Personality, clinical features, and test instructions can affect executive functions in Eating Disorders

Testing associations between assessments of cognitive flexibility and eating disorder symptoms in adolescent bulimia nervosa

OBJECTIVE

Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents.

METHODS

Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT).

RESULTS

Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT.

DISCUSSION

The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes.

PUBLIC SIGNIFICANCE

Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impulsivity and compulsivity in gambling disorder and bulimic spectrum eating disorders: Analysis of neuropsychological profiles and sex differences

BACKGROUND

Gambling disorder (GD) and bulimic spectrum eating disorders (BSDs) not only share numerous psychopathological, neurobiological, and comorbidity features but also are distinguished by the presence of inappropriate behaviours related to impulsivity and compulsivity. This study aimed to emphasise the differences and similarities in the main impulsivity and compulsivity features between GD and BSD patients, and to analyse the potential influence of sex in these domains.

METHODS

Using self-reported and neurocognitive measures, we assessed different impulsive-compulsive components in a sample of 218 female and male patients (59 with BSD and 159 with GD) and 150 healthy controls.

RESULTS

We observed that GD and BSDs exhibited elevated levels of impulsivity and compulsivity in all the dimensions compared to healthy controls. Moreover, these disorders showed differences in several personality traits, such as high novelty seeking in GD, and low persistence and high harm avoidance in BSDs. In addition, patients with BSDs also displayed a trend towards greater impulsive choice than GD patients. Regarding sex effects, GD women presented higher overall impulsivity and compulsivity than GD men. Nevertheless, no sex differences were found in BSDs.

CONCLUSIONS

Clinical interventions should consider these deficits to enhance their effectiveness, including adjunctive treatment to target these difficulties. Our findings also provide support to the relevance of sex in GD, which should also be considered in clinical interventions.

Measuring cognitive flexibility in anorexia nervosa: Wisconsin Card Sorting Test versus cued task-switching

PURPOSE

The Wisconsin Card Sorting Test (WCST) is the most common measure of cognitive flexibility in anorexia nervosa (AN), but task-switching paradigms are beginning to be utilized. The current study directly compared performance on a cued task-switching measure and the WCST to evaluate their association in participants with a lifetime diagnosis of AN, and to assess which measure is more strongly associated with clinical symptoms.

METHODS

Forty-five women with a lifetime diagnosis of AN completed the WCST, cued color-shape task-switching paradigm, Anti-saccade Keyboard Task, Running Memory Span, Eating Disorder Examination Questionnaire, Depression Anxiety Stress Scales short form and Eating Disorder Flexibility Index.

RESULTS

There was no evidence of a significant association between WCST perseverative errors and cued task-switching switch costs. Results suggest lower working memory capacity is a determinant of higher perseverative error rate. When controlling for mood variables, neither cognitive flexibility measure was a significant independent predictor of symptom severity.

CONCLUSIONS

Results provide support for previous suggestions that WCST perseverative errors could occur due to difficulties with working memory, sensitivity to feedback, and issues with concept formation. Cued task-switching paradigms may provide a useful measure of cognitive flexibility for future eating disorders research by reducing task-specific confounds.

LEVEL OF EVIDENCE

Level III Case-control analytic study.

Intact general and food-specific task-switching abilities in bulimia-spectrum eating disorders

OBJECTIVE

Prior work evaluating cognitive flexibility (i.e., the ability to alter behavior in response to environmental changes) in bulimia-spectrum eating disorders (BN-ED) has produced mixed findings, perhaps due to reliance on set-shifting paradigms that do not effectively isolate cognitive flexibility. Task-switching paradigms are more precise, but no study has examined task-switching in BN-ED. Further, no study has examined whether cognitive flexibility deficits in BN-ED are disorder-specific (e.g., confined to food-related responses). Thus, the present study re-evaluated cognitive flexibility in BN-ED using general and food-specific task-switching paradigms.

METHOD

Individuals with BN-ED (n = 28) and healthy controls (HC; n = 39) completed a cued color-shape switching task (CCSST) and a novel food-specific variation (FCCSST). We compared BN-ED and HC on switch costs (reflective of transient task-switching) and mix costs (reflective of maintenance of switching behavior).

RESULTS

Switch and mix costs were not significantly different between BN-ED and HC in terms of either accuracy or reaction time on the CCSST or FCCSST.

CONCLUSIONS

Findings suggest neither general nor food-specific cognitive flexibility is impaired in BN-ED. Rigidity in BN-ED (e.g., continued engagement in compensatory behaviors despite psychoeducation that these behaviors are ineffective for weight loss) may be a result of other neurocognitive impairments rather than cognitive flexibility deficits.

Considerations for using the Wisconsin Card Sorting Test to assess cognitive flexibility

The Wisconsin Card Sorting Test (WCST) is a popular neurocognitive task used to assess cognitive flexibility, and aspects of executive functioning more broadly, in research and clinical practice. Despite its widespread use and the development of an updated WCST manual in 1993, confusion remains in the literature about how to score the WCST, and importantly, how to interpret the outcome variables as indicators of cognitive flexibility. This critical review provides an overview of the changes in the WCST, how existing scoring methods of the task differ, the key terminology and how these relate to the assessment of cognitive flexibility, and issues with the use of the WCST across the literature. In particular, this review focuses on the confusion between the terms 'perseverative responses' and 'perseverative errors' and the inconsistent scoring of these variables. To our knowledge, this critical review is the first of its kind to focus on the inherent issues surrounding the WCST when used as an assessment of cognitive flexibility. We provide recommendations to overcome these and other issues when using the WCST in future research and clinical practice.

Central coherence and set-shifting between nonunderweight eating disorders and anorexia nervosa: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis compared previously documented inefficiencies in central coherence and set-shifting between people with nonunderweight eating disorders (bulimia nervosa and binge-eating disorder) and people with anorexia nervosa.

METHOD

We performed random-effects meta-analyses on 16 studies (1,112 participants) for central coherence and 38 studies (3,505 participants) for set-shifting. Random effects meta-regressions were used to test whether the effect sizes for people with nonunderweight eating disorders were significantly different from the effect sizes for people with anorexia nervosa.

RESULTS

People with anorexia nervosa (Hedge's g = -0.53, 95% CIs: -0.80, -0.27, p < .001) and bulimia nervosa (Hedge's g = -0.70, 95% CIs: -1.14, -0.25, p = .002), but not binge-eating disorder, had significantly poorer central coherence than healthy controls. Similarly, people with anorexia nervosa (Hedge's g = -0.38, 95% CIs: -0.50, -0.26, p < .001) and bulimia nervosa (Hedge's g = -0.55, 95% CIs: -0.81, -0.29, p < .001), but not binge-eating disorder, had significantly poorer set-shifting than healthy controls. The effect sizes for people with nonunderweight eating disorders did not significantly differ from those for people with anorexia nervosa.

DISCUSSION

Our meta-analysis was underpowered to make definitive judgments about people with binge-eating disorder. However, we found that people with bulimia nervosa clearly have central coherence and set-shifting inefficiencies which do not significantly differ from those observed in people with anorexia nervosa. Clinically, this suggests that people with bulimia nervosa might benefit from adjunctive approaches to address these inefficiencies, such as cognitive remediation therapy.

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

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

Impulsivity and compulsivity in anorexia and bulimia nervosa: A systematic review

This study aimed to systematically appraise cross-sectional research that compared the cognitive performance of individuals in the acute phase of BN and/or AN to HCs on measures of impulsivity and compulsivity. The results of the systematic review showed support for the trans-diagnostic approach to eating disorders. There was no strong evidence to support the characterisation of AN as high in compulsivity (and low in impulsivity), nor to support the characterisation of BN as high in impulsivity (and low in compulsivity). There appeared to be mixed findings for both impulsivity and compulsivity across AN and BN. Results were highly variable due to the heterogeneous tasks used, and lack of replication across studies. There was no consensus amongst the included studies on the most appropriate task and/or outcome measures that should be used to study the constructs of impulsivity and compulsivity.

The Cognitive Drivers of Compulsive Eating Behavior

Compulsivity is a central feature of obsessive-compulsive and addictive disorders, which share considerable overlap with excessive eating in terms of repetitive behavior despite negative consequences. Excessive eating behavior is characteristic of several eating-related conditions, including eating disorders [bulimia nervosa (BN), binge eating disorder (BED)], obesity, and food addiction (FA). Compulsivity is proposed to be driven by four distinct cognitive components, namely, contingency-related cognitive flexibility, task/attentional set-shifting, attentional bias/disengagement and habit learning. However, it is unclear whether repetitive behavior in eating-related conditions is underpinned by deficits in these cognitive components. The current mini-review synthesizes the available evidence for performance on compulsivity-related cognitive tasks for each cognitive domain among populations with excessive eating behavior. In three of the four cognitive domains, i.e., set-shifting, attentional bias and habit learning, findings were mixed. Evidence more strongly pointed towards impaired contingency-related cognitive flexibility only in obesity and attentional bias/disengagement deficits only in obesity and BED. Overall, the findings of the reviewed studies support the idea that compulsivity-related cognitive deficits are common across a spectrum of eating-related conditions, although evidence was inconsistent or lacking for some disorders. We discuss the theoretical and practical importance of these results, and their implications for our understanding of compulsivity in eating-related conditions.

An ecological approach to the behavioral assessment of executive functions in anorexia nervosa

The use of ecological tests to assess executive functions (EFs) in patients with anorexia nervosa (AN) has not examined extensively. The objective of this study was to analyze and compare the performance of patients with AN and healthy controls (HCs) on standard versus ecologically valid tests on EFs. Sixty-two females aged between 16 and 42 who were diagnosed with AN and 70 matched HCs completed 2 neuropsychological test batteries: standard tests (WCST, TMT, Stroop, ToL, fluency test) and the Behavioral Assessment of Dysexecutive Syndrome (BADS). On the standard tests, patients with AN produced more perseverative response and were slower than HCs in the TMT; in contrast, they scored as well as HCs on tasks that assessed categorization, interference in color naming, planning and semantic fluency. Conversely, there were differences in the ecological tests with patients with AN systematically slower in the resolution of complex tasks. Results demonstrated the power of ecological tests in capturing selective impairments in multifaceted and unstructured tests. Patients with AN experienced systematic deceleration in the resolution of ecological tasks. Also, the increased time needed to solve the tasks, was not reflected in overall improvement in performance. This evidence is further discussed with respect to central coherence.

Anorexia nervosa and bulimia nervosa: A meta-analysis of executive functioning

OBJECTIVE

Research investigating the link between eating disorder (ED) diagnosis and executive dysfunction has had conflicting results, yet no meta-analyses have examined the overall association of ED pathology with executive functioning (EF).

METHOD

Effect sizes were extracted from 32 studies comparing ED groups (27 of anorexia nervosa, 9 of bulimia nervosa) with controls to determine the grand mean effect on EF. Analyses included effects for individual EF measures, as well as an age-based subgroup analysis.

RESULTS

There was a medium effect of ED diagnosis on executive functioning, with bulimia nervosa demonstrating a larger effect (Hedges's g=-0.70) than anorexia nervosa (g=-0.41). Within anorexia nervosa studies, subgroup analyses were conducted for age and diagnostic subtype. The effect of anorexia nervosa on EF was largest in adults; however, subgroup differences for age were not significant.

CONCLUSIONS

Anorexia and bulimia nervosa are associated with EF deficits, which are particularly notable for individuals with bulimia nervosa. The present analysis includes recommendations for future studies regarding study design and EF measurement.

Cognitive performance in children with acute early-onset anorexia nervosa

When anorexia nervosa (AN) occurs in children below the age of 14 years, it is referred to as early-onset AN (EO-AN). Over the last years, there has been an increased focus on the role of cognitive functioning in the development and maintenance of AN. Adults with AN show inefficiencies in cognitive functions such as flexibility and central coherence. Systematic neuropsychological examinations of patients with EO-AN are missing. Thirty children with EO-AN and 30 adolescents with AN, as well as 60 healthy controls (HC) underwent an extensive neuropsychological examination. ANOVAs with post hoc tests and explorative regression analyses were conducted. Patients with EO-AN (mean age = 2.17 ± 1.57 years) showed no significant differences in flexibility, inhibition, planning, central coherence, visuospatial short- and long-term memory or recognition in comparison to HC (mean age = 11.62 ± 1.29 years). Performance of adolescents with AN (mean age = 15.93 ± 0.70 years) was not significantly different compared to HC (mean age = 16.20 ± 1.26 years). Explorative regression analyses revealed a significant interaction of age and group for flexibility (adjusted R ²  = 0.30, F = 17.85, p = 0.013, η _p²  = 0.32). Contrary to expectations, the current study could not confirm the presence of inefficient cognitive processing in children with EO-AN compared to HC. Nonetheless, the expected age-related improvement of flexibility might be disrupted in children and adolescents with AN. Longitudinal neuropsychological examinations are necessary to provide more information about the role of cognitive functioning in the development and maintenance of AN.

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.

Psychometric properties of the Greek TCI-R and its clinical correlates: schizotypy and the self-regulation of affective and cognitive functioning

Background. The revised Temperament and Character Inventory (TCI-R) measures Cloninger’s psychobiological model of personality. The average effects of individual temperament and character traits have been associated with schizotypy and with impaired regulation of affect and cognition. We extended prior research by testing predictions about the association of specific multidimensional configurations of temperament and character traits on schizotypy, affect balance, and self-perceived cognitive functioning.

Method. A well-educated sample of native Greeks (N = 483), completed a new Greek translation of the TCI-R, as well as the Schizotypal Personality Questionnaire (SPQ), the Positive/Negative Affect Schedule (PANAS) and the Cognitive Failures Questionnaire (CFQ). The factor structure of the TCI-R was examined with exploratory and confirmatory tests. Associations between reported measures were examined with correlational and regression analyses.

Results. The TCI-R had good psychometric properties as expected from studies in other countries. As predicted, specific configurations of temperament and character were associated with schizotypy, negative affect balance, and cognitive lapses. The “Borderline/Explosive temperament” (high Novelty Seeking, high Harm Avoidance, low Reward Dependence), “Schizotypal/Disorganized character” (low Self-directedness, low Cooperativeness, high Self-transcendence), and “Low Ego Strength/Fragile” profile (high Harm Avoidance, low Persistence, low Self-Directedness) were each strongly associated with higher stereotypy, negative affect balance (low positive affect and high negative affect), and subjective cognitive lapses compared to their contrast groups.

Discussion. Multidimensional TCI profiles are strongly related to individual differences in schizotypy and self-reported regulation of affect and cognition. The Greek translation of the TCI-R is psychometrically sound and useful for clinical assessment and research.

Literature Review of Cognitive Neuroscience and Anorexia Nervosa

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

Are There Differences in Central Coherence and Set Shifting Across the Subtypes of Anorexia Nervosa?: A Systematic Review

Anorexia nervosa (AN) has been associated with weaknesses in central coherence and set shifting. In this line, it has been proposed to directly address these neuropsychological features in treatment (e.g., cognitive remediation therapy). It is not clear, however, whether the 2 subtypes of AN, the restricting (AN-R) and bingeing/purging (AN-BP) type, have the same amount of problems in these domains. A systematic search of the literature was conducted, using the databases Web of Science and PubMed, looking for studies on the comparison of AN-R and AN-BP in performing central coherence/set-shifting tasks. Notably, very few authors describe the results of a direct comparison of the performance of patients with AN-R and AN-BP. In summary, the available indications for possible group differences are not strong enough to draw definitive conclusions.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Decision making, central coherence and set-shifting: a comparison between Binge Eating Disorder, Anorexia Nervosa and Healthy Controls

BACKGROUND

Several studies have investigated the cognitive profile in patients with Anorexia Nervosa (AN) and Bulimia Nervosa (BN); on the contrary few studies have evaluated it in patients with Binge Eating Disorder (BED). The purpose of this study was to compare decision making, central coherence and set-shifting between BED and AN patients.

METHODS

A battery of neuropsychological tests including the Iowa Gambling Task (IGT), the Rey-Osterrieth Complex Figure Test (RCFT), the Wisconsin Card Sorting Test (WCST), the Trial Making Task (TMT) and the Hayling Sentence Completion Task (HSCT) were administered in a sample of 135 women (45 AN, 45 BED, 45 Healthy Controls [HC]). Furthermore, Beck Depression Inventory (BDI) was administered to evaluate depressive symptoms. Years of education, age, Body Mass Index (BMI) and depression severity were considered as covariates in statistical analyses.

RESULTS

BED and AN patients showed high rates of cognitive impairment compared to HC on the domains investigated; furthermore, the cognitive profile of BED patients was characterised by poorer decision making and cognitive flexibility compared to patients with AN. Cognitive performance was strongly associated with depressive symptoms.

CONCLUSIONS

In the present sample, two different neurocognitive profiles emerged: a strong cognitive rigidity and a central coherence based on the details was predominant in patients with AN, while a lack of attention and difficulty in adapting to changes in a new situation seemed to better describe patients with BED. The knowledge of the different cognitive profiles of EDs patients may be important for the planning their psychotherapeutic intervention.

Set-shifting ability across the spectrum of eating disorders and in overweight and obesity: a systematic review and meta-analysis

BACKGROUND

In this meta-analysis we review the findings from neuropsychological studies on set-shifting in people with eating disorders (EDs) or overweight/obesity.

METHOD

Four databases (PubMed, PsycINFO, PSYNDEX and Web of Science) were searched for eligible studies. Effect sizes (ESs) were pooled using random-effects models. Moderator analyses were conducted for ED and overweight/obese subgroups, adult/adolescent samples and measures of set-shifting.

RESULTS

Sixty-four studies with a total of 1825 ED patients [1394 anorexia nervosa (AN), 376 bulimia nervosa (BN) and 55 binge eating disorder (BED)] and 10 studies with a total of 449 overweight/obese individuals were included. The meta-analysis revealed a small to medium ES for inefficient set-shifting across all three ED diagnoses (Hedges' g = -0.45). Subgroup analyses yielded small to medium ESs for each ED subtype (g = -0.44 for AN, -0.53 for BED, -0.50 for BN), which did not differ significantly. There was a medium ES for restricting type AN (ANR; g = -0.51) but no significant ES for binge/purge type AN (AN/BP; g = -0.18). A medium ES was found across obesity studies (g = -0.61). The ES across overweight studies was not significant (g = -0.07). Adult samples did not differ from adolescent samples in either ED or overweight/obesity studies. The different set-shifting measures were associated with largely varying ESs.

CONCLUSIONS

The meta-analysis provides strong support that inefficient set-shifting is a salient neuropsychological phenomenon across ED subtypes and obesity, but is less prominent in AN/BP and overweight. Compulsivity seems to be a common underlying factor supporting a dimensional and transdiagnostic conceptualization of EDs and obesity.

Clinical investigation of set-shifting subtypes in anorexia nervosa

While evidence continues to accumulate on the relevance of cognitive inflexibility in anorexia nervosa (AN), its clinical correlates remain unclear. We aimed at examining the relationship between set-shifting and clinical variables (i.e., eating psychopathology, depression, and personality) in AN. Ninety-four individuals affected by AN and 59 healthy controls (HC) were recruited. All participants were assessed using: Eating Disorders Inventory-2 (EDI-2), Temperament and Character Inventory (TCI), Beck Depression Inventory (BDI), and Wisconsin Card Sorting Test (WCST). The AN group scored worse than HCs on set-shifting. According to their neuropsychological performances, AN patients were split into two groups corresponding to poor (N=30) and intact (N=64) set-shifting subtypes. Interoceptive awareness, impulse regulation, and maturity fears on the EDI-2 and depression on the BDI differed across all groups (HC, intact, and poor set-shifting subtype). Self-directedness on the TCI differed significantly among all groups. Cooperativeness and reward dependence differed instead only between HC and AN poor set-shifting subtype. After controlling for depression, only interoceptive awareness remained significant with reward dependence showing a trend towards statistical significance. These findings suggest that multiple clinical variables may be correlated with set-shifting performances in AN. The factors contributing to impaired cognitive inflexibility could be more complex than heretofore generally considered.

Temperamental characteristics in childhood migraine without aura: a multicenter study

BACKGROUND

Children with migraine seem to be more anxious, sensitive, deliberate, cautious, fearful, vulnerable to frustration, tidy, and less physically enduring than comparisons. To the best our knowledge no studies about the temperamental and the characterial dimension aspects in childhood migraine was conducted. Therefore, the aim of the present study was to describe the temperamental and character aspects in a sample of children affected by migraine without aura (MoA) and their relationship with clinical aspects of MoA such as frequency, duration, and severity of attacks.

MATERIALS AND METHODS

In our study, 486 children affected by MoA (239 male, 247 female) aged 7-12 years, (mean 10.04 ± 2.53 years) and 518 typical developing children comparable for age (P = 0.227) and sex (P = 0.892) were enrolled to assess their temperamental characteristics. The mothers of all subjects filled out the Junior Temperament and Character Inventory: Parent Version.

RESULTS

Children affected by migraine show a higher prevalence of harm avoidance and persistence temperamental domains (P < 0.001) and significantly lower prevalence of the self-directedness character trait (P = 0.023) with respect to the comparisons, according to Cloninger's model. The Spearman rank correlation analysis shows a significant relationship between migraine characteristics and temperamental domains.

CONCLUSION

The present study first identified differences in temperamental characteristics in children affected by MoA with respect to the comparisons, suggesting the need for this evaluation in order for better psychological pediatric management of children with migraine, with possible consequences and impact on the future outcomes of these subjects.