Anorexia Nervosa and Somatoform Dissociation: A Neglected Body-Centered Perspective

Disgust drivers do not impact on the altered body in action representation in anorexia nervosa

Disgust is a powerful emotion that evolved to protect us from contamination and diseases; it also cores to very human feelings, such as shame. In anorexia nervosa, most of the knowledge on disgust regards food. However, disgust can be elicited by varied drivers, including body-related self-disgust, which may be more central to this condition. Here, we investigate in depth how disgust triggers related to the body influence altered representations in anorexia nervosa. Women with anorexia nervosa and healthy women performed the Hand Laterality Task, in which they were asked to judge the laterality of hands without and with a disgust charging feature (i.e., with a body product or with a body violation). We computed accuracy and reaction time for the effect of biomechanical constraints, an index of motor imagery. We also measured the general disgust sensitivity through a self-report questionnaire. Participants with anorexia nervosa were overall less accurate and slower compared with controls, suggesting a non-canonical (i.e., not based on motor imagery) approach to solving the task. However, they showed the same pattern of responses as controls for disgust-charged stimuli, despite reporting higher levels of disgust sensitivity. Our results suggested the absence of specific effects of disgust drivers on the (altered) body in action representation in anorexia nervosa. We discuss this evidence focusing on the role of the psychopathological symptoms characterising anorexia nervosa. We also reflect on the efficacy of experimental methodologies used to detect alterations in body representation in this clinical condition.

A quantitative study on peripersonal space in anorexia nervosa and healthy subjects: Role of social variables and association with psychopathology

Objectives

This study investigates peripersonal space (PPS) modulation in patients with anorexia nervosa (AN) versus healthy controls (HCs) and explores associations between PPS, eating-related, and general psychopathology.

Method

Forty-six patients and 42 HCs completed a computer-based task observing videos of an approaching actor (male or female) displaying different facial expressions along with a non-social condition. Then, participants completed self-report questionnaires assessing eating-related and general psychopathology.

Results

Mixed-models revealed that both groups adjusted PPS based on task conditions, with a gender effect favoring closer proximity to female actor. HCs reduced PPS amplitude progressively during the task, while patients did not show this effect. In patients, wider PPS correlated with lower self-esteem and facial expression identification accuracy, while in HCs, PPS was associated to body dissatisfaction and anxiety symptoms.

Conclusion

These findings enhance understanding of bodily self-consciousness, suggesting PPS consideration in therapeutic interactions with patients with AN and as a potential target in treatments addressing social impairment.

Non-interpersonal traumatic events in patients with eating disorders: a systematic review

Objectives

The purpose of the systematic review was to synthesize literature on eating disorders (ED) and non-interpersonal traumatic events (NTE) and consolidate the reported prevalence of NTE in patients with an ED.

Methods

The literature search was performed in Embase, PsycInfo, and PubMed. The keywords in the search were "eating disorder," "trauma" and "non-interpersonal," using index-terms and free-search keywords related to NTE and ED. The PRISMA guidelines were followed. Relevant studies were screened using Rayyan.

Results

Of the 16 studies included in the quantitative synthesis, five overall types of NTE were identified: accidents, illness, injury, natural disaster and war. Findings provided tentative evidence for illness and injury being more prevalent in patients suffering from an ED compared to controls. The remaining subtypes of NTE did not show a higher prevalence in patients with an ED when compared to controls. Findings also suggest that those with binge/purge subtype of anorexia nervosa (AN) had a higher prevalence of non-interpersonal traumatic events compared to the restrictive subtype of AN.

Discussion

This systematic review provided a clear synthesis of previous findings related to NTE among patients with an ED. Noteworthy, is that many studies do not take into account if the trauma happened prior or after to ED onset, which may affect the association. Furthermore, the body of research on NTE in patients with ED is exceedingly limited, and more research is needed.

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.

Anorexia nervosa through the lens of a severe and enduring experience: 'lost in a big world'

BACKGROUND

Severe and enduring anorexia nervosa (SE-AN), is a serious and persistent illness, despite 'state of the art' treatment. Criteria have been theoretically proposed, but not tested, and may not adequately capture illness complexity, which potentially inhibits treatment refinements. The clinical reality of death as an outcome for some people who experience SE-AN (1 in 20) and broadening access to voluntary assisted dying, further complicates the field, which is undeveloped regarding more fundamental concepts such as nosology, treatment, recovery definitions and alternative conceptualisations of SE-AN. The present paper is in response to this and aims to build upon qualitative literature to enhance phenomenological understandings of fatal SE-AN.

METHOD

A published book, being the legacy of a 32-year-old professional artist offers a rich account of a life lived with AN, for 18 years with continuous treatment. A polysemous narrative via the interrelationship between the languages of the artist's words and visual art is translated via interpretative phenomenological analysis (IPA), offering rich insight into the SE-AN experience.

FINDINGS

The process of analysis induced three superordinate themes (1) Disappearing Self (2) Dialectical Dilemma (3) Death and Dying: Finding Meaning. Two cross cutting themes traversed these themes: (a) Colour and (b) Shifting Hope, where the former produced a visual representation via the 'SE-AN Kaleidoscope'. Collectively the themes produce a concept of SE-AN, grounded in the data and depicted visually through the artist's paintings.

CONCLUSIONS

The picture of SE-AN revealed in the analysis extends upon conceptualisations of SE-AN, highlighting key processes which are thus far under explored. These factors are implicated in illness persistence eliciting opportunities for further research testing including diagnostic considerations and treatment directions. In SE-AN, distorted body image extends to a global distortion in the perception of self. Additional criteria for the severe and enduring stages of illness related to (1) self and identity processes (2) measures of 'global impoverishment' across life domains are proposed for consideration in the future testing of putative defining features of SE-AN.

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy

Objective

Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder.

Methods

We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments.

Results

During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient.

Conclusion

The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

Dissociative experiences of compartmentalization are associated with food addiction symptoms: results from a cross-sectional report

PURPOSE

Studies have shown significant associations of dissociative symptoms with both eating and addictive disorders; however, the different forms of dissociation have been relatively understudied in relation to food addiction (FA). The main aim of this study was to investigate the association of certain forms of dissociative experiences (i.e., absorption, detachment and compartmentalization) with FA symptoms in a nonclinical sample.

METHODS

Participants (N = 755; 543 women; age range: 18-65; mean age: 28.22 ± 9.99 years) were evaluated using self-report measures of FA, dissociation, eating disturbances, and general psychopathology.

RESULTS

Compartmentalization experiences (defined as pathological over-segregation of higher mental functions) were independently associated with FA symptoms (β = 0.174; p = 0.013; CI = [0.008; 0.064]) even when confounding factors were controlled for.

CONCLUSION

This finding suggests that compartmentalization symptoms can have a role in the conceptualization of FA, with such two phenomena possibly sharing common pathogenic processes.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.