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Lu Y, Chen Y, Zhao Y, Wang Y, Chen H, Zhang F, Li X. Analysis of the effects of eating and emotions on reproductive axis function in patients with functional hypothalamic amenorrhea. J Psychosom Obstet Gynaecol 2024; 45:2375718. [PMID: 38975957 DOI: 10.1080/0167482x.2024.2375718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/30/2024] [Indexed: 07/09/2024] Open
Abstract
Objective: To investigate the effects of eating and emotions on reproductive axis function in patients with functional hypothalamic amenorrhea (FHA). Methods: A retrospective cohort study was conducted to summarize the clinical and endocrine characteristics of 58 patients with FHA at initial diagnosis and to follow up the recovery of ovulation and spontaneous menstruation in the patients to investigate these biochemical indicators and their effects on recovery outcomes. Results: Among patients with FHA, 13.8% (8/58) and 15.5% (9/58) had above moderately severe depressive and severe anxiety symptoms respectively, and 25.9% (15/58) were at high risk for eating disorders. 34.5% (20/58) were included assessed as having recovered. The non-recovered group had higher scores on the Patient Health Questionnaire (PHQ-9) (p = .022) and higher scores on the Eating Attitude Test-26 (EAT-26) (p = .03) as well as bulimia and food preoccupation (p = .041). Follicle diameter >5 mm at initial diagnosis was an independent factor influencing recovery of reproductive axis function (odds ratio = 7.532; 95% confidence interval, 1.321-42.930; p = .023). Conculsions: Mood disorders and a certain risk of eating disorders were present in FHA.These, together with weight loss, endocrine and follicle size, could influence the outcome.
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Affiliation(s)
- Ye Lu
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yao Chen
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuting Zhao
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yulu Wang
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Hang Chen
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Feifei Zhang
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xin Li
- Department of Reproductive Endocrinology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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Męczekalski B, Niwczyk O, Battipaglia C, Troia L, Kostrzak A, Bala G, Maciejewska-Jeske M, Genazzani AD, Luisi S. Neuroendocrine disturbances in women with functional hypothalamic amenorrhea: an update and future directions. Endocrine 2024; 84:769-785. [PMID: 38062345 PMCID: PMC11208264 DOI: 10.1007/s12020-023-03619-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 01/31/2024]
Abstract
Functional hypothalamic amenorrhea (FHA) is one of the most common causes of both primary and secondary amenorrhea in women of reproductive age. It is characterized by chronic anovulation and the absence of menses that appear as a result of stressors such as eating disorders, excessive exercise, or psychological distress. FHA is presumed to be a functional disruption in the pulsatile secretion of hypothalamic gonadotropin-releasing hormone, which in turn impairs the release of gonadotropin. Hypoestrogenism is observed due to the absence of ovarian follicle recruitment. Numerous neurotransmitters have been identified which play an important role in the regulation of the hypothalamic-pituitary-ovarian axis and of which the impairment would contribute to developing FHA. In this review we summarize the most recent advances in the identification of contributing neuroendocrine disturbances and relevant contributors to the development of FHA.
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Affiliation(s)
- Błażej Męczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland.
| | - Olga Niwczyk
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Christian Battipaglia
- Gynecological Endocrinology Center, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Modena, Italy
| | - Libera Troia
- Department of Gynecology and Obstetrics, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Anna Kostrzak
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
| | - Gregory Bala
- UCD School of Medicine University College Dublin, D04 V1W8, Dublin, Ireland
| | | | - Alessandro D Genazzani
- Gynecological Endocrinology Center, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Luisi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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Giannakopoulos A, Chrysis D. Reversibility of disturbed pituitary function in pediatric conditions with psychological stressors: implications for clinical practice. Hormones (Athens) 2024:10.1007/s42000-024-00536-z. [PMID: 38421589 DOI: 10.1007/s42000-024-00536-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
The complex communication network between the central nervous system and the hypothalamic-pituitary axis forms the basis of endocrine functional plasticity, which facilitates adaptation to changing internal and external conditions, but also makes it vulnerable to the negative effects of stressful psychological factors. Herein, clinical conditions such as functional hypothalamic amenorrhea, eating disorders, growth faltering, post-traumatic stress disorder, and pubertal disorders that may emerge during childhood or adolescence, their origin possibly including psychological stressors, are analyzed regarding their genetic susceptibility and reversibility of endocrine function. A discussion on the optimization of therapeutic management defined by managing stress and maximizing the degree and rate of reversibility follows.
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Affiliation(s)
- Aristeidis Giannakopoulos
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, Rio, 26504, Patras, Greece.
| | - Dionisios Chrysis
- Division of Pediatric Endocrinology, Department of Pediatrics, Medical School of Patras, University Hospital, Rio, 26504, Patras, Greece
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Strock NCA, De Souza MJ, Mallinson RJ, Olmsted M, Allaway HCM, O'Donnell E, Plessow F, Williams NI. 12-months of increased dietary intake does not exacerbate disordered eating-related attitudes, stress, or depressive symptoms in women with exercise-associated menstrual disturbances: The REFUEL randomized controlled trial. Psychoneuroendocrinology 2023; 152:106079. [PMID: 36947969 DOI: 10.1016/j.psyneuen.2023.106079] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Abstract
Disordered eating-related attitudes are a leading cause of energy deficiency and menstrual disturbances in exercising women. Although treatment recommendations include psychological counseling with increases in dietary intake, a key concern is whether increased dietary intake may exacerbate negative eating behaviors. OBJECTIVE To determine the effects of a 12-month nutritional intervention on eating-related attitudes and psychological characteristics in exercising women with oligomenorrhea/amenorrhea (Oligo/Amen). METHODS Intent-to-treat analysis of the REFUEL randomized controlled trial (#NCT00392873) in 113 exercising women (age [mean±SEM]:] 21.9 ± 0.4 yrs; BMI: 20.9 ± 0.2 kg/m2). Women were randomized to increase energy intake 20-40% above baseline energy needs (Oligo/Amen+Cal, n = 40) or maintain energy intake (Oligo/Amen Control, n = 36) while maintaining their exercise behaviors. A reference group of ovulatory women (OVref, n = 37) maintained diet and exercise behaviors. Body composition, eating attitudes, stress, and depressive symptoms were assessed at baseline and every 3 months. RESULTS At baseline, the Oligo/Amen groups had higher drive for thinness, cognitive restraint, and eating disorder risk than OVref group (p < 0.001). Increased energy intake led to increases in percent body fat and fat mass (p < 0.010), but not psychobehavioral outcomes, in the Oligo/Amen+Cal compared to Oligo/Amen Control group. Independent of group, cognitive restraint decreased (p < 0.001) and resilient coping increased (p < 0.007) over 12-months, while perceived stress (p = 0.143) and depressive symptoms (p = 0.344) were unchanged. DISCUSSION Long-term nutritional intervention consisting of modest increases in dietary intake with guidance from a registered dietician and a psychologist increases body and fat mass without increasing disordered eating-related attitudes, stress, or depressive symptoms in exercising women with Oligo/Amen.
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Affiliation(s)
| | | | - Rebecca J Mallinson
- Penn State University, University Park, PA, USA; Penn State Harrisburg, Middletown, PA, USA
| | | | - Heather C M Allaway
- Penn State University, University Park, PA, USA; Louisiana State University, Baton Rouge, LA, USA
| | - Emma O'Donnell
- University of Toronto, Toronto, Ontario, Canada; Loughborough University, Loughborough, Leicestershire, UK
| | - Franziska Plessow
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
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Bonazza F, Politi G, Leone D, Vegni E, Borghi L. Psychological factors in functional hypothalamic amenorrhea: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:981491. [PMID: 36777338 PMCID: PMC9911452 DOI: 10.3389/fendo.2023.981491] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Psychological factors have been found to be associated with functional hypothalamic amenorrhea (FHA); however, their role in the onset or persistence of FHA is still understudied. The study aims to assess the associations of psychological factors with the presence vs the absence of FHA. METHODS A systematic literature search has been conducted across the major databases (PubMed, PsycINFO, Scopus, and Embase) to explore the psychological factors associated with FHA. The search was limited to English-written articles published from 2000 onwards. Articles were selected based on stringent inclusion/exclusion criteria. After data extraction, meta-analysis and meta-synthesis were conducted. RESULTS Of 349 retrieved articles, eight studies were included. Findings indicate that the main psychological factors associated to FHA seem to be depression and eating attitudes, especially drive for thinness. FHA women present higher levels of anxiety, sleep disorders, dysfunctional attitudes, and alexithymia. The meta-analysis on drive for thinness revealed that the pooled MD across the studies was statistically significant both in the fixed 0.63 (95% CI: 0.31-0.95) and random model 0.70 (95% CI: 0.13-1.26). Likewise, as for depression, the pooled MD across the studies was statistically significant both in the fixed 0.60 (95% CI: 0.36-0.84) and random model 0.61 (95% CI: 0.20-1.01). DISCUSSION Findings showed the association of psychological factors and FHA and recognized their involvement in the persistence of the disorder. A multidisciplinary approach should involve a collaborative process between gynecologists, clinical psychologists, and psychiatrists, from diagnosis to treatment. Longitudinal studies should be implemented with a comparison/control group or by including clinical psychologists in the psychological assessment and study design.
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Affiliation(s)
- Federica Bonazza
- Department of Health Sciences, University of Milan, Milan, Italy
- *Correspondence: Federica Bonazza,
| | - Giuliana Politi
- Azienda Socio-Sanitaria Territoriale (ASST) Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Daniela Leone
- Department of Health Sciences, University of Milan, Milan, Italy
- Azienda Socio-Sanitaria Territoriale (ASST) Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Elena Vegni
- Department of Health Sciences, University of Milan, Milan, Italy
- Azienda Socio-Sanitaria Territoriale (ASST) Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Lidia Borghi
- Department of Health Sciences, University of Milan, Milan, Italy
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Maiorana N, Brugnera A, Galiano V, Ferrara R, Poletti B, Marconi AM, Garzia E, Ticozzi N, Silani V, Priori A, Ferrucci R. Emotional and autonomic response to visual erotic stimulation in patients with functional hypothalamic amenorrhea. Front Endocrinol (Lausanne) 2022; 13:982845. [PMID: 36531461 PMCID: PMC9755206 DOI: 10.3389/fendo.2022.982845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/11/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Functional hypothalamic amenorrhea (FHA) is a clinical condition associated with high levels of physiological and psychological stress ranging from weight loss to maladaptive behavior and coping skills. A reliable measure of the psychophysiological response to stress and the ability to cope with stimuli is heart rate variability (HRV). Through the sympathetic (SNS) and parasympathetic nervous system (PNS), the autonomic nervous system (ANS) promotes various changes in HRV that reflect the individual's psychophysiological response to stress. FHA patients are characterized by high levels of PNS activation during psychological load, suggesting that parasympathetic hyperactivation could be a pathology marker. Methods In the present study, we examine changes in HRV during observation of erotic, neutral, and disgusting images in 10 patients with FHA [(mean ± S.D.) age: 26.8 ± 5.9] and in 9 controls (age: 25.4 ± 6.4; BMI: 22.47 ± 2.97) to assess the differential activation of PNS and SNS between FHA patients and controls matched for age and without other clinical conditions. Results Our results showed that FHA patients had significantly higher HRV activation while observing high emotional value images and not during the observation of neutral images confirming a parasympathetic hyperactivation. Discussion HRV and cognitive and psychological testing, could provide new insights into understanding such a clinically understudied condition and provide further tools for clinical diagnosis and treatment.
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Affiliation(s)
- Natale Maiorana
- Aldo Ravelli Research Center, Department of Health Science, University of Milan, Milan, Italy
| | - Agostino Brugnera
- Department of Human and Social Sciences, University of Bergamo, Bergamo, Italy
| | | | - Rosanna Ferrara
- Aldo Ravelli Research Center, Department of Health Science, University of Milan, Milan, Italy
| | - Barbara Poletti
- Department of Neurology and Laboratory of Neuroscience, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Anna Maria Marconi
- ASST-Santi Paolo e Carlo, Milan, Italy
- Department of Health Science, University of Milan, Milan, Italy
| | | | - Nicola Ticozzi
- Department of Neurology and Laboratory of Neuroscience, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, Dino Ferrari Center, University of Milan, Milan, Italy
| | - Vincenzo Silani
- Department of Neurology and Laboratory of Neuroscience, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, Dino Ferrari Center, University of Milan, Milan, Italy
| | - Alberto Priori
- Aldo Ravelli Research Center, Department of Health Science, University of Milan, Milan, Italy
- ASST-Santi Paolo e Carlo, Milan, Italy
| | - Roberta Ferrucci
- Aldo Ravelli Research Center, Department of Health Science, University of Milan, Milan, Italy
- ASST-Santi Paolo e Carlo, Milan, Italy
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Pruneti C, Guidotti S. Cognition, Behavior, Sexuality, and Autonomic Responses of Women with Hypothalamic Amenorrhea. Brain Sci 2022; 12:1448. [PMID: 36358374 PMCID: PMC9688049 DOI: 10.3390/brainsci12111448] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 10/13/2022] [Accepted: 10/22/2022] [Indexed: 02/11/2024] Open
Abstract
(1) Background: Functional Hypothalamic Amenorrhea (FHA) can be caused by the hyper activation of neuro-endocrine responses to stress. Among other endocrine factors and hypothalamic dysfunctions, the psychophysiological stress response can very frequently lead to an inhibition of the gonadal-pituitary axis. The aim of this study was to investigate the level of neurovegetative activation in a group of young women affected by this condition. (2) Methods: Twenty-five women (mean age = 21.1 ± 4.34) with FHA were consecutively recruited. Information on psycho-physiological distress was collected through a Psychopathological assessment (with the administration of three psychometric tests) and the Psychophysiological Stress Profile (PSP). Their data were compared with a control group. (3) Results: In the PSP, the patients displayed significantly higher values compared to controls in terms of the parameters of muscle tension (sEMG), skin conductance (SCL/SCR), heart rate (HR), and peripheral temperature (PT). Furthermore, autonomic hyper-activation at rest, marked reactivity to stress, and reduced recovery were seen. Moreover, a condition characterized by psychological distress (anxiety and somatic complaints, depressed and irritable mood, obsessive-compulsive traits) emerged. (4) Conclusions: The results highlight autonomic hyper-activation in FHA, which is also associated with psychological distress. Considering that FHA is a condition that affects multiple systems between mind and body, a multimodal, multidimensional, and multidisciplinary assessment of stress is becoming an emerging need.
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Affiliation(s)
- Carlo Pruneti
- Clinical Psychology, Clinical Psychophysiology and Clinical Neuropsychology Laboratory, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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8
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Has Menstruation Disappeared? Functional Hypothalamic Amenorrhea-What Is This Story about? Nutrients 2021; 13:nu13082827. [PMID: 34444987 PMCID: PMC8401547 DOI: 10.3390/nu13082827] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/10/2021] [Accepted: 08/14/2021] [Indexed: 01/14/2023] Open
Abstract
Functional hypothalamic amenorrhea (FHA) is a very common condition affecting women of procreative age. There are many reasons for this disorder, including a low availability of energy in the diet, low micro- and macronutrient intake, overly intensive physical activity, disturbed regeneration processes, sleep disorders, stress, and psychological disorders. The main determinant is long-term stress and an inability to handle the effects of that stress. FHA is a very complex disorder and often goes undiagnosed. Moreover, therapeutic interventions do not address all the causes of the disorder, which could have implications for women’s health. As shown by scientific reports, this condition can be reversed by modifying its causes. This review of the literature aims to update the current knowledge of functional hypothalamic amenorrhea and underscores the complexity of the disorder, with particular emphasis on the nutritional aspects and potential interventions for restoring balance.
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Armento A, VanBaak K, Seehusen CN, Sweeney EA, Wilson JC, Howell DR. Presence and Perceptions of Menstrual Dysfunction and Associated Quality of Life Measures Among High School Female Athletes. J Athl Train 2021; 56:1094-1099. [PMID: 33626156 DOI: 10.4085/624-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Adolescent female athletes are at risk for menstrual dysfunction in the setting of exercise and low energy availability. Education regarding menstrual dysfunction and its associated consequences is important to promote athlete well-being. OBJECTIVES The primary aim was to determine the prevalence and characteristics of female athletes who believe that losing their period is a normal response to high training demands. The secondary aim was to explore the relationship between menstrual dysfunction and patient-reported quality of life measures. DESIGN Cross-sectional study. SETTING Pre-participation evaluations for a local high school district. PARTICIPANTS Female athletes,13-18 years old. INDEPENDENT VARIABLES Presence of menstrual dysfunction, and response (yes/no) to the question, "Do you think it is normal to lose your period during high levels of athletic training?" MAIN OUTCOME MEASURES Health history, family affluence, and patient-reported quality of life measures. RESULTS Forty four percent (n=40) of 90 adolescent athletes answered that losing their period was a normal response to a high level of training, and this group had lower BMI, were less likely to report being worried about current weight, and had a higher family affluence level than those who answered losing their period was not a normal response to training. The overall prevalence of menstrual dysfunction was 28%. After adjusting for age and BMI, menstrual dysfunction was significantly associated with higher levels of anxiety, fatigue, and pain interference. CONCLUSION Nearly half of our sample of adolescent female athletes perceive losing their period as a normal response to high training demands. Females with menstrual dysfunction reported higher levels of anxiety, fatigue, and pain interference than those without. Understanding adolescent perceptions of menstrual dysfunction and the characteristics of those with menstrual dysfunction can guide future educational interventions aimed at athletes at risk for the female athlete triad.
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Affiliation(s)
- Aubrey Armento
- 1Sports Medicine Center, Children's Hospital Colorado, Aurora, CO.,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Karin VanBaak
- 2Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO.,3Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO.,Karin VanBaak:
| | - Corrine N Seehusen
- 1Sports Medicine Center, Children's Hospital Colorado, Aurora, CO.,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO.,Corrine Seehusen:
| | - Emily A Sweeney
- 1Sports Medicine Center, Children's Hospital Colorado, Aurora, CO.,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO.,Emily Sweeney:
| | - Julie C Wilson
- 1Sports Medicine Center, Children's Hospital Colorado, Aurora, CO.,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO.,4Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.,Julie Wilson:
| | - David R Howell
- 1Sports Medicine Center, Children's Hospital Colorado, Aurora, CO.,2Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO.,David Howell:
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10
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Relative Energy Deficiency in Sport: an Orthopaedic Perspective. J Am Acad Orthop Surg 2021; 29:e14-e21. [PMID: 33273407 DOI: 10.5435/jaaos-d-20-00460] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
Relative energy deficiency in sport (RED-S) is a constellation of clinical findings related to low energy availability. Manifestations are variable but may include endocrine and reproductive dysfunction, impaired bone and muscle health, psychological complaints, and performance issues, among many others. Unlike the previously common terminology, the female athlete triad, RED-S encompasses a broader range of signs and symptoms and includes descriptions for the male athlete. Since first being described in 2014 by the International Olympic Committee, an abundance of research has sought to define, prevent, and treat the underlying condition of RED-S. Although medicine, and society in general, has tried to expose the hazardous training and lifestyle behaviors that can underpin RED-S, further research and education is required on the part of the clinician and athlete to reshape the culture and prevent the deleterious consequences of low energy availability.
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11
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Strock NCA, De Souza MJ, Williams NI. Eating behaviours related to psychological stress are associated with functional hypothalamic amenorrhoea in exercising women. J Sports Sci 2020; 38:2396-2406. [PMID: 32619140 DOI: 10.1080/02640414.2020.1786297] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Functional hypothalamic amenorrhoea (FHA) can occur due to the independent or combined effects of psychogenic and energetic stressors. In exercising women, research has primarily focused on energy deficiency as the cause of FHA while psychological stressors have been ignored. To assess both psychological and metabolic factors associated with FHA in exercising women, we performed across-sectional comparison of 61 exercising women (≥2 hours/week, age 18-35 years, BMI 16-25kg/m2), who were eumenorrheic or amenorrhoeic confirmed by daily urine samples assayed for reproductive hormone metabolites. Psychological factors and eating behaviours were assessed by self-report questionnaires. Exercising women with FHA had lower resting metabolic rate (p=0.023), T3 (p<0.001), T4 (p=0.013), leptin (p=0.002), higher peptide YY (p<0.001), greater drive for thinness (p=0.017), greater dietary cognitive restraint (p<0.001), and displayed dysfunctional attitudes, i.e., need for social approval (p=0.047) compared to eumenorrheic women. Amenorrhoeic women displayed asignificant positive correlation between the need for social approval and drive for thinness with indicators of stress, depression, and mood, which was not apparent in eumenorrheic women. In exercising women with FHA, eating behaviours are positively related to indicators of psychological stress and depression.
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Affiliation(s)
- Nicole C A Strock
- 109 Noll Laboratory, Penn State University, University Park , PA.,Women's Health and Exercise Laboratory, Penn State University,University Park , PA
| | - Mary Jane De Souza
- Women's Health and Exercise Laboratory, Penn State University,University Park , PA
| | - Nancy I Williams
- Women's Health and Exercise Laboratory, Penn State University,University Park , PA
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12
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Adolescents and young women with functional hypothalamic amenorrhoea: is it time to move beyond the hormonal profile? Arch Gynecol Obstet 2020; 301:1095-1101. [DOI: 10.1007/s00404-020-05499-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
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Lania A, Gianotti L, Gagliardi I, Bondanelli M, Vena W, Ambrosio MR. Functional hypothalamic and drug-induced amenorrhea: an overview. J Endocrinol Invest 2019; 42:1001-1010. [PMID: 30742257 DOI: 10.1007/s40618-019-01013-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/24/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Functional hypothalamic amenorrhea (FHA) is a form of chronic anovulation not due to identifiable organic causes and with adverse health consequences. The identification of women with this disorder or the precocious identification of women at risk is based on the knowledge of lifestyle risk factors or behaviors such as stress, weight loss, and excessive physical exercise that are known to negatively impact gonadal axis activity. METHODS In this overview, we described the most common forms of FHA, in particular stress-induced amenorrhea and overtraining-induced amenorrhea. In addition, although its mechanisms can differ from those involved in FHA, we reviewed the available literature on drug-induced amenorrhea, highlighting the clear connection between this condition and psychoactive drugs such as antipsychotics, antidepressants and anti-epilectics thus raising concern about the role that the abuse of substances such as opioids or alcohol can possibly have on the growing unexplained infertility of the female population.
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Affiliation(s)
- A Lania
- Endocrinology Unit, Department of Biomedical Sciences, Humanitas University and Humanitas Research Hospital, Rozzano, Italy
| | - L Gianotti
- Division of Endocrinology Diabetology and Metabolism, S. Croce and Carle Hospital, Cuneo, Italy
| | | | | | - W Vena
- Endocrinology Unit, Department of Biomedical Sciences, Humanitas University and Humanitas Research Hospital, Rozzano, Italy.
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14
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Kästner D, Löwe B, Gumz A. The role of self-esteem in the treatment of patients with anorexia nervosa - A systematic review and meta-analysis. Int J Eat Disord 2019; 52:101-116. [PMID: 30488479 DOI: 10.1002/eat.22975] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We aimed to provide a comprehensive overview of the role of self-esteem in the treatment of patients with anorexia nervosa (AN). Specifically, our objectives were to investigate the differences in self-esteem between individuals with AN and healthy controls, or individuals with other eating disorders, and to examine self-esteem as an outcome, predictor, moderator, and mediator in AN treatment. METHOD The databases PsycINFO, PSYNDEXplus, Ovid MEDLINE®, and ProQuest were searched for studies published from 1990 to 2018. To estimate aggregated effect sizes, we performed random-effects meta-analyses. RESULTS A screening of 1,596 abstracts and 203 full-texts identified 68 relevant publications. Results suggest a significantly lower global self-esteem in individuals with AN than in healthy controls (d = -1.90, p < .001). In contrast, global self-esteem of AN and bulimia nervosa (BN) patients was found to be comparable (d = 0.05, p = .529). It might be specific to AN patients that negative self-evaluations may not affect scholastic and professional abilities. Significantly moderate self-esteem increases were observed in treated AN patients at the end of treatment (d = 0.56, p < .001), short-term (d = 0.50, p < .001), and long-term (d = 0.75, p < .001) follow-up. Self-esteem did not predict end of treatment remission-or weight-related outcome and treatment dropout. However, small to moderate predictive effects were detected on short-term (r = .15, p = .007) and long-term remission or weight (r = .33, p = .017). Finally, first indications point to self-esteem as a mediator in adult AN inpatient treatment. DISCUSSION The review provides insights relevant for theory, research, and practice. Implications concern the overall support for transdiagnostic approaches and the recommendation to consider low initial self-esteem for decisions on after-care.
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Affiliation(s)
- Denise Kästner
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf & Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf & Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | - Antje Gumz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf & Schön Clinic Hamburg Eilbek, Hamburg, Germany
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Ackerman KE, Holtzman B, Cooper KM, Flynn EF, Bruinvels G, Tenforde AS, Popp KL, Simpkin AJ, Parziale AL. Low energy availability surrogates correlate with health and performance consequences of Relative Energy Deficiency in Sport. Br J Sports Med 2018; 53:628-633. [DOI: 10.1136/bjsports-2017-098958] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2018] [Indexed: 12/29/2022]
Abstract
Low energy availability (EA) is suspected to be the underlying cause of both the Female Athlete Triad and the more recently defined syndrome, Relative Energy Deficiency in Sport (RED-S). The International Olympic Committee (IOC) defined RED-S as a syndrome of health and performance impairments resulting from an energy deficit. While the importance of adequate EA is generally accepted, few studies have attempted to understand whether low EA is associated with the health and performance consequences posited by the IOC.ObjectiveThe purpose of this cross-sectional study was to examine the association of low EA with RED-S health and performance consequences in a large clinical population of female athletes.MethodsOne thousand female athletes (15–30 years) completed an online questionnaire and were classified as having low or adequate EA. The associations between low EA and the health and performance factors listed in the RED-S models were evaluated using chi-squared test and the odds ratios were evaluated using binomial logistic regression (p<0.05).ResultsAthletes with low EA were more likely to be classified as having increased risk of menstrual dysfunction, poor bone health, metabolic issues, haematological detriments, psychological disorders, cardiovascular impairment and gastrointestinal dysfunction than those with adequate EA. Performance variables associated with low EA included decreased training response, impaired judgement, decreased coordination, decreased concentration, irritability, depression and decreased endurance performance.ConclusionThese findings demonstrate that low EA measured using self-report questionnaires is strongly associated with many health and performance consequences proposed by the RED-S models.
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International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. Int J Sport Nutr Exerc Metab 2018; 28:316-331. [PMID: 29771168 DOI: 10.1123/ijsnem.2018-0136] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Mountjoy M, Sundgot-Borgen JK, Burke LM, Ackerman KE, Blauwet C, Constantini N, Lebrun C, Lundy B, Melin AK, Meyer NL, Sherman RT, Tenforde AS, Klungland Torstveit M, Budgett R. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med 2018; 52:687-697. [DOI: 10.1136/bjsports-2018-099193] [Citation(s) in RCA: 345] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 01/20/2023]
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Pentz I, Nakić Radoš S. Functional hypothalamic amenorrhea and its psychological correlates: a controlled comparison. J Reprod Infant Psychol 2017. [DOI: 10.1080/02646838.2016.1278201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Sandra Nakić Radoš
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
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Corbetta F, Tremolizzo L, Conti E, Ferrarese C, Neri F, Bomba M, Nacinovich R. Paradoxical increase of plasma vitamin B12 and folates with disease severity in anorexia nervosa. Int J Eat Disord 2015; 48:317-22. [PMID: 25446249 DOI: 10.1002/eat.22371] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anorexia nervosa (AN) is a complex disorder involving severe psychological manifestations and multiple organ damage, including liver dysfunction. The primary aim of this study consisted in assessing plasma levels of vitamin B12 and folates with respect to liver function enzymes considering the liver-storage properties of this vitamin. METHOD We recruited 70 restrictive type AN adolescents and the severity of psychopathological traits was assessed using EDI-3 scale. Plasma levels of vitamin B12 , folates, transaminases (AST, ALT), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP) and cholinesterase (CHE) were determined. RESULTS About 38.5% of patients displayed vitamin B12 values (H-B12) above the upper range of normal reference; 4.3% of patients had increased values of folates; 20 and 11.4% of patients displayed ALT and AST values above reference limits; none had GGT values above normal range. Albeit low CHE and ALP values were found in 55 and 20% of patients, respectively, a linear correlation with both transaminases was present only for vitamin B12 and folates; furthermore, H-B12 patients had both higher AST and ALT values. EDI- 3 subscores significantly correlated with vitamin B12 and folates plasma values and H-B12 patients displayed EDI-3 higher values. DISCUSSION These data suggest that plasma levels of vitamin B12 might be an early marker of liver dysfunction, possibly also related to more severe psychopathological aspects. The identification of patients with higher fasting plasma vitamin B12 levels could therefore lead to earlier and more careful refeeding interventions. Further studies will clarify the potential role of this vitamin in AN clinical practice.
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Affiliation(s)
- Fabiola Corbetta
- Department of Child and Adolescent Mental Health, San Gerardo Hospital and Department of Surgery and Translational Medicine, University of Milano-Bicocca, Monza, Italy
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Meczekalski B, Katulski K, Czyzyk A, Podfigurna-Stopa A, Maciejewska-Jeske M. Functional hypothalamic amenorrhea and its influence on women's health. J Endocrinol Invest 2014; 37:1049-56. [PMID: 25201001 PMCID: PMC4207953 DOI: 10.1007/s40618-014-0169-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 08/21/2014] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Functional hypothalamic amenorrhea (FHA) is one of the most common causes of secondary amenorrhea. There are three types of FHA: weight loss-related, stress-related, and exercise-related amenorrhea. FHA results from the aberrations in pulsatile gonadotropin-releasing hormone (GnRH) secretion, which in turn causes impairment of the gonadotropins (follicle-stimulating hormone and luteinizing hormone). The final consequences are complex hormonal changes manifested by profound hypoestrogenism. Additionally, these patients present mild hypercortisolemia, low serum insulin levels, low insulin-like growth factor 1 (IGF-1) and low total triiodothyronine. AIM The aim of this work is to review the available data concerning the effects of FHA on different aspects of women's health. RESULTS Functional hypothalamic amenorrhea is related to profound impairment of reproductive functions including anovulation and infertility. Women's health in this disorder is disturbed in several aspects including the skeletal system, cardiovascular system, and mental problems. Patients manifest a decrease in bone mass density, which is related to an increase in fracture risk. Therefore, osteopenia and osteoporosis are the main long-term complications of FHA. Cardiovascular complications include endothelial dysfunction and abnormal changes in the lipid profile. FHA patients present significantly higher depression and anxiety and also sexual problems compared to healthy subjects. CONCLUSIONS FHA patients should be carefully diagnosed and properly managed to prevent both short- and long-term medical consequences.
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Affiliation(s)
- B Meczekalski
- Department of Gynecological Endocrinology, Poznan University of Medical Sciences, Poznan, Poland,
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Bomba M, Marfone M, Brivio E, Oggiano S, Broggi F, Neri F, Nacinovich R. Autobiographical memory in adolescent girls with anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2014; 22:479-86. [PMID: 25267565 DOI: 10.1002/erv.2321] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/26/2014] [Accepted: 09/02/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of the study is to investigate deficits in autobiographical memory in adolescents with anorexia nervosa (AN). METHODS Sixty female individuals with AN and 60 healthy volunteers with an age range of 11-18 years were enrolled. The Autobiographical Memory Test (AMT), the Eating Disorder Inventory-3, the Toronto Alexithymia Scale-20 for the evaluation of alexithymia and Children's Depression Inventory to evaluate depressive traits were administered. In addition to classical AMT words, we proposed seven experimental cues, chosen from words often used by individuals with eating disorders in daily life. RESULTS Girls with AN showed a massive overgeneral memory effect. This effect was not related to the presence of depression or alexithymia but increased with the duration of the disorder rather than with its severity. DISCUSSION The alteration of autobiographical memory manifests in adolescence. Girls with AN showed a dysregulation of both negative and positive emotional experiences that seemed to be influenced by the disease duration.
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Affiliation(s)
- Monica Bomba
- Department of Child and Adolescent Psychiatry, San Gerardo Hospital, Monza, Italy; Department of Surgery and Translational Medicine, University of Milano-Bicocca, Italy
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Tremolizzo L, Conti E, Bomba M, Uccellini O, Rossi MS, Marfone M, Corbetta F, Santarone ME, Raggi ME, Neri F, Ferrarese C, Nacinovich R. Decreased whole-blood global DNA methylation is related to serum hormones in anorexia nervosa adolescents. World J Biol Psychiatry 2014; 15:327-33. [PMID: 24286295 DOI: 10.3109/15622975.2013.860467] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The one-carbon metabolism, also known as methionine-homocysteine cycle, governs the dynamics of DNA methylation, epigenetically regulating gene expression, and has been reported altered in anorexia nervosa (AN) adult patients. The aim of this study consisted in assessing whole-blood DNA methylation in adolescent AN patients, assessing its significance in relationship to clinical and hormonal variables. METHODS Whole-blood global DNA methylation was measured as incorporation of [(3)H]dCTP following HpaII cut in 32 adolescent females affected by restrictive type AN and compared to 13 healthy controls. Homocysteine, vitamin B12 and folate plasma levels were assessed as well as fasting plasma levels of leptin and steroid hormones. Clinical variables, including severity and associate states and traits, were assessed by means of the EDI-3, CDI and STAI-Y scales. RESULTS We confirm that whole-blood global DNA methylation is modestly albeit significantly reduced in AN adolescents with respect to controls, correlating with plasma leptin and steroid hormone levels. Conversely, clinical traits did not correlate with the outcome variable. CONCLUSIONS A better definition of the epigenetic dysregulation underlying AN pathology or vulnerability might lead to develop useful markers for diagnosis, prognostic classification and tailored therapeutic interventions in these vulnerable patients since the earliest phases of their disease.
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Bomba M, Corbetta F, Gambera A, Nicosia F, Bonini L, Neri F, Tremolizzo L, Nacinovich R. Heart rate variability in adolescents with functional hypothalamic amenorrhea and anorexia nervosa. Psychiatry Res 2014; 215:406-9. [PMID: 24359810 DOI: 10.1016/j.psychres.2013.11.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 10/16/2013] [Accepted: 11/12/2013] [Indexed: 11/15/2022]
Abstract
Aim of this study consisted in assessing the 24-h heart rate variability (HRV), a measure of autonomic nervous system (ANS) imbalance, in 21 adolescents with functional hypothalamic amenorrhea (FHA, 11 normogonadotropic, N-FHA, and 10 hypogonadotropic, Hy-FHA) compared to 21 patients with anorexia nervosa (AN) and 21 controls. As expected, subjects with AN showed a significant dysregulation in multiple HRV parameters, while Hy-FHA patients presented with a dysregulation in a few domains (SDNN, HFr), which was not present in girls with N-FHA, who showed values largely similar to controls. FHA might represent part of the AN biological spectrum, and a link between these two conditions might exist, possibly related to the degree of psychological and/or hormonal dysfunction.
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Affiliation(s)
- Monica Bomba
- Clinic of Child and Adolescent Mental Health, San Gerardo Hospital, University of Milan Bicocca, Monza, Italy.
| | - Fabiola Corbetta
- Clinic of Child and Adolescent Mental Health, San Gerardo Hospital, University of Milan Bicocca, Monza, Italy
| | - Alessandro Gambera
- Department of Gynecological Endocrinology, Spedali Civili, Brescia, Italy
| | - Franco Nicosia
- Geriatric Unit, Spedali Civili, Department of Medical and Surgery Sciences, University of Brescia, Brescia, Italy
| | - Luisa Bonini
- Department of Childhood and Adolescent Neuropsychiatry, Spedali Civili, Brescia, Italy
| | - Francesca Neri
- Clinic of Child and Adolescent Mental Health, San Gerardo Hospital, University of Milan Bicocca, Monza, Italy
| | - Lucio Tremolizzo
- Department of Neurology - University of Milano-Bicocca, San Gerardo Hospital, University of Milan Bicocca, Monza, Italy
| | - Renata Nacinovich
- Clinic of Child and Adolescent Mental Health, San Gerardo Hospital, University of Milan Bicocca, Monza, Italy
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Balottin L, Nacinovich R, Bomba M, Mannarini S. Alexithymia in parents and adolescent anorexic daughters: comparing the responses to TSIA and TAS-20 scales. Neuropsychiatr Dis Treat 2014; 10:1941-51. [PMID: 25336959 PMCID: PMC4200172 DOI: 10.2147/ndt.s67642] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A growing body of literature has been focusing on individual alexithymia in anorexia nervosa, while there are only scarce and conflicting studies on alexithymia in the families of anorexic patients, despite the important role played by family dynamics in the development of the anorexic disorder, especially in adolescent patients. The aim of this study is to assess alexithymia in anorexic adolescent patients and in their parents using a multimethod measurement to gain more direct, in-depth knowledge of the problem. METHODS Forty-six subjects, anorexic adolescent patients and their parents, underwent the Toronto Alexithymia Scale (TAS-20) along with the Toronto Structured Interview for Alexithymia (TSIA), which represents the first comprehensive clinically structured interview focused specifically on assessing alexithymia. The use of latent trait Rasch analysis allowed a comparison of the two instruments' sensitivity and ability to detect the presence and intensity of alexithymic components in patients and parents. RESULTS Significant discordance was found between the two measures. The clinical instrument allowed detection of a greater level of alexithymia compared with the self-report, in particular in our adult parent sample. Moreover, a significant alexithymic gap emerged within families, particularly within parental couples, with noticeably more alexithymic fathers compared with the mothers. CONCLUSION The TSIA clinical interview may be a more sensitive instrument in detecting alexithymia, minimizing parents' negation tendency. Clinical questions have arisen on how useful it would be to give greater weight to family functioning (ie, alexithymic gap) in order to predict the possibility of establishing a therapeutic alliance, and thus the outcome of the anorexic adolescent.
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Affiliation(s)
- Laura Balottin
- Interdepartmental Center of Family Research, Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padova, Italy
| | - Renata Nacinovich
- Childhood and Adolescence Neuropsychiatric Unit, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Monica Bomba
- Childhood and Adolescence Neuropsychiatric Unit, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Stefania Mannarini
- Interdepartmental Center of Family Research, Department of Philosophy, Sociology, Education, and Applied Psychology, Section of Applied Psychology, University of Padova, Padova, Italy
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