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.

The psychological impact of COVID-19-related lockdown measures among a sample of Italian patients with eating disorders: a preliminary longitudinal study

PURPOSE

To explore the prevalence of symptoms of anxiety and depression, along with PTSD- and ED-related symptoms, across a sample of patients with Eating Disorders (EDs) compared to a group of healthy controls (HC) during the lockdown period in Italy; to assess whether patients' reported aforementioned psychiatric symptoms improved, remained stable or worsened with the easing of the lockdown measures.

METHODS

t0 assessment (during lockdown): 59 ED patients and 43 HC completed an online survey, including the Depression, Anxiety and Stress Scale-21 items (DASS-21), the Impact of Event Scale-Revised (IES-R), the Perceived Stress Scale (PSS), and specific ad-hoc questions extracted from the Eating Disorder Examination-Questionnaire; t1 assessment (post-lockdown): 40 EDs patients, a subset of the t0 sample, completed the same assessment 2 months after t0.

RESULTS

EDs patients scored higher than HC at the DASS-21, IES-R and PSS. At t1, levels of stress, anxiety and depression were not different than at t0, but symptoms related to post-traumatic stress disorder (PTSD), patients' reported level of psychological wellbeing and specific EDs symptomatology improved.

DISCUSSION

During the lockdown, EDs patients presented significantly higher levels of stress, anxiety, depression, PTSD- and ED-related symptoms than HC. With the easing of the lockdown, PTSD- and ED-related symptoms improved, but high levels of stress, anxiety and depression persisted.

LEVEL OF EVIDENCE

Level I, experimental study.

The effect of a single yoga class on interoceptive accuracy in patients affected by anorexia nervosa and in healthy controls: a pilot study

PURPOSE

To evaluate interoceptive accuracy (Iac) before and after a single yoga class in a population of patients with anorexia nervosa (AN) and in a population of healthy controls (HC).

METHODS

Fifteen patients with AN and twenty HC were included in the study. All individuals participated in a single yoga class. Before (T0) and after (T1) the yoga class, they underwent the heartbeat detection task for the evaluation of Iac. At T0, all participants also underwent a psychological assessment, including evaluation of depression, anxiety, body awareness, alexithymia, self-objectification and eating disorders psychopathology.

RESULTS

Patients with AN had lower Iac than HC at T0. A significant improvement of Iac at T1 was found in the HC group but not in the group of patients with AN.

CONCLUSION

We infer that our findings might be linked to the fact that patients with AN, differently from HC, did not properly attend to their bodies, despite the yoga class. This hypothesis is consistent with previous studies showing that patients with AN have decreased Iac during self-focused behavior because of body-related avoidance. Moreover, we surmise that HC might be keener to improve their perception of internal body signals even after a single yoga class because their emotional awareness system is not impaired. Patients with AN, on the contrary, may have an intrinsic impairment of their emotional awareness, making it harder for them to modulate their Iac.

LEVEL OF EVIDENCE

Level III, evidence obtained from well-designed cohort or case-control analytical studies.

The effect of eight yoga sessions on interoceptive accuracy, confidence and awareness in a sample of patients with eating disorder: A preliminary study

Introduction

Previous research from our group showed that, after a single yoga class, Interoceptive Accuracy (IAc), tested through the Heartbeat Counting Task, improved in a group of Healthy Controls (HC), but not in a group of patients with Anorexia Nervosa (AN).

Objectives

To evaluate three levels of interoception (accuracy, confidence (IC) and awareness (IAw)) before and after eight sessions of Yoga in a sample of patients with Eating Disorders (ED: AN, Bulimia Nervosa (BN) and Binge Eating Disorder (BED)).

Methods

15 patients with ED were included. Before the first yoga session (T0) and 72 hours after the last session (T1), participants underwent: (i) the Heartbeat Counting Task for the evaluation of IAc, IC and IAw; (ii) a psychometric assessment evaluating depression, anxiety, body awareness, alexithymia, self-objectification and eating disorders symptomatology.

Results

At T1, ED patients’ IAc appeared higher than at T0, but not IC and IAw. A trend towards significance (p = 0.055) emerged for the interaction effect between IAc and diagnosis, with BED patients having a higher increase of IAc at T1 than AN and BN patients. Significant correlations between IAc and Alexithymia, Anxiety and Depression emerged at T0, but were not maintained at T1.

Conclusions

After a program of eight Yoga sessions, IAc in ED patients (but not IC and IAw) increases, especially in BED patients. Moreover, the improvement of IAc following the yoga course seems to be unrelated to the course of depressive, anxious and alexithymic symptoms of ED patients.

COVID-19 pandemic and eating disorders: What impact on specific and general psychopathology?

Introduction

The coronavirus disease 2019 (COVID-19) pandemic and the resulting containment measures, such as “lockdown” and “social distancing”, have had important consequences on people’s mental and physical health.

Objectives

We aimed to study the effect of social isolation and subsequent re- exposure and eventual changes in general and ED-specific psychopathology in people with Eating Disorders (EDs).

Methods

Three-hundred twelve Italian people with EDs (179 Anorexia Nervosa, 83 Bulimia Nervosa, 48 Binge Eating Disorder and 22 Other Specific Feeding Eating Disorder) were asked to fill-in an online survey to explore several dimensions such as: anxiety, depression, panic, insomnia, suicide ideation, stress, post-traumatic stress and obsessive-compulsive symptoms. Differences in ED specific and general symptoms among the 3 investigated time periods (before, during and after the end of lockdown) were assessed with a one-way ANOVA with repeated measures. Subsequently, ED diagnosis was introduced as covariate in the analysis in order to investigate the possible contribution on psychopathological changes.

Results

ED core symptoms increased during the lockdown but most of them returned to pre-COVID19 levels at re-opening. The severity of general psychopathology also increased during the lockdown and persisted high in the following phase, except for depression and suicide ideation. None of this symptoms was affected by ED diagnosis, participants’age and illness duration.

Conclusions

People with EDs showed worsening of both general and specific psychopathology; moreover, changes in general psychopathology persisted in the re-opening period suggesting a higher stress vulnerability in this kind of patients.

Disclosure

No significant relationships.

Keyword

COVID19 and Eating Disorders

Anorexia Nervosa and Functional Motor Symptoms: Two Faces of the Same Coin?

The aim of this study was to compare anorexia nervosa (AN) patients and functional motor symptoms (FMS) patients by assessing their variability in demographic and clinical characteristics, risk factors, precipitators, and family history. The authors assessed levels of depression and anxiety, alexithymia, dissociation, body awareness, self-objectification, and interoception in the two groups, using 20 healthy controls (HCs) as a control group for psychometric assessment and for interoception. Unexpectedly, no differences in the three groups were observed for the measures related to awareness of physical state, including body awareness, self-objectification, and interoceptive ability via the heartbeat task. However, the AN and FMS groups were not different from each other but were different from the HC group with regard to anxiety, depression, alexithymia, and dissociation. In light of the similarities found, these data support the hypothesis of a common etiology involving emotional dysfunction in both disorders. These findings suggest that AN and FMS may be disorders belonging to the same spectrum (where emotional dysregulation is a key feature) and that there exist potential opportunities for collaborative, integrated investigations of etiology, diagnosis, and management of these disorders.

Microbiota in anorexia nervosa: The triangle between bacterial species, metabolites and psychological tests

Anorexia nervosa (AN) is a psychiatric disease with devastating physical consequences, with a pathophysiological mechanism still to be elucidated. Metagenomic studies on anorexia nervosa have revealed profound gut microbiome perturbations as a possible environmental factor involved in the disease. In this study we performed a comprehensive analysis integrating data on gut microbiota with clinical, anthropometric and psychological traits to gain new insight in the pathophysiology of AN. Fifteen AN women were compared with fifteen age-, sex- and ethnicity-matched healthy controls. AN diet was characterized by a significant lower energy intake, but macronutrient analysis highlighted a restriction only in fats and carbohydrates consumption. Next generation sequencing showed that AN intestinal microbiota was significantly affected at every taxonomic level, showing a significant increase of Enterobacteriaceae, and of the archeon Methanobrevibacter smithii compared with healthy controls. On the contrary, the genera Roseburia, Ruminococcus and Clostridium, were depleted, in line with the observed reduction in AN of total short chain fatty acids, butyrate, and propionate. Butyrate concentrations inversely correlated with anxiety levels, whereas propionate directly correlated with insulin levels and with the relative abundance of Roseburia inulinivorans, a known propionate producer. BMI represented the best predictive value for gut dysbiosis and metabolic alterations, showing a negative correlation with Bacteroides uniformis (microbiota), with alanine aminotransferase (liver function), and with psychopathological scores (obsession-compulsion, anxiety, and depression), and a positive correlation with white blood cells count. In conclusion, our findings corroborate the hypothesis that the gut dysbiosis could take part in the AN neurobiology, in particular in sustaining the persistence of alterations that eventually result in relapses after renourishment and psychological therapy, but causality still needs to be proven.

Self-awareness of cognitive functioning in schizophrenia: patients and their relatives

Cognitive impairment has been recognized since the earliest descriptions of schizophrenia as a core feature of the illness and different programmes have been developed to remediate these deficits. In all likelihood it is important for compliance and adherence to treatment that not only the patients but also their relatives be aware of the patients; cognitive deficits. Sixty-two patients with a diagnosis of schizophrenia and, for each one of them, one family member and an informant from the medical staff, were recruited and administered the Schizophrenia Cognition Rating Scale (SCoRS) ratings. Patients were tested for cognitive deficits with a neuropsychological battery and their performance was compared to the ratings of cognitive functioning provided by the patient himself, his family member and the informant. Results show no significant association between cognitive performance and SCoRS ratings in patients; only for executive functions the patient's performance was found to be predictive of the respective judgment on the SCoRS that was given by the relative. This is the first study to investigate awareness of the patients' cognitive deficits, both in the patients themselves and in their first degree relatives, through a direct comparison between subjective clinical ratings and objective measures of cognitive performances. When both patients and relatives are unaware of the patients' cognitive deficits, this could affect adherence to remediation treatment and need to be specifically addressed in future rehabilitation strategies.

Effect of 5-HT1A-receptor functional polymorphism on Theory of Mind performances in schizophrenia

Theory of Mind (ToM) abilities are known to be impaired in schizophrenia and data from functional brain imaging studies showed that ToM deficit is correlated to prefrontal cortex (PFC) dysfunction. Moreover, several lines of evidence suggest a critical role for dopaminergic-serotoninergic interactions at the PFC level. In this view, we aimed to analyse the specific effect of the -1019C/G functional polymorphism of the serotonin 1A receptor (5-HT1A-R), involved in both serotonin and dopamine transmission regulation. A total of 118 clinically stabilised schizophrenia patients was assessed with a neuropsychological battery, including evaluation of IQ, verbal memory, attention and executive function and a ToM task; they also underwent 5-HT1A-R genotyping. We observed a significant effect of the 5-HT1A-R genotype on ToM performances, with the CC genotype performing significantly better. The finding suggests an effect of the 5-HT1A-R polymorphism on ToM cognitive performance in schizophrenia patients, probably through complex interactions between dopaminergic and serotoninergic systems, involved in mentalising.

HTTLPR functional polymorphism in schizophrenia: executive functions vs. sustained attention dissociation

BACKGROUND

Recently attention has been addressed to the role of 5-HT in cognition and several experimental studies revealed that manipulations of the central 5-HT system can produce quite specific changes in cognitive functioning. These results may suggest new treatment strategies to improve cognition in psychiatric conditions characterized by neuropsychological impairments, such as schizophrenia. It is possible to investigate the involvement of 5-HT in cognition by examining the impact of genetic variation in key regulators of serotoninergic neurotransmission. Among these, the serotonin transporter (5-HTT) presents a functional polymorphism in the transcriptional control region of the gene (5-HTTLPR) affecting transcriptional efficiency. In the present study, we aimed to analyze the effect of 5-HTTLPR polymorphism on specific cognitive functions, known to be affected by 5-HT manipulation and altered in schizophrenia.

METHODS

223 schizophrenia patients were tested with Wisconsin Card Sorting Test (WCST), for the evaluation of cognitive flexibility, Continuous Performance Test (CPT), for the evaluation of attention, and genotyped for the 5-HTTLPR.

RESULTS

We found a significant association between HTT polymorphism and executive functions and inversely with sustained attention. The presence of the high-activity long (L) allele in homozygosis was a predictor of better executive performances and poorer performances of attention.

CONCLUSIONS

Our findings suggest that factors affecting serotonin availability may play a specific role in cognitive processes, probably through complex modulation of the different performance components.

The comprehension of idiomatic expressions in schizophrenic patients

Recent fMRI and TMS studies on idiom comprehension have shown that the prefrontal cortex is involved in idiom processing. Since schizophrenic patients exhibit prefrontal structural changes and dysexecutive behavioural deficits, we hypothesised an impairment in idiom comprehension, correlating with performance on executive tasks. In this study, idiom comprehension was evaluated by means of a sentence-to-picture-matching task in 45 schizophrenic patients and 45 control subjects, matched for age and educational level. The task included 62 idiomatic and 62 literal sentences. Participants were presented with a written sentence, either literal or idiomatic, followed by a picture, which appeared below the sentence. They were instructed to judge whether the picture represented the meaning of the sentence or not, and responded by pressing one of two response keys. Half of the items correctly represented the meaning, half did not. Reaction times and accuracy were measured. Schizophrenics were impaired in both types of idiomatic sentence. However, their performance was particularly poor in the case of ambiguous idioms. Wisconsin Card Sorting Test and Digit Sequencing were the unique predictors of performance for idiom comprehension in general, while thought disorganization was not. Cognitive decline either did not appear to predict performance.

'Theory' of mind impairment in patients affected by schizophrenia and in their parents

"Theory of mind" (ToM) is the ability to judge the mental states of the self and others. It is currently considered as a part of the broader concept of social cognition, known to influence the social behaviour of patients affected by schizophrenia. Recently it has been hypothesized that the impairment of ToM is a trait that can be detected both in patients with schizophrenia and in non-psychotic relatives of patients, but it still not clear what the contribution of the familial patterns of cognitive impairment is. The aim of this study is to assess parental impairments of ToM performance considering the effects of the neurocognitive abilities known to be impaired in their first-degree relatives and to influence ToM in schizophrenic patients. Patients, their parents and control trios were assessed with the Wisconsin Card Sorting Test (WCST), the Symbol Coding Task and the ToM Picture Sequencing Task. The ANCOVA analysis on 47 trios including a schizophrenic offspring and 47 healthy trios showed a statistically significant poorer performance of patients and their parents in comparison to control trios at Symbol Coding Task and ToM task. Moreover a regression analysis showed that the neuropsychological abilities tested were significant predictors of ToM performance only in patients. Results confirm a ToM impairment among parents of patients with schizophrenia that is not directly correlated to other aspects of neurocognitive functioning.

Computer-aided neurocognitive remediation as an enhancing strategy for schizophrenia rehabilitation

Cognitive dysfunction is a chronically disabling feature of schizophrenia, associated with limits in obtaining rehabilitation improvements. The purpose of this study is to assess the effectiveness of intensive computer-aided cognitive remediation treatment (CRT) added to a standard rehabilitation treatment (SRT), in enhancing neuropsychological performances and daily functioning in patients with schizophrenia. A 12-week, randomized, controlled, single-blind trial of neurocognitive remediation was carried out on 86 patients with clinically stabilized DSM-IV schizophrenia. Patients were assessed on cognitive and daily functioning before and after either CRT or placebo training that had been added to their SRT. After 3 months the repeated measure ANOVA showed a significant time x treatment interaction for executive function and attention performances and in daily functioning assessment in favour of patients in the SRT+CRT treatment. Results confirmed that cognitive remediation added to the SRT of schizophrenia enhanced its neuropsychological effects and increased the effects of a long-term rehabilitation programme in terms of functional outcomes.

Influence of catechol-O-methyltransferase Val158Met polymorphism on neuropsychological and functional outcomes of classical rehabilitation and cognitive remediation in schizophrenia

Neurocognitive deficits are recognized as core features of schizophrenia and have a great impact on functional outcome. Recent reports have suggested that a functional polymorphism, Val158Met, of the catechol-O-methyltransferase (COMT) gene, partially influences cognitive performances (mainly cognitive flexibility and working memory) both in schizophrenic patients and in healthy controls, probably by modulating prefrontal dopamine function. While previous studies focused on single evaluation of cognitive functioning, we aimed to analyse the additive effect of COMT genotype and cognitive exercise on dynamic modulation of cognitive performances. We analysed the COMT Val158Met polymorphism in 50 patients with chronic schizophrenia randomly allocated to two treatment conditions for 3 months: standard rehabilitation treatment (SRT) alone and SRT plus specific cognitive exercise of impaired functions. We then divided our sample in four subgroups on the basis of genotype (Val/Val versus Met carriers) and treatment (placebo versus active). We assessed patients with a neuropsychological battery, the Positive and Negative Symptoms Scale (PANSS) and the Quality of Life Scale (QLS) at enrolment, after 3 months of therapy and after further 3 months of follow-up. We found significantly greater improvement of cognitive flexibility performance and QLS total score for Met carriers on active treatment in comparison to Val/Val on placebo. The findings support the hypothesis that COMT polymorphism influences individual capacity to recover from cognitive deficit through rehabilitation therapy after a wider intervention also including deficit-specific cognitive exercise as a potentiating tool.

Psychopathological and neuropsychological correlates of source monitoring impairment in schizophrenia

Schizophrenic patients are known to show a deficit in the source monitoring function, which refers to the set of processes involved in the attribution of an origin to memories and beliefs. A failure in source monitoring was found to be associated with Schneiderian delusions in the recent literature. This study aimed to explore in a sample of schizophrenic patients and controls two aspects of the source monitoring process-recognition and source attribution- and their possible correlation with psychopathology and basic neuropsychological performances. A group of 45 stabilized schizophrenic patients and 54 normal volunteers were studied with a Source Monitoring Task and a battery of neurocognitive functions known to be disturbed in schizophrenia. Recognition of self-generated items was significantly worse than control values in Schneiderian delusional patients only, while source attribution of recognized self-generated items was significantly biased towards the external sources in all delusional patients in comparison to controls. Among schizophrenic patients, source misattribution of self-generated items was significantly correlated to an executive, planning performance. Both performances were correlated to verbal memory in controls. Results confirm an impairment of different subcomponents of source monitoring performance in schizophrenia, heterogeneously related to psychopathological features and neuropsychological performances known to be impaired in schizophrenia.