A.

Functional gastrointestinal disorders

B. Eating disorders
A.
Biopsychosocial model of FGID
 Etiology and pathogenesis

Perceived endogenous corticotrophine – releasing factor (CRF) could play

stress has a key an important part in this process via the stress-mediated
role in FGID: activation of CRF receptors in the brain.
2. psychoindividual factors:

Anxiety: these patients tend to

amplify or to interpret in a wrong way
their somatic sensations, or to have
difficulties in disentangling normal
body reactions to emotional
circumstances from abnormal ones.

Alexithymia: can influence the

individual‘s ability to adapt to
stressful situations and is associated
with pathogenic behaviors, such as
poor diet, bad eating habits (e.g., fast
eating), alcohol consumption or being
sedentary.
Coping style

- inefficient;
- dominated by hypochondria, phobias
and somatic preoccupations.
A common behavior resulting from this
coping style is avoidance, this leading
in turn to catastrophic beliefs and a low
feeling of control over symptoms.
Both play a key role in triggering depression
on a long run.

Coping style may be significantly

connected to adherence (e.g., patients
with dyspepsia who consulted a doctor
presented a higher level of self-
monitorization and a more active
coping style).
3. psychosocial factors:

- low social acceptance.

These patients are often not taken

seriously and their concerns are
minimized, even by physicians.
They may be reluctant to come to the
consultation, as they are often considered
(directly or indirectly) to exaggerate their
symptoms and even to attempt to obtain a
benefit from their disease.

A direct pathogenic role is played by

the lack of perceived social support.
In families, daily quarrels are
considered to be associated with a high
risk of FGID.
4. genetic vulnerability:

- literature consensus over the

possibility of FGID aggregation within
the same family.
Confusing factors:
- shared diet routines;
- shared coping mechanisms;
-(possibly) shared alexithymia,
anxiety.
Common myths

- „FGID are always correlated to

depression of other psychiatric
diseases“:
in fact, with the exception of anxiety /
alexithymia, psychiatric symptoms
occur from FGID, rather than generate
them.

-„FGID patients are difficult“:

Society may play a role in this, with
many
FGID patients labeled, not being taken
seriously, or even stigmatized.

A subgroup of FGID patients may have a

history of abuse.Typically, these
patients do not even complain about
their symptoms (self-blame).
PSYCHIATRIC PSYCHOSOMATIC
 Examples of FGID
1. Gastroesophagial reflux disease (GERD)

Gastric acid or, occasionally, gastric

content, flows back into esophagus,
generating most typically heartburn
and interference with daily life and
habits.

Threshold: > 2 times / week.

Modifications of esophageal mucosa

(esophagitis) are common in advanced
GERD.
Symptoms
- a burning sensation in the chest
(heartburn), usually after eating;
- chest pain;
- difficulty swallowing;
- regurgitation of food or sour liquid;
- sensation of a lump in the throat

If the reflux is higher by night time:

- chronic cough;
- laryngitis;
- new or worsening asthma;
-disrupted sleep.

Can be aggravated by obesity (which

can be also psychosomatic): vicious
circle stress – obesity – GERD – more
stress.
GERD pathophysiology

Impaired esophageal
clearance Impaired salivary
function
Hiatal hernia
Impaired
esophageal
Transient, inappropriate
mucosal
relaxation of LES
defence
Gastric acid and pepsine
secretion high
Reduced resting
pressure of LES
„Pyloric
incompetence“:
duodenogastric Delayed gastric
reflux emptying
Examples of FGID
Psychological symptoms

- depression;
- anxiety;
- maladaptive behaviors;
- suicidal thoughts;
- absenteeism;
- perceived stigmatization;
- poor quality of life.

Cultural factors may significantly

influence the perception of
these symptoms!
Treatment
1. Pharmacological approach
2. Psychotherapy
Cognitive-behavioral therapy

Objectives:
B.Eating disorders
B1. Overeating
 c es
n
q ue
s e
C on
Facts
The past two decades: a striking
increase in the rates of
overeating and obesity
throughout the industrialized
world.

Prevalence:
USA: adults 40%;
European countries:
increase of 10-40%.

Obesity-related conditions:
hypertension, dyslipidemia, type
2 diabetes mellitus, coronary
heart disease, stroke,
osteoarthritis, respiratory
disease, and certain types of
cancer.
Facts
Mortality ratios rise above
average as BMI exceeds 25, and
all-cause mortality rates increase
by 50–100% when BMI surpasses
30.

In addition to its adverse impact

on health and longevity, obesity
also diminishes quality of life.

It can trigger stigma, major

depressive disorder, suicidal
ideation, and suicide attempts,
especially among women.
Causes
- genetic (leptine deficit);
- endocrine (CSR excess).

Behavioral: overconsumption of energy-dense, nutrient-poor foods (not

only in fast foods, but also in supermarkets, vending machines, or at
home)
Sedentary lifestyle also appears to be a significant contributor.

Few occupations now require vigorous levels of physical activity.

Moreover, labor-saving devices such as cars, elevators, escalators,
motorized walkways, and remote controls have had a significant
cumulative impact in decreasing daily energy expenditure.

From this point of view, overeating and obesity may be considered

“diseases of civilization”, resulting from the discordance between modern
lifestyle and the lifestyles for which humans (and our genes) evolved over
tens of thousands of years.
Causes
Dysfunctional coping with stress:

- food and the control of food is used as an

attempt to cope with feelings and emotions
that seem overwhelming;

- often initiated at those youngsters who did

not learn to become independent (always
having followed the wishes of others) („food as
the last resort“);

- life positions: „I am not ok, you are ok“;

- failures in achievement-oriented individuals;

-loneliness, but also external reinforcement

and acceptance (higher social tolerance for
obesity).
More extreme forms of eating disorders:
anorexia and bulimia nervosa

Pathogenesis

(Schwerin et al., 2010)

B2. Anorexia nervosa

A. restriction of energy intake below what is necessary to maintain a healthy

weight;
B. intense fear of fat, as evidenced by verbalizations or behaviors that interfere
with the maintenance of a healthy weight;
C. body image disturbance, undue influence of body shape / weight on self-
evaluation, or persistent denial of the seriousness of low weight.

Two subtypes:
Restricting subtype: weight loss is accomplished exclusively through caloric
restriction (i.e., dieting, fasting) and / or excessive exercise; the individual
has not binged or purged in the last 3 months.
Binge-eating / purging subtype: the individual has binged (subjective or objective
binge episodes) or purged in the last three months.
Complications of anorexia nervosa
B3.
Complications of bulimia nervosa
Psychometric instruments

Eating Disorder Inventory (EDI)

Is a 64 item, self-report questionnaire, used for the assessment of

psychological and behavioral traits common in anorexia nervosa
(AN) and bulimia nervosa (BN).

Consists of 8 subscales measuring:

- drive for thinness;
- bulimia;
- body dissatisfaction;
- ineffectiveness;
- perfectionism;
- interpersonal distrust;
- interoceptive awareness;
- maturity fears.
Therapy
B1. Overeating

Medical treatment:

Noradrenergic agents (ex. phentermine) suppress appetite by stimulating

catecholamine neurotransmission. A 3 months treatment of phentermine
plus low-calorie diet produces a mean weight loss of 6.2 kg, compared
with a 2.9 kg loss for placebo plus diet. Still, this effect is reversible,
when the drug is withdrawn.

+ SSRI (e.g. sibutramine): weight loss occurs in the first six months of use and
tends to plateau thereafter. Side effects: typically, a modest mean
increase in blood pressure (about 2 mm Hg systolic and diastolic at the 15
mg dose). However, some users (approximately 17%) experience an
increase of >10 mmHg in blood pressure, with an additional risk of
coronary heart disease (6%) and stroke (15%).
Sibutramine users should have their blood pressure monitored frequently, and
patients with a history of heart disease, stroke, hypertension, or other
risk factors for heart disease must not take sibutramine.
Therapy
B1. Overeating
Bariatric surgery: especially at BMI > 40 and obesity-related comorbidity.
Variants:
- gastroplasty (the stomach is stapled, so as create a small vertical pouch).
The stomach‘s capacity is reduced to about 15 ml.
This procedure prevents overeating through aversive conditioning: fear of
vomiting provides a disincentive for overeating, and the perception of fullness
associated with the distention of the stomach pouch serves as a cue to stop
eating.
Unfortunately, gastroplasty does not limit the consumption of high-caloric
liquids or soft foods.
- by-pass: ingested food bypasses 90% of the stomach, the duodenum, and a small
portion of the proximal jejunum.
This facilitates weight loss, through three mechanisms: (1) the pouch can hold
a limitated amount of food (15 ml), (2) the emptying of the food from the
pouch directly into the small intestine results in malabsorption, and (3) the
consumption of sweety foods creates negative consequences (e.g., nausea)
(„dumping syndrome“).
Therapy
B1 Overeating

Self-management:

Include computer-assisted interventions, and self-help groups, and represent

the most cost-effective methods of weight loss.

Successful maintainers use 3 basic strategies:

First, they regularly consume a low-calorie diet (i.e., <1400 kcal/day) that is
low in fat (<25%) and high in carbohydrates (>55%).

Second, they regularly engage in high levels of physical activity, about one
hour per day of moderate activity such as brisk walking.

Third, they regularly monitor their body weight: 44% weigh themselves daily
and 31% weigh themselves at least once per week.
Therapy
B1. Overeating

Cognitive-behavioral therapy

Phases:
(a) goal-setting and daily self-monitoring of eating and physical activity;
(b) nutritional training aimed at the consumption of a balanced low-calorie
diet (i.e., typically 1000–1500 kcal/day), sufficient to produce a weight
loss of 0.5 kg per week;
(c) increased physical activity through the development of a walking program
and/or increased lifestyle activities;
(d) arrangement of environmental cues and behavioral reinforcers to support
changes in eating and exercise behaviors;
(e) cognitive restructuring techniques to identify and change negative
thoughts and feelings that interfere with weight-loss progress;
(f) training in problem-solving or relapse prevention procedures to enhance
coping with setbacks and obstacles to progress.
Therapy
B1. Overeating

Group therapy

- 15-26 weeks;
- when the
compulsive food
behavior was
learned (use the
modeling
method);
- mean losses of
approximately
8.5 kg or
approximately
9% reduction in
body weight.
Therapy
B1. Overeating

Hypnosis Milling, L. S., Gover, M. C., & Moriarty, C. L. (2018). The effectiveness of
hypnosis as an intervention for obesity: A meta-analytic review. Psychology of
Consciousness: Theory, Research, and Practice, 5(1), 29–45.
- effective in Two meta-analyses were performed quantifying the effectiveness of hypnosis
emotional eating; as an intervention for obesity and the impact of adding hypnosis to cognitive–
behavioral therapy (CBT) in producing weight loss. The primary meta-analysis
- cuts the comparing hypnosis with a control condition produced large effect sizes of
1.58 (p ≤ .001) for 14 trials at the end of active treatment and 0.88 (p ≤ .001)
unconscious impulse for 6 trials at the longest follow-up. The average participant receiving some
of eating in form of hypnosis lost more weight than about 94% of control participants at
the end of treatment and about 81% of controls at follow-up. The secondary
intensely stressful meta-analysis comparing CBT with the same intervention augmented by
situations; hypnosis generated a small effect size of 0.25 (p ≤ .05) for 11 trials at the end
of active treatment and a large effect size of 0.80 (p ≤ .001) for 12 trials at
- may build aversive the longest follow-up in favor of the blended intervention. The average
participant receiving CBT plus hypnosis lost more weight than about 60% of
behaviors; participants receiving only CBT at the end of treatment and about 79% of
participants receiving only CBT at follow-up. Our findings suggest hypnosis is
- useful in very effective in producing weight loss over a relatively short span of time, but
increasing self- more research is needed on the long-term benefits in follow-up periods of 1 to
5 years. Clinicians should view hypnosis as a promising treatment option for
esteem and self- obesity, especially when used in conjunction with CBT techniques for weight
efficacy. loss.
Therapy
B1. Overeating

Both CBT and group therapy have still a high rate of relapse: during the year
following behavioral treatment, participants typically regain 30–40% of their
lost weight. From this, the importance of a real lifestyle change – with
formulation of new goals and coping strategies.

Yo-yo obesity: the consequence of exaggerated expections from diet.

Therapy
B1. Overeating

Policy interventions

e.g., creating a healthier food environment for children:

- restrict children’s food advertising;
- ban soft drinks from schools;
- tax more unhealthy foods;
- invest in community improvements that would promote the integration
of physical activity into everyday life.
For example, new urban
developments could eliminate
homogenizing zoning
requirements which discourage
walking.
 Therapy
B2, B3. Anorexia nervosa and bulimia nervosa
Psychotherapists
Medical
treatment of Social workers
the condition
itself Physiotherapists
Psychological
Physicians support / Spiritual
therapy
counselors
Management of
medical Rehabilitation
complications

Pharmaco-
therapy for
psychiatric
comorbidity Multidisciplinary
teams are
essential!
Therapy
B2, B3. Anorexia nervosa and bulimia nervosa
Specific interventions (beside those mentioned at B1):

- art-therapy;

- psychoanalysis sessions;

- family therapy;
Especially used at those patients which have a
traumatic family history, where anorexia /
bulimia were distorted ways of communication
or of opposition.
These instruments may increase catharsis and
unblock the patients, so that they can follow
later classical forms of therapy, oriented
towards a specific goal.