Anorexia & Set-Shifting Challenges

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Those suffering from Anorexia Nervosa (AN) experience significant declines in physical and psychological health [1]. Poor set-shifting ability has been associated with illness severity, increased severity of eating disorder rituals and longer duration of illness [1].

Many individuals suffering from AN present with reductions in social interactions often leading to isolation and loss of relationships [1]. Unfortunately, the response to and engagement in treatment are often negatively impacted by inflexibility [1].

Set-shifting or cognitive flexibility is the ability to switch thoughts or actions according to situational demands [2]. Individuals with AN presenting with cognitive inflexibility may suffer from further impairments and declining quality of life.

Set-Shifting Factors & Impairments in AN

Systematic reviews of neuropsychological task performance found set-shifting deficits present in many with eating disorders. However, the cause is unclear and thought to potentially be related to characteristics of the eating disorder [2].

Common characteristics of those with AN often include the need to control their eating and weight, along with cognitive and behavioral rigidity [2].

Cognitive and behavioral rigidity may be a cause of poor set-shifting or the inability to shift perspectives from rules and rituals surrounding food, eating and body weight [2].

Another characteristic of AN is an increased attention to detail. This could be linked to poor global processing or again the inability to see the bigger picture or beyond the eating disorder [2].

Severity of Eating Disorder

In AN neuropsychological impairments may be characteristic of the disorder or a consequence of malnutrition [2]. There is some research revealing cognitive deficits may be related to nutritional deficits as well as genetic traits [1].

The least global flexibility style and the most fragmented perseverative cognitive style were found in more severe or chronic AN cases. This was explored using Eating disorder examination questionnaire (EDE-Q) global score and lower BMI [2].

The impact of body weight or BMI on cognitive impairment is uncertain. However, some studies have found a significant association between BMI and poor cognitive flexibility [2]. One study reported poor set-shifting abilities and global processing for those with lower lifetime BMI [2].

Overall, it is understood that cognitive impairments are seen in those suffering from AN. However, when looking at all systematic reviews the results are unclear, with some studies revealing no relationship between severity of eating disorder and set-shifting.

Comorbid Conditions 

Individuals with AN often suffer from comorbid conditions. These may include mood disorders, personality disorders, anxiety disorders, obsessive-compulsive disorders, and developmental disorders [2].

A recent study, reported poor set-shifting ability in those with increased anxiety, however the effects were small [2]. Other studies have found differing evidence. Overall, the research reveals high levels of anxiety may play a roll in set-shifting abilities.

Some studies have reported increased depression in those with poor set-shifting abilities [2]. The relationship is unclear as to which comes first, depression or poor set-shifting. Overall, both depression and anxiety are linked to cognitive impairments [2], impacting cognitive flexibility to some extent.

Functional Impairments

Comorbid conditions such as depression and anxiety can be debilitating, leading to functional impairments related to everyday living. These may include occupational, academic, and social functioning.

The perfectionist nature or detail-oriented processing style individuals with AN possess [1] may be a cause of decline in reaction time [1]. The ability to make decisions is delayed in those with AN [1].

One adult study used the Behavioral Assessment of Dysexecutive Syndrome (BADS).

This study found adults with AN were slower to complete tasks, but were just as accurate [1].

Functional impairments related to eating disorders are self-reported in the Clinical Impairment Assessment (CIA). Concerns surrounding body weight and binge eating frequency are often predictive of CIA scores [1].

Important to note improvement in CIA scores are seen through treatment [1]. Functional improvements are markers of recovery [1] and improvement in flexibility.

Impact on Quality of Life (QoL)

When is come to eating disorders, using Quality of Life (QoL) assessments are complicated. Individuals with AN often interpret aspects of the eating disorder to align with true wants and desires.

If in the midst of an eating disorder individuals may interpret QoL improvements oppositely. As they restore weight or as health improves they may report a reduction in QoL [1]. This shows inflexibility in an all of nothing thinking pattern.

Lower QoL scores often predict increased eating disorder symptoms and severity [1]. QoL, mood, and social adjustments should be active components and markers for recovery and improvements in set-shifting ability.

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Brain-Directed Treatment Strategies 

Understanding the impact AN has on brain function it may be beneficial to shift treatment to focus to brain-directed treatments? With this shift some potential treatment options could include:

Cognitive Remediation Therapy (CRT):

  • CRT is applied to aid in improving set-shifting and central coherence [1]. CRT aims to support reducing perfectionism and bring awareness to dysfunctional thinking styles [2]. CRT brings awareness to the process of thinking rather than the content [1].

Temperament based treatment with support (TBT-S):

  • TBT-S aims to explain underlying neurobiological mechanism causing AN. The goal is to support individuals with AN in developing coping strategies to mange temperament traits related to risk factors for an eating disorder [2]. This treatment is detail oriented, well-structured, and predictable to align with neuropsychological thinking style.

The Maudsley Model of Anorexia Nervous Treatment for Adults (MANTRA):

  • MANTRA aims to treat the neuropsychological, emotional, relational, and biological aspects of AN. It helps patients understand what the causes of AN are and encourages patients to start changing behaviors when they are ready [2].

The objective of treatment is always to serve the patient with the best possible care and compassion. Medical professionals can provide more quality and individualized care if we continue to further our understanding of the causes and the fueling factors of eating disorders.


[1] Dann, K. M., Hay, P., & Touyz, S. (2021). Are poor set-shifting and central coherence associated with everyday function in anorexia nervosa? A systematic review. Journal of Eating Disorders9(1).

[2] Fuglset, T. S. (2021). Is set-shifting and central coherence in anorexia nervosa influenced by body mass index, anxiety or depression? A systematic review. BMC Psychiatry21(1).

About the Author:

BioRaylene Hungate, RD/N, LD/N is a registered dietitian dedicated to providing the utmost care and support to those struggling with mental health. As a supporter of the Health at Every Size movement and the idea that all foods fit, she is passionate about helping others explore a life full of nourishment and bursting with flavor.

As an eating disorder dietitian, Raylene works not only in Private Practice, but also as a dietitian for an eating disorder treatment center in Los Angeles, California. She finds great joy in guiding others through an empowering journey of self-discovery and healing.

The opinions and views of our guest contributors are shared to provide a broad perspective on eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published July 2, 2021 on
Reviewed & Approved on July 2, 2021, by Jacquelyn Ekern MS, LPC