Neuropsicologia dos transtornos alimentares: revisão sistemática da literatura

The impact of continuous calorie restriction and fasting on cognition in adults without eating disorders

Research into the effects of calorie restriction continues to intrigue those interested in whether it may allow humans to live longer and healthier lives. Animal studies of continuous calorie restriction (CCR) and fasting have demonstrated substantial advantages to health and longevity. However, concerns remain about the impact of restricting calorie intake on human health and cognition. Given the emerging evidence of cognitive impairments in eating disorders, studies investigating restricted calorie intake in healthy humans (in an ethical way) may also have implications for understanding restrictive eating disorders. In this review, the published literature on the impact of CCR and fasting on cognitive function in healthy human participants is synthesized. Of the 33 studies of CCR and fasting in humans identified, 23 demonstrated significant changes in cognition. Despite variation across the cognitive domains, results suggest CCR benefits inhibition, processing speed, and working memory, but may lead to impairments in cognitive flexibility. The results of fasting studies suggest fasting is associated with impairments in cognitive flexibility and psychomotor abilities. Overall, the results of these studies suggest the degree (ie, the severity) of calorie restriction is what most likely predicts cognitive improvements as opposed to impairments. For individuals engaging in sustained restriction, this may have serious, irreversible consequences. However, there are mixed findings regarding the impact of CCR and fasting on this aspect of human functioning, suggesting further research is required to understand the costs and benefits of different types of calorie restriction.

Brain functional changes in individuals with bulimia nervosa: a protocol for systematic review and meta-analysis

INTRODUCTION

Bulimia nervosa (BN) is a disorder with high health and socioeconomic burdens that typically arises in late adolescence and early adulthood. Previous neuroimaging studies have found functional brain changes in patients with BN. This study aims to review the latest neurobiological evidence from studies of individuals with BN, examine the consistency of these findings and evaluate the food addiction hypothesis of the disease.

METHODS AND ANALYSIS

A systematic search will be performed using the Cochrane Library, PubMed, Embase and Web of Science databases, covering the period from database inception to 30 November 2021. Two researchers will be responsible for study selection, quality assessment and data extraction. The anisotropic effect size version of the signed differential mapping method will be used to conduct a coordinate-based meta-analysis. Publication bias will be examined with the Egger test. The quality of studies will be evaluated using the Newcastle-Ottawa Scale.

ETHICS AND DISSEMINATION

No ethics approval is required for this is a systematic review protocol and does not require the collection of primary data. Findings will be disseminated through peer-reviewed journal or related conferences.

PROSPERO REGISTRATION NUMBER

CRD42022307233.

The imputation of structure in random patterns as a cognitive factor predicting adult picky eating behavior

We raise the hypothesis that adult picky eating behavior may be related to subjects' tendency to impute structure in random stimuli. We test said hypothesis in an empirical study which operationalizes subjects' objective abilities and subjective decision criteria in discriminating between correlated and independent signals in terms of the classic Signal Detection Theory. A robust regularized Bayesian multiple regression analysis indicates that liberal subjective decision criteria which indicate a tendency to over-impute structure when trying to discriminate between random and correlated patterns are associated with elevated scores of picky eating while controlling for several other variables. The predictive power of our discriminating procedure appears comparable to that of related eating dispositions. Our results strongly suggest that cognitive factors might indeed have substantial and meaningful relationships with certain eating behaviors.

The impact of theory of mind and neurocognition on delusionality in anorexia nervosa

The current study aimed to examine the impact of theory of mind (ToM) deficits on body image delusionality in anorexia nervosa (AN) while accounting for the effect of other cognitive functions. ToM and other cognitive functions were assessed in 46 patients with AN and 42 healthy controls. We used the Brown Assessment of Beliefs Scale to assess the degree of delusionality of body image beliefs in AN patients. Delusional body image beliefs were identified in 26.1% and overvalued ideas in 30.4% of the AN patients. Moderate but significant associations were found between impairments in ToM-overall capacity, cognitive and affective components-and body image delusionality. The effect of overall ToM performance on delusionality remained significant after controlling for other cognitive factors. General intelligence was also significantly associated with delusionality. Our findings support the notion that difficulties in taking the perspective of others contribute to insight impairment in AN. Further investigation is required to examine the effect of failures in social cognition and metacognition on insight in AN.

Abnormal Spontaneous Regional Brain Activity in Young Patients With Anorexia Nervosa

OBJECTIVE

Functional magnetic resonance imaging (fMRI) studies have repeatedly shown alterations in patients with anorexia nervosa (AN). These alterations might be driven by baseline signal characteristics such as the (fractional) amplitude of low frequency fluctuations (fALFF/ALFF), as well as regional signal consistency (ie, regional homogeneity [ReHo]) within circumscribed brain regions. Previous studies have also demonstrated gray matter (pseudo-) atrophy in underweight individuals with AN. Here we study fALFF/ALFF and ReHo in predominantly adolescent patients with AN, while taking gray matter changes into consideration.

METHOD

Resting state fMRI data were acquired from a sample of 148 female volunteers: 74 underweight patients with AN and 74 age-matched female healthy controls (HC).

RESULTS

Group differences for fALFF and ReHo measures were found in several AN-relevant brain regions, including networks related to cognitive control, habit formation, and the ventral visual stream. Furthermore, the magnitude of correlation between gray matter volume/thickness and fALFF and ReHo were reduced in AN compared to HC.

CONCLUSION

Abnormal local resting state characteristics in AN-related brain-networks as well as reduced structure-function relationships may help to explain previously reported task-related and classical resting state neural alterations in underweight AN. Patients with AN may serve as a valuable population for investigating dynamic changes in the relationships between brain structure and function.

The multidisciplinary therapy in binge eating disorder is able to influence the interdaily stability and sleep quality?

We have recently shown that rest-activity circadian rhythm significantly differed in women with Binge Eating Disorder (BED) compared to the Ctrl group. In details, patients with BED exhibited significantly reduced levels of MESOR and Amplitude with respect to the Ctrl group. In addition, in this previous study, the results of the actigraphic sleep monitoring provided no evidence of differences in sleep parameters between the two groups. We expanded the original sample obtaining a total of 28 volunteered women, 14 BED women, and 14 Ctrl. We recorded in all 28 participants a 5-day actigraphic monitoring to detect the rhythmometric parameters, interdaily stability, intradaily variability, L5, M10, and sleep parameters. During the study, BED's women group kept an individual multidisciplinary therapy lasting five weekly days, from Monday to Friday, consisting in cognitive-behavioral therapy and nutritional program, administered in outpatient care from 8:00 a.m. at 5:00 p.m. The combination of both our previous and current study supports the conclusion that the sleep quality of the BED group is significantly better compared to Ctrl. The non-parametric indexes showed how interdaily stability, significantly correlated to sleep efficiency, was higher in BED group compared to the Ctrl group, indicating a better synchronization of rest-activity circadian rhythm. In conclusion, the maintenance of a regular lifestyle, such as imposed by the multidisciplinary therapy, is important to avoid alterations in the sleep-wake cycle, particularly in patients with eating disorders.

Associations between ADHD and eating disorders in relation to comorbid psychiatric disorders in a nationally representative sample

The objective of this study was to examine whether previously observed associations of attention-deficit/hyperactivity disorder (ADHD) with eating disorders (EDs) are at least partially attributable to other underlying psychopathology. Data came from 4719 participants aged 18-44 years in the National Comorbidity Survey Replication and the National Survey of American Life. DSM-IV diagnoses were assessed using the World Health Organization Composite International Diagnostic Interview. Multinomial logistic regression assessed associations between DSM-IV lifetime and past-12 month diagnoses of ADHD with EDs in unadjusted models and in models adjusted for demographic variables and other psychopathology. Lifetime ADHD was strongly and significantly associated with lifetime bulimia nervosa (BN), binge eating disorder (BED), and any ED in unadjusted models, but not with anorexia nervosa or subthreshold BED. After adjusting for demographic variables and psychiatric comorbidities, all associations of lifetime ADHD with EDs were substantially attenuated, and only the association of ADHD with BN remained statistically significant. Similar results were found using past-12 month diagnoses. These results suggest that previously observed associations of ADHD with EDs might be due - at least in part - to additional psychiatric disorders that are often comorbid with both ADHD and EDs.

Rest-activity circadian rhythm and sleep quality in patients with binge eating disorder

Recent findings suggest that altered rest-activity circadian rhythms (RARs) are associated with a compromised health status. RARs abnormalities have been observed also in several pathological conditions, such as cardiovascular, neurological, and cancer diseases. Binge eating disorder (BED) is the most common eating disorder, with a prevalence of 3.5% in women and 2% in men. BED and its associate obesity and motor inactivity could induce RARs disruption and have negative consequences on health-related quality of life. However, the circadian RARs and sleep behavior in patients with BED has been so far assessed only by questionnaires. Therefore, the purpose of this study was to determine RARs and sleep parameters by actigraphy in patients with BED compared to a body mass index-matched control group (Ctrl). Sixteen participants (eight obese women with and eight obese women without BED diagnosis) were recruited to undergo 5-day monitoring period by actigraphy (MotionWatch 8®, CamNtech, Cambridge, UK) to evaluate RARs and sleep parameters. In order to determine the RARs, the actigraphic data were analyzed using the single cosinor method. The rhythmometric parameters of activity levels (MESOR, amplitude and acrophase) were then processed with the population mean cosinor. The Actiwatch Sleep Analysis Software (Cambridge Neurotecnology, Cambridge, UK) evaluated the sleep patterns. In each participant, we considered seven sleep parameters (sleep onset: S-on; sleep offset: S-off; sleep duration: SD; sleep latency: SL; movement and fragmentation index: MFI; immobility time: IT; sleep efficiency: SE) calculated over a period of five nights. The population mean cosinor applied to BED and Ctrl revealed the presence of a significant circadian rhythm in both groups (p < 0.001). The MESOR (170.0 vs 301.6 a.c., in BED and Ctrl, respectively; p < 0.01) and amplitude (157.66 vs 238.19 a.c., in BED and Ctrl, respectively p < 0.05) differed significantly between the two groups. Acrophase was not different between BED and Ctrl, as well as all sleep parameters. Both groups displayed a low level of sleep quality (SE 80.7% and 75.7% in BED and Ctrl, respectively). These data provided the first actigraphy-based evidence of RARs disruption and sleep behavior disorder in patients with BED. However, while sleep disorders could be reasonably ascribed to overweight/obesity and the related lower daily physical activity, RARs disruption in this pathology should be ascribed to factors other than reduced physical activity. The circadian timing approach can represent a novel potential tool in the treatment of patients with eating disorders. These data provide exploratory evidence of behavioral association in a small population of patients that, if confirmed in a wider number of subjects and across different populations, may lead to a revision and enhancement of interventions in BED patients.

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.

Attention Network Dysfunction in Bulimia Nervosa - An fMRI Study

OBJECTIVE

Recent evidence has suggested an increased rate of comorbid ADHD and subclinical attentional impairments in bulimia nervosa (BN) patients. However, little is known regarding the underlying neural mechanisms of attentional functions in BN.

METHOD

Twenty BN patients and twenty age- and weight-matched healthy controls (HC) were investigated using a modified version of the Attention Network Task (ANT) in an fMRI study. This design enabled an investigation of the neural mechanisms associated with the three attention networks involved in alerting, reorienting and executive attention.

RESULTS

The BN patients showed hyperactivation in parieto-occipital regions and reduced deactivation of default-mode-network (DMN) areas during alerting compared with HCs. Posterior cingulate activation during alerting correlated with the severity of eating-disorder symptoms within the patient group. Conversely, BN patients showed hypoactivation during reorienting and executive attention in anterior cingulate regions, the temporo-parietal junction (TPJ) and parahippocampus compared with HCs, which was negatively associated with global ADHD symptoms and impulsivity, respectively.

DISCUSSION

Our findings demonstrate altered brain mechanisms in BN associated with all three attentional networks. Failure to deactivate the DMN and increased parieto-occipital activation required for alerting might be associated with a constant preoccupation with food or body image-related thoughts. Hypoactivation of executive control networks and TPJ might increase the likelihood of inattentive and impulsive behaviors and poor emotion regulation. Thus, dysfunction in the attentional network in BN goes beyond an altered executive attentional domain and needs to be considered in the diagnosis and treatment of BN.

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.

Escaping the Golden Cage: Animal Models of Eating Disorders in the Post-Diagnostic and Statistical Manual Era

Eating disorders (EDs) are severe, life-threatening mental illnesses characterized by marked disturbances in body image and eating patterns. Attempts to understand the neurobiological basis of EDs have been hindered by the perception that EDs are primarily socially reinforced behaviors and not the result of a pathophysiologic process. This view is reflected by the diagnostic criteria of anorexia nervosa and bulimia nervosa, which emphasize intrapsychic conflicts such as "inability to maintain body weight," "undue influence of body weight or shape on self-evaluation," and "denial of the seriousness of low body weight" over neuropsychological measures. The neuropsychological constructs introduced within the research domain criteria (RDoC) matrix offer new hope for determining the neural substrate underlying the biological predisposition to EDs. We present selected studies demonstrating deficits in patients with EDs within each domain of the RDoC and propose a set of behavioral tasks in model systems that reflect aspects of that deficit. Finally, we propose a battery of tasks to examine comprehensively the function of neural circuits relevant to the development of EDs.

Fatores sociodemográficos e imagem corporal em adolescentes do ensino médio

O objetivo deste artigo é investigar associações entre a insatisfação com a imagem corporal e indicadores sociodemográficos em adolescentes. Participaram 1126 adolescentes do ensino médio do município de Santa Maria/RS. Foram analisadas questões sobre a insatisfação com a imagem corporal e indicadores sociodemográficos. As análises de associação foram realizadas por meio de regressão de Poisson bruta e ajustada por sexo e faixa etária. Rapazes estão insatisfeitos pela magreza e moças pelo excesso de peso. Os adolescentes cujo chefe de família possui menor escolaridade, de classes econômicas mais baixas e com menor renda apresentam maior probabilidade de insatisfação pela magreza. Já aqueles com o chefe de família apresentando ensino superior completo e os que residem no centro da cidade têm maior probabilidade de insatisfação pelo excesso de peso. Indicadores sociodemográficos estão associados à insatisfação com a imagem corporal. A insatisfação pela magreza é explicada pela menor escolaridade do chefe de família, pertencer às classes econômicas mais populares e ter menor renda. Já a insatisfação pelo excesso de peso, pela maior escolaridade do chefe de família e residir no centro.

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.

Cognitive and emotional functioning in binge-eating disorder: A systematic review

OBJECTIVE

Binge-eating disorder (BED) is characterized by recurrent episodes of binge eating and is associated with eating disorder and general psychopathology and overweight/obesity. Deficits in cognitive and emotional functioning for eating disorders or obesity have been reported. However, a systematic review on cognitive and emotional functioning for individuals with BED is lacking.

METHOD

A systematic literature search was conducted across three databases (Medline, PubMed, and PsycINFO). Overall, n = 57 studies were included in the present review.

RESULTS

Regarding cognitive functioning (CoF), individuals with BED consistently demonstrated higher information processing biases compared to obese and normal-weight controls in the context of disorder-related stimuli (i.e., food and body cues), whereas CoF in the context of neutral stimuli appeared to be less affected. Thus, results suggest disorder-related rather than general difficulties in CoF in BED. With respect to emotional functioning (EmF), individuals with BED reported difficulties similar to individuals with other eating disorders, with a tendency to show less severe difficulties in some domains. In addition, individuals with BED reported greater emotional deficits when compared to obese and normal-weight controls. Findings suggest general difficulties in EmF in BED. Thus far, however, investigations of EmF in disorder-relevant situations are lacking.

DISCUSSION

Overall, the cross-sectional findings indicate BED to be associated with difficulties in CoF and EmF. Future research should determine the nature of these difficulties, in regards to general and disorder-related stimuli, and consider interactions of both domains to foster the development and improvement of appropriate interventions in BED.

Central Coherence, Visuoconstruction and Visual Memory in Patients with Eating Disorders as Measured by Different Scoring Methods of the Rey Complex Figure Test

OBJECTIVE

The aims of this study were to examine the performance of eating disorder (ED) patients on the Rey Complex Figure Test and to investigate the validity of the Q-score as a new method for measuring central coherence (CC).

METHOD

Forty-one patients with anorexia nervosa, 40 patients with bulimia nervosa and 40 healthy controls completed the Rey Complex Figure Test, which was scored both quantitatively and qualitatively.

RESULTS

Both ED groups scored lower than the healthy controls on copy, recall and the Q-score. For the anorexia nervosa group, performance on the Central Coherence Index was associated with the nadir body mass index. Performance on the recall measures was independently associated with the nadir body mass index and depressive symptoms for the bulimia nervosa group. There was a strong correlation between the Q-score and the Central Coherence Index (r = 0.77).

DISCUSSION

The study reveals different levels of CC and suggests that the Q-score might be an applicable method for measuring CC in ED patients.

The neuropsychology of starvation: set-shifting and central coherence in a fasted nonclinical sample

OBJECTIVES

Recent research suggests certain neuropsychological deficits occur in anorexia nervosa (AN). The role of starvation in these deficits remains unclear. Studies of individuals without AN can elucidate our understanding of the effect of short-term starvation on neuropsychological performance.

METHODS

Using a within-subjects repeated measures design, 60 healthy female participants were tested once after fasting for 18 hours, and once when satiated. Measures included two tasks to measure central coherence and a set-shifting task.

RESULTS

Fasting exacerbated set-shifting difficulties on a rule-change task. Fasting was associated with stronger local and impaired global processing, indicating weaker central coherence.

CONCLUSIONS

Models of AN that propose a central role for set-shifting difficulties or weak central coherence should also consider the impact of short-term fasting on these processes.

Serum brain-derived neurotrophic factor and cognitive functioning in underweight, weight-recovered and partially weight-recovered females with anorexia nervosa

Several studies support the assumption that the brain-derived neurotrophic factor (BDNF) plays an important role in the pathophysiology of eating disorders. In the present cross-sectional and longitudinal study, we investigated BDNF levels in patients with anorexia nervosa (AN) at different stages of their illness and the association with cognitive functioning. We measured serum BDNF in 72 acutely underweight female AN patients (acAN), 23 female AN patients who successfully recovered from their illness (recAN), and 52 healthy control women (HCW). Longitudinally, 30 acAN patients were reassessed after short-term weight gain. The association between BDNF levels and psychomotor speed was investigated using the Trail Making Test. BDNF serum concentrations were significantly higher in recAN participants if compared to acAN patients and increased with short-term weight gain. In acAN patients, but not HCW, BDNF levels were inversely associated with psychomotor speed. AcAN patients with higher BDNF levels also had lower life time body mass indexes. Taken together, our results indicate that serum BDNF levels in patients with AN vary with the stage of illness. Based on the pleiotropic functions of BDNF, changing levels of this neurotrophin may have different context-dependent effects, one of which may be the modulation of cognitive functioning in acutely underweight patients.

Increased set shifting costs in fasted healthy volunteers

We investigated the impact of temporary food restriction on a set shifting task requiring participants to judge clusters of pictures against a frequently changing rule. 60 healthy female participants underwent two testing sessions: once after fasting for 16 hours and once in a satiated state. Participants also completed a battery of questionnaires (Hospital Anxiety and Depression Scale [HADS]; Persistence, Perseveration and Perfectionism Questionnaire [PPPQ-22]; and Eating Disorders Examination Questionnaire [EDE-Q6]). Set shifting costs were significantly increased after fasting; this effect was independent of self-reported mood and perseveration. Furthermore, higher levels of weight concern predicted a general performance decrement under conditions of fasting. We conclude that relatively short periods of fasting can lead to set shifting impairments. This finding may have relevance to studies of development, individual differences, and the interpretation of psychometric tests. It also could have implications for understanding the etiology and maintenance of eating disorders, in which impaired set shifting has been implicated.

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.

[An international neuropsychological assessment tool for children, adolescents, and adults with anorexia nervosa – the German adaptation of the Ravello Profile]

OBJECTIVE

Adults with anorexia nervosa (AN) show weaknesses in several cognitive functions before and after weight restoration. There is a great demand for standardized examinations of executive functioning in the field of child and adolescent AN. Previous studies exhibited methodological inconsistencies regarding test selection and operationalization of cognitive functions, making the interpretation of their findings difficult. In order to overcome these inconsistencies, a neuropsychological assessment tool, the "Ravello Profile," was developed, though previously not available in German. This paper presents a German adaptation of the Ravello Profile and illustrates its applicability in children and adolescents via three case descriptions.

METHODS

The Ravello Profile was adapted for the German-speaking area. The applicability of the Ravello Profile was evaluated in three children and adolescents with AN.

RESULTS AND CONCLUSIONS

The cases presented confirm the feasible implementation of this adaptation of the Ravello Profile, both in children and adolescents. Hence, it enables a methodologically consistent examination of executive functioning in German-speaking children, adolescents, and adults with AN. Using the Ravello Profile, the role of cognitive functions in the development of AN can be systematically examined over a broad age range.

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.

Inhibitory control in bulimic-type eating disorders: a systematic review and meta-analysis

The aim of this meta-analysis was to summarise data from neuropsychological studies on inhibitory control to general and disease-salient (i.e., food/eating, body/shape) stimuli in bulimic-type eating disorders (EDs). A systematic literature search was conducted to identify eligible experimental studies. The outcome measures studied included the performance on established inhibitory control tasks in bulimic-type EDs. Effect sizes (Hedges' g) were pooled using random-effects models. For inhibitory control to general stimuli, 24 studies were included with a total of 563 bulimic-type ED patients: 439 had bulimia nervosa (BN), 42 had anorexia nervosa of the binge/purge subtype (AN-b), and 82 had binge eating disorder (BED). With respect to inhibitory control to disease-salient stimuli, 12 studies were included, representing a total of 218 BN patients. A meta-analysis of these studies showed decreased inhibitory control to general stimuli in bulimic-type EDs (g = −0.32). Subgroup analysis revealed impairments with a large effect in the AN-b group (g = −0.91), impairments with a small effect in the BN group (g = −0.26), and a non-significant effect in the BED group (g = −0.16). Greater impairments in inhibitory control were observed in BN patients when confronted with disease-salient stimuli (food/eating: g = −0.67; body/shape: g = −0.61). In conclusion, bulimic-type EDs showed impairments in inhibitory control to general stimuli with a small effect size. There was a significantly larger impairment in inhibitory control to disease salient stimuli observed in BN patients, constituting a medium effect size.

[Anorexia nervosa - from a neuroscience perspective]

Anorexia nervosa is a frequent disorder especially among adolescent girls and young women, with high morbidity, mortality, and relapse rates. To date, no single therapeutic approach has proved to be superior to others (Herpertz et al., 2011). It remains unclear how its etiology and pathology are encoded within cognitive, neural, and endocrinological processes that modulate important mechanisms in appetitive processing and weight regulation. Yet, several trait characteristics have been identified in AN which might reflect predisposing factors. Further, altered levels of neuropeptides and hormones that regulate appetite and feeding behavior have been found during both the acute and the recovered state, pointing to dysfunctional mechanisms in AN that persist even after malnutrition has ceased. Researchers are also hoping that brain imaging techniques will allow for a more detailed investigation of the neural basis of reward and punishment sensitivity that appears to be altered in AN. The integration and extension of recent findings in these areas will hopefully provide a more comprehensive understanding of the disorder and hence enable the development of more effective treatments.

Neuropsychological variables and clinical status in anorexia nervosa: relationship between visuospatial memory and central coherence and eating disorder symptom severity

AIM

To explore the relationship between visuospatial memory, weak central coherence, and eating disorder (ED) symptoms in anorexia nervosa (AN) inpatients.

SAMPLE

31 female AN inpatients.

METHODS

Rey complex figure test (RCFT) was used to assess both visuospatial memory and central coherence. RCFT consisted of copy and recall trials. ED symptoms were assessed by The Eating Disorder Examination-Questionnaire (EDE-Q) and The Clinical and Research Inventory for Eating Disorders (CR-EAT).

RESULTS

We found a statistically significant negative correlation between recall accuracy and the total EDE-Q score. Furthermore, recall accuracy and recall central coherence significantly negatively correlate with several EDE-Q and CR-EAT scales.

CONCLUSIONS

These findings may contribute to a better understanding of cognitive impairments specifically in ED, and to refining interventions aiming at their improvement.

Central coherence, organizational strategy, and visuospatial memory in children and adolescents with anorexia nervosa

The vast majority of studies in anorexia nervosa that have investigated the domains of central coherence, organizational strategy, and visuospatial memory have focused on adult samples. In addition, studies investigating visuospatial memory have focused on free recall. No study to date has reported the association between recognition memory and central coherence or organizational strategy in younger people with this disorder, yet the capacity to recognize previously seen visual stimuli may contribute to overall visuospatial ability. Therefore, we investigate these domains in children and adolescents with anorexia nervosa compared to age- and gender-matched healthy controls. There were no significant group differences in immediate, delayed, or recognition memory, central coherence, or organization strategy. When compared with controls, patients with anorexia nervosa scored significantly higher on accuracy and took significantly longer when copying the Rey Complex Figure Task. Caution must be taken when interpreting these findings due to lower-than-expected scores in memory performance in the control group and because of a potential lack of sensitivity in the measures used when assessing this younger population. For neuropsychological functions where no normative data exist, we need a deeper, more thorough knowledge of the developmental trajectory and its assessment in young people in the general population before drawing conclusions in anorexia nervosa.

Group cognitive remediation therapy for adult anorexia nervosa inpatients: first experiences

AIM

In this study, we aim to explore the feasibility and acceptability of group cognitive remediation therapy (CRT) for anorexia nervosa (AN) inpatients, and to suggest modifications for future use.

METHODS

We performed ten 45-min CRT sessions, once a week, in two consecutive groups of adult AN inpatients. The groups consisted of 14 and 20 participants, respectively. At the end of each session, participants filled in a questionnaire asking them to evaluate whether and how they benefited from the exercise

RESULTS

Group-based CRT could be well incorporated into the therapeutic program of the Eating Disorders Unit, and was well received by the participants. Based on patients' feedback and our observations, we discuss several options for future modifications.

Executive functioning in anorexia nervosa patients and their unaffected relatives

Formal genetic studies suggested a substantial genetic influence for anorexia nervosa (AN), but currently results are inconsistent. The use of the neurocognitive endophenotype approach may facilitate our understanding of the AN pathophysiology. We investigated decision-making, set-shifting and planning in AN patients (n=29) and their unaffected relatives (n=29) compared to healthy probands (n=29) and their relatives (n=29). The Iowa Gambling Task (IGT), the Tower of Hanoi (ToH) and the Wisconsin Card Sorting Test (WCST) were administered. Concordance rates and heritability indices were also calculated in probands/relatives. Impaired performance on the IGT and the WCST were found in both AN probands and their relatives, although planning appeared to be preserved. The IGT heritability index suggested the presence of genetic effects that influence this measure. No evidence for genetic effects was found for the WCST. The results suggest the presence of a shared dysfunctional executive profile in women with AN and their unaffected relatives, characterized by deficient decision-making and set-shifting. Concordance analysis strongly suggests that these impairments aggregate in AN families, supporting the hypothesis that they may constitute biological markers for AN. Decision-making impairment presents a moderate heritability, suggesting that decision-making may be a candidate endophenotype for AN.

Executive functioning and behavioral impulsivity of young women who binge eat

OBJECTIVE

To examine the link between binge eating, executive functioning, and behavioral impulsivity.

METHOD

Fifty women who reported engaging in weekly binge eating in the absence of regular compensatory behaviors and 66 women with no history of binge eating completed several self-report questionnaires and a brief neuropsychological battery, including the Wisconsin Card Sorting Task and Conner's Continuous Performance Task.

RESULTS

Hierarchical regression analyses revealed that groups did not differ in executive functioning after controlling for depression, anxiety, body mass, general intelligence, and psychotropic medication use. Correlation analyses suggest that individuals who endorse more frequent binge eating might have greater difficulties thinking flexibly or shifting attention. Individuals who binge eats are also more likely to behave impulsively, but only for emotional reasons.

DISCUSSION

Although this study is unable to determine whether these cognitive and behavioral factors precede or follow binge-eating episodes, outcomes have implications for treatment and prevention.

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.

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.

Neuropsychological weaknesses in anorexia nervosa: set-shifting, central coherence, and decision making in currently ill and recovered women

OBJECTIVE

The purpose of this study is to examine set-shifting, central coherence, and decision making in women currently ill with anorexia nervosa (AN), women recovered from AN, and healthy control women. We aim to test whether these neuropsychological weaknesses persist after recovery, and explore relations between the impairments

RESULTS

Compared to control women, ill and recovered women showed poor set-shifting and decision making. There were strong correlations between set-shifting and central coherence in the ill and recovered women. Decision making did not correlate with the other measures.

DISCUSSION

The present findings suggest that impaired set-shifting and decision making are stable traits in women with AN. Because individual differences within these groups were large, a rigid thinking style is only present in a (sub)population of ill and recovered women. Decision-making performance is not related to a rigid thinking style, but further research in this area is warranted.

Assessment of interpersonal skills in obese women with binge eating disorder

Based upon interpersonal theory that suggests an association between binge eating disorder (BED) and interpersonal problems, the present study examined empathy and other social skills of obese women with BED. The findings showed that five social skills were statistically associated with the chance of presenting BED. Obese women with less assertiveness, lower ability to express feelings, lower capacity to deal with strangers, lower ability to understand the perspective of others, and with higher levels of distress in interpersonal situations had a higher probability of presenting the diagnosis of BED. These results highlight an association between social skills deficits and BED.

Heart Rate Variability Modulates Eye-Blink Startle in Women With Bulimic Symptoms

The aim of the present study was to examine the modulatory influence of heart rate variability (HRV), an index of autonomic regulation, on eye-blink startle in women with bulimic symptoms. Twenty-four women with bulimic symptoms and 24 control women underwent a psychophysiological test to assess their HRVs during a rest period. They then underwent 20 trials designed to measure their startle motor reflexes while viewing pictures of food and pleasant, neutral, and unpleasant pictures. Women with bulimic symptoms and low HRV had larger startle magnitudes while viewing the pictures than women with both bulimic symptoms and high HRV and control women. A negative relationship between HRV and startle magnitude while viewing food pictures was also found in this group. These findings suggest that poor autonomic regulation, indicated by low HRV, plays a modulatory influence in women with bulimic symptoms.

Neuropsychological psychopathology measures in women with eating disorders, their healthy sisters, and nonrelated healthy controls

OBJECTIVE

To assess the familial influence on neuropsychological dysfunction in eating disorders (ED) patients by comparing 16 patients with restricting type anorexia nervosa (AN-R), 18 patients with bingeing purging type anorexia nervosa, 20 patients with bulimia nervosa binge-purge type, 21 of the patients' nonaffected sisters, and 20 nonrelated healthy controls.

METHODS

Self-report questionnaires assessing psychopathology and 2 computerized cognitive tasks measuring hemispheric asymmetry for language and visuospatial abilities were administered to all participant groups.

RESULTS

On the self-report questionnaires, ED patients scored significantly more pathological than the healthy controls, whereas the healthy sisters were similar to the nonrelated healthy control group. For both of the computerized tasks, the behavior pattern of the sisters was similar to that of all, or most ED groups, and were significantly different from the nonrelated healthy controls. In addition, AN-R patients performed significantly worse on the visuospatial task than the other ED groups.

CONCLUSIONS

The dissociation between the performance on the cognitive tasks and psychopathology measures in healthy sisters, when compared to the ED and nonrelated healthy control groups, suggests that disturbances in neurocognitive functioning in ED patients are not necessarily the result of ED-related dysfunction. Rather, this may indicate general individual differences in cognitive processes that may run in families irrespective of the ED condition of the family member. The findings, with respect to the AN-R patients, support a neurocognitive continuum model of EDs in which AN-R represents the most severe form of the illness.

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.

[Evidence-based practices published in Brazil: identification and analysis of their types and methodological approches]

This is an integrative review of Brazilian studies on evidence-based practices (EBP) in health, published in ISI/JCR journals in the last 10 years. The aim was to identify the specialty areas that most accomplished these studies, their foci and methodological approaches. Based on inclusion criteria, 144 studies were selected. The results indicate that most EBP studies addressed childhood and adolescence, infectious diseases, psychiatrics/mental health and surgery. The predominant foci were prevention, treatment/rehabilitation, diagnosis and assessment. The most used methods were systematic review with or without meta-analysis, protocol review or synthesis of available evidence studies, and integrative review. A strong multiprofessional expansion of EBP is found in Brazil, contributing to the search for more selective practices by collecting, recognizing and critically analyzing the produced knowledge. The study also contributes to the analysis itself of ways to do research and new research possibilities.

The Ravello Profile: development of a global standard neuropsychological assessment for young people with anorexia nervosa

Recent research suggests that neuropsychological factors may play an important role in the development and maintenance of anorexia nervosa. However, it has been difficult to draw firm conclusions because of the wide range of assessments and norms that have been used. The aim of the Ravello Profile is to define a common shared neuropsychological assessment battery that can be adopted by researchers and clinicians working with young people. We describe the background to the Ravello Profile and the process of developing it, before specifying the recommended tests. We present an illustrative case example and consider some of the potential clinical and research applications of the profile with young people suffering from anorexia nervosa.

A case series investigating distinct neuropsychological profiles in children and adolescents with anorexia nervosa

A number of specific deficits in neuropsychological functioning in anorexia nervosa (AN) have been identified. However, it is not known whether these specific deficits cluster together to form one or more clear neuropsychological profiles. We present a case series of nine participants who were recruited as part of a wider, ongoing investigation of the neuropsychological profile of eating disorders (the Ravello Profile). Results show that there was a wide range of different neuropsychological profiles at initial assessment. This suggests a spectrum of neuropsychological strengths and weaknesses that would otherwise be masked in a cohort analysis. It is anticipated that factor and cluster analytic studies will establish one or more common profiles of neuropsychological deficits in AN.

Is decision making really impaired in eating disorders?

OBJECTIVE

Decision making has been reported to be reduced in eating disorders. However, studies are sparse and have been carried out in various selected populations. In the current study we arranged to confirm previous observations and to assess the relationship between decision making and dimensions relevant to eating disorders.

METHOD

Patients suffering from anorexia nervosa (n = 49), bulimia nervosa (n = 38), and healthy controls (n = 83) were assessed using the Iowa Gambling Task (IGT). All patients were euthymic and free of psychotropic medication. Self-questionnaires (Eating Disorder Inventory-2; Gardner, 1991; and Eating Attitude Test; Garner & Garfinkel, 1979) were used to assess clinical dimensions relevant to eating disorders.

RESULTS

No significant differences in IGT performance were observed between patients and healthy controls or between restrictive and purging types of anorexia nervosa. No correlations were found between IGT performance and eating disorder questionnaires.

CONCLUSION

These results do not support reduced decision making in patients with eating disorders, and suggest that previously reported alterations could be related to other clinical characteristics. This should stimulate new topic-related studies designed to reach a firm conclusion.

Preliminary evidence for a role for impulsivity in cognitive disinhibition in bulimia nervosa

The present study investigated cognitive disinhibition in bulimia nervosa (BN) and examined whether impulsivity could account for this neuropsychological deficiency. Inhibitory processing of 13 women with BN (16-29 years) was compared against that of 13 healthy control participants matched for age, education, and socioeconomic status on a battery of widely used tasks: Stroop task, Haylings sentence completion test, excluded letter fluency, and Matching Familiar Figures Test. The women were also administered the Barratt Impulsiveness Scale (BIS-11). The BN patients displayed significant impairments on all inhibition measures and posited significantly higher impulsivity scores than the controls. Moreover, controlling for impulsivity reduced the group differences in Stroop color naming and excluded letter fluency to nonsignificance, indicating that poor inhibitory control in BN is at least partly attributable to an impulsive disposition.