Exploring the neurocognitive signature of poor set-shifting in anorexia and bulimia nervosa

Social communication and restricted, repetitive behavior as assessed with a diagnostic tool for autism (ADOS-2) in women with anorexia nervosa

OBJECTIVE

In anorexia nervosa (AN), the traits of autism spectrum disorder (ASD) are associated with poor outcomes. However, the subtle nature of these characteristics remains poorly understood. We investigated the in-depth patterns of ASD traits using Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) in women with AN.

METHODS

Of 28 women with ICD-10 AN, 16 (age 19-30 years) participated in the ADOS-2, a video-recorded, semistructured diagnostic assessment for social communication and interaction and restricted, repetitive behaviors and interests related to ASD. None of the participants had previously been diagnosed with ASD. Other measurements included the Eating Disorder Examination Questionnaire and the Wechsler Abbreviated Scale of Intelligence-IV.

RESULTS

Five individuals (18% of all, 31% of those assessed) scored above the cutoff for autism in ADOS-2. They had challenges in social communication and interaction, manifesting as sustained difficulties in social relationships and deficits in conversation skills. Few described being frequently misunderstood by others, including in the eating disorder treatment settings. Three individuals showed prominent restricted and repetitive behaviors such as ritual seeking, eating-related routines, sensory sensitivity related to food texture and selective eating, and intense interest in specific topics. The mean duration of AN in women above the cutoff was twice as long compared with those below (12.3 vs. 6.2 years).

DISCUSSION

The ASD-related characteristics and behavior appear to contribute to the manifestation and duration of AN in a subgroup of women. Among these women, the traits of ASD appear to be mixed with eating disorder symptoms, which should be taken into account in the treatment.

Disentangling cognitive flexibility: a model-based assessment of women with anorexia nervosa

Cognitive flexibility (CF) has been proposed as a potential trait marker in anorexia nervosa (AN), although findings have been inconsistent. To address this inconsistency, we applied a model that distinguishes between three subtypes of CF: task switching, switching sets, and stimulus-response mapping, which we then assessed using a paradigm-based task battery. The aim of the study was to investigate how AN is associated with these three CF subtypes. Thirty-three women with AN and 37 age- and education-matched controls performed a battery of computerized cognitive tasks to assess the three CF subtypes. Compared to the control group, individuals with AN exhibited poorer performance on the task switching and switching sets subtypes, as measured by response time switch cost, but not on the stimulus-response mapping subtype. No differences were found between the groups in response accuracy. Furthermore, switching sets as compared to the task switching and stimulus-response mapping subtypes was found to better explain the differences between the groups. These findings indicate a domain-specific impairment in CF among patients with AN, reflecting deficits observed in subtypes related to the disorder's characteristics, particularly that associated with visual perception. Therefore, CF impairment in AN should not be viewed dichotomously, but rather as a relative impairment that varies depending on the specific CF subtype.

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.

Longitudinal changes in brain-derived neurotrophic factor (BDNF) but not cytokines contribute to hippocampal recovery in anorexia nervosa above increases in body mass index

BACKGROUND

Physical sequelae of anorexia nervosa (AN) include a marked reduction in whole brain volume and subcortical structures such as the hippocampus. Previous research has indicated aberrant levels of inflammatory markers and growth factors in AN, which in other populations have been shown to influence hippocampal integrity.

METHODS

Here we investigated the influence of concentrations of two pro-inflammatory cytokines (tumor necrosis factor-alpha [TNF-α] and interleukin-6 [IL-6]) and brain-derived neurotrophic factor (BDNF) on the whole hippocampal volume, as well as the volumes of three regions (the hippocampal body, head, and tail) and 18 subfields bilaterally. Investigations occurred both cross-sectionally between acutely underweight adolescent/young adult females with AN (acAN; n = 82) and people recovered from AN (recAN; n = 20), each independently pairwise age-matched with healthy controls (HC), and longitudinally in acAN after partial renourishment (n = 58). Hippocampal subfield volumes were quantified using FreeSurfer. Concentrations of molecular factors were analyzed in linear models with hippocampal (subfield) volumes as the dependent variable.

RESULTS

Cross-sectionally, there was no evidence for an association between IL-6, TNF-α, or BDNF and between-group differences in hippocampal subfield volumes. Longitudinally, increasing concentrations of BDNF were positively associated with longitudinal increases in bilateral global hippocampal volumes after controlling for age, age2, estimated total intracranial volume, and increases in body mass index (BMI).

CONCLUSIONS

These findings suggest that increases in BDNF may contribute to global hippocampal recovery over and above increases in BMI during renourishment. Investigations into treatments targeted toward increasing BDNF in AN may be warranted.

Cognitive flexibility in women who recovered from anorexia nervosa - a model-based approach

Research findings on cognitive flexibility (CF) functioning in women who recovered from anorexia nervosa (RAN) were found to be inconsistent. This was attributed to the multiple definitions of CF and the diverse measuring tools used to assess it. Applying a deductive approach to explore CF function may address these inconsistencies; thus, we used a model that divides CF into three subtypes, namely, stimulus-response mapping, switching sets and task switching. Additionally, we explored the association between CF subtypes and the disorder's clinical measures to assess the relation of CF to recovery. Forty-three RAN and 54 healthy controls performed tasks designed to assess CF subtypes based on the model's division, and the RAN group completed the Eating Disorder Examination Questionnaire. The results showed that the RAN group performed significantly worse than controls only in the stimulus-response mapping subtype. Additionally, there were no correlations between CF subtypes and clinical symptoms or the disorder measures - current and nadir body mass index, age of onset, time since recovery, and disorder duration. In conclusion, the study revealed CF impairment after recovery from AN, specifically in stimulus-response mapping. The variability in performance of the CF subtypes supports the application of a theory-driven perspective viewing CF as a modular ability in RAN. Additionally, CF is unrelated to clinical measures post-recovery and thus may not be used as a criterion for evaluating recovery.

Prospective associations between cognitive flexibility and eating disorder symptoms in anorexia nervosa and bulimia nervosa

This study investigated concurrent and prospective associations between measures of reversal learning and attentional set-shifting and eating disorder symptoms at baseline, 3 months, and 6 months among individuals with anorexia nervosa restricting subtype (AN-R, n = 26), AN binge eating/purging subtype (AN-BP, n = 22), bulimia nervosa (BN, n = 35), and healthy controls (n = 27), and explored whether these associations differed by diagnosis. At baseline, participants completed diagnostic interviews, height/weight measurements, and measures of set-shifting (the Intradimensional/Extradimensional shift task) and reversal learning (a probabilistic reversal learning task). At 3- and 6-month follow-up, participants with eating disorders completed assessments of weight and eating disorder symptoms. A one-way analysis of variance found no evidence that baseline reversal learning and attentional set-shifting differed across diagnostic groups. Multilevel modeling analyses indicated that perseverative errors (an index of reversal learning) predicted an increase in purging over time for individuals with AN-BP and BN. Set-shifting errors differentially predicted frequency of loss of control eating for individuals with AN-BP and BN; however, set-shifting was not related to loss of control eating when examined separately in AN-BP and BN. These findings suggest that disentangling facets of cognitive flexibility may help understand change in eating disorder symptoms.

Factor structure of the Eating Disorder Flexibility Index in U.S. nonclinical collegiate and clinical adolescent samples

Cognitive and behavioral inflexibility are transdiagnostic maintaining mechanisms of varied psychopathologies, including eating disorders (ED). The Eating Disorder Flexibility Index (EDFLIX) is the only psychometrically validated self-report measure of general and ED-specific flexibility in the published literature. The EDFLIX was originally developed in Scandinavian adult clinical and healthy control samples but is increasingly used in its English version in other populations, including adolescent and nonclinical samples, raising questions about its validity and reliability in diverse groups. This study examined the factor structure of the previously published English EDFLIX in undergraduates (n = 578, 57.6 % female, 50.2 % White). Parallel and exploratory factor analysis suggested the EDFLIX may comprise two or three underlying factors. However, follow-up confirmatory factor analyses from nonclinical student and clinical ED-diagnosed (n = 69, 87.0 % female, 91.3 % White) samples did not support either model. Further, EDFLIX scores did not correlate with established neuropsychological measures of cognitive flexibility typically used in prior research on flexibility in EDs. Findings suggest the EDFLIX has poor psychometric properties in certain groups and may not capture underlying aspects of flexibility as previously proposed. Future research should explore alternative versions of the EDFLIX along with its psychometric properties across various samples.

Mental flexibility assessment: A research protocol for patients with Parkinson's Disease and Anorexia Nervosa

Mental Flexibility oscillates between adaptive variability in behavior and the capacity to restore homeostasis, linked to mental health. It has recently been one of the most investigated abilities in mental and neurological diseases such as Anorexia nervosa and Parkinson's disease, studied for rigidity or cognitive inflexibility. Patients with anorexia nervosa have rigid cognitive processes about food and weight, which leads to restrictive eating and excessive exercise. People who struggle to adapt their cognitive processes and actions to change their diet and exercise habits may have a harder time recovering from the disorder. On the other hand, research suggests that Parkinson's disease patients may have cognitive flexibility impairments that impair their ability to perform daily tasks and adapt to new environments. Although of clinical interest, mental flexibility lacks theoretical liberalization and unified assessment. This study introduces "IntellEGO" a protocol for a new, multidimensional psychometric assessment of flexibility. This assessment evaluates a person's authentic ability to handle daily challenges using cognitive, emotional, and behavioral factors. Since traditional assessments often focus on one domain, we aim to examine flexibility from multiple angles, acknowledging the importance of viewing people as whole beings with mental and physical aspects. The study protocol includes two assessment phases separated by a rehabilitation period. T0, the acute phase upon admission, and T1, the post-rehabilitation phase lasting 15 days for Parkinson's patients and 4 weeks for eating disorder patients, will be assessed. Neuropsychological performance, self-report questionnaires, psychophysiological measures, and neuroendocrine measures will be collected from Anorexia Nervosa and Parkinson's Disease patients during each study phase. The objective of this procedure is to provide clinicians with a comprehensive framework for conducting meticulous assessments of mental flexibility. This framework considers emotional, cognitive, and behavioral factors, and is applicable to various patient populations.

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.

Novel treatments for anorexia nervosa: Insights from neuroplasticity research

OBJECTIVE

Treatment for anorexia nervosa (AN) remains challenging; there are no approved psychopharmacological interventions and psychotherapeutic strategies have variable efficacy. The investigation of evidence-based treatments has so far been compounded by an underdeveloped understanding into the neurobiological changes associated with the acute stages of AN. There is converging evidence of deficiencies in neuroplasticity in AN.

METHOD

This paper provides an overview of neuroimaging, neuropsychological, molecular and qualitative findings relating to neuroplasticity in AN, translating these findings to the identification of novel biological and psychotherapeutic strategies.

RESULTS

Novel psychopharmacological approaches that may ameliorate deficiencies in neuroplasticity include medications such as ketamine, psilocybin and human recombinant leptin. Anti-inflammatory medications and brain-derived neurotrophic factor mimetics may emerge as potential treatments following further research. Psychotherapeutic strategies that may target neuroplastic deficiencies, as well as having wider effects on identity, include imagery rescripting, memory specificity training, cognitive remediation therapy, exposure therapies, narrative therapies, cultural interventions (e.g. music and arts therapies) and yoga/mindfulness-based interventions.

CONCLUSIONS

Treatments specifically targeted towards mitigating the neurobiological sequalae of AN are warranted, and emerging neurobiological and neuropsychological research utilising longitudinal designs and large sample sizes, as well as initial feasibility studies, are necessitated to bolster translational efforts.

Cognitive flexibility and DSM-5 severity criteria for eating disorders: assessing drive for thinness and duration of illness as alternative severity variables

BACKGROUND

The severity criteria for eating disorders (EDs) proposed in the DSM-5 have been established without sufficient empirical support. Drive for thinness (DT) and duration of illness have been proposed as two alternative severity measures, however their empirical evidence is also limited. To date, no research has assessed the validity of current eating disorder (ED) severity criteria regarding cognitive flexibility factors. Cognitive flexibility is often impaired in EDs, becoming a possible severity symptom. The current study assessed for the first time (1) whether the severity indexes for EDs proposed in the DSM-5 were associated with deficits in cognitive flexibility and, (2) whether drive for thinness and illness duration, acted as an alternative, more meaningful severity indices for deficiencies in cognitive flexibility.

METHODS

Participants were 161 patients diagnosed with an ED, who were categorized according to DSM-5 severity categories, DT and duration of illness. Discriminative capacity of each classification was assessed for cognitive flexibility measured by Wisconsin card sorting test (WCST).

RESULTS

The findings for the DSM-5 classification comprised: (a) In the anorexia nervosa (AN) group, patients with moderate severity showed better scores in WCST than patients with mild and severe/extreme severity. Also, patients with moderate severity showed lower percentage of cognitive flexibility deficits than the other two severity categories; (b) For the binge spectrum disorders (BSD) group, the patients with mild severity showed a higher percentage of cognitive flexibility deficits than did the moderate and severe/extreme categories. When assessing the alternative severity index of DT, no differences were found in cognitive flexibility in any of the groups. Regarding illness duration, in the AN group the task performance of the patients with longer illness duration was worse than the performance of the short duration group and, in the BSD group, patients with longer duration also showed more deficits in cognitive flexibility than the patients with shorter duration of illness.

CONCLUSIONS

Our findings point out the limitations of the DSM-5 severity criteria to categorize cognitive flexibility in EDs and support illness duration as an alternative severity approach for EDs.

Chronic food restriction in mice and increased systemic ghrelin induce preference for running wheel activity

OBJECTIVES

In eating disorders, particularly anorexia nervosa (AN), patients exhibit intense physical activity which is inappropriate regarding food restriction and chronic undernutrition, and exacerbates weight loss and energy deprivation. Rodent models of food restriction exhibit increased running wheel activity in the food anticipation period, also known as Food Anticipatory Activity (FAA). FAA probably has various physiological and/or neurobiological origins. Plasma concentrations of the orexigenic hormone ghrelin are, for example, increased during FAA. We hypothesize that the drive for physical activity in chronic food restriction is triggered by metabolic factors but also relies on motivational aspects that we aim to decipher in this study.

METHODS

Young female C57Bl6/J mice were exposed to a paradigm based on a progressive 50% quantitative food restriction alone (FR) or associated with running wheel activity (Food Restriction Wheel: FRW) in their home-cage during 15 days. We measured preference for running wheel in a three-chamber apparatus in which animals could choose to explore either a known running wheel or a novel object. Testing took place either during resting or during FAA. We calculated the time spent in each compartment and the activity in running wheels. After progressive refeeding over 10 days, mice were tested again when refed. Plasma levels of both ghrelin isoforms were measured with selective immunoassays.

RESULTS

When tested during FAA period, food restricted mice displayed increased preference for the running wheel compared to ad libitum fed controls. Both FR and FRW mice exhibited increased running time and distance in the wheel and running distance was correlated with ghrelin levels. Similar preference and behavior were found when testing took place during the resting period. Animals housed without an active wheel also exhibited active running. Progressive refeeding resulted in body weight restoration, a decrease in FAA and completely abolished preference for the running wheel. Refed animals displayed similar behavior as ad libitum fed controls.

CONCLUSIONS

These data provide evidence that food restriction-induced physical activity is closely correlated with metabolic adaptations to nutritional status implicating ghrelin in the quantity of physical activity.

Temporal dynamics of cognitive flexibility in adolescents with anorexia nervosa: A high-density EEG study

Impairment in cognitive flexibility is a core symptom of anorexia nervosa (AN) and is associated with treatment resistance. Nevertheless, studies on the neural basis of cognitive flexibility in adolescent AN are rare. This study aimed to investigate brain networks underlying cognitive flexibility in adolescents with AN. To address this aim, participants performed a Dimensional Change Card Sorting task during high-density electroencephalography (EEG) recording. Anxiety was measured with the State-Trait Anxiety Inventory. Data were collected on 22 girls with AN and 23 controls. Evoked responses were investigated using global-spatial analysis. Adolescents with AN showed greater overall accuracy, fewer switch trial errors and reduced inverse efficiency switch cost relative to controls, although these effects disappeared after adjusting for trait and state anxiety. EEG results indicated augmented early visual orienting processing (P100) and subsequent impaired attentional mechanisms to task switching (P300b) in subjects with AN. During task switching, diminished activations in subjects with AN were identified in the posterior cingulate, calcarine sulcus and cerebellum, and task repetitions induced diminished activations in a network involving the medial prefrontal cortex, and several posterior regions, compared with controls. No significant associations were found between measures of cognitive flexibility and anxiety in the AN group. Findings of this study suggest atypical neural mechanisms underlying cognitive flexibility in adolescents with AN. More importantly, our findings suggest that different behavioural profiles in AN could relate to differences in anxiety levels. Future research should investigate the efficacy of cognitive training to rebalance brain networks of cognitive flexibility in AN.

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

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

Altered Reinforcement Learning from Reward and Punishment in Anorexia Nervosa: Evidence from Computational Modeling

OBJECTIVES

Anorexia nervosa (AN) is associated with altered sensitivity to reward and punishment. Few studies have investigated whether this results in aberrant learning. The ability to learn from rewarding and aversive experiences is essential for flexibly adapting to changing environments, yet individuals with AN tend to demonstrate cognitive inflexibility, difficulty set-shifting and altered decision-making. Deficient reinforcement learning may contribute to repeated engagement in maladaptive behavior.

METHODS

This study investigated learning in AN using a probabilistic associative learning task that separated learning of stimuli via reward from learning via punishment. Forty-two individuals with Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 restricting-type AN were compared to 38 healthy controls (HCs). We applied computational models of reinforcement learning to assess group differences in learning, thought to be driven by violations in expectations, or prediction errors (PEs). Linear regression analyses examined whether learning parameters predicted BMI at discharge.

RESULTS

AN had lower learning rates than HC following both positive and negative PE (p < .02), and were less likely to exploit what they had learned. Negative PE on punishment trials predicted lower discharge BMI (p < .001), suggesting individuals with more negative expectancies about avoiding punishment had the poorest outcome.

CONCLUSIONS

This is the first study to show lower rates of learning in AN following both positive and negative outcomes, with worse punishment learning predicting less weight gain. An inability to modify expectations about avoiding punishment might explain persistence of restricted eating despite negative consequences, and suggests that treatments that modify negative expectancy might be effective in reducing food avoidance in AN.

Social attention in anorexia nervosa and autism spectrum disorder: Role of social motivation

LAY ABSTRACT

Research suggests a relationship between autism and anorexia nervosa. For example, rigid and inflexible behaviour, a preference for routine and social difficulties are seen in both conditions. In this study, we examined whether people with anorexia and people with autism show similarities in social attention (where they look while engaging in social interactions or watching a scene with people interacting). This could help us understand why people with anorexia and autism experience difficulties in social situations. Participants with either anorexia or autism, as well as participants with no mental health problems watched a video of a social scene while we recorded which parts of the scene they looked at with an eye-tracker. Participants also completed questionnaires to assess characteristics of autism. We found that autistic participants looked at faces less than typically developing participants. However, participants with anorexia did not show a similar reduction in attention to faces, contrary to our predictions. Autistic features were not related to attention in either group. The results suggest that autistic people may miss important social cues (like facial expressions), potentially contributing to social difficulties. However, this mechanism does not appear explain social difficulties in people with anorexia.

Evaluating thinking styles in adults with an eating disorder: Associations with life satisfaction, psychological symptoms, and treatment engagement

Cognitive weaknesses have been implicated as a vulnerability factor in the development and maintenance of eating disorders. Despite this, cognitive styles are not routinely assessed in adult outpatient eating disorder programs and little is known about how they may impact patients' functional outcomes, psychological symptoms, or treatment engagement. The aim of this study was to evaluate thinking styles (i.e., cognitive rigidity and attention to detail) among adults attending specialized outpatient treatment for an eating disorder and assess whether such styles were associated with participants' satisfaction with life, psychological symptoms, and engagement in the outpatient group therapy program. Demographic and physical health information was collected from 95 adults who were eligible for an outpatient program. Participants completed the Detail and Flexibility Questionnaire, Satisfaction with Life Scale, Beck Depression Inventory second edition, and Beck Anxiety Inventory. Elevated scores for cognitive rigidity and attention to detail were transdiagnostic rather than specific to eating disorder diagnoses. Cognitive rigidity and attention to detail were associated with lower satisfaction with life, and increased anxiety and depression. Cognitive styles of cognitive rigidity and attention to detail were not associated with engagement in treatment or treatment completion. Cognitive patterns may be important for clinicians to evaluate as part of routine outpatient care given that they occur transdiagnostically and are linked with psychological symptoms and functional outcomes for adults struggling with an eating disorder.

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.

Cognitive flexibility and the risk of anorexia nervosa: An investigation using self-report and neurocognitive assessments

Impaired cognitive flexibility has been suggested as a risk factor for the development of anorexia nervosa (AN). The current study aimed to 1) investigate cognitive flexibility in people at various levels of risk of AN; and 2) compare people with a history of AN to people at different levels of risk of AN in cognitive flexibility. The sample comprised of 262 community participants (79% female) and 36 participants with a lifetime diagnosis of AN (97.2% female) aged between 18 and 64 years old. Participants completed self-report (the Depression Anxiety Stress Scale short-form version, the Eating Disorders Examination-Questionnaire, the Neuroticism Scale, and the Cognitive Flexibility Inventory) and neurocognitive (the Trail Making Test and the Wisconsin Card Sorting Test) assessments online to evaluate eating disorder symptoms, depression, neuroticism, and cognitive flexibility. Using a cluster analysis, participants were allocated into low-, medium-, and high-risk of AN groups (n = 88, 128, 46, and 36 respectively). Although high-risk participants self-reported significantly poorer cognitive flexibility than the other risk groups, performance on the neurocognitive tasks was similar across groups. Further, participants with lifetime AN reported significantly poorer cognitive flexibility than the low-risk group. People at high-risk of AN may perceive themselves to have poorer cognitive flexibility compared to those at a lower risk of AN. These results have implications for early identification of people at high-risk of AN.

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.

Comparing executive functions profiles in anorexia nervosa and autism spectrum disorder in adolescence

Objective

Executive functions (EFs) inefficiencies in anorexia nervosa (AN), especially in set‐shifting and central coherence, suggest a link between AN and autism spectrum disorders (ASDs). This study aimed at comparing EF profiles in AN and ASD, and investigating clinical variables associated with the identified EF difficulties.

Method

One hundred and sixty‐two adolescents with AN or ASD completed self‐report questionnaires assessing depression, anxiety and autism symptoms. Parents completed the behaviour rating of executive functions parent‐form (BRIEF‐P). Besides comparing EFs in AN and ASD, we also analysed clinical variables scoring below and above the mean age score across the all sample. We additionally examined the relationship between clinical variables and the BRIEF‐P indexes in AN.

Results

Participants with ASD had greater EF difficulties than participants with AN on all BRIEF‐P scales. In the whole sample, higher autistic features were related to poorer EF. In AN, lower body mass index and particularly higher autism‐spectrum quotient (BRI: Beta = 0.55; p < 0.001 and GEC: Beta = 0.50; p < 0.001) were most strongly associated with poorer EF.

Conclusion

Although participants with ASD showed greater difficulties, autistic traits were related to alter EFs in AN. Exploring further this dimension can undeniably allow better adaptive cognitive remediation programs.

Participants with autism spectrum disorder (ASD) had greater executive function (EF) difficulties than participants with anorexia nervosa (AN) on all behaviour rating of executive functions parent‐form scales

In AN, lower body mass index and particularly higher autism‐spectrum quotient were most strongly associated with poorer EF

Our study highlights the importance of autistic features in the alteration of EF in AN

Cognitive Behavioral and Cognitive Remediation Strategies for Managing Co-Occurring Anorexia Nervosa and Elevated Autism Spectrum Traits

Anorexia nervosa (AN) is a potentially severe eating disorder whose core characteristics include energy intake restriction leading to low body weight. Autism spectrum disorder (ASD) is a developmental disorder characterized by deficits in social interaction and communication as well as repetitive, stereotyped behavior and interests. Both high ASD traits and diagnosed ASD are overrepresented among individuals with AN, and AN and ASD appear to share certain neurocognitive features. These features are associated with the severity of eating disorder symptoms and prolongation of AN. Thus, individuals with AN and high ASD traits or ASD may benefit less from traditional treatment when compared to those with low ASD traits. No previous reviews have summarized what is known about treatment adaptations for individuals with AN and high ASD traits or ASD. The purpose of this narrative review was to investigate the feasibility of cognitive remediation therapy (CRT), cognitive remediation and emotional skill training (CREST), and cognitive behavioral therapy (CBT), and give an overview of treatment modifications for individuals with AN and co-occurring ASD or high ASD traits. We found nine studies that fulfilled our inclusion criteria. The combined results suggest that individuals with AN and high ASD traits or ASD benefit less from CRT, CREST, and CBT than those with AN and low ASD traits. However, CRT and CREST administered in individual format may be associated with improved cognitive flexibility, motivation for change, and decreased alexithymia among adults with AN and high ASD traits or ASD. Individuals with comorbid AN and ASD themselves highlight the importance of treatment adaptations that take the characteristics of ASD into account. In the future, controlled studies of the treatment strategies for individuals with AN and ASD/high ASD traits are needed in order to improve the outcome of individuals with this challenging comorbidity.

Can Cognitive Flexibility and Clinical Perfectionism Be Used to Identify People with Anorexia Nervosa?

Poor cognitive flexibility and perfectionism are common features in anorexia nervosa (AN). The current study aimed to investigate cognitive flexibility and clinical perfectionism as potential predictors of AN. Twenty women with a current diagnosis of AN (M age = 28.25, SD = 7.62) and 170 community participants with no lifetime history of an eating disorder (M age = 29.23, SD = 9.88) took part in an online cross-sectional study that included self-report questionnaires of cognitive flexibility and clinical perfectionism. It was found that compared to the community sample, women with AN self-reported significantly poorer cognitive flexibility and significantly greater clinical perfectionism. In a regression model, clinical perfectionism (but not self-reported cognitive flexibility) significantly predicted group membership. The specificity and sensitivity of the model were high. These preliminary findings indicate that clinical perfectionism may represent a key feature of AN and may accurately discriminate between participants with and without AN, though more research is required.

Common Predictive Factors of Social Media Addiction and Eating Disorder Symptoms in Female College Students: State Anxiety and the Mediating Role of Cognitive Flexibility/Sustained Attention

This study aimed to investigate the common predictive factors between social media addiction (SMA) and eating disorder symptoms (EDS), in a group of Chinese female college students. A total of 216 students completed the behavioral assessments of cognitive flexibility and sustained attention, as well as the questionnaires on anxiety, social media dependence, and eating disorders. The results indicate that SMA is significantly correlated with EDS. Structural equation modeling was used to test the model in which state anxiety, cognitive flexibility, and sustained attention predicted social gain and EDS. Additionally, the results confirmed the mediating role of cognitive flexibility and sustained attention between state anxiety and SMA/EDS in the participants. The findings revealed that in the sample group, state anxiety was related to SMA and EDS through cognitive flexibility and sustained attention. These proposals reflect the significance of improving cognitive flexibility/sustained attention and reducing state anxiety to prevent EDS and SMA in female college students.

Olfactory capacity in anorexia nervosa: correlations with set-shifting ability

PURPOSE

The purpose of this study is to examine olfactory capacity in adults with anorexia nervosa (AN), in terms of odor identification and odor threshold and search for possible correlations between odor identification and cognitive flexibility in this population.

METHODS

Thirty-nine patients diagnosed with AN and 60 healthy participants, participated. Odor identification was assessed using the University Pennsylvania Smell Identification Test and a two alternative forced choice, ascending method with n-butanol was used to assess odor threshold. Cognitive flexibility was determined using the Intra/Extra-Dimensional Set-Shift test (IED), a subtest of the Cambridge Neuropsychological Test Automated Battery (CANTAB).

RESULTS

Patients with AN presented a poorer performance in odor identification compared with controls (p = 0.001). No differences were found in odor threshold, between the two groups. Patients with AN exhibited poor cognitive flexibility compared with controls (p = 0.003). A significant correlation between odor identification and cognitive flexibility was documented in AN (p = 0.01), but not in controls.

CONCLUSION

Our findings suggest that olfactory capacity is altered in AN: Qualitative characteristics of olfaction were affected in patients with AN (lower odor identification), while there was no difference in quantitative characteristics (odor threshold) compared with controls. Furthermore, odor identification in AN was correlated to cognitive flexibility.

LEVEL OF EVIDENCE

Level III: case-control analytic study.

Early detection of eating disorders: a scoping review

PURPOSE

Early detection of eating disorders (EDs) could improve their prognosis, decrease morbidity and mortality, and prevent the risk of evolution towards a chronic form and somatic, psychiatric and psychosocial complications. The objective of this review was to examine the current scientific data concerning the early detection of EDs, which is one of the facets of secondary prevention.

METHOD

A scoping literature review was carried out following the PRISMA-ScR criteria, including all articles on ED detection published up to 2021 on PUBMED and PSYCINFO.

RESULTS

43 articles were included. Anorexia nervosa and bulimia nervosa were the most widely studied disorders. The articles focused on professionals from the medical field (GPs, psychiatrists, gynaecologists, gastroenterologists and residents), from the paramedical field, from education and sport, and from the general population. The assessments conducted with the professionals receiving interventions aiming to improve detection demonstrated their efficacy. Interventions for ED detection in the general population and at school seemed less efficacious.

CONCLUSION

The results highlighted some lines of action to be implemented. They pointed towards improving initial and continuing education for professional carers; e-learning could be an interesting solution for continuing education. Improving training with specific instructors, school personnel and sports professionals is also one of the solutions for a better detection of EDs. Specific recommendations could be published for fitness centre professionals to help them to deal with clients suspected of having an ED. Among secondary school students and in the general population, a better dissemination of mental health literacy and the development of mental health first aid programs could help improve early detection.

LEVEL OF EVIDENCE

Level I: Evidence obtained from systematic reviews.

Suppression of Corticostriatal Circuit Activity Improves Cognitive Flexibility and Prevents Body Weight Loss in Activity-Based Anorexia in Rats

BACKGROUND

The ability to adapt behavior to changing environmental circumstances, or cognitive flexibility, is impaired in multiple psychiatric conditions, including anorexia nervosa (AN). Exaggerated prefrontal cortical activity likely underpins the inflexible thinking and rigid behaviors exhibited by patients with AN. A better understanding of the neural basis of cognitive flexibility is necessary to enable treatment approaches that may target impaired executive control.

METHODS

Utilizing the activity-based anorexia (ABA) model and touchscreen operant learning paradigms, we investigated the neurobiological link between pathological weight loss and cognitive flexibility. We used pathway-specific chemogenetics to selectively modulate activity in neurons of the medial prefrontal cortex (mPFC) projecting to the nucleus accumbens shell (AcbSh) in female Sprague Dawley rats.

RESULTS

DREADD (designer receptor exclusively activated by designer drugs)-based inhibition of the mPFC-AcbSh pathway prevented weight loss in ABA and improved flexibility during early reversal learning by reducing perseverative responding. Modulation of activity within the mPFC-AcbSh pathway had no effect on running, locomotor activity, or feeding under ad libitum conditions, indicating the specific involvement of this circuit in conditions of dysregulated reward.

CONCLUSIONS

Parallel attenuation of weight loss in ABA and improvement of cognitive flexibility following suppression of mPFC-AcbSh activity align with the relationship between disrupted prefrontal function and cognitive rigidity in AN patients. The identification of a neurobiological correlate between cognitive flexibility and pathological weight loss provides a unique insight into the executive control of feeding behavior. It also highlights the utility of the ABA model for understanding the biological bases of cognitive deficits in AN and provides context for new treatment strategies.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anorexia nervosa and comorbid autism spectrum disorders

PURPOSE OF REVIEW

Traits of autism spectrum disorder (ASD) are overrepresented among individuals with anorexia nervosa (AN) and may also moderate the behavioral manifestation of AN. This review aims to provide an overview of AN and comorbid ASD.

RECENT FINDINGS

Elevated ASD traits do not seem to precede AN among some individuals but are rather related to the illness stage. However, studies have suggested that there are ASD-specific mechanisms for developing AN in a subgroup of individuals with AN. Pronounced traits of ASD and diagnosed ASD are associated with illness prolongation and poorer outcomes in AN, and individuals with AN and elevated ASD traits may benefit less from many of the current treatments. Studies do not support a specific genetic relationship between ASD and AN.

SUMMARY

Recent research encourages the improved recognition of elevated ASD traits in individuals with AN and provides grounds for developing tailored treatments for those with this comorbidity.

Association of executive function problems and disordered eating behaviours in teens with type 1 diabetes

AIM

To explore cross-sectional associations between executive function problems and disordered eating behaviours in teens with type 1 diabetes.

METHODS

Executive function was assessed by the Behavior Rating Inventory of Executive Function (BRIEF), self-report and parent proxy-report versions. Scores ≥60 (on Global Executive Composite, Behavioral Regulation Index, Metacognition Index or clinical scales) indicated problems with executive function. Disordered eating behaviour was assessed by the Diabetes Eating Problem Survey Revised (DEPS-R) and categorized as follows: <10 low, 10-19 moderate and ≥20 high.

RESULTS

In the 169 teens (46% girls, median age 16.0 years [range 13.7-18.7], median diabetes duration 8.9 years [range 1.4-16.6]), 29% had moderate and 12% had high level of disordered eating behaviours. Executive function problems were present in 9% by self report and 26% by parent proxy-report. Among teens with moderate/high level of disordered eating behaviours, 19% had executive function problems by self report (vs. 2% of teens with low level of disordered eating behaviours, p < 0.001) and 33% had executive function problems by parent proxy-report (vs. 20% of teens with low level of disordered eating behaviours, p = 0.056). A greater level of disordered eating behaviours was associated with executive function problems by teen self report on the General Executive Composite (p < 0.001), Behavioral Regulation Index (p < 0.001), emotional control clinical scale (p < 0.001), shift clinical scale (p < 0.001) and by parent proxy-report on the task initiation clinical scale (p = 0.008).

CONCLUSIONS

Assessing executive function and screening for disordered eating behaviours in teens with type 1 diabetes could help identify a subset of teens at high risk for adverse outcomes and need for intervention.

Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis

OBJECTIVE

Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders.

METHOD

A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns.

RESULTS

41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN.

CONCLUSIONS

Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.

Cognitive rigidity and heightened attention to detail occur transdiagnostically in adolescents with eating disorders

Cognitive inflexibility and attention to detail bias represent a promising target in eating disorder (ED) treatment. While prior research has found that adults with eating disorders exhibit significant cognitive inflexibility and heightened attention to detail, less is known about these cognitive impairments among adolescents, and across EDs transdiagnostically. To address this gap, adolescent females (N = 143) from a residential ED program with anorexia nervosa, bulimia nervosa, or other specified feeding or eating disorder completed the Detail and Flexibility Questionnaire (DFlex) and measures of ED and general psychopathology. Transdiagnostically, adolescents with EDs scored higher than an archival sample of healthy control adolescents on both cognitive rigidity (p < .001; Cohen's d = 1.92) and attention to detail (p < .001; Cohen's d = 1.16). These cognitive impairments were significantly associated with severity of eating pathology, and these relationships existed independent of age, duration of illness, or body mass index (BMI). Our findings suggest cognitive inflexibility and heightened attention to detail occur transdiagnostically in adolescents with eating disorders and are unlikely to be a scar of the disorder. Future prospective research is needed to determine whether these cognitive styles represent an endophenotype of eating disorders.

Are orthorexia nervosa symptoms associated with deficits in inhibitory control?

PURPOSE

This study explored whether inhibitory control is associated with symptoms of orthorexia nervosa, a condition that involves substantial behavioral control in regard to healthy eating.

METHOD

Participants (50 women, 13 men) completed the Eating Habits Questionnaire as a measure of orthorexia symptomatology, along with computerized versions of the Go/No-Go Task, Flanker Task, and Stroop Task.

RESULTS

Orthorexia symptomatology did not correlate with either percent error or response time for any of the three tasks (all p's > 0.10).

CONCLUSION

These results suggest that orthorexia is not associated with deficits or other differences in inhibitory control.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

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

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

Clinical and Cognitive Functioning Changes After Partial Hospitalization in Patients With Anorexia Nervosa

Introduction: Anorexia nervosa is usually associated with emotional and cognitive difficulties. Little knowledge is available about the changes in cognitive functioning in patients undergoing treatments. The aim of the present study was to longitudinally assess the impact of partial hospitalization on clinical and cognitive functioning in anorexia nervosa. Materials and Methods: 56 women with anorexia nervosa according to DSM-5 criteria and 58 healthy women were enrolled in the study. At baseline, all participants underwent clinical, diagnostic and neuropsychological assessment (T0). Patients were also assessed at the end of the treatment program (T1; n = 56). Results: BMI improved significantly throughout treatment. At baseline, patients showed significantly poorer executive abilities and less specific autobiographical memory. After the day-hospital program, decision-making abilities improved significantly. Response to treatment was predicted by BMI at admission and duration of illness, but neuropsychological performance did not contribute to the prediction model. Discussion: Cognitive difficulties, mostly regarding executive functions, resulted differently affected by clinical improvement. In particular, while cognitive monitoring and cognitive inhibition appear to be mostly stable trait-like characteristics, decision-making is both more state-dependent and sensitive to clinical status. None of the cognitive variables added information about the response to day hospital treatment; patients with short duration of illness and a rapidly decreasing BMI would benefit more from intensive interventions than less "acute" patients. These observations, if confirmed by future studies, have important clinical implications in order to understand the impact of malnutrition on cognitive functioning and to provide individualized effective treatment for patients with anorexia nervosa.

The shifting perspectives study protocol: Cognitive remediation therapy as an adjunctive treatment to family based treatment for adolescents with anorexia nervosa

BACKGROUND

Adolescents with anorexia nervosa have set-shifting inefficiencies that can be exacerbated by starvation and that may interfere with outcomes of treatment interventions. Cognitive Remediation Therapy (CRT), an adjunctive treatment focused on improving set-shifting, can target inefficiencies and may augment treatment effectiveness. The best way to add CRT to the standard of care (Family Based Treatment, FBT) for adolescents with anorexia remains understudied.

METHODS/DESIGN

This is a randomized controlled trial designed to determine if CRT is effective in increasing flexibility in adolescents with anorexia and/or their parents. Participants are adolescents 12-18 years old with anorexia and their parents. 54 family groups will be randomized into one of three groups: FBT only, FBT plus Parent-focused CRT, or FBT plus Adolescent-focused CRT. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study.

DISCUSSION

This is the first study of its kind to apply CRT to parents. All forms of CRT in the context of anorexia have targeted the individual with anorexia's thinking style. We propose that it may be impactful to target the parent of the adolescent with anorexia as parents carry the burden of treatment and re-nourishment of their child during FBT and may have similar thinking styles.

CONCLUSION

This study takes an experimental therapeutics approach to further our understanding of the mechanisms of treatment for adolescents with anorexia. It focuses on increasing cognitive flexibility in patients or their parents and determining the appropriate dose of CRT needed to achieve positive change.

TRIAL REGISTRATION

ClinicalTrails.gov Identifier NCT03928028.

Are poor set-shifting and central coherence associated with everyday function in anorexia nervosa? A systematic review

BACKGROUND

There is increasing interest in associations between cognitive impairments and clinical symptoms in Anorexia Nervosa (AN), however, the relationship with everyday function is unclear. The current review synthesizes existing data regarding associations between scores on tests of set-shifting and central coherence and functional outcome measures for individuals with AN.

METHOD

A systematic electronic database search yielded 13 studies which included participants with current or lifetime AN where scores on a neuropsychological test of set-shifting or central coherence were directly or indirectly compared to a functional outcome measure.

RESULTS

Associations between set-shifting and central coherence performance measures and functional outcomes were limited in number and noted only in adult or mixed-age cohorts. Associations were noted at subscale level, suggesting they are specific in nature. In younger cohorts, assessments of executive functioning in everyday life appear sensitive to cognitive-behavioral flexibility issues.

CONCLUSIONS

Associations between cognitive performance and functional outcome have not been as systematically assessed in AN as in other psychiatric disorders. Key factors to address in future research include: (a) the use of function measures which are sensitive to both the level of impairment, and specific rather than general impairments (b) the ecological validity of measures, (c) the task impurity problem, especially in regard to cognitive flexibility assessment, and (d) the need to measure both cognitive deficits and strengths, because tests of specific cognitive processes may underestimate the ability to function in daily life due to compensatory strategies.

Last word: a call to view temperamental traits as dual vulnerabilities and strengths in anorexia nervosa

Research suggests that individuals with anorexia nervosa (AN) have certain temperamental traits (e.g. perfectionism, anxiety, harm avoidance), which often onset prior to the eating disorder (ED), and may persist following recovery. Although these traits are often represented as vulnerabilities to developing an ED, there is reason to believe that within certain contexts, these traits may serve as assets. We propose that traits can be harnessed within or outside of treatment to promote long-term success, and possibly relate to recovery. To do so, the current paper will: (1) outline literature on traits viewed as strengths; (2) review precedents for strengths-based interventions drawing from other areas of research; (3) propose a framework for future research to assess these strengths in AN; and (4) discuss the implications of the proposed research for the destigmatization of EDs. This last word calls for a shift to a dual consideration of traits as vulnerabilities and strengths.

Naturalistic and Uncontrolled Pilot Study on the Efficacy of Vortioxetine in Binge Eating Disorder With Comorbid Depression

Background: Binge eating disorder (BED) is clinically relevant by virtue of the global impairment, poor quality of life, and increased overall medical morbidity. The high comorbidity with psychiatric disorders, particularly depression, has received attention as a possible mediator of the poor outcome. Further, BED and depression share cognitive dysfunctions. This naturalistic and uncontrolled pilot study aimed at evaluating the efficacy of vortioxetine (VTX) on depressive symptoms in patients with BED, secondly the efficacy in improving a broad array of executive functions, and third to explore the effect on eating behavior and body weight. Methods: This pilot study involved 30 patients with BED and comorbid MDD, treated with VTX for 24 weeks. Assessments were run at baseline (t 0), 4 (t 1), 8 (t 2), 12 (t 3), and 24 (t 4) weeks. Changes in depressive symptoms (HDRS and BDI), executive functions, eating behaviors (binge frequency and severity, night eating, food addiction), and body weight were estimated after treatment with VTX through GLM. Results: Significant improvements emerged after treatment with VTX in: depression (HDRS p < 0.001; BDI p = 0.002) regardless the dose of VTX and first diagnosis (BED/MDD), working memory (RAVLT acquisition p = 0.01, delay recall p < 0.001, RCFT percentage of recall p = 0.01, and Attentional Matrices p = 0.05), binge days frequency (p < 0.001), binge eating severity (BES p < 0.001), night eating (p = 0.001), food addiction (YFAS 2.0 p = 0.039), and body weight (p = 0.039). The improvement in depressive symptoms was associated with the concurrent improvement in night eating as assessed by the I-NEQ. Conclusions: VTX can be a valid therapeutic choice for patients with BED with comorbid depression in controlling the depressive symptoms, working memory, and eating behavior. Indeed, by acting on affective symptoms, neurocognitive functioning, and eating behaviors, it confirms the results already obtained with VTX in other disorders, expanding them to BED.

Is set-shifting and central coherence in anorexia nervosa influenced by body mass index, anxiety or depression? A systematic review

BACKGROUND

Anorexia nervosa (AN) is a severe eating disorder, recognized by a relentless pursuit for thinness and extreme low body weight. The disorder is often accompanied by comorbid disorders such as anxiety and depression, and altered neuropsychological function in terms of poor set-shifting and reduced central coherence. The aim of this review was to evaluate whether neuropsychological impairments in AN are influenced by body mass index, anxiety or depression.

METHOD

A systematic review approach was used, following the PRISMA guidelines for systematic reviews. Literature was identified via searches in PubMed, PsychInfo and Embase database, by using the search words [anorexia nervosa] AND [central coherence], and [anorexia nervosa] AND [set-shifting]. Studies were included if they were written in English, peer-reviewed, included individuals with AN, included tests measuring set-shifting and/or central coherence, investigated associations between set-shifting/central coherence with anxiety and/or depression and/or BMI. Risk of bias was assessed by using a critical appraisal checklist from the Joanna Briggs Institute. Results were summarized in a narrative synthesis.

RESULTS

Although results are heterogeneous, the majority of studies report that neither body mass index (BMI), anxiety or depression is associated with altered central coherence and set-shifting in individuals with AN.

CONCLUSIONS

Findings indicate that BMI, depression and anxiety does not influence neuropsychological function in AN, suggesting that it could be a characteristic of the disorder. A complete understanding of predisposing, precipitating and maintaining factors in AN needs to be addressed in future research. This could contribute to the development of better and more targeted treatment strategies.

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.

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

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

Conceptualizing eating disorder psychopathology using an anxiety disorders framework: Evidence and implications for exposure-based clinical research

Eating disorders (EDs) and anxiety disorders (ADs) evidence shared risk and significant comorbidity. Recent advances in understanding of anxiety-based disorders may have direct application to research and treatment efforts for EDs. The current review presents an up-to-date, behavioral conceptualization of the overlap between anxiety-based disorders and EDs. We identify ways in which anxiety presents in EDs, consider differences between EDs and ADs relevant to treatment adaptions, discuss how exposure-based strategies may be adapted for use in ED treatment, and outline directions for future mechanistic, translational, and clinical ED research from this perspective. Important research directions include: simultaneous examination of the extent to which EDs are characterized by aberrant avoidance-, reward-, and/or habit-based neurobiological and behavioral processes; improvement in understanding of how nutritional status interacts with neurobiological characteristics of EDs; incorporation of a growing knowledge of biobehavioral signatures in ED treatment planning; development of more comprehensive exposure-based treatment approaches for EDs; testing whether certain exposure interventions for AD are appropriate for EDs; and improvement in clinician self-efficacy and ability to use exposure therapy for EDs.

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.

Study protocol of comprehensive risk evaluation for anorexia nervosa in twins (CREAT): a study of discordant monozygotic twins with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a severe disorder, for which genetic evidence suggests psychiatric as well as metabolic origins. AN has high somatic and psychiatric comorbidities, broad impact on quality of life, and elevated mortality. Risk factor studies of AN have focused on differences between acutely ill and recovered individuals. Such comparisons often yield ambiguous conclusions, as alterations could reflect different effects depending on the comparison. Whereas differences found in acutely ill patients could reflect state effects that are due to acute starvation or acute disease-specific factors, they could also reflect underlying traits. Observations in recovered individuals could reflect either an underlying trait or a "scar" due to lasting effects of sustained undernutrition and illness. The co-twin control design (i.e., monozygotic [MZ] twins who are discordant for AN and MZ concordant control twin pairs) affords at least partial disambiguation of these effects.

METHODS

Comprehensive Risk Evaluation for Anorexia nervosa in Twins (CREAT) will be the largest and most comprehensive investigation of twins who are discordant for AN to date. CREAT utilizes a co-twin control design that includes endocrinological, neurocognitive, neuroimaging, genomic, and multi-omic approaches coupled with an experimental component that explores the impact of an overnight fast on most measured parameters.

DISCUSSION

The multimodal longitudinal twin assessment of the CREAT study will help to disambiguate state, trait, and "scar" effects, and thereby enable a deeper understanding of the contribution of genetics, epigenetics, cognitive functions, brain structure and function, metabolism, endocrinology, microbiology, and immunology to the etiology and maintenance of AN.