Emotional imagination of negative situations: Functional neuroimaging in anorexia and bulimia.

AIM: The present study aims to extend the knowledge of the neural correlates of emotion processing in first episode subjects affected by anorexia nervosa (AN) or bulimia nervosa (BN). We applied an emotional distress paradigm targeting negative emotions thought to be relevant for interpersonal difficulties and therapeutic resistance mechanisms. METHODS: The current study applied to 44 female participants with newly diagnosed AN or BN and 20 matched controls a neuroimaging paradigm eliciting affective responses. The measurements also included an extensive assessment comprising clinical scales, neuropsychological tests, measures of emotion processing and empathy. RESULTS: AN and BN did not differ from controls in terms of emotional response, emotion matching, self-reported empathy and cognitive performance. However, eating disorder and psychopathological clinical scores, as well as alexithymia levels, were increased in AN and BN. On a neural level, no significant group differences emerged, even when focusing on a region of interest selected a priori: the amygdala. Some interesting findings put in relation the hippocampal activity with the level of Body Dissatisfaction of the participants, the relative importance of the key nodes for the common network in the decoding of different emotions (BN = right amygdala, AN = anterior cingulate area), and the qualitative profile of the deactivations. CONCLUSIONS: Our data do not support the hypothesis that participants with AN or BN display reduced emotional responsiveness. However, peculiar characteristics in emotion processing could be associated to the three different groups. Therefore, relational difficulties in eating disorders, as well as therapeutic resistance, could be not secondary to a simple difficulty in feeling and identifying basic negative emotions in AN and BN participants.

Affectionless control: A parenting style associated with obesity and binge eating disorder in adulthood.

OBJECTIVE: Obesity is rising globally with a heavy health and economic burden. Early attachment experiences are relevant to the development of obesity. The purpose of this study was to investigate if parental care and attachment style experienced in childhood is associated with obesity, with or without binge eating disorder (BED), in adulthood. METHOD: Parental style, personality traits, and psychopathology were assessed in 810 clinically referred adults with obesity, of whom 357 with BED and 453 without BED (non-BED), and 463 healthy subjects (HS). Assessments included the Parental Bonding Instrument, Temperament and Character Inventory, Eating Disorder Inventory-2, Symptom Checklist-90 and Beck Depression Inventory-II. RESULTS: Both BED and non-BED reported lower maternal and paternal care and higher overprotection than HS. BED reported worse levels of parental care than non-BED and HS. 'Affectionless control' parenting style was more frequently reported by both BED and non-BED than HS. No significant differences in parenting style emerged between BED and non-BED. CONCLUSIONS: Perception of parental 'affectionless control' was associated with obesity in adults, and lower quality of parental care was more frequently reported by participants with BED. Parental style may constitute an important target for early interventions to prevent obesity.

The song of Anorexia Nervosa: a specific evoked potential response to musical stimuli in affected participants.

PURPOSE: Research applying electroencephalography (EEG) to Anorexia Nervosa (AN) is still limited, even though in other psychiatric disorders EEG has permitted to find out the hallmarks of the disorder. The aim of the study was to explore whether EEG basal activity and reactivity to musical stimulation differ in participants with AN as compared to healthy subjects (HS). METHODS: Twenty female participants (respectively 10 with AN and 10 healthy controls) were administered a battery of psychometric tests and underwent EEG under three different conditions: (1) at baseline; (2) after a generic music stimulation; and (3) after a favorite musical stimulation. RESULTS: In participants with AN, basal EEG showed the higher absolute amplitude of cortical slow waves (theta) in the parieto-occipital and temporal derivations, with a deficit in the beta band. In AN, there was a higher N100 latency and a reduced P300 latency compared to HS. While the N100 and P300 latencies were sensitive to the musical stimulus in HS, there was no difference after music stimulation in AN. CONCLUSION: These data suggest that AN is accompanied by a state of brain hyperarousal with abnormal reactivity to environmental stimuli, similar to the state of HS after musical stimulation. If confirmed, this finding may have treatment implications. LEVEL OF EVIDENCE: III, Evidence obtained from well-designed cohort or case-control analytic studies.

Development and validation of the Premorbid Childhood Traits Questionnaire (PCT-Q) in eating disorders.

PURPOSE: Some features of eating disorders (EDs) are often present in childhood before the onset of the ED. We developed a novel questionnaire to retrospectively capture such childhood traits. METHODS: Focus groups were conducted at the University of California-San Diego, USA, and at the University of Turin, Italy. Three focus groups were conducted at each site, interviewing patients and parents to identify those traits that most commonly characterize childhood of patients with EDs. A preliminary version of the Premorbid Childhood Traits Questionnaire (PCT-Q) derived from these focus groups was then administered to 94 consecutive inpatients with an ED and to 286 healthy controls (HCs) at the Turin site. Also, 208 participants' parents were enrolled as well; in fact, the PCT-Q was developed with both a proband and an informant version. RESULTS: A 37-item final version of the PCT-Q was generated. Reliability analyses suggested acceptability for harm avoidance (HA), social phobia, alexithymia, interoceptive awareness (IA), and food obsessions. Inter-rater reliability ranged from fair to moderate. ED sufferers scored significantly higher than HCs on HA, social phobia, alexithymia, IA, and food obsessions. CONCLUSIONS: These findings support the possibility that premorbid traits contribute to a risk to develop an ED in some individuals. LEVEL OF EVIDENCE: III: case-control analytic study.

Therapeutic alliance in inpatients with severe anorexia nervosa.

OBJECTIVE: Therapeutic alliance (TA) is a relevant aspect in anorexia nervosa (AN), but data on inpatients are lacking. We aimed to evaluate the influence of motivation to change, diagnostic subtypes, and duration of illness on TA at hospital discharge; we also investigated if baseline clinical characteristics were associated with discharge TA, and the TA-outcome association. METHOD: We enrolled 137 adult inpatients with AN completing Eating Disorder Examination-Questionnaire, Beck Depression Inventory, State-Trait Anxiety Inventory, Anorexia Nervosa Stages of Change-Questionnaire, EuroQoL-Quality of Life Scale-Visual Analogue Scale, and Working Alliance Inventory-Short Revised. RESULTS: Patients with different AN subtypes and duration of illness reported similar TA. Baseline depression, state anxiety, and motivation to change were statistically significantly associated with TA at discharge. After controlling for all these variables and duration of illness, only motivation to change remained statistically significant. Statistically significant correlations were also found between improvements in body mass index and quality of life and discharge TA. CONCLUSIONS: Few data exist on TA in inpatients with AN and a long duration of illness. Our findings suggest that baseline motivation to change correlates with TA at discharge independently of other variables. Future studies should ascertain as to whether a causal link exists or not.

Neuronal variability of Resting State activity in Eating Disorders: increase and decoupling in Ventral Attention Network and relation with clinical symptoms.

BACKGROUND: Despite the great number of resting state functional connectivity studies on Eating Disorders (ED), no biomarkers could be detected yet. Therefore, we here focus on a different measure of resting state activity that is neuronal variability. The objective of this study was to investigate neuronal variability in the resting state of women with ED and to correlate possible differences with clinical and psychopathological indices. METHODS: 58 women respectively 25 with Anorexia Nervosa (AN), 16 with Bulimia Nervosa (BN) and 17 matched healthy controls (CN) were enrolled for the study. All participants were tested with a battery of psychometric tests and underwent a functional Magnetic Resonance Imaging (fMRI) resting state scanning. We investigated topographical patterns of variability measured by the Standard Deviation (SD) of the Blood-Oxygen-Level-Dependent (BOLD) signal (as a measure of neuronal variability) in the resting-state and their relationship to clinical and psychopathological indices. RESULTS: Neuronal variability was increased in both anorectic and bulimic subjects specifically in the Ventral Attention Network (VAN) compared to healthy controls. No significant differences were found in the other networks. Significant correlations were found between neuronal variability of VAN and various clinical and psychopathological indices. CONCLUSIONS: We here show increased neuronal variability of VAN in ED patients. As the VAN is relevant for switching between endogenous and exogenous stimuli, our results showing increased neuronal variability suggest unstable balance between body attention and attention to external world. These results offer new perspective on the neurobiological basis of ED. Clinical and therapeutic implication will be discussed.

Childhood emotional abuse and neglect in obese patients with and without binge eating disorder: Personality and psychopathology correlates in adulthood.

The link between childhood traumatic experiences such as sexual and physical abuse and EDs in adulthood has been widely demonstrated. To date, however, little research focused on the association between emotional abuse and neglect in childhood and Binge Eating Disorder (BED) and obesity in adulthood. We enrolled 127 patients [84 with BED and 43 obese] and 45 healthy controls (HCs). All participants were administered the same battery of psychometric tests. Between-group differences were explored and the relationship between emotional abuse and neglect in childhood and personality and psychopathology in adulthood was tested. Obese patients showed higher scores in emotional abuse and neglect and sexual abuse when compared to HCs. Within obese participants, those with BED reported higher emotional abuse and emotional neglect than obese without BED and HCs; the BED group differed in physical and sexual abuse from obese participants. The association between traumatic experiences in childhood and obesity in adulthood has been confirmed independently of the type of trauma. Therapists should take into account the traumatic etiology of BED, in particular psychological abuse, even in those patients who do not recall physical or sexual abuses. Specific techniques to approach traumatic experiences could be applied to BED or non-BED patients.

Perfectionism and cognitive rigidity in anorexia nervosa: Is there an association?

Little is known about the relationship between neuropsychology, personality, and eating psychopathology in anorexia nervosa (AN). We aimed to investigate the interaction between set shifting and perfectionism in AN and to ascertain the role of perfectionism as a mediator between set shifting and eating psychopathology. Eighty-five patients with AN and 71 healthy controls completed Eating Disorder Inventory-2 (using 8 as a cut-off for generating groups with high vs. low perfectionism), Beck Depression Inventory, Wisconsin Card Sorting Test, Trail Making Task, and Hayling Sentence Completion Task. Our findings support heightened cognitive inflexibility in individuals with AN, particularly in those with high perfectionism. Perfectionism resulted to be a mediator of the relationship between a measure of set shifting and drive for thinness, but this finding did not remain significant when including in the model only those with AN. Taken together, these data suggest a complex and nonexclusive association between set shifting, eating psychopathology, and perfectionism.

Affective temperaments in anorexia nervosa: The relevance of depressive and anxious traits.

BACKGROUND: Affective temperaments have been so far understudied in anorexia nervosa (AN) despite the relevance of personality and both affective and anxious comorbidity with regard to vulnerability, course, and outcome of this deadly disorder. METHODS: Ninety-eight female inpatients diagnosed with AN and 131 healthy controls (HCs) were enrolled in this study and completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in addition to assessments of eating psychopathology, depression, and anxiety. RESULTS: AN patients and HCs differed in all affective temperaments. The diagnostic subtypes of AN differed as well with binge-purging individuals being more cyclothymic and anxious than those with restricting-type AN. TEMPS-A scores correlated with body mass index and eating psychopathology but not with duration of illness. Concerning comorbidity, grater scores on the depressive and lower scores on the hyperthymic temperaments were found in depressed patients. Those who had either an anxious or irritable temperament were significantly more diagnosed with an anxious disorder than those who did not show this temperament. When logistic regression was performed, high depressive/low hyperthymic and high irritable/anxious traits resulted to be associated with depressive and anxious comorbidity, respectively, independently of confounding factors. LIMITATIONS: Cross-sectional design, some patients on medications, few baseline clinical differences between diagnostic subtypes, no other personality assessments. CONCLUSIONS: An affective continuum strongly associated with mood and anxious comorbidity emerged in AN. Such an evaluation could have several research and clinical implications given the need of improving treatment individualization and early interventions for such a complex disorder.

Psychopathological Functioning Levels (PFLs) and their possible relevance in psychiatric treatments: a qualitative research project.

BACKGROUND: Symptoms description is often not enough to provide clinicians with guidelines for treatments and patients' clinical history does not represent an exhaustive source of data. Psychopathological dysfunctions are known to relate to the core disturbances that underlie different forms of psychopathology so the identification of such dysfunctions could be helpful for treatments. Some tools are available although highly complex and lengthy. This study aimed to provide clinicians with an easy-to-administer instrument able to capture different levels of impairment in psychopathological functioning, namely the Psychopathological Functioning Levels - Rating Scale (PFL-RS). METHODS: The Psychopathological Functioning Level - Research and Training Committee (PFL-RTC) has been established in Turin since 2002 including psychiatrists and clinical psychologists with extensive clinical and research experience. Our research was grounded on the Qualitative Research Criteria (QRC) 1-7 and conducted with subsequent steps in order to identify those core psychopathological dysfunctions to be rated by this tool. RESULTS: From 2002 until 2014, 316 outpatients were administered the clinical interview on at least two different occasions. Diagnoses were mixed and included: Schizophrenic and Psychotic Disorders, Depressive Disorders, Anxiety Disorders, Obsessive-Compulsive Disorder, Post- Traumatic Stress Disorder, Somatic Symptoms Disorders, Eating Disorders and Personality Disorders. Focus groups were conducted to identify those psychopathological dysfunctions which needed to be rated, according to two Phenomenological Selection Criteria (PhSC) and four Etiopathogenetic Selection Criteria (EtSC). As a result, five dysfunctional areas emerged: Identity (ID); Comprehension (CO); Negative Emotions (NE); Action-Regulation (AR); Social Skills (SS). After checking such dimensions for consistency with the existing instruments, 7 levels of severity were identified for each area. Finally, a provisional Italian schedule of Psychopathological Functioning Levels - Rating Scale (PFL-RS) was obtained and checked for semantic comprehension and then administered gathering preliminary data. CONCLUSIONS: Psychopathological dysfunctions underlying mental disorders have been recognized in the present study with the PFL-RS. This instrument seems promising to inform in a specific way treatments strategies and goals, specifically concerning psychotherapy. Notwithstanding, further research is needed in order to confirm validity, sensitivity and reliability of this instrument.

Is Anorexia Nervosa a Disorder of the Self? A Psychological Approach.

The debate concerning the pathogenesis and the maintaining factors of eating disorders, anorexia nervosa in particular, is ongoing especially since therapeutic interventions do not result in satisfactory and enduring rates of remission. This paper presents a model for the pathogenesis of eating disorders, based on the hypothesis of a deficiency in the development of the self. We present the theory in light of new evidence concerning the role of attachment insecurity in the development and maintenance of eating disorders. In particular, we define the self in eating disorders in a comprehensive way by taking into account recent evidence from experimental psychology and neurobiology. The paper considers the development of the self in terms of its synchronic (i.e., experienced in the moment) and diachronic (i.e., experienced as continuous over time) aspects. Both synchronic and diachronic aspects of the self are relevant to the expression of eating disorder symptoms. Further, the maturation of the self is interwoven with the development of attachment functioning from infancy to adolescence. This interplay between these developmental processes of the self and of attachment could be crucial in understanding the pathogenesis of eating disorders. The final part of the paper suggests a neurobiological link between the theory of the self in the eating disorders and the spatiotemporal functioning of the brain. Disturbances in spatiotemporal functioning may represent the neurobiological pathway by which deficiencies in the self is related to attachment functions in individuals with eating disorders.

A factor analysis of the meanings of anorexia nervosa: intrapsychic, relational, and avoidant dimensions and their clinical correlates.

BACKGROUND: Anorexia nervosa (AN) is a difficult to treat disorder characterized by ambivalence towards recovery and high mortality. Eating symptomatology has a sort of adaptive function for those who suffer from AN but no studies have to date investigated the relationship between the reported meanings of AN and patients' clinical characteristics. Therefore, we aimed to perform a factor analysis of a new measure testing its psychometric properties in order to clarify whether subjective meanings of AN can be related to AN severity, to ascertain if some personality traits correlate with the meanings attributed to AN by patients, and finally to verify to what extent such meanings relate to patients' duration of both illness and treatment. METHODS: Eighty-one inpatients affected by AN were recruited for this study and clinical data were recorded. Participants were asked to complete a novel instrument, the Meanings of Anorexia Nervosa Questionnaire (MANQ) focused on the measurement of values that patients attribute to AN and other measures as follows: Eating Disorders Inventory-2, Beck Depression Inventory, Temperament and Character Inventory, and Anorexia Nervosa Stages of Change Questionnaire. RESULTS: As measured by the MANQ, body dissatisfaction, problems of adolescence, and distress at school or work mainly triggered the onset of AN. Balance and self-control were mostly reported as meanings of AN while the most frequent negative effects were: being controlled by the illness, obsessive thoughts about body shape, and feeling alone. Differences were found between diagnostic subtypes. When a factorial analysis was performed, three factors emerged: intrapsychic (e.g., balance/safety, self-control, control/power, way to be valued), relational (e.g., communication, way to be recognized), and avoidant (e.g., the avoidance of negative feelings, emotions, and experiences). These factors correlated with patients' personality and motivation to treatments but were unrelated to duration of both illness and treatments. CONCLUSIONS: Given the ego-syntonic nature of AN, the understanding of patients' value of their disorder could be relevant in treatment; moreover, the positive value of AN resulted to be unrelated to the duration of both illness and treatments. Future research is warranted to replicate these findings and test their clinical implications.

A comprehensive review of psychodynamic treatments for eating disorders.

PURPOSE: To comprehensively review the existing literature on the effectiveness of psychodynamic psychotherapies in eating disorders (EDs) and to stimulate both debate and research on this topic. METHODS: Online and hand searches were conducted to identify papers published between 1980 and 2015 on psychodynamic treatments delivered to adults with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). RESULTS: A total of 47 studies were finally included in this review. Fifteen studies were available for AN, 9 for BN, 12 for BED, and 11 for samples with mixed diagnoses. Several methodological flaws emerged, but overall psychodynamic interventions showed promising results at the end of treatment and follow-up, when available. CONCLUSIONS: The body of literature on psychodynamic treatments is sparse and sometimes methodologically questionable; nevertheless, current data provide support to the effectiveness of these interventions, particularly for AN. However, both a defined approach (focus, themes, and techniques) and randomized controlled trials (RCTs) are warranted to clarify the effectiveness of psychodynamic psychotherapies.

The relationship between cortical thickness and body mass index differs between women with anorexia nervosa and healthy controls.

Anorexia nervosa (AN) is a severe psychiatric disorder characterized by extreme underweight. Studies conducted with structural MRI found reductions in brain volumes in several areas, but results are mixed. Cortical thickness has shown in other samples specific correlations with BMI in different BMI ranges. In this study, we applied a well validated procedure implemented in Freesurfer software toolkit to investigate cortical thickness in a sample of 21 patients with AN and 18 healthy controls, focusing on group differences and on the relationship between BMI and cortical thickness. Cortical thickness was reduced in patients with AN, but group differences did not survive correction for multiple comparisons. The relationship between BMI and cortical thickness was significantly different in patients with AN compared to controls in the left superior parietal/occipital cortex and left post central cortex. These findings suggest that the relationship between cortical thickness and BMI in patients with AN with less than two years of illness duration significantly differs from that in controls and possible biological mechanisms that may explain this relationship are discussed.

Exploring Parental Bonding in BED and Non-BED Obesity Compared with Healthy Controls: Clinical, Personality and Psychopathology Correlates.

Early inadequate attachment experiences are relevant co-factors in the development of obesity and Binge Eating Disorder (BED), which often concurs with obesity. The relationship of parental bonding with personality and psychopathology may influence treatment strategies for obese subjects, either affected or not with BED. In this study, 443 obese women (BMI ≥ 30 kg/m(2)), including 243 with and 200 without BED, and 158 female controls were assessed with regards to attachment, personality and eating psychopathology measures. Clusters obtained using the scores of the Parental Bonding Instrument (PBI) were compared with each other and with a control subjects' group. Lower scores of parental bonding distinguished obese subjects with respect to healthy controls. The cluster analysis revealed two clusters of parenting among obese subjects. The larger one displayed intermediate care and overprotection between controls and the smaller cluster, with the exception of paternal overprotection which is similar to controls. This larger cluster was characterized by low persistence and levels of psychopathology which are intermediate between healthy controls and the smaller cluster. The smaller cluster displayed lower care and higher overcontrol from both parents. It also displays more extreme personality traits (high novelty seeking and harm avoidance, and lower self-directedness and cooperativeness) and more severe eating and general psychopathology. Different parenting dynamics relate to different personality patterns and eating psychopathology of obese subjects, but not to binge eating conducts. Personality differences between parenting clusters are more extensive than those between BED and non-BED subgroups. The two different typologies of obese subjects based on parenting may be relevant for treatment personalization.

Parents' personality clusters and eating disordered daughters' personality and psychopathology.

The present study explores how parents' personality clusters relate to their eating disordered daughters' personality and psychopathology. Mothers and fathers were tested with the Temperament Character Inventory. Their daughters were assessed with the following: Temperament and Character Inventory, Eating Disorder Inventory-2, Symptom Checklist-90, Parental Bonding Instrument, Attachment Style Questionnaire, and Family Assessment Device. Daughters' personality traits and psychopathology scores were compared between clusters. Daughters' features were related to those of their parents. Explosive/adventurous mothers were found to relate to their daughters' borderline personality profile and more severe interoceptive awareness. Mothers' immaturity was correlated to their daughters' higher character immaturity, inadequacy, and depressive feelings. Fathers who were explosive/methodic correlated with their daughters' character immaturity, severe eating, and general psychopathology. Fathers' character immaturity only marginally related to their daughters' specific features. Both parents' temperament clusters and mothers' character clusters related to patients' personality and eating psychopathology. The cluster approach to personality-related dynamics of families with an individual affected by an eating disorder expands the knowledge on the relationship between parents' characteristics and daughters' illness, suggesting complex and unique relationships correlating parents' personality traits to their daughters' disorder.

Does depression matter in neuropsychological performances in anorexia nervosa? A descriptive review.

OBJECTIVE: This review aims to examine the impact of depressive symptoms on the assessment of cognitive flexibility, central coherence, and decision-making in individuals with anorexia nervosa (AN). METHOD: An online search was carried out using PubMed and PsycInfo. Articles were selected for review if they were published in English between 1990 and 2014 and used the Wisconsin Card Sorting Test, the Trail Making Task parts A and B, the Brixton Test, the Rey-Osterrieth Complex Figure Test, and/or the Iowa Gambling Task. RESULTS: Sixty-two studies were included. Thirty (48%) of the studies statistically assessed the association between depression and neurocognition in AN versus healthy controls. Where significant correlations were found, it became clear that the more serious the depression, the greater the neuropsychological impairment. Only six (10%) studies examined whether increased depressive symptoms were able to eliminate the differences between individuals with AN and healthy controls, and one study found that depressive symptoms did eliminate group differences in cognitive flexibility and decision-making. DISCUSSION: Only a subgroup of articles on neuropsychology in AN adjusted for depression. However, given the role of depression that some articles suggest, future studies should pay closer attention to the evaluation of this potential confounder.

Brain correlates of alexithymia in eating disorders: A voxel-based morphometry study.

AIMS: Alexithymia is a personality trait that consists of difficulty in identifying and acknowledging one's own and others' feelings. Recent studies reported that alexithymia is present in both anorexia (AN) and bulimia nervosa (BN). Brain morphological studies on healthy subjects showed that alexithymia correlates with several brain regions involved in emotions processing. The aim of this study was to investigate the anatomical correlates of alexithymia in AN and BN. METHODS: We performed a voxel-based morphometry study on 21 patients with AN and 18 with BN. Seventeen healthy subjects were used as a control group. Alexithymia, depression and anxiety were assessed with self-administered questionnaires and correlated to gray matter (GM) density in each group. RESULTS: In BN, alexithymia was correlated with the GM of the parietal lobe, in particular of the right angular gyrus. The correlation was predominantly linked with Difficulty Describing Feelings. In AN, we did not find correlations between GM and alexithymia. CONCLUSIONS: In BN, our results support the hypothesis that this trait may represent a relevant pathogenic or maintenance factor that contributes to relational difficulties, present in this pathology. In AN, the lack of correlation between GM volume and alexithymia may be influenced by atrophy in several brain regions that in turn can be, as previously reported, a consequence of caloric restriction. Also, the nature of alexithymia may be different from that of BN and controls and this trait could be secondary to a psychopathologic process specific to AN.

Day Hospital Treatment for Anorexia Nervosa: A 12-Month Follow-up Study.

Day hospitals (DHs) represent a treatment option for anorexia nervosa (AN), a mental disorder that is difficult to treat and has no evidence-based treatments available. We aimed to determine the effectiveness of a DH treatment that was specifically focused on the emotions of severe AN patients. Body mass index and eating psychopathology were the primary outcome measures. Fifty-six adult patients with AN were assessed upon admission, at the end of treatment (EOT) and at a 12-month follow-up evaluation (T18) using Eating Disorders Inventory-2, Beck Depression Inventory, Hamilton Rating Scale for Anxiety and Brief Social Phobia Scale. All participants received a multidisciplinary treatment programme that focused on psychodynamic psychotherapy. Seventy-eight per cent of participants reported positive outcomes at EOT and 68% at T18. Moreover, 82.1% and 65.4% of long-standing patients showed positive outcomes at EOT and T18, respectively. All measures of psychopathology were significantly improved at EOT and were maintained at follow-up. Our DH was effective at treating severe AN patients; however, further investigations of the processes of change are warranted.

Binge-eating disorder diagnosis and treatment: a recap in front of DSM-5.

INTRODUCTION: Binge Eating Disorders is a clinical syndrome recently coded as an autonomous diagnosis in DSM-5. Individuals affected by Binge Eating Disorder (BED) show significantly lower quality of life and perceived health and higher psychological distress compared to the non-BED obese population. BED treatment is complex due to clinical and psychological reasons but also to high drop-out and poor stability of achieved goals. The purpose of this review is to explore the available data on this topic, outlining the state-of-the-art on both diagnostic issues and most effective treatment strategies. METHODS: We identified studies published in the last 6 years searching the MeSH Term "binge eating disorder", with specific regard to classification, diagnosis and treatment, in major computerized literature databases including: Medline, PubMed, PsychINFO and Science Direct. RESULTS: A total of 233 studies were found and, among them, 71 were selected and included in the review. REVIEW: Although Binge Eating Disorder diagnostic criteria showed empirical consistency, core psychopathology traits should be taken into account to address treatment strategies. The available body of evidence shows psychological treatments as first line interventions, even if their efficacy on weight loss needs further exploration. Behavioral and self-help interventions evidenced some efficacy in patients with lower psychopathological features. Pharmacological treatment plays an important role, but data are still limited by small samples and short follow-up times. The role of bariatric surgery, a recommended treatment for obesity that is often required also by patients with Binge Eating Disorder, deserves more specific studies. Combining different interventions at the same time does not add significant advantages, planning sequential treatments, with more specific interventions for non-responders, seems to be a more promising strategy. CONCLUSIONS: Despite its recent inclusion in DSM-5 as an autonomous disease, BED diagnosis and treatment strategies deserve further deepening. A multidisciplinary and stepped-care treatment appears as a promising management strategy. Longer and more structured follow-up studies are required, in order to enlighten long term outcomes and to overcome the high dropout rates affecting current studies.