cognitive functioning and decision making in anorexia nervosa…€¦ · in anorexia nervosa: risk...

DepartmentDepartment ofof NeurosciencesNeurosciencesSchoolSchool ofof MedicineMedicineUniversityUniversity ofof PaduaPadua

Angela Favaro, Angela Favaro, MDMD, , PhDPhDPaolo Santonastaso, MDPaolo Santonastaso, MD

COGNITIVE FUNCTIONING AND DECISION MAKING COGNITIVE FUNCTIONING AND DECISION MAKING IN ANOREXIA NERVOSA: RISK FACTORS AND IN ANOREXIA NERVOSA: RISK FACTORS AND

PROGNOSTIC IMPLICATIONSPROGNOSTIC IMPLICATIONS

AlpbachAlpbach -- OctoberOctober 20102010

The Padua Chartreuse

Paper Paper readread at at thethe JubileeJubilee Congress on Congress on EatingEating DisordersDisorders 2010, 2010, TheThe 18th 18th International International ConferenceConference, , OctoberOctober 2121--23, 2010, Alpbach, 23, 2010, Alpbach, TyrolTyrol, , AustriaAustria

Cognitive Cognitive assessmentassessment in AN: in AN: WhyWhy??

Identification of endophenotype candidates forunderstanding and study pathogenetic pathways

Improving treatment outcome or, at least, understandingtreatment failures

IdentificationIdentification ofof endophenotypeendophenotype candidatescandidates forforunderstandingunderstanding and and studystudy pathogenetic pathogenetic pathwayspathways

ImprovingImproving treatment treatment outcomeoutcome or, at or, at leastleast, , understandingunderstandingtreatment treatment failuresfailures

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AN controls

Handedness

AN patient were more left-handed than controlsOR=2.8, 95% C.I. 1.1-7.2

Perinatal Perinatal complicationscomplications asas riskrisk factorsfactors forfor impairmentimpairment ofofexecutive executive functionsfunctions in ANin AN

Subjects with lifetime AN (n=193) and controls (170) Structured clinical interview for EDNeuropsychological assessment

- set-shifting (WCST, Trial A and B)- visuo-spatial impairment (Rey Complex Figure)- decision making (Iowa Gambling Task)- working memory (interference)

Genetic assessment (ongoing)COMT, BDNF, 5HT transporter

SubjectsSubjects withwith lifetimelifetime AN (n=193) and AN (n=193) and controlscontrols (170)(170) StructuredStructured clinicalclinical interviewinterview forfor EDEDNeuropsychologicalNeuropsychological assessmentassessment

-- setset--shiftingshifting (WCST, Trial A and B)(WCST, Trial A and B)-- visuovisuo--spatialspatial impairmentimpairment ((ReyRey ComplexComplex Figure)Figure)-- decisiondecision makingmaking ((IowaIowa GamblingGambling Task)Task)-- workingworking memorymemory ((interferenceinterference))

GeneticGenetic assessmentassessment ((ongoingongoing))COMT, BDNF, 5HT COMT, BDNF, 5HT transportertransporter

Wisconsin Card Sorting Task

Perseverance, set-shifting deficitCognitive inflexibility

Wisconsin Card Wisconsin Card SortingSorting TaskTask

PPerseveranceerseverance, set, set--shifting deficitshifting deficitCognitive inflexibilityCognitive inflexibility

Cognitive Cognitive functioningfunctioning

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Total errors* perseveration*

ANcontrols

Wisconsin Card Sorting Task

Perseverance, set-shifting deficitCognitive inflexibility

Wisconsin Card Wisconsin Card SortingSorting TaskTask

PPerseveranceerseverance, set, set--shifting deficitshifting deficitCognitive inflexibilityCognitive inflexibility

Cognitive Cognitive functioningfunctioning

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Total errors* perseveration*

ANcontrolssisters

Rey-Osterrieth Complex Figure Test

AN: Deficit in central coherence

It appraises different cognitive functions such perception, visuospatial ability, planning and visuospatial memory. The subject must copy and recall, after an interval of three minutes, a complex geometric figure.

The index of central coherence (ICC), that derives from the order of construction index and style index.

ReyRey--OsterriethOsterrieth Complex Figure TestComplex Figure Test

AN: Deficit in AN: Deficit in centralcentral coherencecoherence

It appraises different cognitive functions such perception, It appraises different cognitive functions such perception, visuospatialvisuospatial ability, planning and ability, planning and visuospatialvisuospatial memory. The memory. The subject must copy and recall, after an interval of three subject must copy and recall, after an interval of three minutes, a complex geometric figureminutes, a complex geometric figure..

The index of central coherence (ICC), that derives from the The index of central coherence (ICC), that derives from the order of construction index and style indexorder of construction index and style index..

CentralCentral coherencecoherence in AN in AN


Deficit in central coherence


Deficit in Deficit in centralcentral coherencecoherence

CentralCentral coherencecoherence

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copy recall* centralcoherence*

ANcontrols





CentralCentral coherencecoherence

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copy recall* centralcoherence*

ANcontrolssisters

Figure aggrovigliateRicostruzione oggettiBlock design

Figure Figure aggrovigliateaggrovigliateRicostruzioneRicostruzione oggettioggettiBlock designBlock design

VisuoVisuo--spatialspatial abilitiesabilities

05

101520253035404550

overlapping* objectassembly*

blockunsegm*

block segm*

ANcontrols





VisuoVisuo--spatialspatial abilitiesabilities

05

101520253035404550

Overlapping* Objectassembly*

Blockunsegm*

Block segm*

ANcontrolssisters

Figure aggrovigliateRicostruzione oggettiBlock design

Figure Figure aggrovigliateaggrovigliateRicostruzioneRicostruzione oggettioggettiBlock designBlock design

ImpairmentImpairment in executive in executive functioningfunctioning isis notnot a a functionfunction ofofbrainbrain atrophyatrophy

37 37 yearsyears oldold24 24 yearsyears ofof ANANBMI BMI ofof 10,410,4

WCST n. WCST n. persevpersev. 13% (. 13% (normalnormal))TMT B = 98 (TMT B = 98 (normalnormal))ReyRey Figure ICC = 1.06 (Figure ICC = 1.06 (normalnormal))ReyRey copy = 26 (low)copy = 26 (low)ReyRey memo = 15 (memo = 15 (normalnormal))IOWA net score = IOWA net score = --2 (low)2 (low)

23 23 yearsyears oldold4 4 yearsyears ofof ANANBMI BMI ofof 16,116,1

WCST n. WCST n. persevpersev. 36% (high). 36% (high)TMT B = 152 (high)TMT B = 152 (high)ReyRey Figure ICC = 1.06 (Figure ICC = 1.06 (normalnormal))ReyRey copy = 32 (low)copy = 32 (low)ReyRey memo = 12 (low)memo = 12 (low)IOWA net score = IOWA net score = --2 (low)2 (low)

ButBut weightweight status can status can changechange the the relationshiprelationship betweenbetweencognitive cognitive functionfunction and and geneticgenetic polymorphismspolymorphisms

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val/val val/met met/met0

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val/val val/met met/met

acute AN

weight-restoredAN

Healthy controls Anorexia nervosa

Wisconsin Card Wisconsin Card SortingSorting Task: Task: numnum. . perseverativeperseverative errorserrors

**

COMT COMT genotypegenotype ((met=lowmet=low functionfunction allele)allele)

Normal dopamineHigh dopamine

DecisionDecision makingmaking

•• ComplexComplex processprocessguidedguided byby bothbothcognitive and cognitive and emotionalemotional issuesissues. .

•• AbilityAbility toto considerconsiderfuture future consequencesconsequencesin in orderorder toto obtainobtain the the best best gaingain in the long in the long termterm..

Padova, Palazzo della Ragione

BrainBrain and and decisiondecision--makingmaking

Dorsolateral Prefrontalcortex = cognitive component: planning, reasoning, learning fromerrors, and delaying actions

Ventromedial Prefrontalcortex and insula = emotional component: impulsive choice towardsimmediate gain, but alsoautomatic intuition aboutgood choices for the future (somatic marker hypothesis)

Iowa Gambling Task (IGT)

The IGT has been used as a behavioral indicator of riskydecision making that may reflect dysfunction of frontallobe structures or frontal connections.

IowaIowa GamblingGambling Task (IGT)Task (IGT)

The IGT The IGT hashas beenbeen usedused asas a a behavioralbehavioral indicatorindicator ofof riskyriskydecisiondecision makingmaking thatthat maymay reflectreflect dysfunctiondysfunction ofof frontalfrontallobelobe structuresstructures or or frontalfrontal connectionsconnections..

DecisionDecision makingmaking

IowaIowa GamblingGambling TaskTask

IowaIowa GamblingGambling TaskTaskGeneral Performance

Net score = (number of choice of good decks) – (number ofchoices of bad decks)

Learning score = (number of good choices in the last 40 decks) – (number of good choices in the first 40 decks)

Expectancy-Valence model(estimation of cognitive parameters)

a = attention to recent outcomes (updating) as opposite ofpersistence on initial choices (from 0 to 1)

w = attention to wins as opposite to attention to losses (from 0 to 1)

c = choice consistency during the task (from -5 to 5)


Yechiam, Busemeyer, Stout, & Bechara, 2005

OurOur studystudy

A sample of A sample of 168 subjects with lifetime AN 168 subjects with lifetime AN 169 healthy controls 169 healthy controls

-- Structured diagnostic interviewStructured diagnostic interview-- Iowa Gambling TaskIowa Gambling Task

Other cognitive measures:Other cognitive measures:-- Wisconsin Card Wisconsin Card SortingSorting TestTest-- ReyRey ComplexComplex FigureFigure-- InterferenceInterference memorymemory test (test (workingworking memorymemory))

IGT net score: t=5.17; p<0.001

IGT learning:t=3.35; p=0.001


No difference

-3

-2

-1

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block 1 (0-20)

block 2 (21-40)

block 3 (41-60)

block 4 (61-80)

block 5 (81-100)

acute ANweight-recovered AN


ExpectancyExpectancy--Valence modelValence model

a: 0.36 a: 0.36 ±± 0.40 among controls; 0.33 0.40 among controls; 0.33 ±± 0.40 among AN; t=0.56; 0.40 among AN; t=0.56; p=0.58p=0.58w: 0.46 w: 0.46 ±± 0.31 among controls; 0.40 0.31 among controls; 0.40 ±± 0.33 among AN; t=2.00; p<0.050.33 among AN; t=2.00; p<0.05c: 0.75 c: 0.75 ±± 1.67 among controls; 0.60 1.67 among controls; 0.60 ±± 1.81 among AN; t=0.41; p=0.681.81 among AN; t=0.41; p=0.68

Given the high variance in the EV model parameters in both Given the high variance in the EV model parameters in both AN and controls, we performed a cluster analysis.AN and controls, we performed a cluster analysis.

Two clusters emerged:Two clusters emerged:Cluster 1 (Cluster 1 (‘‘perseverativeperseverative’’))

-- low a (low updating)low a (low updating)-- low w (strong attention to losses)low w (strong attention to losses)-- high c (high consistency)high c (high consistency)

Cluster 2 (Cluster 2 (‘‘impulsiveimpulsive’’))-- high a (high updating)high a (high updating)-- high w (strong attention to wins)high w (strong attention to wins)

l (l i )l (l i t )



In AN, the two clusters did not show significant differences.In AN, the two clusters did not show significant differences.Among controls, the impulsive cluster reported a poorer Among controls, the impulsive cluster reported a poorer performance, due to low learning.performance, due to low learning.


Yechiam, Busemeyer, Stout, & Bechara, 2005

AN cluster 2

AN cluster 1

In AN, the two clusters showed significant differences:In AN, the two clusters showed significant differences:

The impulsive cluster in comparison to the The impulsive cluster in comparison to the perseverativeperseverativeis associated to:is associated to:-- younger age of onset (p<0.02)younger age of onset (p<0.02)-- higher number of perinatal hypoxic complications higher number of perinatal hypoxic complications (p<0.05)(p<0.05)

-- In the impulsive cluster (less true in the In the impulsive cluster (less true in the perseverativeperseverative), ), a good performance is associated to good response to a good performance is associated to good response to treatment.treatment.

In the In the perseverativeperseverative cluster, a good performance is cluster, a good performance is associated to:associated to:-- low cognitive inflexibilitylow cognitive inflexibility-- absence of met allele in BDNF val66met polymorphismabsence of met allele in BDNF val66met polymorphism-- presence of met allele COMT val158met polymorphismpresence of met allele COMT val158met polymorphism


ConclusionsConclusions

Decision making is significantly impaired in AN patients. Decision making is significantly impaired in AN patients.

However, some patients are unable to make good However, some patients are unable to make good decisions because of their impulsiveness and inability to decisions because of their impulsiveness and inability to delay gratification and learn from errors, while others are delay gratification and learn from errors, while others are so so perseverativeperseverative and avoidant that fail to learn during and avoidant that fail to learn during the task. the task.

This distinction may have important implications for This distinction may have important implications for phenotype characterization and treatment, because they phenotype characterization and treatment, because they are associated to different genetic and environmental are associated to different genetic and environmental risk factors.risk factors.

Prenatal and perinatal Prenatal and perinatal factorsfactors: : WhyWhy are are theythey importantimportant??

Two possible pathways:

Prenatal/perinatal hypoxic complications = damage ofspecific brain structures resulting in cognitive impairment

Developmental dysfunction of stress response systems due to fetal programming = inability to cope with stressfulsituations or trauma, effects on brain development

TwoTwo possiblepossible pathwayspathways::

Prenatal/perinatal Prenatal/perinatal hypoxichypoxic complicationscomplications = = damagedamage ofofspecificspecific brainbrain structuresstructures resultingresulting in cognitive in cognitive impairmentimpairment

DevelopmentalDevelopmental dysfunctiondysfunction ofof stress stress responseresponse systemssystems due due toto fetalfetal programmingprogramming = = inabilityinability toto copecope withwith stressfulstressfulsituationssituations or trauma, or trauma, effectseffects on on brainbrain developmentdevelopment


Risk of developing AN AN onset

OR = 1.8 3.3 (Kruskal-Wallis χ2=7.73; d.f.=2;

(1.1-3.2) (1.6-6.6) p<0.03)

10,5

17,7

28

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0 1 to 5 > 5

number of complications

1515,5

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0 1 to 5 > 5

number of complications


Subjects with lifetime AN (n=193) and controls (170) Structured clinical interview for EDNeuropsychological assessment

- set-shifting (WCST, Trial A and B)- visuo-spatial impairment (Rey Complex Figure)- decision making (Iowa Gambling Task)- working memory (interference)

Perinatal history Obstetric clinical records for 117 AN and 88 control subjects(86 AN and 61 controls born in Padua Hospital)

Genetic assessment (ongoing)COMT, BDNF, 5HT transporter

SubjectsSubjects withwith lifetimelifetime AN (n=193) and AN (n=193) and controlscontrols (170)(170) StructuredStructured clinicalclinical interviewinterview forfor EDEDNeuropsychologicalNeuropsychological assessmentassessment

-- setset--shiftingshifting (WCST, Trial A and B)(WCST, Trial A and B)-- visuovisuo--spatialspatial impairmentimpairment ((ReyRey ComplexComplex Figure)Figure)-- decisiondecision makingmaking ((IowaIowa GamblingGambling Task)Task)-- workingworking memorymemory ((interferenceinterference))

Perinatal Perinatal historyhistory ObstetricObstetric clinicalclinical recordsrecords forfor 117 AN and 88 117 AN and 88 controlcontrol subjectssubjects(86 AN and 61 (86 AN and 61 controlscontrols bornborn in in PaduaPadua Hospital)Hospital)

GeneticGenetic assessmentassessment ((ongoingongoing))COMT, BDNF, 5HT COMT, BDNF, 5HT transportertransporter


Interactions with other risk factors (genetic) are probable, because most subjects with perinatal complications did notdisplay psychopathology or cognitive impairment

InteractionsInteractions withwith otherother riskrisk factorsfactors ((geneticgenetic) are ) are probableprobable, , becausebecause mostmost subjectssubjects withwith perinatal perinatal complicationscomplications diddid notnotdisplay display psychopathologypsychopathology or cognitive or cognitive impairmentimpairment

Central coherence index iscorrelated with the numberof hypoxic complications in AN (F(1, 81)=7.96; p=0.006)

CentralCentral coherencecoherence indexindex isiscorrelatedcorrelated withwith the the numbernumberofof hypoxichypoxic complicationscomplications in in AN (F(1, 81)=7.96; AN (F(1, 81)=7.96; p=0.006)p=0.006)

BDNF (val66met BDNF (val66met polymorphismpolymorphism) ) absenceabsence ofof metmet alleleallele presencepresence ofof metmet allelealleleF(1, 36)=0.68; F(1, 36)=0.68; n.s.n.s. F(1, 24)=13.21; p<0.001F(1, 24)=13.21; p<0.001


Two possible pathways:

Prenatal/perinatal hypoxic complications = damage ofspecific brain structures resulting in cognitive impairment

Developmental dysfunction of stress response systems due to fetal programming = inability to cope with stressfulsituations or trauma, effects on brain development

TwoTwo possiblepossible pathwayspathways::

Prenatal/perinatal Prenatal/perinatal hypoxichypoxic complicationscomplications = = damagedamage ofofspecificspecific brainbrain structuresstructures resultingresulting in cognitive in cognitive impairmentimpairment

DevelopmentalDevelopmental dysfunctiondysfunction ofof stress stress responseresponse systemssystems due due toto fetalfetal programmingprogramming = = inabilityinability toto copecope withwith stressfulstressfulsituationssituations or trauma, or trauma, effectseffects on on brainbrain developmentdevelopment


Subjects with AN had more signs of dysmaturity at birth (hypothermia, hyporeactivity, hypotonia, early feeding problems).

Dysmaturity at birth is a predictor of high harm avoidance.

Stress and Stress and BrainBrain

The The effectseffects ofof stress are stress are correlatedcorrelated toto brainbrain maturationmaturation at the at the timetimeofof traumatrauma

FetalFetal programmingprogramming hypothesishypothesis

CortisolCortisol exposureexposure duringduringpregnancypregnancy

NeonatalNeonataldysmaturitydysmaturity

LowerLowerglucocorticoidglucocorticoidreceptorreceptorexpressionexpression in the in the hippocampushippocampus (HPA (HPA hyperactivityhyperactivity))

IncreasedIncreased glucocorticoidglucocorticoidreceptorreceptor expressionexpression in the in the amygdalaamygdala ((increasedincreasedanxietyanxiety and and avoidanceavoidanceresponsesresponses))

AssessmentAssessment ofof stress stress duringduring pregnancypregnancy

Interview with parents (the mother or both parents) aboutpregnancy for 113 AN and 84 control subjects.

Subjective distress:4 questions about feelings and distress duringpregnancy

Objective stressstructured interview investigating a list of stressfulevents (aggressions, death of loved ones, caraccidents, natural disasters, conflicts with partner or separation), their severity and time during pregnancy

InterviewInterview withwith parentsparents (the (the mothermother or or bothboth parentsparents) ) aboutaboutpregnancypregnancy forfor 113 AN and 84 113 AN and 84 controlcontrol subjectssubjects..

SubjectiveSubjective distressdistress::4 4 questionsquestions aboutabout feelingsfeelings and and distressdistress duringduringpregnancypregnancy

ObjectiveObjective stressstressstructuredstructured interviewinterview investigatinginvestigating a a listlist ofof stressfulstressfuleventsevents ((aggressionsaggressions, , deathdeath ofof lovedloved onesones, , carcaraccidentsaccidents, , naturalnatural disastersdisasters, , conflictsconflicts withwith partner or partner or separationseparation), ), theirtheir severityseverity and and timetime duringduring pregnancypregnancy

Mothers of AN patients reported more often thanmothers of controls (64% vs. 48%; χ2=4.55; df=1; p=0.03) a stressful event during pregnancy.

In addition, the number and severity of stressfulevents was greater in mothers of AN patients(p<0.002).

Subjective maternal distress during pregnancywas higher in mothers of AN than in mothers of controls, but the difference was not significant.1.6 ± 2.1 vs. 0.9 ± 1.0; z = 1.60; p=0.10

MothersMothers ofof AN AN patientspatients reportedreported more more oftenoften thanthanmothersmothers ofof controlscontrols (64% vs. 48%; (64% vs. 48%; χχ2=4.55; df=1; 2=4.55; df=1; p=0.03) a p=0.03) a sstressfultressful eventevent duringduring pregnancypregnancy..

In In additionaddition, the , the numbernumber and and severityseverity ofof stressfulstressfuleventsevents waswas greatergreater in in mothersmothers ofof AN AN patientspatients(p<0.002).(p<0.002).

SubjectiveSubjective maternalmaternal distressdistress duringduring pregnancypregnancywaswas higherhigher in in mothersmothers ofof AN AN thanthan in in mothersmothers ofof controlscontrols, , butbut the the differencedifference waswas notnot significantsignificant..1.6 1.6 ±± 2.1 vs. 0.9 2.1 vs. 0.9 ±± 1.0; z = 1.60; p=0.101.0; z = 1.60; p=0.10

StressfulStressful eventsevents duringduring pregnancypregnancy

In both AN patients and controls, maternal stressduring pregnancy was associated to lowerEdinburgh scores (p=0.02 in AN, p=0.07 in controls)

In AN, maternal stress was associated with:

Higher number of perinatal complications (p<0.001)Higher number of pregnancy complications (p<0.006)Higher number of neonatal dysmaturity signs (p<0.05)

Higher perfectionism (p=0.03)Higher persistence at TPQ (p=0.004)

Higher WCST perseverative errors (p=0.002)Poor global score WCST (p=0.01)

In In bothboth AN AN patientspatients and and controlscontrols, , maternalmaternal stressstressduringduring pregnancypregnancy waswas associatedassociated toto lowerlowerEdinburgh Edinburgh scoresscores (p=0.02 in AN, p=0.07 in (p=0.02 in AN, p=0.07 in controlscontrols))

In AN, In AN, maternalmaternal stress stress waswas associatedassociated withwith::

HigherHigher numbernumber ofof perinatal perinatal complicationscomplications (p<0.001)(p<0.001)HigherHigher numbernumber ofof pregnancypregnancy complicationscomplications (p<0.006)(p<0.006)HigherHigher numbernumber ofof neonatalneonatal dysmaturitydysmaturity signssigns (p<0.05)(p<0.05)

HigherHigher perfectionismperfectionism (p=0.03)(p=0.03)HigherHigher persistencepersistence at TPQ (p=0.004)at TPQ (p=0.004)

HigherHigher WCST WCST perseverativeperseverative errorserrors (p=0.002)(p=0.002)PoorPoor global score WCST (p=0.01)global score WCST (p=0.01)

StressfulStressful eventsevents duringduring pregnancypregnancy


Cognitive functioning is impaired in anorexia nervosa and both genetic and early environmental risk factors are implicated

Prefrontal dopamine and COMT polymorphism haveimportant effects on cognitive perseveration in anorexianervosa.

Hypoxic perinatal complications might be risk factors forlower central coherence in AN, and BDNF probablyimpact recovery from neonatal hypoxia.

Cognitive Cognitive functioningfunctioning isis impairedimpaired in in anorexiaanorexia nervosa and nervosa and bothboth geneticgenetic and and earlyearly environmentalenvironmental riskrisk factorsfactors are are implicatedimplicated

PrefrontalPrefrontal dopamine and COMT dopamine and COMT polymorphismpolymorphism havehaveimportantimportant effectseffects on cognitive on cognitive perseverationperseveration in in anorexiaanorexianervosa.nervosa.

HypoxicHypoxic perinatal perinatal complicationscomplications mightmight bebe riskrisk factorsfactors forforlowerlower centralcentral coherencecoherence in AN, and BDNF in AN, and BDNF probablyprobablyimpact impact recoveryrecovery fromfrom neonatalneonatal hypoxiahypoxia..


Stressful events are more often reported by mothers of AN patients than by mothers of healthy controls, but theydid not report significantly more subjective distressduring pregnancy.

Maternal reporting of stress during pregnancy seems to beassociated to ‘core’ AN symptoms, such as perfectionismand temperamental persistence, but also to cognitive inflexibility and lower levels of right-handedness.

StressfulStressful eventsevents are more are more oftenoften reportedreported byby mothersmothers ofof AN AN patientspatients thanthan byby mothersmothers ofof healthyhealthy controlscontrols, , butbut theytheydiddid notnot report report significantlysignificantly more more subjectivesubjective distressdistressduringduring pregnancypregnancy..

MaternalMaternal reportingreporting ofof stress stress duringduring pregnancypregnancy seemsseems toto bebeassociatedassociated toto ‘‘corecore’’ AN AN symptomssymptoms, , suchsuch asas perfectionismperfectionismand and temperamentaltemperamental persistencepersistence, , butbut alsoalso toto cognitive cognitive inflexibilityinflexibility and and lowerlower levelslevels ofof rightright--handednesshandedness..

Many thanks to all Many thanks to all the Padova group!the Padova group!

Tatiana Tatiana ZanettiZanetti Elena Elena TenconiTenconiDaniela Daniela DegortesDegortes Romina Romina BoselloBoselloAngela VeroneseAngela Veronese Francesca Francesca TittonTittonLucia Lucia CeschinCeschin Manuela SoaveManuela Soave

allall the the residentsresidents

andandallall the the patientspatients and and theirtheir familiesfamilies

cognitive functioning and decision making in anorexia nervosa…€¦ · in anorexia nervosa: risk...

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