Silvia Serino

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

Predictors of initiation and persistence of recurrent binge eating and inappropriate weight compensatory behaviors in college men

OBJECTIVE The transition to college is considered as a risk period for the development of behavioral symptoms of eating disorders (BSEDs) and some evidence suggests that, amongst men, these symptoms occurring on a regular basis remain relatively stable over the college period. Nevertheless, little is known about factors associated with persistent engagement in and initiation of recurrent (or regular) binge eating and inappropriate weight compensatory behaviors in this population. The objective of this report was to address these research gaps. METHOD Data were examined from 2,555 male first-year college students who completed an assessment of potential vulnerability factors and BSEDs at the beginning of the autumn semester (baseline) and nine months later (end of the spring semester; follow-up). RESULTS Elevated negative affectivity, body dissatisfaction, self-objectification, and lower self-esteem at baseline were predictive of persistent engagement in regular binge eating and four compensatory behaviors (self-induced vomiting, laxative/diuretic abuse, fasting, exercise) at follow-up, as well as initiation of all these behaviors occurring regularly (i.e., at least weekly for 3 months). Self-objectification (thinking and monitoring the bodys outward appearance from a third-person perspective) emerged as the largest contributor of both the initiation and persistence of all behavioral symptoms. DISCUSSION Data emphasize that the same psychological factors underlie initiation and persistence of recurrent BSEDs and should shape the focus of future interventions for college men.

Pain in the body. Altered interoception in chronic pain conditions: A systematic review

Interoception is the sense of the physiological condition of the body. Modern definitions differentiated three separated sub-constructs: accuracy (IAc), i.e., the ability to detect physiological states, sensibility (IAs), i.e., a self-evaluated measure of interoception, and awareness (IAw) i.e., a metacognitive awareness of the accuracy. Preliminary researches correlated pain with alterations in the interoceptive matrix albeit, to the best of our knowledge, interoceptive alterations in chronic pain conditions have never been studied systematically. We searched for studies that assessed interoception in subjects with chronic pain and compared it to healthy population. Eleven studies were included among different chronic pain conditions. Results suggested that chronic pain subjects might present low IAc and, allegedly, that IAc negatively correlates with symptoms severity in specific disorders. Data were inconclusive for IAs and IAw. The high risk of bias across multiple dimensions suggests to consider these conclusions with cautions. Nonetheless, deficits in interoceptive processes indicate a promising path for new form of therapies, and they require further attention and a more defined line of research.

Embodied medicine: Mens sana in corpore virtuale sano

Progress in medical science and technology drastically improved physicians’ ability to interact with patient’s physical body. Nevertheless, medicine still addresses the human body from a Hippocratic point of view, considering the organism and its processes just as a matter of mechanics and fluids. However, the interaction between the cognitive neuroscience of bodily self-consciousness (BSC), fundamentally rooted in the integration of multisensory bodily inputs, with virtual reality (VR), haptic technologies and robotics is giving a new meaning to the classic Juvenal’s latin dictum “Mens sana in corpore sano” (a healthy mind in a healthy body). This vision provides the basis for a new research field, “Embodied Medicine”: the use of advanced technologies for altering the experience of being in a body with the goal of improving health and well-being. Up to now, most of the research efforts in the field have been focused upon how external bodily information is processed and integrated. Despite the important results, we believe that existing bodily illusions still need to be improved to enhance their capability to effectively correct pathological dysfunctions. First, they do not follow the suggestions provided by the free-energy and predictive coding approaches. More, they lacked to consider a peculiar feature of the human body, the multisensory integration of internal inputs (interoceptive, proprioceptive and vestibular) that constitute our inner body dimension. So, a future challenge is the integration of simulation/stimulation technologies also able to measure and modulate this internal/inner experience of the body. Finally, we also proposed the concept of “Sonoception” as an extension of this approach. The core idea is to exploit recent technological advances in the acoustic field to use sound and vibrations to modify the internal/inner body experience.

Egocentric and allocentric spatial reference frames in aging: A systematic review

HIGHLIGHTSAging does not affect egocentric navigational strategies, whereas allocentric and switching abilities show a gradual decline.A general age‐related weakening of spatial memory has been observed, even if not frame‐specific;.Executive functions may play a critical role in age‐related spatial difficulties. ABSTRACT Aging affects many aspects of everyday living, such as autonomy, security and quality of life. Among all, spatial memory and spatial navigation show a gradual but noticeable decline, as a result of both neurobiological changes and the general slowing down of cognitive functioning. We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines to identify studies that specifically investigated the role of allocentric and egocentric frames in healthy aging. Concerning spatial navigation, our results showed a preservation of egocentric strategies, along with specific impairments in the use of allocentric and switching abilities. Regarding spatial memory, instead, outcomes were more divergent and not frame‐specific. With this perspective, spatial impairments were discussed considering the cognitive profile of mild cognitive impairment (MCI) and Alzheimers Disease (AD).

A Novel Technique for Improving Bodily Experience in a Non-operable Super–Super Obesity Case

Introduction: The available clinical guidelines for super-super obese patients (i.e., with body mass index (BMI) > 60 kg/m2) that are not suitable for bariatric surgery mandate a palliative multidisciplinary treatment (i.e., production and maintenance of weight loss) provided in a center of excellence. However, the modality and the impact of this approach are still controversial. Moreover, it is not able to address the high level of body dissatisfaction and body distortions that are common among these patients. Clinical Presentation: We report the case of a non-operable super–super obesity – a 37 year old woman with a BMI of 62 kg/m2 – receiving a specialized treatment for her obstructive sleep apnea. She entered a multidisciplinary program that promoted healthy behaviors, including physical activities and psychological intervention. To improve body dissatisfaction, which was linked to a significant multisensory impairment of body perception, she also entered a virtual reality (VR) body-swapping illusion protocol. At the end of the current investigation, the patient continued her multidisciplinary program, reporting an increase in the motivation for undertaking healthy behavior and a decrease in the anxiety feelings associated with her clinical condition. Conclusion: This case provides preliminary evidence that both body dissatisfaction and body-size distortions of non-operable super-super obesity patients could be addressed by a VR body-swapping protocol, which is important because the palliative multidisciplinary treatment recommended for these patients is not able to address them. Interestingly, the use of a VR body-swapping illusion protocol seems to be able to improve not only the experience of the body in these patients but their motivation for change, too.

Ghosts in the machine. Interoceptive modeling for chronic pain treatment

Pain is a complex and multidimensional perception, embodied in our daily experiences through interoceptive appraisal processes. The article reviews the recent literature about interoception along with predictive coding theories and tries to explain a missing link between the sense of the physiological condition of the entire body and the perception of pain in chronic conditions, which are characterized by interoceptive deficits. Understanding chronic pain from an interoceptive point of view allows us to better comprehend the multidimensional nature of this specific organic information, integrating the input of several sources from Giffords Mature Organism Model to Melzacks neuromatrix. The article proposes the concept of residual interoceptive images (ghosts), to explain the diffuse multilevel nature of chronic pain perceptions. Lastly, we introduce a treatment concept, forged upon the possibility to modify the interoceptive chronic representation of pain through external input in a process that we call interoceptive modeling, with the ultimate goal of reducing pain in chronic subjects.

Classifying Adults with Binge Eating Disorder Based on Severity Levels

The clinical utility of the severity criterion for binge eating disorder (BED), introduced in the DSM-5 as a means of addressing heterogeneity and variability in the severity of this disorder, was evaluated in 189 treatment-seeking adults with (DSM-5) BED. Participants classified with mild, moderate, severe and extreme severity of BED, based on their weekly frequency of binge eating episodes, differed significantly from each other in body mass index (BMI), eating disorder features, putative factors involved in the maintenance process of the disorder, comorbid mood, anxiety and personality disorders, psychological distress, social maladjustment and illness-specific functional impairment (medium-to-large effect sizes). They were also statistically distinguishable in metabolic syndrome prevalence, even after adjusting for BMI (large effect size), suggesting the possibility of non-BMI-mediated mechanisms. The implications of the findings, providing support for the utility of the binge frequency as a severity criterion for BED, and directions for future research are outlined. Copyright

A novel virtual reality-based training protocol for the enhancement of the "mental frame syncing" in individuals with Alzheimer's disease: A development-of-concept trial

A growing body of evidence suggests that people with Alzheimers Disease (AD) show compromised spatial abilities. In addition, there exists from the earliest stages of AD a specific impairment in “mental frame syncing,” which is the ability to synchronize an allocentric viewpoint-independent representation (including object-to-object information) with an egocentric one by computing the bearing of each relevant “object” in the environment in relation to the stored heading in space (i.e., information about our viewpoint contained in the allocentric viewpoint-dependent representation). The main objective of this development-of-concept trial was to evaluate the efficacy of a novel VR-based training protocol focused on the enhancement of the “mental frame syncing” of the different spatial representations in subjects with AD. We recruited 20 individuals with AD who were randomly assigned to either “VR-based training” or “Control Group.” Moreover, eight cognitively healthy elderly individuals were recruited to participate in the VR-based training in order to have a different comparison group. Based on a neuropsychological assessment, our results indicated a significant improvement in long-term spatial memory after the VR-based training for patients with AD; this means that transference of improvements from the VR-based training to more general aspects of spatial cognition was observed. Interestingly, there was also a significant effect of VR-based training on executive functioning for cognitively healthy elderly individuals. In sum, VR could be considered as an advanced embodied tool suitable for treating spatial recall impairments.

Virtual Reality as an embodied tool to enhance episodic memory in elderly

In the last decade, embodiment has dramatically influenced our conception of cognition. In this new frame, episodic memory, and particularly memory decline have been reinterpreted. Interventions supporting memory in the aging population address the connection between mind and body. Here, we discuss the use of Virtual Reality (VR) as an innovative tool to support episodic memory in older adults.