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Rossi E, Cassioli E, Dani C, Marchesoni G, Monteleone AM, Wonderlich SA, Ricca V, Castellini G. The maltreated eco-phenotype of eating disorders: A new diagnostic specifier? A systematic review of the evidence and comprehensive description. Neurosci Biobehav Rev 2024; 160:105619. [PMID: 38462152 DOI: 10.1016/j.neubiorev.2024.105619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/01/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
This systematic review aimed to summarize the evidence on the existence of a distinct phenotypic expression of Eating Disorders (EDs) associated with childhood maltreatment (CM), the so-called maltreated eco-phenotype of EDs. PRISMA standards were followed. Articles providing data about the characteristics of individuals with an ED reporting CM were included. Relevant results were extracted and summarized. A quality assessment was performed. A total of 1207 records were identified and screened, and 97 articles published between 1994 and 2023 were included. Findings revealed distinct biological and clinical features in patients with EDs reporting CM, including neuroanatomical changes, altered stress responses, ghrelin levels, inflammation markers, and gut microbiota composition. Clinically, CM correlated with severer eating behaviors, higher psychiatric comorbidity, impulsivity, emotional dysregulation, and risky behaviors. Additionally, CM was associated with poorer treatment outcomes, especially in general psychopathology and psychiatric comorbidities. This review highlighted the need to move towards an etiologically informed nosography, recognizing CM not merely as a risk factor, but also as an etiologic agent shaping different eco-phenotypic variants of EDs.
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Affiliation(s)
- Eleonora Rossi
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Emanuele Cassioli
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Cristiano Dani
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giorgia Marchesoni
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | | | | | - Valdo Ricca
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giovanni Castellini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy.
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Rossi E, Cassioli E, Cecci L, Arganini F, Martelli M, Redaelli CA, Anselmetti S, Bertelli S, Fernandez I, Ricca V, Castellini G. Eye movement desensitisation and reprocessing as add-on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi-experimental multicenter study. EUROPEAN EATING DISORDERS REVIEW 2024; 32:322-337. [PMID: 37903082 DOI: 10.1002/erv.3044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/29/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023]
Abstract
OBJECTIVE This quasi-experimental study aimed to compare the outcome of patients with Anorexia Nervosa (AN) reporting moderate/severe childhood maltreatment (CM) treated exclusively with Enhanced Cognitive Behaviour Therapy (CBT-E) or with CBT-E plus Eye Movement Desensitisation and Reprocessing (EMDR). METHOD A total of 75 patients with AN reporting moderate/severe CM were initially assessed regarding body mass index (BMI), general and eating disorder (ED)-specific psychopathology, and dissociative symptoms, and re-evaluated after 40 CBT-E sessions (T1). Then, 18 patients received EMDR, whereas the others were placed on a waiting list and continued CBT-E. T2 assessment was performed after 20-25 sessions of EMDR or CBT-E. A control group of 67 patients without CM was also enroled and treated with CBT-E. RESULTS Contrary to patients without CM, neither of the traumatised groups improved in BMI, general and ED psychopathology, or dissociation at T1. However, at T2, both traumatised groups improved in BMI and ED-specific psychopathology, with the CBT + EMDR group demonstrating greater improvements. Moreover, only the CBT + EMDR group improved in general psychopathology and dissociative symptoms. The reduction of ED symptoms in traumatised patients was mediated by the amelioration of dissociation. DISCUSSION The addition of EMDR to CBT-E may benefit patients with AN reporting moderate/severe CM.
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Affiliation(s)
- Eleonora Rossi
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Emanuele Cassioli
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Lucia Cecci
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Francesca Arganini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Michela Martelli
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | | | | | - Sara Bertelli
- Department of Mental Health, ASST Santi Paolo e Carlo, Milan, Italy
| | | | - Valdo Ricca
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giovanni Castellini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
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Cascino G, Monteleone AM. Early traumatic experiences and the hypothalamus-pituitary-adrenal axis in people with eating disorders: A narrative review. Psychoneuroendocrinology 2024; 159:106665. [PMID: 37944210 DOI: 10.1016/j.psyneuen.2023.106665] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
Exposure to trauma during childhood is a non-specific risk factor for psychiatric disorders, including eating disorders (EDs), over the life course. Moreover, an association between stressful life events and the onset/maintenance of EDs has been documented. Therefore, the hypothalamus-pituitary-adrenal (HPA) axis, namely the main component of the endogenous stress response system, has been proposed to be implicated in the pathophysiology of EDs. In this narrative review the current knowledge concerning the effects of early trauma exposure on the HPA axis activity and their putative role in the pathophysiology of EDs will be illustrated. Research findings corroborate the idea that childhood trauma exposure has long-lasting dysregulating effects on the activity of the HPA axis, which may contribute to the biological background of the early trauma-related risk for the development of EDs across the life span. Moreover, literature data support the existence of a "maltreated ecophenotype" in EDs characterized by specific clinic and neuroendocrine features, which may have important implications in treatment programming for such a type of patients.
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Affiliation(s)
- Giammarco Cascino
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Salerno, Italy.
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Convertino AD, Mendoza RR. Posttraumatic stress disorder, traumatic events, and longitudinal eating disorder treatment outcomes: A systematic review. Int J Eat Disord 2023; 56:1055-1074. [PMID: 36916450 PMCID: PMC10247514 DOI: 10.1002/eat.23933] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Many individuals diagnosed with an eating disorder (ED) have been exposed to traumatic events, and some of these individuals are diagnosed with posttraumatic stress disorder (PTSD). Although theorized by researchers and clinicians, it is unclear whether traumatic event exposure or PTSD interferes with outcomes from ED treatment. The objective of the current study was to systematically review the literature on traumatic events and/or PTSD as either predictors or moderators of psychological treatment outcomes in EDs. METHOD A PRISMA search was conducted to identify studies that assessed the longitudinal association between traumatic events or PTSD and ED outcomes. Eighteen articles met the inclusion criteria for review. RESULTS Results indicated that traumatic event exposure was associated with greater ED treatment dropout, but individuals with a traumatic event history benefited from treatment similarly to their unexposed peers. Findings also indicated that traumatic events may be associated with greater symptom relapse posttreatment. DISCUSSION Given the limited number of studies examining PTSD, results are considered very tentative; however, similar to studies comparing trauma-exposed and nontrauma-exposed participants, individuals with PTSD may have similar treatment gains compared to individuals without PTSD, but individuals with PTSD may experience greater symptom relapse posttreatment. Future researchers are encouraged to examine whether trauma-informed care or integrated treatment for EDs and PTSD mitigates dropout from treatment and improves symptom remission outcomes. Furthermore, researchers are encouraged to examine how the developmental timing of traumatic events, self-perceived impact of trauma, and cumulative trauma exposure may be associated with differential ED treatment outcomes. PUBLIC SIGNIFICANCE Eating disorders (EDs), trauma, and posttraumatic stress disorder (PTSD) often co-occur. Individuals with traumatic event exposure and/or PTSD demonstrate greater ED symptoms; it is unclear whether these individuals benefit similarly in ED treatment to their peers. The current study found that individuals with traumatic event exposure are more likely to drop out of treatment but benefit from treatment with similar symptom remission. Traumatic history was associated with greater relapse posttreatment.
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Affiliation(s)
- Alexandra D. Convertino
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, Suite 103, San Diego, CA 92120, USA
| | - Rebecca R. Mendoza
- Department of Psychology, College of Sciences, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA
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Sjögren M, Lichtenstein MB, Støving RK. Trauma Experiences Are Common in Anorexia Nervosa and Related to Eating Disorder Pathology but Do Not Influence Weight-Gain during the Start of Treatment. J Pers Med 2023; 13:jpm13050709. [PMID: 37240879 DOI: 10.3390/jpm13050709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/16/2023] [Accepted: 04/22/2023] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVE The main characteristics of Anorexia Nervosa (AN) in adults are restriction of energy intake relative to requirements leading to significant weight loss, disturbed body image, and intense fear of becoming fat. Traumatic experiences (TE) have been reported as common, although less is known about the relationship with other symptoms in severe AN. We investigated the presence of TE, PTSD, and the relation between TE, eating disorder (ED) symptoms, and other symptoms in moderate to severe AN (n = 97) at admission to inpatient weight-restoration treatment. All patients were enrolled in the Prospective Longitudinal all-comer inclusion study on Eating Disorders (PROLED). METHODS TE were assessed using the Post-traumatic stress disorder checklist, Civilian version (PCL-C), and ED symptoms using the Eating Disorder Examination Questionnaire (EDE-Q); depressive symptoms were assessed using the Major Depression Inventory (MDI), and the presence of Post-traumatic Stress Disorder (PTSD) was diagnosed according to ICD-10 criteria. RESULTS The mean score on PCL-C was high (mean 44.6 SD 14.7), with 51% having a PCL-C score at or above 44 (n = 49, suggested cut-off for PTSD), although only one individual was clinically diagnosed with PTSD. There was a positive correlation between baseline scores of PCL-C and EDE-Q-global score (r = 0.43; p < 0.01) as well as of PCL-C and all EDE-Q subscores. None of the included patients were admitted for treatment of TE/PTSD during the first 8 weeks of treatment. CONCLUSIONS In a group of patients with moderate to severe AN, TE were common, and scores were high, although only one had a diagnosis of PTSD. TE were related to ED symptoms at baseline, but this association diminished during the weight restoration treatment.
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Affiliation(s)
- Magnus Sjögren
- Eating Disorder Research Unit, Psychiatric Center Ballerup, 2750 Ballerup, Denmark
- Institute for Clinical Science, Sundsvall Regional Hospital, Umeå University, 851 86 Sundsvall, Sweden
| | - Mia Beck Lichtenstein
- Center for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5230 Odense, Denmark
- Mental Health Services in the Region of Southern Denmark, 5230 Odense, Denmark
- Clinical Institute, University of Southern Denmark, 5000 Odense, Denmark
| | - Rene Klinkby Støving
- Center for Eating Disorders, Odense University Hospital, 5000 Odense, Denmark
- Research Unit for Medical Endocrinology, Odense University Hospital, 5230 Odense, Denmark
- Mental Health Services in the Region of Southern Denmark, 5230 Odense, Denmark
- Clinical Institute, University of Southern Denmark, 5000 Odense, Denmark
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Rienecke RD, Johnson C, Mehler PS, Le Grange D, Manwaring J, Duffy A, McClanahan S, Blalock DV. Adverse childhood experiences among a treatment-seeking sample of adults with eating disorders. EUROPEAN EATING DISORDERS REVIEW 2022; 30:156-167. [PMID: 35001471 DOI: 10.1002/erv.2880] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 12/16/2021] [Accepted: 12/24/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The purpose of the current study was to examine the prevalence of adverse childhood experiences (ACEs) among adults with eating disorders (EDs), to assess whether experiencing a greater number of ACEs is associated with more severe ED psychopathology, and to determine whether ACEs predict treatment outcome. METHOD Participants were 1819 patients (88.5% female, ages 18-72) admitted to one of two treatment facilities at inpatient, residential, or partial hospitalisation levels of care. The Adverse Childhood Experiences Survey and the Eating Pathology Symptom Inventory (EPSI) were completed at admission and the EPSI at discharge. RESULTS Female patients reported higher ACEs than males (p = 0.03), and all diagnoses except avoidant/restrictive food intake disorder had significantly higher ACEs than patients with anorexia nervosa-restricting type (AN-R) (p's < 0.01). Across diagnoses, higher ACEs were associated with decreases in binge eating scores during treatment, but were not associated with changes in purging or restricting. Within diagnoses, higher ACEs scores were associated with decreases in purging for patients with AN-R and increases in purging for patients with binge eating disorder. CONCLUSIONS Results partially supported the hypothesis that higher ACEs would be associated with more severe ED psychopathology.
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Affiliation(s)
- Renee D Rienecke
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA
| | - Craig Johnson
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA
| | - Philip S Mehler
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA.,ACUTE at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado, Denver, Colorado, USA
| | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, Colorado, USA.,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois, USA
| | - Jamie Manwaring
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA
| | - Alan Duffy
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA
| | - Susan McClanahan
- Eating Recovery Center and Pathlight Mood and Anxiety Centers, Denver, Colorado, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA.,Rush University Medical Center, Chicago, Illinois, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Monteleone AM, Cascino G, Ruzzi V, Pellegrino F, Patriciello G, Barone E, Carfagno M, Monteleone P, Maj M. Emotional traumatic experiences significantly contribute to identify a maltreated ecophenotype sub-group in eating disorders: Experimental evidence. EUROPEAN EATING DISORDERS REVIEW 2020; 29:269-280. [PMID: 33378110 DOI: 10.1002/erv.2818] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/21/2020] [Accepted: 12/11/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Eating disorders (EDs) are associated with a high prevalence of childhood maltreatment (CM). We aimed to experimentally assess if people with EDs and history of CM show altered biological, emotional and behavioural responses to the Trier Social Stress Test (TSST). METHODS According to Childhood Trauma Questionnaire cut-off scores, 29 participants (14 with anorexia nervosa [AN] and 15 with bulimia nervosa [BN]) were classified as maltreated (Mal) ED participants while 19 participants (11 with AN and eight with BN) without CM were identified as no maltreated (noMal) ED participants. Cortisol, anxiety and hunger responses to TSST and post-stress body dissatisfaction were measured. RESULTS Mal ED people showed heightened emotional reactivity, lower levels of hunger and more severe post-stress body dissatisfaction in comparison with noMal ones. Higher cortisol production was observed in people with AN, regardless of CM history, and in those with BN and emotional CM. Emotional trauma was the main CM type contributing to the experimental differences observed in Mal ED people. CONCLUSIONS This is the first study providing experimental and multi-level support to the maltreated ecophenoptype hypothesis in people with EDs. These findings may promote new insights into the biological bases of EDs and provide novel therapeutic implications.
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Affiliation(s)
| | - Giammarco Cascino
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neurosciences, University of Salerno, Salerno, Italy
| | - Valeria Ruzzi
- Department of Psychiatry, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Francesca Pellegrino
- Department of Psychiatry, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | | | - Eugenia Barone
- Department of Psychiatry, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Marco Carfagno
- Department of Psychiatry, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Palmiero Monteleone
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neurosciences, University of Salerno, Salerno, Italy
| | - Mario Maj
- Department of Psychiatry, University of Campania 'Luigi Vanvitelli', Naples, Italy
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Fertility and Reproduction after Recovery from Anorexia Nervosa: A Systematic Review and Meta-Analysis of Long-Term Follow-Up Studies. Diseases 2020; 8:diseases8040046. [PMID: 33339411 PMCID: PMC7768504 DOI: 10.3390/diseases8040046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 12/26/2022] Open
Abstract
Reproductive health is compromised during anorexia nervosa (AN). However, it is still unclear whether this medical complication is reversible after recovery from AN. The purpose of this paper was to conduct a systematic review of the major reproductive health outcomes in females after recovery from AN. The review was conducted in adherence to preferred reporting items for systematic review and meta-analyses (PRISMA) guidelines. Data were collated using meta-analysis and a narrative approach. Of the 1186 articles retrieved, five studies met the inclusion criteria and were reviewed. These studies monitored weight-restored females who had recovered from AN for a follow-up period of between six and 18 years. Their narrative analysis revealed that appropriate treatment of AN leads to the normalization of reproductive function, especially in terms of fertility, pregnancy, and childbirth rates. The meta-analysis confirmed this finding, where the pooled odds of childbirth rates between the AN group and the general population was not statistically significant (OR = 0.75, 95% CI: 0.43–1.29, p = 0.41). We conclude that if patients undergo appropriate eating-disorder treatment and weight restoration, it appears to be unlikely that reproductive health is affected by AN. However, since this finding is derived from only a few studies, it requires replication and confirmation.
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