Trauma in Anorexia Nervosa: Investigating the Mediating Role of Cognitive Inflexibility

Abstract

Introduction

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by restrictive eating behaviours, intense fear of weight gain, and distorted body image. Beyond these hallmark symptoms, individuals with AN frequently display cognitive and emotional disturbances, particularly impaired cognitive flexibility – the capacity to adapt behaviour and thought in response to changing environmental demands. Cognitive inflexibility has been implicated in the maintenance of AN, contributing to rigid eating patterns and resistance to change [1].

Despite the well-established association between trauma and eating disorders, the mechanisms through which trauma influences AN symptomatology remain underexplored. Trauma – especially complex forms involving emotional, physical, or sexual abuse – has been strongly linked to maladaptive coping strategies such as food restriction and compulsive exercise. These behaviours may serve as attempts to regulate distress and regain a sense of control following traumatic experiences [2]. Although cognitive flexibility has been studied in both acute and remitted AN cases, its potential mediating role between trauma and AN severity has not yet been empirically tested.

Hypothesis

This study tested whether perseverative errors – a neuropsychological marker of cognitive inflexibility – mediate the relationship between trauma exposure and AN symptom severity. We hypothesized that trauma-related cognitive rigidity, reflected in higher perseveration rates on the Wisconsin Card Sorting Test (WCST), would predict greater eating disorder pathology.

Methodology

Data were drawn from an fMRI study on social cognition in AN. Participants (N = 88) completed the Early Trauma Inventory (ETI), the WCST, and the Eating Disorder Inventory (EDI). We conducted mediation analyses using the PROCESS macro (Model 4) in SPSS to test whether perseverative errors mediate the relationship between trauma history and eating disorder severity.

Results

Trauma severity significantly predicted eating disorder symptoms, with a strong total (β = .437, p < .001) and direct effect (β = .424, p < .001). However, trauma did not significantly predict perseverative errors (β = .144, p = .162), nor did perseverative errors significantly predict AN severity after controlling for trauma (β = .092, p = .116). The indirect effect was not statistically significant, indicating that no mediation was observed.

Discussion

While the hypothesis that cognitive inflexibility mediates the trauma-AN link was theoretically grounded, our results do not support a significant mediating role for perseverative errors. This suggests that while cognitive inflexibility is a known feature of AN, it may not be directly shaped by trauma – or at least not in a way measurable by perseverative error rates on the WCST. Alternatively, cognitive flexibility may play a more nuanced or condition-specific role that is not captured by this task alone. Further research should explore alternative cognitive and affective mediators, or employ dynamic measures of flexibility beyond error-based scoring.

References

[1] Miles, S. et al., “Cognitive flexibility and the risk of anorexia nervosa: An investigation using self-report and neurocognitive assessments,” Journal of Psychiatric Research, vol. 151, pp. 531–538, 2022. doi: 10.1016/j.jpsychires.2022.05.043.

[2] Groth, T. et al., “Relationship between trauma history and eating disorders in adolescents,” Journal of Child & Adolescent Trauma, 2019. doi: 10.1007/s40653-019-00275-z.