Author response

We appreciate the point that elevated feelings of disgust have not been assessed in our study. However, we are at variance to his conclusion. In Vicario’s former letter to the editor of the American Journal of Psychiatry,1 he has strengthened the point of altered insula activation being associated with feelings of disgust. However, we have not observed altered insula activation during pain perception in our patients. In addition, Vicario cites the work by Oaten and colleagues,2 which demonstrates that the experience of disgust is generating an increase in pain sensitivity. However, the opposite is true in patients with anorexia. They are less sensitive to pain, as shown in our study. In addition, it is generally assumed that disgust is accompanied by increased activation of the parasympathetic nervous system (PNS). However, empirical support for the role of PNS in disgust is scarce. Probably, the story is far more complicated. He and colleagues3 reported an increase of heart rate associated with unpleasant odors and facial expressions of disgust, while de Jong and colleagues4 suggested some PNS involvement. However, physiologic reactions were independent from disgust sensitivity. To our knowledge, the specific relation between disgust and PNS activity has not been studied in patients with anorexia nervosa. Thus, we would like to express our sincere doubts on the relation between disgust and our findings as raised by Vicario.