Set shifting and central coherence as neurocognitive endophenotypes in eating disorders: a preliminary investigation in twins

Conceptualizing avoidant/restrictive food intake disorder via an executive functioning lens

Avoidant/restrictive food intake disorder (ARFID) is a heterogeneous disorder wherein restrictive eating is primarily attributed to non-shape/weight-based reasons (e.g., sensory sensitivity) that empirical research continues to explore. Mounting evidence suggests that ARFID often presents alongside neurodevelopmental diagnoses (NDs) or divergent neurodevelopment broadly. Executive functioning (EF) differences often characterize divergent neurodevelopmental trajectories. Additionally, restrictive eating in anorexia nervosa has been conceptualized as related to EF factors (e.g., set shifting). Given the neurodevelopmental phenotype that may be associated with ARFID and the role of EF in anorexia nervosa, this paper proposes EF as a potentially important, yet understudied factor in ARFID pathology. We posit that various observed ARFID behavioral/cognitive tendencies can be conceptualized in relation to EF differences. We contextualize commonly observed ARFID presentations within "core" EF components (i.e., cognitive flexibility, working memory, inhibitory control), leading to hypotheses about EF in ARFID. Finally, we offer additional considerations/directions for future research on EF in ARFID. Increased research on EF in ARFID is needed to consider this potential common factor in the etiology and maintenance of this heterogeneous disorder. We aim to promote further consideration of EF in ARFID etiology, maintenance, and treatment-outcome research. PUBLIC SIGNIFICANCE: This article proposes that aspects of executive functioning (EF) may play a role in the onset and maintenance of avoidant/restrictive food intake disorder (ARFID), although this notion is largely untested by existing research. Further research on the role of EF in ARFID may assist with refining models and treatments for this heterogeneous disorder.

Neurocognitive Endophenotypes for Eating Disorders: A Preliminary High-Risk Family Study

Eating disorders (EDs) are psychiatric disorders with a neurobiological basis. ED-specific neuropsychological and brain characteristics have been identified, but often in individuals in the acute phase or recovered from EDs, precluding an understanding of whether they are correlates and scars of EDs vs. predisposing factors. Although familial high-risk (FHR) studies are available across other disorders, this study design has not been used in EDs. We carried out the first FMH study in EDs, investigating healthy offspring of women with EDs and controls. We preliminarily aimed to investigate ED-related neurocognitive and brain markers that could point to predisposing factors for ED. Sixteen girls at FHR for EDs and twenty control girls (age range: 8−15), completed neuropsychological tests assessing executive functions. Girls also underwent a resting-state fMRI scan to quantify functional connectivity (FC) within resting-state networks. Girls at FHR for EDs performed worse on a cognitive flexibility task compared with controls (F = 5.53, p = 0.02). Moreover, they showed different FC compared with controls in several resting-state networks (p < 0.05 FDR-corrected). Differences identified in cognitive flexibility and in FC are in line with those identified in individuals with EDs, strongly pointing to a role as potential endophenotypes of EDs.

MICEmi: A method to identify cognitive endophenotypes of mental illnesses

BACKGROUND

Characterizing neurocognitive endophenotypes of mental illnesses (MIs) could be useful for identifying at-risk individuals, increasing early diagnosis, improving disease subtyping, and proposing therapeutic strategies to reduce the negative effects of the symptoms, in addition to serving as a scientific basis to unravel the physiopathology of the disease. However, a standardized algorithm to determine cognitive endophenotypes has not yet been developed. The main objective of this study was to present a method for the identification of endophenotypes in MI research.

METHODS

For this purpose, a 14-expert working group used a scoping review methodology and designed a method that includes a scoring template with five criteria and indicators, a strategy for their verification, and a decision tree.

CONCLUSIONS

This work is ongoing since it is necessary to obtain external validation of the applicability of the method in future research.

Experiences of eating difficulties in siblings of people with anorexia nervosa: a reflexive thematic analysis

BACKGROUND

Siblings of people with anorexia nervosa (AN) have been found to experience strong emotions, changing family roles and poorer wellbeing as a consequence of experiencing the effects of the illness on their sibling and family system. These factors, combined with genetic influences, may put siblings at an increased risk of developing eating disorder psychopathology in addition to other mental health issues. This research aims to explore the experiences of siblings of people with AN who have had eating difficulties themselves and investigate issues that may be important to the development and prevention of eating difficulties in this population.

METHODS

This qualitative study used a reflexive thematic analysis approach. Ten adults who had witnessed a sibling with AN and experienced eating difficulties themselves participated in semi-structured interviews.

ANALYSIS

Participants' own eating difficulties were affected by the specific experience of witnessing a sibling with AN through mealtimes becoming emotionally charged, an increased focus on body size and diet, and comparisons with their sibling. Difficult experiences, such as marital discord amongst parents were common, as was a difficulty in managing emotions. The onset of AN within the family caused participants to take on caring responsibilities for their sibling and to hide their own difficulties for fear of adding additional burden to their parents. This reduced their perceived ability to access support and for some increased a desire to restrict as a coping mechanism for the stress they were experiencing. Systemic beliefs regarding the value of thinness were prevalent and influential. Protective factors, such as not wanting to become as unwell as a sibling with AN and an understanding of the negative consequences of AN, aided recovery.

CONCLUSIONS

Eating difficulties in siblings of people with AN may be influenced by competition for slimness, increased focus on diet and body size, and a need to manage difficult emotions. The disruption to social connections and a difficulty finding emotional support that may be experienced by people when a sibling develops AN may further influence susceptibility to eating difficulties. Further research is needed into the best ways to support siblings of people with AN.

Evaluation of Web-Based Health Information From the Perspective of Women With Eating Disorders: Thematic Analysis

Background

Users with experience of eating disorders use the internet as a source of information, whether for prorecovery activities (such as web-based treatment, looking for information, support, and sharing) or activities that promote eating disorder behavior as a desirable lifestyle choice (such as pro–eating disorder communities and reading and creating pro–eating disorder posts). Their assessment of web-based eating disorder–related information is crucial for understanding the context of the illness and for health professionals and their web-based interventions.

Objective

This study aimed to understand the criteria young women with the experience of eating disorders use in evaluating eating disorder–related web-based information and what eating disorder–related characteristics of these women are involved in their evaluation.

Methods

We analyzed 30 semistructured individual interviews with Czech women aged 16 to 28 years with past or present eating disorder experience using a qualitative approach. Thematic analysis was adopted as an analytical tool.

Results

The specifics of eating disorder phases (the disorder stage and the treatment process) emerged as important aspects in the process of information assessment. Other specific characteristics of respondents (eg, motivation, abilities, and resources) addressed how the respondents arrived at certain web-based information and how they evaluated it. In addition, the respondents described some content cues as features of information (eg, novelty and social information pooling). Another finding is that other users’ attitudes, experiences, activities, and personal features are involved in the information evaluation of these users and the information presented by them. Finally, the respondents evaluated the websites’ visual look and graphic components.

Conclusions

This study shows that web-based information evaluation reported by women with experience of eating disorders is a complex process. The assessment is influenced by current personal characteristics related to the illness (mainly the motivation for maintaining or curing the eating disorder) using cues associated with information content, other users, and website look. The study findings have important implications for health professionals, who should ask their clients questions about web-based communities and their needs to understand what information and sources they choose.

Research Review: Neuropsychological functioning in young anorexia nervosa: A meta-analysis

BACKGROUND

Cognitive inflexibility and compulsive behaviours are commonly observed in patients with anorexia nervosa (AN) and are often considered to be caused by impairments in executive functioning and visuospatial processing. Despite an increasing number of young individuals presenting with AN, there is a lack of meta-analytic evidence on the neuropsychological functioning in this population. Our primary aim was to review and synthesize the differences in neuropsychological test performance between young people with AN and healthy controls, and to explore potential moderators.

METHODS

A database search following PRISMA guidelines of MEDLINE, PsycINFO, ISI Web of Science and Epistemonikos was conducted. Hedges' g served as an effect size indicating the standardized mean differences. We utilized mixed-effects meta-regression and machine learning meta-analyses to identify relevant moderators.

RESULTS

Sixteen studies met the inclusion criteria with a total of 1333 participants (665 with AN) and 59 effect sizes. Random-effects meta-analyses demonstrated a small and insignificant difference between young individuals with AN and controls ( g¯  = -0.144, 95% CI [-0.328, 0.041]) in overall neuropsychological functioning. However, the difference was significant for the cognitive domains of memory, working memory and visuospatial abilities. Moderator and machine-learning analyses revealed a stronger negative effect in older participants and moderator effects of country and assessment quality.

CONCLUSIONS

Our findings highlight the significant impact of age on neuropsychological test performance in patients with AN. There is a need for a more widespread inclusion of potentially confounding variables in primary studies as well as instruments specifically targeted at younger populations.

Cognitive and Experienced Flexibility in Patients With Anorexia Nervosa and Obsessive Compulsive Disorder

OBJECTIVE

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) share a neuropsychological profile characterized by cognitive inflexibility as evident in set-shifting problems, and by strong detail focus. Clinically, both patient groups display a strong rigidity which may be explained by these neurocognitive difficulties. Cognitive inflexibility may hinder treatment uptake and help explain suboptimal treatment outcomes in both AN and OCD. This is the first study to compare clinical AN and OCD groups andto examine similarities and differences in cognitive flexibility. Specifically, this study aims to investigate neuropsychological outcomes and self-reported difficulties in both clinical groups and a control group, and explore associations between the different flexibility outcomes and illness.

METHOD

Two hundred participants (61 AN, 72 OCD and 67 HC) performed neuropsychological tasks on set-shifting abilities (Trail Making Task, Stroop color-word interference, Intradimensional-Extradimensional shift task), detail focus (Group Embedded Figures Test) and self-reported set-shifting abilities and attention to detail (DFlex).

RESULTS

Similarities between patient groups were found in terms of reduced set-shifting ability on the Trail Making Task and detail focus. Moreover, both patient groups self-reported more set-shifting problems but a less strong detail focus than HC, which in turn were not related to neuropsychological task outcomes in either of the groups. In both patient groups longer illness duration was associated to longer reaction times in the switching tasks and for both groups symptom severity was associated to higher experienced inflexibility and attention to detail.

CONCLUSION

Cognitive inflexibility processes are largely similar in patients with AN and OCD. Both patient groups report inflexibility, yet this is unrelated to neuropsychological outcomes. Illness duration seems to contribute to poorer set-shifting and higher illness severity is linked to more experienced inflexibility. Findings highlight the need for entangling different domains of cognitive flexibility and detail focus and examining self-report measures for a cohesive understanding of clinically relevant flexibility weaknesses in AN and OCD.

Clinical factors predicting impaired executive functions in eating disorders: The role of illness duration

Poor performance in executive functions is observed in individuals with eating disorders (EDs). These impairments have usually been associated with the presence of comorbid psychopathology or with higher severity of EDs. However, few studies have explored the interaction between illness duration and deficits in executive functions. The present study investigates the association between ED duration and performance in decision-making, inhibitory control, and cognitive flexibility in the anorexia nervosa restrictive subtype (AN-R), bulimic/purging subtype (AN-BP), and binge spectrum disorders (BSDs) (namely, bulimia nervosa and binge eating disorder) among 116 women with EDs compared with 123 women healthy controls (HCs). Using cumulative survival analysis, we estimated the risk of deficits related to illness duration. Predictors of executive dysfunctions were assessed by regression analysis, including as potential predictors illness duration, severity of general psychopathology, and ED symptomatology. Results showed poor decision-making and cognitive flexibility in participants with EDs compared with HCs. ED duration was associated with poor inhibitory control in the AN-BP group and poor cognitive flexibility in the BSD group. The illness duration increased the risk of presenting early deficits in executive function. In decision-making and inhibitory control, the AN-R group showed the earliest deficits, whereas in cognitive flexibility it was the BSD group. ED duration predicted impaired cognitive flexibility in the BSD group and impaired inhibitory control in the AN-BP group, whereas the severity of general psychopathological symptoms was a predictor of impaired cognitive flexibility in individuals with AN-R. These results highlight the relevance of illness duration in executive dysfunctions in EDs.

The longitudinal relationship between set-shifting at 4 years of age and eating disorder related features at 9 years of age in the general pediatric population

BACKGROUND

Individuals with anorexia nervosa (AN) tend to have rigid thoughts and behaviors regarding their body weight, body image, and eating habits. While a diagnosis of AN implies severe levels of impairment, AN traits can vary on a continuum within the population. However, little is known about how early markers of AN relate to rigid thought patterns and to what extent cognitive rigidity is already present in early childhood. We examined the association of set-shifting abilities as a measure of cognitive flexibility in preadolescents with AN-related features.

METHODS

Participants included 3,987 children participating in the Generation R Study, a Dutch population-based birth cohort. Set-shifting abilities (mother report) were assessed at 4 years of age, body mass index (BMI) was determined at 4 and 9 years and restrictive eating patterns (mother report) and body image (child report) were assessed at 9 years.

RESULTS

Lower set-shifting abilities at 4 years were associated with a lower BMI (β = -.44, p = 2.2 × 10^-4 ) in girls, and more restrictive eating (β = 0.15, p = 2.7 × 10^-6 ) in both boys and girls at 9 years of age. Moreover, set-shifting at age 4 was not associated with body image at age 9.

CONCLUSION

These findings contribute to the idea that the association between set-shifting problems and AN-related features are present early in childhood, prior to the typical range of the onset of eating disorders (EDs). Longitudinal studies that capture the peak age for the development of EDs will be important to assess whether early cognitive inflexibility is an early marker of AN.

Neuropsychological functioning in adult anorexia nervosa: A meta-analysis

Several studies have conceptualized neuropsychological dysfunction as part of the core pathology and defining behaviors seen in the eating disorder anorexia nervosa (AN). The aim of the current review was to synthesize the differences in neuropsychological test performance between individuals with AN and healthy controls, quantify and explain their heterogeneity. The search and screening procedures resulted in fifty studies that comprised 186 neuropsychological test results. Utilizing random-effects meta-analyses, the results revealed evidence for significant, moderate underperformance in people with AN in overall neuropsychological functioning (g¯ = -0.43, 95 % CI [-0.50, -0.36]). Weighted mean effect sizes ranged from g¯ = -0.53 for visuospatial abilities to g¯ = -0.10 for planning. Study and participant characteristics, including body mass index (BMI) and age, had significant moderator effects, especially on executive function, memory, and visuospatial abilities. The findings from the current study provide an extensive and comprehensive overview of the possible impairments in neuropsychological functioning in adult patients diagnosed with AN.

What's the Link Between Theory of Mind and Other Cognitive Abilities - A Co-twin Control Design of Neurodevelopmental Disorders

Theory of mind (ToM), or the ability to attribute mental states to oneself and others, is a core element of social cognition (SC). Even though its importance for social functioning in general, and neurodevelopmental disorders (NDDs), in particular, is well established, the links between ToM and other cognitive functions are not. Especially the familial underpinnings of such links remain unclear. Using a co-twin control design, we examined N = 311 twins (mean age M = 17.19 years, 47% females) diagnosed with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), other NDDs, or typically developing individuals. We used the Reading the Mind in the Eyes Test to operationalize ToM, the Fragmented Pictures Test for central coherence (CC), the Tower Test for executive functioning (EF), and the general ability index in the Wechsler Intelligence Scales for IQ. In the linear regressions, weak CC and a lower IQ were associated with a reduced ToM ability across pairs. Female sex and higher age were robustly associated with increased ToM ability, whereas EF was not associated with ToM. In the within-pair analyses, where unmeasured familial confounders are implicitly adjusted, the associations between ToM and other cognitive functions, were attenuated and the association with CC was non-significant. The result suggests that familial factors shared by the twins, such as genetic and shared environment, influence the association between CC, IQ, and ToM. Future studies need to include a larger sample of monozygotic twins, who are genetically identical, in order to draw more firm conclusions regarding the influence of familial factors, and to differentiate between shared environmental and genetic effects on the associations between cognitive functions.

Current directions in biomarkers and endophenotypes for anorexia nervosa: A scoping review

There are currently no validated biomarkers for anorexia nervosa (AN), though recent literature suggests an increased research interest in this area. Biomarkers are objective, measurable indicators of illness that can be used to assist with diagnosis, risk assessment, and tracking of illness state. Related to biomarkers are endophenotypes, which are quantifiable phenomena that are distinct from symptoms and which link genes to manifest illness. In this scoping review, we sought to provide a summary of recent research conducted in the pursuit of biomarkers and endophenotypes for AN. The findings indicate that a number of possible biomarkers which can assess the presence or severity of AN independently of weight status, including psychophysical (e.g., eye-tracking) and biological (e.g., immune, endocrine, metabolomic, neurobiological) markers, are currently under investigation. However, this research is still in early phases and lacking in replication studies. Endophenotype research has largely been confined to the study of several neurocognitive features, with mixed evidence to support their classification as possible endophenotypes for the disorder. The study of biomarkers and endophenotypes in AN involves significant challenges due to confounding factors of illness-related sequalae, such as starvation. Future research in these areas must prioritise direct evaluation of the sensitivity, specificity and test-retest reliability of proposed biomarkers and enhanced control of confounding physical consequences of AN in the study of biomarkers and endophenotypes.

Increased cognitive flexibility mediates the improvement of eating disorders symptoms, depressive symptoms and level of daily life functioning in patients with anorexia nervosa treated in specialised centres

OBJECTIVE

Poor cognitive flexibility has been highlighted in patients with anorexia nervosa (AN), contributing to the development and maintenance of symptoms. The aim of the present study is to investigate how enhanced cognitive flexibility is involved in treatment outcomes in patients with AN.

METHOD

One hundred thirty female out-patients treated for AN have been assessed at baseline and after 4 months of treatment. Path analyses were used to investigate the mediating role of cognitive flexibility, measured through the Brixton test, on a wide range of outcomes: body mass index, eating disorder symptoms, daily life functioning, anxiety, depression, emotions, self-rated silhouette.

RESULTS

Cognitive flexibility was improved during treatment, and enhanced cognitive flexibility explains a significant part of level of the improvement in daily life functioning (26%), reduction of eating disorder symptoms (18%) and reduction of depressive symptoms (17%). Others outcomes were also improved, but these improvements were not mediated by cognitive flexibility.

CONCLUSIONS

Results suggest that enhancing cognitive flexibility could help reduce rigid cognitive and behavioural patterns involved in AN, thus improving everyday functioning and clinical severity. Further studies combining different types of cognitive flexibility evaluation as well as neuroimaging may be necessary to better establish which of its aspects are involved in patients' improvement.

Childhood trauma determines different clinical and biological manifestations in patients with eating disorders

PURPOSE

There is a significant relationship between childhood trauma and the development of an eating disorder in adolescence or adulthood, possibly influenced by circulating levels of inflammatory parameters. The main objective is to identify and describe a subgroup of patients with eating disorders and a history of trauma in childhood or adolescence with differential clinical features.

METHODS

An observational study on a sample of 55 patients who met the diagnostic criteria for any DSM-5 eating disorder was carried out. Inflammatory parameters in white blood cells were examined. Patients underwent different assessments, including clinical and personality scales.

RESULTS

Patients with a history of trauma had higher scores in the delirious and narcissistic items of the Millon Clinical Multiaxial Inventory (MCMI-II) (p < 0.05) and a higher score in the paranoid item of the SCID-5 Personality Disorders Version (SCID-5-PD) (p < 0.05). Patients with distinguishing personality features were grouped according to the Childhood Trauma Questionnaire sexual subscale. Tumor necrosis alpha (TNF-α) showed a significant association with childhood trauma history.

CONCLUSIONS

There is a profile of patients with eating disorders who have increased activity in the inflammatory pathways that, if identified precociously, can benefit from specifically aimed interventions.

LEVEL OF EVIDENCE

Level V, observational study.

Subjective cognitive rigidity and attention to detail: A cross-cultural validation of the Detail and Flexibility Questionnaire (DFlex) in a French clinical sample

Introduction: People diagnosed with Anorexia Nervosa (AN) are at risk for poor cognitive flexibility and excessive attention to detail. These difficulties are traditionally quantified using neuropsychological tests. These tests do not capture the subjective repercussions of these cognitive styles. The Detail and Flexibility Questionnaire (DFlex) has been specifically developed to measure these repercussions. The aim of this study was to evaluate the psychometric properties of the French version of this scale (F-DFlex) and to adapt it if needed. Methods: The instrument factor structure, internal consistency, convergent, and discriminant validity were assessed in a sample of 107 French women AN inpatients. For convergent validity, associations between F-DFlex scores, perceived levels of autistic traits (Autism Quotient questionnaire - AQ) and eating disorders symptomatology (Eating Disorder Examination Questionnaire - EDE-Q), as well as neuropsychological evaluations (Wisconsin Card Sorting Test - WCST, Rey Complex Figure - RCF) were tested. Discriminant validity was assessed by comparing F-DFlex scores of the patients with a chronic versus non-chronic illness. Results: The results of the exploratory factorial analysis led to the removal of four items. Internal consistency indices of this shortened version were good. Correlation coefficients directions and values between F-DFlex factors and relevant AQ Switching and Detail subscores were satisfactory, indicating good convergent validity. F-DFlex Rigidity scores were associated with the WCST percentage of perseverative errors, but the F-DFlex Attention to Detail scores were not associated with the RCF central coherence index. F-DFlex scores were associated with the severity of eating disorders symptomatology independently of BMI, illness duration, or anxiety, and depression. Conclusion: This study indicates good psychometric properties of this new version of the DFlex. The F-DFlex appears as a promising self-report screening tool of important cognitive dimensions for use in clinical management of people diagnosed with AN.

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.

Executive functioning and spatial processing in anorexia nervosa: an experimental study and its significance for the allocentric lock theory

PURPOSE

The allocentric lock theory (ALT) suggests that people with eating disorders have difficulties in multisensory integration in two reference frames-egocentric and allocentric, whereby the egocentric, but not allocentric, is impaired. This leads to a distorted body image that contributes to the development and maintenance of the disorder. The current study aimed to explore a facet of the ALT, namely, the visuo-spatial aspect, and its relation to cognitive flexibility in patients with anorexia nervosa (AN).

METHODS

Fifty-five participants took part in the study: 20 AN patients and 35 controls, matched by age and education. The object perspective taking test (OPTT) and the mental rotation test (MRT), tapping egocentric and allocentric representations, respectively, and a set-shifting task were administered. The brief symptom inventory was used to measure overall levels of distress.

RESULTS

AN patients showed higher level of distress. They performed poorer on the OPTT and set-shifting task but not on the MRT. The OPTT and MRT were correlated for controls but not for AN patients, while the set-shifting task and body mass index were associated with the OPTT but not with the MRT for the AN patients.

CONCLUSIONS

The findings support the ALT by demonstrating impaired visual egocentric representations and intact allocentric visual functions in AN patients, with cognitive flexibility associated only with the egocentric frame. Therefore, egocentric frame impairment in AN patients may be influenced by visual perception and cognitive flexibility deficiency.

LEVEL OF EVIDENCE

Level III: case-control analytic study.

Characteristics of autism spectrum disorders are associated with longer duration of anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

Anorexia nervosa (AN) is associated with neuropsychological characteristics such as impairments in central coherence, cognitive flexibility, and emotion recognition. The same features also manifest in autism spectrum disorders (ASD) and have been suggested to be associated with illness prolongation in AN. The purpose of this meta-analysis was to examine whether pronounced neuropsychological characteristics related to ASD are associated with illness duration in AN.

METHOD

Four databases (Medline, PsycINFO, Scopus, PubMed) were searched for eligible studies. Search terms were (a) "anorexia nervosa" and (b) "cognitive flexibility" or "set-shifting" or "central coherence" or "emotion recognition" or "theory of mind". The final sample consisted of 53 studies. Duration of AN was divided into three categories in order to investigate differences between the groups with varying illness duration. The meta-analysis was performed with Review Manager using a random-effects model.

RESULTS

Deficits in central coherence, cognitive flexibility, and emotion recognition were pronounced among individuals with prolonged AN compared to those with shorter illness duration.

DISCUSSION

A prolonged course of AN appears to be associated with underlying neuropsychological characteristics that are also distinctive to ASD. Neuropsychological impairments may lead to prolonged AN, and prolonged illness may contribute to the subsequent "neurological scar effect," further strengthening these impairments.

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).

A process approach to verbal memory assessment: Exploratory evidence of inefficient learning in women remitted from anorexia nervosa

Introduction: Anorexia nervosa (AN) is associated with deficits in set-shifting and cognitive flexibility, yet less is known about the persistence of these deficits after recovery and how they might contribute to reported difficulties organizing and learning new information. To address this question, the current study applied a process-focused approach, that accounts for errors and strategies by which a score is achieved, to investigate the relationship between verbal memory and executive function in women remitted from AN. Method: Twenty-six women remitted from anorexia nervosa (RAN) and 25 control women (CW) aged 19-45 completed the California Verbal Learning Test, Second edition (CVLT-II) and the Wisconsin Card Sorting Test (WCST). Groups were compared on overall achievement scores, and on repetition, intrusion, and perseverative errors on both tests. Associations between learning and memory performance and WCST errors were also examined. Results: RAN and CW groups did not differ on overall CVLT-II learning and memory performance or errors on the WCST, though the RAN group trended towards greater WCST non-perseverative and total errors. On the CVLT-II, the RAN group made significantly more repetition errors than CW (p = 0.010), and within-trial perseveration (WTP) errors (p = 0.044). For the CW group, CVLT-II learning and memory performance were negatively associated with errors on the WCST, whereas among RAN, primarily delayed memory was negatively correlated with WCST errors. Notably, for RAN, greater WCST perseverative responses were correlated with greater CVLT-II repetition and WTP errors, showing the convergence of perseverative responding across tasks. Conclusions: Despite similar overall learning and memory performance, difficulties with executive control seem to persist even after symptom remission in patients with AN. Results indicate an inefficient learning process in the cognitive phenotype of AN and support the use of process approaches to refine neuropsychological assessment of AN by accounting for strategy use.

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.

Cognitive impairment in eating disorder patients of short and long-term duration: a case-control study

Introduction: Several studies have noted the potentially negative effect of eating disorders (ED) on cognitive performance. Objective: To compare the impact of the duration of abnormal eating behaviors on cognitive performance in a sample of people with short- and long-term eating disorders and in two control groups matched for age. Method: The neuropsychological performance of 82 women diagnosed with an eating disorder were compared with two control groups from the community of 66 healthy women. Time of duration of the disorder was less than two years in half of the clinical sample, and more than 10 years in the other half. The following instruments were used to measure neuropsychological performance: the Matrix Test, the Stroop task, the Trail-Making Test, the Tower of London Test, the Posner Spatial Task, the Rey's Complex Figure, the Wechsler Vocabulary Test, and the Hayling Completion Test. Results: It showed that persons with long-term ED presented more impaired neuropsychological profiles, but not in all areas. In contrast, the short-term ED group presented similar profiles to the control groups. Discussion: This study highlights the positive association between cognitive impairment and time of evolution of ED, above all in perceptual measures and non-verbal memory. Considering the effect of the evolution of ED cognitive performance (especially in long-term patients) may further our understanding of the development of the disorder and the factors that may favor its persistence.

Executive functioning in adolescent anorexia nervosa: Neuropsychology versus self- and parental-report

There is limited research concerning the relationship between neuropsychological assessment and self-report of executive functioning in adolescent anorexia nervosa (AN); available studies demonstrate only low to moderate correlations. Therefore, this study examines the association between neuropsychological test performance and self-report in AN. Forty adolescent inpatients with AN completed an extensive neuropsychological assessment, including set-shifting, central coherence, and questionnaires assessing executive functioning in daily life (BRIEF-SR). Their parents filled out an analog version (BRIEF-PF). Statistical analyses revealed low to medium positive and negative correlations between neuropsychological measures and BRIEF subscales. Similarly, self- and parental ratings were only slightly positively correlated, with patients scoring significantly higher than their parents on two subscales. The results support previous findings of modest correlations between self-report and performance-based testing and emphasize the importance of a multiple format assessment of executive functioning in adolescent AN.

Supporting Carers of Children and Adolescents with Eating Disorders in Austria (SUCCEAT): Study protocol for a randomised controlled trial

Supporting Carers of Children and Adolescents with Eating Disorders in Austria (SUCCEAT) is an intervention for carers of children and adolescents with anorexia nervosa and atypical anorexia nervosa. This paper describes the study protocol for a randomised controlled trial including the process and economic evaluation. Carers are randomly allocated to one of the 2 SUCCEAT intervention formats, either 8 weekly 2‐hr workshop sessions (n = 48) or web‐based modules (n = 48), and compared with a nonrandomised control group (n = 48). SUCCEAT includes the cognitive‐interpersonal model, cognitive behavioural elements, and motivational interviewing. The goal is to provide support for carers to improve their own well‐being and to support their children. Outcome measures include carers' distress, anxiety, depression, expressed emotions, needs, motivation to change, experiences of caregiving, and skills. Further outcome measures are the patients' eating disorder symptoms, emotional problems, behavioural problems, quality of life, motivation to change, and perceived expressed emotions. These are measured before and after the intervention, and 1‐year follow‐up.

Impaired central coherence in patients with anorexia nervosa

The purpose of this study was to investigate the characteristics of central coherence in patients with anorexia nervosa (AN). 22 female patients with AN (median age = 31.50 (QD = 8.13) years) and 33 female healthy controls (HC) (median age = 28.00 (QD = 8.50) years) participated in the study. Their central coherence was assessed with the Rey Complex Figure Task (RCFT). Clinical symptoms were evaluated with the Beck Depression Inventory-II and the State-Trait Anxiety Inventory-Form JYZ. The results showed that AN patients' Central Coherence Index and accuracy scores in copy, 3-min delayed recall and 30-min delayed recall tasks of the RCFT were significantly lower than those of HC. Moreover, the significant differences in Central Coherence Index score in copy task and accuracy scores in 3-min delayed recall and 30-min delayed recall tasks remained when the effects of depression, anxiety and starvation were eliminated statistically. These findings may explain some characteristics of AN patients such as focusing on local rather than global picture in their perception of body or life.

Altered Reward Reactivity as a Behavioural Endophenotype in Eating Disorders: A Pilot Investigation in Twins

Altered reward reactivity is a potential risk endophenotype for eating disorders (EDs). The aim of this study was to examine reward reactivity in female twins with EDs and compare it with a twin control group. A sample of 112 twins [n = 51 met lifetime DSM-IV ED criteria (anorexia nervosa n = 26; bulimic disorders n = 24), n = 19 unaffected cotwins and n = 42 control twins] was administered measures assessing reward reactivity, including the Game of Dice Task, the Behavioural Inhibition/Activation (BIS/BAS) Scales and the Appetitive Motivation Scale (AMS). Within pair, correlations for monozygotic and dizygotic twins were calculated and generalised estimating equations compared probands with non-ED cotwins and controls. The BAS and the AMS were reduced in EDs and negatively associated with restrictive symptoms. In addition, monozygotic twins pairs demonstrated significant within pair similarity for the BAS and AMS. Conversely, there was less evidence to support the BIS or risky decision-making as measured by the Game of Dice Task as an endophenotype in EDs. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Weak central coherence in weight-restored adolescent anorexia nervosa: Characteristics and remediation

OBJECTIVE

Weak central coherence (WCC) refers to a bias towards processing details (local processing) at the expense of paying attention to the bigger picture (global processing). Multiple studies reported WCC in adults with anorexia nervosa (AN). Evidence for WCC in adolescents with AN has been inconsistent. The current study characterizes WCC in weight-restored adolescents with AN (WR-AN) using a direct measure of WCC, and examines whether WCC can be remediated by increasing alertness level-a manipulation that was found useful in enhancing global processing in healthy individuals and clinical populations.

METHODS

40 adolescents (18 WR-AN and 22 healthy adolescents) performed a global/local processing task (Navon task). Auditory alerting cues that elevate alertness level were integrated into the task.

RESULTS

Both groups processed global information faster than local information. However, compared with controls, adolescents with WR-AN were better at ignoring an irrelevant bigger picture while attending to details (smaller global interference) and had greater difficulty ignoring irrelevant details while attending to the bigger picture (larger local interference). These differences were attenuated when adolescents with WR-AN were under a state of high alertness. Additionally, the local interference effect was positively correlated with three independent self-report questionnaires assessing eating disorders symptomatology.

DISCUSSION

This study suggests that abnormal interference by irrelevant global and local information is a central characteristic of WCC in adolescents with WR-AN that cannot be accounted for by enduring illness or malnourishment. Additionally, this study demonstrates that WCC can be temporarily remediated by encouraging a state of high alertness.

Influence of cognitive function on quality of life in anorexia nervosa patients

AIM

The purpose of this study was to elucidate determinants of quality of life (QOL) in anorexia nervosa (AN) patients.

METHODS

Twenty-one female patients with AN participated in the study. QOL was assessed with the 36-Item Short Form Health Survey (SF-36), and cognitive function was evaluated using the Wisconsin Card Sorting Test Keio version, the Rey Complex Figure Test, and the Social Cognition Screening Questionnaire. Clinical symptoms were evaluated with the Beck Depression Inventory-II, the State-Trait Anxiety Inventory-Form JYZ (STAI-JYZ), and the Maudsley Obsessive Compulsive Inventory.

RESULTS

The Difficulty Maintaining Set score of the Wisconsin Card Sorting Test Keio version was negatively correlated to the SF-36 Physical Component Summary. Scores of the Beck Depression Inventory-II and the STAI-JYZ State and Trait were negatively correlated to the SF-36 Mental Component Summary (MCS), and the Central Coherence Index 30-min Delayed Recall score of the Rey Complex Figure Test was positively correlated with the MCS. Stepwise regression analysis showed that the Difficulty Maintaining Set score was an independent predictor of the Physical Component Summary and scores for Central Coherence Index 30-min Delayed Recall and the STAI-JYZ Trait-predicted MCS.

CONCLUSION

These results suggest that not only trait anxiety but also poor central coherence and impaired ability to maintain new rule worsen AN patients' QOL.

Cognitive Flexibility in Juvenile Anorexia Nervosain Relation to Comorbid Symptoms of Depression, Obsessive Compulsive Symptoms and Duration of Illness

OBJECTIVE

Whereas the evidence in adolescents is inconsistent, anorexia nervosa (AN) in adults is characterized by weak cognitive flexibility. This study investigates cognitive flexibility in adolescents with AN and its potential associations with symptoms of depression, obsessive compulsive disorder (OCD), and duration of illness.

METHODS

69 patients and 63 age-matched healthy controls (HC) from 9 till 19 years of age were assessed using the Trail-Making Test (TMT) and self-report questionnaires.

RESULTS

In hierarchical regression analyses, set-shifting ability did not differ between AN and HC, whereas AN patients reported significantly higher rates of depression symptoms and OCD symptoms. Age significantly predicted set-shifting in the total sample. Only among AN patients aged 14 years and older did set-shifting decline with increasing age.

DISCUSSION

The presence of AN with depression or OCD symptoms or the duration of illness do not influence cognitive flexibility in children and adolescents. Early interventions may be helpful to prevent a decline in cognitive flexibility in adolescent AN with increasing age.

Is inefficient cognitive processing in anorexia nervosa a familial trait? A neuropsychological pilot study of mothers of offspring with a diagnosis of anorexia nervosa

OBJECTIVES

Inefficient set shifting and poor global processing are thought to be possible traits in anorexia nervosa (AN). This study aimed to investigate the neuropsychological processing style of unaffected mothers of offspring with AN (unaffected AN mothers).

METHODS

The performance of 21 unaffected AN mothers were compared to 20 mothers of healthy control offspring on neuropsychological measures of set shifting (Wisconsin Card Sorting Test, WCST) and central coherence (Fragmented Pictures Task, FPT, and Rey Osterrieth Complex Figures Task, ROCFT). Associations between neuropsychological performance and clinical measures were examined in the unaffected AN mothers group.

RESULTS

There were significant differences in perseverative errors on the WCST (P≤0.01), with the unaffected mothers displaying a more inflexible thinking style compared to the control group. There were also significant differences on the FPT (P ≤ 0.01) and the ROCFT (P ≤ 0.01), whereby unaffected AN mothers showed lower levels of global processing.

CONCLUSIONS

The results of this study support the idea of the familial nature of cognitive styles in AN. The implications of these findings are discussed.

Planning Abilities in Patients with Anorexia Nervosa Compared with Healthy Controls

OBJECTIVE

Altered cognitive functioning could have an important role in the development and maintenance of Anorexia Nervosa (AN). The majority of previous research has focused on flexibility and global-detail processing. The aim of this study was to explore planning abilities in women with AN.

METHOD

Women with AN (n = 32) were compared to healthy controls (n = 42) using two different types of neuropsychological tasks for the assessment of planning abilities: Tower of London (ToL), a classic measure of planning abilities, and Zoo Map test, a more ecologically valid planning measure. Measures of AN psychopathology, anxiety, depression, and obsessive compulsivity were also collected.

RESULTS

The AN group did not differ from controls in the ToL (all p-values p > .05), although they performed significantly worse than controls in the main score of the Zoo Map (p = .02). A worse performance in the Zoo Map test More was associated with more eating disorders (rho = -.44, p = .018) and depressive (rho = -.42, p = .026) symptoms in the AN group.

CONCLUSIONS

Our study suggests the presence of subtle planning difficulties in women with AN which might be better detected using tasks with increased ecological validity.

Literature Review of Cognitive Neuroscience and Anorexia Nervosa

Studies published between the beginning of 2013 and May 2015 on the neuropsychological functioning of patients with anorexia nervosa compared with healthy participants framed in the context of the Research Domain Criteria matrix identifies evidence for functional differences in three domains: Negative Valance Systems-negative attentional biases and lack of neural responsivity to hunger; Cognitive Systems-limited congruence between clinical and cognitive performance, poorer non-verbal than verbal performance, altered attentional styles to disorder related stimuli, perceptual processing impairment in discriminating body images, weaknesses in central coherence, set shifting weaknesses at low weight status, decision-making weaknesses, and greater neural resources required for working memory; Systems for Social Processes-patients appear to have a different attentional response to faces, and perception and understanding of self and others. Hence, there is evidence to suggest that patients with anorexia nervosa have a specific neuropsychological performance style across tasks in three domains of functioning. Some current controversies and areas for future development are identified.

Impaired social cognition in anorexia nervosa patients

BACKGROUND

The purpose of this study was to investigate the characteristics of social cognition in patients with anorexia nervosa (AN).

METHODS

Eighteen female patients with AN (mean age =35.4±8.6 years) and 18 female healthy controls (HC) (mean age =32.8±9.4 years) participated in the study. Their social cognition was assessed with the Social Cognition Screening Questionnaire (SCSQ).

RESULTS

The results showed that total score of the SCSQ and scores of theory of mind and metacognition were significantly lower in AN group than those in HC group. Moreover, significant differences in theory of mind, metacognition, and total score of the SCSQ remained when the effects of depression, anxiety, and starvation were eliminated statistically.

CONCLUSION

These results suggest that patients with AN may have difficulty inferring other people's intention and also monitoring and evaluating their own cognitive activities. Therefore, these features may explain some aspects of the pathology of AN.

Research Review: What we have learned about the causes of eating disorders - a synthesis of sociocultural, psychological, and biological research

BACKGROUND

Eating disorders are severe psychiatric disorders with a complex etiology involving transactions among sociocultural, psychological, and biological influences. Most research and reviews, however, focus on only one level of analysis. To address this gap, we provide a qualitative review and summary using an integrative biopsychosocial approach.

METHODS

We selected variables for which there were available data using integrative methodologies (e.g., twin studies, gene-environment interactions) and/or data at the biological and behavioral level (e.g., neuroimaging). Factors that met these inclusion criteria were idealization of thinness, negative emotionality, perfectionism, negative urgency, inhibitory control, cognitive inflexibility, serotonin, dopamine, ovarian hormones. Literature searches were conducted using PubMed. Variables were classified as risk factors or correlates of eating disorder diagnoses and disordered eating symptoms using Kraemer et al.'s (1997) criteria.

FINDINGS

Sociocultural idealization of thinness variables (media exposure, pressures for thinness, thin-ideal internalization, thinness expectancies) and personality traits (negative emotionality, perfectionism, negative urgency) attained 'risk status' for eating disorders and/or disordered eating symptoms. Other factors were identified as correlates of eating pathology or were not classified given limited data. Effect sizes for risk factors and correlates were generally small-to-moderate in magnitude.

CONCLUSIONS

Multiple biopsychosocial influences are implicated in eating disorders and/or disordered eating symptoms and several can now be considered established risk factors. Data suggest that psychological and environmental factors interact with and influence the expression of genetic risk to cause eating pathology. Additional studies that examine risk variables across multiple levels of analysis and that consider specific transactional processes amongst variables are needed to further elucidate the intersection of sociocultural, psychological, and biological influences on eating disorders.

Does depression matter in neuropsychological performances in anorexia nervosa? A descriptive review

OBJECTIVE

This review aims to examine the impact of depressive symptoms on the assessment of cognitive flexibility, central coherence, and decision-making in individuals with anorexia nervosa (AN).

METHOD

An online search was carried out using PubMed and PsycInfo. Articles were selected for review if they were published in English between 1990 and 2014 and used the Wisconsin Card Sorting Test, the Trail Making Task parts A and B, the Brixton Test, the Rey-Osterrieth Complex Figure Test, and/or the Iowa Gambling Task.

RESULTS

Sixty-two studies were included. Thirty (48%) of the studies statistically assessed the association between depression and neurocognition in AN versus healthy controls. Where significant correlations were found, it became clear that the more serious the depression, the greater the neuropsychological impairment. Only six (10%) studies examined whether increased depressive symptoms were able to eliminate the differences between individuals with AN and healthy controls, and one study found that depressive symptoms did eliminate group differences in cognitive flexibility and decision-making.

DISCUSSION

Only a subgroup of articles on neuropsychology in AN adjusted for depression. However, given the role of depression that some articles suggest, future studies should pay closer attention to the evaluation of this potential confounder.

Central Coherence, Visuoconstruction and Visual Memory in Patients with Eating Disorders as Measured by Different Scoring Methods of the Rey Complex Figure Test

OBJECTIVE

The aims of this study were to examine the performance of eating disorder (ED) patients on the Rey Complex Figure Test and to investigate the validity of the Q-score as a new method for measuring central coherence (CC).

METHOD

Forty-one patients with anorexia nervosa, 40 patients with bulimia nervosa and 40 healthy controls completed the Rey Complex Figure Test, which was scored both quantitatively and qualitatively.

RESULTS

Both ED groups scored lower than the healthy controls on copy, recall and the Q-score. For the anorexia nervosa group, performance on the Central Coherence Index was associated with the nadir body mass index. Performance on the recall measures was independently associated with the nadir body mass index and depressive symptoms for the bulimia nervosa group. There was a strong correlation between the Q-score and the Central Coherence Index (r = 0.77).

DISCUSSION

The study reveals different levels of CC and suggests that the Q-score might be an applicable method for measuring CC in ED patients.

Central coherence in eating disorders: an updated systematic review and meta-analysis

OBJECTIVES

A bias towards local information over the global "gist" (weak central coherence, WCC), has been identified as a possible contributing and maintaining factor in eating disorders (ED). The present study aimed to provide an updated review of the WCC literature and examine the hypothesis that individuals with ED have WCC.

METHODS

The new search found 12 eligible studies. Meta-analyses were performed on nine of these 12 studies, the remaining three were commented on individually. Data were combined with data from the previous 2008 review, and meta- analyses were performed on 16 studies (nine studies from the new search and seven studies from 2008 review).

RESULTS

Meta-analysis of the Group Embedded Figures Task provided evidence of superior local processing across all ED subtypes (pooled effect size of d = -0.62 (95% CI = -0.94, -0.31), P < 0.001). Evidence of poorer global processing in ED groups was found from meta-analyses of the Rey-Osterrieth Complex Figures task (d = -0.63 (95% CI = -0.77, -0.49, P < 0.001), and the Object Assembly Task (d = -0.65 (95% CI = -0.94, -0.37), P < 0.0001).

CONCLUSIONS

As well as supporting the results of previous studies by providing evidence of inefficient global processing, this review has provided evidence of superior local processing, which supports the WCC hypothesis in ED.

Increased set shifting costs in fasted healthy volunteers

We investigated the impact of temporary food restriction on a set shifting task requiring participants to judge clusters of pictures against a frequently changing rule. 60 healthy female participants underwent two testing sessions: once after fasting for 16 hours and once in a satiated state. Participants also completed a battery of questionnaires (Hospital Anxiety and Depression Scale [HADS]; Persistence, Perseveration and Perfectionism Questionnaire [PPPQ-22]; and Eating Disorders Examination Questionnaire [EDE-Q6]). Set shifting costs were significantly increased after fasting; this effect was independent of self-reported mood and perseveration. Furthermore, higher levels of weight concern predicted a general performance decrement under conditions of fasting. We conclude that relatively short periods of fasting can lead to set shifting impairments. This finding may have relevance to studies of development, individual differences, and the interpretation of psychometric tests. It also could have implications for understanding the etiology and maintenance of eating disorders, in which impaired set shifting has been implicated.

Psychopathological traits of adolescents with functional hypothalamic amenorrhea: a comparison with anorexia nervosa

BACKGROUND

Functional hypothalamic amenorrhea (FHA) is a form of anovulation, due to the suppression of hypothalamic-pituitary-ovarian axis, not related to identifiable organic causes. Like adolescents with anorexia nervosa (AN), subjects with FHA show dysfunctional attitudes, low self-esteem, depressive mood, anxiety and inability to cope with daily stress. The aim of the study is to examine similarities and differences between FHA and AN in terms of clinical profiles and psychological variables.

METHODS

21 adolescents with FHA, 21 adolescents with anorexia nervosa, and 21 healthy adolescents were included in the study. All the teenagers completed a battery of self-administered psychological tests for the detection of behaviors and symptoms attributable to the presence of an eating disorder (EDI-2), depression (CDI), and alexithymia (TAS-20).

RESULTS

Different from healthy controls, subjects with FHA and with AN shared common psychopathological aspects, such as maturity issues, social insecurity and introversion, a tendency to depression, excessive concerns with dieting, and fear of gaining weight. Nevertheless, adolescents with AN presented a more profound psychopathological disorder as observed at test comparisons with subjects with FHA.

CONCLUSIONS

Results show a clinical spectrum that includes AN and FHA and suggest the necessity to treat FHA with a multidisciplinary approach for both organic and psychological aspects.

[Anorexia nervosa - from a neuroscience perspective]

Anorexia nervosa is a frequent disorder especially among adolescent girls and young women, with high morbidity, mortality, and relapse rates. To date, no single therapeutic approach has proved to be superior to others (Herpertz et al., 2011). It remains unclear how its etiology and pathology are encoded within cognitive, neural, and endocrinological processes that modulate important mechanisms in appetitive processing and weight regulation. Yet, several trait characteristics have been identified in AN which might reflect predisposing factors. Further, altered levels of neuropeptides and hormones that regulate appetite and feeding behavior have been found during both the acute and the recovered state, pointing to dysfunctional mechanisms in AN that persist even after malnutrition has ceased. Researchers are also hoping that brain imaging techniques will allow for a more detailed investigation of the neural basis of reward and punishment sensitivity that appears to be altered in AN. The integration and extension of recent findings in these areas will hopefully provide a more comprehensive understanding of the disorder and hence enable the development of more effective treatments.

Advances in the neurobiology of eating disorders

PURPOSE OF REVIEW

To systematize new neurobiological findings on the cause and treatment of eating disorders.

RECENT FINDINGS

The conceptual framework of the cause of eating disorders has undergone great changes in the past decades. Recently, the National Institute of Mental Health proposed a new set of criteria for research purposes--the Research Domain Criteria (RDoC). We aim to structure this study as much as possible using these constructs across biological units of analysis, summarizing new findings. Brain imaging techniques have become sophisticated in identifying brain circuits related to illness behaviour and to fundamental traits such as reward and social processing. Genetic studies have moved from candidate gene studies onto genome-wide association studies; however, the field needs to cooperate to collect larger samples in order to benefit from this approach. Hormonal changes as the results of starvation or as underlying factors for behavioural changes still receive attention in both animal and human studies. Advances made in neuropsychology show problems in cognition (set shifting and central coherence) and in other RDoC domains. Some of these findings have been translated into treatment.

SUMMARY

New biological models are being developed which explain causal and maintaining factors. The RDoC construct may be used to systematize these findings.

The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors

AIM

To describe the evidence base relating to the Cognitive-Interpersonal Maintenance Model for anorexia nervosa (AN).

BACKGROUND

A Cognitive-Interpersonal Maintenance Model maintenance model for anorexia nervosa was described in 2006. This model proposed that cognitive, socio-emotional and interpersonal elements acted together to both cause and maintain eating disorders.

METHOD

A review of the empirical literature relating to the key constructs of the model (cognitive, socio-emotional, interpersonal) risk and maintaining factors for anorexia nervosa was conducted.

RESULTS

Set shifting and weak central coherence (associated with obsessive compulsive traits) have been widely studied. There is some evidence to suggest that a strong eye for detail and weak set shifting are inherited vulnerabilities to AN. Set shifting and global integration are impaired in the ill state and contribute to weak central coherence. In addition, there are wide-ranging impairments in socio-emotional processing including: an automatic bias in attention towards critical and domineering faces and away from compassionate faces; impaired signalling of, interpretation and regulation of emotions. Difficulties in social cognition may in part be a consequence of starvation but inherited vulnerabilities may also contribute to these traits. The shared familial traits may accentuate family members' tendency to react to the frustrating and frightening symptoms of AN with high expressed emotion (criticism, hostility, overprotection), and inadvertently perpetuate the problem.

CONCLUSION

The cognitive interpersonal model is supported by accumulating evidence. The model is complex in that cognitive and socio-emotional factors both predispose to the illness and are exaggerated in the ill state. Furthermore, some of the traits are inherited vulnerabilities and are present in family members. The clinical formulations from the model are described as are new possibilities for targeted treatment.