Fabio Bernardoni, PhD*; Nadine Bernhardt, PhD*; Shakoor Pooseh, PhD; Joseph A. King, PhD; Daniel Geisler, MSc; Franziska Ritschel, PhD; Ilka Boehm, PhD; Maria Seidel, PhD; Veit Roessner, MD; Michael N. Smolka, MD; Stefan Ehrlich, MD, PhD
Background: Patients with anorexia nervosa forgo eating despite emaciation and severe health consequences. Such dysfunctional decision-making might be explained by an excessive level of self-control, alterations in homeostatic and hedonic regulation, or an interplay between these processes. We aimed to understand value-based decision-making in anorexia nervosa and its association with the gut hormone ghrelin. Besides its homeostatic function, ghrelin has been implicated in the hedonic regulation of appetite and reward via the modulation of phasic dopamine signalling.
Methods: In a cross-sectional design, we studied acutely underweight (n = 94) and recovered (n = 37) patients with anorexia nervosa of the restrictive subtype, as well as healthy control participants (n = 119). We assessed plasma concentrations of desacyl ghrelin and parameters of delay discounting, probability discounting for gains and losses, and loss aversion.
Results: Recovered patients displayed higher risk aversion for gains, but we observed no group differences for the remaining decision-making parameters. Desacyl ghrelin was higher in acutely underweight and recovered participants with anorexia nervosa relative to healthy controls. Moreover, we found a significant group × desacyl ghrelin interaction in delay discounting, indicating that in contrast to healthy controls, acutely underweight patients with anorexia nervosa who had high desacyl ghrelin concentrations preferably chose the delayed reward option.
Limitations: We probed decision-making using monetary rewards, but patients with anorexia nervosa may react differently to disorder-relevant stimuli. Furthermore, in contrast to acyl ghrelin, the functions of desacyl ghrelin are unclear. Therefore, the interpretation of the results is preliminary.
Conclusion: The propensity for risk aversion as found in recovered patients with anorexia nervosa could help them successfully complete therapy, or it could reflect sequelae of the disorder. Conversely, ghrelin findings might be related to a mechanism contributing to disease maintenance; that is, in acutely underweight anorexia nervosa, a hungry state may facilitate the ability to forgo an immediate reward to achieve a (dysfunctional) long-term goal.
*These authors contributed equally to this work.
Submitted Feb. 13, 2019; Revised May 17, 2019; Revised July 15, 2019; Accepted Sep. 3, 2019; Published online Mar. 4, 2020
Acknowledgments: The authors are grateful to all junior researchers and student workers for their assistance with data collection, and thank all participants for their time and cooperation. N. Bernhardt receives financial support from DFG grant FOR 1617 (grant numbers SM80/7-1). S. Ehrlich receives financial support from a collaborative research center grant (DFG, SFB 940/2) and from a DFG research grant: Hormonal modulation of neural networks in anorexia nervosa EH 367/5-1 (PI S. Ehrlich).
Affiliations: From the Division of Psychological and Social Medicine and Developmental Neuroscience, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany (Bernardoni, King, Geisler, Ritschel, Boehm, Seidel, Ehrlich); the Department of Psychiatry and Psychotherapy, Technische Universität Dresden, Dresden, Germany (Bernhardt, Pooseh, Smolka); the Freiburg Center for Data Analysis and Modeling, Albert-Ludwigs-Universität Freiburg, Germany (Pooseh); and the Translational Developmental Neuroscience Section, Eating Disorder Research and Treatment Center, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany (Roessner, Ehrlich).
Competing interests: V. Roessner has received lecture fees from Eli Lilly, Janssen-Cilag, Medice and Novartis, and was a member of the advisory boards of Eli Lilly and Novartis. All other authors declared that they have no competing interests.
Contributors: S. Ehrlich designed the study with help from V. Roessner and M. Smolka. F. Bernardoni, J. King, D. Geisler, F. Ritschel, I. Boehm and M. Seidel acquired the data, which F. Bernardoni, N. Bernhardt, S. Pooseh and S. Ehrlich analyzed. F. Bernardoni, N. Bernhardt, J. King and S. Ehrlich wrote the article, which all authors reviewed. All authors approved the final version to be published and can certify that no other individuals not listed as authors have made substantial contributions to the paper.
Correspondence to: S. Ehrlich, Technische Universität Dresden, Faculty of Medicine, University Hospital C. G. Carus, Dresden, Division of Psychological and Social Medicine and Developmental Neuroscience, Fetscherstraße 74, 01307 Dresden, Germany; Stefan.Ehrlich@tu-dresden.de