Sexuality, embodiment and attachment style in anorexia nervosa.

PURPOSE: Recent studies hypothesized that sexual dysfunctions represent not just complications of eating disorders (EDs), rather they should be attributed to the core psychopathology of these disorders. Therefore, disorders of the embodiment and insecure attachment may play a role in maintaining an abnormal sexual functioning, given their known relations with core ED features. The aim of the study was to investigate the relationship between sexual dysfunctions and both disorders of the embodiment and attachment style in people with anorexia nervosa (AN). METHODS: 111 adult women with AN and 120 healthy subjects completed the Symptom Checklist-90, Eating Disorder Examination Questionnaire, Identity and Eating Disorders, Attachment Style Questionnaire and the Childhood Trauma Questionnaire-Short Form. RESULTS: Patients reported worse scores than controls in all areas assessed. In patients, low sexual desire was found to be associated with general and ED-specific psychopathology, and with disorders of embodiment and attachment style. Sexual dysfunctions had no associations with traumatic experiences. Dietary restriction showed an association with low sexual desire through embodiment disorder and Discomfort with Closeness, as confirmed by the serial mediation model. CONCLUSION: The present study suggests that disorders of embodiment maintained by pathological eating behaviours have a key role in the development of sexual dysfunctions in EDs, through the compromise of intimacy. LEVEL OF EVIDENCE: Level III, cross-sectional study with comparisons between cases and controls.

Deviance or Normalcy? The Relationship Among Paraphilic Thoughts and Behaviors, Hypersexuality, and Psychopathology in a Sample of University Students.

INTRODUCTION: The actual definitions of paraphilic thoughts or behaviors and hypersexuality are still a matter of debate in the scientific community, and few studies have evaluated their psychopathological correlates in non-clinical samples of both men and women. AIM: This study aimed at shedding light on the gender differences in terms of frequency of paraphilic fantasies and behaviors, and the relationship among paraphilias, hypersexuality, and general psychopathology. METHODS: A sample of 775 university students (243 men, 532 women) was recruited from 6 Italian universities using questionnaires posted in social networks. Paraphilic behaviors, fantasies, and masturbation during these fantasies were evaluated, as well as hypersexuality, psychopathological correlates, self-perceived gender identity, and a history of adverse childhood conditions. MAIN OUTCOME MEASURES: Participants were assessed on the presence of paraphilic fantasies, behaviors, and masturbation related to paraphilic thoughts, and evaluated by means of the Symptom Checklist 90-Revised, the Hypersexual Disorder Screening Inventory, the International Index of Erectile Function, the Female Sexual Function Index, the Gender Identity/Gender Dysphoria Questionnaire, and the Childhood Experience of Care and Abuse Questionnaire. RESULTS: In the present survey, 50.6% of the men and 41.5% of the women reported at least 1 behavior considered paraphilic. A gender difference in the prevalence of the main paraphilic interests and behaviors was observed, with men reporting a higher prevalence of voyeurism, exhibitionism, sadism, and frotteurism, and a higher prevalence of fetishism and masochism in women. Both general psychopathology and sexual dysfunctions were associated with hypersexuality, rather than with the content of sexual fantasies. Finally, an association between childhood adversities and hypersexuality was found in women but not in men. CLINICAL IMPLICATIONS: Understanding the psychopathological correlates of paraphilic fantasies/behaviors and hypersexuality may allow clinicians to develop specific psychological and pharmacological interventions. STRENGTHS & LIMITATIONS: This is one of the few studies assessing paraphilic phenomenology and psychopathological correlates of hypersexuality in a non-clinical sample of both men and women. CONCLUSION: The results seem to demonstrate that paraphilic thoughts and behaviors are not really a deviation from normalcy, rather they are quite widespread in the young population, and the distinction between healthy and pathological sexual interests may be better replaced by an all-encompassing approach considering ego-dystonic sexuality, hypersexuality, and their psychopathological correlates. Castellini G, Rellini AH, Appignanesi C, et al. Deviance or Normalcy? The Relationship Among Paraphilic Thoughts and Behaviors, Hypersexuality, and Psychopathology in a Sample of University Students. J Sex Med 2018;15:1322-1335.

Comparison of two different treatments in depressed pregnant women: fetal growth characteristics and neonatal outcomes.

Background In this pilot study, the effects of selective serotonin reuptake inhibitors (SSRIs) and psychological intervention on fetal growth characteristics and neonatal outcomes were evaluated in two different groups of women affected by prenatal depression. Methods Forty-seven pregnant women diagnosed with major depression were divided into two different treatment groups according to the severity of their depression. The first group was treated with a combination of pharmacotherapy and psychological support. The second group (milder depression) was treated with psychological support only. The control group (CG) was made up of 26 healthy pregnant women. All of the patients and controls were assessed by means of a structured clinical interview and different self-reported questionnaires. Fetal ultrasonography assessments were performed in the second and third trimesters. Neonatal outcomes were evaluated at delivery. Results The infants of both treatment groups showed significant alterations in fetal biometry and a higher rate of low birth weight (LBW) with respect to controls. The infants of the patients treated with psychological support showed only a significantly higher rate of head circumference, <10th percentile with respect to controls. No significant difference was found between the two patient groups when fetal growth characteristics and neonatal outcomes were taken into account. Conclusion The data obtained from this study shed light on the effects of pharmacological and psychological treatment of prenatal depression on fetal growth.

Different outcomes, psychopathological features, and comorbidities in patients with eating disorders reporting childhood abuse: A 3-year follow-up study.

The aim of this study was to evaluate the role of childhood adversities in long-term outcomes in eating disorders (EDs). One hundred thirty-three eating disorder patients were studied by means of the Structured Clinical Interview for DSM-IV and psychometric tests, at baseline, at the end of individual cognitive behavioural therapy, and at 3-year follow-up. As compared with the other patients, those reporting childhood abuse (overall: 24.8%; physical abuse: 20.3%; sexual abuse: 13.6%) showed higher impulsivity, psychiatric comorbidity, lower full recovery at follow-up (12.1% vs. 31%), and higher diagnostic crossover (39.4% vs. 13.0%). The different rates of recovery were mostly due to a higher persistence of depression in abused patients (77.8% vs. 26.7%). Patients with both abuse and neglect had a higher probability of dropout. Eating disorder patients with childhood abuse represent a group of persons with more complex psychopathological features and a worse long-term outcome, thus requiring specific treatment strategies.

The effects of switching from oral to LAI antipsychotic treatment on subjective experience of schizophrenic and schizoaffective patients: Preliminary results.

OBJECTIVE: To present real-world preliminary evidence on the specific effects of switching from oral to long-acting injectable (LAI) antipsychotic treatment on patient's subjective experience and quality of life (QoL) in a sample of clinically stable psychotic subjects. METHODS: Twenty-six clinically stable adult schizophrenic and schizoaffective outpatients were recruited. All patients were under a stabilized therapy with a single oral second-generation antipsychotic and were switched to the equivalent maintenance regimen with the long-acting formulation of the same antipsychotic. Two subgroups of patients were created on the basis of the presence/absence of a complete clinical remission at enrollment. Anthropometric (body mass index), psychometric (Montgomery-Asberg Depression Rating Scale, Young Mania Rating Scale, and Positive And Negative Syndrome Scale), and patient's reported outcome (Subjective Well-Being Under Neuroleptics scale short form, Drug Attitude Inventory short version, and Short Form-36 health survey) data were collected at enrollment (T0) and after 6 months from the treatment switch (T1). RESULTS: Significant improvements in psychometric indexes, and patients' subjective experience of treatment and attitudes toward drug (reflecting in an enrichment of patients' health-related QoL) were found both in initial remitters and non-remitters. CONCLUSIONS: Our preliminary results suggest that the switch from oral to LAI antipsychotic treatment may help to address the subjective core of an optimal and satisfying recovery of psychotic patients. Size and duration of this study need to be expanded in order to produce more solid and generalizable results.

Associations between liver enzymes, psychopathological and clinical features in eating disorders.

Elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels are frequently reported in patients with anorexia nervosa (AN) and in subjects who are overweight or with hyperlipidemia, which can be found to be associated with binge eating disorder (BED) and bulimia nervosa (BN). Liver functioning and psychopathological features have been evaluated in 43 patients with AN, 33 with BN, and 32 with BED. Body mass index was found to be inversely associated with AST and ALT in AN, and directly associated with AST and ALT in BED. A positive association between ALT and AST and body shape concern in AN was observed. Liver enzymes could be considered as an index of severity in AN and BED patients.

Childhood sexual abuse moderates the relationship between sexual functioning and eating disorder psychopathology in anorexia nervosa and bulimia nervosa: a 1-year follow-up study.

INTRODUCTION: Sexual dysfunctions that affect all aspects of sexuality are common in patients with eating disorders. However, only few studies have provided longitudinal information on sexual functioning in patients with eating disorders. AIM: To evaluate the longitudinal course of sexual functioning, and how changes in psychopathology and history of childhood abuse interact with sexual functioning in patients with anorexia nervosa (AN) and bulimia nervosa (BN). METHODS: A total of 27 patients with AN and 31 with BN were assessed at baseline and at 1-year follow-up after a standard individual cognitive behavioral therapy (CBT). MAIN OUTCOME MEASURES: Subjects were studied by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV, Female Sexual Function Index (FSFI), Eating Disorder Examination Questionnaire, Beck Depression Inventory, Spielberg's State-Trait Anxiety Inventory, Symptom Checklist-90, and Childhood Experience of Care and Abuse Questionnaire. RESULTS: After treatment, both patients with AN and BN showed a significant improvement in the FSFI total score (P < 0.01 for both AN and BN) and all FSFI subscales, without significant between groups differences. Patients reporting childhood sexual abuse did not show a significant improvement in sexual functioning (ß = 0.05; P = 0.58). Reduction in eating disorder severity was directly associated with FSFI improvement, but only in those subjects with no history of sexual abuse (ß = 0.28; P = 0.01). CONCLUSIONS: Eating disorder-specific psychopathology could be considered as a specific maintaining factor for sexual dysfunction in eating disorders subjects. Subjects reporting a history of childhood sexual abuse represent a subpopulation of patients with a profound uneasiness, involving body perception, as well as sexual functioning, which appeared not to be adequately challenged during standard CBT intervention. The results, though original, should be considered as preliminary, given the relatively small sample size.

Gender identity disorder and eating disorders: similarities and differences in terms of body uneasiness.

INTRODUCTION: Subjects with gender identity disorder (GID) have been reported to be highly dissatisfied with their body, and it has been suggested that the body is their primary source of suffering. AIMS.: To evaluate quality and intensity of body uneasiness in GID subjects, comparing them with a sample of eating disorder patients and a control group. To detect similarities and differences between subgroups of GID subjects, on the basis of genotypic sex and transitional stage. METHODS: Fifty male-to-female (MtF) GID (25 without and 25 with genital reassignment surgery performed), 50 female-to-male (FtM) GID (28 without and 22 with genital reassignment surgery performed), 88 eating disorder subjects (26 anorexia nervosa, 26 bulimia nervosa, and 36 binge eating disorder), and 107 healthy subjects were evaluated. MAIN OUTCOME MEASURES: Subjects were studied by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Symptom Checklist (SCL-90), and the Body Uneasiness Test (BUT). RESULTS: GID and controls reported lower psychiatric comorbidity and lower SCL-90 General Severity Index (GSI) scores than eating disorder subjects. GID MtF without genital reassignment surgery showed the highest BUT values, whereas GID FtM without genital reassignment surgery and eating disorder subjects showed higher values compared with both GID MtF and FtM who underwent genital reassignment surgery and controls. Considering BUT subscales, a different pattern of body uneasiness was observed in GID and eating disorder subjects. GID MtF and FtM without genital reassignment surgery showed the highest BUT GSI/SCL-90 GSI ratio compared with all the eating disorder groups. CONCLUSIONS: GID and eating disorders are characterized by a severe body uneasiness, which represents the core of distress in both conditions. Different dimensions of body uneasiness seem to be involved in GID subsamples, depending on reassignment stage and genotypic sex. In eating disorder subjects body uneasiness is primarily linked to general psychopathology, whereas in GID such a relationship is lacking.

Psychopathological and clinical features of remitted anorexia nervosa patients: a six-year follow-up study.

OBJECTIVE: Remission from anorexia nervosa (AN) is a controversial issue, as remitted individuals have been found to show residual anorectic attitudes and concerns about weight and shape. The aims of this study were to evaluate the psychopathological features of remitted AN subjects 6 years after the end of a cognitive behavioural therapy and the predictors of reduction in psychopathology. METHODS: The sample was composed of 134 AN subjects, evaluated at baseline, at the end of treatment, 3 and 6 years after the end of treatment, by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and several self-reported questionnaires. RESULTS: Remitted patients at 6 years of follow-up still showed higher eating and shape concerns, compared with healthy controls. Duration of illness, obsessive-compulsive and depressive symptoms were moderators of change in psychopathology across time. DISCUSSION: Psychopathological features represent an enduring trait for AN patients. General psychopathology showed different effects on symptoms reduction across time.

Anorectic and bulimic patients suffer from relevant sexual dysfunctions.

INTRODUCTION: Sexual life is often impaired in anorexia nervosa (AN) and bulimia nervosa (BN), and few studies have evaluated the possible relationships between body image concerns, eating disorder psychopathology, and sexual functioning in these syndromes. AIM: To evaluate sexual functioning in AN patients, BN patients, and healthy controls, and to define the predictors of sexual dysfunction in the AN and BN groups. METHODS: Eighty-eight eating disorders patients (44 AN, 44 BN) referring to the Outpatient Clinic for Eating Disorders of the University of Florence, and 72 healthy females were evaluated. MAIN OUTCOME MEASURES: The subjects were studied by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV, the Female Sexual Function Index (FSFI), the Eating Disorder Examination Questionnaire, the Emotional Eating Scale, the Beck Depression Inventory, the Spielberg's State-Trait Anxiety Inventory, the Barratt Impulsiveness Scale, and the Symptom Checklist 90. RESULTS: AN restricting/type patients had lower FSFI total scores (median; quartiles: 4.8; 2.1-15.4), compared with AN binge/purging type (28.3; 20.6-30.7) and BN patients (20.1; 3.8-30.3). Multiple linear regression analysis showed that shape concern was associated with sexual dysfunction in AN restricting type patients (ß=-0.61, P<0.01), whereas emotional eating (ß=-0.42, P<0.01), and subjective binge eating (ß=-0.55, P<0.01) were significantly associated with FSFI scores in AN binge/purging type and BN patients. CONCLUSIONS: Considering the sample size, the present results must be considered as preliminary. Sexual dysfunction was found to be a relevant concern in both AN and BN patients and was associated with different pathological eating behaviors. Sexual functioning should be carefully investigated in eating disorders patients, and treatments focused on shape concern, emotional eating, and binge eating could improve the sexual life of AN and BN patients.

Association between serotonin transporter gene polymorphism and eating disorders outcome: a 6-year follow-up study.

Eating disorder patients show different long-term outcomes, and trait-related alterations of serotonergic function, which might be related with the serotonin transporter (5-HTT) gene. We studied the relationships between 5-HTTLPR polymorphism, eating specific and general psychopathology and the long-term outcome of anorexia nervosa (AN) and bulimia nervosa (BN) patients. We evaluated the distribution of the functional 5-HTTLPR polymorphism in a series of 201 Italian, Caucasian, eating disorder patients (113 with AN and 88 with BN binge/purging (BP subtype) and in 150 Caucasian unrelated controls. Prior to starting an individual cognitive behavior therapy, a clinical assessment was performed by means of the structured clinical interview for DSM-IV axis I disorders and several self-report questionnaires. This assessment was repeated at the end of treatment, 3 years after the end of treatment and 3 years after the first follow-up. Diagnostic changes between AN and BN were frequent (28.3%), and the presence of depressive disorders was associated with a higher rate of diagnostic crossover during the follow-up period. The S-allele of the 5-HTTLPR genotype increases the risk susceptibility for both depressive comorbidity (OR = 4.23; 95% CI, 1.45-12.37) and diagnostic crossover during the follow-up period in AN patients (OR = 5.04; 95% CI, 1.69-14.98). Logistic regression analyses confirmed these findings, when the interaction between genotype and psychiatric comorbidity as predictors of diagnostic instability in AN patients were taken into account. No significant association was found between 5-HTTLPR genotype and recovery. The S-allele of the 5-HTTLPR genotype increases the risk for depressive disorders comorbidity, and moderates the long-term outcome of anorectic patients.

Depression prevalence based on the Edinburgh Postnatal Depression Scale compared to Structured Clinical Interview for DSM DIsorders classification: Systematic review and individual participant data meta-analysis.

OBJECTIVES: Estimates of depression prevalence in pregnancy and postpartum are based on the Edinburgh Postnatal Depression Scale (EPDS) more than on any other method. We aimed to determine if any EPDS cutoff can accurately and consistently estimate depression prevalence in individual studies. METHODS: We analyzed datasets that compared EPDS scores to Structured Clinical Interview for DSM (SCID) major depression status. Random-effects meta-analysis was used to compare prevalence with EPDS cutoffs versus the SCID. RESULTS: Seven thousand three hundred and fifteen participants (1017 SCID major depression) from 29 primary studies were included. For EPDS cutoffs used to estimate prevalence in recent studies (≥9 to ≥14), pooled prevalence estimates ranged from 27.8% (95% CI: 22.0%-34.5%) for EPDS ≥ 9 to 9.0% (95% CI: 6.8%-11.9%) for EPDS ≥ 14; pooled SCID major depression prevalence was 9.0% (95% CI: 6.5%-12.3%). EPDS ≥14 provided pooled prevalence closest to SCID-based prevalence but differed from SCID prevalence in individual studies by a mean absolute difference of 5.1% (95% prediction interval: -13.7%, 12.3%). CONCLUSION: EPDS ≥14 approximated SCID-based prevalence overall, but considerable heterogeneity in individual studies is a barrier to using it for prevalence estimation.

[Retrospective assessment of childhood trauma: review of the instruments]. / La valutazione retrospettiva del trauma infantile: una revisione degli strumenti.

AIM: Childhood trauma has a crucial and proved role for the development of psychopathology during adulthood. The results of a systematic review on the instruments for the retrospective assessment of childhood trauma are reported in order to compare their reliability, validity, comprehensiveness and use. METHODS: A literature search on this argument was conducted on Medline electronic archives and by canvassing English-language and other European languages publications. Eligible instruments were restricted to the ones with: available publications, retrospective assessment on adult population, independence from specific diagnostic categories, sufficient data regarding the main features. RESULTS: Of the 19 eligible instruments, the Familial Experiences Interview (FEI) and the Early Trauma Inventory Self Report (ETI-SR) evaluate the highest number of "trauma areas" considered in this review. The reliability and validity data provided by Authors, when available, are reported to be good to excellent. The four most used instruments in the clinical and epidemiological practice appear to be the Parental Bonding Instrument (PBI), the Adult Attachment Interview (AAI), the Childhood Experience of Care and Abuse (CECA.Q) and the Childhood Trauma Questionnaire (CTQ). DISCUSSION: Our review on the currently available instruments has pointed out some weaknesses that narrow their actual use and evaluation capability. Such issues should be taken in consideration and further discussed especially considering the increasing consent of research on the role of childhood trauma for the development of adult psychopathology.

Reward and psychopathological correlates of eating disorders: The explanatory role of leptin.

It has been hypothesized that leptin level alterations in Eating Disorders (EDs) represent a maintaining factor for pathological reward-related ED behaviors, given leptin role in the dopaminergic reward systems. The aim of the present study was to evaluate the role of leptin in EDs as a mediator for the relationship between Body Mass Index (BMI) and several pathological behaviors, such as dietary restraint, compensatory exercise, vomiting, binge eating and emotional eating. Sixty-two patients with EDs and 41 healthy controls (HC) had their blood drawn and completed psychometric tests for the evaluation of general psychopathology, ED psychopathology and emotional eating. Moderated linear regression models showed that, in the presence of high levels of ED psychopathology, leptin levels were negatively associated with dietary restraint and compensatory exercise, and positively with emotional eating and binge eating. Finally, leptin showed an indirect effect on the association between BMI and all these reward-related behaviors. These results suggest that a variation of BMI maintains these pathological ED behaviors through a variation in leptin levels. Considering the role of leptin in reward circuits, the results seem to confirm an aberrant food-related reward mechanism in ED patients.

[Epidemiology of social phobia]. / Epidemiologia della fobia sociale.

AIM: Social phobia (SP) represents one of the most frequent psychiatric disorders. The results of a systematic review of the literature published between 1987 and 2008 on the prevalence of SP in general population are reported. METHODS: A literature search of epidemiologic studies of SP was conducted on PubMed and Medline electronic archives and by canvassing English-language and other European languages publications. Eligible publications were restricted to community surveys on adult population (age 16 to 65), using DSM and ICD criteria and analysing lifetime, 12 months and 1 month prevalence rates of SP. RESULTS: Of the general population studies, 45 prevalence studies met the criteria of eligibility. The prevalence rates ranged 0.53%-45.6% (lifetime prevalence); 1.0%-9.10% (12 months prevalence) and 0.96%-7.90% (one month prevalence). In those community samples SP appears to be from 1.1 to 2.6 times more frequent in females than in males. DISCUSSION: Our review suggests that SP is a very common disorder worldwide. Epidemiologic data on SP seem to be controversial, especially when considering the prevalence rates. The large variations in prevalence figures are mostly due to methodological differences, whereas an actual lower rate of SP seems to exist in the far East areas. Among the Western countries the rates of SP seem to be similar. A possible explanation to the finding of such a variability in the estimated SP prevalence rates across different countries could involve the transcultural differences regarding each population's expectations about appropriate social and sexual roles.

Relationships between eating disorder psychopathology, sexual hormones and sexual behaviours.

A growing body of evidences demonstrated that sexuality is an important topic in the clinical research of eating disorders (EDs), due to its association with specific psychopathological features, and etiological factors. The present review took into consideration the complex relationship between sexual behaviours, hormonal alterations and EDs psychopathology. Studies pertaining sexual behaviours in EDs were divided into those focusing on sexual dysfunctions, and those related to risky sexual behaviours. The limited number of studies on sexual dysfunctions, reported a controversial association with weight status and hormonal alterations, and a clear relationship with severity of specific psychopathology (e.g. body image disturbance). Risky sexual behaviours have been associated with impulsivity and dissociation, as well as with abnormal stress response. Finally, both restriction and uncontrolled eating have been found to be responsible for several complex metabolic alterations, determining varied sexual and gynecologic problems, such as amenorrhea, hypogonadism, genital vascular problems, infertility, and miscarriage, although it is also possible that alterations in feeding and stress hormones contribute to altered eating behaviour.

Cortisol levels before and after cognitive behavioural therapy in patients with eating disorders reporting childhood abuse: A follow-up study.

The etiopathogenesis of eating disorders (EDs) is complex and still not well understood. Biological, psychological and environmental factors (e.g. childhood abuse) have all been considered to be involved in the onset and the persistence of EDs. The hypothalamic-pituitary-adrenal (HPA) axis is a relevant biological factor capable of influencing the onset and the course of EDs and not many information are available about the impact of a Cognitive Behavioral Therapy (CBT) on cortisol changes in EDs. The HPA-axis functioning has been evaluated before and after CBT in a group of patients with Anorexia Nervosa (n = 34) and Bulimia Nervosa (n = 35) according to the presence/absence of a history of sexual/physical abuse. At baseline, only patients reporting childhood abuse showed lower morning cortisol levels as compared with other patients of the same diagnostic group and Healthy Controls. After CBT, a variation of cortisol levels has been found only in patients without abuse, suggesting a role of childhood adversities in the persistence of HPA-axis alterations in Eating Disorders.