocognitive improvements in SZ patients following CRT. Another limitation is that while CRT appears to have great promise for improving cognitive deficits, consensus suggests that there may be limited real-life, day-to-day applicability (e.g., remembering a grocery list better). Therefore, more research is deemed necessary to further assess applicability and practicality for individuals.

DISCUSSION
Hi, this is for a class project for which I receive a grade; I am happy to go through and edit to make the references more appropriate, but please please please do not erase the entire thing!!! ...particularly as the preexisting article had several inaccuracies. Thanks! Arielschvarcz (talk) 03:36, 30 November 2014 (UTC)

Also, it seems like the previous version of this page utilized way more non-review articles than I did; I'm not sure how reverting back to that is more accurate at this point - so I would be greatly appreciative if we could allow me some time to edit the references in the most recent draft. I think our class misunderstood the appropriate references idea. Thanks so much!! Arielschvarcz (talk) 03:45, 30 November 2014 (UTC)
 * On Wikipedia, the previous version (however flawed) stays if another editor takes issue with your intended changes. You need to gain consensus for your edits since you were bold, you were reverted, and now you must discuss. Nobody cares about how Dr. Karney is going to grade you. I thought I was clear about these issues when I gave the presentation to your class. Chris Troutman  ( talk ) 03:52, 30 November 2014 (UTC)

Sure, I understand no one cares about me getting a grade, but since the current version is such a mess I didn't realize my need to edit the references would make my entire weeks worth of work and research void. So what happens from here, I post all the suggested changes here and they need to be confirmed before I can enact them again? Arielschvarcz (talk) 04:00, 30 November 2014 (UTC)

changes to be made and agreed upon

1.remove AFNI image; does not relate at all to CRT and is likely used without permission

2.references: remove primary sources (change to reviews); add PMID. Is it sufficient if multiple primary scholarly sources have found the exact same thing, rather than a formal review which simply may not have been conducted yet?

3.anything else that needs to be done? Thanks! Arielschvarcz (talk) 04:12, 30 November 2014 (UTC)


 * Thanks again for your feedback! Since I'm new at this, what would be the best way to proceed? I've gone through and editing the first part of the piece, which contains (as far as I understand) secondary sources only, and added in PMIDs where possible (or ISBNs/DOIs). Some sources are older than 10 years; but that's simply the nature of historical reviews (no one has needed to create as thorough of a review since then). I'm not sure what's best so I've pasted the edited parts below; perhaps you could briefly review this and see if it appears to conform to standards better? Let me know if there's a better method for this! Thanks! Arielschvarcz (talk) 07:58, 30 November 2014 (UTC)
 * about your #2. Hell no - a pile of primary sources does not add up to a secondary source.  More broadly - my intention had been that you would simply edit the copy/pasted version I already put here but the way you are proceeding is OK.  Finally, thanks for working with the community - some students are completely selfish and just keep edit-warring to get their version into the article.  Jytdog (talk) 16:31, 30 November 2014 (UTC)
 * Understood re: sources, and no problem! Regardless of the assignment, I picked this area because it is related to my own research, and is something I am passionate about. I simply want the public to have access to better, more updated information, and I am certainly willing to work to get that accomplished! I apologize for any mistakes or inconvenience due to my lack of Wikipedia-editing knowledge and I hope we can work together on this! Arielschvarcz (talk) 21:21, 30 November 2014 (UTC)

Cognitive remediation therapy (CRT), also referred to as cognitive rehabilitation or cognitive enhancement, has been defined by the Cognitive Remediation Experts Workshop as a ″behavioral-training based intervention that aims to improve cognitive processes (attention, memory, executive function, social cognition, or metacognition) with the goal of durability and generalization″. CRT also aims to affect the domains of working memory, cognitive flexibility, and problem solving, ultimately intending to improve functioning in everyday life. Cognitive remediation is used to treat the deficits in neurocognitive abilities that may have resulted from a range of neurological and psychiatric disorders or from other brain injuries. CRT aims to take advantage of the brain’s plasticity, or its ability to change, in order to improve deficits in abilities.

History
The theory of applying methods to improve cognitive deficits has been discussed as early as 1896. However, the earliest documented examples of CRT date back to World War I, during which time soldiers returning from war evidenced brain injuries necessitating assessment and rehabilitation. Clinics treating these soldiers developed internationally in Germany, Great Britain, and Russia, with the Soviet neuropsychologist Alexander Luria providing much information about injury-related brain dysfunction. In particular, Luria assessed the current functioning of soldiers on a neurosurgical unit, investigated medications that could improve memory skills, and identified the functions of various brain regions.

Within the United States, the rehabilitation field was developing with psychologists such as Shepherd Franz commenting on related “reeducation” techniques. Others, such as Kurt Goldstein continued studying soldiers who had sustained brain injuries, noting their restrictions and suggesting psychotherapy treatments as remedies. Later advances in neurocognition and cognitive psychology in the 1960s led to the modern remediation methods used today, with the burgeoning field of neuropsychology and its testing tools aiding in the assessment of cognitive deficits needing intervention. For example, the earliest known study on CRT in psychotic patients dates back to 1973. The additional advances in modern technology throughout the 1980s and 1990s, in particular, the development of computers and video gaming systems (e.g., Atari) allowed for the introduction of educational and rehabilitation software that could be used with individuals who had experienced traumatic brain injuries. Although current CRT iterations were developed in the early 1990s, the accepted, formalized definition above was not ratified until 2010 by the Cognitive Remediation Experts Workshop.

CRT training techniques and assumptions
One CRT technique is to teach individuals "errorless learning," or learning to complete tasks in structured situations that minimize the number of errors that can be made. This can be accomplished by initially presenting a task very slowly and then increasing the speed, or by breaking down a task into smaller, simpler steps. Other technique are "self-monitoring," for which the individual is taught to develop routines for remembering instructions and completing the task, and "scaffolding," where assistance is provided based on the person’s level of competency and is altered as the skill grows. CRT can focus on extended practice on a single task, or can involve multiple tasks and strategies intended to improve functioning on a particular skill. Cognitive training is provided either though computer-based tasks or pencil-and-paper activities, during which either an examiner or a computer-based program will provide feedback and alter task difficulty.

In order to determine which tasks should be used to address deficits in certain cognitive abilities, researchers rely on several assumptions of CRT, which one group deemed the "higher-order assumption," the "central-deficit assumption," and the "task-purity assumption". The higher-order assumption refers to the idea that certain functions are targeted for treatment because they are thought to influence several downstream cognitive processes; therefore, improvement in this function would lead to improvement in many others. The central-deficit assumption states that the deficit targeted by CRT must be one that is centrally related to the disorder in question. Lastly, that the training exercise is known to target the impaired ability. Although these assumptions are often employed by researchers, the research highlights some theoretical weakness regarding the validity of them.

Mechanisms of change
CRT aims to improve cognition to a noticeable, long lasting extent in one of three main ways: helping to regain lost skills, aiding in the acquiring of new skills, or improving global functioning. It does so by affecting and altering existing neural pathways in the brain. In a typical brain, regions communicate with one another through connections established by neural synapses. These highly organized connections become damaged or atypical due to various psychiatric/neurological disorders, and can cause observable cognitive deficits associated with those disorders. However, due to the brain’s plasticity, or the ability of experience to modify brain structures and corresponding function, neural circuitry can be altered in many ways to restore such deficits. By providing an enriched environment, CRT has been shown to facilitate such neural plasticity and promote recovery.

For example, a recent review of the neural substrates altered by CRT in schizophrenia (SZ) patients showed significant post-CRT increases in activation within frontal brain regions such as the prefrontal cortex, as well as in changes in limbic, parietal, temporal, and parahippocampal] areas using [[functional magnetic resonance imaging (fMRI) techniques. Structural MRI techniques have revealed changes in gray matter volume in medial temporal areas of SZ patients (e.g., amygdala, hippocampus, anterior cingulate cortex) following CRT, namely that CRT appears to have neuroprotective effects of reducing gray matter loss in those regions or even facilitating localized increases in gray matter volume. Changes to white matter organization have also been reported via diffusion tensor imaging techniques.

These neural changes are then measured by comparing pre-CRT performance on standardized neuropsychological tests to performance on these tests following CRT, with the goal to find improvements in the areas examined. Indeed, observed neural changes often correlate with such enhancements in neurocognitive performance.

Effects of CRT on psychiatric conditions
Overall, CRT has been reported to have small to moderate effects on global cognition, social cognition, verbal working memory, and daily functioning that at times appear relatively long-lasting. However, some differences within individual psychiatric conditions exist.

Schizophrenia
The largest CRT literature on severe mental illness exists among the schizophrenia (SZ) cohort, in part due to the inability of other existing treatments to address the persistent declines in cognition often observed in psychosis-spectrum disorders. Computerized CRT has been shown to increase attention, processing speed, verbal memory and working memory with small effect sizes, with the largest (medium) effect size observed in the improvement in social cognition; results were independent of whether or not these domains were specifically targeted by CRT tasks. Treatment duration, remediation approach, and training delivery method (e.g., computerized or not) were reported not have an effect on cognitive changes, but functioning outcome appears most affected by the increased clinical stability of patients and the conjunction of CRT with other treatment options. The benefits of CRT have also been demonstrated in disorders related to SZ, such as schizoaffective disorder.

Eating Disorders
There is a large body of research addressing CRT as a treatment for the cognitive deficits associated with anorexia nervosa (AN), an eating disorder, such as cognitive inflexibility (e.g., the ability to switch between strategies and multitask), and extreme detail-oriented thinking that leads to restrictive eating. CRT for AN, the creation of which has been credited to Tchanturia and Davies, has been described as broadly targeting cognitive style (thought process) rather than focusing on the more specific symptoms of emotions, weight, or eating (thought content). CRT for AN has also been reported to have low drop-out rates, suggesting that this is a promising treatment approach among a cohort that usually has difficulty engaging in therapy.

Mood Disorders
Mood disorders such as Major Depressive Disorder (MDD) have been associated with cognitive impairment in a wide range of executive function and neuropsychological tasks such as those assessing attention, memory, working memory, and psychomotor skills. Similar deficits in processing speed, attention, memory, and executive functioning have been reported in bipolar disorder as well. There is some effect of diagnostic variability, with greater cognitive deficits accompanying bipolar disorder(BP) than unipolar depression (MDD), and mood disorders with psychotic features showing the greatest impairments. Some of the cognitive dysfunction appears to persist even after clinical symptoms have remitted, necessitating the use of tools such as CRT to combat these effects.

A recent review of CRT for mood disorders revealed improvements in depressive symptoms and psychosocial functioning, as well as increased occupational functioning that correlated with better executive functioning, following remediation in individuals with BP. However, people with more severe cognitive functioning prior to treatment appeared to benefit less from CRT, suggesting that CRT may need to be more individualized for those with greater impairments. Given the paucity of current research addressing the benefits of CRT for BP, replication of such findings among independent samples is recommended.

Much more work has been done reviewing the effects of CRT on individuals with depression though with inconsistent findings reported; increases in executive functioning and decreases in depressive symptoms and rumination among adults with MDD have been suggested after remediation intervention. Given these inconsistencies in the literature, a recent review suggested that sample sizes have been too small to be conclusive in their findings, but that additional research using more well-defined criteria is warranted to continue to assess the impact of CRT on mood disorders.

Substance Use Disorders
The negative effects of substance use on cognition and brain development have been well documented especially in the domains of memory and attention,  with particular detrimental effects observed in adolescents. The effects of CRT on improving cognition in individuals with alcohol dependence has been demonstrated in several studies using attentional retraining methods, Although this field is reportedly in its infancy with limited data available, CRT has been proposed as a potentially effective and efficacious treatment for several other substance use disorders including stimulant abuse.

Attention-Deficit/Hyperactivity Disorder
Cognitive deficits have long been associated with Attention-Deficit/Hyperactivity disorder (ADHD), particularly within executive function, inhibitory control, organizational skills, and divided, selective, and sustained attention. Although there is a large literature on CRT treatment of adults with ADHD, there is evidence of success among children as well. In fact, there appears to be more support for the transferring of improvement between the targeted ability and other cognitive areas among children as compared to adults. Children with ADHD have had successful reductions in ADHD symptoms and improved academic skills following CRT, as well as improved working memory and attention.

Other Disorders/Conditions
CRT has shown efficacy for improving cognition among a range of other disorders and conditions. Children with language-based learning disabilities have shown post-CRT improvements in auditory perception were observed, while attention training has decreased impulsive behaviors and the frequency of tics and improved quality of life among children with Tourette Syndrome. CRT has also been applied to disorders of aging, such as Alzheimer’s Disease and dementia. Several computer-based CRT programs modified for Alzheimer’s have led to a wide range of documented improvements in cognition, working memory, depressive symptoms, and executive functioning according to a recent review. Additionally, the combination of one-on-one CRT with motor movements increases positive effects over and above those caused by psychosocial support alone, for example. However, other reviews were unable to find positive effects of CRT on alleviating memory deficits among those with vascular dementia or Alzheimer’s Disease due to poor quality of the randomized controlled trials, highlighting inconsistencies in this line of research.

Cognitive rehabilitation, a more comprehensive cognitive enhancement program that takes place in a rehabilitation setting, has also been substantially shown (i.e., via reviews and meta-analyses) to aid in cognitive disability brought on by brain injuries such as traumatic brain injuries and strokes.

Multimodal Clinical Approach
CRT was not necessarily developed as a tool to be used in place of pharmacological, cognitive behavioral therapy (CBT), or other interventions. Instead, a multimodal approach may in fact be ideal, in which CRT is used in addition to those other methodologies in order to best combat cognitive decline. For example, CRT combined with trauma therapy, psychosocial and vocational rehabilitation, or CBT may be most effective for treating severe mental illness and creating lasting cognitive improvement,  while aspects of CRT incorporated into school curricula may help children with attentional or language-based difficulties.

Limitations
Researchers caution that assessing salient cognitive changes from a research framework (e.g., using statistical significance) does not always translate into clinical significance. . Specifically, the use of neuropsychological tests that examine larger cognitive indices may make it difficult to assess subtle changes in cognition. This often leads to modest group-wide treatment effect sizes reported in meta-analyses that may underestimate the important and practical changes that may have taken place within the individual’s daily life. Additionally, the variation in outcome measures used by each study makes comparisons between them challenging, limiting the generalizability of results. Therefore, more research is deemed necessary to further assess applicability and practicality for individuals.

CRT in Non-psychiatric Populations
CRT, or the more broad brain training], has been shown to boost general cognitive skills within healthy or typically-developing populations in addition to psychiatric ones such as through programs like BrainHQ by Posit Science or Lumosity. Literature reviews demonstrate that such training may be beneficial for children, adults, and elderly individuals alike. Additionally, the category of brain training has extended to encompass areas outside of traditional CRT, such as music-based training, [[meditation, and physical exercise, which have all been shown to positively impact and enhance cognitive functioning.

discussion again
There is still a boatload of very old sources here. You don't get points for more sources. The key thing is to have as-recent-as-possible, very reliable sources. To find great sources, the best thing to do, is to search pubmed for reviews. See here for such a search. You don't use many of these articles... why not? Also, please clean up the typos and stray footnote marks from your copy/paste. Thank you for adding PMIDs.Jytdog (talk) 17:04, 30 November 2014 (UTC)
 * I see that WP:MEDDATE specifies looking for "reviews published in the last five years or so, preferably in the last two or three years". That doesn't sound like a prohibition from using older sources and many of the sources provided fall into the required timespan. I want to see adherence to guidelines but I don't want to see good content eliminated because of overzealous interpretation. Chris Troutman  ( talk ) 20:57, 30 November 2014 (UTC)


 * Hi, thanks for the message. Unfortunately the link you provided does not seem to work, but from a pubmed search of "cognitive remediation therapy review", the sources that come up do not cover the same information. They discuss CRT specifically within each psychiatric condition, and are in fact sources that I have now included in those individual sections. They do not, however, cover the historical background of CRT dating back to WWI, etc. The sources that do describe the historical background of this treatment are older than the past 10 years. Even if newer sources exist, they are either a) not nearly as detailed (e.g., one line on how it started decades ago) or b) simply refer the read back to the original articles I cited here. As an advanced PhD student I am well familiarized with pubmed, but it seemed like a disservice to the general public to cite something that was simply saying, "see this other source for the real information." Same goes for the historical sources regarding neural mechanisms, but I will see what I can do! Arielschvarcz (talk) 21:21, 30 November 2014 (UTC)


 * If changing them does not seem feasible, how would you feel about leaving in the older sources for the historical content only? Arielschvarcz (talk) 21:21, 30 November 2014 (UTC)


 * I'm certainly not trying to overwhelm with sources, but simply trying to show how documented all of this information is across several reviews (and to ensure credit is given where it is due). Let me know if it is preferable to only have one source listed for each statement and I can certainly change! And sorry for the stray footnotes - they are from my Zotero; I edited out and pasted new version above. Lastly, is it ok with you if I go ahead and remove the AFNI image? It truly does not relate to CRT at all, and as the original author suggests, is simply a demonstration of activation from a motor task. I fear this image was also used without proper authorization from the author/publisher. 21:21, 30 November 2014 (UTC)Arielschvarcz (talk)


 * Hi, are the edits you made simply about moving where the reference tag falls (e.g., after the period, not before?). If so, I redid the entire page to accommodate that and pasted it above. I did not realize you had edited anything further. I will edit in-line instead of pasting from now on, but I wonder if it would be helpful to check in with me before simply reverting? Thanks! Arielschvarcz (talk) 21:32, 30 November 2014 (UTC)


 * Please stop restoring errors!!! I am trying to work with you but I will stop treating you as acting in good faith if you keep restoring errors. if you paid attention to my edit notes (which is what we do here - we actually pay attention to edit notes and content changes of other editors) you would see that i described exactly what I fixed as I went.   And Chris the point here is not "do whatever meets the lowest standard possible". Jytdog (talk) 21:37, 30 November 2014 (UTC)


 * and you have very old sources outside of the History section -e.g. Linsker 1990 in the mechanisms section. Is there really no more recent discussion for this neuroscience topic in secondary or tertiary sources than one that is twenty four years old?  Jytdog (talk) 21:43, 30 November 2014 (UTC)


 * I'm truly sorry - that was not my intent, and I certainly did not mean to anger you or cause conflict. As I mentioned, I am new to Wikipedia editing and was not aware that I was undoing something you had edited. I did of course notice that you fixed the way the tags were formatted, and moved forward with that helpful change. As I mentioned, I will only edit in-line from now rather than pasting changes in bulk from the document I am working from. Please understand that my intent here is only to better this page for the general public based on the extensive literature I have reviewed, and any mistakes are simply from Wikipedia world/editing ignorance. I'm sure you can appreciate the learning curve that happens when you attempt to engage in something new. I will try my best to find a more recent article than the Linsker one. Arielschvarcz (talk) 21:46, 30 November 2014 (UTC)
 * its ok, thanks. please note that i brought up Linsker as one example.  Jytdog (talk) 22:20, 30 November 2014 (UTC)
 * and by the way, this article really is awful and your changes are going to be a huge improvement. so thanks! Jytdog (talk) 22:34, 30 November 2014 (UTC)

Hi, I updated the references (aside from the historical section) so that they are all within 10 years, but still reflect the most accurate source for the original information. Please let me know what you think and how it looks! I'd love to be able to include these parts on the main page and switch to editing the next few sections, so let me know if I can proceed doing so. Thanks! Arielschvarcz (talk) 19:30, 7 December 2014 (UTC)

Hi, I added more sections for you to review - Let me know what you think! Thanks! Arielschvarcz (talk) 03:39, 10 December 2014 (UTC)
 * thank you for your patience! have been crazy busy elsewhere.  feedback:
 * overall...getting better! but i am sorry to say i found a lot of woo. :(
 * reference 4 is a book. generally it is best to provide page numbers every time you  cite a book. (please do that throughout)
 * would love to have this sentence fleshed out: "Although these assumptions are often employed by researchers, the research highlights some theoretical weakness regarding the validity of them" This is garbled. it seems like you are trying to say that experimentally, they don't hold up.  Is that right? if so, why talk about them.  or is their controversy here?
 * very uncomfortable with this sentence, which verges on WP:PROMO "By providing an enriched environment, CRT has been shown to facilitate such neural plasticity and promote recovery". The article cited is very clear: "For these programs to be clinically useful, they will have to accomplish what few interventions, if any, have achieved: generalize circumscribed laboratory and computer skills to tangible gains in the classroom, during play, and in other ecological settings. This lofty goal, however, has hardly been achieved....(discussion of some limited successes)...These programs, however, have rarely made a trailblazing breakthrough in improving symptoms and resolving impairments. In this regard, such approaches to cognitive remediation show promise, but hardly represent stand-alone treatments."  Right?
 * The following 2 paragraphs are also pretty dramatic oversell. The effect is 'small to moderate' right? So we expect some brain changes, sure. Not huge dramatic ones. I note that you rely on Ref 9 a lot particularly in this section. I don't know if you aware of it but most "Frontiers" issues are special-edited by an advocate for some idea, and the articles in that issue are pretty "woo" for that idea (since the editor picks other advocates for the idea).  This is not a great source. (which you should know, for your scientific career too :) )
 * skipping to the Effects section, you include the phrase "that at times appear relatively long-lasting" In other words, most times they are short lasting, right? Please describe outcomes.
 * schizophrenia section.
 * source says "virtually all"; your content says "The largest". that is too much of a difference, I think!
 * this sentence is garble, can you please say it simply: "functioning outcome appears most affected by the increased clinical stability of patients and the conjunction of CRT with other treatment option" (i think you are saying that CRT works best on less-sick people when used in combination with other treatments" but I am not sure.) (please get rid of mumbo-jumbo like "other treatment options".  You just mean "other treatments")
 * "The benefits of CRT have also been demonstrated". I think you mean: "CRT has shown small to moderate (?) benefits for..." right?
 * Eating disorders
 * "There is a large body of..." ? but other source said that "virtually all" research has been done on schiz. And source 24 says "a small case series and production of a treatment manual, a further early case series was carried out/.  How is that a "large body"?  (note, source 25 is a book and needs a page #) (Please note, I am starting to not trust you as an editor by now.  Sorry but that is a pretty bad distortion.)
 * maybe you want to describe the therapy a bit? (8-10 brief sessions, with homework between)
 * please avoid PROMO language like "suggesting that this is a promising treatment ". Just describe what we know.  Don't geek out -  stay in plain English, but don't do WP:CRYSTALBALL
 * Mood disorders
 * "necessitating the use of tools such as CRT to combat these effects." ugh. puffery and colorful language. You can just delete this phrase as it doesn't add any information.
 * the recent review you cite stresses it is about "early evidence" in the title, and the abstract says "emerging evidence suggests". and the article describes a handful of studies with small N.  Right?  please communicate accurate information about the status of this field
 * "people with more severe cognitive functioning prior to treatment appeared to benefit less from CRT, suggesting that CRT may need to be more individualized for those with greater impairments". two things: 1) I think you mean, "more severe cognitive deficits or the like, right? 2) second part of sentence after comma, is all PROMO.  doesn't that result also suggest that it doesn't work for those people, period?  do you see how that is promo?
 * "Much more work has been done reviewing the effects of CRT on individuals with depression though with inconsistent findings reported" again, you are overplaying the state of play here. A little tiny bit of work has been done!
 * and.. I am gonna stop here. So please fix the stuff above, and then take that same approach to what follows.  good luck! Jytdog (talk) 02:40, 12 December 2014 (UTC)

merged content
I found an article called Cognitive remediation that essentially duplicated this one. Is mostly essay-like, so I copied what was sourced into this article, removed the rest, and created a redirect. Jytdog (talk) 22:35, 30 November 2014 (UTC)
 * Yes thank you so much! I saw that earlier but was having trouble navigating the coding complexities of merging articles, etc. Arielschvarcz (talk) 22:59, 30 November 2014 (UTC)