Skip to main content Accessibility help

Subliminal and supraliminal processing of reward-related stimuli in anorexia nervosa

  • I. Boehm (a1) (a2), J. A. King (a1) (a2), F. Bernardoni (a1) (a2), D. Geisler (a1) (a2), M. Seidel (a1) (a2), F. Ritschel (a1) (a2), T. Goschke (a3), J.-D. Haynes (a4), V. Roessner (a5) and S. Ehrlich (a1) (a2)...



Previous studies have highlighted the role of the brain reward and cognitive control systems in the etiology of anorexia nervosa (AN). In an attempt to disentangle the relative contribution of these systems to the disorder, we used functional magnetic resonance imaging (fMRI) to investigate hemodynamic responses to reward-related stimuli presented both subliminally and supraliminally in acutely underweight AN patients and age-matched healthy controls (HC).


fMRI data were collected from a total of 35 AN patients and 35 HC, while they passively viewed subliminally and supraliminally presented streams of food, positive social, and neutral stimuli. Activation patterns of the group × stimulation condition × stimulus type interaction were interrogated to investigate potential group differences in processing different stimulus types under the two stimulation conditions. Moreover, changes in functional connectivity were investigated using generalized psychophysiological interaction analysis.


AN patients showed a generally increased response to supraliminally presented stimuli in the inferior frontal junction (IFJ), but no alterations within the reward system. Increased activation during supraliminal stimulation with food stimuli was observed in the AN group in visual regions including superior occipital gyrus and the fusiform gyrus/parahippocampal gyrus. No group difference was found with respect to the subliminal stimulation condition and functional connectivity.


Increased IFJ activation in AN during supraliminal stimulation may indicate hyperactive cognitive control, which resonates with clinical presentation of excessive self-control in AN patients. Increased activation to food stimuli in visual regions may be interpreted in light of an attentional food bias in AN.


Corresponding author

*Address for correspondence: S, Ehrlich, M.D., Division of Psychological and Social Medicine and Developmental Neurosciences, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany and Translational Developmental Neuroscience Section, Fetscherstraße 74, Dresden 01307, Germany. (Email:


Hide All
Ashburner, J (2007). A fast diffeomorphic image registration algorithm. Neuroimage 38, 95113.
Baars, BJ (2002). The conscious access hypothesis: origins and recent evidence. Trends in Cognitive Sciences 6, 4752.
Baldauf, D, Desimone, R (2014). Neural mechanisms of object-based attention. Science 344, 424427.
Berridge, KC, Kringelbach, ML (2015). Pleasure systems in the brain. Neuron 86, 646664.
Bischoff-Grethe, A, McCurdy, D, Grenesko-Stevens, E, Irvine, LE, Wagner, A, Wendy Yau, W-Y, Fennema-Notestine, C, Wierenga, CE, Fudge, JL, Delgado, MR (2013). Altered brain response to reward and punishment in adolescents with anorexia nervosa. Psychiatry Research: Neuroimaging 214, 331340.
Blundell, J, De Graaf, C, Hulshof, T, Jebb, S, Livingstone, B, Lluch, A, Mela, D, Salah, S, Schuring, E, Van Der Knaap, H, Westerterp, M (2010). Appetite control: methodological aspects of the evaluation of foods. Obesity Reviews 11, 251270.
Botvinick, M, Braver, T (2015). Motivation and cognitive control: from behavior to neural mechanism. Annual Review of Psychology 66, 83113.
Botvinick, MM, Cohen, JD (2014). The computational and neural basis of cognitive control: charted territory and new frontiers. Cognitive science 38, 12491285.
Brass, M, Derrfuss, J, Forstmann, B, von Cramon, DY (2005). The role of the inferior frontal junction area in cognitive control. Trends in Cognitive Sciences 9, 314316.
Brett, M, Anton, J, Valabregue, R, Poline, J (2002). Region of interest analysis using an SPM toolbox. Paper presented at 8th International Conference on Functional Mapping of the Human Brain, Sendai, Japan.
Brooks, S, O'Daly, O, Uher, R, Schiöth, H, Treasure, J, Campbell, I (2012a). Subliminal food images compromise superior working memory performance in women with restricting anorexia nervosa. Consciousness and Cognition 21, 751763.
Brooks, S, Owen, G, Uher, R, Friederich, H, Giampietro, V, Brammer, M, Williams, S, Schiöth, H, Treasure, J, Campbell, I (2011a). Differential neural responses to food images in women with bulimia versus anorexia nervosa. PLoS ONE 6, e22259.
Brooks, S, Prince, A, Stahl, D, Campbell, I, Treasure, J (2011b). A systematic review and meta-analysis of cognitive bias to food stimuli in people with disordered eating behaviour. Clinical Psychology Review 31, 3751.
Brooks, SJ, Savov, V, Allzén, E, Benedict, C, Fredriksson, R, Schiöth, HB (2012b). Exposure to subliminal arousing stimuli induces robust activation in the amygdala, hippocampus, anterior cingulate, insular cortex and primary visual cortex: a systematic meta-analysis of fMRI studies. NeuroImage 59, 29622973.
Camus, M, Halelamien, N, Plassmann, H, Shimojo, S, O'Doherty, J, Camerer, C, Rangel, A (2009). Repetitive transcranial magnetic stimulation over the right dorsolateral prefrontal cortex decreases valuations during food choices. European Journal of Neuroscience 30, 19801988.
Childress, AR, Ehrman, RN, Wang, Z, Li, Y, Sciortino, N, Hakun, J, Jens, W, Suh, J, Listerud, J, Marquez, K, Franklin, T, Langleben, D, Detre, J, O'Brien, CP (2008). Prelude to passion: limbic activation by ‘unseen’ drug and sexual cues. PLoS ONE 3, e1506.
Cole, MW, Repovš, G, Anticevic, A (2014). The frontoparietal control system A central role in mental health. The Neuroscientist 20, 652664.
Cowdrey, FA, Park, RJ, Harmer, CJ, McCabe, C (2011). Increased neural processing of rewarding and aversive food stimuli in recovered anorexia nervosa. Biological Psychiatry 70, 736743.
Dehaene, S, Changeux, J-P, Naccache, L, Sackur, J, Sergent, C (2006). Conscious, preconscious, and subliminal processing: a testable taxonomy. Trends in Cognitive Sciences 10, 204211.
Derrfuss, J, Brass, M, Neumann, J, von Cramon, DY (2005). Involvement of the inferior frontal junction in cognitive control: meta-analyses of switching and stroop studies. Human Brain Mapping 25, 2234.
Dickson, H, Brooks, S, Uher, R, Tchanturia, K, Treasure, J, Campbell, I (2008). The inability to ignore: distractibility in women with restricting anorexia nervosa. Psychological Medicine 38, 17411748.
Ehrlich, S, Geisler, D, Ritschel, F, King, JA, Seidel, M, Boehm, I, Breier, M, Clas, S, Weiss, J, Marxen, M, Smolka, MN, Roessner, V, Kroemer, NB (2015). Elevated cognitive control over reward processing in recovered patients with anorexia nervosa. Journal of Psychiatry and Neuroscience 40, 307315.
Fichter, M, Quadflieg, N (1999). SIAB. Struckturiertes Inventar Fuer Anorektische und Bulimische Essstoerungen Nach DSM-IV und ICD-10. Huber: Bern.
Foerde, K, Steinglass, JE, Shohamy, D, Walsh, BT (2015). Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nature Neuroscience 18, 15711573.
Frank, G, Shott, ME, Hagman, JO, Mittal, VA (2013). Alterations in brain structures related to taste reward circuitry in ill and recovered anorexia nervosa and in bulimia nervosa. American Journal of Psychiatry 170, 11521160.
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, 4157.
Hacker, MJ, Ratcliff, R (1979). A revised table of d’ for M-alternative forced choice. Perception & Psychophysics 26, 168170.
Hare, TA, Camerer, CF, Rangel, A (2009). Self-control in decision-making involves modulation of the vmPFC valuation system. Science 324, 646648.
Heatherton, TF, Wagner, DD (2011). Cognitive neuroscience of self-regulation failure. Trends in Cognitive Sciences 15, 132139.
Joos, AAB, Saum, B, van Elst, LT, Perlov, E, Glauche, V, Hartmann, A, Freyer, T, Tüscher, O, Zeeck, A (2011). Amygdala hyperreactivity in restrictive anorexia nervosa. Psychiatry Research: Neuroimaging 191, 189195.
Kaye, W, Fudge, J, Paulus, M (2009). New insights into symptoms and neurocircuit function of anorexia nervosa. Nature Reviews Neuroscience 10, 573584.
Kim, KR, Ku, J, Lee, J-H, Lee, H, Jung, Y-C (2012). Functional and effective connectivity of anterior insula in anorexia nervosa and bulimia nervosa. Neuroscience Letters 521, 152157.
King, JA, Geisler, D, Bernardoni, F, Ritschel, F, Böhm, I, Seidel, M, Mennigen, E, Ripke, S, Smolka, MN, Roessner, V, Ehrlich, S (2016). Altered neural efficiency of decision making during temporal reward discounting in anorexia nervosa. Journal of the American Academy of Child & Adolescent Psychiatry 55, 972979.
Kroemer, NB, Krebs, L, Kobiella, A, Grimm, O, Vollstädt-Klein, S, Wolfensteller, U, Kling, R, Bidlingmaier, M, Zimmermann, US, Smolka, MN (2013). (Still) longing for food: insulin reactivity modulates response to food pictures. Human Brain Mapping 34, 23672380.
Lang, PJ, Bradley, MM, Cuthbert, BN (1999). International Affective Picture System (IAPS): Instruction Manual and Affective Ratings, vol. 2. Center of Research in Psychophysiology, University of Florida: Gainesville, Florida, USA.
Lopez, C, Tchanturia, K, Stahl, D, Booth, R, Holliday, J, Treasure, J (2008). An examination of the concept of central coherence in women with anorexia nervosa. The International Journal of Eating Disorders 41, 143152.
McAdams, CJ, Lohrenz, T, Montague, PR (2015). Neural responses to kindness and malevolence differ in illness and recovery in women with anorexia nervosa. Human Brain Mapping 36, 52075219.
McClelland, J, Bozhilova, N, Nestler, S, Campbell, IC, Jacob, S, Johnson-Sabine, E, Schmidt, U (2013). Improvements in symptoms following neuronavigated repetitive transcranial magnetic stimulation (rTMS) in severe and enduring anorexia nervosa: findings from two case studies. European Eating Disorders Review 21, 500506.
McLaren, DG, Ries, ML, Xu, G, Johnson, SC (2012). A generalized form of context-dependent psychophysiological interactions (gPPI): a comparison to standard approaches. NeuroImage 61, 12771286.
Meneguzzo, P, Tsakiris, M, Schioth, HB, Stein, DJ, Brooks, SJ (2014). Subliminal versus supraliminal stimuli activate neural responses in anterior cingulate cortex, fusiform gyrus and insula: a meta-analysis of fMRI studies. BMC Psychology 2, 5263.
Miller, EK, Cohen, JD (2001). An integrative theory of prefrontal cortex function. Annual Review of Neuroscience 24, 167202.
Mudrik, L, Faivre, N, Koch, C (2014). Information integration without awareness. Trends in Cognitive Sciences 18, 488496.
O'Hara, CB, Campbell, IC, Schmidt, U (2015). A reward-centred model of anorexia nervosa: a focussed narrative review of the neurological and psychophysiological literature. Neuroscience & Biobehavioral Reviews 52, 131152.
Paul, T, Thiel, A (2005). Eating Disorder Inventory-2 (EDI-2): Deutsche Version. Hogrefe: Goettingen.
Pop-Jordanova, N (2000). Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Pediatrics International 42, 7681.
Sackville, T, Schotte, DE, Touyz, SW, Griffiths, R, Beumont, P (1998). Conscious and preconscious processing of food, body weight and shape, and emotion-related words in women with anorexia nervosa. International Journal of Eating Disorders 23, 7782.
Sanders, N, Smeets, PA, van Elburg, AA, Danner, UN, van Meer, F, Hoek, HW, Adan, RA (2015). Altered food-cue processing in chronically ill and recovered women with anorexia nervosa. Frontiers in Behavioral Neuroscience 9, 46.
Schmidt, U, Treasure, J (2006). Anorexia nervosa: valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology 45, 343366.
Seeley, WW, Menon, V, Schatzberg, AF, Keller, J, Glover, GH, Kenna, H, Reiss, AL, Greicius, MD (2007). Dissociable intrinsic connectivity networks for salience processing and executive control. The Journal of Neuroscience 27, 23492356.
Shafran, R, Lee, M, Cooper, Z, Palmer, R, Fairburn, C (2007). Attentional bias in eating disorders. International Journal of Eating Disorders 40, 369380.
Steinglass, JE, Walsh, BT (2016). Neurobiological model of the persistence of anorexia nervosa. Journal of Eating Disorders 39, 267275.
Sundermann, B, Pfleiderer, B (2012). Functional connectivity profile of the human inferior frontal junction: involvement in a cognitive control network. BMC Neuroscience 13, 119.
Toffoletto, S, Lanzenberger, R, Gingnell, M, Sundström-Poromaa, I, Comasco, E (2014). Emotional and cognitive functional imaging of estrogen and progesterone effects in the female human brain: a systematic review. Psychoneuroendocrinology 50, 2852.
Via, E, Soriano-Mas, C, Sánchez, I, Forcano, L, Harrison, BJ, Davey, CG, Pujol, J, Martínez-Zalacaín, I, Menchón, JM, Fernández-Aranda, F, Cardoner, N (2015). Abnormal social reward responses in anorexia nervosa: an fMRI study. PLoS ONE 10, e0133539.
Wagner, A, Aizenstein, H, Mazurkewicz, L, Fudge, J, Frank, G, Putnam, K, Bailer, U, Fischer, L, Kaye, W (2007a). Altered insula response to taste stimuli in individuals recovered from restricting-type anorexia nervosa. Neuropsychopharmacology 33, 513523.
Wagner, A, Aizenstein, H, Venkatraman, V, Fudge, J, May, J, Mazurkewicz, L, Frank, G, Bailer, U, Fischer, L, Nguyen, V (2007b). Altered reward processing in women recovered from anorexia nervosa. American Journal of Psychiatry 164, 18421849.
Walsh, BT (2013). The enigmatic persistence of anorexia nervosa. The American Journal of Psychiatry 170, 477484.
Wang, KS, Smith, DV, Delgado, MR (2016). Using fMRI to study reward processing in humans: past, present, and future. Journal of Neurophysiology 115, 16641678.
Wessa, M, Kanske, P, Neumeister, P, Bode, K, Heissler, J, Schönfelder, S (2010). Emopics: subjektive und psychophysiologische evaluation neuen bildmaterials für die klinisch-biopsychologische forschung. Available from Michele Wessa,
Whitfield-Gabrieli, S, Thermenos, HW, Milanovic, S, Tsuang, MT, Faraone, SV, McCarley, RW, Shenton, ME, Green, AI, Nieto-Castanon, A, LaViolette, P (2009). Hyperactivity and hyperconnectivity of the default network in schizophrenia and in first-degree relatives of persons with schizophrenia. Proceedings of the National Academy of Sciences of the United States of America 106, 12791284.
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.
Wildes, JE, Marcus, MD (2011). Development of emotion acceptance behavior therapy for anorexia nervosa: a case series. International Journal of Eating Disorders 44, 421427.
Xu, Y (2014). Inferior frontal junction biases perception through neural synchrony. Trends in Cognitive Sciences 18, 447448.
Zanto, TP, Rubens, MT, Bollinger, J, Gazzaley, A (2010). Top-down modulation of visual feature processing: the role of the inferior frontal junction. NeuroImage 53, 736745.
Zedelius, CM, Veling, H, Aarts, H (2011). Boosting or choking–how conscious and unconscious reward processing modulate the active maintenance of goal-relevant information. Consciousness and Cognition 20, 355362.


Type Description Title
Supplementary materials

Boehm et al supplementary material
Boehm et al supplementary material 1

 Word (1.3 MB)
1.3 MB

Subliminal and supraliminal processing of reward-related stimuli in anorexia nervosa

  • I. Boehm (a1) (a2), J. A. King (a1) (a2), F. Bernardoni (a1) (a2), D. Geisler (a1) (a2), M. Seidel (a1) (a2), F. Ritschel (a1) (a2), T. Goschke (a3), J.-D. Haynes (a4), V. Roessner (a5) and S. Ehrlich (a1) (a2)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed