Maladaptive Rule-Governed Behavior in Anorexia Nervosa: The Need for Certainty and Control

Anorexia nervosa (AN) is a deadly disorder characterized by the persistence of dangerous behaviors (e.g., dietary restriction) even when deleterious health outcomes occur. Despite this, our understanding of factors that promote and maintain such rigidity is lacking. The current paper proposes a model suggesting that rigid behaviors in AN can be formulated as maladaptive rule-governed behavior (RGB) that emerges in situations of uncertainty, such as in the presence of affective arousal. An empirical study examining differences in RGB between individuals weight-­recovered from AN (AN-­WR) and healthy controls (CN) in neutral and stressful situations is described. Seventy-­four adults (AN-­WR: 36; CN: 38) were randomized to undergo either a stressful or neutral mood manipulation and then completed a laboratory assessment of RGB, the Wisconsin Card Sorting Test (WCST), along with questionnaires assessing degree of uncertainty experienced during the WCST and general intolerance of uncertainty. While the mood manipulation did not significantly impact WCST performance in either group, the AN-­WR group demonstrated significantly more total correct items but a greater number of perseverative errors than the CN group. Furthermore, these outcomes were related to greater levels of uncertainty experienced during the task along with general fears of uncertainty. Results provide support for using the frame of maladaptive RGB in as a model of rigidity in AN and may explain why dangerous behaviors continue even when health consequences emerge. These findings extend our current knowledge of rigidity in AN and suggest that targeting difficulties with uncertainty may be an important treatment component needed in interventions.