Cognitive and Experienced Flexibility in Patients With Anorexia Nervosa and Obsessive Compulsive Disorder

Objective: Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) share a neuropsychological profile characterized by cognitive inflexibility as evident in set-shifting problems, and by strong detail focus. Clinically, both patient groups display a strong rigidity which may be explained by these neurocognitive difficulties. Cognitive inflexibility may hinder treatment uptake and help explain suboptimal treatment outcomes in both AN and OCD. This is the first study to compare clinical AN and OCD groups and to examine similarities and differences in cognitive flexibility. Specifically, this study aims to investigate neuropsychological outcomes and self-reported difficulties in both clinical groups and a control group, and explore associations between the different flexibility outcomes and illness. Method: Two hundred participants (61 AN, 72 OCD and 67 HC) performed neuropsychological tasks on set-shifting abilities (Trail Making Task, Stroop color-word interference, Intradimensional-Extradimensional shift task), detail focus (Group Embedded Figures Test) and self-reported set-shifting abilities and attention to detail (DFlex). Results: Similarities between patient groups were found in terms of reduced set-shifting ability on the Trail Making Task and detail focus. Moreover, both patient groups self-reported more set-shifting problems but a less strong detail focus than HC, which in turn were not related to neuropsychological task outcomes in either of the groups. In both patient groups longer illness duration was associated to longer reaction times in the switching tasks and for both groups symptom severity was associated to higher experienced inflexibility and attention to detail. Conclusion: Cognitive inflexibility processes are largely similar in patients with AN and OCD. Both patient groups report inflexibility, yet this is unrelated to neuropsychological outcomes. Illness duration seems to contribute to poorer set-shifting and higher illness severity is linked to more experienced inflexibility. Findings highlight the need for entangling different domains of cognitive flexibility and detail focus and examining self-report measures for a cohesive understanding of clinically relevant flexibility weaknesses in AN and OCD

Understanding relations between intolerance of uncertainty and body checking and body avoiding in anorexia nervosa

Background: A key feature of anorexia nervosa is body image disturbances and is often expressed by dysfunctional body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of AN, yet empirical evidence is scarce. One variable that may contribute to the need for engaging in these behaviours is intolerance of uncertainty. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127). Methods: Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. One-way ANOVAS were used to test group differences. Moderation analyses were used to investigate associations between variables. Results: Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill followed by AN-rec and, lastly, the control group, confirming group differences. Intolerance of uncertainty was associated with body checking in the AN-rec group and the control group but not in the AN-ill group. The association between intolerance of uncertainty and body avoiding was reported in the AN-rec group and only marginally in the control group. Conclusion: Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill, however still elevated in AN-rec, confirming the presence of body image disturbances, even after recovery. The unique associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may eventually have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty. Plain English summary: Women with anorexia nervosa often experience disturbances in their body image and are expressed in body-related behaviours such as body checking and body avoiding. These behaviours are thought to contribute to both the maintenance and relapse of anorexia nervosa. Intolerance of uncertainty is defined as the incapacity to tolerate uncertainty and may contribute to the need for engaging in these behaviours. This study aims to investigate body checking and body avoiding and its relations with intolerance of uncertainty in women with anorexia nervosa (AN-ill; 70), women recovered from AN (AN-rec; 85) and control group (127). Three questionnaires were completed, measuring eating pathology, intolerance of uncertainty and body checking and body avoiding. Levels of intolerance of uncertainty, body checking and body avoiding were highest in AN-ill and still elevated in AN-rec, even after recovery. The associations between intolerance of uncertainty and body checking and body avoiding within the studied groups may represent different stages of the illness. In the AN-rec group, the relation between intolerance of uncertainty, body checking and body avoiding may be driven by trait anxiety. For AN-ill group, body checking and body avoiding may have grown into habitual patterns, rather than a strategy to ameliorate anxiety and uncertainty

The acceptability, feasibility and possible benefits of a group-based intervention targeting intolerance of uncertainty in adolescent inpatients with anorexia nervosa

Despite the effectiveness of family-based interventions for adolescents with anorexia nervosa (AN), up to 30% of patients may not fully benefit. Comorbidity such as depression and anxiety, of which Intolerance of Uncertainty (IU) is established as a key predictor, may account for this reduced treatment response. This pilot study evaluates the acceptability, feasibility and possible benefits of a group-based intervention targeting IU in adolescent inpatients with AN. Ten female patients received a 12-session open-group intervention adapted from a previously developed intervention for adults which took a cognitive behavioural stance and included sessions on psychoeducation and raising awareness around IU, problem-solving in the context of uncertainty, beliefs about worry, behavioural experiments and relapse prevention. Fifty-five staff hours were required to run the group and resources were suitably adapted from adult materials. Patients rated the intervention as acceptable and there were no dropouts. Qualitative outcomes highlighted patients benefited from the group and there was a trend towards IU reducing after the intervention and at 3-month follow-up, although the improvements fell short of a meaningful change in therapy cut-off. Results suggest the group was feasible to run and acceptable to patients and warrants further investigation to optimise possible clinical benefits

The link between anxiety and assessment of body attitudes and body size estimation in anorexia nervosa

Although body size estimation (BSE) tasks are frequently used to investigate distorted body representation in anorexia nervosa (AN), the link between anxiety and task performance has been overlooked. To investigate this, 30 female healthy controls (HCs) and 29 female AN patients completed two body attitude questionnaires and three BSE tasks (the Visual Estimation Task, the Tactile Estimation Task and the Hoop Task). Participants completed two body attitude questionnaires and three BSE tasks; the Visual Estimation Task, the Tactile Estimation Task, and the Hoop Task. The STAI-6 was administered before and after each body-related task to assess state anxiety. Results showed that state anxiety levels increased significantly more in AN patients than in HC after completing each task. Thus, performance of AN patients on BSE and other body-related tasks might not just indicate the (mis)perception of their body but also co-occur with increased state anxiety. This has implications for the interpretation of these tasks and for furthering our understanding of the mechanisms that underlie distorted body image in AN

Do anxiety, depression, and intolerance of uncertainty contribute to social problem solving in adult women with anorexia nervosa?

INTRODUCTION: Inefficient problem solving in the social domain may be one of the difficulties underlying the interpersonal challenges thought to maintain anorexia nervosa (AN). However, past studies have neglected to control for depression, anxiety, and intolerance of uncertainty (IU), which are known to contribute to social problem solving. METHODS: This study aimed to investigate whether adults with AN would show differences in social problem solving on an experimental task (Means-End Problem Solving; MEPS) and report differences in their attitudes (positive, negative) toward social problem solving and their use of social problem-solving styles (rational, impulsive-careless, avoidant) on the Social Problem-Solving Inventory Revised (SPSRI) compared to a non-AN control group. RESULTS: Seventy-four adult women took part (30 with AN and 44 non-AN controls), and data show that those with AN generated significantly less effective solutions on the MEPS (d = 1.96) reported overall poorer social problem solving on the SPSRI (d = 0.58), reporting more negative and less positive attitudes toward social problem solving, and less impulsive and more avoidant social problem-solving styles. However, those with AN did not differ from controls in being able to rationalize social problems. Once depression (Beck Depression Inventory: BDI), state anxiety (State-Trait Anxiety Inventory: STAI), and IU (Intolerance of Uncertainty Scale-12; IUS-12) were included as covariates, these differences were no longer significant, suggesting that comorbid depression, anxiety, and IU symptoms may contribute to social problem solving in AN. CONCLUSIONS: There was no specific effect of depression. Treating anxiety and IU might help to improve social problem solving and enable people with AN to be able to better access social support to aid their recovery

The experience of intolerance of uncertainty for young people with a restrictive eating disorder : a pilot study

Purpose: Research is consistently reporting elevated levels of intolerance of uncertainty (IU) in individuals with an eating disorder (ED). Less is known about the phenomenology of uncertainty for this clinical group. The present study aims to advance our understanding of the relationship between IU and restrictive EDs by providing insight into young people’s subjective experiences of uncertainty. Methods: Thirteen young people with a restrictive ED were recruited from multi-family therapy groups run within the Maudsley Centre for Child and Adolescent Eating Disorders at the South London and Maudsley NHS Foundation Trust. Three focus groups were conducted asking young people to discuss their views, experiences and coping strategies when faced with uncertainty. Results: Data were analysed using interpretative phenomenological analysis which yielded five superordinate themes: (1) young people perceived uncertainty as something negative; (2) high levels of anxiety and stress were identified as primary responses to uncertainty; (3) ED behaviours were given a functional role in reducing uncertainty; (4) need to control various aspects of young peoples’ lives was of high importance; (5) young people discussed how they struggled to find ways to cope with uncertainty and often used behaviours associated with the eating disorder psychopathology as coping strategies. Conclusion: Young people’s experiences of what uncertainty is like for them revealed a dynamic interplay between ED symptoms and fear of uncertainty. Findings support IU as a relevant concept for young people suffering from a restrictive ED and indicate that further exploration of IU from both theoretical and clinical perspectives could be fruitful. Level of evidence: V

Persistence, Reward Dependence, and Sensitivity to Reward Are Associated With Unexpected Salience Response in Girls but Not in Adult Women: Implications for Psychiatric Vulnerabilities

Background: Adolescence is a critical period for the development of not only personality but also psychopathology. These processes may be specific to sex, and brain reward circuits may have a role. Here, we studied how reward processing and temperament associations differ across adolescent and adult females. Methods: A total of 29 adolescent girls and 41 adult women completed temperament assessments and performed a classical taste conditioning paradigm during brain imaging. Data were analyzed for the dopamine-related prediction error response. In addition, unexpected stimulus receipt or omission and expected receipt response were also analyzed. Heat maps identified cortical-subcortical brain response associations. Results: Adolescents showed stronger prediction error and unexpected receipt and omission responses (partial η2 = 0.063 to 0.166; p = .001 to .043) in insula, orbitofrontal cortex (OFC), and striatum than adults. Expected stimulus receipt response was similar between groups. In adolescents versus adults, persistence was more strongly positively related to prediction error (OFC, insula, striatum; Fisher's z = 1.704 to 3.008; p = .001 to .044) and unexpected stimulus receipt (OFC, insula; Fisher's z = 1.843 to 2.051; p = .014 to .033) and negatively with omission (OFC, insula, striatum; Fisher's z = −1.905 to −3.069; p = .001 to .028). Reward sensitivity and reward dependence correlated more positively with unexpected stimulus receipt and more negatively with stimulus omission response in adolescents. Adolescents showed significant correlations between the striatum and FC for unexpected stimulus receipt and omission that correlated with persistence but were absent in adults. Conclusions: Associations between temperamental traits and brain reward response may provide neurotypical markers that contribute to developing adaptive or maladaptive behavior patterns when transitioning from adolescence to adulthood

Mental capacity, decision-making and emotion dysregulation in severe enduring anorexia nervosa

Severe and Enduring Anorexia Nervosa (SE-AN) is a chronic eating disorder characterized by long-term starvation and its physical and psychological sequelae, and severe loss of quality of life. Interactions between neurobiological changes caused by starvation, vulnerability (personality) traits, and eating behaviors play a role. Several other factors, such as increased fear and decreased social cognition, have also been found in relation to SE-AN. With this in mind, we aim to add to the understanding of SE-AN by introducing the concept of mental capacity (MC), which refers to the ability to understand and process information—both on a cognitive and an emotional level—and then make a well-informed choice. MC may be an important construct within the context of SE-AN. Furthermore, we will argue how impaired decision-making processes may underlie, fuel, or contribute to limited MC in SE-AN. We will speculate on the importance of dysfunctional emotion processing and anxiety-related processes (e.g., a high intolerance of uncertainty) and their potential interaction with decision-making. Lastly, we will propose how these aspects, which to our knowledge have previously received little attention, may advise research and treatment or help in dealing with the “want but cannot” situation of life-threatening AN

Negative body attitudes and sexual dissatisfaction in men : The mediating role of body self-consciousness during physical intimacy

Previous research indicated that negative attitudes about the body and appearance are common among men and demonstrated that negative body attitudes are associated with negative sexual experiences. The present study investigated the association between body attitudes and sexual dissatisfaction and themediating role of body self-consciousness during physical intimacy. In a cross-sectional design, 201 Dutch men completedanonline surveyregardingbodyattitudestowardmuscularity, body fat, height, and genitals, body self-consciousness during physical intimacy, and sexual dissatisfaction. Hypotheses were tested using correlation analyses and a mediation analysis withbodyattitudesaspredictors,bodyself-consciousnessasmediator, and sexual dissatisfaction as outcome. Correlation analyses showed that negative body attitudes and body self-consciousness during physical intimacy were significantly related to sexual dissatisfaction. The mediation analysis revealed that negative attitudestowardmuscularity, bodyfat,andgenitalshadindirecteffects on sexual dissatisfaction through body self-consciousness during physical intimacy. Negative attitudes toward genitals additionally hadadirecteffectonsexual dissatisfaction.Thesefindings indicate that body image interventions focused onmale body attitudesmay bebeneficial inimprovingmen’sbodyimage,whichmayultimately increase sexual satisfaction

Negative body attitudes and sexual dissatisfaction in men : The mediating role of body self-consciousness during physical intimacy

Previous research indicated that negative attitudes about the body and appearance are common among men and demonstrated that negative body attitudes are associated with negative sexual experiences. The present study investigated the association between body attitudes and sexual dissatisfaction and themediating role of body self-consciousness during physical intimacy. In a cross-sectional design, 201 Dutch men completedanonline surveyregardingbodyattitudestowardmuscularity, body fat, height, and genitals, body self-consciousness during physical intimacy, and sexual dissatisfaction. Hypotheses were tested using correlation analyses and a mediation analysis withbodyattitudesaspredictors,bodyself-consciousnessasmediator, and sexual dissatisfaction as outcome. Correlation analyses showed that negative body attitudes and body self-consciousness during physical intimacy were significantly related to sexual dissatisfaction. The mediation analysis revealed that negative attitudestowardmuscularity, bodyfat,andgenitalshadindirecteffects on sexual dissatisfaction through body self-consciousness during physical intimacy. Negative attitudes toward genitals additionally hadadirecteffectonsexual dissatisfaction.Thesefindings indicate that body image interventions focused onmale body attitudesmay bebeneficial inimprovingmen’sbodyimage,whichmayultimately increase sexual satisfaction