Reactivity to interpersonal stress in patients with eating disorders: A systematic review and meta-analysis of studies using an experimental paradigm

Momentary physiological indices related to eating disorders: A systematic and methodological review

Eating disorders (ED) are serious psychiatric illnesses, with no everyday support to intervene on the high rates of relapse. Understanding physiological indices that can be measured by wearable sensor technologies may provide new momentary interventions for individuals with ED. This systematic review, searching large databases, synthesises studies investigating peripheral physiological (PP) indices commonly included in wearable wristbands (heart rate [HR], heart rate variability [HRV], electrodermal activity [EDA], peripheral skin temperature [PST], and acceleration) in ED. Inclusion criteria included: (a) full peer-reviewed empirical articles in English; (b) human participants with active ED; and (c) containing one of five wearable physiological measures. Kmet risk of bias was assessed. Ninety-four studies were included (Anorexia nervosa [AN; N = 4418], bulimia nervosa [BN; N = 916], binge eating disorder [BED; N = 1604], other specified feeding and eating disorders [OSFED; N = 424], and transdiagnostic [N = 47]). Participants with AN displayed lower HR and EDA and higher HRV compared to healthy individuals. Those with BN showed higher HRV, and lower EDA and PST compared to healthy individuals. Other ED and Transdiagnostic samples showed mixed results. PP differences are indicated through various assessments in ED, which may suggest diagnostic associations, although more studies are needed to validate observed patterns. Results suggest important therapeutic potential for PP in ED, and larger studies including diverse participants and diagnostic groups are needed to fully uncover their role in ED.

Mediation role of interpersonal problems between insecure attachment and eating disorder psychopathology

PURPOSE

Although insecure attachment and interpersonal problems have been acknowledged as risk and maintaining factors of eating disorders (EDs), the mediating role of interpersonal problems between attachment style and ED psychopathology has been poorly explored. The purpose of this study was to investigate the mediating role of interpersonal problems between insecure attachment and ED psychopathology.

METHODS

One-hundred-nine women with anorexia nervosa and 157 women with bulimia nervosa filled in the Eating Disorder Inventory-2 (EDI-2) and the Experiences in Close Relationships (ECR) revised scale to assess ED core symptoms and attachment styles, respectively. Interpersonal difficulties were evaluated by the Inventory of Interpersonal Problems (IIP-32). A mediator's path model was conducted with anxious and avoidant attachment subscores as independent variables, ED core symptoms as dependent variables and interpersonal difficulties as mediators. The diagnosis was entered in the model as a confounding factor.

RESULTS

The socially inhibited/avoidant interpersonal dimension was a mediator between avoidant attachment and the drive to thinness as well as between avoidant attachment and body dissatisfaction. An indirect connection was found between attachment-related anxiety and bulimic symptoms through the mediation of intrusive/needy score.

CONCLUSIONS

Social avoidance and intrusiveness mediate the relationships between avoidant and anxious attachment styles and ED psychopathology. These interpersonal problems may represent specific targets for psychotherapeutic treatments in individuals with EDs and insecure attachment.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Momentary stress-induced food craving: An ecological momentary assessment study comparing perceived interpersonal and non-interpersonal stressors

Daily-life stressors and food cravings are dynamic and vary within and across persons. Some evidence suggests interpersonal stressors increase appetite. However, little is known about the association of food craving with different types of stressors at the momentary level in the general population. We aimed to explore the momentary relationships between daily-life stressful events and food craving in a non-clinical community sample, and to compare the associations with food craving when the most stressful event was perceived as interpersonal versus non-interpersonal. We used ecological momentary assessment (EMA) to collect reports on the most stressful event, perceived stressor type, stressor appraisal, and food craving from 123 adults three times a day scheduled at fixed intervals over 10 days. Mixed effects random intercepts and slopes models examined the within- and between-person associations. Experiencing a stressor was significantly positively associated with within-person food craving at the same measurement. No differences in momentary food craving were found when the most stressful event was perceived as interpersonal or non-interpersonal (within-person level). However, frequently reporting the most stressful event as interpersonal (vs. non-interpersonal) was positively associated with food craving across the study (between-person level), particularly when the stressor was appraised as more unpleasant. Daily-life stressors were associated with momentary food craving. Individuals who generally perceived interpersonal stressors as their most stressful event tended to experience food cravings. Future research could further investigate the role of interpersonal stressors as a factor for overeating in daily life and the potential benefits of stress management in interventions.

Reconsidering the role of interpersonal stress in eating pathology: Sensitivity to rejection might be more important than actual experiences of peer stress

Rejection sensitivity (i.e., the tendency to anxiously expect, readily perceive, and overreact to real or perceived rejection) is theorized to play a role in the onset and maintenance of disordered eating. Although rejection sensitivity has repeatedly been associated with eating pathology in clinical and community samples, the pathways through which this psychological trait influences eating pathology have been not fully established. The current study investigated peer-related stress, which can be influenced by rejection sensitivity and is associated with eating pathology, as a mechanism linking these constructs. In two samples of women - 189 first-year undergraduate students and 77 community women with binge eating - we examined whether rejection sensitivity was indirectly associated with binge eating and weight/shape concerns via ostracism and peer victimization, both cross-sectionally and longitudinally. Our hypotheses were not supported: there were no indirect associations between rejection sensitivity and eating pathology via interpersonal stress in either sample. However, we did find that rejection sensitivity was directly associated with weight/shape concerns in both samples and with binge eating in the clinical sample in cross-sectional (but not longitudinal) analyses. Our findings suggest that the association between rejection sensitivity and disordered eating is not dependent on actual experiences of interpersonal stress. That is, simply anticipating or perceiving rejection may be sufficient to play a role in eating pathology. As such, interventions targeting rejection sensitivity may be helpful in the treatment of eating pathology.

Prospectively predicting naturalistic exposure to fitspiration and thinspiration in young women with disordered eating by leveraging an ecological momentary assessment design

OBJECTIVE

Although a growing body of research has examined the impacts of ED-salient content, such as fitspiration and thinspiration, on eating disorder (ED) symptoms, there is less known about the characteristics of who may be at risk for accessing this content on Instagram. Current research is limited by cross-sectional and retrospective designs. This prospective study used ecological momentary assessment (EMA) to predict naturalistic exposure to ED-salient content on Instagram.

METHODS

Female university students with disordered eating (N = 171, Mage = 20.23, SD = 1.71, range = 18-25) completed a baseline session, followed by a seven-day EMA protocol, in which they reported on Instagram use and exposure to fitspiration and thinspiration. Mixed-effects logistical regressions were used to predict exposure to ED-salient content on Instagram from four principal components (e.g., behavioral ED symptoms and trait social comparison) controlling for duration of Instagram use (i.e., dose) and day of study.

RESULTS

Duration of use was positively associated with all types of exposure. Purging/cognitive restraint and excessive exercise/muscle building prospectively predicted access to any ED-salient content and fitspiration only. Restricting positively predicted thinspiration only access. Purging/cognitive restraint positively predicted accessing fitspiration and thinspiration (dual exposure). Day of study was negatively associated with any exposure, fitspiration only, and dual exposure.

CONCLUSIONS

Baseline ED behaviors were differentially associated with exposure to ED-salient Instagram content; however, duration of use was also a significant predictor. Limiting use of Instagram may be important for young women with disordered eating to reduce probability of encountering ED-salient content.

The impact of the COVID-19 pandemic on eating disorders risk and symptoms: a retrospective study

BACKGROUND

Social distancing and quarantine imposed by the authority during the COVID-19 pandemic caused restrictions, which had a negative impact on eating behavior, especially among adolescents. We proposed a retrospective study aimed to evaluate the effect of the COVID-19 pandemic on eating disorders risk and symptoms.

METHODS

In this study, a group of 127 pediatric patients (117 females and 10 males) with eating disorders admitted to the Bambino Gesù Children's Hospital of Rome (Italy), in the period between August 2019 and April 2021, was analyzed. All patient data were collected from patients' electronic medical records.

RESULTS

We found that 80.3% of patients were at the onset of eating disorders and that 26% of patients had familiarity for psychotic disorders. Often these patients had comorbidities and alterations in blood parameters such as leukocytopenia, neutropenia, hypovitaminosis and hormonal problems that could affect their future.

CONCLUSIONS

Our findings could provide a framework for developing clinical and educational interventions to mitigate the short- and long-term negative impact of the pandemic on adolescent future health.

Disordered eating is related to deficits in emotional processing: A correlational study with a subclinical sample

BACKGROUND

Both clinical and non-clinical levels of disordered eating behaviours have been associated with deficits in emotional processing.

METHODS

Through a correlational design, the present study examined the relationship between different types of disordered eating behaviours and various forms of emotional processing. N = 209 female undergraduate participants completed self-report measures of disordered eating behaviours, perceived emotion intensity, emotion regulation skills, and self-compassion. Four groups of participants were identified based on self-reported disordered eating behaviours: a healthy control group (n = 90), dieting group (n = 22), binging group (n = 59), and binging/purging group (n = 38).

RESULTS

Greater severity of disordered eating was associated with greater emotional processing deficits including greater perceived emotion intensity, greater emotion regulation difficulties, and diminished self-compassion. Emotion regulation skills mediated the relationship between emotion intensity and disordered eating behaviours. A continuum of emotional processing deficits was observed wherein the healthy control group exhibited the fewest emotional processing deficits, and these deficits became increasingly severe among the dieting group, binging group, and binging/purging group, respectively. Each disordered eating type was associated with a specific profile of emotional processing difficulties.

LIMITATIONS

This study examined a subclinical sample of only female participants.

CONCLUSIONS

Findings bear clinical importance for the prevention, treatment, and understanding of disordered eating behaviours.

Virtual Rejection and Overinclusion in Eating Disorders: An Experimental Investigation of the Impact on Emotions, Stress Perception, and Food Attitudes

(1) Background: the investigation of how interpersonal functioning affects eating psychopathology has been receiving increasing attention in the last decade. This study evaluates the impact of virtual social inclusion or ostracism on emotions, perceived stress, eating psychopathology, and the drive to binge or restrict in patients across the eating disorder spectrum. (2) Methods: a group of 122 adolescent and adult females with different eating disorder diagnoses were compared to 50 healthy peers with regards to their performance on, and responses to the Cyberball task, a virtual ball-tossing game. Each participant was randomly assigned to playing a social inclusion or a social exclusion block of the Cyberball task and completed self-report assessments of emotions, perceived stress and urge to restrict/binge before and after the task. (3) Results: patients with anorexia nervosa showed a more negative impact on psychological well-being evaluated with the need threat scale after the excluding block, while patients with bulimia nervosa reported more negative effects after the overincluding condition. Patients with binge eating disorder showed a reduction in specific negative emotions after the overincluding block, unlike all other participants. (4) Conclusions: findings show significant correlations between restraint thoughts in patients with bulimia nervosa and binge thoughts in patients with binge eating disorder after being exposed to the inclusion condition. Different reactions in cognitive and emotional states of patients with eating disorders after different interpersonal scenarios confirm the impact of inclusive or exclusive relationships on eating psychopathology, with specific and different responses across the eating disorder spectrum, that have been discussed, linked to their eating behavioral cognition.

Non-verbal social communication in individuals with eating disorders: an ethological analysis in experimental setting

PURPOSE

Evidence that social difficulties promote the development and the maintenance of eating disorders (EDs) derive from self-reported data and only partially from experimental tasks. This study objectively assessed non-verbal behaviors of individuals with EDs in a psycho-social stress scenario.

METHODS

Thirty-one women suffering from EDs (13 with anorexia nervosa and 18 with bulimia nervosa) and 15 healthy women underwent the Trier Social Stress Test (TSST), the paradigm of psycho-social stress, and were videotaped. Throughout the procedure, anxiety feelings were measured by the State-Trait Anxiety Inventory state subscale and saliva samples were collected to evaluate cortisol levels. Non-verbal behaviors were analyzed through the Ethological Coding System for Interviews and were compared between study samples through multivariate analysis of variance. Multivariate regression analyses were performed to assess the association between anxiety, cortisol and behavioral responses to TSST.

RESULTS

Women with EDs showed reduced submissiveness, flight (cutoff from social stimuli) and gesture compared to healthy peers during TSST. Submissiveness and flight behaviors were negatively associated with stress-induced anxiety, while TSST-induced anxiety and cortisol increases were positively associated with looking at the other's face behavior in participants with EDs. In this population, cortisol reactivity was also positively associated with submissiveness and negatively with gesture.

CONCLUSION

Women with EDs showed a hostile and freezing response to acute psycho-social stress: reduced submissiveness and flight may represent strategies to manage social anxiety. These findings confirm that the non-verbal behavior assessment provides complementary information to those derived from traditional measurements and suggests research and clinical implications.

LEVEL OF EVIDENCE I

Evidence obtained from experimental study.

One year of COVID-19 pandemic on patients with eating disorders, healthy sisters, and community women: evidence of psychological vulnerabilities

PURPOSE

The COVID-19 pandemic has been a psychological burden worldwide, especially for individuals with eating disorders (EDs). In addition, the healthy sisters of patients with EDs are known to present specific psychological vulnerabilities. This study evaluates differences between the general population, patients with EDs, and their healthy sisters.

METHOD

A group of 233 participants (91 patients with EDs, 57 of their healthy sisters and 85 community women) was enrolled in an online survey on general and specific psychopathology 1 year after the beginning of the COVID-19 pandemic. The survey examined associations between posttraumatic symptoms and depression, anxiety, obsessive-compulsiveness, interpersonal sensitivity, and eating-related concerns.

RESULTS

Clinically relevant scores for posttraumatic disorders were found in patients with EDs. Healthy sisters scored similarly to patients for avoidance. Regression analysis showed specific associations between interpersonal sensitivity and posttraumatic symptomatology in patients and healthy sisters, but not in community women.

CONCLUSION

The psychological burden in patients with EDs is clinically relevant and linked to interpersonal sensitivity, obsessive-compulsiveness, and global symptom severity. Differences between patients, healthy sisters, and community women are discussed regarding vulnerability factors for EDs.

LEVEL OF EVIDENCE

Level III: evidence obtained from well-designed cohort or case-control analytic studies.

Interpersonal, affective and compulsive features of driven exercise in anorexia nervosa

BACKGROUND

This preregistered (https://osf.io/g9ajb) analysis sought to integrate the current literature on trait compulsivity into maintenance models of driven exercise in anorexia nervosa (AN). We tested whether compulsivity increases the likelihood of driven exercise via interpersonal and affect-regulatory pathways.

METHODS

We used multilevel structural equation modeling to test the hypothesis that trait compulsivity predicts a stronger within-person link between affect-regulatory difficulties or interpersonal sensitivity and driven exercise in female adolescents and adults with AN. We used data from five assessments across inpatient treatment and 6-months follow-up of 207 adult and adolescent patients with AN (1035 datapoints).

RESULTS

In line with our hypotheses, patients who generally experienced more affect-regulatory difficulties or stronger interpersonal sensitivity tended to engage in driven exercise more strongly. Moreover, high levels of trait compulsivity amplified the effect of interpersonal sensitivity on driven exercise across time. Contrary to our hypotheses, the link between affect regulation and driven exercise was not moderated by compulsivity. Similar effects on general eating disorder psychopathology were found, but no cross-level moderation effect of compulsivity.

LIMITATIONS

Due to sample size, potential AN subtype-dependent effects were not analyzed.

CONCLUSION

Our results suggest that driven exercise coincides with self-reported experiences of interpersonal sensitivity and that this link varies as a function of compulsivity such that the within-person coupling is stronger among those scoring high on compulsivity. To derive clinically useful functional models of driven exercise, future studies might use intensive longitudinal data to investigate its momentary associations with affect and interpersonal sensitivity in the context of compulsive traits.

Measuring Ostracism-Induced Changes in Consumption of Palatable Food: Feasibility of a Novel Behavioral Task

Purpose

Ostracism is a highly aversive interpersonal experience. Previous research suggests that it can increase consumption of highly palatable food in some individuals, but decrease it in others. Thus, we developed the Cyberball-Milkshake Task (CMT), to facilitate research investigating individual differences in ostracism's effects on consumption of highly palatable food. We present data on feasibility for the CMT in a sample of young adult women.

Materials and Methods

Participants were 22 women, 18-30 years old, reporting very low or very high levels of emotional eating at screening. Participants performed the CMT, which consisted of 12 trials. Each trial included: playing a round of Cyberball (a computerized game of catch with fictitious "other participants" programmed to either include or exclude the participant); viewing a chocolate image; and then consuming a participant-determined amount of milkshake. Participants subsequently played an additional inclusion and exclusion round of Cyberball, each immediately followed by questionnaires assessing current mood and recent Cyberball experience.

Results

Cyberball exclusion (vs. inclusion) was associated with large, significant increases in reported ostracism and threats to self-esteem; exclusion's effects on affect were in the expected direction (e.g., increased negative affect), but generally small and non-significant. Milkshake intake was measurable for 95% of participants, on 96% of trials. Intake decreased quadratically across trials, with a steep negative slope for low trial numbers that decreased to the point of being flat for the highest trial numbers.

Discussion

The CMT is a generally feasible approach to investigating ostracism's effects on consumption of highly palatable food. The feasibility (and validity) of the CMT may benefit from modification (e.g., fewer trials and longer rounds of Cyberball). Future research should examine whether performance on a modified version of the CMT predicts real-world behavior in a larger sample.

Negative mood induction effects on problem-solving task in women with eating disorders: a multi-method examination

BACKGROUND

The effects of negative affect on problem-solving and its psychophysiological correlates are poorly understood in eating disorder populations.

METHODS

This study examined respiratory sinus arrhythmia (RSA) and skin conductance responses of women with Binge Eating Disorder (BED: n = 56), Anorexia Nervosa (AN: n = 12), Bulimia Nervosa (BN: n = 32), and 24 healthy controls (HCs) at baseline, and then during: a negative mood induction task, an adapted Means Ends Problem-Solving (MEPS) task, and recovery. The MEPS task included four interpersonal scenarios: (1) binge-eating as a solution to stress, (2) job loss, (3) rejection by friends, and (4) by a significant other.

RESULTS

We found that individuals with eating disorders reported less positive mood than HCs and individuals with BN and BED reported more negative mood and greater urges to binge than HCs. After a negative mood induction, women with BED provided significantly less effective problem-solving strategies compared to HCs and women with BN for the binge-eating MEPS scenario. Relative to baseline and the negative mood induction, all participants exhibited significantly higher skin conductance measures throughout the MEPS scenarios and recovery. BED showed significantly lower respiratory sinus arrhythmia (RSA) levels than individuals with BN and HCs throughout the protocol.

CONCLUSIONS

The multimethod findings suggest individuals with BED are likely to have disorder-specific problem-solving difficulties after a negative mood induction.

Dorsolateral prefrontal cortex and amygdala function during cognitive reappraisal predicts weight restoration and emotion regulation impairment in anorexia nervosa

BACKGROUND

Although deficits in affective processing are a core component of anorexia nervosa (AN), we lack a detailed characterization of the neurobiological underpinnings of emotion regulation impairment in AN. Moreover, it remains unclear whether these neural correlates scale with clinical outcomes.

METHODS

We investigated the neural correlates of negative emotion regulation in a sample of young women receiving day-hospital treatment for AN (n = 21) and healthy controls (n = 21). We aimed to determine whether aberrant brain activation patterns during emotion regulation predicted weight gain following treatment in AN patients and were linked to AN severity. To achieve this, participants completed a cognitive reappraisal paradigm during functional magnetic resonance imaging. Skin conductance response, as well as subjective distress ratings, were recorded to corroborate task engagement.

RESULTS

Compared to controls, patients with AN showed reduced activation in the dorsolateral prefrontal cortex (dlPFC) during cognitive reappraisal [pFWE<0.05, threshold-free cluster enhancement (TFCE) corrected]. Importantly, psycho-physiological interaction analysis revealed reduced functional connectivity between the dlPFC and the amygdala in AN patients during emotion regulation (pFWE<0.05, TFCE corrected), and dlPFC-amygdala uncoupling was associated with emotion regulation deficits (r = -0.511, p = 0.018) and eating disorder severity (r = -0.565, p = .008) in the AN group. Finally, dlPFC activity positively correlated with increases in body mass index (r = 0.471, p = 0.042) and in body fat mass percentage (r = 0.605, p = 0.008) following 12 weeks of treatment.

CONCLUSIONS

Taken together, our findings indicate that individuals with AN present altered fronto-amygdalar response during cognitive reappraisal and that this response may serve as a predictor of response to treatment and be linked to clinical severity.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

Adult attachment style and salivary alpha-amylase and emotional responses to a psychosocial stressor in women with eating disorders

BACKGROUND

The fine-tuning of the endogenous stress response system, which includes the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system (SNS), is influenced by early attachment relationships. A higher prevalence of insecure attachment has been detected in people with eating disorders (EDs). Thus, we investigated the emotional and the SNS reactivity to the Trier Social Stress Test (TSST) in women with EDs in relation to their attachment profiles.

METHODS

Fifty women with EDs and 20 healthy women participated into an experimental study. Attachment was evaluated by Experience in Close Relationship questionnaire. Salivary α-amylase (sAA) levels were measured to assess the SNS reactivity to TSST while the emotional response was measured by the STAI state scale.

RESULTS

Compared to women with EDs and low attachment anxiety and healthy controls, women with EDs and high attachment anxiety showed lower TSST-induced sAA production without difference in anxiety scores. Women with EDs and high attachment avoidance showed similar sAA response to TSST but higher levels of anxiety scores compared to those with low attachment avoidance and healthy controls.

CONCLUSIONS

Our findings corroborate the idea that adult attachment may be associated with variability in emotional and biological responses to a psychosocial stressor in women with EDs.

Stress-induced alterations in HPA-axis reactivity and mesolimbic reward activation in individuals with emotional eating

BACKGROUND

Emotional eating has emerged as a contributing factor to overeating, potentially leading to obesity or disordered eating behaviors. However, the underlying biological mechanisms related to emotional eating remain unclear. The present study examined emotional, hormonal, and neural alterations elicited by an acute laboratory stressor in individuals with and without emotional eating.

METHODS

Emotional (n = 13) and non-emotional eaters (n = 15) completed two main study visits, one week apart: one visit included a Stress version and the other a No-stress version of the Maastricht Acute Stress Task (MAST). Immediately pre- and post-MAST, blood was drawn for serum cortisol and participants rated their anxiety level. After the MAST, participants completed a Food Incentive Delay (FID) task during functional magnetic resonance imaging (fMRI), followed by an ad libitum snack period.

RESULTS

Emotional eaters exhibited elevated anxiety (p = 0.037) and cortisol (p = 0.001) in response to the Stress MAST. There were no changes in anxiety or cortisol among non-emotional eaters in response to the Stress MAST or in either group in response to the No-stress MAST. In response to the Stress MAST, emotional eaters exhibited reduced activation during anticipation of food reward in mesolimbic reward regions (caudate: p = 0.014, nucleus accumbens: p = 0.022, putamen: p = 0.013), compared to non-emotional eaters. Groups did not differ in snack consumption.

CONCLUSIONS

These data indicate disrupted neuroendocrine and neural responsivity to psychosocial stress amongst otherwise-healthy emotional eaters, who demonstrated hyperactive HPA-axis response coupled with hypoactivation in reward circuitry. Differential responsivity to stress may represent a risk factor in the development of maladaptive eating behaviors.

Risk and resilience factors for specific and general psychopathology worsening in people with Eating Disorders during COVID-19 pandemic: a retrospective Italian multicentre study

PURPOSE

The COVID-19 pandemic restrictions had negative impact on the psychopathology of people with Eating Disorders (EDs). Factors involved in the vulnerability to stressful events have been under-investigated in this population. We aimed to assess which factors contributed to COVID-19-induced worsening in both general and specific psychopathology.

METHODS

Three-hundred and twelve people with a clinically defined diagnosis of an ED and undergoing a specialist ED treatment in different Italian ED services before the spreading of COVID-19 pandemic filled in an online survey. ED specific and general psychopathology changes after COVID-19 quarantine were retrospectively evaluated. Factors related to COVID-19 concerns (financial condition, fear of contagion, perceived social isolation/support, satisfaction in peer, family or sentimental relationships), illness duration and treatment-related variables (type of treatment provided, type of access to care, satisfaction with therapeutic relationships) were included as predicting factors in a structural equational model, which included latent variables consisting of general and ED psychopathology items as outcomes.

RESULTS

A perceived low quality of therapeutic relationships, fear of contagion and increased isolation were positively associated with psychopathology worsening. Reduced satisfaction with family and with friends' relationships and reduced perceived social support were associated with ED and general symptoms deterioration, respectively. No significant effect emerged for intimate relationships, illness duration, economic condition and type of treatment.

CONCLUSIONS

This study provides a comprehensive evaluation of clinical variables associated with psychopathological changes during the COVID-19 lockdown period highlighting potential risk and resilience factors and, possibly, informing treatment as well as prevention strategies for EDs.

LEVEL OF EVIDENCE IV

Evidence obtained from multiple time series analysis such as case studies.

Health-related quality of life assessment in eating disorders: adjustment and validation of a specific scale with the inclusion of an interpersonal domain

PURPOSE

Quality of life is a fundamental aspect of both clinical practice and research on eating disorders (ED) due to the significant impacts these disorders have on everyday life. Disorder-specific scales can improve the quality of research and findings and offer greater sensitivity and responsiveness. However, no specific instrument is available in Italian for ED. The aim of this paper is to adjust and to validate a reliable scale with specific items regarding physical and interpersonal well-being.

METHODS

The Italian version of the Eating Disorder Quality of Life (IEDQOL) scale was developed, on the basis of the original English scale, with the addition of items pertaining to physical well-being and interpersonal interactions. In this study, 180 ED patients and 190 healthy controls from the community were enrolled both from inpatient units and outpatient services. A statistical analysis with an exploratory factorial approach was performed in order to validate the tool.

RESULTS

The results showed that the IEDQOL has very good psychometric properties with test-retest validity and sensitivity between patients and controls (d = 2.17 for total score). Moreover, the interpersonal domain showed excellent psychometric values (Cronbach's α > 0.70 in all the subgroups) and a robust correlation with other quality of life constructs.

CONCLUSION

Future studies on the Italian population should use IEDQOL as outcome element that can be useful also with other disorder-specific psychopathological constructs and corroborate the reliability of the data. Future research in the ED field should only use this specific tool.

LEVEL OF EVIDENCE

Case-control analytic study, Level III.

Socio-cognitive processing in people with eating disorders: Computerized tests of mentalizing, empathy and imitation skills

OBJECTIVE

Eating disorders are psychiatric illnesses characterized by extreme eating behaviors, such as sustained food restriction or loss of control over eating. Symptoms are thought to be maintained by a variety of mechanisms, one of which may be the socio-cognitive impairments associated with eating disorders. While some previous work has addressed socio-cognitive impairments in eating disorders, this work has relied mostly on self-report data.

METHOD

Here we employed computerized tests of (a) mentalizing (ability to infer the mental states of others); (b) empathy (the degree to which the emotional states of others can be identified and the degree to which the states of others impact one's own emotional state); and (c) imitation (the degree to which observation of another's actions prompts the performance of those actions); in a group of 78 women with an eating disorder and a matched control group of 66 healthy women.

RESULTS

People with eating disorders showed both hyper- and hypo-mentalizing and reduced accuracy of emotional and cognitive mental state inference. They displayed less imitation of observed actions, but no differences in empathy compared to healthy controls. Although anxiety and depressive symptoms had significant effects on mentalizing, most of the observed inter-group differences persisted.

DISCUSSION

Women with eating disorders have difficulties mentalizing and imitating observed actions despite intact non-social automatic imitation, compared to healthy controls. These findings provide an indication that intervention modules to strengthen specific areas of social cognition might be helpful to improve patients' social skills.

Coping With Adolescents Affected by Anorexia Nervosa: The Role of Parental Personality Traits

Introduction

Anorexia nervosa (AN) promotes psychological distress in caregivers who adopt different coping strategies. Dysfunctional caregiving styles exacerbate further distress in the patient promoting the maintenance of the illness. We aimed to assess the possible contribution of personality traits of caregivers to the adoption of different coping strategies to deal with the affected relative.

Methods

About 87 adolescents with AN were recruited. Their parents completed the Family Coping Questionnaire for Eating Disorders (FCQ-EDs) and the Temperament and Character Inventory-Revised (TCI-R). Differences between mothers and fathers were assessed through the independent sample t-test. Multivariate regression analyses were run to assess if personality traits, the occurrence of psychiatry conditions in the parents, the marital status, and the duration of the illness predicted parental coping strategies.

Results

The group of mothers showed higher levels of avoidance and seeking for information coping strategies than the sample of fathers. Lower illness duration predicted higher collusion with the illness in both parents. Harm avoidance, cooperativeness, and self-directedness positively predicted parental coercion, collusion, and seeking for information strategies with some differences between mothers and fathers.

Discussion

Illness duration and personality traits of parents affect the type of parental coping strategies developed to face AN in adolescents. These variables should be considered in the assessment of families of adolescents with AN and may be addressed to promote more fine-tuned clinical interventions for caregivers.

Is this the 'new normal'? A mixed method investigation of young person, parent and clinician experience of online eating disorder treatment during the COVID-19 pandemic

INTRODUCTION

Prior to the COVID-19 pandemic, research in virtual care for young people with eating disorders was preliminary and implementation rare. This study explored the experience of young people, parents and clinicians when therapy was transitioned to virtual provision as a result of the UK lockdown in March 2020.

METHODS

A mixed-method approach was used in this study. Online questionnaires that included a mixture of rating (Likert scale) and free-text response questions were completed by 53 young people with any eating disorder, 75 parents and 23 clinicians. Questions focused on the experience of online treatment as well as the impact on engagement, perceived treatment efficacy and preferences around treatment mode in the future. Likert scale questions were analysed using a summary approach. Free-text responses were analysed qualitatively using reflexive thematic analysis.

RESULTS

Responses to rating scale questions indicate satisfaction with treatment, good engagement and ability to manage technology. Young people who had transitioned care, rather than started care virtually in lockdown, rated therapy as less effective. However, individual accounts of experience were more varied. Reflexive thematic analysis of free-text responses identified key themes of 1) Making it work, 2) Home as a therapeutic space, and 3) Disrupted connection and 4) Into the future.

CONCLUSIONS

These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and therapeutic engagement and depth and need for consideration of equal access to treatment in socially unequal societies.

Bad mood food? Increased versus decreased food cue reactivity in anorexia nervosa and bulimia nervosa during negative emotions

OBJECTIVE

Emotion regulation difficulties in anorexia nervosa (AN) and bulimia nervosa (BN) might underlie bingeing and purging in BN, extreme fasting in AN, or combinations of these symptoms in binge-purge type AN. In this study, we tested for decreased food cue reactivity in response to negative emotions in AN, and the opposite pattern for BN. Furthermore, we explored subgroup differences (restrictive vs. binge-purging AN; history of AN in BN).

METHOD

Patients with AN (n = 41), BN (n = 39), and matched controls (n = 70) completed an emotional eating questionnaire. In a laboratory experiment, we induced negative emotions and measured food cue reactivity (pleasantness, desire to eat (DTE), and corrugator muscle activity).

RESULTS

AN reported emotional undereating, while BN reported emotional overeating. In the laboratory task, BN showed increased DTE and an appetitive corrugator response during negative emotions, selectively towards high-calorie foods. AN showed generalized reduced cue reactivity to high-calorie food regardless of emotional state. This pattern appears to be characteristic of restrictive AN, while cue reactivity of both BN subgroups pointed towards emotional overeating.

CONCLUSIONS

The emotional over- versus undereating framework might help to explain bingeing and restricting along the anorectic-bulimic disorder spectrum, which calls for novel transdiagnostic theories and subgroup-specific treatments.

Risk factors for eating disorders: an umbrella review of published meta-analyses

Objective:

To grade the evidence about risk factors for eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder) with an umbrella review approach.

Methods:

This was a systematic review of observational studies on risk factors for eating disorders published in PubMed/PsycInfo/Embase until December 11th, 2019. We recalculated random-effect meta-analyses, heterogeneity, small-study effect, excess significance bias and 95% prediction intervals, grading significant evidence (p < 0.05) from convincing to weak according to established criteria. Quality was assessed with the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool.

Results:

Of 2,197 meta-analyses, nine were included, providing evidence on 50 risk factors, 29,272 subjects with eating disorders, and 1,679,385 controls. Although no association was supported by convincing evidence, highly suggestive evidence supported the association between childhood sexual abuse and bulimia nervosa (k = 29, 1,103 cases with eating disorders, 8,496 controls, OR, 2.73, 95%CI 1.96-3.79, p = 2.1 x 10-9, AMSTAR-2 moderate quality) and between appearance-related teasing victimization and any eating disorder (k = 10, 1,341 cases with eating disorders, 3,295 controls, OR 2.91, 95%CI 2.05-4.12, p = 1.8x10-9, AMSTAR-2 moderate quality). Suggestive, weak, or no evidence supported 11, 29, and 8 associations, respectively.

Conclusions:

The most credible evidence indicates that early traumatic and stressful events are risk factors for eating disorders. Larger collaborative prospective cohort studies are needed to identify risk factors for eating disorders, particularly anorexia nervosa.

Depression and physical health as serial mediators between interpersonal problems and binge-eating behavior among hospital nurses in South Korea

This cross-sectional study examined the relationship between depression, physical health, interpersonal problems, and binge-eating behavior among South Korean nurses. Self-report questionnaires were answered by 187 nurses from five hospitals. Mediating roles of depression and physical health between interpersonal problems and binge-eating behavior were examined using mediation analyses with bootstrapping. Total and direct effects of interpersonal problems on binge-eating behavior were significant. Indirect effects of path through depression and physical health as mediators, and through single mediation of physical health were significant, while indirect effects through depression were not. Thus, physical health affects nurses' vulnerability to interpersonal problems and binge-eating behavior.

Hunger games: Associations between core eating disorder symptoms and responses to rejection by peers during competition

OBJECTIVE

Individuals with eating disorder (ED) symptoms are sensitive to social threat and report maladaptive interpersonal styles that may contribute to and exacerbate negative evaluation from others. Research in this area has relied primarily on self-report. The current study examined associations between behavioral responses to social threat and core ED symptoms using a behavioral paradigm. Based on previous findings that individuals with binge-eating report being more reactive and confrontational, whereas individuals with dietary restriction tend to be more submissive and avoidant of conflict, we hypothesized that binge eating would be associated with a greater tendency to retaliate against rejection perpetrators, whereas dietary restriction would be associated with a lower tendency to retaliate when rejected.

METHOD

Undergraduate women (N = 132) completed a self-report measure of ED symptoms and participated in an online "Survivor"-type game in which they voted to either accept or reject computerized coplayers, while also receiving acceptance or rejection feedback from others.

RESULTS

Neither ED symptom was associated with how often participants retaliated against coplayers who rejected them. However, dietary restriction was related to more rejection votes overall (i.e., the tendency to reject others regardless of how others voted).

DISCUSSION

Findings suggest that individuals with dietary restriction may rely on a maladaptive defensive strategy aimed at pre-empting rejection, or alternatively, have difficulty shifting from habitual self-isolating behavior that results from over-involvement with restricting symptoms. Interventions targeting hypersensitivity to social threat or interpersonal flexibility may help reduce interpersonal stress and mitigate its impact on restricting symptoms.

The impact of COVID-19 lockdown and of the following "re-opening" period on specific and general psychopathology in people with Eating Disorders: the emergent role of internalizing symptoms

BACKGROUND

We assessed the impact of the coronavirus disease 2019 (COVID-19) pandemic on specific Eating Disorder (ED) and general psychopathology in people with an ED diagnosis during the lockdown period and after the end of the related containment measures.

METHODS

People with clinically defined diagnosis and undergoing treatment for an ED completed an online survey, which included adapted questions from standardized psychometric scales. Data relative to three different time periods (before, during and after the end of lockdown) were collected. Psychopathological changes over these periods were investigated and compared through one-way analysis of variance or covariance with repeated measures.

RESULTS

Three hundred twelve people completed the survey (57.4% diagnosed with Anorexia Nervosa (AN) or atypical AN, 20.2% with Bulimia Nervosa, 15.4% with Binge Eating Disorder, 7.05% with Other Specified Feeding or Eating Disorders). The severity of both specific and general psychopathology increased during the lockdown and the rise of general symptoms persisted in the following re-opening phase, except for suicide ideation. Almost all of these findings were not affected by ED diagnosis, participants' age and illness duration.

LIMITATIONS

The retrospective nature of data collection is the main limitation of the study.

CONCLUSIONS

People with EDs showed a COVID-19 emergency-induced worsening of both general and specific psychopathology. The effect on general psychopathology persisted in the re-opening period. These findings suggest a high stress vulnerability of ED individuals with important effects on internalizing symptoms, which are worth of attention by clinicians.

Autonomic Nervous System Response to Psychosocial Stress in Anorexia Nervosa: A Cross-Sectional and Controlled Study

To foster understanding in the psychopathology of patients with anorexia nervosa (P_AN) at the psychological and physiological level, standardized experimental studies on reliable biomarkers are needed, especially due to the lack of disorder-specific samples. To this end, the autonomic nervous system (ANS) response to a psychosocial stressor was investigated in n = 19 P_AN (BMI: 18.7 ± 3.3 kg/m²), age, and gender-matched to n = 19 healthy controls (HC; BMI: 24.23 ± 3.0 kg/m²). For this purpose, heart rate (HR) and heart rate variability (HRV) parameters were assessed in a cross-sectional study design under two experimental conditions: (1) rest and (2) stress (Trier Social Stress Test). In addition, psychological indicators of stress were assessed. An 2 × 2 × 8 ANOVA demonstrated similar HR and HRV patterns (except LF-HRV) between P_AN and HC at rest. Under stress, P_AN (vs. HC) demonstrated a blunted HR [condition^*time^*group: F_{(2.91, 104.98)} = 9.326, p = 0.000, η² = 0.206] and an attenuated HRV response (reduced SNS/PNS reactivity). Significant effects of stress appraisal (SA) and BMI on HRV-reactivity were revealed. SA on SDNN = Condition^*time^*SA = F_{(4.12, 140.15)} = 2.676, p = 0.033, η² = 0.073. BMI on LF/HF-Ratio = Condition^*time^*BMI = F_{(3.53, 60.16)} = 3.339, p = 0.019, η² = 0.164. Psychological indices suggested higher levels of chronic and appraised stress in P_AN relative to HC. Additional analyses demonstrated that ED-symptoms are highly correlated with the latter constructs, as well as with psychological burden, but not with weight. Further, it was shown that abnormalities in reactivity persisted despite normalized ANS activity. Overall, we suggested that besides weight recovery, improvement in stress appraisal could be beneficial for cardiac health. In this light, a combination of therapy (e.g., development and activation of coping skills, cognitive reappraisal) and biofeedback training may improve treatment outcomes and regulate stress reactivity.

Adolescent Eating Disorder Day Programme Treatment Models and Outcomes: A Systematic Scoping Review

Background: Adolescent eating disorder day programmes (DP), or partial hospitalization programs, are becoming increasingly widespread worldwide. They typically function as an alternative to inpatient care and/or a step up or down in treatment intensity. There has been an increase in the number of publications within the last 5 years investigating DP outcomes. While there are now numerous programmes operating internationally, there is large variability in the content, structure and theoretical underpinnings of each programme. This makes it difficult to compare programme outcomes, and the impact the therapeutic model may have. Aims: To review existing literature on adolescent eating disorder DP treatment models and outcomes. Methods: A systematic scoping review was conducted. Four databases (PsychInfo, EMBASE, Medline, CENTRAL) were searched for relevant peer-reviewed journal articles and book chapters investigating adolescent eating disorder DPs that function as alternatives to inpatient treatment. No restrictions on study methodology were imposed. Studies were first mapped by location, study characteristics and day programme treatment characteristics, then narratively synthesized. Results: Forty nine studies were included in this review. All used a quantitative methodology. One study also included qualitative methods. The majority of studies included describe DPs in the USA (69%). Seventy-six percent of the studies described DPs that operate 5-days per week and most (57%) either only admit or only report on outcomes for restrictive eating disorders. Two-thirds (69%) reported on DPs that had a family focused treatment model, the remainder had a more integrated treatment model informed mostly by individual psychotherapeutic models. Generally, DP treatment is associated with weight gain and improvements in eating disorder and comorbid psychopathology. The studies that include follow-up data (27%) reveal improvements are usually maintained from 3 months to 2 years post-treatment. Early weight gain, early psychological change and early therapeutic alliance are associated with improved end of treatment outcomes. Findings regarding other potential predictors of outcome are mixed. Conclusions: Current evidence suggests day programmes are an effective alternative to inpatient treatment that lead to sustained improvements. DPs tend to either be young-person-only with a family-focused treatment model or all age with a more integrative model. Controlled, empirical investigations into the impact of the therapeutic model on outcomes are needed, as are investigations into treatment mechanisms and the individual and parent experience of day programme treatment.

COVID-19 Pandemic and Eating Disorders: What Can We Learn About Psychopathology and Treatment? A Systematic Review

PURPOSE OF REVIEW

This systematic review aims to collect evidence regarding the impact of the SarsCov-2 pandemic on people affected by eating disorders (EDs) targeting the following variables: psychopathology changes, mechanisms of vulnerability or resilience, and perception of treatment modifications during the pandemic.

RECENT FINDINGS

Since the beginning of the pandemic, a mental health deterioration has been detected in the general population and especially in people affected by pre-existing psychiatric conditions. Furthermore, mental healthcare has moved toward online treatment. ED people showed a trend toward worsening of ED-specific psychopathology and impairment in general psychopathology. The most common vulnerability mechanisms were social isolation and feelings of uncertainty, while heightened self-care and reduced social pressure were resilience factors. The online treatment, although raising many concerns related to its quality, was considered the best alternative to the face-to-face approach. These findings may support the idea that stressful events contribute to the exacerbation of ED psychopathology and highlight the relevance of internalizing symptoms in EDs. The identification of putative risk and resilience variables as well as of subjective factors affecting online treatment perception may inform healthcare professionals and may promote more personalized approaches.

Autonomic response to the Adult Attachment Projective in anorexia nervosa

PURPOSE

Cardiovascular complications associated with anorexia nervosa (AN) are well recognized. Whether a wide array of studies has investigated autonomic nervous system (ANS) functioning at rest in people with AN, few is yet known on their reactivity ability during stress conditions. The aim of the current study is testing ANS reactivity to a stressful task activating attachment system among adolescents with AN.

METHODS

Heart rate (HR) and its variability, as derived by high-frequency-heart rate variability (HF-HRV), were continuously assessed while 13 AN patients and 12 healthy controls (HCs) responded to a set of attachment-related drawings (Adult Attachment Projective, AAP).

RESULTS

Findings showed that patients with AN displayed a stronger parasympathetic activity, as indicated by generally a lower heart rate (HR) during the entire task and a higher HF-HRV for drawings eliciting dyadic interactions compared to HCs.

CONCLUSION

The study findings suggest a novel understanding of cardiovascular functioning in AN.

LEVEL OF EVIDENCE

Level V, descriptive study.

Multiple levels assessment of the RDoC "system for social process" in Eating Disorders: Biological, emotional and cognitive responses to the Trier Social Stress Test

BACKGROUND

Social dysfunction is a putative risk and maintaining factor for Eating Disorders (EDs). We assessed biological, emotional, and cognitive responses to a psychosocial stressor, in order to provide a multilevel investigation of the RDoC social process system in EDs.

METHODS

Patients were recruited among those seeking treatment for an ED. Cortisol response to Trier Social Stress Test (TSST) was measured in 105 subjects: 35 women with anorexia nervosa (AN), 32 with bulimia nervosa (BN) and 38 healthy women. Anxiety, hunger, and desire to eat throughout TSST were rated in a subgroup of them (23 AN, 21 BN, and 25 control women). Two-way ANOVAs with repeated measures were run to assess differences among groups.

RESULTS

The TSST-induced cortisol secretion of AN women was significantly higher than in BN and healthy women; this significance disappeared after controlling for body mass index. Compared to healthy women, both AN and BN women showed reduced cortisol reactivity that disappeared after controlling for trait anxiety and ineffectiveness. Both ED groups displayed increased anxiety response to TSST, while only AN group reported greater decreases in hunger and desire to eat. No significant correlations were found between cortisol and anxiety, hunger, or desire to eat in response to TSST.

CONCLUSIONS

People with EDs are characterized by blunted cortisol reactivity and greater anxiety, hunger, and desire to eat responses to a psychosocial stressor without any significant association between these measures. This study provides the first empirical and multilevel support to a deranged functioning of the RDoC "system for social process" in EDs.

A Critical Review of Studies Assessing Interpretation Bias Towards Social Stimuli in People With Eating Disorders and the Development and Pilot Testing of Novel Stimuli for a Cognitive Bias Modification Training

People with eating disorders display a negative interpretation bias towards ambiguous social stimuli. This bias may be particularly relevant to young people with the illness due to the developmental salience of social acceptance and rejection. The overall aim of this study was to systematically develop and validate stimuli for a cognitive bias modification training to reduce a social rejection-related negative interpretation bias in young people with eating disorders. A mixed-methods design was used to achieve this aim. A review of the literature was conducted using EMBASE, MEDLINE, PsycINFO, Web of Science, and PubMed. Six studies were included in the review. Focus groups were held with patients with eating disorders, carers and healthcare professionals. Content analysis was used to identify key themes from the qualitative data. Based on these themes, a total of 339 scenarios were generated by the researchers. Salient themes identified from the focus group data included virtual rejection/exclusion, rejection associated with an aspect of the eating disorder, rejection triggered by ambiguous/benign comments or behaviors of others and rejection perceived when confiding in others. Patients rated these scenarios in terms of their age-relevance and emotional salience and 301 scenarios were included in the final stimulus set. These materials may be used by researchers conducting future experimental research into the potential benefits of interpretation bias training for young people with eating disorders.

Emotional reactivity and eating disorder related attitudes in response to the trier social stress test: An experimental study in people with anorexia nervosa and with bulimia nervosa

BACKGROUND

In order to experimentally asses the role of socio-emotional problems in Eating Disorder (ED) psychopathology, we have measured affective states and ED-related attitudes in response to an acute psychosocial stress and their relationships with interpersonal sensitivity in people with Anorexia Nervosa (AN) and Bulimia Nervosa (BN).

METHODS

Twenty-one women with AN, 21 with BN and 27 healthy women underwent an acute psycho-social challenge, the Trier Social Stress Test. Anxiety feelings, hunger perception, amount of desired food and body dissatisfaction were measured throughout the experimental procedure. The relationships between these variables and with interpersonal sensitivity measures were explored through Pearson's correlation and mediation analyses.

RESULTS

Stress-induced anxiety was increased in people with EDs. People with AN showed reduced hunger perception, decreased desire for food and a negative association between anxiety feelings and desire for food. In people with EDs, baseline ineffectiveness predicted post-stress body dissatisfaction through the mediation of post-stress anxiety levels.

LIMITATIONS

The relatively low sample size and the lack of an experimental control condition are the main limitations of the study.

CONCLUSIONS

The present findings show, for the first time, the relationships between socio-emotional distress and ED-related attitudes in people with EDs, providing experimental support to the interpersonal model of EDs. This gives empirical evidence to treatments targeting interpersonal problems in EDs.

Cortisol reactivity in patients with anorexia nervosa after stress induction

There is a need of experimental studies on biomarkers in patients with anorexia nervosa (P_AN), especially in the context of stress, in order to foster understanding in illness maintenance. To this end, the cortisol response to an acute stressor was investigated in n = 26 P_AN (BMI: 19.3 ± 3.4 kg/m²), age, and gender matched to n = 26 healthy controls (HC; BMI: 23.08 ± 3.3 kg/m²). For this purpose, salivary cortisol parameters were assessed in two experimental conditions: (1) rest/no intervention and (2) stress intervention (TSST; Trier Social Stress Test). In addition, psychological indicators of stress were assessed (Primary Appraisal Secondary Appraisal, Visual Analogue Scale, and Trier Inventory for the assessment of Chronic Stress), as well as psychological distress, depression, and eating disorder (ED) symptoms. A 2 × 2 × 8 ANOVA demonstrated elevated cortisol levels in P_AN in the resting condition. In the stress intervention no significant group effect in terms of cortisol (F (1, 50) = 0.69; p = 0.410; [Formula: see text]). A significant condition (F (1, 50) = 20.50; p = 0.000; [Formula: see text]) and time effect (F(2.71, 135.44) = 11.27; p = 0.000; [Formula: see text]) were revealed, as well as two significant interaction effects. First: Condition × group (F (1, 50) = 4.17, p = 0.046; [Formula: see text]) and second: Condition × time (F (2.71, 135.44) = 16.07, p = 0.000, [Formula: see text]). In terms of AUC_G, no significant differences between both groups were exhibited. Regardless, significant results were evinced in terms of an increase (AUC_i: F(1, 50) = 20.66, p = 0.015, [Formula: see text]), baseline to peak (+20 min post-TSST: t₅ = 16.51 (9.02), p = 0.029) and reactivity (M_PAN = 0.73 vs. M_HC = 4.25, p = 0.036). In addition, a significant correlation between AUC_G and BMI: r (24) = -0.42, p = 0.027 was demonstrated, but not between AUC_i and BMI (r (24) = -0.26, p = 0.20). Psychological indices suggested higher levels of chronic and perceived stress in P_AN relative to HC. However, stress perception in the stress condition (VAS) was comparable. Additional analyses demonstrated that ED-symptoms are highly correlated with psychological distress and depression, but not with BMI. In addition, it could be demonstrated that reactivity is rather related to ED-symptoms and psychological burden than to BMI. In conclusion, P_AN showed elevated basal cortisol levels at rest and exhibited a blunted cortisol reactivity to the TSST as evinced by salivary cortisol parameters. Further, it was shown that weight recovery influences reversibility of hypercortisolemia, i.e., cortisol levels normalize with weight gain. However, HPAA (hypothalamus-pituitary-adrenal axis) irregularities in terms of reactivity persist even at a BMI ≤ 19.3 (±3.4). Our data suggest that pronounced psychological burden in P_AN, have a greater impact on the HPAA functionality (secondary to the ED) than BMI itself.

Early traumatic experiences impair the functioning of both components of the endogenous stress response system in adult people with eating disorders

Childhood trauma is a non-specific risk factor for eating disorders (EDs). It has been suggested that this risk is exerted through trauma-induced long-lasting changes in the body stress response system. Therefore, we explored the activity of the hypothalamus-pituitary-adrenal axis and of the sympathetic nervous system in adult ED patients with or without a history of childhood trauma exposure. Salivary cortisol and alpha-amylase, a marker of the sympathetic nervous system activity, were measured at awakening and after 15, 30 and 60 min in 35 women with EDs. The Childhood Trauma Questionnaire (CTQ) was employed to assess exposure to childhood trauma and, according to the CTQ cut-off scores, 21 ED women were classified as maltreated (Mal) participants and 14 women as no-maltreated (noMal) ED participants. Compared to noMal ED women, Mal ED participants showed significantly decreased cortisol awakening response (between group difference: p = 0.0003) and morning salivary alpha-amylase secretion (between group difference: p = 0.02). Present results confirm that the cortisol awakening response of adult ED patients with childhood trauma exposure is lower than that of adult ED patients without childhood trauma experiences and show for the first time that also the morning secretion of salivary alpha-amylase is decreased in adult ED patients who have been exposed to early traumatic experiences. These results point for the first time to a dampening in the basal activity of both components of the endogenous stress response system in childhood maltreated adult ED women.

Treatment-Resistant Blunted HPA Activity, but Reversible Cardiovascular Stress Reactivity in Young Women With Eating Disorders

Previous research has provided evidence for a reduced neuroendocrine stress response in women with eating disorders (EDs). In the present study female in-patients with Anorexia and Bulimia nervosa were compared to female healthy controls (HC) before and after completing an in-patient treatment program. Salivary cortisol, alpha-amylase (sAA), heart rate response (HR), high-frequency heart rate variability (HF-HRV) and negative affective state were measured before, during and after exposure to the Trier Social Stress Test (TSST) at pre- and post-treatment. Patients with EDs (n = 13) showed significantly less ED symptoms at post-treatment. Compared to HC (n = 22), patients displayed a blunted cortisol stress response combined with overall attenuated sAA levels at pre-treatment. At post-treatment, the blunted cortisol stress response was still observable, while the differences in sAA responses disappeared. HR was attenuated at pre-treatment in patients, also indicated by a stronger HF-HRV throughout the TSST. These cardiovascular differences disappeared at post-treatment. Patients reported in general (pre- and post-treatment) more negative affect compared to HC. This study provides further evidences of a hypo-reactive hypothalamus-pituitary-adrenal axis (HPA) in patients with EDs which persists even after symptom recovery while initial low cardiovascular stress reactivity apparently can be restored by psychotherapy. Given the small sample size the findings have to be considered preliminary.

The Role of the Embodiment Disturbance in the Anorexia Nervosa Psychopathology: A Network Analysis Study

Anorexia Nervosa (AN) is characterized by body image distortion. From a phenomenological perspective, body image disturbance has been associated with a more profound disturbance encompassing disorders of the way persons experience their own body. The aim of this study was to disentangle the complex dynamics that connect the experience of one’s own body and self-identity to the psychopathological features of AN by applying a network analysis. Fifty-seven patients with AN restrictive subtype and 27 with AN binge–purging subtype participated in the study. Eating Disorders Inventory-2 and Identity and Eating Disorders subscores, measuring the embodiment dimensions, were included in the network. Two of the main dimensions of embodiment—feeling extraneous from one’s own body and feeling oneself through objective measures—were the nodes with the highest strength together with interoceptive awareness (IA). IA was a node included in several pathways connecting embodiment dimensions with most of the AN psychopathological dimensions. The centrality of the embodiment disorder suggests the importance of considering the body image disturbance in people with AN as resulting from their difficulty in experiencing inner states and as a tool to build its own self. This assumption may orient therapeutic interventions.

The vulnerability to interpersonal stress in eating disorders: The role of insecure attachment in the emotional and cortisol responses to the trier social stress test

BACKGROUND

Vulnerability to interpersonal stress is an important risk factor for Eating Disorders (EDs). Adult insecure attachment involves different emotional, biological and behavioural strategies to cope with social stressors. However, although attachment has proved to play a pivotal role in EDs, no study has yet explored the effects of attachment on the emotional and hypothalamic-pituitary-adrenal (HPA) axis responses to a psychosocial stressor in EDs.

METHODS

Fifty-two ED women (29 with anorexia nervosa, 23 with bulimia nervosa) underwent the Trier Social Stress Test (TSST). Their emotional response was measured by means of the State-Trait Anxiety Inventory state scale while saliva samples were collected to measure cortisol secretion.

RESULTS

According to the Experience in Close Relationship questionnaire scores, 21 ED patients had high attachment anxiety and 31 low attachment anxiety, whilst 34 had high attachment avoidance and 18 low attachment avoidance. Patients with high attachment anxiety or avoidance displayed heightened TSST-induced cortisol secretion and anxiety feelings, in comparison to those with low insecure attachment scores. Anxiety perception was associated with cortisol recovery after the test exposure but not with the HPA axis reactivity in insecure attached patients.

CONCLUSIONS

The present findings corroborate the hypothesis that attachment modulates the biological and emotional reactivities to an acute social threat in ED patients. The role of these attachment-mediated changes in vulnerability to interpersonal stress in EDs needs to be clarified in future studies.

Psychometric Properties of the Interpersonal Outcome Expectancies for Thinness (IOET) Scale: Evidence for Validity, Reliability, and Utility in the Study of Eating Disturbances in Females

Introduction: Interpersonal context is believed to represent a powerful factor that often fosters and sustains eating disturbances in females. The present study focused on the development of a measure tapping into positive interpersonal expectancies predicated on being thin believed to be positively involved in eating disorders in females, namely, the Interpersonal Outcome Expectancies for Thinness (IOET).

Method: In Study 1, a total of 361 U.S. female college students completed the IOET for factor analysis. In Study 2, to assess for construct validity, an independent sample of 184 U.S. female college students completed a test battery including the IOET and measures of eating attitudes and disturbances, positive and negative affectivity, and general optimism.

Results: In Study 1, results from an exploratory factor analysis indicated a one-factor solution for the IOET accounting for 76.70% of the total variance. In Study 2, the IOET was found to possess good test-retest reliability (6-week) in a subset sample of U.S. female participants. Moreover, in support for construct validity, we found IOET scores were positively associated with scores on measures of eating disturbances (e.g., bulimic symptoms) and negative affectivity. Additionally, IOET scores were negatively associated with scores on a measure of general optimism. Finally, in support of utility, the IOET was found to add incremental validity to the prediction of eating disturbances, even after accounting for general optimism and affectivity.

Discussion: The present findings provide promising evidence for the validity, reliability, and utility of the IOET as a measure of a maladaptive cognitive schema associated with eating disorders in females. Implications for the theory and clinical assessments were discussed.

Deranged emotional and cortisol responses to a psychosocial stressor in anorexia nervosa women with childhood trauma exposure: Evidence for a "maltreated ecophenotype"?

Exposure to trauma in the childhood and abnormal interpersonal stress reactivity are believed to contribute to the pathophysiology of anorexia nervosa (AN), which suggests a possible role of the hypothalamus-pituitary adrenal (HPA) axis. Although an effect of early traumatic experiences on the cortisol awakening response has been proved in patients with AN, the consequences of childhood trauma exposure on HPA axis reactivity to psychosocial stressors has been never investigated in such individuals. Therefore, we have assessed emotional and cortisol responses to an acute psycho-social stress in AN patients with a history of childhood trauma exposure. Twenty-four AN women and 17 healthy women were enrolled in the study. Patients were classified as maltreated (Mal) or non-maltreated (noMal) according to their Childhood Trauma Questionnaire scores. Participants underwent the Trier Social Stress Test (TSST) and their emotional responses were measured through the state scale of the State-Trait Anxiety Inventory. Saliva samples were collected to measure cortisol production. Compared to both healthy subjects and noMal AN patients, Mal AN women exhibited a blunted cortisol response to TSST. With respect to healthy controls, pre-TSST anxiety levels were enhanced in both AN groups; moreover, Mal AN patients displayed a reduced anxiety increase after TSST as compared to both noMal patients and healthy women. Our findings for the first time provide the evidence of deranged biological and emotional responses to an acute social stress in AN patients with childhood trauma exposure, corroborating the idea of a maltreated ecophenotype in AN as in other psychiatric disorders.