Skip to main content Accessibility help

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. (JINS, 2004, 10, 513–520.)

Corresponding author
Reprint requests to: Kate Tchanturia, P059 Eating Disorders Research Unit, Institute of Psychiatry, King's College, University of London, De Crespigny Park, London, SE5 8AF, UK. E-mail:
Hide All


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.
Bastiani, A.M., Rao, R., Weltzin, T., & Kaye, W.H. (1995). Perfectionism in anorexia nervosa. International Journal of Eating Disorders, 17, 147152.
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.
Braun, M.J. & Chouinard, M.J. (1992). Is anorexia nervosa a neuropsychological disease. Neuropsychology Review, 3, 171212.
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.
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.
Connan, F., Campbell, I.C., Katzman, M., Lightman, S.L., & Treasure, J. (2003). A neurodevelopmental model for anorexia nervosa. Physiology and Behaviour, 79, 1324.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Hamsher, K., Halmi, K.A., & Benton, A.L. (1981). Prediction of outcome in anorexia nervosa from neuropsychological status. Psychiatry Research, 4, 7988.
Hodgson, R.J. & Rachman, S. (1977). Obsessional-compulsive complaints. Behaviour Research and Therapy, 15, 389395.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Reitan, R.M. (1958). Validity of the Trail Making Test as indicator of organic brain damage. Perceptual and Motor Skills, 8, 271276.
Surguladze, S. (1995). Insight and characteristics of fixed set in patients with schizophrenia. Journal of Georgian Medicine, 2, 5860.
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.
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.
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.
Toner, B., Garfinkel, P., & Garner, D. (1987). Cognitive style of patients with bulimic and diet-restricting anorexia nervosa. American Journal of Psychiatry, 144, 510512.
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.
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.
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.
Zigmond, A.S. & Snaith, R.P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361370.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Journal of the International Neuropsychological Society
  • ISSN: 1355-6177
  • EISSN: 1469-7661
  • URL: /core/journals/journal-of-the-international-neuropsychological-society
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed