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The Stress Response in Anorexia Nervosa

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Patients with eating disorders have been found to have problems with Interoceptive Awareness. This study seeks to examine this issue in an experimental paradigm. In the present study, we investigated the hypothesis that, in addition to lowering a body's autonomic stress response, a state of starvation also lowers the psychological stress response. Results indicated that those with anorexia nervosa showed a muted physiology, but they did not show a complete denial of negative emotion. No relation was seen, however, between their affective and physiological responses to a stress task, which contrasted results found for the controls.
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The Stress Response in Anorexia Nervosa
Samantha P. Miller, BA
Allison D. Redlich, PhD
Hans Steiner, Dr. med. univ.
Stanford University
ABSTRACT: Patients with eating disorders have been found to have problems with
Interoceptive Awareness. This study seeks to examine this issue in an experimental
paradigm. In the present study, we investigated the hypothesis that, in addition to
lowering a body’s autonomic stress response, a state of starvation also lowers the psy-
chological stress response. Results indicated that those with anorexia nervosa showed
amuted physiology, but they did not show a complete denial of negative emotion. No
relation was seen, however, between their affective and physiological responses to a
stress task, which contrasted results found for the controls.
KEY WORDS: affect regulation; stress response; anorexia nervosa; stress coping strate-
gies.
Previous research has shown that individuals with eating disorders
show difficulties self-regulating and coping with their emotions.
1,7,14
Patients are often described as having a lack of “Interoceptive Aware-
ness” manifesting itself in a deficient mapping of affect and autonomic
arousal.
1
In comparison, age-matched, non-clinical females have pre-
dictable responses to standardized stressors that link positive and
negative affect and autonomic arousal.
2
Difficulties in regulating and
coping can create a greater vulnerability to stressful life events that
have been associated with the commencement of anorexia.
14
In addi-
tion to patients’ less effective coping strategies, their stressed physiol-
ogy in response to standardized stressors also seems to have some
predictive value for the course of their illness, those patients who ex-
hibit more stress having poorer outcomes. For example, eating-disor-
dered patients who responded to a Stress Inducing Speech Task with
Address correspondence to Dr. med. univ. Hans Steiner, Department of Child & Ado-
lescent Psychiatry, Stanford University, 401 Quarry Rd., Stanford, CA 94305; e-mail:
steiner@stanford.edu.
Child Psychiatry and Human Development, Vol. 33(4), Summer 2003 2003 Human Sciences Press, Inc. 295
Child Psychiatry and Human Development296
higher cortisol levels faired worse (determined by weight and psycho-
logical functioning) on one- and two-year follow up assessments than
those patients who did not respond with cortisol levels quite as high.
7
Working under the assumption that the state of starvation lowers
the body’s autonomic stress response, the goal of the present research
was to investigate if the lowering of physiological arousal psychologi-
cally benefits the anorexic patient by lowering the psychological stress
response. The view that psychopathology contains, in part, potentially
adaptive features which serve to manage conflicting demands of a cer-
tain social environment is a uniquely, developmentally based view.
11
This conceptualization can be used to explain features of disorders
that render them especially difficult to treat, as is the case in anorexia
nervosa. During treatment, physicians often encounter paradoxical re-
sistance from their patients with anorexia nervosa.
4
Perhaps the disorder allows for stressors to be more easily man-
aged, thus explaining patients’ inclination to sustain an otherwise
devastating disorder. We hypothesized that 1) Those with anorexia
nervosa will be habitually more anxious and distressed than age-
matched, non-clinical controls. 2) Patients’ response during a stan-
dardized stressor will be muted in comparison to the control group
in both heart rate (autonomic arousal) and negative affect, reflecting
perhaps a defensive unwillingness to acknowledge their negative emo-
tions, especially with regards to anger and aggression. 3) When ex-
posed to a standardized stressor, a significant relationship between
autonomic arousal and affective self-ratings will emerge for those
without anorexia nervosa. Such will not be the case for the patients
with anorexia nervosa.
Method
Participants
Participants were 25 clinically diagnosed (DSM-III-R criteria) anorexic
girls. All participants were medically stable, ambulatory and partially weight
rehabilitated: mean weight 93.9 lbs. (SD: 14.9), range 57117 lbs., mean
height 64.3 in. (SD: 2.6), range 5968 in. The average Body Mass Index (BMI)
for the clinical population was 16.1. All participants were between the ages of
13–19: mean age 15.6 years (SD: 1.9). Findings were compared to standard-
ized norms of age appropriate, non-clinical female controls to examine differ-
ences between the two groups. The control group was recruited from Palo Alto
Samantha P. Miller, Allison D. Redlich, and Hans Steiner 297
High School in Palo Alto, CA. The control subjects consisted of 73 girls be-
tween the ages of 14 and 18: mean age = 16 (SD = 1.23).
10
Instruments
Weinberger Adjustment Inventory (WAI-84). This 84-item self-report instru-
ment measures personality characteristics and has been validated for use
with both clinical and non-clinical populations across a wide range of ages.
15
This nationally standardized inventory measures two primary dimensions
that are distress (anxiety, depression, low self-esteem, and low well-being)
and self-restraint (impulse control, considerations of others, suppression of
aggression, responsibility). The interactions of scores on these scales can be
used to predict different behavior potentials. These predictions can be essen-
tial in assessing environmental adjustment along the lines of neuroticism
(anxiety and depression) and resilience (impulse control vs. acting out). For
the purposes of this study, this questionnaire provides a baseline assessment
of certain personality dimensions within the subject.
Visual Analogue Arousal Scale (VAAS).
12
This 12-item measure indicates
how subjects are currently feeling. Subjects make a tic mark on a 100mm line
that ranges from one extreme of a feeling to the other (e.g., “very angry” to
“not at all angry”). This measures the subject’s current affective state.
10
The
eight negative affect dimensions (scared, worried, angry, sad, guilty, upset,
stressed, ashamed) and the four positive affective dimensions (excited, inter-
ested, pleased, happy) serve to measure stressful emotional arousal in a vi-
sual analogue format.
Stress Induced Speech Task (SIST). A psycholinguistic data collection proce-
dure proposed to study speech patterns,
12
was used to study verbal behavior
as it relates to psychopathology. It has been shown to produce speech samples
of adequate length and content in the majority of adults and child subjects. It
is a mildly to moderately stressful task in which subjects are asked to partici-
pate in two tasks. Each is a 10-minute audiotaped speech task on the follow-
ing topics: Stress Task (ST): The most traumatic situation that the speaker
has encountered in her past. Free Association Task (FA): An unstructured
free association period where the speaker discusses any topic of her choosing.
Procedure
Subjects completed the WAI. Subjects were then administered the SIST,
where presentation order of the two speech task were randomized. Heart rate
was measured at baseline (BL), 5 minutes into the FA, 10 minutes into the
FA, 5 minutes into the ST, and 10 minutes into the ST. Subjects completed
the VAAS at BL, after the FA, and after the ST.
Statistical Analyses
We employed Pearson product moment correlations as measures of associa-
tion and ANOVAs, t-tests with corrections for unequal variances and repeated
measures ANOVA as tests of dispersity, as appropriate.
Child Psychiatry and Human Development298
Results
Hypothesis 1) Those with anorexia nervosa will be habitually more
anxious and distressed than age-matched, non-clinical controls. Find-
ings from the WAI indicated that those with anorexia nervosa, scoring
well above the 50th percentile on most variables (Table 1), were in-
deed habitually more anxious and distressed then the age-matched
controls. Those with anorexia scored much higher on repressive defen-
siveness and self-restraint in comparison to denial of distress. This
result seems to show a habitual pattern among patients to avert at-
tention from negative emotional arousal and de-emphasize as ways
of defending themselves against psychological and interpersonal con-
flict.
Hypothesis 2) Patients’ response during a standardized stressor will
be muted in comparison to the control group in both heart rate (auto-
nomic arousal) and negative affect, especially with regards to anger
and aggression. Using repeated measures analysis of variance, there
Figure 1. Pulse Rate Comparison of Anorexics and Controls During the SIST
Samantha P. Miller, Allison D. Redlich, and Hans Steiner 299
Table 1
Subscales (distress measures 1–4, restraint measures 58) and
WAI Primary Dimensions (9–12)
Anorexic Control
Anorexic Raw Percentile Control Raw Percentile
Score (SD) Rank Score (SD) Rank
1) Anxiety** 28.29 (6.16) 85 24.03 (5.87) 60
2) Depression 21.92 (6.50) 75 19.19 (6.08) 55
3) Low self-esteem** 21.29 (7.61) 85 17.03 (6.49) 66
4) Low well-being** 19.58 (6.87) 85 15.13 (5.82) 60
5) Suppression of 26.50 (5.34) 55 26.19 (4.81) 50
aggression
6) Impulsivity 29.62 (4.66) 66 28.10 (4.59) 50
7) Consideration of 27.63 (4.68) 66 26.43 (4.27) 50
others
8) Responsibility 33.79 (4.05) 60 33.14 (5.06) 55
9) DEFENSIVENESS 27.79 (8.10) 66 25.76 (7.35) 55
10) DENIAL 22.75 (6.82) 30 23.39 (5.70) 30
11) DISTRESS** 89.83 (23.62) 90 73.00 (16.90) 60
12) RESTRAINT 116.74 (13.70) 60 112 (14.80) 50
** = p < .01.
was significant interaction in pulse rate between the two populations
at all points throughout the task, except at 5 minutes in to the ST: at
baseline F(1, 113) = 7.10, p < .01, at 5 minutes into the FA F(1, 113) =
6.72, p < .05, at 10 minutes into the FA F(1, 113) = 7.49, p < .01, and
at 10 minutes into the ST F(1, 113) = 4.95, p < .05. The between sub-
jects effects were F (1, 113) = 9.82, p < .01. There was a within subjects
effects for time with F (4, 452) = 2.86, p < .05 (see Figure 1). For the
positive emotions, there was only a trend of interaction at the baseline
VAAS assessment and for the within subject effects for time, but a
significant interaction between subject group and time F (2, 212) =
3.10, p < .05 (as seen in the differently shaped curves of Figure 2). For
the negative emotions, there was a significant interaction at BL F (1,
105) = 5.26, p < .05 and FA F (1, 105) = 10.66, p < .01. There was a
between subject effects, F (1, 105) = 5.31, p < .05 and a significant
within subject effects for subject group and time F (2, 210) = 5.60, p <
.01 (see Figure 3).
Those with anorexia showed a muted physiology (see Figure 1) at
all points throughout the tasks: at baseline t (113) =−2.66, p < .01,
five minutes into the FA t (113) =−2.59, p < .01, ten minutes into the
Child Psychiatry and Human Development300
Figure 2. Positive Affect Ratings on VAAS for Anorexics and Controls During
the SIST
FA t (113) =−2.74, p < .01, five minutes into the ST t (113) =−1.89,
p < .06, and ten minutes into the ST t(113) =−2.23, p < .03. Through-
out the SIST task, patients’ self-reported negative emotion was signif-
icantly higher than that of age-matched, non-clinical females at base-
line t (30.37) = 1.86, p < .04, and during the free association t (30.39) =
2.52, p < .00. Those with anorexia were also more likely to rate them-
selves as angry in comparison to the controls, especially at baseline
and free association. On the VAAS Anger variable: At BL, Anorexics =
17.9 (SD: 23.4), Controls = 11.4 (SD: 18.3). At FA, Anorexics = 19.4
(SD: 24.9), Controls = 12.9 (SD: 18.8). At ST, Anorexics = 17.4 (SD:
23.1), Controls = 17.8 (SD: 22.6). Patients’ positive emotion, while sim-
ilar in magnitude to control responses, presented a different curve,
reaching it’s peak during the FA and returning near BL during the
ST (see Figure 2).Contrary to our hypothesis, patients did not show a
complete denial of negative emotion (see Figure 3).
Hypothesis 3) When exposed to a standardized stressor a significant
congruence between arousal and affect is expected but only for non-
clinical controls.Aswould be reasonable to expect, controls reacted to
the two conditions by an increase of negative affect and a correspond-
ing decrease in positive emotion as the demands of the situation called
for a description of stressful events. With the exception of 5 minutes
into the FA, the control group maintains a stable heart rate. In con-
Samantha P. Miller, Allison D. Redlich, and Hans Steiner 301
Figure 3. Negative Affect Ratings on VAAS for Anorexics and Controls Dur-
ing the SIST
trast, patients show their highest heart rate during the ST, but a de-
crease in their expression of negative affect during the ST, returning
to near baseline levels. (see Tables 2, 3; Figures 1, 2, 3).
For controls, however, there were small, but significant correlations,
Table 2
Means and Standard Deviations for Heart Rate, Negative VAAS,
and Positive VAAS Ranges
Anorexics Controls
Heart rate range 17.08 (13.12) 22.13 (9.55)
Negative VAAS range 16.59 (11.16) 15.77 (13.48)
Positive VAAS range 21.85 (17.48) 18.02 (15.36)
Child Psychiatry and Human Development302
Table 3
Title clc center
Au: Please supply table title.
Free Association Stress Task
Baseline 5min 10min 5min 10min
Anorexic N = 25
Mean PULSE 68.4 (SD 14.7) 67.4 (SD 14.4) 66.4 (SD 15.1) 72.3 (SD 14.0) 68.1 (SD 16.9) (mean = 68.5)
Mean POS VAAS 52.2 (SD 19.6) 56.1 (SD 24.1) 52.9 (SD 22.7) (mean = 53.7)
Mean NEG VAAS 29.3 (SD 23.9) 33.4 (SD 26.2) 26.7 (SD 24.2) (mean = 29.9)
Correlation posvaas(.26) .14 .07 .22 .13
negvaas(.18 .01 .06 .05 .16
Controls N = 69
Mean PULSE 76.7 (SD 11.5) 78.1 (SD 13.9) 75.9 (SD 11.7) 76.3 (SD 13.9) 76 (SD 12.7) (mean = 76.6)
Mean POS VAAS 57.8 (SD 12.0) 54.9 (SD 17.1) 49 (SD 16.4) (mean = 53.9)
Mean NEG VAAS 22.2 (SD 15.1) 20.7 (SD 17.8) 24.7 (SD 18.3 242) (mean = 20.9)
Correlation 5 minutes into either task 10 minutes into either task
posvaas 0.2 0.13
negvaas 0.16 0.28**
*p .05.
Samantha P. Miller, Allison D. Redlich, and Hans Steiner 303
between positive and negative affective rating on the VAAS and pulse
rate throughout the SIST (see Table 3). Interestingly, the patients’
patterns of arousal and reported affect in the two conditions differed
from the controls’: their negative affect showed no increase in the
stress condition, whereas their heart rate showed a significant in-
crease, suggesting affect and arousal incongruence.
Discussion
In conclusion, it was confirmed that patients with anorexia nervosa
scored in the top percentile on measures of anxiety and distress on
the WAI. In addition, patients showed a muted physiology, most likely
due to their state of starvation and malnutrition, but did not show
a denial of negative emotion. Whereas affective response was clearly
present in similar (positive affect) if not greater (negative affect) mag-
nitude than the control populations, the shape of the clinical and non-
clinical affective curves were distinctly different. Patients’ decrease in
negative affect during the ST and increase during the FA may be ex-
plained by their anxiety regarding the vague, open-ended nature of
the FA. The ST, on the other hand, may have offered the patients,
who anecdotally adhere to structure, a defined topic on which to
speak, which may have had an unexpected calming effect.
3
In the case
that the narratives show a complete absence of a stressful event being
discussed, the greater magnitude of patients’ negative affect during
the task, decline in negative affect during the ST combined with a
distinctly elevated pulse during the ST may be explained by the fact
that previous research has shown that denial of expression, or hiding
a feeling may induce a physiological stress response, despite the ap-
pearance of a calmed affective self-report.
3
At the beginning of the protocol, controls’ displayed a slight eleva-
tion of heart rate, most probably due to an initial nervousness about
talking while being recorded. As the task progresses, controls’ positive
emotions decrease, while their negative emotions remain steady. In
contrast to this pattern of reaction, patients show a marked increase
in heart rate during the stressor; however, report the same amount of
negative emotion as at baseline. This shows a disconnect between self-
reported emotion and patients’ physiological response to the task. Per-
haps because patients’ heart rate is so significantly muted due to mal-
nutrition, despite the increase in heart rate during the ST, those with
anorexia nervosa do not get emotionally aroused by the stressor. In a
Child Psychiatry and Human Development304
sense, patients may have inadvertently created a physiological system
of minimal arousal for the “purpose” of minimizing their own psycho-
logical arousal, and thereby displaying the lack of Interoceptive Aware-
ness of which the literature speaks. It is a possibility that the clinical
group’s lack of responsiveness to the stressor task reflected their com-
fort in discussing negative experiences due to their status as psychiat-
ric patients.
Despite the presence of negative affect, there were no significant
correlations between any of the patients’ affective responses and their
physiology. This differed from the control population that showed sig-
nificant correlations between affect and physiology throughout the
task. From these results, it may be inferred that anorexia nervosa,
rather than serving to mute affective response, creates a disconnect-
ion between the two processes. By muting the autonomic arousal lev-
els, a state of starvation may be self-reinforcing by creating a state in
which negative events or stressors may be more easily managed and
more positively viewed, as seen in the decrease in negative emotion
reported by the patients during the ST. This would make starvation
an adaptive reaction to certain stressors, thus making anorexia ner-
vosa a difficult disease to relinquish. On the other hand, despite the
fact that affective and physiological processes appear to be incongru-
ent in those with anorexia nervosa, however this result may be con-
founded by the small power of this limited sample size. An increase in
the anorexic cell size may result in trends similar to that of the control
group, but, while the magnitude of association may decrease, an in-
crease in error must also be accounted for.
Weaknesses of the study include that fact that no males were in-
cluded, there was a small sample size, no continuous arousal measure
was used, and there were no follow-up assessments. In addition, there
was no return to baseline between speech tasks. Also, without a clini-
cal comparison group, one cannot assume that it is the anorexia ner-
vosa per se driving the findings or simply psychiatric distress. Finally,
causality between physiology and affective response cannot be in-
ferred, rather this investigation highlights a relationship that could
go in either direction. Strengths of the study include the linking of in
vitro with self-report, examining the processes by which patients might
have difficulty with stressful events, and adding to the existing,
sparse literature on pathophysiology and psychopathology of anorexia
nervosa. In conclusion, these results may expose possible mechanisms
by which those with anorexia nervosa react under stress, thereby
serving both clinical application and future research.
Samantha P. Miller, Allison D. Redlich, and Hans Steiner 305
Summary
In our study, we found that girls with eating disorders have prob-
lems with Interoceptive Awareness as measured in an experimental
paradigm. We investigated the hypothesis that, in addition to lower-
ing a body’s autonomic stress response, a state of starvation also low-
ers the psychological stress response. Results mostly in line with our
expectation: those with anorexia nervosa showed a muted physiology,
a lack of relationship with affective self-appraisal, but contrary to our
predictions, they did not show a complete denial of negative emotion.
These results were different from controls. Our data also has implica-
tions for clinical practice. In order to help these young women on their
road to recovery, we could focus on a new target for intervention in
girls with anorexia nervosa. Working more directly with anorexic pa-
tients on making their subjectively experienced affect and their objec-
tively measured arousal more congruent. Such a goal could help these
patients in using their emotions, especially negative ones, to better
navigate their interpersonal and intra-psychic environment. By ex-
ploring with patients a series of possible motivations to adhere to their
status quo (avoidance of intra-psychic and interpersonal conflict, un-
comfortable emotional states), professionals could help patients achieve
recovery. Finally, tasks similar to the one presented in this study
could be used as a subtle process measure of therapeutic progress and
an indicator for recovery, using patients’ increasing affect and physio-
logical congruence. Professionals could then follow up patients’ task
results who are and are not completely recovered, and make more
finely graded judgements about prognosis.
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... A link between emotional experience and the behavioral expression of AN is clear: potential emotion is avoided by eliciting predictable and controllable behavioral patterns from others ; focus on food, eating, weight, and shape, as well as cognitive processes such as worry and rumination, affords cognitive distraction from negative thoughts/emotion (Sternheim et al., 2011;Startup et al., 2013). Once starved, suppressed physiological experience numbs emotions and is valued (Miller et al., 2003(Miller et al., , 2009Serpell et al., 2004); while starvation and emaciation enables a maladaptive expression of distress (Serpell et al., 2004) and ever-narrowing interpersonal life fuels greater reliance on AN (Schmidt and Treasure, 2006). Systematic reviews of emotional experience in AN expand on this understanding by providing summaries of experimental and self-report data (Oldershaw et al., , 2015Lavender et al., 2015), integrating pre-existing theory from the field of emotion regulation (Aldao et al., 2010;Gross, 2013). ...
... Starvation perpetuates difficulties via its influence on physiological feedback from the body. People with AN struggle to discriminate between bodily sensations (Skǎrderud, 2007), with limited access to physiological experience of emotion when underweight (Miller et al., 2003). Interoceptive cues are abnormally interpreted, resulting in erroneous judgments about internal bodily states (Kaye et al., 2009) and an imbalance between external and internal perception of body relating to ED symptomatology severity (Eshkevari et al., 2014). ...
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... Consistent with the present findings, literature data (for a review see Monteleone et al., 2018a) suggest that people with EDs have higher levels of negative affect either before or after social stress exposure, according to the evidence of emotion regulation difficulties in EDs (Mallorqui-Baguè et al., 2018). Furthermore, in agreement with the present results, previous studies did not find significant relationships between cortisol and anxiety responses to TSST in individuals with AN (Het et al., 2015;Miller et al., 2003Miller et al., , 2009 or with binge-eating disorder (BED) (Rosenberg et al., 2013). Therefore, it can be concluded that the cortisol response to a psychosocial stressor is not associated with anxiety perception. ...
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Objective: Body image disturbances and the attendant negative emotions are two of the major clinical symptoms of eating disorders. The objective of the present experimental study was to shed more light on the degree of association or dissociation between the physiological and emotional response to mirror exposure in patients with restrictive mental anorexia, and on the relationships between the physiological response and characteristics connected with emotional processing. Materials and Methods: Thirty adolescent girls with the restrictive type of anorexia and thirty matched healthy controls underwent bilateral measurement of skin conductance (SC) during rest, neutral stimulus exposure, and mirror exposure, and completed a set of measures focused on emotion regulation competencies, affectivity, and eating disorder pathology. Results: Compared to healthy controls, girls with restrictive anorexia rated mirror exposure as a subjectively more distressful experience. Differences in skin conductance response (SCR) were not significant; however, variance in SCR was substantially greater in the group of anorexia patients as compared to healthy controls. The overall skin conductance level (SCL) was lower in anorexia patients. Increase in SCR during mirror exposure, as opposed to exposure to neutral stimuli, was positively related to the tendency to experience negative emotions, interoceptive sensitivity, body dissatisfaction and suppression, but not to other symptoms of eating pathology or emotional awareness. A post hoc analysis suggested that physiological reactivity might be associated with interoceptive sensitivity to mirror exposure especially in anorectic patients. Conclusion: The study seems to demonstrate some degree of dissociation between psychophysiological reactivity and subjective response to body exposure in patients with restrictive anorexia. Factors affecting differences in psychophysiological responsiveness to body exposure in anorectic patients require further exploration.
... These results support the idea that AN patients have difficulty evaluating positive stimulus intensity and that they present a dissociation between objective and subjective measures of hedonic processes. These findings are partially in accordance with Miller et al. (2003), who observed that AN patients lacked a relationship with affective self-appraisal, unlike the control participants. Such a dissociation was also observed by Soussignan et al. ...
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Introduction Anorexia nervosa (AN) is a severe psychiatric illness with alarming mortality rates. Nevertheless, despite former and recent research results, the etiology of AN is still poorly understood. Of particular interest is that, despite exaggerated response control and increased perfectionism scores, patients with AN seem not to perform better that those unaffected in tasks that require inhibitory control. One reason might be aberrant processing of errors. The objective of our study was thus to obtain further insight into the pathopsychology of AN. We were particularly interested in neuronal and autonomic responses during error processing and their association with behavior. Methods We analyzed 16 acute patients suffering from restrictive type AN and 21 healthy controls using functional magnetic resonance imaging (fMRI) with simultaneous physiological recordings during a Go/Nogo response inhibition task. Data were corrected for noise due to cardiac and respiratory influence. Results Patients and controls had similarly successful response inhibition in Nogo trials. However, in failed Nogo trials, controls had significantly greater skin conductance responses (SCR) than in correct Nogo trials. Patients did not exhibit elevated SCR to errors. Furthermore, we found significantly increased neuronal responses, especially in the amygdala and hippocampus, in controls compared to patients during error trials. We also found significant positive correlations in controls but not in patients between Nogo performance and activation in the salience network core regions after errors. Conclusion Acute restrictive type AN patients seem to lack neuronal and autonomic responses to errors that might impede a flexible behavior adaption.
... Due to this starvation, AN patients show on a variety of tasks reduced activity in the prefrontal cortex, a brain region involved in ER [146][147][148][149][150]. A neuroimaging study revealed less activation in the dorsolateral prefrontal cortex (dlPFC) when using cognitive reappraisal, suggesting dlPFC hypoactivity when processing affective stimuli might be a vulnerability factor for AN [132]. Furthermore, this study also found that fronto-amygdalar connectivity was negatively associated with overall eating disorder severity and endorsed difficulties in emotion regulation in patients with AN. [151,152] found that low body weight is also associated with limited access to physiological experience of emotions, moreover these emotions are experienced as vague and overwhelming. A recent study found that lower BMI was associated with less ER difficulties in women who suffer from acute AN [138]. ...
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Objective Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders. Method A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns. Results 41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN. Conclusions Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.
... S ocioemotional impairments constitute a crucial and widely described dimension of anorexia nervosa (AN) and have a detrimental impact on treatment outcomes and prognosis (Arcelus et al., 2013;Oldershaw et al., 2010;Schmidt and Treasure, 2006;Zucker et al., 2007). The facets of socioemotional functioning that seem to be compromised in AN include a poor awareness of personal emotion (Miller et al., 2003;Parling et al., 2010), deficits in the processing of emotional information including the perception of one's own emotions and the perception of the emotions of others (Connan et al., 2003;Courty et al., 2015), emotion regulation difficulties (Hambrook et al., 2012;Harrison et al., 2010), and a reduced capacity to tolerate emotional distress (Brockmeyer et al., 2014). Another aspect of socioemotional impairments in AN is the ability to respond empathically to the emotions of other people (Beadle et al., 2013;Morris et al., 2014). ...
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The present research examined a model that evaluates the mediating role of both intrapersonal and interpersonal emotional competences (ECs) between attachment insecurity and the cognitive and emotional dimensions of empathy in patients with anorexia nervosa (AN). Women with AN completed the Experiences in Close Relationships Scale, the Profile of Emotional Competence, the Interpersonal Reactivity Index, the State-Trait Anxiety Inventory, and the Beck Depression Inventory. The results revealed that intrapersonal EC mediated the relationships between attachment insecurity (i.e., attachment anxiety and attachment avoidance) and emotional empathy in patients with AN. Importantly, a high emotional empathy in AN was associated with increased depression and anxiety symptoms. The results also indicated that a high level of attachment avoidance was indirectly associated with lower cognitive empathy through lower levels of interpersonal EC in AN. The present study emphasizes the importance of differentiating affective empathy from cognitive empathy and suggests clinical interventions in patients with AN.
... Several studies document difficulties with interoceptive awareness in AN. These difficulties include reduced sensitivities to sensations of hunger and satiety, 144e146 difficulty recognizing signs of physiological stress such as an increased heart rate 147,148 and altered processing of taste and pain. 149,150 Patients with AN also show differences in integrating visual and proprioceptive information. ...
Chapter
This chapter provides a review of the main clinical alterations of body representation in neurological and psychiatric diseases. First, we describe instances of altered body representations in neurological conditions, either constrained to a specific body part (e.g., personal neglect, somatoparaphenia, phantom limbs) or impacting the whole body (autoscopic phenomena, feeling of a presence). In the second part of this chapter, we present body representation disorders associated with chronic pain and psychiatric conditions including anorexia nervosa, schizophrenia, and gender dysphoria. Beyond their clinical relevance, these conditions provide valuable insights into understanding the way our body is normally represented, and the way it is consciously experienced.
... Several studies document difficulties with interoceptive awareness in AN. These difficulties include reduced sensitivities to sensations of hunger and satiety, 144e146 difficulty recognizing signs of physiological stress such as an increased heart rate 147,148 and altered processing of taste and pain. 149,150 Patients with AN also show differences in integrating visual and proprioceptive information. ...
... In addition to body size estimation tasks, several other methods of assessment have been performed. Therefore, literature on AN tried to expand the available knowledge on the analysis of the different senses that are involved in body representations, including haptic perception [30,31], altered interoceptive awareness [32,33], integration of visual and proprioceptive information [34][35][36], and tactile stimuli [37,38]. For a review on this topic, see Gaudio and Quattrocchi [39]. ...
Chapter
Anorexia nervosa (AN) is a severe mental illness with largely unknown etiology. It is characterized by disordered eating behaviors leading to extremely low body weight. Body image is also severely distorted in AN so an altered body image is a hallmark of this disorder. Body image has been theorized as a multidimensional construct with attitudinal and perceptual dimensions representing entrenched aspects in determining and evaluating one’s own body size and shape. Body image disturbances play a role as risk, maintaining, and relapse factors in AN. Broadly speaking, the available body of evidence shows that patients with AN overestimate their body sizes when compared to healthy individuals. Also, it remains unclear as to whether the disturbance in body perception refers only to patients’ own body or not. Literature is overall sparse on the neural basis of body image disturbances in AN. However, posterior parietal regions have been linked to perceptive body attitudes while prefrontal and insula regions resulted as mainly involved in affective body attitudes. Also, dorsolateral prefrontal cortex, supplementary motor, insular, inferior parietal, fusiform, occipito-temporal and cingulate regions have been found to be involved in body image processing in AN. The available therapeutic approaches for body image in AN showed encouraging results although larger controlled studies are needed to replicate current findings. At now, mainly cognitive behavioral interventions exist, delivered in both individual and group setting also including mirror exposure. Clinical research is warranted since body image disturbances impact also on long-term outcome of AN.
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The development and validation of a new measure, the Eating Disorder Inventory (EDI) is described. The EDI is a 64 item, self-report, multiscale measure designed for the assessment of psychological and behavioral traits common in anorexia nervosa (AN) and bulimia. The EDI consists of eight sub-scales measuring: 1) Drive for Thinness, 2) Bulimia, 3) Body Dissatisfaction, 4) Ineffectiveness, 5) Perfectionism, 6) Interpersonal Distrust, 7) Interoceptive Awareness and 8) Maturity Fears. Reliability (internal consistency) is established for all subscales and several indices of validity are presented. First, AN patients (N = 113) are differentiated from female comparison (FC) subjects (N = 577) using a cross-validation procedure. Secondly, patient self-report subscale scores agree with clinician ratings of subscale traits. Thirdly, clinically recovered AN patients score similarly to FCs on all subscales. Finally, convergent and discriminate validity are established for subscales. The EDI was also administered to groups of normal weight bulimic women, obese, and normal weight but formerly obese women, as well as a male comparison group. Group differences are reported and the potential utility of the EDI is discussed.
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After several decades of dedicated research, the precise relationship between psychological and physiological components of acute stress response is still not known (Elliott et al., 1982). The problem is of particular interest for three reasons: (1) Psychological stimuli are among the most powerful activators of physiological stress responses (Mason, 1975). (2) Coping and defense mechanisms are able to protect the organism from arousal (Lazarus, 1964) or even prevent lethal consequences of hormonal stress response (MacLennan et al., 1983). (3) Without proper knowledge of the relationship between these variables, significant progress in stress response is unlikely. Individual responses show a wide variability, impeding experimental exploration. It is thought that this variability is at least in part a function of the large number of unknown mediators in the response. And, in turn, a great number of those mediators are psychological (Elliott et al., 1982).
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