Enrica Marzola

Cognitive flexibility in verbal and nonverbal domains and decision making in anorexia nervosa patients: a pilot study

BackgroundThis paper aimed to investigate cognitive rigidity and decision making impairments in patients diagnosed with Anorexia Nervosa Restrictive type (AN-R), assessing also verbal components.MethodsThirty patients with AN-R were compared with thirty age-matched healthy controls (HC). All participants completed a comprehensive neuropsychological battery comprised of the Trail Making Test, Wisconsin Card Sorting Test, Hayling Sentence Completion Task, and the Iowa Gambling Task. The Beck Depression Inventory was administered to evaluate depressive symptomatology. The influence of both illness duration and neuropsychological variables was considered. Body Mass Index (BMI), years of education, and depression severity were considered as covariates in statistical analyses.ResultsThe AN-R group showed poorer performance on all neuropsychological tests. There was a positive correlation between illness duration and the Hayling Sentence Completion Task Net score, and number of completion answers in part B. There was a partial effect of years of education and BMI on neuropsychological test performance. Response inhibition processes and verbal fluency impairment were not associated with BMI and years of education, but were associated with depression severity.ConclusionsThese data provide evidence that patients with AN-R have cognitive rigidity in both verbal and non-verbal domains. The role of the impairment on verbal domains should be considered in treatment. Further research is warranted to better understand the relationship between illness state and cognitive rigidity and impaired decision-making.

Attachment insecurity, personality, and body dissatisfaction in eating disorders.

The aim of this study is assessing interactions between attachment style and personality in predicting body dissatisfaction (BD). A total of 586 outpatients with eating disorders (EDs) were recruited: 101 with anorexia nervosa, restricting type; 52 with anorexia nervosa, binge-eating/purging type; 184 with bulimia nervosa, purging type; and 249 with an eating disorder not otherwise specified. Participants completed Temperament and Character Inventory, Body Shape Questionnaire, Beck Depression Inventory, and Attachment Style Questionnaire. An insecure attachment was found in all EDs, as well as in eating disorder not otherwise specified. In all diagnostic groups, need for approval, as measured by the Attachment Style Questionnaire and depressive symptomatology, was found to be the best predictor of BD. Personality traits are weaker predictors of BD. This study supports the hypothesis that attachment insecurity is directly correlated with BD, core element in predicting and perpetuating EDs, independently of personality. Implications for treatment are discussed.

Effectiveness of cognitive remediation therapy (CRT) in anorexia nervosa: A case series

We investigated whether cognitive remediation therapy (CRT) is effective in improving cognitive flexibility in anorexia nervosa (AN). Twenty AN outpatients were consecutively recruited at the Eating Disorders Center of the Turin University. All participants completed 10 sessions of CRT. Neuropsychological performances improved with CRT. Data showed also a significant improvement of impulse regulation and interoceptive awareness (subscales of the Eating Disorders Inventory–2). CRT was also associated with improvement of reflexive skills and awareness. These preliminary findings are promising, but further work is necessary to find ways of enhancing the effects of this treatment.

Genetic association of recovery from eating disorders: The role of GABA receptor SNPs

Follow-up studies of eating disorders (EDs) suggest outcomes ranging from recovery to chronic illness or death, but predictors of outcome have not been consistently identified. We tested 5151 single-nucleotide polymorphisms (SNPs) in approximately 350 candidate genes for association with recovery from ED in 1878 women. Initial analyses focused on a strictly defined discovery cohort of women who were over age 25 years, carried a lifetime diagnosis of an ED, and for whom data were available regarding the presence (n=361 ongoing symptoms in the past year, ie, ‘ill’) or absence (n=115 no symptoms in the past year, ie, ‘recovered’) of ED symptoms. An intronic SNP (rs17536211) in GABRG1 showed the strongest statistical evidence of association (p=4.63 × 10−6, false discovery rate (FDR)=0.021, odds ratio (OR)=0.46). We replicated these findings in a more liberally defined cohort of women age 25 years or younger (n=464 ill, n=107 recovered; p=0.0336, OR=0.68; combined sample p=4.57 × 10−6, FDR=0.0049, OR=0.55). Enrichment analyses revealed that GABA (γ-aminobutyric acid) SNPs were over-represented among SNPs associated at p<0.05 in both the discovery (Z=3.64, p=0.0003) and combined cohorts (Z=2.07, p=0.0388). In follow-up phenomic association analyses with a third independent cohort (n=154 ED cases, n=677 controls), rs17536211 was associated with trait anxiety (p=0.049), suggesting a possible mechanism through which this variant may influence ED outcome. These findings could provide new insights into the development of more effective interventions for the most treatment-resistant patients.

Short‐Term Intensive Family Therapy for Adolescent Eating Disorders: 30‐Month Outcome

Family therapy approaches have generated impressive empirical evidence in the treatment of adolescent eating disorders (EDs). However, the paucity of specialist treatment providers limits treatment uptake; therefore, our group developed the intensive family therapy (IFT)-a 5-day treatment based on the principles of family-based therapy for EDs. We retrospectively examined the long-term efficacy of IFT in both single-family (S-IFT) and multi-family (M-IFT) settings evaluating 74 eating disordered adolescents who underwent IFT at the University of California, San Diego, between 2006 and 2013. Full remission was defined as normal weight (≥ 95% of expected for sex, age, and height), Eating Disorder Examination Questionnaire (EDE-Q) global score within 1 SD of norms, and absence of binge-purging behaviours. Partial remission was defined as weight ≥ 85% of expected or ≥ 95% but with elevated EDE-Q global score and presence of binge-purging symptoms (<1/week). Over a mean follow-up period of 30 months, 87.8% of participants achieved either full (60.8%) or partial remission (27%), while 12.2% reported a poor outcome, with both S-IFT and M-IFT showing comparable outcomes. Short-term, intensive treatments may be cost-effective and clinically useful where access to regular specialist treatment is limited.

Major Depression and Avoidant Personality Traits in Eating Disorders

Statistical analyses were carried out using SPSS software, version 13.0 for Windows. Categorical data were compared using the 2 test, and continuous data were analyzed using a two-tailed independent t test. Subjects with MD represented 17.4% (n = 121) of the sample, with the following ED subtypes: 13.2% restricting type of AN (n = 20), 24% binge-eating/purging type of AN (n = 18), 21.2% BN (n = 40) and 15.4% ED not otherwise specified (n = 43). No significant differences were found among ED subtypes ( 2 : 7.162; p ! 0.067), but patients with MD reported more frequent episodes of binge eating than patients without MD (5.6 8 8.2 vs. 3.51 8 5.9 episodes/week; F: 8.46; p ! 0.004) after controlling for BMI (based on investigators’ measurements), age, duration of the disorder and ED diagnosis (clinical variables). Moreover, subjects with MD more often reported self-induced vomiting (5.1 8 8.8 vs. 3.3 8 6.2; F: 5.89; p ! 0.015), after controlling for age and clinical variables. Patients with MD did not differ from those without MD with regard to age, age of onset of the disorder, duration of the disorder and BMI (data not shown). The BMI in the binge-eating/purging AN subgroup was lower in patients with MD than in those without MD (data not shown). The BDI scores of subjects with MD were significantly different from those without MD (35.1 8 3.3 vs. 10.9 8 5.8; F: 550.5; p ! 0.001), after controlling for age and clinical variables. In addition, the BDI scores of 306 patients (44.1% of the sample) who were not diagnosed with MD were The lifetime prevalence of mood disorders in anorexia nervosa (AN) varies between 64.1 and 96%, and between 50 and 90% in bulimia nervosa (BN). Moreover, the prevalence of comorbid mood disorders among patients diagnosed with eating disorders (ED) is also high, between 12.7 and 68% among those with AN and 40% among those with BN [1] . The severity of depressive symptomatology seems to correlate with the severity of the ED [2–4] . Unfortunately, previous studies showed several limitations. Other factors that should be addressed are depressive personality traits. Instability and emotional liability, avoidant behaviors and depressive traits have been frequently found in ED patients [5, 6] . Some studies [7–9] have identified groups of patients with comorbid avoidant behaviors, depressed mood and constricted affect. This study aimed to (a) assess the prevalence of current major depression (MD) in a clinical sample of female patients with ED, (b) confirm the correlation between ED severity and diagnosis of MD, and (c) assess the differences in personality traits between ED patients with and without MD. The sample consisted of 693 patients admitted to the outpatient service of the ED Program of Turin University between January 1, 2003, and October 30, 2007. All subjects were diagnosed with an ED: AN, restricting type, n = 151; AN, binge-eating/purging type, n = 75; BN, purging type, n = 188; ED not otherwise specified, n = 279. Diagnoses of ED and MD were based on the Structured Clinical Interview for DSM-IV [10] . Exclusion criteria were (a) severe medical comorbidity (e.g. epilepsy or diabetes), (b) current drug abuse and (c) male gender. The first two assessment interviews were conducted by psychiatrists experienced in the diagnosis and treatment of ED. Between the first and the second interviews, patients completed some self-report questionnaires: Eating Disorder Inventory 2 [11] , Beck Depression Inventory (BDI) [12] and Temperament and Character Inventory [13] . After complete description of the study to the subjects, written informed consent was obtained. Received: February 3, 2009 Accepted after revision: February 1, 2011 Published online: June 30, 2011

Reduced Resting-State Functional Connectivity of the Somatosensory Cortex Predicts Psychopathological Symptoms in Women with Bulimia Nervosa

Background: Alterations in the resting-state functional connectivity (rs-FC) of several brain networks have been demonstrated in eating disorders. However, very few studies are currently available on brain network dysfunctions in bulimia nervosa (BN). The somatosensory network is central in processing body-related stimuli and it may be altered in BN. The present study therefore aimed to investigate rs-FC in the somatosensory network in bulimic women. Methods: Sixteen medication-free women with BN (age = 23 ± 5 years) and 18 matched controls (age = 23 ± 3 years) underwent a functional magnetic resonance resting-state scan and assessment of eating disorder symptoms. Within-network and seed-based functional connectivity analyses were conducted to assess rs-FC within the somatosensory network and to other areas of the brain. Results: Bulimia nervosa patients showed a decreased rs-FC both within the somatosensory network (t = 9.0, df = 1, P = 0.005) and with posterior cingulate cortex and two visual areas (the right middle occipital gyrus and the right cuneus) (P = 0.05 corrected for multiple comparison). The rs-FC of the left paracentral lobule with the right middle occipital gyrus correlated with psychopathology measures like bulimia (r = −0.4; P = 0.02) and interoceptive awareness (r = −0.4; P = 0.01). Analyses were conducted using age, BMI (body mass index), and depressive symptoms as covariates. Conclusion: Our findings show a specific alteration of the rs-FC of the somatosensory cortex in BN patients, which correlates with eating disorder symptoms. The region in the right middle occipital gyrus is implicated in body processing and is known as extrastriate body area (EBA). The connectivity between the somatosensory cortex and the EBA might be related to dysfunctions in body image processing. The results should be considered preliminary due to the small sample size.

Psychosomatic syndromes and anorexia nervosa.

BackgroundIn spite of the role of some psychosomatic factors as alexithymia, mood intolerance, and somatization in both pathogenesis and maintenance of anorexia nervosa (AN), few studies have investigated the prevalence of psychosomatic syndromes in AN. The aim of this study was to use the Diagnostic Criteria for Psychosomatic Research (DCPR) to assess psychosomatic syndromes in AN and to evaluate if psychosomatic syndromes could identify subgroups of AN patients.Methods108 AN inpatients (76 AN restricting subtype, AN-R, and 32 AN binge-purging subtype, AN-BP) were consecutively recruited and psychosomatic syndromes were diagnosed with the Structured Interview for DCPR. Participants were asked to complete psychometric tests: Body Shape Questionnaire, Beck Depression Inventory, Eating Disorder Inventory–2, and Temperament and Character Inventory. Data were submitted to cluster analysis.ResultsIllness denial (63%) and alexithymia (54.6%) resulted to be the most common syndromes in our sample. Cluster analysis identified three groups: moderate psychosomatic group (49%), somatization group (26%), and severe psychosomatic group (25%). The first group was mainly represented by AN-R patients reporting often only illness denial and alexithymia as DCPR syndromes. The second group showed more severe eating and depressive symptomatology and frequently DCPR syndromes of the somatization cluster. Thanatophobia DCPR syndrome was also represented in this group. The third group reported longer duration of illness and DCPR syndromes were highly represented; in particular, all patients were found to show the alexithymia DCPR syndrome.ConclusionsThese results highlight the need of a deep assessment of psychosomatic syndromes in AN. Psychosomatic syndromes correlated differently with both severity of eating symptomatology and duration of illness: therefore, DCPR could be effective to achieve tailored treatments.

Emotions in Eating Disorders: Changes of Anger Control After an Emotion‐focused Day Hospital Treatment

OBJECTIVE Emotional states are key elements of eating disorders (EDs), with anger and aggressiveness playing an important role. This study aimed to investigate anger features in ED patients before and after an intensive day hospital (DH) specifically focused on emotions. METHOD Forty-one ED patients were admitted to our DH, which specifically includes emotion-focused activities. They completed self-reported questionnaires at the beginning and after the intervention: Eating Disorders Inventory-2, State-Trait Anger Expression Inventory (STAXI) and Beck Depression Inventory (BDI). RESULTS Anger Control (Axcon) subscale of STAXI decreased significantly, and both BDI and body mass index - in case of underweight patients - significantly improved after completion of DH. Axcon decrease correlated with BMI improvement. The majority of individuals showing good outcome reported also a significant improvement in Axcon levels. DISCUSSION This study provided preliminary data about the effectiveness - mainly in anger coping - of an emotion-focused DH.

Clinical investigation of set-shifting subtypes in anorexia nervosa

While evidence continues to accumulate on the relevance of cognitive inflexibility in anorexia nervosa (AN), its clinical correlates remain unclear. We aimed at examining the relationship between set-shifting and clinical variables (i.e., eating psychopathology, depression, and personality) in AN. Ninety-four individuals affected by AN and 59 healthy controls (HC) were recruited. All participants were assessed using: Eating Disorders Inventory-2 (EDI-2), Temperament and Character Inventory (TCI), Beck Depression Inventory (BDI), and Wisconsin Card Sorting Test (WCST). The AN group scored worse than HCs on set-shifting. According to their neuropsychological performances, AN patients were split into two groups corresponding to poor (N=30) and intact (N=64) set-shifting subtypes. Interoceptive awareness, impulse regulation, and maturity fears on the EDI-2 and depression on the BDI differed across all groups (HC, intact, and poor set-shifting subtype). Self-directedness on the TCI differed significantly among all groups. Cooperativeness and reward dependence differed instead only between HC and AN poor set-shifting subtype. After controlling for depression, only interoceptive awareness remained significant with reward dependence showing a trend towards statistical significance. These findings suggest that multiple clinical variables may be correlated with set-shifting performances in AN. The factors contributing to impaired cognitive inflexibility could be more complex than heretofore generally considered.