A 1-year follow-up study of the longitudinal interplay between emotion dysregulation and childhood trauma in the treatment of anorexia nervosa

The maltreated eco-phenotype of eating disorders: A new diagnostic specifier? A systematic review of the evidence and comprehensive description

This systematic review aimed to summarize the evidence on the existence of a distinct phenotypic expression of Eating Disorders (EDs) associated with childhood maltreatment (CM), the so-called maltreated eco-phenotype of EDs. PRISMA standards were followed. Articles providing data about the characteristics of individuals with an ED reporting CM were included. Relevant results were extracted and summarized. A quality assessment was performed. A total of 1207 records were identified and screened, and 97 articles published between 1994 and 2023 were included. Findings revealed distinct biological and clinical features in patients with EDs reporting CM, including neuroanatomical changes, altered stress responses, ghrelin levels, inflammation markers, and gut microbiota composition. Clinically, CM correlated with severer eating behaviors, higher psychiatric comorbidity, impulsivity, emotional dysregulation, and risky behaviors. Additionally, CM was associated with poorer treatment outcomes, especially in general psychopathology and psychiatric comorbidities. This review highlighted the need to move towards an etiologically informed nosography, recognizing CM not merely as a risk factor, but also as an etiologic agent shaping different eco-phenotypic variants of EDs.

A Systematic Review of the Effect of PTSD and Trauma on Treatment Outcomes for Eating Disorders

There is growing evidence of prior experiences of trauma and trauma-related symptoms among people with eating disorders; however, there is little understanding as to how post-traumatic stress disorder (PTSD) and exposure to traumatic events affect treatment outcomes. Without this knowledge, eating disorder clinicians are unable to tailor treatment to ensure good outcomes for the large percentage of this population that is affected by PTSD and trauma. This systematic review aimed to identify how PTSD and trauma exposure influence outcomes in eating disorder treatment. Systematic searches of PsycINFO, MEDLINE, PubMed, and Scopus databases identified 16 articles that met the inclusion criteria. The results indicated a negative effect on rates of eating disorder treatment completion and eating disorder psychopathology posttreatment. These findings were evident across studies that investigated the impact of a history of traumatic events as well as studies that investigated the impact of the presence of trauma-related symptoms seen in PTSD. Several methodological limitations were identified in the literature. These include: heterogeneous and unstandardized measures of PTSD and trauma, high attrition rates with follow-up, and insufficient data to enable comparisons by treatment setting, diagnostic presentation, and type of trauma exposure. The findings of this review have implications for future research and clinical care, including the importance of considering PTSD and trauma in assessment, treatment planning, and provision of both trauma-informed care and trauma-focused treatments for individuals with eating disorders.

Eye movement desensitisation and reprocessing as add-on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi-experimental multicenter study

OBJECTIVE

This quasi-experimental study aimed to compare the outcome of patients with Anorexia Nervosa (AN) reporting moderate/severe childhood maltreatment (CM) treated exclusively with Enhanced Cognitive Behaviour Therapy (CBT-E) or with CBT-E plus Eye Movement Desensitisation and Reprocessing (EMDR).

METHOD

A total of 75 patients with AN reporting moderate/severe CM were initially assessed regarding body mass index (BMI), general and eating disorder (ED)-specific psychopathology, and dissociative symptoms, and re-evaluated after 40 CBT-E sessions (T1). Then, 18 patients received EMDR, whereas the others were placed on a waiting list and continued CBT-E. T2 assessment was performed after 20-25 sessions of EMDR or CBT-E. A control group of 67 patients without CM was also enroled and treated with CBT-E.

RESULTS

Contrary to patients without CM, neither of the traumatised groups improved in BMI, general and ED psychopathology, or dissociation at T1. However, at T2, both traumatised groups improved in BMI and ED-specific psychopathology, with the CBT + EMDR group demonstrating greater improvements. Moreover, only the CBT + EMDR group improved in general psychopathology and dissociative symptoms. The reduction of ED symptoms in traumatised patients was mediated by the amelioration of dissociation.

DISCUSSION

The addition of EMDR to CBT-E may benefit patients with AN reporting moderate/severe CM.

Treatment of patients with anorexia nervosa and comorbid post-traumatic stress disorder; where do we stand? A systematic scoping review

Objective

Comorbid post-traumatic stress disorder in patients with anorexia nervosa may negatively affect the course of anorexia nervosa treatment, which is already challenging. There are currently no guidelines or recommendations on concurrent treatment approaches for both anorexia nervosa and post-traumatic stress disorder. This systematic scoping review aims to explore the feasibility, acceptability and effectiveness of psychological trauma-focused treatment concurrently offered to underweight patients receiving anorexia nervosa treatment.

Method

A multi-step literature search, according to an a priori protocol was performed. Databases PubMed, Embase, APA PsycINFO, Web of Science, Scopus and Cochrane Central were searched up to September 19th 2022, and the search was rerun June 19th 2023. For quality assessment, Risk of Bias in Non-randomised Studies-of Interventions tool was used.

Results

The extensive search yielded 1769 reports, out of which only three observational pilot studies, both English and German, published between 2004 and 2022, could be included. The included studies reported on a total of 13 female participants between 16 and 58 years old, with anorexia nervosa or otherwise specified feeding or eating disorder, baseline BMI ranging between 14.6 and 16.5, who received concurrent anorexia and post-traumatic stress disorder treatment. In all participants, the emotional and cognitive functioning was sufficient to process the offered trauma-focused interventions, despite their significantly low body weight.

Discussion

The findings of this review identify a dearth of treatment research on knowledge of concurrent trauma-focused treatments for patients with anorexia nervosa. Refraining patients with anorexia nervosa from trauma-focused treatment may not be warranted.

Reconceptualizing emotion regulation and coping strategy usage in eating disorders research: The utility of a regulatory flexibility framework

Emotion regulation and coping strategies are often conceptualized in eating disorder (ED) research as inherently adaptive or maladaptive, and successful regulation is often defined as greater overall use of adaptive strategies. However, recent empirical work outside of the field of EDs challenges this categorical conceptualization of strategies, demonstrating that adaptiveness is determined by the ability to flexibly implement and adjust strategies based on contextual demands (i.e., regulatory flexibility). Despite evidence that emotion regulation and coping strategies are best conceptualized in terms of flexibility in the broader literature, few ED studies have adopted this model. We review the current conceptual framework of emotion regulation and coping strategies used in ED research and present regulatory flexibility as an alternative approach to conceptualizing these strategies. The lack of research on regulatory flexibility among individuals with EDs limits our understanding of the role of emotion regulation and coping difficulties in ED risk and maintenance. Adopting a regulatory flexibility model of strategies in EDs may extend knowledge of the role of emotion regulation difficulties in the development and maintenance of EDs. We highlight the potential utility of investigating regulatory flexibility and present recommendations for future research on regulatory flexibility in EDs. PUBLIC SIGNIFICANCE STATEMENT: Research on emotion regulation and coping strategy usage in eating disorders often view regulatory strategies as inherently adaptive or maladaptive. However, recent studies support defining strategies in terms of flexibility. Adopting a regulatory flexibility model of strategies in eating disorders research may advance knowledge of the role of emotion regulation difficulties in the development and maintenance of eating disorders, ultimately enhancing prevention and treatment efforts.

Therapeutic outcome and long-term naturalistic follow-up of female adolescent outpatients with AN: clinical, personality and psychopathology evolution, process indicators and outcome predictors

BACKGROUND

Anorexia nervosa (AN) is a serious mental illness of growing prevalence in childhood and adolescence. Despite its severity, there are still no completely satisfactory evidence-based treatments. Follow-up studies represent the most effective attempt to enlighten treatment effectiveness, outcome predictors and process indicators.

METHODS

Seventy-three female participants affected with AN were assessed at intake (T0) and at 6 (T1) and 12 (T2) months of an outpatient multimodal treatment program. Nineteen participants were assessed 15 years after discharge (T3). Changes in diagnostic criteria were compared with the chi-square test. Clinical, personality and psychopathology evolution were tested with ANOVA for repeated measures, using the t-test or Wilcoxon test as post-hoc. T0 features among dropout, stable and healed participants were compared. Healed and unhealed groups at long-term follow-up were compared using Mann-Whitney U test. Treatment changes were correlated to each other and with intake features using multivariate regression.

RESULTS

The rate of complete remission was 64.4% at T2, and 73.7% at T3. 22% of participants maintained a full diagnosis at T2, and only 15.8% at T3. BMI significantly increased at each time-point. A significant decrease of persistence and increase in self-directedness were evidenced between T0 and T2. Interoceptive awareness, drive to thinness, impulsivity, parent-rated, and adolescent-rated general psychopathology significantly decreased after treatment. Lower reward dependence and lower cooperativeness characterized the dropout group. The healed group displayed lower adolescent-rated aggressive and externalizing symptoms, and lower parent-rated delinquent behaviors. BMI, personality and psychopathology changes were related with each other and with BMI, personality and psychopathology at intake.

CONCLUSION

A 12-months outpatient multimodal treatment encompassing psychiatric, nutritional and psychological approaches is an effective approach for the treatment of mild to moderate AN in adolescence. Treatment was associated not only with increased BMI but also with positive personality development, and changes in both eating and general psychopathology. Lower relational abilities may be an obstacle to healing. Approaches to treatment resistance should be personalized according to these finding.

Trauma Experiences Are Common in Anorexia Nervosa and Related to Eating Disorder Pathology but Do Not Influence Weight-Gain during the Start of Treatment

OBJECTIVE

The main characteristics of Anorexia Nervosa (AN) in adults are restriction of energy intake relative to requirements leading to significant weight loss, disturbed body image, and intense fear of becoming fat. Traumatic experiences (TE) have been reported as common, although less is known about the relationship with other symptoms in severe AN. We investigated the presence of TE, PTSD, and the relation between TE, eating disorder (ED) symptoms, and other symptoms in moderate to severe AN (n = 97) at admission to inpatient weight-restoration treatment. All patients were enrolled in the Prospective Longitudinal all-comer inclusion study on Eating Disorders (PROLED).

METHODS

TE were assessed using the Post-traumatic stress disorder checklist, Civilian version (PCL-C), and ED symptoms using the Eating Disorder Examination Questionnaire (EDE-Q); depressive symptoms were assessed using the Major Depression Inventory (MDI), and the presence of Post-traumatic Stress Disorder (PTSD) was diagnosed according to ICD-10 criteria.

RESULTS

The mean score on PCL-C was high (mean 44.6 SD 14.7), with 51% having a PCL-C score at or above 44 (n = 49, suggested cut-off for PTSD), although only one individual was clinically diagnosed with PTSD. There was a positive correlation between baseline scores of PCL-C and EDE-Q-global score (r = 0.43; p < 0.01) as well as of PCL-C and all EDE-Q subscores. None of the included patients were admitted for treatment of TE/PTSD during the first 8 weeks of treatment.

CONCLUSIONS

In a group of patients with moderate to severe AN, TE were common, and scores were high, although only one had a diagnosis of PTSD. TE were related to ED symptoms at baseline, but this association diminished during the weight restoration treatment.

Longitudinal Coupling between Eating Disorder Psychopathology and Depression in Patients with Anorexia Nervosa and Bulimia Nervosa Treated with Enhanced Cognitive Behavior Therapy: A One-Year Follow-Up Study

BACKGROUND

The relationship between eating disorder (ED) specific psychopathology and depressive symptomatology in EDs is often debated. The aim of this study was to provide an explicative model regarding the mechanisms by which enhanced cognitive-behavior therapy (CBT-E) might determine an amelioration of depressive symptoms in patients with anorexia nervosa (AN) or bulimia nervosa (BN).

METHODS

A total of 157 women with AN or BN and no history of childhood trauma or bipolar disorder were evaluated before treatment and after 12 months of CBT-E. Self-administered questionnaires were used to measure ED psychopathology and depressive symptoms.

RESULTS

All psychopathological measures improved after treatment, with no significant additional improvement with the concomitant use of antidepressants. Structural equation modeling using the bivariate latent change score approach showed that higher levels of depressive symptoms at baseline were associated with a worse longitudinal trend of ED psychopathology, and vice versa. Finally, the amelioration of ED psychopathology predicted the improvement in depressive symptoms at follow-up, whereas data did not support the inverse path.

CONCLUSION

This study elucidated the complex longitudinal interplay between ED psychopathology and depression during CBT-E, underlining the importance of addressing ED symptoms as a primary target in the case of comorbidity between AN or BN and depressive symptoms.

Brief emotional eating scale: A multinational study of factor structure, validity, and invariance

Emotional eating or the tendency to eat in response to emotional states can be assessed using self-report measures. The Emotional Eating Scale-II is a commonly used and reliable instrument that measures the desire to eat in response to a range of unpleasant and pleasant emotions. The current study aimed to corroborate the validity of the EES-II and expand its utility by investigating its dimensionality and testing its measurement invariance in samples from English-speaking and non-English-speaking countries. Convergent and predictive validity in respect of food craving, eating, and health indicators were also examined. This cross-national study included a total of 2485 adult participants recruited from Finland, North America, Philippines, United Kingdom, China, Italy, Spain, and South Korea, who completed the EES-II in six different languages. Factor analyses supported a four-factor structure including valence (pleasant, unpleasant) and activation (high, low) for a 12-item English version and slightly modified non-English adaptations. The model exhibited good fit in all samples, and convergent validity was demonstrated. Full invariance of factor loadings and partial invariance of factor loading, intercepts, and error variances was established across samples. Structural equation models revealed that high activation (pleasant and unpleasant) states predicted food cravings and reported eating. Overall findings across multiple samples and countries supported the factorial structure, reliability, invariance, and validity of the resulting Brief Emotional Eating Scale (BEES).

Novel ketamine and zinc treatment for anorexia nervosa and the potential beneficial interactions with the gut microbiome

Anorexia nervosa (AN) is a severe illness with diverse aetiological and maintaining contributors including neurobiological, metabolic, psychological, and social determining factors. In addition to nutritional recovery, multiple psychological and pharmacological therapies and brain-based stimulations have been explored; however, existing treatments have limited efficacy. This paper outlines a neurobiological model of glutamatergic and γ-aminobutyric acid (GABA)-ergic dysfunction, exacerbated by chronic gut microbiome dysbiosis and zinc depletion at a brain and gut level. The gut microbiome is established early in development, and early exposure to stress and adversity contribute to gut microbial disturbance in AN, early dysregulation to glutamatergic and GABAergic networks, interoceptive impairment, and inhibited caloric harvest from food (e.g., zinc malabsorption, competition for zinc ions between gut bacteria and host). Zinc is a key part of glutamatergic and GABAergic networks, and also affects leptin and gut microbial function; systems dysregulated in AN. Low doses of ketamine in conjunction with zinc, could provide an efficacious combination to act on NMDA receptors and normalise glutamatergic, GABAergic and gut function in AN.

Anorexia nervosa as a disorder of the subcortical-cortical interoceptive-self

PURPOSE

Anorexia nervosa (AN) is characterized by a diminished capacity in perceiving the physiological correlates of interoceptive sensations, namely bodily self-consciousness. Given the neural division of self-processing into interoceptive-, exteroceptive- and mental-self, we hypothesize neural deficits in the interoceptive-processing regions in AN.

METHODS

To prove this, we reviewed resting state (rs), task and rest-task studies in AN literature.

RESULTS

Neuronal data demonstrate the following in AN: (i) decreased rs-functional connectivity (rsFC) of subcortical-cortical midline structures (SCMS); (ii) reduced rsFC between medial (default-mode network/DMN and salience network/SN) and lateral (executive-control network/ECN) cortical regions; (iii) decreased rsFC in mainly the regions of the interoceptive-self; (iv) altered activity with overall increased activity in response to sensory/body image stimuli, especially in the regions of the interoceptive-self; (v) lack of a clear task-related distinction between own's and others' body image.

CONCLUSION

These data may indicate that rs-hypoconnectivity between SCMS, as neural correlate of a reduced intero-exteroceptive integration resulting in self-objectification, might be linked to overall increased activity in interoceptive regions during sensory/body image stimuli in AN, engendering an "anxious bodily self."

LEVEL OF EVIDENCE

I: Systematic review.

Attachment insecurity predicts worse outcome in patients with eating disorders treated with enhanced cognitive behavior therapy: A one-year follow-up study

OBJECTIVE

This study aimed to explore the role of attachment insecurity in predicting a worse longitudinal trend of eating disorder (ED) psychopathology and body uneasiness in patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) treated with Enhanced Cognitive Behavior Therapy, considering the longitudinal interplay between these dimensions.

METHOD

In total, 185 patients with AN or BN performed the baseline assessment, and 123 were re-evaluated after 1 year of treatment. Participants completed questionnaires evaluating ED psychopathology (Eating Disorders Examination Questionnaire) and body uneasiness (body uneasiness test). For the assessment of adult attachment, the Experiences in Close Relationships-Revised was administered at baseline. Bivariate latent change score analysis within the structural equation modeling framework was performed to investigate the evolution of ED psychopathology and body uneasiness, their longitudinal interplay, and the role of attachment style as an outcome predictor.

RESULTS

After treatment, all psychopathological features showed an overall improvement. Higher baseline levels of body uneasiness predicted a worse course of ED psychopathology. The change in body uneasiness over time depended on changes over time in ED psychopathology, but not vice versa. Insecure attachment predicted a worse longitudinal trend of ED psychopathology, and, through this impairment, it indirectly maintained higher levels of body uneasiness, as confirmed by mediation analyses.

DISCUSSION

The role of attachment insecurity as a predictor of treatment outcome suggests the need for an integration of the cognitive-behavioral conceptualization of EDs with a developmental perspective that considers attachment-related issues.

PUBLIC SIGNIFICANCE STATEMENT

Considering the burden of EDs in terms of public health and the unsatisfactory response to standard treatments, the identification of outcome predictors is of considerable clinical interest. This study demonstrated that attachment insecurity was associated with worse longitudinal trends of ED psychopathology and body uneasiness in patients with AN and BN treated with CBT-E, highlighting the importance of personalizing treatment programs taking into account a developmental perspective on these disorders.