social emotional functioning and cognitive styles in eating disorders

261

British Journal of Clinical Psychology (2012), 51, 261–279C© 2011 The British Psychological Society

TheBritishPsychologicalSociety

www.wileyonlinelibrary.com

Social emotional functioning and cognitive stylesin eating disorders

Amy Harrison1∗, Kate Tchanturia1, Ulrike Naumann2,and Janet Treasure1

1Psychological Medicine, Section of Eating Disorders, King’s College London,Institute of Psychiatry, London, UK

2Department of Biostatistics and Computing, King’s College London, Institute ofPsychiatry, London, UK

Objectives. Contemporary models of eating disorders (EDs) argue that both cognitivestyle (weak coherence and poor set shifting) and social emotional difficulties are involvedin the maintenance of EDs. This study aimed to explore the factor structure of cognitiveand social emotional functioning and to investigate whether a particular cognitive orsocial emotional profile was associated with a more severe and chronic form of illness.

Design. A cross-sectional design was used to investigate cognitive and social emotionalfunctioning in people with EDs compared to healthy controls (HCs) and those recoveredfrom an ED.

Methods. Two hundred twenty-five participants were assessed (100 with an ED, 35recovered from an ED, and 90 HCs) using a battery of set shifting, coherence, and socialemotional measures.

Results. There were no significant correlations between the cognitive or social emo-tional variables. A principal components analysis (PCA) identified three components: afragmented perseverative cognitive style, for which the ED group scored highly, a globalflexible cognitive style, for which HCs scored highly, and a social emotional difficultiesprofile, for which those with EDs scored highly. Individuals in recovery from an ED didnot differ from the acute group, suggesting this cognitive and social emotional profilemay be a trait associated with EDs. ED participants scoring highest for the fragmentedperseverative cognitive style and social emotional difficulties had a more severe andchronic form of illness.

Conclusions. The findings provide empirical support for Schmidt and Treasure’s (2006)maintenance model of EDs and suggest both cognition and emotional functioning shouldbe considered in treatment.

∗Correspondence should be addressed to Amy Harrison, Eating Disorders Research Unit, Kings College London, Instituteof Psychiatry, Department of Psychological Medicine, Eating Disorders Research Unit, 5th Floor, Bermondsey Wing, Guy’sHospital, London, SE1 9RT, UK (e-mail: [email protected]).

DOI:10.1111/j.2044-8260.2011.02026.x

262 Amy Harrison et al.

Eating disorders (EDs), such as anorexia nervosa (AN) and bulimia nervosa (BN),are severe mental disorders characterized by disturbances in eating behaviour, self-perception, cognition, and social emotional functioning. Contemporary models of EDs,such as the cognitive interpersonal maintenance model proposed by Schmidt andTreasure (2006), argue that both cognitive style (rigidity and detail focus) and socialemotional difficulties are involved in the maintenance of EDs. This model conceptualizesAN as being ‘valued and visible’ and suggests that maintaining factors such as cognitiverigidity and interpersonal difficulties may also be important in maintaining BN. The modelproposes that rigidity may contribute to the development of the disorder, as dietingprovides individuals with the opportunity to define and adhere to, with high levels ofdetail, rigid rules and rituals, a situation that may provide a sense of mastery and control.This preference for rigidity and detail is thought to be a vulnerability trait intensified bystarvation. The model also predicts that exclusive focus on the body and food is associatedwith reduced emotional salience, the experience of numbness, said to be valued bypatients, and an increase in the avoidance of social interactions that are viewed asincreasingly threatening and intolerable due to their potential for conflict, criticism, andthe arousal of negative emotion. The model suggests that through decreasing emotionalavoidance and reducing cognitive rigidity, ED symptomatology will improve. Othercontemporary models of EDs, such as Nunn, Frampton, Gordon, and Lask (2008) alsoemphasize the role of cognitive style and social emotional difficulties in the developmentand maintenance of EDs. It is therefore important to explore experimentally whetherthe predictions made by these models are supported and the current evidence base isdescribed below.

Two systematic reviews (Lopez, Tchanturia, Stahl, & Treasure, 2008; Roberts,Tchanturia, Stahl, Southgate, & Treasure, 2007) support the presence of a rigid anddetail focused cognitive style in EDs. Roberts, Tchanturia, and Treasure (2010) foundinflexibility is a familial trait associated with a longer duration of illness and moresevere ED rituals. Informed by the neuropsychology field, the inflexible cognitive stylehighlighted by Roberts et al. (2007) can be understood as being related to poor setshifting or cognitive flexibility, defined as the ability to shift one’s ‘course of thoughtor action according to the demands of the situation’ (Lezak, 1995, p. 666). Clinically,poor set shifting, amongst other factors, might be observed in patients’ reluctance toalter their rigid exercise regime. Alongside high levels of rigidity in the acute form,Tchanturia, Morris, Anderluh, Collier, et al. (2004) found set shifting difficulties persist,to some extent, in those recovered from AN.

The detail focused cognitive style highlighted by Lopez et al. (2008) can be con-ceptualized neuropsychologically as relating to poor central coherence, or a weaknessin the ability to process information in context. Happe and Booth’s (2008) recentre-conceptualization of weak coherence is particularly helpful for understanding thesuperior detail focus observed in EDs, as they include two facets: strengths in detailprocessing alongside difficulties with global integration. Clinically, difficulties withcoherence may be observed as a patient skilled in analysing the minutia of the ingredientsof a food item, but cannot see the bigger contextual picture of nutrition. Preliminaryevidence suggests that alongside the superior detail focus documented by Lopez et al.(2008), assessed using the Fragmented Pictures Task (FPT; Snodgrass, Smith, Feenan, &Convin, 1987), a specific measure of global integration, difficulties with global integrationwere observed in acute AN only (Harrison, Tchanturia, & Treasure, 2011). Data alsosuggest superior detail focus may persist into recovery (Lopez, Tchanturia, Stahl, &Treasure, 2009; Pendleton Jones, Duncan, Brouwers, & Mirsky, 1991). It is perhaps

Cognitive style and social emotional functioning in EDs 263

debatable to what extent measures of set shifting and coherence reflect the everydaydifficulties faced by individuals with EDs. In fact, this has been argued elsewhere inthe autism field (Geurts, Corbett, & Soloman, 2009). However, as a starting point inaddressing the predictions of Schmidt and Treasure’s (2006) model, using valid andreliable neuropsychological measures of set shifting and coherence represents a steptowards addressing the potential maintaining role of cognitive style in EDs.

Social emotional difficultiesOne model of social emotional functioning has been described by Ochsner (2008), whichposits that successful social emotional functioning is supported by a range of abilities.These include the acquisition of social emotional values and responses (e.g., conditioningand reward learning, in which difficulties may be indicated by heightened sensitivity andbias towards, or avoidance of social emotional stimuli perceived as threatening), therecognition of and responses to social emotional information, complex mental stateinference (e.g., theory of mind and emotional theory of mind for the self and others),and context-sensitive emotion regulation. Providing support for Schmidt and Treasure’s(2006) predictions concerning the role of social emotional difficulties in EDs, a recentreview found individuals with AN demonstrated difficulties across these areas of socialemotional functioning, with moderate effect sizes (Oldershaw et al., 2011). The authorsnoted that preliminary findings suggest difficulties in the acquisition of social affectiveresponses and the ability to recognize and respond to social emotional information maypersist after recovery, whereas complex mental state inference and emotion regulationskills may ameliorate following recovery. To limit patient burden and enhance thefeasibility of the present study, it was possible to assess only a limited area of thesocial emotional functioning skills described in Ochsner’s model; therefore, the studyassessed skills from domains encompassing the acquisition of social affective responsesand the ability to recognize social emotional information.

Many models of developmental disorders, personality difficulties, and psychologicaldisorders aside from EDs incorporate cognitive and social emotional elements. Due tothe broad range of skills and components likely to be involved in cognition and adaptivesocial emotional functioning, to make sense of datasets encompassing a wide range ofcognitive and social emotional variables, researchers have begun to explore the factorstructure of these components of functioning. Studying infant development, Leerkes,Paradise, O’Brien, Calkins, & Langel (2008) using structural equation modelling andconfirmatory factor analytic techniques, found that cognition and emotion were separatefactors. In individuals with autistic spectrum conditions (ASCs), Burnette et al. (2005),using correlation analyses, found that coherence and social emotional functioning werenot related. This was replicated by Dworzynski, Happe, Bolton, and Ronald (2009)who applied PCA to data from the Development and Wellbeing Assessment (DAWBA;Goodman, Ford, Richards, Gatward, & Meltzer, 2000) for 189 children with ASCs andfound that social functioning and flexibility were separate domains. Finally, in those withdepression, Compton, Wirtz, Pajoumaud, Claus, and Heller (2004), using PCA, found thataffect, measured using the Profile of Mood States (McNair, Lorr, & Droppleman, 1971)and attentional switching (flexibly switching attention between two or more items) werepsychometrically separated.

In summary, using a form of factor analysis may provide a parsimonious approach toassisting the present study in clearly highlighting the cognitive style and social emotionalfunctioning profile that may be maintaining EDs. This is because this methodology


commences with a broad, and therefore potentially valid and reliable approach to datacollection across several domains of functioning and subsequently reduces the numberof variables to provide clarity regarding the pattern of cognitive and social emotionalfunctioning across clinical and non-clinical groups. This may enable clinicians to identifysubgroups of patients who require targeted interventions around particular cognitive orsocial emotional skills.

Although several contemporary models of EDs posit the role of both cognitionand emotion in the development and maintenance of the disorder, few studies havesystematically addressed both domains in the same group of participants and this studyaims to reduce this gap in the literature. The aim of this study is to explore the factorstructure of cognitive and social emotional variables in order to test the cognitiveinterpersonal model of Schmidt and Treasure (2006), which predicts that a detail focused,rigid cognitive style, and high levels of social emotional difficulty are associated withmaintaining EDs. Thus, we will examine whether high levels of cognitive and socialemotional difficulties are associated with a more severe and chronic form of illness andexplore whether these difficulties are a potential trait relevant to the illness by includinga recovered group.

The first hypothesis was that cognitive and social emotional functioning variableswould be psychometrically separated, assessed first using correlations and secondlyusing principal components analysis (PCA).

The second hypothesis was that people with EDs would show difficulties with socialemotional functioning, measured by assessing attentional biases for social emotionalstimuli (Stroop task; Ashwin, Wheelwright, & Baron-Cohen, 2006) and emotion recogni-tion skills (Reading the Mind in the Eyes Task; Baron-Cohen, Wheelwright, Hill, Raste, &Plumb, 2001) and a cognitive style comprising of weak coherence, such that there wouldbe superior detail focus, measured using the Group Embedded Figures Task (GEFT) andthe Rey–Osterreith Complex Figure (Osterrieth, 1944) alongside poor global integration,measured using the FPT (Snodgrass et al., 1987), and poor flexibility, measured usingthe Brixton Task (Burgess & Shallice, 1997) and the Wisconsin Card Sort Task (WCST;Heaton, Chelune, Talley, Kay, & Curtiss, 1993).

The third hypothesis was that a less adaptive cognitive style and social emotionalprofile would be a trait associated with EDs, such that it would be present in thoserecovered from an ED, and a maintaining factor, such that having the least adaptivecognitive style and social emotional profile would be associated with a more chronicand severe form of the illness.

MethodsParticipantsThe 225 female participants whose data are used in these analyses are the same as thosereported in Harrison, Sullivan, Tchanturia, and Treasure (2010), Harrison, Tchanturia, &Treasure (2010), and Harrison et al. (2011). One hundred women with EDs; 50 with BNand 50 with AN (15 had a binge-purge subtype and 35 had the restricting subtype), 35recovered from AN, and 90 non-ED controls were recruited to take part.

Participants were eligible to take part if they were aged between 18 and 55 years. Participants were excluded if they were colour blind, reported a neurological illness,serious head injury or were not native English speakers. Participants were recruited fromthe South London and Maudsley National Health Service (NHS) Foundation Trust Eating


Disorder Services, the Institute of Psychiatry Eating Disorders Research Unit’s volunteerdatabase, through a circular e-mail sent out to the staff and students at Kings CollegeLondon and through putting up posters in local libraries. Data collection took place over12 months between 2008 and 2009.

Eating disorder groupA DSM-IV (American Psychiatric Association (APA), 1994) diagnosis of either AN orBN was obtained from clinicians, patient notes, and through using the Eating DisorderExamination (EDE) interview (Fairburn, 2008). Body mass index (BMI) (weight/height2)was calculated based on the weight and height of participants, measured on the day oftesting. Participants were asked to report menstruation frequency and pattern duringthe past year.

Healthy control (HC) groupHCs were required to have a BMI between 19 and 25, measured on the day of testing andwere excluded if they had a personal history of psychiatric disorder [examined usingthe Structured Clinical Interview for DSM-IV diagnosis (SCID) screening module] (First,Spitzer, Gibbon, & Williams, 1996), or reported a first degree relative with a diagnosedpsychological disorder. These exclusion criteria were implemented to control for anypotential effects of psychiatric illness on social emotional functioning or cognitive style.

Recovered groupRecovered participants were required to have experienced one or more episodes of AN(either restricting subtype or binge purge subtype). The SCID Extended Module H (Firstet al., 1996) was used to confirm the previous episode of AN based on DSM-IV criteria.Based on criteria provided by Kordy et al. (2002), Couturier and Lock (2006), and VonHolle et al. (2008), participants were eligible for participation if they currently reportedrestored, regular menstruation for at least the previous year, did not report clinicallysignificant scores (4 or above) on the EDE Questionnaire (EDE-Q) (Fairburn & Beglin,1994) and if their BMI had been maintained at >18.5 for at least the previous year.During recruitment, it proved difficult to recruit those recovered from BN, thereforeonly a recovered AN group was included.

ProcedureThe study received ethical approval from the NHS Research Ethics Committee (Oxford-shire C). After a complete description of the study to the participants, written, informedconsent was obtained. Participants subsequently completed the following measures ina quiet testing room at Guy’s Hospital, London. The measures were administered in afixed order which began with the completion of questionnaires (DASS, OCI, EDE-Q) andinterviews (EDE and SCID), followed by the National Adult Reading Test (NART), WCST,Pictorial Stroop Task, GEFT, FPT, Rey Osterrieth Complex Figure, the Reading the Mindin the Eyes task, and the Brixton Task, described below. The testing session took up to1.5 hr and participants were offered rest breaks whenever required. To reduce cognitivedemand on the day of testing, participants were asking to complete the questionnairesthe week before they came in to complete the other measures.


MeasuresThe measures were selected based on a variety of factors, including sensitivity within anED group demonstrated in systematic reviews by Lopez, Tchanturia, Stahl, & Treasure(2008) and Roberts et al. (2007), cost and availability, with the aim of assessing setshifting and coherence and social emotional functioning in a relatively broad fashion,considering construct validity and reliability, whilst also considering patient burden.

Social emotional measuresThe Pictorial Stroop Task (Ashwin et al., 2006) was used to measure attentional biases tosocial affective cues and the response times of participants to say the colour (red, yellow,blue, or green) of angry and neutral faces, as well as chairs presented are measured usinga computer programme called DMDX (Forster & Forster, 2003). The outcome measureswere an attentional bias to social stimuli (faces) and an attentional bias to angry-threatstimuli (angry faces). The Reading the Mind in the Eyes Task (Baron-Cohen et al., 2001)was used to measure emotion recognition and requires the participant to select fromfour options the emotion depicted in 36 sets of eyes, with the outcome measure beingthe percentage of correct responses.

Set shifting/coherence measuresThe WCST (Computerized version by Heaton et al., 1993), was used as a measure ofset shifting, in which participants are required to sort a series of cards based on arule they must learn and the sorting strategy must be adapted when the rule changes.The number of perseverative errors was used as the outcome measure. The Brixton Task(Burgess & Shallice, 1997) was also used to measure set shifting, and requires participantsto predict the movement of a blue circle across 10 different positions, adapting theirpredictions as the pattern of movement changes. The number of errors was used as theoutcome measure. To explore the concept using a broad approach, two, rather thanone measures aiming to assess set shifting were used. A confirmatory factor analyticstudy (Greve, Stickle, Love, Bianchini, & Stanford, 2005) found that the WCST is a goodmeasure of general executive functioning with one of its potential outcome measuresrelating to difficulties switching set; thus to complement this measure, the Brixton Task,arguably a more simple and focused measure of basic rule attainment and switchingwas also administered. Using another measure in addition to the Brixton Task was alsodeemed necessary as Roberts et al.’s (2007) systematic review showed this task has onlya small effect size for this patient group.

The coherence measures included the FPT (Snodgrass et al., 1987) to measureglobal integration, in which participants are requested to identify line drawings thatappear on a computer screen initially in a highly fragmented state and graduallybecome more complete. The outcome measure was the mean frame at which thepicture was correctly identified. The Rey–Osterrieth Complex Figure Task (RCFT) CopyAdministration (Osterrieth, 1944) in which participants were instructed to copy thecomplex figure and the central coherence index, as calculated by Booth (2006) wasused as the outcome measure to assess whether the participant used a detailed or globalstrategy. Finally, the GEFT (Witkin, Oltman, Raskin, & Karp, 2002) was used to measuredetail processing and participants were instructed to search for a simple shape hiddenwithin a complex shape. The median response latency was the outcome measure.


Clinical/demographic measuresThe Depression, Anxiety and Stress Scale (DASS-21) – 21 Item Version (Lovibond &Lovibond, 1995) was used to measure self-reported levels of depression and anxiety, theObsessive Compulsive Inventory (OCI) Revised (Foa et al., 2002) was used to measureobsessive compulsive symptomatology, the EDE-Q (Fairburn and Beglin, 1994) was usedto assess eating disorder behaviours and cognitions, and the NART (Nelson & Willison,1991) was used as an estimate of IQ.

Data analysis

Exploring the data for assumptions of normal distributionThe data were assessed for normal distribution using Kolmogorov–Smirnov tests. TheStroop task, Reading the Mind in the Eyes Task, WCST, Brixton Task, and GEFT were notnormally distributed, whereas the FPT and RCFT were normally distributed.

As the majority of the data were not normally distributed, Spearman’s Rho CorrelationCoefficients were used to explore associations between the emotional and cognitivetasks, controlling for anxiety and depression. A Bonferroni correction was applied tocorrect for multiple testing (0.05/9 = 0.005). To address hypothesis 1, a PCA wassubsequently carried out using the entire sample (n = 225) to increase power in linewith Nunnally’s (1978) recommendation that adequate power is obtained when thereare >10 participants per variable. All set shifting (Brixton Task number of errors, WCSTnumber of perseverative errors), coherence (FPT mean number of frames required toidentify pictures, GEFT median response latency, RCFT central coherence index), andsocial emotional (Stroop social attentional bias, Stroop angry-threat attentional bias andReading the Mind in the Eyes Task percentage of correct responses) variables wereentered into the PCA (total number of variables = 8). The decision to continue withPCA was based on an examination of whether Bartlett’s test of sphericity was significant,whether the Kaiser–Meyer Olkin measure of sampling adequacy was >0.05, based onKaiser (1974) and whether each variable correlated with one other variable >0.5 (Field,2005; Kaiser, 1974). Components with eigen values >1 on the Scree Plot and abovethe point of inflexion of the curve (Cattell, 1966) were selected and interpretation ofthe components was carried out by examining the correlation of each variable witheach of the three components. The component structure was extracted using theVarimax with Kaiser Normalization rotation method, recommended by Field (2005).To assess how those in the ED and recovered groups scored on these three compo-nents compared to HCs, composite variables were constructed by multiplying eachparticipant’s raw score for each of the eight variables by the eigen vector (correlationof the variable with the component) for each of the components. The analysis planwas to explore the data first using a trans-diagnostic approach to enhance power andexplore potential trans-diagnostic factors, followed by comparisons between diagnosticsubgroups.

The PCA is followed by an exploration of extreme scorers (those scoring in the10th or 90th percentile, depending on whether a high or a low score indicates moreadaptable functioning) on the components extracted from the PCA and illness features,such as years of illness and EDE-Q global score. This analysis was carried out to addresspredictions from hypothesis 3 that having the least adaptive cognitive style and socialemotional profile would be associated with a more chronic and severe form of the illness.


ResultsThe final sample consisted of 225 female participants: 100 with EDs; 50 with BN and50 with AN (15 had the binge-purge subtype and 35 had the restricting subtype), 35recovered from AN, and 90 HCs. Clinical and demographic data are provided in Table 1.

Table 2 provides information regarding the magnitude of effect for clinical groupsin comparison to the control group for the set shifting, coherence and social emotionalmeasures for the ED, recovered, and HC groups. To aid interpretation, effect sizesare reported categorically, rather than numerically, as Cohen’s D (Cohen, 1988, 1992)(mean1 −mean2/pooled standard deviation) was calculated for normally distributed data(with an effect size of 0.2 defined as small, 0.5 defined as medium, and 0.8 defined aslarge) (Cohen, 1992) and Rosenthal’s r (Rosenthal, 1991) (z score/n) was used as anestimation of effect size for non-normally distributed data, with an effect size of 0.1defined as small, 0.3 defined as medium, and 0.5 defined as large.

Analysis 1: Correlations between social emotional functioning and cognitive skills

Associations within the three domains: Set shifting, coherence, and social emotional functioningA correlation analysis was carried out for the entire sample exploring differences withinthe three domains from which data were collected: set shifting, coherence, and socialemotional functioning. The results did not differ whether or not depression and anxiety,measured using the DASS-21, were controlled for.

Set shifting tasks. The WCST and the Brixton Task were positively correlated (Spear-man’s Rho = −0.282, p ≤ .05), such that a higher number of perseverative errors on theWCST were associated with a higher number of errors on the Brixton Task.

Coherence tasks. There were no significant correlations between the three coherencetasks Rey-Osterrieth Complex Figure Task (RCFT), FPT, and GEFT.

Social emotional functioning measures. The two outcome measures from the StroopTask (social and angry-threat attentional bias) were significantly and positively correlated(Spearman’s Rho = 0.417, p = .01), with higher response latencies for social stimuli(angry and neutral faces compared to chairs) associated with higher responses latenciesfor angry-threat (angry faces compared to neutral faces) stimuli. The Reading the Mindin the Eyes task did not correlate with the Stroop outcome measures.

Associations between the three domains: Set shifting, coherence, and social emotional functioningAssociations between set shifting, coherence, and social emotional functioning taskswere explored for the entire sample. The results did not differ whether or not depressionand anxiety, measured using the DASS-21, were controlled for.

There was a small, significant negative correlation between the WCST and the Readingthe Mind in the Eyes Task (Spearman’s Rho = −0.281, p = .05), such that a greaternumber of perseverative errors on the WCST (indicating greater set shifting difficulties)was associated with a lower number of correct responses on the Reading the Mind inthe Eyes Task (indicating greater emotion recognition difficulties).


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sure

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48)

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nm

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111.

4(8

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109.

7(6

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109.

1(8

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112.

3(7

.4)

F(3,

177)

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3,p

=.0

79t=

−1.4

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185,

p=

.155

t=−1

.6,d

f=96

,p

=.1

14t=

1.2,

df=

82,

p=

.238

t=−2

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f=12

2,p

=.0

96

Year

sof

educ

atio

nM

ean

(SD

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15.1

2(1

.88)

15.9

(2.3

9)16

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.12)

15.9

(2.0

9)F(

3,18

4)=

1.6,

p=

.198

t=−2

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f=18

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df=

96,

p=

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t=−2

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Table 2. Effect sizes for the set shifting, coherence and social emotional tasks comparing the eatingdisorder, recovered, and healthy control groups

effect size (each group compared to HCs)

Task ED AN BN Recovered AN

Set shifting tasks

Brixton task + + + + + + + +Wisconsin card sort task + + + + + + + +

Coherence tasksRey-Osterrieth complex figure task + + + + + + + + + + +Fragmented pictures task + + + + + + + +Group embedded figures task + + + + + + + + +

Social emotional tasksSocial attentional bias + + + + + + + + + +Angry-threat attentional bias + + + + + + + + + + + +Reading the mind in the eyes task + + − +

Note. ED, eating disorder; AN, anorexia nervosa; BN, bulimia nervosa; HC, healthy controls. Effectsizes: − = negligible effect compared to HCs. + = small effect size compared HCs. + + = mediumeffect size compared to HCs. + + + = large effect size compared to HCs.

There was a small significant negative correlation between the GEFT and the WCST(Spearman’s Rho = −0.274, p = .05), such that a shorter response latency on theGEFT (indicating a superior detail focus ability) was associated with a greater number ofperseverative errors on the WCST (indicating greater difficulties with set shifting).

In summary, the correlation analysis indicates that the associations between thethree sets of measures (coherence, set shifting, and social emotional functioning) arerelatively weak, and indeed these associations are not significant once a Bonferronipost hoc correction for multiple testing was applied. The Spearman’s Rho correlationcoefficients are displayed in Table 3.

Analysis 2: Principle components analysis of social emotional functioning, setshifting, and coherence variablesThree components emerged from the data and these were labelled as: fragmentedperseverative (component 1), reflecting a cognitive style characterized by detail focusand global integration difficulties and rigidity, global flexible (component 2), reflectinga cognitive style characterized by strong global integration and flexibility, and socialemotional difficulties (component 3), reflecting difficulties with social emotionalfunctioning.

Analysis of composite variablesAfter calculating composite variables, the composites were assessed for assumptions ofnormal distribution using Kolmogorov–Smirnov Tests. The fragmented perseverativecomposite was not normally distributed and therefore medians and interquartile range(IQR) are reported. The global flexible and social emotional difficulties compositeswere normally distributed, so means and standard deviations are reported. For normally


Table 3. Correlation coefficients for the relationship between set shifting, coherence, and socialemotional functioning variables

Brixtontask

WCST per-severative

errors GEFTFragmented

pictures

Rey-Osterriethcomplex

figure task

Eyes taskpercent-

agecorrect

Stroop:Social at-tentional

bias

Stroop:Angry at-tentional

bias

Brixton task 1.000 .282∗

.048 .183 −.041 −.086 .201 .044WCST per-

severativeerrors

1.000 .274∗

.158 −.141 −.281∗ .240 .162

GEFT 1.000 .171 .065 .049 .104 −.089Fragmented

pictures1.000 −.070 −.155 .075 .125

Rey-Osterriethcomplexfigure task

1.000 −.018 −.098 −.148

Eyes taskpercentagecorrect

1.000 −.001 −.065

Stroop:Socialattentionalbias

1.000 .417∗ ∗

Stroop:Angryattentionalbias

1.000

Note. ∗p = .05; ∗∗p = .01; WSCT, Wisconsin card sort task.

distributed data, analyses of variance (ANOVAs) are reported below, with Bonferronicorrected post hoc tests. For non-normally distributed data, Kruskall–Wallis tests arereported below, with Bonferonni corrected post hoc tests.

The results of the composite variable analysis are displayed in Table 4.

Fragmented perseverative cognitive style. The ED group scored significantly higherthan HCs for the fragmented perseverative cognitive style with a medium effect size(r = 0.35). The recovered group also scored significantly higher than HCs, with a mediumeffect size. There was no difference between the ED and recovered groups.

Global flexible cognitive style. The ED group scored significantly lower than HCs, globalflexible cognitive style with a medium effect size (d = 0.62). The recovered group scoredsignificantly lower than HCs, with a medium effect size. There was no difference betweenthe ED and recovered groups.


Table 4. Scores for the fragmented perseverative, global flexible and social emotional compositevariables for the eating disorder, healthy control, and recovered groups

ED Recovered HC Test ED vs. ED vs. Rec vs.group group group statistic HC Rec HC

Fragmentedpersevera-tivemedian/IQR

19.3(14.4–21.3)

16.2(12.7–20.4)

13.2(11.2–14.4)

� 2 = 22.8,df = 2,p ≤ .001

U = 1036.5,p ≤ .001

U = 969.5,p ≤ .199

U = 636,p ≤ .018

Globalflexiblemean/SD

−0.4 (5.5) −0.04 (6.2) 3.41 (5.2) F(2,122) =5.7,p = .004.

t = −3.5,df = 188,p = .001

t = −0.4,df = 86,p = .683

t = −2.3,df = 59,p = .028

Socialemotionaldifficultiesmean/SD

1675.3(536.1)

1542.6(308.2)

1252.7(430.6)

F(2,122) =17.9, p ≤.001.

t = 5.7,df = 188,p ≤ .001

t = 1.317,df = 188,p = .190

t = 3.4,df = 188,p = .001

Note. ED, eating disorder; HC, healthy control; Rec, recovered group; IQR, interquartile range; SD,standard deviation. Test statistics are Kruskall–Wallis tests (fragmented perseverative) followed byBonferroni corrected post hoc tests (Mann–Whitney U) and ANOVAs (global flexible and emotionalfunctioning difficulties), followed by Bonferroni corrected post hoc tests (t-tests).

Social emotional difficulties profile. The ED group scored significantly higher than HCs,for the social emotional difficulties profile with a medium effect size (d = 0.86). Therecovered group scored significantly higher than HCs, with a medium effect size. Therewas no difference between the ED and recovered groups.

The radar chart in Figure 1, represents graphically how the three groups performedacross the three domains of fragmented perseverative, global flexible, and socialemotional difficulties. The data were converted to z scores (z = (x – �)/�), to permitthe same scale to be used for all three cognitive/social emotional styles.

Subtypes analysisThe diagnostic subtypes [restricting anorexia nervosa (RAN), binge purge anorexianervosa (BPAN), and BN] did not differ significantly for the fragmented perseverativecognitive style (F(2.98) = 0.157, p = .855), the global flexible cognitive style (F(2,98) =0.107, p = .898), or the emotional functioning difficulties profile (F(2, 98) = 0.48, p =.543).

Extreme scores analysis in the ED groupsTo further explore the clinical and demographic variables associated with the leastadaptive cognitive or emotional styles, the ED sample was split according to whetherparticipants scored in the extreme range of the composite variables. The extreme rangewas defined as scoring in the 90th percentile of HC data for the fragmented perseverativecognitive style and the emotional functioning difficulties profile, as scoring highon these components was related to a less adaptive cognitive/emotional profile. Theextreme range was defined as scoring in the 10th percentile of HC data for the globalflexible cognitive style, as scoring low on this component was related to a less adaptivecognitive style.


Figure 1. Radar chart illustrating the performance of the eating disorder, healthy control, andrecovered groups for the inflexible fragmented, flexible global, and emotional functioning difficultiescognitive/emotional styles.

Scoring in the extreme range on more than one cognitive or social emotional style:Eating disorder groupThe Venn diagram in Figure 2 provides the percentage of participants in the ED groupwho scored in the extreme range for either one of the cognitive styles or social emotionaldifficulties profile, as well as in two or more of these domains. The diagram is taken froman applet designed by Chow and Rodgers (2005) and represents the approximate areafor each zone based on the population values (given in percentages).

As illustrated in Figure 2, a subgroup of those in the ED group (11%) had extremescores for all three components. Three of these patients were outpatients with BN; twowere outpatients with RAN; two were outpatients with BPAN, and four were inpatientswith RAN. The following section will explore whether being in this subgroup is relatedto particular illness characteristics, such as severity or chronicity.

Scoring in the extreme ranges for the fragmented perseverative, global flexiblecognitive styles, and social emotional difficulties profileThose in the ED group were divided according to whether they scored in the extremeranges for all of the three dimensions (n = 11, 11%) or not (n = 81, 81%) and comparedon measures of severity, chronicity, and comorbidity.


Figure 2. A Venn diagram to illustrate the percentage of participants in the eating disorder groupscoring in the extreme range for the cognitive styles and social emotional profile.

Table 5. Differences in clinical variables between those in the ED group scoring in the extreme rangefor all components and participants who did not

Extreme Not scoringscores for all in the extreme range Testcomponents for all components statistic

Length of illness (years) mean (SD) 8.3 (4.7) 5.5 (3) t = 2.7, df = 88.5, p = .009Current BMI 16.3 (2.5) 18.6 (3.6) t = −2.5, df = 98, p = .003EDE-Q global score 4.9 (0.8) 4.6 (1.1) t = −2.4, df = 98, p = .02Lowest ever BMI 13.9 (2.7) 15.9 (4.5) t = 2.1, df = 41.2, p = .04OCI 24.6 (4.2) 17.5 (3.2) t = 1.8, df = 98, p ≤ .001

Note. SD, standard deviation; BMI, body mass index; EDE-Q, eating disorders examination questionnaire;OCI, obsessive compulsive inventory.

As indicated in Table 5, those with the most fragmented perseverative cognitive style,the least global flexible cognitive style, and the most social emotional difficulties had amore chronic (longer length of illness) and more severe form of the ED (higher EDE-Qglobal score, lower BMI, lower lifetime BMI), with a higher level of obsessive compulsivesymptoms compared to those who did not. There were no differences between groupsregarding depression and anxiety, as measured by the DASS-21.


DiscussionThis study aimed to explore the factor structure of coherence, set shifting, and emotionalfunctioning, in order to investigate the performance of people with EDs and those inrecovery across these domains, compared to HCs. The first hypothesis, which was thatthe cognitive and social emotional variables would be psychometrically separated, wassupported by the data. There were no significant correlations between the cognitiveand social emotional functioning domains and the PCA identified three independentcomponents; a fragmented perseverative cognitive style, global flexible cognitive style,and a social emotional difficulties profile. This parsimonious approach to the datapermitted further predictions to be explored, as explained below.

The second hypothesis was that people with EDs would show difficulties withsocial emotional functioning and a cognitive style comprising of a focus on detail, poorglobal integration of information, and poor flexibility. This hypothesis was supportedby the data. Those with EDs scored significantly higher than HCs for the fragmentedperseverative cognitive style, with a medium effect size, significantly lower than HCsfor the global flexible cognitive style, with a medium effect size and significantly higherthan HCs for the social emotional difficulties profile, with a large effect size.

The third hypothesis was that a less adaptive cognitive style and social emotionalprofile would be a trait associated with EDs, such that it would be present in thoserecovered from an ED, and a maintaining factor, such that having the least adaptivecognitive style would be associated with a more chronic and severe form of theillness. This hypothesis was supported by the data, as there was no difference betweenthe recovered and acute ED groups for either of the cognitive styles, nor the socialemotional difficulties profile. Demonstrating the least adaptive profile (scoring in the90th percentile for the fragmented perseverative cognitive style, or scoring in the 10thpercentile on the global flexible cognitive style, as well as scoring in the 90th percentilefor the social emotional difficulties profile) was associated with a more severe andchronic form of the illness.

The findings provide support for maintaining role of cognitive style and socialemotional difficulties in EDs, proposed by Schmidt and Treasure (2006), as those withthe most extreme scores on the perseverative fragmented cognitive style, with poorglobal flexible skills, and social emotional difficulties had a more severe and chronicform of the illness.

In line with Schmidt and Treasure’s (2006) model and Treasure, Claudino, and Zucker(2010), it may be that a fragmented perseverative cognitive style and social emotionaldifficulties are also traits present in people with a history of EDs, which contribute toa vulnerability to developing an ED, as this profile was also present in the recoveredgroup. A vulnerability to social emotional difficulties may contribute to the interpersonalproblems proposed by Schmidt and Treasure (2006) to maintain the illness. Where theindividual has extreme levels of difficulties in both these domains, they may becomepowerful maintaining forces, hence the more severe and chronic illness characteristicsin this group. Longitudinal studies, such as Gillberg et al. (2010) who found executivefunctioning and mentalizing difficulties persisted in women with AN after 18 years follow-up would be useful to explore this finding further. This methodology would allow usto assess whether the cognitive/social emotional style is a predisposing and maintainingfactor, or a scar of the illness.

These findings imply that successful interventions targeting the maintaining factorsof EDs should include both cognitive and social emotional factors as treatment targets.


The data suggest that emotion focused cognitive therapy, described by Power (2010)may be helpful and it may also be beneficial to combine emotion focused therapy,described, for example, by Dolhanty and Greenberg (2009) with cognitive remediationtechniques, described by Tchanturia and Davies (2010) aimed at increasing flexibilityand global integration. Components of dialectical behaviour therapy programmes mayalso be applicable.

These findings corroborate those reported by Compton et al. (2004) in individualswith depression, the work of Burnette et al. (2005), Dworzynski et al. (2009), andSouth, Ozonoff, and McMahon (2007) in the field of autism spectrum disorders andLeerkes et al., (2008) work in infants who found that cognitive and social emotionalfunctioning were psychometrically separated. These findings, alongside those reportedin this study are not supported by Constantino et al. (2004), who applied PCA to socialfunctioning, as measured by the Social Responsiveness Scale (Constantino, 2002) andflexibility, as measured by the Autism Diagnostic Interview (Revised) (Lord, Rutter, &Le Couteur, 1994) and found social functioning and flexibility did not separate into twodimensions, but instead were part of a single, underlying factor. However, it is notablethat this negative finding is supported by self-report methodology, whereas the otherstudies primarily included experimental measures.

There are a number of limitations to consider. Generalization of the findings maybe limited by the relatively small battery of neuropsychological and social emotionaltasks used. While the measures were selected to explore the cognitive styles and socialemotional difficulties previously found to be associated with EDs, there may be othercognitive or social emotional difficulties relevant to this patient group that were notmeasured in the study. However, the reasonably small battery of tasks used may makefuture replications more possible concerning research time and cost implications.

It should be acknowledged that a narrow category of social emotional functioningskills was assessed and future work should aim to encompass a broader range of skills.It was a limitation that participants in the recovered group self-reported a previoushistory of AN and the methodology would have been strengthened by referring to theirpast medical records to confirm this diagnosis. The findings are limited to women,and further work should be carried out to explore whether the same cognitive/socialemotional styles are present in men with EDs. It was difficult to recruit a recovered BNgroup due to low interest despite widespread advertising of the study, and thereforeonly recovered AN participants were included in the study. The tests were provided in afixed order and therefore a bias due to the order of representation cannot be excluded.Additionally, patient fatigue may have been a confounding variable. Future work wouldbe improved through the inclusion of this diagnostic group. In addition, it would havebeen useful to have included a clinical control group to explore the specificity of thefindings, as well as measures of personality, such as obsessive compulsive personalitydisorder (OCPD) traits. In addition, the percentile criterion used for the extreme scoresanalysis meant that the groups were of unequal sample size, which may have reducedpower and this should be taken into account when interpreting the findings. Finally, anexclusion criterion for the HC group was a history of psychiatric disorder and this maynot be representative of the broader population.

In conclusion, cognitive and social emotional functioning may be separate com-ponents of functioning. People currently ill with, and recovered from EDs have afragmented perseverative cognitive style with social emotional difficulties. However,HCs tend towards a global flexible cognitive style, with fewer social emotionaldifficulties. This is consonant with Schmidt and Treasure’s (2006) cognitive interpersonal


model in that a rigid cognitive style with social emotional difficulties is associated with amore persistent and severe form of illness. Specific treatments may need to be developedfor this subgroup of patients. Future work should use a longitudinal design to explorewhether these cognitive/social emotional styles are an endophenotype of EDs.

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Received 9 September 2010; revised version received 29 September 2011

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