Today I wanted to return to an ongoing series I am doing regarding different facets of “understanding anorexia.” This series will focus on various factors related to anorexia, including biological predispositions, genetic/epigenetic factors, personality traits, micronutrient deficiencies, hormonal imbalances, environmental factors, and more. Anorexia is certainly a complex illness with many “pieces to the puzzle” (many of which are still not well understood). My hope is that these posts will continue to shine more and more light on aspects of what might be going on for each person suffering. (Or, bring more clarity to anyone who has recovered).

You can read my first post in this series on zinc deficiency and anorexia here.

Today I wanted to focus on the concept of “set-shifting” as it relates to anorexia.

This post will discuss:

• What is set-shifting?
• How might set-shifting relate to anorexia?
• What are some practical tips and strategies to consider?

What is set-shifting? 

Set-shifting can be defined as:

“The ability to move back and forward between different tasks or mental sets, and is often used as a measure of cognitive flexibility.” (1)

“The ability to switch thoughts or actions according to situational demands.”  (2)

Difficulty set-shifting might look like having a more rigid thinking style, difficulty switching gears and/or adjusting, difficulty letting things/situations be unresolved, and experiencing obsessive thought patterns (focusing a lot on particular details or subjects, compulsively thinking about things over and over, difficulty “turning your brain off,” feeling like your brain is “stuck” or “engrained” in various thought loops, etc.).

From a positive standpoint, those who struggle with set-shifting are often great at focusing for extensive periods of time, are typically very driven, and are usually good at getting projects or work done that require extensive time, strategy, commitment, and/or delayed gratification.

When I learned about the concept of set-shifting, I immediately resonated with having challenges in this area. In my everyday life, this might look like:

• Anxiety and stress with plans changing
• Feeling mentally flooded or caught in obsessive thinking spirals
• Overwhelm with multitasking or too many random things to do
• Over-fixating on one “right” way to do things, or too narrowly focusing on one way to view a complex situation or problem
• Anxiety with transitions or shifts in schedules/routines; stress over “not knowing how I will get everything done”

Thankfully, I have come a LONG way in these areas, but they are still things that I struggle with from time to time (although usually to lesser degrees).

Difficulties set-shifting are also related to conditions such as obsessive compulsive personality disorder and obsessive compulsive disorder, both of which are common in those with anorexia. (Two different conditions which you can read about here. I personally experience OCPD. In some scenarios, the anorexia can more or less be thought of as a “manifestation” of the OCPD or OCD in food/weight/exercise form.)

How might set-shifting relate to anorexia? 

It’s not necessarily clear from a research standpoint whether difficulties set-shifting are present before the onset of anorexia (and thus may be part of the etiology of the illness), or if this is a result of the brain changes that occur with malnutrition. Personally, I tend to think that this is more a challenge that is typically present before the onset of the illness. That being said, we also know from other studies (such as the extensively documented Minnesota Starvation Experiment) that malnutrition alone (not in this case initially driven by disordered eating) can lead to increased rigidity with food and beyond. It seems that both facets are at play (as in, likely there is a predisposition to difficulties with set-shifting in people more likely to develop anorexia, and there is increased rigidity caused by the extended malnutrition of anorexia).

One systematic review on 23 studies related to anorexia and set-shifting found that most studies showed that difficulties in set-shifting persisted even after recovery from anorexia. Again, this could indicate challenges in flexible thinking as a predetermining factor, or could also indicate lasting changes as a result of the period of malnutrition. It is hard to know for sure from a research standpoint due to methodological challenges / the challenges of studying complex human beings.

What challenges with set-shifting can look like in the context of anorexia:

• Rigidity with food patterns/preferences
• Constantly/obsessively thinking about food, calories, other minute details of nutrition
• Inability to see the “forest” (one’s declining health) for the “trees” (obsession with food, etc)
• Rigidity with exercise patterns/routines
• Fixation on a certain weight or size
• Other general rigid patterns (with schedules, routines, planning, environments, etc.)

Decreased set-shifting is also related to biological factors associated with anorexia:

• Zinc deficiency, the most common micronutrient deficiency in anorexia (also a common precursor), is related to increased anxiety
• Pyrrole disorder, which is associated with imbalances of copper and zinc, leads to difficulty calming down from stress
• Undermethylation (common in people who are more “type A”, nervous, anxious, rigid, obsessive, etc.)

Set-shifting challenges can have many “root causes” –> maybe genetics, family environment, epigenetics (impact of environment on gene expression), stressful situations growing up or throughout life, nutrient imbalances, and more!

3 practical tips and strategies to grow in flexibility / ability to set-shift: 

Practice dialectical thinking:

Dialectical thinking is a type of thinking that can help you broaden your perspective and your perceived options. It is a flexible mindset that considers new solutions and options, in contrast to a more rigid, all-or-nothing way to view a problem or a situation.

It involves holding two seemingly contradictory viewpoints at the same time, by recognizing that there “is always more than one way to view a situation and more than one way to solve a problem.” (Opens up options rather than leaving you feeling boxed in).

You can practice dialectical thinking by using “and” statements.

For example: “I am feeling frustrated that I didn’t sleep well last night, and I can adjust some of the things I have to do today.”

Or: “It is hard having my body change and continuing to eat regularly in recovery, and I can trust this process and that things will get better over time.”

And one more: “I am feeling overwhelmed by my courseload this semester, and I can drop one of my classes or adjust my extracurriculars if I need to.”

Consider “mini-exposures”:

What might be some “mini-exposures” to help you grow in flexibility?

Some examples of what this could look like:

• If you feel like you always need to wake up 6:00am, you could try a mini-variety of wake-up times: 5:57am one day, 6:04am another day, etc.
• If you feel like you need to measure your food, maybe try not measuring a meal (such as breakfast) 1-2 times per week.
• If you feel the need to do the exact same workout every day, consider taking a group class (such as yoga) where you aren’t in charge / won’t know exactly what to expect.
• If you feel the need to plan all of your time, try leaving a couple of hours open each week and see what comes up. Maybe what “comes up” is that it is hard and feels terrible at first!

I could come up with many more examples, as I *for better or worse* have plenty of experience thinking about all of this!! 🙂

Mini-exposures can help train/rewire your brain that change, novelty, and “not being exact” are okay and generally all will be well. For most cases like those that I’m describing in this post, our bodies don’t need to be in fight-or-flight mode in reaction to these sorts of scenarios (the key is training them to not react to these situations). Although, as described above, it MAKES SENSE on some level if your body IS reacting this way (given genetics, previous life stressors, environmental dynamics, nutrient imbalances, etc. that are causing your body/mind to react this way).

Stepping back and looking for multiple paths forward:

When feeling boxed in or overly rigid in regard to something (food, plans, daily schedule, stressful situation), what might it look like to try and take a step back and consider multiple paths forwards or multiple ways of doing something?

Do you really HAVE to do it this way? Is there really only ONE option? Maybe sometimes. But, I’m guessing, oftentimes not.

Talking to a therapist, dietitian, or close friend/family member can be incredibly helpful in providing additional perspective. You could let this person know that you are looking for listening/understanding from him or her as well as added perspective (and potentially advice or possible solutions, if you are interested in this as well).

I hope this post helps you gain a little more clarity that you aren’t “crazy” for developing anorexia… there are very real biological, psychological, and environmental factors at play. AND, more empowering, there are very REAL ways you can get help.

(1) Journal of Eating Disorders: “Set-shifting, central coherence and decision making in individuals recovered from anorexia nervosa: a systematic review” (June 20, 2019).
(2) “Anorexia and Set-Shifting Challenges,” Eating Disorder Hope (July 2, 2021).  https://www.eatingdisorderhope.com/blog/anorexia-set-shifting-challenges