Service users' feedback on cognitive training in the treatment of anorexia nervosa: a qualitative study

OBJECTIVE

There is little evidence to guide the treatment of anorexia nervosa (AN). Cognitive Remediation Therapy (CRT) may be helpful in reducing perfectionism and rigidity and preparing patients for involvement in later psychological interventions. The aim of this study was to examine service users' experiences of participating in CRT.

METHOD

Written feedback, following 10 CRT sessions, from 19 AN patients was analyzed using grounded theory approach.

RESULTS

Patients' feedback was generally positive. They found CRT refreshing and appreciated that it did not revolve around food. Patients found CRT helpful in reducing perfectionism and rigidity. The majority expressed how they were able to implement skills in their real life. Some changes were suggested, these included varying levels of difficulty and more guidance in implementing skills.

CONCLUSION

CRT is a promising component in the treatment of AN. Further research is being conducted to evaluate CRT.

Present and lifetime comorbidity of tobacco, alcohol and drug use in eating disorders: a European multicenter study

OBJECTIVES

To assess the differences in comorbid lifetime and current substance use (tobacco, alcohol and drug use) between eating disorder (ED) patients and healthy controls in five different European countries.

METHOD

A total of 1664 participants took part in the present study. ED cases (n=879) were referred to specialized ED units in five European countries. The ED cases were compared to a balanced control group of 785 healthy individuals.

ASSESSMENT

Participants completed the Substance Use Subscale of the Cross Cultural (Environmental) Questionnaire (CCQ), a measure of lifetime tobacco, alcohol and drug use. In the control group, also the GHQ-28, the SCID-I interview and the EAT-26 were used.

RESULTS

ED patients had higher lifetime and current tobacco and general drug use. The only non-significant result was obtained for lifetime and current alcohol use. Significant differences across ED subdiagnoses and controls also emerged, with BN and AN-BP generally presenting the highest and AN-R and controls the lowest rates. The only exception was detected for alcohol use where EDNOS demonstrated the highest values. Only a few cultural differences between countries emerged.

CONCLUSIONS

With the exception of alcohol consumption, tobacco and drug use appear to be more prevalent in ED patients than healthy controls. The differential risk observed in patients with bulimic features might be related to differences in temperament or might be the result of increased sensitivity to reward.

Information processing bias in anorexia nervosa

The aim of this study was to investigate preferential information processing style in Eating Disorders (ED). We compared the performance of participants with EDs against healthy controls in a task that measures cognitive style (reflection-impulsivity) and cognitive efficiency (inefficient-efficient). Sixty non-medicated female participants (healthy controls n=26, anorexia nervosa n=20, bulimia nervosa n=14) took part in the Matching Familiar Figures Test (MFFT), a difficult visual search paradigm with high response uncertainty. Participants with anorexia scored significantly higher on the efficiency dimension score than the control group. No significant differences were found across groups on the dimension 'reflection-impulsivity'. Participants with anorexia are more efficient (quicker response latencies in conjunction with fewer errors) in this visual search task that requires an analytic approach. This supports the hypothesis that individuals with anorexia have a positive bias toward local detail processing, indicative of weak central coherence.

Weak central coherence in eating disorders: a step towards looking for an endophenotype of eating disorders

Previous work has found that women with anorexia nervosa and bulimia nervosa have weak coherence. The aim of this study was to examine whether women who had recovered from an eating disorder (ED) also had weak coherence. A total of 42 recovered ED women and 42 healthy women were assessed with a battery of five neuropsychological tests that measure aspects of global or local functioning. The recovered ED group showed superior local processing and poorer global processing than the healthy group. These results are indicative of weak coherence. The finding that weak coherence is a stable characteristic rather than a state effect suggests that it may be an endophenotype for ED.

Central coherence in women with bulimia nervosa

OBJECTIVE

To examine the concept of central coherence in women with bulimia nervosa (BN) and address similarities and difference with those with anorexia nervosa (AN) METHOD: Forty two women with BN and 42 matched healthy women, completed neuropsychological testing measuring aspects of central coherence: Rey-Osterrieth Complex Figure (RCFT), Embedded Figures Test (EFT), Block Design Test (BD), Homograph Reading Test (HRT), and Sentence Completion Task (SCT).

RESULTS

The BN group showed superiority in local processing as measured by EFT and lesser relative advantage from segmentation in BD, and difficulties in global processing in both visual and verbal domains as examined by RCFT, HRT, and SCT. Anxiety levels were associated with low central coherence indices in RCFT.

CONCLUSION

People with BN displayed a profile consistent with the weak central coherence hypothesis. Their pattern of cognitive performance resembles that seen in AN although some differences are apparent.

An examination of the concept of central coherence in women with anorexia nervosa

OBJECTIVE

To examine central coherence (local and global processing) in women with anorexia nervosa (AN).

METHOD

42 women with AN and 42 healthy women (HC) completed neuropsychological testing measuring visuospatial and verbal aspects of central coherence: Rey-Osterrieth Complex Figure (RCFT), Embedded Figures Test (EFT), Homograph Reading Test (HRT), and Sentence Completion Task (SCT).

RESULTS

People with AN displayed superior performance on the EFT and poorer performance in RCFT with the exception of accuracy in the copy trial. Long hesitations in the SCT were observed. Verbal coherence tasks were not sensitive enough to detect coherence anomalies in AN.

CONCLUSION

Women with AN have strengths in tasks requiring local processing (EFT) and weaknesses on tasks benefited by global processing (RCFT and SCT). These results are consistent with the weak central coherence account. This trait might play a role in the maintenance of AN and can be addressed in specific clinical interventions.

Empathy, systemizing, and autistic traits in anorexia nervosa: a pilot study

OBJECTIVES

This pilot study examined whether patients with anorexia nervosa (AN) would display an empathizing-systemizing psychometric profile similar to that found in autism spectrum disorders (ASD), and whether people with AN would score highly on a measure of autistic traits.

METHOD

Self-report measures of empathy, systemizing, and autistic traits were administered to 22 female AN patients and 45 female healthy controls (HC).

RESULTS

AN patients and HCs did not differ significantly in their self-reported empathy and systemizing. AN patients scored significantly higher than HCs on the autism-spectrum quotient.

CONCLUSIONS

Replication of these findings is required with larger samples and more sensitive measures.

A systematic review and meta-analysis of set-shifting ability in eating disorders

BACKGROUND

The aim was to critically appraise and synthesize the literature relating to set-shifting ability in eating disorders. PsycINFO, Medline, and Web of Science databases were searched to December 2005. Hand searching of eating-disorder journals and relevant reference sections was also undertaken.

METHOD

The 15 selected studies contained both eating disorder and healthy control groups, and employed at least one of the following six neuropsychological measures of set-shifting ability; Trail Making Test (TMT), Wisconsin Card Sort Test (WCST), Brixton task, Haptic Illusion, CatBat task, or the set-shifting subset of the Cambridge Neuropsychological Test Automated Battery (CANTAB). The outcome variable was performance on the set-shifting aspect of the task. Pooled standardized mean differences (effect sizes) were calculated.

RESULTS

TMT, WCST, CatBat and Haptic tasks had sufficient sample sizes for meta-analysis. These four tasks yielded acceptable pooled standardized effect sizes (0.36; TMT -1.05; Haptic) with moderate variation within studies (as measured by confidence intervals). The Brixton task showed a small pooled mean difference, and displayed more variation between sample results. The effect size for CANTAB set shifting was 0.17.

CONCLUSION

Problems in set shifting as measured by a variety of neuropsychological tasks are present in people with eating disorders.

An investigation of decision making in anorexia nervosa using the Iowa Gambling Task and skin conductance measurements

The objective of this study is to determine (a) if decision making ability is impaired in patients with anorexia nervosa (AN) and in people with good recovery from AN and (b) whether any impairment in decision making is associated with alterations in skin conductance responses (SCR). Patients with AN (n = 29), healthy controls comparable in age and IQ (HC, n = 29), and women long term recovered from AN (n = 14), completed the Iowa Gambling Task (IGT) while their SCR were measured. AN patients performed poorly in the IGT compared to the HC and to the recovered AN participants. AN patients had decreased anticipatory SCR prior to choosing cards and reduced SCR after losses compared to HC. IGT performance and the SCR of recovered AN participants did not differ from the HC. Decision making ability is impaired in AN. It is associated with a significantly attenuated SCR. Neither of these features are found in recovered AN. The association between impaired decision making ability and a decreased autonomic response is consistent with the predictions of the Somatic Marker Hypothesis.

Cognitive remediation therapy for patients with anorexia nervosa: preliminary findings

BACKGROUND

Anorexia nervosa (AN) is a severe mental illness. Drug treatments are not effective and there is no established first choice psychological treatment for adults with AN. Neuropsychological studies have shown that patients with AN have difficulties in cognitive flexibility: these laboratory based findings have been used to develop a clinical intervention based on Cognitive Remediation Therapy (CRT) which aims to use cognitive exercises to strengthen thinking skills.

AIMS

1) To conduct a preliminary investigation of CRT in patients with AN 2) to explore whether cognitive training improves performance in set shifting tasks 3) to explore whether CRT exercises are appropriate and acceptable to AN patients 4) to use the data to improve a CRT module for AN patients.

METHODS

Intervention was comprised of ten 45 minute sessions of CRT. Four patients with AN were assessed before and after the ten sessions using five set shifting tests and clinical assessments. At the end, each patient wrote a letter providing feedback on the intervention.

RESULTS

Post intervention, three of the five set shifting assessments showed a moderate to large effect size in performance and two showed a large effect size in performance, both indicative of improved flexibility. Patients were aware of an improvement in their cognitive flexibility qualitative feedback was generally positive towards CRT.

DISCUSSION

This preliminary study suggests that CRT changed performance on flexibility tasks and may be beneficial for acute, treatment resistant patients with AN. Feedback gathered from this small case series has enabled modification of the intervention for a future larger study, for example, by linking exercises with real life behavioural tasks and including exercises that encourage global thinking.

CONCLUSION

This exploratory study has produced encouraging data supporting the use of CRT in patients with AN: it has also provided insight into how the module should be tailored to maximise its effectiveness for people with acute AN.

Reduced specificity of autobiographical memory and depression: the role of executive control

It has been widely established that depressed mood states and clinical depression, as well as a range of other psychiatric disorders, are associated with a relative difficulty in accessing specific autobiographical information in response to emotion-related cue words on an Autobiographical Memory Test (AMT; J. M. G. Williams & K. Broadbent, 1986). In 8 studies the authors examined the extent to which this relationship is a function of impaired executive control associated with these mood states and clinical disorders. Studies 1–4 demonstrated that performance on the AMT is associated with performance on measures of executive control, independent of depressed mood. Furthermore, Study 1 showed that executive control (as measured by verbal fluency) mediated the relationship between both depressed mood and a clinical diagnosis of eating disorder and AMT performance. Using a stratified sample in Study 5, the authors confirmed the positive association between depressed mood and impaired performance on the AMT. Studies 6–8 involved experimental manipulations of the parameters of the AMT designed to further indicate that reduced executive control is to a significant extent driving the relationship between depressed mood and AMT performance. The potential role of executive control in accounting for other aspects of the AMT literature is discussed.

Can cognitive exercises help treat anorexia nervosa?

Cognitive remediation therapy (CRT) is used as an intervention for people with brain lesions and psychosis. This case report demonstrates the possible benefits of introducing CRT into treatment packages for anorexia nervosa (AN). In our previous work, we reported that people with AN demonstrate inflexibility in cognitive set-shifting tasks. Weight gain alone does not improve the neuropsychological profile in set-shifting tasks. This case report illustrates how training programmes can address problems in cognitive rigidity. We acknowledge the limitations of case studies, however, this is a starting point in exploring the possibilities of introducing CRT as part of the treatment of AN.

Is impaired set-shifting an endophenotype of anorexia nervosa?

OBJECTIVE

Set-shifting difficulties have been reported in subjects with anorexia nervosa and appear to persist after recovery; therefore, they may be endophenotypic traits. The goals of this study were to investigate whether set-shifting difficulties are familial by examining discordant sister-pairs in comparison with healthy unrelated women and to replicate, with a broader battery, the lack of influence of an acute illness state on neuropsychological performance.

METHOD

Forty-seven pairs of sisters discordant for anorexia nervosa and 47 healthy unrelated women who were comparable in age and IQ completed neuropsychological tasks selected to assess set-shifting ability. Analyses of variance with standard errors that are robust against correlations within family clusters were used to compare the groups. Results were adjusted for obsessive-compulsive, anxiety, and depression symptoms. Subjects with acute (N=24) and fully remitted (N=23) anorexia nervosa were compared to assess state versus trait effects.

RESULTS

Sisters with and without anorexia nervosa took significantly longer than unrelated healthy women to shift their cognitive set (CatBat task) and demonstrated greater perceptual rigidity (Haptic Illusion task) but did not differ significantly from each other. Women with anorexia nervosa were slower than other groups on Trail Making tasks. Women who had fully recovered from anorexia nervosa made significantly fewer errors than those with acute anorexia nervosa on the Trail Making alphabet task, but these subgroups did not differ on other measures.

CONCLUSIONS

Both affected and unaffected sisters had more set-shifting difficulties than unrelated healthy women. This finding, together with the replicated finding that set-shifting difficulties persist after recovery, suggests that set-shifting difficulties are trait characteristics and may inform the search for the endophenotype in anorexia nervosa.

Neuropsychological studies in anorexia nervosa

Neuropsychological findings in eating disorders are somewhat inconsistent. This may be because individual studies have used a broad range of tests on relatively small, heterogeneous clinical groups, thus limiting the detection of subtle neuropsychological differences in these patients. Therefore, rather than using broad assessments of a variety of neuropsychological functions, adoption of a more focused, hypothesis-driven approach based on clinical practice is proposed. This will allow more in-depth investigations of targeted functions and will improve the chances of detecting a problem, of exploring its ecologic validity, and of tailoring a treatment. We have demonstrated this approach using our neuropsychological studies of cognitive flexibility in anorexia nervosa (AN).

Set shifting in anorexia nervosa: an examination before and after weight gain, in full recovery and relationship to childhood and adult OCPD traits

Deficits in set shifting tasks are present in anorexia nervosa (AN), but it is not known whether these deficits are traits independent of current disease or nutritional status or merely a temporary consequence of starvation or psychopathology. The aims of the present study were to determine if set-shifting sub-optimal performance are state or trait-related by examining set shifting in patients with current or past AN, and the extent of association of these deficits with obsessive compulsive traits and behaviours. To achieve this we examined set shifting abilities in three groups of subjects: (a) AN patients with current illness, prior to receiving treatment (AN); (b) people with past AN currently in long term recovery (ANRec) and a healthy comparison group (HC). We also longitudinally followed up a subset for the AN group who showed weight recovery in response to in patient treatment (ANWR). We administered a group of set shifting tests, which included cognitive, perceptual and motor shifting tasks. A semi-structured interview was obtained to ascertain obsessive compulsive personality disorder (OCPD) traits as a child and adult. Set-shifting difficulties were observed in the AN group, but to a lesser extent in the ANRec group. In the AN group these difficulties did not show any improvement follow re-testing after weight recovery. Performance on set shifting tasks was associated with childhood rigidity and inflexibility. Some aspects of set shifting sub-optimal performance in AN appear to be a trait rather than a state marker.

Cognitive flexibility in anorexia nervosa and bulimia nervosa

The aim of this study was to determine if there are differences in cognitive flexibility in anorexia nervosa and bulimia nervosa. Fifty-three patients with an eating disorder (34 with anorexia nervosa and 19 with bulimia nervosa) and 35 healthy controls participated in the study. A battery of neuropsychological tests for cognitive flexibility was used, including Trail Making B, the Brixton Test, Verbal Fluency, the Haptic Illusion Test, a cognitive shifting task (CatBat) and a picture set test. Using exploratory factor analysis, four factors were obtained: 1: Simple Alternation; 2: Mental Flexibility; 3: Perseveration; and 4: Perceptual Shift. Patients with anorexia nervosa had abnormal scores on Factors 1 and 4. Patients with bulimia nervosa showed a different pattern, with significant impairments in Factors 2 and 4. These findings suggest that differential neuropsychological disturbance in the domain of mental flexibility/rigidity may underlie the spectrum of eating disorders.

Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype

OBJECTIVE

The authors retrospectively examined a spectrum of childhood traits that reflect obsessive-compulsive personality in adult women with eating disorders and assessed the predictive value of the traits for the development of eating disorders.

METHOD

In a case-control design, 44 women with anorexia nervosa, 28 women with bulimia nervosa, and 28 healthy female comparison subjects were assessed with an interview instrument that asked them to recall whether they had experienced various types of childhood behavior suggesting traits associated with obsessive-compulsive personality. The subjects also completed a self-report inventory of obsessive-compulsive disorder (OCD) symptoms.

RESULTS

Childhood obsessive-compulsive personality traits showed a high predictive value for development of eating disorders, with the estimated odds ratio for eating disorders increasing by a factor of 6.9 for every additional trait present. Subjects with eating disorders who reported perfectionism and rigidity in childhood had significantly higher rates of obsessive-compulsive personality disorder and OCD comorbidity later in life, compared with eating disorder subjects who did not report those traits.

CONCLUSIONS

Childhood traits reflecting obsessive-compulsive personality appear to be important risk factors for the development of eating disorders and may represent markers of a broader phenotype for a specific subgroup of patients with anorexia nervosa.

Self-reported parental abuse relates to autobiographical memory style in patients with eating disorders

Previous research has shown a relationship between levels of self-reported childhood abuse and overgeneral memory style. This relationship was further clarified in patients with an eating disorder (ED). Patients and healthy controls completed a task in which they had to generate specific autobiographical memories to emotional cue words. The results showed that first, the ED group, relative to the controls, produced more first memories that were "overgeneral" and fewer first memories that were specific. Second, in the ED group, the level of self-reported parental abuse was positively correlated with the tendency to produce overgeneral memories to negative cues. This effect remained significant even after levels of depressed mood were controlled for.

An examination of perceptual and cognitive set shifting tasks in acute anorexia nervosa and following recovery

OBJECTIVES

People with anorexia nervosa have a broad spread of symptoms including disturbances in perception, cognition, emotions and behaviour. The aim of this study was to examine tests of executive function (in particular, perceptual and cognitive set shifting tasks) in patients with a current or past diagnosis of anorexia nervosa (AN).

METHOD

30 AN patients, 16 subjects recovered from anorexia nervosa (ANR) and 23 healthy controls were examined using tests of executive function (initiation tasks and perceptual and cognitive set shifting).

RESULTS

The AN and ANR subjects had significantly higher perceptual and cognitive set shifting scores than the controls.

CONCLUSIONS

Impaired executive function in terms of set shifting tasks could represent a vulnerability factor for AN.

An exploration of eating disorders in a Georgian sample

BACKGROUND

There is debate as to whether eating disorders may be culture-bound. However, accumulating evidence suggests that eating disorders may be found outside of the West, although the precise form of the eating disorder may differ.

AIMS

There were two aims of this study: (1) to translate and establish the psychometric properties of standard questionnaires to measure eating pathology in a Georgian sample; (2) to use these measures to determine whether cases of eating disorders exist in Georgia.

METHODS

We held focus groups of various health professionals to establish how eating disorders present in Georgia and to identify groups perceived to be at high risk of having an eating disorder. We obtained translated versions of a number of standardized questionnaires (measuring eating and general psychopathology) from 245 women from these identified high risk groups and a subsample were given a structured clinical interview.

RESULTS

We estimated from the responses to the questionnaires, that as many as 5% may have clinically significant bulimia nervosa, 7% fell in the weight range for anorexia nervosa with a further 7% in the weight range for obesity. We interviewed a sample of the high scoring group which confirmed the presence of clinically significant eating pathology in the majority of those identified as possible cases.

CONCLUSIONS

The results of this study suggest there may be women in Georgia with significant eating problems.

Future-directed thinking in eating disorders

OBJECTIVES

The aim of the study was to examine future-directed thinking in individuals with eating disorders, given the possible role of such cognitions in the maintenance of anorexia nervosa and bulimia nervosa.

METHOD

Twenty-six anorexics, 18 bulimics and 34 female controls were interviewed using the 'Future Thinking Task', assessing quantitative and qualitative aspects of positive and negative anticipated events.

RESULTS

Patients with anorexia nervosa had similar levels of positive future-oriented cognitions and significantly more negative future-oriented cognitions than controls. The most common positive themes in this group concerned the social/interpersonal and leisure/pleasure domains. The negative theme most commonly mentioned by anorexics was that of their own health, followed by the social/interpersonal domain, whereas controls were most preoccupied with achievement/failure and a broad range of other issues. Bulimics had significantly fewer positive future-oriented cognitions and significantly more negative future-oriented cognitions than controls, most commonly concerning the patient's own health.

CONCLUSION

In anorexia nervosa, anticipated positive future outcomes may to some extent help to maintain the disorder; however, these patients are also highly preoccupied with the possibility of negative future outcomes, i.e. a failure of recovery. Bulimia nervosa sufferers are relatively hopeless about their future. The clinical implications of these findings are discussed.

Perceptual illusions in eating disorders: rigid and fluctuating styles

This study investigated perceptual styles in anorexia nervosa (AN) and bulimia nervosa (BN) using a perceptual set task. We hypothesised that, consistent with personality style research. AN patients might be more rigid in style than those with BN or no eating disorder. We found that once an illusion had been established, participants with AN and BN showed more illusions than non-ED women. However, while AN patients responded rigidly, giving the same response repeatedly, BN patients were more likely to change their responses. The study suggests interesting differences to be followed up in future research. Differences in rigid and fluctuating perceptual styles may have implications for understanding the phenomenology of eating disorders, and have implications for treatment.