Adolescent Anorexia Nervosa: cognitive performance after weight recovery

Patient and clinician perspectives on supported mealtimes as part of anorexia nervosa treatment: A systematic review and qualitative synthesis

OBJECTIVE

To systematically review the literature on clinicians' and patients' experiences of supported mealtimes in the treatment of anorexia nervosa.

METHOD

This systematic review was conducted in accordance with PRISMA guidelines and registered on PROSPERO (CRD42022372565). PsycINFO, MEDLINE and Embase were searched up to the 20th of November 2023 for qualitative articles investigating the perspectives of healthcare professionals and patients on clinician-supported meals across all clinical settings. Data were analysed using thematic synthesis. The Critical Appraisal Skills Programme was used to evaluate the quality of selected studies.

RESULTS

This review comprised of 26 studies; eight concerned with the perspectives of clinicians only, 16 addressing patients' views, and two studies exploring the views of both groups. Experiences of both groups were generally negative, and three overlapping themes were identified: lack of consistency in care provided, high levels of negative emotions and an uncomfortable power dynamic.

CONCLUSIONS

This review suggests that supported mealtimes are experienced more positively by patients when rules are clear and consistently enforced, and when clinicians make informal conversation and supportive comments. Our findings highlight the need for best practice guidelines and clinician training to improve the delivery of supported mealtimes. Such guidelines and training should be coproduced in collaboration with patients and carers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Factors predicting long-term weight maintenance in anorexia nervosa: a systematic review

PURPOSE

Eating disorder recovery is a poorly defined concept, with large variations among researchers' definitions. Weight maintenance is a key aspect of recovery that remains relatively underexplored in the literature. Understanding the role of weight maintenance may help guide the development of treatments. This paper aims to address this by (1) investigating the factors predicting long-term weight maintenance in anorexia nervosa (AN) patients; (2) exploring differences in predictive factors between adolescent and adult populations; and (3) exploring how weight maintenance is conceptualised in the literature.

METHODS

We conducted a systematic review following PRISMA guidelines to address our research questions. Five databases were searched and filtered according to our exclusion criteria.

RESULTS

From the search, 1059 studies were yielded, and 13 studies were included for review. A range of weight, biological and psychological factors were found to predict weight maintenance among these papers. BMI at admission and discharge from inpatient treatment was the most common predictor among the papers. Few studies investigated biological factors and mixed evidence was found for psychological factors. We found no observable differences between adult and adolescent populations. Finally, weight maintenance was defined and measured differently across studies.

CONCLUSION

This review's findings can help contribute to a well-rounded understanding of weight maintenance, and ultimately, of recovery. This can help support clinicians in tailoring interventions to improve long-term outcomes in AN. Future research should aim to replicate studies to better understand the relationship between the factors identified and weight maintenance.

LEVEL I

Systematic review.

A 10-Year-Old Girl's Dysfunctional 'Self-Help' in ADHD: Suppression of Hyperkinetic Symptoms via Self-Induced Weight Loss in the Context of Anorexia Nervosa-A Case Report

Anorexia Nervosa (AN) and Attention Deficit Hyperactivity Disorder (ADHD) are frequent mental disorders in child and adolescent psychiatry. Comorbidity of these disorders is, however, rare among minors. Thus, little is known about their mutual impact on illness development as well as diagnostic and therapeutic influencing factors. We report the case of a 10-year old girl with AN and massive underweight. At the age of 5, ADHD had been diagnosed. Application of ADHD-specific medication had been refused by her caregiver. As of 3rd grade, hyperkinetic symptoms were significantly reduced, which was later linked to beginning AN-induced weight loss. At inpatient admission, no clinically relevant ADHD-related symptoms were present. Accompanying weight gain, rather 'sudden' appearance of attention difficulties, motoric hyperactivity and impulsivity were reported, widely impairing our patient's schoolwork and further daily life. Methylphenidate medication showed good clinical response and tolerability. We hypothesize that the former massive underweight had suppressed ADHD-specific behaviour. AN with significant weight loss could possibly mask hyperkinetic symptoms in children. Thus, sufficient clinical diagnostics and intense monitoring during ED treatment are required. Physicians and therapists should be sensitized for interactions in the joint occurrence of these mental disorders among minors.

Verbal memory following weight gain in adult patients with anorexia nervosa: A longitudinal study

BACKGROUND

Patients with Anorexia Nervosa (AN) show a moderate deficit in overall neuropsychological functioning. Since previous studies on memory performance mainly employed cross-sectional designs, the present study aims to investigate changes in verbal memory following weight-gain.

METHODS

Verbal memory was assessed with the Wechsler Memory Scale-Revised (WMS-R; 'logical memory'-story-recall-subtest) and the California Verbal Learning Test-II (CVLT-II; 'verbal learning'). Included were 31 female patients with AN (18 restricting-, 13 purging-subtype; average disease duration: 5.1 years; average baseline BMI: 14.4 kg/m² ) and 24 medication-free normal-weight healthy women adjusted for age at baseline (T0). In a post-treatment assessment of approx. 6 weeks with weight increase (T1), 18 patients with AN and 20 healthy women were assessed again. Group differences in verbal memory (i.e., WMS-R, CVLT-II) were assessed for the baseline comparisons with a multivariate ANOVA and longitudinal data were analysed with repeated measures (RM) ANOVAs.

RESULTS

At baseline, patients with AN as compared to healthy women displayed deficits in logical memory. In the follow-up assessment, patients with AN improved their logical memory significantly compared to healthy controls (p < 0.006). Furthermore, groups did not differ in verbal learning neither before nor after inpatient treatment.

CONCLUSIONS

Enhanced logical memory in patients with AN following weight-gain is probably due to the impaired memory as compared to healthy controls at T0. A survivorship bias could explain the improved memory performance in longitudinal data in contrast to cross-sectional studies. Patients with AN with poorer memory performance before inpatient treatment are at higher risk to drop out and need support.

Pathway-specific GABAergic inhibition contributes to the gain of resilience against anorexia-like behavior of adolescent female mice

Anorexia nervosa is one of the most debilitating mental illnesses that emerges during adolescence, especially among females. Anorexia nervosa is characterized by severe voluntary food restriction and compulsive exercising, which combine to cause extreme body weight loss. We use activity-based anorexia (ABA), an animal model, to investigate the neurobiological bases of vulnerability to anorexia nervosa. This is a Mini-Review, focused on new ideas that have emerged based on recent findings from the Aoki Lab. Our findings point to the cellular and molecular underpinnings of three ABA phenomena: (1) age-dependence of ABA vulnerability; (2) individual differences in the persistence of ABA vulnerability during adolescence; (3) GABAergic synaptic plasticity in the hippocampus and the prefrontal cortex that contributes to the suppression of the maladaptive anorexia-like behaviors. We also include new data on the contribution to ABA vulnerability by cell type-specific knockdown of a GABA receptor subunit, α4, in dorsal hippocampus. Although the GABA system recurs as a key player in the gain of ABA resilience, the data predict why targeting the GABA system, singularly, may have only limited efficacy in treating anorexia nervosa. This is because boosting the GABAergic system may suppress the maladaptive behavior of over-exercising but could also suppress food consumption. We hypothesize that a sub-anesthetic dose of ketamine may be the magic bullet, since a single injection of this drug to mid-adolescent female mice undergoing ABA induction enhances food consumption and reduces wheel running, thereby reducing body weight loss through plasticity at excitatory synaptic inputs to both excitatory and inhibitory neurons. The same treatment is not as efficacious during late adolescence but multiple dosing of ketamine can suppress ABA vulnerability partially. This caveat underscores the importance of conducting behavioral, synaptic and molecular analyses across multiple time points spanning the developmental stage of adolescence and into adulthood. Since this is a Mini-Review, we recommend additional literature for readers seeking more comprehensive reviews on these subjects.

Group cognitive remediation therapy for children and adolescents in intensive day-patient treatment for anorexia nervosa: a feasibility study

Background

Cognitive Remediation Therapy (CRT) is an adjunct treatment targeting set-shifting (SS) and weak central coherence (CC) thought to play a role in maintaining anorexia nervosa (AN). This study aimed to test the feasibility of brief group CRT for young people with AN in a day-patient setting using neuropsychological assessment of SS and CC. It also explored the benefit for young people with Autism Spectrum Disorder (ASD) features.

Methods

Twenty female day-patients (12–18 years) with AN or Atypical AN completed neuropsychological assessment of SS (using the Wisconsin Card Sorting Task and the Brixton Spatial Anticipation Test) and of CC (using the Rey Osterrieth Complex Figures Task) pre and post 4 sessions of group CRT. Baseline ASD features and weight change pre and post were measured. Feasibility was assessed regarding the recruitment process, intervention feedback, suitability of neuropsychological assessment measures, and effect sizes.

Results

Study uptake was 95%, intervention retention was 91%, and group CRT was rated as acceptable. Medium to large effect size improvements were found across measures of SS (d_z = 0.44 to d_z = 0.90) and medium size improvements found in CC (d_z = 0.59). Young people with ASD features showed smaller to similar size improvements in SS and larger improvements in CC. There was a moderate (not significant) correlation with level of weight restoration.

Conclusions

Important study parameters have been estimated in order to plan a future definitive trial of brief group CRT in a day-patient setting using neuropsychological assessment. These findings also have implications for the use of brief group CRT in young people with ASD features.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

I, systematic review.

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

Neuropsychological functioning in adult anorexia nervosa: A meta-analysis

Several studies have conceptualized neuropsychological dysfunction as part of the core pathology and defining behaviors seen in the eating disorder anorexia nervosa (AN). The aim of the current review was to synthesize the differences in neuropsychological test performance between individuals with AN and healthy controls, quantify and explain their heterogeneity. The search and screening procedures resulted in fifty studies that comprised 186 neuropsychological test results. Utilizing random-effects meta-analyses, the results revealed evidence for significant, moderate underperformance in people with AN in overall neuropsychological functioning (g¯ = -0.43, 95 % CI [-0.50, -0.36]). Weighted mean effect sizes ranged from g¯ = -0.53 for visuospatial abilities to g¯ = -0.10 for planning. Study and participant characteristics, including body mass index (BMI) and age, had significant moderator effects, especially on executive function, memory, and visuospatial abilities. The findings from the current study provide an extensive and comprehensive overview of the possible impairments in neuropsychological functioning in adult patients diagnosed with AN.

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.

Understanding implicit and explicit learning in adolescents with and without anorexia nervosa

BACKGROUND

Cognitive disturbances such as impairments in learning are thought to play a role in adult Anorexia Nervosa (AN). It is remains unclear to what extent these disturbances result from starvation of the brain, or relate to an abnormal premorbid cognitive profile. This study investigates learning processes in adolescents with AN, hypothesizing that implicit learning is intact, as found previously in explicit learning tasks. Secondly, we hypothesized that anxiety and depression symptoms, inherent to AN, are associated to learning processes in AN.

METHODS

In total 46 adolescents diagnosed with AN and 44 control participants were administered an implicit category learning task in which they were asked to categorize simple perceptual stimuli (Gabor patches) based on a linear integration (i.e., an implicit task) of orientation and spatial frequency of the stimulus. A subgroup of adolescents (n = 38) also completed a task assessing explicit learning.

RESULTS

Model-based analyses indicated that adolescents with AN performed significantly more accurately compared to their healthy peers regardless of whether they used the optimal strategy or not. Depression and anxiety did not relate to learning performance in the AN group.

CONCLUSIONS

Overall, our findings of augmented implicit and explicit learning in adolescents with AN corroborate recent studies that suggested higher stimulus-response learning during prediction error paradigms. Learning disturbances in adult AN may then be at least partly due to long-term malnourishment, highlighting the importance of early recognition and refeeding in treatments for AN.

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.

Cognitive Function in Adults with Enduring Anorexia Nervosa

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

Haptic Perception in Extreme Obesity: qEEG Study Focused on Predictive Coding and Body Schema

Haptic perception (HP) is a perceptual modality requiring manual exploration to elaborate the physical characteristics of external stimuli through multisensory integrative cortical pathways. Cortical areas exploit processes of predictive coding that collect sensorial inputs to build and update internal perceptual models. Modifications to the internal representation of the body have been associated with eating disorders. In the light of this, obese subjects were selected as a valid experimental model to explore predictive coding in haptic perception. To this purpose, we performed electroencephalographic (EEG) continuous recordings during a haptic task in normally weighted versus obese subjects. EEG power spectra were analyzed in different time intervals. The quality of haptic performance in the obese group was poorer than in control subjects, though exploration times were similar. Spectral analysis showed a significant decrease in theta, alpha and beta frequencies in the right temporo-parietal areas of obese group, whereas gamma bands significantly increased in the left frontal areas. These results suggest that severe obesity could be characterized by an impairment in haptic performances and an altered activation of multisensory integrative cortical areas. These are involved in functional coding of external stimuli, which could interfere with the ability to process a predicted condition.

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Case report: cognitive performance in an extreme case of anorexia nervosa with a body mass index of 7.7

BACKGROUND

Studies show that adult patients with anorexia nervosa display cognitive impairments. These impairments may be caused by illness-related circumstances such as low weight. However, the question is whether there is a cognitive adaptation to enduring undernutrition in anorexia nervosa. To our knowledge, cognitive performance has not been assessed previously in a patient with anorexia nervosa with a body mass index as low as 7.7 kg/m2.

CASE PRESENTATION

We present the cognitive profile of a 35-year-old woman with severe and enduring anorexia nervosa who was diagnosed at the age of 10 years. She was assessed with a broad neuropsychological test battery three times during a year. Her body mass index was 8.4, 9.3, and 7.7 kg/m², respectively. Her general memory performance was above the normal range and she performed well on verbal and design fluency tasks. Her working memory and processing speed were within the normal range. However, her results on cognitive flexibility tasks (set-shifting) were below the normal range.

CONCLUSIONS

The case study suggests that it is possible to perform normally cognitively despite extreme and chronic malnutrition though set-shifting ability may be affected. This opens for discussion whether patients with anorexia nervosa can maintain neuropsychological performance in spite of extreme underweight and starvation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02502617. Registered 20 July 2015.

Prospective associations between childhood neuropsychological profiles and adolescent eating disorders

OBJECTIVE

Cross-sectional associations between eating disorders (EDs) and deficits in neuropsychological functioning have been well documented; however, limited research has examined whether neuropsychological functioning is prospectively associated with EDs. The current study investigated prospective associations between neuropsychological functioning in childhood (ages 8 and 10) and ED behaviours and disorders in adolescence (at ages 14, 16, and 18 years) in a population-based sample.

METHOD

Participants (N = 4,803) were children enrolled in the Avon Longitudinal Study of Parents and Children, a population-based, prospective study of women and their children. Regression methods tested associations between facets of neuropsychological functioning (attention, working memory, and inhibition) and eating disorder symptoms and diagnoses.

RESULTS

Better scores on working memory tasks in childhood were associated with decreased risk of fasting but increased risk of excessive exercise during adolescence. Better inhibitory control was associated with decreased risk for disordered eating at age 14, and attentional difficulties were associated with increased risk for binge eating disorder during adolescence among boys but not girls.

CONCLUSIONS

Neuropsychological functioning may enhance risk for disordered eating behaviours in specific ways. Overall, effect sizes were small, and results did not support global associations between neuropsychological differences and ED risk in this sample.

Association Between Weight Status and Executive Function in Young Adults

Background and objectives: To explore the association between weight status and executive function in young adults. Materials and Methods: Ninety-seven young males (age 17–26 years) underwent adiposity and body composition measurements using body composition analyzer. Inhibitory control and working memory were measured using the Cambridge Neuropsychological Test Battery (CANTAB). Results: Multiple linear regression using both unadjusted and adjusted analyses revealed no association between adiposity and body composition variables with executive tasks, apart from a significant association between skeletal muscle mass (SMM) and mean reaction time on go trial (standardized B = -0.28; p = 0.02). Multivariate analysis of covariance (MANCOVA) revealed that underweight participants presented inferior working memory compared to their normal weight (p = 0.001) or overweight peers (p = 0.008). However, according to the percentage fat quartiles (Q) participants with the highest quartile (Q4) were inferior in inhibitory control than their peers with Q2 (p = 0.04), and participants with the lowest quartile (Q1) were inferior in working memory compared with their peers with Q2 (p = 0.01) or Q3 (p = 0.02). A worse inhibitory control was observed for participants with the highest fat/SMM (Q4) compared to participants in Q3 (p = 0.03), and in contrast worse working memory was observed for participants with the lowest fat/SMM (Q1) compared to participants in Q2 (p = 0.04) or Q3 (p = 0.009). Conclusions: Low adiposity is associated with worse working memory, whereas high adiposity is associated with worse inhibitory control. Therefore, our findings show that normal adiposity, but greater SMM may have a positive impact on executive function in young adults.

Functional MRI with a set-shifting task in adolescent anorexia nervosa: A cross-sectional and follow-up study

Studies of set-shifting in adolescent AN present conflicting results, since not all have found differences with regard to controls. To date, no functional Magnetic Resonance Imaging (fMRI) studies have been carried out in adolescent patients, nor have patients been assessed after weight recovery. In this study, 30 female AN patients aged 12-17 and 16 matched control subjects were assessed both at baseline and after six months and renutrition using a structured diagnostic interview, clinical and neurocognitive scales, and fMRI during a set-shifting task. Adolescent AN patients presented similar performance on different neurocognitive tests and also on a set-shifting task during fMRI, but they showed a lower activation in the inferior and middle occipital and lingual gyri, fusiform gyri and cerebellum during the set-shifting task. No correlations were found between decreased activation and clinical variables such as body mass index, eating or depressive symptoms. After six months of treatment and renutrition in AN patients, there were no differences between patients and controls. These results show that adolescent AN patients have lower activation in relevant brain areas during a set-shifting task, and support the use of fMRI with set-shifting paradigms as a biomarker in future studies.

Evaluation of individual cognitive remediation therapy (CRT) for the treatment of young people with anorexia nervosa

PURPOSE

Research suggests that there are cognitive inefficiencies underlying Anorexia Nervosa (AN), with CRT showing promise in improving these inefficiencies in adults. This area has yet to be explored in a younger population. The aim of this study was to evaluate the use of CRT for young people.

METHODS

A within-subjects design was used to compare the performance of children and adolescents with AN on several neuropsychological measures administered before and after a course of CRT.

RESULTS

Ninety-two female participants diagnosed with AN aged between 11 and 17 (M = 14.8, SD = 1.6), all receiving treatment at a specialist inpatient unit. The assessment consisted of the Rey-Osterrieth Complex Figure test (ROCFT), the Behaviour Rating Inventory of Executive Function-Self-Report (BRIEF-SR), and the D-KEFS Colour-Word Interference Test (CWT). Repeated-measures t tests were used to analyse the ROCFT and BRIEF-SR data. There was a significant improvement in Central Coherence Index (p < .001), Immediate Recall (p < .001), Shift (p < .001) Cognitive Shift (p = 002), Behavioural shift (p < .001), Emotional Control (p < .001), Working Memory (p = .001), Plan/Organize (p < .001), Monitor (p = .001) BRI (p < .001), MI (p = .001), and GEC (p < .001). On the D-KEFS CWT, a repeated-measure Wilcoxon signed-rank test revealed a significant improvement in Error Rate (p = .019) and a repeated-measures t test revealed a significant improvement in time taken (p < .001).

CONCLUSIONS

Results suggest that CRT for children and adolescents with AN could strengthen specific cognitive domains.

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.

Weak central coherence in weight-restored adolescent anorexia nervosa: Characteristics and remediation

OBJECTIVE

Weak central coherence (WCC) refers to a bias towards processing details (local processing) at the expense of paying attention to the bigger picture (global processing). Multiple studies reported WCC in adults with anorexia nervosa (AN). Evidence for WCC in adolescents with AN has been inconsistent. The current study characterizes WCC in weight-restored adolescents with AN (WR-AN) using a direct measure of WCC, and examines whether WCC can be remediated by increasing alertness level-a manipulation that was found useful in enhancing global processing in healthy individuals and clinical populations.

METHODS

40 adolescents (18 WR-AN and 22 healthy adolescents) performed a global/local processing task (Navon task). Auditory alerting cues that elevate alertness level were integrated into the task.

RESULTS

Both groups processed global information faster than local information. However, compared with controls, adolescents with WR-AN were better at ignoring an irrelevant bigger picture while attending to details (smaller global interference) and had greater difficulty ignoring irrelevant details while attending to the bigger picture (larger local interference). These differences were attenuated when adolescents with WR-AN were under a state of high alertness. Additionally, the local interference effect was positively correlated with three independent self-report questionnaires assessing eating disorders symptomatology.

DISCUSSION

This study suggests that abnormal interference by irrelevant global and local information is a central characteristic of WCC in adolescents with WR-AN that cannot be accounted for by enduring illness or malnourishment. Additionally, this study demonstrates that WCC can be temporarily remediated by encouraging a state of high alertness.

Neural correlates of altered feedback learning in women recovered from anorexia nervosa

Anorexia nervosa (AN) is associated with exaggerated self-control and altered reward-based decision making, but the underlying neural mechanisms are poorly understood. Consistent with the notion of excessive cognitive control, we recently found increased dorsal anterior cingulate cortex (dACC) activation in acutely ill patients (acAN) on lose-shift trials in a probabilistic reversal learning (PRL) task. However, undernutrition may modulate brain function. In attempt to disentangle trait from state factors, the current fMRI study investigated cognitive control in recovered patients (recAN). Thirty-one recAN and 31 healthy controls (HC) completed a PRL task during fMRI. Based on previous findings, we focused on hemodynamic responses during lose-shift behaviour and conducted supplementary functional connectivity analysis. RecAN showed elevated lose-shift behaviour relative to HC. On the neural level, recAN showed normal dACC responses, but increased activation in fronto-parietal control regions. A trend for increased coupling between frontal and parietal regions of interest was also evident in recAN. The current findings in recAN differ from those in our previous study in acAN. While aberrant dACC response to negative feedback may be a correlate of the underweight state in acAN, impaired behavioural adaptation and elevated activation of cognitive control regions in recAN is suggestive of altered neural efficiency.

Neurocognitive functions and social functioning in young females with recent-onset anorexia nervosa and recovered individuals

BACKGROUND

Young individuals with anorexia nervosa (AN) or recovered from AN display impairments of social function. To date, however, it is not clear whether they differ from controls with respect to neurocognitive performance and whether those functions contribute to the compromised social function observed in individuals with AN.

METHODS

We included 43 young females with first-episode AN, 28 individuals recovered from adolescent-onset AN, and 41 control individuals (14-22 yr), all without comorbid autism spectrum disorder. We compared the performance of participants across groups in seven neurocognitive functions relevant to social functioning: set-shifting, local processing, processing speed, working memory, sustained attention, verbal memory, and verbal abstraction. Further, we tested the association between neurocognitive function and social function, measured by Autism Diagnostic Observation Schedule (ADOS), with an ordinal logistic regression model.

RESULTS

First, participants did not differ on any neurocognitive function across groups. Second, only the neurocognitive function "verbal memory" was significantly associated with social function. Higher performance in verbal memory was associated with lower odds of impaired social function. Diagnostic group remained a significant factor, but the absence of an interaction between group and neurocognitive performance indicated that the association between verbal memory and social function was independent of group membership.

CONCLUSION

Young individuals with AN and those recovered from AN did not differ from controls with respect to neurocognitive performance. Verbal memory was associated with social function in all groups.

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.

Memory impairment is associated with the loss of regular oestrous cycle and plasma oestradiol levels in an activity-based anorexia animal model

OBJECTIVES

Patients with anorexia nervosa (AN) suffer from neuropsychological deficits including memory impairments. Memory partially depends on 17β-oestradiol (E2), which is reduced in patients with AN. We assessed whether memory functions correlate with E2 plasma levels in the activity-based anorexia (ABA) rat model.

METHODS

Nine 4-week-old female Wistar rats were sacrificed directly after weight loss of 20-25% (acute starvation), whereas 17 animals had additional 2-week weight-holding (chronic starvation). E2 serum levels and novel object recognition tasks were tested before and after starvation and compared with 21 normally fed controls.

RESULTS

Starvation disrupted menstrual cycle and impaired memory function, which became statistically significant in the chronic state (oestrous cycle (P < 0.001), E2 levels (P = 0.011) and object recognition memory (P = 0.042) compared to controls). E2 reduction also correlated with the loss of memory in the chronic condition (r = 0.633, P = 0.020).

CONCLUSIONS

Our results demonstrate that starvation reduces the E2 levels which are associated with memory deficits in ABA rats. These effects might explain reduced memory capacity in patients with AN as a consequence of E2 deficiency and the potentially limited effectiveness of psychotherapeutic interventions in the starved state. Future studies should examine whether E2 substitution could prevent cognitive deficits and aid in earlier readiness for therapy.

Planning Abilities in Patients with Anorexia Nervosa Compared with Healthy Controls

OBJECTIVE

Altered cognitive functioning could have an important role in the development and maintenance of Anorexia Nervosa (AN). The majority of previous research has focused on flexibility and global-detail processing. The aim of this study was to explore planning abilities in women with AN.

METHOD

Women with AN (n = 32) were compared to healthy controls (n = 42) using two different types of neuropsychological tasks for the assessment of planning abilities: Tower of London (ToL), a classic measure of planning abilities, and Zoo Map test, a more ecologically valid planning measure. Measures of AN psychopathology, anxiety, depression, and obsessive compulsivity were also collected.

RESULTS

The AN group did not differ from controls in the ToL (all p-values p > .05), although they performed significantly worse than controls in the main score of the Zoo Map (p = .02). A worse performance in the Zoo Map test More was associated with more eating disorders (rho = -.44, p = .018) and depressive (rho = -.42, p = .026) symptoms in the AN group.

CONCLUSIONS

Our study suggests the presence of subtle planning difficulties in women with AN which might be better detected using tasks with increased ecological validity.

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.

ESCAP Expert Paper: New developments in the diagnosis and treatment of adolescent anorexia nervosa--a European perspective

Anorexia nervosa is a potentially life-threatening disorder with a typical onset in adolescence and high rates of medical complications and psychiatric comorbidity. This article summarizes issues relating to classification in DSM-5 and presents a narrative review of key evidence-based medical and behavioral interventions for adolescent AN and subthreshold restricting eating disorders, mainly, but not exclusively published between 2012 and 2014. In addition, it systematically compares the clinical guidelines of four European countries (Germany, Spain, The Netherlands, and United Kingdom) and outlines common clinical practice, in relation to treatment settings, nutritional rehabilitation, family-oriented and individual psychotherapy, and psychopharmacological treatment. With the exception of family-based treatment, which is mainly evaluated and practiced in Anglo-American countries, the evidence base is weak, especially for medical interventions such as refeeding and pharmacological intervention. There is a need for common European research efforts, to improve the available evidence base and resulting clinical guidance.

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

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Antioxidant activity and nutritional status in anorexia nervosa: effects of weight recovery

Few studies are focused on the antioxidant status and its changes in anorexia nervosa (AN). Based on the hypothesis that renutrition improves that status, the aim was to determine the plasma antioxidant status and the antioxidant enzymes activity at the beginning of a personalized nutritional program (T₀) and after recovering normal body mass index (BMI) (T₁). The relationship between changes in BMI and biochemical parameters was determined. Nutritional intake, body composition, anthropometric, hematological and biochemical parameters were studied in 25 women with AN (19.20 ± 6.07 years). Plasma antioxidant capacity and antioxidant enzymes activity were measured. Mean time to recover normal weight was 4.1 ± 2.44 months. Energy, macronutrients and micronutrients intake improved. Catalase activity was significantly modified after dietary intake improvement and weight recovery (T₀ = 25.04 ± 1.97 vs. T₁ = 35.54 ± 2.60μmol/min/mL; p < 0.01). Total antioxidant capacity increased significantly after gaining weight (T₀ = 1033.03 ± 34.38 vs. T₁ = 1504.61 ± 99.73 μmol/L; p < 0.01). Superoxide dismutase activity decreased (p < 0.05) and glutathione peroxidase did not change. Our results support an association between nutrition improvement and weight gain in patients with AN, followed by an enhancement of antioxidant capacity and catalase antioxidant system.