Neuropsychological assessments before and after treatment in patients with anorexia nervosa and bulimia nervosa

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.

The relationship between moderate to vigorous physical activity and cognitive rigidity in anorexia nervosa

A drive for physical activity despite underweight is a core feature of anorexia nervosa. This pilot study detects which aspect of physical activity, if any, could be related to cognitive rigidity in anorexia nervosa. Twenty-eight outpatients with anorexia nervosa and 24 healthy participants were assessed for cognitive flexibility with the Trail Making Test (TMT) and for multiple dimensions of physical activity by subjective and objective assessments. Correlation analysis was conducted to disentangle the relationship between cognitive rigidity and the different aspects of physical activity, then, the moderating effect of anorexia nervosa on this relationship was assessed. A principal component analysis was performed to incorporate all variables of physical activity in (a) global factor(s) reflecting the multidimensional nature of this construct. Cognitive rigidity (TMT b - a score) was significantly correlated to the amount of objectively assessed physical activity estimated, only in the sample of patients with anorexia nervosa. The principal component analysis confirms the correlation between a single construct of "physical activity" and cognitive rigidity in anorexia nervosa only. This pilot study suggests a relationship between cognitive rigidity and physical activity that could help explain the persistence of the latter despite ongoing malnutrition in patients with anorexia nervosa.

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.

Insensitivity to Losses: A Core Feature in Patients With Anorexia Nervosa?

BACKGROUND

Patients with anorexia nervosa (AN) demonstrate aberrations in choice behavior, including impairments in laboratory measures of decision making. Although a wealth of studies suggest that these aberrations arise from alterations in value processing, it remains unclear by which core component of value processing this is mediated.

METHODS

We fit trial-by-trial data of patients with AN (n = 60 first cohort, n = 216 second cohort) and healthy control participants (n = 55) performing the Iowa Gambling Task to a computational model based on prospect utility theory. We determined, per participant, the best-fit model parameters and compared these between the groups.

RESULTS

Analyses revealed a decreased estimate of model parameter λ in patients with AN, indicative of an attenuation of loss-aversive behavior in the Iowa Gambling Task. In comparison, measures of reward sensitivity, value-based learning, and exploration versus exploitation were unaltered in patients with AN. A measurement in a second independent cohort replicated the finding that loss aversion, typically observed in healthy individuals, is reduced in patients with AN.

CONCLUSIONS

We show that patients with AN, in contrast to healthy control participants, demonstrate reduced loss-aversive behavior. This finding provides important fundamental insights into the decision-making capacity of patients with AN, suggesting alterations in the mechanisms involved in value processing related to negative feedback.

The complexity of the interaction between binge-eating and attention

OBJECTIVE

To investigate whether binge-eating in patients with eating disorders (EDs) is associated with attentional deficits.

METHODS

We studied ED patients with binge-eating (n = 51), no binge-eating (n = 59) and controls (n = 58). ED patients were assessed following the stabilization of weight and ED pathology. Attention assessment included evaluation of attention deficit hyperactivity disorder (ADHD) diagnosis, the Adult ADHD Self-Report (ASRS) and ADHD Rating Scale-IV-Home Version (ADHD-RS) questionnaires, and attention functioning assessed with neuropsychological tools. The severity of eating-related pathology, depression, anxiety and obsessionality was also monitored.

RESULTS

Patients with binge-eating showed more ADHD symptomatology on the ADHD-RS compared with non-binge-eating patients. No differences were found between binge-eating and non-binge-eating patients in ADHD diagnosis and neuropsychological functioning. Among the specific ED subtypes, patients with anorexia nervosa binge/purge type (AN-B/P) showed the highest rates of ADHD symptomatology on the ADHD-RS, and were characterized with sustained attention deficits.

CONCLUSION

Binge-eating is not associated with attention deficits as measured by objective neuropsychological tools. Nonetheless, it is associated with attentional difficulties as measured with the self-reported ADHD-RS. AN-B/P patients are the only ED category showing objective sustained attention deficits.

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

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

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

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

Associations Between Core Symptoms of Attention Deficit Hyperactivity Disorder and Both Binge and Restrictive Eating

INTRODUCTION

It is unclear whether core symptoms of attention deficit hyperactivity disorder (ADHD) relate to specific types of disordered eating and little is known about the mediating mechanisms. We investigated associations between core symptoms of ADHD and binge/disinhibited eating and restrictive eating behavior and assessed whether negative mood and/or deficits in awareness and reliance on internal hunger/satiety cues mediate these relationships.

METHODS

In two independent studies, we used a dimensional approach to study ADHD and disordered eating. In Study 1, a community-based sample of 237 adults (72.6% female, 18-60 years [M = 26.8, SE = 0.6]) completed an online questionnaire, assessing eating attitudes/behaviors, negative mood, awareness, and reliance on internal hunger/satiety cues and ADHD symptomatology. In Study 2, 142 students (80.3% female, 18-32 years [M = 19.3, SE = 0.1]) were recruited to complete the same questionnaires and complete tasks assessing interoceptive sensitivity and impulsivity in the laboratory.

RESULTS

In each study, core symptoms of ADHD correlated positively with both binge/disinhibited and restrictive eating and negative mood mediated the relationships. Deficits in awareness and reliance on internal hunger/satiety signals also mediated the association between inattentive symptoms of ADHD and disordered eating, especially binge/disinhibited eating. The results from both studies demonstrated that inattentive symptoms of ADHD were also directly related to binge/disinhibited eating behavior, while accounting for the indirect pathways of association via negative mood and awareness and reliance on internal hunger/satiety signals.

CONCLUSION

This research provides evidence that core symptoms of ADHD are associated with both binge/disinhibited eating and restrictive eating behavior. Further investigation of the role of inattentive symptoms of ADHD in disordered eating may be helpful in developing novel treatments for both ADHD and binge eating.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Cognitive Flexibility in Juvenile Anorexia Nervosain Relation to Comorbid Symptoms of Depression, Obsessive Compulsive Symptoms and Duration of Illness

OBJECTIVE

Whereas the evidence in adolescents is inconsistent, anorexia nervosa (AN) in adults is characterized by weak cognitive flexibility. This study investigates cognitive flexibility in adolescents with AN and its potential associations with symptoms of depression, obsessive compulsive disorder (OCD), and duration of illness.

METHODS

69 patients and 63 age-matched healthy controls (HC) from 9 till 19 years of age were assessed using the Trail-Making Test (TMT) and self-report questionnaires.

RESULTS

In hierarchical regression analyses, set-shifting ability did not differ between AN and HC, whereas AN patients reported significantly higher rates of depression symptoms and OCD symptoms. Age significantly predicted set-shifting in the total sample. Only among AN patients aged 14 years and older did set-shifting decline with increasing age.

DISCUSSION

The presence of AN with depression or OCD symptoms or the duration of illness do not influence cognitive flexibility in children and adolescents. Early interventions may be helpful to prevent a decline in cognitive flexibility in adolescent AN with increasing age.

Investigating Cognitive Deficits as Risk Factors for Developing Eating Disorders During Adolescence

Adolescents with eating disorders (ED) suffer from deficits in executive functions and "theory of mind." It is unclear whether these indicate state or trait characteristics. We examined cognitive functioning in 150 adolescents, comparing those at high risk and those not at risk for ED. Deficits in set shifting and in theory of mind were found in all high-risk groups. Adolescents at high risk for bulimia were found to be higher in impulsivity and in theory of mind deficits, compared to adolescents at high risk for anorexia. These are trait characteristics rather than state vulnerabilities and preexist the development of ED.

Comprehensive neurocognitive assessment of patients with anorexia nervosa

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

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

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

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Differences in the Pattern of Hemodynamic Response to Self-Face and Stranger-Face Images in Adolescents with Anorexia Nervosa: A Near-Infrared Spectroscopic Study

There have been no reports concerning the self-face perception in patients with anorexia nervosa (AN). The purpose of this study was to compare the neuronal correlates of viewing self-face images (i.e. images of familiar face) and stranger-face images (i.e. images of an unfamiliar face) in female adolescents with and without AN. We used near-infrared spectroscopy (NIRS) to measure hemodynamic responses while the participants viewed full-color photographs of self-face and stranger-face. Fifteen females with AN (mean age, 13.8 years) and 15 age- and intelligence quotient (IQ)-matched female controls without AN (mean age, 13.1 years) participated in the study. The responses to photographs were compared with the baseline activation (response to white uniform blank). In the AN group, the concentration of oxygenated hemoglobin (oxy-Hb) significantly increased in the right temporal area during the presentation of both the self-face and stranger-face images compared with the baseline level. In contrast, in the control group, the concentration of oxy-Hb significantly increased in the right temporal area only during the presentation of the self-face image. To our knowledge the present study is the first report to assess brain activities during self-face and stranger-face perception among female adolescents with AN. There were different patterns of brain activation in response to the sight of the self-face and stranger-face images in female adolescents with AN and controls.

Structural and functional differences in the cingulate cortex relate to disease severity in anorexia nervosa

BACKGROUND

The dysfunction of specific brain areas might account for the distortion of body image in patients with anorexia nervosa. The present study was designed to reveal brain regions that are abnormal in structure and function in patients with this disorder. We hypothesized, based on brain areas of altered activity in patients with anorexia nervosa and regions involved in pain processing, an interrelation of structural aberrations in the frontoparietal-cingulate network and aberrant functional activation during thermal pain processing in patients with the disorder.

METHODS

We determined pain thresholds outside the MRI scanner in patients with anorexia nervosa and matched healthy controls. Thereafter, thermal pain stimuli were applied during fMRI imaging. Structural analyses with high-resolution structural T1-weighted volumes were performed using voxel-based morphometry and a surface-based approach.

RESULTS

Twenty-six patients and 26 controls participated in our study, and owing to technical difficulties, 15 participants in each group were included in our fMRI analysis. Structural analyses revealed significantly decreased grey matter volume and cortical thickness in the frontoparietal-cingulate network in patients with anorexia nervosa. We detected an increased blood oxygen level-dependent signal in patients during the painful 45 °C condition in the midcingulate and posterior cingulate cortex, which positively correlated with increased pain thresholds. Decreased grey matter and cortical thickness correlated negatively with pain thresholds, symptom severity and illness duration, but not with body mass index.

LIMITATIONS

The lack of a specific quantification of body image distortion is a limitation of our study.

CONCLUSION

This study provides further evidence for confined structural and functional brain abnormalities in patients with anorexia nervosa in brain regions that are involved in perception and integration of bodily stimuli. The association of structural and functional deviations with thermal thresholds as well as with clinical characteristics might indicate a common neuronal origin.

Neuropsychological function in patients with anorexia nervosa or bulimia nervosa

OBJECTIVE

This study explored the neuropsychological performance of patients diagnosed with anorexia nervosa (AN) or bulimia nervosa (BN) compared with healthy controls (HCs). An additional aim was to investigate the effect of several possible mediators on the association between eating disorders (EDs) and cognitive function.

METHOD

Forty patients with AN, 39 patients with BN, and 40 HCs who were comparable in age and education were consecutively recruited to complete a standardized neuropsychological test battery covering the following cognitive domains: verbal learning and memory, visual learning and memory, speed of information processing, visuospatial ability, working memory, executive function, verbal fluency, attention/vigilance, and motor function.

RESULTS

The AN group scored significantly below the HCs on eight of the nine measured cognitive domains. The BN group also showed inferior performance on six cognitive domains. After adjusting for possible mediators, the nadir body mass index (lowest lifetime BMI) and depressive symptoms explained all findings in the BN group. Although this adjustment reduced the difference between the AN and HC groups, the AN group still performed worse than the HCs regarding verbal learning and memory, visual learning and memory, visuospatial ability, working memory, and executive functioning.

DISCUSSION

Patients with EDs scored below the HCs on several cognitive function measures, this difference being most pronounced for the AN group. The nadir BMI and depressive symptoms had strong mediating effects. Longitudinal studies are needed to identify the importance of weight restoration and treatment of depressive symptoms in the prevention of a possible cognitive decline.

Longitudinal examination of decision-making performance in anorexia nervosa: before and after weight restoration

BACKGROUND

This study aimed to extend previous work on decision-making deficits in anorexia nervosa (AN) by using a longitudinal design to examine decision-making before and after weight restoration.

METHODS

Participants were 22 women with AN and 20 healthy comparison participants who completed the Iowa Gambling Task (IGT). Decision-making was assessed both before and after weight restoration in a subset of 14 AN patients. Self-report and interview assessments were used to measure psychological correlates of decision-making performance including depression, anxiety, and eating disorder symptoms, and magnetic resonance imaging (MRI) scans were conducted to explore associations between brain volume in the orbitofrontal cortex (OFC) and decision-making in individuals with AN.

RESULTS

Currently ill AN patients performed worse on the IGT compared to the control group. Although decision-making performance did not improve significantly with weight restoration in the full AN sample, AN patients who were poor performers at baseline did improve task performance with weight-restoration. When actively ill, lower body mass index (BMI) and decreased left medial OFC volume were significantly associated with worse IGT performance, and these associations were no longer significant after weight restoration.

CONCLUSIONS

Findings suggest that decision-making deficits in AN in the acute phase of illness are associated with low weight and decreased left medial OFC volume, but increases in brain volume and BMI may not have been sufficient to improve decision-making in all patients. Findings contribute to a model for understanding how some patients may sustain self-starvation, and future work should examine whether decision-making deficits predict relapse.

The effectiveness of cognitive remediation therapy in patients with a severe or enduring eating disorder: a randomized controlled trial

BACKGROUND

Individuals with eating disorders show deficits in neuropsychological functioning which might preexist and underlie the etiology of the eating disorders and influence relapse. Deficits in cognitive flexibility, i.e., set-shifting and central coherence, might perpetuate the symptoms. Cognitive remediation therapy (CRT) was developed to improve cognitive flexibility, thereby increasing the likelihood of improved outcome. The focus of CRT is on how patients think, rather than on what patients think. The present study investigated the effectiveness of CRT for patients with a severe or enduring eating disorder by means of a randomized controlled trial comparing intensive treatment as usual (TAU) to CRT plus TAU.

METHODS

Eighty-two patients were randomly assigned to CRT plus TAU (n = 41) or TAU alone (n = 41). Outcome measures were set-shifting, central coherence, eating disorder and general psychopathology, motivation, quality of life and self-esteem. Assessments were performed at baseline (n = 82) and after 6 weeks (T1; n = 75) and 6 months (T2; n = 67). Data were analyzed by means of linear mixed model analyses.

RESULTS

Patients who received CRT in addition to TAU improved significantly more with regard to eating disorder-related quality of life at the end of treatment (T1) and eating disorder psychopathology at follow-up (T2), compared to those who received TAU only. Moreover, moderator analyses revealed that patients with poor baseline set-shifting abilities benefited more from CRT than patients with no deficits in set-shifting abilities at baseline; the quality of life of the former group was higher than that of the latter at follow-up.

CONCLUSIONS

CRT seems to be promising in enhancing the effectiveness of concurrent treatment.

Intellectual function in patients with anorexia nervosa and bulimia nervosa

OBJECTIVE

This study aimed to examine cognitive function in individuals with anorexia nervosa (AN) and bulimia nervosa (BN) on the basis of IQ measures, indexes and subtests of the Wechsler Adult Intelligence Scale – Third Edition (WAIS-III).

METHODS

A total of 41 patients with AN, 40 patients with BN and 40 healthy controls (HC), matched for sex, age and education, were recruited consecutively to complete the WAIS-III.

RESULTS

The AN group showed a significantly lower performance than the HC group on most global measures and on eight of the 13 administered subtests. Minor differences in verbal function were detected between the BN group and the HC group.

CONCLUSION

The patients with eating disorders showed normal intellectual functions compared with the normative population. However, the AN group displayed a consistently lower performance than the matched HC group, which performed above normative means. The BN group performed at a level between that of the AN and HC groups.

Adolescent Anorexia Nervosa: cognitive performance after weight recovery

OBJECTIVE

Although there is no definitive consensus on the impairment of neuropsychological functions, most studies of adults with Anorexia Nervosa (AN) find impaired functioning in cognitive domains such as visual-spatial abilities. The objective of this study is to assess the cognitive functions in adolescents with AN before and after weight recovery and to explore the relationship between cognitive performance and menstruation.

METHODS

Twenty-five female adolescents with AN were assessed by a neuropsychological battery while underweight and then following six months of treatment and weight recovery. Twenty-six healthy female subjects of a similar age were also evaluated at both time points.

RESULTS

Underweight patients with AN showed worse cognitive performance than control subjects in immediate recall, organization and time taken to copy the Rey's Complex Figure Test (RCFT). After weight recovery, AN patients presented significant improvements in all tests, and differences between patients and controls disappeared. Patients with AN and persistence of amenorrhea at follow-up (n=8) performed worse on Block Design, delayed recall of Visual Reproduction and Stroop Test than patients with resumed menstruation (n=14) and the control group, though the two AN groups were similar in body mass index, age and psychopathological scale scores.

CONCLUSION

Weight recovery improves cognitive functioning in adolescents with AN. The normalization of neuropsychological performance is better in patients who have recovered at least one menstrual cycle. The normalization of hormonal function seems to be essential for the normalization of cognitive performance, even in adolescents with a very short recovery time.

The sorting test of the D-KEFS in current and weight restored anorexia nervosa patients

OBJECTIVE

Efforts have been made to characterize executive functions (EF) in anorexia nervosa (AN) both in the acute stage of the illness and after weight gain, yet many questions remain. The question of verbal versus visuo-perceptual stimuli in this regard has not been adequately addressed. The aim of this study is to further examine EF in women with past and present AN and to compare their performances in verbal and visual modalities with women who have never suffered from an eating disorder.

METHOD

Thirty-five underweight AN patients, 33 weight-restored patients symptom-free for at least 2 years, and 48 healthy female controls completed the Delis-Kaplan Executive Function System Sorting Test, so as to evaluate their EF.

RESULTS

No differences were observed between the scores of women with current and past AN. Both groups scored lower than controls on most test variables. However, while in the visuo-perceptual domain the performance of the AN groups was worse than that of controls, in the verbal domain they performed similarly to them.

DISCUSSION

Women with a past or present diagnosis of AN show difficulties in visuo-perceptual EF, whereas verbal EF seem to be preserved. There may be a dissociation between verbal and visuo-perceptual EF that persists after weight restoration.

Executive function in eating disorders: the role of state anxiety

OBJECTIVE

We examined the influence of depression and anxiety on executive function in individuals with a DSM-IV diagnosis of anorexia nervosa-restricting type, anorexia nervosa-binge-eating/purging type, bulimia nervosa, or eating disorder not otherwise specified.

METHOD

We assessed 106 women after their inpatient treatment in an eating disorders program. All participants were nutritionally stable at the time of testing.

RESULTS

Thirty percent of the total sample showed impaired performance on one or more tests of executive function. No differences in executive function were observed among diagnostic groups. Anxiety scores accounted for significant variance in performance for all groups.

DISCUSSION

Executive function deficits were found in a minority of our sample, with significant variance in performance accounted for by self-reported anxiety. State anxiety appears to contribute to diminished executive function in women with eating disorders.

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

Cognitive deficits in Eating Disorders have been related to the executive function domain. Yet, to date, only few works investigated the relationship between neuropsychological and clinical issues, and these studies were separately conducted either on Anorexia Nervosa (AN) or Bulimia Nervosa (BN). In this study, three groups of AN, BN and matched controls were administered the Trail Making Test, the Wisconsin Card Sorting Test, and the Hayling Sentence Completion Test, in addition to personality and clinical assessments (Temperament and Character Inventory, SCL-90-R, EDI-2). Results from AN indicated a relationship between cognitive rigidity and fixed psychological traits. Conversely, BN showed broader correlations among slowness, inhibition, and psychopathology-state indexes, confirming the clear relation published in the literature. We also hypothesize that task peculiar characteristics can affect high-order attentional activities in Eating Disorders. In fact, these patients do not differ from controls when the examiner provides overt instruction and run-in examples, but they can find serious difficulties when the correct rule is to be derived and modified from feedbacks during the test, as in the Wisconsin Card Sorting Test. Perfectionist stable traits support this hypothesis, especially in AN, as excessive cognitive control can either improve or damage set-shifting and decision-making procedures.

Visoconstructive Deficits and Risk of Developing Eating Disorders

In order to explore if neuropsychological deficits on visual constructional ability could be related to risk eating behaviors, a total of 102 women were evaluated, 51 of the participants had been formally diagnosed with eating disorders and 51 did not. All participants were given the Eating Attitude Test (EAT-40), The Rey-Osterrieth Complex Figure and The Tower of London Task. Results revealed the existence of a deficit on visual integration similar to those observed in other studies with diagnosed patients. The group at risk showed a comparatively reduced ability on the tasks and the control participants' execution was on the average. Findings revealed the need for designing studies to evaluate neuropsychological processes as possible risk factors which predict eating disorders.

Neuropsychology of eating disorders: 1995-2012

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

Decision-making and planning in full recovery of anorexia nervosa

OBJECTIVE

Based on findings of persisting neuropsychological impairments in women recovered from anorexia nervosa (rec AN), this study examined decision-making and planning, for achieving a desired goal, as central executive functions in a large sample of rec AN. The definition of recovery included physiological, behavioral, and psychological variables.

METHOD

A total of 100 rec AN women were compared to 100 healthy women, 1:1 matched for age and educational level. Decision-making was assessed with the Iowa Gambling Task and planning with the Tower of London. Expert interviews and self-ratings were used for assessing the inclusion/exclusion criteria and control variables.

RESULTS

Compared to healthy controls, rec AN women were better in decision-making and worse in planning even after considering control variables.

DISCUSSION

This study does not support results from other studies showing that rec AN participants perform better in decision-making. Results from this study show that planning is impaired even after full recovery from AN.

Executive functions profile in extreme eating/weight conditions: from anorexia nervosa to obesity

Background

Extreme weight conditions (EWC) groups along a continuum may share some biological risk factors and intermediate neurocognitive phenotypes. A core cognitive trait in EWC appears to be executive dysfunction, with a focus on decision making, response inhibition and cognitive flexibility. Differences between individuals in these areas are likely to contribute to the differences in vulnerability to EWC. The aim of the study was to investigate whether there is a common pattern of executive dysfunction in EWC while comparing anorexia nervosa patients (AN), obese subjects (OB) and healthy eating/weight controls (HC).

Methods

Thirty five AN patients, fifty two OB and one hundred thirty seven HC were compared using the Wisconsin Card Sorting Test (WCST); Stroop Color and Word Test (SCWT); and Iowa Gambling Task (IGT). All participants were female, aged between 18 and 60 years.

Results

There was a significant difference in IGT score (F(1.79); p<.001), with AN and OB groups showing the poorest performance compared to HC. On the WCST, AN and OB made significantly more errors than controls (F(25.73); p<.001), and had significantly fewer correct responses (F(2.71); p<.001). Post hoc analysis revealed that the two clinical groups were not significantly different from each other. Finally, OB showed a significant reduced performance in the inhibition response measured with the Stroop test (F(5.11); p<.001) compared with both AN and HC.

Conclusions

These findings suggest that EWC subjects (namely AN and OB) have similar dysfunctional executive profile that may play a role in the development and maintenance of such disorders.

What can cognitive neuroscience teach us about anorexia nervosa?

Anorexia nervosa (AN) is a complex illness and highly challenging to treat. One promising approach to significantly advance our understanding of the underlying pathophysiology of AN involves developing a cognitive neuroscience model of illness. Cognitive neuroscience uses probes such as neuropsychological tasks and neuroimaging techniques to identify the neural underpinnings of behavior. With this approach, advances have been made in identifying higher-order cognitive processes that likely mediate symptom expression in AN. Identification of related neuropathology is beginning. Such findings led to the development of complex neurobehavioral models that aim to explain the etiology and persistence of AN. Future research will use these advanced tools to test and refine hypotheses about the underlying mechanisms of AN.

Neurobiological status at initial presentation predicts neuropsychological functioning in early onset anorexia nervosa at four-year follow up

This study explores whether neurobiological status (indexed by regional cerebral blood flow) at initial presentation predicts neuropsychological status at four-year follow up in a sample of children with early onset anorexia nervosa. Neuropsychological assessment was conducted on 15 females four years after their initial treatment, and matched controls. At follow up there were significant differences between subgroups (based on neurobiological status at initial presentation) and matched controls in long-term visual memory and cognitive inhibition. This study offers preliminary evidence that neurobiological abnormalities at initial presentation predict neuropsychological status at follow up, suggesting a distinct neurodevelopmental subtype of early onset anorexia nervosa.

Clinical neuropsychology within adolescent and young-adult psychiatry: conceptualizing theory and practice

Historically, clinical neuropsychology has made significant contributions to the understanding of brain-behavior relationships, particularly in neurological conditions. During the past several decades, neuropsychology has also become established as an important discipline in psychiatric settings. Cognition is increasingly recognized as being core to psychiatric illnesses and predictive of functional outcomes, augmenting theories regarding symptomatology and illness progression. Adult-type psychiatric disorders (including schizophrenia and other psychotic, mood, anxiety, eating, substance-related, and personality disorders) typically emerge during adolescence or young adulthood, a critical neurodevelopmental period. Clinical neuropsychological assessment in adolescent psychiatric patients is particularly valuable in informing clinical formulation and intervention and can be therapeutic across a number of levels. This article articulates the theoretical considerations and practical challenges and applications of clinical neuropsychology within adolescent and young-adult psychiatry. The importance of considering the neurodevelopmental context and its relationship to current theoretical models underpinning clinical practice are discussed.

Altered implicit category learning in anorexia nervosa

OBJECTIVE

Recent research has identified specific cognitive deficits in patients with anorexia nervosa (AN), including impairment in executive functioning and attention. Another such cognitive process, implicit category learning has been less studied in AN. This study examined whether implicit category learning is impaired in AN.

METHOD

Twenty-one women diagnosed with AN and 19 control women (CW) were administered an implicit category learning task in which they were asked to categorize simple perceptual stimuli (Gabor patches) into one of two categories. Category membership was based on a linear integration (i.e., an implicit task) of two stimulus dimensions (orientation and spatial frequency of the stimulus).

RESULTS

AN individuals were less accurate on implicit category learning relative to age-matched CW. Model-based analyses indicated that, even when AN individuals used the appropriate (i.e., implicit) strategy they were still impaired relative to CW who also used the same strategy. In addition, task performance in AN patients was worse the higher they were in self-reported novelty seeking and the lower they were in sensitivity to punishment.

CONCLUSIONS

These results indicate that AN patients have implicit category learning deficits, and given this type of learning is thought to be mediated by striatal dopamine pathways, AN patients may have deficits in these neural systems. The finding of significant correlations with novelty seeking and sensitivity to punishment suggests that feedback sensitivity is related to implicit learning in AN.

Clinical and biological correlates of adolescent anorexia nervosa with impaired cognitive profile

Some neuropsychological studies of anorexia nervosa (AN) have yielded conflicting results, and it has been established that not all adult patients with AN are cognitively impaired. The objective of this study is to determine the percentage of adolescents with AN who present worse cognitive functioning according to neuropsychological criteria of cognitive impairment, and to study their clinical characteristics. Thirty-seven adolescents (11-18 years) with a diagnosis of AN in an acute state of the illness and with low body mass index (BMI) were compared with 41 healthy subjects of the same sex and similar age and intelligence using a comprehensive neuropsychological battery. Overall, AN patients took longer to copy Rey's Figure than the control group (p = 0.001). Thirty per cent of patients showed impaired neuropsychological functioning (defined as scoring two standard deviations lower than the average or lower than their intelligence level in two tasks) with worse performance on visuo-spatial tasks. This subgroup of patients presented lower BMI (p = 0.023) and higher trait anxiety (p = 0.028). The performance of adolescents in an acute state of AN was similar to that of the healthy control group, with the exception of lower time to completion in copying a complex figure. However, cognitive performance varied in these patients, being clearly impaired in one-third of the sample. The cognitive impairment subgroup showed lower BMI and higher anxiety. Longitudinal follow-up studies are necessary to assess the stability of this profile after longer treatment periods.

Normative data for the letter-cancellation task in school children

Aims:

To establish the norms for the letter-cancellation task—a psychomotor performance task.

Materials and Methods:

Eight hundred nineteen school students were selected in the present study in an age range between nine and 16 years (M = 12.14; SD = 1.78 years). Subjects were assessed once for the cancellation task.

Results:

Both age and sex influenced performance on the SLCT; therefore, correction scores were obtained on the basis of these factors.

Conclusions:

The availability of Indian normative data for the SLCT will allow wider application of this test in clinical practice.

Psychological treatment for anorexia nervosa: a meta-analysis of standardized mean change

BACKGROUND

For the German treatment guidelines for eating disorders, the literature on psychological treatment of anorexia nervosa (AN) was reviewed systematically. As a common meta-analysis of randomized clinical trials proved to be impossible, a review of all available clinical trials was conducted, statistically integrating standardized mean change scores. Research questions comprised differential effects of therapeutic techniques and settings as well as determining which weight gains could be expected.

METHODS

After an extensive literature search, studies were selected, rated by 3 independent raters. Weight gain as the main outcome criterion was transformed into standardized mean change scores. Effect sizes were checked for homogeneity.

RESULTS

57 studies containing 84 treatment arms and 2,273 patients could be integrated. Studies differed considerably in quality. The strongest bias identified was reporting selectively on completers or failures, versus intention-to-treat samples. No significant differences between effect sizes could be identified concerning treatment setting, technique or patient characteristics. If treatment time is taken into account, inpatient treatment produced a faster weight gain than outpatient treatment.

CONCLUSION

The study describes weight gains which can be reached in outpatient and inpatient settings. It yielded no salient results speaking for a certain therapy technique, setting or procedure. Treatment guidelines for psychological treatment of AN still have to rely on lower level evidence.

Clinical and biological correlates of adolescent anorexia nervosa with impaired cognitive profile

Some neuropsychological studies of anorexia nervosa (AN) have yielded conflicting results, and it has been established that not all adult patients with AN are cognitively impaired. The objective of this study is to determine the percentage of adolescents with AN who present worse cognitive functioning according to neuropsychological criteria of cognitive impairment, and to study their clinical characteristics. Thirty-seven adolescents (11-18 years) with a diagnosis of AN in an acute state of the illness and with low body mass index (BMI) were compared with 41 healthy subjects of the same sex and similar age and intelligence using a comprehensive neuropsychological battery. Overall, AN patients took longer to copy Rey's Figure than the control group (p = 0.001). Thirty per cent of patients showed impaired neuropsychological functioning (defined as scoring two standard deviations lower than the average or lower than their intelligence level in two tasks) with worse performance on visuo-spatial tasks. This subgroup of patients presented lower BMI (p = 0.023) and higher trait anxiety (p = 0.028). The performance of adolescents in an acute state of AN was similar to that of the healthy control group, with the exception of lower time to completion in copying a complex figure. However, cognitive performance varied in these patients, being clearly impaired in one-third of the sample. The cognitive impairment subgroup showed lower BMI and higher anxiety. Longitudinal follow-up studies are necessary to assess the stability of this profile after longer treatment periods.

Neurocognition in bulimic eating disorders: a systematic review

Van den Eynde F, Guillaume S, Broadbent H, Stahl D, Campbell IC, Schmidt U, Tchanturia K. Neurocognition in bulimic eating disorders: a systematic review.

OBJECTIVE

  The aim of this study was to review the literature on neurocognition comparing people with a bulimic eating disorder in the acute phase of the illness with healthy controls (HC).

METHOD

  The review follows the PRISMA (preferred reporting items for systematic reviews and meta-analysis) statement guidelines. Three databases (Medline, Web of Science, and Scopus) were searched combining the search terms 'bulimic disorder', 'bulimia nervosa (BN)', 'binge-eating disorder (BED)' with terms referring to cognitive domains (e.g. 'executive functions').

RESULTS

  Thirty-seven studies on people with BN and four on people with BED were selected for review. Overall, sample sizes were relatively small [bulimic disorders: median and range 22 (12-83); HC: 27 (13-172)]. The diversity in methodology precluded a meta-analytical approach. People with a bulimic disorder did not present with a clear neurocognitive profile. Inclusion of salient, disorder-related stimuli (e.g. body weight/shape words) in the neurocognitive paradigms tended to generate differences between people with a bulimic disorder and HC.

CONCLUSION

  Neurocognition in bulimic eating disorders is under researched, and the available evidence is inconclusive. This review outlines strategies for further research in this area.

Prefrontal systems involvement in binge eating

OBJECTIVE

This study examined whether severity of binge eating is associated with dysfunction in behaviors mediated by the three main areas of the prefrontal cortex (PFC).

METHODS

One hundred fifty-one adults (mean BMI=49.50) were classified into three groups based on the presence and severity of binge eating behaviors: Binge Eating Disorder (BED) group (N=22), Binge Eating Prone (BEP) group (N=47), and non-Eating Disorder (non-ED) group (N=82). Participants completed the Frontal Systems Behavior Scale (FrSBe), a widely used measure of neurobehavioral traits associated with the three primary regions of the PFC corresponding with the behavioral traits of apathy, disinhibition, and executive dysfunction.

RESULTS

The BED and BEP groups scored significantly higher than the non-ED group on the three FrSBe subscales, as well as the FrSBe Total score. There were no significant correlations between the FrSBe and participant BMI.

DISCUSSION

As expected, individuals who engaged in binge eating endorsed greater PFC dysfunction than those who did not binge eat. These results provide a complement to studies utilizing neuroimaging and neuropsychological methodologies and further support for the role of prefrontal systems in the regulation of eating behavior.

Memory performance in acute and weight-restored anorexia nervosa patients

BACKGROUND

Anorexia nervosa (AN), at the stage of starvation and emaciation, is characterized by abnormalities in cognitive function, including memory performance. It is unclear whether memory impairment persists or is reversible following weight restoration, and whether memory function differs between AN subtypes. The aim of the present study was to investigate general memory performance in currently ill and fully weight-restored patients of different AN subtypes.

METHOD

Memory performance was assessed using the Wechsler Memory Scale-Revised (WMS-R) in a total of 99 participants, including 34 restricting-type AN patients (AN-RESTR), 19 binge-eating/purging-type AN patients (AN-PURGE), 16 weight-restored AN patients (AN-W-R) and 30 healthy controls (CONTROL). Cognitive evaluation included a battery of standardized neuropsychological tasks for validating the findings on memory function.

RESULTS

Deficits were found with respect to immediate and delayed story recall in currently ill AN patients irrespective of AN subtype. These deficits persisted in weight-restored AN patients. Currently ill and weight-restored AN patients did not differ significantly from healthy controls with respect to working memory or other measures of neuropsychological functioning.

CONCLUSIONS

The findings suggest that impaired memory performance is either a stable trait characteristic or a scar effect of chronic starvation that may play a role in the development and/or persistence of the disorder.

Neurocognitive functioning in bulimia nervosa: the role of neuroendocrine, personality and clinical aspects

BACKGROUND

Studies investigating neurocognitive impairment in subjects with eating disorders (EDs) have reported heterogeneous patterns of impairment and, in some instances, no dysfunction. The present study aimed to define the pattern of neurocognitive impairment in a large sample of bulimia nervosa (BN) patients and to demonstrate that neuroendocrine, personality and clinical characteristics influence neurocognitive performance in BN.

METHOD

Attention/immediate memory, set shifting, perseveration, conditional and implicit learning were evaluated in 83 untreated female patients with BN and 77 healthy controls (HC). Cortisol and 17β-estradiol plasma levels were assessed. Cloninger's Temperament and Character Inventory - Revised (TCI-R), the Bulimic Investigation Test Edinburgh (BITE) and the Montgomery-Asberg Depression Rating Scale (MADRS) were administered.

RESULTS

No impairment of cognitive performance was found in subjects with BN compared with HC. Cortisol and 'Self-directedness' were associated with better performance on conditional learning whereas 17β-estradiol had a negative influence on this domain; 'Reward dependence' was associated with worse performance on implicit learning; and depressive symptomatology influenced performance on the Wisconsin Card Sorting Test (WCST) negatively.

CONCLUSIONS

No cognitive impairment was found in untreated patients with BN. Neuroendocrine, personality and clinical variables do influence neurocognitive functioning and might explain discrepancies in literature findings.

Prefrontal brain function in children with anorexia nervosa: a near-infrared spectroscopy study

To investigate the prefrontal hemodynamic response during a cognitive task in childhood anorexia nervosa (AN), we measured regional cerebral blood volume changes in terms of changes in hemoglobin concentrations [Hb], using near-infrared spectroscopy (NIRS). Sixteen females with AN (mean age 14.2 years old) and 12 age-matched healthy female control subjects (mean age 14.3 years old) participated in this study. Waveform patterns for [Hb] during the word fluency task differed between the two groups, although their task performances showed no significant difference. In the control group, the [total-Hb] and [oxy-Hb] immediately increased and the [deoxy-Hb] immediately decreased after the beginning of the task and gradually reached the baseline level after the end of the task. The patients with AN were consistently characterized by an unchanged or less fluctuating response pattern of [total-Hb], [oxy-Hb] and [deoxy-Hb] during the task and rest periods. In the AN group, subjects with higher Eating Attitudes Test (EAT-26) scores showed higher [oxy-Hb] during the task. On the other hand, in the control group, subjects with higher EAT-26 scores showed lower [oxy-Hb] during the task. The grand waveforms of each [Hb] during a motor activation task, which was applied as a control task, did not differ significantly between two groups. The different prefrontal hemodynamic responses might indicate that AN subjects might apply fewer brain circuits or fewer neurons per circuit during cognitive tasks and might use different brain circuits in relation to their preoccupation with eating behaviors.

Assessment of executive functions in obese individuals with binge eating disorder

OBJECTIVE: The aim of this study was to assess executive functions of obese individuals with binge eating disorder. METHOD: Thirty-eight obese individuals with binge eating disorder were compared to thirty-eight obese controls without binge eating disorder in terms of their executive functions. All individuals were assessed using the following instruments: Digit Span, Trail Making Tests A and B, Stroop Test and the Wisconsin Card Sorting Test. In addition, four subtests from the Behavioral Assessment of the Dysexecutive Syndrome Battery were also used, namely the Zoo Map Test, the Modified Six Elements Test, the Action Program Test and the Rule Shift Cards Test. RESULTS: When compared to obese controls, obese individuals with binge eating disorder presented significant impairment in the following tests: Digit Span backward, Zoo Map Test, Modified Six Elements Test, and Action Program Test. Subjects with binge eating disorder also showed significant more set shifting and perseverative errors in the Wisconsin Card Sorting Test. In other measures such as the Digit Span Forward, the Trail Making Test, the Stroop Test and the Rule Shift Cards Test, obese subjects with binge eating disorder did not differ significantly from obese subjects without binge eating disorder. CONCLUSION: These results suggest that, in the present sample, obese individuals with binge eating disorder presented executive deficits, especially impairments relating to problem-solving, cognitive flexibility and working memory.