{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T03:54:08Z","timestamp":1781236448135,"version":"3.54.1"},"reference-count":49,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2023,6,15]],"date-time":"2023-06-15T00:00:00Z","timestamp":1686787200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"University of Southern Denmark (PhD scholarship)","award":["17-2-0788"],"award-info":[{"award-number":["17-2-0788"]}]},{"name":"University of Southern Denmark (PhD scholarship)","award":["6237"],"award-info":[{"award-number":["6237"]}]},{"name":"Beckett Foundation","award":["17-2-0788"],"award-info":[{"award-number":["17-2-0788"]}]},{"name":"Beckett Foundation","award":["6237"],"award-info":[{"award-number":["6237"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPM"],"abstract":"<jats:p>Objective: To investigate whether cognitive inflexibility could be identified using the Wisconsin Card Sorting Test (WCST) in patients with severe and extreme anorexia nervosa (AN) compared to healthy control participants (HCs). Method: We used the WCST to assess 34 patients with AN (mean age: 25.9 years, mean body mass index (BMI): 13.2 kg\/m2) 3\u20137 days after admission to a specialized nutrition unit and 34 HCs. The Beck Depression Inventory II and the Eating Disorder Inventory 3 were distributed. Results: The patients displayed more perseveration than HCs controlled for age and years of education, with moderate effect sizes (perseverative responses (%): adjusted difference = \u22127.74, 95% CI: \u221214.29\u2013(\u22121.20), p-value: 0.021; perseverative errors (%): adjusted difference = \u22126.01, 95% CI: \u221211.06\u2013(\u22120.96), p-value: 0.020). There were no significant relationships between perseveration and depression, eating disorder symptoms, illness duration, or BMI. Discussion: Patients with severe and extreme AN demonstrated lower cognitive flexibility compared to HCs. Performance was not related to psychopathology or BMI. Patients with severe and extreme anorexia nervosa may not differ from less severe patients in cognitive flexibility performance. As this study exclusively focused on patients suffering from severe and extreme AN, potential correlations might be masked by a floor effect.<\/jats:p>","DOI":"10.3390\/jpm13061000","type":"journal-article","created":{"date-parts":[[2023,6,16]],"date-time":"2023-06-16T01:31:31Z","timestamp":1686879091000},"page":"1000","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Cognitive Flexibility in Hospitalized Patients with Severe or Extreme Anorexia Nervosa: A Case-Control Study"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6789-7105","authenticated-orcid":false,"given":"Simone Daugaard","family":"Hemmingsen","sequence":"first","affiliation":[{"name":"Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark"},{"name":"Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark"},{"name":"Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark"},{"name":"Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark"},{"name":"Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicolaj","family":"Daugaard","sequence":"additional","affiliation":[{"name":"Department of Molecular Medicine, University of Southern Denmark, 5000 Odense, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2060-1914","authenticated-orcid":false,"given":"Magnus","family":"Sj\u00f6gren","sequence":"additional","affiliation":[{"name":"Institute for Clinical Science, Department of Psychiatry, Ume\u00e5 University, 901 87 Ume\u00e5, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mia Beck","family":"Lichtenstein","sequence":"additional","affiliation":[{"name":"Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark"},{"name":"Centre for Digital Psychiatry, Region of Southern Denmark, 5000 Odense, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claire","family":"Gudex","sequence":"additional","affiliation":[{"name":"Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark"},{"name":"Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederikke","family":"Piil","sequence":"additional","affiliation":[{"name":"Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark"},{"name":"Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark"},{"name":"Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4255-5544","authenticated-orcid":false,"given":"Ren\u00e9 Klinkby","family":"St\u00f8ving","sequence":"additional","affiliation":[{"name":"Centre for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark"},{"name":"Research Unit for Medical Endocrinology, Odense University Hospital, 5000 Odense, Denmark"},{"name":"Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, 5000 Odense, Denmark"},{"name":"Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark"},{"name":"Open Patient Data Explorative Network (OPEN), 5000 Odense, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,6,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"724","DOI":"10.1001\/archgenpsychiatry.2011.74","article-title":"Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies","volume":"68","author":"Arcelus","year":"2011","journal-title":"Arch. Gen. Psychiatry"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1097\/YCO.0000000000000739","article-title":"Incidence, Prevalence and Mortality of Anorexia Nervosa and Bulimia Nervosa","volume":"34","author":"Hoek","year":"2021","journal-title":"Curr. Opin. Psychiatry"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1016\/j.cpr.2013.11.001","article-title":"Cognitive Behavioural Therapy for anorexia nervosa: A systematic review","volume":"34","author":"Allan","year":"2014","journal-title":"Clin. Psychol. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Touyz, S., Grange, D.L., Lacey, J.H., and Hay, P. (2016). Managing Severe and Enduring Anorexia Nervosa: A Clinician\u2019s Guide, Routledge, Taylor & Francis Group. Available online: https:\/\/books.google.dk\/books?id=SzCBrgEACAAJ.","DOI":"10.4324\/9781315772349"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"American Psychiatric Association DSM-5 Task Force (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5, American Psychiatric Publishing, Inc.. [5th ed.].","DOI":"10.1176\/appi.books.9780890425596"},{"key":"ref_6","unstructured":"World Health Organization (2019). International Statistical Classification of Diseases and Related Health Problems, WHO. [11th ed.]. Available online: https:\/\/icd.who.int\/."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"611","DOI":"10.1002\/eat.22715","article-title":"Labeling and defining severe and enduring anorexia nervosa: A systematic review and critical analysis","volume":"50","author":"Broomfield","year":"2017","journal-title":"Int. J. Eat. Disord."},{"key":"ref_8","first-page":"302","article-title":"Effects of Anorexia Nervosa on the Endocrine System","volume":"14","author":"Baskaran","year":"2017","journal-title":"Pediatr. Endocrinol. Rev."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"402","DOI":"10.1002\/erv.2796","article-title":"Cognitive improvement following weight gain in patients with anorexia nervosa: A systematic review","volume":"29","author":"Hemmingsen","year":"2021","journal-title":"Eur. Eat. Disord. Rev."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Keys, A., Brozek, J., Henschel, A., Mickelsen, O., and Taylor, H.L. (1950). The Biology of Human Starvation (2 Volumes), University of Minnesota Press.","DOI":"10.5749\/j.ctv9b2tqv"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"376","DOI":"10.1007\/s13668-021-00370-4","article-title":"How Does Fasting Affect Cognition? An Updated Systematic Review (2013\u20132020)","volume":"10","author":"Benau","year":"2021","journal-title":"Curr. Nutr. Rep."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1080\/13803395.2012.760536","article-title":"Neuropsychological functioning in children and adolescents with restrictive-type anorexia nervosa: An in-depth investigation with NEPSY-II","volume":"35","author":"Calderoni","year":"2013","journal-title":"J. Clin. Exp. Neuropsychol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Abbate-Daga, G., Buzzichelli, S., Amianto, F., Rocca, G., Marzola, E., McClintock, S.M., and Fassino, S. (2011). Cognitive flexibility in verbal and nonverbal domains and decision making in anorexia nervosa patients: A pilot study. BMC Psychiatry, 11.","DOI":"10.1186\/1471-244X-11-162"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"101905","DOI":"10.1016\/j.cpr.2020.101905","article-title":"Cognitive flexibility in acute anorexia nervosa and after recovery: A systematic review","volume":"81","author":"Miles","year":"2020","journal-title":"Clin. Psychol. Rev."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1002\/eat.20244","article-title":"Habit learning and anorexia nervosa: A cognitive neuroscience hypothesis","volume":"39","author":"Steinglass","year":"2006","journal-title":"Int. J. Eat. Disord."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"492","DOI":"10.1002\/eat.22106","article-title":"Cognitive remediation therapy for anorexia nervosa: Current evidence and future research directions","volume":"46","author":"Tchanturia","year":"2013","journal-title":"Int. J. Eat. Disord."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Abbate-Daga, G., Amianto, F., Delsedime, N., De-Bacco, C., and Fassino, S. (2013). Resistance to treatment and change in anorexia nervosa [corrected]: A clinical overview. BMC Psychiatry, 13.","DOI":"10.1186\/1471-244X-13-294"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2269","DOI":"10.1176\/appi.ajp.162.12.2269","article-title":"Is impaired set-shifting an endophenotype of anorexia nervosa?","volume":"162","author":"Holliday","year":"2005","journal-title":"Am. J. Psychiatry"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1016\/j.jpsychires.2014.05.015","article-title":"Longitudinal examination of decision-making performance in anorexia nervosa: Before and after weight restoration","volume":"56","author":"Bodell","year":"2014","journal-title":"J. Psychiatr. Res."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Tchanturia, K., Davies, H., Roberts, M., Harrison, A., Nakazato, M., Schmidt, U., Treasure, J., and Morris, R. (2012). Poor cognitive flexibility in eating disorders: Examining the evidence using the Wisconsin Card Sorting Task. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0028331"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"258","DOI":"10.3109\/15622975.2015.1112035","article-title":"Is inefficient cognitive processing in anorexia nervosa a familial trait? A neuropsychological pilot study of mothers of offspring with a diagnosis of anorexia nervosa","volume":"17","author":"Lang","year":"2016","journal-title":"World J. Biol. Psychiatry"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1809","DOI":"10.1017\/S0033291716000581","article-title":"The set-shifting profiles of anorexia nervosa and autism spectrum disorder using the Wisconsin Card Sorting Test: A systematic review and meta-analysis","volume":"46","author":"Westwood","year":"2016","journal-title":"Psychol. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1007\/s00787-011-0216-y","article-title":"Clinical and biological correlates of adolescent anorexia nervosa with impaired cognitive profile","volume":"20","author":"Puig","year":"2011","journal-title":"Eur. Child. Adolesc. Psychiatry"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1186\/s40337-017-0137-3","article-title":"Neurocognitive functions and social functioning in young females with recent-onset anorexia nervosa and recovered individuals","volume":"5","author":"Bentz","year":"2017","journal-title":"J. Eat. Disord."},{"key":"ref_25","first-page":"43","article-title":"Polymorphisms of the SNAP-25 gene and performance on the Wisconsin Card Sorting Test in anorexia nervosa and in healthy adolescent participants","volume":"13","author":"Slopien","year":"2011","journal-title":"Arch. Psychiatry Psychother."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"708536","DOI":"10.3389\/fpsyg.2021.708536","article-title":"The Neuropsychological Profile of Severe and Enduring Anorexia Nervosa: A Systematic Review","volume":"12","author":"Broomfield","year":"2021","journal-title":"Front. Psychol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1016\/j.psychres.2004.03.012","article-title":"Neuropsychological investigation of decision-making in anorexia nervosa","volume":"127","author":"Cavedini","year":"2004","journal-title":"Psychiatry Res."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"939225","DOI":"10.3389\/fpsyt.2022.939225","article-title":"Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients with Severe Anorexia Nervosa","volume":"13","author":"Hemmingsen","year":"2022","journal-title":"Front. Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Hemmingsen, S.D., Lichtenstein, M.B., Hussain, A.A., Sj\u00f6gren, J.M., and St\u00f8ving, R.K. (2020). Case report: Cognitive performance in an extreme case of anorexia nervosa with a body mass index of 7.7. BMC Psychiatry, 20.","DOI":"10.1186\/s12888-020-02701-1"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","article-title":"Research electronic data capture (REDCap)\u2014A metadata-driven methodology and workflow process for providing translational research informatics support","volume":"42","author":"Harris","year":"2009","journal-title":"J. Biomed. Inform."},{"key":"ref_31","unstructured":"World Health Organization (2016). The ICD-10 International Statistical Classification of Diseases and Related Health Problems. 10th Revision, World Health Organization. [5th ed.]. Available online: https:\/\/icd.who.int\/browse10\/Content\/statichtml\/ICD10Volume2_en_2016.pdf."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Beck, A.T., Steer, R.A., and Brown, G.K. (1996). Manual for the Beck Depression Inventory (BDI-II), Psychological Corporation.","DOI":"10.1037\/t00742-000"},{"key":"ref_33","unstructured":"Garner, D. (2004). Eating Disorder Inventory-3 (EDI-3) Professional Manual, Psychological Assessment Resources."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1002\/erv.2338","article-title":"An investigation of the factor structure of the beck depression inventory-II in anorexia nervosa","volume":"23","author":"Fuss","year":"2015","journal-title":"Eur. Eat. Disord. Rev."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1007\/s10862-010-9207-4","article-title":"Validating the Eating Disorder Inventory-3 (EDI-3): A Comparison Between 561 Female Eating Disorders Patients and 878 Females from the General Population","volume":"33","author":"Clausen","year":"2011","journal-title":"J. Psychopathol. Behav. Assess."},{"key":"ref_36","unstructured":"Heaton, R.K., Chelune, G.J., Talley, J.L., Kay, G.G., and Curtiss, G. (1993). Wisconsin Card Sorting Test Manual Revised and Expanded, Psychological Assessment Resources, Inc.. [2nd ed.]."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"248","DOI":"10.1177\/1073191119866257","article-title":"The Reliability of the Wisconsin Card Sorting Test in Clinical Practice","volume":"28","author":"Kopp","year":"2021","journal-title":"Assessment"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1951","DOI":"10.1017\/S0033291710002539","article-title":"Insight in eating disorders: Clinical and cognitive correlates","volume":"41","author":"Konstantakopoulos","year":"2011","journal-title":"Psychol. Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1007\/s40519-016-0331-3","article-title":"Cognitive flexibility and decision-making in eating disorders and obesity","volume":"22","author":"Perpina","year":"2017","journal-title":"Eat. Weight Disord."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1016\/j.psychres.2014.06.024","article-title":"Clinical investigation of set-shifting subtypes in anorexia nervosa","volume":"219","author":"Buzzichelli","year":"2014","journal-title":"Psychiatry Res."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1038\/s41398-020-00955-7","article-title":"Cortisol reactivity in patients with anorexia nervosa after stress induction","volume":"10","author":"Schmalbach","year":"2020","journal-title":"Transl. Psychiatry"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1016\/j.neubiorev.2021.08.021","article-title":"Neuropsychological functioning in adult anorexia nervosa: A meta-analysis","volume":"130","author":"Stedal","year":"2021","journal-title":"Neurosci. Biobehav. Rev."},{"key":"ref_43","unstructured":"Lezak, M.D., Howieson, D.B., Loring, D.W., and Fischer, J.S. (2004). Neuropsychological Assessment, Oxford University Press."},{"key":"ref_44","first-page":"24","article-title":"The cognitive neuropsychology of obsessive-compulsive disorder: A critical review","volume":"5","author":"Abramovitch","year":"2015","journal-title":"J. Obs. Compuls. Relat. Disord."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Seidel, M., Brooker, H., Lauenborg, K., Wesnes, K., and Sj\u00f6gren, M. (2021). Cognitive Function in Adults with Enduring Anorexia Nervosa. Nutrients, 13.","DOI":"10.3390\/nu13030859"},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Sj\u00f6gren, M., and St\u00f8ving, R.K. (2022). Anorexia Nervosa: Reduction in Depression during Inpatient Treatment Is Closely Related to Reduction in Eating Disorder Psychopathology. J. Pers. Med., 12.","DOI":"10.3390\/jpm12050682"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1002\/(SICI)1098-108X(1997)21:4<367::AID-EAT10>3.0.CO;2-W","article-title":"Relationship of depression, anxiety, and obsessionality to state of illness in anorexia nervosa","volume":"21","author":"Pollice","year":"1997","journal-title":"Int. J. Eat. Disord."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1383","DOI":"10.4088\/JCP.tk16043ah5c","article-title":"Cognitive Impairment in Patients with Depression: Awareness, Assessment, and Management","volume":"78","author":"Culpepper","year":"2017","journal-title":"J. Clin. Psychiatry"},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Miles, S., Nedeljkovic, M., and Phillipou, A. (2023). Investigating differences in cognitive flexibility, clinical perfectionism, and eating disorder-specific rumination across anorexia nervosa illness states. Eat. Disord., 1\u201322.","DOI":"10.1080\/10640266.2023.2206751"}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/13\/6\/1000\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:55:36Z","timestamp":1760126136000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/13\/6\/1000"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,15]]},"references-count":49,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2023,6]]}},"alternative-id":["jpm13061000"],"URL":"https:\/\/doi.org\/10.3390\/jpm13061000","relation":{},"ISSN":["2075-4426"],"issn-type":[{"value":"2075-4426","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,6,15]]}}}