Psychobiology of borderline personality traits related to subtypes of eating disorders: a study of platelet MAO activity

Increased and decreased levers of platelet monoamine oxidase (MAO) activity have been reported in patients with eating disorders, indicating abnormalities of the serotonin turnover. However, whether these findings are related to eating disorders or are rather reflecting the pathophysiology of borderline personality traits in these patients is still unknown. Platelet MAO activity and comorbid personality disorders were investigated in 72 patients with different subtypes of eating disorders (ED) and in a group of 28 healthy controls. ED patients comprised the following subtypes: 25 anorexia nervosa (AN) restrictive, 14 AN binge eating-purging (AN b-p), 3 anorexia nervosa not otherwise specified (AN NOS) and 30 bulimia nervosa (BN). Personality disorders and traits were assessed with the Structured Interview for Personality Disorders (SCID-II), the Zanarini Rating Scale for Borderline Personality Disorder, and the Barrat Impulsiveness Scale. Platelet MAO activity was significantly lower in ED patients with comorbid borderline personality disorder (BPD) than in ED without Borderline personality disorder (BDP). Platelet MAO activity was significantly and inversely correlated with the number and severity of BPD clinical features. In the subsample of patients with binge eating-purging symptoms (AN b-p, AN NOS and BN), platelet MAO activity was significantly lower in binge-purge patients with comorbid BPD than in binge-purge patients without BPD. The whole group of eating disorders had a significantly reduced lever of platelet MAO activity compared with the control group. The results suggest that low platelet MAO activity might characterize eating disorders with comorbid borderline personality traits, reflecting greater serotonin dysfunction in these patients. The role of decreased platelet MAO as an endophenotype with specific clinical manifestations should be explored in future studies.     

Platelet MAO activity in anorexia nervosa patients with and without a major depressive disorder

Platelet MAO activity was determined in 33 anorexia nervosa patients. A subgroup of 15 patients who met Research Diagnostic Criteria for a concomitant major depressive disorder were found to have, both initially and after 5 weeks of treatment, significantly lower mean platelet monoamine oxidase (MAO) activity than 28 matched normal control subjects. In contrast, mean platelet MAO activity in the patients who did not meet criteria for major depressive disorder was similar to values in control subjects. The authors found that significantly more depressed patients had low MAO activity compared with nondepressed patients and controls. Platelet MAO activity may be useful in discriminating among subtypes of anorexia nervosa patients.     

Biochemical abnormalities of the serum in anorexia nervosa

Biochemical analyses of sera from 27 patients with anorexia nervosa were performed and compared with those of normal female volunteers and other anorectic groups including patients who had undergone digestive tract surgery and patients with malignancies. There were significant increases in gamma-glutamyltranspeptidase, lactate dehydrogenase, glutamic pyruvic transaminase, glutamic oxaloacetic transaminase, cholesterol, and amylase activity and significant decreases in total serum protein, blood sugar, albumin, globulins, and cholinesterase in anorexia nervosa patients compared with normal control subjects. At discharge, these values slightly improved. Similar alterations were also observed in two other anorectic groups. Compared with anorexia nervosa patients, the two other anorectic groups showed a severe reduction in the albumin level and increase in the globulin level. In two other anorectic groups cholesterol levels were lower, and in the malignancy group cholinesterase level was lower than in the anorexia nervosa patients. In anorexia nervosa patients, biochemical abnormalities in the serum were more frequent in total serum protein (93%), blood sugar (85%), and globulins (78%) than in other serum factors, such as blood urea nitrogen (15%), uric acid (15%), and alkaline phosphatase (7%). These results suggest that detection of biochemical abnormalities in the above-mentioned serum factors in routine analyses would be valuable in making an early diagnosis of anorexia nervosa from various anorectic disorders.     

Anorectic family dynamics: temperament and character data

Modern psychobiologic research conceptualizes personality as a complex adaptive system involving a bidirectional interaction between heritable neurobiologic dispositions (temperament) and social learning (character). In this study, we evaluated temperament and character traits of patients with anorexia nervosa and their mothers and fathers, and we analyzed the correlation of temperament and character traits among family members in anorectic families. Finally, we tested the ability of the Temperament and Character Inventory (TCI) to discriminate between normal controls and anorectic subjects, their parents, and their families. Temperament and character features of 50 restricter anorectic patients and their parents (23 fathers and 25 mothers) were analyzed and then compared with a control group of 60 women and their 20 fathers and 20 mothers using the TCI. Data suggest that both temperament and character factors are involved in anorexia nervosa (AN). Anorectic individuals were high in harm avoidance (HA), low in novelty seeking (NS), and high in persistence (P) ("obsessive temperament type"). Their character was remarkable for low self-directedness (SD). Their mothers were distinguished by low SD. The fathers were high in HA, but also low in P, and high in reward dependence (RD). Again, they were low in SD. The anorectic family had low SD as a common denominator observed in all family members. This finding indicates that the psychopathology of AN extends beyond obsessiveness, but combines obsessiveness with low character development. None of the above temperament and character profiles is pathognomic of restricter anorectics. The observation that both temperament and character have an important role in the etiopathogenesis of AN has important treatment ramifications. The TCI was useful in discriminating between normal controls and anorectic subjects, their parents, and the whole anorectic family.     

Entero-insular axis in children with anorexia nervosa

Entero-insular axis plays an important role in generating satiety signal. Thus disturbances in this axis may influence the course of anorexia nervosa. The aim of the study was analysis of the function of the hormonal part of the entero-insular axis in girls with anorexia nervosa. Thirteen girls with anorexia nervosa and in 10 healthy girls were studied. Each girl was subjected to oral glucose tolerance test and standard meal test. Blood was collected before stimulation and within 15, 30, 60, and 120 min thereafter. The concentrations of all peptides were determined by radioimmunoassay commercial kits. Fasted and postprandial levels of these peptides as well as integrated outputs were measured. Fasting insulin concentration was significantly higher in the group of girls with anorexia nervosa than in the control group (p<0.03). What more in girls with anorexia the integrated output of insulin was significantly lower in oral glucose tolerance test than after the meal (p<0.001). Also the integrated output of glucagon in both tests was higher in the group of girls with anorexia than in the control group. The mean output of pancreatic polypeptide and cholecystokinin in anorexia group was significantly higher (p<0.001 in both cases) than that in the control group but only after the test meal. The integrated outputs of gastric inhibitory peptide in both tests were significantly higher in anorectic girls than those in the control group (oral glucose tolerance test, p<0.02; meal test, p<0.001), However, mean values of the integrated output of glucagon-like peptide 1 in both tests were significantly higher in the control group than in the girls with anorexia (p<0.001 in each case). Highly significant correlation was found between glucose concentration and the concentrations of insulin, cholecystokinin, and gastric inhibitory peptide in both tests and for the both groups. In the anorectic girls, significant correlation between insulin concentration and the concentration of gastric inhibitory peptide was found after both stimulation tests and between insulin and cholecystokinin after oral glucose only. Conclusion: the disturbed secretion of the hormones of entero-insular axis after the meal in anorectic girls may have negative influence on the course of anorexia nervosa. This disease has no effect on the incretin function of cholecystokinin, gastric inhibitory peptide and glucagon-like peptide 1.     

Psychological traits and platelet monoamine oxidase activity in eating disorder patients: their relationship and stability

Self-reported behavior and attitudes towards eating [Eating Disorder Inventory-2; Garner DM (1991). Eating Disorder Inventory-2: Professional Manual. Odessa, Fl.: Psychological Assessment Resources; Estonian version Podar I, Hannus A, Allik J (1999). Personality and Affectivity Characteristics Associated With Eating Disorders: a Comparison of Eating Disordered, Weight-Preoccupied, and Normal Samples. J Pers Assess; 73(1), 133-147] and the activity of platelet monoamine oxidase (MAO) was studied in 11 patients with anorexia nervosa (AN), 43 patients with bulimia nervosa (BN) and a healthy control group (n=138). Nineteen patients filled in the EDI-2 questionnaire and donated blood samples three times with three month intervals in order to determine platelet MAO activity. Eating disordered (ED) patients scored higher on all EDI-2 subscales and had lower MAO activity compared to the control group. They also scored higher than the control group on the Neuroticism domain but lower on the Extraversion, Openness, and Conscientiousness domains of the NEO-PI-R questionnaire. The average stability of MAO on different occasions (r=.56) was slightly smaller than the stability of the EDI-2 scores (r=.70). The lack of correlations between personality dispositions and MAO activity indicates that they have independent influence on eating disorders. A possible relationship between neurochemical mechanisms and psychological symptoms of eating disordered behavior is discussed.     

Relationship of clinical factors to caloric requirements in subtypes of eating disorders

Caloric requirements for weight gain in subgroups of anorectic patients (anorectic restrictors, anorectic binge-purgers) and weight maintenance in subgroups of anorectic and bulimic patients (bulimics with and without a prior history of anorexia nervosa) were studied in a total of 36 patients. No significant differences were found between subgroups of anorectic patients either in calories to gain weight or to maintain a normal weight. Bulimic patients, as a group, were found to require significantly fewer [corrected] calories than the group of anorectic patients to maintain a normal weight. Bulimic patients with a prior history of anorexia nervosa were found to require more calories for weight maintenance than bulimics with no such prior history. In the entire eating disorder population, there was a significant negative correlation between highest premorbid body mass index (BMI) and calories required to maintain weight. These findings suggest that differences in energy metabolism may be present in the eating disorder subgroups.     

Temperament and character in italian men with anorexia nervosa: a controlled study with the temperament and character inventory.

This study compares personality traits of men and women with anorexia nervosa and matched controls. The Temperament and Character Inventory was used to assess personality traits of 15 male and 50 female anorectics and 28 male and 58 female controls matched for age and education. Male anorectic patients displayed overall lower reward dependence and cooperativeness. Male and female anorectics displayed higher persistence and lower self-directedness than controls. Anorectic men had lower harm avoidance than anorectic women. Discriminating analysis revealed the anorectic male group as the most clearly defined. Anorectic men shared more traits with anorectic women than with male controls. Temperament and character of anorectic men reflect features partly similar to those of women with anorexia. Personal history and discriminating analysis led to interesting inferences about the gender identity of anorectic men. These results should be helpful in directing pharmacologic and psychotherapeutic approaches that consider the specific personality traits of these patients.     

Insulin sensitivity in patients with anorexia nervosa and bulimia

Insulin sensitivity was studied using the euglycemic insulin clamp technique in 5 female patients with anorexia nervosa and 4 females with bulimia. The results were compared with those of 15 male patients with non-insulin-dependent diabetes mellitus. Euglycemic insulin clamp is performed for 2 h using the Biostator, during which time insulin was infused at a rate of 0.77 mU kg-1 min-1. Fasting plasma glucose and immunoreactive insulin tended to be lower in patients with anorexia nervosa than in those with bulimia (69.8 +/- 6.7 vs 75.9 +/- 7.7 mg/dl, and 5.9 +/- 2.0 vs 9.8 +/- 3.4 U/ml). The mean metabolic clearance rate (MCR) was 9.2 +/- 3.9 ml kg-1 min-1 for patients with anorexia nervosa, 5.1 +/- 2.2 ml kg-1 min-1 for patients with bulimia, and 3.8 +/- 0.3 ml kg-1 min-1 for patients with diabetes mellitus. However, one anorectic had a significantly high MCR. One anorectic and 3 bulimics had a significantly low MCR. These results suggest that insulin sensitivity varied in patients with anorexia nervosa, whereas it tended to decrease in some patients with bulimia but not to the same degree as in patients with diabetes mellitus.     

Average total energy expenditure in anorexia nervosa, bulimia nervosa, and healthy young women

The double-labeled water method was used to measure average daily total energy expenditure (EE) in 11 healthy normal-weight women classified as unrestrained eaters, in 8 patients with anorexia nervosa, and in 8 patients with bulimia nervosa. The body mass index was 20.0 +/- 1.3 kg/m2 in the control group, 15.2 +/- 5.6 kg/m2 in the anorectic groups, and 19.7 +/- 1.9 kg/m2 in the bulimic group. EE was measured over a 2-week period during which weight remained constant in all groups and was 2357 +/- 504 kcal/day for the controls, 2510 +/- 920 kcal/day for the bulimics, and 2899 +/- 656 kcal/day for the anorectics. Differences were not significant among groups. Physical activity was recorded in diaries by all subjects. Anorectic patients showed significantly more activity than all other groups. The data suggest that EE is high in anorectic patients as a consequence of physical activity.     

Temperament, character and suicide attempts in anorexia nervosa, bulimia nervosa and major depression.

OBJECTIVE: We examined the relation between personality traits as measured by the Temperament and Character Inventory (TCI) and a reported history of suicide attempts in women with anorexia nervosa, bulimia nervosa and major depression. METHOD: We compared the prevalence and severity of suicide attempts in women with anorexia nervosa (n = 68), bulimia nervosa (n = 152) and major depression with no history of an eating disorder (n = 59), and we examined the relation between the TCI scales and suicide attempts. RESULTS: Comparable numbers of women across the three groups had attempted suicide. The temperament dimension of high persistence and the character dimensions of low self-directedness and high self-transcendence were associated with a reported history of suicide attempts. CONCLUSION: Suicide attempts are equally common in women with eating disorders and women with depression. Whether the observed association between temperament and suicide attempts reflects correlates, causal factors or sequelae of suicide attempts is unknown.     

Blood platelet monoamine oxidase activity, serotonin uptake and release rates in anorexia and bulimia patients and in healthy controls

Platelet monoamine oxidase (MAO) activity, serotonin uptake rate and serotonin efflux rate have all been suggested to be markers for central serotonergic mechanisms. Platelet MAO activity is associated with certain personality traits, with low activity linked to traits such as impulsiveness, sensation-seeking and avoidance of monotony, all possible expressions of low central serotonergic activity. Low platelet serotonin uptake rate has been connected to unipolar depression and the rate of efflux, in the presence of the ATP uncoupler CCP, higher in bipolar depressives than in controls. Platelet MAO was found to be lower in 16 consecutive female inpatients fulfilling the DSM-III criteria for bulimia nervosa than in 12 female controls. Rates of serotonin uptake and efflux in the presence of CCP were, on the other hand, similar to the controls. In the controls there were no correlations between platelet MAO activity and any of the other parameters estimated. Vmax for the platelet uptake of serotonin correlated positively with the Km for the uptake, but not with any other parameter. The uninfluenced rate of efflux of serotonin correlated positively with the efflux in the presence of the ATP uncoupler CCP.     

Structural brain abnormalities in patients with bulimia nervosa

Computed tomographic (CT) brain scans were performed in 50 inpatients with bulimia nervosa, 50 anorectic inpatients, and 50 age-matched control subjects. A number of patients with bulimia nervosa had enlarged ventricles and/or sulcal widening, but the degree and frequency of ventricular dilatation and sulcal widening were not so pronounced as in patients with anorexia nervosa. As the bulimic patients were of normal body weight, the CT abnormalities cannot be attributed to emaciation, which has often been suggested as the cause of abnormalities found in anorectic patients. Since many bulimic patients repeatedly attempt to lose weight by going on restrictive diets, the morphological brain alterations may reflect the endocrine and metabolic reactions to starvation--regardless of whether starvation has led to emaciation, as in the case of anorexia nervosa, or only counterbalanced the binges of high-caloric food. This assumption is supported by the finding that in both bulimic and anorectic patients ventricular size is inversely correlated with the plasma levels of triiodothyronine, a low concentration of which is an indicator for starvation.     

Fatigue mood as an indicator discriminating between anorexia nervosa and bulimia nervosa

In order to clarify the differences in mood states between anorexia and bulimia nervosa, the Profile of Mood States (POMS) with tension-anxiety, depression, anger-hostility, vigour, fatigue and confusion scales was administered to 32 female patients with anorexia nervosa (age range 14 to 32 years, mean age 20 years), 49 female patients with bulimia nervosa (age range 15 to 33 years, mean age 23 years) and 410‘normal’ female subjects (age range 14 to 35 years, mean age 23 years). The scores on the depression, fatigue and confusion scales for both anorexia and bulimia nervosa and those on the tension-anxiety and anger-hostility scales for bulimia nervosa were significantly higher than those for the control subjects. The score on the fatigue scale for bulimia nervosa was significantly higher than that for anorexia nervosa. Moreover, the result of the multiple logistic regression analysis including all of the POMS scales indicated that the fatigue scale significantly discriminated between the two disorders. Fatigue mood appears to be a principal indicator for differentiating between the two disorders.     

Hypnotizability in patients with anorexia nervosa and bulimia

Hypnotizability was assessed with the use of three standardized hypnosis scales in 86 patients with eating disorders. All diagnoses were made according to DSM-III criteria. Sixty-five patients had anorexia nervosa and 21 had bulimia. The anorectic patients were divided into subgroups of 19 abstainers and 46 vomiters and purgers. Bulimic patients were highly hypnotizable, significantly more so than the patients with anorexia nervosa and age-matched populations. There was also a trend for the purging subgroup of anorectics to have higher hypnotic capacity than abstaining anorectics.     

Abnormal neuronal network in anorexia nervosa studied with I-123-IMP SPECT

Single photon emission computed tomography was used to study 14 female patients with anorexia nervosa and 8 female normal comparison subjects. Automatic voxel-based analysis of the images was carried out using statistical parametric mapping (SPM) software. Statistics across the entire brain were displayed as Z scores (threshold: P<0.05). Compared with the normal comparison subjects, the anorectic patients were characterized by hypoperfusion in the medial prefrontal cortex and the anterior cingulate gyrus, and hyperperfusion in the thalamus and the amygdala-hippocampus complex. These results suggest that a dysfunction in neuronal circuitry may be related to anorexia nervosa.     

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.     

Influence of Video Confrontation on the Self-Evaluation of Anorexia Nervosa Patients: A Controlled Study

The confrontation with one's body appearance as recorded on a video might have an impact on the body experience of anorexia nervosa patients. Such a video confrontation was applied to a group of 12 anorectic females. After the procedure, these patients rated their actual body (using Osgood's Semantic Differential) as thinner and more active; the control group of 12 female anorectics did not change their evaluations. The patients' evaluation of their ideal body image was not influenced.     

Altered cerebrospinal fluid neuropeptide Y and peptide YY immunoreactivity in anorexia and bulimia nervosa

The related central nervous system peptides neuropeptide Y and peptide YY have been found to be among the most potent endogenous stimulants of feeding behavior. We measured these neuropeptides in cerebrospinal fluid to determine whether they contributed to the pathophysiologic characteristics of anorexia and bulimia nervosa. Cerebrospinal fluid neuropeptide Y concentrations were significantly elevated in underweight anorectic patients and in many of the anorectic patients studied at intervals after weight restoration. These levels normalized in long-term weight-restored anorectic patients who had a return of normal menstrual cycles. Increased neuropeptide Y activity may contribute to several characteristic disturbances in anorexia, including menstrual dysregulation. Cerebrospinal fluid peptide YY concentrations were significantly elevated in normal-weight bulimic patients abstinent from pathological eating behavior for a month compared with themselves when actively bingeing and vomiting or compared with healthy volunteers. Increased peptide YY activity may contribute to a drive to overfeed in normal-weight bulimic patients.     

Pain sensitivity in anorexia nervosa and bulimia nervosa

Pain threshold was measured with short heat stimuli using a contact thermode in 19 patients with anorexia nervosa, 20 patients with bulimia nervosa, and 21 control subjects. Both patient groups had significantly elevated pain thresholds compared with the control subjects. In the total sample, no substantial covariation could be demonstrated among pain threshold and clinical, physiological, metabolic, or psychological data. However, in separate regression analyses pain threshold correlated significantly (negatively) with local skin temperature in the anorectic patients and almost significantly (positively) with body weight in the bulimic patients. This finding suggests that the reduced pain sensitivity in the two kinds of eating disorders might have different causes.