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Cognitive flexibility in anorexia nervosa and bulimia nervosa

Published online by Cambridge University Press:  01 July 2004

Division of Psychological Medicine, Eating Disorders Research Unit, Institute of Psychiatry, King's College, De Crespigny Park, London, UK
Division of Psychological Medicine, Eating Disorders Research Unit, Institute of Psychiatry, King's College, De Crespigny Park, London, UK
Department of Psychology, Institute of Psychiatry, London, UK
Department of Biostatistics and Computing, Institute of Psychiatry, King's College, De Crespigny Park, London, UK
Division of Psychological Medicine and Social, Genetic and Developmental Psychiatry Research Centre, Institute of Psychiatry, King's College, De Crespigny Park, London, UK
Division of Psychological Medicine, Eating Disorders Research Unit, Institute of Psychiatry, King's College, De Crespigny Park, London, UK
Division of Psychological Medicine, Eating Disorders Research Unit, Institute of Psychiatry, King's College, De Crespigny Park, London, UK


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. (JINS, 2004, 10, 513–520.)

Research Article
2004 The International Neuropsychological Society

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American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Austin, M.P., Mitchell, P., & Goodwin, G.M. (2001). Cognitive deficits in depression: Possible implications for functional neuropathology. British Journal of Psychiatry, 178, 200206.CrossRefGoogle Scholar
Bastiani, A.M., Rao, R., Weltzin, T., & Kaye, W.H. (1995). Perfectionism in anorexia nervosa. International Journal of Eating Disorders, 17, 147152.3.0.CO;2-X>CrossRefGoogle Scholar
Brecelj-Anderluh, M., Tchanturia, K., Rabe-Hesketh, S., & Treasure, J. (2003). Childhood obsessive-compulsive personality traits in adult women with eating disorders: Defining a broader eating disorder phenotype. American Journal of Psychiatry, 160, 242247.CrossRefGoogle Scholar
Braun, M.J. & Chouinard, M.J. (1992). Is anorexia nervosa a neuropsychological disease. Neuropsychology Review, 3, 171212.CrossRefGoogle Scholar
Bulik, C.M., Tozzi, F., Anderson, C., Mazzeo, S.E., Aggen, S., & Sullivan, P.F. (2003). The relation between eating disorders and components of perfectionism. American Journal of Psychiatry, 160, 366368.CrossRefGoogle Scholar
Burgess, P.W. & Shallice, T. (1997). The Hayling and Brixton Tests. Bury St. Edmonds, UK: Thames Valley Test Company Ltd.
Cassidy, E., Allsopp, M., & Williams, T. (1999). Obsessive Compulsive symptoms at initial presentation of adolescent eating disorders. European Child and Adolescent Psychiatry, 8, 193199.CrossRefGoogle Scholar
Connan, F., Campbell, I.C., Katzman, M., Lightman, S.L., & Treasure, J. (2003). A neurodevelopmental model for anorexia nervosa. Physiology and Behaviour, 79, 1324.CrossRefGoogle Scholar
Cnattingius, S., Hultman, C.M., Dahl, M., & Sparen, P. (1999). Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls. Archives of General Psychiatry, 56, 634638.CrossRefGoogle Scholar
Cooper, M.J. & Fairburn, C.G. (1992). Selective processing of eating, weight and shape related words in patients with eating disorders and dieters. British Journal of Clinical Psychology, 31, 363365.CrossRefGoogle Scholar
Eliava, N. (1964). A problem of set in cognitive psychology. Tbilisi, Georgia: Academic Press.
Fassino, S., Piero, A., Daga, G.A., Leombruni, P., Mortara, P., & Rovera, G.G. (2002). Attentional biases and frontal functioning in anorexia nervosa. International Journal of Eating Disorders, 31, 274283.CrossRefGoogle Scholar
Fontenelle, L., Marques, C., Engelhardt, E., & Versiani, M. (2001). Impaired set-shifting ability and therapeutic response in obsessive-compulsive disorder. Journal of Neuropsychiatry and Clinical Neuroscience, 13, 508510.CrossRefGoogle Scholar
Gillberg, C., Gillberg, C., Rastam, M., & Johansson, M. (1996). The cognitive profile of anorexia nervosa: A comparative study including a community based sample. Comprehensive Psychiatry, 37, 2330.CrossRefGoogle Scholar
Gillberg, C., Rastam, M., & Gillberg, I.C. (1994). Anorexia nervosa: Physical health and neurodevelopment at 16 and 21 years. Developmental Medicine and Child Neurology, 36, 567575.Google Scholar
Green, M.W., Elliman, N.A., Wakeling, A., & Rogers, P.J. (1996). Cognitive functioning, weight change and therapy in anorexia nervosa. Journal of Psychiatric Research, 30, 401410.CrossRefGoogle Scholar
Grunwald, M., Ettrich, C., Busse, F., Assmann, B., Dahne, A., & Gertz, H. (2002). Angle paradigm: A new method to measure right parietal dysfunction in anorexia nervosa. Archives of Clinical Psychology, 17, 485496.Google Scholar
Halmi, K.A., Casper, R.C., Eckert, E.D., Goldberg, S.C., & Davis, J.M. (1979). Unique features associated with age of onset of anorexia nervosa. Psychiatry Research, 1, 209215.CrossRefGoogle Scholar
Hamsher, K., Halmi, K.A., & Benton, A.L. (1981). Prediction of outcome in anorexia nervosa from neuropsychological status. Psychiatry Research, 4, 7988.CrossRefGoogle Scholar
Hodgson, R.J. & Rachman, S. (1977). Obsessional-compulsive complaints. Behaviour Research and Therapy, 15, 389395.CrossRefGoogle Scholar
Katzman, D.K., Christensen, B., Young, A.R., & Zipursky, R.B. (2001). Starving the brain: Structural abnormalities and cognitive impairment in adolescents with anorexia nervosa. Seminars in Clinical Neuropsychiatry, 6, 146152.CrossRefGoogle Scholar
Katzman, D.K., Lambe, E.K., Mikulis, D.J., Ridgley, J.N., Goldbloom, D.S., & Zipursky, R.B. (1996). Cerebral gray matter and white matter volume deficits in adolescent girls with anorexia nervosa. Journal of Pediatrics, 129, 794803.CrossRefGoogle Scholar
Katzman, D.K., Zipursky, R.B., Lambe, E.K., & Mikulis, D.J. (1997). A longitudinal magnetic resonance imaging study of brain changes in adolescents with anorexia nervosa. Archives of Pediatics and Adolescent Medicine, 151, 793797.CrossRefGoogle Scholar
Kaye, W.H., Bastiani, M.A., & Moss, H. (1995). Cognitive style of patients with anorexia nervosa and bulimia nervosa. International Journal of Eating Disorders, 18, 287290.3.0.CO;2-Y>CrossRefGoogle Scholar
Kingston, K., Szmukler, G., Andrewers, B., Tress, B., & Desmond, P. (1996). Neuropsychological and structural brain changes in anorexia nervosa before and after refeeding. Psychological Medicine, 26, 1528.CrossRefGoogle Scholar
Kravariti, E. (2001). A neuropsychological investigation of adolescent onset schizophrenia. Unpublished Ph.D. thesis, Institute of Psychiatry, King's College, University of London.
Kravariti, E., Morris, R.G., Rabe-Hesketh, S., Murray, R.M., & Frangou, S. (2003). The Maudsley early onset schizophrenia study: Cognitive function in adolescents with recent onset schizophrenia. Schizophrenia Research, 61, 137148.CrossRefGoogle Scholar
Laessle, R.G., Bossert, S., Hank, G., Hahlweg, K., & Pirke, K.M. (1990). Cognitive performance in patients with bulimia nervosa: Relationship to intermittent starvation. Biological Psychiatry, 27, 549551.CrossRefGoogle Scholar
Lauer, C.J. (2002). Neuropsychological findings in eating disorders. In H. D'haenen, J.A. den Boer, H. Westenberg, & P. Willner (Eds.), Biological psychiatry (pp. 11671172). Swansey, UK: John Wiley & Sons.
Lauer, C.J., Gorzewski, B., Gerlinghoff, M., Backmund, H., & Zihl, J. (1999). Neuropsychological assessments before and after treatment in patients with anorexia nervosa and bulimia nervosa. Journal of Psychiatric Research, 33, 129138.CrossRefGoogle Scholar
Levine, B., Robertson, I.H., Clare, L., Carter, G., Hong, J., Wilson, B.A., Duncan, J., & Stuss, D.T. (2000). Rehabilitation of executive functioning: An experimental-clinical validation of goal management training. Journal of the International Neuropsychological Society, 6, 299312.CrossRefGoogle Scholar
Lezak, M.D. (1983). Neuropsychological assessment. Oxford, UK: Oxford University Press.
Miyake, A., Friedman, N., Emerson, A.H., Witzki, A.H., Howertrt, A., & Wager, T.D. (2000). The unity and diversity of executive functions and their contributions to complex “Frontal Lobe” tasks: A latent variable analysis. Cognitive Psychology, 41, 49100.CrossRefGoogle Scholar
Naruo, T. (2002). Brain imaging. In H. D'haenen, J.A. den Boer, & P. Willner (Eds.), Biological psychiatry (pp. 11811189). Chichester, UK: John Wiley & Sons.
Nelson, H.E. & Willison, J.W. (1991). The National Adult Reading Test (2nd ed.). Windsor, UK: NFER Nelson.
Pendleton Jones, B., Duncan, C., Brouwers, P., & Mirsky, A. (1991). Cognition in eating disorders. Journal of Clinical and Experimental Neuropsychology, 13, 711728.CrossRefGoogle Scholar
Rastam, M. (1992). Anorexia nervosa in 51 Swedish adolescents: Premorbid problems and comorbidity. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 819829.CrossRefGoogle Scholar
Reitan, R.M. (1958). Validity of the Trail Making Test as indicator of organic brain damage. Perceptual and Motor Skills, 8, 271276.CrossRefGoogle Scholar
Surguladze, S. (1995). Insight and characteristics of fixed set in patients with schizophrenia. Journal of Georgian Medicine, 2, 5860.Google Scholar
Szmukler, G.I., Andrewes, D., Kingston, K., Chen, L., Stargatt, R., & Stanley, R. (1992). Neuropsychological impairment in anorexia nervosa: Before and after refeeding. Journal of Clinical and Experimental Neuropsychology, 14, 347352.CrossRefGoogle Scholar
Tchanturia, K., Serpell, L., Troop, N., & Treasure, J. (2001). Perceptual illusions in eating disorders: Rigid and fluctuating styles. Journal of Behavior Therapy and Experimental Psychiatry, 32, 107115.CrossRefGoogle Scholar
Tchanturia, K., Morris, R., Surguladze, S., & Treasure, J. (2002). An examination of perceptual and cognitive set shifting tasks in acute anorexia nervosa and following recovery. Eating and Weight Disorders, 7, 312316.CrossRefGoogle Scholar
Toner, B., Garfinkel, P., & Garner, D. (1987). Cognitive style of patients with bulimic and diet-restricting anorexia nervosa. American Journal of Psychiatry, 144, 510512.Google Scholar
Toulopoulou, T., Morris, R.G., Rabe-Hesketh, S., & Murrey, R.M. (2003). Selectivity of verbal memory deficit in schizophrenic patients and their relatives. American Journal of Medical Genetics, 116, 17.Google Scholar
Touyz, S. & Beumont, P.J.V. (1994). Neuropsychological assessment of patients with anorexia and bulimia nervosa. In S. Touyz, D. Byrne, & A. Gilandas (Eds.), Neuropsychology in clinical practice (pp. 305329). Sydney, Australia: Academic Press.
Treasure, J. & Collier, D. (2001). The spectrum of eating disorders in humans. In J. Owen, J. Treasure, & D. Collier (Eds.), Animal models—Disorders of eating behaviour and body composition (pp. 1951). London: Kluwer Academic Publishers.
Uher, R., Treasure, J., & Campbell, I.C. (2002). Neuroanatomical bases of eating disorders. In H. D'haenen, J.A. den Boer, & P. Willner (Eds.), Biological psychiatry (pp. 11731179). Swansea, UK: John Wiley & Sons.
Uznadze, D.N. (1966). The psychology of set. New York: Consultants' Bureau.
Von Cramon, D.Y., Matthes von Cramon, G., & Mai, N. (1991). Problem solving deficits in brain-injured patients: A therapeutic approach. Neuropsychological Rehabilitation, 1, 4564.CrossRefGoogle Scholar
Wentz, E., Gillberg, I.C., Gillberg, C., & Rastam, M. (2000). Ten-year follow-up of adolescent-onset anorexia nervosa: Physical health and neurodevelopment. Developmental Medicine and Child Neurology, 42, 328333.CrossRefGoogle Scholar
Zigmond, A.S. & Snaith, R.P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361370.CrossRefGoogle Scholar