Phenomenologic relationship of eating disorders to major affective disorder

We administered the National Institute of Mental Health Diagnostic Interview Schedule to 41 patients with a lifetime history of anorexia nervosa (25 with and 16 without bulimia) and to 49 patients with bulimia alone. Results showed that 77% of the patients with eating disorders had a lifetime diagnosis of DSM-III major affective disorder, a rate significantly higher than that found in comparison groups composed of the first-degree relatives of probands with schizophrenia and bipolar disorder. High lifetime rates of anxiety disorders, substance use disorders, and kleptomania were also observed. By contrast, few cases of personality disorders and no cases of schizophrenia were found. These findings combine with the results of studies of family history, long-term outcome, response to biological tests, and treatment response to suggest that anorexia nervosa and bulimia may be closely related to major affective disorder.     

The prevalence of personality disorders in 210 women with eating disorders.

BACKGROUND: The purpose of this study was to assess the prevalence, reliability, and predictive value of comorbid personality disorders in a large sample of 210 women seeking treatment for anorexia nervosa (N = 31), bulimia nervosa (N = 91), or mixed disorder (N = 88). METHOD: All subjects were interviewed using the Structured Interview for DSM-III Personality Disorders as part of a longitudinal outcome study of eating disorders currently underway at Massachusetts General Hospital. RESULTS: Of the 210 subjects, 27% had at least one personality disorder; the most commonly observed was borderline personality disorder in 18 subjects (9%). The highest prevalence of personality disorders was found in the anorexia nervosa/bulimia nervosa group at 39%, followed by 22% in the anorexics and 21% in the bulimic sample. We found statistically significant differences regarding the distribution of personality disorders across eating disorder groups. The dramatic personality disorder cluster was differentially distributed across groups; this finding was accounted for by higher rates of borderline personality disorder in the bulimia nervosa and anorexia nervosa/bulimia nervosa groups than in the anorexia nervosa group. The anxious personality disorder cluster was differentially distributed across groups with higher rates in the anorexia nervosa and anorexia nervosa/bulimia nervosa samples. Those subjects with a comorbid personality disorder had a significantly slower recovery rate than those without a comorbid personality disorder. CONCLUSION: The prevalence of personality disorders is not high in treatment-seeking women with eating disorders compared with previously studied samples. The greatest frequency of comorbid personality disorders is in the anorexia nervosa/bulimia nervosa group; this subset also had longer duration of eating disorder illness and much greater comorbid Axis I psychopathology compared with the rest of the sample. Future studies should address whether personality disorders have predictive value in the long-term course and outcome of eating disorders.     

Alcohol use disorder comorbidity in eating disorders: a multicenter study

BACKGROUND: Eating disorders and alcohol use disorders (AUDs) commonly co-occur, although the patterns of comorbidity differ by eating disorder subtype. Our aim was to explore the nature of the co-morbid relation between AUDs and eating disorders in a large and phenotypically well-characterized group of individuals. METHOD: We compared diagnostic and personality profiles of 97 women with lifetime anorexia nervosa only, 282 women with lifetime bulimia nervosa only, and 293 women with a lifetime history of both anorexia nervosa and bulimia nervosa or anorexia nervosa with binge eating (ANBN) (DSM-IV criteria). All individuals were participants in a multicenter study of the genetics of anorexia nervosa and bulimia nervosa. We explored pattern of onset, Axis I and II comorbidity, and personality characteristics of individuals with and without AUDs by eating disorder subtype. Personality characteristics were assessed with the Multidimensional Perfectionism Scale, the Temperament and Character Inventory, and the Barratt Impulsivity Scale. RESULTS: Alcohol use disorders were significantly more prevalent in women with ANBN and bulimia nervosa than in women with anorexia nervosa (p =.0001). The majority of individuals reported primary onset of the eating disorder, with only one third reporting the onset of the AUD first. After eating disorder subtype was controlled for, AUDs were associated with the presence of major depressive disorder, a range of anxiety disorders, and cluster B personality disorder symptoms. In addition, individuals with AUDs presented with personality profiles marked by impulsivity and perfectionism. CONCLUSIONS: Individuals with eating disorders and AUDs exhibit phenotypic profiles characterized by both anxious, perfectionistic traits and impulsive, dramatic dispositions. These traits mirror the pattern of control and dyscontrol seen in individuals with this comorbid profile and suggest that anxiety modulation may be related to alcohol use in this group.     

Efficacy of intervention with externalization therapy for eating disorders]

Externalization has been one of the effective methods in the fields of brief therapy, family therapy, and psycho-education in recent years. In this study, we investigated the efficacy of intervention with externalization at the first stage of therapy in 25 patients with eating disorders. The subjects consisted of 11 patients with anorexia nervosa (AN) and 14 with bulimia nervosa (BN). The Eating Disorder Inventory (EDI) was evaluated at the first session, the 10th session, and six months later. The obtained results showed intervention with externalization resulted in significant decreases in not only total EDI score but also all the EDI subscale scores. We also found that there were great differences between the EDI subscale scores of anorexia nervosa and bulimia nervosa patients. Therapy was significantly less effective for patients with anorexia nervosa than for those with bulimia nervosa, and much less effective for the restricting type of anorexia nervosa. In addition, all the EDI subscale scores were significantly decreased, irrespective of the complication of personality disorder. The efficacy of intervention with externalization continued for six months. Especially in patients with anorexia nervosa, there were significant decreases in the EDI subscale scores when compared with the scores in the 10th session. The present findings indicates that initial intervention with externalization is effective for treating eating disorders, regardless of the severity of illness.     

DSM-III-R personality disorders in patients with eating disorders

The authors conducted a systematic examination of DSM-III-R personality disorders among 35 patients with eating disorders. Fifty-seven percent of the patients met the criteria for at least one axis II diagnosis; borderline, self-defeating, and avoidant were the most frequently assigned personality disorders. Forty percent of the patients were given two or more diagnoses, and 17% of the patients met criteria for five to seven diagnoses. No differences were found between patients with anorexia nervosa, anorexia and bulimia nervosa, and bulimia nervosa in the distribution of diagnoses or the frequency with which individual criteria (traits) were assigned.     

The Prevalence of Personality Disorders Among Those with Eating Disorders

The genuine prevalence of personality disorders among those with eating disorders is unknown. However, in this paper, we summarize the existing data, with careful acknowledgment of our approach to interpretation as well as the limitations of previous studies. Our findings indicate that obsessive-compulsive personality is the most common personality disorder in restricting-type anorexia nervosa, while borderline personality is the most common personality disorder in binge-eating/purging type anorexia nervosa. Borderline personality is the most common personality disorder in bulimia nervosa, as well. In those with binge eating disorder, obsessive-compulsive personality is the most common personality disorder although, compared with the preceding eating disorder diagnoses, there are broader clusters of personality disorders represented in this group. We discuss the implications of these findings.     

The prevalence of personality disorders among those with eating disorders

The genuine prevalence of personality disorders among those with eating disorders is unknown. However, in this paper, we summarize the existing data, with careful acknowledgment of our approach to interpretation as well as the limitations of previous studies. Our findings indicate that obsessive-compulsive personality is the most common personality disorder in restricting-type anorexia nervosa, while borderline personality is the most common personality disorder in binge-eating/purging type anorexia nervosa. Borderline personality is the most common personality disorder in bulimia nervosa, as well. In those with binge eating disorder, obsessive-compulsive personality is the most common personality disorder although, compared with the preceding eating disorder diagnoses, there are broader clusters of personality disorders represented in this group. We discuss the implications of these findings.     

Symptom fluctuation in eating disorders: correlates of diagnostic crossover

OBJECTIVE: The course of anorexia nervosa often includes the emergence of bulimic symptoms and a crossover to the full syndrome of bulimia nervosa. However, clinicians' ability to predict who will develop bulimia nervosa is limited. The converse phenomenon, crossover from bulimia nervosa to anorexia nervosa, has not been investigated as thoroughly. The authors identified factors that are associated with crossover from anorexia nervosa to bulimia nervosa and from bulimia nervosa to anorexia nervosa. METHOD: All participants were from the International Price Foundation Genetic Study. Two groups were studied. The first comprised 88 individuals with an initial diagnosis of anorexia nervosa, of whom 32 developed bulimia nervosa. The second included 350 individuals with bulimia nervosa, of whom 93 developed anorexia nervosa. Several variables, including DSM-IV axis I and II disorders and personality traits, were evaluated as potential predictors of crossover. RESULTS: For the majority of affected individuals, crossover occurred by the fifth year of illness. A low level of self-directedness was associated with crossover in both directions. Other factors differed by diagnosis: high parental criticism was associated with crossover from anorexia nervosa to bulimia nervosa, whereas alcohol abuse/dependence and a low level of novelty seeking were associated with crossover from bulimia nervosa to anorexia nervosa. CONCLUSIONS: Low self-directedness may be associated with diagnostic instability in general, whereas other specific factors are related to the direction of diagnostic crossover. These results indicate that personality and family characteristics may influence the course of eating disorders and may be informative for planning interventions.     

A preliminary investigation of the lifetime prevalence of anorexia and bulimia nervosa in patients with obsessive compulsive disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) is currently classified as an anxiety disorder although it possesses many characteristics that distinguish it from other anxiety disorders. Clinically and neurobiologically, OCD appears to overlap somewhat with the eating disorders. METHOD: To assess in a controlled fashion the lifetime prevalence of the eating disorders in patients with OCD, we administered portions of the Structured Clinical Interview for DSM-III-R, Patient Version (SCID-P), to 62 patients (31 men, 31 women) with a primary DSM-III-R diagnosis of OCD. RESULTS: Among the OCD patients, the lifetime prevalence of anorexia nervosa and/or bulimia nervosa was 12.9% (N = 8), and an additional 17.7% (N = 11) met subthreshold criteria for either anorexia or bulimia nervosa. Interestingly, unlike multiple epidemiologic studies that have reported a substantial female preponderance among patients diagnosed with anorexia or bulimia nervosa, there was no significant gender difference in the lifetime prevalence of eating disorders among the patients with OCD. Almost 13% (N = 4) of the men and 6.5% (N = 2) of the women with OCD met criteria for a lifetime diagnosis of anorexia nervosa and 3.2% (N = 1) of the men and 6.5% (N = 2) of the women with OCD met criteria at some time in their lives for bulimia nervosa. In addition, subthreshold criteria for anorexia nervosa or bulimia nervosa were met by an additional 12.9% (N = 4) of the men and 22.6% (N = 7) of the women. CONCLUSION: These data suggest that OCD patients, regardless of gender, have a substantial lifetime prevalence of anorexia and/or bulimia nervosa.     

Psychiatric comorbidity in treatment-seeking anorexics and bulimics.

Current and lifetime psychiatric diagnoses were compared in 229 female patients seeking treatment for current episodes of anorexia nervosa (N = 41), bulimia nervosa (N = 98) and mixed anorexia nervosa and Schizophrenia-Lifetime Version, which was modified to include a section for DSM-III-R eating disorders, the Longitudinal Interval Follow-up Evaluation, and the Structured Interview for DSM-III Personality Disorders. Seventy-three percent of the anorexia nervosa subjects, 60% of the bulimia nervosa subjects, and 82% of the mixed anorexia nervosa and bulimia nervosa subjects had a current comorbid Axis I diagnosis. Major depression was the most commonly diagnosed comorbid disorder. Low rates of alcohol and substances abuse disorder were diagnosed, and personality disorder occurred in a minority of the sample. The subjects with mixed disorder manifested a higher lifetime prevalence of kleptomania than either the anorexics or the bulimics. High levels of comorbidity were noted across the eating disorder samples. Mixed disorder subjects manifested the most comorbid psychopathology and especially warrant further study.     

The Prevalence of Personality Disorders Among Those with Eating Disorders

The genuine prevalence of personality disorders among those with eating disorders is unknown. However, in this paper, we summarize the existing data, with careful acknowledgment of our approach to interpretation as well as the limitations of previous studies. Our findings indicate that obsessive-compulsive personality is the most common personality disorder in restricting-type anorexia nervosa, while borderline personality is the most common personality disorder in binge-eating/purging type anorexia nervosa. Borderline personality is the most common personality disorder in bulimia nervosa, as well. In those with binge eating disorder, obsessive-compulsive personality is the most common personality disorder although, compared with the preceding eating disorder diagnoses, there are broader clusters of personality disorders represented in this group. We discuss the implications of these findings.     

Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype

OBJECTIVE: The authors retrospectively examined a spectrum of childhood traits that reflect obsessive-compulsive personality in adult women with eating disorders and assessed the predictive value of the traits for the development of eating disorders. METHOD: In a case-control design, 44 women with anorexia nervosa, 28 women with bulimia nervosa, and 28 healthy female comparison subjects were assessed with an interview instrument that asked them to recall whether they had experienced various types of childhood behavior suggesting traits associated with obsessive-compulsive personality. The subjects also completed a self-report inventory of obsessive-compulsive disorder (OCD) symptoms. RESULTS: Childhood obsessive-compulsive personality traits showed a high predictive value for development of eating disorders, with the estimated odds ratio for eating disorders increasing by a factor of 6.9 for every additional trait present. Subjects with eating disorders who reported perfectionism and rigidity in childhood had significantly higher rates of obsessive-compulsive personality disorder and OCD comorbidity later in life, compared with eating disorder subjects who did not report those traits. CONCLUSIONS: Childhood traits reflecting obsessive-compulsive personality appear to be important risk factors for the development of eating disorders and may represent markers of a broader phenotype for a specific subgroup of patients with anorexia nervosa.     

Personality pathology and its influence on eating disorders

Personality disorders appear to be present in a significant minority of individuals with eating disorders. For example, in contrast to reported rates in the general population of eight percent, obsessive compulsive personality is present in approximately 22 percent of individuals with anorexia, restricting type. Likewise, in contrast to rates in the general population of six percent, borderline personality is present in approximately 25 percent of individuals with anorexia nervosa, binge-eating purging type, and in 28 percent of individuals with bulimia nervosa. Could these high rates of comorbidity indicate a partially causal relationship? At the very least, these specific personality disorders may be shaping corresponding styles of eating pathology, with obsessive compulsive personality disorder partially accounting for restrictive eating pathology and borderline personality disorder partially accounting for impulsive eating pathology. These potential associations are explored.     

An empirical study of the classification of eating disorders

OBJECTIVE: The nosology for eating disorders, despite having been extensively revised over time, may not capture the natural clustering of eating-related pathology as it occurs in general population samples.METHOD: Detailed information about anorectic and bulimic behaviors was assessed through personal interviews of 2,163 Caucasian female twins from a population-based registry. Latent class analysis was applied to nine eating disorder symptoms to develop an empirically based typology. Demographic, comorbidity, personality, and co-twin diagnosis data were used to validate the resultant classes.RESULTS: A six-class solution provided the best fit. One class displayed distorted eating attitudes without low body weight. Two classes demonstrated low weight without the psychological features of eating disorders. Three classes broadly resembled the DSM-IV classifications of anorexia nervosa, bulimia nervosa, and binge-eating disorder. For all classes, and especially for the three that reflected current diagnoses of eating disorders, monozygotic twins resembled one another much more in terms of class membership than did dizygotic twins.CONCLUSIONS: The authors found within a community sample, and through an empirical method, classes of eating-related pathology that broadly resembled the current classifications of anorexia nervosa, bulimia nervosa, and binge-eating disorder. Additional classes were marked by either the psychological features of eating disorders or low body weight. Individuals in the three eating-disorder classes had similar personality profiles but displayed differences in symptom expression and co-twin risk for anorexia nervosa, bulimia nervosa, and obesity.     

Effects of milnacipran on binge eating - a pilot study

Selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors are effective in the treatment of bulimia nervosa. There have been relatively few studies of the efficacy of specific serotonin and norepinephrine reuptake inhibitors in the treatment of eating disorders. Twenty-five outpatients with binge eating episodes, diagnosed as anorexia nervosa, binge-eating/purging type, bulimia nervosa/purging type, or bulimia nervosa/non-purging type, were treated with milnacipran and 20 patients completed the 8-week study. Symptom severity was evaluated using the Bulimic Investigatory Test, Edinburgh (BITE) self-rating scale before administration of milnacipran and after 1, 4, and 8 weeks treatment. The scores improved after 8 weeks, especially drive to, and regret for, binge eating. Milnacipran was more effective in patients without purging and in younger patients, while there was no difference in the efficacy of milnacipran among subtypes of eating disorders.     

Cognitive flexibility in anorexia nervosa and bulimia nervosa.

The aim of this study was to determine if there are differences in cognitive flexibility in anorexia nervosa and bulimia nervosa. Fifty-three patients with an eating disorder (34 with anorexia nervosa and 19 with bulimia nervosa) and 35 healthy controls participated in the study. A battery of neuropsychological tests for cognitive flexibility was used, including Trail Making B, the Brixton Test, Verbal Fluency, the Haptic Illusion Test, a cognitive shifting task (CatBat) and a picture set test. Using exploratory factor analysis, four factors were obtained: 1: Simple Alternation; 2: Mental Flexibility; 3: Perseveration; and 4: Perceptual Shift. Patients with anorexia nervosa had abnormal scores on Factors 1 and 4. Patients with bulimia nervosa showed a different pattern, with significant impairments in Factors 2 and 4. These findings suggest that differential neuropsychological disturbance in the domain of mental flexibility/rigidity may underlie the spectrum of eating disorders.     

Differences in DSM-III-R and DSM-IV diagnoses in eating disorder patients

Two hundred eighty-eight eating disorder patients were administered the DSM-III-R Structured Clinical Interview (SCID) and the DSM-IV SCID for axis I and II. Concordance between DSM-III-R and DSM-IV was excellent for the axis I affective and anxiety disorders, bulimia nervosa, and substance abuse/dependence. It was also excellent for axis II paranoid, schizoid, borderline, and antisocial personality disorders. Agreement between the two nosological systems was lower for alcohol abuse/dependence with a kappa of.63. Kappas were also poor for the following personality disorders: schizotypal (.44), histrionic (.29), dependent (.54), obsessive-compulsive (.62) and not otherwise specified (.63). There was a substantial difference in the diagnosis of anorexia nervosa between DSM-III-R and DSM-IV. Fourteen patients were diagnosed with anorexia nervosa, binge/purge type, using DSM-IV criteria, while only six received the diagnoses of anorexia nervosa and bulimia nervosa using DSM-III-R criteria. Kappa was.49 and the percent agreement was 79%. While there are considerable areas of overlap in DSM-IV and DSM-III-R, there are also areas of substantial differences. Clinicians and researchers must be very cautious when attempting to compare data from the different nosologies.     

Pre-menarchal bulimia nervosa.

Although pre-pubertal anorexia nervosa has been well described, pre-pubertal bulimic behaviour in the context of this disorder appears to be uncommon. There have been no published reports of pre-pubertal bulimia nervosa occurring independently. Of 323 patients with bulimia nervosa attending an eating disorders research clinic between 1980 and 1989, the authors identified six patients who described pre-menarchal binge eating in the absence of a concurrent history of anorexia nervosa or massive obesity. Three (0.93%) of these patients described a pre-menarchal onset of bulimia nervosa, but there was no evidence that they were pre-pubertal. The implications of these findings are discussed.     

Anger and personality in eating disorders

Objective: This study was designed to examine how anger, temperament and character profiles differ across subtypes of eating disorders (EDs) in comparison to healthy controls and to analyze the relationship between anger expression, eating attitudes and personality dimensions. Method: One hundred and thirty-five outpatients (50 of whom suffered from anorexia nervosa restrictor type [AN-R], 40 from anorexia nervosa binge/purging [AN-BP] and 45 from bulimia nervosa [BN]) and 50 control subjects were recruited and administered State-Trait Anger Expression Inventory (STAXI), Temperament and Character Inventory (TCI) and Eating Disorder Inventory II (EDI-II). Results: STAXI showed greater levels of anger in patients with BN than in those with AN. TCI showed different personality profiles, in accordance with previous studies. Correlations were found between the management of anger feelings and psychological and personality traits typical of patients with EDs. Conclusions: Clinically, impulsivity seems to be the psychopathologic element most strongly correlated to anger. Moreover, it appears clear that anger is better managed by individuals with greater character strength.