Central coherence in eating disorders: a systematic review

Weak central coherence, cognitive rigidity and disordered eating in a community sample

Recent evidence has highlighted that a moderate degree of disordered eating has become the norm among the general population. While previous research has demonstrated that individuals with eating disorders exhibit heightened weak central coherence (i.e., attention to detail) and cognitive rigidity, and this plays a key role in the development and maintenance of the disorders, less is known about the relationship between disordered eating and these cognitive styles in subclinical community samples. A community sample of females completed self-report measures of weak central coherence, cognitive rigidity and eating disorder pathology. Unlike previous studies in the area, we first excluded participants with a diagnosis of eating disorder and then confined the analyses to those without clinically significant disordered eating. In line with the clinical literature, we found both cognitive rigidity and weak central coherence to correlate with severity and frequency of disordered eating behaviours and cognitions, suggesting the relationship also exists in subclinical samples. If replicated and expanded upon, these findings may bear important implications for the prevention and early identification of disordered eating in the community.

"Maze Out": a study protocol for a randomised controlled trial using a mix methods approach exploring the potential and examining the effectiveness of a serious game in the treatment of eating disorders

BACKGROUND

Eating Disorders (ED) are severe and costly mental health disorders. The effects of existing treatment approaches are limited and there is a need to develop novel interventions, including digital strategies that can increase engagement and effectiveness. Maze Out is a new serious game coproduced by patients and ED therapists, which allows patients to "play" with the reality of an ED and reflect on associated challenges.

OBJECTIVES

The present study has two main objectives: (1) to evaluate the effectiveness of adding Maze Out to treatment as usual (TAU) in a randomised controlled trial (RCT); and (2) to examine in depth the potential of Maze Out by examining how it is perceived and used in the context of an RCT.

METHODS

Participants will be recruited from mental health care services, endocrinology departments or Community Centres offering treatment for ED. Patients suffering from ED (N = 94) will be randomised to either TAU or TAU plus Maze Out. Primary outcome will be measured in terms of changes in self-efficacy, measured by a 5-item self-efficacy questionnaire (5-item SE_ED). Secondary outcome measures will include feelings of ineffectiveness and self-image, as measured by Eating Disorder Inventory, version 3 (EDI-3), Brief INSPIRE-O and Structural Analysis of Social Behaviour Intrex Questionnaire (SAS-B). Data will be collected at baseline (enrolment in the study), and subsequently 8 and 15 weeks after inclusion. Experiences of playing Maze Out will be examined in a sub-sample of participants, utilising both quantitative user analytics and qualitative interview data of patients, interview data of significant others, and healthcare professionals to explore the possible impact of Maze Out on disorder insight, communication patterns between patients and therapists and understanding of their disorder.

DISCUSSION

To our knowledge Maze Out is the first serious game coproduced by patients and therapists. It is a novel and theoretically grounded intervention that may significantly contribute to the healing process of ED. If found effective, the potential for wide-spread impact and scalability is considerable. Trial registration ClinicalTrials.gov NCT05621018.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sizing up the crowd: Assessing spatial integration difficulties in body size judgements across eating disorder symptomatology

Introduction

Body size judgements are frequently biased, or inaccurate, and these errors are further exaggerated for individuals with eating disorders. Within the eating disorder literature, it has been suggested that exaggerated errors in body size judgements are due to difficulties with integration. Across two experiments, we developed a novel integration task, named the Ebbinghaus Illusion for Bodies in Virtual Reality (VR), to assess whether nearby bodies influence the perceived size of a single body. VR was used to simulate the appearance of a small crowd around a central target body.

Method and Results

In Experiment 1 (N = 412), participants were required to judge the size of a central female target within a crowd. Experiment 1 revealed an Ebbinghaus Illusion, in which a central female appeared larger when surrounded by small distractors, but comparatively smaller when surrounded by large distractors. In other words, the findings of Experiment 1 demonstrate that surrounding crowd information is integrated when judging an individual's body size; a novel measure of spatial integration (i.e., an Ebbinghaus Illusion for Bodies in VR). In Experiment 2 (N = 96), female participants were selected based on high (n = 43) and low (n = 53) eating disorder symptomatology. We examined whether the magnitude of this illusion would differ amongst those with elevated versus low eating disorder symptomatology, in accordance with weak central coherence theory, with the high symptomatology group displaying less spatial integration relative to the low group. The results of Experiment 2 similarly found an Ebbinghaus Illusion for Bodies in VR. However, illusion magnitude did not vary across high and low symptomatology groups.

Discussion

Overall, these findings demonstrate that surrounding crowd information is integrated when judging individual body size; however, those with elevated eating disorder symptomatology did not show any integration deficit on this broader measure of spatial integration.

The neural correlates of socio-cognitive factors and eating disorders in young people: A systematic review

BACKGROUND

Although the primary aetiology of Eating Disorders (ED) remains unknown, research suggests a complex interplay of biological, psychological, and cultural/environmental factors. This paper aims to systematically review the literature on neuroimaging studies that measure socio-cognitive factors, in the context of body dissatisfaction and EDs in young people. Specifically, our aim was to identify patterns in the findings linked to social media-type behaviours.

METHODS

The review was conducted in accordance with PRISMA guidelines using PubMed, Scopus, and Web of Science databases. 799 papers were identified in the database search and 38 studies were selected based on exclusion and inclusion criteria. Selected studies were assessed using the National Institute of Health study quality assessment tool.

RESULTS

Findings point to state-related impairments in inhibitory control and salient emotional processing. Anorexia Nervosa(AN) showed impaired set-shifting abilities, working memory and decision making, while altered activation in attention networks and associated difficulties with conflict resolution were seen for Bulimia Nervosa(BN) and Other Specified Feeding and Eating Disorders(OSFED). AN and BN also demonstrated altered sensitivity to food-related stimuli in striatal regions, suggesting aberrant top-down emotional-cognitive control. ED participants also show deficits in body representation, impaired control over social behaviours and altered integration of visual and body perception.

DISCUSSION

These findings support the notion that socio-cognitive dysfunctions in ED are underpinned by a distributed network of structural and functional brain changes which influence the way young people with ED interact with and respond to social media, and ultimately places at them at increased risk for body image disturbances. This Review was registered with the PROSPERO International Register of Systematic Reviews, Registration number CRD42021270696.

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

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

Eating disorders and autism spectrum: links and risks

In the last decades, increasing attention has been provided to socio-cultural and neurobiological factors involved in the psychopathology of feeding and eating disorders (FED), encouraging a multifactorial approach. In this framework, several authors stressed an association between FED and other kinds of psychiatric disorders from both a psychopathological and a neurobiological point of view. In particular, many promising contributions are focusing on the possible link between FED and autism spectrum disorder (ASD). Growing interest about this association rose from the frequently reported evidence of ASD-like traits amongst FED patients and abnormal eating behaviors amongst patients with ASD. This narrative review overview aims to summarize the most relevant findings about the overlap between different kinds of FED and the autism spectrum, taking into account the most recent hypotheses about the psychopathology of both these conditions. While most of the studies focused on anorexia nervosa, both ASD and autistic traits seem to be detectable also in other kinds of FED. In addition, the recently increased interest toward a dimensional approach to psychopathology led to progressively broadening the concept of ASD, focusing on its subthreshold and gender-specific manifestations and on its link with other psychiatric conditions, including FED. Globally the studies summarized here provide further support to theoretical models featuring a neurodevelopmental approach for mental disorders. In particular, FED have been conceptualized as a possible psychopathological trajectory of a neurodevelopmental alteration, toward which female gender would act as one of many predisposing factors.

Anorexia Nervosa, Body Image Perception and Virtual Reality Therapeutic Applications: State of the Art and Operational Proposal

Anorexia Nervosa (AN) patients exhibit distorted body representation. The purpose of this study was to explore studies that analyze virtual reality (VR) applications, related to body image issues, to propose a new tool in this field. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, Scopus, and Web of Science databases were explored; the review included 25 studies. Research has increased over the last five years. The selected studies, clinical observational studies (n = 16), mostly concerning patients' population with AN (n = 14) or eating disorders (EDs) diagnosis, presented multiple designs, populations involved, and procedures. Some of these studies included healthy control groups (n = 7). Studies on community sample populations were also selected if oriented toward clinical applications (n = 9). The VR technologies in the examined period (about 20 years) have evolved significantly, going from very complex and bulky systems, requiring very powerful computers, to agile systems. The advent of low-cost VR devices has given a big boost to research works. Moreover, the operational proposal that emerges from this work supports the use of biofeedback techniques aimed at evaluating the results of therapeutic interventions in the treatment of adolescent patients diagnosed with AN.

Exploratory study on the use of HMD virtual reality to investigate individual differences in visual processing styles

Purpose

Global and local processing is part of human perceptual organisation, where global processing helps extract the “gist” of the visual information and local processing helps perceive the details. Individual differences in these two types of visual processing have been found in autism and ADHD (Attention-Deficit Hyperactivity Disorder). Virtual reality (VR) has become a more available method of research in the last few decades. No previous research has investigated perceptual differences using this technology.

Design/methodology/approach

The objective of the research is to threefold: (1) identify if there is association between ADHD and autistic traits and the performance on the Rey-Osterrieth complex figure (ROCF) task, (2) investigate practical effects of using VR drawing tools for research on perceptual experiences and (3) explore any perceptual differences brought out by the three-dimensional nature of the VR. The standard ROCF test was used as a baseline task to investigate the practical utility of using VR as an experimental platform. A total of 94 participants were tested.

Findings

Attention-to-detail, attention switching and imagination subscales of autism quotient (AQ) questionnaire were found to be predictors of organisational ROCF scores, whereas only the attention-to-detail subscale was predictive of perceptual ROCF scores.

Originality/value

The current study is an example of how classic psychological paradigms can be transferred into the virtual world. Further investigation of the distinct individual preferences in drawing tasks in VR could lead to a better understanding of individual differences in the processing of visuospatial information.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

The Neuropsychological Profile of Severe and Enduring Anorexia Nervosa: A Systematic Review

Characteristics of Severe and Enduring Anorexia Nervosa (SE-AN) are being investigated to differentiate the patients experiencing SE-AN from those at earlier stages of the AN disease. The current systematic review was the first step in exploring neuropsychological functioning as a potentially identifying characteristic for long-term presentations. With a subgroup of AN patients reflecting a unique neuropsychological profile that is proportionate to the quantity of patients that go on to develop SE-AN, it was the aim of this review to assess neuropsychological functioning in the later stage of the disease. In accordance with PRISMA guidelines, a literature search was conducted using four electronic databases (PsycINFO, MEDLINE, Web of Science, and Scopus) for neuropsychological research on AN participants with a seven or more year illness duration. Datasets that met inclusion criteria were screened for SE-AN participants (N = 166) and neuropsychological data extracted together with potentially confounding variables and information required to conduct a quality assessment. In research investigating decision-making, participants with a SE-AN presentation demonstrated significantly lower functioning compared to healthy controls. There was conflicting evidence for differences in intellectual functioning and set-shifting abilities with no variability indicated in central coherence, memory, attention, reasoning, or processing speed. If findings from this preliminary analysis are confirmed through empirical research, implications include earlier identification of SE-AN patients and more effective treatment development.

Is poor global processing a transdiagnostic feature of Body Dysmorphic Disorder and Anorexia Nervosa? A meta-analysis

Body dysmorphic disorder (BDD) and anorexia nervosa (AN) are characterised by body image disturbance. It has been suggested that poor global integration in visual processing may underlie distorted body image, but empirical studies have yielded mixed results. The current study involved two meta-analyses aimed at examining the extent to which poor global processing is evident in BDD and AN. Studies were identified through a systematic literature search up to October 2020. The BDD search yielded 16 studies and the AN search yielded 18 studies. Random-effect models demonstrated a small pooled effect size for BDD (g = -0.44, 95 % CI -0.70, -0.17, p < 0.001) and a moderate pooled effect size for AN (g = -0.63, 95 % CI -0.77, -0.49, p <  .001), with no evidence of significant publication bias for either. The results provide evidence that poor global processing is a transdiagnostic feature of both BDD and AN, although effects may be more pronounced in AN. Our findings highlight the possibility that interventions aimed at promoting global visual processing could prove beneficial in disorders characterised by distorted body image.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

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

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

Central coherence in adults with a high-functioning autism spectrum disorder. In a search for a non-self-reporting screening tool

BACKGROUND

Autism spectrum disorder in adults, especially high-functioning ones, is often difficult to differentiate from other mental disorders. Therefore, many adults with ASD are misdiagnosed, and their social difficulties are not adequately addressed. Moreover, frequent comorbid issues make diagnosis a challenging prospect. Most of the available screening and diagnostic tools rely on self-reporting, which can be a biased method. Weak Central Coherence is one of the main cognitive theories of ASD. According to research, individuals with ASD are slower in comparison to typically developed control on the uptake of context. The study goal was to see if the central coherence tasks could be used as a reliable screening marker that differentiates between high-functioning ASD and typically developed controls.

METHOD

Thirty males with ASD (as in DSM-5) and 30 demographically matched controls were investigated with Central Coherence Inferences Tests. Tests' scores and reaction times needed to complete the tasks in both groups were compared.

RESULTS

High-functioning participants with ASD achieved a similar score in central coherence tests as the typically developed control group, but they needed significantly more time to solve them. The ROC analysis for both central coherence tests revealed AUC values of 0.73 in differentiating ASD from typically developed controls.

CONCLUSIONS

The results are discussed in reference to the clinical application of central coherence as a possible screening marker. Further research directions are proposed in terms of differential diagnosis of adults with ASD.

Short-Term Fasting Selectively Influences Impulsivity in Healthy Individuals

Previous research has shown that short-term fasting in healthy individuals is associated with changes in risky decision-making. The current experiment was designed to examine the influence of short-term fasting in healthy individuals on four types of impulsivity: reflection impulsivity, risky decision-making, delay aversion, and action inhibition. Participants were tested twice, once when fasted for 20 h, and once when satiated. Participants demonstrated impaired action inhibition when fasted; committing significantly more errors of commission during a food-related Affective Shifting Task. Participants also displayed decreased reflection impulsivity when fasted, opening significantly more boxes during the Information Sampling Task (IST). There were no significant differences in performance between fasted and satiated sessions for risky decision-making or delay aversion. These findings may have implications for understanding eating disorders such as Bulimia Nervosa (BN). Although BN has been characterized as a disorder of poor impulse control, inconsistent findings when comparing individuals with BN and healthy individuals on behavioral measures of impulsivity question this characterization. Since individuals with BN undergo periods of short-term fasting, the inconsistent findings could be due to differences in the levels of satiation of participants. The current results indicate that fasting can selectively influence performance on the IST, a measure of impulsivity previously studied in BN. However, the results from the IST were contrary to the original hypothesis and should be replicated before specific conclusions can be made.

Functional MRI investigation of verbal working memory in adults with anorexia nervosa

Literature regarding verbal working memory (vWM) in anorexia nervosa (AN) has been inconsistent due to a misunderstanding of the key components of vWM and introduction of confounding stimuli. Furthermore, there are no studies looking at how brain function in people with AN relates to vWM performance. The present study used functional magnetic resonance imaging (fMRI) with a letter n-back paradigm to study the effect of increasing vWM task difficulty on cortical functioning in the largest AN sample to date (n = 31). Although the AN group had low BMI and higher anxious and depressive symptomology compared to age-matched controls (HC), there were no between-group differences in accuracy and speed at any task difficulty. fMRI data revealed no regions exhibiting significant differences in activation when groups were compared at each difficulty separately and no regions showing group x condition interaction. Although there was a trend towards lower accuracy as duration of illness increased, this was not correlated with activity in regions associated with vWM. These findings indicate that vWM in AN is as efficient and performed using the same cognitive strategy as HC, and that there may not be a need for therapies to pursue remediation of this particular neurocognitive faculty.

Weight and age do not account for a worse executive functioning among BED-obese patients

PURPOSE

Research has demonstrated impaired executive functioning among Binge Eating Disorder (BED) patients that could be influenced by age and weight. We aim to compare decision-making, set-shifting and central coherence between BED-obese patients (BED-Ob), non-BED-obese patients (non-BED-Ob), and normal-weight healthy controls (NW-HC) without the influence of these variables.

METHODS

Overall, 35 BED-Ob, 32 non-BED-Ob and 26 NW-HC participants completed the Iowa Gambling Task, the Trail Making Test and the Rey-Osterrieth Complex Figure Test.

RESULTS

BED-Ob patients showed higher cognitive impairment compared to NW-HC on decision-making, set-shifting, visual attention and memory.

CONCLUSIONS

BED-Ob patients have an impaired cognitive profile on decision-making, set-shifting, visual attention and memory but not impaired central coherence. As all groups were aged-matched and no significant differences between BED-Ob and non-BED-Ob participants were evident, our results demonstrate that this impairment is independent from weight/age, pointing out that it is BED itself to account for inefficiencies in cognitive functioning.

LEVEL OF EVIDENCE

Level III, case-control study.

Updates on Treatments for Adolescent Anorexia Nervosa

This article provides background information, descriptions, and evidential support for the more recent treatments for adolescents with anorexia nervosa, including family-based treatment, adolescent focused therapy, cognitive behavioral therapy, systemic family therapy, and psychopharmacologic treatments. At this time, family-based treatment has the best evidence of efficacy and cost-effectiveness. Future directions in treatment research for adolescent anorexia nervosa are discussed.

A process approach to verbal memory assessment: Exploratory evidence of inefficient learning in women remitted from anorexia nervosa

Introduction: Anorexia nervosa (AN) is associated with deficits in set-shifting and cognitive flexibility, yet less is known about the persistence of these deficits after recovery and how they might contribute to reported difficulties organizing and learning new information. To address this question, the current study applied a process-focused approach, that accounts for errors and strategies by which a score is achieved, to investigate the relationship between verbal memory and executive function in women remitted from AN. Method: Twenty-six women remitted from anorexia nervosa (RAN) and 25 control women (CW) aged 19-45 completed the California Verbal Learning Test, Second edition (CVLT-II) and the Wisconsin Card Sorting Test (WCST). Groups were compared on overall achievement scores, and on repetition, intrusion, and perseverative errors on both tests. Associations between learning and memory performance and WCST errors were also examined. Results: RAN and CW groups did not differ on overall CVLT-II learning and memory performance or errors on the WCST, though the RAN group trended towards greater WCST non-perseverative and total errors. On the CVLT-II, the RAN group made significantly more repetition errors than CW (p = 0.010), and within-trial perseveration (WTP) errors (p = 0.044). For the CW group, CVLT-II learning and memory performance were negatively associated with errors on the WCST, whereas among RAN, primarily delayed memory was negatively correlated with WCST errors. Notably, for RAN, greater WCST perseverative responses were correlated with greater CVLT-II repetition and WTP errors, showing the convergence of perseverative responding across tasks. Conclusions: Despite similar overall learning and memory performance, difficulties with executive control seem to persist even after symptom remission in patients with AN. Results indicate an inefficient learning process in the cognitive phenotype of AN and support the use of process approaches to refine neuropsychological assessment of AN by accounting for strategy use.

Sex Differences in Adolescent Anorexia and Bulimia Nervosa: Beyond the Signs and Symptoms

PURPOSE OF REVIEW

We review research related to sex differences in eating disorders (EDs) in adolescents. Prior work has explored clinical differences; thus, we examine literature in areas identified as playing an etiological or maintenance role in EDs including: genetics, hormones, neurocognitive inefficiencies, and reward circuitry.

RECENT FINDINGS

Sex steroids appear to a play role in the unmasking of genetic risk for development of EDs and puberty may be a heightened period of risk for females. While neurocognitive differences have been well studied in adults with ED, research with adolescents has been less conclusive. Recent work suggests that neural circuitry involved in reward and punishment may play role in development and maintenance of EDs in females. Males are underrepresented in these areas of research. Given known sex differences in healthy adolescents, it is likely there are sex differences in the putative biological etiology/maintenance of EDs. Males should be included in future research.

The improvement in neurocognitive functioning in anorexia nervosa adolescents throughout the integrative model of psychotherapy including cognitive remediation therapy

BACKGROUND

Patients with anorexia nervosa (AN) experience difficulties in neurocognitive functioning in the acute phase of illness which might be related to clinical presentation, but also in the apparently remitted state after weight recovery. Among the most commonly reported persistent deficits is cognitive inflexibility, which can be interpreted as a vulnerability trait or a "neuropsychological scar" reflecting the detrimental effect of prolonged semi-starvation in patients with a long duration of illness. Studies of adolescent samples with a relatively short clinical course may enable avoiding the effect of prolonged illness and help to determine whether neuropsychological deficits are trait or state dependent. The aim of this study is to assess cognitive functioning in adolescents with AN before and after the inpatient treatment programme, including cognitive remediation therapy (CRT).

METHODS

Forty-seven adolescent female inpatients with AN diagnosed according to DSM-5 and fifty healthy female adolescents matched for the education level and age were recruited. The patients underwent a multimodal treatment including a ten-week CRT. The standardized and cross-validated neuropsychological (Trail Making Test - TMT A and B, Color-Word Stroop Task - CWST, Ruff Figural Fluency Test - RFFT) and clinical measurements (Beck Depression Inventory - BDI, Eating Attitude Test - EAT-26, Yale-Brown Obsessive Compulsive Scale - Y-BOCS) were used to assess both clinical (in the acute phase and after partial weight recovery) and control subjects.

RESULTS

Initially, AN patients performed significantly worse compared to the controls, but afterwards, inpatient treatment improvement was noted on all examined measures. In a few subtests (TMT, CWST) performance of AN patients after the programme was still significantly poorer than in HC.

CONCLUSIONS

Cognitive inflexibility in adolescent AN patients, as measured with TMT, CWST, and RFFT tends to improve after therapy. Nevertheless, a few neuropsychological subtests which did not show complete normalization may warrant attention in subsequent studies. Further research including control intervention is needed to conclude whether CRT intervention affects the outcome.

Similarities and Differences in Theory of Mind Responses of Patients With Anorexia Nervosa With and Without Autistic Features

Theory of Mind (ToM) is the ability to understand and represent mental states of others, a skill that plays a key role in how we interact with people around us. Difficulties with ToM have been posited as an underlying mechanism for autism and implicated in difficulties faced by those with anorexia nervosa (AN). This study examined, both quantitatively and qualitatively, the responses of women between the ages of 14 and 25 years on the Frith-Happé Triangle Animations, a well-validated test of ToM. Participants were split into healthy controls (HCs), AN patients (AN), and AN patients with high levels of autistic features (AN+ASF). We found no significant quantitative differences between groups in performance on the task. Qualitatively, there were differences between groups such that AN patients, especially those in the AN+ASF group, were more focused on describing the videos than creating narratives, were more negative in their interpretations, and were much more anxious about their performance. These qualitative differences have clinical implications, including that not all AN patients with autistic features should be assumed to have difficulties with ToM.

Do autism spectrum disorder and anorexia nervosa have some eating disturbances in common?

A possible overlap between autism spectrum disorder (ASD) and anorexia nervosa (AN), in terms of both behavioural and cognitive features, has led to new areas of research. The aim of the present study was to examine the occurrence of eating behaviours frequently seen in ASD among adolescents and young adults with AN. The participants were females within the age range 15-25 years: 36 with current AN (32 were followed up after 1 year), 19 with ASD, and 30 healthy females. The participants completed the SWedish Eating Assessment for Autism spectrum disorders (SWEAA) and the Autism Spectrum Quotient tool (AQ). AN groups had significantly higher SWEAA scores than the healthy comparison group, also when patients had gained weight. Typical autistic eating behaviours, such as selective eating, were more common in the AN groups than in the ASD group. This is the first time that SWEAA has been implemented in an AN population. Eating behaviours frequently seen in ASD seem to be frequent in AN and some remain also after weight gain.

A systematic review of reviews of neurocognitive functioning in eating disorders: The state-of-the-literature and future directions

OBJECTIVE

In recent years there has been increasing clinical and empirical interest in neurocognitive functioning in eating disorders (EDs), which has resulted in numerous quantitative and qualitative reviews. However, there has yet to be a comprehensive synthesis or critical review of this literature to identify future directions to advance the field in this area. Therefore the aim of this systematic review of systematic reviews was to (a) characterize the existing literature on neurocognitive functioning in EDs based on recent reviews (i.e., published since 2010), (b) describe related limitations, and (c) suggest avenues for future research to address gaps in the current literature.

METHOD

Electronic databases were queried for reviews of neurocognitive domains (i.e., inhibitory control, decision-making, central coherence, set-shifting, working memory, and attention bias) in EDs, which identified 28 systematic and meta-analytic reviews.

RESULTS

Broadly, the literature indicates deficits across these neurocognitive domains in EDs, though heterogeneity was noted in the magnitude of these effects, which varied to some extent across ED subtypes, sample characteristics, and methodological approaches.

DISCUSSION

While these reviews have generally suggested varying patterns of neurocognitive deficits across EDs, there remain critical limitations regarding the methodological quality of these studies (e.g., the lack of prospective designs, consideration of confounding influences, or examination of interrelationships between neurocognitive domains and relationships between neurocognition and other relevant behavioral constructs). Specifically, we outline 10 key areas that are imperative to address in future research in this area in order to move our field forward.

Cognitive remediation therapy (CRT) as a pretreatment intervention for adolescents with anorexia nervosa during medical hospitalization: a pilot randomized controlled trial protocol

BACKGROUND

Anorexia nervosa (AN) is a severe psychiatric condition characterized by low body weight, fear of weight gain/becoming fat and/or behavior that interferes with weight gain, and body disturbance. Though there have been recent advances in the treatment of AN, there continues to be an urgent need to increase treatment options. Cognitive remediation therapy (CRT) has been successfully used as an adjunctive treatment for individuals with AN. In this study, we pilot the use of CRT plus an innovative parent involvement component as a pre-treatment intervention on a medical unit. We hypothesize that adding CRT with parent involvement to a standard hospital stay is feasible, acceptable by patients and staff, and may improve treatment outcomes post-hospitalization.

METHODS/DESIGN

This is a pilot randomized controlled trial with three arms. Participants are adolescents aged 12-18 with AN; 60 participants will be included. They are randomized into one of three groups: treatment as usual (TAU, standard care at Children's Hospital of Philadelphia), CRT + contact control (known as "Family Fun Time"), and CRT + Teach the Parent. Intervention will occur on an inpatient basis. Follow-up will be outpatient and will continue until 6 months post-discharge. Psychosocial, neurocognitive, and behavioral measures will be collected throughout the study, and group differences will be evaluated at 4 weeks, 3 months, and 6 months post-discharge. The study will take place at The Children's Hospital of Philadelphia.

DISCUSSION

This pilot randomized controlled trial will inform feasibility of the integration of a pre-treatment intervention into a medical hospital stay for AN. We will assess recruitment procedures, treatment administration, and participant retention. Finally, a comprehensive assessment battery will be evaluated. Secondary goals are to conduct a preliminary evaluation of whether or not CRT with parent involvement increases rate of weight gain and treatment engagement and decreases parental accommodation of symptoms post-discharge. If successful, this pilot study will inform a larger controlled trial fully powered to examine the secondary goals.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02883413.

Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice

Informed consent requires adequate mental capacity to consent to treatment. Mental capacity (MC) to consent to treatment refers to the ability to make medical decisions. MC is assessed in a general psychiatric interview, but this clinical assessment is known to overestimate mental capacity in patients and the inter rater reliability is low. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) has emerged as the gold standard to assess mental capacity to consent to treatment. The MacCAT-T is a semi-structured interview designed to aid clinicians in this assessment and has shown good inter rater reliability in patients with schizophrenia and other mental disorders, but has hardly been studied in patients with anorexia nervosa. Patients with anorexia nervosa (AN) regularly avoid treatment, even when severely ill and discussion includes assessing MC to consent to treatment. The aim of this study is to compare clinical judgment and the MacCAT-T in evaluating MC in patients with AN which in turn may influence use of the MacCAT-T in daily practice. In a sample of 70 consecutively referred severely ill patients with AN with a mean BMI of 15.5 kg/m² and a mean duration of illness of 8.6 years, clinical assessment of MC by experienced psychiatrists and the outcome of the MacCAT-T interview were compared. Agreement (κ-value) was calculated. Agreement between clinical assessment and outcome of the MacCAT-T was questionable (κ 0.23). Unlike in other psychiatric populations, clinicians judged a high proportion of patients with AN as having diminished MC. The MacCAT-T can be useful in assessing MC in AN when used in addition to clinical judgment to aid clinicians in complex cases. Why clinicians judge a relatively high proportion of patients with AN as having diminished MC, in contrast to lower proportions in other psychiatric disorders, is an area in need of further research.

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.

Autism spectrum disorder and interoception: Abnormalities in global integration?

Research over the past three decades has seen a revived interest in the way the human body—and the way in which it is perceived—interacts with aspects of our experience. Consequently, interoception (i.e. the perception of physiological feedback from the body) has recently been shown to be associated with a wide range of cognitive, emotional, and affective functions, making it broadly relevant to the study of autism spectrum disorder. Although limited qualitative accounts and empirical studies suggest that individuals with autism spectrum disorder encounter abnormalities when perceiving and integrating physiological feedback from their bodies, other studies have suggested that people with/without autism spectrum disorder do not differ in interoceptive ability after accounting for alexithymia. In this article, we discuss the newly recognized importance of interoception in autism spectrum disorder with a focus on how deficits in the perception of bodily feedback might relate to the core features and co-occuring psychopathology of autism spectrum disorder. Finally, a new integrated theory is advanced which posits that people with autism spectrum disorder may experience a reduced capacity to integrate interoceptive information that may result in a narrow attentional bodily focus and reduced motivational and behavioral drives.

Visual-Constructional Ability in Individuals with Severe Obesity: Rey Complex Figure Test Accuracy and the Q-Score

The aims of this study were to investigate visual-construction and organizational strategy among individuals with severe obesity, as measured by the Rey Complex Figure Test (RCFT), and to examine the validity of the Q-score as a measure for the quality of performance on the RCFT. Ninety-six non-demented morbidly obese (MO) patients and 100 healthy controls (HC) completed the RCFT. Their performance was calculated by applying the standard scoring criteria. The quality of the copying process was evaluated per the directions of the Q-score scoring system. Results revealed that the MO did not perform significantly lower than the HC on Copy accuracy (mean difference −0.302, CI −1.374 to 0.769, p = 0.579). In contrast, the groups did statistically differ from each other, with MO performing poorer than the HC on the Q-score (mean −1.784, CI −3.237 to −0.331, p = 0.016) and the Unit points (mean −1.409, CI −2.291 to −0.528, p = 0.002), but not on the Order points score (mean −0.351, CI −0.994 to 0.293, p = 0.284). Differences on the Unit score and the Q-score were slightly reduced when adjusting for gender, age, and education. This study presents evidence supporting the presence of inefficiency in visuospatial constructional ability among MO patients. We believe we have found an indication that the Q-score captures a wider range of cognitive processes that are not described by traditional scoring methods. Rather than considering accuracy and placement of the different elements only, the Q-score focuses more on how the subject has approached the task.

Treatment of anorexia nervosa: a multimethod investigation translating experimental neuroscience into clinical practice

Background

Anorexia nervosa (AN) is a severe psychiatric condition and evidence on how to best treat it is limited.

Objectives

This programme consists of seven integrated work packages (WPs) and aims to develop and test disseminable and cost-effective treatments to optimise management for people with AN across all stages of illness.

Methods

WP1a used surveys, focus groups and a pre–post trial to develop and evaluate a training programme for school staff on eating disorders (EDs). WP1b used a randomised controlled trial (RCT) [International Standard Randomised Controlled Trial Number (ISRCTN) 42594993] to evaluate a prevention programme for EDs in schools. WP2a evaluated an inpatient treatment for AN using case reports, interviews and a quasi-experimental trial. WP2b used a RCT (ISRCTN67720902) to evaluate two outpatient psychological therapies for AN. WP3 used a RCT (ISRCTN06149665) to evaluate an intervention for carers of inpatients with AN. WP4 used actimetry, self-report and endocrine assessment to examine physical activity (PA) in AN. WP5 conducted a RCT (ISRCTN18274621) of an e-mail-guided relapse prevention programme for inpatients with AN. WP6 analysed cohort data to examine the effects of maternal EDs on fertility and their children’s diet and growth. WP7a examined clinical case notes to explore how access to specialist ED services affects care pathways and user experiences. Finally, WP7b used data from this programme and the British Cohort Study (1970) to identify the costs of services used by people with AN and to estimate annual costs of AN for England.

Results

WP1a: a brief training programme improved knowledge, attitudes and confidence of school staff in managing EDs in school. WP1b: a teacher-delivered intervention was feasible and improved risk factors for EDs in adolescent girls. WP2a: both psychological therapies improved outcomes in outpatients with AN similarly, but patients preferred one of the treatments. WP2b: the inpatient treatment (Cognitive Remediation and Emotional Skills Training) was acceptable with perceived benefits by patients, but showed no benefits compared with treatment as usual (TAU). WP3: compared with TAU, the carer intervention improved a range of patient and carer outcomes, including carer burden and patient ED symptomatology. WP4: drive to exercise is tied to ED pathology and a desire to improve mood in AN patients. PA was not increased in these patients. WP5: compared with TAU, the e-mail-guided relapse prevention programme resulted in higher body mass index and lower distress in patients at 12 months after discharge. WP6: women with an ED had impaired fertility and their children had altered dietary and growth patterns compared with the children of women without an ED. WP7a: direct access to specialist ED services was associated with higher referral rates, lower admission rates, greater consistency of care and user satisfaction. WP7b: the annual costs of AN in England are estimated at between £45M and £230M for 2011.

Conclusions

This programme has produced evidence to inform future intervention development and has developed interventions that can be disseminated to improve outcomes for individuals with AN. Directions for future research include RCTs with longer-term outcomes and sufficient power to examine mediators and moderators of change.

Trial registration

Current Controlled Trials ISRCTN42594993, ISRCTN67720902, ISRCTN06149665 and ISRCTN18274621.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 16. See the NIHR Journals Library website for further project information.

Mental capacity to consent to treatment and the association with outcome: a longitudinal study in patients with anorexia nervosa

BACKGROUND

Relevance of diminished mental capacity in anorexia nervosa (AN) to course of disorder is unknown.

AIMS

To examine prognostic relevance of diminished mental capacity in AN.

METHOD

A longitudinal study was conducted in 70 adult female patients with severe AN. At baseline, mental capacity was assessed by psychiatrists, and clinical and neuropsychological data (decision-making) were collected. After 1 and 2 years, clinical and neuropsychological assessments were repeated, and remission and admission rates were calculated.

RESULTS

People with AN with diminished mental capacity had a less favourable outcome with regard to remission and were admitted more frequently. Their appreciation of illness remained hampered. Decision-making did not improve, in contrast to people with full mental capacity.

CONCLUSIONS

People with AN with diminished mental capacity seem to do less well in treatment and display decision-making deficiencies that do not ameliorate with weight improvement.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Obesity is associated with lack of inhibitory control and impaired heart rate variability reactivity and recovery in response to food stimuli

Recent theories compare obesity with addiction in terms of lack of inhibitory control in both clinical populations. The present study hypothesized impaired inhibition in obese patients reflected both in executive functions and reduced vagal tone (indexed by a decrease in heart rate variability; HRV) in response to food stimuli. Twenty-four inpatients with obesity (19 women) and 37 controls (24 women) underwent ECG monitoring during baseline, food stimuli viewing, and a recovery phase. Tests and questionnaires assessing inhibitory control and psychopathological dispositions were also administered. As hypothesized, patients were characterized by deficits in all the tests measuring inhibitory capacities. Results also show greater HRV reduction and impaired HRV recovery in response to food stimuli in obese patients compared to controls. The drive to eat experienced by obese patients in the absence of caloric need may rely on impairments in inhibitory and vagal functioning. Results are discussed in terms of implications for therapy.

Similarities and Differences of Neuropsychological Profiles in Children and Adolescents with Anorexia Nervosa and Healthy Controls Using Cluster and Discriminant Function Analyses

OBJECTIVE

This study aimed to identify discrete neuropsychological profiles and their relationship to clinical symptoms in 253 female children and adolescents with anorexia nervosa (AN) and 170 healthy controls (HCs) using a standardised neuropsychological assessment battery.

METHOD

Hierarchical cluster analysis was used to identify the optimum number of clusters, and participants were assigned using K-means cluster analysis. Confirmatory discriminant function analysis determined which combination of neuropsychological variables best distinguished the clusters.

RESULTS

Three distinct clusters in the AN sample emerged- AN cluster 1 (19%) - "neuropsychologically low average to average"; AN cluster 2 (33%) - "verbal/visuo-spatial discrepancy"; and AN cluster 3 (48%) - "verbally strong and neuropsychologically average to high average". Two distinct clusters in HCs were identified. HC cluster 1 (48%) demonstrated poor visuo-spatial memory scores and high verbal fluency scores, whilst HC cluster 2 (52%) scored within the average range on all neuropsychological tasks. Neuropsychological performance was associated with clinical symptoms of body mass index centile, Eating Disorder Examination subscale and global score, anxiety, depression and obsessions, and compulsions between the AN and HC groups. However, niether significant differences emerged between AN clusters only nor HC clusters only at the post-hoc level.

DISCUSSION

An underlying neuropsychological heterogeneity may exist in AN. We encourage future studies to investigate whether the identified profiles and their association with clinical characteristics are replicable. We cautiously suggest that neuropsychological profiling may have potential to both inform future research and have possible clinical benefits through individually tailored treatment strategies.

Central Coherence in Eating Disorders: A Synthesis of Studies Using the Rey Osterrieth Complex Figure Test

Background

Large variability in tests and differences in scoring systems used to study central coherence in eating disorders may lead to different interpretations, inconsistent findings and between study discrepancies. This study aimed to address inconsistencies by collating data from several studies from the same research group that used the Rey Osterrieth Complex Figure Test (Rey Figure) in order to produce norms to provide benchmark data for future studies.

Method

Data was collated from 984 participants in total. Anorexia Nervosa, Bulimia Nervosa, recovered Anorexia Nervosa, unaffected family members and healthy controls were compared using the Rey Figure.

Results

Poor global processing was observed across all current eating disorder sub-groups and in unaffected relatives. There was no difference in performance between recovered AN and HC groups.

Conclusions

This is the largest dataset reported in the literature and supports previous studies implicating poor global processing across eating disorders using the Rey Figure. It provides robust normative data useful for future studies.

A Virtual Reality Full Body Illusion Improves Body Image Disturbance in Anorexia Nervosa

BACKGROUND

Patients with anorexia nervosa (AN) have a persistent distorted experience of the size of their body. Previously we found that the Rubber Hand Illusion improves hand size estimation in this group. Here we investigated whether a Full Body Illusion (FBI) affects body size estimation of body parts more emotionally salient than the hand. In the FBI, analogue to the RHI, participants experience ownership over an entire virtual body in VR after synchronous visuo-tactile stimulation of the actual and virtual body.

METHODS AND RESULTS

We asked participants to estimate their body size (shoulders, abdomen, hips) before the FBI was induced, directly after induction and at ~2 hour 45 minutes follow-up. The results showed that AN patients (N = 30) decrease the overestimation of their shoulders, abdomen and hips directly after the FBI was induced. This effect was strongest for estimates of circumference, and also observed in the asynchronous control condition of the illusion. Moreover, at follow-up, the improvements in body size estimation could still be observed in the AN group. Notably, the HC group (N = 29) also showed changes in body size estimation after the FBI, but the effect showed a different pattern than that of the AN group.

CONCLUSION

The results lead us to conclude that the disturbed experience of body size in AN is flexible and can be changed, even for highly emotional body parts. As such this study offers novel starting points from which new interventions for body image disturbance in AN can be developed.

Using the Autism-Spectrum Quotient to Measure Autistic Traits in Anorexia Nervosa: A Systematic Review and Meta-Analysis

Interest in the link between Autism Spectrum Disorder (ASD) and Anorexia Nervosa (AN) has led to estimates of the prevalence of autistic traits in AN. This systematic review and meta-analysis assessed the use of the Autism-Spectrum Quotient (AQ) or abbreviated version (AQ-10) to examine whether patients with AN have elevated levels of autistic traits. Seven studies were identified and subsequent meta-analysis indicated that those with AN appear to have significant difficulties of a manner characteristic of ASD, relative to controls. Whilst this analysis supports previous indications of higher prevalence of ASD in AN, the aetiology of these traits remains unclear. Studies using more robust clinical measures of ASD within AN are needed to confirm what self-report measures appear to show.

Emotion-focused treatments for anorexia nervosa: a systematic review of the literature

PURPOSE

The present review explores emotion-focused treatments for anorexia nervosa (AN).

METHODS

We conducted a systematic literature search across key databases (PsychINFO, PubMed/Medline, and Web of Science) prior to September 2015. Twenty studies were selected for systematic review.

RESULTS

The present review found initial evidence supporting the acceptability and feasibility of emotion-focused treatments for AN. Although preliminary results are promising, further controlled studies are necessary to establish the efficacy of emotion-focused treatments for AN.

CONCLUSIONS

Future controlled trials should compare emotion-focused treatments against each other and against other AN treatments. Future studies should also examine the mechanisms of action for the emotion-focused treatments and treatment moderators.

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.

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.

Mental capacity to consent to treatment in anorexia nervosa: explorative study

BACKGROUND

Mental capacity to consent to treatment in anorexia nervosa is a neglected area in clinical decision-making.

AIMS

To examine clinical and neuropsychological parameters associated with diminished mental capacity in anorexia nervosa.

METHOD

An explorative study was conducted in 70 adult female patients with severe anorexia nervosa. Mental capacity to consent to treatment was assessed by experienced psychiatrists. Further measurements included the MacCAT-T (to assess mental capacity status), a range of clinical measures (body mass index (BMI) and comorbidity) and neuropsychological tests assessing decision-making, central coherence and set-shifting capacity.

RESULTS

Diminished mental capacity occurs in a third of patients with severe anorexia nervosa and is associated with a low BMI, less appreciation of illness and treatment, previous treatment for anorexia nervosa, low social functioning and poor set shifting.

CONCLUSIONS

Assessment of diminished mental capacity in anorexia nervosa requires careful evaluation of not only BMI, but also the degree of appreciation of illness and treatment, history and the tendency to have a rigid thinking style.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Local and global visual processing and eating disorder traits: An event-related potential study

Recent studies have suggested that individuals with eating disorders show a stronger local processing bias and/or a weaker global bias in visual processing than typical individuals. In this study, healthy participants with varying scores on the Eating Disorder Examination Questionnaire (EDE-Q) performed the Navon task, a standard task of local and global visual processing, whilst electrophysiological measures were recorded. Global stimuli were presented that were made up of many local parts, and the information between levels was either compatible or incompatible. Participants were instructed to report the identity of either a global or a local target shape, while ignoring the other level. Higher EDE-Q scores were associated with enhanced amplitude of the P3 component during local visual processing, as well as greater P1 amplitude during local incompatible trials. These findings support the claim that eating disorders are associated with differences in local and global visual processing.

Increased frontal electroencephalogram theta amplitude in patients with anorexia nervosa compared to healthy controls

OBJECTIVE

To conduct a blind study of quantitative electroencephalogram-band amplitudes in patients with anorexia nervosa (AN) and healthy controls.

METHODS

Twenty-one patients with AN and 24 controls were examined with eyes-closed 16-channel electroencephalogram. Main variables were absolute alpha, theta, and delta amplitudes in frontal, temporal, and posterior regions.

RESULTS

There were no significant differences between the AN patients and controls regarding absolute regional band amplitudes in μV. Borderline significance was found for anterior theta (P=0.051). Significantly increased left and right frontal electrode theta amplitude was found in AN patients (F3, P=0.014; F4, P=0.038) compared to controls. Significant differences were also observed for secondary variables: lower values for relative parietooccipital delta and frontocentral alpha activity among AN patients than among controls.

CONCLUSION

We observed slight excess frontal theta and lower relative alpha and delta amplitudes among AN patients than among controls. This pattern is possibly related to a slight frontal lobe dysfunction in AN, or it may reflect increased attention/vigilance or another state-related change in patients with AN compared to healthy controls.

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

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