Impaired cortisol awakening response in eating disorder women with childhood trauma exposure: evidence for a dose-dependent effect of the traumatic load

The maltreated eco-phenotype of eating disorders: A new diagnostic specifier? A systematic review of the evidence and comprehensive description

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.

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

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.

Early traumatic experiences and the hypothalamus-pituitary-adrenal axis in people with eating disorders: A narrative review

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.

Trauma Experiences Are Common in Anorexia Nervosa and Related to Eating Disorder Pathology but Do Not Influence Weight-Gain during the Start of Treatment

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.

Novel ketamine and zinc treatment for anorexia nervosa and the potential beneficial interactions with the gut microbiome

Anorexia nervosa (AN) is a severe illness with diverse aetiological and maintaining contributors including neurobiological, metabolic, psychological, and social determining factors. In addition to nutritional recovery, multiple psychological and pharmacological therapies and brain-based stimulations have been explored; however, existing treatments have limited efficacy. This paper outlines a neurobiological model of glutamatergic and γ-aminobutyric acid (GABA)-ergic dysfunction, exacerbated by chronic gut microbiome dysbiosis and zinc depletion at a brain and gut level. The gut microbiome is established early in development, and early exposure to stress and adversity contribute to gut microbial disturbance in AN, early dysregulation to glutamatergic and GABAergic networks, interoceptive impairment, and inhibited caloric harvest from food (e.g., zinc malabsorption, competition for zinc ions between gut bacteria and host). Zinc is a key part of glutamatergic and GABAergic networks, and also affects leptin and gut microbial function; systems dysregulated in AN. Low doses of ketamine in conjunction with zinc, could provide an efficacious combination to act on NMDA receptors and normalise glutamatergic, GABAergic and gut function in AN.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

Child maltreatment and hypothalamic-pituitary-adrenal axis functioning: A systematic review and meta-analysis

Alterations in hypothalamic-pituitary-adrenal (HPA) axis and its effector hormone cortisol have been proposed as one possible mechanism linking child maltreatment experiences to health disparities. In this series of meta-analyses, we aimed to quantify the existing evidence on the effect of child maltreatment on various measures of HPA axis activity. The systematic literature search yielded 1,858 records, of which 87 studies (k = 132) were included. Using random-effects models, we found evidence for blunted cortisol stress reactivity in individuals exposed to child maltreatment. In contrast, no overall differences were found in any of the other HPA axis activity measures (including measures of daily activity, cortisol assessed in the context of pharmacological challenges and cumulative measures of cortisol secretion). The impact of several moderators (e.g., sex, psychopathology, study quality), the role of methodological shortcomings of existing studies, as well as potential directions for future research are discussed.

Urinary free cortisol and childhood maltreatments in eating disorder patients: New evidence for an ecophenotype subgroup

Introduction

Increasing neurobiological evidence has suggested the presence of a specific ecophenotype in people with eating disorders (EDs) linked to early maltreatment. Urinary‐free cortisol could strengthen the data and show specific relationships between maltreated subtypes and the hormonal profiles of patients with EDs. This study aims to evaluate the presence of different urinary cortisol in drug‐free patients in the acute phase of the disorder and its relationship with childhood maltreatment.

Methods

A sample of 78 female patients with ED is included in the study. Childhood maltreatment history and 24‐h urinary free cortisol (24‐h UFC) are evaluated at a specialised ED ward admission.

Results

Patients with a maltreatment history show more blunted 24‐h UFC levels than peers without childhood maltreatment (p = 0.001). Regression analysis showed that child abuse is a predictor of the reduction of 24‐h UFC (p < 0.001), with physical abuse (p = 0.011) and sexual abuse (p = 0.050) that could have a more specific impact than other maltreatment subtypes.

Discussion

Childhood maltreatment should be evaluated in ED patients due to its biological impact on the hormonal stress axis, which could impair the ability of patients to respond to standardized ED treatment.

Eating disorder patients with history of maltreatment showed a reduced 24‐h urinary free cortisol.

New data support the evidence about the presence of an ecophenotype ED subgroup.

Reduced 24‐h urinary free cortisol is significantly correlated with child abuses.

The connection between childhood maltreatment and eating disorder psychopathology: a network analysis study in people with bulimia nervosa and with binge eating disorder

PURPOSE

Childhood maltreatment (CM) experiences are associated with heightened risk of Eating disorders (EDs). The psychopathological pathways promoting this association in people with Bulimia nervosa (BN) and in those with Binge eating disorder (BED) are under-investigated.

METHODS

One hundred and eighty-one people with BN and 144 with BED filled in the Eating Disorder Inventory-2, to measure ED psychopathology, and the Childhood Trauma Questionnaire, to assess their early traumatic experiences. Network analysis was conducted to investigate the interplay between those variables. The shortest pathways function was employed to investigate the shortest out of all routes conveying the association between CM and ED-specific symptoms.

RESULTS

In both people with BN and with BED, all CM types were connected to the ED psychopathology through the emotional abuse node. The association between emotional abuse and ED-specific symptoms (bulimia and body dissatisfaction) differed in the two groups: in people with BN, it included ineffectiveness, while in people with BED, it involved impulsivity. Interoceptive awareness, an indirect measure of emotion regulation, was included in these pathways in both groups.

CONCLUSION

In the light of literature showing that emotional abuse has a connecting role between CM and ED psychopathology also in anorexia nervosa, the present findings support the idea that emotional abuse conveys such association in all the main ED diagnoses. Ineffectiveness and impulsivity may represent the specific psychopathological dimensions connected to emotional abuse and promoting the maintenance of ED-specific symptoms in BN and in BED, respectively. These findings are worth of attention by clinicians.

LEVEL OF EVIDENCE

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

Deciphering the Association Between Hypothalamus-Pituitary-Adrenal Axis Activity and Obesity: A Meta-Analysis

OBJECTIVE

Both the cortisol awakening response (CAR; corresponding to the state measurement) and hair cortisol concentration (HCC; corresponding to the trait measurement) are considered reliable markers of hypothalamus-pituitary-adrenal axis activity. Because cortisol has long been associated with adiposity, this systematic review and meta-analysis aims to summarize and compare the literature around CAR and HCC and their association with obesity or fat distribution indices.

METHODS

The PubMed, Web of Science (Web of Science Core Collection and Medline), EBSCO Information Services, Embase, and PsycNET databases were searched, and full-text articles investigating the association between CAR or HCC and markers of adiposity in humans were included. Meta-analyses were then performed to compare studies associating CAR or HCC with BMI (a marker of general adiposity) and waist circumference (a marker of fat distribution).

RESULTS

The results of this review highlight inconsistencies in cortisol sampling and CAR computation, which makes comparisons between studies difficult. It was found that adiposity indices are not associated with CAR but that they correlate significantly and positively with HCC. The subgroup analysis hinted to possible age differences in the magnitude of the association between HCC and BMI.

CONCLUSIONS

Trait rather than state measurement of the hypothalamus-pituitary-adrenal axis activity is associated with increased general and abdominal adiposity in humans.

Early childhood adversity and HPA axis activity in adulthood:The importance of considering minimal age at exposure

Early adversity (EA) modulates stress hormone secretion in mixed directions. The Accumulation Model suggests that the number of EA predicts patterns of cortisol dysregulations, while the Life Cycle Model of Stress highlights the importance of considering the timing at which EA began, given that brain regions sensitive to stress hormones follow distinct developmental trajectories. We aimed to test these two models in 85 healthy men and women, aged 21-40 years old who reported having been exposed to EA during childhood. Participants were grouped based on the number of EA events to which they were exposed during their lifespan (Accumulation Model) and the age of first exposure to EA (Life Cycle Model). Diurnal and stress-induced reactive cortisol secretion were measured in all participants. Results showed that although the number of EA was not associated with patterns of basal or reactive cortisol secretion, adults first exposed to EA between the ages of 3 and 7 - an important time window for amygdala development - showed greater cortisol awakening response and lower cortisol reactivity relative to those first exposed to EA before 3 or after 7. These results provide support for the Life Cycle Model of Stress and highlight the importance of considering minimal age at exposure to EA when assessing the effects of early adversity on patterns of cortisol secretion.

Emotional traumatic experiences significantly contribute to identify a maltreated ecophenotype sub-group in eating disorders: Experimental evidence

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.

Clinical and neuroendocrine correlates of childhood maltreatment history in adults with bipolar disorder

OBJECTIVES

Childhood maltreatment has been associated to an increased risk of developing bipolar disorder (BD). A role of the hypothalamus-pituitary-adrenal (HPA) axis in mediating trauma-related risk for adult psychopathology has been suggested but scarcely investigated in BD. Therefore, we explored the impact of childhood maltreatment on clinical features of BD and on the activity of the HPA axis.

METHODS

One hundred and six patients participated in the study. On the basis of their history of childhood trauma, as assessed by the Childhood Trauma Questionnaire (CTQ), they were divided into a group with a history of childhood maltreatment (CM+) and a group without (CM-). Twenty-nine participants (16 with a history of childhood trauma and 13 without) underwent the cortisol awakening response (CAR) test.

RESULTS

Sixty-two patients had a history of childhood maltreatment and 44 had not. Maltreatment was significantly more frequent in females than males. CM+ patients showed a significant higher body mass index, a significant higher number of suicide attempts, and more severe mania symptoms than CM- ones. Logistic regression indicated a significant association between lifetime suicide attempts and any type of childhood maltreatment and between emotional abuse and the presence of psychotic symptoms or mixed mood episodes. CM+ individuals with BD exhibited a significantly reduced CAR with respect to CM- ones.

DISCUSSION

Our results add to literature findings showing a worse clinical course in BD patients with a history of childhood maltreatments and show for the first time that childhood trauma exposure is associated to an impaired CAR in adults with BD.

Recognizing and Responding to Child Maltreatment: Strategies to Apply When Delivering Family-Based Treatment for Eating Disorders

Child maltreatment encompasses a constellation of adverse parental behaviors that include physical, sexual, or emotional abuse, physical or emotional neglect, as well as exposure to violence between parents. A growing body of literature indicates that exposure to child maltreatment is a significant risk factor for the development and maintenance of eating disorders (EDs) and that practitioners experience challenges related to recognizing and responding to various forms of child maltreatment in their practice. Parent-child interactions signifying possible child maltreatment can be subtle; furthermore, the emotional and behavioral symptoms associated with an ED can overlap with those linked with child maltreatment, making it difficult for practitioners to distinguish whether children's symptoms are attributable to underlying psychopathology versus exposure to child maltreatment. This challenge can be further complicated in the context of delivering family-based treatment (FBT); FBT reaffirms that there is no single cause of EDs and asserts the leadership role of parents in their child's recovery process-both of which may lead practitioners to inadvertently miss indicators of child maltreatment. In this article, we provide an overview of the evidence linking child maltreatment to EDs among children and adolescents, as well as evidence-informed strategies for practitioners to safely recognize and respond to suspected child maltreatment when delivering FBT to children and adolescents in their practice.

Parental bonding, childhood maltreatment and eating disorder psychopathology: an investigation of their interactions

PURPOSE

Childhood trauma and parental bonding have been widely recognized as risk factors for eating disorders (EDs). However, their interplay in determining ED psychopathology has been poorly investigated. Consequently, we have assessed their interaction with core ED psychopathological symptoms.

METHODS

Fifty-seven patients with anorexia nervosa, 43 with bulimia nervosa and 77 healthy women completed the Childhood Trauma Questionnaire, the Parental Bonding Instrument and the Eating Disorder Inventory-2. Chi square test and regression analyses with a moderation model were performed to investigate the interplay between childhood trauma, parental bonding and ED symptoms such as ineffectiveness, social insecurity, drive to thinness, interoceptive awareness, impulsivity and perfectionism.

RESULTS

Compared to controls, patients with EDs showed higher levels of trauma and parental control perception and lower levels of parental care. Childhood maltreatment was more prevalent in patients with the affectionless control parental style. Moderation analyses revealed that higher maternal control significantly predicted the ED symptom of social insecurity only when participants experienced lower levels of emotional abuse.

CONCLUSIONS

These findings demonstrate an interplay between deranged problematic parental bonding and childhood trauma in promoting a possible vulnerability to social insecurity, one of the most central dimensions of ED psychopathology. This interaction might have psychotherapeutic implications.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

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

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

Epigenetic Modifications in Stress Response Genes Associated With Childhood Trauma

Adverse childhood experiences (ACEs) may be referred to by other terms (e.g., early life adversity or stress and childhood trauma) and have a lifelong impact on mental and physical health. For example, childhood trauma has been associated with posttraumatic stress disorder (PTSD), anxiety, depression, bipolar disorder, diabetes, and cardiovascular disease. The heritability of ACE-related phenotypes such as PTSD, depression, and resilience is low to moderate, and, moreover, is very variable for a given phenotype, which implies that gene by environment interactions (such as through epigenetic modifications) may be involved in the onset of these phenotypes. Currently, there is increasing interest in the investigation of epigenetic contributions to ACE-induced differential health outcomes. Although there are a number of studies in this field, there are still research gaps. In this review, the basic concepts of epigenetic modifications (such as methylation) and the function of the hypothalamic-pituitary-adrenal (HPA) axis in the stress response are outlined. Examples of specific genes undergoing methylation in association with ACE-induced differential health outcomes are provided. Limitations in this field, e.g., uncertain clinical diagnosis, conceptual inconsistencies, and technical drawbacks, are reviewed, with suggestions for advances using new technologies and novel research directions. We thereby provide a platform on which the field of ACE-induced phenotypes in mental health may build.

Stress hormones and eating disorders

AIMS

The aim of this paper is to emphasize the role of stress processes in the aetiology of eating disorders.

METHODS

We have examined the literature for evidence that people with eating disorders might exhibit markers of stress and show signs of the "maltreated ecophenotype".

RESULTS

Early adversity is more common among people with binge eating behaviours. The secondary effects of malnutrition, which are mostly marked in anorexia nervosa, may be an added stressor that could also contribute to the stress related phenotype. People with eating disorders have anomalies in brain structure, reward and punishment sensitivity, and the balance between HPA and SMA function. These may be potential targets for treatment.

Exploring the Link Between Emotional Child Abuse and Anorexia Nervosa: A Psychopathological Correlation

Eating disorders (ED) are well known psychiatric disorders associated with dysregulated eating behaviors and related thoughts and emotions. Common eating disorders are bulimia nervosa (BN), anorexia nervosa (AN), and binge eating disorders (BED). There is an active link between child abuse and eating disorders, emotional child abuse being the important subtype of CA and has a strong comorbid psychopathological relationship with EDs, including AN. The PubMed database was searched for the related articles about child abuse, including emotional childhood maltreatment and their psychopathology associated with EDs, especially AN. No filters were used for the date of publication and article types. Childhood abuse, including physical, sexual, and emotional maltreatment, has an active link with psychopathology associated with dysregulated eating behaviors. However, emotional childhood maltreatment including emotional abuse, neglect, and/or exposure to intimate partner violence (IPV) has been least studied, but studies have shown a strong relationship with the symptoms of anorexia nervosa such as weight concern, negative self-image, and maladaptive emotional response. Emotional dysregulation is the crucial psychopathological factor involved in mediating the effects of emotional childhood maltreatment and symptoms of anorexia nervosa and is strongly associated with long-term morbidity in patients with AN. Conducting more clinical studies in the future would help explore the temporal causation, and this association may help the practitioners to develop new diagnostic and therapeutic strategies in the management of AN.

Cortisol levels before and after cognitive behavioural therapy in patients with eating disorders reporting childhood abuse: A follow-up study

The etiopathogenesis of eating disorders (EDs) is complex and still not well understood. Biological, psychological and environmental factors (e.g. childhood abuse) have all been considered to be involved in the onset and the persistence of EDs. The hypothalamic-pituitary-adrenal (HPA) axis is a relevant biological factor capable of influencing the onset and the course of EDs and not many information are available about the impact of a Cognitive Behavioral Therapy (CBT) on cortisol changes in EDs. The HPA-axis functioning has been evaluated before and after CBT in a group of patients with Anorexia Nervosa (n = 34) and Bulimia Nervosa (n = 35) according to the presence/absence of a history of sexual/physical abuse. At baseline, only patients reporting childhood abuse showed lower morning cortisol levels as compared with other patients of the same diagnostic group and Healthy Controls. After CBT, a variation of cortisol levels has been found only in patients without abuse, suggesting a role of childhood adversities in the persistence of HPA-axis alterations in Eating Disorders.

Relation between Psychological Restorativeness and Lifestyle, Quality of Life, Resilience, and Stress-Coping in Forest Settings

Previous research has mainly dealt with the physiological and psychological restorative effects of the forest environment. However, comparatively few studies have focused on how the traits and attributes of individuals (individual traits) affect the restorative effects of the forest environment. In this study, we examined the relationships between the psychological restorative effects offered by perceived restorativeness of outdoor settings and the individual traits. Then, we investigated the relationships between the restorative indicators that are useful in examining the restorative properties (i.e., the Perceived Restorativeness Scale (PRS); seven indicators in total), the psychological restorative effect (Profile of Mood States (POMS), Restorative Outcome Scale (ROS), positive and negative affect schedule (PANAS), and Subjective Vitality Scale (SVS); 10 indicators in total), and the individual trait indicators that could be used to investigate individual traits (Development of Health and Life Habit Inventory for lifestyle, Lazarus-type Stress Coping Inventory for stress coping, World Health Organization Quality of Life Assessment 26 for quality of life (QOL), and Sukemune-Hiew Resilience test for resilience; 28 indicators in total) in forest and urban settings. Respondents consisted of 46 male students in their twenties. A short-term experiment was conducted using the same method in both environmental settings. We then analyzed the intrinsic restorative properties and the restorative effects of the settings and referred to prior research to determine the restorative effects. Furthermore, we analyzed the relationship between the restorative indicators and the individual trait indicators by correlation analysis and multiple regression (step-wise) analysis. These new findings were obtained: (1) the forest setting was a restorative environment with a higher restorative effect than the urban setting; (2) although the forest setting had a higher restorative effect than the urban setting, and the influence of individual traits was small; (3) in the forest setting, the relationship between the restorative indicators and individual traits indicators were arranged; (4) distancing (Stress coping), psychological health (QOL), and satisfaction with living environment (QOL) were likely important indicators that are related to the restorative effects in the forest setting.

Early adversity and the regulation of gene expression: Implications for prenatal health

Early life, including prenatal development and childhood, is a period of sensitivity, with potential for developmental programming under conditions of adversity. The intergenerational effects of early adversity have received attention, most often studied in relation to fetal development according to maternal exposures. Less often considered but critically important is the effect of early adversity on future prenatal risk (e.g., risk for preeclampsia, preterm birth), which threatens the health of mother and infant. The body's ability to turn collections of genes "on" or "off" across a range of tissues via receptor-driven transcription factors and epigenetic mechanisms (i.e., chemical modifications to the genome) in response to the perceived environment may help to explain such associations. This review aims to summarize discoveries surrounding the effects of early adversity on gene expression, emphasizing prenatal populations. First, we review findings from gene expression studies examining the effects of early adversity on various tissues known to contribute to prenatal health in adulthood. Next, we review several gene regulatory mechanisms thought to underlie differences in gene expression. Finally, we discuss potential implications for prenatal risk among early adversity-exposed mothers according to our current understanding of the biology that contributes to the development of prenatal syndromes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The potential of calibrated fMRI in the understanding of stress in eating disorders

Eating disorders (ED), including Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED), are medically dangerous psychiatric disorders of unknown etiology. Accumulating evidence supports a biopsychosocial model that includes genetic heritability, neurobiological vulnerability, and psychosocial factors, such as stress, in the development and maintenance of ED. Notably, stress hormones influence appetite and eating, and dysfunction of the physiological stress response has been implicated in ED pathophysiology. Stress signals also appear associated with food reward neurocircuitry response in ED, providing a possible mechanism for the role of stress in appetite dysregulation. This paper provides a review of some of the interacting psychological, behavioral, physiological, and neurobiological mechanisms involved in the stress response among individuals with ED, and discusses novel neuroimaging techniques to address potential physiological confounds of studying neural correlates of stress in ED, such as calibrated fMRI.

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

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