Pica is the consumption of non-nutritive substances, which is inappropriate to the individual's cultural practices or developmental level. It is frequently associated with mental retardation, and occasionally observed in pregnant women and children.

We describe a case of long-standing pica in a woman with no co-morbid psychiatric condition.

Madam NA is a 27-year old married Malay housewife, with 4 sons and 4 miscarriages. Her mother had addiction problems. She sought help from the Eating Disorders Clinic, Singapore General Hospital, for uncontrollably eating uncooked rice. This started at age 8, when she was left alone at home with no food. Since then, she had been eating up to 10 cups of raw rice daily. She was unable to leave the house without carrying a bag of raw rice; if she forgot, she would feel intense discomfort and would need to return to get the rice. She persisted in eating raw rice despite it causing friction in her marriage. When she tried to stop, she would get irritable and crave it. This behavior only ceased during her pregnancies but would restart soon after delivery. There was no other psychiatric history. Blood investigations showed anemia, with iron and zinc deficiency, as well as newly diagnosed Grave's disease. After iron and zinc supplementation, her raw rice intake decreased substantially.

We report an unusual case of long-standing pica with compulsive features in a young woman with no psychiatric co-morbidity, which improved during pregnancy and with iron and zinc supplementation.

The authors have not supplied their declaration of competing interest.

The prevalence of eating disorders has been increasing in the Asian countries. Malays in Singapore are at the crossroads because they are largely traditional in practice and almost all are Muslim, but are exposed to western culture. Studies found that Malays at increased risk of eating disorders but yet those that present for treatment are very small, and this study aims to study Malays with eating disorders to unveil this contradiction.

All Malay patients presenting to Singapore General Hospital (SGH), which hosts the only specialized eating disorder programme in Singapore, between 2003 and 2014 were identified and medical records studied retrospectively.

Malays constitute only 42 out of 1340 patients treated in the same period. The mean age at presentation is 18.81 years (SD = 5.54) and the majority are students (78.6%). A total of 92.9% are single. There are more cases of bulimia nervosa than anorexia nervosa (45.2% vs. 26.2%). In total, 54.8% have psychiatric comorbidities, the most common is depression (31.0%), 38.1% have a history of deliberate self-harm and 21.4% attempted suicide. A total of 52.4% reported teasing as a trigger, while 16.7% were triggered by being overweight.

There is only a small number of Malays that presented. Fasting is commonly which may be confused with restriction. Other factors could be lack of awareness. The higher prevalence of bulimia nervosa suggests that purging is recognized as abnormal. High prevalence of comorbidities suggests that family members recognize comorbidities better. Outreach programs for Malay will help increase awareness.

The authors have not supplied their declaration of competing interest.

Eating disorders (EDs) are an important public health problem and not all patients respond adequately to psychotherapy. In the last decade, researchers report a significant comorbidity of EDs and attention-deficit/hyperactivity disorder (ADHD), especially binge eating disorder and bulimia nervosa. Some studies postulate the hypothesis of a common neurobiological substrate, such as noradrenergic pathways among others.

To revise the possible use of atomoxetine, a highly selective noradrenergic reuptake inhibitor, for the treatment of EDs.

We describe the effect of atomoxetine in a young woman with purging disorder and history of ADHD in childhood added to cognitive behavioural therapy (CBT).

patient had selective/restrictive eating behaviours, daily purges and occasional binges for last five years. At age 14 she was diagnosed with ADHD by impulsivity/aggressiveness and poor school performance, but she did not take drugs and left medical consultations. She came to our specific unit of EDs in november-2015. Her BMI was 24.88 kg/m2. We initiated CBT and atomoxetine (80 mg/day). In this first year of treatment binges and purges have disappeared and exposure to new foods and body image have improved partially. We found clear improvement in mood, motivation and attention/concentration in relation with introduction of atomoxetine. These facts have positive impact on the clinical evolution. Her current BMI is 26.90 kg/m2.

Identify comorbid ADHD to assess the use of specific drugs for this disorder could be beneficial in the treatment and prognosis of EDs. However, more studies are needed to determine effectivenes, particularly of non-stimulant drugs.

The authors have not supplied their declaration of competing interest.

to date, studies on the relationship between Theory of Mind (ToM) and eating disorders (ED) have never considered binge eating disorder (BED).

Aims a) to assess ToM abilities in a sample of patients suffering from BED comparing them with healthy controls; b) to evaluate the influence of several variables (demographic, clinical and neuropsychological dimensions, attachment styles, traumatic events, comorbid Axis I and II disorders) on ToM abilities.

we assessed ToM in a sample of 20 BED patients and 22 women from the general population using the Reading the Mind in the Eyes Test (RMET) and the Faux Pas Test (FPT).

regarding the first aim, the comparison between groups showed that the clinical group scored significantly lower than the control group on the RMET as well as on FPT. Regarding the second aim, two different multiple regression models were performed: one for the RMET and one for the FPT. Both of them led to significant results. When modeling RMET score, it emerged that age and Binge Eating Scale significantly reduce the score, while vocabulary and drive for thinness have a positive effect (r2 = 0.62). When modeling FPT score, we found that central coherence and binge eating significantly reduce the total score (r2 = 0.33).

our study begins to shed light on the relationship between ToM and BED; in particular, it suggests that BED patients have lower mentalization skills than healthy controls and ToM abilities are partially influenced by clinical variables related to eating pathology.

The authors have not supplied their declaration of competing interest.

Strong evidence establishes a close relationship between personality traits and mental illness; where personality can be said to influences the likelihood, severity and longevity of a mental disorder. Personality is usually seen as fixed, yet there is a growing body of evidence for the changeability of personality, though this has rarely been studied in relation to mental disorders.

To study the longitudinal interplay between personality and eating disorders (EDs), particularly the associations between personality, recovery and treatment modality.

To investigate changes in the five domains and thirty lower-level facets of personality in non-underweight EDs, and its associations to intervention and outcome.

Two hundred and nine adults with EDs enrolled either in a four-month multimodal psychodynamic group-therapy (DAY) or four-six month internet-based supported cognitive behavioural therapy (iCBT). ED diagnosis and personality (by the five-factor model) were assessed at baseline, termination and 6-month follow up. Structural equation modeling was used to analyze domain-level development, and reliable change (RCI) for facet-level development.

Remission rate at end of treatment was 71% in DAY and 55% in iCBT. Over time, Neuroticism decreased significantly while Extraversion, Openness and Conscientiousness increased (P < 0.01). Treatment and outcome had little influence on domain-level change. At the facet-level, 28% of patients reliably changed in any given facet, and there were several differences in pattern based on treatment and outcome.

This study lends support for the possibility of personality change and its relevance for recovery from EDs.

The authors have not supplied their declaration of competing interest.

Rigorous exercise to control weight and/or shape and to avoid negative affect has been proposed as significant in the etiology, development and maintenance of eating disorders (EDs), resulting in more severe and enduring pathology. However, few studies have investigated compulsive exercise (CE) among adolescents with EDs.

To study the longitudinal relationship between EDs and CE in adolescents.

Aims to investigate if adolescent ED patients show a similar relation between EDs and CE as previous research has found in adults.

A total of 3116 girls and 139 boys from a nationwide clinical EDs database were investigated on CE prevalence and frequency in relation to ED diagnosis, psychiatric symptoms, associated features and outcome. Denial of illness in self-ratings was adjusted for.

Adjusted CE prevalence in girls was 44%; with highest prevalence in bulimia nervosa. Average CE frequency was 3.9 times/week (SD = 2.6). Those with CE scored significantly higher than non-CE on total ED severity, dietary restriction and negative perfectionism (P < 0.001). There were only minor differences between CE and non-CE patients on emotional distress, hyperactivity, suicidality and self-esteem. Among boys, adjusted CE prevalence was 38%, and only total ED severity was significantly related to CE (P < 0.05). Initial CE did not impact prognosis, yet cessation of CE during 1-year follow-up was associated with ED remission.

CE is a common clinical feature in adolescents with EDs, as previously found in adults. CE had less detrimental impact on EDs than predicted and cessation was associated with better outcome.

The authors have not supplied their declaration of competing interest.

Enteroceptive awareness is defined as the ability to perceive the body states. Such ability is provided by the enteroceptors, organs and structures specifically designated to receive both internal and external stimuli. This capability, especially the perception of satiation, seems to be lacking in individuals suffering from Eating Disorders and there is no procedure to increase this ability.

The primary purpose is to improve patient's enteroceptive awareness. We tested whether patients diagnosed with binge eating disorder (BED), while deprived of eyesight, would better focus on their internal signals, such as the satiation feeling, and therefore eat less and slower.

For the first time, 29 patients with BED were deprived of vision during a meal. In a standardized procedure, participants ate two different meals, the first one while deprived of eyesight, the second one, a week later, in normal conditions. Both the amount of eaten food and the total time to complete the meal were taken into account during each of the meals. The patients filled in a Visual Analogue Scale (VAS) questionnaire at the end of each meal, in order to evaluate the experience and their internal feelings.

The results show that patients suffering from BED, when deprived of eyesight, eat less food, take more time to finish the meal and experience the same level of satiation with respect to the normal condition.

This procedure could be of great interest for the implementation of specific intervention protocols that are aimed at the recovery of enteroceptive awareness in patients with eating disorders.

The authors have not supplied their declaration of competing interest.

The Eating Attitudes Test-40 (EAT-40) is a valid index of symptoms frequently observed in eating disorders. The EAT-40 was adapted and validated for the Portuguese population. Thereafter a short-version composed of 25 items selected from the exploratory factor analysis (EAT-25) was developed. Apart from the total score, the TAA-25 evaluates three dimensions: Diet, Bulimic Behaviours and Social Pressure to Eat.

To examine the factor structure of the EAT-25 using confirmatory factor analysis (CFA) in a sample of Portuguese women.

The sample was composed of 433 women (mean age = 36.07; SD = 15.15). CFA was used to test the model suggested by prior exploratory factor analyses of EAT-25. AMOS software was used.

After four items were deleted and some errors were correlated, CFA indicated a good fit for the second-order factor (χ2/df = 3.066; CFI = 0.918; GFI = 0.883, RMSEA = 0.069; P[rmsea ≤ 0.05] < 0.001). The 19-item TAA showed excellent internal consistency (α = 0.91) and the three dimensions presented good Cronbach's alphas (α > 0.80).

These findings suggest that the 21-item TAA model obtained through CFA is a reliable and valid measure to assess disordered eating attitudes among women.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

The student population seems to be vulnerable to eating disorders (ED) but is this in relation to their ability to express their emotions or alexithymia?

Studying the prevalence of ED and alexithymia among medical students, and establish the relationship between these entities.

It was a cross-sectional study of 97 students in Sfax University Medicine (Tunisia). We used:

– a questionnaire containing demographic and clinical data;

– Eating Attitudes Test (EAT-26): a score ≥ 20 indicates ED;

– Toronto Alexithymia Scale (TAS-20): a score ≥ 61 indicates alexithymia.

The average age of participants was 24.07 years (± 2.71); the sex ratio (M/W) was 0.4. Their average BMI was 22.85 kg/m2 (± 3.36). They were smoking in 36.1% and sedentary in 43.3% of case. They had a nibbling activity in 57.7%. The average score of the EAT-26 was 11.66 ± 8.66 and prevalence of TCA was 19.6%. The average score of TAS-20 was 50.92, 0.46 and alexithymia was found in 16.5% of students. ED was significantly correlated with nibbling (P = 0.02), BMI or overweight (P = 0.012), smoking (P = 0.006) and physical inactivity (P < 0.00). Also alexithymia was significantly correlated with smoking (P = 0.003) and physical inactivity (P = 0.025). A significant correlation was found between alexithymia and ED (P = 0.008).

It is clear from our study an association between alexithymia and the ED. Psychological support aimed specifically alexithymic dimension is indispensable, not only for decreasing the emergence of ED but also contributing to lower any addictive behavior.

The authors have not supplied their declaration of competing interest.

Prenatal risk factors, such as gestational complications and exposure to stress during pregnancy, may have a role in the development of many psychiatric disorders including eating disorders.

To investigate the impact of prenatal stress exposure on the development and clinical features of anorexia nervosa.

One hundred and nine patients with a lifetime diagnosis of anorexia nervosa and 118 healthy controls underwent a clinical assessment, which included interviews, questionnaires and a neuropsychological battery. The mothers of the patients and controls underwent a specific interview focused on stressful life events, which occurred during pregnancy. Obstetric and neonatal records were consulted.

The mothers of patients experienced more severe stressful episodes during pregnancy than the mothers of controls and the perceived distress showed significant positive correlation with both total number of obstetrical complications and placental weight. In patients, the severity of stressful events was strongly associated to cognitive rigidity and perseverance.

Prenatal stress exposure might be a risk factor for the development of anorexia nervosa and it is associated with cognitive traits of rigidity and perseverance.

The authors have not supplied their declaration of competing interest.

According to the trans-diagnostic perspective, disturbances in eating patterns of eating disorders (EDs) are considered as epiphenomena secondary to the patient's overvaluation of his/her body shape and weight.

The phenomenological theory states that the main feature of ED psychopathology is a disturbance in the way affected persons experience their own body (embodiment). Insecure attachment may promote the development of unstable self-identity leading to use body weight as a source of self-definition.

The aim of our study was to assess the role of embodiment impairments in the relationships between attachment stiles and ED psychopathology.

One hundred twelve ED patients and 108 healthy subjects filled in the Identity and Eating Disorders (IDEA) questionnaire, which assesses embodiment and personal identity abnormalities, the eating disorder inventory-2 (EDI-2) and the experiences in close relationships (ECR) scale, which defines attachment styles.

ED patients showed IDEA, EDI-2 and ECR scores significantly higher than controls. Significant correlations between IDEA scores, insecure attachment and almost all EDI-2 sub-item scores emerged in ED patients but not in controls. IDEA total score mediated the relationship between avoidant attachment and EDI-2 interoceptive awareness.

These findings demonstrate that in ED patients insecure attachment is correlated to disorder of identity and lived corporeality that, in turn, mediates the association between attachment and a specific ED psychopathological trait. Therefore, we suppose that early relationships, through the development of disturbances in identity and embodiment, lead to altered perception of bodily signals and deranged discrimination of one's emotions, which could contribute to EDs.

The authors have not supplied their declaration of competing interest.

Eating disorder (ED) are an important mental health problem because of theirs overall prevalence, especially in children and adolescents. Low self-esteem is considered, along with others, one of the risk factors for the development of these disorders, without having clarified the real impact of low self-esteem on the development of ED. The aim of this study is to analyze the relationship between self-esteem and the risk of developing an eating disorder.

Material and method 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 Rosenberg self-esteem scale, and the EAT-26 scale for ED. We used logistic regression using SPSS to analyze the relationship between both variables.

In addition to analyzing clinical and sociodemographic characteristics of the sample, we have found that for every decrease of 1 point in Rosenberg scale, there is an increase of 9 % in the probability of being a case of ED for the EAT-26 scale (P < 0.05).

Regarding these results, we can conclude that, in our sample, having low self-esteem score, significantly increases the likelihood of having a high score on the scale of ED. This data can be useful in establishing a preventive strategy and an adequate treatment.

The authors have not supplied their declaration of competing interest.

Anorexia nervosa (AN) is a complex psychiatric disorder characterized by severe restriction of food intake and aberrant behaviours. The endogenous stress response system, including the hypothalamus-pituitary-adrenal (HPA) axis, may have a role in the pathophysiology of AN.

It has been shown that specific clinical traits of AN, such as binge-purging behaviours, may be associated with higher psychopathology and poorer outcomes. Therefore, the HPA axis functioning could differ between patients with restrictive AN (ANR) and those with binge-purging AN (ANBP).

In order to evaluate whether HPA axis functioning differs between the two subtypes of AN, we assessed the cortisol awakening response (CAR) of symptomatic ANR and ANBP patients.

Our sample included 17 ANBP and 18 ANR patients, and 42 healthy women. All of them filled in the Eating Disorder Inventory-2 (EDI-2). For CAR assessment, participants collected saliva samples at home. Saliva cortisol concentrations were measured by an enzyme immunoassay method.

ANR and ANBP patients exhibited a CAR significantly higher than healthy women. Furthermore, the CAR of ANBP women was higher than that of ANR women and positively correlated with the bulimia subitem score of the EDI-2.

Present findings show, for the first time, differences in the CAR between ANBP and ANR subtypes supporting the idea that binge-purging behaviours may have a specific connection with HPA axis.

The authors have not supplied their declaration of competing interest.

Eating Disorders (ED) as Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge Eating Disorder (BED) are severe and debilitating psychiatric diseases whose etiology is complex and still largely unknown. Several studies seem to suggest that serotonin could be involved and notably there are several associations with 5-HTTLPR polymorphism, especially with the S allele and the S/S genotype.

The purpose of this study is to evaluate if an association between ED and 5-HTTLPR (especially the S allele frequency) can be shown.

A group of about 100 subjects attending the eating disorders unit of Ancona will be tested. Their DNA will be taken and the frequency of the S allele will be compared with a control subjects group negative for ED. Then, the ED group will be divided, according to the DSM-5 criteria, in 3 subgroups (AN, BN, BED) and potential differences will be evaluated.

At the moment, we are still collecting patients. According to other studies involving 5-HTTLPR, the S allele frequency in Italy is comparable with the European one, so there is reason to believe that an association could be found.

Serotonin involvement in ED in literature is shown, but it still has to be completely expounded. Studies as this one could help in describing the etiology and the development of this disease.

The authors have not supplied their declaration of competing interest.

Several studies recently investigated how Anorexia Nervosa patients (ANp) process multimodal information. Longo (2015) hypothesized that ANp might be less reliant on visual perception of bodies than healthy controls (HC). Case et al. showed that processing of multimodal information might be disrupted in ANp. Literature lacks of studies that measure precisely and compare directly the contributions of each sensory input.

To investigate the integration of visual and haptic inputs in ANp compared with HC and measure the weight of each input.

We used a visuo-haptic integration task with a setup adapted from Gori et al. (2008) to measure each sensory input's when judging the size of a cube according to Maximum Likelihood Estimation theory which describes the optimal multimodal integration behaviour (Ernst and Banks, 2002). Fifteen ANp and 16 HCs were recruited.

Regardless the group, we found considerable individual variability about the integration processes; moreover, many participants did not integrate optimally. Correlation analysis suggested that ANp rely less on visual information then HC.

Despite using a setup previously validated with children, the observation that many HC did not integrate optimally is not in line with the results of previous studies, making it difficult the comparison with the AN group. The setup might not be adapted to adults and it needs to be improved. Our study shows for the first time how it might be possible to measure and compare directly the contribution of two different sensory modalities. This could provide precious information to deeply investigate the pathology.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Family members of patients with Eating Disorders(EDs)–in dealing with the relatives’ disease–report negative feelings such as self-blame and criticism, but little is known regarding their coping strategies.

To describe coping strategies in a sample of relatives of patients with EDs using the Family Coping Questionnaire–Eating Disorder version (FCQ-ED).

Aims (1) To evaluate coping strategies in relatives of patients with EDs; (2) to describe differences in coping strategies according to type of kinship with the patient; (3) to identify correlations among socio-demographic characteristics, patients’ clinical characteristic, and type of coping strategies.

Relatives’ coping strategies were evaluated using the FCQ-ED, a self-administered questionnaire, consisting of 32 items, grouped in 5 subscales: coercion; positive communication; collusion; seeking for information; avoidance, plus one item on seeking for spiritual help.

Seventy-two patients and 127 relatives were recruited. The most frequently adopted coping strategies were seeking for information, positive communication, seeking for spiritual help; the former were positively correlated with the level of education of both patients and relatives. Mothers avoided the patients less frequently than other relatives.

This is one of the first studies focused on coping strategies in families of patients with EDs showing that problem-oriented ones are used quite often. Socio-demographic characteristics and type of kinship can have an impact on the adoption of coping strategies, but further longitudinal studies are needed in order to identify other possible factors implied in their development.

This represents an initial attempt to understand how clinical, social and personal variables can have an impact on the development of coping strategies.

The authors have not supplied their declaration of competing interest.

Breast cancer (BC) may cause problems on body perception and awareness which can be perceived as a threat on body attitude among women with breast cancer.

The Body Attitude Test (BAT) assesses subjective attitude toward women's own body.

The aim of the present study was to develop the Turkish version of the BAT and examine its reliability and validity.

The study group (SD) consisted of 72 women diagnosed with BC while 100 healthy women (HW). The women evaluated by BAT, Eating Disorder Inventory (EDI) and Self Esteem Inventory (SEI) in 7–10 days intervals. Internal consistency was determined with Cronbach's alpha coefficient. Factor analysis was conducted on BAT ratings given by control group.

The mean age was 43.7 ± 8.76 of women with BC while 46.4 ± 10.84 in HW. Mean duration of cancer was 2.4 ± 0.7 years. Factor analysis showed BAT was composed of two factors as body dissatisfaction and lack of familiarity with one's body. The BAT demonstrates satisfactory level of internal reliability (α = 0.932). BAT was related with EDI subscales: drive for thinness (r = 0.741, P < 0.001), ineffectiveness (r = 0.736, P < 0.001) and body dissatisfaction (P = 0.718, P < 0.001) and SEI subscale: familial self-esteem (r = -0.629, P < 0.001).

The results support the validity and reliability of BAT which is able to differentiate the clinical and non-clinical form of subjective attitude toward women's own body. Turkish version of BAT could be used as an appropriate measure for assessing subjective attitude towards own body in women with and without breast cancer in Turkey.

The authors have not supplied their declaration of competing interest.

To study prevalence of self-reported body image and eating distress symptoms among Finnish adolescents, and to study associations between psychopathology, body image and eating distress.

Cross-sectional population-based, survey subjects, 7th to 9th grade students aged 13–15: 3154 in Finland in 2014.

Data were collected by student self-reported questionnaire including scale designed for evaluating attitudes and behaviors towards body shape and eating, and Strengths and Difficulties Questionnaire (SDQ) for assessing emotional and behavioral problems.

The female adolescents reported much more dissatisfaction and concerns with their bodies than the males, high levels of distress with body emotional, behavioral and peer problems measured with SDQ. Body image and eating problems were higher in Finnish than Japanese females with peer problems.

The finding was in accordance with previous studies that found that body image and eating distress are associated with to gender and wide range of psychiatric problems.

The authors have not supplied their declaration of competing interest.