Altered value-based decision-making in anorexia nervosa: A systematic review

Alterations in decision-making are considered core to anorexia nervosa (AN) phenomenology and may maintain illness through maladaptive choice behavior. This systematic review ( n = 77) aimed to extend prior reviews beyond standard neuropsychological batteries by incorporating novel value-based choice tasks and computational methods. We organize findings across key factors, including: 1) illness state, 2) developmental stage, and 3) AN subtype, and highlight available neuroimaging findings. Differences in decision-making appear consistent during illness, including in weight-restored samples, but not in recovery and not in all domains. Differences are not consistently present in adolescence, although punishment sensitivity may be heightened; AN subtypes are not consistently distinguishable. Overall, decision-making varies by context and is influenced by reward/punishment processing, risk/uncertainty, and flexibility/control. Utilization of computational modeling methods, possibly increasing precision, highlight that, although raw behavior may not differ at recovery, latent decision-making processes appear impacted. Clinical interventions may benefit from consideration of context when working to shape choice behavior and from consideration of latent decision-making processes that influence how choices are made. • Poorer performance on value-based decision-making is frequently observed in anorexia nervosa. • Decision-making deficits are greater in low weight compared to weight-restored ill individuals. • Decision-making deficits are more pronounced in adults than adolescents. • Although choice behavior may not differ in recovered individuals, latent decision-making processes may be different.