Changes in mental rigidity and attitude to one's body during treatment of adolescent girls suffering from anorexia nervosa

Shevelenkova Tatyana Dmitrievna ORCID: 0000-0002-5133-273X PhD in Psychology Associate Professor, Department of Neuro- and Pathopsychology L.S. Vygotsky Institute of Psychology, Russian State University for Humanities 125047, Russia, Moscow region, Moscow, Miusskaya square, 6 shevelenkova.@gmail.com

Salnikova Mariya Maksimovna Postgraduate student, Department of Neuro- and Pathopsychology, L.S. Vygotsky Institute of Psychology, Russian State Humanitarian University 125047, Russia, Moscow region, Moscow, Miusskaya square, 6 thranduillih@gmail.com

Anorexia nervosa is the third most common chronic disease in adolescent girls ^[1]: from 35 to 57% of them adhere to strict diets, purposefully starve, self-induce vomiting, take weight loss pills or laxatives ^[2]. According to rough estimates (only documented cases of anorexia nervosa), 0.9% to 4.3% of women suffered from problems associated with anorexia at least once in their lives ^[3]. On average, about 4% of women and girls in developed countries suffer from anorexia ^[4]. Approximately 5-10% of patients with anorexia are expected to die ^[5].

One of the main features of anorexia nervosa is cognitive rigidity, manifested in the primary symptoms of this disease, such as dietary restrictions and distortion of body image ^[6]. Rigidity is understood as the inability of a person, in the case of the requirements of an objective situation, to change his mental attitude, reacting to a new one; to change an action or attitude; to put himself in the place of another person; to change behavior; to reorganize problematic material; to restructure behaviors; to assimilate new means of adaptation, etc. ^{[7, 8, 9]}.

T. Brockmeyer ^[8], K. Tchanturia ^{[9, 10]}, J. Cholet 111], K.M. Dann ^[12], G. Abbate-Daga ^[13], A. Rner ^[14], Y. Sato ^[15] have established that cognitive rigidity is a factor supporting anorexia nervosa: people suffering from anorexia nervosa it is difficult to change the mode of experience about their body, they get "stuck" on ideas of thinness, which, in turn, "feeds" cognitive rigidity.

For many years, in Russian psychology and psychiatry, it was believed that the most important factor in the development of anorexia nervosa is a negative attitude towards one's body. This study considers the attitude towards the body as a multidimensional construct, including the results of self-perception and attitudes related to one's own body. However, modern research shows that dissatisfaction with one's body does not always mean the development of eating disorders and, in particular, anorexia nervosa ^[16]. Dissatisfaction with one's body can have negative consequences and be not only a situational state ^[17].

Despite the huge body of research on anorexia nervosa, many questions remain open: there is no research on the relationship of rigidity in anorexia nervosa with body attitude as a multidimensional (multidimensional) construct; it is not clear which aspects of attitude to one's body are "supported" by cognitive rigidity.

At the moment, there is also a lack of longitudinal studies affecting the change (dynamics) of psychological characteristics during the treatment of anorexia nervosa. It is important to investigate how quickly the mental sphere of a person suffering from anorexia nervosa is changing, is one month of intensive patient work with psychiatrists, nutrition consultants, clinical psychologists, cognitive behavioral psychotherapists and other specialists enough to noticeably restore the physical condition and overcome the psychological characteristics specific to anorexia nervosa?

As a rule, when evaluating the effectiveness of treatment after a month, patients primarily have weight correction, improvement in physical condition, but the question remains whether positive mental changes have occurred in patients: has the level of mental rigidity decreased, and has the attitude towards the body shifted towards the positive pole.

The present study pursued the following goals: firstly, to identify changes in mental rigidity and attitude to one's body during inpatient treatment in patients suffering from anorexia nervosa, and, secondly, to establish a link between cognitive rigidity and attitude to the body, to determine which aspects of attitude to one's body are associated with ("supported") cognitive rigidity.

The paper tested the assumption that during inpatient treatment (with an increase in body weight), the level of rigidity in anorexia nervosa decreases, and the negative attitude towards one's body shifts towards the positive pole. It was also assumed that a negative attitude towards one's body in anorexia nervosa positively correlates with a high level of rigidity and, accordingly, with a low level of flexibility.

Research methods and procedure

The study was conducted at the Center for the Study of Eating Disorders (CIRD) in Moscow from November 27, 2021 to September 10, 2022. It was attended by teenage girls aged 13 to 17 years (the average age of the study participants was 15.15 ± 1.14 years). A total of 41 patients were examined (33 girls suffering from anorexia nervosa, 7 girls suffering from bulimia nervosa and 1 patient suffering from compulsive overeating), but 20 people with a diagnosis of anorexia nervosa completed the study. The criteria for inclusion in the sample were: (1) the consent of the patients to participate in the study; the diagnosis of "anorexia nervosa" (F50.0 Anorexia nervosa) by a psychiatrist, significant weight loss in all patients at the time of admission to the hospital; (2) Completed participation in two stages of the study. The criteria for exclusion from the sample: disagreement to participate in the study, the diagnosis of "bulimia nervosa" made by a psychiatrist, incomplete participation in any of the stages of the study.

When the patients were admitted to the hospital (before starting treatment and research), informed consent was obtained from the girls' parents for their daughters to participate in medical and psychological research. Participation in this study was voluntary for the patients. They had previously received information about the purpose and procedure of the study, and they were also informed that they could refuse to participate in the study at any stage without prejudice to the ongoing treatment.

The patients who participated in the study received pharmacotherapeutic treatment in combination with individual and group psychotherapy under the supervision of doctors (psychiatrists, nutrition consultants, etc.) and psychologists. Also, in addition to mandatory nutrition, the patients received parenteral nutrition.

The study used a variant of the longitudinal method: patients underwent the study in two stages: at the beginning of inpatient treatment and a month after its start – at the end.

The following methods were used in the study.

1) The classical test of J. R. Stroop (1935) ^[18], which determines the indicator of cognitive rigidity (narrowness, rigidity of cognitive control); a relative indicator of interference arising as a result of a conflict of verbal and sensory-perceptual functions (not specifically analyzed in this work); an indicator of verbality, indicating the predominance of the verbal method of processing information over the sensory-perceptual.

2) A simplified version of the Tomsk rigidity Questionnaire by G.V. Zalevsky (1987) ^{[19, 20]}. Four scales were used: "Actual rigidity" (rigidity in its own or narrow sense as an inability to change an opinion, attitude, attitude, motives, mode of experience, etc.); "Sensitive rigidity" (the personal level of manifestation of mental rigidity, the emotional reaction of a person to new things, to situations requiring changes); "Rigidity as state" (reaction to adverse events, a tendency to fixed behavior in a state of fear, stress, bad mood, fatigue, etc.) and a scale of lies (questions are isolated from the personal questionnaire of G. Eysenck).

3) Cognitive flexibility questionnaire (adaptation by C.C. Kurginyan and E.Yu., Osavolyuk, 2018) ^[21] measuring three aspects of cognitive flexibility: the ability of an individual to give several explanations for life events and manifestations of human behavior, as well as to offer different ways to resolve difficult situations (the "Alternatives" scale); the ability of an individual to perceive difficult situations as controlled (the "Control" scale); an integrative indicator of cognitive flexibility, indicating the cognitive adaptability of an individual in stressful situations, the ability to adjust their behavior in accordance with the requirements of adverse circumstances (as opposed to cognitive rigidity).

4) The "Attitude to one's body" technique (T.D. Shevelenkova, J.A. Volzhina, 2014) ^[22] is a multidimensional scaling of one's attitude to one's body, including eight scales: the importance of bodily health, the importance of the beauty of one's own body, assessment of the ability to manage one's body, assessment of physical condition, assessment of the attractiveness of one's body to others, an assessment of the attractiveness of one's body to oneself, an assessment of the ability to establish and maintain contact with one's body, an assessment of the ability to identify oneself with one's body. An integrative indicator of one's attitude towards one's body is also calculated. The severity of the negative attitude towards the body was considered: the lower the result on each of the scales and the integrative indicator of the attitude towards one's body, the more positive it is.

The methods of mathematical and statistical analysis were used in the study. Statistical data processing was carried out using Microsoft Office Excel 2019 and IBM SPSS Statistics 20.0 © SPSS Inc. (2011). The normality of the distribution of primary data was checked according to the Kolmogorov-Smirnov agreement criterion on all scales of each methodology. To identify the differences, the Student's t-test was used for dependent samples, and to identify the relationships, a factor analysis was performed based on data from the beginning and end of inpatient treatment.

Diagnostic accuracy was determined by the introduction of the "lie scale" into the study (Tomsk Rigidity Questionnaire). 80% of the respondents gave low results on this scale, which indicates the reliability of the data received from them. 20% of the respondents gave relatively high scores on this scale, which indicates a possible distortion of the results, but their results were still included in the overall results of the study in order to: 1) to identify whether the tendency to give unreliable results has increased or decreased in the sample as a whole; 2) to determine with which parameters of rigidity / flexibility and attitude to the body the level of lying of the respondents correlates.

Results

The results of a comparative study of the indicators of group dynamics of rigidity and flexibility (at the beginning and end of the stay in the clinic.

Table 1.

The ratio at the beginning and end of treatment of patients with different indicators of rigidity/flexibility (nn (nn%))

According to Table 1, at the beginning of inpatient treatment, the percentage of adolescent girls suffering from anorexia nervosa with low flexibility (according to the Cognitive Flexibility Questionnaire) sharply exceeds those with high flexibility. Accordingly, the percentage of respondents with high rigidity is many times higher than the percentage of those with low rigidity (according to all scales of the Tomsk Rigidity Questionnaire). Moreover, no patients with a low level of actual and sensitive rigidity were found at all. Most of the patients had a very high level of rigidity as a condition (80%), sensitive rigidity (65%), as well as general rigidity (75%). At the end of inpatient treatment, the picture changes fundamentally, but not in all diagnosed parameters. The number of patients with low cognitive flexibility and high levels of rigidity, both mental and cognitive, decreased, and the percentage of patients with high scores on all scales of cognitive flexibility, as well as with low cognitive and current rigidity, increased. At the same time, the percentage of patients with low indicators of sensitive rigidity (0%), rigidity as a condition (0%) and general rigidity (5%) did not change. Also, at the end of treatment, the number of patients with a high level of indicators on the lie scale increased by 10 percent.

Using the Student's t-test, significant differences were revealed in the level of cognitive rigidity, actual rigidity, as well as in such indicators of cognitive flexibility as "control" and "integrative index of cognitive flexibility" in adolescent girls suffering from anorexia nervosa at the beginning and at the end of treatment, that is, after a month of stay in the clinic.

Table 2.

Significant differences in indicators of cognitive, current rigidity and cognitive flexibility at the beginning and end of inpatient treatment

Table 2 shows the scales according to which significant changes occurred by the end of inpatient treatment: the level of cognitive and actual rigidity became significantly lower; the level of cognitive flexibility, respectively, increased. No significant differences were found on the scales of "sensitive rigidity" (0.056), "rigidity as a condition" (0.298) and "verbality" (0.890). Also, such a parameter of cognitive flexibility as "alternatives" has not significantly changed (0.056). There were no significant changes in the indicators of the lie scale (0.402).

The results of a comparative study of changes in the indicators of attitude to one's own body in the group as a whole during inpatient treatment.

Assessing the nature of the attitude of adolescent girls suffering from anorexia nervosa to their bodies at the beginning and end of inpatient treatment, it is necessary, first of all, to note the uneven degree of severity of the negative/positive values of various components in the structure of the multidimensional construct of attitude to the body, as well as the dynamics of their severity at the beginning and end of treatment in the whole study group.

According to the data presented in Table 3, at the beginning of treatment, patients predominate who show high importance for them of bodily health and beauty of their own body (low assessment of the insignificance of parameters). These indicators do not change significantly by the end of treatment. At the same time, at the beginning of inpatient treatment, the assessment of the ability to identify oneself with one's body, the ability to establish and maintain contact with one's body, and the attractiveness of one's body for oneself is clearly negative for most respondents. It is these indicators that reveal a sharp shift towards a positive assessment by the end of inpatient treatment. The negative attitude towards the body retains the greatest stability during treatment in assessing the attractiveness of one's body for oneself: in more than half of the patients, its assessment remains negative. By the end of the treatment period, the number of patients increases, revealing a highly positive value of the "Integrative indicator of attitude to their body", "Assessment of the attractiveness of their body to others", as well as "Assessment of the ability to manage their body".

Table 3.

The ratio of the number of patients with varying degrees of negative attitude towards their body at the beginning and end of inpatient treatment (nn (nn%)).

The results of a statistical analysis of body attitudes in adolescent girls with anorexia nervosa at the beginning and end of treatment showed a significant change in the negative attitude towards the body to a more positive one (Table 4).

Table 4.

 Significant differences in indicators of negative attitude towards the body at the beginning and end of inpatient treatment

According to Table 4, statistically significant shifts in negative attitude towards the body during treatment towards the positive pole in the whole group occurred on the scales: "Integrative indicator of negative attitude towards one's body", "Assessment of the ability to identify oneself with one's body", "Assessment of the ability to establish and maintain contact with one's body", "Assessment of attractiveness your body for yourself", "Assessment of the attractiveness of your body for others", "Assessment of the ability to manage your body". Changes also occurred in the "negative assessment of physical condition" (p=0.015), which became more positive. By the end of inpatient treatment, indicators on such scales as "The importance of bodily health" (p=0.424) and "The importance of the beauty of one's own body" (p=0.572) had not changed.

The results of factor analysis based on the data of the beginning of inpatient treatment. Using factor analysis of all diagnostic results at the beginning of inpatient treatment in patients with anorexia nervosa, 5 factors were isolated (rotation converged in 7 iterations).

The factor analysis we use belongs to the exploratory (search, reconnaissance) type. It is not aimed at testing hypotheses and was used as a tool that allows you to group the variables used and hypothesize about the possible structure of hidden factors. By conducting a factor analysis of the data, we tried to reach certain fundamental variables that are not "grasped" by direct measurements, we sought to build search models that allow us to outline directions and ways of further research.

Factor 1 (20.758% variance) revealed an inverse relationship of cognitive flexibility indicators, namely, the integrative index of cognitive flexibility (-,920), "alternatives" (-,861) and "control" (-,813), with components of a negative attitude towards one's body (including a negative assessment the ability to control one's body (,713), a negative assessment of one's physical condition (,697), as well as an integrative indicator of a negative attitude towards one's body (,507).

Factor 2 (20.065% of the variance) showed a link between the negative indicators of the scales of the "Attitude to one's body" technique. The negative scale "Assessment of the ability to identify oneself with one's body" (,914) has the greatest factor load, associated with such scales as negative "Assessment of the attractiveness of one's body for oneself" (,841), "Integrative indicator of negative attitude towards one's body" (,791), negative "Assessment of the ability to establish and maintain contact with one's body" (,771), as well as a negative scale "Assessment of the attractiveness of one's body to others" (,612).

In a separate factor 3 (17.865% of the variance), a negative relationship between the lie scale (-,695) and positively interrelated scales was distinguished: "sensitive rigidity" (,908), "rigidity as a condition" (,896), "actual rigidity" (,870). The greatest burden is "sensitive rigidity" (the personal level of manifestation of mental rigidity).

Factor 4 (14.869% variance) showed a negative relationship between the overall index of cognitive rigidity (-,843) (according to the test of J. R. Stroop), and positively interrelated characteristics: the insignificance of bodily health (,686) and the level of lying (,513), which indicates that the less cognitively rigid the patients are the more likely they are to lie, and the less important their physical health is.

Factor 5 (7,345% variance) determined a direct relationship between the degree of insignificance of bodily health (,772) and the predominance of the verbal method of information processing (,530) (color "confuses" the cognitive processes of patients and the verbal method of information processing begins to prevail in them); at the beginning of treatment, rigid patients who poorly use the perceptual channel of information processing and As a rule, they have a negative attitude towards their health.

Using factor analysis of all diagnostic results at the end of inpatient treatment in patients with anorexia nervosa, 5 factors were isolated (rotation converged in 7 iterations).

The results of factor analysis based on data obtained at the end of inpatient treatment.

Factor 1 (32.830% variance): the greatest factor load is carried by the scale "Negative assessment of the attractiveness of one's body for oneself" (,899), which groups such parameters of attitude to the body as "An integrative indicator of negative attitude to one's body" (,890), "Negative assessment of the ability to identify oneself with one's body" (,855), "Negative assessment of the ability to establish and maintain contact with your body" (,847), "Negative assessment of the attractiveness of your body to others" (,827), "Negative assessment of physical condition" (,716), "Negative assessment of the ability to control your body" (,696). These directly related indicators of negative attitude towards one's body are inversely related to the parameters of cognitive rigidity/flexibility: a measure of "verbality" (-,685), an integrative indicator of cognitive flexibility (-,516) and the ability to alternative thinking (-,565).

Factor 2 (17.604% of variance) characterized as highly interrelated all the studied variables of the Tomsk rigidity questionnaire: "Actual rigidity" (,894), – rigidity in the proper or narrow sense of the word; "Sensitive rigidity" (,892), – the personal level of manifestation of mental rigidity; "Rigidity as a state" (,887), – as a reaction to adverse events.

Factor 3 (13.740% variance) associated low cognitive rigidity (-,953) with a low index of "verbality" (-,557).

Factor 4 (13.056% variance) showed that a decrease in the ability for patients to perceive difficult situations as controlled (-,840) is associated with a decrease in cognitive flexibility in general (-,801), as well as the ability to give several explanations for life events and manifestations of human behavior, as well as offer many different ways to resolve difficult situations (-,634).

         Factor 5 (11.407% variance) revealed a link between high indicators of the degree of insignificance of one's own body beauty (,800), insignificance of bodily health (,728) and a low level of lying (-,720).

Discussion of the results

The study found at the beginning of treatment a quantitative predominance of patients with a high level of cognitive and personal rigidity (no patients with a low level of actual and sensitive rigidity were found at all) and a low level of cognitive flexibility, which indicates that low cognitive flexibility and high rigidity are an important symptom of anorexia nervosa.

The study confirmed the assumption that during a month-long hospital stay in patients, the level of both cognitive and personal rigidity in the group as a whole decreases and the level of cognitive flexibility significantly increases. By the end of inpatient treatment, the rigidity of cognitive control significantly decreased: control began to cover wider spheres of life; rigidity in its own or narrow sense decreased, there was a relative ability to change one's opinion, attitude, attitude, motives and mode of experience; there was a relative opportunity to perceive difficult situations as controlled. An increase in the integral index of cognitive flexibility at the end of treatment indicates an increase in the cognitive adaptability of adolescent girls suffering from anorexia nervosa in stressful situations, the ability to adjust their behavior in accordance with the requirements of adverse circumstances. Since the percentage of patients with low indicators of sensitive rigidity, rigidity as a condition and the general indicator of rigidity has not changed, these indicators of rigidity can be considered the most resistant in relation to the treatment. By the end of treatment (during a month of stay in the clinic), the personal level of mental rigidity, characterizing the emotional reaction of patients to the new, to situations requiring changes, fear of the new, and neophobia, practically does not change. The reaction of patients to adverse events, the tendency to fixed behavior in a state of fear, stress (distress), bad mood, fatigue or some kind of painful condition remains unchanged. The change in these rigidity parameters most likely does not directly depend on the increase in body weight and requires serious psychological work after the end of the patient's stay in the hospital.

At the beginning of inpatient treatment, most girls suffering from anorexia nervosa show a negative attitude towards their body in most of the parameters studied. Nevertheless, "The importance of bodily health" and "The importance of the beauty of one's own body", even at the beginning of inpatient treatment, are evaluated by them mainly highly positively and remain in this quality until the end of inpatient treatment.

At the beginning of inpatient treatment, the integrative indicator of cognitive flexibility had the greatest factor load, negatively related to the parameters of negative attitude to one's own body (with negative assessments of the ability to control one's body, one's physical condition, as well as with an integrative indicator of attitude to one's body) and indicators of cognitive and personal rigidity. The lower the indicators of cognitive flexibility, the more pronounced the negative attitude towards their bodies in adolescent girls with anorexia nervosa. It can be assumed that it is these indicators of attitude to the body of patients that are "supported" by their characteristic cognitive rigidity (low flexibility). It has also been found that a negative attitude towards one's body in anorexia nervosa positively correlates with a high level of rigidity and, accordingly, with a low level of flexibility both at the beginning and at the end of inpatient treatment.

 The greatest resistance (resistance) to the body during treatment is revealed in the assessment of the attractiveness of one's body for oneself: in more than half of the patients, it remains negative at the end of inpatient treatment. Moreover, as the factor analysis of variables at the end of treatment showed, it is the "Negative assessment of the attractiveness of one's body for oneself" (factor 1) that has the greatest factor load, grouping both other parameters of attitude to the body (direct connection) and indicators of cognitive rigidity/flexibility (feedback). The dominance of reduced cognitive flexibility (at the beginning of treatment) changes to the dominance of the parameters of negative attitude towards the body (at the end of treatment). With an increase in cognitive flexibility, by the end of treatment, the problem of satisfaction with one's body begins to come to the fore.

At the beginning of treatment, the "Negative assessment of the ability to identify oneself with one's body" (factor 2) has the greatest factor load, combining other parameters of negative attitude towards the body into a single factor. Thus, at the beginning of treatment, patients have a kind of "gap" between their own Self and their body, the inability to identify themselves with their own body: "I am not my body." At the end of the treatment, the "Negative assessment of the attractiveness of your body for yourself" begins to take center stage and the main problem becomes satisfaction with your body: "I don't like my body." Thus, from the beginning to the end of inpatient treatment, there is a shift in the psychological problem: low cognitive flexibility, as well as the inability to identify oneself with one's body, cease to be the main problem determining symptoms, and a negative assessment of the attractiveness of one's body for oneself comes to the fore, which at the end of inpatient treatment should become a specific target for psychotherapeutic work. This target appears only at the end of inpatient treatment after the improvement of the physical condition of the patients. This fact makes it possible to plan psychotherapeutic work with patients and identify its main targets after inpatient treatment.

An interesting fact obtained in the study (factor 5 of the start of treatment) was that the insignificance of bodily health was associated with a high rate of "verbality", that is, the less patients value bodily health, the more they tend to use the verbal channel of information processing, ignoring the perceptual channel. At the end of treatment, those patients who have increased the value of health begin to use the perceptual channel to a greater extent.

Statistically significant shifts in negative attitude towards the body during treatment towards the positive pole in the whole group occurred on all scales, except for the "Importance of bodily health" and "Importance of the beauty of one's own body". The latter did not change by the end of inpatient treatment, they remained the same, which, in turn, turned out to be extremely informative. Factor analysis of indicators at the beginning of treatment revealed an inverse relationship between the degree of insignificance of bodily health and the level of cognitive rigidity and a direct relationship with the data of the lie scale.

It turned out that at the beginning of treatment, those teenage girls suffering from anorexia nervosa, for whom bodily health is not important, but who, at the same time, are the least rigid, tend to give incorrect information about themselves and their experiences, opinions and attitudes. It can be assumed that teenage girls suffering from anorexia nervosa, when they agree to go to a clinic for treatment, nevertheless internally do not agree to be treated and change, considering themselves healthy. The least rigid of them, who better understand what is required of them in the clinic, are protected by an increase in the level of lies. The desire to be insincere with medical staff and research psychologists is supported precisely by the low importance of one's own health. Patients have other priorities, often taking the form of secondary benefits: establish relationships with peers, become "happy" in their understanding, accept themselves, do what they love, realize their desire for "people to appreciate them for their rich inner world," etc. Additional research is needed to confirm this fact, since scientific papers There is no discussion on this topic, it has not been conducted either in our country or abroad.

At the end of inpatient treatment, it is precisely those patients who maintain a high level of negative attitude (disregard) to the beauty of their own body and bodily health who have a low level of lies. A negative attitude towards the beauty and health of the body does not generate a desire to defend oneself and lie. Accordingly, teenage girls who maintain a negative attitude towards their own health and the beauty of their own body at the end of inpatient treatment are the most sincere, and the results of their research turn out to be the most trustworthy. A positive shift in these aspects of body attitude, correlated with an increase in the lie scale, is probably a reaction to the attitudes of medical staff towards the formation of a positive attitude in patients and gives rise to their desire to lie so that they are considered "recovered". The revealed facts, apparently, require the medical staff to move from a simple "translation" of the attitude in the form of the importance of their own bodily health and the beauty of their own body to serious psychotherapeutic work in this direction.

Factor analysis shows a change in the relationship of indicators on the lie scale from the beginning to the end of treatment. At the beginning of treatment, they are inversely associated with both mental and personal rigidity, with indicators of cognitive rigidity, as well as directly with the insignificance of bodily health. At the end of treatment, the level of lying is not related to either cognitive rigidity or cognitive flexibility; now it is inversely related only to the parameters of a negative attitude towards one's body, namely, the insignificance of one's own body beauty and bodily health. Once again, we note that at the end of treatment, it is the negative attitude towards the body that becomes the "cornerstone" on which psychological work should be based.

The results of the study indicate that the level of cognitive rigidity in anorexia nervosa decreases during treatment during recovery of body weight (approaching the body mass index to normal), respectively, the level of cognitive flexibility increases. The data obtained are in good agreement with the results presented in the works of M.V. Korkina and co-authors ^{[5, 6]}, as well as in a number of foreign studies: J. Cholet at al. ^[11]; T. Brockmeyer at al. ^[9]; K. Tchanturia at al. ^{[9; 10]}. The above-mentioned foreign studies have shown that reduced cognitive flexibility is a characteristic stable feature of patients with anorexia nervosa, independent of either body mass index or duration of illness, and that cognitive rigidity can be a marker of eating disorders ^[11]. Similar results were obtained by K.M. Dann at al. ^[12]; G. Abbate-Daga at al. ^[13]; A. Rner at al. ^[14]; Di Lodovico L. ^[23]; S.B. Wang at al. ^[24].

Correlating with modern studies of body attitudes in patients suffering from anorexia nervosa, we note that, unlike the presented study, they mainly focus on satisfaction/dissatisfaction with their body and on distortion of body parameters ^{[25, 26, 27]}.

   Conclusion

Indicators of improvement in the condition of patients with anorexia nervosa are an increase in the level of cognitive flexibility, a decrease in the level of actual rigidity and an attitude towards one's body closer to the positive pole. 

The practical significance of the study lies in the fact that the results obtained in it allow us to identify specific targets for psychological work with patients at the beginning and end of treatment, since it establishes which aspects of the attitude to one's body are "supported" by cognitive rigidity, and also records a shift during inpatient treatment from the dominance of reduced cognitive flexibility (at the beginning treatment) towards the dominance of the parameters of negative attitude towards the body (at the end of treatment), showing that with an increase in cognitive flexibility, satisfaction with one's body begins to come to the fore by the end of treatment.

         For the first time, this study draws attention to the importance of the lie factor in assessing the condition and intentions of patients at the beginning and end of their stay in the clinic.

A significant limitation of the study is the small sample size. Further research is needed to understand how well this sample reflects the general population. Since the study was of a pilot nature, its results and conclusions drawn from their analysis do not claim to be universally valid and, above all, provide grounds for putting forward productive hypotheses that require further verification.

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