The structure of motivation: Assessing readiness to change dimensions and their predictive value with the network validation of the Italian version of the Anorexia Nervosa Stages of Change Questionnarie.

OBJECTIVE: Motivation to change is an important predictor for treatment outcomes in individuals with anorexia nervosa (AN), however, the existence and clinical relevance of distinct motivational dimensions are understudied. This study aimed to structurally validate the AN Stage of Change Questionnaire (ANSOCQ) in the Italian adult AN population to identify separate motivational dimensions and their association with clinical variables and outcomes. METHOD: Inpatients and outpatients with AN (N = 300) completed the ANSOCQ and measures assessing eating and depressive psychopathology. Unique Variable Analysis and Exploratory Graph Analysis were employed to identify dimensions in the network structure of ANSOCQ. Cross-sectional associations with clinical variables were assessed in the whole sample. Predictive value on weight and psychopathology was assessed in inpatients. RESULTS: Two dimensions were identified, one comprising items relative to weight gain, and the second items regarding attitudes towards eating, body, and emotional problems. Feelings associated with eating resulted as most central in the network. Higher scores in the first dimension and ANSOCQ total predicted weight gain during hospitalisation. No significant predictors emerged for changes in eating psychopathology. DISCUSSION: These findings confirm the robust psychometric properties of ANSOCQ and provide support for the use of its subdimensions in clinical practice.

A quantitative study on peripersonal space in anorexia nervosa and healthy subjects: Role of social variables and association with psychopathology.

Objectives: This study investigates peripersonal space (PPS) modulation in patients with anorexia nervosa (AN) versus healthy controls (HCs) and explores associations between PPS, eating-related, and general psychopathology. Method: Forty-six patients and 42 HCs completed a computer-based task observing videos of an approaching actor (male or female) displaying different facial expressions along with a non-social condition. Then, participants completed self-report questionnaires assessing eating-related and general psychopathology. Results: Mixed-models revealed that both groups adjusted PPS based on task conditions, with a gender effect favoring closer proximity to female actor. HCs reduced PPS amplitude progressively during the task, while patients did not show this effect. In patients, wider PPS correlated with lower self-esteem and facial expression identification accuracy, while in HCs, PPS was associated to body dissatisfaction and anxiety symptoms. Conclusion: These findings enhance understanding of bodily self-consciousness, suggesting PPS consideration in therapeutic interactions with patients with AN and as a potential target in treatments addressing social impairment.

Nasogastric Tube Feeding in Anorexia Nervosa: A Propensity Score-Matched Analysis on Clinical Efficacy and Treatment Satisfaction.

The choice of a refeeding strategy is essential in the inpatient treatment of Anorexia Nervosa (AN). Oral nutrition is usually the first choice, but enteral nutrition through the use of a Nasogastric Tube (NGT) often becomes necessary in hospitalized patients. The literature provides mixed results on the efficacy of this method in weight gain, and there is a scarcity of studies researching its psychological correlates. This study aims to analyze the effectiveness of oral versus enteral refeeding strategies in inpatients with AN, focusing on Body Mass Index (BMI) increase and treatment satisfaction, alongside assessing personality traits. We analyzed data from 241 inpatients, comparing a group of treated vs. non-treated individuals, balancing confounding factors using propensity score matching, and applied regression analysis to matched groups. The findings indicate that enteral therapy significantly enhances BMI without impacting treatment satisfaction, accounting for the therapeutic alliance. Personality traits showed no significant differences between patients undergoing oral or enteral refeeding. The study highlights the clinical efficacy of enteral feeding in weight gain, supporting its use in severe AN cases when oral refeeding is inadequate without adversely affecting patient satisfaction or being influenced by personality traits.

Role of parental educational level as psychosocial factor in a sample of inpatients with anorexia nervosa and bulimia nervosa.

Introduction: Evidence on parental educational level (PEL) as a risk factor for Eating Disorders (EDs) is mixed, and no study has assessed its role in relation to the compliance and outcomes of treatments in EDs. Further, no study differentiated from the educational level of mothers and fathers, nor considered the possible mediation of perfectionism in fostering EDs. Methods: A clinical sample of 242 first-ever admitted inpatients with EDs provided information on PEL and completed the following questionnaires: the Eating Disorder Examination Questionnaire (EDE-Q) and the Frost Multidimensional Perfectionism Scale (F-MPS). Clinicians also provided information on the Hamilton Rating Scale for Anxiety (HAM-A) and the Hamilton Rating Scale for Depression (HAM-D) for each participant. Results: Individuals with high PEL (whether mothers, fathers, or both parents) showed significantly higher scores on depressive symptoms and lower on parental criticism, were younger, had an earlier age of onset, had fewer years of illness, more were students and employed, and fewer had offspring. Individuals with fathers or both parents with high educational levels suffered more from Anorexia Nervosa rather than Bulimia Nervosa, had a longer length of stay during the current hospitalization, had less dietary restraint, and had higher personal standards. Individuals with mothers with high educational levels showed a lower rate of previous substance or alcohol addiction. Personal standards partially mediated the relationship between higher PEL and lower dietary restraint. Discussion: PEL emerged to be a twofold psychosocial risk factor, being associated with higher depressive symptoms and a longer length of stay, but also with a shorter duration of illness and better scholar and working involvement. Higher PEL was related to higher personal standards but not to global perfectionism. Patterns of eating psychopathology emerged based on the high PEL of mothers or fathers.

Inpatient treatments for adults with anorexia nervosa: a systematic review of literature.

PURPOSE: Anorexia nervosa (AN) is a mental disorder for which hospitalization is frequently needed in case of severe medical and psychiatric consequences. We aim to describe the state-of-the-art inpatient treatment of AN in real-world reports. METHODS: A systematic review of the literature on the major medical databases, spanning from January 2011 to October 2023, was performed, using the keywords: "inpatient", "hospitalization" and "anorexia nervosa". Studies on pediatric populations and inpatients in residential facilities were excluded. RESULTS: Twenty-seven studies (3501 subjects) were included, and nine themes related to the primary challenges faced in hospitalization settings were selected. About 81.48% of the studies detailed the clinical team, 51.85% cited the use of a psychotherapeutic model, 25.93% addressed motivation, 100% specified the treatment setting, 66.67% detailed nutrition and refeeding, 22.22% cited pharmacological therapy, 40.74% described admission or discharge criteria and 14.81% follow-up, and 51.85% used tests for assessment of the AN or psychopathology. Despite the factors defined by international guidelines, the data were not homogeneous and not adequately defined on admission/discharge criteria, pharmacological therapy, and motivation, while more comprehensive details were available for treatment settings, refeeding protocols, and psychometric assessments. CONCLUSION: Though the heterogeneity among the included studies was considered, the existence of sparse criteria, objectives, and treatment modalities emerged, outlining a sometimes ambiguous report of hospitalization practices. Future studies must aim for a more comprehensive description of treatment approaches. This will enable uniform depictions of inpatient treatment, facilitating comparisons across different studies and establishing guidelines more grounded in scientific evidence. LEVEL OF EVIDENCE: Level I, systematic review.

Cognitive Impulsivity in Anorexia Nervosa in Correlation with Eating and Obsessive Symptoms: A Comparison with Healthy Controls.

Impulsivity in eating disorders (ED) has been historically focused on bingeing-purging symptoms, evidencing lower levels in restricting subtypes. In the recent literature, obsessive-compulsive disorder (OCD) has been described as characterized by high cognitive impulsivity. This specific impulsivity factor has been rarely studied in anorexia nervosa (AN). In this study, 53 inpatients with anorexia nervosa and 59 healthy controls completed the following questionnaires: the Barratt Impulsiveness Scale (BIS-11), the Obsessive-Compulsive Inventory (OCI), the Eating Disorders Inventory-2 (EDI-2), the State-Trait Anxiety Inventory (STAI), and the Beck Depression Inventory (BDI). AN individuals showed significantly increased levels of cognitive instability but no difference in global score and other subscales of impulsivity compared to the healthy controls. Among AN individuals, cognitive instability emerged as being associated with the global score and obsession subscale of the OCI. It was also significantly associated with interoceptive awareness and impulse regulation. Cognitive instability was the main predictor of obsessive thoughts and behaviors in AN. Our study supports the hypothesis of AN as being characterized by high cognitive instability and adds the result that the cognitive domain of impulsivity may be associated with the presence of obsessive symptoms, specifically obsessive thoughts.

The Nepean Belief Scale (NBS) as a tool to investigate the intensity of beliefs in anorexia nervosa: psychometric properties of the Italian version.

BACKGROUND: People with anorexia nervosa (AN) show a peculiar impairment of insight regarding their condition, often manifesting a denial of extreme emaciation and sometimes hiding or underreporting socially undesirable abnormal eating patterns. Sometimes the intensity of the beliefs held by patients with AN reach a delusional intensity. OBJECTIVES: In this study, the Italian version of the Nepean Belief Scale was applied to a sample of patients diagnosed with AN to investigate the intensity of their beliefs and convictions and its clinical correlates. METHODS: The Nepean Belief Scale (NBS) was translated and adapted to Italian and applied to a sample of patients diagnosed with AN based on the Structured Clinical Interview for DSM-5 (SCID-5). RESULTS: The Italian version of the 5-item NBS showed excellent reliability. Convergent validity was proved by negative association with levels of insight measured with the Schedule for the Assessment of Insight in Eating Disorders. Beliefs of delusional intensity were reported by 10% of participants. Those with a greater intensity of beliefs, either overvalued or delusional ideas, were more likely to report poorer general cognitive performances on the Montreal Cognitive Assessment. No association was observed between NBS score and age, body mass index, symptoms of eating disorders, body dissatisfaction, or levels of depression. Fear of weight gain and control seeking were the most often reported themes at the NBS. CONCLUSIONS: The Italian version of the NBS is a reasonably reliable, valid, and usable tool for the multidimensional assessment of insight in AN. Level of evidence Level III, Evidence obtained from well-designed cohort or case-control analytic studies.

Exploring Caloric Restriction in Inpatients with Eating Disorders: Cross-Sectional and Longitudinal Associations with Body Dissatisfaction, Body Avoidance, Clinical Factors, and Psychopathology.

Reduction in food intake is an important feature of eating disorders (EDs). However, whereas self-reported cognitive control over food (i.e., dietary restraint) is commonly assessed, we are not aware of any study evaluating the actual reduction in caloric intake (i.e., caloric restriction, CR) and its relationships with psychopathological, clinical, and anamnestic factors in individuals with EDs. In this study, we quantified caloric intake, CR, and weight suppression in 225 ED inpatients and explored significant relationships with self-reported eating symptoms, body dissatisfaction, body avoidance, personality, and affective symptoms. For underweight inpatients (n = 192), baseline predictors of caloric intake and restriction at discharge were assessed through a data-driven approach. CR at admission was significantly related to eating symptomatology, state anxiety, and body image. In regression models, CR, higher BMI, binge-purging symptoms, and the interaction between weight suppression and CR were significantly related to body dissatisfaction. The best psychopathological predictors of caloric intake and restriction at discharge for underweight inpatients were perfectionistic concern over mistakes and state anxiety. These results suggest that caloric restriction is associated to relevant ED features and warrant for a multidimensional assessment of ED psychopathology.

Diagnostic Concordance between Research and Clinical-Based Assessments of Psychiatric Comorbidity in Anorexia Nervosa.

The literature has reported poor concordance in the assessment of psychiatric conditions, and inhomogeneity in the prevalence of psychiatric comorbidities in Anorexia Nervosa (AN). We aimed to investigate concordance level between clinicians' and researchers' diagnoses of psychiatric comorbidity in AN and differences in eating and general psychopathology between patients with and without psychiatric comorbidity assessed by clinicians versus researchers. A clinical psychiatrist interviewed 122 patients with AN; then a researcher administered the Structured and Clinical Interview for DSM-5 (SCID-5). Participants completed the Eating Disorder Examination Questionnaire (EDE-Q), the State-Trait Anxiety Inventory (STAI), and the Beck Depression Inventory (BDI). The agreement between clinicians and researchers was poor for all diagnoses but obsessive-compulsive disorder and substance use disorder. Patients with comorbid disorders diagnosed by researchers reported more severe eating and general psychopathology than those without SCID-comorbidity. The differences between patients with and without comorbidities assessed by a clinician were smaller. Two approaches to psychiatry comorbidity assessment emerged: SCID-5 diagnoses yield a precise and rigorous assessment, while clinicians tend to consider some symptoms as secondary to the eating disorder rather than as part of another psychiatric condition, seeing the clinical picture as a whole. Overall, the study highlights the importance of carefully assessing comorbidity in AN.

Psychometric properties of the Italian body shape questionnaire: an investigation of its reliability, factorial, concurrent, and criterion validity.

PURPOSE: This study was set up to investigate the reliability, factorial, concurrent, and criterion validity of the Italian version of the 34-item Body Shape Questionnaire (BSQ) and its shorter versions. METHODS: The study included 231 patients diagnosed with an eating disorder and 58 putatively healthy people (comparison sample). The Italian BSQ-34 was administered to participants together with the Hamilton Depression Rating Scale and the Hamilton Anxiety Rating Scale. Information on body mass index, caloric intake at baseline, and the number of episodes of self-vomiting per week was also acquired. RESULTS: Cronbach's alpha of BSQ-34 was 0.971 (95% confidence interval [CI] 0.965-0.976) in patients and 0.960 (0.944-0.974) in controls. Test-retest stability in patients (n = 69), measured with intraclass correlation coefficient, was 0.987 (0.983-0.991). Confirmatory factor analysis of the single-factor model yielded acceptable fit for all versions of the BSQ. On all BSQ versions, patients scored higher than controls with a large effect size when calculated as Cliff's delta. BMI and mean caloric intake at baseline had a stronger association with BSQ-34 than levels of anxiety and depression. The analysis with the receiver operating characteristics (ROC) curve showed that the BSQ-34 distinguished patients with an eating disorder from controls with good accuracy (Area Under the Curve = 86.5; 95% CI 82.2-90.7). CONCLUSION: The Italian version of the BSQ possesses good psychometric properties, in both the long and the shortened versions, and it can be applied to measure body dissatisfaction for both clinical and research purposes. LEVEL OF EVIDENCE: Level III, Evidence obtained from well-designed cohort or case-control analytic studies.

Body Mass Index Specifiers in Anorexia Nervosa: Anything below the "Extreme"?

The validity of body mass index (BMI) specifiers for anorexia nervosa (AN) has been questioned, but their applicability to inpatients with extremely low BMIs and their prognostic validity are currently unknown. Therefore, we designed this study: (a) to test current BMI specifiers in severe inpatients; (b) to explore a "very extreme" specifier (VE-AN; BMI ≤ 13.5); and (c) to verify inpatients' hospitalization outcome according to BMI severity. We enrolled 168 inpatients with AN completing the following: Eating disorder Examination-Questionnaire, Eating Disorder Inventory-2, State-Trait Anxiety Inventory, Beck Depression Inventory, Body Shape Questionnaire, and EQ-5D-VAS. According to the current BMI classification, those with a BMI < 15 versus those with non-extreme AN (NE-AN, BMI ≥ 15) differed on all measures but the quality of life with those with NE-AN reporting more impaired scores on all measures. Adopting an exploratory classification comparing VE-AN, extreme AN (E-AN, BMI = 13.6-14.99), and NE-AN, no differences emerged between VE-AN and E-AN, while those with NE-AN reported significantly more impaired scores on all variables while the quality of life again did not differ across groups. Hospitalization outcome improved for all groups, independently of BMI. Groups differed concerning the length of stay that mirrored BMI severity and impacted also hospitalization outcomes. Taken together, our data support the lack of validity of current BMI specifiers in AN, even in the acute setting. Moreover, the exploratory subgroup of patients with BMI ≤ 13.5 did not delineate a clinically different group.