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.

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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 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. 

Secondary Consequences of Malnutrition in 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

The onset on anorexia nervosa is thought to be the result of a combination of predisposing factors and a triggering event or events that predate onset. Triggers often include teasing, bullying, or criticism, especially pertaining to food, weight, or body shape.

Triggers for Anorexia Nervosa

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. 

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