Publications by authors named "Alessio Maria Monteleone"

71 Publications

A systematic review of network analysis studies in eating disorders: Is time to broaden the core psychopathology to non specific symptoms.

Eur Eat Disord Rev 2021 May 3. Epub 2021 May 3.

Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neurosciences, University of Salerno, Salerno, Italy.

Objective: Network theory considers mental disorders as the product of symptom interaction. A growing number of studies employing this methodology has been conducted in eating disorders (EDs). We aimed to review those studies to provide evidence and limitations for a novel conceptualisation of EDs.

Methods: According to PRISMA guidelines and PICOS criteria, studies eligible for inclusion were those employing network analysis in people with a clinically defined diagnosis of ED. Twenty-five studies were included and were analysed in relation to diagnosis, comorbidity, and treatment outcome.

Results: Despite the central role of overvaluation of body shape and weight and cognitive restraint across ED diagnoses, ineffectiveness, interoceptive awareness and affective problems appear central symptoms. Ineffectiveness and interoceptive awareness emerge as bridge symptoms promoting comorbidity in people with anorexia nervosa and in mixed ED samples. Although few studies assessed treatment outcome, there is evidence supporting the predictive role of central network nodes.

Conclusions: Ineffectiveness, interoceptive ability and affective problems may be included in the core ED psychopathology, in addition to ED-specific symptoms. Network analysis is a promising method to reconceptualize comorbidity. Future studies are recommended to include general psychopathology in ED networks, to assess connections with the external field and clinical meaning of network connectivity.
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http://dx.doi.org/10.1002/erv.2834DOI Listing
May 2021

The connection between childhood maltreatment and eating disorder psychopathology: a network analysis study in people with bulimia nervosa and with binge eating disorder.

Eat Weight Disord 2021 Mar 28. Epub 2021 Mar 28.

Psychiatric Division, Rambam, Health Care Campus, Eating Disorders Institution, Haifa, Israel.

Purpose: Childhood maltreatment (CM) experiences are associated with heightened risk of Eating disorders (EDs). The psychopathological pathways promoting this association in people with Bulimia nervosa (BN) and in those with Binge eating disorder (BED) are under-investigated.

Methods: One hundred and eighty-one people with BN and 144 with BED filled in the Eating Disorder Inventory-2, to measure ED psychopathology, and the Childhood Trauma Questionnaire, to assess their early traumatic experiences. Network analysis was conducted to investigate the interplay between those variables. The shortest pathways function was employed to investigate the shortest out of all routes conveying the association between CM and ED-specific symptoms.

Results: In both people with BN and with BED, all CM types were connected to the ED psychopathology through the emotional abuse node. The association between emotional abuse and ED-specific symptoms (bulimia and body dissatisfaction) differed in the two groups: in people with BN, it included ineffectiveness, while in people with BED, it involved impulsivity. Interoceptive awareness, an indirect measure of emotion regulation, was included in these pathways in both groups.

Conclusion: In the light of literature showing that emotional abuse has a connecting role between CM and ED psychopathology also in anorexia nervosa, the present findings support the idea that emotional abuse conveys such association in all the main ED diagnoses. Ineffectiveness and impulsivity may represent the specific psychopathological dimensions connected to emotional abuse and promoting the maintenance of ED-specific symptoms in BN and in BED, respectively. These findings are worth of attention by clinicians.

Level Of Evidence: Level III: evidence obtained from well-designed cohort or case-control analytic studies.
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http://dx.doi.org/10.1007/s40519-021-01169-6DOI Listing
March 2021

Childhood maltreatment and clinical response to mood stabilizers in patients with bipolar disorder.

Hum Psychopharmacol 2021 Mar 5. Epub 2021 Mar 5.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy.

Objective: The association between childhood maltreatment (CM) and clinical response to mood stabilizers has been scarcely investigated in bipolar disorder (BD). Therefore, we assessed whether CM affects the response to lithium or anticonvulsant treatments in BD patients.

Methods: A retrospective assessment of clinical response to mood stabilizers was conducted in 97 euthymic patients with BD by means of the Alda scale. History of CM was investigated through the Childhood Trauma Questionnaire.

Results: Thirty-seven patients (24 with a history of CM and 13 without CM) were on stable lithium treatment while sixty (35 with a history of CM and 25 without CM) were on stable anticonvulsant treatment. Clinical response to drug treatment did not differ between BD with CM and those without CM in the whole sample as well as in the anticonvulsant-treated subgroup. In the lithium-treated subgroup, a significant negative correlation emerged between childhood physical abuse and clinical response and patients with CM showed a significantly reduced Alda score.

Conclusions: In BD patients, CM did not influence the clinical response to anticonvulsant mood stabilizers whereas it was associated with a poorer response to lithium with childhood physical abuse playing a major role in this effect.
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http://dx.doi.org/10.1002/hup.2783DOI Listing
March 2021

The impact of COVID-19 lockdown and of the following "re-opening" period on specific and general psychopathology in people with Eating Disorders: the emergent role of internalizing symptoms.

J Affect Disord 2021 04 18;285:77-83. Epub 2021 Feb 18.

Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neurosciences, University of Salerno, Salerno, Italy.

Background: We assessed the impact of the coronavirus disease 2019 (COVID-19) pandemic on specific Eating Disorder (ED) and general psychopathology in people with an ED diagnosis during the lockdown period and after the end of the related containment measures.

Methods: People with clinically defined diagnosis and undergoing treatment for an ED completed an online survey, which included adapted questions from standardized psychometric scales. Data relative to three different time periods (before, during and after the end of lockdown) were collected. Psychopathological changes over these periods were investigated and compared through one-way analysis of variance or covariance with repeated measures.

Results: Three hundred twelve people completed the survey (57.4% diagnosed with Anorexia Nervosa (AN) or atypical AN, 20.2% with Bulimia Nervosa, 15.4% with Binge Eating Disorder, 7.05% with Other Specified Feeding or Eating Disorders). The severity of both specific and general psychopathology increased during the lockdown and the rise of general symptoms persisted in the following re-opening phase, except for suicide ideation. Almost all of these findings were not affected by ED diagnosis, participants' age and illness duration.

Limitations: The retrospective nature of data collection is the main limitation of the study.

Conclusions: People with EDs showed a COVID-19 emergency-induced worsening of both general and specific psychopathology. The effect on general psychopathology persisted in the re-opening period. These findings suggest a high stress vulnerability of ED individuals with important effects on internalizing symptoms, which are worth of attention by clinicians.
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http://dx.doi.org/10.1016/j.jad.2021.02.037DOI Listing
April 2021

The Gut Microbiome and Metabolomics Profiles of Restricting and Binge-Purging Type Anorexia Nervosa.

Nutrients 2021 Feb 4;13(2). Epub 2021 Feb 4.

Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, 84081 Baronissi, Italy.

Alterations in the gut microbiome and fecal metabolites have been detected in anorexia nervosa (AN), but differences in those profiles between restricting AN (ANR) and binge-purging AN (ANBP) type have not been explored. We made a secondary analysis of our previous data concerning microbiome and metabolomics profiles of 17 ANR women, six ANBP women and 20 healthy controls (HC). Twelve fecal metabolites differentiating ANR patients, ANBP patients and HC were identified. Both patient groups showed decreased intra-individual bacterial richness with respect to healthy controls (HC). Compared to ANR subjects, ANBP patients had a significant increase in relative abundances of , Bifidobacteriaceae, Bifidobacteriales, and Eubacteriacae and a significant decrease in relative abundances of , , Pasteurellaceae, and Pasteurellales. The heatmaps of the relationships of selected fecal metabolites with microbial families showed different structures among the three groups, with the heatmap of ANBP patients being drastically different from that of HC, while that of ANR patients resulted more similar to HC. These findings, although preliminary because of the relatively small sample size, confirm the occurrence of different gut dysbiosis in ANR and ANBP and demonstrate different connections between gut microorganisms and fecal metabolites in the two AN types.
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http://dx.doi.org/10.3390/nu13020507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915851PMC
February 2021

Prevalence of antipsychotic-induced extrapyramidal symptoms and their association with neurocognition and social cognition in outpatients with schizophrenia in the "real-life".

Prog Neuropsychopharmacol Biol Psychiatry 2021 Jan 20;109:110250. Epub 2021 Jan 20.

Department of Psychiatry, University of Campania "Luigi Vanvitelli" Naples, Italy.

First generation antipsychotics (FGAs) are more likely to induce extrapyramidal side-effects (EPS) than second generation antipsychotics (SGAs), and EPS have been shown associated to cognitive deficits in schizophrenia. So far, no study has explored the relationships between EPS and social cognition (SC) in people with schizophrenia. Therefore, we assessed the prevalence of EPS in a large sample of drug-treated community-dwelling persons with schizophrenia and explored their relationships with patients' neurocognitive and SC abilities. 875 patients underwent EPS, psychopathological, neurocognitive and SC assessments by means of standardized measures. Relationships between EPS, psychopathology and neurocognitive and SC measures were investigated by correlation tests. Moreover, a partial correlation network was computed by means of a network analysis. 256 patients were treated with FGAs alone or in combination with SGA and 619 with SGAs. EPS were significantly more frequent in FGA-treated group than in the SGA-treated one. Patients with EPS disclosed a more severe psychopathology and were more impaired in neurocognitive and SC measures compared to those without EPS. Disorganization, expressive deficit, and duration of illness were significantly associated to both neurocognitive and SC measures while EPS were associated to neurocognitive measures only. The network analysis showed that parkinsonism was the sole EPS directly connected to both psychopathological and neurocognitive indices whereas no direct connection emerged between EPS and SC measures. Present findings confirm that EPS are still present in the era of SGAs and contribute, together with other clinical variables, to the neurocognitive but not to the SC impairment of patients with schizophrenia.
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http://dx.doi.org/10.1016/j.pnpbp.2021.110250DOI Listing
January 2021

Risk and resilience factors for specific and general psychopathology worsening in people with Eating Disorders during COVID-19 pandemic: a retrospective Italian multicentre study.

Eat Weight Disord 2021 Jan 10. Epub 2021 Jan 10.

Department of Medicine, Surgery and Dentistry Scuola Medica Salernitana, Section of Neurosciences, University of Salerno, Salerno, Italy.

Purpose: The COVID-19 pandemic restrictions had negative impact on the psychopathology of people with Eating Disorders (EDs). Factors involved in the vulnerability to stressful events have been under-investigated in this population. We aimed to assess which factors contributed to COVID-19-induced worsening in both general and specific psychopathology.

Methods: Three-hundred and twelve people with a clinically defined diagnosis of an ED and undergoing a specialist ED treatment in different Italian ED services before the spreading of COVID-19 pandemic filled in an online survey. ED specific and general psychopathology changes after COVID-19 quarantine were retrospectively evaluated. Factors related to COVID-19 concerns (financial condition, fear of contagion, perceived social isolation/support, satisfaction in peer, family or sentimental relationships), illness duration and treatment-related variables (type of treatment provided, type of access to care, satisfaction with therapeutic relationships) were included as predicting factors in a structural equational model, which included latent variables consisting of general and ED psychopathology items as outcomes.

Results: A perceived low quality of therapeutic relationships, fear of contagion and increased isolation were positively associated with psychopathology worsening. Reduced satisfaction with family and with friends' relationships and reduced perceived social support were associated with ED and general symptoms deterioration, respectively. No significant effect emerged for intimate relationships, illness duration, economic condition and type of treatment.

Conclusions: This study provides a comprehensive evaluation of clinical variables associated with psychopathological changes during the COVID-19 lockdown period highlighting potential risk and resilience factors and, possibly, informing treatment as well as prevention strategies for EDs.

Level Of Evidence Iv: Evidence obtained from multiple time series analysis such as case studies.
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http://dx.doi.org/10.1007/s40519-020-01097-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797193PMC
January 2021

Factors influencing lithium versus valproate prescription preference in the maintenance treatment of bipolar patients: a report from the Italian Early Career Psychiatrists (SOPSI-GG).

Int J Psychiatry Clin Pract 2021 Mar 30;25(1):82-89. Epub 2020 Dec 30.

Department of Psychiatry, University of Campania "L. Vanvitelli", Largo Madonna Delle Grazie, Naples, Italy.

Background: Objective of the present manuscript is to investigate, among Italian early career psychiatrists (ECPs), prescriber and patient-related factors associated with lithium or valproate preference to treat patients affected by Bipolar Disorder (BD).

Methods: An on-line survey was carried out among 252 ECPs, investigating their prescription patterns in relation to lithium and the differences with prescription of valproate. Collected data were compared according to lithium or valproate prescription preference in the long-term treatment of BD by tests for qualitative variables.

Results: Over two thirds of ECPs preferred lithium over valproate for the maintenance treatment of BD. Less than half of the sample used lithium as first-line agent for mania or major depression, and less than one third for mixed episodes. Factors associated with lithium preference as first-line maintenance treatment include perception of having a good knowledge of lithium ( < 0.001) and complete satisfaction with education on lithium ( < 0.001). One of the main factors to prefer valproate was the concern about long-term side effects of lithium ( < 0.001).

Conclusions: Type of education, source of information, clinical experience and safety concerns influence the choice of lithium versus valproate in the long-term treatment of BD. Present findings may guide educational training of ECPs.KEY POINTSLithium has been less prescribed in the last years for long-term treatment of Bipolar Disorder.Educational and clinical factors seem to influence the attitude to prescribe lithium.Only half of the Italian early career psychiatrists declare to have at least an adequate knowledge of lithium.Residency program in psychiatry should consider the implementation of education on lithium.
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http://dx.doi.org/10.1080/13651501.2020.1865405DOI Listing
March 2021

Emotional traumatic experiences significantly contribute to identify a maltreated ecophenotype sub-group in eating disorders: Experimental evidence.

Eur Eat Disord Rev 2021 Mar 30;29(2):269-280. Epub 2020 Dec 30.

Department of Psychiatry, University of Campania 'Luigi Vanvitelli', Naples, Italy.

Objective: Eating disorders (EDs) are associated with a high prevalence of childhood maltreatment (CM). We aimed to experimentally assess if people with EDs and history of CM show altered biological, emotional and behavioural responses to the Trier Social Stress Test (TSST).

Methods: According to Childhood Trauma Questionnaire cut-off scores, 29 participants (14 with anorexia nervosa [AN] and 15 with bulimia nervosa [BN]) were classified as maltreated (Mal) ED participants while 19 participants (11 with AN and eight with BN) without CM were identified as no maltreated (noMal) ED participants. Cortisol, anxiety and hunger responses to TSST and post-stress body dissatisfaction were measured.

Results: Mal ED people showed heightened emotional reactivity, lower levels of hunger and more severe post-stress body dissatisfaction in comparison with noMal ones. Higher cortisol production was observed in people with AN, regardless of CM history, and in those with BN and emotional CM. Emotional trauma was the main CM type contributing to the experimental differences observed in Mal ED people.

Conclusions: This is the first study providing experimental and multi-level support to the maltreated ecophenoptype hypothesis in people with EDs. These findings may promote new insights into the biological bases of EDs and provide novel therapeutic implications.
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http://dx.doi.org/10.1002/erv.2818DOI Listing
March 2021

The validity of the fifth and the 10th Body Mass Index percentile as weight cut-offs for anorexia nervosa in adolescence: No evidence from quantitative and network investigation of psychopathology.

Eur Eat Disord Rev 2021 Mar 14;29(2):232-244. Epub 2020 Dec 14.

Department of Neuroscience, Child Neuropsychiatry Unit, I.R.C.C.S. Children Hospital Bambino Gesù, Rome, Italy.

Objective: Although the fifth Body Mass Index (BMI) percentile is the Diagnostic and Statistic Manual of Mental Disorders -5 weight cut-off criterion to diagnose anorexia nervosa (AN) in children and adolescents, its validity has not been proved, and the 10th percentile value is often applied. We aimed to investigate the diagnostic validity of these weight cut-offs.

Method: We compared general and eating-disorder (ED) specific psychopathology in 380 adolescents with AN or atypical AN. They were grouped first with respect to the fifth BMI percentile and then with respect to the 10th BMI percentile and differences between groups were analysed. Network analyses on psychopathological symptoms were also conducted.

Results: Adolescents with BMI above the fifth and the 10th percentile reported more severe ED specific symptomatology compared to those with BMI below these cut-offs. No significant differences emerged between groups neither in general psychopathology nor in the network structure of psychopathology.

Conclusions: The fifth BMI percentile does not discriminate psychopathology severity in adolescents with AN. From the psychopathology perspective, our findings suggest that adolescents with atypical AN deserve the same clinical and research attention as those with full AN. Future studies are needed to identify a more accurate definition of underweight in adolescents.
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http://dx.doi.org/10.1002/erv.2814DOI Listing
March 2021

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

Clin Psychol Psychother 2020 Dec 7. Epub 2020 Dec 7.

Eating Disorders Center for Treatment and Research, Department of Neuroscience, University of Turin, Turin, Italy.

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.
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http://dx.doi.org/10.1002/cpp.2535DOI Listing
December 2020

Alexithymia and cortisol awakening response in people with eating disorders.

World J Biol Psychiatry 2020 Nov 11:1-6. Epub 2020 Nov 11.

Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Section of Neurosciences, University of Salerno, Salerno, Italy.

Objectives: Alexithymia, which is the inability to recognise and describe one's own emotions, is a transdiagnostic feature across eating disorders (EDs) and it has been associated with prolonged stress exposure. Therefore, we evaluated whether alexithymia was associated with hypothalamus-pituitary-adrenal (HPA) axis functioning, the main endogenous stress response system, in patients with anorexia nervosa (AN) or bulimia nervosa (BN).

Methods: 26 women with AN and 26 with BN participated in the study. Alexithymia was evaluated by the Toronto Alexithymia Scale-20 and eating-related psychopathology was measured by the Eating Disorder Inventory-2. The activity of the HPA axis was assessed by measuring the salivary cortisol awakening response (CAR).

Results: The prevalence of alexithymia did not differ significantly between the two diagnostic groups. Alexithymia was associated with more severe eating-related psychopathology in AN women but not in BN women. A significant reduction in the magnitude of CAR occurred in alexithymic patients with BN compared to non-alexithymic patients, but not in alexithymic women with AN.

Conclusions: These results confirm the presence of a more severe specific psychopathology in alexithymic individuals with AN and show, for the first time, an association between alexithymia and a dampened basal activity of the HPA axis in BN.
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http://dx.doi.org/10.1080/15622975.2020.1844291DOI Listing
November 2020

Network intervention analysis to assess the trajectory of change and treatment effects associated with the use of online guided self-help for anorexia nervosa.

Early Interv Psychiatry 2020 Oct 15. Epub 2020 Oct 15.

Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Aim: The aim of this study was to use the innovative technique of Network Intervention Analysis (NIA) to examine the trajectory of symptom change associated with the use of a digital guided self-help intervention (RecoveryMANTRA) to augment treatment as usual in adult anorexia nervosa.

Methods: Self-reported eating disorder symptoms and mood (stress, anxiety and depression), work and social adjustment, motivation and treatment (Treatment as usual + RecoveryMANTRAand Treatment as usual) were included as nodes in the network and examined using NIA. Networks were computed at baseline (n = 88, 99), at end of treatment (6 weeks, n = 71, 75) and at 6- (n = 58, 63) and 12-month (n = 52, 63) follow-up.

Results: RecoveryMANTRA was associated with a direct effect on anxiety, shape concern and restraint at the end of the intervention. This effect was not maintained at follow-up. There were no direct effects of RecoveryMANTRA on motivation, stress and depression.

Conclusions: These findings indicate that RecoveryMANTRA exerts a direct effect on eating disorder symptoms and anxiety. NIA is a promising method to evaluate trajectories of clinical change and direct and indirect effects of a therapeutic intervention compared to a control condition.
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http://dx.doi.org/10.1111/eip.13064DOI Listing
October 2020

Risk factors for eating disorders: an umbrella review of published meta-analyses.

Braz J Psychiatry 2020 Sep 28. Epub 2020 Sep 28.

Unità di Psichiatria, Dipartimento Scienze della Salute, Università degli studi di Firenze, Firenze, Italy.

Objective: To grade the evidence about risk factors for eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder) with an umbrella review approach.

Methods: This was a systematic review of observational studies on risk factors for eating disorders published in PubMed/PsycInfo/Embase until December 11th, 2019. We recalculated random-effect meta-analyses, heterogeneity, small-study effect, excess significance bias and 95% prediction intervals, grading significant evidence (p < 0.05) from convincing to weak according to established criteria. Quality was assessed with the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool.

Results: Of 2,197 meta-analyses, nine were included, providing evidence on 50 risk factors, 29,272 subjects with eating disorders, and 1,679,385 controls. Although no association was supported by convincing evidence, highly suggestive evidence supported the association between childhood sexual abuse and bulimia nervosa (k = 29, 1,103 cases with eating disorders, 8,496 controls, OR, 2.73, 95%CI 1.96-3.79, p = 2.1 x 10-9, AMSTAR-2 moderate quality) and between appearance-related teasing victimization and any eating disorder (k = 10, 1,341 cases with eating disorders, 3,295 controls, OR 2.91, 95%CI 2.05-4.12, p = 1.8x10-9, AMSTAR-2 moderate quality). Suggestive, weak, or no evidence supported 11, 29, and 8 associations, respectively.

Conclusions: The most credible evidence indicates that early traumatic and stressful events are risk factors for eating disorders. Larger collaborative prospective cohort studies are needed to identify risk factors for eating disorders, particularly anorexia nervosa.
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http://dx.doi.org/10.1590/1516-4446-2020-1099DOI Listing
September 2020

Dysregulated Sexuality in Women with Eating Disorders: The Role of Childhood Traumatic Experiences.

J Sex Marital Ther 2020 16;46(8):793-806. Epub 2020 Sep 16.

Psychiatric Unit, Department of Health Sciences, University of Florence, Florence, Italy.

The present study explored the psychopathological, behavioral, and putative biological underpinnings of dysregulated sexuality in eating disorders (EDs), focusing on the role of childhood trauma - evaluated with the Childhood Trauma Questionnaire (CTQ). The comparison between Binge-Purging and Restricting patients outlined the predominance of markers of dysregulated sexuality in the first subgroup. In the clinical sample, hypersexuality - measured through the Hypersexual Behavior Inventory (HBI) - was associated with severe psychopathology, emotion dysregulation, childhood trauma, adverse consequences, and higher ghrelin levels. Moderation analyses showed that hypersexuality was associated with emotion dysregulation and psychopathology only in those patients reporting childhood traumatic experiences.
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http://dx.doi.org/10.1080/0092623X.2020.1822484DOI Listing
February 2021

Multiple levels assessment of the RDoC "system for social process" in Eating Disorders: Biological, emotional and cognitive responses to the Trier Social Stress Test.

J Psychiatr Res 2020 11 2;130:160-166. Epub 2020 Aug 2.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy.

Background: Social dysfunction is a putative risk and maintaining factor for Eating Disorders (EDs). We assessed biological, emotional, and cognitive responses to a psychosocial stressor, in order to provide a multilevel investigation of the RDoC social process system in EDs.

Methods: Patients were recruited among those seeking treatment for an ED. Cortisol response to Trier Social Stress Test (TSST) was measured in 105 subjects: 35 women with anorexia nervosa (AN), 32 with bulimia nervosa (BN) and 38 healthy women. Anxiety, hunger, and desire to eat throughout TSST were rated in a subgroup of them (23 AN, 21 BN, and 25 control women). Two-way ANOVAs with repeated measures were run to assess differences among groups.

Results: The TSST-induced cortisol secretion of AN women was significantly higher than in BN and healthy women; this significance disappeared after controlling for body mass index. Compared to healthy women, both AN and BN women showed reduced cortisol reactivity that disappeared after controlling for trait anxiety and ineffectiveness. Both ED groups displayed increased anxiety response to TSST, while only AN group reported greater decreases in hunger and desire to eat. No significant correlations were found between cortisol and anxiety, hunger, or desire to eat in response to TSST.

Conclusions: People with EDs are characterized by blunted cortisol reactivity and greater anxiety, hunger, and desire to eat responses to a psychosocial stressor without any significant association between these measures. This study provides the first empirical and multilevel support to a deranged functioning of the RDoC "system for social process" in EDs.
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http://dx.doi.org/10.1016/j.jpsychires.2020.07.039DOI Listing
November 2020

Multi-omics data integration in anorexia nervosa patients before and after weight regain: A microbiome-metabolomics investigation.

Clin Nutr 2021 Mar 31;40(3):1137-1146. Epub 2020 Jul 31.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy.

Background & Aims: We have recently reported specific fecal metabolomic changes in acute and short-term weight restored patients with anorexia nervosa (AN). In this study we explored the association between those metabolomic changes and patients' gut microbiome composition.

Methods: The gut microbiome of AN women was sequenced in both the underweight phase (n = 21) and after short-term weight restoration (n = 16) and compared to that of 20 healthy women. According to a multi-omics approach, microbiome data were correlated with 49 relevant fecal metabolites previously characterized in our participants by an untargeted metabolomic procedure.

Results: Compared to healthy women, AN patients showed a decreased intra-individual bacterial richness, an increased Bacteroidetes-to-Firmicutes abundance ratio and significant changes in the relative abundances of several bacteria at phylum, class, order, family and genus levels. These changes were observed in both the underweight and weight-restored condition. Moreover, the relationships among the 49 previously selected fecal metabolites and bacteria genera showed structures of different complexity among the 3 groups. In particular, a quarter of those relationships showed a divergent direction in the acutely ill patients with respect to the weight-restored ones or normal controls. Finally, in acutely ill patients 70% of those correlations showed a negative sign suggesting a prevalent metabolites consummation by gut microbiome.

Conclusions: These data confirm a profound perturbation in the gut microbiome composition of AN patients. Moreover, for the first time, they provide the evidence that in AN gut bacteria are connected with several fecal metabolites in a different way from normal controls and with divergent directions in the acute phase with respect to the weight-restored phase.
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http://dx.doi.org/10.1016/j.clnu.2020.07.021DOI Listing
March 2021

Emotional reactivity and eating disorder related attitudes in response to the trier social stress test: An experimental study in people with anorexia nervosa and with bulimia nervosa.

J Affect Disord 2020 09 21;274:23-30. Epub 2020 May 21.

Department of Psychiatry, University of Campania "Luigi Vanvitelli" Largo Madonna delle Grazie, 80138 , Naples, Italy.

Background: In order to experimentally asses the role of socio-emotional problems in Eating Disorder (ED) psychopathology, we have measured affective states and ED-related attitudes in response to an acute psychosocial stress and their relationships with interpersonal sensitivity in people with Anorexia Nervosa (AN) and Bulimia Nervosa (BN).

Methods: Twenty-one women with AN, 21 with BN and 27 healthy women underwent an acute psycho-social challenge, the Trier Social Stress Test. Anxiety feelings, hunger perception, amount of desired food and body dissatisfaction were measured throughout the experimental procedure. The relationships between these variables and with interpersonal sensitivity measures were explored through Pearson's correlation and mediation analyses.

Results: Stress-induced anxiety was increased in people with EDs. People with AN showed reduced hunger perception, decreased desire for food and a negative association between anxiety feelings and desire for food. In people with EDs, baseline ineffectiveness predicted post-stress body dissatisfaction through the mediation of post-stress anxiety levels.

Limitations: The relatively low sample size and the lack of an experimental control condition are the main limitations of the study.

Conclusions: The present findings show, for the first time, the relationships between socio-emotional distress and ED-related attitudes in people with EDs, providing experimental support to the interpersonal model of EDs. This gives empirical evidence to treatments targeting interpersonal problems in EDs.
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http://dx.doi.org/10.1016/j.jad.2020.05.051DOI Listing
September 2020

Reward and psychopathological correlates of eating disorders: The explanatory role of leptin.

Psychiatry Res 2020 08 17;290:113071. Epub 2020 May 17.

Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy. Electronic address:

It has been hypothesized that leptin level alterations in Eating Disorders (EDs) represent a maintaining factor for pathological reward-related ED behaviors, given leptin role in the dopaminergic reward systems. The aim of the present study was to evaluate the role of leptin in EDs as a mediator for the relationship between Body Mass Index (BMI) and several pathological behaviors, such as dietary restraint, compensatory exercise, vomiting, binge eating and emotional eating. Sixty-two patients with EDs and 41 healthy controls (HC) had their blood drawn and completed psychometric tests for the evaluation of general psychopathology, ED psychopathology and emotional eating. Moderated linear regression models showed that, in the presence of high levels of ED psychopathology, leptin levels were negatively associated with dietary restraint and compensatory exercise, and positively with emotional eating and binge eating. Finally, leptin showed an indirect effect on the association between BMI and all these reward-related behaviors. These results suggest that a variation of BMI maintains these pathological ED behaviors through a variation in leptin levels. Considering the role of leptin in reward circuits, the results seem to confirm an aberrant food-related reward mechanism in ED patients.
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http://dx.doi.org/10.1016/j.psychres.2020.113071DOI Listing
August 2020

Clinical and neuroendocrine correlates of childhood maltreatment history in adults with bipolar disorder.

Bipolar Disord 2020 11 16;22(7):749-756. Epub 2020 May 16.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy.

Objectives: Childhood maltreatment has been associated to an increased risk of developing bipolar disorder (BD). A role of the hypothalamus-pituitary-adrenal (HPA) axis in mediating trauma-related risk for adult psychopathology has been suggested but scarcely investigated in BD. Therefore, we explored the impact of childhood maltreatment on clinical features of BD and on the activity of the HPA axis.

Methods: One hundred and six patients participated in the study. On the basis of their history of childhood trauma, as assessed by the Childhood Trauma Questionnaire (CTQ), they were divided into a group with a history of childhood maltreatment (CM+) and a group without (CM-). Twenty-nine participants (16 with a history of childhood trauma and 13 without) underwent the cortisol awakening response (CAR) test.

Results: Sixty-two patients had a history of childhood maltreatment and 44 had not. Maltreatment was significantly more frequent in females than males. CM+ patients showed a significant higher body mass index, a significant higher number of suicide attempts, and more severe mania symptoms than CM- ones. Logistic regression indicated a significant association between lifetime suicide attempts and any type of childhood maltreatment and between emotional abuse and the presence of psychotic symptoms or mixed mood episodes. CM+ individuals with BD exhibited a significantly reduced CAR with respect to CM- ones.

Discussion: Our results add to literature findings showing a worse clinical course in BD patients with a history of childhood maltreatments and show for the first time that childhood trauma exposure is associated to an impaired CAR in adults with BD.
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http://dx.doi.org/10.1111/bdi.12923DOI Listing
November 2020

Recurring sequences of multimodal non-verbal and verbal communication during a human psycho-social stress test: A temporal pattern analysis.

Physiol Behav 2020 07 8;221:112907. Epub 2020 Apr 8.

Psychiatric Unit, Department of Health Sciences, University of Florence, Florence, Italy. Electronic address:

Background: The Trier Social Stress Test (TSST) is a widely used protocol to study human psycho-social stress responses. Quantitative reports of non-verbal behaviors have been carried out by means of the Ethological Coding System for Interviews (ECSI). However, no data have described whether and how non-verbal and verbal behaviors take part in the composition of multimodal sequences of communication during the test.

Method: Five non-verbal ECSI categories and four verbal behaviors related with communication were included in the Ethogram. A focal sampling was employed to ensure a high temporal resolution of the behavioral annotation. T-Pattern Analysis was employed to detect statistically-grounded behavioral sequences.

Results: As a first step, frequency, overall duration and mean time length were reported for each component of the Ethogram. Besides, T-Pattern Analysis revealed that communication during TSST is organized according to a complex temporal patterning. We found 51 different sequences (T-patterns): 8 T-patterns included exclusively non-verbal behaviors; 17 T-patterns included verbal behaviors and 26 T-patterns encompassed mixed non-verbal and verbal behaviors. T-patterns were discussed depending on their putative functional meaning since non-verbal behaviors almost did not overlap within patterns.

Conclusions: The implementation of an Ethogram including non-verbal and verbal components highlights the multimodal human communication in TSST. T-Pattern Analysis unveils the real-time interplay among these components. In this study results are discussed according to Jakobson's six constitutive factors of communication.
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http://dx.doi.org/10.1016/j.physbeh.2020.112907DOI Listing
July 2020

Cortical thickness, local gyrification index and fractal dimensionality in people with acute and recovered Anorexia Nervosa and in people with Bulimia Nervosa.

Psychiatry Res Neuroimaging 2020 05 17;299:111069. Epub 2020 Mar 17.

Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', University of Salerno, Via Salvador Allende, 84081 Baronissi, Italy.

Eating disorders (EDs) have a possible neurodevelopmental pathogenesis. Our study aim was to assess regional cortical thickness (CT), local gyrification index (lGI) and fractal dimensionality (FD), as specific markers of cortical neurodevelopment in ED females. Twenty-two women with acute anorexia nervosa (acuAN), 10 with recovered anorexia nervosa (recAN), 24 with bulimia nervosa (BN) and 35 female healthy controls (HC) underwent a 3T MRI scan. All data were processed by FreeSurfer. Compared to recAN group women with acuAN showed a lower CT in multiple areas, while compared to HC they showed lower CT in temporal regions. BN group showed higher CT values in temporal and paracentral areas compared to HC. In multiple cortical areas, AcuAN group showed greater values of lGI compared to recAN group and lower values of lGI compared to HC. The BN group showed lower lGI in left medial orbitofrontal cortex compared to HC. No significant differences were found in FD among the groups. Present results provide evidence of CT and lGI alterations in patients with AN and, for the first time, in those with BN. Although these alterations could be state-dependent phenomena, they may underlie psychopathological aspects of EDs.
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http://dx.doi.org/10.1016/j.pscychresns.2020.111069DOI Listing
May 2020

Early traumatic experiences impair the functioning of both components of the endogenous stress response system in adult people with eating disorders.

Psychoneuroendocrinology 2020 05 5;115:104644. Epub 2020 Mar 5.

Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neurosciences, University of Salerno, Salerno, Italy. Electronic address:

Childhood trauma is a non-specific risk factor for eating disorders (EDs). It has been suggested that this risk is exerted through trauma-induced long-lasting changes in the body stress response system. Therefore, we explored the activity of the hypothalamus-pituitary-adrenal axis and of the sympathetic nervous system in adult ED patients with or without a history of childhood trauma exposure. Salivary cortisol and alpha-amylase, a marker of the sympathetic nervous system activity, were measured at awakening and after 15, 30 and 60 min in 35 women with EDs. The Childhood Trauma Questionnaire (CTQ) was employed to assess exposure to childhood trauma and, according to the CTQ cut-off scores, 21 ED women were classified as maltreated (Mal) participants and 14 women as no-maltreated (noMal) ED participants. Compared to noMal ED women, Mal ED participants showed significantly decreased cortisol awakening response (between group difference: p = 0.0003) and morning salivary alpha-amylase secretion (between group difference: p = 0.02). Present results confirm that the cortisol awakening response of adult ED patients with childhood trauma exposure is lower than that of adult ED patients without childhood trauma experiences and show for the first time that also the morning secretion of salivary alpha-amylase is decreased in adult ED patients who have been exposed to early traumatic experiences. These results point for the first time to a dampening in the basal activity of both components of the endogenous stress response system in childhood maltreated adult ED women.
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http://dx.doi.org/10.1016/j.psyneuen.2020.104644DOI Listing
May 2020

Shared genetic risk between eating disorder- and substance-use-related phenotypes: Evidence from genome-wide association studies.

Addict Biol 2021 01 16;26(1):e12880. Epub 2020 Feb 16.

Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, RWTH Aachen University, Aachen, Germany.

Eating disorders and substance use disorders frequently co-occur. Twin studies reveal shared genetic variance between liabilities to eating disorders and substance use, with the strongest associations between symptoms of bulimia nervosa and problem alcohol use (genetic correlation [r ], twin-based = 0.23-0.53). We estimated the genetic correlation between eating disorder and substance use and disorder phenotypes using data from genome-wide association studies (GWAS). Four eating disorder phenotypes (anorexia nervosa [AN], AN with binge eating, AN without binge eating, and a bulimia nervosa factor score), and eight substance-use-related phenotypes (drinks per week, alcohol use disorder [AUD], smoking initiation, current smoking, cigarettes per day, nicotine dependence, cannabis initiation, and cannabis use disorder) from eight studies were included. Significant genetic correlations were adjusted for variants associated with major depressive disorder and schizophrenia. Total study sample sizes per phenotype ranged from ~2400 to ~537 000 individuals. We used linkage disequilibrium score regression to calculate single nucleotide polymorphism-based genetic correlations between eating disorder- and substance-use-related phenotypes. Significant positive genetic associations emerged between AUD and AN (r = 0.18; false discovery rate q = 0.0006), cannabis initiation and AN (r = 0.23; q < 0.0001), and cannabis initiation and AN with binge eating (r = 0.27; q = 0.0016). Conversely, significant negative genetic correlations were observed between three nondiagnostic smoking phenotypes (smoking initiation, current smoking, and cigarettes per day) and AN without binge eating (r = -0.19 to -0.23; qs < 0.04). The genetic correlation between AUD and AN was no longer significant after co-varying for major depressive disorder loci. The patterns of association between eating disorder- and substance-use-related phenotypes highlights the potentially complex and substance-specific relationships among these behaviors.
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http://dx.doi.org/10.1111/adb.12880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429266PMC
January 2021

Structural and functional brain correlates of altered taste processing in anorexia nervosa: A systematic review.

Eur Eat Disord Rev 2020 03 17;28(2):122-140. Epub 2019 Dec 17.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy.

Objective: A growing body of empirical literature indicates altered taste perception in individuals with anorexia nervosa (AN). However, it remains unknown whether the observed impairments in the neural processing of taste stimuli represent etiopathogenetic factors of AN or whether they are a secondary consequence of malnutrition.

Method: In the current systematic review, scientific studies were identified using the MEDLINE, PsycINFO, and Scopus databases. A supplemental search was performed by searches through reference lists of the relevant publications and via Google Scholar.

Results: On the basis of the searches conducted, 16 publications were identified and included in this literature review. The results of those studies point to disturbances in the structure and functioning of brain regions involved in taste processing in AN.

Conclusions: The findings of the reviewed studies suggest that altered reward, interoceptive, and cognitive-emotional processing may contribute to abnormal taste processing in AN.
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http://dx.doi.org/10.1002/erv.2713DOI Listing
March 2020

Metabolomics signatures of acutely ill and short-term weight recovered women with anorexia nervosa.

Mol Psychiatry 2019 Nov 7. Epub 2019 Nov 7.

Department of Mental Health, University of Campania "Luigi Vanvitelli", Naples, Italy.

Although metabolomics studies are recently spreading and have allowed the characterization of putative biomarkers in many diseases, they are relatively scanty in anorexia nervosa (AN). In this explorative study we analyzed the fecal metabolomics profiles of women with AN in the underweight phase (n = 24) and after short-term weight restoration (n = 16) and compared them with 20 healthy women. An untargeted metabolomic procedure allowed the characterization of 224 metabolites involved in energy, lipid, and amino acid metabolism. A partial least square discriminant analysis identified 14 metabolites with a variable importance in projection score >1.5 that clearly differentiated underweight from weight-restored patients from healthy women. Compared with healthy women, fecal concentrations of valeric acid and 3-methyl,2-ketobutyric acid were increased in both underweight and weight-restored patients; fecal concentrations of propionic acid, stearic acid, linolenic acid, methyl-galactoside, coprosterol, cycloserine, and lauric acid were increased while fecal levels of xylose, fucose, and rhamnose were decreased in underweight patients and normalized after weight-restoration; fecal concentrations of piperine, phenylalanine, butyric acid, and meso-erythritol-1 were decreased while fecal levels of hydroxystearic acid were increased in weight-restored but normal in underweight AN patients. All these changes point to peculiar fecal metabolomics profiles of acute and short-term weight restored AN patients. The value of these changes to improve our understanding of the pathophysiology of AN and to characterize potential biomarker targets for developing new treatment strategies needs further studies to be clarified.
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http://dx.doi.org/10.1038/s41380-019-0573-3DOI Listing
November 2019

Sexuality, embodiment and attachment style in anorexia nervosa.

Eat Weight Disord 2020 Dec 2;25(6):1671-1680. Epub 2019 Nov 2.

Department of Psychological, Humanistic and Territorial Sciences, University "G. d'Annunzio", Chieti, Italy.

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.
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http://dx.doi.org/10.1007/s40519-019-00805-6DOI Listing
December 2020

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

Brain Sci 2019 Oct 15;9(10). Epub 2019 Oct 15.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.

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.
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http://dx.doi.org/10.3390/brainsci9100276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826416PMC
October 2019

The association between childhood maltreatment and eating disorder psychopathology: A mixed-model investigation.

Eur Psychiatry 2019 09 19;61:111-118. Epub 2019 Aug 19.

Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy.

Background: Childhood maltreatment (CM) is recognized as a non-specific risk factor for Eating Disorders (EDs), but the mechanisms explaining this association have been insufficiently assessed. We aim to explore the psychological pathways through which CM experiences promote ED core symptoms.

Methods: Two-hundred-twenty-eight people with EDs, 94 with anorexia nervosa restricting (ANR) type and 134 with binge-purging (BP) symptoms (including 23 with AN purging type and 111 with bulimia nervosa), completed the Eating Disorder Inventory-2, the State-Trait Anxiety Inventory and the Childhood Trauma Questionnaire. The variables provided by these questionnaires were included in a network analysis to identify the shortest pathways between CM nodes and ED core symptoms. Then mediation analysis was performed in order to confirm the mediation role of the nodes included in the shortest pathways from CM to ED core symptoms.

Results: All types of CM experiences were connected to the ED psychopathology through emotional abuse. In the ANR group, interoceptive awareness was included in the shortest path between emotional abuse and drive to thinness and mediated this relationship. In the BP group, the shortest routes between CM and ED core symptoms included both ineffectiveness and interoceptive awareness.

Conclusions: Combining the network analysis approach with the mediation analyses provides for the first time a putative hybrid model, which reveals that all CM types converge towards ED symptoms through emotional abuse and that interoceptive awareness and ineffectiveness mediate these connections in people with ANR and BP symptoms, respectively. These findings may have possible implications for both research and treatment of EDs.
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http://dx.doi.org/10.1016/j.eurpsy.2019.08.002DOI Listing
September 2019

Re-conceptualization of anorexia nervosa psychopathology: A network analysis study in adolescents with short duration of the illness.

Int J Eat Disord 2019 11 16;52(11):1263-1273. Epub 2019 Jul 16.

Child Neuropsychiatry Unit, Department of Neuroscience, I.R.C.C.S. Children Hospital Bambino Gesù, Rome, Italy.

Objective: Research evidence suggests the need to identify treatments based on a more precise characterization of psychopathology and psychiatric comorbidity in anorexia nervosa. Network analysis provides a new method to conceptualize psychopathology. We use this approach to investigate the relationships between eating disorder and general psychiatric symptoms in adolescents with anorexia nervosa.

Methods: Four-hundred and five adolescents with anorexia nervosa and illness duration less than 3 years were consecutively recruited from those admitted to inpatient treatment. They completed the following questionnaires: the Eating Disorder Inventory-3, the Multidimensional Anxiety Scale for Children, the Children's Depression Inventory, and the Youth Self Report. A network analysis was conducted, including eating psychopathology measures, anxiety and depressive symptoms, and obsessive-compulsive and post-traumatic stress problems. We employ a novel approach, the bridge function, to identify symptom clusters.

Results: Depression symptoms and personal alienation were the nodes with the highest centrality in the network, followed by asceticism, post-traumatic stress problems, drive to thinness, low self-esteem, and anxiety physical symptoms. Three symptom clusters (relative to eating disorder psychopathology, self-esteem problems, and internalizing difficulties) were identified. Depression symptoms, personal alienation, low self-esteem, and interoceptive deficits showed the highest bridge centrality. Besides eating disorder core symptoms, negative affect and internalizing symptoms seem to contribute to anorexia nervosa psychopathology independently from illness duration effects.

Discussion: These findings suggest that anorexia nervosa is characterized by a broad psychopathological spectrum rather than the mere eating disorder core symptoms, confirm the need to re-conceptualize psychiatric comorbidity in this disorder, and provide intriguing diagnostic and therapeutic implications.
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http://dx.doi.org/10.1002/eat.23137DOI Listing
November 2019