Baseline personality characteristics of responders to 6-month psychotherapy in eating disorders: preliminary data

Exploring effectiveness of CBT in obese patients with binge eating disorder: personality functioning is associated with clinically significant change

BACKGROUND

Binge eating disorder (BED), as the most prevalent eating disorder, is strongly related to obesity and other somatic and psychiatric morbidity. Despite evidence-based treatments a considerable number of BED patients fail to recover. There is preliminary evidence for the association between psychodynamic personality functioning and personality traits on treatment outcome. However, research is limited and results are still contradictory. Identifying variables associated with treatment outcome could improve treatment programs. The aim of the study was to explore whether personality functioning or personality traits are associated with Cognitive Behavioral Therapy (CBT) outcome in obese female patients with BED or subthreshold BED.

METHODS

Eating disorder symptoms and clinical variables were assessed in 168 obese female patients with DSM-5 BED or subthreshold BED, referred to a 6-month outpatient CBT program in a pre-post measurement design. Personality functioning was assessed by the Developmental Profile Inventory (DPI), personality traits by the Temperament and Character Inventory (TCI). Treatment outcome was assessed by the Eating Disorder Examination-Questionnaire (EDE-Q) global score and self-reported binge eating frequency. According to the criteria of clinical significance, 140 treatment completers were categorized in four outcome groups (recovered, improved, unchanged, deteriorated).

RESULTS

EDE-Q global scores, self-reported binge eating frequency and BMI significantly decreased during CBT, where 44.3% of patients showed clinically significant change in EDE-Q global score. Treatment outcome groups showed significant overall differences on the DPI Resistance and Dependence scales and the aggregated 'neurotic' scale. Significant overall differences were found between groups on TCI Harm avoidance, although post hoc t-tests were non-significant. Furthermore, multiple logistic regression analysis, controlling for mild to moderate depressive disorder and TCI harm avoidance showed that 'neurotic' personality functioning was a significant negative predictor of clinically significant change.

CONCLUSION

Maladaptive ('neurotic') personality functioning is significantly associated with a less favorable outcome after CBT in patients with binge eating. Moreover, 'neurotic' personality functioning is a predictor of clinically significant change. Assessment of personality functioning and personality traits could support indication for more specified or augmented care, tailored towards the patients' individual strengths and vulnerabilities.

TRIAL REGISTRATION

This study protocol was retrospectively evaluated and approved on 16-06-2022 by the Medical Ethical Review Committee (METC) of the Amsterdam Medical Centre (AMC). Reference number W22_219#22.271.

Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis

OBJECTIVE

Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders.

METHOD

A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns.

RESULTS

41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN.

CONCLUSIONS

Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.

Personality and Psychopathology in Patients With Mixed Sensory-Motor Functional Neurological Disorder (Conversion Disorder): A Pilot Study

The purpose of this pilot study was to explore differences in the level of personality functioning, symptom severity, and personality pathology in patients with mixed sensory-motor functional neurological disorder (conversion disorder). Individuals with psychogenic nonepileptic seizures were not included. We recruited 15 patients, mean age of 33.5 years (SD, 11.4 years), 13 females and 2 males, from an outpatient clinic for psychotherapeutic treatment. We assessed the patients using the Structured Clinical Interview for DSM-4 Axis II Personality Disorders, the SCL-90-R, the Karolinska Psychodynamic Profile, and the Defense Style Questionnaire. We were able to distinguish two levels of difficulty in relation to personality functioning as distinct subgroups: 1) "neurotic" with less severe or moderate personality psychopathology and 2) "borderline" with severe personality psychopathology. Furthermore, we concluded that all patients showed severe deficits in personality functioning. The study points out the clinical relevance of identifying personality functioning as part of an assessment in the preparation of a treatment strategy.

Other Specified Feeding or Eating Disorders (OSFED): Clinical heterogeneity and cognitive-behavioral therapy outcome

BACKGROUND

with the DSM-5 new eating disorders (EDs) diagnostic subtypes were identified within the Other Specified Feeding or Eating Disorders (OSFED) category, which have so far been under-researched. Objectives of this study were to examine differential features among OSFED subtypes, exploring short-term cognitive-behavioral therapy (CBT) response and identifying clinical predictors of therapy outcome.

METHODS

the sample included 176 female patients diagnosed with OSFED [82 atypical anorexia nervosa (atypical-AN), 57 purging disorder (PD), and 37 subthreshold bulimia nervosa (sub-BN)]. Assessment included eating-related, psychopathological and personality measures.

RESULTS

results showed similar clinical and personality profiles between the diagnostic subtypes, with hardly any differences, only observable in the core symptoms of each diagnosis. The sub-BN group was the one which showed more social impairment. Regarding treatment outcome, the three groups did not reveal significant differences in remission rates, therapeutic adherence or dropout rates, reaching rates of dropout from 36.8% to 50% (p = .391). However, different ED subtype predictors appear related with full remission or dropout risk, specifically personality traits.

CONCLUSIONS

our results suggest that OSFED patients may benefit similarly from the same CBT outpatient group approach. However, high dropout rates and low motivation seems to be an important limitation and challenge for future approaches.

Affective temperaments in anorexia nervosa: The relevance of depressive and anxious traits

BACKGROUND

Affective temperaments have been so far understudied in anorexia nervosa (AN) despite the relevance of personality and both affective and anxious comorbidity with regard to vulnerability, course, and outcome of this deadly disorder.

METHODS

Ninety-eight female inpatients diagnosed with AN and 131 healthy controls (HCs) were enrolled in this study and completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) in addition to assessments of eating psychopathology, depression, and anxiety.

RESULTS

AN patients and HCs differed in all affective temperaments. The diagnostic subtypes of AN differed as well with binge-purging individuals being more cyclothymic and anxious than those with restricting-type AN. TEMPS-A scores correlated with body mass index and eating psychopathology but not with duration of illness. Concerning comorbidity, grater scores on the depressive and lower scores on the hyperthymic temperaments were found in depressed patients. Those who had either an anxious or irritable temperament were significantly more diagnosed with an anxious disorder than those who did not show this temperament. When logistic regression was performed, high depressive/low hyperthymic and high irritable/anxious traits resulted to be associated with depressive and anxious comorbidity, respectively, independently of confounding factors.

LIMITATIONS

Cross-sectional design, some patients on medications, few baseline clinical differences between diagnostic subtypes, no other personality assessments.

CONCLUSIONS

An affective continuum strongly associated with mood and anxious comorbidity emerged in AN. Such an evaluation could have several research and clinical implications given the need of improving treatment individualization and early interventions for such a complex disorder.

A comprehensive review of psychodynamic treatments for eating disorders

PURPOSE

To comprehensively review the existing literature on the effectiveness of psychodynamic psychotherapies in eating disorders (EDs) and to stimulate both debate and research on this topic.

METHODS

Online and hand searches were conducted to identify papers published between 1980 and 2015 on psychodynamic treatments delivered to adults with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

RESULTS

A total of 47 studies were finally included in this review. Fifteen studies were available for AN, 9 for BN, 12 for BED, and 11 for samples with mixed diagnoses. Several methodological flaws emerged, but overall psychodynamic interventions showed promising results at the end of treatment and follow-up, when available.

CONCLUSIONS

The body of literature on psychodynamic treatments is sparse and sometimes methodologically questionable; nevertheless, current data provide support to the effectiveness of these interventions, particularly for AN. However, both a defined approach (focus, themes, and techniques) and randomized controlled trials (RCTs) are warranted to clarify the effectiveness of psychodynamic psychotherapies.

The neurobiology of eating disorders--a clinical perspective

OBJECTIVE

To provide a neurobiological basis of eating disorders for clinicians and to enlighten how comparing neurobiology and eating disorders with neurobiology of other psychiatric illnesses can improve treatment protocols.

METHOD

A selective review on the neurobiology of eating disorders. The article focuses on clinical research on humans with consideration of the anatomical, neural, and molecular basis of eating disorders.

RESULTS

The neurobiology of people with eating disorders is altered. Many of the neurobiological regions, receptors, and chemical substrates that are affected in other mental illnesses also play an important role in eating disorders. More knowledge about the neurobiological overlap between eating disorders and other psychiatric populations will help when developing treatment protocols not the least regarding that comorbidity is common in patients with EDs.

CONCLUSION

Knowledge about the underlying neurobiology of eating disorders will improve treatment intervention and will benefit from comparisons with other mental illnesses and their treatments.

Simulating category learning and set shifting deficits in patients weight-restored from anorexia nervosa

OBJECTIVE

To examine set shifting in a group of women previously diagnosed with anorexia nervosa who are now weight-restored (AN-WR) and then apply a biologically based computational model (Competition between Verbal and Implicit Systems [COVIS]) to simulate the pattern of category learning and set shifting performances observed.

METHOD

Nineteen AN-WR women and 35 control women (CW) were administered an explicit category learning task that required rule acquisition and then a set shift following a rule change. COVIS was first fit to the behavioral results of the controls and then parameters of the model theoretically relevant to AN were altered to mimic the behavioral results.

RESULTS

Relative to CW, the AN-WR group displayed steeper learning curves (i.e., hyper learning) before the rule shift, but greater difficulty in learning the new categories after the rule shift (i.e., a deficit in set shifting). Hyper learning and set shifting deficits in the AN-WR group were not associated and differentially correlated with clinical measures. Hyper learning in the AN-WR group was simulated by increasing the model parameter that represents sensitivity to negative feedback (δ parameter), whereas the deficit in set shifting was simulated by altering the parameters that represent changes in rule selection and flexibility (λ and γ parameters, respectively).

CONCLUSIONS

These simulations suggest that multiple factors can impact category learning and set shifting in AN-WR individuals (e.g., alterations in sensitivity to negative feedback, rule selection deficits, and inflexibility) and provide an important starting point to further investigate this pervasive deficit in adult AN.

Temperamental factors predict long-term modifications of eating disorders after treatment

BACKGROUND

Eating Disorders (EDs) are complex psychiatric pathologies characterized by moderate to poor response to treatment. Criteria of remission and recovery are not yet well defined. Simultaneously, personality plays a key role among the factors that determine treatment outcome. The aim of the present research is to evaluate the possibility of temperamental and character traits to predict the long-term outcome of ED.

METHOD

A sample of 25 AN and 28 BN female patients were re-assessed face-to-face after a minimum 5-years-follow-up through SCID-I, EDI-2 and TCI-R. Regression Analyses were performed to ascertain the possibility of TCI-R dimensions at the first visit to predict the long-term outcome.

RESULTS

Clinical and psychopathological symptoms significantly decreased over the time and 23% of participants no longer received a categorical ED diagnosis after at least 5 years of follow-up. TCI-R dimensions failed to predict the absence of a DSM-IV-TR diagnosis in the long term, but Novelty Seeking, Harm Avoidance and Reward Dependence demonstrated to predict the clinical improvement of several EDI-2 scales.

CONCLUSIONS

Our results support the idea that temperamental dimensions are relevant to the long-term improvement of clinical variables of ED. Low Novelty Seeking is the strongest predictor of poor outcome.

Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview

BACKGROUND

Current literature on Eating Disorders (EDs) is devoid of evidence-based findings providing support to effective treatments, mostly for anorexia nervosa (AN). This lack of successful guidelines may play a role in making these disorders even more resistant. In fact, many individuals do not respond to the available treatments and develop an enduring and disabling illness. With this overview we aimed to highlight and discuss treatment resistance in AN--with an in-depth investigation of resistance-related psychological factors.A literature search was conducted on PubMed and PsychINFO; English-language articles published between 1990 and 2013 investigating the phenomenon of resistance to treatment in AN have been considered.

DISCUSSION

The selected papers have been then grouped into four main thematic areas: denial of illness; motivation to change; maintaining factors and treatment outcome; and therapeutic relationship. Eating symptomatology was found to only partially explain resistance to treatment. The role of duration of illness has been questioned whilst some maintaining factors seemed promising in providing a useful framework for this phenomenon. Emotive and relational aspects have been investigated on their role in resistance as well as therapists' countertransference.

SUMMARY

Remarkably there has been little research done on resistance to treatment in the ED field, in spite of its clinical relevance. Motivation, insight and subjective meaning of the illness can be useful tools to manage the resistance phenomenon when coupled with a wider approach. The latter enables the therapists to be aware of their role in the therapeutic alliance through countertransference aspects and to consider the EDs as disorders of the development of both personality and self, entailing severe impairments as regards identity and relationships.

Does anger mediate between personality and eating symptoms in bulimia nervosa?

The goals of the study were to explore anger correlation with bulimic symptoms and to test the mediation power of anger between personality and eating psychopathology. A total of 242 bulimia nervosa (BN) outpatients and 121 healthy controls were recruited. Assessment was performed using Temperament and Character Inventory (TCI); State-Trait Anger Expression Inventory 2 (STAXI-2); Eating Disorder Inventory-2 (EDI-2); Body Shape Questionnaire (BSQ); Binge Eating Scale (BES); and Beck Depression Inventory (BDI). Mediation was tested on the whole BN group, on controls and on two BN subgroups based on a previous history of anorexia nervosa. Self-Directedness and Cooperativeness extensively relate to anger and psychopathology in bulimic group. Bulimic symptoms are related to Trait Reactive Anger. Trait Anger and Anger Expression fully mediate Cooperativeness effects on binge eating and Impulsiveness in the BN subjects. Anger Expression-In partially mediates between Harm Avoidance and Social Insecurity/Interpersonal Distrust in BN subjects. The comparison with controls and the analysis of subgroups underlines that these patterns are specific for BN. Anger mediation between Cooperativeness, and binge eating and impulsive behaviours confirm the relevance of relational dynamics in the expression of these core eating symptoms. Relational skills may represent a relevant target for the treatment of BN.

Emotions in eating disorders: changes of anger control after an emotion-focused day hospital treatment

OBJECTIVE

Emotional states are key elements of eating disorders (EDs), with anger and aggressiveness playing an important role. This study aimed to investigate anger features in ED patients before and after an intensive day hospital (DH) specifically focused on emotions.

METHOD

Forty-one ED patients were admitted to our DH, which specifically includes emotion-focused activities. They completed self-reported questionnaires at the beginning and after the intervention: Eating Disorders Inventory-2, State-Trait Anger Expression Inventory (STAXI) and Beck Depression Inventory (BDI).

RESULTS

Anger Control (Axcon) subscale of STAXI decreased significantly, and both BDI and body mass index - in case of underweight patients - significantly improved after completion of DH. Axcon decrease correlated with BMI improvement. The majority of individuals showing good outcome reported also a significant improvement in Axcon levels.

DISCUSSION

This study provided preliminary data about the effectiveness - mainly in anger coping - of an emotion-focused DH.

An investigation of Goodman's addictive disorder criteria in eating disorders

The aim of this study was to examine how far Goodman's addictive disorder criteria were met by individuals with eating disorders according to subtypes. The study provided a cross-sectional comparison among three samples of eating disorders [restricting anorexia nervosa (R-AN), N = 68; purging anorexia nervosa (P-AN), N = 42; and bulimia nervosa (BN), N = 66], a sample of substance-related disorders (SRDs, N = 48) and a sample of matched controls (N = 201). Diagnosis of addictive disorder was made following Goodman's criteria. Addictive personality traits were assessed with the Addiction Potential Scale of the Minnesota Multiphasic Personality Inventory--2 and with the Zuckerman's Sensation Seeking Scale. Results showed that individuals with BN met Goodman's addictive disorder criteria in the same proportion as drug-addicted individuals (65% vs 60%, p = NS). They both showed higher rates than R-AN individuals (35%; R-AN versus BN: F = 11.9, p < 0.001 and R-AN versus SRD: F = 7.16, p < 0.01). Although BN and SRD showed higher rates of addictive disorders compared with P-AN, differences were not significant. Scores on the Sensation Seeking and on the Addictive Potential scales paralleled the distribution of addictive disorders, with individuals with BN and with P-AN showing higher levels than individuals with R-AN. Results showed that a subgroup of individuals with an eating disorder experiences their disorder as an addiction and may deserve specific therapeutic attention.

Bulimia nervosa with history of anorexia nervosa: could the clinical subtype of anorexia have implications for clinical status and treatment response?

OBJECTIVE

To investigate whether the subtype of anorexia nervosa (AN) could influence the bulimic syndrome and treatment response in bulimia nervosa (BN) patients with a history of AN (BN/AN+).

METHOD

Seventy female BN patients were assessed for eating disorder, psychopathology and personality, and treated for 6 months.

RESULTS

BN/AN+ patients retained some traits of their past condition: lower body weight, higher perfectionism, and higher reward dependence. They also had more severe symptoms, longer evolution time, and worse response to treatment. A history of restricting AN was associated to higher age, longer evolution time, higher impulsivity, and greater tendency to use diet pills and diuretics. A history of binge-purging AN was associated to more severe vomiting, lower body dissatisfaction and less depressive symptoms, as well as better outcome.

DISCUSSION

The influence of the AN subtype in BN/AN+ patients is worthy of further study as it might have clinical implications.

Day hospital programmes for eating disorders: a review of the similarities, differences and goals

Day hospital (DH) treatments for eating disorders (EDs) provide intensive daily care and allow patients to maintain and test their social relations and coping skills at home and outside. Although widespread, their description is lacking. This review compares the different types of DH described in the literature and presents our DH experience in Turin, Italy. We searched Psychinfo and Pubmed with the following keywords: anorexia nervosa, bulimia nervosa, EDs, DH, day treatment and partial hospitalisation. We found and reviewed the DH programmes of eleven specialised centres, which have some shared features but also many differences, suggesting that DH treatments are still largely experimental. Briefly, the shared elements are: biopsychosocial model as reference frame; cognitive-behavioural model or techniques; behavioural contract; patients' selection; body image therapy; involvement of family; weight normalisation/weight gain and modification/normalisation of eating behaviour as objectives. Nonetheless, shared opinions concerning inclusion criteria are lacking; the duration of DH treatment is surprisingly different among centres (from 3 to 39 weeks); the approach to eating and compensation behaviours ranges from control to autonomy; followup and psychometric assessment can be either performed or not; psychological and behavioural objectives can be different. This review suggests the existence of two different DH models: the first has a shorter duration and is mainly symptom-focused; the second is more individual-focused, has a longer duration and is focused on patients' relational skills, psychodynamic understanding of symptoms and more gradual changes in body weight. Further investigation is required to make DH treatment programmes measurable and comparable.

Are obsessive-compulsive personality traits associated with a poor outcome in anorexia nervosa? A systematic review of randomized controlled trials and naturalistic outcome studies

OBJECTIVE

Obsessive-compulsive personality disorder (OCPD) traits are commonly associated with anorexia nervosa (AN). The aim of this review was to systematically search the literature to examine whether OCPD traits have an impact on the outcome of AN.

METHOD

A systematic electronic search of the literature (using Medline, PsycINFO, and the Cochrane Central Register of Controlled Trials) was undertaken to identify relevant publications (randomized controlled trials (RCT's) and naturalistic studies), until February 2006.

RESULTS

Eleven prospective longitudinal studies and 12 RCT's met criteria for inclusion. A meta-analysis was not feasible as the studies were too heterogeneous. Just over half of published longitudinal studies found that OCPD traits were associated with a negative outcome in AN. Additionally, results from three RCTs suggested that these traits may moderate outcome. OCPD traits were reduced after treatment in five RCTs.

CONCLUSION

There is tentative support to suggest that individuals with AN and concomitant OCPD traits have a poorer prognosis, and that these traits moderate outcome. A reduction in these traits may mediate this change. An individualized case formulation with treatment tailored to OCPD traits may improve the outcome of AN.

A 12-month comparison of brief psychodynamic psychotherapy and pharmacotherapy treatment in subjects with generalised anxiety disorders in a community setting

Little information is available on the use of brief psychotherapy among subjects with generalised anxiety disorder (GAD) within community mental health services. This study compared results among subjects treated with brief Adlerian psychodynamic psychotherapy (B-APP), those treated with medication (MED), or those who experienced combined treatment (COM). Symptomatology and occupational functioning were assessed using the Hamilton Anxiety and Depression scales (HAM-A; HAM-D), Clinical Global Impression (CGI), and Social and Occupational Functioning Assessment Scale (SOFAS) at intake (T1) and at 3, 6, and 12 months later (T3, T6, T12). The study sample included 87 patients with GAD (B-APP 34; MED 33; COM 20), and an ANOVA was applied for analysing repeated measures while controlling for personality disorder. After 6 months, CGI, HAM-A, HAM-D, and SOFAS scores significantly improved independently from the type of treatment. Subjects with personality disorders treated with B-APP exhibited superior results to those treated using other methods only in SOFAS scores at T6. These results were generally maintained at T12. Remission rates among subjects (HAM-A scores <7) varied between 55% (MED) and 74% (B-APP) at T6 and between 63% (MED) and 78% (COM) at T12; no significant differences appeared between the three treatment groups. A logistic regression model predicted anxiety remission only by CGI at T1. This paper discusses these results in relation to the use of brief psychotherapy within community mental health services.