Eating disorders and cognitive impairment: A brief review and consideration for telehealth testing

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?

What is 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.

Variables impacting cognition

There is an almost endless list of individual and environmental factors that can impact cognition, including:²

• Nutrition
• Organ function
• Nutrition
• Our thoughts, e.g., “metacognition” or “thinking about thinking”
• Our emotions, e.g., self-doubt and anxiety
• Medication
• Infections
• Environmental factors, e.g., loud traffic or construction noises, crowds, etc.

Cognitive impairment vs. cognitive deficit

Mild Cognitive Impairment (MCI)

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

Cognitive deficit

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.

Do eating disorders impair cognition?

We already know that eating disorders have wide-ranging impacts, affecting things like:

• Medical presentation
• Social and work life
• Relationships
• Family life
• Psychological/psychiatric status

There is a growing body of evidence that indicates that eating disorders can also impact cognition, in particular, certain cognitive traits: 

• Cognitive rigidity and heightened attention to detail have been linked to compulsive eating disorder behaviors, such as bodychecking and ritualistic eating. (6) This cognitive inflexibility, or inability to mentally adapt to new demands and information, can make it difficult for clients to engage in eating disorder treatment fully.‍
• Impulsivity has been linked to the feelings of urgency that precede episodes of purging or binge eating. 

Eating disorders and alterations in brain structure

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.

So, do eating disorders impact cognition?

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.

What does the research say?

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:

• Both groups scored lower in visual learning and social cognition compared to healthy controls.
• Those with AN-BP scored significantly lower in processing speed, attention, and reasoning/problem-solving.
• Compared to the AN-R group, those with AN-BP scored significantly lower in attention/vigilance.

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. 

Proposed domains

Regarding testing cognition, what can we do as telehealth clinicians?

When delivering cognitive testing to clients through videoconference, there are important factors to consider, including but not limited to:¹¹

• Partially feasible and reliable: Is the cognitive test a reliable one that has some relevance to eating disorders?‍
• Full capability: Is the clinician capable or accredited to deliver cognitive testing?‍
• Normative data: Is there data from a reference population that provides a reliable baseline measurement?‍
• Technology: Does the client have access to the right technology and a reliable internet connection? Do they have the technological know-how to take a test virtually?‍
• Ethical concerns: Are there any privacy concerns? Is the client able to provide informed consent?

‍

RBANS: An example of a cognitive assessment suitable for virtual administration

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:

• Immediate memory: Low scores suggest difficulties with verbal learning.
• Visiospatial/constructional: Low scores indicate challenges in using and processing visuospatial information.
• Attention: Low scores indicate problems with information processing and basic attention processes.
• Language: Low scores indicate issues with fluent language use, including receptive and expressive language.
• Delayed Memory: Low scores suggest problems with retrieval and recognition of information from long-term memory.

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.

When to consider cognitive testing

How do we determine which clients are at risk of cognitive decline, which could prevent them from reaching their treatment milestones?

• Do you suspect changes in cognitive function from the onset of treatment?
• Has there been a change in functional status, i.e., a decline in self-care in terms of cooking, hygiene, finances, etc.?
• Are there physical symptoms that can impact cognition, such as nausea, vomiting, vision, hearing, speech impairments, balance and motor function issues, etc.?
• Are there psychiatric symptoms that can impact cognition, like mood, behavior, and personality changes?
• Could medical presentation/diagnosis impact cognition?

References

1. Sternberg, R. J. (2010). Cognition and Intelligence: Identifying the mechanisms of the mind. Cambridge University Press. 
2. Jaywant, A. (2022). Key factors that influence cognitive health. Psychology Today. Accessed Oct 2023.
3. Mild cognitive impairment (MCI). (n.d.). Alzheimer’s Disease and Dementia. Accessed Oct 2023.
4. Cognitive impairment. (2022). healthdirect. Accessed Oct 2023
5. Dhakal, A., & Bobrin, B. D. (2023). Cognitive Deficits. StatPearls Publishing.
6. Altman, S. E., & Shankman, S. A. (2009). What is the association between obsessive–compulsive disorder and eating disorders? Clinical psychology review, 29(7), 638-646. 
7. Gay, P., Rochat, L., Billieux, J., d'Acremont, M., & Van der Linden, M. (2008). Heterogeneous inhibition processes involved in different facets of self-reported impulsivity: evidence from a community sample. Acta psychologica, 129(3), 332–339. 
8. Fonville, L., Giampietro, V., Williams, S. C., Simmons, A., & Tchanturia, K. (2014). Alterations in brain structure in adults with anorexia nervosa and the impact of illness duration. Psychological Medicine, 44(9), 1965–1975. 
9. Tamiya, H., Ouchi, A., Chen, R., Miyazawa, S., Akimoto, Y., Kaneda, Y., & Sora, I. (2018). Neurocognitive impairments are more severe in the binge-eating/purging anorexia nervosa subtype than in the restricting subtype. Frontiers in Psychiatry, 9, 138. 
10. Tenconi, E., Collantoni, E., Meregalli, V., Bonello, E., Zanetti, T., Veronese, A., et. al. (2021). Clinical and cognitive functioning changes after partial hospitalization in patients with anorexia nervosa. Frontiers in Psychiatry, 12, 653506. 
11. Bilder, R. M., Postal, K. S., Barisa, M., Aase, D. M., Cullum, C. M., Gillaspy, S. R., Harder, L., Kanter, G., Lanca, M., Lechuga, D. M., Morgan, J. M., Most, R., Puente, A. E., Salinas, C. M., Woodhouse, J. (2020). InterOrganizational Practice Committee Recommendations/Guidance for Teleneuropsychology in Response to the COVID-19 Pandemic. The Clinical Neuropsychologist, 35(6), 647-659. 
12. Novitski, J., Steele, S., Karantzoulis, S., Randolph, C. (2012). The Repeatable Battery for the Assessment of Neuropsychological Status Effort Scale. Archives of Clinical Neuropsychology, 27(2), 190–195,