Paolo Santonastaso

Set-shifting abilities, central coherence, and handedness in anorexia nervosa patients, their unaffected siblings and healthy controls: Exploring putative endophenotypes

Abstract Objective. There is consistent evidence that anorexia nervosa (AN) is associated with an impairment of set-shifting abilities and central coherence. No study to date investigated handedness in AN. Our aim was to study set-shifting abilities, central coherence, and handedness in subjects with lifetime AN, in a sample of unaffected sisters and in healthy controls, in order to explore their suitability as endophenotypes of AN. Methods. The Edinburgh Handedness Inventory and several neuropsychological tasks (Wisconsin Card Sorting Test, Trail Making Test, Rey-Osterrieth Complex Figure Test, Overlapping Figures Test, Object Assembly and Block Design) were administered to 153 subjects with lifetime AN, 28 unaffected sisters and 120 healthy controls. Results. AN subjects and their healthy sisters showed poorer performances on most tasks investigating set-shifting and central coherence. In addition, we did not find any differences between long-term recovered subjects, weight-restored AN patients and those in an acute phase of their illness. AN subjects were significantly more likely to be left-handed than healthy controls (OR=2.8, 95% C.I. 1.1–7.2). Conclusions. Set-shifting and central coherence seem to be promising cognitive endophenotypes that might help in the understanding of the pathogenetic processes involved in AN. Further studies on larger samples are needed to explore the generalizability and implications of our findings concerning handedness.

Impulsive and compulsive self-injurious behavior in bulimia nervosa : Prevalence and psychological correlates

A specific link between self-injurious behavior and bulimia nervosa has been observed. In affective spectrum disorders, some authors propose a distinction between impulsive and compulsive self-injurious behavior. One of the aims of the present study is to examine how different kinds of self-injurious behavior, including purging behavior, may be classified in bulimia nervosa. The clinical impact of the different types of self-injury will be studied. The subjects of the study were 125 consecutive patients with bulimia nervosa, diagnosed by DSM-IV criteria. Subjects were evaluated by means of a semistructured interview and self-report questionnaires (Eating Disorders Inventory and Hopkins Symptom Checklist). In our sample, the distinction between compulsive and impulsive self-injurious behavior appeared to be confirmed by a principal component analysis. Self-induced vomiting loaded on the compulsive dimension and laxative abuse on the impulsive dimension. To study the clinical impact of the two kinds of behavior, bulimic subjects were divided according to their position in the two dimensions. The presence of impulsive self-injurious behavior is associated with a history of sexual abuse and with higher scores on the Symptom Checklist. The presence of both impulsive and compulsive behavior is associated with greater depression, whereas the presence of impulsive features in the absence of compulsive ones seems to be linked to a longer duration of illness and to a higher dropout rate. Both compulsive and impulsive self-injurious behaviors are associated with a greater lack of interoceptive awareness.

Suicidality in eating disorders: clinical and psychological correlates

Although many authors have described eating disorders as often being associated with suicidal feelings and behaviour, few studies to date have evaluated the prevalence and characteristics of suicidal behaviour in eating disordered patients. In the present study, in which a consecutive series of 495 out‐patients was studied, 13% of the patients reported at least one suicide attempt and 29% reported current suicidal ideation; 26% of attempters reported multiple attempts. A history of suicide attempt was more prevalent among binge‐eating/purging anorexics and among purging bulimics than in the other subgroups. In cases with anorexia nervosa, suicide attempters were older, had a longer illness duration, weighed less, had more often used drugs and/or alcohol and tended to be more obsessive than non‐attempters. In cases with bulimia nervosa, attempters presented with more psychiatric symptoms and had more frequently been sexually abused.

Self-injurious behavior in anorexia nervosa

Recent reports have postulated the existence of two different types of self-injurious behavior: impulsive and compulsive. The aim of the present study is to analyze the dimensionality of self-injurious behavior and to study the link between self-injurious behavior and clinical features in anorexia nervosa. The study involved 236 consecutive patients with anorexia nervosa, diagnosed by DSM-IV criteria. Subjects were evaluated by means of a semistructured interview and self-reported questionnaires, such as the Eating Disorders Inventory and Hopkins Symptom Checklist. A principal component analysis was used to study the dimensionality of different types of self-injurious behavior, including purging. Our findings confirm the distinction between impulsive and compulsive self-injurious behavior. The dimensions appear to be represented as a continuum in both the anorexia nervosa diagnostic subgroups. A third distinct dimension emerged that included self-induced vomiting and laxative/diuretics abuse. Childhood sexual abuse and anxiety significantly predict the presence of impulsive self-injury, whereas obsessionality and age predict compulsive self-injury. The coexistence of a positive score on both dimensions of self-injurious behavior was the strongest predictor of treatment dropout. The present study highlights the importance of self-injurious behavior; it should be given due consideration in future outcome studies on anorexia nervosa

Time trends in age at onset of anorexia nervosa and bulimia nervosa.

OBJECTIVE This study aims to explore the time trends in age at onset of anorexia nervosa and bulimia nervosa. METHOD The sample was composed of 1,666 anorexia nervosa subjects and 793 bulimia nervosa subjects (according to DSM-IV criteria) without previous anorexia nervosa consecutively referred to our outpatient unit in the period between 1985 and 2008. Time trends in illness onset were analyzed according to the year of birth of subjects. RESULTS In both anorexia nervosa and bulimia nervosa, age at onset showed a significant decrease according to year of birth. A regression model showed a significant independent effect of socioeconomic status, age at menarche, and number of siblings in predicting age at onset lower than 16 years. CONCLUSION Age at onset of anorexia nervosa and bulimia nervosa is decreasing in younger generations. The implications of our findings in terms of long-term outcome remain to be understood. Biologic and sociocultural factors explaining this phenomenon need to be explored in future studies.

Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large‐scale meta‐analysis of 3,211,768 patients and 113,383,368 controls

People with severe mental illness (SMI) – schizophrenia, bipolar disorder and major depressive disorder – appear at risk for cardiovascular disease (CVD), but a comprehensive meta‐analysis is lacking. We conducted a large‐scale meta‐analysis assessing the prevalence and incidence of CVD; coronary heart disease; stroke, transient ischemic attack or cerebrovascular disease; congestive heart failure; peripheral vascular disease; and CVD‐related death in SMI patients (N=3,211,768) versus controls (N=113,383,368) (92 studies). The pooled CVD prevalence in SMI patients (mean age 50 years) was 9.9% (95% CI: 7.4‐13.3). Adjusting for a median of seven confounders, patients had significantly higher odds of CVD versus controls in cross‐sectional studies (odds ratio, OR=1.53, 95% CI: 1.27‐1.83; 11 studies), and higher odds of coronary heart disease (OR=1.51, 95% CI: 1.47‐1.55) and cerebrovascular disease (OR=1.42, 95% CI: 1.21‐1.66). People with major depressive disorder were at increased risk for coronary heart disease, while those with schizophrenia were at increased risk for coronary heart disease, cerebrovascular disease and congestive heart failure. Cumulative CVD incidence in SMI patients was 3.6% (95% CI: 2.7‐5.3) during a median follow‐up of 8.4 years (range 1.8‐30.0). Adjusting for a median of six confounders, SMI patients had significantly higher CVD incidence than controls in longitudinal studies (hazard ratio, HR=1.78, 95% CI: 1.60‐1.98; 31 studies). The incidence was also higher for coronary heart disease (HR=1.54, 95% CI: 1.30‐1.82), cerebrovascular disease (HR=1.64, 95% CI: 1.26‐2.14), congestive heart failure (HR=2.10, 95% CI: 1.64‐2.70), and CVD‐related death (HR=1.85, 95% CI: 1.53‐2.24). People with major depressive disorder, bipolar disorder and schizophrenia were all at increased risk of CVD‐related death versus controls. CVD incidence increased with antipsychotic use (p=0.008), higher body mass index (p=0.008) and higher baseline CVD prevalence (p=0.03) in patients vs. controls. Moreover, CVD prevalence (p=0.007), but not CVD incidence (p=0.21), increased in more recently conducted studies. This large‐scale meta‐analysis confirms that SMI patients have significantly increased risk of CVD and CVD‐related mortality, and that elevated body mass index, antipsychotic use, and CVD screening and management require urgent clinical attention.

The influence of illness-related variables, personal resources and context-related factors on real-life functioning of people with schizophrenia.

In people suffering from schizophrenia, major areas of everyday life are impaired, including independent living, productive activities and social relationships. Enhanced understanding of factors that hinder real‐life functioning is vital for treatments to translate into more positive outcomes. The goal of the present study was to identify predictors of real‐life functioning in people with schizophrenia, and to assess their relative contribution. Based on previous literature and clinical experience, several factors were selected and grouped into three categories: illness‐related variables, personal resources and context‐related factors. Some of these variables were never investigated before in relationship with real‐life functioning. In 921 patients with schizophrenia living in the community, we found that variables relevant to the disease, personal resources and social context explain 53.8% of real‐life functioning variance in a structural equation model. Neurocognition exhibited the strongest, though indirect, association with real‐life functioning. Positive symptoms and disorganization, as well as avolition, proved to have significant direct and indirect effects, while depression had no significant association and poor emotional expression was only indirectly and weakly related to real‐life functioning. Availability of a disability pension and access to social and family incentives also showed a significant direct association with functioning. Social cognition, functional capacity, resilience, internalized stigma and engagement with mental health services served as mediators. The observed complex associations among investigated predictors, mediators and real‐life functioning strongly suggest that integrated and personalized programs should be provided as standard treatment to people with schizophrenia.

Purging behaviors, suicide attempts, and psychiatric symptoms in 398 eating disordered subjects.

OBJECTIVE The present work investigates differences in psychiatric symptoms and self-injurious behaviors among different forms of purging behavior in eating disorders (ED). METHOD The sample was composed of 398 subjects consecutively referred to an outpatient ED unit. RESULTS Both in anorexia nervosa (AN) and bulimia nervosa (BN), psychiatric symptoms were significantly more serious in purging compared to nonpurging groups, while no significant difference emerged among divergent forms of purging behaviors. The presence of multiple methods to control weight appeared to be a predictor of impulsive behaviors, as subjects who used both vomiting and laxatives reported significantly higher frequency of self-injurious behaviors. In BN, the self-injury was often a suicide attempt. DISCUSSION The impact of purging behavior on the prognosis of AN and BN should be further studied since our research has shown a trend towards more frequent self-damaging behaviors in subjects who resort to multiple forms of purging behavior.

Olanzapine therapy in anorexia nervosa: psychobiological effects.

Dopamine impairments occur in anorexia nervosa. The aim of this study was to see whether treatment with the atypical dopamine antagonist antipsychotic olanzapine improves the disorder. Thirty anorexics, 18 restricted and 12 bingeing–purging, underwent a 3-month course of cognitive behavioral therapy, plus at random and double-blinded oral olanzapine (2.5 mg for 1 month, 5 mg for 2 months) in half and oral placebo in the other half of them. BMI, psychopathological aspects (eating disorder inventory, Hamilton Rating Scale, Buss–Durkee Rating Scale, Yale Brown Cornell for Eating Disorders Rating Scale, temperament–character inventory), and homovanillic acid blood concentrations for dopamine secretion, were monitored at baseline and then monthly during the trial. At the end of the trial BMI, total eating disorder inventory, total Yale Brown Cornell for Eating Disorders Rating Scale, Buss–Durkee Rating Scale, Hamilton Rating Scale scores and in olanzapine-treated patients the subitems of eating disorder inventory ineffectiveness and maturity fear, of Buss–Durkee Rating Scale direct aggressiveness, of temperament–characteristic inventory persistence had improved significantly. When stratified for anorexia nervosa subtype, BMI changes were significant among anorexia nervosa bingeing-purging patient, ‘depression’ (Hamilton Rating Scale) and ‘direct aggressiveness’ (Buss–Durkee Rating Scale) among anorexia nervosa bingeing–purging patients, ‘persistence’ (temprerament–characteristic inventory), among anorexics restricted patients, with a trend toward significance for obsessivity–compulsivity (Yale Brown Cornell for Eating Disorders Rating Scale). homovanilic acid blood levels increased significantly in the cognitive behavioral therapy+olanzapine group. No correlations were observed between homovanilic acid concentrations and psychopathological parameters. The pharmacological treatment can significantly improve specific aspects of anorexia nervosa.

Full and Partial Syndromes in Eating Disorders: A 1-Year Prospective Study ofRisk Fa ctors among Female Students

The present study is an investigation into the risk factors and natural history of full and partial syndrome eating disorders in a sample of 394 16-year-old female students. We used a two-stage procedure (screening and clinical interviews) and the same procedure was repeated after a 1-year follow-up. A stepwise multiple regression analysis showed that drive for thinness and tendency towards somatization are associated with an increased risk of later developing an eating disorder. Use of hypocaloric diets and a desire to be thinner characterized those asymptomatic subjects who were later to develop a partial syndrome. Perfectionism appeared to be a maintenance factor for subjects who presented a full or partial eating disorder at baseline.