Family functioning of adolescents with restrictive eating disorders with or without nonsuicidal self-injury.

Family influence is a crucial factor in the onset and maintenance of eating disorders. Nonsuicidal self-injury (NSSI) and restrictive eating disorders (REDs) co-occur in a significant percentage of subjects but family functioning of these families remains underexplored. This study examines the family functioning perceptions of 80 families with adolescents experiencing RED, comparing those with and without NSSI, alongside a control group, utilising the FACES-IV assessment. The study also aims to compare the triadic (adolescent-mother-father) perception of family functioning in the three groups. The results reveal distinct family dynamics in adolescents with both RED and NSSI, marked by problematic functioning perceptions from all family members and low parental agreement. A further understanding of the family functioning of adolescents with RED with NSSI can help clinicians in defining the treatment setting.

Through a relational lens: reflections about foster care experience in Italian emancipated foster youth.

The study aimed to investigate relational outcomes of Italian emancipated foster youth across open-ended reflections about their perceptions of their relationships with the biological and foster family, with partner and peers. A total of 26 Italian emancipated foster youth (19-25 years old) recruited by social services completed a single in-depth interview. A qualitative thematic analysis was selected for this study. The results revealed two major themes of foster care experience that emerged often simultaneously from the participants' narration: (1) Positive Relational Outcomes including "Feeling supported," "Sense of belonging," "Good memories," "Relationship with family of choice," and "Staying in touch"; and (2) Negative Relational Outcomes referring "Devaluation," "Refuse," "Bad memories," and "Isolation." Foster care experience leads to complex relational perceptions in emerging adulthood according to different relational outcomes and ways of processing foster care experience. Professionals could work on relational outcomes and memories, especially during a critical transition like emerging adulthood, to support youth in making sense of their past experiences.

Investigating Functioning Profile of Adolescents with Anorexia before and during the COVID-19 Pandemic: A Cross-Sectional Study on Mentalizing, Alexithymia, and Impulsiveness.

Anorexia nervosa (AN) usually emerges in adolescence when important changes occur in cognitive, emotional, and social processes. Mentalizing, alexithymia, and impulsiveness represent key dimensions for the understanding and interpretation of psychological difficulties in AN. The outbreak of the COVID-19 pandemic has impacted adolescents with AN, showing a worsening of the disease. The main aims of the present paper are (1) to compare adolescents with AN before and during the COVID-19 pandemic and (2) to explore the relationship between mentalizing, alexithymia, impulsiveness, and psychological difficulties related to eating disorders in adolescents with AN during the COVID-19 pandemic. One hundred and ninety-six AN female adolescents (N = 94 before COVID-19; N = 102 during COVID-19) participated in this study. The results show that adolescents with AN during the COVID-19 pandemic had a more impaired functioning profile than the before COVID-19 group. Mentalizing, alexithymia, and impulsiveness had a predictive role on psychological difficulties related to eating disorders in adolescents with AN during the COVID-19 pandemic. In conclusion, our data reveal that the COVID-19 pandemic has likely represented a stress condition that affects mental health; worsening the severity of adolescents with AN clinical condition. Lastly, predictive patterns suggest the existence of a link between difficulties in the ability to face the problems of the present time using effective strategies and the severity of psychological symptoms.

The catcher in the mind: validation of the brief-mentalized affectivity scale for adolescents in the Italian population.

The concept of mentalized affectivity (MA) encompasses the dimensions of identifying, processing, and expressing emotions and describes the process of making sense of and reevaluating one's affects in light of autobiographical memory. This construct was developed within the theoretical framework of mentalization and, due to its interpersonal nature, added further complexity to the emotion regulation construct. This research aimed to examine the factor structure and psychometric properties of the Brief-Mentalized Affectivity Scale for adolescents (B-MAS-A) on an Italian sample of young people (aged 13-19 years). Data were collected using non-probabilistic sampling and an online survey. Participants were asked to complete a large battery of instruments, including the B-MAS-A, the Toronto Alexithymia Scale, the Reflective Functioning Questionnaire, the Epistemic Trust, Mistrust, and Credulity Questionnaire, the Strengths and Difficulties Questionnaire, and the General Self-Efficacy Scale. In study 1, factor analyses carried out on a total sample of 566 adolescents identified 3 distinct dimensions of the same components of MA found in the adult population: i) identifying; ii) processing; iii) expressing emotions. The subscales showed excellent internal consistency. Study 2 (involving a subsample of 288 participants) demonstrated good levels of construct and criterion validity. These results confirm that the B-MAS-A represents a valid and robust instrument for assessing the complex and multifaceted characteristics of MA in adolescents. The B-MAS-A can make a significant contribution to clinical practice and research and encourage systematic studies on MA in psychotherapy, taking into account the developmental stage of adolescence.

Psychological Counseling Service "Together" at University of Genoa: Students' Psychological Profile in Pre and Post Pandemic.

The present explorative study aims to analyze the profiles of students seeking help in the two areas (emotion/relation or learning areas) of a psychological counseling service for students at the University of Genoa to better understand their request for support in pre- and post-pandemic periods. A total of 229 university students seeking for help from November 2018 to December 2021 completed a psychological battery investigating emotion regulation difficulties and pathological domains of personality (students taken in charge by the emotion/relation area) or motivation issues and anxiety and resilience levels (students taken in charge by the learning area). Regarding the emotion/relation area, results show that problems in emotion dysregulation, and especially in regulating positive emotions, are associated to several pathological domains of personality, such as Psychoticism, Antagonism, Disinhibition, Detachment, and Negative Affectivity. Among the learning area, motivational aspects concerning confidence in one's intelligence, academic self-efficacy, and learning goals are differently associated with anxiety and resilience above and beyond other aspects, such as attributions. Some limited but significant differences emerge from the comparison between pre- and post-COVID periods: a reduction in detachment in students attending the emotion/relation area, an increase of students with high levels of anxiety in the learning area. These results support the importance of continually operating on emotional and motivational aspects to enhance the students' well-being and thus sustaining their academic careers.

Emerging adults facing the COVID-19 pandemic: emotion dysregulation, mentalizing, and psychological symptoms.

Settled in the context of the COVID-19 pandemic, the present short-term longitudinal study aims to investigate the relation between emotion dysregulation, mentalizing (both certainty and uncertainty about mental states), and psychological symptoms in a sample of 83 emerging adults (Mage = 22.18 years, SD = 4.36) over a continuous period started with COVID-19 spreads. Results display significant positive associations between psychological symptoms and both emotion dysregulation and uncertainty about mental states, while an inverse association with certainty about mental states was found. A moderation model was also performed, showing a significant negative association between emotion dysregulation and psychological symptoms at low levels of uncertainty about mental states. Conversely, a marginally significant positive association occurs at high levels of uncertainty about mental states. In other words, the presence of individual impairments in perceiving one's own/others mind may increase the negative consequences of emotion dysregulation on reported psychological symptoms. To sum up, our findings highlight the importance of considering mentalizing as a possible key factor for the promotion of emerging adults' mental health also in the context of the ongoing COVID-19 pandemic.

Parental Mentalizing during Middle Childhood: How Is the Adoption of a Reflective Stance Associated with Child's Psychological Outcomes?

This exploratory cross-sectional study attempts to understand the mechanisms underlying the role of parental mentalizing in a child's psychological functioning during middle childhood by using Parental Reflective Functioning (PRF) and Parental Insightfulness (PI) constructs. The main aims are to examine the role of PI and PRF as processes capable of influencing a child's psychological functioning in terms of emotional-behavioral difficulties and social-emotional competencies. Eighty-six community parents (48 mothers, 38 fathers) and their 50 children in middle childhood (Mage = 10.10, SD = 1.13) participated in this study, recruited through a non-probabilistic sampling. The following measures were used to assess the aims of this study: Insightfulness Assessment, Parental Reflective Functioning Questionnaire, Child Behavior Checklist (CBCL) and Devereux Student Strengths Assessment (DESSA) questionnaires. Results showed that parental mentalizing was found to be significantly associated with both child's internalizing and externalizing symptoms and social-emotional competencies as reported by parents through the CBCL and DESSA questionnaires. This study may offer a contribution to the study of parental mentalizing during middle childhood, supporting the hypothesis that both parents' ability to understand their child's mental states could affect the child's psychological functioning. Clinical and theoretical implications are geared toward a family-based view with a specific focus on the importance of fostering in both parents a positive attitude toward mentalizing processes.

Advancement in the child attachment interview and the child and adolescent reflective functioning scale using a PDM-2 framework: case reports.

The Child Attachment Interview (CAI) is a well-established semi-structured interview, widely used to identify attachment representations in middle childhood and adolescence. The application of the Child and Adolescent Reflective Functioning Scale (CRFS) to CAI narratives allows for an assessment of child mentalization, considered a strong predictor of attachment security. The 2nd edition of the Psychodynamic Diagnostic Manual (PDM-2) includes CAI and CRFS as valid and reliable assessment measures in order to assess the dominion of the Mental Functioning axis. The aim of the present paper is to investigate the informative power of CAI and CRFS for the overall understanding of mental functioning and personality in a PDM-2 framework. The present report includes the discussion of two clinical cases of school-aged children in applying the Psychodiagnostic Chart-Second Edition (PDC-2) to the CAI transcript. The first case concerns a young male, aged 10, suffering from Oppositional-Provocative Disorder (externalizing disorder), while the second case concerns a young female, aged 15, suffering from Somatic Symptoms Disorder (internalizing disorder). PDC-2 for children and adolescents was used. Data from the scoring of CAI and CRFS were combined with a systematic evaluation of the qualitative contents emerging from CAI transcripts. A detailed analysis suggests that both the CAI and CRFS are useful attachment-oriented measures, able to explore child's mental states, and together with the application of PDC-2 they provide an essential contribution in the understanding of developmental psychopathology. Implications of this innovative approach for clinical assessment, treatment design, and interventions are further discussed.

The Italian version of the Reflective Functioning Questionnaire: Validity within a sample of adolescents and associations with psychological problems and alexithymia.

OBJECTIVES: This study aims to test the psychometric proprieties of the Reflective Functioning Questionnaire (RFQ) applied to younger (13-16 years) and older (17-20 years) Italian adolescents examining (1) the factorial structure of RFQ; (2) its invariance across age and sex; (3) correlations between RFQ subscale scores, as well as the associations of the RFQ with (4) psychological problems and alexithymia dimensions. METHODS: A cross-sectional study was conducted with 593 adolescents between the ages of 13 and 20 years old recruited from the community within Italy. These participants completed the RFQ, Symptom Checklist-90, and Toronto Alexithymia Scale. RESULTS: The two-factor structure of the RFQ was confirmed. However, higher internal consistency of RFQ was obtained by removing two items that seemed problematic within this sample. Using a six-item version of RFQ, the two-factor structure was invariant across adolescent age and sex. Significant correlations among RFQ subscale scores, and between RFQ subscales with both psychological problems and alexithymia dimensions were found. CONCLUSIONS: Preliminary results reveal a short version of RFQ (six-item) is a suitable measure to assess mentalizing in adolescents in the Italian context.

Physiological Factors Linking Insecure Attachment to Psychopathology: A Systematic Review.

Although many studies have documented associations between insecure attachment and psychopathology, attachment may not confer risk for psychopathology independently, but rather through its interaction with emotional, social, and biological factors. Understanding the variables through which attachment may lead to psychopathology is therefore important. Within this domain of research, the role of physiological factors is poorly investigated. What are the relevant domains and why, when, or for whom do they influence mental disorders relating to attachment? The current systematic review aims to answer these questions. Results reveal that physiological indices of emotional regulation play a role in explaining and/or determining the relationship between attachment and psychopathology. Specifically: (1) combined with insecure attachment, higher skin conductance level (SCL), lower cardiac slowing, and respiratory sinus arrhythmia modulation (RSA) contribute to different psychopathological indicators and behavioral/psychological dysfunctions, although the latter predicts a contradictory pattern of findings; (2) insecure-avoidant attachment is more consistently linked with stress and emotional dysregulation when combined with RSA, while anxious attachment confers risk of depressive symptoms when combined with SCL. We concluded our discussion of the results of seven studies by outlining a plan to move the field forward. We discuss the quality of the assessment, methodological limitations, and future directions, highlighting the need to extend the research to clinical samples.

Attachment representations to parents and emotional-behavioral problems: A comparison between children with type 1 diabetes mellitus and healthy children in middle childhood.

Type 1 diabetes mellitus (T1D) is one of the most demanding chronic diseases for children and their families, since controlling diabetes involves a process of co-regulation with attachment figures. However, there is insufficient evidence in middle childhood on psychological mechanisms involved that might complicate the adaptation of these children. Therefore, 106 children (N = 31 with T1D and N = 75 as matched healthy group [HG]) aged 8 to 13 were assessed using the Child Attachment Interview, the Child Behavior Checklist, and the measure of glycated hemoglobin. Results showed that insecure T1D children did not have worse diabetes control than the secure ones. However, T1D children differed from HG for higher levels of idealization to father and withdrawn/depressed problems. Moreover, T1D children with insecure attachment to mother scored significantly higher in anxious/depressed, withdrawn/depressed, attention problems, and rule-breaking behavior, while T1D children with insecure attachment to father scored significantly higher only in the withdrawn/depressed scale compared to the remaining children. Therefore, diabetes does not in itself determine a psychological vulnerability in middle childhood, but the presence of an insecure attachment, especially to the mother, worsens the psychological adaptation of T1D children. Psychological support should be provided for these young patients and their families.

Attachment representation to caregivers and mentalizing ability in early adolescents with primary headache.

Primary headache (PH) is a common somatic disorder in childhood with a strong impact in terms of quality of life. There are several risk factors related to the development of this disorder including environmental factors as attachment bonds. However, studies in this direction are relatively few and have often used self-report or semi-projective measures looking at the only maternal attachment. Moreover, several studies have shown a link between somatoform pains and mentalizing abilities, but the relation between mentalizing and PH in childhood is unexplored. Therefore, this study aims at exploring attachment bonds, focusing on both maternal and paternal representations and mentalizing abilities in early adolescents with and without PH within a cross-sectional case-controlled design. A sample of 94 early adolescents aged 10-14 years (47 with PH and 47 without PH as a comparison group) completed the Child Attachment Interview to assess attachment representations to caregivers. Mentalizing abilities were assessed applying to the interviews in the Child and Adolescent Reflective Functioning Scale. PH adolescents showed a greater percentage of insecure-preoccupied attachment to both parents, with higher level of preoccupied anger especially to father than the comparison group (p values from 0.000 to 0.014, effect size values from.31 to.45), while no differences emerged about mentalizing (p values from.264 to 0.312). The over-representation of insecure-preoccupied attachment to both parents suggests a key role of parent-child interaction in early adolescents with PH, while the role of mentalizing abilities remains controversial and further studies are needed to address this issue. Clinical implications are discussed.

Psychometric Properties of the Child Attachment Interview in Italian Context: A Focus on Normative and Specific Clinical Groups in School-Aged Children.

While attachment assessments developed for infancy and adulthood are well established, no such gold standard measure exists for school years, where measures are not yet sufficiently robust. Nevertheless, the last decade has witnessed some progress in this field with the development of the Child Attachment Interview (CAI), a semistructured interview designed to access children's mental representations of their attachment relationships. This study aimed to test the validity and reliability of the CAI for an Italian population, using a normative group and a clinical group of disruptive behavior disorder and somatic symptom disorder patients. A total sample of 311 Italian children (213 normative and 98 clinical) aged 8 to 15 years completed a battery of measures assessing attachment, verbal IQ, and symptomatology. The psychometric properties of the CAI alongside other children (Kerns Security Scale, Inventory of Parent and Peer Attachment) and parents (Adult Attachment Interview) attachment measures in normative sample, as well as the distribution of attachment patterns in normative and clinical samples, were examined. The results revealed the CAI to have adequate interrater and test-retest reliability, as well as discriminant, and convergent validity. Significant differences in the CAI's distribution of attachment patterns for normative and specific clinical groups were found. Taken together, the findings show that the CAI Italian version is a reliable and valid measure for assessing attachment in school years and beyond.

Attachment representations in children with disruptive behavior disorders: A special focus on insecurity in middle childhood.

According to the emotional and social problems encountered in disruptive behaviour disorder (DBD), there is little available information regarding the attachment processes during middle childhood. Therefore, this study aims to investigate the attachment representations to both caregivers in a sample of 84 children, aged 8-12 years (N = 42 with a diagnosis of DBD; N = 42 as a comparison group). Attachment is assessed through the Child Attachment Interview, a semi-structured interview that incorporates both narrative and behavioural assessments of attachment, permits the assessment of attachment representations using dimensional and categorical approaches, and allows for the detection of disorganisation to both parents individually. Our results point to the presence of high frequencies of insecure attachment (more than 80%) in the DBD group, with a higher percentage of dismissing attachment, and an over-representation of disorganised attachment (more than 50%). Higher levels of dismissal and lower levels of security are found in DBD than in the comparison group. No attachment differences with respect to both parents are found. Understanding how different aspects of attachment during a specific developmental phase plays a role within the broader emotional functioning of DBD has great potential to lead to innovations in evaluations and treatment processes.

Attachment and reflective functioning in children with somatic symptom disorders and disruptive behavior disorders.

Our goal in conducting this study was to examine whether children with somatic symptom disorders (SSD) and disruptive behavior disorders (DBD) have higher rates of insecure or disorganized attachment and difficulties in mentalizing (operationalized as reflective functioning) as compared to a control group. Participants were 131 children (8-15 years) spanning two groups-a clinical group (n = 85), comprised of children fitting the criteria of our target diagnostic classifications (SSD: N = 45; DBD: N = 40), as well as a comparison group of healthy control children (n = 46). Children completed the Child Attachment Interview, which was later coded by reliable raters for attachment security and reflective functioning (RF). Consistent with our predictions, children in the clinical group had significantly lower RF and were significantly more likely to have insecure (over 80%) and disorganized attachment (over 40%) than children in the comparison group. In addition, RF was significantly lower in children with DBD than children with SSD. Furthermore, in the SSD group, children's RF regarding self was significantly lower than RF regarding others. Finally, consistent with prior studies, RF and attachment were associated. The findings indicate that school-aged children with SSD and DBD have higher rates of insecure and disorganized attachment. Consistent with theory, RF and attachment were loosely coupled, but RF alone differentiated among the diagnostic subgroups. Implications for treatment and prevention are discussed.

Spinal Dural Arteriovenous Fistulas: Clinical Results and Quality of Life Assessment with Surgical Treatment as a Crucial Therapy. The Joint Experience of Two Centers.

OBJECTIVE: Dorsal intradural arteriovenous fistulas (AVFs) consist of a direct connection between a radicular feeding artery and the coronal venous plexus; this direct connection leads to arterialization of the venous plexus, venous congestion, and myelopathy. Controversy still exists regarding the best treatment modality of spinal dural AVFs. Surgical disconnection of spinal dural AVFs is a straightforward procedure with a high success rate and virtually no risk of recurrence or incomplete treatment. To identify factors associated with the clinical progression of dorsal intradural AVFs and quantify the range of surgical outcomes in terms of neurologic improvement as well as patients' perception of quality of life (QOL). METHODS: A retrospective observational study of 19 consecutive patients treated with surgery over a 10-year period was carried out. We analyzed surgical results and clinical outcomes. We also evaluated the impact of this disease and its sequelae on the patients' postoperative health-related QOL. RESULTS: The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL. CONCLUSIONS: Our series confirmed that surgical obliteration of dorsal intradural AVFs is an effective and safe procedure. The results of this retrospective analysis make us believe that surgery, given its low morbidity and high success rate, represents a safe and effective first therapeutic option for these spinal vascular malformations. It could be considered to avoid unsuccessful endovascular attempts that could delay the definitive treatment of this disease. The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL.

Domestic Violence in Separated Couples in Italian Context: Communalities and Singularities of Women and Men Experiences.

Relationship breakdown and separation represent a critical aspect in domestic violence. Few studies have investigated domestic violence in separated couples. Moreover, there is a need for a more in depth analysis of gender differences that could enhance the comprehension of the phenomenon. The primary aim of this research was to analyze, through a qualitative approach, which kinds of domestic violence are characteristic or major in separated couples in the Italian context, where this phenomenon has not yet been sufficiently investigated. Participants are 60 separated couples (mean age: M = 48; F = 44) who attended a Family Mediation Center. A descriptive study was conducted using grounded theory methodology. A brief narrative task was administered to both ex-partners separately. The transcriptions were analyzed using NVivo 11 software. From data analysis, some themes emerged regarding typology of domestic violence specific of the separation context and shared by both men and women. The analyses of gender differences showed that there is a gender specific experience of domestic violence. Results highlight that women narrate both physical and psychological violence, while men relate only psychological abuse focused on limiting access to children. We discuss these findings in relation to possible appropriate gender specific intervention and prevention efforts.

A Long-Term Psychological Observation in an Adolescent Affected with Gardner Diamond Syndrome.

Gardner-Diamond syndrome (GDS) is an uncommon disease clinically characterized by a wide spectrum of psycho-emotive symptoms associated with painful ecchymoses/purpuric lesions and positivity of auto-erythrocyte sensitization skin test. Herein, a perspective clinical and psychological observation of an adolescent GDS is firstly reported focusing on her psychological features long-term monitored for a 1-year period. The administration of a standardized tools battery allowed us to define psychological features of the young patient over time and to monitored clinical course and response to treatment.

When parenting fails: alexithymia and attachment states of mind in mothers of female patients with eating disorders.

INTRODUCTION: In recent years alexithymia and attachment theory have been recognized as two parallel research lines trying to improve the information on the development and maintenance of eating disorders (EDs). However, no research has analyzed these constructs among patients' families. In this study we compared alexithymia and attachment in mothers of patients with EDs and a control group. Further, we hypothesized that mothers of daughters with EDs with insecure and unresolved states of mind will reported high levels of alexithymia. Lastly, we explored the daughters' evaluations of maternal alexithymia. METHODS: 45 mothers of ED women and 48 mothers of healthy controls (N = 93) matched for age and socio-demographic variables were administered by the Toronto Alexithymia Scale-20 (TAS-20) (S), while two sub-groups of "ED" mothers (n = 20) and "non-ED" ones (n = 22) were assessed by the Adult Attachment Interview (AAI). Moreover, the Observer Alexithymia Scale (OAS) was administered to the daughters for evaluating maternal alexithymia. RESULTS: Regarding alexithymia, no differences were found between ED and non-ED mothers according to the TAS-20, while ED mothers showed more unresolved AAI classifications than non-ED mothers. No correlations were found between the TAS-20 and the AAI. Lastly, ED mothers were evaluated more alexithymic by their daughters with the OAS than those in the control group, and their alexithymic traits were significantly correlated with dismissing states of mind (idealization and lack of memory) in the AAIs. DISCUSSION: Our results highlighted an interesting discrepancy among mothers with ED daughters between the low level of alexithymia provided by their self-reports and the high level of alexithymia observed by their daughters, although the OAS showed severe methodological limitations. Maternal attachment states of mind characterized by the lack of resolution of past losses could be connected to a confusing and incoherent quality of parenting.

Emotion Dysregulation Mediates the Relation between Mindfulness and Rejection Sensitivity.

BACKGROUND: The role of rejection sensitivity (RS; the tendency to anxiously expect, readily perceive, and overreact to implied or overt interpersonal rejection) in psychopathology has mainly been studied with regard to borderline personality disorder (BPD). In the present study, we first sought to extend previous evidence of heightened RS in a clinical group with psychiatric disorders other than BPD, when compared with a community sample. Then, we tested whether emotion dysregulation and mindfulness were associated with RS in both sample, further hypothesizing that emotion dysregulation would mediate the relation between mindfulness deficits and RS. SUBJECTS AND METHODS: We adopted a cross-sectional design involving 191 psychiatric patients and 277 community participants (total N=468). All participants completed the Rejection Sensitivity Questionnaire, the Five Facet Mindfulness Questionnaire, and the Difficulties in Emotion Regulation Scale. RESULTS: Our hypotheses were supported, with psychiatric patients reporting greater levels of rejection sensitivity and emotion dysregulation, and lower level of mindfulness. Mindfulness deficits and emotion dysregulation explained a significant amount of variance in RS, in both samples. Finally, bootstrap analyses revealed that mindfulness deficits played an indirect effect on RS through the mediating role of emotion dysregulation. In particular, two different patterns emerged. Among psychiatric patients, an impairment in the ability to assume a non-judgmental stance towards own thoughts and feelings was related to RS through the mediation of limited access to emotion regulation strategies. Conversely, in the community sample, overall emotion dysregulation mediated the effect of lack of attention and awareness for present activities and experience on RS. CONCLUSIONS: Longitudinal studies could help in delineating etiological models of RS, and the joint role of deficits in mindfulness and emotion regulation should inform treatment programs.