Pre-operative micronutrient deficiencies in patients with severe obesity candidates for bariatric surgery.

PURPOSE: In patients with obesity, micronutrient deficiencies have been reported both before and after bariatric surgery (BS). Obesity is a chronic pro-inflammatory status, and inflammation increases the risk of micronutrient malnutrition. Our objective was to assess in pre-BS patients the prevalence of micronutrient deficiencies and their correlation with blood values of C-reactive protein (CRP). METHODS: Anthropometric data, instrumental examinations, and blood variables were centrally measured in the first 200 patients undergoing a pre-BS evaluation at the "Città della Salute e della Scienza" Hospital of Torino, starting from January 2018. RESULTS: At least one micronutrient deficiency was present in 85.5% of pre-BS patients. Vitamin D deficiency was the most prevalent (74.5%), followed by folate (33.5%), iron (32%), calcium (13%), vitamin B12 (10%), and albumin (5.5%) deficiency. CRP values were high (> 5 mg/L) in 65% of the patients. These individuals showed increased rate of iron, folate, vitamin B12 deficiency, and a higher number of micronutrient deficiencies. In a multiple logistic regression model, increased CRP levels were significantly associated with deficiencies of vitamin B12 (OR = 5.84; 95% CI 1.25-27.2; p = 0.024), folate (OR = 4.02; 1.87-8.66; p < 0.001), and with the presence of ≥ 2 micronutrient deficiencies (OR = 2.31; 1.21-4.42; p = 0.01). CONCLUSIONS: Micronutrient deficiencies are common in patients with severe obesity undergoing BS, especially when inflammation is present. In the presence of increased CRP values before surgery, it might be advisable to search for possible multiple micronutrient deficiencies.

Identifying neuroanatomical signatures of anorexia nervosa: a multivariate machine learning approach.

BACKGROUND: There are currently no neuroanatomical biomarkers of anorexia nervosa (AN) available to make clinical inferences at an individual subject level. We present results of a multivariate machine learning (ML) approach utilizing structural neuroanatomical scan data to differentiate AN patients from matched healthy controls at an individual subject level. METHOD: Structural neuroimaging scans were acquired from 15 female patients with AN (age = 20, s.d. = 4 years) and 15 demographically matched female controls (age = 22, s.d. = 3 years). Neuroanatomical volumes were extracted using the FreeSurfer software and input into the Least Absolute Shrinkage and Selection Operator (LASSO) multivariate ML algorithm. LASSO was 'trained' to identify 'novel' individual subjects as either AN patients or healthy controls. Furthermore, the model estimated the probability that an individual subject belonged to the AN group based on an individual scan. RESULTS: The model correctly predicted 25 out of 30 subjects, translating into 83.3% accuracy (sensitivity 86.7%, specificity 80.0%) (p < 0.001; χ 2 test). Six neuroanatomical regions (cerebellum white matter, choroid plexus, putamen, accumbens, the diencephalon and the third ventricle) were found to be relevant in distinguishing individual AN patients from healthy controls. The predicted probabilities showed a linear relationship with drive for thinness clinical scores (r = 0.52, p < 0.005) and with body mass index (BMI) (r = -0.45, p = 0.01). CONCLUSIONS: The model achieved a good predictive accuracy and drive for thinness showed a strong neuroanatomical signature. These results indicate that neuroimaging scans coupled with ML techniques have the potential to provide information at an individual subject level that might be relevant to clinical outcomes.

Longitudinal trajectories of psychosocial functioning in patients with pre-existing mental disorders after one year of COVID-19 pandemic.

Aims of the present study were to prospectively assess psychosocial functioning trajectories during the COVID pandemic and the possible impact of sociodemographic variables, as well as of COVID-19 pandemic-related factors, on these trajectories, in a sample of patients with pre-existing severe mental disorders. Moreover, we aimed at identifying predictors of impairment in psychosocial functioning over a period of 9 months of COVID-19 pandemic. Patients were recruited during the 3rd wave of the COVID-19 pandemic (T0, March-April 2021) while strict containment measures were applied in Italy, and reassessed after 3 months (T1, June-July 2021), and after 6 months from T1 (T2- November-December 2021), during the 4th wave of COVID pandemic. A sample of 300 subject (out of the 527 subjects recruited at baseline) completed the T2 evaluation. Patients were assessed by: Work and Social Adjustment Scale (WSAS) for psychosocial functioning, Generalized Anxiety Disorder 7-Item (GAD-7) for anxiety symptoms, Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms and the Impact of Events Scale-Revised, for post-traumatic symptoms. Cluster analyses identified 4 trajectories of functioning: the High, Stable Functioning group (N = 77), the Improvement Functioning group (N = 62), the Progressive Impairment group (N = 83) and the Persistent Severe Impairment group (N = 78) respectively. We found that predictors of higher WSAS score at T2 were higher WSAS score at T0 (B = 0.43, p < .001), PHQ scores at baseline >10 (B = 2.89, p < .05), while not living alone was found to be a protective factor (B = -2.5, p < .05). Results of the present study provides insights into the vulnerability of individuals with psychiatric disorders during times of crisis. Study findings can contribute to a better understanding of the specific needs of this population and inform interventions and support strategies.

Intrinsic connectivity networks within cerebellum and beyond in eating disorders.

Cerebellum seems to have a role both in feeding behavior and emotion regulation; therefore, it is a region that warrants further neuroimaging studies in eating disorders, severe conditions that determine a significant impairment in the physical and psychological domain. The aim of this study was to examine the cerebellum intrinsic connectivity during functional magnetic resonance imaging resting state in anorexia nervosa (AN), bulimia nervosa (BN), and healthy controls (CN). Resting state brain activity was decomposed into intrinsic connectivity networks (ICNs) using group spatial independent component analysis on the resting blood oxygenation level dependent time courses of 12 AN, 12 BN, and 10 CN. We extracted the cerebellar ICN and compared it between groups. Intrinsic connectivity within the cerebellar network showed some common alterations in eating disordered compared to healthy subjects (e.g., a greater connectivity with insulae, vermis, and paravermis and a lesser connectivity with parietal lobe); AN and BN patients were characterized by some peculiar alterations in connectivity patterns (e.g., greater connectivity with the insulae in AN compared to BN, greater connectivity with anterior cingulate cortex in BN compared to AN). Our data are consistent with the presence of different alterations in the cerebellar network in AN and BN patients that could be related to psychopathologic dimensions of eating disorders.

Amenorrhea in eating disorders: poor stability of symptom after a one-year treatment.

OBJECTIVE: To examine whether patients with Eating Disorders (ED) who restore menses differ from those who remain amenorrheic after treatment and to provide longitudinal data about this debated criterion of Anorexia Nervosa (AN). METHODS: 184 outpatients were recruited: 50 patients with AN Restrictive type, 75 amenorrheic Eating Disorder Not Otherwise Specified (EDNOS) patients, 24 patients who recovered from AN with persistent amenorrhea, and 35 amenorrheic patients without ED. All participants were clinically assessed by psychiatrists and gynaecologists at the beginning of treatment and at the one-year follow-up. They also completed several psychometric tests: Eating Disorder Inventory-2, Temperament and Character Inventory, and Beck Depression Inventory. RESULTS: After treatment, a large portion of the sample resumed menses but very few recovered completely from the ED. No psychopathological variables could clearly predict the recovery of menses in the different groups. However, Body Mass Index and some biological variables were associated with restoration of menses in ED patients. CONCLUSION: Resumption of menses was not associated with a less severe eating symptomatology at the beginning of treatment nor with unequivocal psychopathological changes after treatment. It is important that clinicians consider not only the presence or absence of regular menses but also that they improve both ED screening and assessment in amenorrheic patients. Amenorrhea does not seem to represent a specific predictor of severity of illness or to show prognostic value.

Day hospital programmes for eating disorders: a review of the similarities, differences and goals.

Day hospital (DH) treatments for eating disorders (EDs) provide intensive daily care and allow patients to maintain and test their social relations and coping skills at home and outside. Although widespread, their description is lacking. This review compares the different types of DH described in the literature and presents our DH experience in Turin, Italy. We searched Psychinfo and Pubmed with the following keywords: anorexia nervosa, bulimia nervosa, EDs, DH, day treatment and partial hospitalisation. We found and reviewed the DH programmes of eleven specialised centres, which have some shared features but also many differences, suggesting that DH treatments are still largely experimental. Briefly, the shared elements are: biopsychosocial model as reference frame; cognitive-behavioural model or techniques; behavioural contract; patients' selection; body image therapy; involvement of family; weight normalisation/weight gain and modification/normalisation of eating behaviour as objectives. Nonetheless, shared opinions concerning inclusion criteria are lacking; the duration of DH treatment is surprisingly different among centres (from 3 to 39 weeks); the approach to eating and compensation behaviours ranges from control to autonomy; followup and psychometric assessment can be either performed or not; psychological and behavioural objectives can be different. This review suggests the existence of two different DH models: the first has a shorter duration and is mainly symptom-focused; the second is more individual-focused, has a longer duration and is focused on patients' relational skills, psychodynamic understanding of symptoms and more gradual changes in body weight. Further investigation is required to make DH treatment programmes measurable and comparable.

Personality and psychopathology correlates of dropout in an outpatient psychiatric service.

AIM: The dropout from care in public psychiatric units is a frequent event and strategies to reduce its incidence are still debated. This study aims to determine which personality and psychopathology dimensions influence the dropout in a psychiatric unit. METHODS: All new patients referred to a public psychiatric outpatient service were tested with self-administered inventories assessing personality traits (TCI), parental bonding (PBI), and psychopathology (SCL-90; BDI; STAXI). Completers were divided into nondropout, late dropout, and early dropout groups which were compared with each other with respect to diagnosis, referral, demographic data and the inventories. Logistic regression was performed between dropout and non dropout subjects with respect to the significantly differing variables. RESULTS: No clinical or demographic characteristic predict dropout. Numerous SCL-90 psychopathology scales, state anger and some TCI personality facets distinguish dropout from in care subjects. Psychoticism and sentimentalism have been evidenced independent predictors of dropout. CONCLUSION: In the present study dropout from the psychiatric unit is more related to personal characteristics than to sociodemographic variables or diagnosis. Dropout is related to personality and psychopathology characteristics which may reduce subject's relational skills and impair therapeutic alliance. These traits may also influence subjects' perception of the service quality and of the assessment procedure. The acknowledgement of such traits as possible determinants of dropout may orient service organization and personnel education to prevent this phenomenon in health care services. Strategies for preventing dropout are discussed.

Naturalistic follow-up of subjects affected with anorexia nervosa 8 years after multimodal treatment: Personality and psychopathology changes and predictors of outcome.

BACKGROUND: Eating disorders (EDs) are serious mental illnesses of growing clinical and social impact. Despite their severity, there is still no satisfactory evidence-based treatment. Follow-up investigations are the most reliable studies to enlighten long-term outcome predictors and modifiers. METHODS: In total, 59 subjects affected with anorexia nervosa were assessed 8 years after their admission into an outpatient multimodal treatment program for eating disorders. The follow-up changes in diagnostic criteria were compared with Chi-square test. Improved and not-improved subjects were compared. Clinical, personality and psychopathology features between T0 and T1 were compared with t-test for repeated measures. Correlation between T0 features and changes at T1 in personality and psychopathology features were assessed. RESULTS: The rate of complete remission was 42%, an overall rate of 67.8% improved, a rate of 18.6% worsened. Concerning personality, a significant decrease of harm avoidance and increase in self-directedness were evidenced. Interoceptive awareness, drive for thinness, bulimia were significantly reduced at follow-up. Many T0 personality facets were related to personality and psychopathology improvement at follow-up. CONCLUSION: Multimodal treatment encompassing psychiatric, nutritional and psychological approaches is at the moment the most reliable approach for the treatment of moderate to severe anorexia nervosa with a discrete rate of improvement. Some personality and psychopathology characteristics may represent specific factors which favor resistance and impair improvement. Future approaches should consider the personalization of therapeutic approach according to these features.

Eating disorders and the Internet: cure and curse.

OBJECTIVE: The role of culture and the mass-media in relation to eating disorders (EDs) is widely acknowledged, and the Internet has become an important part of this over the last few years. The aim of this report is to suggest the general features and potential clinical implications of "pro-Ana" websites and those concerning the treatment of EDs. METHOD: We conducted a Google search using the key words "anorexia nervosa (AN) and treatment", "AN and psychotherapy", "AN and pharmacotherapy", and then "pro-anorexia", "pro-ana sites", "thinspiration" and "anorexicnation". RESULTS: The first group of queries gave respectively 546,000, 212,000 and 39,100 results; the second 257,000, 18,600, 14,200 and 577. Forty-seven of 100 randomly selected pro-ana websites were thoroughly visited. CONCLUSIONS: Internet websites may increase the accessibility of treatments but also strengthen some of the core psychopathological and symptomatological issues of AN, such as asceticism, competition, purging behaviours and obsession for control. Greater attention should be paid to the health policy of countries in which pro-ana websites flourish, and the clinical implications of the websites themselves.

Hormonal and metabolic responses to acute ghrelin administration in patients with bulimia nervosa.

Ghrelin is generally influenced by energy balance status and is inversely associated with body mass index (BMI), being reduced in simple obesity, notable exception being Prader Willi syndrome, and elevated in several conditions of undernutrition, including anorexia nervosa (AN). Interestingly, ghrelin levels have also been found elevated in patients with bulimia nervosa (BN) in spite of normal BMI. In humans, intravenous (iv) ghrelin administration induces endocrine (increase in GH, PRL, ACTH and cortisol) and metabolic (increase in glucose and decrease in insulin) effects as well as an increase in appetite and food intake. In AN, ghrelin administration surprisingly leads to a decreased GH response and absence of glycemic variations but normal PRL, ACTH and insulin response. This pattern would reflect a decrease in sensitivity to ghrelin or, alternatively, the metabolic status of AN. To further clarify the function of ghrelin in eating disorders, the endocrine and metabolic response to acute iv ghrelin (1.0 microg/kg) was studied in seven young women with purging BN (BW, BMI, mean+/-SEM: 20.3+/-0.5 kg/m2). Circulating total ghrelin levels were also measured. The results in BW were compared to those recorded in a group of nine healthy women (HW; BMI 22.3+/-2.5 kg/m2). The GH response to ghrelin in BW overlapped with that in HW. Ghrelin administration also led to a similar increase in PRL, ACTH, cortisol and glucose levels in the two groups. Insulin levels were not significantly modified by ghrelin administration in either group. The overlapping endocrine and metabolic response to ghrelin in the two groups occurred with regard to circulating total ghrelin levels which were higher in BW than in HW. In conclusion, BN, a condition of ghrelin hypersecretion, is connoted by a normal endocrine and metabolic response to exogenous ghrelin administration.

Geophagia leading to hypokalemic quadriparesis in a postpartum patient.

Pica is an eating disorder associated with ingestion of variety of non-food substances. A postpartum patient who presented with acute flaccid quadriparesis was detected to have severe hypokalemia. After extensive investigations for cause of hypokalemia, history of geophagia (clay-eating) was obtained. Approach to hypokalemia and health hazards of pica are discussed.

Quality of life and personality disorders in heroin abusers.

OBJECTIVE: The aim of this study is to describe the personality disorders (PD) and personality profile of heroin-abusers and their quality of life (QoL), and to investigate the correlation between the two. METHOD: One hundred and eighty heroin-abusers during their residential treatment participated in the study. The Structured Clinical Interview-II (SCID-II) allowed the identification of two subgroups of heroin-abusers on the basis of presence/absence of a PD. All patients filled in the Temperament and Character Inventory (TCI), the McGill QoL Questionnaire (MQOL) and an anamnestic sheet. A control group of 63 non-clinical subjects was recruited. RESULTS: Abusers with a PD differ in their personality profile from abusers without PD and score lower on the total MQOL. As regards TCI scales, novelty seeking (NS), reward dependence (RD) and self-directedness (SD) predict the age of onset of the abuse, while cooperativeness (C) is a predictor of the number of community admissions. DISCUSSION: Low scores on self-directedness and cooperativeness in abusers support the hypothesis of an immature character and relational difficulties. Novelty seeking is the only dimension which is altered both in abusers with and without a PD and is not strictly dependent on Axis II comorbidity. QoL is lower in abusers than in controls, according to their physical, psychological and existential suffering. Last, an interesting link emerged between personality and perceived QoL.

Anger and personality in eating disorders.

OBJECTIVE: This study was designed to examine how anger, temperament and character profiles differ across subtypes of eating disorders (EDs) in comparison to healthy controls and to analyze the relationship between anger expression, eating attitudes and personality dimensions. METHOD: One hundred and thirty-five outpatients (50 of whom suffered from anorexia nervosa restrictor type [AN-R], 40 from anorexia nervosa binge/purging [AN-BP] and 45 from bulimia nervosa [BN]) and 50 control subjects were recruited and administered State-Trait Anger Expression Inventory (STAXI), Temperament and Character Inventory (TCI) and Eating Disorder Inventory II (EDI-II). RESULTS: STAXI showed greater levels of anger in patients with BN than in those with AN. TCI showed different personality profiles, in accordance with previous studies. Correlations were found between the management of anger feelings and psychological and personality traits typical of patients with EDs. CONCLUSIONS: Clinically, impulsivity seems to be the psychopathologic element most strongly correlated to anger. Moreover, it appears clear that anger is better managed by individuals with greater character strength.

Psychological treatment of eating disorders. A review of the literature.

The aim of this study is to review the existing literature (PubMed database) on the psychological treatments for eating disorders (EDs), subdivided in individual, group and family therapies. Moreover new approaches and directions in this field are addressed. An extensive literature review is performed to identify the psychological treatment trials in anorexia nervosa (AN) and bulimia nervosa (BN) published over the past 2 decades. Eighty-two studies focused on psychotherapeutic treatment of EDs are reviewed. Only a minor part of these studies are randomised and controlled. While there is evidence of the efficacy of cognitive behavioral therapy (CBT), this is still missing for other psychotherapeutic approaches. However, there is general agreement about the importance of psychotherapy in multimodal treatments. There is still a need for a shared concept of outcome in EDs, since the efficacy of psychological treatment is greatly influenced by the definition of outcome adopted (concerning symptoms, psychosocial functioning, personality).

Nonresponder anorectic patients after 6 months of multimodal treatment: predictors of outcome.

Currently the therapy of anorexia nervosa is a relevant clinical problem. The percentage of patients who respond to short-term pharmacotherapy and psychotherapy is still low and the condition often leads to chronic pathology or death. The present study aims to determine outcome predictors beyond personality traits, eating psychopathology, or particular clinical features. Forty patients with restricter type anorexia nervosa were tested, at T0 and after 180 days, with psychometric tests and clinical evaluation instruments. Patients were then divided into two groups. One group included patients who showed relevant clinical improvement; the other included not-yet-improved patients. A lower Novelty Seeking, higher levels of Ascetism and Maturity Fears characterised the not-yet-improved group. Correlation showed evidence of diverse bonds between personality and psychopathology in the improved and not-yet-improved groups. The psychopathology of non-yet-improved patients seemed to be more linked to their temperamental features, whereas improved patients seemed to be more influenced by their character. Different levels of psychological functioning can be expressed. The present data suggest focusing pharmacotherapy and psychotherapy, even family counseling, with a progression more strictly related to the current personality functioning level and psychopathology of each patient.

Rehabilitative residential treatment in patients with severe mental disorders: personality features associated with short-term outcome.

The aims of this study were to evaluate the outcome of inpatients with severe psychiatric disorders after 6 months of multimodal residential treatment. Ninety-one subjects admitted to residential prolonged treatment at an Italian rehabilitative complex were included in the study. Within 6 months, the program of treatment was effective in reducing symptoms and improving the patients' psychosocial functioning. The study of personality can be useful to "dose" symptomatic (pharmacological and psychotherapeutic) and rehabilitative treatments in the therapy program.

Problems of inference from hypothesis-generating studies on lung cancer and occupation based on routine hospital records.

This paper discusses inference from hypothesis-generating studies on occupational risks for lung cancer based on routine hospital records. A hospital-based case-control study on 567 male lung cancer patients and 906 controls provided a practical example. Among possible causes of bias, the effects of poor detail in the occupational information, of a large proportion of exclusions due to incomplete information, of cardiovascular diseases as the prevalent diagnosis among controls, of selecting cases and controls from different hospitals with likely differences in referring areas, and the problem of multiple comparisons are highlighted. Significant excess lung cancer risks were found for farmers, miners, crushers, stonemasons and cement plant workers, and stock handlers and stevedores. Positive findings with small numbers of observations are more likely to be artificially generated, but also the precision of more robust risk estimates may be affected. The limits to inference from hypothesis generating case-control studies based upon routine hospital records, such as in the example described, outweigh the advantage of the ready availability of these data-bases.

Does it exist a personality core of mental illness? A systematic review on core psychobiological personality traits in mental disorders.

AIM: Research investigating the relationship between mental disorders and personality traits leads to interesting results. Individuals affected by several mental disorders have been worldwide assessed according to the psychobiological model of personality. This review aims to explore which temperament and character traits are recurrent in mental disorders and to highlight what traits may be shared determinants or consequences of the expression of a mental disorder. METHODS: Systematic search of Medline database between 1998 and 2011 has been conducted to select the studies exploring the Temperament and Character Inventory (TCI) dimensions in the most relevant axis I psychiatric disorders. Of the 110 studies that were retrieved, 88 met the inclusion/exclusion criteria and were analyzed. RESULTS: High HA (HA) and low self-directedness are recurrent and can be considered as a "personality core" regardless of the diagnosis. They may be risk factors and relapse-related, they can indicate incomplete remission or chronic course of mental disorders, and consistently influence patients' functioning. Furthermore, they can be modified by medications or psychotherapy and represent outcome predictors of treatments. CONCLUSION: This "core" may represent a personality diathesis to psychopathology. Relational environment can influence the development of both temperament and character, thus prevention of mental disorders should promote a positive development of these traits. Although further research is needed, psychotherapeutic interventions should be performed also considering that mental disorders could benefit from HA desensitization and SD reinforcement. Finally, these traits may be used to provide diagnostic, prognostic, quality of life and efficacy inferences on psychiatric treatments.

The borderline personality organization in a dimensional perspective: the TCI and SWAP-200 in comparison.

AIM: The categorical assessment of personality disorders, in particular of the borderline personality disorder is being debated by most authors. This study focuses on the structural organization of personality, namely on Kernberg's borderline personality organization (BPO). It aims to explore the dimensional personality assessment and to test the convergence on this construct of two dimensional instruments: the Temperament and Character Inventory (TCI) and the Shedler-Westen Assessment Procedure (SWAP-200). METHODS: BPO was assessed with the Temperament and Character Inventory (TCI) and the Shedler-Westen Assessment Procedure (SWAP-200). Thirty-four BPO subjects were recruited in the study. TCI profiles of BPO subjects were compared with 34 non-BPO matched controls. TCI and SWAP-200 profiles were correlated with each other and with clinical data. RESULTS: BPO subjects showed higher harm avoidance and lower self-directedness (TCI). The SWAP-200 evidenced a schizotypal configuration (categorical classification) and histrionic and schizoid traits (Q-sort classification). CONCLUSION: The instruments displayed limited correlation. Instead they both extensively correlated with clinical history of BPO subjects. Implications for BPO assessment and its relationship with mental disorders are discussed. The knowledge of the BPO dimensional characteristics will improve clinical management and therapeutic strategies for BPO patients. Moreover the comparison of two dimensional instruments on the construct of BPO may shed a light on their strengths and weaknesses.