Presented by Ronnie Lee, PsyD
Eating disorder treatment and its varied forms of therapy and education can put a strain on cognitive capacity. Furthermore, it can be challenging to absorb all the information presented to clients if they cannot work at a high level of cognition.
What does this mean for clients due to co-occurring diagnoses, such as ADHD, that are impacting their level of cognition? How are clinicians preparing treatment maps to consider the co-occurring diagnoses and their impact on cognition?
Cognition refers to the range of mental processes relating to acquiring, storing, manipulating, and retrieving information. It underpins many daily activities in health and disease across the age span.1
Cognition can be separated into multiple distinct functions, depending on particular brain circuits and neuromodulators.
In simple terms, cognition refers to the mental processes an organism uses to organize information, including attention, thinking, memory, learning, decision-making, emotions, and more.
There is an almost endless list of individual and environmental factors that can impact cognition, including:2
MCI can be described as the stage between a more expected cognitive decline (e.g., for aging) and signs of a more insidious onset of a neurocognitive disorder. MCI is not an illness in itself, and in some individuals, MCI reverts to normal cognition or remains stable.3
The causes and risks of MCI are varied and may include head injuries, severe anxiety/depression, dehydration, medication, infections, and recreational drug use.4
By contrast, cognitive deficit is a more general term that describes a disruption of a person’s mental processes that lead to acquiring information and knowledge but does not impact their overall ability to function appropriately. Cognitive deficit does not explicitly suggest or lead to a neurocognitive diagnosis or condition.5
Cognitive deficits can prevent cognitive functioning at the highest level, which can be relevant to eating disorder treatment. As previously alluded to, clients need to be functioning at a high cognitive level to get the most out of eating disorder treatment.
We already know that eating disorders have wide-ranging impacts, affecting things like:
There is a growing body of evidence that indicates that eating disorders can also impact cognition, in particular, certain cognitive traits:
Several studies have looked at the relationship between eating disorders and brain structure. Without going into too much detail, studies have found that those with anorexia nervosa (AN) were shown to have smaller brain volume and a global decrease in grey matter volume. It’s hypothesized that there is a correlation between grey matter size and the duration of the eating disorder.8
These findings have significance as the grey matter of the brain is responsible for cognitive processing. This potential indicates the importance of early diagnoses and intervention to prevent a cognitive decline in clients, which could impact their ability to cope well with treatment.
Yes, but it’s complicated. It’s challenging to find a direct correlation between eating disorders and cognition. However, several studies have sought to identify the impact of eating disorders on cognitive abilities, but accounting for the prevalence of co-occurring disorders known to impact cognition—such as personality and mood disorders and malnutrition—has proven difficult.
We’ve identified several studies that have tried to account for co-occurring disorders with exclusion criteria.
For example, Tamiya, et. al. (2019)9 carried out several cognitive tests—including Trail Making Test (TMT) A, Hopkins Verbal Learning Test (HVLT-R), and Letter-Number Sequencing (LNS), to name a few—with those diagnosed with AN-BP and AN-R. Results showed:
Research has also found that cognitive function in eating disorder patients can improve following treatment.
Tenconi, et. al. (2021)10 found baseline cognitive testing in those with an AN diagnosis demonstrated significantly poorer executive abilities and decreased autobiographical memory. Plus, they showed poor task switching and abstract thinking abilities compared to controls, which could be linked to cognitive rigidity. However, following a partial hospitalization program (PHP), AN participants showed a significant improvement in decision-making abilities.
It’s also important to mention that there is also a body of research that has found no evidence supporting a cognitive decline in eating disorder patients. However, these studies have been primarily focused on short-term eating disorders and adolescent patients. If cognitive decline is correlated with the duration of an eating disorder, in cases of short-term disorders, cognitive decline may not yet have developed.
Furthermore, adolescents are still in a phase of neuroplasticity, i.e., their minds are not yet fully developed, which may protect against cognitive decline.
When delivering cognitive testing to clients through videoconference, there are important factors to consider, including but not limited to:11
Although there are many others, Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS) is a solid example of a cognitive test that can be delivered to clients via telehealth.
The RBANS is a brief standardized screening tool to measure neuropsychological status. (12) It consists of 12 subsets that provide 5 scores of cognitive functioning:
It was initially created to assess older adults but has since been adapted to screen younger patients. The RBANS is quick to administer, taking just 20 to 30 minutes.
How do we determine which clients are at risk of cognitive decline, which could prevent them from reaching their treatment milestones?