In first presentation adolescent anorexia nervosa, do cognitive markers of underweight status change with weight gain following a refeeding intervention?

[Therapy of Food Refusal and Anorexia Nervosa in German-Language Psychiatry Textbooks of the Past 200 Years]

The aim of this study was to describe how the therapy of anorexia nervosa (AN) and food refusal have been discussed in leading textbooks used in German-speaking academic psychiatry over the past 200 years. For this purpose, 18 textbooks of important school psychiatrists were selected. These were analyzed in a structured way to determine the content of the subject taught at universities in German-speaking countries at a given period. We found that AN was not taught as a distinct disorder until the end of the 20th century, although great attention had been paid to food refusal as a symptom and manifold therapeutic concepts had been developed much earlier. Whereas at the beginning of the 19th century forced feeding using feeding tubes was established, in the following years pharmacotherapies and special diets were developed. It is noteworthy that since the beginnings of academic psychiatry, some early forms of psychotherapy have been developed; for instance, special kinds of behavior were recommended when dealing with the patient, as the therapist was supposed to serve as a role model to encourage patients to eat. Treatment of food refusal by means of structured psychotherapeutic approaches were not established before AN was generally accepted as a distinct disease entity. The understanding of etiological factors that might lead to AN as well as potential psychotherapeutic interventions have changed fundamentally over the past decades.

Autobiographical memory following weight gain in adult patients with Anorexia Nervosa: A longitudinal study

BACKGROUND

Patients with anorexia nervosa (AN) show overgeneralization of memory (OGM) when generating autobiographical episodes related to food and body shape. These memories are central for the construction of a coherent self-concept, interpersonal relationships, and problem-solving abilities. The current study aims to investigate changes in autobiographical memory following weight gain.

METHODS

OGM was assessed with an adapted version of the Autobiographical Memory Test including food-, body-, depression-related, and neutral cues. N = 41 female patients with AN (28 restricting-, 13 binge-eating/purging-subtype; mean disease duration: 4.5 years; mean BMI: 14.5 kg/m2) and N = 27 healthy controls (HC) were included at baseline. After inpatient treatment (mean duration: 11 weeks), 24 patients with AN and 24 age-matched HC were reassessed. Group differences were assessed using independent samples t-tests for cross-sectional comparisons and repeated measures ANOVAs for longitudinal data.

RESULTS

At baseline, patients with AN generated significantly fewer specific memories than HC, independent of word category (F(1.66) = 27.167, p < 0.001). During inpatient stay, the average weight gain of patients with AN was 3.1 body mass index points. At follow-up, patients with AN showed a significant improvement in the number of specific memories for both depression-related and neutral cues, but not for food- and body-related cues.

CONCLUSIONS

Generalised OGM (i.e., independent of word category) in patients with AN before weight restoration may be a general incapacity to recall autobiographical memory. After weight gain, the previously well-studied pattern of eating disorder-related OGM emerges. The clinical relevance of the continuing disorder-related OGM in patients with AN after weight gain is discussed.

A Cognitive Biotype of Depression and Symptoms, Behavior Measures, Neural Circuits, and Differential Treatment Outcomes: A Prespecified Secondary Analysis of a Randomized Clinical Trial

Importance

Cognitive deficits in depression have been associated with poor functional capacity, frontal neural circuit dysfunction, and worse response to conventional antidepressants. However, it is not known whether these impairments combine together to identify a specific cognitive subgroup (or "biotype") of individuals with major depressive disorder (MDD), and the extent to which these impairments mediate antidepressant outcomes.

Objective

To undertake a systematic test of the validity of a proposed cognitive biotype of MDD across neural circuit, symptom, social occupational function, and treatment outcome modalities.

Design, Setting, and Participants

This secondary analysis of a randomized clinical trial implemented data-driven clustering in findings from the International Study to Predict Optimized Treatment in Depression, a pragmatic biomarker trial in which patients with MDD were randomized in a 1:1:1 ratio to antidepressant treatment with escitalopram, sertraline, or venlafaxine extended-release and assessed at baseline and 8 weeks on multimodal outcomes between December 1, 2008, and September 30, 2013. Eligible patients were medication-free outpatients with nonpsychotic MDD in at least the moderate range, and were recruited from 17 clinical and academic practices; a subset of these patients underwent functional magnetic resonance imaging. This prespecified secondary analysis was performed between June 10, 2022, and April 21, 2023.

Main Outcomes and Measures

Pretreatment and posttreatment behavioral measures of cognitive performance across 9 domains, depression symptoms assessed using 2 standard depression scales, and psychosocial function assessed using the Social and Occupational Functioning Assessment Scale and World Health Organization Quality of Life scale were analyzed. Neural circuit function engaged during a cognitive control task was measured using functional magnetic resonance imaging.

Results

A total of 1008 patients (571 [56.6%] female; mean [SD] age, 37.8 [12.6] years) participated in the overall trial and 96 patients participated in the imaging substudy (45 [46.7%] female; mean [SD] age, 34.5 [13.5] years). Cluster analysis identified what may be referred to as a cognitive biotype of 27% of depressed patients with prominent behavioral impairment in executive function and response inhibition domains of cognitive control. This biotype was characterized by a specific profile of pretreatment depressive symptoms, worse psychosocial functioning (d = -0.25; 95% CI, -0.39 to -0.11; P < .001), and reduced activation of the cognitive control circuit (right dorsolateral prefrontal cortex: d = -0.78; 95% CI, -1.28 to -0.27; P = .003). Remission was comparatively lower in the cognitive biotype positive subgroup (73 of 188 [38.8%] vs 250 of 524 [47.7%]; P = .04) and cognitive impairments persisted regardless of symptom change (executive function: ηp2 = 0.241; P < .001; response inhibition: ηp2 = 0.750; P < .001). The extent of symptom and functional change was specifically mediated by change in cognition but not the reverse.

Conclusions and Relevance

Our findings suggest the presence of a cognitive biotype of depression with distinct neural correlates, and a functional clinical profile that responds poorly to standard antidepressants and instead may benefit from therapies specifically targeting cognitive dysfunction.

Trial Registration

ClinicalTrials.gov Identifier: NCT00693849.

Phonological working memory is adversely affected in adults with anorexia nervosa: a systematic literature review

PURPOSE

Cognitive restraint has potentiating and deleterious effects on working memory (WM) in anorexia nervosa (AN). Conflicting evidence may be due to heterogeneity of tasks examining different WM components (e.g., verbal/auditory versus visuospatial), and differences in adolescent versus adult AN. Additionally, differential cognitive profiles of restricting versus binge/purging subtypes, comorbid psychiatric disorders and psychotropic medication use may confound findings.

METHODS

To address these conflicts, 25 studies, published between 2016 and 2021, investigating WM in children, adolescents and adults with AN were systematically reviewed using PRISMA guidelines.

RESULTS

In 71% of WM tasks, no difference in performance between AN patients and age-matched controls was reported, while 29% of WM tasks showed worse performance. Adults with AN displayed deficits in 44% of the verbal/auditory tasks, while performance remained unaffected in 86% of visuospatial tasks.

CONCLUSION

Examining age groups and WM subsystems separately revealed novel findings of differentially affected WM components in AN. Comorbidities and psychotropic medications were common among AN participants and should be regarded as critical confounding factors for WM measures. Future studies examining different components of WM, acknowledging these confounding factors, may reveal specific deficits in AN to aid treatment improvement strategies.

LEVEL OF EVIDENCE

I, systematic review.

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

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

Restrictive Eating Disorders: Accelerating Treatment Outcomes in the Medical Hospital

Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children's hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.

Cognitive Function in Adults with Enduring Anorexia Nervosa

Anorexia Nervosa (AN) is a severe and often enduring disorder characterized by restriction of food intake, low body weight, fear of weight gain, and distorted body image. Investigations on cognition performance in AN patients have yielded conflicting results. Using an established and sensitive computerized cognitive test battery, we aimed to assess core aspects of cognitive function, including attention span, information processing, reasoning, working and episodic memory, in AN patients and controls. Patients were recruited from the Danish Prospective Longitudinal all-comer inclusion study in Eating Disorders (PROLED). Included were 26 individuals with AN and 36 healthy volunteers (HV). All were tested with CogTrack (an online cognitive assessment system) at baseline, and AN patients were tested again at a follow-up time point after weight increase (n = 13). At baseline, AN patients showed faster reaction times in the attention tasks, as well as increased accuracy in grammatical reasoning compared to HV. There were no differences in cognitive function between AN patients and HV in the other cognitive domains measured (sustained attention, working and episodic memory, speed of retrieval, and speed of grammatical reasoning). No differences were visible in the AN sample between baseline and follow-up. Performance did not correlate with any clinical variables in the AN sample. These findings supplement results from other studies suggesting increased concentration and reasoning accuracy in patients suffering from AN, who showed increased performance in cognitive tasks despite their illness.

Cognitive improvement following weight gain in patients with anorexia nervosa: A systematic review

OBJECTIVE

Anorexia nervosa (AN) has been associated with cognitive impairment. While re-nutrition is one of the main treatment targets, the effect on cognitive impairments is unclear. The aim of this review was to examine whether cognitive functions improve after weight gain in patients with AN.

METHOD

A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses statement guidelines (PROSPERO CRD42019081993). Literature searches were conducted May 20^th , 2019 in PubMed, EMBASE, PsychINFO and Cochrane Library. Pairs of reviewers screened reports independently based on titles/abstracts (N = 6539) and full texts (N = 378). Furthermore, they assessed the quality of reports, including whether practice effects were accounted for.

RESULTS

Twenty-four longitudinal reports were included featuring 757 patients and 419 healthy controls. Six studies examined children and adolescents. Four out of four studies found processing speed to improve above and beyond what could be assigned to practice effects and three out of four studies found that cognitive flexibility was unaffected after weight gain in children and adolescents. Results from studies of adults were inconclusive.

DISCUSSION

The literature on cognitive change in patients with AN following weight gain is sparse. Preliminary conclusions can be made only for children and adolescents, where weight gain appeared to be associated with improved processing speed.

Evaluation of cognitive function in patients with severe anorexia nervosa before and after medical stabilization

BACKGROUND

The purpose of this study was to quantify cognitive deficits in severe anorexia nervosa (AN) before and after medical stabilization.

METHODS

This was a prospective study of 40 females between the ages of 18 and 50 admitted to a medical stabilization unit with severe AN (%IBW < 70). The primary outcome of the study was change in test scores on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline and after medical stabilization.

RESULTS

There were no statistically significant differences in baseline RBANS scores between AN patients overall and controls (p = 0.0940). There was a statistically significant change in RBANS from baseline 94.1 + 12.7 to medical stabilization 97.1 + 10.6 (p = 0.0173), although notably both mean values fell within the average range. There were no significant differences in baseline RBANS scores between controls and AN-BP patients (p = 0.3320) but significant differences were found between controls and AN-R patients (p = 0.0434).

CONCLUSIONS

No baseline deficits in cognition were found in this sample of women with severe AN.

Clinical, Psychopathological, Physical, and Sleep Evolution in Adolescents with Restrictive Anorexia Nervosa Participating in a Day Hospital Program

OBJECTIVE

To analyze the clinical, psychopathological, physical, and sleep-related evolution of adolescents with restricting-type of anorexia nervosa (AN-R) after 10 weeks of a daytime hospital program.

METHODS

Body composition, physical activity and sleep were measured objectively before and after 10 weeks of treatment. In addition, psychopathology and body image disturbances were measured with a self-report questionnaire.

RESULTS

Fourteen female adolescents with AN-R (14.3±1.6 years old) participated in the study. A significant increase was found in eight of the ten variables for body composition (p<0.05). There were no significant changes in psychopathology, body image disturbances or physical activity. Concerning sleep, a significant, moderately standardized and substantial increase in night latency was found (p=0.002), and there was a significant, small standardized and substantial decrease in night efficiency (p=0.035).

CONCLUSION

After 10 weeks of follow-up with adolescent patients with AN-R who attended a day hospital program, there was a positive evolution of body composition. However, with regard to sleep patterns, there was a worsening of latency and night efficiency. Therefore, sleep care should be addressed in acute treatment programs for adolescents with AN-R.

Lower gray matter volumes of frontal lobes and insula in adolescents with anorexia nervosa restricting type: Findings from a Brain Morphometry Study

BACKGROUND

Brain atrophy in anorexia nervosa (AN) is one of the most marked structural brain changes observed in mental disorders. In this study, we propose a whole brain analysis approach to characterize global and regional cerebral volumes in adolescents with restricting-type anorexia nervosa (AN-r).

METHODS

A total of 48 adolescent females (age range 13-18 years) were enrolled in the study (24 right-handed AN-r in the early stages of the illness and treated in the same clinical setting and 24 age-matched healthy controls [HC]). High-resolution T1-weighted magnetic resonance images were acquired. Cerebral volumes, including the total amounts of gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) were obtained with the Statistical Parametric Mapping software (SPM8); specific cortical regional volumes were computed by applying an atlas-based cortical parcellation to the SPM8 GM segments. Analysis of variance (ANOVA) was performed to identify any significant between-group differences in global and regional brain volumes.

RESULTS

The analyses revealed reduced total GM volumes (p = 0.02) and increased CSF (p = 0.05) in AN-r, compared with HC. No significant between-group difference was found in WM volumes. At the regional level, significantly lower GM volumes in both frontal lobes (p = 0.006) and in the left insula (p = 0.016) were detected. No significant relationships were found between cerebral volumes and duration of illness, psychiatric comorbidities, psychopharmacological treatment, prepubertal phase, or presence of amenorrhea.

CONCLUSIONS

The topographic distribution of GM reduction in a homogenous group of AN-r involves regions responsible for the emotional and cognitive deficits associated with the illness. These findings are discussed in relation to the roles of the insular cortex and the frontal lobes.

Clinical and personality characteristics of adolescents with anorexia nervosa with or without non-suicidal self-injurious behavior

PURPOSE

About one-fifth of patients with anorexia nervosa (AN) engage in non-suicidal self-injury (NSSI). This study examined clinical and temperament profile of female adolescents with both disorders (AN+NSSI) as compared with peers with AN only.

METHODS

A consecutive sample of 73 female adolescents with AN (mean age: 13.77 years), who had been admitted to inpatient or day-hospital services, received clinical, cognitive, and temperament/character evaluations. Of them, 32 met DSM-5 criteria also for NSSI. Assessments included demographics, standard nutrition parameters, Youth Self-Report (YSR), Wechsler Intelligence Scale for Children IV (WISC-IV), Temperament and Character Inventory (TCI), and Global Assessment of Functioning (GAF).

RESULTS

No differences were detected between AN+NSSI and AN in demographics, body mass index, or age at onset of AN. AN+NSSI had higher rate of binging and purging, higher YSR scores for both internalizing and externalizing psychopathology, lower total IQ, and lower Self-directedness and Cooperativeness scores.

CONCLUSIONS

These data suggest that adolescents with AN+NSSI have psychopathological, cognitive and overall character features that differ from patients with AN only. These characteristics may have implications for treatment and outcome.

The use of enteral nutrition in the treatment of eating disorders: a systematic review

PURPOSE

Enteral nutrition (EN) is frequently used in the treatment of anorexia nervosa (AN), and less commonly, bulimia nervosa (BN); yet, no standardized guidelines for treatment exist at this time. The aim of this review is to investigate the efficacy of EN in the treatment of eating disorders and make recommendations for clinical practice and future research.

METHODS

An exhaustive literature search of 7 databases was completed. The search strategy combined key terms anorexia nervosa, bulimia, and eating disorders with terms associated with EN. There were no restrictions on publication date or language. Studies that assessed the effect of EN on weight restoration, refeeding syndrome, and binge/purge behaviors in the treatment of AN and BN were included.

RESULTS

Of 73 full-text articles reviewed, 22 met inclusion criteria. Nineteen studies reported that significant short-term weight gain was achieved when EN was used for refeeding malnourished AN patients; however, results varied for the six studies reporting on long-term weight gain, maintenance, and recovery. In studies with a comparator, no significant differences were found between the EN and oral refeeding cohorts regarding gastrointestinal disturbance, refeeding syndrome, or electrolyte abnormalities. Five studies examined the effect of EN on binge/purge behaviors, suggesting that temporary exclusive EN decreases the frequency and severity of binge/purge episodes.

CONCLUSION

Although EN is an essential life-saving treatment in severe cases of AN, it does not guarantee long-term success or recovery. The results of this systematic review highlight the need for prospective controlled trials with adequate sample sizes to make comparisons between specific feeding methods, formulations, and defined short and long-term outcomes. Evidence-based standards for clinical practice are needed with specific guidelines for best results for AN and BN treatment.

LEVEL OF EVIDENCE

I, systematic review.

Cognitive Impairments in Abstinent Male Residents of a Therapeutic Community for Substance-Use Disorders: A Five-Year Retrospective Study

BACKGROUND AND OBJECTIVES

Prior studies of residual cognitive deficits in abstinent substance-use disorder (SUD) patients, exhibited conflicting reports and a substantial patient selection bias. The aim of this study was to test the cognitive function of a sample of chronic abstinent SUD patients in a therapeutic-community.

METHODS

The IntegNeuro^TM cognitive test battery was used for a retrospective cross-sectional study of cognitive functioning of an unselected sample (n = 105) of abstinent male residents of a therapeutic-community. The results were compared to a large age-, gender-, and education-matched normative cohort.

RESULTS

A significant negative deviance from the normal cohorts' mean was present in most of the cognitive test results and in all the cognitive domains that were tested. The most substantial deficit was found in the executive function domain (d = 1.02, 95%CI (±0.11)). Correct identification of facial emotions was significantly lower selectively in expressions of disgust and sadness. Substance-use starting at an early age (12.4 ± 0.8 years) was associated with lower performance in tests of sustained attention and impulsivity as well as with varied ability to identify correctly "negative" emotions in the emotion identification domain.

CONCLUSIONS

This 5-year retrospective study demonstrates substantial cognitive impairments in an unselected sample of abstinent SUD patients. Impairment in multiple cognitive domains may lower the probability for remission and successful social integration. Early-age substance initiation may be associated with larger impairments in cognitive performance.

Appetite Perceptions, Gastrointestinal Symptoms, Ghrelin, Peptide YY and State Anxiety Are Disturbed in Adolescent Females with Anorexia Nervosa and Only Partially Restored with Short-Term Refeeding

Factors underlying disturbed appetite perception in anorexia nervosa (AN) are poorly characterized. We examined in patients with AN whether fasting and postprandial appetite perceptions, gastrointestinal (GI) hormones, GI symptoms and state anxiety (i) differed from healthy controls (HCs) and (ii) were modified by two weeks of refeeding. 22 female adolescent inpatients with restricting AN, studied on hospital admission once medically stable (Wk0), and after one (Wk1) and two (Wk2) weeks of high-calorie refeeding, were compared with 17 age-matched HCs. After a 4 h fast, appetite perceptions, GI symptoms, state anxiety, and plasma acyl-ghrelin, cholecystokinin (CCK), peptide tyrosine tyrosine (PYY) and pancreatic polypeptide (PP) concentrations were assessed at baseline and in response to a mixed-nutrient test-meal (479 kcal). Compared with HCs, in patients with AN at Wk0, baseline ghrelin, PYY, fullness, bloating and anxiety were higher, and hunger less, and in response to the meal, ghrelin, bloating and anxiety were greater, and hunger less (all p < 0.05). After two weeks of refeeding, there was no change in baseline or postprandial ghrelin or bloating, or postprandial anxiety, but baseline PYY, fullness and anxiety decreased, and baseline and postprandial hunger increased (p < 0.05). We conclude that in AN, refeeding for 2 weeks was associated with improvements in PYY, appetite and baseline anxiety, while increased ghrelin, bloating and postprandial anxiety persisted.

Attention networks in adolescent anorexia nervosa

Anorexia nervosa (AN) usually develops during adolescence when considerable structural and functional brain changes are taking place. Neurocognitive inefficiencies have been consistently found in adults with enduring AN and were suggested to play a role in maintaining the disorder. However, such findings are inconsistent in children and adolescents with AN. The current study conducted a comprehensive assessment of attention networks in adolescents with AN who were not severely underweight during the study using an approach that permits disentangling independent components of attention. Twenty partially weight-restored adolescents with AN (AN-WR) and 24 healthy adolescents performed the Attention Network Test which assesses the efficiency of three main attention networks-executive control, orienting, and alerting. The results revealed abnormal function in the executive control network among adolescents with AN-WR. Specifically, adolescents with AN-WR demonstrated superior ability to suppress attention to task-irrelevant information while focusing on a central task. Moreover, the alerting network modulated this ability. No difference was found between the groups in the speed of orienting attention, but reorienting attention to a target resulted in higher error rates in the AN-WR group. The findings suggest that adolescents with AN have attentional abnormalities that cannot be explained by a state of starvation. These attentional dysregulations may underlie clinical phenotypes of the disorder such as increased attention of details.

"Motoring in idle": The default mode and somatomotor networks are overactive in children and adolescents with functional neurological symptoms

Objective

Children and adolescents with functional neurological symptom disorder (FND) present with diverse neurological symptoms not explained by a disease process. Functional neurological symptoms have been conceptualized as somatoform dissociation, a disruption of the brain's intrinsic organization and reversion to a more primitive level of function. We used EEG to investigate neural function and functional brain organization in children/adolescents with FND.

Method

EEG was recorded in the resting eyes-open condition in 57 patients (aged 8.5-18 years) and 57 age- and sex-matched healthy controls. Using a topographical map, EEG power data were quantified for regions of interest that define the default mode network (DMN), salience network, and somatomotor network. Source localization was examined using low-resolution brain electromagnetic tomography (LORETA). The contributions of chronic pain and arousal as moderators of differences in EEG power were also examined.

Results

Children/adolescents with FND had excessive theta and delta power in electrode clusters corresponding to the DMN-both anteriorly (dorsomedial prefrontal cortex [dmFPC]) and posteriorly (posterior cingulate cortex [PCC], precuneus, and lateral parietal cortex)-and in the premotor/supplementary motor area (SMA) region. There was a trend toward increased theta and delta power in the salience network. LORETA showed activation across all three networks in all power bands and localized neural sources to the dorsal anterior cingulate cortex/dmPFC, mid cingulate cortex, PCC/precuneus, and SMA. Pain and arousal contributed to slow wave power increases in all three networks.

Conclusions

These findings suggest that children and adolescents with FND are characterized by overactivation of intrinsic resting brain networks involved in threat detection, energy regulation, and preparation for action.

Transdiagnostic Symptom Clusters and Associations With Brain, Behavior, and Daily Function in Mood, Anxiety, and Trauma Disorders

IMPORTANCE

The symptoms that define mood, anxiety, and trauma disorders are highly overlapping across disorders and heterogeneous within disorders. It is unknown whether coherent subtypes exist that span multiple diagnoses and are expressed functionally (in underlying cognition and brain function) and clinically (in daily function). The identification of cohesive subtypes would help disentangle the symptom overlap in our current diagnoses and serve as a tool for tailoring treatment choices.

OBJECTIVE

To propose and demonstrate 1 approach for identifying subtypes within a transdiagnostic sample.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from the Brain Research and Integrative Neuroscience Network Foundation Database that had been collected at the University of Sydney and University of Adelaide between 2006 and 2010 and replicated at Stanford University between 2013 and 2017. The study included 420 individuals with a primary diagnosis of major depressive disorder (n = 100), panic disorder (n = 53), posttraumatic stress disorder (n = 47), or no disorder (healthy control participants) (n = 220). Data were analyzed between October 2016 and October 2017.

MAIN OUTCOMES AND MEASURES

We followed a data-driven approach to achieve the primary study outcome of identifying transdiagnostic subtypes. First, machine learning with a hierarchical clustering algorithm was implemented to classify participants based on self-reported negative mood, anxiety, and stress symptoms. Second, the robustness and generalizability of the subtypes were tested in an independent sample. Third, we assessed whether symptom subtypes were expressed at behavioral and physiological levels of functioning. Fourth, we evaluated the clinically meaningful differences in functional capacity of the subtypes. Findings were interpreted relative to a complementary diagnostic frame of reference.

RESULTS

Four hundred twenty participants with a mean (SD) age of 39.8 (14.1) years were included in the final analysis; 256 (61.0%) were female. We identified 6 distinct subtypes characterized by tension (n=81; 19%), anxious arousal (n=55; 13%), general anxiety (n=38; 9%), anhedonia (n=29; 7%), melancholia (n=37; 9%), and normative mood (n=180; 43%), and these subtypes were replicated in an independent sample. Subtypes were expressed through differences in cognitive control (F5,383 = 5.13, P < .001, ηp2 = 0.063), working memory (F5,401 = 3.29, P = .006, ηp2 = 0.039), electroencephalography-recorded β power in a resting paradigm (F5,357 = 3.84, P = .002, ηp2 = 0.051), electroencephalography-recorded β power in an emotional paradigm (F5,365 = 3.56, P = .004, ηp2 = 0.047), social functional capacity (F5,414 = 21.33, P < .001, ηp2 = 0.205), and emotional resilience (F5,376 = 15.10, P < .001, ηp2 = 0.171).

CONCLUSIONS AND RELEVANCE

These findings offer a data-driven framework for identifying robust subtypes that signify specific, coherent, meaningful associations between symptoms, behavior, brain function, and observable real-world function, and that cut across DSM-IV-defined diagnoses of major depressive disorder, panic disorder, and posttraumatic stress disorder.

Neurocognitive Impairments Are More Severe in the Binge-Eating/Purging Anorexia Nervosa Subtype Than in the Restricting Subtype

Objective: To evaluate cognitive function impairment in patients with anorexia nervosa (AN) of either the restricting (ANR) or binge-eating/purging (ANBP) subtype. Method: We administered the Japanese version of the MATRICS Consensus Cognitive Battery to 22 patients with ANR, 18 patients with ANBP, and 69 healthy control subjects. Our participants were selected from among the patients at the Kobe University Hospital and community residents. Results: Compared to the healthy controls, the ANR group had significantly lower visual learning and social cognition scores, and the ANBP group had significantly lower processing speed, attention/vigilance, visual learning, reasoning/problem-solving, and social cognition scores. Compared to the ANR group, the ANBP group had significantly lower attention/vigilance scores. Discussion: The AN subtypes differed in cognitive function impairments. Participants with ANBP, which is associated with higher mortality rates than ANR, exhibited greater impairment severities, especially in the attention/vigilance domain, confirming the presence of impairments in continuous concentration. This may relate to the impulsivity, an ANBP characteristic reported in the personality research. Future studies can further clarify the cognitive impairments of each subtype by addressing the subtype cognitive functions and personality characteristics.

Feasibility Study Combining Art Therapy or Cognitive Remediation Therapy with Family-based Treatment for Adolescent Anorexia Nervosa

Adolescents with anorexia nervosa who have obsessive-compulsive (OC) features respond poorly to family-based treatment (FBT). This study evaluated the feasibility of combining FBT with either cognitive remediation therapy (CRT) or art therapy (AT) to improve treatment response in this at-risk group. Thirty adolescents with anorexia nervosa and OC features were randomized to 15 sessions of FBT + CRT or AT. Recruitment rate was 1 per month, and treatment attrition was 16.6% with no differences between groups. Suitability, expectancy and therapeutic relationships were acceptable for both combinations. Correlations between changes in OC traits and changes in cognitive inefficiencies were found for both combinations. Moderate changes in cognitive inefficiencies were found in both groups but were larger in the FBT + AT combination. This study suggests that an RCT for poor responders to FBT because of OC traits combining FBT with either CRT or AT is feasible to conduct. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

The Role of Working Memory for Cognitive Control in Anorexia Nervosa versus Substance Use Disorder

Prefrontal cortex executive functions, such as working memory (WM) interact with limbic processes to foster impulse control. Such an interaction is referred to in a growing body of publications by terms such as cognitive control, cognitive inhibition, affect regulation, self-regulation, top-down control, and cognitive–emotion interaction. The rising trend of research into cognitive control of impulsivity, using various related terms reflects the importance of research into impulse control, as failure to employ cognitions optimally may eventually result in mental disorder. Against this background, we take a novel approach using an impulse control spectrum model – where anorexia nervosa (AN) and substance use disorder (SUD) are at opposite extremes – to examine the role of WM for cognitive control. With this aim, we first summarize WM processes in the healthy brain in order to frame a systematic review of the neuropsychological, neural and genetic findings of AN and SUD. In our systematic review of WM/cognitive control, we found n = 15 studies of AN with a total of n = 582 AN and n = 365 HC participants; and n = 93 studies of SUD with n = 9106 SUD and n = 3028 HC participants. In particular, we consider how WM load/capacity may support the neural process of excessive epistemic foraging (cognitive sampling of the environment to test predictions about the world) in AN that reduces distraction from salient stimuli. We also consider the link between WM and cognitive control in people with SUD who are prone to ‘jumping to conclusions’ and reduced epistemic foraging. Finally, in light of our review, we consider WM training as a novel research tool and an adjunct to enhance treatment that improves cognitive control of impulsivity.

Grey matter abnormalities in children and adolescents with functional neurological symptom disorder

Objective

Functional neurological symptom disorder refers to the presence of neurological symptoms not explained by neurological disease. Although this disorder is presumed to reflect abnormal function of the brain, recent studies in adults show neuroanatomical abnormalities in brain structure. These structural brain abnormalities have been presumed to reflect long-term adaptations to the disorder, and it is unknown whether child and adolescent patients, with illness that is typically of shorter duration, show similar deficits or have normal brain structure.

Method

High-resolution, three-dimensional T1-weighted magnetic resonance images (MRIs) were acquired in 25 patients (aged 10–18 years) and 24 healthy controls. Structure was quantified in terms of grey matter volume using voxel-based morphometry. Post hoc, we examined whether regions of structural difference related to a measure of motor readiness to emotional signals and to clinical measures of illness duration, illness severity, and anxiety/depression.

Results

Patients showed greater volumes in the left supplementary motor area (SMA) and right superior temporal gyrus (STG) and dorsomedial prefrontal cortex (DMPFC) (corrected p < 0.05). Previous studies of adult patients have also reported alterations of the SMA. Greater SMA volumes correlated with faster reaction times in identifying emotions but not with clinical measures.

Conclusions

The SMA, STG, and DMPFC are known to be involved in the perception of emotion and the modulation of motor responses. These larger volumes may reflect the early expression of an experience-dependent plasticity process associated with increased vigilance to others' emotional states and enhanced motor readiness to organize self-protectively in the context of the long-standing relational stress that is characteristic of this disorder.

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We used high-resolution MRI to investigate brain structure in children presenting with acute functional neurological symptom disorder (FND).

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Patients had multiple antecedent stressors, a long-standing history of relational stress and at-risk attachment strategies.

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Patients had greater volumes in the SMA—where motor-, cognitive-, and emotion-processing signals interact to influence motor function.

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FND may involve experience-dependent changes in brain structure alongside experience-dependent changes in brain function.

Meaningful Memory in Acute Anorexia Nervosa Patients-Comparing Recall, Learning, and Recognition of Semantically Related and Semantically Unrelated Word Stimuli

OBJECTIVE

It is unclear whether observed memory impairment in anorexia nervosa (AN) depends on the semantic structure (categorized words) of material to be encoded. We aimed to investigate the processing of semantically related information in AN.

METHOD

Memory performance was assessed in a recall, learning, and recognition test in 27 adult women with AN (19 restricting, 8 binge-eating/purging subtype; average disease duration: 9.32 years) and 30 healthy controls using an extended version of the Rey Auditory Verbal Learning Test, applying semantically related and unrelated word stimuli.

RESULTS

Short-term memory (immediate recall, learning), regardless of semantics of the words, was significantly worse in AN patients, whereas long-term memory (delayed recall, recognition) did not differ between AN patients and controls.

DISCUSSION

Semantics of stimuli do not have a better effect on memory recall in AN compared to CO. Impaired short-term versus long-term memory is discussed in relation to dysfunctional working memory in AN. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Nasogastric Tube Feeding for Individuals With Anorexia Nervosa: An Integrative Review

BACKGROUND

The use of nasogastric (NG) feeding in individuals with anorexia nervosa (AN) is endorsed by national professional organizations; however, no guidelines currently exist.

OBJECTIVES

The objectives of this review were to identify and evaluate outcomes of NG feedings for individuals with AN and to develop recommendations for future research, policy, and practice.

DESIGN

An integrative review of the research literature was conducted.

RESULTS

Of the 19 studies reviewed, all indicated short-term weight gain following NG feeding. Four studies examined adherence; nearly 30% of subjects were nonadherent as evidenced by tube manipulation. Seven studies reported psychiatric outcomes, suggesting NG feeding reduces eating disorder behaviors but not overall symptomology.

CONCLUSIONS

NG feeding promotes short-term weight gain; however, long-term outcomes are poorly understood. Future research, using rigorous methods, is still needed to inform practice.

Impact of short-term refeeding on appetite and meal experiences in new onset adolescent eating disorders

Restrictive eating disorders (ED) are increasing and represent a serious risk to the health of adolescent females. Restrictive ED in youth are often treated through aggressive short-term refeeding. Although evidence supports that this intervention is the "gold standard" for improving ED outcomes in youth, little research has specifically probed appetite and meal-related responses to this type of intensive, short-term refeeding in newly diagnosed individuals. Information about appetite and meal-related dysfunction could provide valuable insights regarding treatment-interfering features of ED in both acute inpatient and longer-term outpatient treatment. The purpose of this study was to evaluate the hunger, fullness, olfactory, and gustatory responses of adolescents with newly-diagnosed restrictive ED and to probe how and when these responses are altered by refeeding. Using a quasi-experimental ecologically valid methodology, this study described and compared profiles of hunger, fullness, olfactory, and gustatory responses in adolescent females (n = 15) with newly diagnosed restrictive ED at hospital admission (i.e., severe malnutrition) and after medical refeeding, in comparison to healthy controls (n = 15). Results showed that newly diagnosed (i.e., malnourished) adolescents with ED showed significantly different meal-related experiences than controls. Refeeding improved some of these differences, but not all. Following refeeding, females with ED continued to show lower hunger, greater fullness, and lower pleasantness of smell ratings compared to controls. Unpleasantness of taste ratings maladaptively increased, such that females who were re-fed reported more aversive scents than pre-treatment. Profiles of meal-related responses were also identified and compared between groups. The applicability of these findings are discussed within the context of critical periods of change during refeeding treatment and potentially promising intervention targets that might enhance treatment outcomes for adolescents with newly onset, restrictive ED.

Are Weight Status and Cognition Associated? An Examination of Cognitive Development in Children and Adolescents with Anorexia Nervosa 1 Year after First Hospitalisation

Objective

The aim of this study was to characterise the association between the cognitive profile and weight restoration in children and adolescents with anorexia nervosa.

Methods

The study was a longitudinal, matched case–control, multicentre study. An assessment of cognitive functions was conducted by using the Wechsler Intelligence Scale for Children–III/the Wechsler Adult Intelligence Scale–III, the Test of Memory and Learning–second edition, Trail Making Tests A and B, the Rey–Osterrieth Complex Figure Test and the Cambridge Neuropsychological Test Automated Battery.

Results

One hundred twenty individuals, 60 patients with anorexia nervosa with mean age of 14.65 (SD 1.820) years and 60 healthy controls with mean age of 14.76 (SD 1.704) years, participated. No association was found between weight recovery and cognitive functions. However, a significant increase in motor speed was found in Trail Making Test A (p = 0.004), Reaction Time (RTI) five‐choice movement time (p = 0.002) and RTI simple movement time (p = 0.011), resulting in a normalisation corresponding to that found in healthy controls. Furthermore, a significantly lower score in the perceptual organization index (p = 0.029) was found at follow‐up.

Conclusions

Weight recovery appears not to be associated with cognition. Copyright © 2016 The Authors European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd

A systematic review of approaches to refeeding in patients with anorexia nervosa

OBJECTIVE

Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings.

METHODS

Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic.

RESULTS

Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown;

DISCUSSION

Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.

A debate on working memory and cognitive control: can we learn about the treatment of substance use disorders from the neural correlates of anorexia nervosa?

BACKGROUND

Anorexia Nervosa (AN) is a debilitating, sometimes fatal eating disorder (ED) whereby restraint of appetite and emotion is concomitant with an inflexible, attention-to-detail perfectionist cognitive style and obsessive-compulsive behaviour. Intriguingly, people with AN are less likely to engage in substance use, whereas those who suffer from an ED with a bingeing component are more vulnerable to substance use disorder (SUD).

DISCUSSION

This insight into a beneficial consequence of appetite control in those with AN, which is shrouded by the many other unhealthy, excessive and deficit symptoms, may provide some clues as to how the brain could be trained to exert better, sustained control over appetitive and impulsive processes. Structural and functional brain imaging studies implicate the executive control network (ECN) and the salience network (SN) in the neuropathology of AN and SUD. Additionally, excessive employment of working memory (WM), alongside more prominent cognitive deficits may be utilised to cope with the experience of negative emotions and may account for aberrant brain function. WM enables mental rehearsal of cognitive strategies while regulating, restricting or avoiding neural responses associated with the SN. Therefore, high versus low WM capacity may be one of the factors that unites common cognitive and behavioural symptoms in those suffering from AN and SUD respectively. Furthermore, emerging evidence suggests that by evoking neural plasticity in the ECN and SN with WM training, improvements in neurocognitive function and cognitive control can be achieved. Thus, considering the neurocognitive processes of excessive appetite control and how it links to WM in AN may aid the application of adjunctive treatment for SUD.

Comprehensive neurocognitive assessment of patients with anorexia nervosa

AIM: To utilise a comprehensive cognitive battery to gain a better understanding of cognitive performance in anorexia nervosa (AN).

METHODS: Twenty-six individuals with AN and 27 healthy control participants matched for age, gender and premorbid intelligence, participated in the study. A standard cognitive battery, the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery, was used to investigate performance on seven cognitive domains with the use of 10 different tasks: speed of processing [Brief Assessment Of Cognition In Schizophrenia: Symbol Coding, Category Fluency: Animal Naming (Fluency) and Trail Making Test: Part A], attention/vigilance [Continuous Performance Test - Identical Pairs (CPT-IP)], working memory [Wechsler Memory Scale (WMS^®-III): Spatial Span, and Letter-Number Span (LNS)], verbal learning [Hopkins Verbal Learning Test - Revised], visual learning [Brief Visuospatial Memory Test - Revised], reasoning and problem solving [Neuropsychological Assessment Battery: Mazes], and social cognition [Mayer-Salovey-Caruso Emotional Intelligence Test: Managing Emotions]. Statistical analyses involved the use of multivariate and univariate analyses of variance.

RESULTS: Analyses conducted on the cognitive domain scores revealed no overall significant difference between groups nor any interaction between group and domain score [F(1,45) = 0.73, P = 0.649]. Analyses conducted on each of the specific tasks within the cognitive domains revealed significantly slower reaction times for false alarm responses on the CPT-IP task in AN [F(1,51) = 12.80, P < 0.01, Cohen’s d = 0.982] and a trend towards poorer performance in AN on the backward component of the WMS^®-III Spatial Span task [F(1,51) = 5.88, P = 0.02, Cohen’s d = -0.665]. The finding of slower reaction times of false alarm responses is, however, limited due to the small number of false alarm responses for either group.

CONCLUSION: The findings are discussed in terms of poorer capacity to manipulate and process visuospatial material in AN.

Neuropsychological assessment in adolescents with anorexia nervosa - exploring the relationship between self-report and performance-based testing

OBJECTIVE

Research investigating the relationship between neuropsychological test performances and self-reported cognitive functioning in patients with anorexia nervosa (AN) is limited, and existing experimental studies only demonstrate a low-to-moderate relationship between the performance based tests and everyday behaviour. The objective of the current study was to explore the association between neuropsychological test performance and self-reports of executive functioning in adolescents with AN.

METHOD

Twenty adolescent females diagnosed with AN, aged 13 to 18, completed neuropsychological test battery "the Ravello Profile" and the self-report version of the Behaviour Rating Inventory of Executive Function (BRIEF-SR). The BRIEF Parent Form (BRIEF-PF) was employed to provide additional information of the patients' executive functioning.

RESULTS

Based on group level analyses, the results support the existing literature in failing to find consistent weaknesses in neuropsychological functioning in adolescents with AN. Further, with few exceptions, the Ravello Profile was insubstantially correlated with the majority of the BRIEF clinical scales, indicative of a lack of association between these two assessment methods.

CONCLUSION

The current study accentuates the need for concern regarding the generalizability of neuropsychological assessments in adolescent patients with AN.

Verbal Versus Figural Fluency Tests in Currently Ill and Weight Restored Anorexia Nervosa Patients

Fluency tests allow domain-specific assessment of verbal and non-verbal executive functions (EF) comparison and also enable utilizing of both quantitative and qualitative scoring methods. Thirty-five currently ill anorexia nervosa patients (PANs), 33 weight-restored patients (WRAN) and 47 healthy controls (HCs) were administered the word fluency test and the five-point test. Results show that WRANs tended to perseverate more than HCs in the verbal-fluency test. In addition, PANs produced significantly less correct figures and perseverated more than HCs and WRANs; HCs used more strategy methods than PANs and WRANs. Additionally, a positive correlation was found in the HC group between the total number of words in the verbal phonemic test and the number of designs produced and the number of correct designs. No such correlations were found in both anorexia groups. In conclusion, there is a differentiation between verbal and non-verbal EF in PANs and WRANs, showing a deficiency in the non-verbal domain. These findings may contribute to our understanding of the cognitive nature of the disorder.

Integrating fundamental concepts of obesity and eating disorders: implications for the obesity epidemic

Physiological mechanisms promote weight gain after famine. Because eating disorders, obesity, and dieting limit food intake, they are famine-like experiences. The development of the concept of meeting an ideal weight was the beginning of increasing obesity. Weight stigma, the perception of being fat, lack of understanding of normal growth and development, and increased concern about obesity on the part of health providers, parents, and caregivers have reinforced each other to promote dieting. Because weight suppression and disinhibition provoke long-term weight increase, dieting is a major factor producing the obesity epidemic. The integrated eating disorder-obesity theory included in this article emphasizes that, contrary to dieters, lifetime weight maintainers depend on physiological processes to control weight and experience minimal weight change.

First results of a refeeding program in a psychiatric intensive care unit for patients with extreme anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is associated with a high mortality rate. This study describes a compulsory re-feeding program established in Munich for extremely underweight patients.

METHODS

The contract between the patient and the therapeutic team included mandatory inpatient status, establishment of guardianship and compulsory re-feeding with a percutaneous gastric feeding tube, as indicated. The predefined target was a body mass index (BMI) of 17 kg/m(2). Data on the first 68 patients with AN are presented.

RESULTS

65 (95.6%) patients were female and mean age at admission was 26.5 ± 8.5 years. BMI increased from 12.3 ± 1.4 kg/m(2) at admission to 16.7 ± 1.7 kg/m(2) at discharge. Thirty-two (47.1%) patients had the restrictive subtype (ANR) and 36 (52.9%) had the binging and purging subtype (ANBP). Duration of illness before admission (p = .004), days of treatment until discharge (p = .001) and weight increase (p = .02) were significantly different between subgroups in favor of patients with ANR. Also, seasonal differences could be found. Comparison of feeding methods showed that percutaneous tube feeding was superior. Almost half of the patients were treated with psychotropic medication. To date, however, the number of patients included in this program is too small to assess rare complications of this acute treatment program and long term outcomes of AN.

CONCLUSIONS

An intensive care program for severely ill AN patients has been successfully established. Besides averting physical harm in the short term, this program was designed to enable these patients to participate in more sophisticated psychotherapeutic programs afterwards. To our knowledge, this is the first such program that regularly uses percutaneous feeding tubes.

Cognitive profile of children and adolescents with anorexia nervosa

Objective

Few studies of cognitive functioning in children and adolescents with anorexia nervosa (AN) have been conducted. The aim of this study was to examine the neurocognitive and intelligence profile of this clinical group.

Method

The study was a matched case–control (N = 188), multi-centre study including children and adolescents with AN (N = 94) and healthy control participants (N = 94).

Results

The results suggest that Full Scale Intelligence Quotient (Wechsler Intelligence Scale for Children-III/Wechsler Adult Intelligence Scale-III) in this patient group is close to the normal population mean of 100. Individuals with AN exhibited significantly worse performance in nonverbal intelligence functions (i.e. Wechsler Intelligence Scale for Children-III/Wechsler Adult Intelligence Scale-III, Perceptual Organization Index) and in verbal memory (Test of Memory and Learning—Second Edition, Memory for Stories) and motor speed (Cambridge Neuropsychological Test Automated Battery, Simple and Choice Reaction Time) compared with healthy control participants. No significant difference in set-shifting ability (Cambridge Neuropsychological Test Automated Battery, Intra-Extra Dimensional Set Shift and Trail Making Test B) was found.

Conclusions

Inefficiency in nonverbal intelligence functions and in specific cognitive functions was found in this study of children and adolescents with AN. © 2014 The Authors. European Eating Disorders Review published by John Wiley & Sons, Ltd.

Neuropsychology of eating disorders: 1995-2012

Eating disorders are considered psychiatric pathologies that are characterized by pathological worry related to body shape and weight. The lack of progress in treatment development, at least in part, reflects the fact that little is known about the pathophysiologic mechanisms that account for the development and persistence of eating disorders. The possibility that patients with eating disorders have a dysfunction of the central nervous system has been previously explored; several studies assessing the relationship between cognitive processing and certain eating behaviors have been conducted. These studies aim to achieve a better understanding of the pathophysiology of such diseases. The aim of this study was to review the current state of neuropsychological studies focused on eating disorders. This was done by means of a search process covering three relevant electronic databases, as well as an additional search on references included in the analyzed papers; we also mention other published reviews obtained by handsearching.

Set-shifting among adolescents with anorexia nervosa

OBJECTIVE

Set-shifting difficulties are documented for adults with anorexia nervosa (AN). However, AN typically onsets in adolescents and it is unclear if set-shifting difficulties are a result of chronic AN or present earlier in its course. This study examined whether adolescents with short duration AN demonstrated set-shifting difficulties compared to healthy controls (HC).

METHOD

Data on set-shifting collected from the Delis-Kaplan executive functioning system and Wisconsin card sort task (WCST) as well as eating psychopathology were collected from 32 adolescent inpatients with AN and compared with those from 22 HCs.

RESULTS

There were no differences in set-shifting in adolescents with AN compared to HCs on most measures.

DISCUSSION

The findings suggest that set-shifting difficulties in AN may be a consequence of AN. Future studies should explore set-shifting difficulties in a larger sample of adolescents with the AN to determine if there is sub-set of adolescents with these difficulties and determine any relationship of set-shifting to the development of a chronic from of AN.

Cognitive set-shifting in anorexia nervosa

OBJECTIVE

Adult anorexia nervosa (AN) is associated with inefficient cognitive flexibility and set-shifting. Whether such inefficiencies also characterize adolescent AN is an important area of research.

METHOD

Adolescents with AN and matched controls were administered a computerized task that required initial learning of an explicit rule using corrective feedback and learning of a new rule after a set number of trials. Adult patients with AN and controls were also examined.

RESULTS

Adolescents with AN did not differ from matched controls with respect to set-shifting cost (decrease in performance after rule change), whereas adults with AN had significantly greater set-shifting cost compared with controls.

DISCUSSION

This study suggests that set-shifting inefficiencies may not be a vulnerability factor for AN development in adolescents with AN, but might become an important aspect of the disorder at later age, and could point towards developmental neurobiologic brain changes that could affect AN at different ages.

International Study to Predict Optimized Treatment for Depression (iSPOT-D), a randomized clinical trial: rationale and protocol

Background

Clinically useful treatment moderators of Major Depressive Disorder (MDD) have not yet been identified, though some baseline predictors of treatment outcome have been proposed. The aim of iSPOT-D is to identify pretreatment measures that predict or moderate MDD treatment response or remission to escitalopram, sertraline or venlafaxine; and develop a model that incorporates multiple predictors and moderators.

Methods/Design

The International Study to Predict Optimized Treatment - in Depression (iSPOT-D) is a multi-centre, international, randomized, prospective, open-label trial. It is enrolling 2016 MDD outpatients (ages 18-65) from primary or specialty care practices (672 per treatment arm; 672 age-, sex- and education-matched healthy controls). Study-eligible patients are antidepressant medication (ADM) naïve or willing to undergo a one-week wash-out of any non-protocol ADM, and cannot have had an inadequate response to protocol ADM. Baseline assessments include symptoms; distress; daily function; cognitive performance; electroencephalogram and event-related potentials; heart rate and genetic measures. A subset of these baseline assessments are repeated after eight weeks of treatment. Outcomes include the 17-item Hamilton Rating Scale for Depression (primary) and self-reported depressive symptoms, social functioning, quality of life, emotional regulation, and side-effect burden (secondary). Participants may then enter a naturalistic telephone follow-up at weeks 12, 16, 24 and 52. The first half of the sample will be used to identify potential predictors and moderators, and the second half to replicate and confirm.

Discussion

First enrolment was in December 2008, and is ongoing. iSPOT-D evaluates clinical and biological predictors of treatment response in the largest known sample of MDD collected worldwide.

Trial registration

International Study to Predict Optimised Treatment - in Depression (iSPOT-D) ClinicalTrials.gov Identifier: NCT00693849

URL: http://clinicaltrials.gov/ct2/show/NCT00693849?term=International+Study+to+Predict+Optimized+Treatment+for+Depression&rank=1

Using brain-based cognitive measures to support clinical decisions in ADHD

Measures of cognition support diagnostic and treatment decisions in attention deficit hyperactivity disorder. We used an integrative neuroscience framework to assess cognition and associated brain-function correlates in large attention deficit hyperactivity disorder and healthy groups. Matched groups of 175 attention deficit hyperactivity disorder children/adolescents and 175 healthy control subjects were assessed clinically, with the touch screen-based cognitive assessment battery "IntegNeuro" (Brain Resource Ltd., Sydney, Australia) and the "LabNeuro" (Brain Resource Ltd., Sydney, Australia) platform for psychophysiologic recordings of brain function and body arousal. IntegNeuro continuous performance task measures of sustained attention classified 68% of attention deficit hyperactivity disorder patients with 76% specificity, consistent with previous reports. Our additional cognitive measures of impulsivity, intrusive errors, inhibition, and response variability improved sensitivity to 88%, and specificity to 91%. Positive predictive power was 96%, and negative predictive power, 88%. These metrics were stable across attention deficit hyperactivity disorder subtypes and age. Consistent with their brain-based validity, cognitive measures were correlated with corresponding brain-function and body-arousal measures. We propose a combination of candidate cognitive "markers" that define a signature for attention deficit hyperactivity disorder: "sustained attention," "impulsivity," "inhibition," "intrusions," and "response variability." These markers offer a frame of reference to support diagnostic and treatment decisions, and an objective benchmark for monitoring outcomes of interventions.