Clinical and genetic correlates of decision making in anorexia nervosa

Introduction: Decision-making (DM) abilities have been found to be impaired in anorexia nervosa (AN), but few data are available about the characteristics and correlates of this cognitive function. The aim of the present study was to provide data on DM functioning in AN using both veridical and adaptive paradigms. While in veridical DM tasks, the individual’s ability to predict a true/false response is measured, adaptive DM is the ability to consider both internal and external demands in order to make a good choice, in the absence of a single true “correct” answer. Method: The participants were 189 women, of whom 91 were eating-disordered patients with a lifetime diagnosis of anorexia nervosa, and 98 were healthy women. All the participants underwent clinical, neuropsychological, and genetic assessment. The cognitive evaluation included a set of neuropsychological tasks and two decision-making tests: The Iowa Gambling Task and the Cognitive Bias Task. Results: Anorexia nervosa patients showed significantly poorer performances on both decision-making tasks than healthy women. The Cognitive Bias Task revealed that anorexia nervosa patients employed significantly more context-independent decision-making strategies, which were independent from diagnostic subtype, handedness, education, and psychopathology. In the whole sample (patients and controls), Cognitive Bias Task performance was independently predicted by lifetime anorexia nervosa diagnosis, body mass index at assessment, and 5-HTTLPR genotype. Conclusions: Patients displayed poor decision-making functioning in both veridical and adaptive situations. The difficulties detected in anorexia nervosa individuals may affect not only the ability to consider the future outcomes of their actions (leading to “myopia for the future”), but also the capacity to update and review one’s own mindset according to new environmental stimuli.     

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

Objective

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

Methods

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

Results

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

Conclusions

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

Validation of the Inventory of Interpersonal Problems (IIP-64): a comparison of Swedish female outpatients with anorexia nervosa or bulimia nervosa and controls

Aim: The aim of the study was to explore the psychometric properties of the Inventory of Interpersonal Problems (IIP-64) and to compare levels of interpersonal distress in Swedish female outpatients with anorexia nervosa or bulimia nervosa with age- and gender-matched controls.

Methods: Totally, 401 participants were included; anorexia nervosa (n?=?74), bulimia nervosa (n?=?85) and controls (n?=?242). All participants completed the IIP-64. The eating disorder (ED) patients also filled out the Eating Disorder Inventory-2/3 (EDI).

Results: Internal consistency of IIP-64 was acceptable to high. Principal component analyses with varimax rotation of the IIP-64 subscales confirmed the circumplex structure with two underlying orthogonal dimensions; affiliation and dominance. Significant correlations between EDI-3 composite scales ineffectiveness and interpersonal problems and IIP-64 were found. ED patients reported higher levels of interpersonal distress than controls on all but one subscale (intrusive/needy).

Conclusions: IIP-64 can be considered to have acceptable to good reliability and validity in a Swedish ED sample. IIP-64 can be a useful complement in assessment of interpersonal problems in ED.     

Emotional conflict processing in adolescent chronic fatigue syndrome: A pilot study using functional magnetic resonance imaging

Introduction: Studies of neurocognition suggest that abnormalities in cognitive control contribute to the pathophysiology of chronic fatigue syndrome (CFS) in adolescents, yet these abnormalities remain poorly understood at the neurobiological level. Reports indicate that adolescents with CFS are significantly impaired in conflict processing, a primary element of cognitive control. Method: In this study, we examine whether emotional conflict processing is altered on behavioral and neural levels in adolescents with CFS and a healthy comparison group. Fifteen adolescent patients with CFS and 24 healthy adolescent participants underwent functional magnetic resonance imaging (fMRI) while performing an emotional conflict task that involved categorizing facial affect while ignoring overlaid affect labeled words. Results: Adolescent CFS patients were less able to engage the left amygdala and left midposterior insula (mpINS) in response to conflict than the healthy comparison group. An association between accuracy interference and conflict-related reactivity in the amygdala was observed in CFS patients. A relationship between response time interference and conflict-related reactivity in the mpINS was also reported. Neural responses in the amygdala and mpINS were specific to fatigue severity. Conclusions: These data demonstrate that adolescent CFS patients displayed deficits in emotional conflict processing. Our results suggest abnormalities in affective and cognitive functioning of the salience network, which might underlie the pathophysiology of adolescent CFS.     

Elevation of homocysteine levels is only partially reversed after therapy in females with eating disorders

Recent studies have shown elevated homocysteine levels in patients with eating disorders. In a prospective, longitudinal study, we investigated differences of homocysteine plasma levels in patients with anorexia nervosa (N = 12) and bulimia nervosa (N = 17) compared to healthy controls (N = 20) and alteration of homocysteine levels in patients during specific in-patient treatment. We found significantly elevated homocysteine levels in both patient groups (anorexia nervosa and bulimia nervosa) and a non-significant decrease of homocysteine during the 12-week treatment period. Furthermore, we found a significant association between low homocysteine levels and cognitive deficits, pointing toward a beneficial effect of elevated homocysteine levels on cognition in this patient group. We suppose that during effective treatment with significant increase of the body mass index, the observed hyperhomocysteinemia in patients with eating disorders is partially reversible. These findings add further evidence to the hypothesis that homocysteine might be involved in the pathophysiology of anorexia and bulimia nervosa.     

Cognitive flexibility in anorexia nervosa and bulimia nervosa.

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.     

Guided self-help for binge eating/purging anorexia nervosa before inpatient treatment

Abstract

The goal of this study was to develop a cognitive–behavioral self-help manual for anorexia nervosa. Patients diagnosed with anorexia nervosa (N=102), binge eating/purging type (AN-B/P), were consecutively assigned to one of two conditions: 6-week manualized guided self-help or a wait-list control. All patients thereafter received inpatient treatment in a hospital for behavioral medicine. The primary outcome variable was the number of days in inpatient treatment. Secondary outcome variables were measures of psychopathology. Results showed that duration of inpatient treatment was significantly shorter (by 5.2 days) among participants receiving guided self-help. Body image, slimness ideal, general psychopathology, and some bulimic symptoms improved significantly during self-help. The authors conclude that, to increase effects of therapist-guided self-help in AN-B/P, additional variants of a self-help manual should be tried in different therapeutic settings.     

Information processing bias in anorexia nervosa

The aim of this study was to investigate preferential information processing style in Eating Disorders (ED). We compared the performance of participants with EDs against healthy controls in a task that measures cognitive style (reflection-impulsivity) and cognitive efficiency (inefficient-efficient). Sixty non-medicated female participants (healthy controls n=26, anorexia nervosa n=20, bulimia nervosa n=14) took part in the Matching Familiar Figures Test (MFFT), a difficult visual search paradigm with high response uncertainty. Participants with anorexia scored significantly higher on the efficiency dimension score than the control group. No significant differences were found across groups on the dimension 'reflection-impulsivity'. Participants with anorexia are more efficient (quicker response latencies in conjunction with fewer errors) in this visual search task that requires an analytic approach. This supports the hypothesis that individuals with anorexia have a positive bias toward local detail processing, indicative of weak central coherence.     

Psychotherapy for eating disorders: A meta-analysis of direct comparisons

Abstract

Objective: We conducted a meta-analysis of randomized controlled trials (RCTs) of bona fide psychotherapy for adults with eating disorders (EDs). Method: Thirty-five RCTs with 54 direct comparisons were included. The majority of RCTs included participants with bulimia nervosa and/or binge-ED, while only two RCTs included participants with anorexia nervosa, and three RCTs included participants with an ED not otherwise specified. Results: There was a clear advantage of bona fide psychotherapy over wait-list controls. Bona fide psychotherapy was superior to non-bona fide treatment; however, the majority of results were not stable. There were no significant differences between bona fide cognitive–behavioral therapy (CBT) and bona fide non-CBT, with the exception of bona fide CBT resulting in greater reductions in ED psychopathology assessed by the ED Examination, which primarily assesses maintenance factors according to the CBT model. Conclusions: Generally, the results indicate that any bona fide psychotherapy will be equally effective. While the number of trials remains modest, we hope that as more research becomes available, treatment guidelines can be updated, and more evidence-based treatment options will be available for treating EDs.     

Theory of mind and central coherence in eating disorders: Two sides of the same coin?

The aim of this study was to evaluate central coherence and theory of mind (ToM) and explore the relationships between these domains in patients with eating disorders (ED). ToM and central coherence were assessed in 72 women [24 with anorexia nervosa (AN), 24 with bulimia nervosa (BN) and 24 healthy controls (HC)]. The Reading the Mind in the Eyes (RME) and the Faux Pas Test (FPT) to measure ToM, and the copy strategy of the Rey–Osterrieth Complex Figure Test to assess central coherence were used. It was observed that patients with ED had a decrease in central coherence skills compared with the control group; that patients with anorexia had a poor performance on RME ToM task compared with BN patients and HCs, and also that these measures were related in both clinical groups. The statistically significant correlation between them suggests that the central coherence and ToM measures might involve common cognitive processes. These results provide a better understanding of the nature of the socio-cognitive deficits observed in patients with eating disorders.     

Control over interfering memories in eating disorders

Introduction: Recent studies have suggested that patients suffering from either anorexia nervosa (AN) or bulimia nervosa (BN) exhibit abnormal performance in the ability to control cognitive interference in response selection. Method: We assessed the status of cognitive control in episodic memory by addressing the ability to inhibit interfering memories. To this end, we used the retrieval-practice paradigm, which allows for measuring both the beneficial and the detrimental effects of memory practice. The latter phenomenon, known as retrieval-induced forgetting (RIF), is thought to reflect an adaptive inhibitory mechanism aimed at reducing competition in memory retrieval. Twenty-seven healthy controls and 27 patients suffering from eating disorders (either AN or BN) performed a retrieval-practice paradigm and a control task addressing general reactivity and filled a self-report questionnaire on impulsivity. Results: No differences between patients and healthy controls were observed for the beneficial effects of practice. The same pattern also emerged for RIF. However, when patients with AN and BN were analyzed separately, a clear dissociation emerged: patients with AN displayed no hint of RIF, whereas patients with BN showed an intact memory suppression performance. No group differences emerged in the control task. Conclusions: Our findings suggest a specific impairment in the ability to suppress interfering memories in patients with AN, thus extending current evidence of cognitive control deficits in AN to episodic memory.     

Resting-state synchrony between anterior cingulate cortex and precuneus relates to body shape concern in anorexia nervosa and bulimia nervosa

Cortical areas supporting cognitive control and salience demonstrate different neural responses to visual food cues in patients with eating disorders. This top-down cognitive control, which interacts with bottom-up appetitive responses, is tightly integrated not only in task conditions but also in the resting-state. The dorsal anterior cingulate cortex (dACC) is a key node of a large-scale network that is involved in self-referential processing and cognitive control. We investigated resting-state functional connectivity of the dACC and hypothesized that altered connectivity would be demonstrated in cortical midline structures involved in self-referential processing and cognitive control. Seed-based resting-state functional connectivity was analyzed in women with anorexia nervosa (N=18), women with bulimia nervosa (N=20) and age matched healthy controls (N=20). Between group comparisons revealed that the anorexia nervosa group exhibited stronger synchronous activity between the dACC and retrosplenial cortex, whereas the bulimia nervosa group showed stronger synchronous activity between the dACC and medial orbitofrontal cortex. Both groups demonstrated stronger synchronous activity between the dACC and precuneus, which correlated with higher scores of the Body Shape Questionnaire. The dACC-precuneus resting-state synchrony might be associated with the disorder-specific rumination on eating, weight and body shape in patients with eating disorders.     

Understanding catastrophic worry in eating disorders: process and content characteristics

Background and objectives

The majority of people with eating disorders (ED) experience high levels of comorbid anxiety and depression, yet the maintenance processes of these in ED remain largely unknown. Worry, a defining cognitive feature and important maintenance factor of anxiety, has not been well-studied amongst people with ED. This is the first study to explore both the process and content characteristics of catastrophic worry in ED.

Methods

Twenty-nine patients with anorexia nervosa (AN), 15 patients with bulimia nervosa (BN) and 37 healthy controls (HC) completed measures assessing anxiety, depression, worry and eating disorder pathology. Catastrophic worry was assessed using the Catastrophizing Interview and catastrophic worry content was explored using qualitative Thematic Analysis.

Results

Compared to HCs, ED groups had higher levels of anxiety, depression and worry and they generated a greater number of catastrophic worry steps. Worry was further found associated with depressive symptomatology in those with ED. Worry content for the ED groups included ED themes, but also themes reflecting broader inter and intrapersonal concerns.

Limitations

The degree to which worry is driven by depressive versus anxious symptomatology remains unclear. The current study does not include an anxious or depressed control group, and results should be considered in the light of relatively small samples sizes.

Conclusion

Findings indicate that interventions that target worry processes may be a useful adjunct to treatment for those ED patients with clinical worry levels.     

Neuropsychological Characteristics of Patients in a Hospital-Based Eating Disorder Program

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.     

Literature Review of Cognitive Neuroscience and Anorexia Nervosa

Studies published between the beginning of 2013 and May 2015 on the neuropsychological functioning of patients with anorexia nervosa compared with healthy participants framed in the context of the Research Domain Criteria matrix identifies evidence for functional differences in three domains: Negative Valance Systems—negative attentional biases and lack of neural responsivity to hunger; Cognitive Systems—limited congruence between clinical and cognitive performance, poorer non-verbal than verbal performance, altered attentional styles to disorder related stimuli, perceptual processing impairment in discriminating body images, weaknesses in central coherence, set shifting weaknesses at low weight status, decision-making weaknesses, and greater neural resources required for working memory; Systems for Social Processes—patients appear to have a different attentional response to faces, and perception and understanding of self and others. Hence, there is evidence to suggest that patients with anorexia nervosa have a specific neuropsychological performance style across tasks in three domains of functioning. Some current controversies and areas for future development are identified.     

Neural signature of behavioural inhibition in women with bulimia nervosa

BackgroundImpaired inhibitory control is considered a behavioural phenotype in patients with bulimia nervosa. However, the underlying neural correlates of impaired general and food-specific behavioural inhibition are largely unknown. Therefore, we investigated brain activation during the performance of behavioural inhibition to general and food-related stimuli in adults with bulimia nervosa.MethodsWomen with bulimia and healthy control women underwent event-related fMRI while performing a general and a food-specific no-go task.ResultsWe included 28 women with bulimia nervosa and 29 healthy control women in our study. On a neuronal level, we observed significant group differences in response to general no-go stimuli in women with bulimia nervosa with high symptom severity; compared with healthy controls, the patients showed reduced activation in the right sensorimotor area (postcentral gyrus, precentral gyrus) and right dorsal striatum (caudate nucleus, putamen).LimitationsThe present results are limited to adult women with bulimia nervosa. Furthermore, it remains unclear whether impaired behavioural inhibition in patients with this disorder are a cause or consequence of chronic illness.ConclusionOur findings suggest that diminished frontostriatal brain activation in patients with bulimia nervosa contribute to the severity of binge eating symptoms. Gaining further insight into the neural mechanisms of behavioural inhibition problems in individuals with this disorder may inform brain-directed treatment approaches and the development of response inhibition training approaches to improve inhibitory control in patients with bulimia nervosa. The present study does not support greater behavioural and neural impairments to food-specific behavioural inhibition in these patients.     

Aggressiveness, anger, and hostility in eating disorders

Objective

Despite evidence of a link between the behavioral and cognitive dimensions of aggressiveness and eating disorders, only few studies have tested this relation empirically.

Methods

A total of 112 female patients with anorexia nervosa (n = 61) or bulimia nervosa (n = 51) and 631 young girls attending 7 high schools in the same health district as the patients (northeast Italy) were invited to fill in a set of self-report instruments including the Eating Attitudes Test, the Bulimic Investigatory Test of Edinburgh, the Body Attitudes Test, and the Buss-Perry Aggression Questionnaire (AQ).

Results

In both healthy controls and patients, scores on the measures of eating disorder symptoms were positively related to the scores on the AQ: the strength of the association did not differ between healthy controls and patients. However, patients diagnosed with eating disorders were not more likely to disclose a propensity to aggression than the healthy controls drawn from the community: patients with anorexia nervosa scored lower than controls on the physical aggression and on the verbal aggression subscales of the AQ (P < .05). On the other hand, patients with bulimia nervosa scored higher than controls on the anger subscale of the AQ (P < .05) but did not differ from them on the other subscales of the questionnaire.

Conclusions

The results confirm the higher propensity to anger in patients with bulimia nervosa; in patients with anorexia nervosa, difficulties in expressing anger and outward-directed aggressiveness can be a prevailing feature. The younger age of controls and exclusive reliance on self-report measures might have concealed some differences between patients and community subjects.     

Childhood maltreatment is associated with cortical thinning in people with eating disorders

Childhood maltreatment (CM) is a non-specific risk factor for eating disorders (ED) and is associated with a greater severity in their clinical presentation and poorer treatment outcome. These data suggest that maltreated people with ED may be biologically other than clinically different from non-maltreated people. The aim of the present study was to investigate cortical thickness (CT), a possible biomarker of neurodevelopment, in people with ED with or without history of CM and in healthy women. Twenty-four healthy women, 26 with anorexia nervosa and 24 with bulimia nervosa underwent a 3T MRI scan. All participants filled in the childhood trauma questionnaire. All neuroimaging data were processed by FreeSurfer. Twenty-four participants with ED were identified as maltreated and 26 participants with ED as non-maltreated. All healthy women were non-maltreated. Compared to healthy women, maltreated people with ED showed lower CT in the left rostral anterior cingulate gyrus, while compared to people with ED without history of CM showed lower CT values in the left superior frontal and in right caudal middle frontal and superior parietal gyri. No significant differences emerged in CT measures between healthy women and people with ED without history of CM. The present findings show for the first time that in adult people with ED childhood maltreatment is associated with cortical thinning in areas implicated in the modulation of brain processes that are acknowledged to play a role in the psychopathology of ED.

     

Emotional inhibition and personality traits: a comparison of women with anorexia, bulimia, and normal controls.

BACKGROUND: Clinical experience has suggested that women with eating disorders (ED) are prone to displace negative feelings about the self onto the body. This study sought to evaluate these clinical observations by examining emotional inhibition and personality traits in women with ED. METHODS: Female inpatients and intensive outpatients diagnosed with anorexia nervosa (N = 14) or bulimia nervosa (N = 11) were compared to women without an ED (N = 31). RESULTS: The results of the study indicate that participants with ED inhibit their expression of both positive and negative emotions, even after controlling for neuroticism. Women with ED also reported higher levels of hostility and neuroticism. In addition, participants with ED were less aware of their inner thoughts and feelings (private self-consciousness) and had a heightened awareness of the thoughts and expectations of others (public self-consciousness). Finally, women with bulimia nervosa reported higher levels of emotional inhibition, neuroticism, public self-consciousness, and hostility when compared to women with anorexia nervosa. CONCLUSIONS: These data suggest that individuals who are not able to identify, and consequently, express their emotions may learn to handle emotional distress, interpersonal conflicts, and unexpressed hostility by turning their expression and lack of insight inward (viz., feeling "fat").     

Magnetic resonance spectroscopy of the anterior cingulate cortex in eating disorders

The anterior cingulate cortex plays a key role in eating disorders (ED), but it remains an open question whether there are deviations of the neurochemistry of this region in patients with ED. Seventeen adult female patients with ED (10 with bulimia nervosa, 7 with anorexia nervosa) were compared to 14 matched female healthy controls using single voxel magnetic resonance spectroscopy of the anterior cingulate cortex. Group comparisons did not reveal any differences between patients and controls, but a positive correlation between glutamate and myo-inositol signals with “drive for thinness” in patients with bulimia nervosa was found in exploratory correlation analyses.