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Eating disorders (EDs) are syndromes with a multifactorial etiopathogenesis, involving childhood traumatic experiences, as well as biological factors. Human microbiome has been hypothesised to play a fundamental role, impacting on emotion regulation, as well as with eating behaviours through its metabolites such as short chain fatty acids (SCFAs). The present study investigated the interactions between psychopathology of EDs, the gut microbiome and SCFAs resulting from bacterial community metabolic activities in a population of 47 patients with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder and in healthy controls (HCs). Bacterial gut microbiota composition differences were found between subjects with EDs and HCs, especially in association with different pathological behaviours (binge-purge vs restricting). A mediation model of early trauma and ED-specific psychopathology linked reduction of microbial diversity to a typical microbiota-derived metabolite such as butyric acid. A possible interpretation for this model might be that childhood trauma represents a risk factor for gut dysbiosis and for a stable modification of mechanisms responsible for SCFAs production, and that this dysfunctional community is inherited in the passage from childhood to adulthood. These findings might open the way to novel interventions of butyric acid-like compounds as well as faecal transplant.

Purpose Recent studies demonstrated that the embodiment disorder represents a core feature of eating disorders (EDs). The aim of this study was to evaluate the role of its variation as a possible mediator of the efficacy of enhanced cognitive behavioural therapy (CBT-E) on classic ED symptomatology, including body uneasiness. Methods 73 patients with anorexia nervosa and 68 with bulimia nervosa were treated with a multidisciplinary approach including CBT-E. Psychometric questionnaires were administered at baseline (T0) and after one (T1) and 2 years (T2) to evaluate general and ED-specific psychopathology, body uneasiness and the embodiment disorder. Data regarding diagnostic crossover and remission were also collected. Results Longitudinal analysis showed an improvement of all psychopathological dimensions at T1, which remained stable at T2 ( p  < 0.05). Remission rate at T2 was 44.7%, and diagnostic crossover occurred in 17.0% of patients. Higher levels of embodiment disorder predicted increased diagnostic instability (OR: 1.80 [1.01–3.20], p  = 0.045). The amelioration of the embodiment disorder mediated the decrease in both ED-specific psychopathology (indirect effect: 0.67 [0.46–0.92]) and body uneasiness (indirect effect: 0.43 [0.28–0.59]). Conclusion For the first time, these findings highlighted the role of the embodiment disorder as a maintaining factor of ED symptomatology, supporting the importance of integrating CBT-E with a phenomenological model of EDs. Level of evidence Level IV, longitudinal observational study (case series).

Purpose Orthorexia is a recent construct describing an unhealthy and extreme concern for healthy food. To date, its relationship with other eating disorders (EDs) remains unclear, and little is known about the development of this condition. Current literature suggests that a thorough knowledge about nutrition and alimentation, as in the case of experts in the field of dietetics, could foster the development of orthorexic tendencies. The aim of this study was to compare orthorexia between ED patients, student dietitians and general population. Methods A total of 90 female participants (age: 18–29 years) were recruited: 30 ED patients, 30 student dietitians and 30 control subjects, matched for age and sex. Orthorexia, ED-specific and general psychopathology were evaluated using self-report questionnaires (ORTO-15, Eating Disorder Examination Questionnaire and Symptom Checklist-90-Revised). Results Eating disorder patients had significantly higher orthorexic tendencies than other groups ( p  < 0.001), while student dietitians and general population showed no difference between each other ( p  = 0.96). Moreover, orthorexia positively correlated to ED psychopathology in ED patients ( p  = 0.004), but not in control groups. Conclusion Our data do not confirm previous suggestions that experts in the field of dietetics may display a higher level of orthorexia. Level of evidence Level IV, cross-sectional observational study (case series).

Purpose Adolescence represents a critical period for the onset of eating disorders (EDs). The present study aimed to provide the prevalence of individuals at risk for EDs psychopathology in a representative population of adolescents aged 14–19 and to characterize this population regarding interpersonal and psychological factors. Methods The percentage of participants at risk for EDs in a representative high school population was assessed through the SCOFF screening questionnaire (cut-off score: 3) in the total sample (N: 6551) and in gender-based subgroups for different body mass index (BMI) categories. Odds ratios for being at risk of ED (SCOFF ≥ 3) were esteemed in a multivariable analysis including self-reported parental education, quality of family and peer relationships, bullying victimization, age at first sexual intercourse, and psychological distress. Results A SCOFF score ≥ 3 was found in 31.0% of participants (boys: 19.4%; girls: 44.6%), with a greater prevalence among higher BMI categories. Bad family relationships, being bullied, having the first sexual intercourse before the age of 14, and experiencing high distress were associated with this risk condition. Among girls, bad peer relationships were associated with a low-risk SCOFF score. Conclusion A remarkable percentage of adolescents reported significant body image or eating concerns. Screening programs are deeply needed, and particular attention should be devoted to interpersonal factors, such as the quality of family relationships and interactions with peers, which represent potential indicators of this vulnerability. Level of evidence Level V – Cross-sectional study.

Background/Objectives: Dialectical Behaviour Therapy (DBT) has emerged as a promising intervention for Eating Disorders (Eds), especially Binge Eating Disorder (BED), which is often characterized by severe emotion dysregulation. The aims of this study were to evaluate the longitudinal course of BED symptomatology following a group-based DBT intervention focused on two specific modules, Emotion Regulation and Distress Tolerance, and to examine the mediating role of emotion dysregulation and alexithymia in symptom improvement. Methods: This non-randomized longitudinal clinical study involved 170 patients with BED who received a 16-week DBT group treatment including modules targeting emotion regulation and distress tolerance. Self-report questionnaires were administered at baseline (T0) and at the end of treatment (T1). Linear mixed models were used to analyze the longitudinal trend, and a mediation analysis was conducted to examine whether changes in emotion dysregulation and alexithymia mediated symptom improvement. Results: Longitudinal analyses showed a significant reduction in BED symptoms at the end of treatment as well as in the levels of emotion dysregulation and alexithymia. Mediation analyses revealed that both emotion dysregulation (indirect effect: −0.68 [−1.20; −0.31]) and alexithymia (indirect effect: −0.59 [−1.33; −0.20]) significantly mediated the improvement in BED symptoms over time. Conclusions: These findings support the application of focused DBT group interventions targeting emotion regulation and distress tolerance in reducing BED symptomatology. Emotion dysregulation and alexithymia were identified as mediators of longitudinal clinical improvement, highlighting the importance of modular and precision-based approaches in the treatment of BED.

Anorexia Nervosa (AN) is characterized by body image distortion. From a phenomenological perspective, body image disturbance has been associated with a more profound disturbance encompassing disorders of the way persons experience their own body. The aim of this study was to disentangle the complex dynamics that connect the experience of one’s own body and self-identity to the psychopathological features of AN by applying a network analysis. Fifty-seven patients with AN restrictive subtype and 27 with AN binge–purging subtype participated in the study. Eating Disorders Inventory-2 and Identity and Eating Disorders subscores, measuring the embodiment dimensions, were included in the network. Two of the main dimensions of embodiment—feeling extraneous from one’s own body and feeling oneself through objective measures—were the nodes with the highest strength together with interoceptive awareness (IA). IA was a node included in several pathways connecting embodiment dimensions with most of the AN psychopathological dimensions. The centrality of the embodiment disorder suggests the importance of considering the body image disturbance in people with AN as resulting from their difficulty in experiencing inner states and as a tool to build its own self. This assumption may orient therapeutic interventions.

Purpose Individuals with anorexia nervosa (AN) and bulimia nervosa (BN) frequently exhibit Non-Suicidal Self-Injury (NSSI), yet their co-occurrence is still unclear. To address this issue, the aim of this study was to elucidate the role of impairments in interoception in explaining the NSSI phenomenon in AN and BN, providing an explanatory model that considers distal (insecure attachment/IA and traumatic childhood experiences/TCEs) and proximal (dissociation and emotional dysregulation) risk factors for NSSI. Method 130 patients with AN and BN were enrolled and administered self-report questionnaires to assess the intensity of NSSI behaviors, interoceptive deficits, IA, TCEs, emotional dysregulation and dissociative symptoms. Results Results from structural equation modeling revealed that impairments in interoception acted as crucial mediators between early negative relational experiences and factors that contribute to NSSI in AN and BN, particularly emotional dysregulation and dissociation. Precisely, both aspects of IA (anxiety and avoidance) and various forms of TCEs significantly exacerbated interoceptive deficits, which in turn are associated to the emergence of NSSI behaviors through the increase in levels of dissociation and emotional dysregulation. Conclusions The proposed model provided a novel explanation of the occurrence of NSSIs in patients with AN and BN by accounting for the significance of interoception. Level of evidence : Level V–Cross-sectional observational study.

Purpose Clinical studies describe a higher risk in individuals with Gender Dysphoria (GD) to engage in disordered eating practices, as well as dietary restraint. To the present day, clinical assessments on eating psychopathology in GD are principally oriented towards assessing behaviors, rather than the lived experience underlying these behaviors. Methods A sample of 141 individuals with GD (40 assigned male at birth—AMAB, 101 assigned female—AFAB), 153 individuals from the general population and 294 patients with AN were enrolled. Body Uneasiness Test (BUT), the Eating Disorders Examination Questionnaire (EDE) and the Identity and Eating Disorders questionnaire (IDEA) were administered. Analysis of variance and linear models were employed to estimate group differences, adjusted for age, education, and body mass index. Results Body uneasiness (BUT global severity index: F value 47.44, p < 0.001), and eating behaviors (EDE total score: F value 66.19, p < 0.001) lied on a spectrum of severity between patients with AN (highest), individuals with GD (elevated) and the general population. Patients with AN reported markedly greater embodiment disturbances in comparison with both the general population and AMAB or AFAB individuals with GD (IDEA total score: minimum T value 4.03, p < 0.001). However, AMAB individuals with GD also reported moderate embodiment disturbances in comparison with the general population (IDEA total score: T value 3.41, p < 0.01). Discussion Lived experiences may better highlight core differences between GD and clinical populations of patients with eating disorders. Embodiment disturbances were also reported by AMAB individuals, suggesting a role for gendered expectations in embodiment. Level of evidence III, evidence obtained from cohort or case–control analytic studies.

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.