Complex Dynamics in Mental Functioning With Anorexia

Having poor cognitive functioning can be frustrating and perpetuate the state that (probably) caused it. One of the most dangerous global features of anorexia is how it creates the conditions for its own survival. In the cognitive domain, the specific patterns of cognitive change entailed by the illness make more likely specific behavioural changes that, in turn, exacerbate the cognitive impairment.

There’s a general consensus in the literature that cognitive deficits tighten the noose through potent feedback effects and that the inflexibility aspect is a particular killer in these feedback dynamics:

• Impairment in cognitive flexibility, as consistently seen in patients with anorexia, “is thought to be associated with the persistence of AN because it leads to deeply ingrained patterns of thought and behaviour that are highly resistant to change” (Huang & Foldi, 2022).
• “Rumination about body weight/figure as well as food is common in patients with anorexia nervosa (AN) and may be a maintenance factor of the disorder” (Fürtjes et al., 2018).
• “Disturbed cognition is figural in the presentation of eating disorders and may serve to play an integral role in its cause and maintenance” (Zakzanis et al., 2009).
• “The deviation from normal brain development, and particularly the impairment in cognitive flexibility, sustain the maintenance of aberrant behaviors, and a vicious cycle is established, perpetuating restraint over eating and other AN-related behaviors” (Olivo et al., 2019).

So rigidity in the mind gets and keeps repetitive restrictive behaviours in place, and vice versa, each looping effect setting up the next. Cognitive-behavioural feedback is in play in other ways too. We spent some time (in parts four and five) looking at surprising findings of no impairment in anorexia or no improvement in recovery, and another way of accounting for these results is to remember that humans are great at finding workarounds.

The authors of one study that generated surprising findings (Seidel et al. 2021; see part 4) observed:

Cognitive performance in this patient sample with enduring AN and a very low BMI, similar to that of HV [healthy volunteers], is even more astonishing considering the severe atrophic changes found during the acute state. Increased or unchanged scores in performance might reflect the brain’s extensive compensatory mechanisms to adapt to extreme conditions.

Of course, compensations are not free lunches. Just like when you compensate for a pulled muscle by shifting your weight differently or finding other instinctive fixes that put more pressure on opposing limbs and joints, compensations that aren’t carefully designed tend to generate their own damage, potentially exacerbating the original problem.

Digging into the details a little more, Dann et al. (2021) looked at links between flexibility and executive function and a broad definition of everyday functioning, including social function, quality of life scales, and measures of cognitive flexibility or detail-oriented processing in everyday life, and they found a range of associations that suggest cognitive-behavioural feedback. Specifically, they found that individuals with anorexia use high levels of inhibitory control to do well in set-shifting tasks and that when you control for the use of that tactic, their performance drops below the control level.

The finding about falling back on inhibitory control for a set-shifting task is something that had already been noted in previous research. The general idea is that to do well on this type of test, you need to do two things: 1.) switch between task principles or perspectives (which is the essence of set-shifting) and 2.) inhibit inappropriate responses (with inhibitory control). If you’re rubbish at 1.) but great at 2.), you can still perform okay by eliminating most of the wrong choices even though you don’t detect or enact the right ones well (Weinbach et al., 2020).

Inhibitory control (along with reduced pleasure from standard rewards and reduced interoceptive awareness) is linked to dietary restriction in anorexia (Hill et al., 2016; also, my post on liking versus wanting). So increasing your cognitive reliance on this strength is likely to further impair your ability to use other strategies–both directly (because you practise everything else less) and also indirectly (because you eat less, exercise more, narrow down the rest of your life even more and so weaken the brain and the rest of the body further and intensify the imbalance between the availability of the two strategies).

The world is full of people with eating disorders compensating right, left, and centre for the damage their eating habits are doing, to the point where they and others might easily forget what their life and personality–and cognitive style–might have been without the compensations.

Speaking of cognitive styles–there is another more relativist angle on all this. Throughout this series, I’ve used normative terms like “impairment,” “deficit,” and “damage.” But humans have vastly varied ways of thinking, varying along dimensions including big-picture to detail-oriented, abstract to concrete, global to sequential, convergent to divergent, and visual to verbal. Each style has niches in which it manifests as a strength or a weakness, and one aspect of the privilege of modern career design, for instance, is to find the niche that lets you play to your strengths.

Eating Disorders Essential Reads

How Children with Eating Disorders Are Groomed Online

Reevaluating Military Fitness Standards

Of course, even playing to your strengths can be risky if it involves avoidant tendencies in which you shy away from what you don’t think you can do and rely ever more heavily on ways of doing things that create their own damage. You might take on a very detail-oriented job, let’s say proofreader, in a context where perfectionism is already causing work/life problems and so make everything worse. But it’s perfectly possible to create expansive enriching kinds of feedback rather than the depleting and narrowing sort by knowing what you already do well, doing plenty of that, and making sure you keep in some elements that test you, make you a bit uncomfortable, answer questions about yourself you didn’t already know (or think you knew) the answer to.

Ultimately, no cognitive style is inherently worse than any other–until it is for you. And here, it’s crucial to be clearsighted about malleability: Is this a temporary state or an enduring trait? To take one example–in both the recovery and the work/life context, I’ve worked with clients who have ADHD, Asperger’s, or ASD. Our work has always involved 1.) using their “neurodivergent” cognitive traits to our advantage to aid the process of change and 2.) defining success in a way that honours the specific contours of their cognitive styles.

But for many individuals, anorexia makes it seem like you’re a far more detail-oriented, concrete, sequential, convergent thinker (often to the point of ruminative obsessive-compulsion) than you would have been if you hadn’t been ill, and that illusion is far from cost-free. In these cases, it’s always beautiful to see other styles of thinking and being flow back in, to the point where both the individual and those around her often say: It’s like being a different person.

In these cases, I think damage and deficits are the right words to use, and breaking the deadly feedback loops–usually starting by eating differently–is the best way to go.

*Thanks to reader AR for thought-provoking comments on cognitive diversity.*