Differences in set-shifting and central coherence across anorexia nervosa subtypes in children and adolescents

Investigating differences in cognitive flexibility, clinical perfectionism, and eating disorder-specific rumination across anorexia nervosa illness states

INTRODUCTION

Cognitive inflexibility, clinical perfectionism, and eating disorder (ED)-specific rumination are common characteristics reported in anorexia nervosa (AN) and may contribute to the maintenance of the illness. It is suggested that clinical perfectionism and rumination may mediate the relationship between cognitive flexibility and AN pathology; however, research to date has not investigated all these factors together. The aim of the current study was to explore the relationships between these factors and how they may relate to ED symptoms in AN.

METHODS

Participants included 15 women with a current diagnosis of AN, 12 women who had a past diagnosis of AN and were currently weight-restored, and 15 healthy controls (HCs).

RESULTS

The results revealed that participants with both acute and weight-restored AN self-reported poorer cognitive flexibility than HCs, but the groups did not differ in performance on objective assessments of cognitive flexibility. Participants with AN also reported significantly greater clinical perfectionism and ED-specific rumination than HC. A parallel mediation analysis found that ED-specific rumination mediated the relationship between subjective cognitive flexibility and ED symptoms. Further, subjective cognitive flexibility directly influenced ED symptoms. However, the mediation model was not significant for objective cognitive flexibility.

CONCLUSION

The findings of this study have implications for potential treatment barriers and factors which might contribute to the risk of relapse.

Executive dysfunction in eating disorders: Relationship with clinical features

Eating disorders (ED) are severe mental disorders that may result in significant functional impairment and disability. Neuropsychological studies have consistently found impaired executive function (EF) among ED patients. EF is particularly involved in fundamental skills of daily living and in behavioral and emotional regulation. In this study, impairment of executive functioning is investigated in patients with eating disorders and the associations with clinical features and clinical subtypes are analyzed.

METHOD

75 female patients (m = 22.01 years, sd = 9.15) with eating disorder (43 restrictive anorexia, 30 binge-eating anorexia and 13 bulimia nervosa) and 37 healthy controls (m = 18.54 years, sd = 4.21) were included in the study. An extensive assessment of executive function domains (verbal fluency, set shifting, attention span, selective attention, working memory, inhibitory control and processing speed) was carried out in both groups. Clinical scales for food intake restriction, binge-eating/purging, depression, anxiety and impulsivity were also administered and correlated with scores on executive function tests.

RESULTS

Patients with an ED had significantly lower scores than healthy controls in performance of several executive function tests, particularly in set shifting, interference control and processing speed (p < .01, in all three domains). Executive function impairment was related to anxious, depressive and eating disorder symptoms (p < .05), regardless of clinical subtype.

CONCLUSIONS

Executive function impairment in eating disorders is associated with greater ED symptomatic severity and might involve a negative treatment outcome. Therefore, cognitive remediation techniques should probably be considered in a number of severe patients with ED.

Emotional eating and disordered eating behaviors in children and adolescents with type 1 diabetes

Disordered eating behaviors (DEB) are more common in adolescents with type 1 diabetes (T1D) than in peers without diabetes. Emotional eating is a risk factor for binge eating in children and adolescents in the general population and is associated with increased intake of high energy-dense foods rich in sugars and fats. The primary objective is to evaluate whether emotional eating is associated with the metabolic control (glycated hemoglobin, plasma lipids and uric acid) in children and adolescents with type 1 diabetes and whether subjects with DEB (DEPS-R ≥ 20) have higher emotional eating than those without DEB. The secondary objective is to evaluate whether emotional eating is associated with the different symptoms of DEB. Emotional eating is positively correlated with HbA1c, total and LDL cholesterol values in children and adolescents with T1D. Subjects with DEB have a higher emotional eating score than subjects without DEB. Disinhibition is the most common disordered eating behavior in children and adolescents with T1D and is associated with a higher emotional eating score. Early identification and treatment of emotional eating could be tools for preventing DEB in people with type 1 diabetes. A total of 212 adolescents with T1D completed two self-administered questionnaires: the Diabetes Eating Problem Survey-Revised (DEPS-R) and the Emotional Eating Scale for Children and Adolescents (EES-C). Demographic (age, sex, duration of the disease), anthropometric (weight, height, BMI, BMI-SDS), therapeutic (type of insulin therapy, daily insulin dose) and metabolic (HbA1c, total cholesterol, HDL, LDL, triglycerides, uric acid) data were taken from the patients' medical records. The presence of other autoimmune diseases was also recorded.

Understanding self-report and neurocognitive assessments of cognitive flexibility in people with and without lifetime anorexia nervosa

Objective: Anorexia nervosa (AN) is a serious eating disorder associated with several cognitive difficulties including poor cognitive flexibility (i.e. difficulties in effectively adapting to changes in the environment and/or changing task demands). AN research has primarily assessed cognitive flexibility using neurocognitive tests, and little is known about the differences or similarities between self-report and neurocognitive assessments of cognitive flexibility. This study investigated the relationship between self-report and neurocognitive assessments of cognitive flexibility in people with no history of an eating disorder (n = 207) and people with a self-reported lifetime diagnosis of AN (n = 19).Methods: Participants completed self-report and neurocognitive assessments of cognitive flexibility through an online study.Results: No significant correlations were found between self-report and neurocognitive assessments of cognitive flexibility for either group of the sample, suggesting that these assessments may evaluate different aspects of cognitive flexibility. Further, negative mood and self-reported eating disorder symptoms were found to significantly relate to self-reported cognitive flexibility, but were not associated with performance on neurocognitive tests of cognitive flexibility.Conclusions: To provide a comprehensive understanding of perceived and objective cognitive flexibility in AN, future research and clinical assessments should include both self-report and neurocognitive assessments.

Orthorexia nervosa and executive dysfunction: symptomatology is related to difficulties with behavioral regulation

PURPOSE

This research explored whether orthorexia nervosa is associated with deficits in executive function.

METHODS

A non-clinical sample of participants (n = 405; 80% women, 53% white, mean age = 24, mean body mass index = 25) completed the Orthorexia Nervosa Inventory (ONI) and the Behavior Rating Inventory of Executive Function-Adult version (BRIEF-A).

RESULTS

ONI scores were weakly to moderately correlated with all BRIEF-A scales (p < 0.001 for eight scales, p < 0.05 for one scale), exhibiting the greatest correlations with the scales assessing behavioral regulation: Emotional Control (r = 0.34), Inhibition (r = 0.30), Set Shifting (r = 0.25), and Self-Monitoring (r = 0.28). Hierarchical regression analyses revealed that eight of these nine relationships remained significant (p < 0.001 for five scales including all behavioral regulation scales, p < 0.01 for two scales, p < 0.05 for one scale) after controlling for demographic variables (e.g., gender, body mass index, age, education level) and diagnoses of an eating disorder, obsessive-compulsive disorder, attention deficit/hyperactivity disorder, autism, and learning disability.

CONCLUSION

These findings suggest that, despite unique manifestations, orthorexia and anorexia may possess an overlapping neuropsychological profile marked by deficits in executive function, which may negatively impact daily life.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Neural Correlates of Executive Functioning in Anorexia Nervosa and Obsessive-Compulsive Disorder

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are commonly reported to co-occur and present with overlapping symptomatology. Executive functioning difficulties have been implicated in both mental health conditions. However, studies directly comparing these functions in AN and OCD are extremely limited. This review provides a synthesis of behavioral and neuroimaging research examining executive functioning in AN and OCD to bridge this gap in knowledge. We outline the similarities and differences in behavioral and neuroimaging findings between AN and OCD, focusing on set shifting, working memory, response inhibition, and response monitoring. This review aims to facilitate understanding of transdiagnostic correlates of executive functioning and highlights important considerations for future research. We also discuss the importance of examining both behavioral and neural markers when studying transdiagnostic correlates of executive functions.

Randomized controlled trial of cognitive remediation therapy in adolescent inpatients with anorexia nervosa: Neuropsychological outcomes

OBJECTIVE

Neuropsychological dysfunction exists in anorexia nervosa (AN). Cognitive Remediation Therapy (CRT), mainly evaluated in adults with AN, targets these impairments.

METHODS

Adolescent inpatients (age = 11-17 years) with AN were randomized to 5 weeks of either 10 sessions of individually delivered CRT or non-specific cognitive-training (NSCT). Co-primary outcomes included cognitive domain 'flexibility' [composite score of Wisconsin Card Sorting Test (WSCT) and Trail Making Test (TMT-4)] and 'central coherence' [composite score of Central Coherence Index (CCI) and Group Embedded Figures Test (GEFT)] at end of treatment (FU1). Secondary outcomes included individual test scores and self-reported everyday-life flexibility at FU1 and at 6-months post-treatment (FU2). Independent sample t-tests, Pearson chi-square-tests and mixed models for repeated measures (MMRM) analyses were conducted.

RESULTS

In 56 females (age = 15.1 ± 1.5 years), CRT was not superior to NSCT at FU1 regarding 'flexibility' (p = 0.768) or 'central coherence' (p = 0.354), nor at FU2 (p = 0.507; p = 0.624) (effect sizes = 0.02-0.26). Both groups improved over time in central coherence (CCI p = 0.001; GEFT p < 0.001), self-reported flexibility (p = 0.002) and WCST (p = 0.18), but not TMT-4 (p = 0.286). NSCT was superior to CRT regarding self-reported planning/organisation ability at FU1 (p < 0.001) and FU2 (p = 0.003).

CONCLUSIONS

CRT was not superior to NSCT in adolescent inpatients with AN. More randomized controlled studies are needed.

Can Cognitive Flexibility and Clinical Perfectionism Be Used to Identify People with Anorexia Nervosa?

Poor cognitive flexibility and perfectionism are common features in anorexia nervosa (AN). The current study aimed to investigate cognitive flexibility and clinical perfectionism as potential predictors of AN. Twenty women with a current diagnosis of AN (M age = 28.25, SD = 7.62) and 170 community participants with no lifetime history of an eating disorder (M age = 29.23, SD = 9.88) took part in an online cross-sectional study that included self-report questionnaires of cognitive flexibility and clinical perfectionism. It was found that compared to the community sample, women with AN self-reported significantly poorer cognitive flexibility and significantly greater clinical perfectionism. In a regression model, clinical perfectionism (but not self-reported cognitive flexibility) significantly predicted group membership. The specificity and sensitivity of the model were high. These preliminary findings indicate that clinical perfectionism may represent a key feature of AN and may accurately discriminate between participants with and without AN, though more research is required.

The perception of food size and food shape in anorexia nervosa

Visual perception of food size and shape in anorexia nervosa (AN) is an understudied topic, notwithstanding its relevance in approaching food, key-element in weight restoration. In addition, it is unclear how visual perception in AN is related to the age and the duration of illness. Here, we compared patients with AN to healthy controls (HCs) on their spatial resolution, biases in perceived food size, and holistic processing of food shape. A total of 122 participants were enrolled: 48 adolescents (27 AN and 21 HCs) and 74 adults (33 AN and 41 HCs). Participants at two academic sites (Israel and Italy) completed measures of psychopathology and experiments measuring visual resolution (Just Noticeable Difference), biases in food-size perception (Points of Subjective Equality), and holistic processing of food shape (indicated by the height-width illusion). Adolescents and adults with AN differed in the duration of illness and body mass index but showed comparable eating psychopathology and body measures. Patients with AN showed preserved visual resolution but distorted perception of food size, perceiving food as bigger than non-food objects, in both age groups. Patients with AN, both adolescents and adults, also processed food stimuli in a more analytic fashion, and were immune to the height-width illusion. The preserved perception of non-food stimuli in AN coupled with biases in food-size perception and in analytic processing of food shape highlight patients' real-world difficulties in approaching food. Future treatments on AN may consider taking these differences into account.

Are poor set-shifting and central coherence associated with everyday function in anorexia nervosa? A systematic review

BACKGROUND

There is increasing interest in associations between cognitive impairments and clinical symptoms in Anorexia Nervosa (AN), however, the relationship with everyday function is unclear. The current review synthesizes existing data regarding associations between scores on tests of set-shifting and central coherence and functional outcome measures for individuals with AN.

METHOD

A systematic electronic database search yielded 13 studies which included participants with current or lifetime AN where scores on a neuropsychological test of set-shifting or central coherence were directly or indirectly compared to a functional outcome measure.

RESULTS

Associations between set-shifting and central coherence performance measures and functional outcomes were limited in number and noted only in adult or mixed-age cohorts. Associations were noted at subscale level, suggesting they are specific in nature. In younger cohorts, assessments of executive functioning in everyday life appear sensitive to cognitive-behavioral flexibility issues.

CONCLUSIONS

Associations between cognitive performance and functional outcome have not been as systematically assessed in AN as in other psychiatric disorders. Key factors to address in future research include: (a) the use of function measures which are sensitive to both the level of impairment, and specific rather than general impairments (b) the ecological validity of measures, (c) the task impurity problem, especially in regard to cognitive flexibility assessment, and (d) the need to measure both cognitive deficits and strengths, because tests of specific cognitive processes may underestimate the ability to function in daily life due to compensatory strategies.

Is set-shifting and central coherence in anorexia nervosa influenced by body mass index, anxiety or depression? A systematic review

BACKGROUND

Anorexia nervosa (AN) is a severe eating disorder, recognized by a relentless pursuit for thinness and extreme low body weight. The disorder is often accompanied by comorbid disorders such as anxiety and depression, and altered neuropsychological function in terms of poor set-shifting and reduced central coherence. The aim of this review was to evaluate whether neuropsychological impairments in AN are influenced by body mass index, anxiety or depression.

METHOD

A systematic review approach was used, following the PRISMA guidelines for systematic reviews. Literature was identified via searches in PubMed, PsychInfo and Embase database, by using the search words [anorexia nervosa] AND [central coherence], and [anorexia nervosa] AND [set-shifting]. Studies were included if they were written in English, peer-reviewed, included individuals with AN, included tests measuring set-shifting and/or central coherence, investigated associations between set-shifting/central coherence with anxiety and/or depression and/or BMI. Risk of bias was assessed by using a critical appraisal checklist from the Joanna Briggs Institute. Results were summarized in a narrative synthesis.

RESULTS

Although results are heterogeneous, the majority of studies report that neither body mass index (BMI), anxiety or depression is associated with altered central coherence and set-shifting in individuals with AN.

CONCLUSIONS

Findings indicate that BMI, depression and anxiety does not influence neuropsychological function in AN, suggesting that it could be a characteristic of the disorder. A complete understanding of predisposing, precipitating and maintaining factors in AN needs to be addressed in future research. This could contribute to the development of better and more targeted treatment strategies.

Cognitive flexibility in acute anorexia nervosa and after recovery: A systematic review

Difficulties in cognitive flexibility-the ability to adapt effectively to changes in the environment and/or changing task demands-have been reported in anorexia nervosa (AN). However, findings are inconsistent across studies and it remains unclear which specific aspects of cognitive flexibility patients with AN may struggle with. This systematic review aimed to synthesise existing research on cognitive flexibility in AN and clarify differences between patients with acute AN, patients who are weight-restored and patients who are fully recovered from AN. Electronic databases were searched through to January 2020. 3,310 papers were screened and 70 papers were included in the final review. Although adults with acute AN performed worse in perceptual flexibility tasks and self-report measures compared to HCs, they did not exhibit deficits across all domains of cognitive flexibility. Adolescents with acute AN did not differ to HCs in performance on neurocognitive tasks despite self-reporting poorer cognitive flexibility. Overall, significant differences in cognitive flexibility between acute and recovered participants was not evident, though, the findings are limited by a modest number of studies. Recovered participants performed poorer than HCs in some neurocognitive measures, however, results were inconsistent across studies. These results have implications for the assessment of cognitive flexibility in AN and targeted treatment approaches.

A preliminary systematic review and meta-analysis of randomized-controlled trials of cognitive remediation therapy for anorexia nervosa

Cognitive remediation therapy (CRT) for anorexia nervosa (AN) was developed as an adjuvant treatment to target set-shifting and central coherence inefficiencies important in AN and to ultimately improve clinical outcomes of those with AN. The primary aim of this preliminary systematic review and meta-analysis was to determine the effect of CRT for AN relative to control treatments in randomized-controlled trials (RCTs) on neuropsychological inefficiencies at end-of-treatment. Secondary aims were to assess the effect of CRT for AN on dropout, eating-disorder-related, and other psychological outcomes at end-of-treatment. Systematic review and meta-analytic procedures were conducted in accordance with PRISMA Guidelines. RCTs evaluating CRT for AN compared to a control treatment were identified via ProQuest, PsycINFO, PubMed, and SCOPUS. Seven RCTs and one quasi-RCT of CRT for AN were included. RCT quality ratings ranged from fair (n = 3) to good (n = 4). Random-effects meta-analysis was conducted using Hedge's g. Study heterogeneity was assessed using I² and publication bias was assessed with Begg's adjusted-rank correlation and the trim-and-fill method. CRT was not associated with improvement in central coherence compared to control treatments at end-of-treatment (g = 0.25, 95% CI = -0.35, 0.85, k = 3). Set-shifting outcomes were mixed due to heterogeneity of set-shifting measures across studies. CRT may prevent dropout; yet, more studies are needed to draw conclusions. CRT did not confer advantage over control treatments for eating-disorder-related and other psychological outcomes at end-of-treatment. Future RCTs of CRT for AN should use precise measures to assess constructs (particularly for set shifting), increase sample size, and implement longitudinal follow-up. (Word Count: 247 words).

Reduced Plasma Orexin-A Concentrations are Associated with Cognitive Deficits in Anorexia Nervosa

Orexins/hypocretins are neuropeptides implicated in numerous processes, including food intake and cognition. The role of these peptides in the psychopathology of anorexia nervosa (AN) remains poorly understood. The aim of the current study was to evaluate the associations between plasma orexin-A (OXA) concentrations and neuropsychological functioning in adult women with AN, and a matched control group. Fasting plasma OXA concentrations were taken in 51 females with AN and in 51 matched healthy controls. Set-shifting was assessed using the Wisconsin Card Sorting Test (WCST), whereas decision making was measured using the Iowa Gambling Task (IGT). The AN group exhibited lower plasma OXA levels than the HC group. Lower mean scores were obtained on the IGT in AN patients. WCST perseverative errors were significantly higher in the AN group compared to HC. In both the AN and HC group, OXA levels were negatively correlated with WCST non-perseverative errors. Reduced plasma OXA concentrations were found to be associated with set-shifting impairments in AN. Taking into consideration the function of orexins in promoting arousal and cognitive flexibility, future studies should explore whether orexin partly underpins the cognitive impairments found in AN.

Set-shifting in adolescents with weight-restored anorexia nervosa and their unaffected family members

Set-shifting difficulties have been suggested to underlie rigid and inflexible thinking in patients with anorexia nervosa (AN). Studies reported set-shifting deficiencies in adults with AN and also in their unaffected family members, suggesting that set-shifting deficits are heritable in AN. Surprisingly, studies failed to show set-shifting difficulties in adolescents with AN. If set-shifting difficulties are heritable, it is not clear why they are absent in adolescents with AN. The current study aimed to elucidate this discrepancy by assessing several components of set-shifting in adolescents with weight-restored AN (WR-AN) and their unaffected parents and siblings. Twenty-one families that include an adolescent who was diagnosed with AN prior to weight restoration (N = 19), an unaffected parent (N = 18), and an unaffected sibling (N = 20) were recruited. Additionally, 28 healthy control families were recruited and included an age-matched adolescent (N = 27), a parent (N = 26), and a sibling (N = 17). Visual-motor set-shifting, verbal set-shifting, and set-shifting clean of inhibition were assessed using the Delis-Kaplan Executive Function System. The results revealed intact set-shifting in parents and siblings of adolescents with WR-AN. Surprisingly, the results revealed superior visual-motor and verbal set-shifting in adolescents with WR-AN compared to age-matched controls. However, when controlling for inhibition abilities, poorer set-shifting was revealed in adolescents with WR-AN. The results suggest that superior inhibition abilities in adolescents with WR-AN may compensate for their set-shifting deficiencies. The study emphasizes the importance of controlling for inhibition abilities when assessing neurocognitive functioning in adolescents with AN. Furthermore, the study does not support the notion that set-shifting deficits are heritable in adolescent AN.