FMRI Study of Neural Responses to Implicit Infant Emotion in Anorexia Nervosa

Difficulties in social–emotional processing have been proposed to play an important role in the development and maintenance of anorexia nervosa (AN). Few studies, thus far, have investigated neural processes that underlie these difficulties, including processing emotional facial expressions. However, the majority of these studies have investigated neural responses to adult emotional display, which may be confounded by elevated sensitivity to social rank and threat in AN. Therefore, the aim of this study was to investigate the neural processes underlying implicit processing of positively and negatively valenced infant emotional display in AN. Twenty-one adult women with AN and twenty-six healthy comparison (HC) women were presented with images of positively valenced, negatively valenced, and neutral infant faces during a fMRI scan. Significant differences between the groups in positive > neutral and negative > neutral contrasts were investigated in a priori regions of interest, including the bilateral amygdala, insula, and lateral prefrontal cortex (PFC). The findings revealed that the AN participants showed relatively increased recruitment while the HC participants showed relatively reduced recruitment of the bilateral amygdala and the right dorsolateral PFC in the positive > neutral contrast. In the negative > neutral contrast, the AN group showed relatively increased recruitment of the left posterior insula while the HC groups showed relatively reduced recruitment of this region. These findings suggest that people with AN may engage in implicit prefrontal down-regulation of elevated limbic reactivity to positively social–emotional stimuli.

Clinical evaluation of autistic symptoms in women with anorexia nervosa

BACKGROUND

Despite a suggested link between anorexia nervosa (AN) and autism spectrum disorder (ASD), previous studies have used self-report or diagnostic criteria to assess for ASD in AN populations, rather than direct observation of symptom characteristic of ASD. The aim of this study was to use a standardised, clinical assessment of ASD, the Autism Diagnostic Observation Schedule, 2nd Edition (ADOS-2), to investigate the presence of autistic symptoms in a cross-sectional sample of women with AN.

METHODS

Sixty women were recruited from inpatient or day-patient specialist eating disorder services. Each participant underwent the ADOS-2 assessment and completed a set of self-report questionnaires assessing eating disorder pathology and other psychiatric symptoms. IQ was also assessed.

RESULTS

Fourteen women (23.3%) scored above clinical cutoff for ASD on the ADOS-2. Only eight of these women displayed repetitive or restrictive behaviours, while all 14 had difficulties with social affect. Elevated ASD symptoms were associated with increased alexithymia and obsessive-compulsive symptoms, but not specific eating disorder pathology.

CONCLUSIONS

ASD symptoms are over-represented in women with severe AN and appear to be associated with other psychiatric symptoms, which warrant further investigation and consideration in treatment.

Effects of Intranasal Oxytocin on the Interpretation and Expression of Emotions in Anorexia Nervosa

Altered social-emotional functioning is considered to play an important role in the development and maintenance of anorexia nervosa (AN). Recently, there has been increasing interest in investigating the role of intranasal oxytocin in social-emotional processing. The present study aimed to investigate the effects of intranasal oxytocin on the interpretation and expression of emotions among people with AN. Thirty women with AN and 29 age-matched healthy women took part in the present study, which used a double-blind, placebo-controlled, cross-over design. The participants received a single dose of 40 IU of intranasal oxytocin in one session and a placebo spray in the other. Fifteen minutes after administration, the participants completed the Reading the Mind in the Eyes Test to assess the interpretation of complex emotions and mental states followed by a video task, which assessed expressions of facial affect when they were viewing humorous and sad film clips. The intranasal oxytocin did not significantly influence the expression or interpretation of emotions in the AN or healthy comparison groups. The AN group expressed significantly less positive emotion, spent more time looking away and reported experiencing a significantly more negative affect in response to the film clips. The finding that intranasal oxytocin had little to no effect on the interpretation or expression of emotions in either group supports the notion that the effects of oxytocin on social-emotional processing are not straightforward and may depend on individual and environmental differences, as well as the emotion being processed. Replication of these findings is necessary to explore the effect of timing on the effects of oxytocin before firm conclusions can be drawn. Nonetheless, these findings add to the steady accumulation of evidence that people with AN have reduced emotional expression and avoidance of emotionally provoking stimuli.

Expression of positive emotions differs in illness and recovery in anorexia nervosa

People with Anorexia Nervosa (AN) display reduced facial expression of emotions. This study investigated the expression of positive affect in response to a film, examining Duchenne and non-Duchenne smiles in 20 women who have recovered from AN (REC), 20 with acute AN and 20 healthy controls (HC). The results indicated that the REC group exhibited Duchenne and non-Duchenne smiles with higher duration and intensity than the AN group, comparable to the HC group. The findings warrant longitudinal studies to confirm that reduced expressivity is linked to acute AN, ameliorating after recovery.

A longitudinal examination of dyadic distress patterns following a skills intervention for carers of adolescents with anorexia nervosa

Family interventions in anorexia nervosa (AN) have been developed to ameliorate maladaptive patterns of patient-carer interaction that can play a role in illness maintenance. The primary aim of this study is to examine the inter-relationship between baseline and post-treatment distress in dyads of carers and patients with AN to examine the interdependence between carers and patients. The secondary aim is to examine whether a carer skills intervention [Experienced Carer Helping Others (ECHO)] impacts on this inter-relationship. Dyads consisting of treatment-seeking adolescents with AN and their primary carer (n = 149; mostly mothers) were randomised to receive a carer skills intervention (ECHO) in addition to treatment as usual (TAU), or TAU alone, as part of a larger clinical trial. Carers and patients completed a standardised measure of psychological distress (The Depression, Anxiety, and Stress Scale) at baseline and 12 months post-treatment. The Actor Partner Interdependence Model was used to examine longitudinal changes in interdependence by treatment group. As expected, post-treatment levels of distress were related to baseline levels in both groups (actor effects). Moreover, carer distress at 12 months was related to patient distress at baseline for the TAU (partner effects), but not for the ECHO group. Finally, carers' distress change was not a significant predictor of patients' body mass index (BMI) change in the two treatment conditions. These findings are limited to predominantly mother-offspring dyads and may not generalise to other relationships. The ECHO intervention which is designed to teach carers skills in illness management and emotion regulation may be an effective addition to TAU for ameliorating interdependence of distress in patients and their primary carers over time.

Central Coherence in Eating Disorders: A Synthesis of Studies Using the Rey Osterrieth Complex Figure Test

Background

Large variability in tests and differences in scoring systems used to study central coherence in eating disorders may lead to different interpretations, inconsistent findings and between study discrepancies. This study aimed to address inconsistencies by collating data from several studies from the same research group that used the Rey Osterrieth Complex Figure Test (Rey Figure) in order to produce norms to provide benchmark data for future studies.

Method

Data was collated from 984 participants in total. Anorexia Nervosa, Bulimia Nervosa, recovered Anorexia Nervosa, unaffected family members and healthy controls were compared using the Rey Figure.

Results

Poor global processing was observed across all current eating disorder sub-groups and in unaffected relatives. There was no difference in performance between recovered AN and HC groups.

Conclusions

This is the largest dataset reported in the literature and supports previous studies implicating poor global processing across eating disorders using the Rey Figure. It provides robust normative data useful for future studies.

Using the Autism-Spectrum Quotient to Measure Autistic Traits in Anorexia Nervosa: A Systematic Review and Meta-Analysis

Interest in the link between Autism Spectrum Disorder (ASD) and Anorexia Nervosa (AN) has led to estimates of the prevalence of autistic traits in AN. This systematic review and meta-analysis assessed the use of the Autism-Spectrum Quotient (AQ) or abbreviated version (AQ-10) to examine whether patients with AN have elevated levels of autistic traits. Seven studies were identified and subsequent meta-analysis indicated that those with AN appear to have significant difficulties of a manner characteristic of ASD, relative to controls. Whilst this analysis supports previous indications of higher prevalence of ASD in AN, the aetiology of these traits remains unclear. Studies using more robust clinical measures of ASD within AN are needed to confirm what self-report measures appear to show.

How anorexia nervosa patients with high and low autistic traits respond to group Cognitive Remediation Therapy

BACKGROUND

The current study aimed to evaluate group Cognitive remediation therapy (CRT) inpatients with Anorexia Nervosa (AN). We aimed to examine the treatment response of group CRT in AN patients with high or low levels of autistic traits.

METHODS

Thirty-five in patients with an AN diagnosis received group CRT intervention for 6 sessions in a national eating disorder unit. All participants completed self-report questionnaires on thinking styles and motivation before and after the intervention.

RESULTS

Patients with low autistic traits had statistically significant medium size effect improvements in self-reported thinking style scales as well as confidence (ability) to change. Patients with high autistic traits showed no statistically significant improvements in any outcome measure.

CONCLUSIONS

The brief group format CRT intervention improves self-reported cognitive and motivational aspects in people with AN without autistic traits. For patients with higher autistic traits brief group CRT does not improve self-reported cognitive style or motivation. This finding suggests that brief group format CRT might not be the best suited format for individuals with elevated autistic traits and individual or more tailored CRT should be explored.

Patients’ perspective of a group intervention for perfectionism in anorexia nervosa: A qualitative study

This study aimed to explore the experiences of adults with anorexia nervosa who took part in a perfectionism group intervention in an inpatient setting. Thematic analysis was used to explore patient feedback collected in focus groups. Patient feedback was generally positive and centred around three main themes: perceived benefits of the group, the content of the group and suggested improvements. The findings suggest that a brief perfectionism group intervention is an acceptable treatment with a range of perceived benefits for patients with severe anorexia nervosa. Understanding patients’ experiences of the intervention can provide further important information to maximise therapeutic impact of the group in inpatient settings.

An Exploration of Social Functioning in Young People with Eating Disorders: A Qualitative Study

Previous research indicates adults with eating disorders (EDs) report smaller social networks, and difficulties with social functioning, alongside demonstrating difficulties recognising and regulating emotions in social contexts. Concurrently, those recovered from the illness have discussed the vital role offered by social support and interaction in their recovery. To date, little is known about the social skills and social networks of adolescents with EDs and this study aimed to conduct focus groups to explore the social functioning of 17 inpatients aged 12-17. Data were analysed using thematic analysis and six core themes were identified: group belonging, self-monitoring, social sensitivity, impact of hospitalisation, limited coping strategies and strategies for service provision. Key areas for service provision were: management of anxiety, development and/or maintenance of a social network and development of inter and intrapersonal skills. The most salient finding was that adolescents with EDs reported social difficulties which appeared to persist over and above those typically experienced at this point in the lifespan and therefore a key area for future focus is the development of appropriate coping strategies and solutions to deal with these reported difficulties.

Inpatient Brief Group Therapy for Anorexia Nervosa: Patient Experience

There is increasing interest in group therapy for the treatment of eating disorders. However, there is a lack of research evaluating group therapy that reflects on patient feedback in order to inform practice and improve treatment. This exploratory qualitative study attempted to evaluate patient feedback about the group therapy offered on a specialist inpatient eating disorders program. This qualitative analysis of patients' feedback highlights areas for improvement that can be targeted to increase the effectiveness of the psychotherapy groups in the future. The research has implications for making inpatient hospitalization more effectively tailored to patients' needs. This study also helps to improve qualitative research protocols.

The set-shifting profiles of anorexia nervosa and autism spectrum disorder using the Wisconsin Card Sorting Test: a systematic review and meta-analysis

Difficulties in set-shifting are commonly reported in both autism spectrum disorder (ASD) and anorexia nervosa (AN) populations. Despite this, it is not known whether this cognitive profile persists across different ages, or whether the profiles seen in ASD and AN are comparable. This systematic review and meta-analyses aimed to compare the set-shifting profiles, as measured by the Wisconsin Card Sorting Test (WCST) in adults and younger people with either ASD or AN, relative to healthy controls (HCs) and to statistically compare performance on the WCST between ASD and AN. In all, 24 studies on ASD and 22 studies on AN were identified. In ASD, there were significant differences between the clinical group and HCs, with the ASD group making significantly more perseverative errors, indicating greater difficulty in set-shifting [pooled effect size of d = 0.67, 95% confidence interval (CI) 0.53-0.81, p ⩽ 0.001]. This effect was consistent across the age span. For AN studies, there was a significant difference between adults with AN and HCs (d = 0.52, 95% CI 0.36-0.68, p ⩽ 0.001) but a non-significant effect in child studies (d = 0.25, 95% CI -0.05 to 0.55, z = 1.66, p = 0.096). Meta-regression indicated no effect of diagnosis (AN or ASD) on performance in adult studies but there was a non-significant trend (p = 0.053) towards children with ASD performing worse than children with AN. While difficulties with set-shifting appear to be stable in ASD, there may be differences between children and adults with AN, which warrant further investigation.

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.

The Objective and Subjective Caregiving Burden and Caregiving Behaviours of Parents of Adolescents with Anorexia Nervosa

OBJECTIVE

The study aimed to examine caregiving burden and levels of distress, accommodating behaviours, expressed emotion (EE) and carers' skills, in parents of adolescents with anorexia nervosa.

METHOD

A semi-structured interview assessed the objective burden (time spent across caregiving tasks) in parents (n = 196) of adolescents (n = 144) receiving outpatient treatment for anorexia nervosa. Subjective burden (carers' distress), accommodating behaviours, EE and carers' skills were measured by self-report.

RESULTS

Mothers, on average, spent 2.5 h/day of care, mainly providing food and emotional support, compared with 1 h/day by fathers. The level of distress and accommodating behaviour was significantly lower in fathers than in mothers. Accommodating behaviours mediated the relationship between objective burden and subjective burden in mothers, whereas EE and carers' skills did not mediate this relationship for either parent.

DISCUSSION

The objective burden for most mothers is high. In order to reduce subjective burden, it may be helpful to target accommodating behaviours.

TRIAL REGISTRATION

ISRCTN83003225 - Expert Carers Helping Others (ECHO). Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Attachment and mentalization and their association with child and adolescent eating pathology: A systematic review

OBJECTIVE

Insecure attachment and mentalizing difficulties have been associated with eating pathology in adulthood. However, it is unclear whether eating pathology is associated with attachment or mentalization in children. The aim of this study is to systematically review the literature in this emerging field.

METHOD

Electronic databases were used to search for articles.

RESULTS

Twenty-two studies were identified. In the 15 studies investigating attachment, an association with eating pathology was found in all studies. Mentalizing difficulties and eating pathology were found to be correlated in the seven studies which examined their association.

DISCUSSION

In keeping with the adult literature, cross-sectional studies of children and adolescents consistently report associations with eating pathology. There is some evidence from prospective studies that insecure attachment may be a risk factor for the development of eating pathology in adolescence. The literature on mentalization and eating pathology suggests that adolescents with anorexia nervosa may have difficulties in recognizing emotions. Further research using clinical samples and well-validated measures of attachment and mentalization are required to shed further light on this area.

Diminished facial emotion expression and associated clinical characteristics in Anorexia Nervosa

This study aimed to investigate emotion expression in a large group of children, adolescents and adults with Anorexia Nervosa (AN), and investigate the associated clinical correlates. One hundred and forty-one participants (AN=66, HC= 75) were recruited and positive and negative film clips were used to elicit emotion expressions. The Facial Activation Coding system (FACES) was used to code emotion expression. Subjective ratings of emotion were collected. Individuals with AN displayed less positive emotions during the positive film clip compared to healthy controls (HC). There was no significant difference between the groups on the Positive and Negative Affect Scale (PANAS). The AN group displayed emotional incongruence (reporting a different emotion to what would be expected given the stimuli, with limited facial affect to signal the emotion experienced), whereby they reported feeling significantly higher rates of negative emotion during the positive clip. There were no differences in emotion expression between the groups during the negative film clip. Despite this individuals with AN reported feeling significantly higher levels of negative emotions during the negative clip. Diminished positive emotion expression was associated with more severe clinical symptoms, which could suggest that these individuals represent a group with serious social difficulties, which may require specific attention in treatment.

Facial expression to emotional stimuli in non-psychotic disorders: A systematic review and meta-analysis

Facial expression of emotion is crucial to social interaction and emotion regulation; therefore, altered facial expressivity can be a contributing factor in social isolation, difficulties with emotion regulation and a target for therapy. This article provides a systematic review and meta-analysis of the literature on automatic emotional facial expression in people with non-psychotic disorders compared to healthy comparison groups. Studies in the review used an emotionally salient visual induction method, and reported on automatic facial expression in response to congruent stimuli. A total of 39 studies show alterations in emotional facial expression across all included disorders, except anxiety disorders. In depression, decreases in facial expression are mainly evident for positive affect. In eating disorders, a meta-analysis showed decreased facial expressivity in response to positive and negative stimuli. Studies in autism partially support generally decreased facial expressivity in this group. The data included in this review point towards decreased facial emotional expressivity in individuals with different non-psychotic disorders. This is the first review to synthesise facial expression studies across clinical disorders.

Post graduate clinical placements: evaluating benefits and challenges with a mixed methods cross sectional design

BACKGROUND

Systematic evaluations of clinical placements are rare, especially when offered alongside academic postgraduate courses. An evidence-based approach is important to allow pedagogically-driven provision, rather than that solely governed by opinion or market demand. Our evaluation assessed a voluntary clinical placement scheme allied to a mental health course.

METHODS

Data were collected over academic years 2010/11- 2013/14, from participating students (n = 20 to 58) and clinician supervisors (n = 10-12), using a mixed-methods cross-sectional design. Quantitative evaluation captured information on uptake, dropout, resource use, attitudes and experience, using standardized (the Placement Evaluation Questionnaire; the Scale To Assess the Therapeutic Relationship - Clinical version and the University of Toronto Placement Supervisor Evaluation) and bespoke questionnaires and audit data. Qualitative evaluation comprised two focus groups (5 clinicians, 5 students), to investigate attitudes, experience, perceived benefits, disadvantages and desired future developments. Data were analysed using framework analysis to identify a priori and emergent themes.

RESULTS

High uptake (around 70 placements per annum), low dropout (2-3 students per annum; 5 %) and positive focus group comments suggested placements successfully provided added value and catered sufficiently to student demand. Students' responses confirmed that placements met expectations and the perception of benefit remained after completion with 70 % (n = 14) reporting an overall positive experience, 75 % (n = 15) reporting a pleasant learning experience, 60 % (n = 12) feeling that their clinical skills were enhanced and 85 % (n = 17) believing that it would benefit other students. Placements contributed the equivalent of seven full time unskilled posts per annum to local health care services. While qualitative data revealed perceived 'mutual benefit' for both students and clinicians, this was qualified by the inherent limitations of students' time and expertise. Areas for development included fostering learning around professionalism and students' confidence on placement.

CONCLUSIONS

The addition of healthcare placements to academic postgraduate taught courses can improve their attractiveness to applicants, benefit healthcare services and enhance students' perception of their learning experiences. Well-positioned and supported placement learning opportunities could become a key differentiator for academic courses, over potential competitors. However, the actual implications for student employability and achievement remain to be established.

Deliberately generated and imitated facial expressions of emotions in people with eating disorders

BACKGROUND

People with eating disorders have difficulties in socio emotional functioning that could contribute to maintaining the functional consequences of the disorder. This study aimed to explore the ability to deliberately generate (i.e., pose) and imitate facial expressions of emotions in women with anorexia (AN) and bulimia nervosa (BN), compared to healthy controls (HC).

METHODS

One hundred and three participants (36 AN, 25 BN, and 42 HC) were asked to pose and imitate facial expressions of anger, disgust, fear, happiness, and sadness. Their facial expressions were recorded and coded.

RESULTS

Participants with eating disorders (both AN and BN) were less accurate than HC when posing facial expressions of emotions. Participants with AN were less accurate compared to HC imitating facial expressions, whilst BN participants had a middle range performance. All results remained significant after controlling for anxiety, depression and autistic features.

LIMITATIONS

The relatively small number of BN participants recruited for this study.

CONCLUSIONS

The study findings suggest that people with eating disorders, particularly those with AN, have difficulties posing and imitating facial expressions of emotions. These difficulties could have an impact in social communication and social functioning. This is the first study to investigate the ability to pose and imitate facial expressions of emotions in people with eating disorders, and the findings suggest this area should be further explored in future studies.

Self-reported and performance based perfectionism in mothers of individuals with Anorexia Nervosa: a pilot study

BACKGROUND

Perfectionism is implicated in the development and maintenance of Anorexia Nervosa and there is some evidence that perfectionism may be elevated in family members. However to date there are no studies investigating behavioural aspects of perfectionism in unaffected mothers.

METHODS

Forty-one participants took part in this pilot study: 21 unaffected mothers of individuals with Anorexia Nervosa and 20 healthy control mothers. Participants completed two performance based tasks assessing perfectionism-a text replication task and a bead sorting task-along with self-report measures of perfectionism.

RESULTS

No group differences were found between unaffected AN mothers and HC mothers on performance measures of perfectionism.

DISCUSSION

The findings are discussed in relation to existing studies and clinical implications explored.

Emotion Recognition in Blended Facial Expressions in Women with Anorexia Nervosa

People with anorexia nervosa (AN) have difficulties in the social domain, and problems in the ability to recognise emotions in people's faces may contribute to these difficulties. This study aimed to investigate emotion recognition in women with AN and healthy controls (HC), using pictures of faces portraying blended emotions at different levels of ambiguity, which resemble real-life expressions more closely than prototypical expressions used in past studies. Seventy-seven participants (35 AN; 42 HC) completed the emotion recognition task. Results indicated that participants with AN were less accurate than HC recognising expressions of disgust, when shown less ambiguously. There were no differences in the recognition of other emotions. Participants with AN also showed response bias towards anger. These findings suggest a generally preserved ability to recognise emotions in women with AN, with the exception of disgust recognition. They also support previous findings of bias towards anger in AN patients.

Do Children and Adolescents with Anorexia Nervosa Display an Inefficient Cognitive Processing Style?

OBJECTIVE

This study aimed to examine neuropsychological processing in children and adolescents with Anorexia Nervosa (AN). The relationship of clinical and demographic variables to neuropsychological functioning within the AN group was also explored.

METHOD

The performance of 41 children and adolescents with a diagnosis of AN were compared to 43 healthy control (HC) participants on a number of neuropsychological measures.

RESULTS

There were no differences in IQ between AN and HC groups. However, children and adolescents with AN displayed significantly more perseverative errors on the Wisconsin Card Sorting Test, and lower Style and Central Coherence scores on the Rey Osterrieth Complex Figure Test relative to HCs.

CONCLUSION

Inefficient cognitive processing in the AN group was independent of clinical and demographic variables, suggesting it might represent an underlying trait for AN. The implications of these findings are discussed.

Aberrant function of learning and cognitive control networks underlie inefficient cognitive flexibility in anorexia nervosa: a cross-sectional fMRI study

Objectives

People with Anorexia Nervosa exhibit difficulties flexibly adjusting behaviour in response to environmental changes. This has previously been attributed to problematic behavioural shifting, characterised by a decrease in fronto-striatal activity. Additionally, alterations of instrumental learning, which relies on fronto-striatal networks, may contribute to the observation of inflexible behaviour. The authors sought to investigate the neural correlates of cognitive flexibility and learning in Anorexia Nervosa.

Method

Thirty-two adult females with Anorexia Nervosa and thirty-two age-matched female control participants completed the Wisconsin Card Sorting Task whilst undergoing functional magnetic resonance imaging. Event-related analysis permitted the comparison of cognitive shift trials against those requiring maintenance of rule-sets and allowed assessment of trials representing learning.

Results

Although both groups performed similarly, we found significant interactions in the left middle frontal gyrus, precuneus and superior parietal lobule whereby blood-oxygenated-level dependent response was higher in Anorexia Nervosa patients during shifting but lower when maintaining rule-sets, as compared to healthy controls. During learning, posterior cingulate cortex activity in healthy controls decreased whilst increasing in the Anorexia Nervosa group, whereas the right precuneus exhibited the opposite pattern. Furthermore, learning was associated with lower blood-oxygenated-level dependent response in the caudate body, as compared to healthy controls.

Conclusions

People with Anorexia Nervosa display widespread changes in executive function. Whilst cognitive flexibility appears to be associated with aberrant functioning of the fronto-parietal control network that mediates between internally and externally directed cognition, fronto-striatal alterations, particularly within the caudate body, were associated with instrumental learning. Together, this shows how perseverative tendencies could be a substrate of multiple high-order processes that may contribute to the maintenance of Anorexia Nervosa.