JPED Journal

Introduction

Anorexia nervosa (AN) is a complex mental disorder that can lead to a clinical and psychopathological condition that make hospital treatment necessary [1]. In recent decades, an increase in the rate of AN patients requiring hospitalization has been highlighted [2]. In particular, during the COVID-19 pandemic, the number of AN patients in need of hospital treatment in some cases doubled (increase of 104%) compared to previous years [3]. Some authors also underlined that a worse psychopathological expression of the AN and greater association with psychiatric comorbidities characterized the adolescents in this historical period [4].

Among the reasons that can cause hospitalization, one of the most relevant is the excessive and/or too rapid weight loss in AN [5]. This condition, without rapid and effective treatment, can severely compromise the patient’s physical, psychological and social health to the point of putting his/her life at risk [6]. Therefore, the guidelines for the treatment of AN indicate the initiation of hospital treatment when the patient’s physical health is seriously compromised, or if a serious psychopathological comorbidity coexists, or if less intensive treatments have proven ineffective [7].

Psychopathological comorbidity represents a very important aspect for the clinical management of EDs. In fact, in addition to being a possible reason for hospitalization, the presence of psychopathology associated with the eating disorder represents an influencing factor on the duration of treatment [8]. Among the disorders most frequently associated with AN, major depression affects up to 64% of patients [9]. Depressive symptoms may be associated with suicide attempts in up to 27% of the AN subjects [10], while suicidal ideation and/or non suicidal self-injuries

(NSSI) are present from 20% up to more than half of patients [1114]. Social withdrawal is very common too in AN adolescents, being present in up to 90% of the patients, and it is possibly related to higher self-harm risk [15,16].

With respect to hospital placement, some evidences from the literature support how adolescents with AN should be assisted in hospital departments which are suitable for their age, such as Child Neuropsychiatry Wards (CNW) and Paediatric Wards (PW), and close to their home in order to provide adequate educational activities during longer hospitalizations [7]. However, the management of the most severe cases of AN, especially when they display critical physical conditions or when they occur in comorbidity with serious psychopathological problems, such as suicidal ideation or suicide attempts, can be difficult in PW since these may be not specialized in nutrition management in severely malnourished and/ or non cooperating AN adolescents [17]. Moreover, PW may not display the requirements (e.g. patient surveillance, closed doors and windows, environmental surveillance) needed for successfully managing psychiatric comorbidity (e.g. suicidality and NSSIs), which may significantly raise the mortality and morbidity risk [18]. Therefore, after the initial hospitalization in a PW, it may be necessary to transfer AN subjects with psychiatric comorbidity to a CNW with a specialized eating disorder unit, even if it can be far from the place of residence, as it is more protective towards suicidal ideation and other psychiatric comorbidity, and/or is better equipped for the management of the eating disorder in the phase of severe malnutrition or opposition to nutrition and/or hydration [19].

Frequently the transfer of the more severe AN patients from a PW to a CNW follows the treatment failure or the manifestation of self-harm or life-threatening behaviors. When an adolescent with AN is admitted to a PW, it is thus useful to explore, along with the weight evolution, also the psychopathological indicators of suicide attempts, suicidal ideation, NSSI, social withdrawal to identify prognostic factors and functional aspects that can help clinicians to address more quickly and effectively their placement in the CNW, guaranteeing a “tailor-made” therapeutic path with respect to their psychopathological situation [20].

Many psychopathological features characterize AN adolescents. Specific personality characteristics are associated with the disorder in adolescence [21], high levels of eating psychopathology [22], high levels of deflected mood and comorbid depression [23, 24]. Moreover, AN adolescents often display alexithymia, i.e. difficulties in deciphering emotions, and elaborate on mental representations [25]. Finally, unsafe attachment styles are important psychopathological aspects in patients with AN [26-28]. A thorough assessment of these features may thus help to trace a psychopathology profile linked to risky behaviors which is detectable in the early phases of PW inpatient treatment, to help the identification of those subjects needing early transfer into the CNW.

The present study aims to explore the psychopathological features of patients with EDs admitted for an inpatient treatment to the PW of a pediatric hospital by exploring through selfadministered psychometric tests their comorbidity with some significant psychopathological behaviors detected at admission: suicide attempts, suicidal ideation, NSSIs, and social withdrawal. We expect to find out personality and psychopathology features specifically correlated with comorbid psychopathological problems which could influence the progress of the hospitalization with respect to duration, BMI increase, upon discharge at home or upon the need for hospitalization in a Neuropsychiatric (NPI) Day Hospital (DH) or upon transfer to the CNW.

Methods

Sample composition

This study involved a sample of 85 adolescents hospitalized at the Regina Margherita Children’s Hospital (OIRM) in Turin between June 2020 and June 2022. Patients with a diagnosis of ED according to the DSM-5-TR [1] criteria admitted to pediatric wards (general pediatrics, nephro-gastroenterological pediatrics, infectious disease pediatrics, emergency pediatrics and lowintensity surgery) not specialized in the management of psychiatric patients due to lack of beds available in the CNW during the pandemic were included.

Inclusion criteria

1. Diagnosis of AN (any subtype of AN and atypical AN) according to the DSM-5; 2. Age-range 14-17 yo; 3. Admission to a PW of the OIRM after a general assessment in the emergency department with the exclusion of physical problems other than those secondary to AN; 4. Absence of intellectual disability; 5. Sufficient knowledge of Italian language in order to fill out the self-administered tests; 6. Patient’s and its parents’ informed consent for participation in the study.

Exclusion criteria

Refusal or incomplete self-administration of the psychometric tests. Hospitalized patients were visited daily by pediatricians and NPI training specialists, while NPI specialists provided a consultation at least three times a week to monitor the progress of the hospitalization by interfacing with the pediatric staff to discuss any further therapeutic intervention and/or transfer to another service (e.g. CNW o NPI DH) or discharge. The AN adolescents were assisted also by the hospital’s clinical nutrition team (specialists and dieticians) and by the NPI psychological team (specialized and trainee psychologists). In all the PWs involved the nursing staff were not specialized in ED care, the ward organization was standard i.e. adapted to solely physical health problems, the PWs were not closed or protected by any security measure for psychiatric patients (e.g. periodical controls of the environment to detect self-harming instruments, inspection of the personal effects of the patients, meal assistance by nurses, etc.). In addition, the presence of a parent or a delegated adult who had the responsibility of supervising the minor was necessary.

The objective of the treatment for all adolescents admitted in a PW was to improve their physical and psychopathological conditions. Possibly the restoration of weight loss in case of malnutrition was prosecuted with the resumption of oral food intake (though a nutritional plan of progressive food resumption) or via nasogastric tube in case of total interruption of caloric and/ or water intake or excessive difficulties in food resumption. An overall stable improvement in psychopathological behaviors and eating habits was then pursued.

The parameters taken into consideration to detect the outcome of the hospitalization were: age and BMI at admission, BMI at discharge, BMI delta (i.e. the difference between BMI at discharge and BMI at admission), duration of hospital admission in the PW, need to transfer the adolescent to the CNW due to lack of weight improvement and/or self-inflicted/hetero-injurious behavior, or poor cooperation with renutrition, or the need to transfer to the NPI Day Hospital due to insufficient or unstable weight or behavioral recovery. The presence of a suicide attempt among the reasons for admission, and/or the presence upon admission of psychopathological comorbidities such as Suicidal Ideation, NSSI, Social Withdrawal were considered as target behaviors for the study. 

During the first week of hospitalization, the patients were tested with self-administered questionnaires for the evaluation of personality traits, eating and general psychopathology, alexithymia, attachment, parenting and family functioning. The questionnaires were provided to all AN adolescents: the patients were included in the study only if they accepted and successfully completed the self-administration of the tests.

Self-administered questionnaires

Temperament and Character Inventory (TCI) [29]

It is a tool for the dimensional assessment of personality and consists of a self-administered questionnaire of 240 items to be answered with true or false.

The test is based on Cloninger’s personality model which divides it into seven dimensions, split into “temperament” (seeking novelty, harm avoidance, dependence on recognition, persistence) and “character” (self-directivity, cooperativeness, self-transcendence), each one containing several subscales.

The dimensions are:

- Novelty Seeking (NS), expresses the approach towards new signals coming from the environment

- Harm Avoidance (HA), denotes excessive worry, pessimism and shyness

- Recognition Dependence (RD), characterized by a tendency to respond to reward signals, particularly verbal signals of approval and social support

- Persistence (PS), indicates perseverance despite a feeling of fatigue or frustration

- Self-directivity (SD), ability to regulate and adapt behavior to the needs of a situation to achieve personally chosen objectives and values

- Cooperativeness (C), concerns the degree to which a person is generally conciliatory in relationships with other people, without aggressive, hostile or egocentric behavior

- Self-transcendence (ST) denotes the expansion of personal boundaries with respect to the external world.

Cronbach’s alpha for Italian population = 0.72

Eating Disorder Inventory-2 (EDI-2) [30]

It is a self-assessment questionnaire used to evaluate psychopathology related to eating disorders. It evaluates the main psychopathological characteristics linked to EDs, using 91 items which are developed into eleven scales:

- Drive for thinness (MI), indicates excessive attention to weight and diet, with an intense fear of gaining weight

- Bulimia (BU), evaluates the tendency to think or engage in binge eating or purging behavior

- Body dissatisfaction (CI), evaluates discontent with one’s physical appearance and body shapes

- Inadequacy (I), measures the feelings of inadequacy, insecurity, uselessness and feeling incapable of having control over one’s life

- Perfectionism (P), evaluates the refusal to accept anything that deviates from perfection

- Interpersonal distrust (SI), measures the resistance towards establishing any form of close social relationship

- Enteroceptive awareness (EC), evaluates the ability to respond correctly to feelings, and to distinguish physical sensations such as hunger and satiety

- Fear of maturity (PM), evaluates a person’s approach to dealing with the demands of adult life

- Asceticism (ASC), measures the tendency to enhance oneself through self-discipline, self-denial and control of one’s body’s needs

- Impulsivity (I), measures the ability to regulate instinctive behaviors, such as substance abuse or incorrect eating behaviors (binge eating and purging behaviors)

- Social insecurity (SI), evaluates the fear and insecurity one has towards social relationships.

Cronbach’s alpha for Italian population = 0.81

The Beck Depression Inventory II (BDI-II) [31]

It is a self-administered psychometric test, useful for assessing the severity of a patient’s depressive state and the typical symptoms of depression such as hopelessness, irritability and guilt, but also physical symptoms such as fatigue, weight loss and lack of sexual interest. It consists of 21 questions to be answered with a score ranging from zero to three based on the perception of the patient of the severity of his symptoms.

The BDI-II also allows us to distinguish the somatic component of depression from the cognitive component, so that it is easier to define the specific origin of mood depression.

Cronbach’s alpha for the Italian version = 0.89

 Symptom Checklist-90 (SCL-90) [32]

It is a tool designed to evaluate a wide range of psychopathological symptoms. It is used to measure the progress and results of the treatments the patient undergoes in a healthcare setting.

It consists of 90 items, to be answered with a score from zero to four, which constitute nine subscales of primary symptoms typically observed in psychotic patients: Somatization, ObsessivenessCompulsivity, Interpersonal sensitivity, Depression, Anxiety, Phobic anxiety, Hostility, Paranoid depression, Psychoticism.

Cronbach’s alpha for Italian population = 0.96

The Toronto Alexithymia Scale (TAS-20) [33]

It is a self-administered questionnaire for assessing alexithymia levels. Alexithymia is a condition that involves a deficit in the ability to get in touch with one’s feelings and describe them, and to distinguish emotional states from physiological perceptions. The test consists of 20 questions to which the patient can answer with a score from one to five.

The score obtained defines whether the patient is “nonalexithymic”, “borderline” or “alexithymic”.

Cronbach’s alpha for Italian population = 0.72

 The Attachment Style Questionnaire (ASQ) [34]

It is a self-assessment questionnaire intended for measuring attachment in adolescents and adults. It consists of 40 items to which an answer must be provided with a score from one (totally disagree) to six points (totally agree).

Based on theoretical expectations and analyzes of main behaviors, the 40 items were assigned to five scales describing attachment:

-  Trust

-  Discomfort with intimacy

-  Need for approval- Concern about relationships

-  Second nature of relationships.

Cronbach’s alpha for Italian population = 0.79

The Parental Bonding Instrument (PBI) [35]

It is a self-administered questionnaire that measures the parenting style of parents during the early adolescence of their sons and daughters (before the age of 16) and is used to retrospectively evaluate how the patient was raised and treated by his parents during the first 16 years of life.

Since this instrument has a cut-off score system for both the father and mother, it is suitable for children with two parents as well as those with a single parent.For both the mother and the father, it is developed on two axes: “Care”, which measures warmth, empathy and emotional support, and “Overprotection”, which captures the parent’s overprotection, control and interference. It is made up of 50 items, 25 per parent, to which the patient must respond with a score ranging from zero to three.

Cronbach’s alpha for Italian population = 0.81

The Family Assessment Device (FAD) [36]

It is a self-administered questionnaire to assess family functioning. It consists of 60 items developing in seven scales:

- Problem Solving, measures the ability to solve problems in order to guarantee the persistence of effective global family functioning

- Communication, indicates the methods of exchanging information limited to verbal exchange

-  Roles, measures the behaviors through which individuals fulfill family functioning

- Emotional resonance, measures the family’s ability to respond to a range of stimuli with feelings of appropriate quality and quantity

- Affective involvement, indicates the interest that the entire nucleus shows in the activities and interests of each member and it is essential to evaluate how much, and in what way, there is mutual interest

- Behavioral control, expresses the model that the family adopts to control behavior in physically dangerous situations, situations that express biological needs and situations that imply socialization behavior with people outside the family

- General functioning, indicates how the subject sees their family functioning overall.

Chronbach’s alpha for Italian population = 0.70

The Narcissistic Personality Inventory (NPI-40) [37]

It is a self-administered questionnaire used to evaluate the patient’s level of narcissism based on the behavioral criteria for the narcissistic personality according to the DSM. It consists of 40 items to which the patient responds by choosing between two options provided by the questionnaire, developing into seven scales that measure: Authority, Exhibitionism, Superiority, Interpersonal exploitation, Self-sufficiency, Vanity, Right.

Chronbach’s alpha for Italian population = 0.62

Data collection

At the time of hospitalization, the neuropsychiatrist who welcomes the patient into the ward collects reported anthropometric parameters, the patient’s clinical history and the reasons for hospitalization reported by the patient and parents, the eating symptoms present at admission, the patient’s criticalities regarding weight gain and loss, the eating habits, and the psychopathological comorbidities.

On the first or second day after hospitalization, the nutritional consultant carries out a physical assessment with objective measurement of the anthropometric parameters (weight in kilos and height in meters, calculating the BMI and identifying the corresponding BMI-P and z-score for nutritional purposes).

Ethics

The study was approved by the Ethics Committee of AOU City of Science and Health, Turin (protocol number: CS2 366). All participants provided written informed consent to take part in the study. All the procedures were conducted according to the 1995 Declaration of Helsinki as revised in Edinburgh in 2000.

Statistical analysis

The statistical analysis was carried out using SPSS 27.0 (Statistical Package for Social Sciences 27.0) software.

The differences in clinical, personality, nutritional and general psychopathology, attachment and family functioning features were compared using t-tests for independent samples, with respect to the following dichotomous variables: suicide attempt at admission, suicidal ideation, self-harm, social withdrawal, need to be transferred to the CNW, discharge with admission to the NPI Day Hospital. The continuous clinical variables (age at admission, duration of hospitalization, BMI at admission, BMI at discharge, delta BMI) were correlated with each other and with the personality variables, eating and general psychopathology, attachment and family functioning using Pearson’s correlation.

In consideration of the large number of variables taken into account but also of the explorative nature of the study, an intermediate level of correction was applied to significance level to reduce type I error, a p <0.01 was considered acceptable.

Results

Description of the sample included in the study 85 adolescents responding to inclusion criteria (age range 14-17) were included in the study: 75 were affected with full diagnosis of AN (66 restricting subtype; 7 binge-purging subtype; 2 purging subtype) (mean age: 14.85±1.76; mean weight 15.06±1.79), 10 were affected with atypical AN (mean age: 15.72±1.67; mean weight: 21.89±3.07). Since the numerosity of the non-ANR subtypes was small, in order to preserve the aims of the study, all the adolescents admitted to a PW responding to inclusion criteria, who were generically considered AN adolescents, were included in the analysis and taken into account as a whole in the statistical analysis (Table 1)Shows the clinical parameters of hospitalization for the whole AN sample.

Table 1: Clinical parameters of the inpatient treatment; BMI = Body Mass Index.

Comparison among the psychopathological characteristics associated with AN 

Suicide attempts

(Table 2) Shows the comparison between subjects who had and those who had not made suicide attempts before hospitalization.

Table 2: T-test comparison among subjects with and without suicide attempts with respect to clinical parameters and behavioral measures; TCI = Temperament and Character Inventory; EDI = Eating Disorder Inventory -2; ASQ = Attachment Style Questionnaire; TAS = Toronto Alexithymia Scale-20; FAD = Family Assessment Device.

Duration of hospitalization appears significantly longer and impulsivity at the TCI appeared higher in the group that did not engage in suicidal behavior (p<.001).

The group that had performed suicide attempts showed greater anticipatory anxiety at the TCI, greater interpersonal distrust at the EDI-2, greater concern about relationships at the ASQ and difficulty describing feelings at the TAS-20, and a worse general family functioning at the FAD (p<.001).

Suicidal ideation

(Table 3) Displays the comparison between subjects who manifested suicidal ideation at admission and those who did not.

Table 3: T-test comparison among subjects with and without suicidal ideation with respect to clinical parameters and behavioral measures; BMI = body mass index; FAD = Family Assessment Device; SCL = Symptom Cecklist 90; PBI = Parental Bonding Instrument; NPI-40 = Narcissistic Personality Inventory

Displays the comparison between subjects who manifested suicidal ideation at admission and those who did not.

The subjects who presented suicidal ideation had higher BMI at admission and at discharge, higher phobic anxiety at SCL-90, higher paternal overprotection at the PBI, higher family general problems and worse family problem solving as well as emotional involvement at the FAD, and higher tendency to Exploitation at the NPI-40 (p<.001).

Those who did not present suicidal ideation showed higher paternal care at the PBI (p<.001).

NSSIs

(Table 4a) Displays the comparison between subjects who presented NSSI at admission and those who did not.

Table 4a: T-test comparison among subjects with and without NSSI with respect to clinical parameters and behavioral measures. NSSI = Non Suicidal Self-Injuries; ASQ = Attachment Style Questionnaire; BDI = Beck Depression Inventory -II

Those who presented NSSI had higher disease for intimacy at the ASQ, higher total and somatic depression at the BDI-II (p<.001).

Social Withdrawal

(Table 4b) Displays the comparison between subjects who presented social withdrawal at admission and those who did not.

Table 4b: T-test comparison among subjects with and without social withdrawal with respect to clinical parameters and behavioral measures; SCL = Symptom Checklist 90; PBI = Parental Bonding Instrument; NPI-40 = Narcissistic Personality Inventory

Those who presented social withdrawal had higher phobic anxiety at the SCL-90, higher maternal and paternal overprotection at the PBI and higher tendency to Exploitation at the NPI-40 (p<.001).

Transfer to CNW or NPI Day Hospital

(Table 5) Displays the comparison between those who were transferred to the CNW and those who were transferred to the NPI DH and those who did not.

Table 5: T-test comparison among subjects with and without NPI Inpatient Ward or Day Hospital transfer with respect to clinical parameters and behavioral measures; NPI = Child Neuropsychiatry; NPI-40 = Narcissistic Personality Inventory.

Those who were transferred to the CNW showed higher treatment duration (p<.001) and higher attitude to defend their rights at the NPI-40 (p<.005). Those who were transferred to the NPI DH showed higher duration of the treatment (p<.010).

Significant correlations between indices of hospitalization and behavioral parameters

(Table 6) displays the correlations between the clinical indices of hospitalization and the person logical and psychopathological traits of the patients.

Table 6: Significant correlations of clinical parameters with clinical and behavioral measures; BMI = body mass index; EDI = Eating