Claudia Ravaldi

Stress, hypothalamic-pituitary-adrenal axis and eating disorders.

The etiopathogenesis of eating disorders (ED) is complex and poorly understood. Biological, psychological and environmental factors have all been considered to be involved in the onset and the persistence of these syndromes, often with conflicting results. The recent literature focused on the possible role of hormonal pathways, in particular the hypothalamic-pituitary-adrenal (HPA) axis, as a relevant factor capable of influencing the onset and the course of ED. Other studies have suggested that the onset of ED is often preceded by severe life events, and that chronic stress is associated with the persistence of these disorders. As the biological response to stress is the activation of the HPA axis, the available literature considering the relationships between stress, HPA axis functioning and anorexia nervosa, bulimia nervosa and binge eating disorder is reviewed by the present article.

Stillbirths: recall to action in high-income countries

Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19,439 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20-30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities.

Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study.

Objective: To evaluate in a 6-year follow-up study the course of a large clinical sample of patients with eating disorders (EDs) who were treated with individual cognitive behavior therapy. The diagnostic crossover, recovery, and relapses were assessed, applying both Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the DSM-V proposed criteria. Patients with EDs move in and out of illness states over time, display frequent relapses, show a relevant lifetime psychiatric comorbidity, and migrate between different diagnoses. Method: A total of 793 patients (including anorexia nervosa, bulimia nervosa, binge eating disorder, and EDs not otherwise specified) were evaluated on the first day of admission, at the end of treatment, 3 years after the end of treatment, and 3 years after the first follow-up. Clinical data were collected through a face-to-face interview; diagnosis was performed by means of the Structured Clinical Interview for DSM-IV and the Eating Disorder Examination Questionnaire was applied. Results: A consistent rate of relapse and crossover between the different diagnoses over time was observed. Mood disorders comorbidity has been found to be an important determinant of diagnostic instability, whereas the severity of shape concern represented a relevant outcome modifier. Using the DSM-V proposed criteria, most patients of EDs not otherwise specified were reclassified, so that the large majority of ED patients seeking treatment would be included in full-blown diagnoses. Conclusions: Among EDs, there are different subgroups of patients displaying various courses and outcomes. The diagnostic instability involves the large majority of patients. An integration of categorical and dimensional approaches could improve the psychopathological investigation and the treatment choices. AN = anorexia nervosa; BED = binge eating disorder; BMI = body mass index; BN = bulimia nervosa; CBT = cognitive behavior therapy; DSM = Diagnostic and Statistical Manual of Mental Disorders; EDs = eating disorders; EDE 12.0D = Eating Disorder Examination Interview; EDNOS = eating disorders not otherwise specified; EDNOS-A = eating disorders not otherwise specified Anorectic type; EDNOS-B = eating disorders not otherwise specified Bulimic type; OBEs = objective binge episodes; SBEs = subjective binge episodes; s-BED = subthreshold BED.

Correlations between binge eating and emotional eating in a sample of overweight subjects

The present study compared threshold, subthreshold BED (Binge Eating Disorder), and subjects without BED in a population of overweight/obese individuals seeking weight loss treatment, considering the sociodemografic features, the eating specific and general psychopathology, the organic and psychiatric comorbidity, the quality of life, and the emotional eating as a trigger factor for binge eating. Four hundred thirty eight overweight subjects seeking weight loss treatment have been evaluated by means of a clinical interview (SCID I), and different self-reported questionnaires, assessing the eating specific and general psychopathology. One hundred five subjects (24% of the sample) fulfilled the DSM-IV criteria of BED, 146 (33.3%) fulfilled the criteria of subthreshold BED, and 187 (42.7%) subjects were diagnosed overweight non-BED. The groups did not differ in terms of psychiatric comorbidity, diet attempts, quality of life, and psychopathology, while the presence of binge eating was associated to higher eating, weight, and shape concerns. Emotional eating was positively correlated to the presence/severity of binge eating.

Eating disorders and body image disturbances among ballet dancers, gymnasium users and body builders.

Background: Eating disorders are frequent among elite performers of certain sports or physical activities; however, little is known about non-professional performers. Method: 113 female non-elite ballet dancers, 54 female gymnasium users, 44 male non-competitive body builders, 105 female controls and 30 male controls were evaluated using the Body Uneasiness Test, the State-Trait Anxiety Inventory, the Beck Depression Inventory, and the Eating Disorder Examination 12th edition (EDE-12). Results: Non-elite ballet dancers reported the highest prevalence of eating disorders (anorexia nervosa 1.8%; bulimia nervosa 2.7%; eating disorders not otherwise specified 22.1%), followed by gymnasium users (anorexia nervosa 2.6%; eating disorders not otherwise specified 18%). Significant differences (p < 0.01) between athletes and their controls were found in the following parameters (median values): Beck Depression Inventory (female dancers 5.7, gymnasium users 6.1, female controls 2.8, body builders 1.6, and male controls 1.3), Body Uneasiness Test (female dancers 1.08, gymnasium users 0.62, female controls 0.54, body builders 0.35, and male controls 0.27), EDE total scores (female dancers 1.6, gymnasium users 1.7, female controls 1.0, body builders 1.0, and male controls 0.4), EDE – restraint subscale scores (female dancers 0.8, gymnasium users 1.6, female controls 0.0, body builders 0.8, and male controls 0.0), EDE – eating concern subscale scores (female dancers 0.4, gymnasium users 0.2, female controls 0.0, body builders 0.0, and male controls 0.0), EDE – weight concern subscale scores (female dancers 2.1, gymnasium users 2.1, female controls 1.6, body builders 1.4, and male controls 0.5), and EDE – shape concern subscale scores (female dancers 2.7, gymnasium users 2.8, female controls 2.0, body builders 2.1, and male controls 0.9). EDE scores were highly related to Body Uneasiness Test scores, especially in non-elite ballet dancers and in non-competitive body builders (p < 0.01). Conclusion: Non-professional performers of sports emphasising thinness or muscularity, such as ballet and body-building, show a high degree of body uneasiness and inappropriate eating attitudes and behaviours.

The Sesto Fiorentino Study: Point and One-Year Prevalences of Psychiatric Disorders in an Italian Community Sample Using Clinical Interviewers

Background: It has been argued that lay interviewers’ use of fully-structured interviews could lead to a diagnostic pattern different to that by treating physicians. Clinical interviewers in community samples should probably identify cases that are closer to those seen in clinical settings. The greatest advantage of using clinical interviewers consists of the immediate assessment of a possible psychopathology, i.e. the evaluation of current disorders. Methods: Two thousand three hundred and sixty-three citizens from the community of Sesto Fiorentino, Italy, were interviewed by their own general practitioners using the Mini International Neuropsychiatric Interview (MINI). Positive cases for any lifetime psychiatric disorder as well as a random sample of the negative cases were re-interviewed by psychiatrists or trained residents in psychiatry using the Florence Psychiatric Interview (FPI). Results: The point prevalence for any current disorder was 8.7%; the two disorders with the highest prevalence were generalised anxiety disorder (2.9%) and major depressive episode (2.7%). The figures increase about 50% when the sub-threshold sequelae of previous disorders are considered. Current comorbidity was generally high. The one-year prevalence of any disorder was 10.6%. Ninety-two percent of the cases sought help, 82% were being treated at the moment of interview. Social impairment was considerable. Conclusions: The period prevalence rates for most of the disorders considered were generally comparable with the range defined by previous studies conducted in other Western countries, despite using different methodologies. Conversely, the use of health facilities, the treatment received and the social impairment were much higher than those reported by the other studies, suggesting a greater similarity with the clinical samples.

The Sesto Fiorentino Study: Background, Methods and Preliminary Results

Background: This paper presents lifetime prevalences and estimated risks of DSM-IV psychiatric disorders from a community survey conducted in Sesto Fiorentino, Italy, using psychiatric interviewers with clinical experience and clinical instruments. Methods: Two thousand five hundred subjects aged 14 or more were randomly selected from the lists of 15 general practitioners (GPs) regardless of wheter or not they had consulted the GP. A three-phase design was adopted, with the GPs using the Mini International Neuropsychiatric Interview (MINI) for the first stage. All positive cases at the MINI and a probability sample of 123 negative cases were re-interviewed by psychiatrists or trained residents in psychiatry using the Florence Psychiatric Interview (FPI) at the second stage. During phase III, the subjects were administered the rating scales specific to the pathology detected by the FPI. Results: Two thousand three hundred and sixty-three subjects were interviewed (response rate 94.5%) by their own GP; 623 were found positive for any psychiatric disorder. The psychiatrists could re-interview 605 of these, along with a random sample of 123 negatives. Almost twenty-five percent (24.4%; 15.7% males, 31.7% females) of the population was found positive for any DSM-IV disorder during their lives. The most common diagnosis was major depressive episode, followed by anxiety not otherwise specified. Women had higher rates for most disorders. Conclusions: The prevalence rates for most of the disorders considered are generally comparable with the range identified by previous studies conducted in other Western countries, even though they were using different methodologies. Exceptions are represented by the high prevalence of residual categories and the lower prevalence of phobias.

Clinical Epidemiology of Eating Disorders: Results from the Sesto Fiorentino Study

Background: It is speculated that clinical samples do not fully reflect the characteristics of eating disorders (EDs) as they are in the general population, especially in their lowest range of severity. The present article reports the prevalence of EDs in a community sample aged >14 years, their clinical and psychopathological features, and their course and outcome on naturalistic grounds. Methods: The Sesto Fiorentino Study is a three-phase community-based survey where 2,355 out of 2,500 people representative of the population aged >14 years living in Sesto Fiorentino were evaluated by their own general practitioner using the Mini International Neuropsychiatric Interview plus six additional questions. All those who had positive results plus a probability sample of the non-cases were re-interviewed by psychiatrists using the Florence Psychiatric Interview. The subjects who reported ED symptoms were subsequently administered the Eating Disorder Examination (12th edition). Results: Overall, the lifetime prevalence of EDs was 1.21%. More precisely, 0.42% had anorexia nervosa, 0.32% bulimia nervosa, 0.32% binge eating disorder and 0.32% eating disorder not otherwise specified. All the subjects suffering from an ED fulfilled diagnostic criteria for at least another DSM-IV axis I psychiatric disorder. At the moment of the interview, conducted a few years (average 7 years) after the onset of the disorder, 50% had fully recovered from EDs, 26.9% were currently affected by an ED, 23.1% showed a persistent body image disturbance and/or the presence of compensatory behaviours. Conclusions: Community surveys conducted by clinicians may provide useful additional information on the psychopathological features, natural course and outcome of these disorders on naturalistic grounds.

Comparison of individual and group cognitive behavioral therapy for binge eating disorder. A randomized, three-year follow-up study

Few long-term follow-up studies evaluated the response to psychotherapeutic interventions in binge eating disorder (BED). The effectiveness of individual and group cognitive-behavioral therapy, and the possible predictors of outcome were evaluated in a randomized controlled trial. At the beginning, at the end of treatments, and three years after the end of treatments, 144 patients affected by threshold or subthreshold BED were assessed using a clinical interview and self-reported questionnaires evaluating the eating attitudes and behavior, emotional eating, and general psychopathology. The following outcome measures were considered: recovery at 3-year follow-up, weight loss, treatment resistance, relapse, and diagnostic change. Both treatments showed similar response in terms of all outcome measures in the long-term, and determined a significant reduction of binge eating frequency, and a mild reduction of weight. The absence of a history of amphetamine derivatives consumption, lower emotional eating and binge eating severity at baseline were predictors of full recovery in the long-term. A low Emotional eating was found to be the only predictor of weight reduction. Overweight during childhood, full blown BED diagnosis, and high emotional eating were predictors of treatment resistance. Treatments considering the relationships between binge eating and emotional eating could improve the outcome of BED patients.

Different Moderators of Cognitive-Behavioral Therapy on Subjective and Objective Binge Eating in Bulimia Nervosa and Binge Eating Disorder: A Three-Year Follow-Up Study

Background: Different studies considered the mechanisms involved in the maintenance of binge eating in bulimia nervosa (BN) and binge eating disorder (BED), suggesting different pathways. The present 3-year follow-up study evaluated the relationships between psychopathological variables, and objective and subjective binge eating episodes in the two syndromes. Methods: 85 BN and 133 BED patients were studied. Objective and subjective binge eating, and psychopathological data were collected in a face-to-face interview, and by means of different self-reported questionnaires. The same assessment was repeated at baseline (T0), at the end of an individual cognitive-behavioral treatment (T1), and 3 years after the end of treatment (T2). Results: At baseline, BN and BED patients showed different emotions associated with binge eating: anger/frustration for BN and depression for BED patients. Objective binge eating frequency reduction across time was associated with lower impulsivity and shape concern in BN patients, and with lower emotional eating and depressive symptoms in BED patients. Lower subjective binge eating frequency at baseline predicted recovery, in both BN and BED patients. Recovery was associated with lower impulsivity and body shape concern at baseline for BN patients, and lower depression and emotional eating for BED patients. Conclusions: Eating psychopathology, psychiatric comorbidity, impulsivity and emotional eating have a different pattern of association with objective and subjective binge eating in BN and BED patients, and they act as different moderators of treatment. A different target of intervention for these two syndromes might be taken into account, and subjective binge eating deserves an accurate assessment.