Do eating disorders co-occur with personality disorders? Comparison groups matter

Reciprocal relationships between personality disorders and eating disorders in a prospective 17-year follow-up study

OBJECTIVE

This study aimed to report the presence of categorical and dimensional personality disorders (PD) in adults with longstanding eating disorders (ED) over a period of 17 years and to investigate whether changes in PD predict changes in ED symptoms or vice versa.

METHODS

In total, 62 of the 80 living patients (78% response rate) with anorexia nervosa (n = 23), bulimia nervosa (n = 25), or other specified feeding or ED (n = 14) at baseline were evaluated during hospital treatment and at 1-year, 2-year, 5-year, and 17-year follow-up. PD were assessed using the Structured Clinical Interview for DSM-IV Axis II disorders, and the eating disorder examination (EDE) interview was used to assess ED. Data were analyzed using multilevel modeling.

RESULTS

From baseline to the 17-year follow-up, the number of patients with any PD decreased significantly from 74.2% to 24.2%, and the total number of PD diagnoses declined from 80 to 22. Mean EDE score was significantly reduced from 4.2 (SD: 1.1) to 2.0 (SD: 1.6). There was a positive association between ED and PD where the initial level of either disorder was followed by similar levels of the other disorder throughout the entire follow-up period. High baseline levels of borderline PD predicted less decrease in ED symptoms. No significant within-person effects were found.

CONCLUSIONS

Both ED and PD significantly declined over time. As the severity of either disorder seems to be associated with the other, thorough assessment and treatment that incorporates both the ED psychopathology and the personality disturbances are advisable.

PUBLIC SIGNIFICANCE STATEMENT

While personality disorders were highly prevalent in the sample of patients with longstanding eating disorders, both disorders were significantly reduced at the 17-year follow-up. The disorders are related in the sense that an initial high level of either disorder is associated with a high level of the other over time. A thorough assessment and attention to both illnesses are advisable in therapy.

CLINICAL TRIAL IDENTIFIER

NCT03968705.

Backstage of Eating Disorder-About the Biological Mechanisms behind the Symptoms of Anorexia Nervosa

Anorexia nervosa (AN) represents a disorder with the highest mortality rate among all psychiatric diseases, yet our understanding of its pathophysiological components continues to be fragmentary. This article reviews the current concepts regarding AN pathomechanisms that focus on the main biological aspects involving central and peripheral neurohormonal pathways, endocrine function, as well as the microbiome-gut-brain axis. It emerged from the unique complexity of constantly accumulating new discoveries, which hamper the ability to look at the disease in a more comprehensive way. The emphasis is placed on the mechanisms underlying the main symptoms and potential new directions that require further investigation in clinical settings.

The comorbidity of personality disorders in eating disorders: a meta-analysis

PURPOSE

The present meta-analysis summarized the proportion of comorbid personality disorders (PDs) in patients with anorexia (AN) and bulimia nervosa (BN), respectively, and examined possible moderating variables.

METHODS

A search of the databases PsychINFO, Embase, and Medline for the period 1980-2016 identified 87 studies from 18 different countries.

RESULTS

The mean proportion of PDs among patients with any type of eating disorder (ED) was .52 compared to .09 in healthy controls. There were no statistically significant differences between AN (.49) and BN (.54) in proportions of any PD or PD clusters except for obsessive-compulsive PD (.23 vs .12 in AN and BN, respectively).

CONCLUSIONS

Both ED diagnoses had a similar comorbidity profile with a high prevalence of borderline and avoidant PDs. Moderator analyses conducted for any ED and any PD yielded significant differences for diagnostic systems with respect to EDs, method for assessing PD as well as patient weight and age.

Trauma in relation to psychological characteristics in women with eating disorders

<b>Background</b><br /> The aim of the article was to present the results of the author’s own study that sought relationships between having experienced psychological trauma and the psychological characteristics of people with eating disorders. The basic research question was the following: To what degree are the traumatic events experienced by females with various types of eating disorders related to these females’ psychological characteristics? <br /> <br /> <b>Participants and procedure</b><br /> The sample comprised 120 females with eating disorders: 30 females aged between 20 and 26 diagnosed with bulimia nervosa, 31 females diagnosed with binge-eating disorder and 59 females aged between 20 and 26 diagnosed with anorexia nervosa. The research was carried out in the years 2007-2012 in outpatient clinics treating neuroses and eating disorders and mental health outpatient clinics in Poland. The study employed a clinical and psychometric (i.e., questionnaires for measuring psychological characteristics) approach.<br /> <br /> <b>Results</b><br /> Statistical analysis confirmed the existence of significant differences between the females with eating disorders who have experienced relational trauma(s) in their lives (particularly in their childhood and adolescence) and those who did not reveal such experience. The females with anorexia and bulimia who have also experienced psychological, physical or sexual violence revealed a significantly different, higher level of bulimic thinking and tendencies for excessively uncontrolled, impulsive behaviors towards food and nutrition (i.e., vomit-provoking and other forms of body purgation, e.g. using purgative drugs and others) than did females with no relational trauma experience.<br /> <br /> <b>Conclusions</b><br /> The frequency of relational trauma occurrence was significantly higher for females with bulimia and bulimic anorexia. For females with restrictive anorexia and binge-eating disorder, no significantly frequent occurrence of trauma was observed. <br /> Diagnosing the occurrence of relational trauma in patients’ histories is a key element that should be involved in the process of psychotherapy for people with eating disorders.

Eating disorders in a large clinical sample of men and women with personality disorders

OBJECTIVE

We assessed and compared the prevalence of anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS) across six Axis II groups (borderline, obsessive-compulsive, avoidant, dependent, paranoid, and personality disorder NOS) and patients with major depressive disorder (MDD) without personality disorders (PD).

METHOD

The sample included 3,266 consecutive and first admissions to 16 different treatment units in the Norwegian Network of Psychotherapeutic Day Hospitals between 1993 and 2009. All patients were interviewed with the SCID-II for DSM-III-R (prior to 1996) or DSM-IV (from 1996) and the MINI for Axis I disorders in accordance with the LEAD (longitudinal, expert, all-data) standard.

RESULTS

The prevalence of any ED in the PD sample was approximately 17% for women and 3% for men. A lower rate of ED (5%) was found for patients with MDD without PD. A significantly higher proportion of patients with borderline personality disorder were diagnosed with BN or EDNOS. The rate of AN was significantly elevated in female patients with obsessive-compulsive personality disorder. Men demonstrated significantly less diagnostic co-occurrence and no significant differential variation across PD groups or MDD.

DISCUSSION

Data which included a psychiatric comparison group showed less co-occurrence and non-significant variation across PD groups for men, but demonstrated a meaningful and specific pattern of comorbidity between ED and PD for women. There was an elevated risk of ED among female patients with PD, most pronounced for borderline. An almost five-fold higher rate of AN was found among women with obsessive-compulsive PD.

Prevalence of personality disorders and their clinical correlates in outpatient adolescents with anorexia nervosa

OBJECTIVE

To evaluate personality disorder (PD) comorbidity and its clinical correlates in a sample of adolescents with anorexia nervosa (AN) and to compare them with similar studies on adults.

METHODS

One hundred one female AN outpatients (16-18 years old)-57 with AN restrictive type and 44 with AN binge-purging type-and 71 age-matched, healthy, female participants were assessed using the Structured Clinical Interview for DSM-IV Axis II Disorders. Five selected clinical variables of AN severity were also assessed.

RESULTS

Overall, 24.8% of AN outpatients had one or more PD compared with 4.2% of the control participants (p < .001). PDs most frequently found in AN outpatients were avoidant, borderline, and obsessive-compulsive. Associations were found between AN binge-purging type and borderline PD and between AN restrictive type and obsessive-compulsive PD. AN outpatients with a PD had an earlier age of onset of AN (mean [standard deviation {SD}] = 15.4 [1.2] versus 16.1 [0.9], p = .002), lower lifetime lowest BMI (mean [SD] = 14.8 [1.5] versus 15.6 [1.3], p = .01), and more hospital admissions for AN (mean [SD] = 1.4 [0.9] versus 0.3 [0.6], p < .001) compared with those without PDs.

CONCLUSIONS

Associations were found between AN and PDs in adolescents similar to those found in adults. The presence of a PD is associated with a greater severity of AN. PD assessment of adolescent AN patients may permit a more accurate diagnosis and better treatment planning.

Personality heterogeneity in female adolescent inpatients with features of eating disorders

OBJECTIVE

This study examined evidence for personality variability in adolescents with eating disorder features in light of previous evidence that personality variability in adult women with eating disorder symptoms carries important clinical implications.

METHOD

Millon Adolescent Clinical Inventory personality data from adolescent girls with disturbed eating who were psychiatrically hospitalized were cluster analyzed, and resulting groups were compared in eating and comorbid psychopathology.

RESULTS

Three subgroups were identified among the 153 patients with eating disorder features: high functioning, internalizing, and externalizing. The internalizing group was marked by eating-related and mood dysfunction; the externalizing group by elevated eating and mood psychopathology as well as impulsivity, aggression, and substance use; and the high-functioning group by lower levels of psychopathology and relatively high self-esteem.

CONCLUSIONS

These findings converge with previous research using different personality models in adult samples and highlight the clinical use of considering personality heterogeneity among adolescent and adult women with disturbed eating.

Personality pathology comorbidity in adult females with eating disorders

Personality pathology is examined in 100 female in-patients diagnosed with eating disorders. The Eating Disorder Inventory-II and the NEO-PI-R were self-administered and personality pathology was assessed using a structured interview. Clinicians additionally evaluated patients' global functioning. The results indicated sizeable personality disorder comorbidity, and two dimensions of personality pathology, for example, an internalizing and an externalizing factor, could be identified. Patients' global functioning was primarily associated with dimensions of personality pathology, but not with eating disorder symptoms. Assessment and therapeutic interventions should focus on this co-occurring pathology in order to improve patients' functioning.

Psychiatric, behavioral, and attitudinal correlates of avoidant and obsessive-compulsive personality pathology in patients with binge-eating disorder

OBJECTIVE

We examined correlates of avoidant and obsessive-compulsive personality pathology--with respect to psychiatric comorbidity, eating disorder psychopathology, and associated psychologic factors--in patients with binge-eating disorder (BED).

METHOD

Three hundred forty-seven treatment-seeking patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), research criteria for BED were reliably assessed with semistructured interviews to evaluate DSM-IV Axis I disorders, personality disorders, and behavioral and attitudinal features of eating disorder psychopathology.

RESULTS

Fifteen percent of subjects had avoidant personality disorder features, 12% had obsessive-compulsive personality disorder features, 8% had features of both disorders, and 66% had features of neither. These groups differed significantly in the frequencies of depressive and anxiety disorders, as well as on measures of psychologic functioning (negative/depressive affect and self-esteem) and eating disorder attitudes (shape and weight concerns). There were no group differences on measures of eating behaviors. The avoidant and obsessive-compulsive groups had more psychiatric comorbidity than the group without these personality features but less than the combined group. The group without these features scored significantly lower than all other groups on negative/depressive affect and significantly higher than the avoidant and combined groups on self-esteem. The combined group had the greatest severity on shape and weight concerns.

CONCLUSIONS

Avoidant and obsessive-compulsive personality features are common in patients with BED. Among BED patients, these forms of personality psychopathology--separately and in combination--are associated with clinically meaningful diagnostic, psychologic, and attitudinal differences. These findings have implications for the psychopathologic relationship between BED and personality psychopathology and may also have implications for assessment and treatment.

Five-year prospective study of personality disorders in adults with longstanding eating disorders

OBJECTIVE

To (1) report the occurrence of personality disorders (PDs) in adults with eating disorders (EDs) during inpatient treatment, and at 1-, 2-, and 5-year follow-up, (2) compare the changes of PDs in anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS), and (3) investigate if recovered patients had lower frequency of PDs.

METHOD

Seventy-four patients with EDs were assessed with Structured Clinical Interview for DSM-IV Axis II disorders during inpatient treatment, and at 1-, 2-, and 5-year follow-up.

RESULTS

During inpatient treatment, 58 patients (78%) had one or more PDs and this was reduced to 32 (43%) at 5-year follow-up. Dimensional PD scores changed significantly over time in both AN, BN, and EDNOS, but no significant differences emerged among the ED groups. Recovered patients had lower frequency of PDs (p < 0.01).

DISCUSSION

The substantial 5-year follow-up reductions in the frequency of PDs in patients with EDs present an optimistic clinical scenario for treating patients with comorbid ED and PD.

The utility of considering interpersonal problems in the assessment of bulimic features

Previous research suggests that heterogeneity in bulimic features can be explained in part by pathoplastic, or varying, interpersonal problems. The present study compared groups of women with bulimic features (N=110) defined by varying interpersonal problems (warm-dominant, warm-submissive, cold-submissive, or cold-dominant) with regard to comorbid psychopathology, personality characteristics, and the influences of dietary restraint and negative affectivity on bulimic psychopathology. As predicted, group differences were not explained by severity of eating-related pathology, socially desirable responding, or the interpretability of interpersonal profiles, although groups unexpectedly differed in depressive symptoms. The warm-submissive group had highest scores on adaptive personality characteristics, including, agreeableness, extraversion, and conscientiousness. As hypothesized, the influence of negative affect and dietary restraint on bulimic symptoms differed as a function of interpersonal style, perhaps suggesting that interpersonal problem heterogeneity may mark different etiological pathways for bulimic psychopathology. Finally, interpersonal problems incremented bulimic features in predicting depressive symptoms. Overall, these results highlight the added value of considering pathoplastic interpersonal problems in addition to clinical diagnoses in the assessment of eating disorders.

A comparison of borderline personality disorder with and without eating disorders

This study examines the degree to which an eating disorder (ED) is associated with the recurrence and severity of suicide attempts, non-suicidal self-injury, rates of co-occurring Axis I and II disorders, and psychosocial functioning among Borderline Personality Disorder (BPD) outpatients. A group of 135 treatment-seeking women with BPD were assessed using structured clinical interviews. BPD was assessed using the International Personality Disorders Examination, confirmed by the Structured Clinical Interview for DSM-IV (SCID)-II, and Axis I disorders were assessed with the SCID I. A total of 17.8% of the sample met criteria for a current ED, with 6.7% meeting criteria for Anorexia Nervosa (AN), 5.9% for Bulimia Nervosa (BN), and 5.2% for Binge-Eating Disorder (BED). In this BPD sample, in the last year, current BN was associated with a significantly greater risk of recurrent suicide attempts while current AN was associated with increased risk of recurrent non-suicidal self-injury. BPD with current AN or BED was associated with a greater number of non-ED current Axis I disorders. Further replication of these results is needed. Women with BPD must be assessed for AN and BN as these diagnoses may confer greater risk for suicidal and self-injurious behavior and may have to be prioritized in treatment.

The relationship between concurrent substance use disorders and eating disorders with personality disorders

Objective:

The current pilot study investigated whether patients with concurrent substance use disorders and eating disorders (SUD and ED) who experienced a reduction in SUD and ED symptoms following treatment for SUD and ED also experienced a reduction in personality disorder (PD) symptoms.

Method:

Twenty patients with SUD and ED and PD were assessed pre and post treatment using clinical interviews, self-report questionnaires, and a therapist questionnaire on DSM-IV-TR symptoms for PD.

Results:

Symptoms for the personality disorders were reduced following treatment. This reduction was correlated with a decrease in the number of symptoms of ED at post treatment.

Discussion:

Chronic concurrent SUD and ED may make it difficult to separate PD symptoms from co-occurring disorders. Many features attributed to PDs may be reduced when problematic substance use and disordered eating are addressed, a fact that may increase clinician and patients’optimism about therapeutic change.

Blood levels of brain-derived neurotrophic factor correlate with several psychopathological symptoms in anorexia nervosa patients

BACKGROUND

Evidence of a role of brain-derived neurotrophic factor (BDNF) in the pathophysiology of eating disorders (ED) has been provided by association studies and by murine models. BDNF plasma levels have been found altered in ED and in psychiatric disorders that show comorbidity with ED.

AIMS

Since the role of BDNF levels in ED-related psychopathological symptoms has not been tested, we investigated the correlation of BDNF plasma levels with the Symptom Checklist 90 Revised (SCL-90R) questionnaire in a total of 78 ED patients.

METHODS

BDNF levels, measured by the enzyme-linked immunoassay system, and SCL-90R questionnaire, were assessed in a total of 78 ED patients. The relationship between BDNF levels and SCL-90R scales was calculated using a general linear model.

RESULTS

BDNF plasma levels correlated with the Global Severity Index and the Positive Symptom Distress Index global scales and five of the nine subscales in the anorexia nervosa patients. BDNF plasma levels were able to explain, in the case of the Psychoticism subscale, up to 17% of the variability (p = 0.006).

CONCLUSION

Our data suggest that BDNF levels could be involved in the severity of the disease through the modulation of psychopathological traits that are associated with the ED phenotype.

Personality disorders in 545 patients with eating disorders

OBJECTIVE

Previous research on the prevalence of personality disorders in patients with eating disorders varies greatly in findings, but a general understanding seem to exist that personality disorders are rather common among eating-disordered patients. The present investigation is aimed at establishing the prevalence of DSM III-R or DSM IV personality disorders in a large population seeking treatment for eating disorders.

METHOD

Five hundred and forty-five patients with DSM IV- eating disorders have been evaluated using the structured clinical interview for DSM III-R or IV-Axis II and the eating disorder examination.

RESULTS

The 29.5% of the population have one or more personality disorders according to DSM III-R or DSM IV criteria. Personality disorders, and specifically borderline personality disorder, are significantly more common in patients with bulimia nervosa.

DISCUSSION

The proportion of eating-disordered patients with co-morbid personality disorder may not be as large as often found in studies. This challenges the understanding of a strong overall connection between the two groups of disorder; however, the connection seems to exist in subsets of eating disorder samples.

Association of NTRK3 and its interaction with NGF suggest an altered cross-regulation of the neurotrophin signaling pathway in eating disorders

Eating disorders (EDs) are complex psychiatric diseases that include anorexia nervosa and bulimia nervosa, and have higher than 50% heritability. Previous studies have found association of BDNF and NTRK2 to ED, while animal models suggest that other neurotrophin genes might also be involved in eating behavior. We have performed a family-based association study with 151 TagSNPs covering 10 neurotrophin signaling genes: NGFB, BDNF, NTRK1, NGFR/p75, NTF4/5, NTRK2, NTF3, NTRK3, CNTF and CNTFR in 371 ED trios of Spanish, French and German origin. Besides several nominal associations, we found a strong significant association after correcting for multiple testing (P = 1.04 x 10(-4)) between ED and rs7180942, located in the NTRK3 gene, which followed an overdominant model of inheritance. Interestingly, HapMap unrelated individuals carrying the rs7180942 risk genotypes for ED showed higher levels of expression of NTRK3 in lymphoblastoid cell lines. Furthermore, higher expression of the orthologous murine Ntrk3 gene was also detected in the hypothalamus of the anx/anx mouse model of anorexia. Finally, variants in NGFB gene appear to modify the risk conferred by the NTRK3 rs7180942 risk genotypes (P = 4.0 x 10(-5)) showing a synergistic epistatic interaction. The reported data, in addition to the previous reported findings for BDNF and NTRK2, point neurotrophin signaling genes as key regulators of eating behavior and their altered cross-regulation as susceptibility factors for EDs.

Contribution of the serotoninergic system to anxious and depressive traits that may be partially responsible for the phenotypical variability of bulimia nervosa

Eating disorders (ED), such as anorexia nervosa (AN) and bulimia nervosa (BN), are complex psychiatric phenotypes influenced by both genetic and environmental factors. We investigated the genetic contribution of four single nucleotide polymorphisms (SNPs) within the serotonin receptor 5HT2C and two sequence variants within the serotonin transporter SLC6A4 to different ED-related psychopathological symptoms in a total sample of 82 ED patients. All patients were diagnosed according to DSM-IV criteria and underwent diagnostic and psychopathological assessments by means of structured clinical interviews and rating scales. We detected significant evidence of association between the -995A/-759T/-697C/Cys23 haplotype of the 5HT2C gene and different anxious and depressive subscales of the SCL90-R instrument, that included Somatization (p = 0.029), Obsessive-Compulsiveness (p = 0.021), Depression (p = 0.032), Anxiety (p = 0.004), Hostility (p = 0.028), Phobic Anxiety (p = 0.029) and Paranoid Ideation (p = 0.008), in BN patients. We also observed a strong association between the 5HTTLPR polymorphism of the SLC6A4 gene and Anxiety in the same group of BN patients (p = 0.004). However, no epistatic effects between the 5HT2C and SLC6A4 genes on the different anxious and depressive subscales were observed. Our preliminary data suggest that the serotoninergic system contributes to the different psychopathological symptoms that may be partially responsible for the phenotypical variability within the bulimic phenotype.

Pathoplasticity of bulimic features and interpersonal problems

OBJECTIVE

Recent research suggests that interpersonal problems and some forms of psychopathology are pathoplastic, or that they mutually affect one another in nonetiological ways. In the current study, the pathoplasticity of bulimic features and interpersonal problems was tested.

METHOD

Inventory of Interpersonal Problems-64 data from 130 women with scores in the top quartile on the Bulimia scale of the Eating Disorder Inventory-2 from a sample of 517 college undergraduates were cluster analyzed. Age, weight, and scores on psychopathology scales were tested for mean differences across the four quadrants of the interpersonal problems circumplex.

RESULTS

Consistent with the pathoplasticity hypothesis, cluster means did not differ on external variables. Furthermore, bulimic features and interpersonal problems independently predicted depression in the total sample.

CONCLUSION

The interpersonal problems reported in the current study suggest differential treatment process that could inform the therapeutic relationship and help prevent premature termination.

Obsessive-compulsive characteristics in women who have recovered from bulimia nervosa

OBJECTIVE

The goal of this study was to follow up on reports that obsessive-compulsive characteristics, which are commonly elevated in bulimia nervosa (BN), may also be elevated in individuals who have recovered from BN (BN-R).

METHOD

Self-ratings on the Maudsley Obsessional-Compulsive Inventory (MOCI), the Restraint Scale (a measure of dieting behavior related to weight concerns), and questionnaires reflecting eating disorder-related symptoms were evaluated for women who met criteria for BN (n = 25) or BN-R (n = 21) and were free of obsessive-compulsive disorder, and for healthy female controls (n = 28).

RESULTS

MOCI scores for the BN-R group (5.5 +/- 5.4) were similar to those for the BN group (5.4 +/- 4.4) and were significantly elevated (p < 0.05, p < 0.02, respectively) in comparison to controls (2.5 +/- 1.9). Of note, MOCI scores for the BN-R group were significantly correlated with scores on the Restraint Scale (r = 0.60, p < 0.02).

CONCLUSION

Further studies are needed to assess the relationship between elevated obsessive-compulsive characteristics and eating patterns in individuals recovered from BN.

Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization

This chapter reviews recent (2000-2005) personality disorder (PD) research, focusing on three major domains: assessment, comorbidity, and stability. (a) Substantial evidence has accrued favoring dimensional over categorical conceptualization of PD, and the five-factor model of personality is prominent as an integrating framework. Future directions include assessing dysfunction separately from traits and learning to utilize collateral information. (b) To address the pervasiveness and extent of comorbidity, researchers have begun to move beyond studying overlapping pairs or small sets of disorders and are developing broader, more integrated common-factor models that cross the Axis I-Axis II boundary. (c) Studies of PD stability have converged on the finding that PD features include both more acute, dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable-similar to normal-range personality traits-with increasing stability until after 50 years of age. A new model for assessing PD-and perhaps all psychopathology-emerges from integrating these interrelated reconceptualizations.

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.

Personality disorders and medical comorbidity

PURPOSE OF REVIEW

Personality disorders are not usually thought of as being associated with medical comorbidity. Research shows that medical comorbidity in personality disorders is clinically important.

RECENT FINDINGS

In general those with personality disorders do not feel as fit as others do. Also, those with personality disorders in addition to other psychiatric disorders, such as depression and antisocial personality disorder, are likely to have more health problems than those without personality disorders. People with active borderline personality disorder have been shown to have more medical problems than those with remitted borderline personality disorder. Personality disorders can complicate the course of chronic medical illnesses. Finally, the use of psychotropic medications is not unusual in personality disorders and in itself can be associated with medical illnesses.

SUMMARY

Clinicians caring for people with personality disorders need to be aware of possible medical comorbidity. More research is needed.

The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications

The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was developed to fill gaps in our understanding of the nature, course, and impact of personality disorders (PDs). Here, we review published findings to date, discuss their implications for current conceptualizations of PDs, and raise questions that warrant future consideration. We have found that PDs are more stable than major depressive disorder, but that meaningful improvements are possible and not uncommon. We have confirmed also that PDs constitute a significant public health problem, with respect to associated functional impairment, extensive treatment utilization, negative prognostic impact on major depressive disorder, and suicide risk. At the same time, we have demonstrated that dimensional models of PDs have clinical validity that categories do not, especially greater temporal stability. Furthermore, dimensional personality traits appear to be the foundation of behaviors described by many PD criteria. Taken together, our results lead us to hypothesize that PDs may be reconceptualized as hybrids of stable personality traits and intermittently expressed symptomatic behaviors.

Difficulties in the assessment of personality traits and disorders in eating-disordered individuals

There are compelling reasons to examine personality variables in the eating disorder (ED) field but many impediments to the collection of useful data. In addition to the conceptual and methodological difficulties associated with personality assessment in the general case, the EDs present a number of special problems. These include patients' young age at onset and evaluation, the "state" effects of semi-starvation and chaotic eating, denial and distortion in self-report, the instability of ED subtypes, and the intrusion of eating and weight concerns into a wide range of apparently unrelated domains. Although there is substantial support for the clinical view that personality variables are linked to anorexia nervosa (AN) and bulimia nervosa (BN), the identification of stable traits and Axis II disorders in individual patients should be deferred until after the initial phase of treatment.

Etiological relationships between eating disorder symptoms and dimensions of personality disorder

A preliminary exploration of the etiological factors that may contribute to the relationship between eating disorder symptoms and personality disorder traits is reported based on a general-population twin sample of 221 pairs. Symptoms of eating disorder, assessed using the Health Information Questionnaire (HIQ), formed 3 factors: Concern for Overeating, Purging, and Body Mass Index (BMI). Modest genetic influences were observed on Concern for Overeating, possible non-additive genetic effects on Purging, and substantial additive genetic effects for BMI. Substantial nonshared environmental effects occurred with the Concern with Overeating and Purging scales, and common environmental effects were noted for the Concern with Overeating scale. Personality disorder traits were assessed using the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ). Phenotypic, genetic, and environmental correlations between the HIQ scales and higher-order personality disorder factors were modest. The strongest relationship was between Concern with Overeating and Emotional Dysregulation. Relationships among DAPP-BQ basic trait scales and eating disorder symptoms were modest and relatively non-specific. The strongest relationships were with the Concern with Overeating scale. Purging also showed a modest relationship with affective lability and self-harm.

Treatment implications of Axis-II comorbidity in eating disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies--the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)--both include the concept that "trait-oriented" interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.

The natural course of bulimia nervosa and eating disorder not otherwise specified is not influenced by personality disorders

OBJECTIVE

To examine prospectively the natural course of bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) and to test the effects of personality disorder (PD) comorbidity on the outcomes.

METHOD

Ninety-two female patients with current BN (N=23) or EDNOS (N=69) were evaluated at baseline enrollment in the Collaborative Longitudinal Personality Disorders Study (CLPS). Eating disorders (EDs) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders. Personality disorders (PDs) were assessed with the Diagnostic Interview for DSM-IV PD (DIPD-IV). The course of BN and EDNOS was assessed with the Longitudinal Interval Follow-up Evaluation and the course of PDs was evaluated with the Follow-Along version of the DIPD-IV at 6, 12, and 24 months.

RESULTS

Probability of remission at 24 months was 40% for BN and 59% for EDNOS. To test the effects of PD comorbidity on course, ED patients were divided into groups with no, one, and two or more PDs. Cox proportional regression analyses revealed that BN had a longer time to remission than EDNOS (p<.05). The number of PDs was not a significant predictor of time to remission, nor was the presence of Axis I psychiatric comorbidity or Global Assessment of Functioning scores. Analyses using proportional hazards regression with time-varying covariates revealed that PD instability was unrelated to changes in ED.

CONCLUSIONS

BN has a worse 24-month course (longer time to remission) than EDNOS. The natural course of BN and EDNOS is not influenced significantly by the presence, severity, or time-varying changes of co-occurring PDs, co-occurring Axis I disorders, or by global functioning.