Personality and eating disorders: a decade in review

Personality traits have been implicated in the onset, symptomatic expression, and maintenance of eating disorders (EDs). The present article reviews literature examining the link between personality and EDs published within the past decade, and presents a meta-analysis evaluating the prevalence of personality disorders (PDs) in anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) as assessed by self-report instruments versus diagnostic interviews. AN and BN are both consistently characterized by perfectionism, obsessive-compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, and traits associated with avoidant PD. Consistent differences that emerge between ED groups are high constraint and persistence and low novelty seeking in AN and high impulsivity, sensation seeking, novelty seeking, and traits associated with borderline PD in BN. The meta-analysis, which found PD rates of 0 to 58% among individuals with AN and BN, documented that self-report instruments greatly overestimate the prevalence of every PD.     

The relationship among three models of personality psychopathology: DSM-III-R personality disorder, TCI scores and DSQ defences.

BACKGROUND: Current systems of describing personality pathology have significant shortcomings. A polydiagnostic approach is used to study the relationship between psychological, psychoanalytical and psychopathological models of personality. METHODS: The subjects were 256 patients enrolled in treatment studies of major depression and bulimia nervosa. Subjects were assessed using the Temperament and Character Inventory (TCI), the Defense Style Questionnaire (DSQ) and the Structured Clinical Interview for DMS-III-R personality disorders (SCID-II). RESULTS: Subjects had high rates of DSM-III-R personality disorders with 52% having at least one personality disorder. Cluster A personality disorders were correlated with low reward dependence, high harm avoidance and low self-directedness and cooperativeness. Cluster B personality disorders were related to high novelty seeking and low self-directedness and cooperativeness. Cluster C personality disorders were correlated with high harm avoidance and low novelty seeking and low self-directedness. Immature defences were related to DSM-III-R personality symptoms, but individual defences were not related to personality clusters in a predictable way. Immature defences were strongly related to low self-directedness and cooperativeness. Both TCI self-directedness scores and immature defence scores were moderately predictive of the presence and number of personality disorders. CONCLUSION: A widely accepted clinical nosology (DSM-III-R personality disorders) rated using a clinical interview correlates reasonably predictably with two theoretical models derived from different paradigms and rated using self-reports. This might be seen as providing concurrent validity for all three models. However, serious methodological shortcomings confront studies of this type, including sample selection and measurement of personality dysfunction. One way to begin to resolve these problems is to study which personality measures are best related to treatment response and prognosis.     

Psychiatric comorbidity in anorexia and bulimia nervosa: nature,prevalence, and causal relationships

Eating disorders are complex, multifactorially determined phenomena. When individuals with eating disorders present for treatment with comorbid conditions, case conceptualization is further complicated and, as a result, it may be difficult to determine optimal psychological or pharmacological treatment. This article reviews the evidence of the association between eating disorders (anorexia nervosa [AN] and bulimia nervosa [BN]) and Axis I depression, obsessive-compulsive disorder (OCD), substance abuse, and Axis II personality disorders, for the purposes of increasing awareness about the different options for case conceptualization. Although other diagnoses comorbid with eating disorders are of interest to clinicians (e.g., posttraumatic stress disorder [PTSD] and social phobia), their comprehensive review is currently premature due to a lack of empirical scrutiny. Finally, future directions for research, including suggestions for the use of particular assessment tools and more sophisticated research designs, are discussed.     

Association between A218C polymorphism of the tryptophan-hydroxylase-1 gene,harm avoidance and binge eating behavior in bulimia nervosa

Genes involved in serotonin transmission are likely involved in the biological predisposition to bulimia nervosa. We investigated whether the A218C polymorphism of the tryptophan-hydroxylase-1 gene was associated to bulimia nervosa and/or to some phenotypic aspects of the disorder. One hundred eighty Caucasian women (91 patients with bulimia nervosa and 89 healthy controls) were enrolled into the study. They underwent a blood sample collection for A218C polymorphism of the tryptophan-hydroxylase-1 genotyping and a clinical evaluation assessing comorbidity for Axis I and II psychiatric disorders, harm avoidance personality dimension and bulimic symptoms. The distribution of both tryptophan-hydroxylase-1 A218C genotypes and alleles did not significantly differ between patients and controls. Bulimic women with the AA genotype exhibited a more severe binge eating behavior and higher harm avoidance scores than those with CC genotype. These findings support the idea that tryptophan-hydroxylase-1 A218C polymorphism does not play a part in the genetic susceptibility to bulimia nervosa, but it seems to be involved in predisposing bulimic patients to a more disturbed eating behavior and higher harm avoidance.     

Self-injurious behavior and attempted suicide in purging bulimia nervosa: associations with psychiatric comorbidity

BACKGROUND: Few studies, to date, have investigated the relationship between self-damaging behavior and the presence of comorbid psychiatric diagnoses in eating disorders. The aim of the present study was to investigate the axis I and II comorbidity in subjects with bulimia nervosa who report self-injurious behavior and/or suicide attempt. METHODS: The subjects were 95 patients with purging type bulimia nervosa who underwent a clinical evaluation assessing the presence of self-injurious behavior and suicide attempts, comorbidity for axis I and II psychiatric disorders and temperament. RESULTS: No axis I diagnosis was associated with any type of self-injurious behavior, whereas social phobia and bipolar disorder were linked to attempted suicide. Significant independent predictors of impulsive self-injurious behavior were the presence of childhood sexual abuse, high harm avoidance scores, and high self-transcendence scores, whereas childhood sexual abuse, the presence of a cluster B personality disorder, and a low self-directedness were predictors of suicide attempts. Compulsive self-injurious behavior was significantly associated with harm avoidance and cluster C personality disorders. Harm avoidance was also associated with skin picking. CONCLUSIONS: Personality disorders are a frequent correlate of the presence of SIB in purging bulimia nervosa. However, temperament seems to play a more important role. Further studies on larger samples are necessary to confirm our findings in bulimia nervosa and to extend them to other patient populations.     

Circulating brain-derived neurotrophic factor is decreased in women with anorexia and bulimia nervosa but not in women with binge-eating disorder: relationships to co-morbid depression, psychopathology and hormonal variables

BACKGROUND: Several lines of evidence indicate a role of the brain-derived neurotrophic factor (BDNF) in the modulation of eating behaviour. Therefore, alterations in the physiology of this neurotrophin may be involved in the pathogenesis of eating disorders. In the present study, we investigated serum levels of BDNF in patients with anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED). METHOD: Ninety-nine drug-free women (27 with AN, 24 with BN, 24 with BED and 24 healthy controls) underwent both a blood sample collection in the morning and diagnostic and psychopathological assessments by means of structured clinical interviews and ad-hoc rating scales. Serum levels of BDNF, 17 beta-oestradiol, FT3 and FT4 were measured. RESULTS: Compared to healthy controls, serum levels of BDNF were significantly reduced in underweight AN women and in normal weight BN women, but not in overweight BED women. Changes in circulating BDNF levels were not affected by the presence of co-morbid depressive disorders. No significant correlation emerged between neurotrophin concentrations and psychopathological, nutritional, demographic and hormonal variables. CONCLUSIONS: These findings evidentiate alterations in serum BDNF levels in malnourished patients with AN or BN, but not in well-nourished individuals with BED. Since BDNF seems to exert a satiety effect, its reduction may represent an adaptive change to counteract the decreased calorie ingestion of AN and BN individuals.     

Screening for Axis II personality disorders in women with bulimic eating disorders

The Personality Diagnostic Questionnaire (PDQ) was completed by 628 eating-disordered women: 300 with normal-weight bulimia, 15 with anorexia nervosa with bulimic features, and 313 with subdiagnostic eating disorders. Three-quarters (75%) of subjects with normal-weight bulimia had personality disorder diagnoses, compared with 50% of those with subdiagnostic eating disorders. The average number of separate PDQ diagnoses was 2.7 for the normal-weight bulimia group, 2.5 for the group with anorexia nervosa with bulimic traits, and 1.5 for the subdiagnostic group. The most common PDQ diagnoses were schizotypal, histrionic, and borderline disorders, but avoidant and dependent personality features also occurred. Personality disturbances may be common in patients with eating disorders.     

Suicidality in eating disorders: occurrence, correlates, and clinical implications

This review summarizes the published studies on suicide and suicide attempts in individuals with eating disorders, highlighting rates of occurrence, clinical correlates, and implications for practitioners. Multiple studies find high rates of suicide in patients with anorexia nervosa (AN) [Standardized Mortality Ratio (SMR) for suicide range from 1.0 to 5.3], whereas suicide rates do not appear to be elevated in bulimia nervosa (BN). In contrast, suicide attempts occur in approximately 3-20% of patients with anorexia nervosa and in 25-35% of patients with bulimia nervosa. Clinical correlates of suicidality in eating disorders include purging behaviors, depression, substance abuse, and a history of childhood physical and/or sexual abuse. Patients with eating disorders, particularly those with comorbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of eating disorder or depressive symptoms.     

Childhood eating and weight in eating disorders: a multi-centre European study of affected women and their unaffected sisters

BACKGROUND: Previous studies have suggested that childhood eating and weight problems may be risk factors for eating disorders. Robust evidence is still lacking. AIMS: To investigate whether childhood eating and weight problems increase the risk of eating disorders in affected women compared to their unaffected sisters. METHODS: Women (150) with anorexia (AN) or bulimia nervosa (BN) recruited from clinical and community samples were compared to their unaffected sister closest in age on maternal reports of childhood eating and weight. RESULTS: Women with BN were significantly more overweight at the ages of 5 and 10 (both OR = 2.8, p < 0.01), ate a lot (OR = 1.3, p < 0.01), were less picky (OR = 0.6, p < 0.05) and ate quickly (OR = 2.3, p < 0.05) between the ages of 6 and 10 compared to their healthy sisters. Significantly more women with AN were described as having a higher weight at 6 months (OR = 0.8, p < 0.01) and 1 year (OR = 0.6, p < 0.01) compared to their healthy sisters. Childhood eating was comparable in the women with AN and their unaffected sisters. CONCLUSIONS: Traits of childhood overeating were more common in bulimic women compared to their unaffected siblings. Subjects with AN did not differ from their sisters on eating variables. The increased risk of BN due to childhood overweight suggests that prevention strategies for childhood obesity and overweight may therefore be applicable in BN.     

51例进食障碍患者的临床特征分析

目的 :了解进食障碍患者的临床特征。方法 :对符合CCMD -2 -R神经性厌食症 (AN)和神经性贪食症 (BN)诊断标准的 5 1例住院进食障碍患者的临床特征进行了回顾性分析。结果 :AN和BN患者的怕胖心理、闭经、采取相似的方式减少食物对于身体的影响等临床相相似 (P >0 0 5 )。但是AN患者较BN患者发病年龄早 (t =2 3 2 0 ,P <0 0 5 ) ,体像障碍比较多见 (χ2 =6 110 ,P <0 0 5 ) ;BN患者的抑郁主诉多 (χ2 =8 612 ,P <0 0 0 1) ,病程长 (t=3 2 17,P <0 0 5 ) ,停工、停学时间长 (t=2 2 16,P <0 0 5 ) ,自知力较好。结论 :进食障碍两大综合征可能是一个疾病进程中的两个不同阶段 ,而贪食症的危害更应引起重视     

The childhood and family background of women with clinical eating disorders: a comparison with women with major depression and women without psychiatric disorder

BACKGROUND: Childhood antecedents are often put forward as being of possible aetiological significance for both anorexia nervosa and bulimia nervosa. METHOD: Comparisons were made of groups of women with eating disorders with groups of women with major depression or without current psychiatric disorder, using the Childhood Experience of Care and Abuse interview (CECA). RESULTS: Women with bulimia nervosa (or mixed bulimia and anorexia nervosa) tended to report more troubled childhood experiences than did women from the non-morbid comparison group. In this respect, they resembled those with major depression. In contrast, those with anorexia nervosa resembled the non-morbid women rather than the other psychiatric groups. CONCLUSIONS: Adversity in childhood as measured by the CECA may play a part in the causation of bulimia nervosa but not of anorexia nervosa. It remains possible that more specific or subtle family influences may be relevant.     

Dropout from brief psychotherapy in anorexia nervosa

BACKGROUND: Dropout from psychotherapy is an important issue that has received little systematic attention. This study investigated the phenomenon of dropout from brief psychotherapy for anorexia nervosa (AN). METHODS: 99 outpatients suffering from AN of the restrictor type (n = 53) or binge/purging type (n = 46) were evaluated. Their clinical and personal characteristics were recorded, and body mass index was calculated for participants. They were administered the Eating Disorder Inventory-II (EDI-II), the State-Trait Anger Expression Inventory (STAXI) and the Temperament and Character Inventory (TCI). RESULTS: Significant differences in some baseline psychopathologic (EDI-II, STAXI) and personality (TCI) variables emerged from the comparison between dropouts and completers. Patients who dropped out of the treatment showed higher levels of anger temperament, anger expression-in and expression-out and lower scores for the dimensions of character (low self-directedness and low cooperativeness). No differences were found between the two groups regarding sociodemographic and clinical variables. CONCLUSIONS: Dropout from brief psychotherapy seems to be related to either psychopathologic or personality aspects, such as the tendency to repress anger, which is encountered also in psychosomatic disorders, and the presence of more compromised dimensions of character, typical of subjects with personality disorders. This study of dropout from brief psychotherapy in AN provided interesting results that will need further confirmation. Possible implications for treatment are addressed.     

What predicts suicide attempts in women with eating disorders?

BACKGROUND: Suicide is a common cause of death in anorexia nervosa and suicide attempts occur often in both anorexia nervosa and bulimia nervosa. No studies have examined predictors of suicide attempts in a longitudinal study of eating disorders with frequent follow-up intervals. The objective of this study was to determine predictors of serious suicide attempts in women with eating disorders. METHOD: In a prospective longitudinal study, women diagnosed with either DSM-IV anorexia nervosa (n = 136) or bulimia nervosa (n = 110) were interviewed and assessed for suicide attempts and suicidal intent every 6-12 months over 8.6 years. RESULTS: Fifteen percent of subjects reported at least one prospective suicide attempt over the course of the study. Significantly more anorexic (22.1%) than bulimic subjects (10.9%) made a suicide attempt. Multivariate analyses indicated that the unique predictors of suicide attempts for anorexia nervosa included the severity of both depressive symptoms and drug use over the course of the study. For bulimia nervosa, a history of drug use disorder at intake and the use of laxatives during the study significantly predicted suicide attempts. CONCLUSIONS: Women with anorexia nervosa or bulimia nervosa are at considerable risk to attempt suicide. Clinicians should be aware of this risk, particularly in anorexic patients with substantial co-morbidity.     

Personality traits among currently eating disordered, recovered and never ill first-degree female relatives of bulimic and control women

BACKGROUND: A combined family study and recovered study design was utilized to examine several hypothesized relationships between personality and bulimia nervosa (BN). METHODS: We studied 47 women with a lifetime history of DSM-III-R BN (31 currently ill and 16 recovered), 44 matched control women (CW) with no history of an eating disorder (ED), and their first-degree female relatives (N = 89 and N = 100, respectively), some of whom had current or previous EDs. RESULTS: BN probands' relatives with no ED history had significantly elevated levels of perfectionism, ineffectiveness, and interpersonal distrust compared to CW probands' relatives with no ED history. In contrast, diminished interoceptive awareness, heightened stress reactivity and perfectionistic doubting of actions were found among the previously eating disordered relatives of bulimic probands compared to their never ill relatives. Finally, a sense of alienation and emotional responsivity to the environment were elevated among currently ill compared to recovered bulimic probands. CONCLUSIONS: The fact that perfectionism, ineffectiveness and interpersonal distrust are transmitted independently of an ED in relatives suggests that they may be of potential aetiological relevance for BN. In contrast, diminished interoceptive awareness, heightened stress reactivity and perfectionistic doubting of actions are more likely consequent to, or exacerbated by, previously having experienced the illness. Finally, a sense of alienation and emotional responsivity to the environment are more likely to be associated with currently having BN.     

Patterns of remission, continuation and incidence of broadly defined eating disorders during early pregnancy in the Norwegian Mother and Child Cohort Study (MoBa)

BACKGROUND: We explored the course of broadly defined eating disorders during pregnancy in the Norwegian Mother and Child Cohort Study (MoBa) at the Norwegian Institute of Public Health. METHOD: A total of 41,157 pregnant women, enrolled at approximately 18 weeks' gestation, had valid data from the Norwegian Medical Birth Registry. We collected questionnaire-based diagnostic information on broadly defined anorexia nervosa (AN), and bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS). EDNOS subtypes included binge eating disorder (BED) and recurrent self-induced purging in the absence of binge eating (EDNOS-P). We explored rates of remission, continuation and incidence of BN, BED and EDNOS-P during pregnancy. RESULTS: Prepregnancy prevalence estimates were 0.1% for AN, 0.7% for BN, 3.5% for BED and 0.1% for EDNOS-P. During early pregnancy, estimates were 0.2% (BN), 4.8% (BED) and 0.1% (EDNOS-P). Proportions of individuals remitting during pregnancy were 78% (EDNOS-P), 40% (BN purging), 39% (BED), 34% (BN any type) and 29% (BN non-purging type). Additional individuals with BN achieved partial remission. Incident BN and EDNOS-P during pregnancy were rare. For BED, the incidence rate was 1.1 per 1000 person-weeks, equating to 711 new cases of BED during pregnancy. Incident BED was associated with indices of lower socio-economic status. CONCLUSIONS: Pregnancy appears to be a catalyst for remission of some eating disorders but also a vulnerability window for the new onset of broadly defined BED, especially in economically disadvantaged individuals. Vigilance by health-care professionals for continuation and emergence of eating disorders in pregnancy is warranted.     

Prevalence of eating disorders in three Cambridge general practices: hidden and conspicuous morbidity.

The aims of this study were to investigate the prevalence of anorexia nervosa, bulimia nervosa and partial syndromes in women general practice attenders to establish the relative proportions of 'conspicuous' and 'hidden' morbidity. A consecutive series of 540 women patients aged 16-35 years attending their family doctor were screened using a specially devised questionnaire, the weight and dietary practices survey. A total of 115 patients were selected for further assessment and of these 101 patients were interviewed using a standardized diagnostic interview for DSM III-R eating disorders. The prevalence of anorexia nervosa was 0.2% (one case), of bulimia nervosa 1.5% (eight cases) and of partial syndrome bulimia nervosa 5.4% (29 cases). Half of the cases of bulimia nervosa had not been identified by the general practitioner and two of these patients had been referred to specialists for treatment of secondary complications of the eating disorder. Hidden cases of bulimia nervosa or partial syndromes are relatively common in general practice. Certain key questions could be used by general practitioners in order to identify women with eating disorders.     

Bulimia nervosa with co-morbid avoidant personality disorder: behavioural characteristics and serotonergic function

BACKGROUND: Separate lines of research link lowered serotonin tone to interpersonal submissiveness and bulimia nervosa (BN). We explored the impact of co-morbid avoidant personality disorder (APD), as a proxy for submissiveness, on behavioural inhibition and serotonin function in women with BN. METHOD: Participants included women with BN with co-morbid APD (BNA +, N = 13); women with BN but without APD (BNA-, N = 23), and control women with neither BN nor APD (N = 23). The women were assessed for psychopathological tendencies and eating disorder symptoms, and participated in a computerized laboratory task that measured behavioural inhibition and disinhibition. Participants also provided blood samples for measurement of serial prolactin responses following oral administration of the partial 5-HT agonist meta-chlorophenylpiperazine (m-CPP). RESULTS: The BNA+ group had higher scores than the other groups on self-report measures of submissiveness, social avoidance, restricted emotional expression, affective instability and self-harming behaviours. Compared with the other groups, the BNA+ group tended to be more inhibited under cues for punishment on the computerized task and to have blunted prolactin response following m-CPP. The bulimic groups did not differ from each other on current eating symptoms or on frequencies of other mental disorders. CONCLUSIONS: Findings indicate that women with BN and co-morbid APD may be characterized by interpersonal submissiveness and avoidance, affective instability, self-harm, behavioural inhibition in response to threat and lower sensitivity to serotonergic activation. These findings may indicate common, serotonergic factors, associated with social submissiveness, behavioural inhibition to threat and BN.     

Eating disorders and comorbidity

Summary This review summarizes the current literature on the comorbidity of psychiatric disorders with anorexia nervosa, bulimia nervosa and binge eating disorder. The elevated prevalence of depres-sion, anxiety disorders, obsessive-compulsive disorders, substance abuse, childhood sexual abuse, and personality disorders will be reviewed. In addition, the relationship of eating disorders to body dysmorphic disorder, the menstrual cycle, pregnancy, and diabetes will be discussed.     

Co-occurrence of eating disorders and alcohol use disorders in women: a meta analysis

Summary This meta analysis involved 41 studies published between January of 1985 and May of 2006, which examined the co-occurrence of eating disorders (ED) and alcohol use disorders (AUD) in women. Studies were reviewed and a quantitative synthesis of their results was carried out via the calculation of standardised effect sizes. Direction and strength of the relationships between AUD and specific disordered eating patterns were examined. Heterogeneity of reported results was also assessed and examined. Only 4 out of 41 studies reported negative associations between ED and AUD. The magnitude of the associations between eating-disordered patterns and AUD ranged from small to medium size and were statistically significant for any ED, bulimia nervosa (BN)/bulimic behavior, purging, binge eating disorder (BED) and eating disorders not otherwise specified (EDNOS). No association was found between anorexia nervosa (AN) and AUD. The magnitude of the association between BN and AUD was the most divergent across studies and those between each of BED and dietary restriction and AUD were the most consistent across studies. Reported associations of different patterns of disordered eating and AUD were generally weakest and most divergent when participants were recruited from clinical settings and strongest and most homogeneous when participants were recruited from student populations.     

神经性厌食症及神经性贪食症的认知行为治疗分析

目的:探讨认知行为治疗对神经性厌食症及神经性贪食症的治疗效果及其有关影响因素.方法:对符合CCMD-2-R论断的2例神经性厌食症(AN)与2例神经性贪食症(BN)做认知行为治疗,对治疗效果及相关因素进行分析,结果1例神经性性贪食症治愈,另1例显效,2例神经性厌食症好转.结论:认知行为治疗对这两种疾患均有肯定的疗效.BN的疗效优于AN.