EMPIRICAL ARTICLE

Neuropsychological Function in Patients with Anorexia

Nervosa or Bulimia Nervosa

Siri Weider, Cand. Psychol1,2* ABSTRACT

Objective: This study explored the neu-
Marit Sæbï Indredavik, MD, ropsychological performance of patients
PhD3,4 diagnosed with anorexia nervosa (AN) or
Stian Lydersen, PhD3 bulimia nervosa (BN) compared with
healthy controls (HCs). An additional aim
Knut Hestad, PhD1,5 was to investigate the effect of several
possible mediators on the association
between eating disorders (EDs) and cogni-
tive function.
Method: Forty patients with AN, 39
patients with BN, and 40 HCs who were
comparable in age and education were
consecutively recruited to complete a
standardized neuropsychological test bat-
tery covering the following cognitive
domains: verbal learning and memory,
visual learning and memory, speed of
information processing, visuospatial abil-
ity, working memory, executive function,
verbal fluency, attention/vigilance, and
mass index (lowest lifetime BMI) and
depressive symptoms explained all find-
ings in the BN group. Although this
adjustment reduced the difference
between the AN and HC groups, the AN
group still performed worse than the HCs
regarding verbal learning and memory,
visual learning and memory, visuospatial
ability, working memory, and executive
functioning.
Discussion: Patients with EDs scored
below the HCs on several cognitive func-
tion measures, this difference being most
pronounced for the AN group. The nadir
BMI and depressive symptoms had
strong mediating effects. Longitudinal
studies are needed to identify the impor-
tance of weight restoration and treat-
ment of depressive symptoms in the
prevention of a possible cognitive decline.
VC 2014 Wiley Periodicals, Inc.

motor function.
Keywords: anorexia nervosa; buli-
Results: The AN group scored signifi- mia nervosa; neuropsychology
cantly below the HCs on eight of the nine
measured cognitive domains. The BN
(Int J Eat Disord 2014; 00:000–000)
group also showed inferior performance
on six cognitive domains. After adjusting
for possible mediators, the nadir body

Accepted 24 March 2014

Additional Supporting Information may be found in the online
Introduction
version of this article.
Supported by The National Program for Integrated Clinical Spe- Several studies have reported neuropsychological
cialist and PhD Training for Psychologists, Norway. [This program impairments in patients with eating disorders
is a joint cooperation between the Universities of Bergen, Oslo, (EDs). Reviews have identified difficulties in atten-
and Tromsï, the Norwegian University of Science and Technology
(Trondheim), the Regional Health Authorities, and the Norwegian tion, executive function, learning, memory, verbal
Psychological Association. The program is funded jointly by the functioning, and visuospatial ability.1–3 These find-
Ministry of Education and Research and the Ministry of Health ings are, however, most consistent in patients with
and Care Services.]
*Correspondence to: Siri Weider, Department of Psychology, anorexia nervosa (AN), where a specific pattern of
Norwegian University of Science and Technology, Dragvoll, 7491 neuropsychological difficulties has been suggested,
Trondheim, Norway. E-mail: siri.weider@svt.ntnu.no
1
encompassing deficits in central coherence4,5 and
Department of Psychology, Norwegian University of Science
and Technology, Trondheim, Norway in aspects of executive functioning associated with
2
Specialised Unit for Eating Disorder Patients, Department of frontal brain function, especially set-shifting.6
Psychiatry, Levanger Hospital, Health Trust Nord-Trïndelag, There is insufficient research on neuropsychologi-
Levanger, Norway
3
Regional Centre for Child and Youth Mental Health and Child cal function in patients with bulimia nervosa
Welfare, Norwegian University of Science and Technology, Trond- (BN),2,7 and existing studies are hampered by small
heim, Norway
4
sample sizes.7 In addition, most earlier studies
Department of Child and Adolescent Psychiatry, St. Olav’s Uni-
versity Hospital, Trondheim, Norway have been domain-specific, studying only a limited
5
Division of Mental Health, Innlandet Hospital Trust, Hamar, area of cognition. At present, there is no evidence
Norway of a specific cognitive profile matching that in AN.7
Published online 00 Month 2014 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.22283 Most studies on EDs have focused on either
VC 2014 Wiley Periodicals, Inc. patients with AN or BN, and few studies have

International Journal of Eating Disorders 00:00 00–00 2014 1

WEIDER ET AL.
investigated the relationship between cognitive
function-associated problems in these closely
related disorders.
The cognitive deficits observed in the ED popu-
lation have been explained either by malnutrition,
assuming that the cognitive problems will improve
after refeeding,8 as persistent problems after
weight gain caused by the detrimental effects of
previous starvation and malnutrition,9 or as predis-
posing traits with increased risk of developing an
ED.10,11 Genetic markers as well as epigenetic influ-
ences contributing to development of EDs are cur-
rently being sought, suggesting that the observed
cognitive difficulties may exist before disease pro-
gression and thus contribute to disease develop-
ment. Twin studies support genetic vulnerability to
EDs,12 and findings of altered brain chemistry and
structure in patients strongly suggest a neurobio-
logical component of ED etiology.13
How ED-related aspects may themselves affect
cognitive functioning is not clear.14 Studies of
patients with AN have generally failed to find asso-
ciations between cognitive difficulties and the cur-
rent body mass index (BMI; kg/m2).9,15
Additionally, the effect of the nadir (lowest lifetime)
BMI on cognitive functioning in EDs is unclear,
although researchers have found this factor to be
important in regard to enduring decrease of cere-
bral gray matter in patients recovered from EDs.16
Findings indicate, however, that the nadir BMI
does not affect performance in central coherence,17
set-shifting,17 or attention to details.18
Patients with EDs have a high prevalence of
comorbid disorders. In a large study on female
inpatients with EDs, the most frequent comorbid-
ities were mood disorders (mainly unipolar depres-
sion), found in 94% of patients.19 Depression also
negatively affects cognitive functioning in various
domains.20 The present understanding of the effect
of such comorbid psychiatric disorders on cogni-
tive function in EDs is incomplete.21 Although
some researchers have failed to find any effect of
depression as a confounding variable,15,22,23 others
have found that depression plays an important role
in ED-associated neuropsychological difficulties.14
Aims of the Study
The aim of this study was to examine the neuro-
psychological profiles of patients with AN or BN
compared with healthy controls (HCs) using a
broad battery of neuropsychological tests. We also
sought to test the possible mediating effects of IQ,
psychotropic medication, and several disease-
2 International Journal of Eating Disorders 00:00 00–00 2014
specific factors such as BMI, the nadir BMI, and
depressive symptoms.
Method
Participants
A total of 95 patients aged between 17 and 63 years
were consecutively invited to participate in this study on
cognitive function in EDs. The patients were recruited
from two special inpatient ED units at Levanger Hospital
between September 2008 and April 2010 and between
August 2011 and February 2013. A total of nine patients
refused to participate or discontinued testing, leaving 86
patients. The inclusion criteria were (a) being admitted
for treatment for AN or BN according to the criteria of
the Diagnostic and Statistical Manual of Mental Disor-
ders, 4th Edition, Text Revision (DSM-IV-TR)24; (b) hav-
ing an ED as the primary diagnosis; (c) speaking
Norwegian as a first language; and (d) being somatically
able to participate in the study. The exclusion criteria
were confirmed brain damage (n 5 1; cerebral infarc-
tion); psychosis; diabetes (n 5 1); neurological disease;
and neuropsychiatric disorders, such as attention-deficit
hyperactivity disorder (ADHD; n 5 3), Tourette’s syn-
drome, autism spectrum disorder, and chronic fatigue
syndrome (n 5 2), leaving a total of 79 enrolled partici-
pants resulting in a participation rate of 89.8%. The five
patients with AN who refused to participate or discontin-
ued the assessment were older than the remaining
patients with AN (M 5 43.6 years vs. M 5 27.5 years,
respectively) and had a lower BMI (M 5 15.6 vs.
M 5 16.2). There were no differences in demographics
between the four patients with BN who refused to partic-
ipate or discontinued the assessment and the remaining
patients with BN.
A total of 40 patients (38 females and two males) were
diagnosed with AN. Among these patients, seven no lon-
ger met the BMI criteria for AN (<17.5) because of weight
gain during current admission. However, all of these
patients fulfilled all other criteria for AN, and none had a
BMI >18.5. It is also worth noting that all of these
patients fulfilled the criteria for AN according to the new
DSM-V. In total, 27 of the patients with AN (67.7%) were
diagnosed with restrictive AN, whereas the remaining 13
(32.3%) were diagnosed with binge-purge AN. Addition-
ally, 39 patients (37 females and two males) fulfilled all
criteria for BN. Among these, five had previously (>1
year prior) been diagnosed with AN. None of them had
been previously hospitalized for AN. Several of the
patients suffered from comorbid diagnoses. The most
prevalent comorbid diagnoses in the AN group were
depression (n 5 17) and post-traumatic stress disorder
(PTSD; n 5 5), followed by bipolar II disorder (n 5 2),
obsessive compulsive disorder (OCD; n 5 3), and
 NEUROPSYCHOLOGICAL PERFORMANCE OF PATIENTS WITH AN OR BN
generalized anxiety disorder (GAD; n 5 3). Depression
was also the most prevalent comorbid diagnosis in the
BN group (n 5 10), followed by PTSD (n 5 4), GAD
(n 5 2), OCD (n 5 1), and bipolar disorder (n 5 2).
The patients were at different stages in their treatment.
However, all patients were recruited in connection with
receiving inpatient care. To avoid the effects of acute
starvation, no patients were recruited before Day 10 of
their admission. In certain instances, because of somatic
complications or patients being too severely emaciated
to participate, testing was postponed until the patients
were more nutritionally and medically stable. At the time
of assessment, 36 of the patients with AN (90.0%) were
receiving inpatient treatment. Additionally, one patient
was in day treatment, and three were outpatients. Among
the patients with BN, 32 (82.1%) were receiving inpatient
treatment. Another patient was in day treatment, and six
were outpatients. The outpatients were between sequen-
tial admissions (n 5 6) or had recently been discharged
from the units (n 5 3) but still fulfilled all diagnostic cri-
teria for their disorders. Thirteen patients with AN
(32.5%) and 14 patients with BN (35.9%) were hospital-
ized for the first time for ED treatment. The remaining
patients were previously hospitalized at least once.
The types and frequencies of medication in the AN
group were as follows: antidepressants (selective sero-
tonin reuptake inhibitors) (n 5 25), antipsychotics
(n 5 15), anxiolytics (n 5 7), hypnotics (n 5 7), thyroid
hormones (n 5 3), and antiepileptics (n 5 3, either as a
mood stabilizer or as a treatment for peripheral neuro-
pathic pain). Medication use in the BN group was as fol-
lows: antidepressants (n 5 26), hypnotics (n 5 7),
antipsychotics (n 5 5), anxiolytics (n 5 3), thyroid hor-
mones (n 5 1), and antiepileptics (n 5 1, as a mood stabi-
lizer) (see Supporting Information Table S1 for
compound names and average doses). Several of the
patients were polymedicated, and the proportion of indi-
viduals being medicated in each patient group was 82.5%
for AN and 84.6% for BN.
On the basis of the skewed sex distribution and a
hypothesized higher-than-average educational level in
the patient groups, we chose to include an HC group
matched for sex, and comparable in age and education,
consisting of 40 healthy individuals. The HCs were
recruited from different educational facilities, including
adult education participants at the Ole Vig Upper Sec-
ondary School in Stjïrdal, Sïr-Trïndelag University Col-
lege, Nord-Trïndelag University College, the Norwegian
University of Science and Technology, and the Folkeuni-
versitetet Adult Education Association, and by word of
mouth (n 5 3). All HCs spoke Norwegian as a first lan-
guage. The exclusion criteria were the same as for the
patient groups, with the following additional criteria: (a)
a lifetime history of EDs or eating problems, (b) currently
on a diet, (c) having a BMI <19 kg/m2 or >26 kg/m2, and
International Journal of Eating Disorders 00:00 00–00 2014
(d) having a known psychiatric diagnosis. Five partici-
pants were excluded based on the exclusion criteria.
Comparability of the groups was assured by an indi-
vidual pairing of one patient with AN with one patient
with BN and a subsequent search for an HC of a similar
age (63 years), the same sex and a similar educational
level. The close match of the patient pairs was possible
due to the homogeneity of age and educational level of
this ED population. There was, however, greater variabili-
ty in age and the level of education in the AN group than
in the BN group. In an attempt to find an HC comparable
with the patients at the extremes, the HCs were, in some
cases, a closer match to the patient with AN in the pair
than to the patient with BN.
This study was approved by the Regional Committee
for Medical and Health Ethics of Central Norway (refer-
ence 4.2007.2229). All participants gave written informed
consent in accordance with the Declaration of Helsinki.
Materials
Clinical Assessment. All diagnoses were drawn by a spe-
cialist on EDs (medical doctor or clinical psychologist)
and validated at the day of testing using the Mini Interna-
tional Neuropsychiatric Interview (MINI)25 based on cri-
teria from the DSM-IV-TR.24 All participants completed
the Beck Depression Inventory-II (BDI-II),26 as a measure
of depressive symptoms, and the Eating Disorder
Inventory-2 (EDI-2),27 as a measure of severity of the ED.
Cognitive Assessment. The patients completed a com-
prehensive battery of internationally well-known neuro-
psychological tests covering a broad age spectrum that
measure numerous cognitive domains (see Table 1). A
number of these tests were chosen based on earlier
research that proved them sensitive to cognitive difficul-
ties in EDs. The level of general intelligence was assessed
by the Wechsler Adult Intelligence Scale, 3rd Edition
(WAIS-III).29 Based on the knowledge that the Working
Memory Index and the Processing Speed Index, as calcu-
lated according to the WAIS-III manual, are indexes sen-
sitive for measuring current pathology,30 the General
Ability Index (GAI)30 was used as a measure of premorbid
intelligence. The GAI is composed of the raw scores from
the following subtests: Picture Completion, Matrix Rea-
soning, Block Design, Vocabulary, Similarities, and Infor-
mation. Raw scores on the subtests for the Working
Memory Index and the Processing Speed Index contrib-
uted to the summary scores for various cognitive
domains. The WAIS-III profiles of the groups (with nearly
identical participants) are presented elsewhere.31
Statistical Analysis
The data were analyzed using SPSS 19.0. One-way,
between-groups analysis of variance with Sidak post hoc
tests were used for comparisons of demographic and
3
WEIDER ET AL.

TABLE 1. Neuropsychological test battery (subtests in brackets)

Cognitive Domain Test Variables
Verbal learning and memory California Verbal Learning Test-II (total recall 1–5, short-delay free recall, long-delay free recall),
Wechsler Memory Scale-Revised (WMS-R) (Logical Memory I and II)
Visual learning and memory WMS-R (Visual Memory I and II), Rey-Osterrieth Complex Figure Test (ROCF) (immediate recall
trial, delayed recall trial)
Speed of information processing Trail Making Test, Part A, Wechsler Adult Intelligence Scale-III (WAIS-III) (Digit Symbol, Symbol
Search), Color-Word Interference Test (CWIT)a (color naming, word reading)
Visuospatial ability WAIS-III (Block Design, Matrix Reasoning), ROCF (copy)
Working memory Paced Auditory Serial Addition Test (PASAT) 3, PASAT 2, WAIS-III (Letter Number Sequencing,
Digit Span), WMS-R (Spatial Span)
Executive function Category Test Computer Version with 108 cards, Wisconsin Card Sorting Test-64 Card Version
(total errors, perseverative responses), Tower Testa (total achievement score), Trail Making
Test, Part B, CWIT (inhibition, inhibition/switching)
Verbal fluency Verbal Fluency Testa (letter, category, switching)
Attention and vigilance Conners’ Continuous Performance Test-II (omissions, commissions, hit RT, hit RT SE, detectabil-
ity, hit RT by block, hit RT by block SE, hit RT by ISI, hit RT by ISI SE)
Motor function Grooved Pegboard Test DH, Grooved Pegboard Test NDH, Grip strength DH, Grip strength NDH
a
Note: From Delis-Kaplan Executive Function System; DH, dominant hand; NDH, nondominant hand. See Strauss et al.28 for test references.

TABLE 2. Demographic and clinical characteristics of groups with anorexia nervosa and bulimia nervosa compared
with healthy controls
AN (n 5 40) BN (n 5 39) HCs (n 5 40)

Mean (SD) Mean (SD) Mean (SD) F p-value

Age 27.53 (9.724) 27.54 (8.741) 27.45 (10.008) 0.001 0.999
BMI 16.24 (1.925)a 21.76 (3.980) 22.41 (1.744) 61.293 <0.001
Nadir BMI 13.64 (2.434)a 16.89 (2.562)b 20.75 (1.648) 100.297 <0.001
Number of years of education 13.53 (2.219) 12.54 (1.819) 13.10 (1.809) 2.517 0.085
Number of years with ED 11.91 (9.520)c 10.79 (7.200)c N/A N/A N/A
Father’s education status 12.93 (3.518) 12.46 (2.732) 12.68 (3.033) 0.219 0.803
Mother’s education status 12.93 (2.956) 12.08 (2.860) 13.08 (2.759) 1.394 0.252
BDI-II 30.35 (13.981)c 23.61 (13.176)c 5.55 (6.756) 47.685 <0.001
EDI-2 92.68 (40.335)c 91.34 (46.117) 16.70 (11.735) 58.492 <0.001
IQ (GAI) 106.53 (19.010) 110.08 (13.519) 114.78 (15.040) 2.654 0.075

Note: Abbreviations: AN, anorexia nervosa; BN, bulimia nervosa; HCs, healthy controls; BMI, body mass index (weight/height2); ED, eating disorder; BDI-
II, Beck Depression Inventory-II; EDI-2, Eating Disorder Inventory-2; GAI, General Ability Index; N/A, not applicable.
a
AN < BN, HC.
b
BN < HC.
c
AN, BN > HC.

clinical characteristics of the AN, BN, and HC groups
(Table 2). All tests were two-tailed, and the level of statis-
tical significance was set at p < 0.05.
The results of the cognitive assessment of all partici-
pants were transformed into comparable Z-scores based
on the results of the control group. For each cognitive
domain, a summarized score was generated based on the
individual test scores within the given domain, as was a
composite Z-score based on the sum of the Z-scores
from each cognitive domain. A general linear model was
used to adjust for the demographic variables that are
known to affect cognition (sex, age, and education) and
to investigate the individual effects of possible mediators
(IQ, psychotropic medication use, BMI, the nadir BMI,
and depressive symptoms [BDI-II]) on the association
between EDs and cognitive function. The mediators had
to be adjusted separately because the sample size did
not allow for multiadjusted model regressions. The nor-
mality of the residuals was checked by visual inspection
of QQ plots.
Results
Demographic and Clinical Characteristics
As shown in Table 2, there were no differences
between the groups regarding age, years of educa-
tion, father or mother’s education status, or IQ, as
measured by the GAI, which was calculated based
on scores on the WAIS-III, as previously reported.
In addition, there were no differences between the
two patient groups in relation to years with an ED.
The AN group had a significantly lower BMI than
did the BN group and the HCs. Both patient groups
had significantly lower nadir BMIs than did the
HCs, and the AN group had a significantly lower

4 International Journal of Eating Disorders 00:00 00–00 2014

 NEUROPSYCHOLOGICAL PERFORMANCE OF PATIENTS WITH AN OR BN
nadir BMI than did the BN group. The level of
depressive symptoms was significantly higher in
both the AN group and the BN group than in the
HC group. Furthermore, the AN group had a signif-
icantly higher level of depressive symptoms than
did the BN group. Both patient groups also had a
significantly higher EDI-2 score than did the HCs;
however, there was no difference between the two
patient groups.
Cognitive Outcome
The test scores and the summed indexes can be
observed in Figure 1 (data are shown in Supporting
Information Table S2). After adjusting for demo-
graphic variables (age, sex, and education), the AN
group scored significantly lower than did the BN
group and the HCs on the composite Z-score for
the entire battery, and the BN group scored signifi-
cantly lower than did the HC group. Furthermore,
the patients in the ED groups scored significantly
below the HCs on the following indices: verbal
learning and memory, visual learning and memory,
visuospatial ability, working memory, executive
functioning, and motor functioning. The two
patient groups only differed in visuospatial ability
and executive functioning, with the AN group scor-
ing significantly below the BN group. Additionally,
the AN group scored below the HCs in the speed of
information processing and verbal fluency.
As shown in Figure 1, additional regressions
were performed to adjust for the separate effects of
IQ, psychotropic medication, BMI, the nadir BMI,
and depressive symptoms in addition to age, sex,
and education on the composite Z-score and nine
summary scores. Adjusting for IQ eliminated the
difference between the AN group and the HCs in
verbal fluency. Adjustments for psychotropic medi-
cation (antidepressants, antipsychotics, anxiolytics,
hypnotics, thyroid hormones, and antiepileptics)
were performed both by adjusting for the joint
effect of all six medications simultaneously, with
no significant effect (see Fig. 1), and by adjusting
for one medication as a covariate at a time (data
not shown). The only observed effect was that the
difference in verbal fluency between the BN group
and the HCs became significant after adjusting for
antidepressants. No effects were detected when
adjusting for the current BMI. Adjusting for the
nadir BMI evened out the difference between the
AN group and the HCs in the summary scores for
the speed of information processing and for motor
function. In addition, the difference between the
BN group and the HCs in the composite Z-score,
visuospatial ability, working memory, executive
International Journal of Eating Disorders 00:00 00–00 2014
function, and motor function became nonsignifi-
cant. Adjusting for depressive symptoms resulted
in the elimination of the difference between the AN
group and the HCs in the speed of information
processing and in verbal fluency. Adjusting for
depressive symptoms also led to a loss of all signifi-
cant differences between the BN group and the
HCs.
Analyses were carried out to compare inpatients
and outpatients on all summary measures adjusted
for demographic variables. There were no differen-
ces in any measures between the inpatients and
the outpatients with either AN or BN (data not
shown).
Discussion
This study explored the neuropsychological func-
tions of patients with AN or BN compared with
HCs, using a broad neuropsychological test battery.
To determine the association between EDs and
cognitive difficulties, we adjusted for three possible
confounders: age, sex, and education, and explored
the effects of IQ, psychotropic medication: and
possible disease-specific mediators, BMI, the nadir
BMI, and depressive symptoms. Overall, the
patients with EDs scored below the HCs. However,
there was a strong, possibly mediating, effect of the
nadir BMI and depressive symptoms, which totally
eliminated the difference between the BN group
and the HCs.
The AN group performed more than one stand-
ard deviation below the HCs in the mean Z-score
after adjusting for demographics (age, sex, and
education), indicating a consistent impairment in
most domains of cognitive function. This impair-
ment was most pronounced in executive function-
ing, visuospatial ability, and motor function. The
finding of executive difficulties is in agreement with
the results of previously published stud-
ies.6,10,17,23,32,33 Poor visuospatial ability has also
been suggested in several studies and has often
been attributed to poor central coherence. Problems
related to executive difficulties, especially set-
shifting problems in addition to poor central coher-
ence, have been introduced as possible endopheno-
types for AN10,11 primarily because these problems
seem to be associated with the illness itself and are
found in recovered patients with ED11,17 and in the
healthy sisters of patients with AN.10,17,18
The BN group also showed minor difficulties in
cognitive functioning and performed 0.5 standard
deviations below the HCs in the mean Z-score,
before adjustments for possible mediators.
5
WEIDER ET AL.

Figure 1 Summed Z-scores and 95% CI for patients with anorexia nervosa (AN) and bulimia nervosa (BN) on tests on verbal learning and memory,
visual learning and memory, speed of information processing, visuospatial ability, working memory, executive function, verbal fluency, attention,
and motor function and the mean Z-score with the healthy controls as reference. The Z-scores were adjusted for the following covariates: age, sex,
and education. Further separate adjustments for IQ, medication, BMI (body mass index [weight/height2]), nadir (lowest lifetime) BMI, and depres-
sive symptoms (depression) were performed for these covariates. The differences in sample size (n) are caused by the fact that not all respondents
completed all tests.

Although the profile of the BN group resembled
that of the AN group with respect to relative
strengths and weaknesses, only differentiated by
degree, there seemed to be more homogeneity in
the scores in the BN group than in the AN group.
The strong association between BN and difficulties
related to motor function was surprising given that
these patients had a normal BMI (M 5 21.8,
SD 5 4.0) and a moderately low nadir BMI
(M 5 16.9, SD 5 2.6). Moreover, none fulfilled the
diagnostic criteria for AN in the last year. This find-
ing might indicate that having had a low BMI may
have a more lasting influence on fine motor skills
and grip strength. There was also a relatively strong
association between BN and problems related to
visuospatial ability and executive function. This
finding is in accordance with the results of earlier
studies that reported problems related to executive
function33 and visuospatial ability34 in patients
with BN, whereas others failed to note such diffi-
culties.35 However, these were the only two
domains in which a significant difference between
the AN group and the BN group was found, indicat-
ing a more severe reduction in these domains in
the AN group. Regarding the remaining findings,
there are few studies on cognitive functioning in
BN, and the available studies are inconclusive.2,7
The finding of intact attention/vigilance in
patients with ED is in accordance with the findings
from the study of Jones et al.,23 who used the same

6 International Journal of Eating Disorders 00:00 00–00 2014

 NEUROPSYCHOLOGICAL PERFORMANCE OF PATIENTS WITH AN OR BN
measure of attention/vigilance as in the current
study (Conners’ Continuous Performance Test-II).
However, this finding is slightly surprising, given
the patients’ frequent complaints of attention diffi-
culties. It is possible that these complaints are
related to other elements of attention or to execu-
tive difficulties rather than to attention difficulties
per se or that perceived attentional difficulties are
mainly related to ED-specific stimuli like food,
weight, and so forth.
Although adjusting for the current BMI did not
have any effect of significance, the nadir BMI
served as a powerful mediator in BN and AN. It
seems that having had an extremely low BMI may
lead to a longer-lasting reduction in cognitive func-
tioning, or alternatively that patients with premor-
bid cognitive difficulties develop a more severe ED.
The prominent effect of the nadir BMI is interest-
ing, given the observed loss of cerebral white and
gray matter of patients with AN, demonstrated by
magnetic resonance imaging and computed
tomography (for a meta-analysis, see Ref. 36).
White matter loss is associated with reduced proc-
essing speed and executive difficulties.37 Few stud-
ies have considered the nadir BMI, a factor we
suggest is of importance for understanding both
the emotional and cognitive functioning of patients
with BN and the relationship between the two.
Depressive symptoms served as a powerful
mediator in this study and could account for the
slower information processing and verbal fluency
of patients with AN. This finding is in accordance
with the results of studies on cognitive function in
depression.20 In addition, the association between
AN and poorer scores was weakened for all other
summary scores after adjusting for depressive
symptoms. In earlier research on cognitive difficul-
ties in AN, however, depression was often rejected
as a possible mediator.22 No previous studies have
investigated the effect of depressive symptoms on
cognitive function in EDs using such a large neuro-
psychological battery. However, in a recent study,
Billingsley-Marshall et al.21 found no significant
effect of depression on variance in executive func-
tioning. This aforementioned study included a
larger number of patients with AN but only 13
patients with BN, which could possibly explain the
different results. In contrast, Giel et al.14 found
depression to be an important mediator of set-
shifting difficulties in patients with AN. Further-
more, in two newer reviews on aspects of cognitive
function in AN, Roberts et al.6 and Stedal et al.38
have noted that few studies in this line of research
have taken comorbidity into consideration, which
International Journal of Eating Disorders 00:00 00–00 2014
are recognized as possible limitations. In the cur-
rent study, depressive symptoms seemed to
account for all the observed cognitive difficulties in
patients with BN, who generally had less deviant
scores than the AN group. This finding builds on
reports by Galderisi et al.,39 who found that execu-
tive problems and difficulties related to learning
and memory in BN are associated with the pres-
ence of depressive symptoms. It therefore seems
that the role of depressive symptoms as a possible
mediator has received too little attention in earlier
research. We consider the strong mediating effect
of depressive symptoms on cognitive functioning
in EDs to be a major, strong finding that expands
our knowledge of cognitive difficulties in EDs, and
we recommend that this finding be investigated
further.
Strengths and Limitations
The strength of this study is the use of a broad
battery of neuropsychological tests; the compari-
son of a sufficient number of patients with EDs to
HCs of comparable age and education; and the
homogeneity of demographic factors between
groups, which also resulted in a match in the
parents’ level of education. The scope of the assess-
ment reveals important nuances and provides a
wider understanding of the cognitive function of
patients with EDs than do most studies on neuro-
psychological function in EDs. The applied tests
were thoughtfully chosen based on their applic-
ability across countries and different age ranges.
The findings of this study may easily be compared
with existing and future research. Furthermore, the
test results were adjusted for several possible con-
founders and mediators in an attempt to isolate
the effect of the EDs. It is, however, important to
interpret the current findings with caution because
the sample size is relatively limited and because
most tested patients had severe and long-lasting
EDs. Adjusting for the nadir BMI and depressive
symptoms as measured by the BDI-II also have cer-
tain limitations, as both of these factors might to
some degree be viewed as reflecting the severity of
the ED. A further limitation is the fact that most
neuropsychological tests, also the ones included in
each of the nine present domains, measure a num-
ber of additional functions to the targeted ability.
Moreover, as the patients were at different stages of
their treatment, and both weight restoration and
treatment of depressive symptoms were treatment
goals, these factors would presumably vary accord-
ing to length of treatment. Furthermore, there is no
adjustment for the level of anxiety in this study,
and the effect of this potential mediator is therefore
7
WEIDER ET AL.
unclear. From the current data, it is not possible to
determine whether the observed cognitive difficul-
ties are ED-specific or whether similar problems
can be observed in other psychiatric disorders. The
strong effect of depressive symptoms might indi-
cate that the importance of comorbid illnesses is
more essential than previously assumed.
The patients with AN seemed to have more cog-
nitive difficulties when compared with the HCs,
than reported in earlier studies, most likely because
of the severity and longevity of disease in the cur-
rent study. Although the three groups were equiva-
lent in intelligence, there was a tendency toward
higher IQ in the HC group, with a GAI of 114.8.
However, the results in this study were analyzed
with IQ as a covariate, with only minimal effect.
Three patients in the AN group and two patients in
the BN group were diagnosed with hypothyroidism
and treated with thyroid substitution; however, it is
unclear whether this treatment might have affected
their psychomotor speed. An additional limitation
is the large age range of the participants, as the age
effect on cognitive function on particular tasks
may differ between people with an ED and HC.
Research and Clinical Implications
Based on this study, there seems to be convinc-
ing evidence for cognitive difficulties associated
with AN. In the BN group, the cognitive difficulties
were less prominent and strongly associated with
nadir BMI and depression. We cannot, however,
from the current study, determine whether the
observed cognitive difficulties were the result of
current underweight, persistent problems due to
brain changes caused by extreme underweight, or
premorbid-occurring predisposing traits. However,
the fact that current BMI has such little impact on
the results may suggest one of the two latter alter-
natives. To better be able to answer this question, a
future follow-up of the participants should be per-
formed. This would require that most patients
reach a normal weight, and it is uncertain whether
this is a realistic goal. Nevertheless, the results
should be replicated and include a thorough
assessment of depression.
As described earlier, the nadir BMI and depressive
symptoms served as powerful mediators in EDs,
especially in BN, but also in AN. Future research
should examine whether early weight gain can pre-
vent cognitive decline. In addition, neuropsychologi-
cal screening of patients with a longstanding history
of being severely underweight should be used to tai-
lor the treatment regimen. It might be worth
attempting to treat the cognitive difficulties through
8 International Journal of Eating Disorders 00:00 00–00 2014
cognitive remediation therapy, a technique that has
shown promising results in improving cognitive
problems in AN.40 Furthermore, the findings under-
score the importance of focusing on treating depres-
sion in patients with EDs. Psychotropic medications
did not seem to have an adverse effect on cognition
in the current study and should be considered
applied when indicated.
In conclusion, patients with EDs showed cognitive
deficits in several domains when compared with
HCs, with the most extensive deficits in the AN group.
Depressive symptoms and the nadir BMI had strong
mediating effects in both disorders, and adjusting for
these factors eliminated the difference between the
BN group and the HCs. Patients with AN and BN did,
however, have similar profiles of strengths and weak-
nesses, which underscores the affinity between these
disorders and expand our knowledge on neuropsy-
chological functioning in EDs.
The authors thank Dr. Sigrid Bjïrnelv, PhD, at the Spe-
cialised Unit for Eating Disorder Patients, Department of
Psychiatry, Levanger Hospital, Health Trust Nord-
Trïndelag, Levanger, Norway, for having facilitated this
work. The authors also thank the patients and control
participants for their contribution.
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