Mental Capacity, Decision-Making and Emotion Dysregulation in Severe Enduring Anorexia Nervosa

Abstract

Severe and Enduring Anorexia Nervosa (SE-AN) is a chronic eating disorder characterized by long-term starvation and its physical and psychological sequelae, and severe loss of quality of life. Interactions between neurobiological changes caused by starvation, vulnerability (personality) traits, and eating behaviors play a role. Several other factors, such as increased fear and decreased social cognition, have also been found in relation to SE-AN. With this in mind, we aim to add to the understanding of SE-AN by introducing the concept of mental capacity (MC), which refers to the ability to understand and process information—both on a cognitive and an emotional level—and then make a well-informed choice. MC may be an important construct within the context of SE-AN. Furthermore, we will argue how impaired decision-making processes may underlie, fuel, or contribute to limited MC in SE-AN. We will speculate on the importance of dysfunctional emotion processing and anxiety-related processes (e.g., a high intolerance of uncertainty) and their potential interaction with decision-making. Lastly, we will propose how these aspects, which to our knowledge have previously received little attention, may advise research and treatment or help in dealing with the “want but cannot” situation of life-threatening AN.

The Neuropsychological Profile of Severe and Enduring Anorexia Nervosa: A Systematic Review

“…If additional research supports this finding, the identification and treatment of these individuals may be improved by testing for this neuropsychological trait during assessment. To the author's knowledge, this study was the first to provide evidence in support of the theory proposed by van Elburg et al ( 2021 ) that poor decision-making skills are a characteristic of SE-AN. However, like central coherence, caution needs to be taken when interpreting these findings given the small sample size of SE-AN participants in this review ( n = 9).…”

“…This hypothesis seems particularly plausible in the context of research suggesting that a longer duration of illness may be associated with certain neuropsychological deficits compared to individuals with shorter durations of the illness (see Abbate-Daga et al, 2011 ; Lang et al, 2014 ; Treasure et al, 2015 ). Additionally, a recent hypothesis proposed by van Elburg et al ( 2021 ) suggested that poor decision-making skills underlie, fuel, or contribute to the mental capacity of patients with SE-AN, which may influence their ability to recover. With no empirical evidence to support or refute this theory, it was crucial to explore this possibility in the current study.…”

Is the Severity of the Clinical Expression of Anorexia Nervosa Influenced by an Anxiety, Depressive, or Obsessive-Compulsive Comorbidity Over a Lifetime?

“…According to Bechara, decision making inherently relies on emotional processes that provide important implicit and explicit knowledge by which the individual is able to make fast and adaptive decisions ( 34 ). Van Elburg explains that “these emotional processes guide decision-making on several levels, including via bioregulatory processes, such as somatic marker signals, and occur both consciously and outside of awareness” ( 35 ). The literature highlights that an “affect-driven belief system profoundly influences the transformation of action into choices” and proposes that affect in particular plays a role in decision making that involves uncertainty, which is similar to the type of decision making mostly studied in AN ( 32 , 35 , 36 ).…”

“…Van Elburg explains that “these emotional processes guide decision-making on several levels, including via bioregulatory processes, such as somatic marker signals, and occur both consciously and outside of awareness” ( 35 ). The literature highlights that an “affect-driven belief system profoundly influences the transformation of action into choices” and proposes that affect in particular plays a role in decision making that involves uncertainty, which is similar to the type of decision making mostly studied in AN ( 32 , 35 , 36 ). The severity of ED symptoms that we observed in conjunction with AD comorbidities could be explained by the link between anxiety and depression with poorer food decision making in AN.…”

Treating PTSD With Imagery Rescripting During An Underweight State In Eating Disorder Patients. A Multiple Baseline Case Series Study

“…Cavan & Connan (2010) described that clinicians report that emotional experiences are dampened as a result of starvation. On the other hand, studies found that underweight eating disorder patients report the same or elevated levels of negative affect or emotions compared to healthy controls, and that negative affect is not related to Body Mass Index (BMI) (Davies et al, 2011;Van Elburg et al, 2021;Vroling et al, 2021).…”