Abnormal diurnal patterns of salivary α-amylase and cortisol secretion in acute patients with anorexia nervosa

The influence of anorexia nervosa on oral health and related parameters potentially relevant to orthodontic treatment: a systematic review and meta-analysis

OBJECTIVES

Information on the oral health of patients with anorexia nervosa remains not satisfactory. The aim of this systematic review is to evaluate oral health parameters in anorexic patients compared to healthy individuals. Furthermore, potential clinical implications for orthodontic treatment are discussed from an orthodontic perspective.

MATERIALS AND METHODS

Electronic databases were searched for case-control and controlled clinical trial studies on dentofacial manifestations in anorexic patients up to 2/2024. Study selection, data extraction and risk of bias assessment was done independently by two authors. Random-effects meta-analyses of mean differences (MDs) or relative risks (RRs) with their 95% confidence intervals (CIs) were conducted, followed by sensitivity analyses.

RESULTS

Eleven out of 573 initially identified studies were included. They involved oral health analyses of general anorexic patients ≥ 12 years (mean age 18.4). The meta-analysis showed that anorexia nervosa was associated with a significantly increased caries experience (DMFT), plaque accumulation and gingival inflammation (BOP). PH and salivary flow rate were significantly altered in patients with anorexia nervosa, although no significant relationship between α-amylase levels and anorexia nervosa was demonstrated.

CONCLUSIONS

These data enabled us to formulate modalities for anorexia-specific orthodontic treatments. Based on the results, patients with anorexia nervosa exhibit an increased risk of caries and gingival inflammatory signs.

CLINICAL RELEVANCE

The systematic information on dentofacial manifestations obtained in this study should be considered to better manage the oral health of anorexia patients.

The Role of Circadian Rhythms and Sleep in Anorexia Nervosa

Importance

Observational studies have associated anorexia nervosa with circadian rhythms and sleep traits. However, the direction of causality and the extent of confounding by psychosocial comorbidities in these associations are unknown.

Objectives

To investigate the association between anorexia nervosa and circadian and sleep traits through mendelian randomization and to test the associations between a polygenic risk score (PRS) for anorexia nervosa and sleep disorders in a clinical biobank.

Design, Setting, and Participants

This genetic association study used bidirectional 2-sample mendelian randomization with summary-level genetic associations between anorexia nervosa (from the Psychiatric Genomics Consortium) and chronotype and sleep traits (primarily from the UK Biobank). The inverse-variance weighted method, in addition to other sensitivity approaches, was used. From the clinical Mass General Brigham (MGB) Biobank (n = 47 082), a PRS for anorexia nervosa was calculated for each patient and associations were tested with prevalent sleep disorders derived from electronic health records. Patients were of European ancestry. All analyses were performed between February and August 2023.

Exposures

Genetic instruments for anorexia nervosa, chronotype, daytime napping, daytime sleepiness, insomnia, and sleep duration.

Main Outcomes and Measures

Chronotype, sleep traits, risk of anorexia nervosa, and sleep disorders derived from a clinical biobank.

Results

The anorexia nervosa genome-wide association study included 16 992 cases (87.7%-97.4% female) and 55 525 controls (49.6%-63.4% female). Genetic liability for anorexia nervosa was associated with a more morning chronotype (β = 0.039; 95% CI, 0.006-0.072), and conversely, genetic liability for morning chronotype was associated with increased risk of anorexia nervosa (β = 0.178; 95% CI, 0.042-0.315). Associations were robust in sensitivity and secondary analyses. Genetic liability for insomnia was associated with increased risk of anorexia nervosa (β = 0.369; 95% CI, 0.073-0.666); however, sensitivity analyses indicated bias due to horizontal pleiotropy. The MGB Biobank analysis included 47 082 participants with a mean (SD) age of 60.4 (17.0) years and 25 318 (53.8%) were female. A PRS for anorexia nervosa was associated with organic or persistent insomnia in the MGB Biobank (odds ratio, 1.10; 95% CI, 1.03-1.17). No associations were evident for anorexia nervosa with other sleep traits.

Conclusions and Relevance

The results of this study suggest that in contrast to other metabo-psychiatric diseases, anorexia nervosa is a morningness eating disorder and further corroborate findings implicating insomnia in anorexia nervosa. Future studies in diverse populations and with subtypes of anorexia nervosa are warranted.

Adult attachment style and salivary alpha-amylase and emotional responses to a psychosocial stressor in women with eating disorders

BACKGROUND

The fine-tuning of the endogenous stress response system, which includes the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system (SNS), is influenced by early attachment relationships. A higher prevalence of insecure attachment has been detected in people with eating disorders (EDs). Thus, we investigated the emotional and the SNS reactivity to the Trier Social Stress Test (TSST) in women with EDs in relation to their attachment profiles.

METHODS

Fifty women with EDs and 20 healthy women participated into an experimental study. Attachment was evaluated by Experience in Close Relationship questionnaire. Salivary α-amylase (sAA) levels were measured to assess the SNS reactivity to TSST while the emotional response was measured by the STAI state scale.

RESULTS

Compared to women with EDs and low attachment anxiety and healthy controls, women with EDs and high attachment anxiety showed lower TSST-induced sAA production without difference in anxiety scores. Women with EDs and high attachment avoidance showed similar sAA response to TSST but higher levels of anxiety scores compared to those with low attachment avoidance and healthy controls.

CONCLUSIONS

Our findings corroborate the idea that adult attachment may be associated with variability in emotional and biological responses to a psychosocial stressor in women with EDs.

Deciphering the Association Between Hypothalamus-Pituitary-Adrenal Axis Activity and Obesity: A Meta-Analysis

OBJECTIVE

Both the cortisol awakening response (CAR; corresponding to the state measurement) and hair cortisol concentration (HCC; corresponding to the trait measurement) are considered reliable markers of hypothalamus-pituitary-adrenal axis activity. Because cortisol has long been associated with adiposity, this systematic review and meta-analysis aims to summarize and compare the literature around CAR and HCC and their association with obesity or fat distribution indices.

METHODS

The PubMed, Web of Science (Web of Science Core Collection and Medline), EBSCO Information Services, Embase, and PsycNET databases were searched, and full-text articles investigating the association between CAR or HCC and markers of adiposity in humans were included. Meta-analyses were then performed to compare studies associating CAR or HCC with BMI (a marker of general adiposity) and waist circumference (a marker of fat distribution).

RESULTS

The results of this review highlight inconsistencies in cortisol sampling and CAR computation, which makes comparisons between studies difficult. It was found that adiposity indices are not associated with CAR but that they correlate significantly and positively with HCC. The subgroup analysis hinted to possible age differences in the magnitude of the association between HCC and BMI.

CONCLUSIONS

Trait rather than state measurement of the hypothalamus-pituitary-adrenal axis activity is associated with increased general and abdominal adiposity in humans.

Effects of a light therapy intervention on diurnal salivary cortisol in fatigued cancer survivors: A secondary analysis of a randomized controlled trial

OBJECTIVE

Altered diurnal cortisol rhythms are a potential mechanism through which symptoms of fatigue are maintained in post-treatment cancer survivors. Exposure to early morning bright light may target this underlying dysregulation, resulting in improved diurnal cortisol patterns, subsequently improving symptoms of fatigue. This research investigates the effects of a 4-week light therapy intervention on the diurnal cortisol slopes and output in fatigued cancer survivors.

METHODS

Post-treatment adult cancer survivors who met diagnostic criteria for cancer-related fatigue were randomly assigned to receive either a bright white light (BWL) or dim red light (DRL) device, used daily for 30 min over four consecutive weeks. Assessments of fatigue and salivary cortisol were collected at baseline and post-intervention. Cortisol was sampled four times per day (waking, noon, 5 pm, bedtime) for three days at each timepoint. Diurnal cortisol slopes and total cortisol output were calculated at baseline and post-intervention. Linear mixed models were used to analyze the data.

RESULTS

Seventy-seven participants were included in this analysis (BWL n = 40; DRL n = 37). Participants in both groups displayed increased steepness in cortisol slope (B = -0.02, p = .01, Cohen's d = 0.57) and increased total cortisol output (B = 9.58, p = .03, Cohen's d = 0.49) from baseline to post-intervention, indicating only a moderate effect of time. Neither diurnal cortisol slopes nor total cortisol output mediated the relationship between the light therapy intervention and fatigue levels.

CONCLUSION

Though the results of this trial are promising for light therapy as an effective intervention to reduce fatigue in cancer survivors, this does not appear to be achieved through alterations in neuroendocrine function. ClinicalTrials.gov registration #: NCT01780623.

Cortisol reactivity in patients with anorexia nervosa after stress induction

There is a need of experimental studies on biomarkers in patients with anorexia nervosa (P_AN), especially in the context of stress, in order to foster understanding in illness maintenance. To this end, the cortisol response to an acute stressor was investigated in n = 26 P_AN (BMI: 19.3 ± 3.4 kg/m²), age, and gender matched to n = 26 healthy controls (HC; BMI: 23.08 ± 3.3 kg/m²). For this purpose, salivary cortisol parameters were assessed in two experimental conditions: (1) rest/no intervention and (2) stress intervention (TSST; Trier Social Stress Test). In addition, psychological indicators of stress were assessed (Primary Appraisal Secondary Appraisal, Visual Analogue Scale, and Trier Inventory for the assessment of Chronic Stress), as well as psychological distress, depression, and eating disorder (ED) symptoms. A 2 × 2 × 8 ANOVA demonstrated elevated cortisol levels in P_AN in the resting condition. In the stress intervention no significant group effect in terms of cortisol (F (1, 50) = 0.69; p = 0.410; [Formula: see text]). A significant condition (F (1, 50) = 20.50; p = 0.000; [Formula: see text]) and time effect (F(2.71, 135.44) = 11.27; p = 0.000; [Formula: see text]) were revealed, as well as two significant interaction effects. First: Condition × group (F (1, 50) = 4.17, p = 0.046; [Formula: see text]) and second: Condition × time (F (2.71, 135.44) = 16.07, p = 0.000, [Formula: see text]). In terms of AUC_G, no significant differences between both groups were exhibited. Regardless, significant results were evinced in terms of an increase (AUC_i: F(1, 50) = 20.66, p = 0.015, [Formula: see text]), baseline to peak (+20 min post-TSST: t₅ = 16.51 (9.02), p = 0.029) and reactivity (M_PAN = 0.73 vs. M_HC = 4.25, p = 0.036). In addition, a significant correlation between AUC_G and BMI: r (24) = -0.42, p = 0.027 was demonstrated, but not between AUC_i and BMI (r (24) = -0.26, p = 0.20). Psychological indices suggested higher levels of chronic and perceived stress in P_AN relative to HC. However, stress perception in the stress condition (VAS) was comparable. Additional analyses demonstrated that ED-symptoms are highly correlated with psychological distress and depression, but not with BMI. In addition, it could be demonstrated that reactivity is rather related to ED-symptoms and psychological burden than to BMI. In conclusion, P_AN showed elevated basal cortisol levels at rest and exhibited a blunted cortisol reactivity to the TSST as evinced by salivary cortisol parameters. Further, it was shown that weight recovery influences reversibility of hypercortisolemia, i.e., cortisol levels normalize with weight gain. However, HPAA (hypothalamus-pituitary-adrenal axis) irregularities in terms of reactivity persist even at a BMI ≤ 19.3 (±3.4). Our data suggest that pronounced psychological burden in P_AN, have a greater impact on the HPAA functionality (secondary to the ED) than BMI itself.

Is there a link between stress and immune biomarkers and salivary opiorphin in patients with a restrictive-type of anorexia nervosa?

Objectives: Opiorphin is a salivary peptide with analgesic and antidepressant properties. Its relationship with the hypothalamic-pituitary-adrenal, autonomic nervous and immune systems may provide understanding of chronic stress, especially in anorexia nervosa (AN). This study investigated a possible correlation between opiorphin and stress/immune biomarkers, cortisol, salivary alpha-amylase (sAA) and secretory immunoglobulin A (sIgA), in saliva of patients with restrictive-type AN.Methods: A case-control clinical trial was conducted in 92 AN patients (+75 healthy controls). Unstimulated salivary samples were taken during the acute stage of AN, measurements of cortisol, sAA, sIgA and opiorphin were performed with a quantitative assay (enzyme-linked immunosorbent assay, P < 0.05).Results: AN patients displayed an increase in cortisol (P < 0.001) and sIgA (P < 0.001) but not in sAA (P = 0.279) levels. Distinct correlation between these two parameters and body-weight indexes were observed. Opiorphin levels were neither correlated to stress and immune biomarkers, nor to salivary flow rate.Conclusions: The effect of stress responses can be reliably assessed in saliva in AN patients. The difference between sIgA and cortisol indicate that they can both be used for mental stress assessment in saliva. Modulation of opiorphin by chronic stress was not confirmed. Unchanged sAA indicates a partial adaptation of human organism to severe condition during malnutrition.

Stress hormones and eating disorders

AIMS

The aim of this paper is to emphasize the role of stress processes in the aetiology of eating disorders.

METHODS

We have examined the literature for evidence that people with eating disorders might exhibit markers of stress and show signs of the "maltreated ecophenotype".

RESULTS

Early adversity is more common among people with binge eating behaviours. The secondary effects of malnutrition, which are mostly marked in anorexia nervosa, may be an added stressor that could also contribute to the stress related phenotype. People with eating disorders have anomalies in brain structure, reward and punishment sensitivity, and the balance between HPA and SMA function. These may be potential targets for treatment.

Young Children Display Diurnal Patterns of Salivary IgA and Alpha-Amylase Expression Which Are Independent of Food Intake and Demographic Factors

BACKGROUND

Salivary alpha-amylase (sAA) and salivary immunoglobulin A (sIgA) have been proposed as biomarkers for research on the mucosal immune system and on stress. Expression of both sAA and sIgA has been described to follow opposing diurnal patterns. This knowledge is crucial for the interpretation of studies using these biomarkers.

AIM

It was hypothesized that sAA and sIgA display diurnal patterns in children and that this is independent of food intake or demographic factors.

METHODS

Whole saliva was collected from 78 healthy children (15-39 months old) in the morning and evening for two random nonconsecutive days. The samples have been analysed for sAA and sIgA. The total daily energy, fat, saturated fat, protein, carbohydrate and fibre, mineral, and vitamin consumption were analysed based on the two-day weighed food records collected by the parents.

RESULTS

It was demonstrated that most young children followed the diurnal pattern when sAA increased and sIgA decreased from morning to evening. No correlation was observed between the intake of any of the nutrients and morning or evening values for both salivary proteins. The morning and evening values of sAA and sIgA did not correlate with age, sex, Asian ethnicity, and BMI of the children.

CONCLUSION

Diurnal patterns of sAA and sIgA exist in healthy young children and are not affected by their nutrient intake, sex, Asian ethnicity, and BMI. Scientists including sIgA and sAA in their research must consider the diurnal pattern that these markers exhibit and design the study accordingly.

Association of Brain Reward Learning Response With Harm Avoidance, Weight Gain, and Hypothalamic Effective Connectivity in Adolescent Anorexia Nervosa

IMPORTANCE

Anorexia nervosa (AN) is associated with adolescent onset, severe low body weight, and high mortality as well as high harm avoidance. The brain reward system could have an important role in the perplexing drive for thinness and food avoidance in AN.

OBJECTIVE

To test whether brain reward learning response to taste in adolescent AN is altered and associated with treatment response, striatal-hypothalamic connectivity, and elevated harm avoidance.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional multimodal brain imaging study, adolescents and young adults with AN were matched with healthy controls at a university brain imaging facility and eating disorder treatment program. During a sucrose taste classical conditioning paradigm, violations of learned associations between conditioned visual and unconditioned taste stimuli evoked the dopamine-related prediction error (PE). Dynamic effective connectivity during sweet taste receipt was studied to investigate hierarchical brain activation across the brain network that regulates eating. The study was conducted from July 2012 to May 2017, and data were analyzed from June 2017 to December 2017.

MAIN OUTCOMES AND MEASURES

Prediction error brain reward response across the insula, caudate, and orbitofrontal cortex; dynamic effective connectivity between hypothalamus and ventral striatum; and treatment weight gain, harm avoidance scores, and salivary cortisol levels and their correlations with PE brain response.

RESULTS

Of 56 female participants with AN included in the study, the mean (SD) age was 16.6 (2.5) years, and the mean (SD) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was 15.9 (0.9); of 52 matched female controls, the mean (SD) age was 16.0 (2.8) years, and the mean (SD) BMI was 20.9 (2.1). Prediction error response was elevated in participants with AN in the caudate head, nucleus accumbens, and insula (multivariate analysis of covariance: Wilks λ, 0.707; P = .02; partial η2 = 0.296), which correlated negatively with sucrose taste pleasantness. Bilateral AN orbitofrontal gyrus rectus PE response was positively correlated with harm avoidance (right ρ, 0.317; 95% CI, 0.091 to 0.539; P < .02; left ρ, 0.336; 95% CI, 0.112 to 0.550; P < .01) but negatively correlated with treatment BMI change (right ρ, -0.282; 95% CI, -0.534 to -0.014; P < .04; left ρ, -0.268; 95% CI, -0.509 to -0.018; P < .045). Participants with AN showed effective connectivity from ventral striatum to hypothalamus, and connectivity strength was positively correlated with insula and orbitofrontal PE response. Right frontal cortex PE response was associated with cortisol, which correlated with body dissatisfaction.

CONCLUSIONS AND RELEVANCE

These results further support elevated PE signal in AN and suggest a link between PE and elevated harm avoidance, brain connectivity, and weight gain in AN. Prediction error may have a central role in adolescent AN in driving anxiety and ventral striatal-hypothalamus circuit-controlled food avoidance.

Hyperactivity of the Sympatho-Adrenomedullary System Without Any Modification of the Hypothalamic-Pituitary-Adrenal Axis After Food Restriction Among High-Level Weightlifters

Durguerian, A, Filaire, E, Drogou, C, Sauvet, F, Bougard, C, and Chennaoui, M. Hyperactivity of the sympatho-adrenomedullary system without any modification of the hypothalamic-pituitary-adrenal axis after food restriction among high-level weightlifters. J Strength Cond Res 32(6): 1643-1655, 2018-We examined the effects of 6 days of food restriction on salivary α-amylase (sAA), cortisol and dehydroepiandrostenedione (DHEA) awakening responses, psychological parameters and performance among 11 international weightlifters. Assessments were made at baseline (T1) and 6 days after a normal period of training while maintaining body weight (T2). Then, participants were assigned to 2 groups depending on whether they lost (Diet group) or maintained (Control group) their body mass. Anthropometric, psychological, physical, and physiological assessments were also realized 6 days (T3) after the restricted dietary period for the Diet group. Food restriction (T3) induced a significant rise of sAA awakening response (364.6%, p ≤ 0.05), whereas no significant variations were observed among the hypothalamic-pituitary-adrenal axis (cortisol and DHEA). Significant alterations of the general Recovery Score and General stress Score, evaluated through the Recovery-Stress Questionnaire for athletes, were noted after food restriction. Weightlifting performance, evaluated during a simulated weightlifting competition, was maintained after the 6-day food restriction; we even noted an increased weightlifting performance related to body mass (Sinclair coefficient). Our findings support the hypothesis that food restriction induces a challenging situation to the organism, resulting in an asymmetry between the 2 stress systems activation. These results reinforce the necessity to cautiously plan and monitor the weight regulation process before competition to avoid potential negative outcomes on psychophysiological parameters. In this regard, the psychobiological approach, especially the awakening responses, seems a useful tool.

Food restriction alters salivary cortisol and α-amylase responses to a simulated weightlifting competition without significant performance modification

The aim of this investigation was to evaluate the effect of a 6-day food restriction period on the physiological responses and performance of 11 high-level weightlifters. After a period of weight maintenance (T₂), they were assigned into two groups depending on whether they lost (Diet group, n = 6) or maintained their body weight (Control group, n = 5) during the course of those 6 days. An evaluation of performance and the measurement of salivary cortisol concentrations and salivary α-amylase (sAA) activity were performed during a simulated weightlifting competition which took place at T₂, after a 6-day period of food restriction (T₃). Dietary data were collected using a 6-day diet record. We noted a 41.8% decrease in mean energy intake during the dietary restriction period, leading to a 4.34% weight loss for the Diet group. Dietary restriction did not modify absolute performance levels, whilst a significant improvement was noted for the Control group. Furthermore, we noted a response of decreased salivary cortisol and increased sAA activity to the simulated competition stress at T₃ for the Diet group. These results may indicate that dietary reduction led to a dissociation of the hypothalamo-pituitary-adrenal axis and the sympatho-adreno-medullary system, which could impair training adaptations and absolute performance development.

The physiology of functional hypothalamic amenorrhea associated with energy deficiency in exercising women and in women with anorexia nervosa

An energy deficiency is the result of inadequate energy intake relative to high energy expenditure. Often observed with the development of an energy deficiency is a high drive for thinness, dietary restraint, and weight and shape concerns in association with eating behaviors. At a basic physiologic level, a chronic energy deficiency promotes compensatory mechanisms to conserve fuel for vital physiologic function. Alterations have been documented in resting energy expenditure (REE) and metabolic hormones. Observed metabolic alterations include nutritionally acquired growth hormone resistance and reduced insulin-like growth factor-1 (IGF-1) concentrations; hypercortisolemia; increased ghrelin, peptide YY, and adiponectin; and decreased leptin, triiodothyronine, and kisspeptin. The cumulative effect of the energetic and metabolic alterations is a suppression of the hypothalamic-pituitary-ovarian axis. Gonadotropin releasing hormone secretion is decreased with consequent suppression of luteinizing hormone and follicle stimulating hormone release. Alterations in hypothalamic-pituitary secretion alters the production of estrogen and progesterone resulting in subclinical or clinical menstrual dysfunction.

Salivary and serum insulin-like growth factor (IGF-1) assays in anorexic patients

OBJECTIVES

The purpose of this study was to measure the salivary and serum free IGF-1 concentration of patients with anorexia nervosa (AN) in comparison to an average population.

METHODS

A controlled clinical trial was designed for an age- and gender-matched group of 121 AN patients and 77 healthy individuals. A clinical examination was made and blood and salivary samples were taken during the acute stage of AN (BMI < 15 kg/m²) in the first week of hospitalization. An enzyme immunoassay (ELISA) suitable for measuring free IGF-1 was used.

RESULTS

Anorexic patients had significant reductions in salivary unstimulated flow rate (UFR), pH and free IGF-1 levels in their saliva and serum. Significant correlations between serum IGF-1 and BMI; salivary IGF-1 and UFR and pH were detected.

CONCLUSIONS

Salivary and serum IGF-1 analyses appear to be a reliable biochemical indicator of malnutrition in AN patients. Measurement of salivary IGF-1 levels would allow new perspectives in monitoring AN in its early stages.

Underweight subjects with anorexia nervosa have an enhanced salivary cortisol response not seen in weight restored subjects with anorexia nervosa

The cortisol response to awakening (CAR) has been reported to be enhanced in symptomatic patients with anorexia nervosa (AN). However, it has been not established whether the dysregulation of CAR was a primary phenomenon or a change secondary to malnutrition. Therefore, we aimed to explore the salivary CAR in both underweight and weigh-restored women with AN. Fifty-nine women volunteered for the study. They were 18 underweight AN women, 15 weight-restored AN women and 26 normal-weight healthy women. Saliva samples were collected in the morning, immediately on awakening and after 15, 30 and 60min to measure saliva levels of cortisol. Participants' anxiety levels in the morning of sampling were measured by the State-Trait Anxiety Inventory. As compared to control women, underweight AN patients showed an enhanced CAR whereas weight-restored patients had a normal CAR. These results could be not explained by group differences in body mass index or levels of anxiety. These findings show, for the first time, that the enhanced CAR occurring in the acute phase of AN is not seen in weight-recovered patients, suggesting that the dysregulated activity of the hypothalamus-pituitary-adrenal axis of symptomatic AN patients is a state-dependent phenomenon.

Salivary alpha-amylase, secretory IgA and free cortisol as neurobiological components of the stress response in the acute phase of anorexia nervosa

Objectives One novel hypothesis of the pathogenesis of anorexia nervosa (AN) is the possible role of mental stress in hyperactivity of the autonomic nervous system (ANS) and of the hypothalamic-pituitary-adrenal (HPA) axis. Two components of stress response - salivary alpha-amylase (sAA) and free cortisol - have been proposed. They can be determined in saliva, which closely reflects their concentrations in plasma. The purpose of this study was to measure salivary free cortisol, sAA and their correlation to secretory IgA (sIgA) of patients with AN in comparison to the average population. Methods A controlled clinical trial was designed for a matched group of 47 AN patients and 54 healthy individuals. After clinical examination, unstimulated salivary samples were taken during the acute stage of AN (BMI < 15 kg/m(2)) in the first week of hospitalisation. An enzyme-linked immunosorbent assay (ELISA) suitable for measuring sAA, sIgA and free cortisol were used. Results Anorexic patients exhibited disturbances in sAA secretion, and significantly increased cortisol and sIgA levels with a distinct correlation between these two parameters. Conclusions The behaviour of cortisol, sAA and sIgA levels can be assessed as an effect of stress reaction among AN patients with hyperactivity of the HPA axis and ANS dysregulation. The effect of stress response can be assessed reliably in saliva.

Anorexia nervosa as a motivated behavior: Relevance of anxiety, stress, fear and learning

The high comorbidity between anorexia nervosa (AN) and anxiety disorders is well recognized. AN is a motivated behavioral disorder in which habit formation is likely to contribute to the persistence of abnormal eating and exercise behaviors. Secondary alterations in brain circuitry underlying the reward value of food and exercise, along with disturbances in neuroendocrine hunger and satiety signaling arising from starvation and excessive exercise, are likely contributors to the maintenance of anorectic behaviors in genetically vulnerable individuals. The potential role of fear conditioning in facilitating onset of AN, or of impaired fear extinction in contributing to the high relapse rates observed following weight restoration, is of interest. Evidence from animal models of anxiety and human laboratory studies indicate that low estrogen impairs fear extinction. Low estradiol levels in AN may therefore play a role in perpetuating fear of food and fat in recently weight restored patients. Translational models including the activity based anorexia (ABA) rodent model of AN, and neuroimaging studies of fear extinction and conditioning, could help clarify the underlying molecular mechanisms and neurocircuitry involved in food avoidance behaviors in AN. Moreover, the adaptation of novel treatment interventions with efficacy in anxiety disorders may contribute to the development of new treatments for this impairing disorder.

Childhood trauma and cortisol awakening response in symptomatic patients with anorexia nervosa and bulimia nervosa

OBJECTIVE

Exposure to trauma during childhood is a risk factor for eating disorders (EDs) in adulthood. The biological mechanisms underlying such increased risk seem to involve the endogenous stress response system (i.e., the hypothalamic-pituitary-adrenal [HPA] axis), which undergoes trauma-induced functional changes that may persist later in life. In the present study, we examined the effects of childhood trauma experiences on HPA-axis activity, comparing saliva cortisol awakening response (CAR) in adult patients with anorexia nervosa (AN) or bulimia nervosa (BN) with CAR in adult healthy controls.

METHOD

Twenty-three patients with symptomatic AN, 21 patients with symptomatic BN, and 29 healthy women collected saliva samples at awakening and again after 15, 30, and 60 min. Participants also completed the Childhood Trauma Questionnaire and eating-related psychopathological rating scales.

RESULTS

According to the Childhood Trauma Questionnaire, 13 individuals with AN and 12 individuals with BN, but none of the healthy women, reported childhood maltreatment. Compared with the control group, the non-maltreated AN patient group exhibited an enhanced CAR, whereas the group of non-maltreated BN patients showed a normal CAR. Moreover, both AN and BN patient groups with childhood maltreatment exhibited statistically significant blunting of CAR compared with non-maltreated groups.

DISCUSSION

The present findings add to the evidence supporting the concept that there is a dysregulation of HPA-axis activity in symptomatic patients with EDs and suggest that childhood trauma exposure may contribute to such dysregulation.

Blunted neuroendocrine stress reactivity in young women with eating disorders

OBJECTIVE

Stress is known to influence risk and progression of eating disorders (EDs). However, studies investigating physiological and psychological stress responses under laboratory conditions in patients with Anorexia nervosa or Bulimia nervosa are scarce and often produce conflicting findings. We therefore aimed to compare the neuroendocrine and affective stress response in ED inpatients and healthy controls.

METHODS

Twenty-eight female inpatients with Anorexia or Bulimia nervosa and 26 healthy women were exposed to the Trier Social Stress Test (TSST). Salivary cortisol and alpha-amylase (sAA) levels were assessed before as well as repeatedly after stress exposure, while heart rate and heart rate variability were determined before and during the TSST. Negative affective state was assessed at baseline and post-TSST.

RESULTS

Compared to healthy controls, ED patients showed blunted cortisol stress responses combined with overall attenuated sAA levels. The latter was reflected in generally enhanced parasympathetic activity indicated by lower heart rate and stronger high-frequency heart rate variability throughout the TSST. Although patients reported more negative affect overall, they did not differ in their affective stress response.

CONCLUSIONS

In summary, patients suffering from eating disorders show a blunted HPA axis reactivity to stress exposure and a generally reduced sympathetic/exaggerated parasympathetic nervous system activity. This combination may contribute to elevated health risks seen in eating disorder patients, such as enhanced inflammatory activity, and thus provide insight into the underlying stress-related mechanisms.

Cortisol awakening response in patients with anorexia nervosa or bulimia nervosa: relationships to sensitivity to reward and sensitivity to punishment

BACKGROUND

Sensitivity to punishment (SP) and sensitivity to reward (SR) are personality characteristics that may have relevance for the pathophysiology of eating disorders (EDs). Moreover, personality characteristics are known to modulate the activity of the hypothalamus-pituitary-adrenal (HPA) axis, which is the main component of the endogenous stress response system. As stress has been implicated in the aetiology and the maintenance of EDs, we aimed to study the HPA axis activity in relation to SP and SR, as conceptualized by Gray's reinforcement sensitivity theory (RST), in patients with anorexia nervosa (AN) or bulimia nervosa (BN).

METHOD

Twenty-five women with AN, 23 women with BN and 19 healthy women volunteered for the study. HPA axis activity was assessed by measurement of the salivary cortisol awakening response (CAR). The subjects' SP and SR were measured by the behavioural inhibition system (BIS)/behavioural approach system (BAS) scales.

RESULTS

The CAR was significantly enhanced in AN patients, but not in BN patients, compared to healthy women. The CAR correlated significantly with BAS measures, negatively in healthy controls and positively in binge-purging AN patients and BN women. SP, measured by the BIS scale, was higher in patients than in controls.

CONCLUSIONS

These findings confirm the occurrence of an enhanced activity of the HPA axis in symptomatic AN, but not in symptomatic BN, and show for the first time that the CAR is associated with SR, as conceptualized by the RST, negatively in healthy subjects but positively in binge-purging ED patients.

Evening salivary alpha-amylase, major depressive disorder, and antidepressant use in the Netherlands Study of Depression and Anxiety (NESDA)

Salivary alpha-amylase (sAA) may be a suitable index for sympathetic activity and dysregulation of the autonomic nervous system. The relationship between antidepressants and depression with sAA levels was studied, since antidepressants were previously shown to have a profound impact on heart rate variability as an ANS indicator. Data are from 1692 participants of the Netherlands Study of Depression and Anxiety (NESDA) who were recruited from the community, general practice, and specialized mental health care. Differences in evening sAA levels were examined between patient groups (i.e., 752 current major depressive disorder [MDD], 611 remitted MDD, and 329 healthy controls) and between 46 tricyclic antidepressant (TCA) users, 307 selective serotonin reuptake inhibitor (SSRI) users, 97 users of another antidepressant, and 1242 non-users. Each participant sampled twice at 22.00h and 23.00h. In multivariable analysis, there was a trend over the three groups with increasing sAA levels from controls to remitted MDD to current MDD that approached significance. Furthermore, in comparison to non-users of antidepressants, TCA rather than SSRI users showed higher sAA levels, that persisted after multivariable adjustment. The present study shows that higher evening sAA levels in depressed patients, indicative of an increased sympathetic activity, may be induced by TCAs.

Is salivary alpha-amylase an indicator of autonomic nervous system dysregulations in mental disorders?--a review of preliminary findings and the interactions with cortisol

During recent years, a growing interest emerged in using salivary alpha-amylase (sAA) as a non-invasive, surrogate marker for sympathetic activity. Numerous studies applying stress protocols have demonstrated that sAA is highly sensitive to stress-related changes (in healthy subjects). Additionally, it was suggested that sAA might moreover serve as an index for pathological dysregulation of the autonomic nervous system (ANS) in patients showing psychopathology. Since then, a small but growing literature investigated sAA in patients with mental disorders. This review aims to give an overview of preliminary findings in this field of research. The results of n=15 studies are described in detail and implications for further research are discussed. Although the number of studies and the samples examined were rather small, changes in sAA, reflecting adrenergic dysregulation, could be demonstrated in psychopathology, especially in anxiety-related disorders. This field of research is still in its early stages. However, the studies included in this review revealed first evidence that the employment of sAA, as an indicator of ANS dysregulation in mental disorders, is promising.

Diurnal patterns of salivary cortisol and DHEA in adolescent anorexia nervosa

Although there is well-documented evidence for hyperactivity of hypothalamic-pituitary-adrenal (HPA) axis function in anorexia nervosa (AN), there has been little research into secretory patterns of salivary cortisol and dehydroepiandrosterone (DHEA) in this condition. The cortisol awakening response (CAR), a prominent and discrete feature of the cortisol cycle, has not been extensively explored in adolescent AN. Saliva samples were collected at awakening, 30 min and 12 h post-awakening on two consecutive weekdays from eight female adolescents with clinically diagnosed AN and 41 healthy control (HC) age-matched females. Adolescent AN patients had greater salivary cortisol and DHEA concentrations than HC girls at all points. Increased hormone secretion was unrelated to body mass index. However, despite hypersecretion of both hormones, the circadian pattern including the CAR paralleled that of the HC group. Findings from this preliminary study confirm dysregulation of HPA axis function in adolescent AN as evidenced by hypersecretion of both cortisol and DHEA, which share the common secretagogue adrenocorticotropic hormone. However, the parallel diurnal profiles for AN and HC participants, including the CAR, may indicate hypersecretion per se rather than differential regulation of the diurnal pattern of these two adrenal steroids in AN.

The role of ghrelin, salivary secretions, and dental care in eating disorders

Eating disorders, including anorexia and bulimia nervosa, are potentially life-threatening syndromes characterized by severe disturbances in eating behavior. An effective treatment strategy for these conditions remains to be established, as patients with eating disorders tend to suffer from multiple relapses. Because ghrelin was originally discovered in the stomach mucosa, it has been widely studied over the past decade in an effort to uncover its potential roles; these studies have shed light on the mechanism by which ghrelin regulates food intake. Thus, studying ghrelin in the context of eating disorders could improve our understanding of the pathogenesis of eating disorders, possibly resulting in a promising new pharmacological treatment strategy for these patients. In addition, early detection and treatment of eating disorders are critical for ensuring recovery of young patients. Oral symptoms, including mucosal, dental, and saliva abnormalities, are typically observed in the early stages of eating disorders. Although oral care is not directly related to the treatment of eating disorders, knowledge of the oral manifestations of eating disorder patients may aid in early detection, resulting in earlier treatment; thus, oral care might contribute to overall patient management and prognosis. Moreover, ghrelin has also been found in saliva, which may be responsible for oral hygiene and digestion-related functions. This review discusses the pharmacological potential of ghrelin in regulating food-intake and the role of saliva and oral care in young patients with eating disorders.

Reward processing in anorexia nervosa

Individuals with anorexia nervosa (AN) demonstrate a relentless engagement in behaviors aimed to reduce their weight, which leads to severe underweight status, and occasionally death. Neurobiological abnormalities, as a consequence of starvation are controversial: evidence, however, demonstrates abnormalities in the reward system of patients, and recovered individuals. Despite this, a unifying explanation for reward abnormalities observed in AN and their relevance to symptoms of the illness, remains incompletely understood. Theories explaining reward dysfunction have conventionally focused on anhedonia, describing that patients have an impaired ability to experience reward or pleasure. We review taste reward literature and propose that patients' reduced responses to conventional taste-reward tasks may reflect a fear of weight gain associated with the caloric nature of the tasks, rather than an impaired ability to experience reward. Consistent with this, we propose that patients are capable of 'liking' hedonic taste stimuli (e.g., identifying them), however, they do not 'want' or feel motivated for the stimuli in the same way that healthy controls report. Recent brain imaging data on more complex reward processing tasks provide insights into fronto-striatal neural circuit dysfunction related to altered reward processing in AN that challenges the relevance of anhedonia in explaining reward dysfunction in AN. In this way, altered activity of the anterior cingulate cortex and striatum could explain patients' pathological engagement in behaviors they consider rewarding (e.g., self-starvation) that are otherwise aversive or punishing, to those without the eating disorder. Such evidence for altered patterns of brain activity associated with reward processing tasks in patients and recovered individuals may provide important information about mechanisms underlying symptoms of AN, their future investigation, and the development of treatment approaches.

Recovery from Adolescent Anorexia Nervosa and Associations with Diurnal Patterns of Salivary Stress Hormones: A Case Report

In the neurodevelopment of adolescent anorexia nervosa (AN), dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is proposed to be a central component. Furthermore, a therapeutic milieu focusing on affect regulation can contribute much to treatment, given the emotional processing difficulties associated with this disorder. Studies of HPA axis function following such specialist treatments for adolescent AN, however, are rare. This study describes the diurnal pattern of HPA axis activation, including the cortisol awakening response (CAR), in a 16-year-old female diagnosed with AN both during illness and at clinical recovery following milieu therapy with a focus on affect regulation. Specialised single-case study statistics were used to assess whether the patient's data were significantly different from the healthy “norm” at illness and recovery. During illness, her measure of affective problems was outside of the normal range and cortisol and DHEA secretory profiles were significantly elevated across the diurnal period. However, at recovery both her affective state and HPA axis function became comparable to healthy controls. This case study suggests that salivary markers of HPA axis function can be feasibly incorporated into the clinical regime within a specialist adolescent AN residential service and could be used by clinicians to monitor prognosis and interventions.