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In First Presentation Adolescent Anorexia Nervosa, Do Cognitive Markers of Underweight Status Change with Weight Gain Following a Refeeding Intervention?
Abstract
To determine the nature and severity of cognitive functioning impairment in adolescent anorexia nervosa (AN) when underweight and following weight gain.
In 37 first admission adolescent (12–18 years) AN patients and 45 matched controls, general cognitive functions were assessed at baseline and follow-up using the IntegNeuro-computerized battery. AN participants were tested between days 3 and 10 of their admission when underweight, with retesting conducted after weight restoration.
When underweight, AN participants performed more poorly than controls on sensori-motor speed tasks and exhibited a susceptibility to interference, but had superior working memory. Once the weight is restored, individuals significantly improved relative to their own performance. Relative to controls, they were significantly faster on attention and executive function tasks, exhibited superior verbal fluency, working memory, and a significantly superior ability to inhibit well-learnt responses.
Cognitive impairments in adolescent AN appear to normalize with refeeding and weight gain. © 2009 by Wiley Periodicals, Inc. Int J Eat Disord 2010
... Neuropsychological investigations in AN patients have revealed heterogeneous findings regarding their performance in different cognitive domains [10][11][12]. For example, while some have shown reduced performance in attentional functions (vigilance and selective attention), memory (verbal recall accuracy and speed), and executive functions (cognitive flexibility, central coherence, and decision-making) [11,13,14], others have shown only selective impairments, no differences, or even better performance compared to control groups [15][16][17][18]. However, the published studies are very heterogeneous regarding the type of cognitive tests used, how many and which domains of cognitive function were covered, and which age groups were included, warranting more standardized measures. ...
... Additionally, Stedal and colleagues [24] found decreased set-shifting and memory capacity, but increased verbal fluency in patients with AN, when using the Ravello profile. Some studies have described normalization or a trend towards normalization after weight restoration of different cognitive domains, especially in younger samples [18,20,25,26], while others have reported persisting alterations even in the recovered state [27][28][29] or inconclusive findings for adult patients [30]. Similarly, findings regarding associations between clinical variables such as body mass index (BMI) and ED symptoms and cognitive functioning appear to be heterogeneous [31][32][33][34][35]. Clarifying the extent of a potential cognitive impairment in moderately and severely underweight AN patients is important, since this may counteract and interfere with treatment attempts and may be an outcome for clinical assessments. ...
... Additionally, the tests permit repeated testing with the ease of parallel form use. However, it is evident from the eating disorder literature that there are only a few studies that have utilized computerized cognitive test batteries, including the CANTAB [36,37], the Cognitive Drug Research (CDR) system [31,38,39], the CogState battery, and the Inte-gNeuro cognitive battery [18]. The results have been conflicting, ranging from subtle changes [36] that normalized with increasing weight [18] to changes in motor inhibition [31,37] and attention [31]. ...
Anorexia Nervosa (AN) is a severe and often enduring disorder characterized by restriction of food intake, low body weight, fear of weight gain, and distorted body image. Investigations on cognition performance in AN patients have yielded conflicting results. Using an established and sensitive computerized cognitive test battery, we aimed to assess core aspects of cognitive function, including attention span, information processing, reasoning, working and episodic memory, in AN patients and controls. Patients were recruited from the Danish Prospective Longitudinal all-comer inclusion study in Eating Disorders (PROLED). Included were 26 individuals with AN and 36 healthy volunteers (HV). All were tested with CogTrack (an online cognitive assessment system) at baseline, and AN patients were tested again at a follow-up time point after weight increase (n = 13). At baseline, AN patients showed faster reaction times in the attention tasks, as well as increased accuracy in grammatical reasoning compared to HV. There were no differences in cognitive function between AN patients and HV in the other cognitive domains measured (sustained attention, working and episodic memory, speed of retrieval, and speed of grammatical reasoning). No differences were visible in the AN sample between baseline and follow-up. Performance did not correlate with any clinical variables in the AN sample. These findings supplement results from other studies suggesting increased concentration and reasoning accuracy in patients suffering from AN, who showed increased performance in cognitive tasks despite their illness.
... Publication years spanned from 2000 to 2017. Nine studies (equivalent to 10 reports) included children and adolescents (Buehren et al., 2011(Buehren et al., , 2012Firk et al., 2015;Grunwald et al., 2001;Hatch et al., 2010;Lozano-Serra, Andrés-Perpiña, Lázaro-García, & Castro-Fornieles, 2014;Neumarker, Bzufka, Dudeck, Hein, & Neumarker, 2000;Sarrar et al., 2011;Telleus et al., 2016;Zwipp et al., 2014). Five studies included adolescents and adults (Ball, Mitchell, Touyz, Griffiths, & Beumont, 2004;Decker, Figner, & Steinglass, 2015;Epstein et al., 2001;Moser et al., 2003;Pieters et al., 2004Pieters et al., , 2005Pieters et al., , 2006. ...
... Of these 15 reports, 11 detected practice effects in the cognitive tests used (Buehren et al., 2011;Buhren et al., 2012;Decker et al., 2015;Foerde & Steinglass, 2017;Lozano-Serra et al., 2014;Moser et al., 2003;Pieters et al., 2004Pieters et al., , 2005Pieters et al., , 2006Sarrar et al., 2011;Telleus et al., 2016), where three of them used alternative measurements at follow-up in a parallel design (Buehren et al., 2011;Lozano-Serra et al., 2014;Moser et al., 2003). The four studies that did not detect any practice effect used alternative measurements at follow-up (Cavedini et al., 2006;Epstein et al., 2001;Firk et al., 2015;Hatch et al., 2010). ...
... Using the Rey Osterrieth Complex Figure Test (RCFT) (Meyers & Meyers, 1995), which measures central coherence, Lozano-Serra et al. (2014) found improvement after weight gain in patients with AN, whereas Telleus et al. (2016) did not. Using the Trail Making Test (TMT) A (Reitan & Wolfson, 1985), which measures processing speed, Sarrar et al. (2011) and Telleus et al. (2016) found improvement for patients with AN after weight gain while Hatch et al. (2010) also noted improvement on a similar test of processing speed, the Switching of Attention Part I (Paul et al., 2005). Telleus et al. (2016) found that patients with AN did not improve after weight gain on the TMT B, which measures cognitive flexibility, and Hatch et al. (2010) found no improvement on a similar test, the Switching of Attention part II. ...
Objective
Anorexia nervosa (AN) has been associated with cognitive impairment. While re‐nutrition is one of the main treatment targets, the effect on cognitive impairments is unclear. The aim of this review was to examine whether cognitive functions improve after weight gain in patients with AN.
Method
A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta‐analyses statement guidelines (PROSPERO CRD42019081993). Literature searches were conducted May 20th, 2019 in PubMed, EMBASE, PsychINFO and Cochrane Library. Pairs of reviewers screened reports independently based on titles/abstracts (N = 6539) and full texts (N = 378). Furthermore, they assessed the quality of reports, including whether practice effects were accounted for.
Results
Twenty‐four longitudinal reports were included featuring 757 patients and 419 healthy controls. Six studies examined children and adolescents. Four out of four studies found processing speed to improve above and beyond what could be assigned to practice effects and three out of four studies found that cognitive flexibility was unaffected after weight gain in children and adolescents. Results from studies of adults were inconclusive.
Discussion
The literature on cognitive change in patients with AN following weight gain is sparse. Preliminary conclusions can be made only for children and adolescents, where weight gain appeared to be associated with improved processing speed.
Highlights
• Wight gain appears to be associated with improved processing speed in children and adolescents with anorexia nervosa (AN)
• It remains unclear whether cognitive functions can improve after weight gain in adults with AN
• We recommend clear distinction between children, adolescents and adults in future longitudinal studies of cognitive performance in patients with AN
... The majority of studies included in this review examined cognitive flexibility in an exclusively female sample, with only six studies including a minority of male participants in the sample of participants with AN (Andrés- Perpiñá et al., 2011;Brown et al., 2018;Cavedini et al., 2004;Dell'Osso et al., 2018;Kjaersdam Telléus et al., 2015;Talbot et al., 2015). Participants in the included studies were typically adults, however, 21 studies were specifically focused on children or adolescents (Andrés- Perpiñá et al., 2011;Bischoff-Grethe et al., 2013;Bohon et al., 2019;Brown et al., 2018;Bühren et al., 2012;Calderoni et al., 2013;Castro-Fornieles et al., 2019;Dmitrzak-Weglarz et al., 2011Fitzpatrick, Darcy, Colborn, Gudorf, & Lock, 2012;Fowler et al., 2006;Hatch et al., 2010;Herbrich, Kappel, van Noort, & Winter, 2018;Kjaersdam Telléus et al., 2015;Lang et al., 2015;Lozano-Serra et al., 2014;McAnarney et al., 2011;Sarrar et al., 2011Sarrar et al., , 2016van Noort, Pfeiffer, Ehrlich, Lehmkuhl, & Kappel, 2016 Grant & Berg, 1948;Heaton, Chelune, Talley, Kay, & Curtiss, 1993) The WCST was the most commonly used cognitive flexibility task across all papers and was used in 47.82% of all included papers. The WCST can be completed as a pen-and-paper task or using a computer. ...
... and a medium effect size. Using the IntegNeuro switching of attention task, Hatch et al. (2010) found that AN-WR adolescents completed all stages of the task significantly faster than HCs. The faster completion time exhibited by the AN-WR sample in the baseline motor speed and cognitive flexibility components of the task suggests that the difference between groups may be a result of superior sensorimotor speed in the adolescent AN-WR group rather than superior cognitive flexibility. ...
... Four longitudinal studies assessed cognitive flexibility using switching type tasks in participants with AN before and after weightrestoration (Bühren et al., 2012;Castro-Fornieles et al., 2019;Hatch et al., 2010;. In adolescents, Bühren et al. (2012) found that compared to after participants had achieved weight-restoration, adolescents with acute AN responded significantly slower in a visual shifting task, with a medium effect size. ...
Difficulties in cognitive flexibility–the ability to adapt effectively to changes in the environment and/or changing task demands–have been reported in anorexia nervosa (AN). However, findings are inconsistent across studies and it remains unclear which specific aspects of cognitive flexibility patients with AN may struggle with. This systematic review aimed to synthesise existing research on cognitive flexibility in AN and clarify differences between patients with acute AN, patients who are weight-restored and patients who are fully recovered from AN. Electronic databases were searched through to January 2020. 3,310 papers were screened and 70 papers were included in the final review. Although adults with acute AN performed worse in perceptual flexibility tasks and self-report measures compared to HCs, they did not exhibit deficits across all domains of cognitive flexibility. Adolescents with acute AN did not differ to HCs in performance on neurocognitive tasks despite self-reporting poorer cognitive flexibility. Overall, significant differences in cognitive flexibility between acute and recovered participants was not evident, though, the findings are limited by a modest number of studies. Recovered participants performed poorer than HCs in some neurocognitive measures, however, results were inconsistent across studies. These results have implications for the assessment of cognitive flexibility in AN and targeted treatment approaches.
... Anorexia nervosa (AN) is associated with adverse effects on cognitive functioning in the domains of attention, processing speed, visual and verbal memory, and visuospatial construction [1][2][3][4][5], as well as high rates of comorbid anxiety, depression, and obsessive compulsive disorder [1,6,7]. Both mental and physical stabilization are essential for full recovery from AN [8][9][10]. ...
... Both mental and physical stabilization are essential for full recovery from AN [8][9][10]. Several neuropsychological studies that have reported cognitive impairment in individuals with anorexia nervosa before formal treatment subsequently noted improvement in many facets of cognitive functioning following weight restoration [2][3][4][5]. However, the findings noted above have been discordant from those of other studies. ...
... We found no differences in cognition between patients with AN-BP and healthy controls as measured by RBANS and TMT. Several previous studies demonstrating cognitive impairment in patients with AN have not investigated potential differences in diagnostic subtypes [2,4,11]. The lack of observed difference in baseline cognition between AN-BP and healthy controls was surprising given the significant differences in body weight. ...
Background:
The purpose of this study was to quantify cognitive deficits in severe anorexia nervosa (AN) before and after medical stabilization.
Methods:
This was a prospective study of 40 females between the ages of 18 and 50 admitted to a medical stabilization unit with severe AN (%IBW < 70). The primary outcome of the study was change in test scores on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) at baseline and after medical stabilization.
Results:
There were no statistically significant differences in baseline RBANS scores between AN patients overall and controls (p = 0.0940). There was a statistically significant change in RBANS from baseline 94.1 + 12.7 to medical stabilization 97.1 + 10.6 (p = 0.0173), although notably both mean values fell within the average range. There were no significant differences in baseline RBANS scores between controls and AN-BP patients (p = 0.3320) but significant differences were found between controls and AN-R patients (p = 0.0434).
Conclusions:
No baseline deficits in cognition were found in this sample of women with severe AN.
... Learning performance describes the ability to acquire information during several acquisition trials, whereas the recognition test assesses the retrieval of previously presented items amongst new information. While some authors reported immediate (Bayless et al., 2002;Hamsher Kde, Halmi, & Benton, 1981;Jones, Duncan, Brouwers, & Mirsky, 1991;Kingston, Szmukler, Andrewes, Tress, & Desmond, 1996;Mathias & Kent, 1998;Moser et al., 2003) and delayed (Bayless et al., 2002;Jones et al., 1991;Mathias & Kent, 1998) verbal recall deficits in acute AN patients, other studies revealed normal (Bosanac et al., 2007;Connan et al., 2006;Lauer, Gorzewski, Gerlinghoff, Backmund, & Zihl, 1999;Mathias & Kent, 1998;Moser et al., 2003;Szmukler et al., 1992) or even superior (Hatch et al., 2010) immediate verbal recall and normal delayed verbal recall in AN sufferers (Bosanac et al., 2007;Hatch et al., 2010;Kingston et al., 1996;Mathias & Kent, 1998). In contrast, verbal recognition performance appears to be less affected in AN (Bayless et al., 2002;Connan et al., 2006;Mathias & Kent, 1998;Moser et al., 2003). ...
... Learning performance describes the ability to acquire information during several acquisition trials, whereas the recognition test assesses the retrieval of previously presented items amongst new information. While some authors reported immediate (Bayless et al., 2002;Hamsher Kde, Halmi, & Benton, 1981;Jones, Duncan, Brouwers, & Mirsky, 1991;Kingston, Szmukler, Andrewes, Tress, & Desmond, 1996;Mathias & Kent, 1998;Moser et al., 2003) and delayed (Bayless et al., 2002;Jones et al., 1991;Mathias & Kent, 1998) verbal recall deficits in acute AN patients, other studies revealed normal (Bosanac et al., 2007;Connan et al., 2006;Lauer, Gorzewski, Gerlinghoff, Backmund, & Zihl, 1999;Mathias & Kent, 1998;Moser et al., 2003;Szmukler et al., 1992) or even superior (Hatch et al., 2010) immediate verbal recall and normal delayed verbal recall in AN sufferers (Bosanac et al., 2007;Hatch et al., 2010;Kingston et al., 1996;Mathias & Kent, 1998). In contrast, verbal recognition performance appears to be less affected in AN (Bayless et al., 2002;Connan et al., 2006;Mathias & Kent, 1998;Moser et al., 2003). ...
... Various types of stimulus material have been used for the assessment of general memory performance (i.e. memory recall using neutral stimuli) in AN patients, including single words (Bayless et al., 2002;Bosanac et al., 2007;Connan et al., 2006;Green, Elliman, Wakeling, & Rogers, 1996;Hatch et al., 2010;Jones et al., 1991;Lauer et al., 1999;Mathias & Kent, 1998;Moser et al., 2003;Szmukler et al., 1992), numbers (Hamsher Kde et al., 1981), as well as story recall (Jones et al., 1991;Kingston et al., 1996;Lauer et al., 1999;Mathias & Kent, 1998;Muller, Hasse-Sander, Horn, Helmstaedter, & Elger, 1997). With regard to story recall, the majority of studies revealed immediate and delayed recall deficits in AN patients (Bayless et al., 2002;Jones et al., 1991;Kingston et al., 1996;Mathias & Kent, 1998;Moser et al., 2003;Nikendei et al., 2008), while others found unimpaired story recall (Kingston et al., 1996;Lauer et al., 1999). ...
Objective:
It is unclear whether observed memory impairment in anorexia nervosa (AN) depends on the semantic structure (categorized words) of material to be encoded. We aimed to investigate the processing of semantically related information in AN.
Method:
Memory performance was assessed in a recall, learning, and recognition test in 27 adult women with AN (19 restricting, 8 binge-eating/purging subtype; average disease duration: 9.32 years) and 30 healthy controls using an extended version of the Rey Auditory Verbal Learning Test, applying semantically related and unrelated word stimuli.
Results:
Short-term memory (immediate recall, learning), regardless of semantics of the words, was significantly worse in AN patients, whereas long-term memory (delayed recall, recognition) did not differ between AN patients and controls.
Discussion:
Semantics of stimuli do not have a better effect on memory recall in AN compared to CO. Impaired short-term versus long-term memory is discussed in relation to dysfunctional working memory in AN. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.
... Similar to the adult literature, few studies with adolescents with AN controlled for depression while analyzing cognitive fl exibility. Most of these studies found no correlation between depression and cognitive fl exibility (Bühren et al., 2012;Hatch et al., 2010;Sarrar et al., 2011). Interestingly, OCD symptoms highly correlate with perfectionism, which was associated with lower set-shifting ability (Bühren et al., 2012). ...
... Our results are in accordance with previous studies, demonstrating no diff erences in cognitive fl exibility in adolescents with AN and HC (Andres-Perpina et al., 2011;Dmitrzak-Weglarz et al., 2011;Fitzpatrick, Darcy, Colborn, Gudorf, & Lock, 2012;Hatch et al., 2010). However, other studies in juvenile AN did demonstrate subtle weak- Figure 1. ...
... In accordance with previous results, symptoms of depression and OCD did not moderate cognitive fl exibility in juvenile AN after controlling for age and motor speed (Andres-Perpina et al., 2011;Hatch et al., 2010;Sarrar et al., 2011). Additionally, the infl uence of depression and OCD symptoms on cognitive fl exibility did not diff er between AN and HC. ...
Objective: Whereas the evidence in adolescents is inconsistent, anorexia nervosa (AN) in adults is characterized by weak cognitive flexibility. This study investigates cognitive flexibility in adolescents with AN and its potential associations with symptoms of depression, obsessive compulsive disorder (OCD), and duration of illness. Methods: 69 patients and 63 age-matched healthy controls (HC) from 9 till 19 years of age were assessed using the Trail-Making Test (TMT) and self-report questionnaires.
Results: In hierarchical regression analyses, set-shifting ability did not differ between AN and HC, whereas AN patients reported significantly higher rates of depression symptoms and OCD symptoms. Age significantly predicted set-shifting in the total sample. Only among AN patients aged 14 years and older did set-shifting decline with increasing age.
Discussion: The presence of AN with depression or OCD symptoms or the duration of illness do not influence cognitive flexibility in children and adolescents. Early interventions may be helpful to prevent a decline in cognitive flexibility in adolescent AN with increasing age.
... In contrast, the picture is less clear with respect to the cognitive profile of children and adolescents with AN. Several studies have found no evidence of cognitive inefficiencies (Buhren et al., 2012;Calderoni et al., 2013;Lang, Stahl, Espie, Treasure & Tchanturia, 2014a;Sarrar et al., 2011), while some have found inefficiencies in visuoconstruction set-shifting abilities, sensorymotor speed, reaction time and nonverbal intelligence of patients with AN (Andres-Perpina et al., 2011;Hatch et al., 2010;Kjaersdam Telleus et al., 2015;Lange & Tchanturia, 2014;Lang et al., 2015;Rose, Frampton, & Lask, 2013;Stedal, Frampton, Landro, & Lask, 2012). ...
... Only a few follow-up studies of cognitive functions in children and adolescents with AN have been conducted (Buehren et al., 2011;Buhren et al., 2012;Hatch et al., 2010). In a follow-up study conducted among juvenile patients with AN, it was found that when patients with AN had a low body weight, they performed significantly worse than control participants in tests of motor speed; these inefficiencies appeared to normalise with weight gain (Hatch et al., 2010). ...
... Only a few follow-up studies of cognitive functions in children and adolescents with AN have been conducted (Buehren et al., 2011;Buhren et al., 2012;Hatch et al., 2010). In a follow-up study conducted among juvenile patients with AN, it was found that when patients with AN had a low body weight, they performed significantly worse than control participants in tests of motor speed; these inefficiencies appeared to normalise with weight gain (Hatch et al., 2010). Another study showed an increased reaction time when engaging in set-shifting tasks and a reduced error rate across time (Buhren et al., 2012). ...
Objective:
The aim of this study was to characterise the association between the cognitive profile and weight restoration in children and adolescents with anorexia nervosa.
Methods:
The study was a longitudinal, matched case-control, multicentre study. An assessment of cognitive functions was conducted by using the Wechsler Intelligence Scale for Children-III/the Wechsler Adult Intelligence Scale-III, the Test of Memory and Learning-second edition, Trail Making Tests A and B, the Rey-Osterrieth Complex Figure Test and the Cambridge Neuropsychological Test Automated Battery.
Results:
One hundred twenty individuals, 60 patients with anorexia nervosa with mean age of 14.65 (SD 1.820) years and 60 healthy controls with mean age of 14.76 (SD 1.704) years, participated. No association was found between weight recovery and cognitive functions. However, a significant increase in motor speed was found in Trail Making Test A (p = 0.004), Reaction Time (RTI) five-choice movement time (p = 0.002) and RTI simple movement time (p = 0.011), resulting in a normalisation corresponding to that found in healthy controls. Furthermore, a significantly lower score in the perceptual organization index (p = 0.029) was found at follow-up.
Conclusions:
Weight recovery appears not to be associated with cognition.
... [30][31][32] In fewer cases, studies were excluded because they did not include the outcomes of interest (weight gain, rate of RH or cognitive/behavioral measures). Seven studies 25,[33][34][35][36][37][38] met eligibility based on initial screening, but details of the refeeding protocols were missing; these details were subsequently obtained via author communication. A total of 27 studies were included in the final systematic review and are summarized in Table 1. ...
... 45 NG feeding approaches were used to deliver both lower and higher calorie loads. Rate of weight gain was reported in all but one study 33 and ranged from 0.63 kg week 21 , in a study purposely designed to deliver lower caloric loads to severely malnourished/critically ill patients, to 2.79 kg weekv in a study of adolescents who were, on average, moderately malnourished on average. 34 Four studies in this group reported using lower calorie approaches. ...
... 48 Three studies reported higher calorie approaches. 33,34 started with 24-72 h of continuous NG feeding in adolescents that began at 2,400 kcal day 21 and then transitioned to a combination of NG feeding and meals for a total of 2400-3,000 kcals day 21 to achieve a target rate of weight gain of 1 kg week 21 (author communication). 33,34 This approach resulted in the largest weight gain (2.79 kg in week 1 34 ) reported among all of the studies included in the present review. ...
Objective:
Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings.
Methods:
Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic.
Results:
Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown; DISCUSSION: Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings.
... Evidence of an impact of ED on working memory shows conflicting results [58,59]. In a community-based study, we showed increased performance in working memory in ...
... Evidence of an impact of ED on working memory shows conflicting results [58,59]. In a community-based study, we showed increased performance in working memory in children of mothers with EDs [31]. ...
Eating disorders (EDs) are psychiatric disorders with a neurobiological basis. ED-specific neuropsychological and brain characteristics have been identified, but often in individuals in the acute phase or recovered from EDs, precluding an understanding of whether they are correlates and scars of EDs vs. predisposing factors. Although familial high-risk (FHR) studies are available across other disorders, this study design has not been used in EDs. We carried out the first FMH study in EDs, investigating healthy offspring of women with EDs and controls. We preliminarily aimed to investigate ED-related neurocognitive and brain markers that could point to predisposing factors for ED. Sixteen girls at FHR for EDs and twenty control girls (age range: 8–15), completed neuropsychological tests assessing executive functions. Girls also underwent a resting-state fMRI scan to quantify functional connectivity (FC) within resting-state networks. Girls at FHR for EDs performed worse on a cognitive flexibility task compared with controls (F = 5.53, p = 0.02). Moreover, they showed different FC compared with controls in several resting-state networks (p < 0.05 FDR-corrected). Differences identified in cognitive flexibility and in FC are in line with those identified in individuals with EDs, strongly pointing to a role as potential endophenotypes of EDs.
... 9 The available studies examining the changes in the psychopathology of adolescents with AN in hospital environments show contradictory results. Some studies found an improvement in general psychopathology, 10,11 while others did not find changes despite weight recovery. 12 Likewise, research on the efficacy and impact of interventions for AN should include evaluation of body image disturbance, in addition to changes in weight and medical stability. ...
... 36 We did not find any significant change in the psychopathology of the anorexia nervosa or in the evaluation of body dissatisfaction. These results agree with other previous studies in which no significant improvement was obtained after weight recovery in adolescents with AN. 12,37 However, Iniesta Sepúlveda et al. 10 observed a decrease in core pathological features, while Hatch et al. 11 obtained improvements in only two of the five psychopathological variables. Several studies have reported the existing gap between physical recovery and psychological change since they did not find significant associations between them, 12,34 which could explain the high rate of relapse of AN after discharge from inpatient units. ...
Objective: To analyze the clinical, psychopathological, physical, and sleep-related evolution of adolescents with restricting-type of anorexia nervosa (AN-R) after 10 weeks of a daytime hospital program.
Methods: Body composition, physical activity and sleep were measured objectively before and after 10 weeks of treatment. In addition, psychopathology and body image disturbances were measured with a self-report questionnaire.
Results: Fourteen female adolescents with AN-R (14.3±1.6 years old) participated in the study. A significant increase was found in eight of the ten variables for body composition (p<0.05). There were no significant changes in psychopathology, body image disturbances or physical activity. Concerning sleep, a significant, moderately standardized and substantial increase in night latency was found (p=0.002), and there was a significant, small standardized and substantial decrease in night efficiency (p=0.035).
Conclusion: After 10 weeks of follow-up with adolescent patients with AN-R who attended a day hospital program, there was a positive evolution of body composition. However, with regard to sleep patterns, there was a worsening of latency and night efficiency. Therefore, sleep care should be addressed in acute treatment programs for adolescents with AN-R.
... On the other hand, neuropsychological assessments of AN patients have consistently evidenced weaknesses in intelligence and executive functioning, and specifically poor set-shifting and weak central coherence [25,26]. In particular, cognitive inflexibility has been associated with poor outcomes, such as longer duration of illness, more severe eating behaviors, lower self-esteem, higher comorbid anxiety and, of interest for this study, higher rate of self-harm [26]. ...
... On the other hand, neuropsychological assessments of AN patients have consistently evidenced weaknesses in intelligence and executive functioning, and specifically poor set-shifting and weak central coherence [25,26]. In particular, cognitive inflexibility has been associated with poor outcomes, such as longer duration of illness, more severe eating behaviors, lower self-esteem, higher comorbid anxiety and, of interest for this study, higher rate of self-harm [26]. While the clinical and cognitive characteristics of AN patients have been described in clinical and population samples, little is known about the subgroup that engages also in NSSI. ...
Purpose:
About one-fifth of patients with anorexia nervosa (AN) engage in non-suicidal self-injury (NSSI). This study examined clinical and temperament profile of female adolescents with both disorders (AN+NSSI) as compared with peers with AN only.
Methods:
A consecutive sample of 73 female adolescents with AN (mean age: 13.77 years), who had been admitted to inpatient or day-hospital services, received clinical, cognitive, and temperament/character evaluations. Of them, 32 met DSM-5 criteria also for NSSI. Assessments included demographics, standard nutrition parameters, Youth Self-Report (YSR), Wechsler Intelligence Scale for Children IV (WISC-IV), Temperament and Character Inventory (TCI), and Global Assessment of Functioning (GAF).
Results:
No differences were detected between AN+NSSI and AN in demographics, body mass index, or age at onset of AN. AN+NSSI had higher rate of binging and purging, higher YSR scores for both internalizing and externalizing psychopathology, lower total IQ, and lower Self-directedness and Cooperativeness scores.
Conclusions:
These data suggest that adolescents with AN+NSSI have psychopathological, cognitive and overall character features that differ from patients with AN only. These characteristics may have implications for treatment and outcome.
... En un esfuerzo por estudiar el papel mediador de distintas variables en la explicación del déficit neuropsicológico en personas con anorexia nerviosa, se ha encontrado peor rendimiento en la toma de decisiones y atención fundamentalmente cuando las pacientes se encontraban en bajo peso durante su primer ingreso, y sus resultados han mejorado con la recuperación del peso [33]. Sin embargo, las adolescentes con anorexia nerviosa y peso recuperado presentaban en relación con el grupo control menor coherencia central, pero también mayor ansiedad [34]. ...
... No obstante, no debemos obviar que los resultados obtenidos en los 18 estudios revisados (Tabla II) proporcionan hallazgos contradictorios respecto a la existencia de un perfil neuropsicológico en TCA [29][30][31][32] y sobre el papel de variables moduladoras, tanto en la anorexia [33][34][35][36][37] como en la bulimia nerviosa [38][39][40]. Así, algunos autores concluyen que los déficits neuropsicológicos desaparecen al controlar las variables emocionales, fundamentalmente la ansiedad [34,36,38], y el IMC [41], o que sólo persisten en la anorexia nerviosa [42]. ...
... En un esfuerzo por estudiar el papel mediador de distintas variables en la explicación del déficit neuropsicológico en personas con anorexia nerviosa, se ha encontrado peor rendimiento en la toma de decisiones y atención fundamentalmente cuando las pacientes se encontraban en bajo peso durante su primer ingreso, y sus resultados han mejorado con la recuperación del peso [33]. Sin embargo, las adolescentes con anorexia nerviosa y peso recuperado presentaban en relación con el grupo control menor coherencia central, pero también mayor ansiedad [34]. ...
... No obstante, no debemos obviar que los resultados obtenidos en los 18 estudios revisados (Tabla II) proporcionan hallazgos contradictorios respecto a la existencia de un perfil neuropsicológico en TCA [29][30][31][32] y sobre el papel de variables moduladoras, tanto en la anorexia [33][34][35][36][37] como en la bulimia nerviosa [38][39][40]. Así, algunos autores concluyen que los déficits neuropsicológicos desaparecen al controlar las variables emocionales, fundamentalmente la ansiedad [34,36,38], y el IMC [41], o que sólo persisten en la anorexia nerviosa [42]. ...
Introduction:
Eating disorders are severe mental disorders that appear in different diagnostic forms, such as anorexia nervosa and bulimia nervosa. In recent years, a number of studies have highlighted the involvement of neuropsychological processes in anorexia and bulimia nervosa.
Aim:
To review the evidence on the deficits in the executive functions, attentional biases and central coherence in anorexia and bulimia nervosa in relation to a neuropsychological risk profile, a different neuropsychological profile associated with the aforementioned eating pathologies and the role of variables (body mass index, age, anxiety, impulsiveness, alexithymia, mood, body image) in the presence of neuropsychological deficits.
Development:
We reviewed the empirical studies conducted in the last seven years found in the Medline and PsycINFO databases for English, and Dialnet and Psicodoc for Spanish. Twenty-eight articles were selected as suitable for the purposes of this study. The documents were chosen on the basis of a set of pre-established criteria.
Conclusions:
According to the evidence available, there seems to be a risk profile characterised by cognitive rigidity and weak central coherence. The results appear to be more consistent as regards the risk profile in anorexia nervosa. Furthermore, in both anorexia and bulimia nervosa there are attentional biases related to the recognition of emotions and social aspects, and the alexithymia trait is a modulating variable in this difficulty.
... Additional studies utilized EN for only a small percentage of patients and results did not differentiate between those who received EN and those who did not [13][14][15][16]. One study evaluated the change in cognitive markers to refeeding protocols [17], while another reported on costs associated with treatment [18]. An additional study compared the use of EN and parenteral nutrition to parenteral nutrition alone [19]. ...
... Psychotherapy is an effective treatment for people with eating disorders and requires adequate cognition to be successful [6]. Perhaps, with the reversal of malnutrition and resulting restoration of cognitive function, patients can participate in psychotherapy treatments more successfully [17]. Several included studies revealed that oral intake increased during EN treatment, suggesting that greater compliance with prescribed interventions is related to improvement in nutrition status [29,30,35,46]. ...
Purpose
Enteral nutrition (EN) is frequently used in the treatment of anorexia nervosa (AN), and less commonly, bulimia nervosa (BN); yet, no standardized guidelines for treatment exist at this time. The aim of this review is to investigate the efficacy of EN in the treatment of eating disorders and make recommendations for clinical practice and future research.
Methods
An exhaustive literature search of 7 databases was completed. The search strategy combined key terms anorexia nervosa, bulimia, and eating disorders with terms associated with EN. There were no restrictions on publication date or language. Studies that assessed the effect of EN on weight restoration, refeeding syndrome, and binge/purge behaviors in the treatment of AN and BN were included.
Results
Of 73 full-text articles reviewed, 22 met inclusion criteria. Nineteen studies reported that significant short-term weight gain was achieved when EN was used for refeeding malnourished AN patients; however, results varied for the six studies reporting on long-term weight gain, maintenance, and recovery. In studies with a comparator, no significant differences were found between the EN and oral refeeding cohorts regarding gastrointestinal disturbance, refeeding syndrome, or electrolyte abnormalities. Five studies examined the effect of EN on binge/purge behaviors, suggesting that temporary exclusive EN decreases the frequency and severity of binge/purge episodes.
Conclusion
Although EN is an essential life-saving treatment in severe cases of AN, it does not guarantee long-term success or recovery. The results of this systematic review highlight the need for prospective controlled trials with adequate sample sizes to make comparisons between specific feeding methods, formulations, and defined short and long-term outcomes. Evidence-based standards for clinical practice are needed with specific guidelines for best results for AN and BN treatment.
Level of evidence
I, systematic review.
... Our results reinforce previous reports that cognitive impairments in AN do not correlate with BMIs or illness durations [6,7,21,47,57,58]. It is reported that cognitive impairment could be a marker of chronicity in AN or a risk indicator for the development of chronic AN [59]. Furthermore, set-shifting impairments, which have been observed in unaffected sisters of AN probands [21] and in patients with AN who recovered to normal weight [4,60], could be an endophenotype [61]. ...
... Furthermore, cognitive impairments in the ANR group were milder than in the ANBP group in the current study, despite the ANR group having significantly lower minimum chart-recorded BMIs and BMIs at assessment. It is therefore unlikely that malnutrition directly relates to cognitive impairment, so just as a previous study [59] suggested that cognitive impairments are a risk factor for chronicity. ...
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.
... [Insert Table 2 about here] (AmericanPsychiatric, 2000;Baddeley et al., 1993;Hatch et al., 2010;Lovibond and Lovibond, 1995;Patrick et al., 2010;Cohen et al., 2006). ...
... The spot-the-word test is an IQ estimate. Subjects are presented with pairs of items comprising one word and one non-word, and requiring the subject to identify the word (Baddeley et al. 1993;Hatch et al. 2010). Performance correlates highly with verbal intelligence and in adult's correlates with performance on the National Adult Reading Test (NART). ...
Objective
Children and adolescents with functional neurological symptom disorder (FND) present with diverse neurological symptoms not explained by a disease process. Functional neurological symptoms have been conceptualized as somatoform dissociation, a disruption of the brain's intrinsic organization and reversion to a more primitive level of function. We used EEG to investigate neural function and functional brain organization in children/adolescents with FND.
Method
EEG was recorded in the resting eyes-open condition in 57 patients (aged 8.5–18 years) and 56 age- and sex-matched healthy controls. Using a topographical map, EEG power data were quantified for regions of interest that define the default mode network (DMN), salience network, and somatomotor network. Source localization was examined using low-resolution brain electromagnetic tomography (LORETA). The contributions of chronic pain and arousal as moderators of differences in EEG power were also examined.
Results
Children/adolescents with FND had excessive theta and delta power in electrode clusters corresponding to the DMN—both anteriorly (dorsomedial prefrontal cortex [dmFPC]) and posteriorly (posterior cingulate cortex [PCC], precuneus, and lateral parietal cortex)—and in the premotor/supplementary motor area (SMA) region. There was a trend toward increased theta and delta power in the salience network. LORETA showed activation across all three networks in all power bands and localized neural sources to the dorsal anterior cingulate cortex/dmPFC, mid cingulate cortex, PCC/precuneus, and SMA. Pain and arousal contributed to slow wave power increases in all three networks.
Conclusions
These findings suggest that children and adolescents with FND are characterized by overactivation of intrinsic resting brain networks involved in threat detection, energy regulation, and preparation for action.
... In the current study, we used the ANT to compare the function of executive control, alerting and orienting between healthy adolescents and those who were diagnosed with AN. In light of evidence suggesting that severe malnourishment and starvation may compromise cognitive abilities in adolescents with AN [22], we used a sample of adolescents who were no longer severely underweight during participation in the study. This mitigates the possibility that potential findings from this study regarding attentional abnormalities are merely a byproduct of severe malnourishment [23,24]. ...
... The attention profile of severely underweight patients may differ from that of patients who are not currently malnourished. However, we decided to assess patients who are medically stable to avoid the confounding influence of starvation on cognitive abilities and this mitigates the possibility that the attention abnormalities found are a consequence of AN rather than a trait [22]. Another limitation is the use of self-report questionnaires rather than a structured interview to confirm an absence of an eating disorder in the control group. ...
Anorexia nervosa (AN) usually develops during adolescence when considerable structural and functional brain changes are taking place. Neurocognitive inefficiencies have been consistently found in adults with enduring AN and were suggested to play a role in maintaining the disorder. However, such findings are inconsistent in children and adolescents with AN. The current study conducted a comprehensive assessment of attention networks in adolescents with AN who were not severely underweight during the study using an approach that permits disentangling independent components of attention. Twenty partially weight-restored adolescents with AN (AN-WR) and 24 healthy adolescents performed the Attention Network Test which assesses the efficiency of three main attention networks—executive control, orienting, and alerting. The results revealed abnormal function in the executive control network among adolescents with AN-WR. Specifically, adolescents with AN-WR demonstrated superior ability to suppress attention to task-irrelevant information while focusing on a central task. Moreover, the alerting network modulated this ability. No difference was found between the groups in the speed of orienting attention, but reorienting attention to a target resulted in higher error rates in the AN-WR group. The findings suggest that adolescents with AN have attentional abnormalities that cannot be explained by a state of starvation. These attentional dysregulations may underlie clinical phenotypes of the disorder such as increased attention of details.
... Although cognitive batteries have been compiled in past research to assess cognition in AN [12,13] , a standardised cognitive battery has rarely been used [23] . Furthermore, although each of the cognitive domains in the MCCB has been investigated in past research in AN, the findings are largely inconsistent. ...
... In relation to visual learning, performance has typically been found to be intact in AN [9,29] . Furthermore, although performance on reasoning and problem solving tasks such as mazes has also been found to be largely intact in AN [23] , other tasks assessing this domain such as object assembly and block design, have been found to result in poorer performance in AN [11,28] . Finally, studies assessing social cognition in AN also show inconsistent findings, with some reporting poorer performance [30] and others failing to find a significant difference from healthy individuals [31] . ...
AIM: To utilise a comprehensive cognitive battery to gain a better understanding of cognitive performance in anorexia nervosa (AN).
METHODS: Twenty-six individuals with AN and 27 healthy control participants matched for age, gender and premorbid intelligence, participated in the study. A standard cognitive battery, the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery, was used to investigate performance on seven cognitive domains with the use of 10 different tasks: speed of processing [Brief Assessment Of Cognition In Schizophrenia: Symbol Coding, Category Fluency: Animal Naming (Fluency) and Trail Making Test: Part A], attention/vigilance [Continuous Performance Test - Identical Pairs (CPT-IP)], working memory [Wechsler Memory Scale (WMS®-Ⅲ): Spatial Span, and Letter-Number Span (LNS)], verbal learning [Hopkins Verbal Learning Test - Revised], visual learning [Brief Visuospatial Memory Test - Revised], reasoning and problem solving [Neuropsychological Assessment Battery: Mazes], and social cognition [Mayer-SaloveyCaruso Emotional Intelligence Test: Managing Emotions]. Statistical analyses involved the use of multivariate and univariate analyses of variance.
RESULTS: Analyses conducted on the cognitive domain scores revealed no overall significant difference between groups nor any interaction between group and domain score [F(1,45) = 0.73, P = 0.649]. Analyses conducted on each of the specific tasks within the cognitive domains revealed significantly slower reaction times for false alarm responses on the CPT-IP task in AN [F(1,51) = 12.80, P < 0.01, Cohen’s d = 0.982] and a trend towards poorer performance in AN on the backward component of the WMS®-Ⅲ Spatial Span task [F(1,51) = 5.88, P = 0.02, Cohen’s d = -0.665]. The finding of slower reaction times of false alarm responses is, however, limited due to the small number of false alarm responses for either group.
CONCLUSION: The findings are discussed in terms of poorer capacity to manipulate and process visuospatial material in AN.
... Few studies have examined the relationship between weight gain and improvement in a range of cognitive functions in AN [12,41,51]. Only the study by Moser et al. was conducted among adults (participants aged 16-42 years), and none of the studies found significant associations in line with the results from our study. ...
Purpose
Severe malnourishment may reduce cognitive performance in anorexia nervosa (AN). We studied cognitive functioning during intensive nutritional and medical stabilization in patients with severe or extreme AN and investigated associations between weight gain and cognitive improvement.
Methods
A few days after admission to a specialized hospital unit, 33 patients with severe or extreme AN, aged 16–42 years, completed assessments of memory, cognitive flexibility, processing speed, and attention. Mean hospitalization was 6 weeks. Patients completed the same assessments at discharge (n = 22) following somatic stabilization and follow-up up to 6 months after discharge (n = 18).
Results
The patients displayed normal cognitive performance at admission compared to normative data. During nutritional stabilization, body weight increased (mean: 11.3%; range 2.6–22.2%) and memory, attention, and processing speed improved (p values: ≤ 0.0002). No relationship between weight gain and cognitive improvement was observed at discharge or follow-up.
Conclusions
Cognitive performance at hospital admission was normal in patients with severe or extreme AN and improved during treatment although without association to weight gain. Based on these results, which are in line with previous studies, patients with severe or extreme AN need not be excluded from cognitively demanding tasks, possibly including psychotherapy. As patients may have other symptoms that interfere with psychotherapy, future research could investigate cognitive functioning in everyday life in patients with severe AN.
Trial registration number: The study is registered at clinicaltrials.gov (NCT02502617).
Level of evidence
Level III, cohort study.
... Sie reduziert die somatischen Komplikationen als Folge der Kachexie wie veränderte Elekrolytkonzentrationen, Amenorrhoe, veränderte Vitalparameter, reduzierte Knochendichte und strukturelle Hirnveränderungen [33]. Zudem ist die mit der Gewichtssteigerung einhergehende Verbesserung kognitiver Funktionen eine wichtige Voraussetzung für den Beginn einer anschließenden Psychotherapie, die oft erst nach einer deutlichen Gewichtssteigerung möglich wird [34,35]. Daher dient die Gewichtssteigerung nicht nur der Verbesserung der somatischen Funktionen, sondern ebenso der Verbesserung des psychischen Status. ...
Zusammenfassung
Die vorliegende Arbeit zeigt auf, wie die Therapie der Anorexia nervosa (AN) und der Nahrungsverweigerung in den führenden Lehrbüchern der deutschsprachigen Schulpsychiatrie in den vergangenen 200 Jahren vermittelt wurde. Hierfür wurden 18 Lehrwerke bedeutender Psychiater ausgewählt. Diese wurden strukturiert analysiert, um jeweils das an Medizinstudenten und junge Nervenärzte an deutschsprachigen Universitäten weitergegebene Wissen zur Thematik zu ermitteln. Es zeigte sich, dass die AN erst Ende des 20. Jahrhunderts als ein eigenständiges Krankheitsbild erfasst und vermittelt wurde. Doch bereits zuvor wurden der Nahrungsverweigerung als Symptom eine große Bedeutung beigemessen und mannigfaltige Therapiekonzepte entwickelt. Beginnend im 19. Jahrhundert mit der Zwangsernährung mittels Magensonden wurden später Pharmakotherapien entwickelt sowie spezielle Diäten diskutiert. Bemerkenswert ist, dass bereits seit den Anfängen der akademischen Psychiatrie besondere Verhaltensweisen mit dem Patienten und eine Vorbildfunktion des Therapeuten als „Psychotherapie im weiteren Sinne“ beschrieben wurden, um Patienten zum Essen zu animieren. Die Therapie der Nahrungsverweigerung mittels strukturierter Psychotherapien wurde erst Ende des 20. Jahrhunderts mit der Anerkennung der AN als eigenständige Krankheitsentität etabliert. Hierbei zeigte sich im Verlauf der letzten Jahrzehnte ein grundlegender Wandel im Verständnis von möglichen auslösenden Faktoren dieser Erkrankung und möglichen psychotherapeutischen Interventionen.
... Similar results have been found by both Peebles and Smith (177,178) . Thus, the high energy intake approach represents the current AN standard of care, beginning with consuming at least 1400 kcal/day or more through meals alone (176,(179)(180)(181)(182) or combined naso-gastric and oral feeding (183) . However, to date, none of the published high energy nutritional refeeding protocols has been tested for possible effects on the intestinal microbiome. ...
Anorexia nervosa (AN) is characterised by the restriction of energy intake in relation to energy needs and a significantly lowered body weight than normally expected, coupled with an intense fear of gaining weight. Treatment of AN is currently based on psychological and refeeding approaches, but their efficacy remains limited, since 40% of patients after ten years of medical care, still present symptoms of AN. The intestine hosts a large community of microorganisms, called the “microbiota”, which live in symbiosis with the human host. The gut microbiota of a healthy human is dominated by bacteria from two phyla: Firmicutes and majorly Bacteroidetes . However, the proportion in their representation differs on an individual basis and depends on many external factors, such as medical treatment, geographical location, and hereditary, immunological and lifestyle factors. Drastic changes in dietary intake may profoundly impact the composition of the gut microbiota, and the resulting dysbiosis may play a part in the onset and/or maintenance of comorbidities associated with AN, such as gastrointestinal disorders, anxiety, and depression, as well as appetite dysregulation. Furthermore, studies have reported the presence of atypical intestinal microbial composition in patients with AN compared to healthy normal-weight controls. This review addresses the current knowledge about the role of the gut microbiota in the pathogenesis and treatment of AN. The review also focuses on the bidirectional interaction between the gastrointestinal tract and the central nervous system (microbiota-gut-brain axis), considering the potential use of the gut microbiota manipulation in the prevention and treatment of AN.
... The heterogeneity of AN itself is also important to consider, as AN-BP symptoms are associated with worse working memory performance, whereas AN-R symptoms are associated with better working memory performance (Israel et al., 2015). For example, superior working memory performance has been reported in female adolescents with AN (Hatch et al., 2010) and female adults with AN-R (Dickson et al., 2008) compared to HCs in variations of the n-back task. These findings highlight the need for future research to examine working memory performance in both AN subtypes compared to HCs. ...
Anorexia nervosa (AN) and obsessive–compulsive disorder (OCD) are commonly reported to co-occur and present with overlapping symptomatology. Executive functioning difficulties have been implicated in both mental health conditions. However, studies directly comparing these functions in AN and OCD are extremely limited. This review provides a synthesis of behavioral and neuroimaging research examining executive functioning in AN and OCD to bridge this gap in knowledge. We outline the similarities and differences in behavioral and neuroimaging findings between AN and OCD, focusing on set shifting, working memory, response inhibition, and response monitoring. This review aims to facilitate understanding of transdiagnostic correlates of executive functioning and highlights important considerations for future research. We also discuss the importance of examining both behavioral and neural markers when studying transdiagnostic correlates of executive functions.
... There are several cognitive theories regarding how excessive cognitive control is preserved. One such hypothesis is that variation in working memory (WM) capacity contributes to the obsessive, ruminative and inflexible thought patterns that appear to underlie fluctuating cognitive deficits, appetite restraint and body image distortion in restrictive AN (AN-R) [11][12][13][14]. A milder degree of restraint may explain the binge-purging subtype of AN (AN-BP) and the progression into binge-purge and bulimia symptoms, where weight-compensatory behaviours are interleaved with bouts of impulsive and excessive food intake [7]. ...
Purpose
Cognitive restraint has potentiating and deleterious effects on working memory (WM) in anorexia nervosa (AN). Conflicting evidence may be due to heterogeneity of tasks examining different WM components (e.g., verbal/auditory versus visuospatial), and differences in adolescent versus adult AN. Additionally, differential cognitive profiles of restricting versus binge/purging subtypes, comorbid psychiatric disorders and psychotropic medication use may confound findings.
Methods
To address these conflicts, 25 studies, published between 2016 and 2021, investigating WM in children, adolescents and adults with AN were systematically reviewed using PRISMA guidelines.
Results
In 71% of WM tasks, no difference in performance between AN patients and age-matched controls was reported, while 29% of WM tasks showed worse performance. Adults with AN displayed deficits in 44% of the verbal/auditory tasks, while performance remained unaffected in 86% of visuospatial tasks.
Conclusion
Examining age groups and WM subsystems separately revealed novel findings of differentially affected WM components in AN. Comorbidities and psychotropic medications were common among AN participants and should be regarded as critical confounding factors for WM measures. Future studies examining different components of WM, acknowledging these confounding factors, may reveal specific deficits in AN to aid treatment improvement strategies.
Level of evidence
I, systematic review.
... The frontal lobes have long been associated with these functions [57]. It has been suggested that the mechanisms leading to AN are related to dysfunctions within the frontostriatal circuits, associated with the strength of the connections between frontal and subcortical areas, as well as with habit learning as in obsessive-compulsive disorder [58,59], selfregulation [60], reward processing difficulties [53], and emotion processing [61]. It has also been shown that lesions occurring in the frontal lobes can cause characteristic eating disorders. ...
Background.:
Brain atrophy in anorexia nervosa (AN) is one of the most marked structural brain changes observed in mental disorders. In this study, we propose a whole brain analysis approach to characterize global and regional cerebral volumes in adolescents with restricting-type anorexia nervosa (AN-r).
Methods.:
A total of 48 adolescent females (age range 13-18 years) were enrolled in the study (24 right-handed AN-r in the early stages of the illness and treated in the same clinical setting and 24 age-matched healthy controls [HC]). High-resolution T1-weighted magnetic resonance images were acquired. Cerebral volumes, including the total amounts of gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) were obtained with the Statistical Parametric Mapping software (SPM8); specific cortical regional volumes were computed by applying an atlas-based cortical parcellation to the SPM8 GM segments. Analysis of variance (ANOVA) was performed to identify any significant between-group differences in global and regional brain volumes.
Results.:
The analyses revealed reduced total GM volumes (p = 0.02) and increased CSF (p = 0.05) in AN-r, compared with HC. No significant between-group difference was found in WM volumes. At the regional level, significantly lower GM volumes in both frontal lobes (p = 0.006) and in the left insula (p = 0.016) were detected. No significant relationships were found between cerebral volumes and duration of illness, psychiatric comorbidities, psychopharmacological treatment, prepubertal phase, or presence of amenorrhea.
Conclusions.:
The topographic distribution of GM reduction in a homogenous group of AN-r involves regions responsible for the emotional and cognitive deficits associated with the illness. These findings are discussed in relation to the roles of the insular cortex and the frontal lobes.
... Regarding neuropsychological functioning in AN, several studies have employed verbal fluency tests (7)(8)(9)(10)(11)(12) . As result, verbal fluency does not seem to be disturbed in patients with AN. ...
Introduction. The aim of this study was to analyse the performance and the semantic organization of patients with anorexia nervosa (AN) and of healthy controls by means of a “Human Body Parts” type of (Semantic Verbal Fluency) SVF task.
Method. A total of 58 participants took part in this study (23 suffered from anorexia nervosa, with a mean age of 21.32 ± 2.53, and 35 healthy participants, with a mean age of 22.41 ± 1.67). The Verbal Fluency Test “Human Body Parts” (a word naming task) was applied. In this task, participants were asked to say as many “Human Body Parts” as possible in a period of 1 minute. Participants were given the instruction not to repeat body parts already said. Responses were recorded and transcribed in order to be analysed.
Results. The mean number of words for the control group was 15.94 ± 7.79 and in case of anorectic patients it was 17.52 ± 5.23. With respect to intrusions and perseverance there were not any significant differences, having obtained 0.10 (control group) and 0.11 (anorectic patients), and 0.42 (control group) and 0,46 (anorectic patients) respectively. With respect to correspondence analysis, a two-dimensional Semantic memory on verbal fluency test in representation yielded 90.01% of the total inertia, thus accepting two-dimensional map as valid.
... Good verbal fluency performance in the acute stage of AN and post recovery was already shown in other studies (Stedal et al., 2012b;Stedal et al., 2013;Hatch et al., 2010). It appears that the patients can manage to cope with time-restricted verbal generation under certain constrained conditions, which involve retrieval and recollection of words based on phonemic or semantic criteria. ...
Purpose
The allocentric lock theory (ALT) suggests that people with eating disorders have difficulties in multisensory integration in two reference frames—egocentric and allocentric, whereby the egocentric, but not allocentric, is impaired. This leads to a distorted body image that contributes to the development and maintenance of the disorder. The current study aimed to explore a facet of the ALT, namely, the visuo-spatial aspect, and its relation to cognitive flexibility in patients with anorexia nervosa (AN).
Methods
Fifty-five participants took part in the study: 20 AN patients and 35 controls, matched by age and education. The object perspective taking test (OPTT) and the mental rotation test (MRT), tapping egocentric and allocentric representations, respectively, and a set-shifting task were administered. The brief symptom inventory was used to measure overall levels of distress.
Results
AN patients showed higher level of distress. They performed poorer on the OPTT and set-shifting task but not on the MRT. The OPTT and MRT were correlated for controls but not for AN patients, while the set-shifting task and body mass index were associated with the OPTT but not with the MRT for the AN patients.
Conclusions
The findings support the ALT by demonstrating impaired visual egocentric representations and intact allocentric visual functions in AN patients, with cognitive flexibility associated only with the egocentric frame. Therefore, egocentric frame impairment in AN patients may be influenced by visual perception and cognitive flexibility deficiency.
Level of evidence
Level III: case-control analytic study.
... Potentially the latter was due to the continued experience of postprandial bloating; in clinical practice the perception of bloating frequently triggers fears of weight gain. The improvement in baseline state anxiety was consistent with previous reports that refeeding and the restoration of body weight results in significant improvement in eating psychopathology, mood and anxiety symptoms [72]. Pre-meal anxiety has been associated with lower caloric intake in patients with AN [33], while improvements in pre-meal anxiety following an exposure and response prevention treatment have been linked to greater food intake [73], thus, targeting pre-meal anxiety may have implications for feeding behaviour. ...
Factors underlying disturbed appetite perception in anorexia nervosa (AN) are poorly characterized. We examined in patients with AN whether fasting and postprandial appetite perceptions, gastrointestinal (GI) hormones, GI symptoms and state anxiety (i) differed from healthy controls (HCs) and (ii) were modified by two weeks of refeeding. 22 female adolescent inpatients with restricting AN, studied on hospital admission once medically stable (Wk0), and after one (Wk1) and two (Wk2) weeks of high-calorie refeeding, were compared with 17 age-matched HCs. After a 4 h fast, appetite perceptions, GI symptoms, state anxiety, and plasma acyl-ghrelin, cholecystokinin (CCK), peptide tyrosine tyrosine (PYY) and pancreatic polypeptide (PP) concentrations were assessed at baseline and in response to a mixed-nutrient test-meal (479 kcal). Compared with HCs, in patients with AN at Wk0, baseline ghrelin, PYY, fullness, bloating and anxiety were higher, and hunger less, and in response to the meal, ghrelin, bloating and anxiety were greater, and hunger less (all p < 0.05). After two weeks of refeeding, there was no change in baseline or postprandial ghrelin or bloating, or postprandial anxiety, but baseline PYY, fullness and anxiety decreased, and baseline and postprandial hunger increased (p < 0.05). We conclude that in AN, refeeding for 2 weeks was associated with improvements in PYY, appetite and baseline anxiety, while increased ghrelin, bloating and postprandial anxiety persisted.
... The state argument proposes that a state of starvation causes neuropsychological impairments in set shifting. Research findings that participants who have gained weight and are in recovery from AN have an intermediate set shifting performance compared to AN and HC groups (Nakazato et al. 2009;Nakazato et al. 2010) and findings that cognitive impairments normalise with refeeding and weight gain (Hatch et al. 2010) suggest neuropsychological functioning is adversely affected by starvation and lend support to the state theory. ...
Aims: This review aims to evaluate and synthesise previous research on set shifting in eating disorders in order to determine whether individuals with eating disorders have impaired set shifting. It also aims to determine whether set shifting difficulties are a risk factor for eating disorders or a consequence of starvation. Method: A summary and critique of the 13 papers specifically exploring set shifting in eating disorders is presented and followed by a synthesis of the results. Results: There is evidence for set shifting difficulties in Anorexia Nervosa (AN) and Bulimia Nervosa (BN) however no research has been conducted into Binge Eating Disorder (BED). This review suggests that starvation may have a mediating or maintaining role in neuropsychological impairments, rather than causing them per se. Increased set shifting impairments in recovered AN participants and genetic relatives suggest that set shifting difficulties may be a predisposing trait, increasing vulnerability to eating disorders. However, there are various methodological limitations (such as no power analyses to estimate required sample sizes) which are discussed and should be kept in mind. Conclusions: Although there is evidence for set shifting difficulties in AN and BN, the evidence is still very mixed and there is a need for use of consistent measures and clear reporting of findings with equal importance given to non-significant results.
... psychosexual development (Hatch et al., 2010;Herpertz-Dahlmann et al., 2001;Ruuska, Koivisto, Rantanen, & Kaltiala-Heino, 2007), including independence from family of origin (Ratnasuriya, Eisler, Szmukler, & Russell, 1991). ...
Maudsley Family-Based Treatment (FBT) is currently the best supported treatment for adolescents with anorexia nervosa (AN); however, little is known about whether it achieves its stated aim in the final phases of promoting the patient’s return to an expected developmental trajectory. This study aimed to explore the perspectives of young people and their parents regarding the developmental impact of AN, and the role of FBT in addressing developmental challenges. Young people (N = 12) who ceased FBT a minimum 1 year prior, and their parents (N = 12), completed face-to-face semi-structured interviews, and data were analysed using a narrative inquiry method. All the participants described AN as highly disruptive to adolescent development, with phase one of FBT accentuating this experience. In phases two and three, FBT helped facilitate adolescent development in three key ways: Supporting return to adolescent pursuits, facilitating autonomy and providing freedom to develop post-FBT. This study offers preliminary insights into the variety of developmental challenges and needs experienced by families, as well as approaches clinicians can take to supporting development in phases two and three of FBT.
... For example, varying degrees of restriction versus binge eating concomitant with switching between subtypes of ED over the course of illness can influence WM ability, with those with AN sometimes having better, but also worse WM ability (e.g., Israel et al., 2015;Weider et al., 2015). A longer duration of illness can also influence WM function (Dickson et al., 2008;Pruis et al., 2012;Lao-Kaim et al., 2014), but often WM ability does not correlate with clinical eating disorder measures (e.g., Seed et al., 2002;Fowler et al., 2006;Hatch et al., 2010;Nikendei et al., 2011), suggesting that clinical symptoms during chronic eating disorder are likely transient and secondary to the core cognitive disturbances in those who develop ED that often manifest during adolescence (Lena et al., 2004). ...
Prefrontal cortex executive functions, such as working memory (WM) interact with limbic processes to foster impulse control. Such an interaction is referred to in a growing body of publications by terms such as cognitive control, cognitive inhibition, affect regulation, self-regulation, top-down control, and cognitive–emotion interaction. The rising trend of research into cognitive control of impulsivity, using various related terms reflects the importance of research into impulse control, as failure to employ cognitions optimally may eventually result in mental disorder. Against this background, we take a novel approach using an impulse control spectrum model – where anorexia nervosa (AN) and substance use disorder (SUD) are at opposite extremes – to examine the role of WM for cognitive control. With this aim, we first summarize WM processes in the healthy brain in order to frame a systematic review of the neuropsychological, neural and genetic findings of AN and SUD. In our systematic review of WM/cognitive control, we found n = 15 studies of AN with a total of n = 582 AN and n = 365 HC participants; and n = 93 studies of SUD with n = 9106 SUD and n = 3028 HC participants. In particular, we consider how WM load/capacity may support the neural process of excessive epistemic foraging (cognitive sampling of the environment to test predictions about the world) in AN that reduces distraction from salient stimuli. We also consider the link between WM and cognitive control in people with SUD who are prone to ‘jumping to conclusions’ and reduced epistemic foraging. Finally, in light of our review, we consider WM training as a novel research tool and an adjunct to enhance treatment that improves cognitive control of impulsivity.
... All studies demonstrated acceptable or good study quality. During the rating process, one study was removed because the EF measure administered was not adequately established and validated as a neuropsychological test (Hatch et al., 2010). Thus, 32 studies were considered for further analyses. ...
Objective:
Research investigating the link between eating disorder (ED) diagnosis and executive dysfunction has had conflicting results, yet no meta-analyses have examined the overall association of ED pathology with executive functioning (EF).
Method:
Effect sizes were extracted from 32 studies comparing ED groups (27 of anorexia nervosa, 9 of bulimia nervosa) with controls to determine the grand mean effect on EF. Analyses included effects for individual EF measures, as well as an age-based subgroup analysis.
Results:
There was a medium effect of ED diagnosis on executive functioning, with bulimia nervosa demonstrating a larger effect (Hedges's g=-0.70) than anorexia nervosa (g=-0.41). Within anorexia nervosa studies, subgroup analyses were conducted for age and diagnostic subtype. The effect of anorexia nervosa on EF was largest in adults; however, subgroup differences for age were not significant.
Conclusions:
Anorexia and bulimia nervosa are associated with EF deficits, which are particularly notable for individuals with bulimia nervosa. The present analysis includes recommendations for future studies regarding study design and EF measurement.
... Previous ERP studies have shown that cortical alterations and pathologically related neurological differences (such as in response to food and body stimuli) are common in those with EDs, even after weight gain (e.g. Blechert, Ansorge, Beckmann, & Tuschen-Caffier, 2011;Hatch et al., 2010;Li et al., 2015;Mai et al., 2015;Otagaki, Tohoda, Osada, Horiguchi, & Yamawaki, 1998;Pollatos, Herbert, Schandry, & Gramann, 2008;Sfärlea et al., 2016). Specifically, Mai et al. (2015) found evidence for an attentional processing bias for overweight body stimuli in participants with Bulimia Nervosa, illustrated by larger P2 amplitudes and higher arousal ratings. ...
Growing evidence suggests that the brain processes bodies distinctively from other stimuli, but little research has addressed whether visual body perception is modulated by the observer's thoughts and feelings about their own body. The present study thus investigated the relationship between body image and electrophysiological signatures of body perception, with the aim of identifying potential biomarkers of body image disturbances. Occipito-parietal (P1 and N1) and fronto-central (VPP) processing of body and non-body stimuli were assessed in 29 weight-restored eating disordered (ED) women and compared to 27 healthy controls. Rapid early visual processing was seen in the ED group, as the entire P1-N1 complex unfolded significantly earlier compared to controls. ED women also showed a gender-selective response to other women's bodies over N1 and VPP components. Such gender-selectivity was not evident in controls. Moreover, ERP effects correlated with scores on the Eating Disorder Inventory-II (EDI-2), indicating a close link between the observers' ED symptomatology, including body image, and the visual analysis of human bodies during very early stages of cortical processing. The temporal dynamics of visual body perception may therefore serve as potential neural markers for the identification of ED symptomatology in 'at risk' populations.
... that effect sizes of differences between ED and healthy controls on neuropsychological tasks 236 tend to range between .16-.73 (Zakzanis, Campbell, & Polsinelli, 2010). Studies evaluating 237 within-group differences in psychological variables for individuals with ED during brief intervals 238 (e.g., 1-4 weeks) show effect sizes ranging from .03-.27 (Hatch et al., 2010;Moser et al., 2003). 239 ...
Restrictive eating disorders (ED) are increasing and represent a serious risk to the health of adolescent females. Restrictive ED in youth are often treated through aggressive short-term refeeding. Although evidence supports that this intervention is the “gold standard” for improving ED outcomes in youth, little research has specifically probed appetite and meal-related responses to this type of intensive, short-term refeeding in newly diagnosed individuals. Information about appetite and meal-related dysfunction could provide valuable insights regarding treatment-interfering features of ED in both acute inpatient and longer-term outpatient treatment. The purpose of this study was to evaluate the hunger, fullness, olfactory, and gustatory responses of adolescents with newly-diagnosed restrictive ED and to probe how and when these responses are altered by refeeding. Using a quasi-experimental ecologically valid methodology, this study described and compared profiles of hunger, fullness, olfactory, and gustatory responses in adolescent females (n = 15) with newly diagnosed restrictive ED at hospital admission (i.e., severe malnutrition) and after medical refeeding, in comparison to healthy controls (n = 15). Results showed that newly diagnosed (i.e., malnourished) adolescents with ED showed significantly different meal-related experiences than controls. Refeeding improved some of these differences, but not all. Following refeeding, females with ED continued to show lower hunger, greater fullness, and lower pleasantness of smell ratings compared to controls. Unpleasantness of taste ratings maladaptively increased, such that females who were re-fed reported more aversive scents than pre-treatment. Profiles of meal-related responses were also identified and compared between groups. The applicability of these findings are discussed within the context of critical periods of change during refeeding treatment and potentially promising intervention targets that might enhance treatment outcomes for adolescents with newly onset, restrictive ED.
... First, WM is regarded as a cognitive mechanism that is shown to exert control over distracting arousing stimulation [32]. In line with this, WM and not other cognitions, such as response-inhibition, have been shown to interact with non-consciously processed appetitive images of food in those with AN [23]. Second, WM function is associated with fronto-parietal cortex activation [33][34][35], brain regions that have been shown be most susceptible to neurobiological changes in those with AN [32,[36][37][38][39][40]. ...
Background:
Anorexia Nervosa (AN) is a debilitating, sometimes fatal eating disorder (ED) whereby restraint of appetite and emotion is concomitant with an inflexible, attention-to-detail perfectionist cognitive style and obsessive-compulsive behaviour. Intriguingly, people with AN are less likely to engage in substance use, whereas those who suffer from an ED with a bingeing component are more vulnerable to substance use disorder (SUD).
Discussion:
This insight into a beneficial consequence of appetite control in those with AN, which is shrouded by the many other unhealthy, excessive and deficit symptoms, may provide some clues as to how the brain could be trained to exert better, sustained control over appetitive and impulsive processes. Structural and functional brain imaging studies implicate the executive control network (ECN) and the salience network (SN) in the neuropathology of AN and SUD. Additionally, excessive employment of working memory (WM), alongside more prominent cognitive deficits may be utilised to cope with the experience of negative emotions and may account for aberrant brain function. WM enables mental rehearsal of cognitive strategies while regulating, restricting or avoiding neural responses associated with the SN. Therefore, high versus low WM capacity may be one of the factors that unites common cognitive and behavioural symptoms in those suffering from AN and SUD respectively. Furthermore, emerging evidence suggests that by evoking neural plasticity in the ECN and SN with WM training, improvements in neurocognitive function and cognitive control can be achieved. Thus, considering the neurocognitive processes of excessive appetite control and how it links to WM in AN may aid the application of adjunctive treatment for SUD.
... Example of behavioral questions are: Psychological and cognitive evaluation: Patients with ED may suffer from cognitive impairment, especially during starvation. Thereby, it is important to assess attention, shortterm memory, thought processing, cognitive flexibility and concentration [46]. On brain imaging, whilst it is not a routine investigation, findings of reduced grey matter volumes that often do not reverse following weight recovery may be found [47]. ...
Background: The mortality of Anorexia Nervosa (AN) is the highest among all psychiatric disorders, and Eating Disorders (ED) overall pose serious health threats to a significant proportion of the population. In spite of an increasing recognition of the clinical impact of ED, often, the general readiness and knowledge of the diagnostic work-up among Physicians is insufficient.
Material and method: A literature search of recent national and international scientific publications on the diagnostic work-up of ED was done in November 2015. PUBMED was the major source of information, but also known publications were utilized to collate the relevant information. Result: The result is presented as essential components in the diagnostic work-up, where potential relevant clinical findings such as e.g. eating behaviours, co-morbidities, laboratory findings, medical risk and risk of suicidality, are all necessary to enable an accurate diagnosis as part of a multilayered clinical problem description, in the diagnostic work-up of ED.Discussion: Early and accurate diagnosis of ED will enable prompt initiation of relevant treatment. This is most optimally served by a multilayered clinical problem description, where the clinical diagnosis is one part, together with several other clinical aspects, of ED.
Importance:
Cognitive deficits in depression have been associated with poor functional capacity, frontal neural circuit dysfunction, and worse response to conventional antidepressants. However, it is not known whether these impairments combine together to identify a specific cognitive subgroup (or "biotype") of individuals with major depressive disorder (MDD), and the extent to which these impairments mediate antidepressant outcomes.
Objective:
To undertake a systematic test of the validity of a proposed cognitive biotype of MDD across neural circuit, symptom, social occupational function, and treatment outcome modalities.
Design, setting, and participants:
This secondary analysis of a randomized clinical trial implemented data-driven clustering in findings from the International Study to Predict Optimized Treatment in Depression, a pragmatic biomarker trial in which patients with MDD were randomized in a 1:1:1 ratio to antidepressant treatment with escitalopram, sertraline, or venlafaxine extended-release and assessed at baseline and 8 weeks on multimodal outcomes between December 1, 2008, and September 30, 2013. Eligible patients were medication-free outpatients with nonpsychotic MDD in at least the moderate range, and were recruited from 17 clinical and academic practices; a subset of these patients underwent functional magnetic resonance imaging. This prespecified secondary analysis was performed between June 10, 2022, and April 21, 2023.
Main outcomes and measures:
Pretreatment and posttreatment behavioral measures of cognitive performance across 9 domains, depression symptoms assessed using 2 standard depression scales, and psychosocial function assessed using the Social and Occupational Functioning Assessment Scale and World Health Organization Quality of Life scale were analyzed. Neural circuit function engaged during a cognitive control task was measured using functional magnetic resonance imaging.
Results:
A total of 1008 patients (571 [56.6%] female; mean [SD] age, 37.8 [12.6] years) participated in the overall trial and 96 patients participated in the imaging substudy (45 [46.7%] female; mean [SD] age, 34.5 [13.5] years). Cluster analysis identified what may be referred to as a cognitive biotype of 27% of depressed patients with prominent behavioral impairment in executive function and response inhibition domains of cognitive control. This biotype was characterized by a specific profile of pretreatment depressive symptoms, worse psychosocial functioning (d = -0.25; 95% CI, -0.39 to -0.11; P < .001), and reduced activation of the cognitive control circuit (right dorsolateral prefrontal cortex: d = -0.78; 95% CI, -1.28 to -0.27; P = .003). Remission was comparatively lower in the cognitive biotype positive subgroup (73 of 188 [38.8%] vs 250 of 524 [47.7%]; P = .04) and cognitive impairments persisted regardless of symptom change (executive function: ηp2 = 0.241; P < .001; response inhibition: ηp2 = 0.750; P < .001). The extent of symptom and functional change was specifically mediated by change in cognition but not the reverse.
Conclusions and relevance:
Our findings suggest the presence of a cognitive biotype of depression with distinct neural correlates, and a functional clinical profile that responds poorly to standard antidepressants and instead may benefit from therapies specifically targeting cognitive dysfunction.
Trial registration:
ClinicalTrials.gov Identifier: NCT00693849.
Introduction
Robust evidence from adult samples indicates that neurocognitive dysfunction is a hallmark of many mental illnesses, contributing to the loss of daily function and quality of life that these illnesses cause. However, it is still unclear whether neurocognitive deficits associated with mental illnesses begin to manifest well before adulthood. The current study addresses this gap by evaluating neurocognitive function in four groups of children and adolescents with different mental illnesses compared to their matched healthy peers.
Methods
We evaluated the neurocognitive performance of four samples of youth diagnosed with ADHD (N=343), Anorexia (N=40), First-onset psychosis (N=25), and Conversion Disorder (N=56) with age-matched healthy controls. Performance was assessed using an objective assessment battery designed for use across diagnoses and settings and validated for its correlations with underlying brain structure and function. The resulting analyses assessed accuracy and reaction time performance for neurocognitive domains well established in the adult literature, such as cognitive flexibility, executive function, response inhibition, verbal fluency, verbal memory, visual memory, sustained attention, and working memory. Clinical and healthy group performance was compared using non-parametric testing.
Results
Distinct profiles of neurocognitive dysfunction were detected for each diagnosis. Particularly, children and adolescents with ADHD diffusely performed worse than their healthy counterparts, with exceptional impairment in working memory. Children and adolescents with anorexia displayed more specific impairments limited to response inhibition and verbal memory. While youth with ADHD had the most cognitive domains affected, youth with first-onset psychosis displayed the most severe impairments compared to healthy controls. Finally, deficits in conversion disorder were limited to cognitive flexibility, executive function, decision making, response inhibition, and working memory. These findings suggest that neurocognitive impairment in mental illness is transdiagnostic and can be detected as early as childhood or adolescence with standardized computerized testing.
Background:
Patients with Anorexia Nervosa (AN) show a moderate deficit in overall neuropsychological functioning. Since previous studies on memory performance mainly employed cross-sectional designs, the present study aims to investigate changes in verbal memory following weight-gain.
Methods:
Verbal memory was assessed with the Wechsler Memory Scale-Revised (WMS-R; 'logical memory'-story-recall-subtest) and the California Verbal Learning Test-II (CVLT-II; 'verbal learning'). Included were 31 female patients with AN (18 restricting-, 13 purging-subtype; average disease duration: 5.1 years; average baseline BMI: 14.4 kg/m2 ) and 24 medication-free normal-weight healthy women adjusted for age at baseline (T0). In a post-treatment assessment of approx. 6 weeks with weight increase (T1), 18 patients with AN and 20 healthy women were assessed again. Group differences in verbal memory (i.e., WMS-R, CVLT-II) were assessed for the baseline comparisons with a multivariate ANOVA and longitudinal data were analysed with repeated measures (RM) ANOVAs.
Results:
At baseline, patients with AN as compared to healthy women displayed deficits in logical memory. In the follow-up assessment, patients with AN improved their logical memory significantly compared to healthy controls (p < 0.006). Furthermore, groups did not differ in verbal learning neither before nor after inpatient treatment.
Conclusions:
Enhanced logical memory in patients with AN following weight-gain is probably due to the impaired memory as compared to healthy controls at T0. A survivorship bias could explain the improved memory performance in longitudinal data in contrast to cross-sectional studies. Patients with AN with poorer memory performance before inpatient treatment are at higher risk to drop out and need support.
Enteral nutrition is a widely used technique for nutritional support which delivers a homogeneous, liquid nutrition admixture into the digestive tract by tube, into the stomach, duodenum, or the proximal jejunum. It is used to preserve nutritional status, support normal growth, and treat malnutrition when oral feeding is inadequate or not possible. The physiological bases underlying its implementation, as well as indications for programs of enteral nutrition in pediatric age, its composition according to the indication, and its complications are detailed in this chapter.
Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children's hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.
Die Angst, die ein zentraler Bestandteil der Anorexia Nervosa ist, ist bei den Patientinnen extrem gesteigert – Angst vor Nahrungsaufnahme, Angst vor Gewichtszunahme, Angst davor schlechte Leistung zu erbringen. Durch unsere Studie wollen wir herausfinden, ob AN-Patientinnen zu einem erleichtertem Angstlernen neigen und wie sich die gefundenen Ergebnisse bei remittierten Probandinnen verhalten (state vs. trait).
Wir verwenden das IF-Paradigma und psychometrische Fragebögen, um die neuronalen Prozesse beim Angstlernen und das subjektive Angstempfinden, bzw. vorhandene Persönlichkeitsstrukturen der beiden Probandengruppen im Vergleich zu Gesunden darzustellen.
Background and objectives:
Prior studies of residual cognitive deficits in abstinent substance-use disorder (SUD) patients, exhibited conflicting reports and a substantial patient selection bias. The aim of this study was to test the cognitive function of a sample of chronic abstinent SUD patients in a therapeutic-community.
Methods:
The IntegNeuroTM cognitive test battery was used for a retrospective cross-sectional study of cognitive functioning of an unselected sample (n = 105) of abstinent male residents of a therapeutic-community. The results were compared to a large age-, gender-, and education-matched normative cohort.
Results:
A significant negative deviance from the normal cohorts' mean was present in most of the cognitive test results and in all the cognitive domains that were tested. The most substantial deficit was found in the executive function domain (d = 1.02, 95%CI (±0.11)). Correct identification of facial emotions was significantly lower selectively in expressions of disgust and sadness. Substance-use starting at an early age (12.4 ± 0.8 years) was associated with lower performance in tests of sustained attention and impulsivity as well as with varied ability to identify correctly "negative" emotions in the emotion identification domain.
Conclusions:
This 5-year retrospective study demonstrates substantial cognitive impairments in an unselected sample of abstinent SUD patients. Impairment in multiple cognitive domains may lower the probability for remission and successful social integration. Early-age substance initiation may be associated with larger impairments in cognitive performance.
Importance
The symptoms that define mood, anxiety, and trauma disorders are highly overlapping across disorders and heterogeneous within disorders. It is unknown whether coherent subtypes exist that span multiple diagnoses and are expressed functionally (in underlying cognition and brain function) and clinically (in daily function). The identification of cohesive subtypes would help disentangle the symptom overlap in our current diagnoses and serve as a tool for tailoring treatment choices.
Objective
To propose and demonstrate 1 approach for identifying subtypes within a transdiagnostic sample.
Design, Setting, and Participants
This cross-sectional study analyzed data from the Brain Research and Integrative Neuroscience Network Foundation Database that had been collected at the University of Sydney and University of Adelaide between 2006 and 2010 and replicated at Stanford University between 2013 and 2017. The study included 420 individuals with a primary diagnosis of major depressive disorder (n = 100), panic disorder (n = 53), posttraumatic stress disorder (n = 47), or no disorder (healthy control participants) (n = 220). Data were analyzed between October 2016 and October 2017.
Main Outcomes and Measures
We followed a data-driven approach to achieve the primary study outcome of identifying transdiagnostic subtypes. First, machine learning with a hierarchical clustering algorithm was implemented to classify participants based on self-reported negative mood, anxiety, and stress symptoms. Second, the robustness and generalizability of the subtypes were tested in an independent sample. Third, we assessed whether symptom subtypes were expressed at behavioral and physiological levels of functioning. Fourth, we evaluated the clinically meaningful differences in functional capacity of the subtypes. Findings were interpreted relative to a complementary diagnostic frame of reference.
Results
Four hundred twenty participants with a mean (SD) age of 39.8 (14.1) years were included in the final analysis; 256 (61.0%) were female. We identified 6 distinct subtypes characterized by tension (n=81; 19%), anxious arousal (n=55; 13%), general anxiety (n=38; 9%), anhedonia (n=29; 7%), melancholia (n=37; 9%), and normative mood (n=180; 43%), and these subtypes were replicated in an independent sample. Subtypes were expressed through differences in cognitive control (F5,383 = 5.13, P < .001, ηp² = 0.063), working memory (F5,401 = 3.29, P = .006, ηp² = 0.039), electroencephalography-recorded β power in a resting paradigm (F5,357 = 3.84, P = .002, ηp² = 0.051), electroencephalography-recorded β power in an emotional paradigm (F5,365 = 3.56, P = .004, ηp² = 0.047), social functional capacity (F5,414 = 21.33, P < .001, ηp² = 0.205), and emotional resilience (F5,376 = 15.10, P < .001, ηp² = 0.171).
Conclusions and Relevance
These findings offer a data-driven framework for identifying robust subtypes that signify specific, coherent, meaningful associations between symptoms, behavior, brain function, and observable real-world function, and that cut across DSM-IV-defined diagnoses of major depressive disorder, panic disorder, and posttraumatic stress disorder.
Adolescents with anorexia nervosa who have obsessive–compulsive (OC) features respond poorly to family-based treatment (FBT). This study evaluated the feasibility of combining FBT with either cognitive remediation therapy (CRT) or art therapy (AT) to improve treatment response in this at-risk group. Thirty adolescents with anorexia nervosa and OC features were randomized to 15 sessions of FBT + CRT or AT. Recruitment rate was 1 per month, and treatment attrition was 16.6% with no differences between groups. Suitability, expectancy and therapeutic relationships were acceptable for both combinations. Correlations between changes in OC traits and changes in cognitive inefficiencies were found for both combinations. Moderate changes in cognitive inefficiencies were found in both groups but were larger in the FBT + AT combination. This study suggests that an RCT for poor responders to FBT because of OC traits combining FBT with either CRT or AT is feasible to conduct. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.
Objective
Functional neurological symptom disorder refers to the presence of neurological symptoms not explained by neurological disease. Although this disorder is presumed to reflect abnormal function of the brain, recent studies in adults show neuroanatomical abnormalities in brain structure. These structural brain abnormalities have been presumed to reflect long-term adaptations to the disorder, and it is unknown whether child and adolescent patients, with illness that is typically of shorter duration, show similar deficits or have normal brain structure.
Method
High-resolution, three-dimensional T1-weighted magnetic resonance images (MRIs) were acquired in 25 patients (aged 10–18 years) and 24 healthy controls. Structure was quantified in terms of grey matter volume using voxel-based morphometry. Post hoc, we examined whether regions of structural difference related to a measure of motor readiness to emotional signals and to clinical measures of illness duration, illness severity, and anxiety/depression.
Results
Patients showed greater volumes in the left supplementary motor area (SMA) and right superior temporal gyrus (STG) and dorsomedial prefrontal cortex (DMPFC) (corrected p < 0.05). Previous studies of adult patients have also reported alterations of the SMA. Greater SMA volumes correlated with faster reaction times in identifying emotions but not with clinical measures.
Conclusions
The SMA, STG, and DMPFC are known to be involved in the perception of emotion and the modulation of motor responses. These larger volumes may reflect the early expression of an experience-dependent plasticity process associated with increased vigilance to others' emotional states and enhanced motor readiness to organize self-protectively in the context of the long-standing relational stress that is characteristic of this disorder.
Anorexia nervosa (AN) is a serious mental health disorder with devastating consequences for sufferers and their families [1]. AN has a peak of onset in early adolescence [2], an age of many developmental changes. AN with pre-pubertal onset (EO-AN) is relatively rare; however, the evidence is mixed on whether outcomes are worse or better compared to AN with onset after puberty. For many individuals, AN becomes a chronic disorder, with impact on the individual's social, physical and psychological functioning. The last 10 years have seen many novel investigations focusing on the neurobiology of AN. Cognitive characteristics of patients with AN have received much attention, parallel to a surge of interest in psychiatry for measurable biological processes or phenotypes that might be more biologically informed than current diagnostic categories.
The present study was designed to assess effect of controlled vestibular stimulation on stress, spatial and verbal memory scores in underweight female students. 8 cases of underweight participants and 8 age matched healthy (controls) of females were included in the present study by convenient sampling after obtaining voluntary, free, written informed consent. No vestibular stimulation was given for healthy participants (control group) and 28 days of vestibular stimulation was given for (intervention group) underweight participants. Vestibular stimulation was achieved by swinging on a swing, according to their comfort. (Back to front direction) as previously described. DASS scale was used to assess depression, anxiety and stress levels and Spatial and verbal memory test used to assess cognitive functions. Underweight participants are having higher depression, anxiety and stress scores than controls on day o and decreased followed by intervention. Within the underweight participants (intervention group), depression and stress scores was significantly lower on 28th day when compared with day 0. Spatial and verbal memory scores were lower in underweight participants and improved after vestibular stimulation. Within the underweight participants (intervention group), verbal memory scores were significantly improved on 28th day when compared with day 0. In conclusion, this study provides preliminary evidence for the beneficial effect of controlled vestibular stimulation in underweight female students. We recommend further detailed study in this area, to recommend vestibular stimulation for underweight students.
Background:
The use of nasogastric (NG) feeding in individuals with anorexia nervosa (AN) is endorsed by national professional organizations; however, no guidelines currently exist.
Objectives:
The objectives of this review were to identify and evaluate outcomes of NG feedings for individuals with AN and to develop recommendations for future research, policy, and practice.
Design:
An integrative review of the research literature was conducted.
Results:
Of the 19 studies reviewed, all indicated short-term weight gain following NG feeding. Four studies examined adherence; nearly 30% of subjects were nonadherent as evidenced by tube manipulation. Seven studies reported psychiatric outcomes, suggesting NG feeding reduces eating disorder behaviors but not overall symptomology.
Conclusions:
NG feeding promotes short-term weight gain; however, long-term outcomes are poorly understood. Future research, using rigorous methods, is still needed to inform practice.
The existence of cognitive deficits associated with eating disorders has been debated for some time. The present study investigated cognitive impairments in a large sample of patients with anorexia nervosa from an inpatient treatment program. Fifty-nine women with anorexia nervosa were given a battery of neuropsychological tests assessing multiple cognitive domains. Over half of the patients had mild cognitive impairments in two or more neuropsychological tasks and approximately one-third failed two or more tasks. Depression level and body mass were not associated with cognitive impairment. Whether effective restoration of weight and resolution of core psychopathology contribute to reversal of cognitive deficits requires further research.
The EDI-2 manual is currently out of print but the attached file provides the table of contents for the EDI-3 which includes all of the EDI-2 items as well as the updated scale structure and scoring system for the EDI-3
Context
The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed
as a screening instrument but its administration time has limited its clinical
usefulness.Objective
To determine if the self-administered PRIME-MD Patient Health Questionnaire
(PHQ) has validity and utility for diagnosing mental disorders in primary
care comparable to the original clinician-administered PRIME-MD.Design
Criterion standard study undertaken between May 1997 and November 1998.Setting
Eight primary care clinics in the United States.Participants
Of a total of 3000 adult patients (selected by site-specific methods
to avoid sampling bias) assessed by 62 primary care physicians (21 general
internal medicine, 41 family practice), 585 patients had an interview with
a mental health professional within 48 hours of completing the PHQ.Main Outcome Measures
Patient Health Questionnaire diagnoses compared with independent diagnoses
made by mental health professionals; functional status measures; disability
days; health care use; and treatment/referral decisions.Results
A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585
had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those
of independent mental health professionals (for the diagnosis of any 1 or
more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%;
specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses
had more functional impairment, disability days, and health care use than
did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the
PHQ was far less than to administer the original PRIME-MD (<3 minutes for
85% vs 16% of the cases). Although 80% of the physicians reported that routine
use of the PHQ would be useful, new management actions were initiated or planned
for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously
recognized.Conclusion
Our study suggests that the PHQ has diagnostic validity comparable to
the original clinician-administered PRIME-MD, and is more efficient to use.
Figures in this Article
Mental disorders in primary care are common, disabling, costly, and
treatable.1- 5
However, they are frequently unrecognized and therefore not treated.2- 6
Although there have been many screening instruments developed,7- 8
PRIME-MD (Primary Care Evaluation of Mental Disorders)5
was the first instrument designed for use in primary care that actually diagnoses
specific disorders using diagnostic criteria from the Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition9(DSM-III-R) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition10(DSM-IV).
PRIME-MD is a 2-stage system in which the patient first completes a
26-item self-administered questionnaire that screens for 5 of the most common
groups of disorders in primary care: depressive, anxiety, alcohol, somatoform,
and eating disorders. In the original study,5
the average amount of time spent by the physician to administer the clinician
evaluation guide to patients who scored positively on the patient questionnaire
was 8.4 minutes. However, this is still a considerable amount of time in the
primary care setting, where most visits are 15 minutes or less.11
Therefore, although PRIME-MD has been widely used in clinical research,12- 28
its use in clinical settings has apparently been limited. This article describes
the development, validation, and utility of a fully self-administered version
of the original PRIME-MD, called the PRIME-MD Patient Health Questionnaire
(henceforth referred to as the PHQ).
DESCRIPTION OF PRIME-MD PHQ
ABSTRACT
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DESCRIPTION OF PRIME-MD PHQ
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STUDY PURPOSE
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METHODS
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RESULTS
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COMMENT
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REFERENCES
The 2 components of the original PRIME-MD, the patient questionnaire
and the clinician evaluation guide, were combined into a single, 3-page questionnaire
that can be entirely self-administered by the patient (it can also be read
to the patient, if necessary). The clinician scans the completed questionnaire,
verifies positive responses, and applies diagnostic algorithms that are abbreviated
at the bottom of each page. In this study, the data from the questionnaire
were entered into a computer program that applied the diagnostic algorithms
(written in SPSS 8.0 for Windows [SPSS Inc, Chicago, Ill]). The computer program
does not include the diagnosis of somatoform disorder, because this diagnosis
requires a clinical judgment regarding the adequacy of a biological explanation
for physical symptoms that the patient has noted.
A fourth page has been added to the PHQ that includes questions about
menstruation, pregnancy and childbirth, and recent psychosocial stressors.
This report covers only data from the diagnostic portion (first 3 pages) of
the PHQ. Users of the PHQ have the choice of using the entire 4-page instrument,
just the 3-page diagnostic portion, a 2-page version (Brief PHQ) that covers
mood and panic disorders and the nondiagnostic information described above,
or only the first page of the 2-page version (covering only mood and panic
disorders) (Figure 1).
Figure 1. First Page of Primary Care Evaluation
of Mental Disorders Brief Patient Health QuestionnaireGrahic Jump Location+View Large |
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View in Article ContextCopyright held by Pfizer Inc, but may be photocopied ad libitum.
For office coding, see the end of the article.
The original PRIME-MD assessed 18 current mental disorders. By grouping
several specific mood, anxiety, and somatoform categories into larger rubrics,
the PHQ greatly simplifies the differential diagnosis by assessing only 8
disorders. Like the original PRIME-MD, these disorders are divided into threshold
disorders (corresponding to specific DSM-IV diagnoses,
such as major depressive disorder, panic disorder, other anxiety disorder,
and bulimia nervosa) and subthreshold disorders (in which the criteria for
disorders encompass fewer symptoms than are required for any specific DSM-IV diagnoses: other depressive disorder, probable alcohol
abuse or dependence, and somatoform and binge eating disorders).
One important modification was made in the response categories for depressive
and somatoform symptoms that, in the original PRIME-MD, were dichotomous (yes/no).
In the PHQ, response categories are expanded. Patients indicate for each of
the 9 depressive symptoms whether, during the previous 2 weeks, the symptom
has bothered them "not at all," "several days," "more than half the days,"
or "nearly every day." This change allows the PHQ to be not only a diagnostic
instrument but also to yield a measure of depression severity that can be
of aid in initial treatment decisions as well as in monitoring outcomes over
time. Patients indicate for each of the 13 physical symptoms whether, during
the previous month, they have been "not bothered," "bothered a little," or
"bothered a lot" by the symptom. Because physical symptoms are so common in
primary care, the original PRIME-MD dichotomous-response categories often
led patients to endorse physical symptoms that were not clinically significant.
An item was added to the end of the diagnostic portion of the PHQ asking
the patient if he or she had checked off any problems on the questionnaire:
"How difficult have these problems made it for you to do your work, take care
of things at home, or get along with other people?" As with the original PRIME-MD,
before making a final diagnosis, the clinician is expected to rule out physical
causes of depression, anxiety and physical symptoms, and, in the case of depression,
normal bereavement and history of a manic episode.
STUDY PURPOSE
ABSTRACT
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DESCRIPTION OF PRIME-MD PHQ
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STUDY PURPOSE
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METHODS
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RESULTS
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COMMENT
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REFERENCES
Our major purpose was to test the validity and utility of the PHQ in
a multisite sample of family practice and general internal medicine patients
by answering the following questions:
Are diagnoses made by the PHQ as accurate as diagnoses
made by the original PRIME-MD, using independent diagnoses made by mental
health professionals (MHPs) as the criterion standard?Are the frequencies of mental disorders found by
the PHQ comparable to those obtained in other primary care studies?Is the construct validity of the PHQ comparable
to the original PRIME-MD in terms of functional impairment and health care
use?Is the PHQ as effective as the original PRIME-MD
in increasing the recognition of mental disorders in primary care patients?How valuable do primary care physicians find the
diagnostic information in the PHQ?How comfortable are patients in answering the questions
on the PHQ, and how often do they believe that their answers will be helpful
to their physicians in understanding and treating their problems?
Neuropsychological measures were administered to 18 patients with anorexia nervosa shortly after admission to hospital and again after substantial weight gain. These patients were compared with a group of 18 normal weight controls, also tested on two occasions, who were matched for age, sex, and estimated premorbid IQ. At low weight, impairment was evident on tests of attentional-perceptual-motor functions and on tests of visuospatial construction and problem-solving. Learning was less affected. Refeeding resulted in significant improvements in performance.
Cognitive functions were investigated in four groups of women: 30 underweight anorexics, 38 normal-weight bulimics, 20 long-term weight-restored anorexics, and 39 normal controls. A MANOVA was used to examine performance on five neuropsychological domains derived from prior principal components analyses of a comprehensive neuropsychological battery. Underweight anorexics performed more poorly than normal controls in four of five neuropsychological domains (focusing/execution, verbal, memory, and visuospatial), while normal-weight bulimics showed poorer performances only in focusing/execution. The absolute differences in scores between eating disorder groups and normal controls were for the most part small, suggesting subtle rather than frank cognitive difficulties. Poorer neuropsychological test performance was associated with anxiety but not depression as measured by the Tryon, Stein, and Chu Tension scale and scale 2 of the MMPI respectively. The findings support previous reports of attentional difficulties in eating disorders but do not support the hypothesis of differential right-hemisphere dysfunction in eating disorders.
Anorexia nervosa patients were found to perform as well or better than control subjects on cognitive tasks that both require considerable cognitive effort and 'direct' the subject to the information that will be tested, but do more poorly than controls on tests that assess automatic or incidental processing of information. The implications of this particular pattern of cognitive alterations for theories concerning the etiology of anorexia nervosa are discussed.
This study assessed brain function in 20 adolescent females with anorexia nervosa (AN) and 20 controls using event-related potentials (ERPs) and a battery of neuropsychological tests. In the AN group, N4 latencies for a nonverbal memory task were significantly longer than for a verbal task, and P3 latencies for the verbal task were significantly longer among anorexics as compared to controls. On the nonverbal task, the AN group failed to show a right > left hemispheric asymmetry for P3 amplitudes which was observed for controls. These group differences for P3 latency and amplitude were particularly pronounced in the central-parietal region of the head. Body Mass Index (BMI) in the anorexic group significantly predicted N4 amplitudes for the verbal task in the left hemisphere and P3 amplitudes for the nonverbal task in the right hemisphere. The two groups did not differ on any of the tests used to assess neuropsychological functioning. Eight nutritionally recovered patients and their matched controls were retested using the same procedures. Anorexics showed larger P3 amplitudes for the verbal as compared to the nonverbal task at follow-up. These findings provide evidence for localized brain dysfunction in anorexia nervosa that only partially normalizes with weight gain.
This study deals with executive functions such as abstraction, use of strategy, and response flexibility (focused attention) seen in patients with anorexia nervosa. The aim was to highlight any correlation between neuropsychological functioning and the degree of pathology for food style, body image, and physical state.
A modified Stroop test, Wisconsin Card Sorting test, Body Shape Questionnaire, and Eating Disorder Inventory-2 were administered to 20 anorexia nervosa restricters (AN-R) and 20 control subjects.
The AN-R subjects showed nonspecific attentional biases, in addition to disorders regarding abstraction and flexibility of thought, similar to those seen in patients with obsessive-compulsive disorder. The disturbance of body image showed a direct correlation to frontal alterations.
This evidence suggested that in the AN-R subjects the disturbances of body image might be linked to the alterations of abstraction and critical abilities and with an obsessive frontal functioning.
The existence of cognitive deficits associated with eating disorders has been debated for some time. The present study investigated cognitive impairments in a large sample of patients with anorexia nervosa from an inpatient treatment program. Fifty-nine women with anorexia nervosa were given a battery of neuropsychological tests assessing multiple cognitive domains. Over half of the patients had mild cognitive impairments in two or more neuropsychological tasks and approximately one-third failed two or more tasks. Depression level and body mass were not associated with cognitive impairment. Whether effective restoration of weight and resolution of core psychopathology contribute to reversal of cognitive deficits requires further research.
Eating disorders (ED), including anorexia and bulimia nervosa, are chronic illnesses with periods of symptom exacerbation and remission. Because symptoms are usually present from 6 to 24 months before a diagnosis is made, aetiological agents are believed to be active well before symptoms appear. It is proposed that neuropsychological deficits in various cognitive domains preexist and underlie the aetiology of ED. This paper provides a comprehensive review of the literature relevant to neuropsychological deficits in ED patients and explores the relationship between cognitive deficits, psychosocial development, and the development of ED. Although the role of neuropsychological deficits in the evolution of ED requires further research, the proposed association has significant implications for clinical practice.
The aim of this study was to determine if there are differences in cognitive flexibility in anorexia nervosa and bulimia nervosa. Fifty-three patients with an eating disorder (34 with anorexia nervosa and 19 with bulimia nervosa) and 35 healthy controls participated in the study. A battery of neuropsychological tests for cognitive flexibility was used, including Trail Making B, the Brixton Test, Verbal Fluency, the Haptic Illusion Test, a cognitive shifting task (CatBat) and a picture set test. Using exploratory factor analysis, four factors were obtained: 1: Simple Alternation; 2: Mental Flexibility; 3: Perseveration; and 4: Perceptual Shift. Patients with anorexia nervosa had abnormal scores on Factors 1 and 4. Patients with bulimia nervosa showed a different pattern, with significant impairments in Factors 2 and 4. These findings suggest that differential neuropsychological disturbance in the domain of mental flexibility/rigidity may underlie the spectrum of eating disorders.
Anorexia nervosa (AN) is frequently associated with symptoms of depression, anxiety, and obsessive-compulsive behavior which also develop secondary to semistarvation. It is less certain if these symptoms persist after recovery. A few studies have already reported on high prevalence rates of anxious, depressive, and obsessive features in long-term recovered patients with AN, but several of these so called "long-term" recovered patients had only maintained weight restoration for six to twelve months. The aim of this study was to determine whether depressive, anxious, and obsessive-compulsive symptoms persist in truly long-term recovered patients (BMI 20.3+/-2.5 kg/m(2)) who no longer had any eating disorder symptoms (including weight phobia) for at least 3 years. Seventeen subjects of an AN sample (n=39) previously described in a 10-year follow-up met our strict criteria of at least 3 years of complete recovery of AN. In comparison to 39 age-, sex-, and occupation-matched healthy subjects without a history of psychiatric or eating disorder, long-term recovered patients had higher levels of depressive (p=0.002), anxious (p=0.006), and obsessive-compulsive (p=0.015) features but did not differ with regard to psychiatric morbidity and psychosocial adaptation. In conclusion, depressive, anxious, and obsessive-compulsive symptoms may be personality traits in subjects with former adolescent anorexia nervosa.
Although many studies have reported impairments of neurocognitive performance in patients with anorexia nervosa (AN), these have involved a wide range of assessment methods and some findings are inconsistent.
Twenty-five female in-patients with a DSM-IV diagnosis of AN, identified from three units specializing in the treatment of eating disorders, volunteered for the study. Twenty-five non-clinical control subjects were recruited, matched for age, gender and estimated IQ. Subjects were assessed with a range of computer-administered neurocognitive tasks from the Cambridge Neuropsychological Test Automated Battery (CANTAB), which has been validated in many studies of neuropsychiatric disorders.
The patient group showed significant but moderate impairments (i.e. less than one standard deviation below the mean performance of the control group) on tests of spatial recognition memory, a planning task and rapid visual information processing, while a subgroup of patients (n = 14) showed greater degrees of impairments on at least one of these tests. The degrees of impairments did not correlate with body mass index (BMI). No impairments were observed on tests of spatial span, pattern recognition memory, spatial working memory, matching-to-sample, paired associates learning and set-shifting.
The findings, in relation to a mean BMI of 15.3, are compatible with, in general, subtle impairments in neurocognition in AN. However, in those patients with relatively severe degrees of impairments, these may have adverse effects on complex tasks of social and occupational functioning. Further research is needed on the nature of relevant causal mechanisms, including the effects of potentially confounding variables.
Set-shifting difficulties have been reported in subjects with anorexia nervosa and appear to persist after recovery; therefore, they may be endophenotypic traits. The goals of this study were to investigate whether set-shifting difficulties are familial by examining discordant sister-pairs in comparison with healthy unrelated women and to replicate, with a broader battery, the lack of influence of an acute illness state on neuropsychological performance.
Forty-seven pairs of sisters discordant for anorexia nervosa and 47 healthy unrelated women who were comparable in age and IQ completed neuropsychological tasks selected to assess set-shifting ability. Analyses of variance with standard errors that are robust against correlations within family clusters were used to compare the groups. Results were adjusted for obsessive-compulsive, anxiety, and depression symptoms. Subjects with acute (N=24) and fully remitted (N=23) anorexia nervosa were compared to assess state versus trait effects.
Sisters with and without anorexia nervosa took significantly longer than unrelated healthy women to shift their cognitive set (CatBat task) and demonstrated greater perceptual rigidity (Haptic Illusion task) but did not differ significantly from each other. Women with anorexia nervosa were slower than other groups on Trail Making tasks. Women who had fully recovered from anorexia nervosa made significantly fewer errors than those with acute anorexia nervosa on the Trail Making alphabet task, but these subgroups did not differ on other measures.
Both affected and unaffected sisters had more set-shifting difficulties than unrelated healthy women. This finding, together with the replicated finding that set-shifting difficulties persist after recovery, suggests that set-shifting difficulties are trait characteristics and may inform the search for the endophenotype in anorexia nervosa.
Adolescence to early adulthood is a period of dramatic transformation in the healthy human brain. However, the relationship between the concurrent structural and functional changes remains unclear. We investigated the impact of age on both neuroanatomy and neurophysiology in the same healthy subjects (n = 138) aged 10 to 30 years using magnetic resonance imaging (MRI) and resting electroencephalography (EEG) recordings. MRI data were segmented into gray and white matter images and parcellated into large-scale regions of interest. Absolute EEG power was quantified for each lobe for the slow-wave, alpha and beta frequency bands. Gray matter volume was found to decrease across the age bracket in the frontal and parietal cortices, with the greatest change occurring in adolescence. EEG activity, particularly in the slow-wave band, showed a similar curvilinear decline to gray matter volume in corresponding cortical regions. An inverse pattern of curvilinearly increasing white matter volume was observed in the parietal lobe. We suggest that the reduction in gray matter primarily reflects a reduction of neuropil, and that the corresponding elimination of active synapses is responsible for the observed reduction in EEG power.
Attentional difficulties reported in individuals with anorexia nervosa (AN) may be due to preferential processing of disease-salient stimuli at a pre-attentive or at a conscious level or to a general problem in attention. Attentional difficulties may be associated with duration of illness.
Female participants with AN (restricting subtype; n=24) and healthy comparison women (n=24) were randomly allocated to subliminal or supraliminal exposure to visual stimuli (food, neutral and aversive images) while performing the 1-back and 2-back working-memory tasks.
Participants with AN made fewer errors than the healthy comparison group in the subliminal condition but significantly more errors in the supraliminal condition [condition x group interaction, F(1, 44)=6.82, p<0.01]: this was irrespective of stimulus type (food, neutral and aversive) and task (1-back or 2-back). The total number of errors made correlated positively with the duration of the AN for both the 1-back task (rs=0.46, p<0.05) and for the 2-back task (rs=0.53, p<0.01).
Decreased ability to concentrate in the presence of explicit distracters is a feature of AN and is associated with longer duration of illness. This phenomenon could be addressed in psychological interventions.
To evaluate the possibility that subtle brain dysfunction may exist in anorexia nervosa and indicate a poor prognosis, 20 anorexia nervosa patients received neuropsychological assessments covering a broad array of cognitive performances. The patients were examined at admission and again at the end of an inhospital treatment program when they were at normal weight for their age and height. Pretreatment performance on the assessment battery was not associated with outcome 1 year after discharge. However, posttreatment performance and significantly associated with outcome. A majority (71%) of patients with two or more cognitive deficits showed an unfavorable outcome (i.e., did not maintain their weight). In contrast, a majority (85%) of patients with less than two cognitive defects had a favorable outcome (i.e., maintained or increased their weight). The findings suggest that the hypothesis of a central nervous system disorder limiting the capacity for anorectics to recover deserves further exploration.
Investigated whether patients with anorexia nervosa would exhibit cognitive deficits on neuropsychological examination. A battery of tests was administered to 35 patients (34 female, 1 male), diagnosed as suffering from anorexia nervosa (
n = 20) or bulimia nervosa (
n = 15) during the early stages of admission to a specialized eating disorders unit. Results revealed no significant differences between the anorexia nervosa and bulimia nervosa Ss on any of the intellectual, neuropsychological, or academic-related tasks. There was no evidence of cognitive deficits in the patient groups compared with theoretical norms. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Although 18% of Australians suffered a psychiatric disorder in the last 12 months, only 38% presented to health services. Of these, the vast majority (76%) consulted their general practitioner [1]. While two-thirds of those who present to primary care have significant psychological symptoms, at least 30% have psychological disorders that result in disability, long-term morbidity and/or mortality [2–4]. These disorders are often co-morbid with other medical disorders and/or substance abuse [1]. Despite the advances in pharmacological and non-pharmacological therapies available [5,6] less than half of the patients who present receive a psychiatric diagnosis and less than half of these receive any specific treatment [7]. Recommendations under the National Mental Health Strategy [8] recognise the urgent need for educational programs and practice support mechanisms to correct these major public health deficits.
Synopsis
Seventeen patients with anorexia nervosa were examined by computed tomography (CT) and psychometry and compared with ten normal control subjects. The patients were found to have enlarged external cerebrospinal fluid spaces compared to controls. No differences were found in ventricular size and X-ray absorption density measurements between patients and controls. The patients performed abnormally on the symbol digit test, the scores of which displayed a significant negative correlation with the CT scan changes.
Objective
The study investigated the effects of anorexia nervosa (AN) on the three components of working memory, and the extent to which these could be attributed to preoccupying cognitions concerning food, weight and body shape.Method
Participants were 24 young women with AN aged from 17 to 27 years. Their performance on the Double Span Memory task was compared against that of 24 dieting and 24 non-dieting controls. The Double Span Memory task presents a series of common objects in randomly chosen locations of a 4 × 4 grid, and requires participants to name the objects (phonological loop), point to the locations (visuo-spatial sketch pad) or both (central executive). Participants also completed a self-report measure of preoccupying thoughts about food, weight and body shape, as well as a measure of crystallised intelligence.ResultsRelative to non-dieting controls, dieters and AN patients performed significantly more poorly on the combined recall. AN patients alone showed impaired performance on the single recall of locations. Covariance analyses indicated that the group × recall type interaction was accounted for by self-reports of preoccupying cognitions.DiscussionAN is associated with disruption of the functioning of the visuo-spatial sketch pad and central executive components of working memory. These deficits are at least partly attributable to an intense preoccupation with dieting-related thoughts, and may contribute to difficulties in processing complex information within the therapeutic context. Copyright © 2006 John Wiley & Sons, Ltd and Eating Disorders Association.