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Weak central coherence in eating disorders: A

step towards looking for an endophenotype of
eating disorders
a a b c
Carolina Lopez , Kate Tchanturia , Daniel Stahl & Janet Treasure
a
Division of Psychological Medicine, Institute of Psychiatry, King's College London,
London, UK
b
Department of Biostatistics and Computing, Institute of Psychiatry, King's College
London, London, UK
c
Department of Academic Psychiatry, Guy's, King's, and St. Thomas's Medical
School, London, UK

Available online: 16 Dec 2008

To cite this article: Carolina Lopez, Kate Tchanturia, Daniel Stahl & Janet Treasure (2009): Weak central coherence
in eating disorders: A step towards looking for an endophenotype of eating disorders, Journal of Clinical and
Experimental Neuropsychology, 31:1, 117-125

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 JOURNAL OF CLINICAL AND EXPERIMENTAL NEUROPSYCHOLOGY
2009, 31 (1), 117–125

Weak central coherence in eating disorders:

NCEN

A step towards looking for an endophenotype

of eating disorders

Carolina Lopez,1 Kate Tchanturia,1 Daniel Stahl,2 and Janet Treasure3

Weak Coherence in Eating Disorders

1
Division of Psychological Medicine, Institute of Psychiatry, King’s College London, London,
UK
2
Department of Biostatistics and Computing, Institute of Psychiatry, King’s College London,
London, UK
3
Department of Academic Psychiatry, Guy’s, King’s, and St. Thomas’s Medical School,
Downloaded by [University College London] at 00:16 09 August 2011

London, UK

Previous work has found that women with anorexia nervosa and bulimia nervosa have weak coherence. The aim
of this study was to examine whether women who had recovered from an eating disorder (ED) also had weak
coherence. A total of 42 recovered ED women and 42 healthy women were assessed with a battery of five
neuropsychological tests that measure aspects of global or local functioning. The recovered ED group showed
superior local processing and poorer global processing than the healthy group. These results are indicative of
weak coherence. The finding that weak coherence is a stable characteristic rather than a state effect suggests that it
may be an endophenotype for ED.

Keywords: Eating disorders; Central coherence; Recovery; Endophenotype; Cognition; Anorexia nervosa;
Bulimia nervosa; Detail focused processing; Global processing.

INTRODUCTION Another trait of recent interest in the field of ED

Eating disorders (ED) are complex disorders that
affect mainly young females and can have severe
consequences (Hudson, Hiripi, Pope, & Kessler,
2007; van Hoeken, Seidell, & Wijbrand, 2003).
ED have been traditionally conceptualized as caused
predominately by environmental and psycholog-
ical factors. Recently the endophenotype concept
has been discussed in several ED reviews (Bulik
et al., 2007; Steiger & Bruce, 2007; Treasure, 2007;
Treasure, Lopez, & Roberts, 2007). The cognitive
feature of impaired set-shifting fulfils some of the
criteria for a potential endophenotype for ED
(Holliday, Tchanturia, Landau, Collier, & Treasure,
2005).
is weak central coherence (Gillberg, Rastam, Wentz,
& Gillberg, 2007; Lopez et al., 2008a; Southgate,
Tchanturia, & Treasure, in press; Tokley & Kemps,
2007). Central coherence was first described by Frith
(1989) as the natural tendency for typically devel-
oping adults to integrate incoming information
into context, gestalt, and meaning. The concept of
weak central coherence was utilized to refer a bias
towards local processing at the expense of global
meaning (Frith, 1989; Happé & Booth, 2008;
Happé & Frith, 2006). This cognitive bias is the
predominant processing style among individuals
with autism spectrum disorders (Happé & Frith,
2006; Shah & Frith, 1993). Following the latest
revision of this concept in research (Happé &

This work was supported by the Nina Jackson Research Into Eating Disorders (RIED). Carolina Lopez was also funded by a
Chilean government scholarship.
Address correspondence to Carolina Lopez, Department of Academic Psychiatry, 5th Floor, Bermondsey Wing, Guy’s Hospital,
London, SE1 9RT, UK (E-mail: c.lopez@iop.kcl.ac.uk).

© 2008 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/jcen DOI: 10.1080/13803390802036092
 118 LOPEZ ET AL.
Booth, 2008), in this paper we underline the inde-
pendence of the two dimensions of weak central
coherence: the bias towards superior local processing
and the reduced tendency to global integration.
There is some evidence that suggests that the
superiority in local processing is a familial trait in
the case of autism spectrum disorders (Baron-Cohen
& Hammer, 1997; Baron-Cohen et al., 2006; Bolte
& Poustka, 2006; Happé, Briskman, & Frith, 2001).
In ED, we have reported that people with current
anorexia nervosa and bulimia nervosa have superior
detail processing and weak global integration
(Lopez et al., 2008a; Lopez, Tchanturia, Stahl, &
Treasure, 2008b).
The aim of this study was to examine whether
weak coherence, both superior detail processing
Downloaded by [University College London] at 00:16 09 August 2011
and a weakness for global integration, was present
in people with past history of ED, currently recovered
(EDRec). Our hypothesis was that weak coherence
would be an endophenotypical trait underpinning
the development of ED and as such will be inde-
pendent of acute illness state.
METHOD AND MATERIALS
The EDRec were 42 women who had a history of
anorexia nervosa or bulimia nervosa according
to DSM-IV criteria (Diagnostic and Statistical Man-
ual of Mental Disorders–Fourth Edition; American
Psychiatric Association, 1994), but had no remaining
symptoms: body mass index (BMI) between 19 and
26 kg/m2 in the current year, with no binging, purg-
ing, food restriction, or excessive exercise according
the EATATE interview (semi-structured diagnostic
interview based upon the Eating Disorder Examina-
tion instrument, EDE; see below). The healthy con-
trol (HC) group was the same sample as that used in
our previous studies of coherence (Lopez et al., 2008a,
2008b), equivalent in age and intellectual ability to the
EDrec group. The inclusion criteria for healthy con-
trols included a BMI between 19 and 26 kg/m2, no
psychoactive medicines, and no personal or family
history of ED or any other psychiatric illness.
Participants were recruited from the staff and
student population of the Institute of Psychiatry
and King’s College of London, from advertise-
ments on the Eating Disorders Unit website, and
from the local community.
The exclusion criteria for all participants were:
use of psychoactive medication, non-native English
speakers, a history of head injury, neurological
disease, psychosis, or learning disability.
Following a complete description of the study,
written informed consent was obtained from all
participants.
Participants in the EDRec group were assessed
with the semi-structured diagnostic interview
EATATE based upon the EDE (C. G. Fairburn
& Cooper, 1993) encompassing lifetime diagnosis
for ED (Part I; Anderluh, Tchanturia, Rabe-
Hesketh, & Treasure, 2003). It produces a descrip-
tion of eating disorder symptoms over the life
course, which in this study helped to determine
the status of recovery of our participants. HC
completed the Eating Disorder Examination–
Questionnaire (EDE-Q; C. Fairburn & Beglin,
1994) modified to provide a lifetime screening
for eating disorder symptoms. Additionally,
Parts II and III of EATATE were administered
to all participants to examine for a history of
other psychiatric problems.
The neuropsychological battery for all the partici-
pants consisted of several paradigms assessing aspects
of coherence.
Tasks in which detail focused processing would
benefit performance were: The Embedded Figures
Test–Form B (Witkin, Oltman, Raskin, & Karp,
1971) and the Unsegmented/Segmented Block Design
Test (Shah & Frith, 1993). These were used as
measures of speed and accuracy in local processing.
In the Embedded Figure Test participants are
asked to find 12 simple shapes embedded in complex
designs within a time limit of 60 s. In this study, the
original administration of the task was modified in
order to omit the memory element of the task by
having the simple shape and the complex design
displayed simultaneously. Total time and number
of false claims (number of times the participant
wrongly claims to have found the figure) are
recorded. Shorter times and fewer false claims indicate
a stronger local processing. In the Unsegmented/
Segmented Block Design Test, participants are
asked to construct replicas of complex designs
presented on a computer screen, with four or nine
wooden blocks. In the unsegmented trial designs
are presented as a whole whereas in the segmented
trial there is a gap between the four or nine constituent
parts of the design. A time limit of 60 s for four-
blocks designs and 180 s for nine-block designs are
allowed. Time and errors are recorded. Shorter
times indicate better local processing. More impor-
tantly, people with weaker coherence are thought
to show less benefit from segmentation (a differ-
ence between the time spent in the unsegmented
and segmented trials).
Measures in which global processing would
benefit performance were: the Rey–Osterrieth
Complex Figure Test–recall form (Rey Figure;
Osterrieth, 1944), the Sentence Completion Task
(Happé et al., 2001), and the Homograph Reading
Task (Happé, 1997; Jolliffe & Baron-Cohen, 1999).

The Rey Figure was used to measure visual spatial
coherence. In this task, participants are asked to
copy and recall (after an interval of 20 minutes) a
complex figure. The drawing process was video-
recorded. Accuracy of the drawing was scored
following Taylor’s (adapted from Osterrieth, 1944)
scoring procedure based on the drawing of 18
elements of the figure awarded a 0 to 2 quality score
(Spreen & Strauss, 1998). Higher scores mean better
accuracy (range 0–36). Additionally, percentage of
recall, a measure of recall corrected by accuracy in
the copy trial (recall/copy × 100) was calculated.
Coherence of drawing style was measured using
two independent indices following Booth’s devel-
opment of the task (2006): order of construction
index (order in which the elements of the figure
Downloaded by [University College London] at 00:16 09 August 2011
were drawn) and style index (continuity of drawing).
A general coherence index was also derived
and consists of a composite score of the previ-
ously mentioned two indices where higher scores
mean a more coherent drawing style (Booth, 2006;
Lopez et al., 2008a). Organizational strategies as
described by Savage and collaborators, which are
linked to executive functioning (Savage et al.,
1999), were examined as an extra measure of
drawing style, in which six main elements of the
figure are scored for continuity of drawing (Sherman
et al., 2006).
The Sentence Completion Task and the Homo-
graph Reading Task were used as verbal coherence
tasks designed to produce conflict between local
and global processing. In the Sentence Completion
Task participants are asked to finish off 25 sentences,
of which 18 have a conflict between local and
global completions. The sentences are presented on
a digital recorder. Answers and times are recorded
by computer software that allows for the determi-
nation of the exact time spent between the end of
the recorded sentence and the beginning of the
participant’s answer. The number of local comple-
tions and time taken to find an appropriate ending
to the sentence are scored. Higher number of
local completions and longer hesitation times are
considered as indicators of either local processing
bias or difficulties in verbal global processing. In
the Homograph Reading Task, participants are
asked to read aloud 16 sentences that contain four
different homographs (e.g., tear, bow). In order to
read them correctly, the context of the sentence
should be considered. The task is tape-recorded,
and the number of correct initial pronunciations
is scored. The number of errors is a marker of a
difficulty in verbal global processing.
A full description of these tests can be found in
our previous studies of central coherence in people
with an active eating disorder (Lopez et al., 2008a,
WEAK COHERENCE IN EATING DISORDERS 119
2008b) and are available on request from the first
author.
Participants also completed the National Adult
Reading Test (NART; 2nd edition) to provide an
estimate of premorbid intellectual ability (Nelson &
Willison, 1991). As the most common concurrent
conditions of ED such as depressive, anxiety, and
obsessive-compulsive symptoms may persist after
recovery (I. C. Gillberg, Rastam, & Gillberg, 1995;
Holtkamp, Müller, Heussen, Remschmidt, & Herpertz-
Dahlmann, 2005; von Ranson, Kaye, Weltzin, Rao,
& Matsunaga, 1999) and also can influence cogni-
tive functioning (Castaneda, Tuulio-Henriksson,
Marttunen, Suvisaari, & Lönnqvist, 2008; Kuelz,
Hohagen, & Voderholzer, 2004), symptom levels
were assessed in this study using the Hospital Anxiety
and Depression Scale (HADS; Zigmond & Snaith,
1983) and the Obsessive-Compulsive Inventory–
Revised (Foa et al., 2002; Foa, Kozak, Salkovskis,
Coles, & Amir, 1998).
Procedure
The procedures for this study were approved by
the South London and Maudsley Trust Research
Ethics Committee. Weight and height were meas-
ured on the day of testing. All the neuropsychological
measures were administered in the same session
order: Rey Figure (copy), Sentences Completion
Task, Embedded Figures Test, Homograph Reading
Task, Rey Figure (recall), Unsegmented Block
Design, EATATE interview, and Segmented Block
Design. Questionnaires were completed a week
before or after the testing session. The NART test
was not obtained from the first 15 participants in
the HC group and 3 in the EDRec group. We do
not expect differences in the intellectual ability as
they were recruited from the same sources as the rest
of the sample. A total of 3 women in the EDRec
group and 1 in the HC did not return part of the
self-report measures. Their data were included in the
analyses of the main outcomes measures.
To ensure reliability in the scoring of neuropsy-
chological measures, some measures were video- or
tape-recorded (Rey Figure and verbal tasks), and a
proportion (30%) of them were scored in parallel
by a researcher blind to the condition of participants.
There were good intraclass correlation coefficients
indicating high interrater agreement (all higher
than .89).
Data analysis
Sample size power calculation was conducted
using NQuery 4.0 Advisor program (Elashoff,
 120 LOPEZ ET AL.

2000) based on a pilot study for this project. It was RESULTS

found that a sample size of 42 participants in each
group would have an 80% power to detect clinical
significant differences (Cohen´s d = 0.60 in the
Embedded Figures Test, or higher) between groups
on the neuropsychological tests with a .05 two-
tailed significance level.
Independent sample t tests were used for group
comparisons, and means (M) and standard devia-
tions (SD) are reported. For those measures without
a normal distribution of the data, nonparametric
Mann–Whitney U tests (MWU) were used, and
medians (Mdn) and 25% and 75% quartiles (Q)
are reported. To explore the relationship between
neuropsychological, demographic, and clinical vari-
ables, Pearson’s correlation coefficient (r) was used
Downloaded by [University College London] at 00:16 09 August 2011
Demographic and clinical characteristics
The results of demographic and clinical character-
istics are shown in Table 1.
EDRec group was comparable to the HC in age,
years of education, and estimated intellectual ability
(all p > .05). Although they were recovered for a
considerable time (M = 6.4 years, SD = 5.75), their
BMI was still lower than that of the HC group,
t(82) = 0.21, p = .03.
The EDRec group consisted of 35 women who
had a history of anorexia nervosa (AN; 83.3%) and
7 who had bulimia nervosa (BN) as their main life-
time diagnosis. A total of 12 (28.6%) had AN with

for normally distributed data, and Spearman’s rank
(rs) correlation was used otherwise. Cohen’s d was
calculated to obtain the effect size for each variable
using an effect size calculator (Wilson, 2001). For
those variables with non-normally distributed data,
d was calculated by transforming the effect-size cor-
relation r = Z (from Rosenthal, 1991) in d using
N
an effect size calculator.
Analysis of covariance was carried out to evaluate
any possible confounding effect of the demographic
and clinical variables on differences between groups
in neuropsychological performance.
Two-tailed tests were used throughout. The
nominal significance level was chosen to be 5%.
Hochberg’s improved Bonferroni correction for
multiple testing was applied on the main outcome
measures (Hochberg, 1988). All analyses were carried
out using SPSS 15.0.
bulimic symptoms (binge and purge); 9 (21.4%)
had purging AN (without binges); 14 (33.3%) had
restricting AN; 5 (16.6%) had purging BN; and 2
(4.8%) had nonpurging BN. A total of 37 out of
the 42 EDrec (88.1%) had a period of AN at some
point in their lives. The mean age of onset was
16.1 years (SD = 3.9), and their mean duration of
illness was 6.1 years (SD = 4.57).
The EDRec group had higher levels of anxiety,
depression, and obsessive-compulsive symptoms
(see Table 1).
Neuropsychological function
The results from tasks thought to benefit from
detail processing are displayed in Table 2. These
results show that EDRec women excelled in the
Embedded Figures Test (all p < .05). However,

TABLE 1
Demographic and clinical characteristics of the sample

N Test statistic

EDRec HC EDRec HC group t testa MWb p-value Effect size (d)

Age (years)b 42 42 25.00 (21.0–31.0) 26.00 (21.6–29.0) na 858.5 .833 0.04

Number years of educationb 41 42 16 (14–17.5) 17 (14.75–19) na 432.0 .123 0.32
Estimated intellectual abilitiesa 39 27 113.6 (5.3) 112.2 (5.4) –1.08 na .281 0.26
BMI (kg/m2)a 42 42 20.9 (2.2) 21.9 (2.7) 0.211 na .032 0.41
HADS Anxietya 41 41 9.9 (3.0) 6.0 (3.2) –5.67 na <.001c 1.26
HADS Depressionb 41 41 9.0 (7–9) 2.0 (1–3) na 52.5 <.001c 2.5
OCI-Rb 39 42 16 (9–25) 6.5 (3–10) na 307.5 <.001c 1.25

Note. Anxiety, depression, and obsessive-compulsive disorder (OCD) symptoms are measured in terms of level of severity, and they do
not indicate a clinical diagnosis. EDRec = eating disorders, currently recovered. HC=healthy controls. MW = Mann–Whitney. BMI =
body mass index. HADS = Hospital Anxiety and Depression Scale. OCI-R = Obsessive-Compulsive Inventory-Revised.
at test statistics for t test pairwise comparisons for data normally distributed, mean values displayed (standard deviations in

parentheses) (na = not applicable).

b
Test statistics for Mann–Whitney U for data not normally distributed, median values displayed with upper and lower quartiles (na =
not applicable).
c
Results that remained significant (p < .05) after Hochberg correction for multiple testing (Hochberg, 1988).
 WEAK COHERENCE IN EATING DISORDERS 121

TABLE 2
Neuropsychological tasks benefited by detail focused processing

Test statistic
EDRec group HC group
(N = 42) (N = 42) t testa MWb p-value Effect size (d)
b c
EFT total time taken (medians) 6.7 (3.7–10.2) 12.2 (7.9–15.3) na 419.0 <.001 1.01
EFT number time out failuresb 0 (0–1) 1 (0–2) na 560.0 .002c 0.72
EFT false claimsb 1 (0–2) 2 (0–3) na 647.5 .030 0.49
Unsegmented Block Designb 47.3 (38.1–66.0) 44.9 (32.3–62.7) na 875.0 .950 0.01
Segmented Block Designb 28.9 (24.7–33.1) 27.7 (25.5–31.5) na 826.5 .620 0.11
Benefit from segmentation (%)a 38.3 (14.9) 40.9 (16.3) .74 na .459 0.17

Note. EDRec = eating disorders, currently recovered. HC = healthy controls. MW = Mann–Whitney. EFT = Embedded Figures Test.
a
t test statistics for t test pairwise comparisons for data normally distributed, mean values displayed (standard deviations in parentheses;
df = 82) (na = not applicable).
b
U test statistics for Mann–Whitney U for data not normally distributed, median values displayed with 25 and 75 percentiles (na = not
applicable).
cResults that remained significant (p < .05) after Hochberg correction for multiple testing (Hochberg, 1988).
Downloaded by [University College London] at 00:16 09 August 2011

TABLE 3
Neuropsychological tasks benefited by global integration

Test statistic
EDRec group HC group
(N = 42) (N = 42) t testa MWb p-value Effect size (d)

Rey Figure
Ordera 2.2 (0.7) 2.5 (0.4) 2.01 na .048 0.53
Stylea 1.4 (0.5) 1.7 (0.3) 3.30 na .002 c 0.73
CC indexa 1.4 (0.4) 1.6 (0.3) 3.03 na < .001 c 0.57
SCT
Local processing scoreb 1.5 (1–3) 0 (0–1) na 391.0 < .001 c 1.15
Number of local completions b 0 (0–0) 0 (0–0) na 819.0 .370 0.18
HRT total scoreb 15 (14–15) 15 (14–16) na 691.5 .075 0.39

Note. CC = Coherence index. EDRec = eating disorders, currently recovered. HC = healthy controls. MW = Mann–Whitney. SCT =
Sentence Completion Task. HRT = Homograph Reading Task.
a
t test statistics for t test pairwise comparisons for data normally distributed (df = 82), mean values displayed (standard deviations in
parentheses) (na = not applicable).
b
U test statistics for Mann–Whitney U for data not normally distributed, median values displayed with 25 and 75 percentiles (na = not
applicable).
c
Results that remained significant (p < .05) after Hochberg correction for multiple testing (Hochberg, 1988).

no differences were found in both the fused and
segmented parts of the Block Design Test in terms
of time spent on the task as in the percentage of
advantage when designs were segmented.
In terms of global processing, the EDRec group
showed poorer global integration in the drawing
process of the Rey Figure than did a HC group,
with low scores on the coherence indices (style,
order of construction, and coherence index). In the
verbal domain, the EDRec group took longer to
produce coherent sentences in the Sentence Com-
pletion Task. In the Homograph Reading Task the
EDRec group made more errors but this did not
reach formal levels of significance (p = .07).
Together these findings indicate that the EDRec
groups had more difficulties in global integration
at both visuospatial and verbal levels than did the
HC group. These results are shown in Table 3.
Additional aspects of the cognitive processing
were obtained from the Rey Figure Test. The
EDRec group obtained poorer scores in copy,
t(82) = 6.9, p < .001, and recall accuracy, t(82) = 3.7,
p < .001, than did the HC group. However, no
significant differences were found in percentage of
recall (how much they recall from their first drawing)
nor in organizational strategy.
Most of the significant results reported above
maintained their formal significance after correc-
tion for multiple testing (see Tables 2 and 3).
Explorative correlation analyses revealed a large
positive relationship between scores in the accuracy
copy and recall in both groups (r = .61 in the HC
 122 LOPEZ ET AL.
and r = .53 in the EDRec group, p < .001) and a
moderate correlation between coherence index and
recall accuracy (r = .37 in the HC and r = .41 in the
EDRec group, p < .05).
A comparison between healthy controls
and people with a lifetime history of
anorexia nervosa
When only individuals who had anorexia as
the main past diagnosis were considered, the signif-
icant difference seen in the whole group in terms of
order index of Rey Figure fell to trend levels only.
However, the difference in the Homograph Reading
Task became significant (p < .05) with an increased
effect size of d = 0.47.
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Relationship between demographic,
comorbid, and clinical variables and
neuropsychological performance
Correlation analyses were performed separately
for each group to explore potential confounder
variables on neuropsychological testing. Only sig-
nificant results in each group are described. In the
EDRec group those who were recovered for a
longer time spent more time in the Unsegmented
Block Design trial (rs = .44, p = .003). Intellectual
ability as measured by NART was negatively
associated with accuracy in the Rey Figure copy
trial (r = .32, p=.05). Older people performed less
well in accuracy recall in the Rey Figure (r = .30, p
= .05) and in the Segmented Block Design (rs =
.32, p = .04). Finally, those with higher scores in
obsessive-compulsive symptoms (OCI-R) scored
lower in copy accuracy of the Rey Figure (rs = .42,
p < .01).
In the HC group, anxiety was negatively corre-
lated with poorer organizational strategies in the
Rey Figure (rs = .33, p = .03) and longer times in
the Segmented Block Design Test (rs = .36, p = .02).
The number of errors in the Embedded Figures
Test was linked with lower intellectual ability and
years of education (rs =.42 and .45, respectively, all
p < .03). Finally, in HC, BMI was positively associ-
ated with the time taken in the Unsegmented Block
Design Test (rs =.34, p < .03).
Correlation analyses involving verbal coherence
tasks were not performed due to the limited vari-
ance of scores on these verbal central coherence
tasks.
Analyses of covariance to examine potential
confounder effects of relevant demographic,
comorbid, and clinical differences between groups
in neuropsychological performance were carried
out, and no effects were found.
DISCUSSION
The aim of this study was to examine the concept
of central coherence in people with a lifetime
diagnosis of ED, currently healthy (EDRec). Our
hypothesis, which was that women with EDRec
would present a performance profile
with enhanced detail processing and weak global
coherence, was mainly confirmed.
EDRec women performed extremely well in a
task that benefited from enhanced detail function—
namely, the Embedded Figure Test—where they
were fast and showed the error-free style described
also in acute AN (Lopez et al., 2008a). Their func-
tioning in the Block Design Test, which is thought
to benefit from piecemeal processing, was compa-
rable to that of HC. On the other hand, the recov-
ered group displayed weaker performance in tasks
that require a global strategy (Rey Figure, Sentence
Completion Task, and—although less impaired—
the Homograph Reading Task). These results
together raise the possibility that our secondary
hypothesis, which was that weak coherence might
be an endophenotype for ED, is correct.
Importantly, indices of weak coherence (strengths
in detail processing and weak integration) were
not associated with comorbid symptoms or BMI
in EDRec group. In the acute illness, anxiety
was associated with measures of coherence in
bulimia nervosa (Lopez et al., 2008b). The results
presented here suggest that weak coherence is
relatively independent from transitory comorbid
conditions.
There are some, albeit minor, differences
between the neuropsychological performance of
these recovered women and those with acute ED
described in our previous work (Lopez et al.,
2008a, 2008b). In general, the groups at normal
weight (bulimia nervosa and recovered) had an
intermediate profile between those with an acute
anorexia and HC. The recovered group was
even more enhanced in detail processing than
those with active anorexia nervosa (e.g., the
times on the Embedded Figures Test are
shorter). In addition, the EDRec group displays
better visual coherence (higher coherence scores
on the Rey Figure Test) than those with acute
anorexia nervosa. This evidence suggests that
weight loss accentuates the difficulty in global
integration and may weaken efficient detail
processing.
Regarding other aspects of cognitive functioning
measured by these tasks it was found that organi-
zational strategy in the Rey Figure, which is
thought to be linked to executive functioning,
was similar to that of controls. This finding adds

support to the proposed relative independence of
central coherence from executive functions (Happé
& Booth, 2008). The EDRec group had lower
scores in accuracy in copy and recall trials of the
Rey Figure than did healthy controls, although
both groups were comparable in terms of the
memory component of the task (percentage of recall).
We are uncertain as to why the recovered group
had lower accuracy in the Rey Figure than both
HC and those with acute anorexia nervosa (Lopez
et al., 2008a). It is possible that the high-detail
focus may interfere with the task. Replication of
this study may help to clarify this effect. The lack
of difference in percentage of recall between
EDRec and HC groups suggests that the loss of
memory was not totally mediated by central coher-
Downloaded by [University College London] at 00:16 09 August 2011
ence indices in the EDRec as seen in anorexia ner-
vosa (Lopez et al., 2008a).
Cross-sectional studies that have examined the
basic neuropsychological performance of long-term
recovered eating disorder samples have demon-
strated that some neuropsychological anomalies
found in the active phase of anorexia are present
in those recovered whereas other studies suggest
that certain functions are restored. For instance,
aspects of set-shifting difficulties (Pendleton Jones,
Duncan, Brouwers, & Mirsky, 1991; Roberts,
Tchanturia, Stahl, Southgate, & Treasure, 2007;
Tchanturia et al., 2004; Tchanturia, Morris, Surguladze,
& Treasure, 2002), immediate memory, and perform-
ance in Morse finger-tapping task (Bosanac et al.,
2007) seem to remain impaired in recovery. In
terms of restored functions, Tchanturia et al.
(2007) found no deficits in decision making in
recovered women as opposed to those with acute
anorexia. Indeed, decision-making abilities has
been described as a good predictor of weight recovery
(Cavedini et al., 2006). Bosanac et al. (2007) found
normal attention in recovered anorexia. Finally,
Pendleton Jones et al. (1991) did not find statistical
differences between the performance of a recov-
ered and a healthy control group on tasks measur-
ing vigilance, memory, executive functions, and
verbal and visuospatial abilities.
This study has several limitations. The cross-
sectional design is somewhat unsatisfactory in that
it is questionable whether those who are able to
achieve recovery are representative of the eating
disorder population as a whole or whether they are
an atypical subgroup, perhaps less severe, of the
eating disorder population. This, however, would
err on the side of reducing any trait effect. How-
ever, the inclusion of a recovered group has been
widely employed in the eating disorder literature to
examine for trait versus state markers (Bailer et al.,
2007; Wagner et al., 2008; Wagner et al., 2007) and
WEAK COHERENCE IN EATING DISORDERS 123
has produced some interesting findings. Longitudinal
studies would add to the interpretation of these
studies. Finally, ceiling effects were observed in
the Homograph Reading Task, which might preclude
the possibility of finding differences between the
recovered and control groups.
We propose that weak coherence may trigger
core behavioral and cognitive traits of ED such as
perfectionism, fear of mistakes, and change. Also
the relative difficulty in integrative processing may
explain in part the neglect of long-term health
consequences. These findings therefore may have
implications for clinical practice and future research.
Integrating these observations into treatment with
motivationally enhanced neuropsychological feed-
back (Lopez, Roberts, Tchanturia, & Treasure,
in press; Treasure et al., 2007) or with cognitive
remediation therapy (CRT) to enhance global
processing strategies (Baldock & Tchanturia, 2007;
Tchanturia, Davies, & Campbell, in press) may
improve metacognitive skills and moderate the bias
towards detail-focused processing of information.
Further study to clarify the relationship between
weak central coherence, eating disorder psychopa-
thology, recovery, and the interplay with other cog-
nitive abnormalities in ED is needed. For example,
as recovered people have also been shown to have
difficulties with set-shifting (Roberts et al., 2007;
Tchanturia et al., 2004) it is possible that the con-
junction between weak central coherence and diffi-
culties in set-shifting together may make recovery
more difficult.
As a final point, this study adds to the evidence
supporting a common endophenotype between
autism spectrum disorders and ED. These findings
give some empirical endorsement to the suggestion
that ED form a diagnostic cluster in association
with obsessive-compulsive disorders (Hollander,
Kim, Khanna, & Pallanti, 2007). Obsessive-
compulsive personality traits were found to contribute
to poor global processing in ED (Tokley &
Kemps, 2007). On the other hand, people with
obsessive-compulsive disorders have also been
found to have a bias towards detail processing
of information in neuropsychological testing as
did women with anorexia nervosa (Savage et al.,
1999; Sherman et al., 2006). In autism spectrum
disorders weak coherence is a potential endophe-
notype as several studies have found that the first-
degree relatives are better in tasks that require
a detail strategy (Baron-Cohen & Hammer,
1997; Baron-Cohen et al., 2006; Bolte & Poustka,
2006; Happé et al., 2001). Also, one study showed
difficulties in global processing in parents of peo-
ple with these disorders as measured by the Sen-
tence Completion Test (Happé et al., 2001).
 124 LOPEZ ET AL.
Collaborative research work would help to clarify
this hypothesis.
In summary, the results of this study support the
potential trait hypothesis of weak coherence in
ED, as opposed to a state, since this characteristic
was present in recovered people. Research into
unaffected family members of people with ED and
genetics are needed to explore the endophenotype
hypothesis further.
Original manuscript received 8 October 2007
Revised manuscript accepted 3 March 2008
First published online 4 June 2008
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