Abstract

The neuropsychological profile of a sample of 155 patients with a clinical diagnosis of anorexia nervosa was assessed using a test battery specifically developed for such patients. The current findings suggest that the patients display a common neuropsychological profile including both strengths and weaknesses when compared with published norms. The patients displayed good verbal fluency skills, but performed poorly on tests of visuospatial memory, associated with relatively weak central coherence. They were within the average range on the assessment of executive functioning except for one measure of set-shifting. This study provides a valuable point of reference for clinicians when considering treatment options.

Introduction

Anorexia nervosa is a disorder characterized by a marked determination to lose weight, or avoid weight gain. This is accompanied by a distorted body image and a pronounced fear about eating. The patients are obsessively anxious to maintain or reduce their body weight through rigid control of their calorie intake and excessive exercise.

Over the last few years, research on brain abnormalities and neuropsychological functioning in patients with anorexia nervosa has received growing attention. Structural brain imaging studies have found ventricular enlargement and cortical atrophy in grey and white matter in patients with anorexia nervosa (Kaye, 2008). Some studies have shown that the atrophy reverses with weight restoration (Golden et al., 1996; Swayze et al., 2003), whereas other studies have reported that some regions of atrophy are slow to reverse or could be irreversible (Katzman et al., 1997; Kingston, Szmukler, Andrewes, Tress, & Desmond, 1996; Lambe, 1997; Rastam, 1994).

Functional imaging studies have generally indicated altered brain metabolism in adolescents with anorexia nervosa, and it has been suggested that these alterations in brain metabolism and brain structures are connected with cognitive deficits (Kerem & Katzman, 2003). Several studies have demonstrated cognitive dysfunction in patients with anorexia nervosa (Zakzanis, Campbell, & Polsinelli, 2010). Some of these abnormalities have been shown to persist after recovery (Gillberg et al., 2010; Tchanturia, Morris, et al., 2004) and may pre-date the onset of the eating disorder. In addition, set-shifting and weak central coherence have been demonstrated in healthy sisters of patients with anorexia nervosa, indicating that it could be an endophenotype of anorexia nervosa (Holliday, Tchanturia, Landau, Collier, & Treasure, 2005; Lopez, Tchanturia, Stahl, & Treasure, 2009; Tenconi et al., 2010).

The majority of the previous studies on cognitive dysfunction in anorexia nervosa are limited by the fact that they have been conducted on small samples, and interpretation of the findings is limited by a lack of consistency in the tests being used. The same tests are used to assess different cognitive functions and the same cognitive functions are assessed with different tests. The Ravello Profile is a neuropsychological test battery developed specifically to assess the areas of functioning that previous research has indicated could be abnormal in patients with anorexia nervosa (Rose, Davis, Frampton, & Lask, 2011). Such a battery of neuropsychological tests can be helpful in producing knowledge and understanding of cognitive strengths and weaknesses in an individual patient or a group of patients.

The aim of the present study is to explore the neuropsychological profile of a clinical sample of patients diagnosed with anorexia nervosa by applying the Ravello Profile.

Material and Methods

Participants

A total of 155 patients (148 women and 7 men) were included in the present study (mean age = 17.13, SD 3.2, range 9.5–27.1; see Table 1 for patient descriptives).

Table 1.

Patient descriptives

 n Mean SD Minimum Maximum 
Verbal IQa 155 107.7    
Performance IQa 155 103.3    
Age 155 17.1 3.2 9.5 27.1 
BMI 142 16.3 2.0 11.9 21.6 
Eating disorder psychopathology 
 EDE-Q global raw score 118 3.7 1.4 0.0 5.7 
Anxiety 
 STAI-S t-scores 79 60.1 12.1 21.0 87.0 
 STAI-T t-scores 79 64.8 12.2 38.0 90.0 
Obsessions-compulsions 
 ChOCI/Y-BOCS global raw score 108 20.3 11.5 0.0 42.0 
Depression 
 BDI raw scores 75 31.1 13.3 55 
 CDI t-scores 45 70.0 15.7 36 92 
 n Mean SD Minimum Maximum 
Verbal IQa 155 107.7    
Performance IQa 155 103.3    
Age 155 17.1 3.2 9.5 27.1 
BMI 142 16.3 2.0 11.9 21.6 
Eating disorder psychopathology 
 EDE-Q global raw score 118 3.7 1.4 0.0 5.7 
Anxiety 
 STAI-S t-scores 79 60.1 12.1 21.0 87.0 
 STAI-T t-scores 79 64.8 12.2 38.0 90.0 
Obsessions-compulsions 
 ChOCI/Y-BOCS global raw score 108 20.3 11.5 0.0 42.0 
Depression 
 BDI raw scores 75 31.1 13.3 55 
 CDI t-scores 45 70.0 15.7 36 92 

Notes: n = number of participants; SD = standard deviation; IQ = intelligence quotient; BMI = body mass index, (weight/m²); EDE-Q = Eating Disorders Examination Questionnaire; STAI-S/T = State-Trait Anxiety Inventory-Strait/Trait; ChOCI = Children's Obsessional Compulsive Inventory; Y-BOCS = Yale-Brown Obsessive Compulsive Scale; BDI = Beck Depression Inventory; CDI = Children's Depression Inventory.

aFigures are prorated from the Wechsler tasks.

The participants meeting the inclusion criteria of an age range between 9 and 27 were selected from a database consisting of 295 patients with eating disorders who have participated in a multicenter study of neuropsychological functioning assessed with the Ravello Profile. Twelve eating disorders treatment centers in the United Kingdom and Norway participated in the study (Table 2).

Table 2.

Characteristics of collaborating sites and number of patients

  Diagnosis
 
 
 Site AN AN-R AN-B/P Total 
United Kingdom Independent Specialist Inpatient Unit 11 
Independent Specialist Inpatient Unit 19 25 
Independent Specialist Inpatient Unit 26 26 
Independent Specialist Inpatient Unit 25 25 
NHS Outpatient Service 
NHS Specialist Inpatient Unit 
Independent Outpatient Service 
NHS Outpatient Service 12 
Norway Specialist Inpatient Unit 25 44 
Child and Adolescent Outpatient Unit 
Total  114 31 10 155 
  Diagnosis
 
 
 Site AN AN-R AN-B/P Total 
United Kingdom Independent Specialist Inpatient Unit 11 
Independent Specialist Inpatient Unit 19 25 
Independent Specialist Inpatient Unit 26 26 
Independent Specialist Inpatient Unit 25 25 
NHS Outpatient Service 
NHS Specialist Inpatient Unit 
Independent Outpatient Service 
NHS Outpatient Service 12 
Norway Specialist Inpatient Unit 25 44 
Child and Adolescent Outpatient Unit 
Total  114 31 10 155 

Notes: AN = anorexia nervosa; AN-R = anorexia nervosa restrictive subtype; AN-B/P = anorexia nervosa binge/purge subtype.

The anonymous results from assessment with the Ravello Profile were sent via e-mail or online registration to a central database for data analysis. Patients who did not have a complete set of scores from the full test battery were excluded from the present study. All participants were clinically diagnosed with anorexia nervosa or an anorexia nervosa subtype based on DSM-IV (American Psychiatric Association, 1994), ICD-10 (World Health Organization, 2009), or Great Ormond Street diagnostic checklist criteria, reflecting best clinical practice given the current lack of diagnostic consensus (Nicholls, Chater, & Lask, 2000). All participants had been informed of their privacy rights. Ethical approval for a multisite study was obtained through Berkshire NHS Research Ethics Committee. For centers participating in Norway, ethical approval was obtained from the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate. Regular supervision meetings were held with administrators from all participating centers to assure data quality.

The range of body mass index (BMI) of the patients in the sample is relatively wide (mean BMI = 16.31, SD 1.95, range 11.94–21.62) due to the patients being in weight restoration treatment at the time of assessment and, thus, having reached a normal BMI. They still met the inclusion criteria for this study if the anorexia nervosa diagnosis was made by an eating disorder specialist.

Neuropsychological Assessment

The Ravello Profile consists of the following tests: Vocabulary and Matrix Reasoning from the Wechsler Intelligence Scale; Rey Complex Figure Test (RCFT); Brixton Test; Hayling Test; Verbal Fluency Tests (VFTs); Trail Making Test (TMT); and Tower Test. The Hayling Sentence Completion Test (Burgess and Shallice, 1997) is language-specific and currently only exists in English, meaning that the participants with another native tongue would be excluded due to an incomplete test profile. As participants in the present study were recruited from both the United Kingdom and Norway, results from the Hayling test are not included.

The RCFT (Meyers & Meyers, 1995) is administered to assess both visual memory and visuospatial constructional ability. The qualitative aspects of the copy performance are assessed by using a flowchart method. The examiner reproduces the patient's drawing on a separate sheet, noting the order and style in which the copy of the complex figure is completed. The drawing performance is scored in line with the Lopez and colleagues' Central Coherence Index (CCI) scoring system (Lopez et al., 2008).  This yields an Order Index score, based on the first six elements the patient chooses to draw, and a Style Index score that informs about the level of continuity in the drawing style. Finally, these two scores are used to calculate the patient's CCI score.

The Ravello Profile also consists of four tests from the D-KEFS battery (Delis, Kaplan, & Kramer, 2001), which assess areas of executive functioning, namely the TMT condition 4 (TMT4), the VFT condition 1 (VFT1) and condition 3 (VFT3), the Tower Test, and condition 3 and 4 of the Color Word Interference Test (CWI3 and CWI4). The Brixton Spatial Anticipation Test (Burgess & Shallice, 1997) is a rule attainment task considered to evaluate behavioral regulation (Strauss, Shermann, & Spreen, 2006). The total number of errors is recorded, and the raw scores are used for analysis.

Vocabulary and Matrix Reasoning from the Wechsler measurements are included in the Ravello Profile as an indication of general verbal and non-verbal abilities. The clinics involved in the study have employed either the Wechsler Abbreviated Scales of Intelligence (Wechsler, 1999) or the Wechsler Adult Intelligence Scale-Third Edition (Wechsler, 1997) versions of the two tests. As Vocabulary and Matrix Reasoning correlate significantly, .88 and .66, respectively, in the two different versions (Wechsler, 1999), the scores are combined in the present study.

The Ravello Profile assessment was conducted by a researcher or clinician with special training in administration and scoring of the Ravello Profile under the supervision of a clinical psychologist. Time taken to complete the test battery was ∼1.5 h. The participants were tested individually. In line with the Ravello Profile manual (www.ravelloprofile.org), the test administrators were encouraged to make sure that the primary focus when administering the tests was the patient's ability. This means that the order of the administration can vary and in some instances might be conducted over several days. The individual Ravello Profile subtests were administered as described by the manual, and special caution was taken to make sure that no visuospatial tasks were administered between the RCFT Copy and Recall Trials, as this potentially could interfere with the recollection of the figure.

Statistical Analysis

Statistical analyses were conducted using the statistical package PASW statistics, version 18.0.3 (SPSS Inc., Chicago, IL, USA). Raw scores obtained on each of the tests were standardized using the published age-based norms for Scandinavia or the United Kingdom (for information on the demographic characteristics of the standardization samples, reference the applicable test manuals). For the purposes of data analysis, all neuropsychological test scores were standardized to z-scores (with a mean of zero and a SD of 1). This was done by calculating the difference between each raw score in the anorexia nervosa sample and the mean score in the respective norm sample, and then dividing the difference by the standard deviation of the norm sample's scores. For the Brixton test and the Central Coherence measurements, 66 healthy controls (mean age 15.4, SD 3.6) were collected from a high school in the United Kingdom and from two colleges and a university in Norway as the published control group scores for these two tests are intended for an adult population. Thus, for patients under the age of 18, the collected scores were used for standardization for the two above-mentioned tests. Higher scores indicate better performance. The direction of the scores was reversed for tests where this is not the case. In order to determine whether the means for the patient group differed significantly from normative test means, a single-sample two-tailed t-test was computed. An independent samples two-tailed t-test was performed to compare underweight patients to the patients with anorexia nervosa with a normal BMI (n = 108 and n = 34, respectively).

Results

Scaled scores on neuropsychological tests are presented in Table 3.

Table 3.

Neuropsychological test performance scores, anorexia nervosa sample

Test n Mean SD Minimum Maximum 
Performance IQ 
 Wechsler Matrix Reasoning 155 10.65 3.14 1.30 16 
Verbal IQ 
 Wechsler Vocabulary 155 11.52 3.12 2.50 19 
Visuospatial Memory 
 RCFT Immediate Recalla 155 42.83 13.06 19 70 
 RCFT Delayed Recalla 155 41.96 13.08 19 68 
Verbal Fluency 
 VFT1 155 12.70 3.73 19 
 VFT3 155 13.67 4.12 19 
Executive Function 
 TMT4 155 9.34 2.96 17 
 Tower Test 155 10.01 2.58 19 
 CWI3 155 10.72 3.09 16 
 CWI4 155 10.17 3.21 15 
Test n Mean SD Minimum Maximum 
Performance IQ 
 Wechsler Matrix Reasoning 155 10.65 3.14 1.30 16 
Verbal IQ 
 Wechsler Vocabulary 155 11.52 3.12 2.50 19 
Visuospatial Memory 
 RCFT Immediate Recalla 155 42.83 13.06 19 70 
 RCFT Delayed Recalla 155 41.96 13.08 19 68 
Verbal Fluency 
 VFT1 155 12.70 3.73 19 
 VFT3 155 13.67 4.12 19 
Executive Function 
 TMT4 155 9.34 2.96 17 
 Tower Test 155 10.01 2.58 19 
 CWI3 155 10.72 3.09 16 
 CWI4 155 10.17 3.21 15 

Notes: Scaled scores. n = number of participants; SD = standard deviation; RCFT = Rey Complex Figure Test; IQ = intelligence quotient; VFT1 = Verbal Fluency Test condition 1; TMT4 = Trail Making Test condition 4; CWI3 = Color Word Interference Test condition 3; CWI4 = Color Word Interference Test condition 4.

at-scores.

Raw scores for patients and the comparison group on the RCFT central coherence measures and the Brixton test are reported in Table 4.

Table 4.

Raw scores, anorexia nervosa and healthy control samples

 Test n Mean SD Minimum Maximum 
Anorexia Nervosa 
 <18 years of age RCFT Order of Construction Index 114 1.95 0.73 0.15 3.33 
RCFT Style Index 114 1.10 0.49 0.00 2.17 
RCFT Central Coherence Index 114 1.16 0.39 0.18 1.91 
Brixton 114 12.39 5.72 47 
 >18 years of age RCFT Order of Construction Index 41 1.88 0.60 0.50 2.84 
RCFT Style Index 41 1.23 0.41 0.50 2.30 
RCFT Central Coherence Index 41 1.20 0.34 0.40 1.74 
Brixton 41 12.66 4.73 31 
Healthy Controls 
 <18 years of age RCFT Order of Construction Index 66 1.88 0.68 0.50 3.30 
RCFT Style Index 66 0.98 0.48 0.00 1.83 
RCFT Central Coherence Index 66 1.06 0.42 0.25 1.75 
Brixton 66 11.18 3.10 19 
 Test n Mean SD Minimum Maximum 
Anorexia Nervosa 
 <18 years of age RCFT Order of Construction Index 114 1.95 0.73 0.15 3.33 
RCFT Style Index 114 1.10 0.49 0.00 2.17 
RCFT Central Coherence Index 114 1.16 0.39 0.18 1.91 
Brixton 114 12.39 5.72 47 
 >18 years of age RCFT Order of Construction Index 41 1.88 0.60 0.50 2.84 
RCFT Style Index 41 1.23 0.41 0.50 2.30 
RCFT Central Coherence Index 41 1.20 0.34 0.40 1.74 
Brixton 41 12.66 4.73 31 
Healthy Controls 
 <18 years of age RCFT Order of Construction Index 66 1.88 0.68 0.50 3.30 
RCFT Style Index 66 0.98 0.48 0.00 1.83 
RCFT Central Coherence Index 66 1.06 0.42 0.25 1.75 
Brixton 66 11.18 3.10 19 

Notes: Raw score patients over and under the age of 18. n = number of patients; SD = Standard Deviation; RCFT = Rey Complex Figure Test; RCFT = Mean score; Brixton = Raw score total errors.

Comparison between the anorexia nervosa sample and the comparison data are summarized in Table 5. The mean z-score for each test is equivalent to Glass' effect size. The z-score profile of the patients on these measures is presented in Fig. 1.

Table 5.

Performance of the anorexia nervosa sample relative to comparison data

Test n Mean SD t-value 
Performance IQ 
 Wechsler Matrix Reasoning 155 0.22 1.05 2.57* 
Verbal IQ 
 Wechsler Vocabulary 155 0.51 1.04 6.05*** 
Visuospatial Memory 
 RCFT Immediate Recall 155 −0.72 1.31 −6.83*** 
 RCFT Delayed Recall 155 −0.80 1.31 −7.65*** 
Visuospatial Processing 
 RCFT Order of Construction Index 155 −0.37 1.40 −3.32** 
 RCFT Style Index 155 −0.31 1.35 −2.84** 
 RCFT Central Coherence Index 155 −0.25 1.19 −2.63** 
Verbal Fluency 
 VFT1 155 0.90 1.24 9.02*** 
 VFT3 155 1.22 1.37 11.08*** 
Executive Functioning 
 Brixton 155 −0.06 1.53 −0.49 
 TMT4 155 −0.22 0.99 −2.79** 
 Tower Test 155 0.00 0.86 0.68 
 CWI3 155 0.24 1.03 2.88** 
 CWI4 155 0.06 1.07 0.62 
Test n Mean SD t-value 
Performance IQ 
 Wechsler Matrix Reasoning 155 0.22 1.05 2.57* 
Verbal IQ 
 Wechsler Vocabulary 155 0.51 1.04 6.05*** 
Visuospatial Memory 
 RCFT Immediate Recall 155 −0.72 1.31 −6.83*** 
 RCFT Delayed Recall 155 −0.80 1.31 −7.65*** 
Visuospatial Processing 
 RCFT Order of Construction Index 155 −0.37 1.40 −3.32** 
 RCFT Style Index 155 −0.31 1.35 −2.84** 
 RCFT Central Coherence Index 155 −0.25 1.19 −2.63** 
Verbal Fluency 
 VFT1 155 0.90 1.24 9.02*** 
 VFT3 155 1.22 1.37 11.08*** 
Executive Functioning 
 Brixton 155 −0.06 1.53 −0.49 
 TMT4 155 −0.22 0.99 −2.79** 
 Tower Test 155 0.00 0.86 0.68 
 CWI3 155 0.24 1.03 2.88** 
 CWI4 155 0.06 1.07 0.62 

Notes: Z-transformed scores. n = number of participants; SD = standard deviation; RCFT = Rey Complex Figure Test; IQ = intelligence quotient; VFT1 = Verbal Fluency Test condition 1; TMT4 = Trail Making Test condition 4; CWI3 = Color Word Interference Test condition 3; CWI4 = Color Word Interference Test condition 4.

*p < .05.

**p < .01.

***p < .001.

Fig. 1.

Neuropsychological profile of patients with anorexia nervosa.

Fig. 1.

Neuropsychological profile of patients with anorexia nervosa.

The patients performed significantly above the normative mean on both of the Wechsler measurements (Vocabulary, t = 6.05 p ≤ .001; Matrix Reasoning, t = 2.57 p = .011) and on the two verbal fluency tasks VFT1 (t = 9.02, p ≤ .001) and VFT3 (t = 11.08, p ≤ .001). The sample mean was significantly below the normative mean on all the tasks measuring visuospatial abilities, namely RCFT Immediate recall (t = −6.83, p ≤ .001), RCFT Delayed Recall (t = −7.65, p ≤ .001), Order of Construction Index (t = −3.32, p = .001), Style Index (t = −2.84, p = .005), and the CCI (t = −2.63, p = .009). Only two of the executive functioning tasks revealed significant differences between the mean scores of patients and norms. The patients scored better than the norm sample on condition 3 of the CWI test (t = −2.88, p = .004) and worse on TMT4 (t = −2.79, p = .006). The patients performed similarly to the normative mean on the three remaining tasks (Brixton, t = −0.49, p = .623; CWI4, t = 0.68, p = .501; Tower Test, t = 0.062 p = .950).

With regard to comparison between underweight patients and those of normal weight, the independent samples t-test revealed no differences on any of the Ravello Profile tests (Vocabulary, t = 1.330, p = .186; Matrix, t = 0.499, p = .619; RCFT Immediate Recall, t = 0.202 p = .841; RCFT Delayed Recall, t = −0.006, p = .996; Order of Construction Index, t = 1.083, p = .281; Style Index, t = 1.284, p = .201; CCI, t = 1.739, p = .084; TMT, t = 0.740, p = .461; Brixton, t = −1.325, p = .187; VFT1, t = 1.869, p = .064; VFT3, t = 1.226, p = .222; CWI3, t = 1.573, p = .118; CWI4, t = 0.407, p = .685; Tower Test, t = 0.150, p = .881).

Discussion

The results suggest that patients with anorexia nervosa exhibit a common neuropsychological profile, with relative weaknesses in visuospatial memory, central coherence, and set-shifting. Conversely, the patient group performed significantly better than norms in verbal fluency.

Several studies have investigated visuospatial memory in patients with anorexia nervosa, and difficulties with both immediate and delayed recall have been demonstrated when compared with healthy controls (Lopez et al., 2008; Mathias & Kent, 1998; Sherman et al., 2006; Thompson, 1993). It is possible that this difficulty could be due to the second area of weakness identified in the profile—a limited central coherence approach to copying the figure. If the complex figure is processed in a fragmented and detail-focused manner, it is likely to also be more difficult to recall (Happe & Booth, 2008).  The participants in the present study demonstrate a lack of coherence in the drawing process of the complex figure, as measured by the CCI. The Order of Construction Index mean score of −0.40 shows that the patients are somewhat more inclined to begin the drawing process by focusing on the detailed features of the figure. In addition, their Style Index score indicates that they have a lower degree of continuity in their drawing style. These results are in line with the previous studies investigating organizational strategy and central coherence in patients with anorexia nervosa (Lopez et al., 2008; Sherman et al., 2006).

The profile also revealed a subtle deficit in set-shifting. On the TMT, the patients had a mean score of 0.22 SD points below the comparison group indicating that their set-shifting difficulties are subtle. Results from previous studies employing the TMT have been somewhat inconsistent. Some studies have reported that patients with anorexia nervosa take significantly longer to complete this task, whereas others have failed to find this difference. However, various versions of the task have been used, which could also influence the results. A meta-analysis of studies that has compared patients and controls on the TMT demonstrates that, overall, patients with anorexia nervosa take significantly longer to complete this task (Stedal, Frampton, Landrø, & Lask, 2011). This indicates some difficulties with set-shifting in patients with anorexia nervosa.

Mental flexibility (set-shifting) in patients with anorexia nervosa has also been assessed with the Brixton test in two previous studies (Tchanturia, Anderluh, et al., 2004; Tchanturia, 2004). Both of these found that patients with the anorexia nervosa score significantly lower than controls on this task. The present study did not reveal any differences between the patients and the norms on the Brixton test. This discrepancy from the two previous studies could be due to the comparison group used. The published norms for the Brixton test spans the age of 18–80; even though data were collected from a comparison control group for patients under the age of 18 for this task, it could be that there is a need to compare the patients with a larger age-matched normative group.

Previous studies assessing verbal fluency have either found no significant differences in performance between patients and controls (Hatch et al., 2010; Steinglass et al., 2006; Tchanturia, Anderluh, et al., 2004; Tchanturia, Morris, et al., 2004; Thompson, 1993) or the patients have performed significantly better than the controls (Mathias & Kent, 1998). In the present study, the patients score almost 1SD above the norm on the VFTs. It could be hypothesized that some of the superiority on this performance is due to a gender difference between the patient sample and the comparison group. The D-KEFS norm sample consists of equal proportions of men and women, whereas only 4.5% of the patients in the study sample are men. Although gender effects on the VFT have generally not been demonstrated (Mathuranath et al., 2003), some studies have shown that women tend to perform better than men on word fluency tasks (Acevedo et al., 2000; Lee, Yuen, & Chan, 2002). This difference might partially account for why the sample in this study is performing significantly above the norm. However, a recently conducted meta-analysis (Stedal et al., 2011) has demonstrated a small but significant effect, showing that across studies, patients with anorexia nervosa score better than controls on this task. Thus, it is plausible that the neuropsychological VFT profile of the patients, when compared with gender-matched controls, will take on a similar structure.

An alternative explanation is that enhanced verbal fluency is the result of strengths in general intelligence quotient (IQ), especially for verbal skills. In this regard, our results on the verbal scale Wechsler tests are in line with a recently published review and meta-analysis of IQ in anorexia nervosa, demonstrating that patients with anorexia nervosa score on average 5.9 units higher on IQ measurement compared with the normative population (Lopez, Stahl, & Tchanturia, 2010). It is noteworthy that our patient group was equally proficient on the assessment of nonverbal intelligence, again consistent with the previous study.

Turning to tests in the Ravello Profile showing no differences between patients and normative data, patients in the present study performed comparable with the published norms on the assessment of rule learning, inhibition, and spatial planning as measured by the Tower test (Delis et al., 2001). The Tower test can be viewed as an assessment tool of several skills, but it has been argued that it is primarily a measure of the ability to inhibit a pre-potent response (the wish to take a shortcut to finishing the tower; Miyake et al., 2000). Women recovered from anorexia nervosa have been shown to display lower medial prefrontal cortex activation on tests measuring inhibition compared with controls, which can be interpreted as greater efficiency in the inhibition of a pre-potent response in recovered patients with anorexia nervosa (Oberndorfer, Kaye, Simmons, Strigo, & Matthews, 2011). It could also be argued that the total achievement score on the Tower test is insufficiently sensitive to capture the full essence of the patient's performance. As long as the tower is completed within the time frame given, the participant is awarded a minimum score, regardless of strategy used to build the tower. The result of this scoring system is that some patients can receive a scaled score within the normal range despite employing a haphazard strategy. This needs to be investigated further with studies not only recording the total achievement score, but also the number of moves engaged.

A comparison was made between a low BMI and a normal BMI group to investigate any profile differences that could hint at the possibility of reversibility of deficits. The analysis, however, did not reveal significant differences on any of the Ravello Profile measure, which suggests that the profile is not influenced by current weight status.

A major constraint of this study is the use of a normative comparison rather than an experimental control group for the standardized measures. One problem with this approach is the gender differences between samples, as discussed above in relation to verbal fluency. Additionally, published norms are representative of sociodemographic characteristics at the population level, whereas patients presenting for clinical treatment at specialist centers may come from selected subgroups. On the other hand, the use of published norms allows clinicians to interpret individual patient's age-based scaled scores against the neuropsychological profile presented in the current study.

Future research studies could explore whether the present neuropsychological profile is specific to anorexia nervosa, and the influence of other factors such as depression (Landrø, Stiles, & Sletvold, 2001), anxiety (Lyche, Jonassen, Stiles, Ulleberg, & Landrø, 2011), and/or obsessive-compulsive disorder (Chamberlain, Blackwell, Fineberg, Robbins, & Sahakian, 2005; Moritz et al., 2002). Finally, starvation may have a moderating effect on performance and this needs further consideration in subsequent studies.

The present study is, to the knowledge of the authors, the largest to date with regard to the number of patients who have completed a wide ranging neuropsychological test battery, specifically developed to assess patients with anorexia nervosa.  Most of the data included in the present study have been collected as part of the routine assessment in the collaborating clinics. The Ravello Profile manual highlights the importance of focusing on the needs of the patient being tested, and as a result, the test administrator might in some instances choose to omit certain tests. Thus, there is a possibility that the patients with an incomplete Ravello Profile are systematically different from the participants included in this study. The study is also constrained by not having information about the patient's level of schooling and demographic characteristics. It is probable that the profile exhibited in the current study is representative of patients with anorexia nervosa as a group, due to the results at large being consistent with previously published studies. Nevertheless, caution should always be taken when generalizing group mean score findings to individual patients. For example, Rose, Frampton, and Lask (2011) have reported that individual patients with anorexia nervosa demonstrate a number of different neuropsychological profiles. Further studies are needed to explore whether these profiles group together to form distinct clusters of patients.

The utility of this type of neuropsychological profile investigation is in the systematic evaluation of relative strengths and weaknesses across functional domains. By investigating whether the patient's performance falls within the average range relative to norms, the current study presents clinicians with valuable comparison data. It can also help to provide a systematic approach for identifying patients in need of a more tailored treatment. In clinical practice, it is worthwhile exploring the neuropsychological functioning of patients with anorexia nervosa, since they may benefit from specific treatments, such as cognitive remediation therapy (Tchanturia et al., 2008). This form of treatment, which aims to tap the plasticity of the brain in an attempt to improve underlying deficits, can greatly benefit from using a test battery such as the Ravello Profile as part of the assessment procedure.

Conclusion

This study provides support for a common neuropsychological profile in patients with anorexia nervosa, consisting of strengths in verbal fluency and weaknesses in visuospatial memory, set-shifting, and central coherence.  Recognition of cognitive impairment in this patient group is important and may not be identified by the routine evaluations administered at initial assessment. By assessing the patient's neuropsychological profile, the possibility for tailoring interventions based on the individual's needs is greatly increased. Profiles of neuropsychological performance can also help determine which areas of functioning are intact. By utilizing areas of strengths, alternative coping strategies that aim to ameliorate the patient's everyday functioning can be developed. This study provides clinicians with a reference point when making treatment recommendations on the basis of their patient's neuropsychological profile.

Funding

This work was supported by Health South-East, Norway (29501508).

Conflict of Interest

None declared.

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