On bells, saliva, and abdominal pain or discomfort: Early aversive visceral conditioning and vulnerability for anorexia nervosa

Abstract

Gastrointestinal (GI) symptoms are common in anorexia nervosa (AN), can predate illness onset, complicate renourishment, and persist after recovery. We explore how, through processes of aversive visceral conditioning, early GI pain and discomfort may increase vulnerability to AN in some individuals. Processes include enhanced preoccupation with the gut resulting from aversive visceral memories and disruptions in the typical acquisition of self-attunement when children learn to map and interpret interoceptive sensations and develop adaptive actions. We question whether a fear of weight gain, in some cases, may be an epiphenomenon of the recapitulation of actual or perceived GI symptoms that is especially relevant during puberty, especially in girls. This conceptualization has immediate clinical implications and offers ideas for future research. We propose that GI discomfort associated with renourishment may reignite prior aversive visceral experiences. We encourage development of a formulation that organizes the individual's current experience of the body with respect to these prior aversive experiences. Our conceptualization underscores the importance of assessment of GI experiences in individuals with AN; the examination of dietary strategies that minimize GI symptoms and enhance renourishment efficacy; and strategies that attempt to alter this aversive visceral conditioning by mapping sensations to meanings and adaptive actions. K E Y W O R D S abdominal pain, anorexia nervosa, avoidant restrictive food intake disorder, bloating, gastrointestinal symptoms, interoception, memory, visceral conditioning

Validating the visceral sensitivity index in an eating disorder sample

“…Results supporting the incremental validity of the VSI in cross‐sectionally predicting restrictive eating, body dissatisfaction, and compensatory (purging, exercise) behaviors further highlight the importance and relevance of examining GI‐specific anxiety in EDs. These findings also extend previous research suggesting that sensory hypersensitivity/hyperresponsiveness and poor interoceptive awareness predict severity of ED symptoms and body image (Brand‐Gothelf et al, 2016; Brown et al, 2017; Zucker et al, 2013; Zucker & Bulik, 2020). Critically, the VSI was associated with ED symptoms above and beyond trait anxiety, a potential etiological and maintenance factor in EDs (Kaye et al, 2004; Pallister & Waller, 2008), as well as anxiety sensitivity, supporting the utility and relevance of studying GI‐specific sensitivity in EDs.…”

“…Notably, across diagnoses, elevations in VSI scores were significantly higher than those of a past sample of IBS patients (Labus et al, 2004), and aligns with findings from a study showing significant associations between higher VSI scores and ED symptom presence among patients with chronic constipation (Murray et al, 2020). Elevated VSI scores suggest that individuals with EDs tend to be anxious and hypervigilant around GI sensations (Boyd et al, 2005; Brand‐Gothelf et al, 2016; Hetterich et al, 2019; Kerr et al, 2016; Perez et al, 2013; Zucker et al, 2013; Zucker & Bulik, 2020), perhaps even more so than in existing disorders of gut–brain interaction.…”

“…As such, there has been increased interest in assessing GI‐related symptoms in EDs and exploring how they may contribute to the onset or maintenance of ED symptoms. Previous research has postulated that GI symptoms may exacerbate and/or maintain food avoidance, body image concerns, and compensatory behaviors in EDs (e.g., Hadley & Walsh, 2003; Zucker et al, 2013), particularly in anorexia nervosa (AN; Zucker & Bulik, 2020). Accordingly, if food consumption in ED patients is often followed by aversive GI symptoms, this may increase eating‐related anxiety and/or body image concerns (e.g., conflating fullness or bloating with feeling “fat”), which may, in turn, lead to food avoidance and/or compensatory behaviors, further exacerbating GI symptoms and maintain disordered eating.…”

Do children with recurrent abdominal pain grow up to become adolescents who control their weight by fasting? Results from a UK population‐based cohort

“…People with eating disorders (ED) are known to suffer from concurrent gastrointestinal (GI) complaints (e.g., abdominal pain, constipation and bloating) (Sato & Fukudo, 2015) and there is an expanding body of evidence that suggests, for a significant group of patients, that GI symptoms may precede their disordered eating (Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004; Wiklund et al, 2019; Zucker & Bulik, 2020). By far the most common GI complaint in childhood is recurrent abdominal pain (RAP).…”

The Phenome-wide Consequences of Anorexia Nervosa Genes

“…Examining the consequences of aberrant predicted gene expression among these patients (i.e., testing for GReX-associations) may reveal clinical and biological consequences of these genes; for example, studying whether AN-associated genes have anthropometric and metabolic consequences among adults with no evidence for previous AN- or ED-diagnoses may disentangle whether certain endophenotypes present as a cause, or consequence of AN. For example, it has been postulated that behaviors of food avoidance and restriction may arise due to gastrointestinal complaints and distress that provoke these behaviors and precede development of AN(86). Likewise, autoimmune disorders of the gastrointestinal tract, such as celiac disease and Crohn’s disease, show a bidirectional relationship with AN, with previous diagnosis of a GI-associated autoimmune disorders increasing the risk of AN and vice versa(8).…”