On Weight and Waiting: Delay Discounting in Anorexia Nervosa Pretreatment and Posttreatment

Individuals with anorexia nervosa (AN) override the drive to eat, forgoing immediate rewards in favor of longer-term goals. We examined delay discounting and its neural correlates in AN before and after treatment to test a potential mechanism of illness persistence.

Inpatients with AN (n = 59) and healthy control subjects (HC, n = 39) performed a delay discounting task at two time points. A subset (n = 30 AN, n = 22 HC) participated in functional magnetic resonance imaging scanning during the task. The task consisted of a range of monetary choices with variable delay times, yielding individual discount rates-the rate by which money loses value over time.

Before treatment, the AN group showed a preference for delayed over earlier rewards (i.e., less steep discount rates) compared with HC; after weight restoration, AN did not differ from HC. Underweight AN showed slower response times for earlier versus delayed choices; this reversed with treatment. Underweight AN showed abnormal neural activity in striatum and dorsal anterior cingulate; normalization of behavior was associated with increased activation in reward regions (striatum and dorsal anterior cingulate) and decision-making regions (dorsolateral prefrontal cortex and parietal cortex).

The undernourished state of AN may amplify the tendency to forgo immediate rewards in favor of longer-term goals. The results suggest that behavior that looks phenotypically like excessive self-control does not correspond with enhanced prefrontal recruitment. Rather, the results point to alterations in cingulostriatal circuitry that offer new insights on the potential role of abnormalities in decision-making neural systems in the perpetuation of AN.