Giuseppe Carrà

Depression after Stroke and Risk of Mortality: A Systematic Review and Meta-Analysis

Background. Depression after stroke may have great burden on the likelihood of functional recovery and long-term outcomes. Objective. To estimate the association between depression after stroke and subsequent mortality. Methods. A systematic search of articles using PubMed and Web of Science databases was performed. Odds ratios (ORs) and hazard ratios (HRs) were used as association measures for pooled analyses, based on random-effects models. Results. Thirteen studies, involving 59,598 subjects suffering from stroke (6,052 with and 53,546 without depression), had data suitable for meta-analysis. The pooled OR for mortality at followup in people suffering from depression after stroke was 1.22 (1.02–1.47). Subgroups analyses highlighted that only studies with medium-term followup (2–5 years) showed a statistically significant association between depression and risk of death. Four studies had data suitable for further analysis of pooled HR. The meta-analysis revealed a HR for mortality of 1.52 (1.02–2.26) among people with depression after stroke. Conclusions. Despite some limitations, this paper confirms the potential role of depression on post stroke mortality. The relationship between depression and mortality after stroke seems to be related to the followup duration. Further research is needed to clarify the nature of the association between depression after stroke and mortality.

Variations in rates of comorbid substance use in psychosis between mental health settings and geographical areas in the UK: A systematic review

BackgroundComorbid substance misuse in psychosis is associated with significant clinical, social and legal problems. An epidemiologically informed approach to planning service delivery requires an understanding of which clinical populations are at particularly high risk for such ‘dual diagnosis’. Evidence has now been accumulating in the UK since the early 1990s, and allows a relatively comprehensive comparison of rates between service settings, geographical areas and social contexts in terms of ethnic background.MethodsA literature search was carried out with the aim of investigating: (a) comorbid alcohol and drug misuse rates in people with established psychosis in different mental health and addiction settings in the UK, (b) variations in such rates between different population groups.ResultsThere are wide variations in reported drug and alcohol misuse rates in psychosis. Most recent UK studies report rates between 20 and 37% in mental health settings, while figures in addiction settings are less clear (6–15%). Rates are generally not as high as in US studies, but appear to be especially high in inpatient and crisis team settings (38–50%) and forensic settings. In terms of geography, rates appear highest in inner city areas. Some ethnic groups are over-represented among clinical populations of people with dual diagnosis.ConclusionsRates of substance misuse in psychosis are likely to be influenced by service setting, population composition and geography. Acute and forensic settings are especially appropriate for the development of targeted interventions.

Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis

BACKGROUND Both individuals with bipolar (BD) and those with alcohol (AUD) and other substance (SUD) use disorders are likely to attempt suicide. Comorbidity of BD and AUD/SUD may increase the likelihood of suicide attempts. We conducted a meta-analysis to estimate the association of comorbid AUD/SUD and suicide attempts in subjects with BD in the literature to date. METHODS Electronic databases through January 2013 were searched. Studies reporting rates of suicide attempts in people with co-occurring BD and AUD/SUD were retrieved. Comorbid AUD and SUD and suicide attempts rates as well as demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors. RESULTS Twenty-nine of 222 studies assessed for eligibility met the inclusion criteria, comprising a total of 31,294 individuals with BD, of whom 6308 (20.1%) had documented suicide attempts. There were consistent findings across the studies included. As compared to controls, subjects with BD and comorbid AUD/SUD were more likely to attempt suicide. The cross-sectional association estimates showed random-effects pooled crude ORs of 1.96 (95% CI=1.56-2.47; p<0.01), 1.72 (95% CI=1.52-1.95; p<0.01), and 1.77 (95% CI=1.49-2.10; p<0.01), for combined AUD/SUD, AUD, and SUD. There was no publication bias and sensitivity analyses based on the highest quality studies confirmed core results. LIMITATIONS The effects of the number and the type of suicide attempts could not be investigated due to insufficient information. CONCLUSIONS Comorbid AUD and SUD in individuals with BD are significantly associated with suicide attempts. Individuals with this comorbidity should be targeted for intensive suicide prevention efforts.

Attachment insecurities, maladaptive perfectionism, and eating disorder symptoms: A latent mediated and moderated structural equation modeling analysis across diagnostic groups

Although 96-100% of individuals with eating disorders (EDs) report insecure attachment, the specific mechanisms by which adult insecure attachment dimensions affect ED symptomatology remain to date largely unknown. This study examined maladaptive perfectionism as both a mediator and a moderator of the relationship between insecure attachment (anxiety and avoidance) and ED symptomatology in a clinical, treatment seeking, sample. Insecure anxious and avoidant attachment, maladaptive perfectionism, and ED symptomatology were assessed in 403 participants from three medium size specialized care centres for EDs in Italy. Structural equation modeling indicated that maladaptive perfectionism served as mediator between both insecure attachment patterns and ED symptomatology. It also interacted with insecure attachment to predict higher levels of ED symptoms - highlighting the importance of both insecure attachment patterns and maladaptive aspects of perfectionism as treatment targets. Multiple-group comparison analysis did not reveal differences across diagnostic groups (AN, BN, EDNOS) in mediating, main and interaction effects of perfectionism. These findings are consistent with recent discussions on the classification and treatment of EDs that have highlighted similarities between ED diagnostic groups and could be viewed through the lens of the Trans-theoretical Model of EDs. Implications for future research and intervention are discussed.

Metabolic Syndrome in People Suffering from Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

BACKGROUND Previous reports showed a high prevalence of obesity, diabetes, hypertension, and dyslipidemia among people suffering from posttraumatic stress disorder (PTSD). However, there is a lack of reviews that systematically analyze the relationship between PTSD and metabolic syndrome. We conducted a systematic review and meta-analysis aimed at estimating the association between PTSD and metabolic syndrome. METHODS We systematically searched PubMed, Embase, and Web of Science. We included observational studies assessing the prevalence of metabolic syndrome in a sample with PTSD and in a comparison group without PTSD. Data were analyzed using Review manager 5.1. Odds ratios (OR) with 95% confidence intervals were used as an association measure for pooled analysis, based on a random-effects model. RESULTS Six articles were eligible according to the inclusion criteria, for an overall number of 528 individuals suffering from PTSD and 846 controls without PTSD. The pooled OR for metabolic syndrome for people with PTSD was 1.37 (1.03-1.82). Statistical heterogeneity between the included studies was low (I(2)=22%). CONCLUSIONS Despite some limitations, the findings of this systematic review and meta-analysis confirmed our hypothesis that individuals suffering from PTSD have a greater risk of metabolic syndrome. The potential role of unknown factors or mediators that might clarify the nature of this association needs further research.

Disentangling the Association Between Child Abuse and Eating Disorders: A Systematic Review and Meta-Analysis.

Objectives The aim of this systematic review and meta-analysis was to estimate the association between distinct types of child abuse—sexual (CSA), physical (CPA), and emotional (CEA)—and different eating disorders (EDs). Methods Electronic databases were searched through January 2014. Studies reporting rates of CSA, CPA, and CEA in people with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), as compared with individuals without EDs, were included. Pooled analyses were based on odds ratios (ORs), with relevant 95% confidence intervals (CIs), weighting each study with inverse variance models with random effects. Risk of publication bias was estimated. Results Thirty-two of 1714 studies assessed for eligibility met the inclusion criteria, involving more than 14,000 individuals. The association between EDs and any child abuse showed a random-effects pooled OR of 3.21 (95% CI = 2.29–4.51, p < .001) with moderate heterogeneity (I2 = 57.2%, p = .005), whereas for CSA, this was 1.92 (95% CI = 1.13–3.28, p = .017), 2.73 (95% CI = 1.96–3.79, p < .001), and 2.31 (95% CI = 1.66–3.20, p < .001), for AN, BN, and BED, respectively. However, adjusting for publication bias, the estimate for CSA and AN was not significant (OR = 1.06, 95% CI = 0.59–1.88, p = .85). Although CPA was associated with AN, BN, and BED, CEA was associated just with BN and BED. Conclusions BN and BED are associated with childhood abuse, whereas AN shows mixed results. Individuals with similar trauma should be monitored for early recognition of EDs. Trial Registration: The protocol was registered in PROSPERO (an international prospective register of systematic reviews) with the reference number CRD42014007360.

The association between expressed emotion, illness severity and subjective burden of care in relatives of patients with schizophrenia. Findings from an Italian population

BackgroundAn appropriate understanding of the association between high-Expressed Emotion (EE) in family members of people with schizophrenia, patients’ and relatives’ correlates is needed to improve adaptation of psychoeducational interventions in diverse cultures. The aim of this study was to test the hypothesis that relatives designated as high EE would report higher subjective burden of care, and would be associated with objective variables that indicate greater illness severity i.e. number of previous hospitalizations and duration of illness.MethodsWe performed secondary analyses of baseline data from a randomized controlled trial conducted in Italy.ResultsHigh-EE relatives reported more subjective burden of care in disturbed behaviours and adverse effects areas, but did not perceive more deficits in social role performances. As regards illness severity characteristics, neither the number of previous hospital admissions nor the duration of illness was associated with high-EE. However, patients’ previous psychosocial functioning, as measured by educational attainments, seems to protect the relative from high-EE status.ConclusionThere is a need for cross-cultural comparisons of the subjective experience of distress and burden among high EE carers as a target for intervention, aimed at reducing family stress as much as improving patient outcomes.

Efforts to make clearer the relationship between body dissatisfaction and binge eating

Meta-analytic data have identified body dissatisfaction as the most consistent and robust causal risk factor for binge eating [1]. A vast majority of girls and young women report substantial body dissatisfaction but do not concomitantly engage in binge eating [2–4]. Thus, the efforts of Holmes et al.’s [4] to compare several theoretical models (dual pathway model, escape from awareness, and objectification theory) in order to explain the body dissatisfaction–binge eating relationship in young women are important in terms of both theoretical and practical implications. However, the mediational sequence that links body dissatisfaction to binge eating through interoceptive deficits tested by Holmes et al.’s [4] seems to be ‘‘paraphrased’’ from the objectification model illustrated by Fredrickson and Roberts [5]. The starting point taken by objectification theory [5] is that, in Western cultures, girls and women are frequently sexually objectified, meaning they are treated as a body rather than a whole person with beauty and attractiveness highly valued [6]. Repeated learned cultural practices of sexual objectification are thought to gradually influence females to adopt an observer’s (or third-person) perspective on their physical self (‘‘self-objectification’’) [5–8]. That is, sadly, they use to view and treat themselves as an object to be looked at and evaluated on the basis of outward external appearance [6–8]. Self-objectification, whose neuropsychological bases have been shed light on [8], is described as a form of selfconsciousness that manifests itself in the act of habitual monitoring of the body in terms of how it looks. In turn, self-objectification can lead to many different negative experiential consequences: body shame, appearance anxiety, lack of awareness of internal bodily states and of physiological sensations signals, and decreased peak motivational states (or flow experiences) [5–7]. The accumulation of each of these experiences, in turn, contributes to disordered eating behaviors (i.e., restrictive eating patterns, binge eating) [5–8]. Hence, the objectification model posits that both body shame and interoceptive deficits resulting from self-objectification lead to binge eating. Apart the lack of support of the mediational sequence of the escape model in Holmes et al.’s [4] study, the authors compared the examined models in terms of their predictive utility (i.e., the percentages of explained variance) and noted the superiority of the dual pathway model over the objectification model. It is not surprising that the ‘‘paraphrased’’ objectification model accounted for less variance in body dissatisfaction–binge eating relationship, since the dual pathway model includes more explanatory factors (i.e., dietary restraint, negative affect). Unfortunately, the authors did not report how well each examined model fit the observed data [2, 9, 10]. They did not also statistically compare the models using parsimony-corrective index of fit that could help to interpret the trade-off between A. Dakanalis (&) Department of Brain and Behavioral Sciences, University of Pavia, P.za Botta 11, 27100 Pavia, Italy e-mail: antonios.dakanalis@unipv.it

Mechanisms of influence of body checking on binge eating

Despite the theorized role of body checking behaviours in the maintenance process of binge eating, the mechanisms by which they may impact binge eating remain unclear. Using objectification model of eating pathology as a theoretical framework, the authors examined the potential intervening roles of body shame, appearance anxiety, and dietary restraint in the pathway between body checking and binge eating. Data collected from a large sample of treatment-seeking people with Bulimic-type Eating Disorders (N = 801) were analysed trough structural equation modelling. Results showed that, regardless of specific DSM-5 diagnostic categories, body checking behaviours were indirectly associated with binge eating and dietary restraint through body shame and appearance anxiety, whereas dietary restraint was directly linked to binge eating. The findings have clinical utility as they contribute to gaining insight into how critical scrutiny of ones body may act in several indirect ways to affect binge eating. We discuss practical implications of the findings.

Body-image distortion in anorexia nervosa

In their recent Primer (Anorexia nervosa. Nat. Rev. Dis. Primers 1, 15074 (2015))1, Janet Treasure and colleagues give an impor‐ tant update on the advances made in the aetio logy, assessment, prevention and treat‐ ment of anorexia nervosa (AN). The authors also highlight the need for better, faster and lasting improvements in the management of this ‘enigmatic’ disorder, which crucially depends on improved understanding of speci fic disease mechanisms. However, in their description, they do not include the consistent evidence that disturbed body image does not only motivate severe dietary restriction and other weight loss behaviours but also plays a central part in the initiation, persistence and relapse of AN2–8. The Primer1 states that the under lying mechanism of the so‐called body‐image distortion (BID), in which emaciated individ uals perceive them‐ selves as fat9, remains obscure. Yet, there is widespread agreement that this evidence — at both the conceptual and the empirical levels — is imperative for elucidating what is behind severe and intense BID2–10. Findings from an increasing number of functional MRI (fMRI) studies, conducted (based on the symptom provocation para‐ digm) over the past 15 years and recently reviewed by one of us7, provide valuable insights into the neural basis of BID in AN. Unfortunately, we felt that these issues were not entirely addressed by the Primer1, making it difficult to understand the ‘reasonably consistent’ (REF. 7) evidence produced by this research3. The review7 summarized that the ‘affective’ component of BID in AN is related to alterations of the prefrontal cortex, the insula and the amygdala and that the ‘per‐ ceptive’ component of BID is related to alter‐ ations of the parietal lobes (which have roles in spatial and body representations4–7,10, body ownership9–12 and other features requiring multisensory integration4–7,11–14) or, more accu‐ rately, the posterior parietal regions (which are involved in visuospatial processing4–7,10,15). A deficit in parietal cortex‐mediated func‐ tions in AN is also underscored by findings from neurocognitive studies4–6. Although both extant neuroimaging and behavioural data2,4,7,8 suggest that two components of body image (the estimation of one’s own body size and the attitude towards one’s own body in terms of an emotional evaluation) are disturbed in individ uals with AN, these aspects might have been described in more detail in the Primer1. In fact, although two (widely accepted) body‐ image components can be distinguished, this does not imply that they are independent4,5,15. Indeed, experimental evidence supports a direct (unidirectional) link between how we perceive and how we feel about our body12. The aforementioned specific neural bases of the affective component of BID in AN also sup‐ port an altered emotional response to unpleas‐ ant (for example, self‐distorted fat image) stimuli7. Furthermore, in the few available fMRI studies based on a word paradigm (that is, tasks using ‘fat’, ‘thin’ and ‘neutral’ words), a variation in amygdala response was absent — making the involvement of this brain region less clear but suggesting the greater rele vance of self‐perception and the mechanism of body‐ image construction5,6,9 (see below). There is the need to take into account these (and other convergent4,5,12,13) clues and the considerable room for improvement that remains from the first‐line prevention and psychotherapeutic interventions2,3,5,8,10,12,13, currently described in the Primer1 (for example, the Body Project and enhanced cognitive–behavioural ther‐ apy), and targeting the ‘affective’ body‐image component2,5,10,12,13. Thus, we would suggest that it is now time to consider the develop‐ ment of intervention strategies that target the perceptive component. Cognitive neuroscientific strides in the field of body self‐consciousness (that is, the experience of being in a body process5, with body ownership being its fundamental con‐ stituent5,11) offer a novel perspective for, if not a paradigm shift in, understanding the mech‐ anism of body‐image construction5,6,10,11,13,15 — only inferred by the already mentioned experimental paradigms used to explore the neural basis of BID in AN4,7. Fundamentally, our spatial experience, including the bodily one, is organized around two different refer‐ ence frames: egocentric, which has its primary source in ‘online’ representations (referring to the temporal flow of information that constructs how our body is right now), and allocentric, which has its primary source in ‘offline’ representations (referring to what our body is normally like)5,6,10,13,15. That is, people use both the memory of how the body, includ‐ ing its shape and size, is believed (or remem‐ bered) to be (offline) and the perception of the body ‘here and now’ (online) to construct their body image5,6. The conceptual distinction between online and offline representations should not imply that these representations of the body are unconnected, as they can and do interact, with the online information about the body being continuously integrating with and compared to the offline model of the body in the brain5,6,10,13,15. Neuroscientifically informed models highlight how a similar process of amending and updating offline representa‐ tions based on new online representations might underline the complex relationship between body image, dietary restriction and weight loss5. From this perspective, individuals who lose large amounts of weight might adapt their offline model of the body accordingly, as the new online information is received and updates the oldest stored model of the body5. Accordingly, an impediment in the transaction between online and offline information might be at play in patients with AN who have a per‐ sistent experience of being fat, even when they are objectively emaciated5. In support, sophis‐ ticated contemporary research10 has shown that individuals with AN in the earliest stages are ‘locked’ in a virtual ‘wrong’ body that they detest, which differs from the real one. Despite the importance of these10 (and additional5,13,14) findings and the known role of brain abnormalities in the (posterior pari‐ etal) areas involved in the block of the online– offline transformation process5,6,11,15, further research is needed to investigate additional factors (for example, stress) involved in the impaired ability of updating5,10, which were previously linked to food intake reduction in AN10. Some additional hypotheses have been proposed based on research on neuropsycho‐ logical functioning1,4,6,10 in patients with AN but they require specific testing. For example, some evidence suggests that people with AN not only focus on details (weak central coher‐ ence) but they also seem to have an attentional bias towards negatively charged details6. This feature has been suggested to affect both the perception of the body and how it is remem‐ bered6. Another hypothesis states that weak set shifting (that is, reduced mental flexibility as indicated by the ability to move back and forth between tasks) and poor visuospatial memory could affect the ability to adapt offline body representation based on new information and form a correct visual representation of the body, respectively6,10,14. C O R R E S P O N D E N C E