The authors have not supplied their declaration of competing interest.

Rumination is a common phenomenon among ruminant animals but in humans, it is always regarded as a symptom indicative of abnormal function of the upper gastrointestinal track. It is characterized by recurrent regurgitation of recently ingested food into the mouth. This syndrome was previously described in children and adults with mental retardation, but this entity is becoming increasingly recognized in children, adolescents and adults with normal mental capacity.

The authors describe a clinical case of a 51-year-old woman with rumination syndrome and bulimia nervosa.

A detailed report of the clinical case was made as well as a literature review of articles published in Pubmed/Medline on the topic “Rumination syndrome” and “Merycism”.

The authors describe a clinical case of a 51-year-old woman who began ruminative behavior when she was 10 years old, describing the regurgitation of the swallowed food back to her mouth shortly after eating and the re-chewing of it. She states that the regurgitated food tastes the same as when she ate it and she denies any pleasure associated with this behavior. When she was 17 years old, by the time she was pregnant, she started bulimic behavior and, as the rumination, it never ceased. Her medical history is significant for chronic gastritis and type 2 diabetes mellitus.

Although rare, merycism is an entity in the clinical practice of eating disorders. With this work, the authors share this case report as well as information concerning this topic.

The authors have not supplied their declaration of competing interest.

Anorexia nervosa (AN) is characterized eating behaviors and body image disturbances. Given poor treatment outcomes are available for AN, treatment innovations are urgently needed. Recently, non-invasive neuromodulation tools have suggested having potential for reducing AN symptomatology targeting brain alterations.

The objective was to verify whether an excitatory transcranial direct current stimulation (tDCS) over the left prefrontal cortex may aid in altering/resetting inter-hemispheric balance in AN patients, re-establishing control over eating behaviors.

Research is aimed to evaluate the potential of tDCS treatment in determining a more rapid improvement compared to classical treatments in adolescents with AN.

Twenty-two adolescents with AN, underwent the treatment as usual (AU) plus the tDCS treatment (TDCS + AU: n = 8, age M 13.7 ± 1.9 years) or a family therapy (FT + AU: n = 14, age M 15.1 ± 1.75 years), for six weeks. Psychopathological scales (EDI-III, EAT 26, BUT, MASC, CDI) and anthropometric indicator of nutritional status (BMI) were assessed before and after treatment.

BMI improved only in the TDCS + AU group (P < 0.01). Mean BMI percentage of improvement was 14.43% + 10.8 in the TDCS + AU and 4.83% ± 5.4 in the FT + AU. Both groups improved in the total scores of the EDI, EAT-26, MASC and CDI scales (all P < 0.01).

tDCS treatment improved BMI values more than classical treatment and determined comparable to the classical treatment improvement in the psychopathological scales. This results may be an important starting point to further explore the beneficial effect of brain based treatments for AN.

The authors have not supplied their declaration of competing interest.

Body image is a multidimensional concept that has assumed a significant role in eating disorders in which affective and perceptual distortions have been documented. Obesity is not a psychiatric disorder according to DSM-5 but several studies highlighted the presence of body image diseases in obesity.

The aim of this work is to evaluate the presence of body uneasiness in obese seeking for Bariatric surgery and to correlate it with psychopathological symptoms, psychosocial and anamnestic variables.

From June 2014 to June 2016, we enrolled 537 Bariatric surgery candidates. Body image was investigated using the Body Uneasiness Test (BUT-A), a 34-item self-report questionnaire which measures weight phobia (WP), body image concerns (BIC), avoidance (A), compulsive self-monitoring (CSM), detachment and depersonalization (D). Psychopathological symptoms and personality traits have been evaluated using SCL90R and MMPI-2.

Descriptive analyzes showed that BUT subscales were altered in most of our sample. Correlations of Pearson underlined significant associations between BUT subscales and SCL90R subscales. No correlation was found between BMI, marital status and BUT scores, while young, female and unemployed people had more difficulties with body.

Our data highlight the presence of considerable body uneasiness in obese, correlated with the severity of psychiatric symptoms but independent from the severity of obesity. This seems to reflect the mind-body split detected both in obesity and in eating disorders. Therefore, a multidisciplinary integrated approach including psychological work on cognitive, emotional and perceptual aspects of body image will help patients to improve coping with corporeal changes achieved through surgery.

The authors have not supplied their declaration of competing interest.

Gender is crucial in many aspects of life, including attitude towards body image perception. Although the well-known female preponderance, recent studies demonstrate an increasing Eating Disorders (EDs) incidence in males but scant literature attention.

This study aims to highlight the growing phenomenon of EDs in males and shed light on sex-related clinical features and psychiatric comorbidities.

Out of 280 persons aged 18–74, consecutively referred to Bologna's outpatients EDs clinic, 267 were included in this retrospective observational study.

The men/women ratio was one to five. The most frequent EDs in males was Binge Eating Disorder, whereas in females Anorexia Nervosa and Bulimia Nervosa prevailed. Excessive exercising and fasting were the most common dysfunctional behaviors in men, while self-induced vomiting and laxative-diuretic abuse were more typical in women. Mood and Somatoform Disorders were more common in women, whereas Anxiety and Psychosis Disorders in males. Within personality disorders, borderline and histrionic prevailed in female, while narcissistic and anti-social in males.

Male compared to female EDs, show differences in clinical presentation, symptoms and comorbidities. The increased proportion of affected men should alert general practitioners, clinicians and psychologists working in non-specialized settings to be more aware of the possibilities of encountering an ED in men and of the need of exploring the eating habits in all male patients. The finding of a more pronounced physical hyperactivity in men in order to achieve an ideal body shape which is muscular and athletic suggests the need of a deeper attention to sex-different symptoms and behaviors declination.

The authors have not supplied their declaration of competing interest.

Growing research show that body image-related shame plays a particularly important role in the vulnerability to and persistence of Binge eating symptoms. Also, shame experiences from childhood and adolescence were found to function as traumatic memories and are significantly associated with eating psychopathology. Nonetheless, little is known about the effect of shame traumatic memories in Binge Eating Disorder (BED), and whether early positive emotional memories of warmth and safeness may buffer against the impact of shame memories on body image shame.

This study examined the moderator effect of positive emotional memories on the association between shame traumatic memories and current body image shame in women diagnosed with BED.

Participants (N = 109) were assessed through the eating disorder examination and the shame experiences interview, and answered to self-report measures assessing the traumatic features of a key shame memory, positive emotional memories s and body image shame.

Body image-related experiences were most frequently recalled as significant shame memories. Positive emotional memories were negatively associated with shame traumatic memories and body image shame, and had a significant moderator effect on the association between shame traumatic memories and current body image shame.

This study was the first to demonstrate that early shame experiences may contribute for BED patients’ shame based on their body image. Data suggest that the access to memories of early feelings of affiliation and safeness may be key to tone down negative affect. These findings have important implications for the conceptualization and treatment of BED.

The authors have not supplied their declaration of competing interest.

On the onset of adolescence there is an increased vulnerability for mental health problems, namely disordered eating symptomatology. Disordered eating symptomatology has been described as a problem of psychological inflexibility. Psychological inflexibility related to eating behaviors, i.e., the adoption of inflexible idiosyncratic dietary rules without considering external and internal contingencies, is associated with disordered eating symptoms in adult populations. Nonetheless, the study of psychological inflexibility related to eating behaviors in adolescence is scarce.

The current study aimed at examining the factor structure and psychometric properties of the Inflexible Eating Questionnaire for Adolescents (IEQ-A).

Participated in this study, 728 adolescents (513 girls and 215 boys), aged 14 to 18 years, who completed self-report measures of psychological inflexibility related to eating behaviors, body image, disordered eating symptoms and general psychopathology symptoms.

Results of the confirmatory factor analysis indicated that the IEQ-A replicated the 11-item one-dimensional structure previously identified in adult samples. A multigroup analysis also demonstrated the scale's structure invariance between genders. The scale presented high internal reliability for both boys and girls (95). Correlation analyses confirmed the scale's convergence with psychological inflexibility with body image. IEQ-A was also positively associated with disordered eating symptoms and depression, anxiety and stress symptoms.

Findings corroborated the adequacy of the IEQ-A factor structure and supported that this is a valid measure to assess psychological inflexibility related to eating behavior in adolescence. This measure is therefore of potential utility for clinicians and researchers focusing on eating-related difficulties in this vulnerable developmental stage.

The authors have not supplied their declaration of competing interest.

Eating disorders (ED) have a significant prevalence in children and adolescents. The use of new technologies allows to access to a big amount of information. Excessive use of these technologies at this stage of life decreases social and family relationships and provides access to online content in favor of these disorders, which can affect to the development of an ED. The aim of this study is to analyze the relationship between the use of new technologies and the risk of developing an ED.

We have selected a sample of 500 patients who were in the 2nd year of secondary school to which has been applied a battery of scales, including the EAT-26 scale for ED; and has been collected socio-demographic data, including the use of internet and mobile phone. We used SPSS to analyze the relationship between these variables.

We have analyzed clinical and socio-demographic characteristics of the sample. In relation to the risk of developing an eating disorder we have found that high frequencies of use of the Internet and high frequencies of use of mobile phones (especially more than 4 hours a day) increases significantly the score in EAT-26 scale for ED (P < 0.05).

Regarding the results, we can say that, in our sample, the use of Internet and/or mobile phone more than 4 hours a day significantly increases the probability of having a high score on the scale for ED. This data can be essential when planning treatment or establishing a preventive strategy.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Recently, anorexia nervosa (AN) has been conceptualized as a reward-related disorder, and brain imaging studies have shown functional and structural abnormalities in areas of the brain involved in reward processes in both acute and recovered AN patients. However, the role of endogenous biochemical mediators, such as Ghrelin, in the modulation of reward processes has been poorly investigated in this eating disorder.

Hedonic eating, that is the consumption of food exclusively for pleasure and not to maintain energy homeostasis, is a useful paradigm to investigate the physiology of food-related reward.

We assessed the Ghrelin response to food-related reward in symptomatic AN women in order to further explore the modulation of reward processes in this severe and debilitating disorder.

Plasma levels of Ghrelin were measured in 7 underweight and 7 recently weight-restored satiated AN patients before and after the ingestion of a favorite (hedonic eating) and non-favorite (non-hedonic eating) food. Ghrelin responses were compared it that of previously studied healthy controls.

We found that in satiated underweight patients with AN plasma Ghrelin levels progressively decreased after the exposure and the consumption of both the favorite and non-favorite food whereas in satiated weight-restored AN patients and satiated healthy controls plasma Ghrelin concentrations significantly increased after the exposure to the favorite food and after eating it, but decreased after the non-favorite food.

These results suggest a derangement in the Ghrelin modulation of food-related pleasurable and rewarding feelings, which might sustain the reduced motivation toward food intake of acute AN patients.

The authors have not supplied their declaration of competing interest.

Despite age at onset (AAO) of eating disorders (EDs) has classically been described in adolescence; to date there is not an univocal definition. While initial studies described a bimodal distribution of AAO for ED, recently several studies didn’t confirm these findings.

AAO thresholds definition for anorexia nervosa (AN) and bulimia nervosa (BN) with statistical validation of proposed cut-offs is highly needed, since AAO represents a crucial clinical feature.

We obtained data from subjects with AN and BN to perform a normal distribution admixture analysis to determine their AAO.

A total of 806 ED patients (792 females; 379 AN and 427 BN) were recruited. Diagnosis of AN and BN were ascertained according to the DSM-IV-TR criteria by means of the SCID – Patient Edition. AAO was assessed by a clinical interview performed by a psychiatrist matched with a systematic review of medical records. To test AAO subgroups, we used a normal distribution admixture analysis.

A bimodal normal distribution of AAO with an early onset and late onset component was found for both AN and BN. Most of the subjects with AN (75.3%) and BN (83.3%) belonged to the early onset group. Both groups had a mean AAO of about 18 years. No significant differences were found concerning the AAO between groups.

Consider clinical history and course of AAO for EDs may be crucial for planning treatment. To our knowledge, this is the first study that applied a validated statistical procedure to identify AAO cut-off points for AN and BN.

The authors have not supplied their declaration of competing interest.

The functional interplay between brain hemispheres is fundamental for behavioral, cognitive and emotional control. Several pathophysiological aspects of eating disorders (EDs) have been investigated by the use of functional Magnetic Resonance Imaging (fMRI).

The objective of the study was to investigate functional brain asymmetry of resting-state fMRI correlations in symptomatic patients with anorexia nervosa (AN) and bulimia nervosa (BN).

We aimed at revealing whether brain regions implicated in reward, cognitive control, starvation and emotion regulation show altered inter-hemispheric functional connectivity in patients with AN and BN.

Using resting-state fMRI, voxel-mirrored homotopic connectivity (VMHC) and regional inter-hemispheric spectral coherence (IHSC) analyses in two canonical slow frequency bands (“Slow-5”, “Slow-4”) were studied in 15AN and 13BN patients and 16 healthy controls (HC). Using T1-weighted and diffusion tensor imaging MRI scans, regional VMHC values were correlated with the left-right asymmetry of corresponding homotopic gray matter volumes and with the white matter callosal fractional anisotropy (FA).

Compared to HC, AN patients exhibited reduced VMHC in cerebellum, insula and precuneus, while BN patients showed reduced VMHC in dorso-lateral prefrontal and orbito-frontal cortices. The regional IHSC analysis highlighted that the inter-hemispheric functional connectivity was higher in the ‘Slow-5′Band in all regions except the insula. No group differences in left-right structural asymmetries and in VMHC vs callosal FA correlations were found.

These anomalies indicate that AN and BN, at least in their acute phase, are associated with a loss of inter-hemispheric connectivity in regions implicated in self-referential, cognitive control and reward processing.

The authors have not supplied their declaration of competing interest.

Hedonic eating refers to the consumption of food just for pleasure and not for energetic needs. Endocannabinoids and endocannabinoid-related compounds play an important role in food-related reward and are likely involved in hedonic eating.

In a previous study we found that in normal weight healthy subjects plasma levels of 2 arachidonoylglycerol (2-AG) decreased progressively after food ingestion in both hedonic and non-hedonic eating condition, but they were significantly higher in hedonic eating. Plasma levels of anandamide (AEA), oleoylethanolamide (OEA) and palmitoylethanolamide (PEA), instead, progressively decreased in both eating conditions without significant differences.

In order to investigate the physiology of endocannabinoids in obesity, we assessed the responses of AEA, 2-AG, OEA and PEA to hedonic and non-hedonic eating in obese individuals.

Fourteen satiated obese patients consumed favorite (hedonic eating) and non-favorite (non-hedonic eating) foods in two experimental sessions. During the tests, blood was collected to measure peripheral levels of AEA, 2-AG, OEA and PEA.

Plasma levels of 2-AG progressively decreased in non-hedonic eating whereas they gradually increased after hedonic eating. Plasma levels of AEA decreased progressively in non-hedonic eating, whereas they initially decreased after the exposure to the favorite food and then returned to baseline values after its consumption. The responses of OEA and PEA to favorite and non-favorite food did not show significant differences.

These findings demonstrate that, compared to normal weight healthy subjects, obese subjects exhibit different responses of peripheral endocannabinoids to the ingestion of food for pleasure and this could have implications for the onset/maintenance of obesity.

The authors have not supplied their declaration of competing interest.

Attachment theory suggests that different attachment styles influence the development of individual's self-esteem and modulate the individual's ability to manage stressful events by responding with adequate affective adjustment. High levels of insecure attachment are present in adults with Eating Disorders (EDs).

The variables that mediate the association between attachment style and EDs have not been investigated enough. The possibility exists that the endogenous stress response system is involved.

To appraise the role of the endogenous stress response system, we studied the effect of attachment styles on the hypothalamus-pituitary-adrenal (HPA) axis functioning in ED patients.

Fifty- two women with EDs and 25 healthy women completed the ECR questionnaire to assess their attachment style. Saliva samples were taken in the morning to measure the Cortisol Awakening Response (CAR). Moreover, the saliva cortisol response to the Trier-Social-Stress-Test (TSST) was measured in 30 ED patients and 15 healthy controls.

Patients with avoidant attachment showed an increased CAR compared to both healthy controls and to patients with anxious and secure attachment styles. In the initial TSST phase, cortisol levels decreased in the secure attachment group but not in patients with avoidant attachment. In the TSST stress response phase, the cortisol raise was higher in insecure patients and delayed in avoidant ones.

In adults with EDs, attachment styles affect the HPA axis functioning and this could have a role in the pathophysiology of EDs.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Attachment is an innate programming whereby a child seeks for security. There is scientific and empirical evidence that insecure attachment is usual in eating disorder patients [1].

To highlight the relevance of attachment between child and caregivers, as well as its significance in therapeutic approach.

A 17-year-old girl hospitalized after attending to emergency department due to fainting. BMI: 12.89. She reports restrictive behavior since age 11 that her mother regards as “child issues”. Divorced parents, she grew up with her mother, diagnosed of hypochondria, who mentions not understanding why she is not the one who is hospitalized.

During hospitalization, she turned 18-years-old. Guardianship of her younger siblings was removed to her mother. She had a secure relationship with her 24-year-old sister, so she decided to move in with her. Later on, she had a positive progress, maintaining the gained weight and mood stability, although cognitive distortions persist.

Among developmental and maintaining factors of eating disorders, impaired attachment is becoming increasingly interesting. Even though the main goal of treatment is weight restoration, exploring attachment patterns can facilitate to achieve that aim. This clinical case emphasizes the importance of attachment in eating disorders among child and young adults.

The authors have not supplied their declaration of competing interest.

Recently, there is an increasing interest in the link between anorexia nervosa and autoimmune diseases. Studies show significant association between anorexia nervosa, diabetes mellitus, autoimmune thyroid disease and Crohn's disease [1]. The findings of significantly elevated autoantibodies (anti α-MSH, anti ACTH) and cytokines (IL-1, IL-6, IFN-γ, TNF-α) support this relationship.

To illustrate with a clinical case the connection between eating disorders and Crohn's disease.

Fourteen years-old boy with moderate depression syndrome after his grandfather's decease. Since overweight diagnosis by his pediatrician, he begins to restrict food intake with an important weight loss (19 kg in 9 months) and over exercising. Blood test reveals microcytic and hypochromic anaemia, rest of the examination shows no other disorder. Psychometric assessment EDI-3 suggests Anorexia Nervosa restricting type.

Two months after clinical stabilization, he is hospitalized due to abdominal pain. Exploration including blood test, serology, coproculture, sonography and colonoscopy reveals severe Crohn's disease.

This case is about a patient diagnosed of moderate depressive syndrome, who develops anorexia nervosa and Crohn's disease during his follow up. It exemplifies the link between stress, immunity and eating disorders. Recent findings suggest that immune diseases are involved in onset and maintenance of eating disorders. More studies are required in order to inference its consequences in evaluation, prognostic, treatment and identification of subgroups of patients.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

One of the key profile features of adolescents with Eating Disorders (ED) is a difficulty with assertiveness. Indeed, current research points to the importance of these patients’ perception of excessive control exerted by their families. Because these adolescents generally live with their families of origin, family-based variables may impact the development and evolution of psychosocial risk factors associated with this psychiatric disorder.

To investigate whether adolescents with ED improve on assertive communication as a result of parental assertiveness training.

The sample was comprised of 50 female adolescents with ED receiving group therapy treatment at Niño Jesús hospital in Madrid. Out of the 77 parents participating in the study, 36 were part of the experimental group and subjected to training in assertive skills (8-week sessions for about 2 hours). In addition, 41 parents formed the control group (with no assertiveness training). Before and after this training (or the same amount of time for the control group), adolescents were administered the psychometric test known as the Rathus Assertiveness Schedule (RAS).

A significant increase in RAS scores was found in adolescents whose parents were subjected to the assertiveness training. Moreover, there was a significant decrease in self-restriction scores in patients with ED after their parental assertiveness intervention. No significant changes were observed, however, in the control group.

Our results indicate that providing families with educational tools that aim at developing assertive communication may boost the level of assertiveness in adolescents and, thereby, presumably help in the prognosis of ED.

The authors have not supplied their declaration of competing interest.

The author has not supplied his/her declaration of competing interest.