Behavioral assessment of activity-based-anorexia: how cognition can become the drive wheel.

Anorexia Nervosa (AN) is a disorder with a dramatic impact on both the individual and society. Besides severe weight loss, excessive physical exercise and cognitive disturbances can be present in patients with AN as primary symptoms of the pathology or as secondary effects induced by physical and metabolic alterations. Mechanistic research in this field has taken advantage of a well characterized animal model, the activity-based anorexia model (ABA). ABA rodents and subjects with AN show clear behavioral and physiological similarities, but a throughout neurocognitive assessment of the model is still missing. Here, we review the available literature in the ABA field, highlighting similarities between ABA and AN at the behavioral, neurophysiological and cognitive level. Furthermore, based on availability, feasibility and adaptability of rodent behavioral protocols, we propose a set of neurocognitive assays that can be performed on the ABA. The proposed assessment represents an important step forward in the validation and extension of the ABA model, opening several routes of investigation related to AN and other eating disorders.

Differences in Symptom Burden Among Cancer Patients With Different Stages of Cachexia.

CONTEXT: Cancer patients with cachexia may suffer from significant burden of symptoms and it can severely impair patients' quality of life. However, only few studies have targeted the symptom burden in cancer cachexia patients, and whether the symptom burden differed in different cachexia stages is still unclear. OBJECTIVES: The aims of this study were to evaluate the symptom burden in cancer cachexia patients and to compare the severity and occurrence rates of symptoms among cancer patients with non-cachexia, pre-cachexia, cachexia, and refractory cachexia. METHODS: Advanced cancer patients (n = 306) were included in this cross-sectional study. Patients were divided into four groups, based on the cachexia stages of the international consensus. The M.D. Anderson Symptom Inventory added with eight more cachexia-specific symptoms were evaluated in our patients. Differences in symptom severity and occurrence rates among the four groups were compared using one-way ANOVA or Kruskal-Wallis test analyses. RESULTS: Lack of appetite, disturbed sleep, fatigue, lack of energy, and distress were the symptoms with highest occurrence rates and severity scores in all four groups and were exacerbated by the severity of cachexia stages. After confounders were adjusted for, significant differences were seen in symptoms of pain, fatigue, disturbed sleep, remembering problems, lack of appetite, dry mouth, vomiting, numbness, feeling dizzy, early satiety, lack of energy, tastes/smell changes, and diarrhea. CONCLUSION: This study identified higher symptom burden in cancer patients with cachexia and it increased with the stages of cachexia, which emphasized the importance of screening in multiple co-occurring symptoms for cachexia patients.

At the core of eating disorders: Overvaluation, social rank, self-criticism and shame in anorexia, bulimia and binge eating disorder.

This study examined the similarities and differences in eating psychopathology symptoms, overvaluation of body shape, weight and eating, general psychopathology, social comparison, self-criticism and shame, between AN, BN and BED patients. Also, the mediator effect of self-criticism and social comparison on the association between overvaluation and shame, was tested. Participants were 119 patients (34 AN, 34 BN and 51 BED) diagnosed through the Eating Disorder Examination. Results indicated that BED patients are older and present higher BMI. The groups differed regarding eating disorders' symptomatology, but no significant differences were observed in overvaluation, self-criticism, shame and overall psychopathology symptoms. The path model confirmed that overvaluation has a significant indirect association with shame, which is mediated by severe self-criticism and negative social comparisons. The model was fond to be invariant between the clinical groups. These findings contribute for the understanding of the common processes that feed the perpetual cycle of eating psychopathology. Thus, these data have potential implications for transdiagnostic approaches to treatment.

[Effects of inpatient treatment on eating disorder symptoms, health-related quality of life and personal resources in anorexia and bulimia nervosa]. / Effekte stationärer Psychotherapie auf Essstörungssymptomatik, gesundheitsbezogene Lebensqualität und personale Ressourcen bei Anorexia und Bulimia nervosa.

The aim of the present prospective-naturalistic study was the evaluation of psychosomatic inpatient treatment for anorexia nervosa (AN) and bulimia nervosa (BN). 128 patients with eating disorders (n=59 AN and n=69 BN) were investigated on admission and discharge using the following standardized questionnaires: eating disorder symptoms (EDI), general psychopathology (BSI), quality of life (SF-12), and personal resources (SOC-13, SWE). Moderate to large effect sizes were achieved for the eating disorder symptoms; in addition, general psychopathology was substantially reduced at the end of treatment, and quality of life as well as personal resources were enhanced. Personal resources were found to be the strongest predictors for therapy outcome. Based on our data, important insights and recommendations may be gained for the inpatient treatment of eating disorders, especially with regard to the potential influence of personal resources.

[Perception of social rank and submissive behavior in eating disorders]. / Percezione del rango sociale e comportamento sottomesso nei disturbi del comportamento alimentare.

OBJECTIVE: The aim of this paper is to study the social behavior in patients with eating disorders, in particular the presence of low social ranking and high submissive behavior. We also considered the relationship between these factors and the presence of some personality traits and pathological eating behaviors. METHOD: We performed a case-control study on 249 young women (124 controls and 125 eating disorders subjects). Eating disorders were diagnosed as anorexia nervosa, bulimia nervosa and eating disorders non otherwise specified. The patients underwent a routine assessment by means of a diagnostic interview and some self-reported questionnaires. All the subjects (cases and controls) also completed two scales for the assessment of social ranking and submissive behaviors. The two questionnaires were translated from English with the back-translation method. RESULTS: The two scales were valid and reliable in their Italian version. We observed a significant difference between cases and controls: social ranking was lower in cases, and submissive behavior was lower in controls. Social ranking had an inverse relationship with submissive behavior both in cases and controls, and a significant correlation was found with other interpersonal aspects (ineffectiveness, interpersonal sensitivity) and with some pathological traits and behaviors, like self-injurious behavior. CONCLUSION: Our study shows that features of low social ranking and submissive behavior are common in eating disorders subjects. These features could represent a risk factor for the development of an eating disorder or, on the contrary, represent a consequence of an eating disorder. A useful therapeutic approach to these disorders could be focused on shifting from submissive to assertive behavior.

How should DSM-V classify eating disorder not otherwise specified (EDNOS) presentations in women with lifetime anorexia or bulimia nervosa?

OBJECTIVE: Anorexia nervosa (AN) and bulimia nervosa (BN) are marked by longitudinal symptom fluctuations. DSM-IV-TR does not address how to classify eating disorder (ED) presentations in individuals who no longer meet full criteria for these disorders. To consider this issue, we examined subthreshold presentations in women with initial diagnoses of AN and BN. METHOD: A total of 246 women with AN or BN were followed for a median of 9 years; weekly symptom data were collected at frequent intervals using the Longitudinal Interval Follow-up Evaluation of Eating Disorders (LIFE-EAT-II). Outcomes were ED presentations that were subthreshold for 3 months, including those narrowly missing full criteria for AN or BN, along with binge eating disorder (BED) and purging disorder. RESULTS: During follow-up, most women (77.6%) experienced a subthreshold presentation. Subthreshold presentation was related to intake diagnosis (Wald chi2=8.065, df=2, p=0.018). Individuals with AN most often developed subthreshold presentations resembling AN; those with BN were more likely to develop subthreshold BN. Purging disorder was experienced by half of those with BN and one-quarter of those with AN binge/purge type (ANBP); BED occurred in 20% with BN. Transition from AN or BN to most subthreshold types was associated with improved psychosocial functioning (p<0.001). CONCLUSIONS: Subthreshold presentations in women with lifetime AN and BN were common, resembled the initial diagnosis, and were associated with modest improvements in psychosocial functioning. For most with lifetime AN and BN, subthreshold presentations seem to represent part of the course of illness and to fit within the original AN or BN diagnosis.

Symptoms in the palliative phase of children with cancer.

BACKGROUND: The aim of the study was to make a comprehensive inventory of the physical, psychological, and social symptoms of children with cancer and their parents during the palliative phase and the extent to which health professionals address those symptoms. PROCEDURE: Forty parents of children who died 1-3 years prior to data collection (structured questionnaire) were invited to participate in the study. RESULTS: The response rate was 32 out of 40 parents (80%). Most frequently mentioned physical symptoms were pain, poor appetite, and fatigue. The children's most mentioned psychological symptoms were sadness, difficulty in talking to their parents about their feelings regarding illness and death and fear of being alone. The symptoms of fear of death of the child and fear of physical symptoms were most frequently mentioned parents' psychological symptoms. Health professionals addressed 82% of the children's physical symptoms, 43% of the children's psychological symptoms, and 56% of the parents' psychological symptoms. Parents indicated that after professional attention the proportion of children's physical symptoms that were completely or partially resolved was 18 and 26%, respectively. For children's psychological symptoms the figures were 9 and 25%, respectively, and for parents' psychological symptoms 2 and 23%, respectively. CONCLUSIONS: The burden of symptoms of the child with cancer during the palliative phase and their parents is high. Health professionals focus mainly on the physical symptoms of the child. Relief of symptoms could not be achieved for a large proportion of symptoms. Further prospective research is necessary to investigate the kind, frequency and intensity of symptoms in order to tailor optimal palliative care to the needs of both child and parent.

Adults with terminal illness: a literature review of their needs and wishes for food.

Food refusal can be a source of conflict between dying people and their caregivers. This review examines: the nature and purpose of food; some reasons for and implications of anorexia in terminal illness; ethical principles underpinning responses to declining appetite and food refusal; social transactions between dying people and their caregivers in relation to needs and wishes for food; and the need for further empirical research. The nature and purpose of food in human societies has been studied extensively by anthropologists but the knowledge gained is not often imported into health care practice, where eating is seen from a medical rather than an anthropological perspective. Food refusal may be a consequence of anorexia which is the result of physiological or psychological changes or it may be a deliberate choice in acceptance of impending death. Ethical principles underpinning responses to declining appetite and food refusal have been studied extensively and clear guidance obtained about what would be appropriate behaviour in given circumstances. There is little published empirical work on social transactions between dying people and their caregivers in relation to needs and wishes for food. As the contribution made to effective care-giving by high-quality interpersonal relationships is widely recognized, further knowledge about how best to sustain such relationships in these important circumstances would be useful. Moreover, as such interpersonal relationships often occur in an institutional context, it may be that more can be learnt from close examination of social transactions about how best to structure organizational processes to maximize autonomy and comfort for patients at the end of life. Further research is indicated.

Using the eating disorder examination in the assessment of bulimia and anorexia: issues of reliability and validity.

OBJECTIVE: The Eating Disorder Examination will be assessed according to its reliability and validity in the assessment of anorexia nervosa and bulimia nervosa. METHOD: A thorough review of the literature was conducted to judge the reliability and validity of the Eating Disorder Examination and its subscales. RESULTS: The review shows that the EDE and its subscales have good interrater reliability and internal consistency reliability. Similarly, high levels of discriminant validity, construct validity, and treatment validity in the assessment of eating disorders were also found. A summary of each study concerning the various types of reliability and validity will be provided. CONCLUSIONS: The EDE is considered to be the "gold standard" by which to identify eating disorders, so this tool used in conjunction with other behavioral measures will be imperative for clinical social work practice.

[A multicenter study of expenditure and success in psychodynamic therapy of eating disorders. Study design and initial results]. / Eine multizentrische Studie zu Aufwand und Erfolg bei psychodynamischer Therapie von Essstörungen. Studiendesign und erste Ergebnisse. Studiengruppe MZ-ESS.

UNLABELLED: Evaluation of psychodynamically oriented treatment of anorectic and bulimic patients, taking into account both quality and cost of therapist ("How much therapy is applied to which patients for a successful treatment?"). Criteria for indication of the kind of therapy and of amount of therapy ("dosage") are provided. METHOD: Prospective naturalistic longitudinal study (comparable to phase IV of effectiveness studies on pharmaceuticals) including 2.5 year follow-up. Consecutive sample (Anorexia nervosa and bulimia nervosa, DSM-III-R). Multidimensional outcome measures including self-rating and expert-ratings. Operationalisation of outcome is layered. Differentiated measurement of amount of therapy and treatment elements. Survival analysis, logistic regression. RESULTS: 1171 completely documented treatment episodes of 43 institutions (30.3% Anorexia nervosa, 55.3% bulimia nervosa, 14.4% double diagnoses). Patients are chronically ill (M = 7.6 years; SD = 6.3 years) and at the beginning of (mostly inpatient) treatment of the index episode 25.5 years of age (SD = 6.0 years). Therapies last appr. 11 weeks (median) and encompass a broad range of therapy measures. DISCUSSION: Study conduction as well as data collection and analysis of this worldwide largest study on treatment of eating disorders is discussed by presenting preliminary results.

Nutritional assessment of drug addicts.

OBJECTIVE: To discern if factors such as organic pathology, sex, duration and/or intensity of drug addiction, alcohol abuse, hepatitis B infection, anorexia with poor food and drink consumption, or disturbance of social and familial networks, are related to an impaired nutritional status in hospitalized drug addicts. DESIGN: Cross-sectional prospective study. SETTING: Detoxication unit and internal medicine unit of a university hospital. PATIENTS: 140 drug addicts without acute organic pathology and 18 with acute organic pathology related to drug addiction. The immunological study was compared with a control group composed of 50 healthy and well-nourished individuals (26 women and 24 men), age-matched with our patients. RESULTS: Drug addicts without organic pathology were under-nourished: 92.4% weighed under the mean weight for the population and 55.7% had had a weight loss above 5%. The distribution of mid-upper arm circumference (MUAC), triceps skinfold (TSF) measurement and mid-arm muscle area (MAMA) compared with the percentiles for the population showed a shift towards lower values. We found a high percentage of patients with a high lymphocyte count (55%). Despite the high lymphocyte count, delayed hypersensitivity was depressed in our patients. Of our patients, 66.4% exhibited anorexia at admission. The mean calorific intake was 978 +/- 89 kcal/day in females and 1265 +/- 64 kcal/day in males. However, in most cases, malnutrition (usually marasmus-like malnutrition) was not very severe; only 30% of the drug addicts weighed less than 80% of the mean weight for the population, or admitted to a weight loss above 10%, and by subjective nutritional assessment, only 18% were deeply malnourished. Otherwise, the nutritional status was very poor in drug addicts with acute organic pathology. We also found a worse nutritional status in our patients related to female sex, intensity of drug addiction, anorexia with poor food and drink consumption, and disturbance of the social and familial networks. CONCLUSIONS: Many drug addicts suffer from calorie and protein malnutrition. This mainutrition is related to female sex, intensity of drug addiction, anorexia and poor food and drink consumption, and disturbance of the social and familial links. Acute organic pathology leads to a significant worsening of the nutritional status of drug addicts.

Anthropometric and biochemical assessment of the nutritional state in depression: evidence for lower visceral protein plasma levels in depression.

Severe depression is characterized by anorexia and weight loss, symptoms that could endanger the patient's nutritional state. In order to investigate the nutritional state of depressed patients we determined the following in 113 healthy controls and depressed inpatients: (1) anthropometric variables such as body weight, ideal body weight (IBW), percentage of IBW, mean arm circumference, triceps skinfold thickness and arm muscle circumference, and (2) biochemical parameters such as albumin (Alb), prealbumin (Prealb), and transferrin (Tf). We were unable to detect any differences in the anthropometric parameters between healthy controls, minor and major depressed patients. Depressed patients exhibited significantly lower Alb and Tf levels than healthy controls. The drop in both plasma proteins was highly sensitive (72%) and specific (92%) for melancholia. These results may point towards the existence of a disorder in protein homeostasis or protein malnutrition without a marasmic component.