Behavioral addictions: a novel challenge for psychopharmacology

Interest of neurofeedback training for cognitive performance and risk of brain disorders in the military context

Operational environments are characterized by a range of psycho-physiological constraints that can degrade combatants' performance and impact on their long-term health. Neurofeedback training (NFT), a non-invasive, safe and effective means of regulating brain activity, has been shown to be effective for mental disorders, as well as for cognitive and motor capacities and aiding sports performance in healthy individuals. Its value in helping soldiers in operational condition or suffering from post-traumatic stress (PTSD) is undeniable, but relatively unexplored. The aim of this narrative review is to show the applicability of NFT to enhance cognitive performance and to treat (or manage) PTSD symptoms in the military context. It provides an overview of NFT use cases before, during or after military operations, and in the treatment of soldiers suffering from PTSD. The position of NFT within the broad spectrum of performance enhancement techniques, as well as several key factors influencing the effectiveness of NFT are discussed. Finally, suggestions for the use of NFT in the military context (pre-training environments, and during and post-deployments to combat zones or field operations), future research directions, recommendations and caveats (e.g., on transfer to operational situations, inter-individual variability in responsiveness) are offered. This review is thus expected to draw clear perspectives for both researchers and armed forces regarding NFT for cognitive performance enhancement and PTSD treatment related to the military context.

"I Can't Do without You": Treatment Perspectives for Affective Dependence: A Scoping Review

Affective Dependence (AD) is a problematic model of the love relationship that is becoming increasingly prevalent and evident in the context of couple relationships. Similarly, the phenomenon is being observed with growing frequency in daily clinical practice, making it increasingly necessary to identify treatment guidelines that can help clinicians in dealing with AD, while waiting for the literature to reach a consensus on its definition and nosographic profile. The main objective of this work is to explore the existing evidence of effectiveness regarding feasible treatments for Affective Dependence through a scoping review of the international literature carried out using the main scientific databases and following the PRISMA-ScR (PRISMA Extension for Scoping Reviews) guidelines. Seven studies were included in this review, and the results show that several pharmaceuticals, as well as different types of individual and group therapies, are proposed as treatment plans for AD. However, there is a lack of clinical trials that can verify the efficacy of the AD treatments reported so far in the literature. Some reflections that may help to distinguish a "healthy" addiction from a dysfunctional or markedly pathological one are considered alongside potential prevention perspectives.

Orthorexia and eating attitudes in health sciences students

Background

The prevalence of eating disorders and orthorexia nervosa has steadily increased and this situation may lead to severe physical, psychological, and social disorders.

Aim

The aim of this study was to investigate the prevalence of disordered eating attitudes and orthorexia tendencies among university students studying in various Health Sciences departments in Turkey.

Subjects and Methods

The study subjects were selected from Health Sciences Faculty students. Among the students who accepted the study, 639 people were reached by simple random sampling method. The EAT-40 and ORTO-15 which are validated instruments for the screening of abnormal eating behaviors and orthorexia nervosa respectively, were used as measurement tools.

Results

The majority of the students who participated in the study were found to exhibit orthorexic tendencies, and male students had a higher orthorexic tendency in comparison to female students (p = 0.022). More specifically, the students studying in the Department of Nutrition and Dietetics had lower orthorexic tendencies compared with the students from other departments. There was no significant relationship between BMI values and the mean ORTO-15 scores, whereas the mean EAT-40 score was found to increase statistically significantly with increased BMI (p = 0.038). There was a statistically significant difference between the departments and classes in terms of mean EAT-40 scores, whereas no difference was found regarding gender.

Conclusion

Orthorexia nervosa is a common problem for university students studying in health-related departments. Interestingly, the orthorexic tendencies of girls and students studying in the Nutrition and Dietetics department were found to be lower in this study. It was determined that all students except the Nutrition and Dietetics department had orthorexia tendencies. More comprehensive studies are needed to better understand orthorexia nervosa and healthy lifestyle interaction.

Investigating the relationship between orthorexia nervosa and autistic traits in a university population

BACKGROUND

Orthorexia nervosa (ON) is an emerging condition featuring restrictive eating behaviors on the basis of subjective beliefs about food healthiness. Many authors have stressed the similarities between ON and anorexia nervosa (AN) in both cognitive and behavioral patterns. Despite that, while the link between AN and female autism presentations is well known in the literature, no study has yet investigated the relationship between ON and autism spectrum. This work aims to investigate the relationship between ON and autistic traits in a university population.

METHODS

An e-mail invitation was sent to all the students and University workers of University of Pisa. Subjects were asked to fulfill the ORTO-15 and the Adult Autism Subthreshold spectrum (AdAS spectrum) questionnaires.

RESULTS

A total of 2426 subjects joined the survey: 623 subjects (26.3%) reported a score associated with significant orthorexic symptoms according to ORTO-15 (ON group), while 1789 subjects (73.7%) did not report ON symptomatology and were considered as healthy controls (HC). The ON group scored significantly higher on almost all AdAS spectrum domains. Moreover, being female and scoring higher on AdAS spectrum were statistically predictive factors for the presence of ON symptomatology. Among AdAS spectrum domains, higher scores on AdAS spectrum inflexibility and adherence to routine and restricted interests and rumination domains, as well as lower scores on verbal communication domain, were statistically predictive of orthorexic symptoms.

CONCLUSIONS

Our findings highlight an overlap between ON and autism spectrum psychopathology. Further studies are needed to clarify the relationship between restrictive eating disorders and female autism phenotypes.

Estimation of Behavioral Addiction Prevalence During COVID-19 Pandemic: A Systematic Review and Meta-analysis

Purpose of Review

The COVID-19 pandemic changed people’s lifestyles and such changed lifestyles included the potential of increasing addictive behaviors. The present systematic review and meta-analysis aimed to estimate the prevalence of different behavioral addictions (i.e., internet addiction, smartphone addiction, gaming addiction, social media addiction, food addiction, exercise addiction, gambling addiction, and shopping addiction) both overall and separately.

Recent Findings

Four databases (PubMed, Scopus, ISI Web of Knowledge, and ProQuest) were searched. Peer-reviewed papers published in English between December 2019 and July 2022 were reviewed and analyzed. Search terms were selected using PECO-S criteria: population (no limitation in participants’ characteristics), exposure (COVID-19 pandemic), comparison (healthy populations), outcome (frequency or prevalence of behavioral addiction), and study design (observational study). A total of 94 studies with 237,657 participants from 40 different countries (mean age 25.02 years; 57.41% females). The overall prevalence of behavioral addiction irrespective of addiction type (after correcting for publication bias) was 11.1% (95% CI: 5.4 to 16.8%). The prevalence rates for each separate behavioral addiction (after correcting for publication bias) were 10.6% for internet addiction, 30.7% for smartphone addiction, 5.3% for gaming addiction, 15.1% for social media addiction, 21% for food addiction, 9.4% for sex addiction, 7% for exercise addiction, 7.2% for gambling addiction, and 7.2% for shopping addiction. In the lockdown periods, prevalence of food addiction, gaming addiction, and social media addiction was higher compared to non-lockdown periods. Smartphone and social media addiction was associated with methodological quality of studies (i.e., the higher the risk of boas, the higher the prevalence rate). Other associated factors of social media addiction were the percentage of female participants, mean age of participants, percentage of individuals using the internet in country, and developing status of country. The percentage of individuals in the population using the internet was associated with all the prevalence of behavioral addiction overall and the prevalence of sex addiction and gambling addiction. Gaming addiction prevalence was associated with data collection method (online vs. other methods) that is gaming addiction prevalence was much lower using online methods to collect the data.

Summary

Behavioral addictions appeared to be potential health issues during the COVID-19 pandemic. Healthcare providers and government authorities should foster some campaigns that assist people in coping with stress during COVID-19 pandemics to prevent them from developing behavioral addictions during COVID-19 and subsequent pandemics.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40429-022-00435-6.

Transcranial Direct Current Stimulation of the Dorsolateral Prefrontal Cortex for Treatment of Neuropsychiatric Disorders

Background

The dorsolateral prefrontal cortex (DLPFC) is a key node of the frontal cognitive circuit. It is involved in executive control and many cognitive processes. Abnormal activities of DLPFC are likely associated with many psychiatric diseases. Modulation of DLPFC may have potential beneficial effects in many neural and psychiatric diseases. One of the widely used non-invasive neuromodulation technique is called transcranial direct current stimulation (or tDCS), which is a portable and affordable brain stimulation approach that uses direct electrical currents to modulate brain functions.

Objective

This review aims to discuss the results from the past two decades which have shown that tDCS can relieve clinical symptoms in various neurological and psychiatric diseases.

Methods

Here, we performed searches on PubMed to collect clinical and preclinical studies that using tDCS as neuromodulation technique, DLPFC as the stimulation target in treating neuropsychiatric disorders. We summarized the stimulation sites, stimulation parameters, and the overall effects in these studies.

Results

Overall, tDCS stimulation of DLPFC could alleviate the clinical symptoms of schizophrenia, depression, drug addiction, attention deficit hyperactivity disorder and other mental disorders.

Conclusion

The stimulation parameters used in these studies were different from each other. The lasting effect of stimulation was also not consistent. Nevertheless, DLPFC is a promising target for non-invasive stimulation in many psychiatric disorders. TDCS is a safe and affordable neuromodulation approach that has potential clinical uses. Larger clinical studies will be needed to determine the optimal stimulation parameters in each condition.

The role of repetitive transcranial magnetic stimulation (rTMS) in the treatment of behavioral addictions: Two case reports and review of the literature

BACKGROUND

Several behaviors, besides consumption of psychoactive substances, produce short-term reward that may lead to persistent aberrant behavior despite adverse consequences. Growing evidence suggests that these behaviors warrant consideration as nonsubstance or "behavioral" addictions, such as pathological gambling, internet gaming disorder and internet addiction.

CASE PRESENTATION

Here, we report two cases of behavioral addictions (BA), compulsive sexual behavior disorder for online porn use and internet gaming disorder. A 57-years-old male referred a loss of control over his online pornography use, started 15 years before, while a 21-years-old male university student reported an excessive online gaming activity undermining his academic productivity and social life. Both patients underwent a high-frequency repetitive transcranial magnetic stimulation (rTMS) protocol over the left dorsolateral prefrontal cortex (l-DLPFC) in a multidisciplinary therapeutic setting. A decrease of addictive symptoms and an improvement of executive control were observed in both cases.

DISCUSSION

Starting from these clinical observations, we provide a systematic review of the literature suggesting that BAs share similar neurobiological mechanisms to those underlying substance use disorders (SUD). Moreover, we discuss whether neurocircuit-based interventions, such as rTMS, might represent a potential effective treatment for BAs.

A Case-Control Study on Behavioral Addictions and Neurocognition: Description of the BANCO and BANCO2 Protocols

INTRODUCTION

Only two behavioral addictions (BAs) are currently recognized in international classifications (gambling disorder: GbD; gaming disorder: GmD), while some of them await further investigation (food addiction: FA; sexual addiction: SA). Neurocognitive functioning is considered a risk factor for BAs. Research is quite abundant for GbD and highlights specific deficits in several cognitive functions. Nevertheless, grey areas still exist. The aim of this research programme is to investigate the neurocognitive profiles of patients presenting with various BAs and to establish parallels between different forms of BA to achieve a common addiction concept.

METHODS AND ANALYSIS

This research program is composed of two studies sharing the same methodology but focusing on different samples: the BANCO study aims to include 30 individuals with a GbD, whereas the BANCO2 study aims to include 30 individuals with a GmD, 30 with a SA, and 30 with a FA. Moreover, for each BA group, 30 healthy controls will be recruited, matched by sex, age and education level. Several cognitive tasks will be completed by participants. Cue reactivity and physiological responses, as well as clinical data regarding addiction characteristics and personality, will also be investigated. A composite score based on the cognitive tasks will be computed using principal component analysis (PCA). Overall cognitive performance and detailed performance on the different cognitive tasks will be compared between individuals with BAs and their matched healthy controls using linear models with random effects. Comparisons will also be made between BA groups to investigate specific alterations associated with each disorder.

DISCUSSION

The results of this research programme will impact both research and clinical areas by (i) providing new knowledge for discussions regarding the inclusion of BAs under the spectrum of addictive disorders; (ii) improving understanding of addiction mechanisms in general; (iii) providing clarity in the grey areas in neurocognitive research on BAs and improving the understanding of less studied BAs, (iv) guiding clinicians to propose therapeutic alternatives and complementary programmes.

TRIAL REGISTRATION

BANCO study (ClinicalTrials.gov NCT03202290); BANCO2 study (ClinicalTrials.gov NCT03967418).

Orthorexia Nervosa in China: An Exploration of Phenomenology and Clinical Correlates Among University Students

Orthorexia nervosa, characterized by pathological preoccupation with healthy eating and food purity, is conceptualized as being linked to cultural concepts of health pervasive in contemporary Western societies. However, little is known about the phenomenology and clinical correlates of orthorexia nervosa in non-Western cultures. The current study examined symptoms of orthorexia nervosa, obsessive-compulsive disorder, depression, anxiety, and fear of negative evaluation among 418 Chinese university students. A minority of participants endorsed frequent or impairing orthorexia nervosa symptoms, and females reported slightly higher severity of orthorexia nervosa symptoms than males. Orthorexia nervosa symptom severity was moderately associated with obsessive-compulsive and anxiety symptoms, and weakly associated with depressive symptoms and fear of negative evaluation. Although this study generates initial data about orthorexia nervosa among Chinese students, further research is greatly needed to establish the prevalence and clinical characteristics of orthorexia nervosa in Western and Non-Western cultures.

Love is a physiological motivation (like hunger, thirst, sleep or sex)

The multitude of terms associated with love has given rise to a false perception of love. In this paper, only maternal and romantic love are considered. Love is usually regarded as a feeling, motivation, addiction, passion, and, above all, an emotion. This confusion has consequences in the lives of human beings, leading not only to divorces, suicides, femicides but possibly also to a number of mental illnesses and suffering. Therefore, it is crucial to first clarify what is meant by emotion, motivation and love. This work aims to finally place love within the category of physiological motivations, such as hunger, thirst, sleep, or sex, on the basis that love is also essential for human survival, especially in childhood. Love is presented from an evolutionary perspective. Some other similarities between love and other physiological motivations are pointed out, such as its importance for appropriate human development, both its ontogeny and its permanence, and the long-lasting consequences of abuse and neglect. There are summarized reasons that account for this, such as the fact that physiological motivations are essential for survival and that love is an essential motivation for the survival of human offspring. Other reasons are that minimum changes in the quantity and quality of love alters development, that there can be a variety of neurophysiological and behavioural states within a motivation, and that motivations (also love) appear and change throughout development. Also, motivations and love sometimes may lead to an addictive behaviour. Finally, it is recognized that once physiological motivations (and love) appear, they become permanent. In a third section, some potential social, cultural, clinical and scientific consequences of the proposed consideration of love as a motivation are discussed. Accordingly, love's recognition as a motivation in the clinical field would imply a better understanding of its disorders and its inclusion in classifications manuals such as The Diagnostic and Statistical Manual of Mental Disorders (DSM), or in the International Classification of Diseases (ICD). Considering love as a motivation rather than an emotion could also impact the results of scientific research (an example is included). A comprehensive understanding of these questions could potentially allow for a new therapeutic approach in the treatment of mental illness, while offering an all-inclusive evolutionary explanation of cultural phenomena such as the origin and diffusion of both language and art. Love should be understood as a physiological motivation, like hunger, sleep or sex, and not as an emotion as it is commonly considered.

Problematic Internet use in drug addicts under treatment in public rehab centers

BACKGROUND

Problematic Internet use (PIU) or Internet addiction has been recognized to be a behavioral addiction characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding computer use and Internet access that leads to impairment or distress resembling substance abuse.

AIM

To investigate the prevalence and characteristics of Internet use and abuse in a group of drug addicts from Southern Italy, by means of a specific questionnaire [“Questionario sull’Utilizzo delle Nuove Tecnologie” (QUNT)].

METHODS

All subjects (183) were heavy smokers, almost 50% of them used heroin and/or opioid compounds, 30% alcohol, 10% cannabis, 8% cocaine, and 5% were polydrug users. Almost 10% of the individuals were also suffering from gambling disorder.

RESULTS

The time spent online was more than 4 hours a day in the total sample, with a slight prevalence in male subjects. Cocaine and cannabis users spent more than 6 hours online, significantly more than opioid and alcohol abusers. Distribution of the QUNT factors was not different in both sexes. Cocaine users showed higher scores at the “loss of control”, “pornography addiction”, and “addiction to social networks” factors, for the stimulant effect of this substance. Moreover, 15 out of the total 17 cocaine users were pathological gamblers. Positive and statistically significant relationships were observed between some QUNT factors and body mass index.

CONCLUSION

These findings indicate that PIU is less severe in subjects taking sedative substances, such as heroin/opioids and alcohol, than in subjects taking stimulants. Alternatively, it may be used as a “stimulant” trigger in cocaine and cannabis users. Flattening effect of abuse drugs was noted on possible sex-related differences in QUNT items. We observed a sort of “protective” effect of a love relationship and/or living together with a partner, as those engaged subjects showed lower scores on different items than single subjects or those living alone. The relationship between time spent online (and related sedentary lifestyle) and body mass index would suggest that Internet use might be a contributing factor to increasing weight gain and obesity amongst adolescents and young adults worldwide. Our findings also highlighted the specific vulnerability of drug addicts who use stimulants, rather than sedative compounds, to other kinds of behavioral addictions, such as gambling disorder.

Definition and diagnostic criteria for orthorexia nervosa: a narrative review of the literature

AIM

In some cases, detrimental consequences on health are generated by self-imposed dietary rules intended to promote health. The pursuit of an "extreme dietary purity" due to an exaggerated focus on food may lead to a disordered eating behavior called "orthorexia nervosa" (ON). ON raises a growing interest, but at present there is no universally shared definition of ON, the diagnostic criteria are under debate, and the psychometric instruments used in the literature revealed some flaws. This narrative review of the literature aims at assessing state of the art in ON definition, diagnostic criteria and related psychometric instruments and provides research propositions and framework for future analysis.

METHODS

The authors collected articles through a search into Pubmed/Medline, Scopus, Embase and Google Scholar (last access on 07 August 2018), using "orthorexia", "orthorexia nervosa" and "obsessive healthy eating" as search terms, and filled three tables including narrative articles (English), clinical trials (English), and articles in languages different from English. The data extrapolated from the revised studies were collected and compared. In particular, for each study, the diagnostic criteria considered, the specific psychometric instrument used, the results and the conclusions of the survey were analyzed.

RESULTS

The terms employed by the different authors to define ON were fixation, obsession and concern/preoccupation. Several adjectives emphasized these expressions (e.g. exaggerated/excessive, unhealthy, compulsive, pathological, rigid, extreme, maniacal). The suitable food and the diet were defined in different ways. Most of the papers did not set the diagnostic criteria. In some cases, an attempt to use DSM (edition IV or 5) criteria for anorexia nervosa, or avoidant/restrictive food intake disorder, or body dysmorphic disorder, was done. Specific diagnostic criteria proposed by the authors were used in few studies. All these studies indicated as primary diagnostic criteria: (a) obsessional or pathological preoccupation with healthy nutrition; (b) emotional consequences (e.g. distress, anxieties) of non-adherence to self-imposed nutritional rules; (c) psychosocial impairments in relevant areas of life as well as malnutrition and weight loss. The ORTO-15 and the Orthorexia Self-Test developed by Bratman were the most used psychometric tools.

CONCLUSIONS

The present review synopsizes the literature on the definition of ON, proposed diagnostic criteria and psychometric instruments used to assess ON attitudes and behaviors. This work represents a necessary starting point to allow a further progression of the studies on the possible new syndrome and to overcome the criticisms that have affected both research and clinical activity until now.

LEVEL OF EVIDENCE

Level V, narrative review.

Structural validation of ORTO-11-ES for the diagnosis of orthorexia nervosa, Spanish version

PURPOSE

The ORTO-11-ES questionnaire is a tool to assess the pathological obsession displayed by some individuals regarding healthy eating. The aims of this study were (1) to confirm the factor structure of the Spanish version of ORTO-11-ES using confirmatory factor analysis (CFA) and (2) to examine the possible association between the ORTO-11-ES score, gender and body mass index (BMI).

METHODS

The sample comprised 492 students from the University of Castilla la Mancha, Spain. Of these, 280 were women (56.9%). Participants were surveyed using the ORTO-11-ES questionnaire.

RESULTS

The confirmatory factor analysis (CFA) supported the 11 elements and 3 domains of this tool as the better fitting model; for the Comparative Fit Index (CFI) and the Tucker-Lewis Index (TLI), the values were 0.94 and 0.91, respectively, and the Root Mean-Square Error of Approximation (RMSEA) was 0.058. The tendency towards orthorexic behavior is more associated with the female gender. The BMI had no influence on the tendency for ON.

CONCLUSIONS

This study is the first attempt to confirm the three-factor structure of a Spanish version of the ORTO-15 questionnaire. These findings suggest that the ORTO-11-ES may be a valuable tool for identifying subjects with specific eating behavior patterns. This information may be useful for health professionals involved in the research, development and implementation of interventions catered to individuals suffering from this eating disorder.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

The framework of clinical occupational medicine to provide new insight for workaholism

There is no single agreed definition of workaholism. Most interventions proposed for people suffering from workaholism target individuals. There is a paucity of descriptions of workplace risk factors. Our study examines case reports of patients suffering from workaholism with a focus on the role of the workplace. We describe case reports from patients of the Occupational Disease Centre in Brest, France between 2013 and 2016. Consultations were conducted within the framework of clinical occupational medicine with a focus on real work situations. Diagnoses of workaholism were made according to Goodman's criteria. The situations of four patients are reported. Three of these suffered from workaholism: a 41 yr-old sales representative, a 51 yr-old nurse in progressive care and a 30 yr-old saleswoman. The last case report concerns the situation of a 41 yr-old team leader who was first suspected to have workaholism, but later diagnosed with a bipolar disorder. Bipolar disorders and other addictive behaviours should be assessed. An exclusive variable remuneration and work organization that could induce confusion between the working and personal environment both constitute risk factors. Some patients were ambivalent to their condition and willing to go on working despite ill-health issues. These elements could be integrated into further research on workaholism.

Comorbidity of Internet gaming disorder and alcohol use disorder: A focus on clinical characteristics and gaming patterns

BACKGROUND AND OBJECTIVES

Although Internet gaming disorder (IGD), which has been considered as a behavioral addiction in DSM-5, shares core features with alcohol use disorder (AUD), there has been minimal research on the clinical implications of the comorbidity between IGD and AUD. The purpose of this study is to investigate clinical psychopathologies and Internet game usage patterns of IGD, AUD, and their comorbid status.

METHODS

Participants (n = 1819) completed a cross-sectional web-based survey. The survey questionnaire included socio-demographic data, the IGD scale according to DSM-5 criteria, the Korean version of Alcohol Use Disorders Identification Test for AUD, the Dickman Impulsivity Inventory (DII)-short version for impulsivity, the Brief Self-Control Scale (BSCS) for self-control, the subscales of the Symptom Check-List 90 Items-Revised (SCL-90-R) for depression and anxiety, and the Behavioral Inhibition System/Behavioral Approach System Scale, and the Internet game usage patterns.

RESULTS

The comorbidity group had substantially more severe clinical features such as impulsivity, impaired self-control, and mood symptoms than either IGD or AUD only. Especially the depression scale for the comorbidity group (26.0) is considerably higher than 13.0 for IGD and 16.0 for AUD alone. Furthermore, the comorbidity group spent twice as much money on Internet gaming as IGD alone (all p < .05).

CONCLUSIONS AND SIGNIFICANCE

The findings of this study indicate that the comorbidity between IGD with AUD showed more severe psychopathological impairments, and the respective persons spent more money on gaming than either IGD or AUD alone. These particular characteristics may serve as feasible therapeutic targets in clinical settings. (Am J Addict 2017;26:326-334).

Anxiety, Stress-Related Factors, and Blood Pressure in Young Adults

Hypertension (HT) is a long-term medical condition characterized by persistently elevated blood pressure (BP) in the arterial vessels. Although HT initially is an asymptomatic condition, it chronically evolves into a major risk factor for cardiovascular, cerebrovascular, and renal diseases that, in turn, represent crucial causes of morbidity and mortality in industrialized countries. HT is a complex disorder that is estimated to affect more than a quarter of the world's adult population. It is classified on the basis of both its pathophysiology (primary and secondary HT) and on the resting BP values (elevated systolic, diastolic, and pulse pressure). It originates from a complicated interaction of genes and several environmental risk factors including aging, smoking, lack of exercise, overweight and obesity, elevated salt intake, stress, depression, and anxiety. Anxiety and depressive disorders are the most commonly diagnosed mental disorders, affecting millions of people each year and impairing every aspect of everyday life, both of them characterized by affective, cognitive, psychomotor, and neurovegetative symptoms. Moreover, work-related stress has been considered as an important risk factor for HT and cardiovascular diseases (CVDs). Although different authors have investigated and suggested possible relations between HT, stress, anxiety, and depression during the last decades, a full understanding of the underlying pathophysiological mechanisms has not been satisfactorily achieved, especially in young adults. The aim of this study was to investigate the impact of anxiety and work-related stress in the development of HT amongst young health care profession students and the possible related consequences of early CVDs.

Historical evolution of the concept of anorexia nervosa and relationships with orthorexia nervosa, autism, and obsessive-compulsive spectrum

Eating disorders have been defined as "characterized by persistence disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs health or psychosocial functioning". The psychopathology of eating disorders changed across time under the influence of environmental factors, determining the emergence of new phenotypes. Some of these conditions are still under investigation and are not clearly identified as independent diagnostic entities. In this review, the historic evolution of the eating disorder concept up to the recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, has been evaluated. We also examined literature supporting the inclusion of new emergent eating behaviors within the eating disorder spectrum, and their relationship with anorexia, autism, and obsessive-compulsive disorder. In particular, we focused on what is known about the symptoms, epidemiology, assessment, and diagnostic boundaries of a new problematic eating pattern called orthorexia nervosa that could be accepted as a new psychological syndrome, as emphasized by an increasing number of scientific articles in the last few years.

Toll-Like Receptor 4 Deficiency Causes Reduced Exploratory Behavior in Mice Under Approach-Avoidance Conflict

Abnormal approach-avoidance behavior has been linked to deficits in the mesolimbic dopamine (DA) system of the brain. Recently, increasing evidence has indicated that toll-like receptor 4 (TLR4), an important pattern-recognition receptor in the innate immune system, can be directly activated by substances of abuse, resulting in an increase of the extracellular DA level in the nucleus accumbens. We thus hypothesized that TLR4-dependent signaling might regulate approach-avoidance behavior. To test this hypothesis, we compared the novelty-seeking and social interaction behaviors of TLR4-deficient (TLR4(-/-)) and wild-type (WT) mice in an approach-avoidance conflict situation in which the positive motivation to explore a novel object or interact with an unfamiliar mouse was counteracted by the negative motivation to hide in exposed, large spaces. We found that TLR4(-/-) mice exhibited reduced novelty-seeking and social interaction in the large open spaces. In less stressful test apparatuses similar in size to the mouse cage, however, TLR4(-/-) mice performed normally in both novelty-seeking and social interaction tests. The reduced exploratory behaviors under approach-avoidance conflict were not due to a high anxiety level or an enhanced fear response in the TLR4(-/-) mice, as these mice showed normal anxiety and fear responses in the open field and passive avoidance tests, respectively. Importantly, the novelty-seeking behavior in the large open field induced a higher level of c-Fos activation in the nucleus accumbens shell (NAcSh) in TLR4(-/-) mice than in WT mice. Partially inactivating the NAcSh via infusion of GABA receptor agonists restored the novelty-seeking behavior of TLR4(-/-) mice. These data suggested that TLR4 is crucial for positive motivational behavior under approach-avoidance conflict. TLR4-dependent activation of neurons in the NAcSh may contribute to this phenomenon.

Transcranial direct current stimulation (tDCS) in behavioral and food addiction: a systematic review of efficacy, technical, and methodological issues

Objectives: Behavioral addictions (BA) are complex disorders for which pharmacological and psychotherapeutic treatments have shown their limits. Non-invasive brain stimulation, among which transcranial direct current stimulation (tDCS), has opened up new perspectives in addiction treatment. The purpose of this work is to conduct a critical and systematic review of tDCS efficacy, and of technical and methodological considerations in the field of BA.

Methods: A bibliographic search has been conducted on the Medline and ScienceDirect databases until December 2014, based on the following selection criteria: clinical studies on tDCS and BA (namely eating disorders, compulsive buying, Internet addiction, pathological gambling, sexual addiction, sports addiction, video games addiction). Study selection, data analysis, and reporting were conducted according to the PRISMA guidelines.

Results: Out of 402 potential articles, seven studies were selected. So far focusing essentially on abnormal eating, these studies suggest that tDCS (right prefrontal anode/left prefrontal cathode) reduces food craving induced by visual stimuli.

Conclusions: Despite methodological and technical differences between studies, the results are promising. So far, only few studies of tDCS in BA have been conducted. New research is recommended on the use of tDCS in BA, other than eating disorders.

Orthorexia nervosa: An integrative literature review of a lifestyle syndrome

Bratman first proposed orthorexia nervosa in the late 1990s, defining it an obsession with eating healthy food to achieve, for instance, improved health. Today, in the Swedish media, excessive exercising plays a central role in relation to orthorexia. A few review articles on orthorexia have been conducted; however, these have not focused on aspects of food and eating, sport, exercise, or a societal perspective. The overall aim of this study was to provide an overview and synthesis of what philosophies of science approaches form the current academic framework of orthorexia. Key questions were: What aspects of food and eating are related to orthorexia? What role do exercise and sports play in relation to orthorexia? In what ways are orthorexia contextualized? Consequently, the concept of healthism was used to discuss and contextualize orthorexia. The method used was an integrative literature review; the material covered 19 empirical and theoretical articles published in peer-reviewed journals. This review demonstrates a multifaceted nature of orthorexia research; this field has been examined from four different philosophies of science approaches (i.e., empirical-atomistic, empirical-atomistic with elements of empirical-holistic, empirical-holistic, and rational-holistic) on individual, social, and societal levels. The majority of the articles followed an empirical-atomistic approach that focused on orthorexia as an individual issue, which was discussed using healthism. Our analysis indicates a need for (a) more empirical-holistic research that applies interpretive qualitative methods and uses a social perspective of health, e.g., healthism and (b) examining the role of sports and exercise in relation to orthorexia that takes the problematizing of “orthorexic behaviours” within the sports context into account.