Cognitive Evaluation of Patients With Eating Disorders (DNA_ARFID)

Neuro-cognitive Profiles of Patients With Nutritional and Eating Disorders

The goal of this cross - sectional observational study is to improve understanding of the psychological and cognitive characteristics of Feeding and Eating Disorders (FEDs), a group of conditions that represent a growing public health concern due to their significant impact on physical health, emotional well-being, and everyday functioning. Within this broader diagnostic category, particular attention is given to Avoidant/Restrictive Food Intake Disorder (ARFID), a diagnosis introduced in the DSM-5 and still relatively underexplored compared to other feeding and eating disorders.

Despite its clinical relevance, ARFID remains less well understood in terms of its underlying cognitive and psychological mechanisms. Individuals with ARFID often experience severe food avoidance or restriction that is not driven by weight or shape concerns, but rather by sensory sensitivities, fear of negative consequences of eating, or a lack of interest in food. For this reason, investigating ARFID can offer important insights into the diversity of mechanisms involved in feeding and eating disorders as a whole.

The study has two main objectives. The first objective is to examine the cognitive profile of individuals with ARFID, with a specific focus on autistic traits and cognitive flexibility, as previous research suggests potential overlaps between ARFID and neurodevelopmental conditions such as Autism Spectrum Disorders. Cognitive flexibility refers to the ability to adapt thoughts and behaviors in response to changing situations, and reduced flexibility may contribute to rigid eating patterns and food avoidance.

The second objective is to explore the role of body representation (how individuals perceive and mentally represent their own body) and inhibitory control (the ability to regulate or suppress automatic responses) in shaping the cognitive and behavioral features of ARFID and other feeding and eating disorders. These processes may help distinguish ARFID from other diagnoses and clarify shared and disorder-specific mechanisms across the FED spectrum.

The study involves adult participants of all genders, including individuals diagnosed with ARFID, anorexia nervosa, and bulimia nervosa, as well as healthy control participants without a history of feeding or eating disorders. This design allows meaningful comparisons between different diagnostic groups and with the general population.

The main questions the study aims to answer are:

Do individuals with ARFID show a distinct cognitive profile, particularly in terms of autistic traits and cognitive flexibility, compared to individuals with other feeding and eating disorders and healthy controls?

How do body representation and inhibitory control contribute to differences in eating-related behaviors across feeding and eating disorders?

Are there differences in brain activity associated with implicit, automatic attitudes toward food in individuals with feeding and eating disorders compared to healthy individuals?

Where comparison groups are included, researchers will compare participants with ARFID, anorexia nervosa, bulimia nervosa, and healthy controls to examine differences in cognitive functioning, psychological characteristics, and neural responses related to food processing.

Participants will be asked to take part in a series of non-invasive and well-established research activities, designed to be accessible and safe. These include:

Completing self-report questionnaires assessing autistic traits, body image perception, and general psychological well-being;

Performing computer-based tasks that assess cognitive flexibility and decision-making;

Completing behavioral tasks designed to measure inhibitory control and automatic associations with food-related stimuli;

Study Overview

• Status: Recruiting
• Conditions: Anorexia Nervosa; Bulimia Nervosa; ARFID; Executive Functions; Cognitive Flexibility; Implicit Association Test
• Intervention / Treatment: Behavioral: Go/No-go; Behavioral: IAT; Behavioral: WCST

• Study Type: Observational
• Enrollment (Estimated): 84

Contacts and Locations

• Study Contact: Name: Giulia Mattavelli, Associated prof., researcher; Phone Number: +39 3397893500; Email: giulia.mattavelli@iusspavia.it

Study Locations

• Italy
  • Milan, Italy, 20157
    • Recruiting
    • Asst Fatebenefratelli Sacco
    • Contact: Lorenzo Casati, MD Psychiatrist; Phone Number: +390239042904; Email: lorenzo.casati@asst-fbf-sacco.it
  • Milan, Italy, 20124
    • Recruiting
    • Istituto Psicologico Italiano s.r.l.s.
    • Contact: Pablo Zuglian, PhD; Phone Number: 349 7430677; Email: pablo.zuglian@istitutopsicologico.it
  • PV
    • Pavia, PV, Italy, 27100
      • Recruiting
      • IUSS Pavia - Istituto Universitario di Studi Superiori
      • Contact: Giulia Camilla Mattavelli; Email: giulia.mattavelli@iusspavia.it

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

The study population includes adolescent and adult participants aged between 14 and 65 years, of both sexes, recruited among individuals diagnosed with Feeding and Eating Disorders and healthy control volunteers. The clinical group consists of patients with a diagnosis of Avoidant/Restrictive Food Intake Disorder, anorexia nervosa, or bulimia nervosa, with a Body Mass Index (BMI) lower than 25.

Eligible participants must meet the diagnostic criteria for a Feeding and Eating Disorder according to DSM-5-TR and must provide written informed consent to participate in the study. For participants under the age of 18, written consent from parents or legal guardians is required in addition to the minor's assent.

A group of healthy control participants will be recruited in order to obtain a sample balanced with the patient group in terms of sex, age, and educational level. The same inclusion and exclusion criteria applied to the patient group will be considered for the control group.

Description

Inclusion Criteria:

• Diagnosis of a Feeding and Eating Disorder (ARFID, anorexia nervosa, or bulimia nervosa);
• Patients of both sexes;
• Age between 14 and 65 years;
• Confirmed diagnosis of a Feeding and Eating Disorder;
• Body Mass Index (BMI) < 25;
• Signed informed consent form for participation in the study.

Exclusion Criteria:

• Diagnosis of Bipolar Disorder according to DSM-5-TR criteria;
• Diagnosis of a Schizophrenia Spectrum Disorder according to DSM-5-TR criteria;
• Intellectual disability according to DSM-5-TR criteria;
• Presence of brain tumors;
• History of seizure events;
• Presence of other moderate to severe neurological disorders;
• Lack of the patient's consent to voluntary participation in the study;
• Lack of parental or legal guardian consent for participation of a minor in the study.

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Healthy control; Every participant recieve all the interventions described, each one of them with the specific randomization of subministration.	Behavioral: Go/No-go; The investigators designed a specific task, base in literature, to evaluate the inibithory response to food stimuli of different types (high calories, low calories, neutral stimuli). The images have been defined by a pilot selection and added to the task designed on Psychopy.; Behavioral: IAT; The investigators designed a specific task, base in literature, to evaluate the implicit association of body images (overweight, underweight, normalweight) and word to different lables. The body images have been defined by a pilot selection and added to the task designed on Psychopy.; Behavioral: WCST; The Wisconsin Card Sorting Test (WCST) is a neuropsychological assessment of executive function, cognitive flexibility, and abstract reasoning. Participants match stimulus cards based on color, form, or number, adapting to changing, unstated rules based on examiner feedback. It measures the ability to display flexibility in the face of changing schedules of reinforcement, specifically "set-shifting". A participant is given a deck of cards and told to match them, but not how. The examiner says "right" or "wrong," forcing the participant to deduce the rule (color, shape, or number). The rule changes unexpectedly after a certain number of correct matches. It provides scores for categories completed, trials, total errors, and, critically, perseverative errors (continuing to use a previous, invalid rule). The investigators used the 128 cards version.
ARFID; Patients with Avoidant Restrictive Food Intake Disorder. Every participant recieve all the interventions described, each one of them with the specific randomization of subministration.	Behavioral: Go/No-go; The investigators designed a specific task, base in literature, to evaluate the inibithory response to food stimuli of different types (high calories, low calories, neutral stimuli). The images have been defined by a pilot selection and added to the task designed on Psychopy.; Behavioral: IAT; The investigators designed a specific task, base in literature, to evaluate the implicit association of body images (overweight, underweight, normalweight) and word to different lables. The body images have been defined by a pilot selection and added to the task designed on Psychopy.; Behavioral: WCST; The Wisconsin Card Sorting Test (WCST) is a neuropsychological assessment of executive function, cognitive flexibility, and abstract reasoning. Participants match stimulus cards based on color, form, or number, adapting to changing, unstated rules based on examiner feedback. It measures the ability to display flexibility in the face of changing schedules of reinforcement, specifically "set-shifting". A participant is given a deck of cards and told to match them, but not how. The examiner says "right" or "wrong," forcing the participant to deduce the rule (color, shape, or number). The rule changes unexpectedly after a certain number of correct matches. It provides scores for categories completed, trials, total errors, and, critically, perseverative errors (continuing to use a previous, invalid rule). The investigators used the 128 cards version.
AN/BN; Patients with a diagnosis of Anorexia Nervosa or Bulimia Nervosa. Every participant recieve all the interventions described, each one of them with the specific randomization of subministration.	Behavioral: Go/No-go; The investigators designed a specific task, base in literature, to evaluate the inibithory response to food stimuli of different types (high calories, low calories, neutral stimuli). The images have been defined by a pilot selection and added to the task designed on Psychopy.; Behavioral: IAT; The investigators designed a specific task, base in literature, to evaluate the implicit association of body images (overweight, underweight, normalweight) and word to different lables. The body images have been defined by a pilot selection and added to the task designed on Psychopy.; Behavioral: WCST; The Wisconsin Card Sorting Test (WCST) is a neuropsychological assessment of executive function, cognitive flexibility, and abstract reasoning. Participants match stimulus cards based on color, form, or number, adapting to changing, unstated rules based on examiner feedback. It measures the ability to display flexibility in the face of changing schedules of reinforcement, specifically "set-shifting". A participant is given a deck of cards and told to match them, but not how. The examiner says "right" or "wrong," forcing the participant to deduce the rule (color, shape, or number). The rule changes unexpectedly after a certain number of correct matches. It provides scores for categories completed, trials, total errors, and, critically, perseverative errors (continuing to use a previous, invalid rule). The investigators used the 128 cards version.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
What is the cognitive profile of patients with ARFID, with particular reference to autistic traits and cognitive flexibility?	The Autism Spectrum Quotient (AQ) questionnarie has the purpose to evaluate the levels of autistic traits in each participant and permit to understand the differences between the groups. The scoring of this questionnaire stays in the range 0-50, where 0 is the minimum and associated with less autistic traits and 50 is the maximum outcome possible, explaining elevated autistic traits. Usually, the cut-off is defined as 32, over that score is possible to define the presence of autistic traits.	Baseline
What is the cognitive profile of patients with ARFID, with particular reference to autistic traits and cognitive flexibility?	The higher the percentage of perseverative errors out of the total errors made on the Wisconsin Card Sorting Test (WCST), the lower the subject's cognitive flexibility. The WCST assesses executive functions, particularly cognitive flexibility, set-shifting ability, and problem-solving strategies. Scoring is typically based on several indices, including number of categories completed, total errors, and perseverative errors, with perseverative errors often expressed as a percentage of total responses. There is no universally accepted clinical cut-off for WCST performance, as interpretation is usually based on comparison with age-adjusted normative data; however, higher percentages of perseverative errors are generally interpreted as indicating greater executive dysfunction. The scale starts at 0%, which indicates full cognitive flexibility, and increases accordingly torwards 100%, indicating cognitive rigidity.	Baseline

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
What is the role of body representation and inhibitory control capacity in the differential diagnosis between ARFID and other eating disorders, such as Anorexia Nervosa and Bulimia Nervosa?	The assessment of body representation is carried out through the scoring and comparison of participants' scores through the scoring of the Implicit Association Task (IAT), involving implicit associations with body images. Scores on the D-scores emerging as outcomes from the computerized IAT task will be evaluated. The interpretation of scoring has this pattern: +0.15 <: no implicit preference; 0.16 - 0.35: weak preference; 0.36 - 0.65: moderate preference; > 0.65: strong preference The theoretical range of D score is between -2 and 2, but in empirical practise it's moreover between -1,5 and 1,5.	Baseline
What is the role of body representation and inhibitory control capacity in the differential diagnosis between ARFID and other eating disorders, such as Anorexia Nervosa and Bulimia Nervosa?	The assessment of body representation is carried out through the scoring and comparison of participants' scores on one of the questionnaires included in the project, namely the Body Image Concern Inventory (BICI). It is a 19-item self-report questionnaire assessing dysmorphic concerns related to body image. Each item is rated on a 5-point Likert scale (1 = never, 5 = always). The total score is obtained by summing all items and ranges from 19 to 95, with higher scores indicating greater body image concern. A commonly used cut-off is ≥55 (95th percentile in normative samples), suggesting clinically relevant dysmorphic concern. The scale also includes two subscales: F1 - Dysmorphic Symptoms (preoccupation with perceived appearance flaws) and F2 - Symptom Interference (impact of these concerns on daily functioning).	Baseline
What is the role of body representation and inhibitory control capacity in the differential diagnosis between ARFID and other eating disorders, such as Anorexia Nervosa and Bulimia Nervosa?	The evaluation of inhibitory control capacity is carried out through a Go/No-go task. The test consists of high and low calorie food pictures or neutral stimuli (circles and squares). This kind of task presents two main outcomes: reaction time (RT) and accuracy. Reaction time is recorded in milliseconds (ms) and has no theoretical maximum, but in this specific protocol the range of evaluations of answers is between 300 and 1000 ms, where stimuli under 300ms reflects a pattern of impulsivity and stimuli over 1000 ms of answers are not registred by the task, defining low reactivity. Accuracy represents the percentage of correct responses (0-100%). The task does not have validated clinical cut-offs, as it is a continuous experimental measure rather than a diagnostic test. Normative interpretation is usually based on sample comparison or statistical ranges (e.g., mean ± 2 SD) rather than fixed thresholds.	Baseline
What is the role of body representation and inhibitory control capacity in the differential diagnosis between ARFID and other eating disorders, such as Anorexia Nervosa and Bulimia Nervosa?	The Eating Disorder Inventory-3 (EDI-3) is a self-report questionnaire used to assess psychological and behavioral traits associated with eating disorders and is commonly used in the differential diagnosis, particularly to evaluate body image disturbance. It includes 91 items rated on a 6-point Likert scale that are recoded from 0 to 4 and summed to produce 12 primary scales. The instrument does not provide a single total score and cut-offs are not strictly diagnostic, although T-scores ≥60-65 are generally considered clinically elevated and ≥70 indicates high clinical concern. Scales most relevant for research on body representation and differential diagnosis are Drive for Thinness, Body Dissatisfaction, and Bulimia, which form the Eating Disorder Risk Composite. Individuals with ARFID are expected to show low scores on these body-image related dimensions compared to those with Anorexia Nervosa or Bulimia Nervosa.	Baseline

Collaborators and Investigators

• Sponsor: Istituti Clinici Scientifici Maugeri SpA
• Collaborators: ASST Fatebenefratelli Sacco; Istituto Psicologico Italiano s.r.l.s.

Study record dates

Study Major Dates

• Study Start (Actual): November 26, 2024
• Primary Completion (Estimated): March 31, 2028
• Study Completion (Estimated): March 31, 2028

Study Registration Dates

• First Submitted: February 2, 2026
• First Submitted That Met QC Criteria: March 13, 2026
• First Posted (Actual): March 17, 2026

Study Record Updates

• Last Update Posted (Actual): April 16, 2026
• Last Update Submitted That Met QC Criteria: April 15, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Mental Disorders; Feeding and Eating Disorders; Avoidant Restrictive Food Intake Disorder; Anorexia Nervosa; Bulimia Nervosa
• Other Study ID Numbers: 0025652/24

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No