Eating disorders

Association between the frontoparietal network, clinical symptoms and treatment response in individuals with untreated anorexia nervosa

Background

Anorexia nervosa (AN) has been characterised as a psychiatric disorder associated with increased control. Currently, it remains difficult to predict treatment response in patients with AN. Their cognitive abilities are known to be resistant to treatment. It has been established that the frontoparietal control network (FPCN) is the direct counterpart of the executive control network. Therefore, the resting-state brain activity of the FPCN may serve as a biomarker to predict treatment response in AN.

Aims

The study aimed to investigate the association between resting-state functional connectivity (RSFC) of the FPCN, clinical symptoms and treatment response in patients with AN.

Methods

In this case-control study, 79 female patients with AN and no prior treatment from the Shanghai Mental Health Center and 40 matched healthy controls (HCs) were recruited from January 2015 to March 2022. All participants completed the Questionnaire Version of the Eating Disorder Examination (version 6.0) to assess the severity of their eating disorder symptoms. Additionally, RSFC data were obtained from all participants at baseline by functional magnetic resonance imaging. Patients with AN underwent routine outpatient treatment at the 4th and 12th week, during which time their clinical symptoms were evaluated using the same measures as at baseline.

Results

Among the 79 patients, 40 completed the 4-week follow-up and 35 completed the 12-week follow-up. The RSFC from the right posterior parietal cortex (PPC) and dorsolateral prefrontal cortex (dlPFC) increased in 79 patients with AN vs 40 HCs after controlling for depression and anxiety symptoms. By multiple linear regression, the RSFC of the PPC to the inferior frontal gyrus was found to be a significant factor for self-reported eating disorder symptoms at baseline and the treatment response to cognitive preoccupations about eating and body image, after controlling for age, age of onset and body mass index. The RSFC in the dlPFC to the middle temporal gyrus and the superior frontal gyrus may be significant factors in the treatment response to binge eating and loss of control/overeating in patients with AN.

Conclusions

Alterations in RSFC in the FPCN appear to affect self-reported eating disorder symptoms and treatment response in patients with AN. Our findings offer new insight into the pathogenesis of AN and could promote early prevention and treatment.

Remote family education and support program for parents of patients with adolescent and early adulthood eating disorders based on interpersonal psychotherapy: study protocol for a pilot randomized controlled trial

BACKGROUND

In cases of adolescent and early adulthood eating disorders, despite the importance of the patients' relationship with their parents, conflict and confusion frequently occur among them. Interpersonal psychotherapy (IPT) is a present-focused psychotherapy that emphasizes the interpersonal context of symptoms. We developed a remote family education and support program exclusively for parents of patients with eating disorders, based on the principle of IPT. The use of IPT is expected to reduce conflicts in the patient-parent relationship. Consequently, parents will be better able to listen to patients, and patients will be better able to express their thoughts and desires. In this study, we describe the protocol for a randomized controlled trial designed to examine the effectiveness of this program in promoting effective communication in their home based on active listening skills of parents of patients with adolescent and early adulthood eating disorders.

METHODS

Participants will be parents of patients aged 12-29 years with adolescent and early adulthood eating disorders. Individually randomized, parallel-group trial design will be employed. Seventy participants will be allocated to one of two treatment conditions: (1) remote family education and support program (four, 150 min weekly group sessions) for parents plus treatment-as-usual for patients (consultation by physicians or no treatment), or (2) waiting for the control condition (parents will wait to start the program for 8 weeks) plus treatment-as-usual for patients. The primary outcome measure will be parents' active listening ability as measured by the Active Listening Attitude Scale at 8 weeks after randomization. Additionally, perception of social support (Social Provision Scale-10 item), loneliness (UCLA Loneliness Scale), mental health status (K6), family function (Family Assessment Device), and parent-evaluated eating disorder symptoms (Anorectic Behavior Observation Scale) will be assessed. Data from the intention-to-treat sample will be analyzed 8 weeks after randomization.

DISCUSSION

This is the first study to evaluate the effectiveness of a family education and support program for parents of patients with adolescent and early adulthood eating disorders based on IPT. If this type of intervention is effective, although indirect, it could be a new support method for this patient population.

TRIAL REGISTRATION

Clinical Trials. gov ID NCT05840614.

Diagnosed eating disorders in Danish registers - incidence, prevalence, mortality, and polygenic risk

Eating disorders are a group of severe and potentially enduring psychiatric disorders associated with increased mortality. Compared to other severe mental illnesses, they have received relatively limited research attention. Epidemiological studies often only report relative measures despite these being difficult to interpret having limited practical use. The aims of this study were to evaluate the incidence and prevalence of diagnosed anorexia nervosa (AN), bulimia nervosa, and eating disorder not otherwise specified recorded in Danish hospital registers and estimate both relative and absolute measures of subsequent mortality - both all-cause and cause-specific in a general nationwide population of 1,667,374 individuals. In a smaller, genetically informed case-cohort sample, the prediction of polygenic scores for AN, body fat percentage, and body mass index on AN prevalence and severity was estimated. Despite males being less likely to be diagnosed with an eating disorder, those that do have significantly increased rates of mortality. AN prevalence was highest for individuals with high AN and low body fat percentage/body mass index polygenic scores.

Cognitive behavioral therapy versus compassion focused therapy for adult patients with eating disorders with and without childhood trauma: A randomized controlled trial in an intensive treatment setting

OBJECTIVE

Treatments for eating disorders are moderately effective, with cognitive behavior therapy (CBT) providing the strongest evidence. However, it remains important to investigate other interventions, particularly for eating disorders with greater complexity (e.g., substantial comorbidity; trauma history) or for patients who have not responded adequately to previous treatments.

METHOD

This randomized controlled trial compared CBT against compassion-focused therapy for eating disorders (CFT-E), where half of the sample had a childhood trauma history. The study was pre-registered and adequately powered. A total of 130 patients were randomly assigned to CBT or CFT-E and were assessed at pre-treatment, post-treatment and one-year follow-up. The primary outcome measure was the total score on the Eating Disorder Examination-Interview (EDE), and secondary outcome measures were the Symptom Checklist-90, Inventory of Interpersonal Problems-64 and Post-Traumatic Symptom Scale. Attrition during treatment was low (13%), suggesting good acceptability.

RESULTS

Eating pathology (EDE scores) reduced substantially overall, with large effect sizes, and there were no differences between therapies. However, at follow-up, for patients with a childhood trauma history, CFT-E maintained benefits better than CBT.

CONCLUSION

While both CBT and CFT-E resulted in significant reductions in eating pathology, CFT-E showed superior maintenance of benefits for patients with a history of childhood trauma at one-year follow-up, underlining the necessity of tailored interventions for specific patient subgroups.

Effects of inpatient treatment on compulsive exercise in adults with longstanding eating disorders: Secondary analysis from a randomized controlled trial with 12-month follow-up

PURPOSE

This study aimed to examine changes in compulsive exercise among adults with eating disorders (ED) admitted for inpatient treatment in a randomized controlled trial comparing cognitive behavioral therapy (CBT) and compassion-focused therapy (CFT) and whether such changes were influenced by treatment condition, childhood trauma, or level of compulsive exercise.

METHOD

A total of 130 adults admitted to inpatient treatment for EDs mean (SD) age 30.9 (9.7) years, mean illness duration 14.2 (8.9) years, were randomized to receive CBT or CFT and analyzed using multilevel modeling. Assessments included Eating Disorders Examination - Interview, Compulsive Exercise Test and Childhood Trauma Questionnaire.

RESULTS

Mean total CET score at baseline was 14.7 (4.0) with no difference between the treatment groups. A total of 63 (48.5%) had CET score ≥ 15, indicating clinical levels. There was an overall time effect on reduction in CET total and all CET subscale scores except Lack of enjoyment, and CFT provided greater reduction compared to CBT on the CET subscale Mood improvements. Patients with clinical CET score levels showed greater reduction on CET total and the subscales Avoidance, Weight, and Rigidity across time compared to persons with non-clinical CET score. Childhood trauma did not predict changes in CET total or subscale scores.

DISCUSSION

Both CBT and CFT improve overall compulsive exercise. The greater effect of CFT than CBT on exercise as a maladaptive mood regulator calls for further research on how affective oriented psychotherapies can not only reduce compulsive exercise but also promote functional exercise among persons with EDs.

PUBLIC SIGNIFICANCE STATEMENT

Understanding and addressing compulsive exercise in adults with eating disorders is crucial. This study comparing cognitive-behavioral therapy and compassion-focused therapy shows both improve compulsive exercise. Importantly, compassion-focused therapy has a greater impact as an emotion-focused regulator. This emphasizes the need for further exploration into how emotion-focused therapies can reduce compulsive exercise and promote healthier, functional physical activity for individuals with eating disorders.

Disordered eating in a 10-year perspective from adolescence to young adulthood: Stability, change, and body dissatisfaction as a predictor

INTRODUCTION

Although there are many studies of disordered eating (DE) in adolescence, studies examining the longitudinal stability and change of DE and its longitudinal associations with other factors are still rather scarce. Such studies are important to inform parents and clinicians how stable DE is and to what extent it will go away with increased maturity. Longitudinal studies may also be of help in establishing predictors of long-term problems. The purpose of the present study was to investigate the stability of DE over a 10-year period from early adolescence to young adulthood, and to explore body dissatisfaction as a predictor in a 10-year perspective.

METHODS

Data were taken from a three-wave longitudinal project (SoL) with survey data collected among the students in Grades 7and 8 in a Swedish municipality in 2007 (T1), 1 year later (T2), and in a 10-year follow-up in 2017 (T3). DE was measured by the eight-item version of the Risk Behaviour Related to Eating Disorders (RiBED-8), and a quasi-clinical criterion of six or more critical answers on the RiBED-8 was used to classify DE cases.

RESULTS

Of the girls, 5.8% passed the cutoff for DE at T1, whereas 9.1% did so at T2 and 7.9% at T3. The boys showed markedly lower figures: 0.5% both at T1 and T2, and 1.5% at T3. There was significant individual stability of DE over the 10-year period, with almost 30% of the girls who passed the cutoff for DE at T1 also doing so 10 years later. Body dissatisfaction in early adolescence predicted the incidence of new cases of DE 10 years later, even when controlling for degree of DE in early adolescence. The results also indicate that DE in early adolescence may be a passing phase among adolescents who express relatively high body satisfaction.

CONCLUSIONS

The present results show a complex picture of different individual trajectories of DE, with degree of body satisfaction playing a significant role for the outcome in a 10-year perspective. Body dissatisfaction appears to be a risk factor for the development of new cases of DE, whereas body satisfaction may protect against the continuation of DE into adulthood.

Persistence of gut dysbiosis in individuals with anorexia nervosa

Recent evidence suggests a crucial role of the gut microbiota in the pathogenesis of anorexia nervosa (AN). In this study, we carried out a series of multiple analyses of the gut microbiota of hospitalized individuals with AN over three months using 16S or 23S rRNA-targeted reverse transcription-quantitative polymerase chain reaction (PCR) technology (YIF-SCAN®), which is highly sensitive and enables the precise quantification of viable microorganisms. Despite the weight gain and improvements in psychological features observed during treatment, individuals with AN exhibited persistent gut microbial dysbiosis over the three-month duration. Principal component analysis further underscored the distinct microbial profile of individuals with AN, compared with that of age-matched healthy women at all time points. Regarding the kinetics of bacterial detection, the detection rate of Lactiplantibacillus spp. significantly increased after inpatient treatment. Additionally, the elevation in the Bifidobacterium counts during inpatient treatment was significantly correlated with the subsequent body weight gain after one year. Collectively, these findings suggest that gut dysbiosis in individuals with AN may not be easily restored solely through weight gain, highlighting the potential of therapeutic interventions targeting microbiota via dietary modifications or live biotherapeutics.

Body image perception, eating disorder behavior, self-esteem and quality of life: a cross-sectional study among female medical students

BACKGROUND

Eating disorders are strongly associated with body image concerns. Eating disorders tend to significantly impact the current and future health and quality of life of affected persons, their caregivers, and society. As body image is based on a social construct of ideal body image, it is essential to evaluate it in its cultural context.

METHODS

The current study explored the relationship among body image perception, perceived stress, eating disorder behaviour and quality of life among female medical students (n = 777). Measurements included Body Shape Questionnaire, Body Image Quality of Life Inventory, Eating Attitudes Test-26 and Rosenberg Self-Esteem Scale. Multivariate analysis was conducted.

RESULTS

There was a significant correlation between eating disorder behaviour and perceived body shape, body image, quality of life and self-esteem among our study participants. We also found eating disorder status was significantly associated with BMI, perceived body shape, quality of life and self-esteem.

CONCLUSIONS

This is of clinical implication to female medical students and healthcare professionals to engage early in primary and secondary prevention of eating pathologies. Increasing awareness of these facts among female students can help identify at-risk students and help them seek timely medical help.

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Day hospital program for anorexia nervosa in children and adolescents: Assessment, management and specific focus on early onset anorexia nervosa

INTRODUCTION

The French day hospital program specialized in eating disorders (ED) opened in January 2018. Our study presents preliminary data on clinical profiles of patients with anorexia nervosa (AN). We describe more specifically clinical characteristics of patients with early onset AN and according to their therapeutics orientations. Then, we compare the weight gain of patients managed only in day-patient (DP) treatment with those managed initially inpatient (IP) treatment and relays in DP.

METHODS

Ninety-two patients with AN, aged between 8 and 18 years, were evaluated with several questionnaires (EDI-2, EDE-Q, BSQ, EDS-R, CDI, STAI-Y, VSP-A, EPN-13).

RESULTS

Patients with early onset AN, n = 23 (25.3%), presented more restrictive behaviors, less marked dietary symptomatology, a lower degree of clinical perfectionism and a less marked feeling of ineffectiveness than adolescent patients with AN. Regarding the choice of hospitalization modality (DP alone or IP-DP), the only difference highlighted was the severity of patient undernutrition. Among the patients who were treated (IP-DP n = 27 vs DP alone n = 25), the weight evolution after one month and at discharge was favorable for both groups.

CONCLUSION

These preliminary data suggest the effectiveness of DP in the care of AN in children and adolescents.

Prevalence of eating disorder symptomatology among outpatients referred to health promotion from somatic hospital departments

BACKGROUND AND AIMS

All eating disorders (EDs) lead to a significant decrease of health status, psychosocial functioning and quality of life (QoL). Individuals with untreated binge eating disorder (BED) tend to gain weight over time, which may contribute to serious health issues. In somatic hospital departments, some outpatients have reduced compliance with lifestyle changes. This may, to some extent, be due to patients with an undiagnosed ED receiving the incorrect treatment. In this cross-sectional study, we aimed to investigate the prevalence of EDs among patients referred to lifestyle courses.

RESULTS

A total of 136 patients referred from somatic hospital departments to lifestyle changes in a specialized hospital unit were included in the study. The response rate was 69.4%. Self-reported ED or sub-clinical symptoms of ED according to the Eating Disorder Examination Questionnaire (EDE-Q) were found in 17.65%. Of these, 11.03% fulfilled the self-reported criteria for an ED (BED, 7.35%; bulimia nervosa, 3.68%). Patients with an ED or subclinical ED symptoms had elevated grazing behaviour compared to those without ED symptomatology. A statistically significant difference in QoL was also found.

DISCUSSION AND CONCLUSIONS

The prevalence of self-reported ED or subclinical ED symptoms in patients referred to a lifestyle course is substantial. This ED group had reduced QoL and larger grazing behaviour compared to patients without ED symptomatology. Thus, the prevalence of undiagnosed EDs among patients within somatic hospital departments may be substantial, underlining the importance of screening and further research within this topic.

LEVEL OF EVIDENCE

Level III, well-designed cohort study.

SIGNIFICANCE

What is already known on this subject? In a review including populations from Scandinavia, the USA and South America, the estimated BED prevalence in individuals with higher body weight seeking help to lose weight is 13-27% [22]. Dawes et al. (2016) conducted a meta-analysis investigating the prevalence of mental health conditions among bariatric surgery candidates and recipients. They included 25 studies with a total of 13,769 patients and found that the prevalence of BED was 17% (13-21%) [10]. What this study adds? We have identified a group of patients who may be receiving inappropriate treatment with weight loss intervention instead of specialized ED intervention. It appears that this issue is valid in various somatic hospital departments. Thus, this is a field that requires further attention and investigation.

The Impact of Stress from Social Isolation during the COVID-19 Pandemic on Psychiatric Disorders: An Analysis from the Scientific Literature

The COVID-19 pandemic generated, in addition to severe symptoms, hospitalizations and deaths worldwide, as well as stress from the fear of the disease and social uncertainties, from restriction measures and social isolation. Stress from social isolation impacts mental health, aggravating existing conditions and triggering neuropsychiatric symptoms in individuals with biopsychosocial vulnerability. During and immediately after the period of social restriction imposed by the pandemic, the scientific community carried out several research protocols. These revealed results that relevantly demonstrate the harmful effect of the stress induced by the pandemic situation. This narrative review reports and discusses research results demonstrating impairments in psychiatric disorders such as autism spectrum disorder, dementia, eating disorders, schizophrenia, anxiety, and depression. In this sense, the community has identified a significant negative influence of social isolation on the mental health of individuals through the modification of individual routines and the absence of social interactions. Moreover, the community identified perceived differences related to the impacts on men and women. In addition to studies showing the effect of social isolation on disorders, an evaluation of protocols with some possible therapeutic intervention strategies during times of social restriction was developed.

Relational attitudes in adolescent girls with and without a diagnosis of anorexia nervosa or atypical anorexia nervosa

BACKGROUND

People with eating disorders experience interpersonal difficulties, but little research explores relational attitudes in this population. We examined sense of relational entitlement towards parents, pathological concern, and psychological distress in adolescent girls with and without anorexia nervosa (AN) or atypical anorexia nervosa (AAN).

METHODS

Questionnaires assessing sense of entitlement towards parents, pathological concern, and symptoms of depression and anxiety were completed by 85 girls with and 100 girls without AN/AAN (mean age 15.06 ± 1.41). The AN/AAN group also completed a measure of ED pathology.

RESULTS

Eating pathology, pathological concern and symptoms of depression and anxiety were positively associated with both restricted and inflated sense of entitlement towards parents. AN/AAN participants scored significantly higher than controls on restricted and inflated sense of entitlement, pathological concern and symptoms of depression and anxiety. Restricted sense of entitlement and pathological concern partially mediation the association between AN/AAN and symptoms of depression and fully mediated the association between AN/AAN and anxiety. Within the AN/AAN group, pathological concern and symptoms of depression explained a large proportion of the variance in ED pathology.

CONCLUSIONS

Adolescent AN/AAN takes a heavy toll on emotional and social health, perhaps in part because crucial aspects of relational mutuality fail to develop. Teens with AN/AAN tend to over-focus on their parents' needs at the expense of their own needs. They also have impaired capacity to realistically appraise expectations from their parents, tending to feel over- and/or under-entitled to need fulfillment. These relational attitudes are associated with symptoms of depression and anxiety and should be addressed in therapy.

Characteristics of white matter alterations along fibres in patients with bulimia nervosa: A combined voxelwise and tractography study

Accumulating evidence supports the hypothesis that white matter (WM) abnormalities are involved in the pathophysiology of bulimia nervosa (BN); however, findings from in vivo neuroimaging studies have been inconsistent. We aimed to investigate the possible brain WM alterations, including WM volume and microstructure, in patients with BN. We recruited 43 BN patients and 31 healthy controls (HCs). All participants underwent structural and diffusion tensor imaging. Differences in WM volume and microstructure were evaluated using voxel-based morphometry, tract-based spatial statistics, and automated fibre quantification analysis. Compared with HCs, BN patients showed significantly decreased fractional anisotropy in the middle part of the corpus callosum (nodes 31-32) and increased mean diffusivity in the right cranial nerve V (CN V) (nodes 27-33 and nodes 55-88) and vertical occipital fasciculus (VOF) (nodes 58-85). Moreover, we found decreased axial diffusivity in the right inferior fronto-occipital fasciculus (node 67) and increased radial diffusivity in the CN V (nodes 22-34 and nodes 52-89) and left VOF (nodes 60-66 and nodes 81-85). Meanwhile, WM microstructural changes were correlated with patients' clinical manifestations. We did not find any significant differences in WM volume and the main WM fibre bundle properties between BN patients and HCs. Taken together, these findings provide that BN shows significant brain WM reorganization, but primarily in microstructure (part of WM fibre bundle), which is not sufficient to cause changes in WM volume. The automated fibre quantification analysis could be more sensitive to detect the subtle pathological changes in a point or segment of the WM fibre bundle.

Avoidant Restrictive Food Intake Disorder: A Narrative Review of Types and Characteristics of Therapeutic Interventions

The diagnosis of avoidant/restrictive food intake disorder (ARFID) was added to the diagnostic and statistical manual of mental disorders (DSM-5) just 10 years ago. This disorder consists of the failure to meet one's nutritional and/or energy needs, which may result in significant weight loss, significant nutritional deficit or functioning dependent on enteral nutrition or oral supplements. In children with this disorder, development is often problematic, and there is also marked interference with psychosocial functioning at all ages. The causes leading to food avoidance in these patients may be related to a lack of interest, to the sensory properties of the food or to the possible adverse consequences associated with it. Given the multitude of aspects involved in this disorder and the impact it has especially on younger patients, more and more studies are addressing treatments and related benefits and/or complications. A narrative review of currently published studies was performed for articles published before 5 March 2023 on therapeutic interventions in patients with ARFID. Because of the large number of results obtained, this review was conducted only via PubMed in order to analyze and discuss children and adolescent ARFID treatments reported in literature. The treatments most often referred to in the literature are cognitive behavioral therapy, family-based therapy and pharmacological treatment. All the data on these treatments are promising. However, due to the recent introduction of this disorder and the limited data still available, a multidisciplinary approach seems to be the best option.

Pharmacological strategies for appetite modulation in eating disorders: a narrative review

BACKGROUND

A substantial increase in the prevalence of eating disorders has been noticed over the past decades. Priority in the treatment of eating disorders is justifiably given to psychosocial interventions. However, it is also well known that centrally acting drugs can significantly affect appetite and food consumption.

AIM

To narratively review the available neurobiological data on the mechanisms of central regulation of eating behavior as a rationale to summarize pharmacological strategies for appetite modulation in eating disorders.

METHODS

The authors have carried out a narrative review of scientific papers published from January 2013 to March 2023 in the PubMed and Web of Science electronic databases. Studies were considered eligible if they included data on the neurobiological mechanisms of appetite regulation or the results of clinical trials of centrally acting drugs in eating disorders. Relevant studies were included regardless of their design. Descriptive analysis was used to summarize the obtained data.

RESULTS

The review included 51 studies. The available neurobiological and clinical data allowed us to identify the following pharmacological strategies for appetite modulation in eating disorders: serotonergic, catecholaminergic, amino acidergic and peptidergic. However, implementation of these data into clinical practice difficult due to an insufficient number of good-quality studies, which is particularly relevant for adolescents as there is a research gap in this population.

CONCLUSION

The progress in neurobiological understanding of the mechanisms of central regulation of appetite opens opportunities for new pharmacotherapeutic approaches aimed at changing the patterns of eating behavior. Obviously, treatment of eating disorders is a much broader problem and cannot be reduced to the correction of eating patterns. Nevertheless, at certain stages of treatment, drug-induced modulation of appetite can play an important role among multi-targeted biological and psychosocial interventions. Translation of neurobiological data into clinical practice requires a large number of clinical studies to confirm the long-term efficacy and safety of pharmacotherapeutic approaches and to develop personalized algorithms for the treatment of various forms of eating disorders in different age groups.

State-specific alterations in the neural computations underlying inhibitory control in women remitted from bulimia nervosa

The neurocomputational processes underlying bulimia nervosa and its primary symptoms, out-of-control overeating and purging, are poorly understood. Research suggests that the brains of healthy individuals form a dynamic internal model to predict whether control is needed in each moment. This study tested the hypothesis that this computational process of inhibitory control is abnormally affected by metabolic state (being fasted or fed) in bulimia nervosa. A Bayesian ideal observer model was fit to behavioral data acquired from 22 women remitted from bulimia nervosa and 20 group-matched controls who completed a stop-signal task during two counterbalanced functional MRI sessions, one after a 16 h fast and one after a meal. This model estimates participants' trial-by-trial updating of the probability of a stop signal based on their experienced trial history. Neural analyses focused on control-related Bayesian prediction errors, which quantify the direction and degree of "surprise" an individual experiences on any given trial. Regardless of group, metabolic state did not affect behavioral performance on the task. However, metabolic state modulated group differences in neural activation. In the fed state, women remitted from bulimia nervosa had attenuated prediction-error-dependent activation in the left dorsal caudate. This fed-state activation was lower among women with more frequent past binge eating and self-induced vomiting. When they are in a fed state, individuals with bulimia nervosa may not effectively process unexpected information needed to engage inhibitory control. This may explain the difficulties these individuals have stopping eating after it begins.

Athletes with Eating Disorders: Analysis of Their Clinical Characteristics, Psychopathology and Response to Treatment

Eating disorders (ED) have frequently been described among athletes. However, their specific features and therapy responses are lacking in the literature. The aims of this article were to compare clinical, psychopathological and personality traits between ED patients who were professional athletes (ED-A) with those who were not (ED-NA) and to explore differences in response to treatment. The sample comprised n = 104 patients with ED (n = 52 ED-A and n = 52 matched ED-NA) diagnosed according to DSM-5 criteria. Evaluation consisted of a semi-structured face-to-face clinical interview conducted by expert clinicians and a psychometric battery. Treatment outcome was evaluated when the treatment program ended. ED-A patients showed less body dissatisfaction and psychological distress. No differences were found in treatment outcome among the groups. Within the ED-A group, those participants who performed individual sport activities and aesthetic sports presented higher eating psychopathology, more general psychopathology, differential personality traits and poor therapy outcome. Individual and aesthetic sports presented more severity and worse prognosis. Although usual treatment for ED might be similarly effective in ED-A and ED-NA, it might be important to develop preventive and early detection programs involving sports physicians and psychologists, coaches and family throughout the entire athletic career and afterwards.

Dimensional personality pathology and disordered eating in young adults: measuring the DSM-5 alternative model using the PID-5

Introduction

The Personality Inventory for DSM-5 (PID-5) is a self-report measure of personality pathology designed to measure pathological personality traits outlined in the DSM-5 alternative model of personality disorders. Within the extensive literature exploring the relationship between personality and disordered eating, there are few that explore the relationship between the PID-5 and disordered eating behaviours in a non-clinical sample of males and females: restrictive eating, binge eating, purging, chewing and spitting, excessive exercising and muscle building.

Methods

An online survey assessed disordered eating, PID-5 traits and general psychopathology and was completed by 394 female and 167 male participants aged 16-30. Simultaneous equations path models were systematically generated for each disordered eating behaviour to identify how the PID-5 scales, body dissatisfaction and age predicted behaviour.

Results

The results indicated that each of the six disordered behaviours were associated with a unique pattern of maladaptive personality traits. The statistical models differed between males and females indicating possible differences in how dimensional personality pathology and disordered eating relate.

Discussion

It was concluded that understanding disordered eating behaviour in the context of personality pathology may assist formulating potentially risky behaviour.

Modification of Body-Related Attentional Bias through Virtual Reality and Eye-Tracking in Healthy Participants: Implications for Anorexia Nervosa Treatments

Cognitive biases have a significant impact on the etiology and treatment of eating disorders (EDs). These biases, including selective attentional bias (AB) to disliked body parts, may reinforce concerns about body shape, fear of gaining weight and body image disturbances and may contribute to dietary restriction and restraint. Decreasing AB could reduce core symptoms in anorexia nervosa (AN). This study represents a preliminary exploration aiming to assess whether AB towards weight-related (WR) and non-weight-related (NW) body parts could be reduced through an AB modification task in a virtual reality (VR) environment in healthy participants. A total of 54 female participants, aged 22.98 ± 1.89, were recruited. The task consisted of directing the participants' attention towards all body parts equally in a VR setting. Eye-tracking (ET) measurements (complete fixation time [CFT] and number of fixations [NF]) were made before and after the task. The results showed a significant reduction of the AB in the two groups with an initial AB towards WR body parts or towards NW body parts. Participants showed a tendency to more balanced (non-biased) attention after the intervention. This study provides evidence of the usefulness of AB modification tasks in a non-clinical sample.

Life Events in the Etiopathogenesis and Maintenance of Restrictive Eating Disorders in Adolescence

Life events (traumatic and protective) may be critical factors associated with eating disorders and their severity. To date, there is little literature concerning the role of life events in adolescence. The main goal of this study was to explore in a sample of adolescent patients with restrictive eating disorders (REDs) the presence of life events in the year before enrolment and to characterize them according to timing. Furthermore, we investigated correlations between REDs severity and the presence of life events. In total, 33 adolescents completed the EDI-3 questionnaire to assess RED severity using EDRC (Eating Disorder Risk Composite), GPMC (General Psychological Maladjustment Composite), and the Coddington Life Events Scales-Adolescent (CLES-A) questionnaires to define the presence of life events in the last year. Of these, 87.88% reported a life event in the past year. A significant association emerged between elevated clinical GPMC and the presence of traumatic events: patients who had experienced at least one traumatic life event in the year before enrolment presented higher clinically elevated GPMC compared to patients who had not. These results suggest that obtaining early information about traumatic events in clinical practice may help prevent the occurrence of new events and improve patient outcomes.

The Family Caregiving Environment Associates with Adolescent Patients' Severity of Eating Disorder and Interpersonal Problems: A Cross-Sectional Study

The quality of family interactions may be a critical factor for restrictive eating disorders (REDs). Adolescent patients with RED have interpersonal problems that can be inferred by observing their behaviours during family interactions. To date, the assessment of the association among RED severity, interpersonal problems, and patients' interactive behaviours in the family is partially explored. This cross-sectional study aimed to explore how adolescent patients' interactive behaviours observed during the Lausanne Trilogue Play-clinical version (LTPc) were associated with both RED severity and interpersonal problems. Sixty adolescent patients completed the EDI-3 questionnaire to assess RED severity using the Eating Disorder Risk Composite (EDRC) and Interpersonal Problems Composite (IPC) subscales. Moreover, patients and their parents took part in the LTPc, and patients' interactive behaviours were coded as participation, organization, focal attention, and affective contact in all the LTPc four phases. A significant association emerged between patients' interactive behaviours during the LTPc triadic phase and both EDRC and IPC. Better patients' organization and affective contact significantly correlated with lower RED severity and fewer interpersonal problems. These findings suggest that investigating the quality of family relationships and patients' interactive behaviours may contribute to better identifying adolescent patients at risk for more severe conditions.

The Follow-Up of Eating Disorders from Adolescence to Early Adulthood: A Systematic Review

Eating disorders (EDs) are common among children and adolescents and are characterized by excessive concerns for physical appearance, distorted body image, and fear of gaining weight. The purpose of this review is to evaluate the follow-up of EDs from adolescence to adulthood, analyzing persistence, relapses, and associated comorbidities. We searched scientific articles in PubMed, PsycInfo, Scopus, and Embase through two research strings, one for quantitative outcomes (recovery/persistence, relapse, and remission) and one for the other outcomes (psychiatric and medical comorbidities, substance use, and social-relational complications). From a total of 8043 retrieved articles, we selected 503 papers after exclusion of duplicates and title/abstract screening. After a full-text evaluation, we included 16 studies eligible for this review. We performed a meta-analysis describing the quantitative results, and we created a narrative synthesis for the qualitative outcomes. Results: Our results confirm that EDs can persist in early adulthood in 40.7% of cases with a relapse percentage of 24.5%. Individuals with an ED more frequently present with an empathy deficit and comorbid anxiety and depressive disorders. EDs are chronic and complex disorders, more frequent in females. In most cases, EDs reduce the autonomy of individuals who present many difficulties in affirming their independence from parental family.

Addressing eating disorders through legislation: The Israeli 'Models' Law'-process, enactment, and dilemmas

Preventing the onset of eating disorders and disordered eating pathology is crucial. While these conditions have a multi-factorial etiology, socio-cultural norms, particularly the media, contribute greatly. Policy and legislative action are warranted to change harmful media images. To the best of our knowledge, Israel was the first country to tackle the problem of unrealistic and unhealthy images in the media through legislation by initiating and passing an innovative law. The "Knesset," the Israeli Parliament, voted in December 2012 to pass new legislation that forbids the appearance of underweight models (BMI of 18.5 or less) in commercial advertising. The law further requires that if a graphic editing program has been used to reduce the dimensions of a model in advertising photographs, this fact must be clearly indicated. The purpose of this article is to describe the law; the process and obstacles to creating and passing the law in the Knesset; national and international reactions to this Israeli law; and the challenges of implementing (enacting and enforcing) this law in Israel. Given that other countries are implementing similar policies, additional legal approaches are described, including ideas for further research on how to enact, enforce, and evaluate the impact of such laws.

Body weight distortions in an auditory-driven body illusion in subclinical and clinical eating disorders

Previous studies suggest a stronger influence of visual signals on body image in individuals with eating disorders (EDs) than healthy controls; however, the influence of other exteroceptive sensory signals remains unclear. Here we used an illusion relying on auditory (exteroceptive) signals to manipulate body size/weight perceptions and investigated whether the mechanisms integrating sensory signals into body image are altered in subclinical and clinical EDs. Participants' footstep sounds were altered to seem produced by lighter or heavier bodies. Across two experiments, we tested healthy women assigned to three groups based on self-reported Symptomatology of EDs (SED), and women with Anorexia Nervosa (AN), and used self-report, body-visualization, and behavioural (gait) measures. As with visual bodily illusions, we predicted stronger influence of auditory signals, leading to an enhanced body-weight illusion, in people with High-SED and AN. Unexpectedly, High-SED and AN participants displayed a gait typical of heavier bodies and a widest/heaviest visualized body in the 'light' footsteps condition. In contrast, Low-SED participants showed these patterns in the 'heavy' footsteps condition. Self-reports did not show group differences. The results of this pilot study suggest disturbances in the sensory integration mechanisms, rather than purely visually-driven body distortions, in subclinical/clinical EDs, opening opportunities for the development of novel diagnostic/therapeutic tools.

Long-term follow-up of a randomized controlled trial comparing systemic family therapy (FT-S) added to treatment as usual (TAU) with TAU alone in adolescents with anorexia nervosa

BACKGROUND

Randomized controlled trials showed the efficacy of family therapy for anorexia nervosa during adolescence, but studies examining its long-term beneficial effect are still needed. This article presents the results of a 54-month post-randomization follow-up of a previously reported randomized controlled trial that compared two post-hospitalization outpatient treatment programs: Treatment As Usual alone versus Systemic Family Therapy added to Treatment As Usual.

METHODS

A consecutive series of 60 female adolescents with anorexia nervosa (DSM-IV) were randomized (30 per group). During the first 18 months, in the Treatment As Usual group, subjects received a multidisciplinary treatment. In the other group, Systemic Family Therapy sessions targeting intra-familial dynamics were added to Treatment As Usual. At 54 months, the primary outcome was defined using the Morgan and Russell global Outcome Categories (Good or Intermediate versus Poor). Secondary outcomes were the Global Outcome Assessment Schedule score, body mass index, amenorrhea, number of hospitalizations, eating disorder symptoms, psychopathological features, and family functioning. Analyses were carried out using an Intention-To-Treat with the Last Observation Carried Forward procedure. Data of 59/60 subjects were available.

RESULTS

At 54 months, significant effects in favor of adding Systemic Family Therapy to Treatment As Usual were shown for the Global Outcome Categories (60% of Good/Intermediate versus 31% in the control group, p = .026), mean body mass index (p = .048), resumption of menses (70.0% vs. 40% p = .020), and mental state score (p = .010). Family cohesion scores were lower in the Systemic Family Therapy group (p = .040).

CONCLUSIONS

Adding Systemic Family Therapy focusing on intra-familial dynamics to a multidimensional outpatient treatment program appeared to lead to a better long-term outcome in young women who suffered from severe anorexia nervosa during adolescence.

Navigating feminist and biomedical conceptual frameworks in educational interventions for eating disorders: Spanish educators’ understandings of the causes and treatment of eating disorders

The biomedical view of eating disorders (EDs) dominates in their classification and treatment regardless of the importance of sociocultural factors in EDs. Critical feminist approaches to EDs try to relate them to oppressive situations, disempowerment and the construction of gender. Educational interventions with people with EDs may be an alternative to biomedical approaches, giving them opportunities to tell their stories, listen to themselves and take control of their lives. This article presents a thematic analysis of semi-structured interviews with professionals who carry out educational interventions for people with EDs. Findings show that the biomedical description and treatment of EDs remain unchallenged and recognising client voice may be a problem, even in educational interventions. Also, the potential negative consequences of the rigid control of the clients’ lives seem to be ignored. Feminist approaches to EDs are acknowledged but do not seem to guide any intervention. Sociocultural critical stances that would recognise the coherence or the transitions between what is considered as healthy and sick eating also seem to be lacking.

The cerebellum gains weight: A systematic review of alterations in cerebellar volume and cerebro-cerebellar functional alterations in individuals with eating disorders

BACKGROUND

Brain imaging studies on eating disorders (EDs) often reported volumetric and functional changes involving the cerebellum. Nevertheless, few studies performed in-depth examinations and suggested a cerebellar role in the EDs' pathophysiology.

METHODS

A systematic literature search on volumetric changes and functional alterations involving the cerebellum in individuals with EDs was conducted using PubMed, PsychInfo and Web of Science. This review was conducted according to the Preferred Reporting Items for Systematic Reviews (PRISMA) statement and Rayyan web application for screening studies.

RESULTS

Twenty-four papers reporting cerebellar alterations in individuals with EDs were included in the study: 9 assessing brain volumetric changes, 9 investigating task-based functional brain activation and 6 investigating brain functional connectivity at rest. Most studies focused on anorectic-type EDs (n.22), while fewer involved bulimic-type EDs (n.9) and eating disorders not otherwise specified (n.2), revealing subtypes-specific patterns of altered cerebellar volume and functionality.

CONCLUSIONS

This review proposes critical arguments to consider the cerebellum as a key structure in the pathophysiology of EDs that requires further forthcoming exploration.

Substantial Fat Loss in Physique Competitors Is Characterized by Increased Levels of Bile Acids, Very-Long Chain Fatty Acids, and Oxylipins

Weight loss and increased physical activity may promote beneficial modulation of the metabolome, but limited evidence exists about how very low-level weight loss affects the metabolome in previously non-obese active individuals. Following a weight loss period (21.1 ± 3.1 weeks) leading to substantial fat mass loss of 52% (−7.9 ± 1.5 kg) and low body fat (12.7 ± 4.1%), the liquid chromatography-mass spectrometry-based metabolic signature of 24 previously young, healthy, and normal weight female physique athletes was investigated. We observed uniform increases (FDR < 0.05) in bile acids, very-long-chain free fatty acids (FFA), and oxylipins, together with reductions in unsaturated FFAs after weight loss. These widespread changes, especially in the bile acid profile, were most strongly explained (FDR < 0.05) by changes in android (visceral) fat mass. The reported changes did not persist, as all of them were reversed after the subsequent voluntary weight regain period (18.4 ± 2.9 weeks) and were unchanged in non-dieting controls (n = 16). Overall, we suggest that the reported changes in FFA, bile acid, and oxylipin profiles reflect metabolic adaptation to very low levels of fat mass after prolonged periods of intense exercise and low-energy availability. However, the effects of the aforementioned metabolome subclass alteration on metabolic homeostasis remain controversial, and more studies are warranted to unravel the complex physiology and potentially associated health implications. In the end, our study reinforced the view that transient weight loss seems to have little to no long-lasting molecular and physiological effects.

Associations between Schizotypal Facets and Symptoms of Disordered Eating in Women

Research has suggested that schizotypy-a personality organisation representing latent vulnerability for schizophrenia-spectrum disorders-may be elevated in women with symptoms of disordered eating. However, studies have not fully considered associations between symptoms of disordered eating and multidimensional schizotypy. To overcome this limitation, we asked an online sample of 235 women from the United States to complete measures of symptoms of disordered eating (drive for thinness, body dissatisfaction, and bulimic symptoms) and multidimensional schizotypy. Correlational analyses indicated significant associations between drive for thinness and bulimic symptoms, respectively, and most schizotypal facets. Body dissatisfaction was significantly associated with only two schizotypal facets. Overall, the strength of correlations was weak-to-moderate. Regression results indicated that only the schizotypal feature of excessive social anxiety was significantly associated with all risk for disordered eating factors. These results are consistent with aetiological models of disordered eating that highlight socio-affective difficulties as risk factors for symptoms of disordered eating.

Parental bonding, depression, and suicidal ideation in medical students

Background

The psychological condition of university students has been the focus of research since several years. In this population, prevalence rates of depression, suicidal ideation, anxiety disorders and substance abuse are higher than those of the general population, and medical students are more likely to have mental health issues than other students.

Aims

This study deals with the psychological condition of medical students, with a focus on correlations between depression, suicidal ideation and the quality of the perceived parenting style. Gender differences were also considered.

Methods

A cross-sectional study was conducted on a population of medical students, with an online questionnaire consisting of a personal data sheet for demographic and anamnestic data, and of three self-rating scales: the Beck Depression Inventory II (BDI-II), for the screening of depressive symptoms; the Beck Hopelessness Scale (BHS), to assess suicidal ideation; the Parental Bonding Instrument (PBI), to investigate the memory of the attitude of one’s parents in the first 16 years of life. Two main affective dimensions were considered by PBI: “care” (affection and empathy) and “protection” (intrusiveness, controlling and constraint). Four different patterns of parenting styles are so evidenced: Neglectful Parenting (low care/low protection), Affectionless Control (low care/high protection), Optimal Parenting (high care/low protection), and Affectionate Constraint (high care/high protection).

Results

Overall, 671 students (182 males and 489 females) participated. Females, compared to males, experienced more distress and self-injurious behaviors, while males experienced more drugs or alcohol abuse. The BHS and BDI-II scores correlated positively with the PBI score for “protection” and negatively with that for “care.” Affectionless Control and Neglectful Parenting were associated with higher medians of BHS and BDI-II scores.

Conclusion

The study confirms that the undergraduate medical student population has higher prevalence of depression and suicidal ideation than those detectable in the general population (respectively, 50.2% and 16.7% vs. 15–18% and 9.2%) and that some specific parenting styles correlate with these two clinical variables. The impact of Affectionless Control and Neglectful Parenting on suicidal ideation and depressive symptomatology was more pronounced in females than in males. For males, the role of the father seemed to have less impact on the affective roots of suicidal thoughts and depression.

The impact of personality disorders and personality traits on psychotherapy treatment outcome of eating disorders: A systematic review

A significant proportion of those with eating disorders (EDs) do not respond to first-line treatments. This systematic review was conducted to identify whether personality disorders (PDs)/traits predict or moderate ED treatment outcomes and whether these outcomes were differentially influenced by ED or PD diagnostic subtypes, or treatment approach. A comprehensive systematic literature search was conducted using the PRISMA guidelines. A total of seven randomised controlled trials (RCTs) plus four follow-up studies were reviewed investigating the impact of PD and PD traits on treatment outcomes for EDs. The majority indicated that PD had some impact on treatment outcomes. Outcome measures and time-point measurements varied across studies. Included studies suggested that bulimia nervosa treatment outcomes were not hindered by co-morbidity of borderline PD; however, psychiatric impairment remained high at post-treatment and follow-up. Cluster C PDs were found to negatively impact treatment outcomes for binge ED and attrition rates for anorexia nervosa. Included studies suggested that interventions that addressed aspects of personality pathology showed greater main effects for ED treatment outcomes. There is an urgent need for future RCTs on ED treatments to include routine measures of core personality features to allow their impacts to be more thoroughly examined and for psychotherapies to be tailored accordingly.

A case series of group-based ketamine-assisted psychotherapy for patients in residential treatment for eating disorders with comorbid depression and anxiety disorders

BACKGROUND

Depression and anxiety outcome measures, safety/tolerability, patient satisfaction, and ease of implementation of group-based ketamine-assisted psychotherapy (G-KAP) delivered to patients in intensive residential eating disorder (ED) treatment were assessed.

CASE PRESENTATION

This study reports on five participants with a diagnosis of an ED and comorbid mood and anxiety disorders who received weekly intramuscular ketamine injections in a group setting over 4 weeks. Measures of anxiety (GAD-7) and depression (PHQ-9) were administered pre-dose, 4-h post-dose, and 24-h post dose. Four of the 5 participants experienced clinically significant improvements on the PHQ-9 score (i.e., change greater than 5) while 2 of the 5 participants experienced clinically significant improvements on the GAD-7 score (i.e., change greater than 4) from pre-dose to 24-h post-dose after the last ketamine session. Dosing sessions were well tolerated, and no serious adverse events were reported. Clinical observations and participant reports corroborated improvements in depression and anxiety symptoms, good tolerability of ketamine treatment, and practical implementation of the G-KAP protocol in a residential ED treatment center.

CONCLUSIONS

This study suggests the potential utility of G-KAP as an adjunct to intensive, specialized ED treatment. Overall, this novel, cross-diagnostic intervention warrants future research to further explore its appropriateness in a treatment setting.

Interoceptive Awareness and Anorexia Nervosa: When Emotions Influence the Perception of Physiological Sensations

ABSTRACT

Anorexia nervosa (AN) is related to difficulties in emotion regulation, including a deficit in interoceptive awareness. The lack of interoceptive awareness is considered a vulnerability involved in the development and maintenance of anorexic symptoms. Surprisingly, no study has been conducted that focuses on these associations in an emotional context. This study measures the interoceptive awareness-using heartbeat self-counting and a sphygmomanometer-of 25 subjects suffering from AN and 25 control subjects, first at rest and then in an emotional situation. The results show that a deficit in interoceptive awareness was observed for the subjects suffering from AN at rest as well as when an emotional context was induced. This study encourages future investigations to focus on the impact of interoceptive deficit in AN to develop as efficient a care regimen as possible for these subjects.

Investigation of Loneliness and Social Support in Patients with Eating Disorders: A Case-Control Study

Loneliness and, to a lesser degree, social support are considered under-researched topics in the literature on eating disorders (ED). This study attempted to expand the relevant body of research by examining loneliness in combination with social support in ED patients and in healthy controls (HC). Binge-eating problems, emotional eating, resilience, anxiety, and depression symptoms were also assessed. Thirty-two patients with ED and twenty-nine HC completed the following measures: UCLA Loneliness Scale, Social Support Questionnaire—Short Form, Binge Eating Scale, Emotional Eating Scale, Connor–Davidson Resilience Scale, Hospital Anxiety and Depression Scale, and the Eating Disorder Examination Questionnaire. Eating-disorder patients showed higher levels of loneliness and lower levels of social support—both in terms of perceived availability and satisfaction—than HC. Anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) subgroups did not differ significantly on either of these variables. In ED patients, loneliness was only correlated with Social Support Satisfaction (negatively) and depressive symptomatology (positively). Patients with ED appear to be lonelier and less satisfied with their social support compared to HC. We found similar levels of loneliness and social support between AN, BN, and BED sufferers. Decreased social support satisfaction and elevated symptoms of depression could account for ED patients’ high levels of loneliness.

Modern neurosurgical techniques for psychiatric disorders

Psychosurgery refers to an ensemble of more or less invasive techniques designed to reduce the burden caused by psychiatric diseases in patients who have failed to respond to conventional therapy. While most surgeries are designed to correct apparent anatomical abnormalities, no discrete cerebral anatomical lesion is evident in most psychiatric diseases amenable to invasive interventions. Finding the optimal surgical targets in mental illness is troublesome. In general, contemporary psychosurgical procedures can be classified into one of two primary modalities: lesioning and stimulation procedures. The first group is divided into (a) thermocoagulation and (b) stereotactic radiosurgery or recently introduced transcranial magnetic resonance-guided focused ultrasound, whereas stimulation techniques mainly include deep brain stimulation (DBS), cortical stimulation, and the vagus nerve stimulation. The most studied psychiatric diseases amenable to psychosurgical interventions are severe treatment-resistant major depressive disorder, obsessive-compulsive disorder, Tourette syndrome, anorexia nervosa, schizophrenia, and substance use disorder. Furthermore, modern neuroimaging techniques spurred the interest of clinicians to identify cerebral regions amenable to be manipulated to control psychiatric symptoms. On this way, the concept of a multi-nodal network need to be embraced, enticing the collaboration of psychiatrists, psychologists, neurologists and neurosurgeons participating in multidisciplinary groups, conducting well-designed clinical trials.

Examining Shared Pathways for Eating Disorders and Obesity in a Community Sample of Adolescents: The REAL Study

Several psychosocial models have been proposed to explain the etiology of eating disorders (EDs) and obesity separately despite research suggesting they should be conceptualized within a shared theoretical framework. The objective of the current study was to test an integrated comprehensive model consisting of a host of common risk and protective factors (socio-environmental, psychological, and behavioral) expected to explain both eating and weight disorders simultaneously in a large school-based sample of adolescents. Data were collected from 3,043 youth (60% female, 14.00 ± 1.61) from 41 schools in the Ottawa region, Canada. Working with interested school staff, validated self-report scales in the form of a questionnaire booklet were administered to participating students to assess several understood risk and protective factors common to both eating disorders and obesity. Anthropometric measurements of weight and height were taken at the end of the questionnaire administration period by trained research staff. Structural equation modeling with cross-validation was used to test the hypothesized model. Findings demonstrated that dysregulated eating was associated with both eating disorder and weight status with diet culture and emotion dysregulation directly associated with some of these disordered eating patterns. It equally pointed to how lifestyle made up of high sedentary behaviors, low vigorous exercise and varied eating patterns contributed to both emotion dysregulation and poor body image which subsequently affected eating issues and weight status simultaneously, signaling the complex interplay of psychosocial factors that underlie these concerns. This study provides evidence for an integrated psychosocial model consisting of socio-environmental, psychological, and behavioral factors may best explain the complex interplay of risk and protective factors influencing eating disorders and obesity. It equally highlights understanding the direct and indirect effects of some of the most salient risk factors involved in eating and weight-related concerns, including the strong effects of diet culture and stressors such as weight-based teasing, providing interventionalists evidence of important risk factors to consider targeting in eating disorder and weight-based prevention efforts.

Shedding light on biological sex differences and microbiota-gut-brain axis: a comprehensive review of its roles in neuropsychiatric disorders

Women and men are suggested to have differences in vulnerability to neuropsychiatric disorders, including major depressive disorder (MDD), generalized anxiety disorder (GAD), schizophrenia, eating disorders, including anorexia nervosa, and bulimia nervosa, neurodevelopmental disorders, such as autism spectrum disorder (ASD), and neurodegenerative disorders including Alzheimer’s disease, Parkinson’s disease. Genetic factors and sex hormones are apparently the main mediators of these differences. Recent evidence uncovers that reciprocal interactions between sex-related features (e.g., sex hormones and sex differences in the brain) and gut microbiota could play a role in the development of neuropsychiatric disorders via influencing the gut–brain axis. It is increasingly evident that sex–microbiota–brain interactions take part in the occurrence of neurologic and psychiatric disorders. Accordingly, integrating the existing evidence might help to enlighten the fundamental roles of these interactions in the pathogenesis of neuropsychiatric disorders. In addition, an increased understanding of the biological sex differences on the microbiota–brain may lead to advances in the treatment of neuropsychiatric disorders and increase the potential for precision medicine. This review discusses the effects of sex differences on the brain and gut microbiota and the putative underlying mechanisms of action. Additionally, we discuss the consequences of interactions between sex differences and gut microbiota on the emergence of particular neuropsychiatric disorders.

The human microbiome is a unique set of organisms affecting health via the gut–brain axis.

Neuropsychiatric disorders, eating disorders, neurodevelopmental disorders, and neurodegenerative disorders are regulated by the microbiota–gut–brain axis in a sex-specific manner.

Understanding the role of the microbiota–gut–brain axis and its sex differences in various diseases can lead to better therapeutic methods.

Patient perspectives on premature termination of eating disorder treatment: a systematic review and qualitative synthesis

BACKGROUND

High rates of premature treatment termination are a well-reported issue in eating disorder treatment, and present a significant barrier for treatment effectiveness and longer term health outcomes of patients with eating disorders. Understanding patient perspectives on this phenomenon is essential in improving treatment completion rates and informing research and intervention development. The aim of this review is to synthesise qualitative literature on patient perspectives of premature termination of eating disorder treatment and to summarise the key issues leading to discontinuation of treatment.

METHODS

A systematic review of 1222 articles was conducted to identify studies using qualitative methods to investigate patient experiences of prematurely terminating eating disorder treatment. Ten articles were included in the review, with thematic synthesis used to analyse the primary research and develop overarching analytical themes.

RESULTS

Conflict around enmeshment of eating disorder with identity, and lack of support with reconstructing a sense of self without the eating disorder; challenges of managing pressures of social and clinical relationships while feeling unheard and misunderstood by both; expectations and disappointments around treatment; and dissatisfaction with progress were key themes behind premature termination of treatment.

CONCLUSIONS

The findings of this review demonstrate the key issues influencing the decision to end treatment early, highlighting the contribution of individual, environmental, and service-level factors. Implications of these factors are discussed and suggestions raised for future research and service development.

The relationship between disordered eating behaviour and the five factor model personality dimensions: A systematic review

The relationship between personality and eating disorders has received significant research attention. This review aimed to synthesize research regarding the Five Factor Model (FFM) and disordered eating behaviors, to gain an improved understanding of the relationship between normal-range personality and subclinical eating disorders. Electronic Databases were used to identify studies published in English that utilized self-report measures of disordered eating and the FFM. A qualitative synthesis of 45 papers was then conducted. High scores on Neuroticism were associated with increased disordered eating behavior. Different disordered eating behaviors were found to have unique relationships with personality dimensions. Facets within domains varied in direction of correlation with disordered eating behaviors, particularly in the Agreeableness, Contentiousness, and Openness domains. The results indicate that, further research is needed before generalizing treatment approaches for eating disorders for females, males, and gender diverse populations.

Anorexia Nervosa, Body Image Perception and Virtual Reality Therapeutic Applications: State of the Art and Operational Proposal

Anorexia Nervosa (AN) patients exhibit distorted body representation. The purpose of this study was to explore studies that analyze virtual reality (VR) applications, related to body image issues, to propose a new tool in this field. We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, Scopus, and Web of Science databases were explored; the review included 25 studies. Research has increased over the last five years. The selected studies, clinical observational studies (n = 16), mostly concerning patients' population with AN (n = 14) or eating disorders (EDs) diagnosis, presented multiple designs, populations involved, and procedures. Some of these studies included healthy control groups (n = 7). Studies on community sample populations were also selected if oriented toward clinical applications (n = 9). The VR technologies in the examined period (about 20 years) have evolved significantly, going from very complex and bulky systems, requiring very powerful computers, to agile systems. The advent of low-cost VR devices has given a big boost to research works. Moreover, the operational proposal that emerges from this work supports the use of biofeedback techniques aimed at evaluating the results of therapeutic interventions in the treatment of adolescent patients diagnosed with AN.

Exploring eating and exercise-related indicators during COVID-19 quarantine in Portugal: concerns and routine changes in women with different BMI

PURPOSE

The present study aimed to understand how quarantine associated with COVID-19 was experienced by women from different BMI groups (underweight, normal weight, pre-obesity, and obesity), by exploring the changes introduced in eating and exercise routines and the differences between BMI groups regarding shape concern, weight concern, and binge eating behaviours reported during this time.

METHODS

This study comprised 580 women aged between 18 and 65 years old, who completed self-report measures, during the mandatory confinement in Portugal due to COVID-19. The total sample was divided into four groups, according to their BMI.

RESULTS

Results revealed that overall, there were no significant differences between the groups regarding the eating and exercise routine changes introduced during quarantine. However, significant differences between the four groups were found in the reported body and eating-related difficulties (shape concern, weight concern, and binge eating behaviours), with the pre-obesity and obesity groups presenting significant higher levels.

CONCLUSIONS

Our study suggests that, even though the changes introduced to the eating and exercise routine are independent of BMI, the pre-obesity and obesity group represent a major vulnerability group for the development of eating disorders. We hope this study allows professionals to understand the need to develop different guidelines and strategies for the pre-obesity and obesity female population during the deconfinement period.

LEVEL OF EVIDENCE

Level V-Descriptive study.

Cortisol, Depression, and Anxiety Levels Before and After Short-Term Intensive Nutritional Stabilization in Patients With Severe Anorexia Nervosa

INTRODUCTION

Depression and anxiety are well-known comorbid conditions in patients with anorexia nervosa (AN). Hypercortisolemia in patients with AN may be pathogenic and contribute to depression and anxiety symptomatology.

OBJECTIVE

The aim of this study was to investigate short-term changes in cortisol levels and depression and anxiety symptomatology following intensive re-nutrition in patients with severe AN and hospitalized in a specialized unit. Furthermore, we investigated the potential association between cortisol levels and psychometric parameters.

METHODS

A total of 36 patients with AN were enrolled in the study. Nine dropped out before follow-up. Patients underwent paraclinical and psychometric examinations at admission and discharge. Measurements included plasma cortisol, cortisol binding globulin (CBG), 24-h urine cortisol, and self-report questionnaires regarding eating disorder, depression, anxiety, and stress symptoms. Patients were hospitalized in the unit for somatic stabilization and intensive re-nutrition. Mean admission length was 41 days. The study was registered at ClinicalTrials.gov (NCT02502617).

RESULTS

Cortisol levels in blood and urine did not change from admission to discharge in patients with severe AN. Symptoms of depression, anxiety, stress, and eating disorder remained elevated at discharge. There were no associations between changes in cortisol levels and changes in psychometrics.

DISCUSSION

Our results suggest that short-term intensive re-nutrition did not alter hypothalamic-pituitary-adrenal axis activity or mental health in patients with severe AN. Long-term stabilization and longer follow-up after hospital discharge may be needed to detect changes in cortisol levels and whether these changes are associated with depression and anxiety symptomatology. Greater knowledge about cortisol levels and mental health in patients with severe AN may help in the development of new treatment choices for the chronically ill patients. Future studies could investigate whether cortisol-lowering drugs have a therapeutic effect on mental health in AN.

Stigmatising views towards individuals with eating disorders: trends and associations from 1998 to 2008 using a repeated cross-sectional design

BACKGROUND

Eating disorders are stigmatised. Little is known about whether stigma has decreased over time and which groups hold more stigmatising beliefs.

AIMS

To explore whether stigma towards eating disorders has changed between 1998 and 2008 and whether it varies by sociodemographic characteristics.

METHOD

We used the Office for National Statistics Omnibus surveys 1998 and 2008. As outcomes, we selected four questions eliciting participants' views on issues of blame and ability to recover, and compared their mean scores across eating disorders, depression and alcohol dependence in both years. We used multivariable linear regressions to investigate associations between sociodemographic characteristics and each stigma domain.

RESULTS

In total, 2720 participants had data on all variables of interest. Compared with 1998, in 2008 stigmatising views towards eating disorders improved. In both years, participants believed it was easier to recover from eating disorders than depression or alcohol dependence. Respondents believed people with eating disorders were more to blame for their condition than those with depression, but less than those with alcohol dependence. Men, those with less formal education, and those from ethnic minority backgrounds were more likely to place greater blame on individuals for their mental illness. Men were more likely than women to think it was possible to recover from an eating disorder.

CONCLUSIONS

Stigmatising attitudes towards people with eating disorders have improved over time, but are still greater than those observed for other mental illnesses. Improving eating disorder mental health literacy could help to reduce these negative views and lead to improved quality of life, greater help-seeking and better prognosis.

Do media portrayals and social consensus information impact anti-fat attitudes and support for anti-weight discrimination laws and policies?

Although weight stigma and discrimination are associated with increased body dissatisfaction and eating disorder risk, reduced opportunities, and poorer well-being, there are few legal protections for such discrimination in the U.S. We addressed one barrier to enacting protective legislation - public attitudes toward anti-weight discrimination laws - by assessing the impact of media representations of fatness and information about peer attitudes. Using a 2 × 2 experimental design, participants (N = 525) completed baseline assessments of political conservatism and weight bias and were randomly assigned to view fat-negative or fat-positive media content that was ostensibly supported or not supported by their peers, followed by questionnaires assessing fat phobia and legislative attitudes. Two-way ANCOVAs controlling for baseline weight bias and political conservatism indicated a significant effect for media framing, with greater fat phobia and less support for anti-discrimination laws and policies among those who viewed the fat-negative frame; however, effects for ostensible peer support and interaction effects were not significant. These preliminary findings suggest that efforts to shift media rhetoric may enhance support for anti-weight discrimination laws. Future research should investigate other barriers to anti-discrimination legislation and estimate their impact on body dissatisfaction, eating disorder risk, and other indicators of population health.

Possible role of the gut microbiota in the pathogenesis of anorexia nervosa

Anorexia nervosa (AN), an eating disorder, is characterized by extreme weight loss and fear of weight gain. Psychosocial factors are thought to play important roles in the development and progression of AN; however, biological factors also presumably contribute to eating disorders. Recent evidence has shown that the gut microbiota plays an important role in pathogenesis of neuropsychiatric disorders including AN. In this article, we describe the possible role of the gut microbiota in the development and persistence of AN, based on the latest research works, including those of our group.

Pretreatment unresolved-disorganized attachment status in eating disorder patients associated with stronger reduction of comorbid symptoms after psychotherapy

Research shows that the Unresolved-disorganized attachment representation (U), resulting from experiences of loss or abuse, is associated with a range of psychiatric conditions. However, clinical implications of U are yet unclear.Objective: To investigate how U is related to symptoms and recovery of eating disorder (ED) patients.Method: First, 38 ED patients starting psychotherapeutic treatment were compared to 20 controls without ED on the prevalence of U, assessed with the Adult Attachment Interview. Second, in the patient group relations between U and ED symptoms, depression, anxiety and subjective experience of symptoms were investigated. Third, we compared, 1 year afterwards, recovery of patients with and without U.Results: The prevalence of U was higher in ED patients than in controls. Symptom severity was not related to U. ED patients with U at the start of treatment improved significantly more regarding anxiety, depression and subjective experience of symptoms than did patients without U.Discussion: The differential recovery of ED patients with or without U confirms the trauma-related heterogeneity of patients found in other diagnostic groups and calls for further investigation into the treatment needs of patients with different attachment representations.

Disturbances in the experiences of embodiment related to attachment, mentalization and self-objectification in anorexia nervosa

BACKGROUND

Body image disturbance is central to both the understanding and treatment of anorexia nervosa (AN); however, the underlying psychological processes involved are still not well understood. One way towards a better understanding of these mechanisms may be to explore the sense of embodiment in these patients in an attempt at integrating the role of the body in our understanding of the development of self in AN. It is hypothesized that difficulties in affective experiences of embodiment is related to insecure attachment, deficits in mentalization and self-objectification.

METHODS

Sixteen inpatients with AN were interviewed with the Mirror Interview (MI). In the interview, the individual is asked a set of questions related to thoughts and feelings about the body while standing in front of a full-length mirror. Furthermore, all patients were assessed with the Adult Attachment Interview, which was coded for both attachment and mentalization (operationalized by the Reflective Functioning scale; RF). Self-objectification was measured with the Objectified Body Consciousness Scale (OBCS).

RESULTS

Results from a multiple regression analysis showed that Global MI scores were significantly associated with Coherence of mind as an indicator of attachment, RF and scores on the OBCS.

CONCLUSIONS

The study suggests that affective experiences of embodiment in patients with AN are associated with negative attachment representations, mentalizing impairments and objectified body consciousness. Body image disturbance is a key diagnostic feature in anorexia nervosa but the underlying psychological processes are poorly understood. Recently, there has been a growing interest in how disturbances in the more psychological experience of the body (embodiment) in anorexia nervosa is related to both attachment, how individuals make sense of both themselves and others and the degree to which they tend to experience ourselves from the outside. In this pilot study, this was assessed with an innovative interview, the Mirror Interview, where the individual is asked a set of question while standing in front of a full length mirror. Results showed that difficulties in embodied experiences in patients with anorexia nervosa were related to more fundamental representations of self and self-objectification. This has potential implications for both the understanding and treatment of anorexia nervosa, as disturbances in body image may be seen as an underlying factor in the development of an eating disorder.

Sleep Quality and Eating Disorder-Related Psychopathologies in Patients with Night Eating Syndrome and Binge Eating Disorders

Night eating syndrome (NES) is an eating disorder (ED) characterized by nocturnal ingestion (NI), evening hyperphagia, morning anorexia, as well as mood and sleep disturbances. This study compared subjective and objective sleep quality and ED-related psychopathologies in patients seeking treatment for ED. Method: The sample was composed of 170 women, aged 18–68, who were referred for an ED assessment from 2011 to 2020. The participants were divided into three subgroups: NES-NI only (n = 30), NES+ binge eating (BE) (including binge eating disorders or bulimia nervosa (n = 52), and BE-only (n = 88). The measures consisted of a psychiatric evaluation, objective sleep monitoring measured by an actigraph for 1 week, a subjective sleep self-report, and ED-related psychopathology questionnaires. Results: Objective sleep monitoring revealed significant group differences, with higher sleep efficiency in participants with BE-only and longer sleep durations for the NES-NI only group. Subjectively, the BE-only group described a significantly lower sleep quality than either the NES-NI only or the NES+BE groups. ED-related psychopathology was lower in the NES-NI-only group. A stepwise linear regression revealed that general psychopathology (the brief symptom inventory total score) was a significant predictor of subjective sleep quality. Conclusion: NES-NI-only was correlated with less psychopathology, but with more subjective and objective sleep disturbances. These results lend weight to the supposition that NES lies on a continuum of ED psychopathologies, and that NES-NI-only appears to be a separate entity from NES+BE and BE-only in terms of its psychopathology.