Neuropsychological assessments before and aftertreatment in patients with anorexia nervosa and bulimianervosa

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Abstract

In psychiatric patients the identification of cognitive deficits which predict a poorclinical outcome is important for the development of specific treatment strategies aimed at theamelioration of these impaired cognitive functions to increase the likelihood of full clinicalremission. However, such attempts are absent in bulimia nervosa (BU), are scarce in anorexianervosa (AN) and, furthermore, provide conflicting results. In the present prospective study weinvestigated the neuropsychological demands in 12 patients with AN and in 14 patients with BUbefore, during, and after a treatment period. At the initial testing session, both patients samplesshowed similar and impaired performance levels on tasks measuring attentional demands andproblem solving abilities, while their mnemonic functions were preserved. At the final testingsession, which took place 7 months thereafter, the impaired cognitive functions had improved to asimilar degree in the AN and the BU subgroups. However, although the eating disordersymptomatology had ameliorated in parallel, no direct associations could be established with theinitial neuropsychological demands and their rectification, respectively. On an individual level, 11patients initially showed obvious cognitive deficits. However, the clinical characteristics of thissubgroup differed not from that found in the 15 {good performers|. These findings indicate thatthe cognitive functions in the acute AN and BU are similarly impaired, but also ameliorate in asimilar manner with clinical remission. Because no associations were obvious between cognitiveand clinical rectifications, significant contributions of mediating factors (e.g., changes in metabolicbrain turnover and in steroid hormones) are suggested. ©1999 Elsevier Science Ltd. All rightsreserved.

Introduction

There is growing evidence that patients with a given psychiatric disorder in parallel withspecific cognitive impairments are more likely to have an unfavorable outcome than patients with asimilar disorder but who perform well on neuropsychological tasks (see: Keefe, 1995). Theidentification of such cognitive deficits predictive for a poor clinical prognosis would allow thedevelopment of additional and specific treatment strategies to increase the likelihood of a favorableoutcome. Furthermore, if the patients cognitive performance are assessed before and after thetreatment period, a significant contribution toward unraveling the unclear interdependencies amongcognitive impairments, primary psychopathology and secondary psychopathology could then beexpected.

In eating disorder patients, this topic was addressed in two investigations using across-sectional design. In the first study (Strupp et al., 1986), which focused mainly oneffortful vs automatic information processing, no differences were obvious between acuteunderweight and weight-recovered anorexic patients. Pendleton-Jones et al., 1991found apoorer performance on tasks corresponding to attentional focussing, verbal memory and visuo-spatialreasoning in their underweight anorexics compared to weight-restored anorexics; however, thesedifferences were subtle and nonsignificant.

Prospective studies reported on more or less mildly impaired skills, such as short-term verbaland visual memory, visuospatial construction/problem solving and reaction time, in acute underweightanorexics; after weight recovery, these cognitive deficits had improved in most (Hamsher et al., 1981; Kohlmeyer et al., 1983; Small et al., 1983; Szmukler et al., 1992)but not all studies (Green et al., 1996; Kingston et al., 1996). In three of these studies,the authors attempted to identify predictors for the clinical outcome (e.g., degree of weight-gain,stability of recovered body weight: Hamsher et al., 1981; Small et al., 1983; Szmukleret al., 1986). However, the results reported are conflicting. Hamsher et al., 1981found theiranorexic patients who showed impaired performance on two or more neuropsychological tasks to bemore likely to exhibit an unfavorable outcome (weight loss) after one year of follow-up than patientswith very mild or no cognitive deficits. Small et al., 1983reported the performance in the digitspan task, which measures immediate (working) memory capacity, to be a powerful predictor ofweight gain in their anorexic patients. In contrast, Szmukler et al., 1992failed to identify anyvaluable predictors, although they had applied a broad range of neuropsychological tasks.

To our knowledge, there has been no investigation published in which a comparableprospective design was applied to patients with bulimia nervosa. Cross-sectional studies, however,provide fairly good evidence that the cognitive performance in bulimic patients is similarly impairedas in underweight anorexic patients (e.g. Laessle et al., 1989; Pendleton-Jones et al., 1991; Cooper and Fairburn, 1992; Perpina et al., 1993).

The purpose of the present prospective study was twofold. First, we monitoredneuropsychological task performance in 12 anorexic as well as in 14 bulimic patients before, duringand after treatment with the initial testing session taking place four weeks before treatment onset. Ourhypothesis was that anorexics and bulimics would show similar cognitive deficits before clinicaladmission and that these deficits would be improved similarly in both disorders at post-treatment. Inaddition, we attempted to identify neuropsychological predictors for the clinical outcome (anorexicpatients: degree of weight gain; bulimic patients: decrease in binges per week). Because the literatureon this issue provides conflicting findings in anorexics and is lacking in bulimics, no specifichypothesis was formulated.

Section snippets

Subjects

A total of 63 female patients were recruited from the Therapy Center for Eating Disorders(TCE) at the Max Planck Institute of Psychiatry. According to the diagnostic criteria of theDSM-III-R (APA, 1987) 18 patients presented with anorexia nervosa (AN), 33 patients withbulimia nervosa (BU), 8 patients with both anorexia and bulimia nervosa, and 4 patients with eatingdisorders not otherwise specified (NOS). During the 7-month study period, 30 patients dropped out(6 patients with AN, 19 patients

Group comparisons at t1 (n = 51)

In order to evaluate group differences between larger subsamples of anorexic and bulimicpatients (n = 18 and n = 33, respectively) and between patients who completed the studyprotocol (n = 26) and those who dropped out (n = 25), a two-factor MANOVAwas performed with the diagnosis (AN, BU) and completers/drop-outs as the two factors. Regardingthe factor diagnosis, a significant main group effect was observed (λ = 0.09, P < 0.001). Subsequent univariate F tests performed within the MANOVA

Discussion

The major finding of the present prospective study was that patients with anorexia nervosa(AN) and bulimia nervosa (BU) did not differ on their neuropsychological task profile assessed fourweeks before the onset of a specific therapeutic program. While the mnemonic capacities were wellpreserved, these patients showed mild to moderate deficits particularly on those tasks coveringattentional demands and problem solving abilities. After seven months (at t4), thespeed of cognitive information

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