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Impaired decision-making in symptomatic anorexia and bulimia nervosa patients: a meta-analysis

  • S. Guillaume (a1), P. Gorwood (a2) (a3), F. Jollant (a4), F. Van den Eynde (a5), P. Courtet (a1) and S. Richard-Devantoy (a4) (a6)...



Impaired decision-making is a potential neurocognitive phenotype of eating disorders. It is therefore important to disentangle the decision-making deficits associated with the eating disorder subtypes and determine whether this putative impairment is a state or trait marker of the disease or more related to starvation. We systematically reviewed the literature on decision-making in eating disorders and conducted a meta-analysis to explore its role in anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED).


A search of the Medline and EMBASE databases and article references was performed. A total of 23 studies (2044 participants) met the selection criteria. When the Iowa gambling task (IGT) was used in at least three of the studies, a meta-analysis was run.


IGT performance was significantly worse in patients with an eating disorder diagnosis (AN, BN or BED) compared with healthy controls, indicating that eating disorders have a negative effect on decision-making. Hedges’ g effect sizes were moderate to large (−0.72 in AN, −0.62 in BN, and −1.26 in BED). Recovered AN patients had IGT scores similar to those of healthy controls. Restrictive AN patients had significantly lower IGT net scores than purging AN patients, and both AN subtypes had worse performances than healthy controls. Age and body mass index did not explain results.


Decision-making was significantly altered in patients with eating disorders. Poor decision-making was more pronounced during the acute phase than in the recovered state of AN. Nutritional status during the acute phase of the disease did not seem to influence decision-making skills.


Corresponding author

* Address for correspondence: S. Guillaume, Psychiatric Emergency and Post Emergency Department, Hospital Lapeyronie, Avenue Gaston Giraud, 34295 Montpellier cedex 5, France. (Email:


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Abbate-Daga, G, Buzzichelli, S, Amianto, F, Rocca, G, Marzola, E, McClintock, SM, Fassino, S (2011). Cognitive flexibility in verbal and nonverbal domains and decision making in anorexia nervosa patients: a pilot study. BMC Psychiatry 11, 162.
Adida, M, Jollant, F, Clark, L, Besnier, N, Guillaume, S, Kaladjian, A, Mazzola-Pomietto, P, Jeanningros, R, Goodwin, GM, Azorin, JM, Courtet, P (2011). Trait-related decision-making impairment in the three phases of bipolar disorder. Biological Psychiatry 70, 357365.
Adoue, C, Jaussent, I, Olie, E, Beziat, S, Van den Eynde, F, Courtet, P, Guillaume, S (2015). A further assessment of decision-making in anorexia nervosa. European Psychiatry 30, 121127.
Aloi, M, Rania, M, Caroleo, M, Bruni, A, Palmieri, A, Cauteruccio, M, De Fazio, P, Segura-Garcia, C (2015). Decision making, central coherence and set-shifting: a comparison between binge eating disorder, anorexia nervosa and healthy controls. BMC Psychiatry 15, 6.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text rev. APA: Washington, DC.
Bischoff-Grethe, A, McCurdy, D, Grenesko-Stevens, E, Irvine, LE, Wagner, A, Yau, WY, Fennema-Notestine, C, Wierenga, CE, Fudge, JL, Delgado, MR, Kaye, WH (2013). Altered brain response to reward and punishment in adolescents with anorexia nervosa. Psychiatry Research 214, 331340.
Bodell, LP, Keel, PK, Brumm, MC, Akubuiro, A, Caballero, J, Tranel, D, Hodis, B, McCormick, LM (2014). Longitudinal examination of decision-making performance in anorexia nervosa: before and after weight restoration. Journal of Psychiatric Research 56, 150157.
Boeka, AG, Lokken, KL (2006). The Iowa gambling task as a measure of decision making in women with bulimia nervosa. Journal of the International Neuropsychological Society 12, 741745.
Boisseau, CL, Thompson-Brenner, H, Pratt, EM, Farchione, TJ, Barlow, DH (2013). The relationship between decision-making and perfectionism in obsessive–compulsive disorder and eating disorders. Journal of Behavior Therapy and Experimental Psychiatry 44, 316321.
Bosanac, P, Kurlender, S, Stojanovska, L, Hallam, K, Norman, T, McGrath, C, Burrows, G, Wesnes, K, Manktelow, T, Olver, J (2007). Neuropsychological study of underweight and “weight-recovered” anorexia nervosa compared with bulimia nervosa and normal controls. International Journal of Eating Disorders 40, 613621.
Bowman, CH, Evans, CE, Turnbull, OH (2005). Artificial time constraints on the Iowa gambling task: the effects on behavioural performance and subjective experience. Brain and Cognition 57, 2125.
Brand, M, Franke-Sievert, C, Jacoby, GE, Markowitsch, HJ, Tuschen-Caffier, B (2007). Neuropsychological correlates of decision making in patients with bulimia nervosa. Neuropsychology 21, 742750.
Brevers, D, Bechara, A, Cleeremans, A, Kornreich, C, Verbanck, P, Noel, X (2014). Impaired decision-making under risk in individuals with alcohol dependence. Alcoholism: Clinical and Experimental Research 38, 19241931.
Brogan, A, Hevey, D, O'Callaghan, G, Yoder, R, O'Shea, D (2011). Impaired decision making among morbidly obese adults. Journal of Psychosomatic Research 70, 189196.
Cavedini, P, Bassi, T, Ubbiali, A, Casolari, A, Giordani, S, Zorzi, C, Bellodi, L (2004). Neuropsychological investigation of decision-making in anorexia nervosa. Psychiatry Research 127, 259266.
Cavedini, P, Zorzi, C, Bassi, T, Gorini, A, Baraldi, C, Ubbiali, A, Bellodi, L (2006). Decision-making functioning as a predictor of treatment outcome in anorexia nervosa. Psychiatry Research 145, 179187.
Chan, TW, Ahn, WY, Bates, JE, Busemeyer, JR, Guillaume, S, Redgrave, GW, Danner, UN, Courtet, P (2014). Differential impairments underlying decision making in anorexia nervosa and bulimia nervosa: a cognitive modeling analysis. International Journal of Eating Disorders 47, 157167.
Cooper, H, Hedges, LV, Valentine, JC (2009). The Handbook of Research Synthesis and Meta-Analysis. Russell Sage Foundation Publications: New York.
Courtet, P, Gottesman, II, Jollant, F, Gould, TD (2011). The neuroscience of suicidal behaviors: what can we expect from endophenotype strategies? Translational Psychiatry 1, e7.
Damasio, AR (1994). Descartes’ Error: Emotion, Reason, and the Human Brain. Penguin Books: New York.
Danner, UN, Evers, C, Sternheim, L, van Meer, F, van Elburg, AA, Geerets, TA, Breteler, LM, de Ridder, DT (2013). Influence of negative affect on choice behavior in individuals with binge eating pathology. Psychiatry Research 207, 100106.
Danner, UN, Ouwehand, C, van Haastert, NL, Hornsveld, H, de Ridder, DT (2012 a). Decision-making impairments in women with binge eating disorder in comparison with obese and normal weight women. European Eating Disorders Review 20, e56e62.
Danner, UN, Sanders, N, Smeets, PA, van Meer, F, Adan, RA, Hoek, HW, van Elburg, AA (2012 b). Neuropsychological weaknesses in anorexia nervosa: set-shifting, central coherence, and decision making in currently ill and recovered women. International Journal of Eating Disorders 45, 685694.
Danner, UN, Sternheim, L, Evers, C (2014). The importance of distinguishing between the different eating disorders (sub)types when assessing emotion regulation strategies. Psychiatry Research 215, 727732.
Davis, C, Patte, K, Curtis, C, Reid, C (2010). Immediate pleasures and future consequences. A neuropsychological study of binge eating and obesity. Appetite 54, 208213.
Decker, JH, Figner, B, Steinglass, JE (2014). On weight and waiting: delay discounting in anorexia nervosa pretreatment and posttreatment. Biological Psychiatry. Published online 23 December 2014. doi:10.1016/j.biopsych.2014.12.016.
Dingemans, AE, Danner, UN, Donker, JM, Aardoom, JJ, van Meer, F, Tobias, K, van Elburg, AA, van Furth, EF (2014). The effectiveness of cognitive remediation therapy in patients with a severe or enduring eating disorder: a randomized controlled trial. Psychotherapy and Psychosomatics 83, 2936.
Egger, M, Davey Smith, G, Altman, D (2001). Systematic Reviews in Health Care: Meta-Analysis in Context. BMJ Publishing Group: London.
Egger, M, Davey Smith, G, Schneider, M, Minder, C (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ 315, 629634.
Fagundo, AB, de la Torre, R, Jimenez-Murcia, S, Aguera, Z, Granero, R, Tarrega, S, Botella, C, Banos, R, Fernandez-Real, JM, Rodriguez, R, Forcano, L, Fruhbeck, G, Gomez-Ambrosi, J, Tinahones, FJ, Fernandez-Garcia, JC, Casanueva, FF, Fernandez-Aranda, F (2012). Executive functions profile in extreme eating/weight conditions: from anorexia nervosa to obesity. PLOS ONE 7, e43382.
Fornasari, L, Gregoraci, G, Isola, M, Laura Negri, GA, Rambaldelli, G, Cremaschi, S, Faleschini, L, Canalaz, F, Perini, L, Balestrieri, M, Fabbro, F, Brambilla, P (2014). Psychopathological and personality traits underlie decision making in recent onset medication naive anorexia nervosa: a pilot study. Psychiatry Research 216, 8996.
Galimberti, E, Fadda, E, Cavallini, MC, Martoni, RM, Erzegovesi, S, Bellodi, L (2013). Executive functioning in anorexia nervosa patients and their unaffected relatives. Psychiatry Research 208, 238244.
Garrido, I, Subirá, S (2013). Decision-making and impulsivity in eating disorder patients. Psychiatry Research 207, 107112.
Glascher, J, Adolphs, R, Damasio, H, Bechara, A, Rudrauf, D, Calamia, M, Paul, LK, Tranel, D (2012). Lesion mapping of cognitive control and value-based decision making in the prefrontal cortex. Proceedings of the National Academy of Sciences of the USA 109, 1468114686.
Goschke, T (2014). Dysfunctions of decision-making and cognitive control as transdiagnostic mechanisms of mental disorders: advances, gaps, and needs in current research. International Journal of Methods in Psychiatric Research 23 (Suppl. 1), 4157.
Guillaume, S, Sang, CN, Jaussent, I, Raingeard, I, Bringer, J, Jollant, F, Courtet, P (2010). Is decision making really impaired in eating disorders? Neuropsychology 24, 808812.
Hedges, LV, Olkin, I (1985). Statistical Methods for Meta-analysis. Academic Press: London.
Kane, MJ, Engle, RW (2002). The role of prefrontal cortex in working-memory capacity, executive attention, and general fluid intelligence: an individual-differences perspective. Psychonomic Bulletin and Review 9, 637671.
Kaye, WH, Wierenga, CE, Bailer, UF, Simmons, AN, Wagner, A, Bischoff-Grethe, A (2013). Does a shared neurobiology for foods and drugs of abuse contribute to extremes of food ingestion in anorexia and bulimia nervosa? Biological Psychiatry 73, 836842.
Keys, A, Brožek, J, Henschel, A, Mickelsen, O, Taylor, H (1950). The Biology of Human Starvation, vols I–II. University of Minnesota Press: Minneapolis, MN.
Lang, K, Lopez, C, Stahl, D, Tchanturia, K, Treasure, J (2014 a). Central coherence in eating disorders: an updated systematic review and meta-analysis. World Journal of Biological Psychiatry 15, 586598.
Lang, K, Stahl, D, Espie, J, Treasure, J, Tchanturia, K (2014 b). Set shifting in children and adolescents with anorexia nervosa: an exploratory systematic review and meta-analysis. International Journal of Eating Disorders 47, 394399.
Liao, PC, Uher, R, Lawrence, N, Treasure, J, Schmidt, U, Campbell, IC, Collier, DA, Tchanturia, K (2009). An examination of decision making in bulimia nervosa. Journal of Clinical and Experimental Neuropsychology 31, 455461.
Lindner, SE, Fichter, MM, Quadflieg, N (2012). Decision-making and planning in full recovery of anorexia nervosa. International Journal of Eating Disorders 45, 866875.
Lock, J, Garrett, A, Beenhakker, J, Reiss, AL (2011). Aberrant brain activation during a response inhibition task in adolescent eating disorder subtypes. American Journal of Psychiatry 168, 5564.
Matsumoto, J, Hirano, Y, Numata, N, Matzuzawa, D, Murano, S, Yokote, K, Iyo, M, Shimizu, E, Nakazato, M (2015). Comparison in decision-making between bulimia nervosa, anorexia nervosa, and healthy women: influence of mood status and pathological eating concerns. Journal of Eating Disorders 3, 14.
McDowd, JM, Oseas-Kreger, DM, Filion, DL (1995). Inhibitory processes in cognition and aging. In Interference and Inhibition in Cognition (ed. Dempster, F. N. and Brainerd, C. J.), pp. 363397. Academic Press: San Diego, CA.
Milham, MP, Erickson, KI, Banich, MT, Kramer, AF, Webb, A, Wszalek, T, Cohen, NJ (2002). Attentional control in the aging brain: insights from an fMRI study of the Stroop task. Brain and Cognition 49, 277296.
Mole, TB, Irvine, MA, Worbe, Y, Collins, P, Mitchell, SP, Bolton, S, Harrison, NA, Robbins, TW, Voon, V (2015). Impulsivity in disorders of food and drug misuse. Psychological Medicine 45, 771782.
Muller, A, Brandl, C, Kiunke, W, Georgiadou, E, Horbach, T, Kohler, H, de Zwaan, M (2014). Food-independent tendency to disadvantageous decisions in obese individuals with regular binge eating. Comprehensive Psychiatry 55, 6470.
Noonan, MP, Walton, ME, Behrens, TE, Sallet, J, Buckley, MJ, Rushworth, MF (2010). Separate value comparison and learning mechanisms in macaque medial and lateral orbitofrontal cortex. Proceedings of the National Academy of Sciences of the USA 107, 2054720552.
Peat, C, Mitchell, JE, Hoek, HW, Wonderlich, SA (2009). Validity and utility of subtyping anorexia nervosa. International Journal of Eating Disorders 42, 590594.
Petticrew, M, Roberts, H (2006). Systematic Reviews in the Social Sciences: A Practical Guide. Blackwell: Oxford.
Richard-Devantoy, S, Berlim, MT, Jollant, F (2013). A meta-analysis of neuropsychological markers of vulnerability to suicidal behavior in mood disorders. Psychological Medicine 44, 16631673.
Riley, RD, Higgins, JP, Deeks, JJ (2011). Interpretation of random effects meta-analyses. BMJ 342, d549.
Ritschel, F, King, JA, Geisler, D, Flohr, L, Neidel, F, Boehm, I, Seidel, M, Zwipp, J, Ripke, S, Smolka, MN, Roessner, V, Ehrlich, S (2015). Temporal delay discounting in acutely ill and weight-recovered patients with anorexia nervosa. Psychological Medicine 45, 12291239.
Roberts, ME, Tchanturia, K, Stahl, D, Southgate, L, Treasure, J (2007). A systematic review and meta-analysis of set-shifting ability in eating disorders. Psychological Medicine 37, 10751084.
Rosenthal, R (1979). The file drawer problem and tolerance for null results. Psychological Bulletin 86, 638641.
Sedgwick, P (2015). Meta-analysis: testing for reporting bias. BMJ 350, g7857.
Steiger, H, Bruce, KR (2007). Phenotypes, endophenotypes, and genotypes in bulimia spectrum eating disorders. Canadian Journal of Psychiatry 52, 220227.
Steinglass, JE, Figner, B, Berkowitz, S, Simpson, HB, Weber, EU, Walsh, BT (2012). Increased capacity to delay reward in anorexia nervosa. Journal of the International Neuropsychological Society 18, 773780.
Svaldi, J, Brand, M, Tuschen-Caffier, B (2010). Decision-making impairments in women with binge eating disorder. Appetite 54, 8492.
Tchanturia, K, Doris, E, Fleming, C (2014). Effectiveness of Cognitive Remediation and Emotion Skills Training (CREST) for anorexia nervosa in group format: a naturalistic pilot study. European Eating Disorders Review 22, 200205.
Tchanturia, K, Liao, PC, Forcano, L, Fernandez-Aranda, F, Uher, R, Treasure, J, Schmidt, U, Penelo, E, Granero, R, Jimenez-Murcia, S, Sanchez, I, Campbell, IC (2012). Poor decision making in male patients with anorexia nervosa. European Eating Disorders Review 20, 169173.
Tchanturia, K, Liao, PC, Uher, R, Lawrence, N, Treasure, J, Campbell, IC (2007). An investigation of decision making in anorexia nervosa using the Iowa gambling task and skin conductance measurements. Journal of the International Neuropsychological Society 13, 635641.
Treasure, J, Claudino, AM, Zucker, N (2010). Eating disorders. Lancet 375, 583593.
Van den Eynde, F, Guillaume, S, Broadbent, H, Stahl, D, Campbell, IC, Schmidt, U, Tchanturia, K (2011). Neurocognition in bulimic eating disorders: a systematic review. Acta Psychiatrica Scandinavica 124, 120140.
Van den Eynde, F, Samarawickrema, N, Kenyon, M, DeJong, H, Lavender, A, Startup, H, Schmidt, U (2012). A study of neurocognition in bulimia nervosa and eating disorder not otherwise specified-bulimia type. Journal of Clinical and Experimental Neuropsychology 34, 6777.
Von Elm, E, Altman, DG, Egger, M, Pocock, SJ, Gøtzsche, PC, Vandenbroucke, JP, STROBE Initiative (2008). The Strengthening the Reporting of Observational Studies in Epidemiology [STROBE] statement: guidelines for reporting observational studies. Journal of Clinical Epidemiology 61, 344349.
Wagner, A, Aizenstein, H, Venkatraman, VK, Fudge, J, May, JC, Mazurkewicz, L, Frank, GK, Bailer, UF, Fischer, L, Nguyen, V, Carter, C, Putnam, K, Kaye, WH (2007). Altered reward processing in women recovered from anorexia nervosa. American Journal of Psychiatry 164, 18421849.
Walton, ME, Behrens, TE, Buckley, MJ, Rudebeck, PH, Rushworth, MF (2010). Separable learning systems in the macaque brain and the role of orbitofrontal cortex in contingent learning. Neuron 65, 927939.
Waxman, SE (2009). A systematic review of impulsivity in eating disorders. European Eating Disorders Review 17, 408425.
Wierenga, CE, Bischoff-Grethe, A, Melrose, AJ, Irvine, Z, Torres, L, Bailer, UF, Simmons, A, Fudge, JL, McClure, SM, Ely, A, Kaye, WH (2015). Hunger does not motivate reward in women remitted from anorexia nervosa. Biological Psychiatry 77, 642652.
Wu, M, Giel, KE, Skunde, M, Schag, K, Rudofsky, G, de Zwaan, M, Zipfel, S, Herzog, W, Friederich, HC (2013). Inhibitory control and decision making under risk in bulimia nervosa and binge-eating disorder. International Journal of Eating Disorders 46, 721728.
Zink, CF, Weinberger, DR (2010). Cracking the moody brain: the rewards of self starvation. Nature Medicine 16, 13821383.


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Impaired decision-making in symptomatic anorexia and bulimia nervosa patients: a meta-analysis

  • S. Guillaume (a1), P. Gorwood (a2) (a3), F. Jollant (a4), F. Van den Eynde (a5), P. Courtet (a1) and S. Richard-Devantoy (a4) (a6)...


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