The Psychological and Medical Landscape of Anorexia Nervosa over a Decade: A Retrospective Study of Possible Physical and Psychological Shifts

In recent years, the definition, clinical characteristics, and psychological aspects of anorexia nervosa (AN) have undergone notable changes, influenced by various factors such as biology, psychology, and the environment. The COVID-19 pandemic is one such external factor that has been preliminarily identified as affecting the clinical presentation of AN. This study specifically aims to assess the alterations in psychological and medical features observed in individuals with AN during the pandemic. This study is a retrospective case review of 252 people diagnosed with AN from two different cohorts: 2010-2012 and 2021. A comparison of psychological and medical data was conducted to identify specific differences in the initial clinical evaluation. Additionally, different effects of the pandemic on age cohorts were assessed, with a focus on distinctions between adolescents and adults. Results revealed that the pandemic cohort had a higher number of new cases, with patients being younger and experiencing more severe psychological symptoms. Hospitalization rates upon first access were also elevated, but no significant differences in medical values were observed. Adolescents during the pandemic showed increased episodes of binge eating, decreased obsessive-compulsive symptoms, and greater difficulty in interoceptive awareness. This study reveals distinct differences in symptomatology among patients, with a particular focus on psychological characteristics such as impulsive behaviors and interoceptive awareness. These behavioral and interoceptive changes could have potential considerations in the treatment pathway. Further investigations are warranted to gain a deeper understanding of the evolving clinical presentation of anorexia nervosa after the pandemic.

Clinical and Cognitive Functioning Changes After Partial Hospitalization in Patients With Anorexia Nervosa

Introduction: Anorexia nervosa is usually associated with emotional and cognitive difficulties. Little knowledge is available about the changes in cognitive functioning in patients undergoing treatments. The aim of the present study was to longitudinally assess the impact of partial hospitalization on clinical and cognitive functioning in anorexia nervosa. Materials and Methods: 56 women with anorexia nervosa according to DSM-5 criteria and 58 healthy women were enrolled in the study. At baseline, all participants underwent clinical, diagnostic and neuropsychological assessment (T0). Patients were also assessed at the end of the treatment program (T1; n = 56). Results: BMI improved significantly throughout treatment. At baseline, patients showed significantly poorer executive abilities and less specific autobiographical memory. After the day-hospital program, decision-making abilities improved significantly. Response to treatment was predicted by BMI at admission and duration of illness, but neuropsychological performance did not contribute to the prediction model. Discussion: Cognitive difficulties, mostly regarding executive functions, resulted differently affected by clinical improvement. In particular, while cognitive monitoring and cognitive inhibition appear to be mostly stable trait-like characteristics, decision-making is both more state-dependent and sensitive to clinical status. None of the cognitive variables added information about the response to day hospital treatment; patients with short duration of illness and a rapidly decreasing BMI would benefit more from intensive interventions than less "acute" patients. These observations, if confirmed by future studies, have important clinical implications in order to understand the impact of malnutrition on cognitive functioning and to provide individualized effective treatment for patients with anorexia nervosa.

The impact of weight suppression and weight loss speed on baseline clinical characteristics and response to treatment

OBJECTIVE

Growing evidence suggests an impact of weight suppression (WS) on severity and course of symptoms in patients with eating disorders (ED), but no study explored also the role of the weight loss speed (WLS) together with WS on the same clinical variables, which is the aim of the present work.

METHOD

A mixed cross-sectional and longitudinal cohort study was employed. Four hundred and fourteen patients with anorexia nervosa (AN = 208) or bulimia nervosa (BN = 206) according to DSM-5 criteria were recruited and assessed at referral by means of clinical interviews and self-reported questionnaires. Body mass index and diagnostic status were re-evaluated at the end of treatment.

RESULTS

WS was positively correlated with body dissatisfaction in patients with AN (p = .005), but negatively correlated in BN (p = .022). In contrast, WLS was significantly inversely correlated with age and duration of illness in all ED (p < .001), and positively correlated with drive for thinness in BN (p = .007). After treatment, WS at intake predicted higher BMI increase in both AN and BN (p < .03), while higher WLS was significantly associated with a lower drop-out rate in patients with BN (p = .02), and predicted BMI increase only in restricting AN patients (p = .02). In the whole group, WLS significantly predicted remission status (p = .039).

DISCUSSION

In our study, both WS and WLS were associated with baseline "core" clinical variables and provided complementary abilities to predict weight gain and remission at the end of treatment. If replicated, our data suggest the importance of considering both WS and WLS as useful clinical variables in the baseline assessment of ED.

Childhood obsessive-compulsive traits in anorexia nervosa patients, their unaffected sisters and healthy controls: a retrospective study

Although there is evidence that childhood perfectionistic traits predate the onset of eating disorders, few studies to date have examined the prevalence and clinical correlates of these traits in patients with anorexia nervosa (AN) and their unaffected sisters. The aim of this work was to study the prevalence of childhood obsessive-compulsive traits in patients with lifetime AN, their unaffected sisters and healthy women. A total of 116 AN patients, 32 healthy sisters and 119 controls were assessed by the EATATE Interview to assess traits such as perfectionism, inflexibility, rule-bound traits, drive for order and symmetry, and excessive doubt and cautiousness. Both self-report and maternal reports were collected. AN patients reported more childhood obsessive-compulsive traits than their healthy sisters and controls. In contrast, no differences between healthy controls and unaffected sisters emerged. In patients with AN, a dose-response relationship was found between the number of childhood obsessive-compulsive traits and psychopathology, including body image distortion, thus indicating that these traits are an important feature to be considered in assessing and treating eating disorders.

Clinical and temperamental correlates of body image disturbance in eating disorders

OBJECTIVE

Although body image disturbance (BID) is considered a core symptom in anorexia nervosa (AN) and bulimia nervosa (BN), little is known about its psychopathological correlates. The present study aimed at analysing the correlation of aspects of BID with psychopathological and temperamental characteristics.

METHOD

A sample of 1288 patients (538 AN and 750 BN) were assessed through a structured diagnostic interview, the Eating Disorders Inventory and Tridimensional Personality Questionnaire. Cognition of body image distortion, weight checking, fear of weight gain and body dissatisfaction were assessed by specific questions during the interview.

RESULTS

Various aspects of BID formed similar, but not identical, dimensions in AN and BN. In both groups, anticipatory anxiety and interoceptive awareness were significantly and independently associated with body image distortion, whereas ineffectiveness was associated with weight checking.

DISCUSSION

Body image disturbance is a multidimensional characteristic linked to psychological features, such as anticipatory anxiety, ineffectiveness and interoceptive awareness. These findings have scientific and treatment implications, and should be considered by clinicians in adopting successful treatment strategies.

In utero exposure to virus infections and the risk of developing anorexia nervosa

BACKGROUND

The study aims to explore, using indirect ecological measures of exposure, the role of viral infections in the development of anorexia nervosa (AN).

METHOD

The cohort of participants consisted of all female subjects born in the Veneto region in the period between 1970 and 1984, and residing in the urban and suburban area of Padua (27,682 female subjects in an area of 424 km2). The main outcome measure was the diagnosis of AN resulting from the Public Mental Health Database, the Register of Hospital Admissions, and the Register of the Eating Disorders Unit (n=402, 1.4%). The number of cases of rubella, chickenpox, influenza and measles was ascertained for each month for the 15-year period.

RESULTS

Exposures during the sixth month of pregnancy to the peaks of chickenpox [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.2-2.0] and rubella infections (OR 1.5, 95% CI 1.1-2.0) were significantly associated with an increased risk of developing AN, even after controlling for socio-economic status, urbanization and month of birth. We found weak evidence of a season-of-birth bias.

CONCLUSIONS

In utero exposure to viral infection could be a risk factor for developing AN. We need further epidemiological and serological studies to confirm this hypothesis.

[Tattoos and piercings in adolescents: family conflicts and temperament]

INTRODUCTION

The phenomenon of body art, such as tattoos and piercings, has ancient roots, rediscovered in Western society during the '70s. The aim of this research is to investigate the prevalence and the characteristics of tattoos and piercings among Italian adolescents of high school in Padua, with particular attention to family context and temperament.

METHODS

Some questionnaires about the presence or the wish of tattoos/piercings, smoke and alcohol use, familiar conflicts, and some temperamental features, such as novelty seeking, harm avoidance and reward dependence, have been administered to a sample of 829 students.

RESULTS

Tattoo and piercing's prevalence among adolescents was respectively 4% and 24%; 2.5% of the sample had both. Respectively 62% and 35% of the subjects expressed the desire of having a tattoo or piercing. A significant association has been found between tattoo/piercing's presence and smoke and alcohol use (p < 0.001). Subjects with tattoos and piercings, are more likely to have familiar conflicts and minor perceived support and they have higher scores on the novelty seeking scale. Those who wish a tattoo/piercing showed higher reward dependence.

CONCLUSIONS

This study confirms that tattoos/piercings are common among young people and it stresses the relevance of familiar and temperamental features, and the association between tattoos/piercings and some maladaptive behaviors, like smoke and alcohol use.

[Perception of social rank and submissive behavior in eating disorders]

OBJECTIVE

The aim of this paper is to study the social behavior in patients with eating disorders, in particular the presence of low social ranking and high submissive behavior. We also considered the relationship between these factors and the presence of some personality traits and pathological eating behaviors.

METHOD

We performed a case-control study on 249 young women (124 controls and 125 eating disorders subjects). Eating disorders were diagnosed as anorexia nervosa, bulimia nervosa and eating disorders non otherwise specified. The patients underwent a routine assessment by means of a diagnostic interview and some self-reported questionnaires. All the subjects (cases and controls) also completed two scales for the assessment of social ranking and submissive behaviors. The two questionnaires were translated from English with the back-translation method.

RESULTS

The two scales were valid and reliable in their Italian version. We observed a significant difference between cases and controls: social ranking was lower in cases, and submissive behavior was lower in controls. Social ranking had an inverse relationship with submissive behavior both in cases and controls, and a significant correlation was found with other interpersonal aspects (ineffectiveness, interpersonal sensitivity) and with some pathological traits and behaviors, like self-injurious behavior.

CONCLUSION

Our study shows that features of low social ranking and submissive behavior are common in eating disorders subjects. These features could represent a risk factor for the development of an eating disorder or, on the contrary, represent a consequence of an eating disorder. A useful therapeutic approach to these disorders could be focused on shifting from submissive to assertive behavior.

Anorexia nervosa: from purgative behaviour to nephropathy. a case report

BACKGROUND

Individuals who suffer from Anorexia Nervosa refuse to maintain a minimally normal body weight, are intensely afraid of gaining weight and exhibit a significant disturbance in the perception of the shape and size of their body. Postmenarchal females with this disorder are amenorrohic. In the Binge-Eating/Purging subtype individuals regularly engage in binge eating and purging behaviour (i.e self-induced vomiting or misuse of laxatives, diuretics, or enemas).Hypokalaemia is often seen in chronic Anorexia Nervosa, especially that of the purging type (ANp), and, as well as electrocardiographic anomalies, this can lead to tubulointerstitial nephritis (hypokalaemic nephropathy) with typical histological characteristics. The physiopathological mechanisms behind this damage are linked to altered stimulation of vasoactive mediators, and to the ammonium-mediated activation of the alternative complement pathway. However, it has not yet been ascertained whether a variant of the pathway specific for ANp 1, exists.

CASE PRESENTATION

We describe herein a case of hypokalaemic nephropathy in a patient affected by chronic ANp who presented to our Centre for Eating Disorders.

CONCLUSION

Hypokalaemia can provoke cardiovascular alterations as well as muscular and renal complications, and thus potential renal damage needs to be investigated in patients suffering from long-term purgative anorexia.

Pregnancy in severe anorexia nervosa

OBJECTIVE

Anorexia nervosa among Arabian girls seems to be rare and pregnancy in condition of extreme underweight seems to be rare as well.

METHOD

We report the case of a 19-year-old Arabian girl living in Italy who referred to an Eating Disorder Unit for her anorexic condition.

RESULTS

She arrived for a consultation when she was at her 33rd week of pregnancy at a Body Mass Index lower than 14.

CONCLUSION

The present case aims to underline the need of medical and psychological attention to pregnancy in anorexia nervosa cases.

Association between low height and eating disorders: cause or effect?

OBJECTIVE

Few studies have explored the relationship between stature and eating disorders (ED). We aimed to investigate the connection between height and risk for ED in a cohort of female subjects.

METHOD

The sample was composed of 1,031 subjects with ED and 832 controls. All participants belonged to the same birth cohort and were living in the same geographical area.

RESULTS

ED subjects were, on average, shorter than control subjects, independently from the age of onset. In early-onset anorexia nervosa only, age of onset and lowest body mass index were significant predictors of height. In the whole sample, a lower height was associated with an increased risk of having an ED, even after controlling for possible confounding variables.

CONCLUSION

The association between EDs and low stature is statistically significant. Further studies are necessary to understand which genetic and/or environmental factors might explain this association.

Anorexia nervosa patients with a prior history of bulimia nervosa

OBJECTIVES

To investigate clinical and psychological features of patients with anorexia nervosa (AN) with a previous history of bulimia nervosa.

METHOD

Three hundred thirty-three patients with a full diagnosis of AN were assessed by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Eating Disorders Inventory, and the Hopkins Symptom Checklist.

RESULTS

Twenty-four patients (7%) reported a previous diagnosis of bulimia nervosa and were compared with a control group of 48 patients without a history of bulimia, matched for diagnostic subtype. Among the patients with a history of bulimia nervosa, 11 were of the restricting type and 13 of the binge eating/purging type. Among restricting anorexic patients, those with a history of bulimia reported greater age of onset, more psychiatric symptoms, more family psychiatric morbidity, and a higher rate of sexual abuse. On the contrary, among patients with the AN bingeing-purging subtype, the presence of a previous bulimia nervosa was not associated with any of the investigated variables.

CONCLUSIONS

Patients with restricting AN who report a history of previous bulimia nervosa are not frequent among those referring to an outpatient eating disorders unit. However, our findings in this small group of subjects confirm that a lifetime history of bingeing and purging in patients with eating disorder, irrespective of when it occurs, is always associated with more psychopathology compared with those restricting patients with AN who have never had a period of bingeing and purging.

Predictors of binge eating in restrictive anorexia nervosa patients in Italy

The aim of the present study was to investigate the predictive factors for the development of binge eating in restricting anorexia nervosa patients who underwent an outpatient treatment. The sample was a group of 168 patients with restricting anorexia nervosa, consecutively admitted to an outpatient unit. All the patients underwent a routine baseline assessment. Information regarding binge eating onset and duration of treatment was prospectively recorded in clinical records. Twenty-three patients developed binge episodes during outpatient treatment. High scores on the Eating Disorders Inventory body dissatisfaction subscale and early age at menarche significantly predict the risk of developing binge eating. High levels of ineffectiveness, as measured by the Eating Disorders Inventory, and early age at menarche are significant predictors of a shortened time to develop binge eating. The identification of subjects at risk for developing binge eating should be considered an important step for a successful treatment of restricting anorexic patients.

Eating disorders and attitudes in Maltese and Italian female students

BACKGROUND

No study to date has investigated the frequency of eating disorders (ED) in Malta. The aim of the present study was to provide a cross-cultural comparison between Malta and Italy as regards the frequency of ED and problematic eating attitudes among female students.

SAMPLING AND METHODS

128 Maltese and 135 Italian female students aged 16-20 were surveyed. Subjects underwent a structured clinical interview and completed some self-reported questionnaires: the Eating Attitudes Test, the Inventory for the Screening of Eating Disorders and the Eating Disorders Examination-Screening Version.

RESULTS

The rates of ED are very similar in the two samples with the exception of the frequency of binge eating disorder which is zero in the Italian sample and 4% among Maltese students. Maltese female students weighed significantly more than their Italian counterparts. They also reported more frequent dieting, fear of fatness and experience of low self-esteem related to body shape and weight.

CONCLUSIONS

Despite the fact that Maltese female students have a greater tendency to be overweight and display more problematic eating and body attitudes, their risk of developing ED, with the exception of binge eating disorder, is similar to that of their Italian counterparts.

Engaging teachers in an eating disorder preventive intervention

OBJECTIVE

This study evaluated the effectiveness at 1-year follow-up of a psychoeducational eating disorders preventive intervention implemented by specifically trained teachers.

METHOD

Participating teachers participated in a 5-week training program. One hundred forty-one female students attending nine classes at a vocational training school in Mestre (Venice) were assessed via a structured clinical interview (Structured Clinical Interview for DSM-IV Axis I disorders) and via the 40-item Eating Attitudes Test (EAT-40). Three classes were randomly selected to participate in a 6-week prevention program conducted by the trained teachers.

RESULTS

Our data show that a disturbing number of the girls who were asymptomatic at baseline had developed a full or partial eating disorder 1 year later. This was the case for 2 (5%) participants and 10 (11%) subjects in the control group. Subjects in the prevention group differed significantly from the control group at the 1-year follow-up. This was the case for their EAT Bulimia subscale scores, which showed a significant improvement. The intervention group also revealed a lower development of food restraint and pathologic body attitudes.

DISCUSSION

Given the sample size, our findings must be considered cautiously. However, they suggest that students can benefit from participation in a preventive intervention program conducted by teachers, and the benefits appear to be particularly pronounced for bulimic symptoms.

Enhanced serum cholesterol and triglyceride levels in bulimia nervosa: relationships to psychiatric comorbidity, psychopathology and hormonal variables

Increased levels of cholesterol have been reported in patients with bulimia nervosa (BN), but all but one of the published studies were performed on non-fasting subjects, which limits the interpretation of this finding. Moreover, the relationships between serum lipids and comorbid psychiatric disorders or bulimic psychopathology have scarcely been investigated. We measured serum levels of total cholesterol, triglycerides, glucose, 17beta-estradiol and thyroid hormones in 75 bulimic women and 64 age-matched healthy females after an overnight fast. Compared with healthy women, bulimic patients exhibited significantly enhanced serum levels of cholesterol and triglycerides, but similar values of glucose, 17beta-estradiol, FT3 and FT4. No significant differences emerged in these variables between patients with or without comorbid depression, borderline personality disorder or lifetime anorexia nervosa. Circulating cholesterol was positively correlated to the patients' drive for thinness, ineffectiveness, enteroceptive awareness and impulse regulation sub-item scores of the Eating Disorder Inventory-2. These findings confirm that BN is associated with increased levels of serum lipids. This alteration may be involved in the pathophysiology of certain psychopathological characteristics of BN and cannot be explained by the co-occurrence of other psychiatric disorders.

The relationship between temperament and impulsive behaviors in eating disordered subjects

To date, few studies have examined the personality characteristics and clinical predictors of impulsive behaviors in eating disorders (ED). The aim of this work was to study the prevalence of a wide range of impulsive behaviors in a sample of 554 ED subjects and to examine the predictors of these behaviors. Subjects were diagnosed according to DSM-IV criteria as having anorexia nervosa restricting type (ANR; n = 183), anorexia nervosa binge eating/purging type (ANBP; n = 65), bulimia nervosa purging type (BNP; n = 244), and bulimia nervosa nonpurging type (BNNP; n = 62). Nine different types of impulsive behaviors were assessed in these groups. About 55% of the whole sample reported at least one type of impulsive behavior, 35% more than one, and about 13% more than three. According to findings, impulsive and multi-impulsive subjects are characterized by the presence of purging behavior and by specific temperamental features such as high levels of novelty seeking and low persistence. The prediction of impulsive behavior is further improved by considering the presence of a history of childhood abuse, maternal psychiatric morbidity, and some specific psychological symptoms such as maturity fears, perfectionism, depression, and obsessive-compulsive symptoms. The presence of impulsive behavior appears to be associated with overall higher levels of psychiatric symptomatology and eating psychopathology, thus indicating that they are an important feature to be considered in the assessment and treatment of ED.

A preventive intervention program in adolescent schoolgirls: a longitudinal study

BACKGROUND

To explore the impact of a prevention program on the eating and body attitudes of a sample of adolescent schoolgirls.

METHODS

The program involved lessons and group discussions of general adolescent problems and eating disorders. A total of 254 16-year-old schoolgirls were evaluated, of whom 154 participated in the program and a further 154 subjects formed the control group. Variations in weight, Eating Attitudes Test and Eating Disorders Inventory at a 1-year follow-up were compared for the two groups.

RESULTS

Among high-risk subjects, no significant differences were found between the prevention and the control group. The preventive program appeared to reduce significantly body dissatisfaction and to decrease the risk of bulimic attitudes in low-risk subjects.

CONCLUSIONS

Providing schoolgirls with the correct information about eating disorders did not encourage unhealthy attitudes to eating and weight regulation practices. However, for high-risk subjects more intensive and specific intervention may be required, for which further research is needed.

Prevalence of eating disorders in Italy: a survey on a sample of 16-year-old female students

BACKGROUND

To date, the number of epidemiological studies on eating disorders (ED) in Italy and in other Mediterranean countries is still limited. This study evaluated the eating attitudes and the prevalence of eating disorders in a sample of 359 16-year-old Italian schoolgirls.

METHODS

The study followed a two-stage procedure consisting in a first screening stage followed by clinical interviews. A third stage consisting in a case register study and a 1-year followup confirmed the importance of evaluating subjects who chose not to participate in the survey.

RESULTS

Prevalence rates found in our sample are consistent with those of other prevalence studies conducted on adolescent girls: 0% for anorexia nervosa, 0.5% for bulimia nervosa and 3.7% for ED not otherwise specified. Also some important features associated with the presence of an ED appeared to be present in Italian female students, as in Anglo-Saxon populations: the tendency towards denial that led to an overrepresentation of ED among nonrespondents, and the ascertainment that just a small proportion of people seeks help for ED. The Italian sample reported higher scores on eating attitudes test compared to Anglo-Saxon samples.

CONCLUSIONS

No evidence of different rates of ED was found in our Italian sample in comparison with non-Mediterranean samples. The importance of using a two-stage design and a third control stage in prevalence studies is emphasized by our findings.