Set shifting, or cognitive flexibility from one mindset to another, is more difficult for people with eating disorders. This may be due to brain development-related genetic factors, as set shifting requires increased activation in the frontal and parietal regions but decreased activation in the striatal regions. Weak set shifting is an inherited vulnerability to anorexia nervosa that is also demonstrated in first-degree relatives, however it is worsened by starvation. Patients with less set shifting impairment are more likely to recover, and set shifting skills improve following recovery.

Set Shifting in Anorexia Nervosa

Central coherence, or the ability to see the bigger picture, is weakened in eating disorder patients due to an imbalance between global and detail processing. Strong focus on details is an inherited vulnerability to anorexia nervosa that is also demonstrated in first-degree relatives. Impaired set shifting contributes to weakened central coherence by making it difficult to alternate between global and detail processing. Although impaired central coherence is a result of food restriction in anorexia nervosa, it also serves to perpetuate the disorder by impeding environmental adaptation. 

Central Coherence in Anorexia Nervosa

An avoidant social phenotype predicts the onset and prognosis of anorexia nervosa, as difficulty relating to and connecting with others predates onset with anorexic patients having a greater risk of insufficient social networks (no childhood close friends, fewer social activities, less social support). People with certain temperamental characteristics such as shyness, internalizing problems, loneliness, feelings of inferiority, and social anxiety are more likely to develop eating disorders. Anxious avoidant behaviors of emotions, social experiences, and attachments are also associated with increased risk of anorexia nervosa development.  These issues are worsened by starvation with social avoidance becoming a core feature of eating disorder patients as their social network further shrinks upon progression of the illness. As the brain shrinks from food restriction, high-level functions that enable communication are impaired and oxytocin levels are drastically reduced, further damaging social connection. These traits sometimes persist after recovery from anorexia nervosa. For example, oxytocin levels continue to be reduced following recovery, but normal brain activation to emotional faces after full recovery indicates that some neurological issues impairing social processing in acute anorexia nervosa may be reversible.

Social Avoidance in Anorexia Nervosa

Signaling of emotions and intentions is impaired in anorexia nervosa patients. Many patients struggle with alexithymia, or issues identifying, expressing, and describing their own emotions, in addition to having generally impaired perceptions and understandings of themselves. They have been found to display reduced facial emotional expression, attentiveness, and reciprocity relative to self-reported actual intense emotions due to inhibited emotional expression and mirroring. This trait is present in first-degree relatives and may thus be an inherited endophenotype.

Social Signaling in Anorexia Nervosa

Anorexia nervosa patients struggle to interpret the emotions and intentions of others, impairing their communication. They often have difficulty in recognizing and identifying facial emotions, vocal emotions, and body language. Theory of mind, or the ability to understand others' mental processes, and social perception, or the ability to recognize social cues based on others' behavior in social contexts, is also somewhat impaired among patients. This trait is not present in first-degree relatives and improves after recovery, and is thus likely to be a result of starvation rather than an inherited vulnerability.

Interpretation of Social Signals in Anorexia Nervosa 

Individuals with anorexia nervosa tend to pay greater attention to social threats and less attention to social rewards. They often have automatic attentional biases towards negative (critical, domineering, angry) faces and away from positive (compassionate, happy) faces, in addition to generally gazing less at the face and eyes. While these traits are inherited and present in first-degree relatives, they are worsened by starvation in acute anorexia nervosa and persist to a lesser degree following recovery. 

Attentional Biases in Anorexia Nervosa

Anorexia nervosa creates a vicious cycle as many of the traits that contribute to the development and maintenance of the disorder are further worsened by malnutrition and starvation as the illness progresses. The starved brain is less plastic and is thus more resistant to treatment and less responsive to therapy. Furthermore, malnutrition further impairs set shifting, global integration, central coherence, and social cognition and communication. This leads anorexic individuals to become even more isolated and avoidant, and worsens obsessive-compulsive traits that perpetuate dieting behaviors. 

Kalamazoo College

A model explaining the intra- and inter-personal maintenance factors for the continued duration of anorexia nervosa, not bound by Western sociocultural limitations. Intrapersonal factors combine to predispose individuals to anorexia nervosa and contribute to its maintenance, eliciting strong reactions from close others which then create interpersonal factors that further perpetuate the illness:

- Perfectionism/cognitive rigidity
- Experiential avoidance
- Pro-anorectic beliefs
- Expressed emotions

Cognitive-Interpersonal Maintenance Model of Anorexia Nervosa

Treasure, J., & Schmidt, U. (2013). The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders, 1, 1-10. https://doi.org/10.1186/2050-2974-1-13

The Cognitive-Interpersonal Maintenance Model of Anorexia Nervosa Revisited: A Summary of the Evidence for Cognitive, Socio-Emotional and Interpersonal Predisposing and Perpetuating Factors

Perfectionism or cognitive rigidity may serve as both a risk factor and a maintenance factor for anorexia nervosa. This includes obsessive-compulsive traits, all-or-nothing/black-or-white thinking, excessive attention to detail, and fear of making mistakes. In children, these traits lead individuals to be more influenced by societal rules and appearance norms, and thus more likely to develop obsessive-compulsive dieting behaviors once they have begun following a trigger event. Perfectionism and OCPD traits are associated with adverse outcomes for patients. Obsessive-compulsive spectrum disorders are present in 50% of ED patients, while other ED patients often have obsessive-compulsive or anxious traits. Obsessive thoughts and compulsive behaviors are often worsened as a result of starvation, leading to increasingly strict dieting rules.

Perfectionism/Cognitive Rigidity in Anorexia Nervosa

Anorexia nervosa patients are often temperamentally avoidant, displaying a sensitivity to negative stimuli, which 25% of anorexic individuals meeting criteria for avoidant personality disorder, including issues with intimacy, emotional expression, and identity. Intimacy and close relationships are often avoided in anorexia nervosa patients prior to onset of the disorder but avoidance is typically worsened following onset, making avoidant traits both a risk factor and maintenance factor for AN.
Experiential avoidance includes refusal to maintain contact with certain experiences/events and taking of measures to reduce their frequency/form/prerequisites. In anorexia nervosa patients, this may include repressing negative emotions and personal needs to cope with resultant stress. Patients are often shy, have few friends, avoid intimate relationships, and display psychosexual inhibition. They are also more likely to struggle to detect emotional signals from themselves and others, retrieve emotional autobiographical memories, and struggle with defensive emotions such as shame, guilty, and jealousy. Starvation worsens and is used as a mechanism for avoidance of emotions, relationships, etc.. Avoidant traits (low novelty seeking, high interpersonal distrust, anxiety disorders, avoidant-dependent personality disorder, OCPDs) are associated with poor outcomes and are common among anorexia nervosa patients, and thus treatments that focus on emotional processing rather than food and weight alone may show more success. 

Avoidance in Anorexia Nervosa

Pro-anorectic beliefs are perceived positive values of functions of anorexia nervosa or its symptoms. These beliefs often make patients reluctant to seek treatment or contribute to denial of the illness. In the early pre-contemplation stage of the disorder, patients perceive more positives than negatives to anorexia nervosa, but in the later action stage, the opposite is true. Some positives described by patients are that their disorder brings them feelings of safety, allows them to indirectly communicate distress, helps them to stifle negative emotions, and makes them feel special. While reducing pro-anorectic beliefs is associated with good outcomes, there is little data to support the relationship between pro-anorectic beliefs and outcomes, and its role as a maintenance factor is thus unclear.

Pro-Anorectic Beliefs in Anorexia Nervosa

Interpersonal factors like the intense emotional responses of close others may be a causal maintaining factor of anorexia nervosa, especially for patients with high levels of contact with their relatives. Expressed emotions (EE) measure criticism, hostility, and emotional over-involvement toward psychiatric patients from relatives, and high EE predicts relapse across numerous psychiatric illness. In cases of conflict with family members, anorexia nervosa patients may feel empowered by thwarting caregivers' attempts to intervene. This feeling of victory over logic and parental authority may reinforce beliefs and behaviors of anorexia nervosa by creating feelings of self-esteem derived from food restriction. On the other hand, excessive reassurance and support by caregivers may also reinforce the disorder by demonstrating that it elicits sympathy, care, and kindness, and may contribute to resentment toward the patient by other family members. High EE is thus correlated with distress among family members as they are unsure how to help and may have difficulty meeting other responsibilities outside of supporting the patient. For patients, having high EE relatives is associated with poorer outcomes, but these outcomes can be modified with family-based interventions. Some traits associated with anorexia nervosa are inherited, such as obsessive-compulsive traits and social impairment which can lead caregivers and family members to be excessively controlling or withdrawn toward the patient, contributing to inflexibility and miscommunication that can worsen the disorder. Instead, caregivers should focus on educating themselves about the nuances of anorexia nervosa's impacts on social cognition and communication, learning skills to support behavioral changes, and modeling a calm, compassionate, and collaborative environment. 

Expressed Emotions in Anorexia Nervosa

Certain factors predispose individuals to greater risk of anorexia nervosa:

- Negative self-evaluation
- Internalizing strategies
- Reduced social processing skills
- Increased sensitivity to social hierarchy,/negative judgements
- Desire to belong or be accepted based on social norms
- Internalized idealization of thinness

Predisposing Factors to Anorexia Nervosa

Secondary Consequences of Malnutrition in Anorexia Nervosa

Behavioral consequences of severe and enduring anorexia nervosa can further perpetuate the illness by creating additional barriers to recovery:

- Neuroadaptation/habit-forming
- Food aversion

Behavioral Consequences of Severe and Enduring Anorexia Nervosa

Chronic stress is at once a predisposing factor to, a result of, and a perpetuating factor of anorexia nervosa. It can result from genetic susceptibilities, developmental trauma, emotional abuse, or starvation. The chronic stress profile of treatment-resistant depression mimics that of anorexia nervosa, causing hyperactivity of the hypothalamic pituitary adrenal (HPA) axis, immune system activation, microbiome anomalies, reduction of neurogenesis and brain volume, and reduced hippocampal volume, which is also associated with increased cortisol levels, anxiety, and depression. This stress response impairs resilience and may cause reduced mesolimbic dopamine function, anhedonia, and decreased motivation, causing or worsening depression. 50% of anorexia nervosa patients report at least one mood disorder episode in their lifetime, and depression often persists regardless of fluctuations in eating disorder symptomatology. Depression is common about anorexic patients but they often present with fewer somatic symptoms (low energy, reduced neural activation) and more severe cognitive symptoms (negative self-image). Patients with a history of depression prior to onset of anorexia nervosa have been found to have reduced recovery rates, and those struggling with mood comorbidities likewise show worsened long-term outcomes. Anxiety traits, such as obsessive-compulsive personality traits, OCD, and anxiety disorders, are also common in childhood prior to onset of anorexia nervosa. Polygenic risk correlations with anorexia nervosa are strongest with OCD, followed by half-sized correlations with neuroticism, depression, and anxiety. Patients with severe and enduring forms of anorexia nervosa may thus benefit from treatments originally targeted towards treatment-resistant depression and OCD.

Learn Before

Related

Learn After