Is feeling extraneous from one's own body a core vulnerability feature in eating disorders?

Psychotic-like anomalous self-experiences in feeding and eating disorders: Their role in eating psychopathology through the mediation of body uneasiness and embodiment and identity disorders

BACKGROUND

Psychotic-like anomalous self-experiences (ASEs) are core and early features of schizophrenia spectrum disorders, which have been recently also postulated to underlie embodiment disturbance in feeding and eating disorders (FEDs). The present study was aimed at investigating the interplay between ASEs and specific psychopathology in FED.

METHODS

Ninety persons with Anorexia Nervosa and 41 with Bulimia Nervosa were evaluated with the inventory of psychotic-like anomalous self-experiences (IPASE), identity and eating disorders (IDEA), body uneasiness test (BUT), and eating disorder examination questionnaire (EDE-Q). The same assessment was performed for 92 subjects recruited from the general population. Structural equation modelling was employed to test the role of embodiment/identity disorders in mediating the relationship between ASEs and ED psychopathology.

RESULTS

Patients with FED displayed high scores on IPASE, comparable with people with schizophrenia spectrum disorders. A significant correlation was also demonstrated between IPASE, BUT and EDE-Q. All IPASE domains were strongly related to feeling extraneous from one's own body by IDEA. All IPASE domains demonstrated a high relationship with BUT Depersonalization scale. A strong correlation was also reported between total scores of IPASE and IDEA. The mediation model confirmed that ASEs impact on FED symptomatology through the mediation of both embodiment/identity disorders and body image.

DISCUSSION

Anomalous interoceptive processes may represent the first step of a maladaptive process-impairing embodiment, selfhood, and identity in FED. Assessment of ASEs might be a valid tool to identify an early-shared vulnerability of severe disorders characterized by embodiment alterations.

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.

The primacy of ocular perception: a narrative review on the role of gender identity in eating disorders

BACKGROUND

Phenomenological research has enriched the scientific and clinical understanding of Eating Disorders (ED), describing the significant role played by disorders of embodiment in shaping the lived experience of patients with ED. According to the phenomenological perspective, disorders of embodiment in ED are associated with feelings of alienation from one's own body, determining an excessive concern for external appearance as a form of dysfunctional coping. The purpose of the present narrative review is to address the role of gender identity as a risk factor for EDs in the light of phenomenological approaches.

METHODS

Narrative review.

RESULTS

The current study discusses the interplay between perception, gender identity, and embodiment, all posited to influence eating psychopathology. Internalized concerns for body appearance are described as potentially associated with self-objectification. Furthermore, concerns on body appearance are discussed in relation to gendered social expectations. The current review also explores how societal norms and gender stereotypes can contribute to dysfunctional self-identification with external appearances, particularly through an excessive focus on the optical dimension. The socio-cultural perspective on gender identity was considered as a further explanation of the lived experience of individuals with ED.

CONCLUSIONS

By acknowledging the interplay between these factors, clinicians and researchers can gain a deeper understanding of these disorders and develop more effective interventions for affected individuals.

LEVEL OF EVIDENCE

Level V narrative review.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

Emotional dysregulation and linguistic patterns as a defining feature of patients in the acute phase of anorexia nervosa

PURPOSE

This research aims to analyze the relationship between emotional regulation and the symbolic process in autobiographical narratives of a group of individuals diagnosed with restrictive anorexia nervosa (AN), compared to a non-clinical group. The study is framed within multiple code theory (MCT) (Bucci, 1997; 2021), which considers mind-body integration. The purposes of this study are to investigate whether participants of the AN group will show greater alexithymia and emotional dysregulation than the non-clinical group; and whether the specific linguistic and symbolic features, such as somato-sensory words, affect words, and difficulty in the symbolizing process will predict the AN group.

METHODS

Twenty-nine female participants hospitalized with AN during an acute phase (mean age 19.8 ± 4.1) and 36 non-clinical female participants (mean age 21 ± 2.4) were selected through snow-ball sampling. The participants completed the Toronto Alexithymia Scale (TAS-20), the Profile of Mood of State (POMS), the Emotion Regulation Questionnaire (ERQ), and the Relationship Anecdotes Paradigm Interview (RAP). The RAP interview was audio-recorded and transcribed to apply the Referential Process (RP) Linguistic Measures. A T test for paired samples and a logistic binary regression was performed.

RESULTS

AN presented a significantly higher emotional dysregulation through the ERQ, TAS20 and POMS measures. Specifically, AN showed higher ER expression/suppression strategies, fewer functional cognitive strategies, higher alexithymia, and higher mood dysregulation. Specific linguistic features such as sensory-somatic, word affect, and difficulty in RP symbolizing predict the AN group (R2 = 0.349; χ2 = 27,929; df = 3; p = .001).

CONCLUSIONS

Emotional dysregulation is connected to AN symptoms and autobiographical narratives. The results can help a clinical assessment phase showing specific linguistic features in AN patients.

LEVEL OF EVIDENCE

Level II, controlled trial without randomization.

Anorexia nervosa as a disorder of the subcortical-cortical interoceptive-self

PURPOSE

Anorexia nervosa (AN) is characterized by a diminished capacity in perceiving the physiological correlates of interoceptive sensations, namely bodily self-consciousness. Given the neural division of self-processing into interoceptive-, exteroceptive- and mental-self, we hypothesize neural deficits in the interoceptive-processing regions in AN.

METHODS

To prove this, we reviewed resting state (rs), task and rest-task studies in AN literature.

RESULTS

Neuronal data demonstrate the following in AN: (i) decreased rs-functional connectivity (rsFC) of subcortical-cortical midline structures (SCMS); (ii) reduced rsFC between medial (default-mode network/DMN and salience network/SN) and lateral (executive-control network/ECN) cortical regions; (iii) decreased rsFC in mainly the regions of the interoceptive-self; (iv) altered activity with overall increased activity in response to sensory/body image stimuli, especially in the regions of the interoceptive-self; (v) lack of a clear task-related distinction between own's and others' body image.

CONCLUSION

These data may indicate that rs-hypoconnectivity between SCMS, as neural correlate of a reduced intero-exteroceptive integration resulting in self-objectification, might be linked to overall increased activity in interoceptive regions during sensory/body image stimuli in AN, engendering an "anxious bodily self."

LEVEL OF EVIDENCE

I: Systematic review.

State of Mind Assessment in Relation to Adult Attachment and Text Analysis of Adult Attachment Interviews in a Sample of Patients with Anorexia Nervosa

BACKGROUND

Attachment theory represents one of the most important references for the study of the development of an individual throughout their life cycle and provides the clinician with a profound key for the purposes of understanding the suffering that underlies severe psychopathologies such as eating disorders. As such, we conducted a cross-sectional study with a mixed-methods analysis on a sample of 32 young women with anorexia nervosa (AN); this study was embedded in the utilized theoretical framework with the following aims: 1. to evaluate the state of mind (SoM) in relation to adult attachment, assuming a prevalence of the dismissing (DS) SoM and 2. to analyze the linguistic attachment profile emerging from the transcripts of the AAIs.

METHODS

Interviews were transcribed verbatim, coded, and analyzed using the linguistic inquiry and word count (LIWC) method.

RESULTS

The results were observed to be consistent with the referenced literature. The prevalence of a DS SoM (68.75%) is observed in the study sample, whereas the results of the lexical analysis of the stories deviate from expectations. Notably, the lexical results indicate the coexistence of the dismissing and entangled aspects at the representational level.

CONCLUSIONS

The study results suggest a high level of specificity in the emotional functioning of patients with AN, with a focusing on a pervasive control of emotions that is well illustrated by the avoidant/ambivalent (A/C) strategy described in Crittenden's dynamic-maturational model. These findings and considerations have important implications for clinical work and treatment, which we believe must be structured on the basis of starting from a reappraisal of emotional content.

Bridging cognitive, phenomenological and psychodynamic approaches to eating disorders

Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for "objective" (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons' lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive-behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since "being anorexic" becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V.Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Anomalous self-experience, body image disturbance, and eating disorder symptomatology in first-onset anorexia nervosa

PURPOSE

Anorexia nervosa-restrictive subtype (AN-R) is a life-threatening disorder relying on behavioural abnormalities, such as excessive food restriction or exercise. Such abnormalities may be secondary to an "objectified" attitude toward body image and self. This is the first study exploring the impact of anomalous self-experience (ASEs) on abnormal body image attitude and eating disorder (ED) symptomatology in individuals with AN-R at onset.

METHODS

We recruited Italian female participants, 40 with AN-R (mean age 18.3 ± 2.3) and 45 age and educational level-matched healthy controls (HCs) (mean age 18.2 ± 2.6). ASEs, body image attitude, and ED symptom severity were assessed through the examination of anomalous self-experience (EASE), the body uneasiness test (BUT), and the eating disorder examination questionnaire (EDE-Q), respectively. We conducted multivariate analysis of variance to investigate distribution patterns of variables of interest, and mediation analysis to test the effect of ASEs and body image on ED symptomatology.

RESULTS

Individuals with AN-R scored higher than HCs on the EASE (p < .0001). A direct effect of ASEs on ED severity (p = 0.009; bootstrapped LLCI = 0.067, ULCI = 0.240) was found in AN-R. After modelling the effect of abnormal body image attitude, the relationship between EASE total score and ED symptomatology was significantly mediated by BUT (p = 0.002; bootstrapped LLCI = 0.001, ULCI = 0.172).

CONCLUSION

Although the exact pathways linking AN-R to self-disorder remain to be identified, a broader exploration of transdiagnostic features in AN, including explorations of different dimensions of self-experience and intersubjectivity, may shed further light on the clinical phenomenology of the disorder.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

The role of embodiment in the treatment of patients with anorexia and bulimia nervosa: a 2-year follow-up study proposing an integration between enhanced cognitive behavioural therapy and a phenomenological model of eating disorders

PURPOSE

Recent studies demonstrated that the embodiment disorder represents a core feature of eating disorders (EDs). The aim of this study was to evaluate the role of its variation as a possible mediator of the efficacy of enhanced cognitive behavioural therapy (CBT-E) on classic ED symptomatology, including body uneasiness.

METHODS

73 patients with anorexia nervosa and 68 with bulimia nervosa were treated with a multidisciplinary approach including CBT-E. Psychometric questionnaires were administered at baseline (T0) and after one (T1) and 2 years (T2) to evaluate general and ED-specific psychopathology, body uneasiness and the embodiment disorder. Data regarding diagnostic crossover and remission were also collected.

RESULTS

Longitudinal analysis showed an improvement of all psychopathological dimensions at T1, which remained stable at T2 (p < 0.05). Remission rate at T2 was 44.7%, and diagnostic crossover occurred in 17.0% of patients. Higher levels of embodiment disorder predicted increased diagnostic instability (OR: 1.80 [1.01-3.20], p = 0.045). The amelioration of the embodiment disorder mediated the decrease in both ED-specific psychopathology (indirect effect: 0.67 [0.46-0.92]) and body uneasiness (indirect effect: 0.43 [0.28-0.59]).

CONCLUSION

For the first time, these findings highlighted the role of the embodiment disorder as a maintaining factor of ED symptomatology, supporting the importance of integrating CBT-E with a phenomenological model of EDs.

LEVEL OF EVIDENCE

Level IV, longitudinal observational study (case series).

Lived body and the Other's gaze: a phenomenological perspective on feeding and eating disorders

According to the phenomenological perspective, the lived body disorder is a core feature of feeding and eating disorders (FEDs). Persons with FEDs experience their own body first of all as an object looked by another person, rather than coenaesthetically or from a first-person perspective. In particular, the main features of this disorder are: alienation from the own body and from the own emotions, disgust for it, shame, and an exaggerated preoccupation for the way in which one appears to the others. Phenomenological research has recently highlighted that the gaze of the Other plays an important role. Because persons with FEDs cannot have an experience of their own body from within or coenesthetically, they need to apprehend their own body from outside through the gaze of the Other. This way of apprehending one's own body when it is looked by another person is called by Sartre the 'lived body-for-others'. Normally, the constitution of one's own body, and consequently of one's own Self and identity depends on the dialectic integration between the first-person apprehension of one's body (lived body) that it is based on coenaesthesia, and the third-person one, that it is based on the sense of sight (lived-body-for-others). When the dialectic is unbalanced toward the pole of the lived-body-for-others, experienced from without, the symptom occurs. Starting from these clinical observations, the so-called Optical-Coenaesthetic Disproportion model has been developed. In this paper, we describe this model, its philosophical and clinical foundations, and finally its clinical implication and its relationship with other disciplines, i.e., neurosciences. Level of evidence: V.

Weaker implicit interoception is associated with more negative body image: Evidence from gastric-alpha phase amplitude coupling and the heartbeat evoked potential

Interoception refers to the processing of internal bodily stimuli, while body image refers to appearance-related perceptions, affect, and cognitions. Previous research has found that body image is associated with self-reported and behavioural indices of interoception. Here, we extended this research by examining associations between measures of positive (i.e., body appreciation, functionality appreciation) and negative body image (i.e., body shame, weight preoccupation) and two electrophysiological indices of interoceptive processing, namely the heartbeat evoked potential (HEP) and gastric-alpha phase-amplitude coupling (PAC), in a sample of 36 adults. Significant negative associations were identified between the indices of negative body image and the interoception variables. Specifically, more negative HEP amplitude and lower gastric-alpha PAC were both associated with greater body shame and weight preoccupation. However, no significant associations were identified for the indices of positive body image. These findings extend previous work by demonstrating that there are significant associations between negative body image and previously unexplored components of cardiac and gastric interoception. This, in turn, could have important clinical applications, such as the HEP and gastric-alpha PAC both serving as biomarkers of negative body image.

Beyond difficulties in self-regulation: the role of identity integration and personality functioning in young women with disordered eating behaviours

BACKGROUND

Past research has established individual relationships between disordered eating behaviours (DEB) and both self-regulation difficulties and identity disturbance. However, no research has looked at the shared influence of these constructs on DEB nor at personality functioning in individuals with DEB.

METHODS

In the present study, self-regulation was explored in terms of effortful control, impulsivity and emotion regulation while identity integration was measured in terms of impairments in self-functioning using a sample of 247 undergraduate students.

RESULTS

Significant associations were found between all components of self-regulation and DEB, with the exception of impulsivity. Identity instability was also associated with self-regulation difficulties and DEB. Structural Equation Modelling analyses indicated that identity instability partially mediated the relationship between self-regulation and DEB. Lastly, disordered eating was associated with difficulties in personality functioning, with young women presenting with DEB reporting significantly greater difficulties in both self and interpersonal personality functioning.

CONCLUSION

Behavioural eating anomalies should be considered as epiphenomena secondary to a possible deeper issue that reflects difficulties related to identity integration and potential personality functioning. The clinical implications of these findings are discussed.

From the patients' perspective: what it is like to suffer from eating disorders

The available treatments of Eating Disorders (EDs) mirror an excessive focus on symptoms to be eliminated rather than on the acknowledgment of what is relevant from the patient's perspective. This Editorial offers a critical review of the limitations of the DSM-5-oriented approaches, as well as of their extreme consequences, namely ocularcentrism, nosographism, and paternalistic moralism. To overcome these limitations, it is suggested to get back to Psychopathology as the basic science of psychiatric practice whose aim is to grasp the distinctly personal dimension of the patient's experience and to connect understanding with care. With the help of Psychopathology, clinicians engaged in the treatment of ED patients will better make sense of what it is like to suffer from these disorders and be encouraged to suspend their judgment and take patient's perspective in the light of their troubled existence which is rich in meanings and not merely in abnormal beliefs and trivial anomalous behavior. According to these principles, treatment is a journey shared with the patient, which allows her/him to feel recognized and accepted in terms of her/his individuality.

Dear Body… An Explorative Study on Anomalous Bodily Experiences in Persons with Feeding and Eating Disorders

OBJECTIVE

The aim of the study was to provide a qualitative analysis of anomalous bodily experiences (ABEs) of persons affected by feeding and eating disorders (FEDs). In particular, this study aimed to refine the description of bodily experiences in persons with FEDs so as to improve their treatment.

SAMPLING AND METHODS

This is a naturalistic explorative study on a group of 29 patients affected by FED in psychotherapeutic treatment and 12 healthy controls. We asked the participants to write a letter on the way they experience their body. Later, we analysed their letters by means of consensual qualitative research.

RESULTS

All patients (29) reported at least 1 ABE. The main categories identified are (1) body-obstacle (the body interposes between the person and the world); (2) body-tyrant (the body imposes itself on the will of the person); (3) body-hyper-visible (the body is experienced as an exposed object); (4) body-geometric (the body is experienced or associated with a geometric form); and (5) body-numerical (the body is defined by numbers). All these categories are present in the clinical group, and they are absent in the control group.

CONCLUSION

To grasp the experiential nuances of ABEs is relevant to understand the disorder of embodied self-hood and personal identity in these patients and thus to refine clinical treatment.

The hyperphagic experience in obesity: a phenomenological study of French and Brazilian contexts

Abstract This article aims to understand the hyperphagic experience in the obesity of patients in the French and Brazilian contexts. Using the critical phenomenological method, twenty subjects were interviewed in health services in Paris and in Fortaleza. We note an objectification and expropriation of the body often experienced in the hyperphagic experience in obesity. We highlight the emphasis on health in the French context and on form and aesthetics in the Brazilian context. In Fortaleza, there seems to be a more evidenced discrimination in relation to obesity and a pathological discourse, whereas in Paris this pathologization is viewed from a critical position regarding the treatments. We conclude that the hyperphagic experience in obesity reveals a subject who is often lost in his/her way of being and having a body, and that clinical work must involve the re-appropriation of this body and the recovery of the condition of the autonomous subject.

Confidence in one-self and confidence in one's own body: The revival of an old paradigm for anorexia nervosa

Impaired interoceptive function represents an important variable in the psychopathology of anorexia nervosa (AN) and is thought to be influenced by maladaptive schemas grounded on early intimate interactions. However, the role of the different psychological processes involved in the interoceptive function has been poorly assessed in AN. We aimed to investigate the associations between adult insecure attachment, interoceptive processes, and psychopathology. One hundred and fifty participants with AN completed self-report questionnaires: the Multidimensional Assessment of Interoceptive Awareness, which measures interoception dimensions; the Attachment Style Questionnaire, assessing adult attachment styles, and the Eating Disorder Inventory-2, exploring eating-related core symptoms. Pearson's correlations were employed to assess the relationships between MAIA and EDI-2 subscores. Structural equation models (SEM) were performed to investigate the relationships between insecure attachment dimensions, interoception, and AN core symptoms as latent variables. Body listening, self-regulating, and trusting were interoceptive dimensions associated with eating psychopathology. As confirmed by an exploratory factor analysis, these interoceptive dimensions are included in a latent variable which points to "confidence" in body sensations. SEM showed that insecure, in particular anxious, attachment predicts body "confidence" and, in turn, AN core symptoms. Confidence in body sensations as a trustworthy source of knowledge represents the specific interoceptive dimension associated with psychopathology in AN. In accordance with Bruch's model of AN, insecure attachment patterns may promote a need to validate inner experiences by external sources conferring vulnerability to symptomatology. These psychopathological pathways could be addressed in clinical interventions.

Sexuality, embodiment and attachment style in anorexia nervosa

PURPOSE

Recent studies hypothesized that sexual dysfunctions represent not just complications of eating disorders (EDs), rather they should be attributed to the core psychopathology of these disorders. Therefore, disorders of the embodiment and insecure attachment may play a role in maintaining an abnormal sexual functioning, given their known relations with core ED features. The aim of the study was to investigate the relationship between sexual dysfunctions and both disorders of the embodiment and attachment style in people with anorexia nervosa (AN).

METHODS

111 adult women with AN and 120 healthy subjects completed the Symptom Checklist-90, Eating Disorder Examination Questionnaire, Identity and Eating Disorders, Attachment Style Questionnaire and the Childhood Trauma Questionnaire-Short Form.

RESULTS

Patients reported worse scores than controls in all areas assessed. In patients, low sexual desire was found to be associated with general and ED-specific psychopathology, and with disorders of embodiment and attachment style. Sexual dysfunctions had no associations with traumatic experiences. Dietary restriction showed an association with low sexual desire through embodiment disorder and Discomfort with Closeness, as confirmed by the serial mediation model.

CONCLUSION

The present study suggests that disorders of embodiment maintained by pathological eating behaviours have a key role in the development of sexual dysfunctions in EDs, through the compromise of intimacy.

LEVEL OF EVIDENCE

Level III, cross-sectional study with comparisons between cases and controls.

Greater gastric interoception is associated with more positive body image: Evidence from adults in Malaysia and the United Kingdom

Gastric interoception refers to the processing of sensory stimuli originating in the gut. Previous research has found that gastric interoception (measured using a water load task) is associated with drive for thinness in young Western women. However, associations with broader facets of body image and in diverse national groups have not been previously investigated. To address these issues, we asked samples of adults in the United Kingdom (UK; N = 91, women n = 54) and Malaysia (N = 100, women n = 50) to complete a 2-stage water load task (WLT) and measures of positive body image (i.e., body appreciation, functionality appreciation). The results indicated that a greater change in the intensity of self-reported WLT-related sensations was associated with significantly higher body appreciation and functionality appreciation after accounting for gender identity, body mass index, and national group. Behavioural performance on the WLT was significantly associated with body appreciation and functionality appreciation for the Malaysian sample, but not the UK adults, after accounting for gender identity and body mass index. These findings extend previous research by demonstrating that there are significant associations between facets of gastric interoception and previously unexplored facets of body image in both Western and non-Western settings.

Abnormal Space Experiences in Persons With Schizophrenia: An Empirical Qualitative Study

Abnormal space experience (ASE) is a common feature of schizophrenia, despite its absence from current diagnostic manuals. Phenomenological psychopathologists have investigated this experiential disturbance, but these studies were typically based on anecdotal evidence from limited clinical interactions. To better understand the nature of ASE in schizophrenia and attempt to validate previous phenomenological accounts, we conducted a qualitative study of 301 people with schizophrenia. Clinical files were analyzed by means of Consensual Qualitative Research, an inductive method for analyzing descriptions of lived experience. Our main findings can be summed up as follows: (1) ASEs are a relevant feature in schizophrenia (70.1% of patients reported at least 1 ASE). (2) ASE in schizophrenia are characterized by 5 main categories of phenomena (listed from more represented to less represented): (a) experiences of strangeness and unfamiliarity (eg "Everything appeared weird. Face distorted, world looks terrible, nasty"); (b) experiences of centrality/invasion of peripersonal space (eg "Handkerchief on scaffolding: message telling him something"); (c) alteration of the quality of things (eg "Buildings leaning down"); (d) alteration of the quality of the environment (eg "Person sitting six feet away seemed to be at an infinite distance"); and (e) itemization and perceptive salience (eg "All patients [in ward] have bright eyes"). (3) ASEs are much more frequent in acute (91.9%) than in chronic (28.15%) schizophrenia patients. Moreover, our findings further empirical support for phenomenological accounts of schizophrenia, including those developed by Jaspers, Binswanger, Minkowski, and Conrad, among others and provide the background for translational research.

The Pathogenic and Therapeutic Potential of the Gaze of the Other in the Clinic of "Eating Disorders"

Building on the optical-coenaesthetic disproportion model of so-called eating disorders, this paper provides a framework for the psychotherapy of people affected by these conditions. This model characterizes "eating disorders" as disorders of embodiment and identity, where a sense of unfamiliarity with one's own flesh, experienced as shifting and incomprehensible, leads to an impairment in the constitution of the Self and thus of one's own identity. Since there is a deficit of the coenaesthetic experience of the embodied Self, greater importance is assumed by body perception conveyed from without. To these persons, their corporeality is principally given as a body-object "to be seen" from a third-person perspective, rather than as a body-subject "to be felt" from a first-person perspective. The Other's look serves as an optical prosthesis to cope with dis-coenaesthesia and as a device through which these persons can define themselves. They are unable to accept the hiatus between "being a body" and "having a body," constitutively present in every human being, forcibly trying to recouple it, and finally ending up objectifying themselves to succeed. The external foundation of the Self thus takes the form of a constriction one can never be completely free of. Psychotherapy should thus accompany persons affected by eating disorders in their encounter with the miscarried dialectic between feeling oneself from within and seeing oneself from without through the gaze of the Other, so keenly feared by people desperately in search of self-control. Tactfully, the clinician accompanies the patient in taking a stance towards her symptom as the outcome of this miscarried dialectics, which is one premise for overcoming it. The clinician's gaze becomes the herald of recognition, allowing the patient to feel accepted in terms of her individuality. Feeling themselves touched by a gaze that waives its alienating potential in order to signify acceptance reactivates the identity-forming dialectics. Their body is thus revealed as the receiver of gazes, but also rediscovers its own possibility for self-determination starting out from these gazes. This intersubjective resonance between the clinician's gaze and the patient reactivates the identity-making dialectics between body-subject and body-object, creating the relational premises for overcoming the symptom.

The Role of the Embodiment Disturbance in the Anorexia Nervosa Psychopathology: A Network Analysis Study

Anorexia Nervosa (AN) is characterized by body image distortion. From a phenomenological perspective, body image disturbance has been associated with a more profound disturbance encompassing disorders of the way persons experience their own body. The aim of this study was to disentangle the complex dynamics that connect the experience of one’s own body and self-identity to the psychopathological features of AN by applying a network analysis. Fifty-seven patients with AN restrictive subtype and 27 with AN binge–purging subtype participated in the study. Eating Disorders Inventory-2 and Identity and Eating Disorders subscores, measuring the embodiment dimensions, were included in the network. Two of the main dimensions of embodiment—feeling extraneous from one’s own body and feeling oneself through objective measures—were the nodes with the highest strength together with interoceptive awareness (IA). IA was a node included in several pathways connecting embodiment dimensions with most of the AN psychopathological dimensions. The centrality of the embodiment disorder suggests the importance of considering the body image disturbance in people with AN as resulting from their difficulty in experiencing inner states and as a tool to build its own self. This assumption may orient therapeutic interventions.

Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa

In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.

The Optical-Coenaesthetic Disproportion Hypothesis of Feeding and Eating Disorders in the Light of Neuroscience

This article builds on and extends the 'optical-coenaesthetic disproportion' (OCDisp) hypothesis of feeding and eating disorders (FEDs) matching data obtained through clinical research with laboratory evidence from neuroscience and neuropsychological studies. The OCDisp hypothesis, developed through the assessment in clinical setting of bodily experience using the IDentity and EAting (IDEA) disorder questionnaire, argues that in persons with FED the internal perception of one's embodied self (i.e., coenaesthesia) is deeply affected (their possibility to feel themselves is weakened or threatened by coenaesthopathic and emotional paroxysms; their bodily feelings are discontinuous over time), and as a compensation to it, these persons experience their own body as an object that is looked at by others. To FED persons, their body is principally given to them as an object 'to be seen.' The other's look serves as an optical prosthesis to cope with hypo- and dis-coenaesthesia and as a device through which persons with FED can define themselves and attenuate the anxiety produced by the conflicts between being-oneself and being-for-others. After describing the OCDisp hypothesis, we will gather evidence supporting it with neuroscience studies on FED. Our focus will be on data pointing to dampened multisensory integration of interoceptive and esteroceptive signals, demonstrating a predominance of the visual afferents toward signals arising within the body. In the final part of the article, we will show consistencies but also draw distinctions between our clinical hypothesis and neuroscience-based data and hypotheses and draft a potential agenda for translational research inspired by these.

"This body is me": Discovering the ways in which the body is salient in people's identities

Although previous research has revealed associations between negative body image and identity problems, there are sound theoretical reasons to assume much greater diversity in relations between body image and identity. The aim of the present qualitative study was to explore the ways people find the body salient to their identities. Young adults (N=121; 51% women) were interviewed, and four main themes were found: identification with the body, body functionality in identity-relevant tasks, appearance and identity in social interactions, and identity-relevant bodily engagement. Both positive and negative ways in which the body is salient in identity were described and descriptions included functionality, embodied experiences, and social environments. Gender differences were not found with one exception: more women than men described experiences of identifying with their bodies. These novel results have implications for the understanding of the interconnection between body image and identity and may open avenues for continued research.

Embodiment Mediates the Relationship between Avoidant Attachment and Eating Disorder Psychopathology

OBJECTIVE

The overvaluation of body shape and weight of persons with eating disorders (EDs) is putatively explained by a disturbance in the way they experience their own body (embodiment). Moreover, attachment disorders seem to promote the use of body as source for self-definition. Therefore, we assessed the role of embodiment in the connection between attachment styles and ED psychopathology.

METHOD

One-hundred and thirteen ED patients and 117 healthy subjects completed the Identity and Eating Disorders (IDEA) Questionnaire, the Eating Disorder Inventory-2 (EDI-2) and the Experiences in Close Relationships Scale.

RESULTS

Eating disorder patients displayed IDEA, EDI-2 and Experiences in Close Relationships scores significantly higher than controls. IDEA total and subtotal scores mediated entirely the influence of avoidant attachment on EDI-2 interoceptive awareness and impulsivity.

DISCUSSION

These findings demonstrate a relationship between insecure attachment and disorders of identity and embodiment and point to embodiment as a possible mediator between avoidant attachment and specific ED psychopathological traits. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Fat mass and obesity-associated gene (FTO) is associated to eating disorders susceptibility and moderates the expression of psychopathological traits

Eating Disorders (EDs) show a multifactorial etiopathogenesis including environmental, psychological and biological factors. In the present study, we propose a model of interactions between genetic vulnerability-represented by Fat Mass and Obesity-Associated (FTO) gene-and stable psychopathological traits, such as bodily disorders and emotion dysregulation for EDs patients. The distribution of a polymorphism of the FTO (rs9939609 T>A) was evaluated in a series of 250 EDs patients and in a group of 119 healthy control subjects. Clinical data were collected through a face-to-face interview and several self-reported questionnaires were applied, including the Emotional Eating Scale and the IDentity and EAting disorders (IDEA) questionnaire for bodily disorders and self-identity. The A-allele was associated with an increased vulnerability to EDs (AA+AT genotypes frequency 72.8% in EDs vs. 52.9% in controls). The presence of the A-allele was associated with binge eating behavior, higher emotional eating and higher IDEA scores. Finally, the FTO rs9939609 SNP was found to influence the relationship between these variables, as an association between disorder of corporeality and emotional eating was found only in A-allele carriers. A-allele seems to represent a potential additive risk factor for EDs persons, with bodily disorders to develop emotional eating and binge eating behaviors.