Adolescent Anorexia Nervosa: Cognitive performance after weight recovery
Introduction
Many studies have found cognitive inefficiencies in patients with Anorexia Nervosa (AN) [1], [2]. Although there is no definitive consensus on the impairment of neuropsychological functions, general studies suggest that patients with AN present alterations in cognitive domains such as visual–spatial abilities [2], [5] and executive functions [6]. Patients with AN show weakness in central coherence, resulting in superior detail processing and a weakness in global integration [7]. Several authors have found difficulties in cognitive flexibility [8], [9], [10] and set-shifting abilities that lead to rigidity [7]. Some studies have compared cognitive performance before and after weight recovery in AN patients. When AN patients achieve weight restoration, improvements in tasks of attention [2], [3] and psychomotor speed [4], [6] tasks have been observed. Nevertheless, almost all follow-up studies have found that alterations persist after refeeding, especially in immediate memory [3], [4], delayed memory [11], motor tasks [3], visual–spatial abilities [2] and executive functions such as cognitive flexibility [12], [13] and problem-solving abilities [6]. These characteristics are also found in some relatives of patients with AN [14], [15]. In the light of these findings, some authors have proposed that impairment in functions such as set-shifting or central coherence may be a stable trait of the illness rather than a state, conforming an endophenotype of the disorder [7], [8], [9], [10], [16].
The majority of these studies have been conducted in adult patients with a long duration of the disorder. Little is known about cognition in adolescent patients, in whom time of evolution of AN and time of starvation are shorter, although some studies in this population have also recorded difficulties in visual–spatial abilities [17], [18], [19]. To our knowledge, few follow-up studies have assessed cognitive performance exclusively in adolescent patients with AN before and after weight restoration. Schmidt et al. [20] evaluated reaction time and concentration in 52 adolescent inpatients with AN, finding improvement in all cognitive measures over the course of inpatient treatment. Grunwald et al. [21] found that the haptic abilities of 10 adolescents with AN improved with refeeding. Pieters et al. [22] compared drawing and copying tasks in 17 patients versus 17 healthy controls, and reported that the AN group had shorter reaction times on tasks after weight restoration. Hatch et al. [23] found that the AN group (n = 37) was significantly faster on attention and executive function tasks, exhibited superior verbal fluency and working memory and a superior ability to inhibit well-learnt responses than controls (n = 45). However, Sarrar et al. [24] found subtle deficits in cognitive flexibility in 30 AN patients compared with 28 control subjects. After weight gain, adolescents with AN improved relative to their baseline values but did not reach control values. Finally, Bühren et al. [25] compared set-shifting abilities in 28 female adolescents with AN before and after weight rehabilitation and 27 healthy controls. They found no set-shifting inefficiencies in adolescent patients with AN and proposed that the shorter duration of illness and the incomplete maturation of the prefrontal cortices compared to adult patients with AN contributed to the explanation of these findings.
Neuropsychological follow-up studies with AN patients have been carried out after weight restoration. Although weight is one indicator of biological recovery from the condition [26], menstrual function may remain abnormal in some weight-recovered patients [27], [28]. Some authors have studied the relation between hormones and cognitive functioning across the female life span, in moments such as pregnancy, post-partum or menopause, and report relationships between estrogens and impairment in some cognitive functions such as verbal memory [29]. To our knowledge, only two studies have studied the relationship between menstrual function and cognitive performance in AN, and their results are conflicting. Chui et al. [30] found that adult subjects with a history of adolescent-onset AN and persistent amenorrhea or irregular menses had lower scores on a variety of domains: verbal ability, thinking ability, cognitive efficiency, working memory, oral language, broad reading, written language and math than participants with regular menses or using oral contraceptives. Also, Bühren et al. [31] found subtle memory impairments in AN adolescents before and after weight recovery and a positive correlation between verbal learning inefficiency and starvation-induced estrogen deficits after weight recovery.
In summary, in comparison with studies with adult AN patients, not all studies with adolescents with AN show impairment in cognitive performance after refeeding. In fact the results are conflicting: while some studies find persistence of cognitive inefficiencies after refeeding [24], the majority show no differences between patients and controls [22], [23], [25]. The main aim of this study is to describe the cognitive performance of adolescents with AN at the moment of diagnosis and after six months of treatment and refeeding. Our second objective is to study the influence of menstruation on the neuropsychological functioning in these patients. We hypothesized that adolescents with AN will show more cognitive impairments similar to those reported in adult patients – visual memory, visual–spatial ability and executive function – while they are underweight than healthy controls. We expected that functions such as velocity would improve after refeeding, but that functions related to visual–spatial abilities would remain below control group levels in the second assessment. We also expected to find subtle cognitive inefficiencies in relation to persistent amenorrhea after six months of treatment.
Section snippets
Participants
Twenty-five patients who met the DSM-IV-TR diagnostic criteria for AN were recruited consecutively at the Department of Child and Adolescent Psychiatry and Psychology at the Hospital Clinic in Barcelona. The patients were adolescents aged between 11 and 18 years. All were in an acute phase of the disorder with a body mass index (BMI) lower than 17.5 kg/m2 in the first assessment. Length of illness ranged between 4 and 20 months (mean = 12.26, SD = 8.1). Patients and their parents were interviewed with
Demographic and clinical characteristics
As shown in Table 1, at baseline assessment there were no significant differences in age or estimated intellectual level between patient and control groups. In the psychopathological questionnaires, the AN group showed higher scores on all scales, with significant differences in depression, state anxiety and eating symptomatology, but in the DSM-IV-TR interview none of the patients fulfilled criteria for diagnoses of depression, anxiety or obsessive disorders.
After six months of treatment, AN
Discussion
The main finding of this study is that cognitive inefficiencies present in adolescents with AN at the time of diagnosis improved significantly after refeeding. Certain functions such as speed of processing visual information, visual memory and organization reached levels similar to those of healthy controls, and the differences recorded in the underweight state disappeared. But not all patients showed the same neuropsychological performance; patients with persistent amenorrhea after six months
Conflict of interest
The authors have no competing interests to report.
Acknowledgments
Supported in part by the Generalitat de Catalunya to the Child Psychiatry and Psychology Group (2009 SGR 1119). I would like to thank all patients and volunteer controls for their participation in this study.
References (59)
- et al.
Neuropsychological assessments before and after treatment in patients with anorexia nervosa and bulimia nervosa
J Psychiatr Res
(1999) - et al.
Cognitive flexibility and Agouti-related protein in adolescent patients with anorexia nervosa
Psychoneuroendocrinology
(2011) - et al.
Schedule for Affective Disorders and Schizophrenia for School-Aged Children—Present and Lifetime Version (K-SADS-PL): initial reliability and validity data
J Am Acad child Adolesc Psychiatry
(1997) - et al.
The cognitive profile of anorexia nervosa: a comparative study including a community-based sample
Compr Psychiatry
(1996) - et al.
A cross-sectional and follow-up voxel-based morphometric MRI study in adolescent anorexia nervosa
J Psychiatr Res
(2009) - et al.
Prefrontal brain metabolites in short-term weight-recovered adolescent anorexia nervosa patients
Prog Neuropsychopharmacol Biol Psychiatry
(2010) - et al.
Reversibility of cerebral ventricular enlargement in anorexia nervosa, demonstrated by quantitative magnetic resonance imaging
J Pediatr
(1996) - et al.
Profile of neurocognitive impairments associated with female in-patients with anorexia nervosa
Psychol Med
(2006) - et al.
Neuropsychological and structural brain changes in anorexia nervosa before and after refeeding
Psychol Med
(1996) - et al.
Neuropsychological study of underweight and “weight-recovered” anorexia nervosa compared with bulimia nervosa and normal controls
Int J Eat Disord
(2007)
Neuropsychological functioning pretreatment and posttreatment in an inpatient eating disorders program
Int J Eat Disord
Neuropsychological impairment in anorexia nervosa: before and after refeeding
J Clin Exp Neuropsychol
Anorexia nervosa in the light of neurocognitive functioning: new theoretical and therapeutic perspectives
Encéphale
Cognitive flexibility in anorexia nervosa and bulimia nervosa
J Int Neuropsychol Soc
Cognitive flexibility and clinical severity in eating disorders
PLoS One
Are the neuropsychological alterations in eating disorders endophenotypes of the disease? Review and state of the art
Rev Neurol
Memory performance in acute and weight-restored anorexia nervosa patients
Psychol Med
An examination of perceptual and cognitive set-shifting task in acute anorexia nervosa and following recovery
J Eat Weight Disord
Poor cognitive flexibility in eating disorders: examining the evidence using the Wisconsin Card Sorting Task
PLoS One
Is impaired set-shifting an endophenotype of anorexia nervosa?
Am J Psychiatry
Set-shifting abilities, central coherence, and handedness in anorexia nervosa patients, their unaffected siblings and healthy controls: exploring putative endophenotypes
World J Biol Psychiatry
Weak central coherence in eating disorders: a step towards looking for an endophenotype of eating disorders
J Clin Exp Neuropsychol
Clinical and biological correlates of adolescent anorexia nervosa with impaired cognitive profile
Eur Child Adolesc Psychiatry
The neuropsychological profile of children, adolescents, and young adults with anorexia nervosa
Arch Clin Neuropsychol
Learning deficits in adolescents with anorexia nervosa
J Nerv Ment Dis
Does cognitive performance of adolescents with anorexia nervosa change with treatment?
Z Kinder Jugendpsychiatr Psychother
Haptic perception in anorexia nervosa before and after weight gain
J Clin Neuropsychol
Fast psychomotor functioning in anorexia nervosa, effect of weight restoration
J Clin Exp Neuropsychol
In first presentation adolescent anorexia nervosa, do cognitive markers of underweight status change with weight gain following a refeeding intervention?
Int J Eat Disord
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