Dimensional assessment of personality pathology in patients with eating disorders

Using the alternative model of personality disorders for DSM-5 traits to identify personality types, and the relationship with disordered eating, depression, anxiety and stress

BACKGROUND

There is a substantial and growing evidence base that has identified three distinct personality types (Overcontrol, Undercontrol and Resilient) among samples of individuals with eating disorders, as well as non-clinical samples. Even in studies where up to six personality types have been identified, the three core types representing Overcontrol, Undercontrol and Resilient consistently emerge. The aim of the research was to explore whether latent Overcontrol and Undercontrol personality types could be identified using pathological personality types as part of the Alternative Model for Personality Disorders published in DSM-5. We further aimed to understand how these personality types were associated with eating pathology, depressed mood and anxiety.

METHODS

A total of 391 women, 167 men and 10 gender-diverse individuals aged 16 to 31 years completed measures of the alternative model of personality disorder traits, disordered eating behaviours, eating pathology, depression, anxiety and stress. A systematic four-step process using hierarchical, k-means, and random forest cluster analyses were used to identify the best fitting cluster solution in the data.

RESULTS

The results revealed a four-cluster solution that represented overcontrol, undercontrol, resilient and an antisocial/psychoticism cluster. The overcontrol, undercontrol, and antisocial/psychoticism types were all associated with increased disordered eating, eating pathology, depression, anxiety and stress compared to the resilient types, with the undercontrol cluster scoring significantly higher than the other three clusters on all measures of clinical pathology.

CONCLUSIONS

Pathological personality traits, as conceptualised within the DSM-5 alternative model of personality disorders may have merit for identifying overcontrol and undercontrol personality types. Our findings provide additional evidence that both overcontrol and undercontrol personality types are associated with increased eating pathology, depression, anxiety and stress.

Identifying overcontrol and undercontrol personality types among young people using the five factor model, and the relationship with disordered eating behaviour, anxiety and depression

BACKGROUND

Overcontrol and undercontrol personality types have been associated with an increase in eating pathology, depression and anxiety. The aim of the research was to explore whether latent overcontrol and undercontrol personality types could be identified using cluster analysis of the facets of the five factor model (FFM). We further aimed to understand how these personality types were associated with eating pathology, depressed mood and anxiety.

METHODS

A total of 561 participants (394 women and 167 men), aged 16-30 years in Australia completed a survey designed to assess disordered eating, FFM personality traits, anxiety, depression and stress. A systematic four-step process using hierarchical, k-means, and random forest cluster analyses were used to identify a meaningful 3-cluster solution.

RESULTS

The results revealed a cluster solution that represented overcontrol, undercontrol and resilient personality types, and highlighted facets of the FFM that were associated with each type. Both overcontrol and undercontrol personality types were associated with increased clinical symptoms compared to the resilient types.

CONCLUSIONS

It was concluded that FFM facets may potentially be more meaningful than broad domains in identifying personality types, and that both overcontrol and undercontrol personality types are likely associated with increased clinical symptoms.

Professional Practice Guidelines for Personality Assessment

The current paper conveys guidelines for personality assessment developed by a work group formed by the Society for Personality Assessment (SPA), which are intended to serve as an aid for best practices specific to personality assessment for professionals, and a source of information for consumers and policy makers. The guidelines were developed after a careful and systematic review of the literature on personality assessment and examination of practice patterns, and were refined through multiple rounds of input from stakeholders including members of SPA and other professionals routinely conducting personality assessment. The guidelines address the scope of personality assessment and current practice trends, minimum education and training qualifications, ethical practices, diversity considerations, assessment procedures, and appropriate applications. By following these guidelines and other established professional standards, psychologists can help ensure that they practice ethically, competently, with appropriate attention to diversity, and to the highest standards of the profession. These guidelines can function as a resource for educators and supervisors of personality assessment. Additionally, the guidelines will serve as a benchmark for best practices in personality assessment and, as such, represent a first step in what is hoped to be an evolution of ever improving personality assessment standards of practice.

Emotional intelligence and eating disorders: a systematic review

BACKGROUND

Prior research indicates that deficits in emotional abilities are key predictors of the onset and maintenance of eating disorders (ED). As a relatively new emotion-related construct, emotional intelligence (EI) comprises a set of basic emotional abilities. Preliminary research suggests that deficits in EI are linked with disordered eating and other impulsive behaviours. Also, previous research reveals that emotional and socio-cognitive abilities, as well as ED symptomatology, varies across lifespan development. However, while the findings suggest promising results for the development of potential effective treatments for emotional deficits and disordered eating, it is difficult to summarise the relationship between EI and ED due to the diversity of theoretical approaches and variety of EI and ED measures.

OBJECTIVE

Our study, therefore, aimed to systematically review the current evidence on EI and ED in both the general and clinical populations and across different developmental stages.

METHODS

The databases examined were Medline, PsycInfo and Scopus, and 15 eligible articles were identified. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used.

RESULTS

All the studies reviewed indicated negative associations between EI and the dimensions of ED. Additionally, several mechanisms involved, namely adaptability, stress tolerance and emotional regulation were highlighted.

CONCLUSION

The systematic review suggests promising but challenging preliminary evidence of the associations between EI and the dimensions of ED across diverse stages of development. In addition, future research, practical implications and limitations are discussed.

LEVEL OF EVIDENCE I

Systematic review.

Differences in Affective Dynamics Among Eating Disorder Diagnostic Groups

Emotion regulation theories suggest that affect intensity is crucial in the development and maintenance of eating disorders. However, other aspects of emotional experience, such as lability, differentiation, and inertia, are not as well understood. This study is the first to use ecological momentary assessment (EMA) to examine differences in several daily negative affect (NA) indicators among adults diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). Using EMA data from three large studies, a series of linear mixed models showed that participants in the AN and BN groups experienced significantly greater NA intensity and better emotion differentiation than participants in the BED group. Alternatively, the BN group demonstrated significantly greater NA lability than the AN group and greater NA inertia than the BED group. These results suggest that several daily affective experiences differ among eating disorders diagnostic groups and have implications towards distinct conceptualizations and treatments.

The role of interpersonal personality traits and reassurance seeking in eating disorder symptoms and depressive symptoms among women with bulimia nervosa

INTRODUCTION

The role of interpersonal factors has been proposed in various models of eating disorder (ED) psychopathology and treatment. We examined the independent and interactive contributions of two interpersonal-focused personality traits (i.e., social avoidance and insecure attachment) and reassurance seeking in relation to global ED psychopathology and depressive symptoms among women with bulimia nervosa (BN).

METHOD

Participants were 204 adult women with full or subclinical BN who completed a battery of self-report questionnaires. Hierarchical multiple OLS regressions including main effects and interaction terms were used to analyze the data.

RESULTS

Main effects were found for social avoidance and insecure attachment in association with global ED psychopathology and depressive symptoms. In addition, two-way interactions between social avoidance and reassurance seeking were observed for both global ED psychopathology and depressive symptoms. In general, reassurance seeking strengthened the association between social avoidance and global ED psychopathology and depressive symptoms.

CONCLUSION

These results demonstrate the importance of reassurance seeking in psychopathology among women with BN who display personality features characterized by social avoidance.

Schedule for personality assessment from notes and documents (SPAN-DOC): Preliminary validation, links to the ICD-11 classification of personality disorder, and use in eating disorders

BACKGROUND

The underlying core of personality is insufficiently assessed by any single instrument. This has led to the development of instruments adapted for written records in the assessment of personality disorder.

AIMS

To test the construct validity and inter-rater reliability of a new personality assessment method.

METHOD

This study (four parts) assessed the construct validity of the Schedule for Personality Assessment from Notes and Documents (SPAN-DOC), a dimensional assessment from clinical records. We examined inter-rater reliability using case vignettes (Part 1) and convergent validity in three ways: by comparison with NEO Five-Factor Inventory in 130 Korean patients (Part 2), with agreed ICD-11 personality severity levels in two populations (Part 3) and determining its use in assessing the personality status in 90 British patients with eating disorders (Part 4).

RESULTS

Internal consistency (alpha = .90) and inter-rater reliability (intraclass correlation coefficient ≥ .88) were satisfactory. Each factor in the five-factor model of personality was correlated with conceptually valid SPAN-DOC variables. The SPAN-DOC domain traits in those with eating disorders were categorized into 3 clusters: self-aggrandisement, emotionally unstable, and anxious/dependent.

CONCLUSIONS

This study provides preliminary support for the usefulness of SPAN-DOC in the assessment of personality disorder. Copyright © 2016 John Wiley & Sons, Ltd.

Temperament and personality in eating disorders

PURPOSE OF REVIEW

In the last decades, three main different personality domains have been investigated in the field of eating disorders: personality traits, temperament, and personality disorders. The use of a wide range of instruments and the presence of many different approaches in the definition of personality dimensions make it difficult to summarize the emerging results from different studies. The aim of this narrative review is to critically highlight and discuss all interesting developments in this field, as reflected in the recent literature.

RECENT FINDINGS

The study of personality and temperament in eating disorders seems to be in line with the recently suggested dimensional approach, which highlights the importance of symptoms aggregation, rather than the categorical diagnoses. Recent literature seems to confirm that specific personality and temperamental profiles can be drawn for patients with eating disorders, which can discriminate different eating disorders' diagnoses/symptoms.

SUMMARY

These observations have relevant clinical implications as treatment of eating disorders is largely based on psychotherapeutic interventions. However, large longitudinal studies are needed to better clarify the suggested relationships and to identify more defined therapeutic strategies.

Personality prototype as a risk factor for eating disorders

OBJECTIVE

To establish whether the risk of suffering from an eating disorder (ED) is associated with the high-functioning, undercontrolled, or overcontrolled personality prototype groups.

METHOD

The Revised NEO Personality Inventory (NEO-PI-R) and the Eating Disorder Inventory 2 (EDI-2) were administered to 69 patients diagnosed as suffering from EDs (cases) and 89 people free of any ED symptoms (control group). A cluster analysis was carried out to divide the participants into three groups based on their scores in the Big Five personality dimensions. A logistic regression model was then created.

RESULTS

Participants in the undercontrolled group had a risk of suffering from an ED 6.517 times higher than those in the high-functioning group (p = 0.019; odds ratio [OR] = 6.517), while those in the overcontrolled subgroup had a risk of ED 15.972 times higher than those in the high-functioning group.

CONCLUSIONS

Two personality subtypes were identified in which the risk of EDs was six times higher (the undercontrolled group) and almost 16 times higher (the overcontrolled group). Prevention and treatment programs for ED could benefit from focusing on the abovementioned personality profiles.

Are Extremes of Consumption in Eating Disorders Related to an Altered Balance between Reward and Inhibition?

The primary defining characteristic of a diagnosis of an eating disorder (ED) is the "disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food" (DSM V; American Psychiatric Association, 2013). There is a spectrum, ranging from those who severely restrict eating and become emaciated on one end to those who binge and overconsume, usually accompanied by some form of compensatory behaviors, on the other. How can we understand reasons for such extremes of food consummatory behaviors? Recent work on obesity and substance use disorders has identified behaviors and neural pathways that play a powerful role in human consummatory behaviors. That is, corticostriatal limbic and dorsal cognitive neural circuitry can make drugs and food rewarding, but also engage self-control mechanisms that may inhibit their use. Importantly, there is considerable evidence that alterations of these systems also occur in ED. This paper explores the hypothesis that an altered balance of reward and inhibition contributes to altered extremes of response to salient stimuli, such as food. We will review recent studies that show altered sensitivity to reward and punishment in ED, with evidence of altered activity in corticostriatal and insula processes with respect to monetary gains or losses, and tastes of palatable foods. We will also discuss evidence for a spectrum of extremes of inhibition and dysregulation behaviors in ED supported by studies suggesting that this is related to top-down self-control mechanisms. The lack of a mechanistic understanding of ED has thwarted efforts for evidence-based approaches to develop interventions. Understanding how ED behavior is encoded in neural circuits would provide a foundation for developing more specific and effective treatment approaches.

A comparative analysis of personality pathology profiles among patients with pure depressive-, pure anxiety-, and pure somatoform disorders

BACKGROUND

Depressive-, anxiety-, and somatoform disorders are among the most common psychiatric disorders. The assessment of comorbid personality pathology or traits in these disorders is relevant, because it can lead to the exacerbation of them or to poorer remission rates. To date, no research findings have been published on the comparison of these three prevalent patient groups with regard to comorbid dimensional personality pathology.

METHODS

Data of participants (18-60 years) came from a web-based Routine Outcome Monitoring (ROM) programme. The present study used baseline data and was designed to compare personality pathology profiles between three separate outpatient groups: pure anxiety disorders (n=1633), pure depressive disorders (n=1794), and pure somatoform disorders (n=479). Personality pathology was measured with the Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF).

RESULTS

The pure depressive disorder group, in comparison to the other two disorder groups, exhibited the worst psychopathological and functional health image and most personality pathology. In the pure anxiety disorder group, the highest mean was found for the personality trait Anxiousness; and in the pure depressive disorder group for the traits Identity problems, Affective lability, Anxiousness, and Restricted expression.

LIMITATIONS

The cross-sectional nature of the study limits the conclusions that can be drawn.

CONCLUSIONS

The assessment of comorbid personality pathology in depressive-, anxiety-, somatoform disorders is clinically relevant, whether a patient has a personality disorder or not. This way, treatment could partly be focused on specific personality traits that may be counterproductive for treatment outcome, especially in depressive disorders.

Personality profiles in Eating Disorders: further evidence of the clinical utility of examining subtypes based on temperament

Despite recent modifications to the DSM-V diagnostic criteria for Eating Disorders (ED; American Psychiatric Association, 2013), sources of variability in the clinical presentation of ED patients remain poorly understood. Consistent with previous research that has used underlying personality dimensions to identify distinct subgroups of ED patients, the present study examined (1) whether we could identify clinically meaningful subgroups of patients based on temperamental factors including Behavioral Inhibition (BIS), Behavioral Activation (BAS) and Effortful Control (EC), and (2) whether the identified subgroups would also differ with respect to ED, Axis-I and Axis-II psychopathology. One hundred and forty five ED inpatients participated in this study. Results of a k-means analysis identified three distinct groups of patients: an Overcontrolled/Inhibited group (n=53), an Undercontrolled/Dysregulated group (n=58) and a Resilient group (n=34). Further, group comparisons revealed that patients in the Undercontrolled/Dysregulated group demonstrated more severe symptoms of bulimia, hostility and Cluster B Personality Disorders compared to the other groups, while patients in the Resilient group demonstrated the least severe psychopathology. These findings have important implications for understanding how individual differences in personality may impact patterns of ED symptoms and co-occurring psychopathology in patients with ED.

The diagnostic classification of eating disorders: current situation, possible alternatives and future perspectives

The current nosography of eating disorders (ED) has various limitations in terms of validity and accuracy. The changes adopted in the DSM-5 limit some of the current problems, such as excessive prevalence of ED not otherwise specified (EDNOS) and the lack of longitudinal stability, but are unlikely to adequately capture the clinical complexity of ED. Many authors suggest the need for a thorough review of the current nosography to support evidence-based classification. In this paper, we discuss the validity of the current diagnostic categories and their possible reorganization. Furthermore, we review the main empirical models of classification and the diagnostic approach from a personality perspective, with particular attention to research and to the prognostic and therapeutic implications.

Personality factors and eating disorders: self-uncertainty

The International Personality Disorder Examination interview (IPDE) was used to examine common features of personality amongst eating disorder (ED) patients. Female inpatients (N=155), aged 18 to 45, BMI<30 kg/m(2), were interviewed. Items present in ≥ 25% of patients were analysed by factor analysis. Five factors emerged - 'interpersonal anxiety', 'instability', 'self-uncertainty', 'obsessionality' and 'perfectionism' accounting for 62% of the variance. Patients with BMI, <18.5 kg/m(2) had significantly greater 'interpersonal anxiety' factor scores. Patients who purged had higher 'interpersonal anxiety', 'instability', and 'perfectionism' factor scores. Differences between ED diagnostic groups were accounted for by body weight and purging. Increasing age was weakly associated with improvement in 'self-uncertainty' and 'instability' scores. This study separates obsessionality and perfectionism, possibly reflecting ED patients' 'need for control', and introduces a new factor 'self-uncertainty' which reflects their poor self-concept. The contribution of this factor structure to development and duration of illness should be studied.

A review of cognitive neuropsychiatry in the taxonomy of eating disorders: state, trait, or genetic?

A greater understanding of neuropsychological traits in eating disorders may help to construct a more biologically based taxonomy. The aim of this paper is to review the current evidence base of neuropsychological traits in people with eating disorders. Evidence of difficulties in set shifting, weak central coherence, emotional processing difficulties, and altered reward sensitivity is presented for people both in the acute and recovered phase of the illness. These traits are also seen in first degree relatives. At present there is limited research linking these neuropsychological traits with genetic and neuroanatomical measures. In addition to improving the taxonomy of eating disorders, neuropsychological traits may be of value in producing targeted treatments.

Personality subtypes in adolescents with anorexia nervosa

The aims of this study are to (1) empirically identify the personality subtypes of adolescents with anorexic disorders and (2) investigate the personality disorders, identity disturbances, and affective features associated with the different subtypes. We assessed 102 adolescent patients with Eating Disorders (anorexia nervosa and eating disorder not otherwise specified) using three clinical instruments: the Shedler-Westen Assessment Procedure for Adolescents (SWAP-200-A) (Westen D, Shedler J, Durrett C, Glass S, Martens A. Personality diagnoses in adolescence: DSM-IV Axis II diagnoses and an empirically derived alternative. Am J Psychiatry 2003;160:952-966), the Affective Regulation and Experience Questionnaire (AREQ) (Zittel Conklin C, Bradley R, Westen D. Affect regulation in borderline personality disorder. J Nerv Ment Dis 2006;194:69-77), and the Identity Disorder Questionnaire (IDQ) (Wilkinson-Ryan T, Westen D. Identity disturbance in borderline personality disorder: An empirical investigation. Am J Psychiatry 2000;157:528-541). We performed a Q factor analysis of the SWAP-200-A descriptions of our sample to identify personality subtypes. We correlated these personality styles with AREQ and IDQ factors and explored the personality differences among individuals with the different types of ED. The Q factor analysis identified three personality subtypes: high-functioning/perfectionist, emotionally dysregulated, and overcontrolled/constricted. Each subtype showed specific identity and affective features, comorbidities with different personality disorders, and clinical implications. These results contribute to the understanding of adolescents with ED and seem to be relevant for treatment planning.

Personality clusters and family relationships in women with disordered eating symptoms

Personality clusters in women with eating disorders predict important clinical variables (e.g., social functioning) better than eating disorder diagnoses. However, it is unknown whether these findings generalize to samples with subclinical pathology. Further, little is known about associations between personality clusters and family relationships. This study sought to address these limitations by replicating personality clusters in a college sample of women with disordered eating symptoms Based on reported symptoms, women were divided into a restricting, binging and purging, or control (i.e., symptom free) group. Participants completed measures of personality, social functioning, and family relationships. Cluster analyses suggested three personality groups (i.e., Adaptive, Rigid, Dysregulated) which corresponded to those identified previously in clinical samples. Personality clusters, and not disordered eating groups, significantly predicted social functioning, and these clusters were differentially associated with family conflict type. Meaningful personality clusters are present in subclinical populations and have clinical utility in predicting social functioning and family relationships.

The dysregulated cluster in personality profiling research: longitudinal stability and associations with bulimic behaviors and correlates

Among cluster analytic studies of the personality profiles associated with bulimia nervosa, a group of individuals characterized by emotional lability and behavioral dysregulation (i.e., a dysregulated cluster) has emerged most consistently. However, previous studies have all been cross-sectional and mostly used clinical samples. This study aimed to replicate associations between the dysregulated personality cluster and bulimic symptoms and related characteristics using a longitudinal, population-based sample. Participants were females assessed at ages 17 and 25 from the Minnesota Twin Family Study, clustered based on their personality traits. The Dysregulated cluster was successfully identified at both time points and was more stable across time than either the Resilient or Sensation Seeking clusters. Rates of bulimic symptoms and related behaviors (e.g., alcohol use problems) were also highest in the dysregulated group. Findings suggest that the dysregulated cluster is a relatively stable and robust profile that is associated with bulimic symptoms.

Personality-based subtypes of anorexia nervosa: examining validity and utility using baseline clinical variables and ecological momentary assessment

OBJECTIVE

This study sought to empirically derive and validate clinically relevant personality-based subtypes of anorexia nervosa (AN).

METHODS

Women (N = 116) with full or subthreshold AN completed baseline measures of personality, clinical variables, and eating disorder (ED) symptoms, followed by two weeks of ecological momentary assessment (EMA). A latent profile analysis was conducted to identify personality subtypes, which were compared on baseline clinical variables and EMA variables.

RESULTS

The best-fitting model supported three subtypes: underregulated, overregulated, and low psychopathology. The underregulated subtype (characterized by high Stimulus Seeking, Self-Harm, and Oppositionality) displayed greater baseline ED symptoms, as well as lower positive affect and greater negative affect, self-discrepancy, and binge eating in the natural environment. The overregulated subtype (characterized by high Compulsivity and low Stimulus Seeking) was more likely to have a lifetime obsessive-compulsive disorder diagnosis and exhibited greater perfectionism; levels of negative affect, positive affect, and self-discrepancy in this group were intermediate between the other subtypes. The low psychopathology subtype (characterized by normative personality) displayed the lowest levels of baseline ED symptoms, co-occurring disorders, and ED behaviors measured via EMA.

CONCLUSIONS

Findings support the validity of these personality-based subtypes, suggesting the potential utility of addressing within-diagnosis heterogeneity in the treatment of AN.

Alternative methods of classifying eating disorders: models incorporating comorbid psychopathology and associated features

There is increasing recognition of the limitations of current approaches to psychiatric classification. Nowhere is this more apparent than in the eating disorders (EDs). Several alternative methods of classifying EDs have been proposed, which can be divided into two major groups: 1) those that have classified individuals on the basis of disordered eating symptoms; and, 2) those that have classified individuals on the basis of comorbid psychopathology and associated features. Several reviews have addressed symptom-based approaches to ED classification, but we are aware of no paper that has critically examined comorbidity-based systems. Thus, in this paper, we review models of classifying EDs that incorporate information about comorbid psychopathology and associated features. Early approaches are described first, followed by more recent scholarly contributions to comorbidity-based ED classification. Importantly, several areas of overlap among the classification schemes are identified that may have implications for future research. In particular, we note similarities between early models and newer studies in the salience of impulsivity, compulsivity, distress, and inhibition versus risk taking. Finally, we close with directions for future work, with an emphasis on neurobiologically-informed research to elucidate basic behavioral and neuropsychological correlates of comorbidity-based ED classes, as well as implications for treatment.

Subtypes in bulimia nervosa: the role of eating disorder symptomatology, negative affect, and interpersonal functioning

BACKGROUND

The aim of the study was to investigate whether patients with bulimia nervosa (BN) could be subdivided into clinically meaningful groups reflecting the complex patterns of eating disorder symptoms and personality characteristics that face the clinician.

METHODS

Seventy patients diagnosed with BN using the Eating Disorder Examination were assessed with measures of negative affect, attachment patterns, and interpersonal problems. An exploratory hierarchical cluster analysis was performed.

RESULTS

The study found two main subtypes differing primarily in terms of symptom severity and level of negative affect, but these subtypes were further subdivided into four clinically relevant subtypes: A dietary restraint/negative affect/high symptomatic group, an emotionally overcontrolled group, a low dietary restraint/emotionally underregulated group, and a high functioning/securely attached group.

CONCLUSIONS

The study indicates that cluster-analytic studies, including a broad range of instruments measuring eating disorder symptoms as well as negative affect, relational patterns, and other personality characteristics, may contribute to an integration of previously suggested models of subtypes in BN.

Personality subtypes in male patients with eating disorder: validation of a classification approach

In the present study, we investigated personality subtypes and their correlates in a sample of 132 male patients with eating disorder (ED). All patients filled out the Temperament and Character Inventory-Revised, the Eating Disorder Inventory-2, and the Symptom Checklist-90-Revised. Three personality subtypes emerged. Cluster 1, the adaptive-like subtype, was characterized by a high prevalence of eating-disorder-not-otherwise-specified and low levels of ED and general psychopathology. Cluster 2, the average or socially detached subtype, showed a high prevalence of eating-disorder-not-otherwise-specified, more social problems, less motivation for treatment, and an intermediate position on the psychopathology dimension between patients of clusters 1 and 3. Finally, cluster 3, the maladaptive subtype, was characterized the highest prevalence of bulimia nervosa and the highest scores on ED and general psychopathology. Our data support the presence of the 3 personality subtypes in male patients with ED. Future studies need to address whether patients of different subtypes differ with respect to therapy outcome.

Association between serotonin transporter gene polymorphism and eating disorders outcome: a 6-year follow-up study

Eating disorder patients show different long-term outcomes, and trait-related alterations of serotonergic function, which might be related with the serotonin transporter (5-HTT) gene. We studied the relationships between 5-HTTLPR polymorphism, eating specific and general psychopathology and the long-term outcome of anorexia nervosa (AN) and bulimia nervosa (BN) patients. We evaluated the distribution of the functional 5-HTTLPR polymorphism in a series of 201 Italian, Caucasian, eating disorder patients (113 with AN and 88 with BN binge/purging (BP subtype) and in 150 Caucasian unrelated controls. Prior to starting an individual cognitive behavior therapy, a clinical assessment was performed by means of the structured clinical interview for DSM-IV axis I disorders and several self-report questionnaires. This assessment was repeated at the end of treatment, 3 years after the end of treatment and 3 years after the first follow-up. Diagnostic changes between AN and BN were frequent (28.3%), and the presence of depressive disorders was associated with a higher rate of diagnostic crossover during the follow-up period. The S-allele of the 5-HTTLPR genotype increases the risk susceptibility for both depressive comorbidity (OR = 4.23; 95% CI, 1.45-12.37) and diagnostic crossover during the follow-up period in AN patients (OR = 5.04; 95% CI, 1.69-14.98). Logistic regression analyses confirmed these findings, when the interaction between genotype and psychiatric comorbidity as predictors of diagnostic instability in AN patients were taken into account. No significant association was found between 5-HTTLPR genotype and recovery. The S-allele of the 5-HTTLPR genotype increases the risk for depressive disorders comorbidity, and moderates the long-term outcome of anorectic patients.

Reflective functioning in 70 patients suffering from bulimia nervosa

OBJECTIVE

This study is the first to evaluate the reflective functioning abilities of patients suffering from bulimia nervosa (BN).

METHOD

Seventy patients fulfilling Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BN were interviewed with the Adult Attachment Interview, which was subsequently coded for reflective functioning (RF).

RESULTS

On average, the sample of patients suffering from BN had close to normal mentalizing abilities. However, the distribution of RF scores was significantly different from the distribution of RF in a non-clinical control group, showing a more polarized pattern with more low and high RF scores.

CONCLUSION

The study indicates that the theory of mentalization may contribute to understanding BN. However, bulimic pathology may develop and be maintained despite good mentalizing abilities.

Compulsive exercise and eating disorders

The aim of this review was to develop an empirically supported cognitive behavioural model of compulsive exercise within the context of the eating disorders. A systematic review of the correlates and predictors of compulsive exercise among eating disordered patients identified four key correlates. These were subsequently validated by a second review, incorporating both the clinical and non-clinical as well as the exercise science literatures. A proposed model is presented which is both evidence-based and testable.

Redefining phenotypes in eating disorders based on personality: a latent profile analysis

To conduct a latent profile analysis (LPA) in eating disorder (ED) patients using temperament and character (TCI-R) measures as indicators. 1312 ED patients including those with anorexia nervosa (AN), bulimia nervosa (BN) and EDNOS were assessed. The final LPA solution was validated using demographics, clinical variables, ED symptomatology (EDI-2) and impulsive behaviors. The best-fitting model consisted of a six-profile solution using the seven subscales of the TCI-R. These profiles were labeled: "self-focused", "inhibited", "average", "impulsive", "adaptive" and "maladaptive". Validation analyses indicated that the "inhibited" and "maladaptive" profiles generally presented with the highest values for ED symptomatology and impulsive behaviors. Whereas high levels of Harm Avoidance and low levels of Novelty Seeking and Persistence characterized the "inhibited" profile, the "maladaptive" profile presented with low levels of Reward Dependence, Self-Directedness and Cooperativeness. The most favorable results on the other hand were exhibited by the "adaptive" profile, characterized by high scores on Reward Dependence, Self-Directedness, Cooperativeness and low levels on Novelty Seeking. Finally, when our six-profile solution was compared with the DSM-IV ED diagnoses, significant differences among profiles and ED diagnoses were observed. Our study shows that ED patients can be meaningfully grouped according to temperament and character.

The hierarchical structure of the Dimensional Assessment of Personality Pathology (DAPP-BQ)

Hierarchical personality models have the potential to identify common and specific components of DSM-IV personality disorders (PDs), and may offer a solution for the re-tooling of personality pathology in future versions of the DSM. In this paper, we examined the hierarchical structure of the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ; Livesley & Jackson, 2009) and the capacity of various trait components at different levels to predict DSM-IV PD symptoms. Participants were 275 psychiatric outpatients and 365 undergraduate students. Goldberg's (2006) bass-ackwards method was used to investigate the hierarchical structure of the DAPP-BQ. The predictive capacity of hierarchy components was assessed. We found that Level 5 of the hierarchy enhanced the capacity of the DAPP-BQ for predicting DSM PD symptoms beyond a four-factor structure, particularly for borderline PD.

General psychopathology in anorexia nervosa: the role of psychosocial factors

The aim of the present study was to investigate psychosocial correlates of comorbid psychopathology. Data were collected from a total of 90 female inpatients with anorexia nervosa (AN). Higher levels of general psychopathology were detected in depression, interpersonal sensitivity, obsessive-compulsive and anxiety subscales of the Symptom Checklist (SCL)-90. Regression analysis also revealed that higher levels of psychopathology across SCL-90 subscales in AN patients are significantly associated with an earlier age of onset of the condition, higher levels of anorectic psychopathology as measured by Eating Disorders Examination, lower self-esteem as measured by Multidimensional Self-Esteem Inventory and social support levels as measured by Quality of Social Network and Social Support Questionnaire. Considering the high levels of general psychopathology in people with AN, routine clinical practice should aim for a comprehensive assessment of such. Given the strong association between psychosocial factors such as self-esteem, social support and general psychopathology, psychological therapies could play an important role in facilitating emotional recovery.

Dimensional measures of personality as a predictor of outcome at 5-year follow-up in women with bulimia nervosa

Dimensional models are commonly used as a supplement to the categorical model within the field of personality disorders. The purpose of this study was to examine personality dimensions as predictors of 5-year outcomes among women with bulimia nervosa. One hundred and thirty-four women with bulimia nervosa participated in a randomised psychotherapy treatment trial. Data was available for 109 out of the 134 participants at follow-up. Outcomes were the presence of any eating disorder (past year), the presence of a mood disorder episode (past year), and the global assessment of functioning at 5-year follow-up. Self-directedness was the only predictor of any eating disorder diagnosis (past year) at 5-year follow-up. Asceticism significantly predicted the presence of a mood disorder episode (past year) at 5 years. Borderline personality disorder symptoms predicted global functioning at 5 years. These results suggest that high self-directedness at pre-treatment may offer potential prognostic information regarding eating disorder status 5 years post-treatment. Furthermore, no single measure predicted outcome for all variables (any eating disorder diagnosis, a mood disorder episode (past year), or global functioning) at 5-year follow-up. This suggests that a comprehensive personality assessment using multiple measures is desirable for predicting outcomes.

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.

A new approach to clustering eating disorder patients: assessing external validity and comparisons with DSM-IV diagnoses

INTRODUCTION

This study assessed the external validity of four statistically distinct clusters identified in a sample of eating disorder patients, derived from eating disorder features, attachment and coping styles. It also compared clusters with DSM-IV diagnoses.

METHODS

Eating disorder psychopathology, attachment, coping, mood, health status and general functioning were measured in 165 patients.

RESULTS

The 'mild eating disorder group' reported significantly lower levels of functional impairment compared with the 'insecure generalised eating disorder' group, and significantly higher levels of social functioning, vitality and general mental health compared with the 'passive/avoidant restrictors' and 'insecure generalised eating disorder' groups. These latter groups reported significantly higher levels of depression compared with the 'bulimic' and 'mild eating disorder' groups. Compared with DSM-IV diagnoses, clusters were more clearly differentiated on a wide range of features, including mood and health status as well as eating disorder features, attachment and coping.

CONCLUSIONS

Findings provide preliminary support for the external validity of the clusters. Future research might extend this work by investigating the clusters in relation to recovery, relapse and treatment response.

Serotonin transporter gene promoter polymorphism affects the severity of binge eating in general population

OBJECTIVE

The s-allele of the 5-HTTLPR has been suggested to lead to the development of less efficient and less flexible 5-HT system and has been associated to different forms of psychopathology. It has also been shown that alterations in serotonergic activity contribute to the pathophysiology of binge eating but it is not clear which changes in 5-HT function observed in eating disorder patients represent trait vs state effect. We investigated the association between the 5-HTTLPR and binge eating in a population-representative sample of women, and tested whether the 5-HTTLPR genotype influences the severity of binge eating.

METHODS

The sample was based on women participating in the third wave of the Estonian Children Personality, Behaviour and Health Study. EDI-2 subscales - drive for thinness and bulimia - were used to assess eating behaviour and attitudes. Barratt Impulsiveness Scale (BIS-11) and State and Trait Anxiety Inventory (STAI) were used to measure impulsivity and anxiety. Participants were genotyped for the 5-HTTLPR.

RESULTS

There was no 5-HTTLPR genotype effect on binge eating even after the covarying effect of impulsivity and anxiety was controlled for. However, women prone to binge eating and carrying the s-allele showed significantly higher levels of bulimia scores, and among them, women with s/s genotype had also higher levels of state anxiety and tendency for higher impulsivity.

CONCLUSIONS

While the 5-HTTLPR genotype does not predict symptoms of eating disorder in general population, the s-allele, and especially the s/s genotype increases the risk for affective instability and symptom severity.

Emotion recognition and regulation in anorexia nervosa

It is recognized that emotional problems lie at the core of eating disorders (EDs) but scant attention has been paid to specific aspects such as emotional recognition, regulation and expression. This study aimed to investigate emotion recognition using the Reading the Mind in the Eyes (RME) task and emotion regulation using the Difficulties in Emotion Regulation Scale (DERS) in 20 women with anorexia nervosa (AN) and 20 female healthy controls (HCs). Women with AN had significantly lower scores on RME and reported significantly more difficulties with emotion regulation than HCs. There was a significant negative correlation between total DERS score and correct answers from the RME. These results suggest that women with AN have difficulties with emotional recognition and regulation. It is uncertain whether these deficits result from starvation and to what extent they might be reversed by weight gain alone. These deficits may need to be targeted in treatment.

An approach to sub-grouping the eating disorder population: adding attachment and coping style

OBJECTIVE

To investigate whether clinically meaningful sub-groups of patients can be identified by clustering eating disorder features, attachment and coping styles.

METHOD

165 patients completed the Eating Disorder Examination (EDE), Attachment Style Questionnaire (ASQ) and Utrecht Coping List (UCL). Cluster analysis was used to identify sub-groups across the sample.

RESULTS

Four clusters were identified. Cluster one had low levels of eating disorder behaviours and the most severe attachment and coping difficulties. Cluster two had high levels of dietary restriction and exercise, and a fearful/avoidant attachment style. Cluster three had high levels of binge eating and vomiting, and few attachment and coping difficulties. Cluster four had low levels of eating disorder features and positive attachment and coping styles.

CONCLUSIONS

Clustering participants on the basis of eating disorder features, attachment and coping yields four sub-groups appearing to have clinical face validity.

Implicit family process rules in eating-disordered and non-eating-disordered families

Family environment has been shown to be one of the factors related to the presence of eating disorders among young-adult females. Clinical experience and theories about eating disorders postulate that implicit family rules are an intricate part of family process that may have a great effect on the creation and maintenance of such problems. This study compared implicit family process rules (specifically rules pertaining to kindness; expressiveness and connection; constraining thoughts, feelings, and self; inappropriate caretaking; and monitoring) in families with a young-adult female diagnosed with an eating disorder-either anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified-and families with a young-adult female without an eating disorder diagnosis. One hundred two families (51 eating disordered and 51 comparison) participated in the study. Mothers, fathers, young-adult female children, and siblings completed the Family Implicit Rules Profile (Harper, Stoll, & Larson, 2007). Results indicated that eating-disordered families are governed by a greater proportion of constraining family rules than are non-eating-disordered families. Additionally, eating-disordered youth reported a lower proportion of facilitative family rules and a higher proportion of constraining family rules than did parents and siblings. Theoretical, research, and clinical implications are discussed.

Anorexia nervosa trios: behavioral profiles of individuals with anorexia nervosa and their parents

BACKGROUND

Anorexia nervosa (AN) is associated with behavioral traits that predate the onset of AN and persist after recovery. We identified patterns of behavioral traits in AN trios (proband plus two biological parents).

METHOD

A total of 433 complete trios were collected in the Price Foundation Genetic Study of AN using standardized instruments for eating disorder (ED) symptoms, anxiety, perfectionism, and temperament. We used latent profile analysis and ANOVA to identify and validate patterns of behavioral traits.

RESULTS

We distinguished three classes with medium to large effect sizes by mothers' and probands' drive for thinness, body dissatisfaction, perfectionism, neuroticism, trait anxiety, and harm avoidance. Fathers did not differ significantly across classes. Classes were distinguished by degree of symptomatology rather than qualitative differences. Class 1 (approximately 33%) comprised low symptom probands and mothers with scores in the healthy range. Class 2 ( approximately 43%) included probands with marked elevations in drive for thinness, body dissatisfaction, neuroticism, trait anxiety, and harm avoidance and mothers with mild anxious/perfectionistic traits. Class 3 (approximately 24%) included probands and mothers with elevations on ED and anxious/perfectionistic traits. Mother-daughter symptom severity was related in classes 1 and 3 only. Trio profiles did not differ significantly by proband clinical status or subtype.

CONCLUSIONS

A key finding is the importance of mother and daughter traits in the identification of temperament and personality patterns in families affected by AN. Mother-daughter pairs with severe ED and anxious/perfectionistic traits may represent a more homogeneous and familial variant of AN that could be of value in genetic studies.

Daily mood patterns and bulimic behaviors in the natural environment

OBJECTIVE

Negative affect has been purported to play an important role in the etiology and maintenance of bulimic behaviors. The objective of this study was to identify daily mood patterns in the natural environment exhibited by individuals with bulimia nervosa and to examine the relationship between these patterns and bulimic behaviors.

METHOD

One hundred thirty-three women aged 18-55 meeting DSM-IV criteria for bulimia nervosa were recruited through clinical referrals and community advertisements. Ecological momentary assessment was used to collect multiple ratings of negative affect, binge eating and purging each day for a two-week period using palmtop computers. Latent growth mixture modeling was used to identify daily mood patterns.

RESULTS

Nine distinct daily mood patterns were identified. The highest rates of binge eating and purging episodes occurred on days characterized by stable high negative affect or increasing negative affect over the course of the day.

CONCLUSIONS

These findings support the conclusion that negative mood states are intimately tied to bulimic behaviors and may in fact precipitate such behavior.

A personality classification system for eating disorders: a longitudinal study

BACKGROUND

Studies of eating disorders (EDs) suggest that empirically derived personality subtypes may explain heterogeneity in ED samples that is not captured by the current diagnostic system. Longitudinal outcomes for personality subtypes have not been examined.

METHOD

In this study, personality pathology was assessed by clinical interview in 213 individuals with anorexia nervosa and bulimia nervosa at baseline. Interview data on EDs, comorbid diagnoses, global functioning, and treatment utilization were collected at baseline and at 6-month follow-up intervals over a median of 9 years.

RESULTS

Q-factor analysis of the participants based on personality items produced a 5-prototype system, including high-functioning, behaviorally dysregulated, emotionally dysregulated, avoidant-insecure, and obsessional-sensitive types. Dimensional prototype scores were associated with baseline functioning and longitudinal outcome. Avoidant-Insecure scores showed consistent associations with poor functioning and outcome, including failure to show ED improvement, poor global functioning after 5 years, and high treatment utilization after 5 years. Behavioral dysregulation was associated with poor baseline functioning but did not show strong associations with ED or global outcome when histories of major depression and substance use disorder were covaried. Emotional dysregulation and obsessional-sensitivity were not associated with negative outcomes. High-functioning prototype scores were consistently associated with positive outcomes.

CONCLUSIONS

Longitudinal results support the importance of personality subtypes to ED classification.

Personality pathology and substance abuse in eating disorders: a longitudinal study

OBJECTIVE

Substance abuse has been shown to predict poor outcome in eating disorder (ED) samples, and prior cross-sectional data on personality subtypes of EDs suggest that substance abuse is associated with dysregulated and possibly avoidant-insecure subtypes. This study investigates longitudinal associations between personality and substance use.

METHOD

Personality pathology and substance use were assessed in 213 individuals with anorexia nervosa and bulimia nervosa at baseline; substance use was assessed at regular follow-up intervals over a 9-year period.

RESULTS

Of the five personality factors identified, the obsessional-sensitive and high-functioning types were negatively associated with substance abuse at baseline, while the behaviorally dysregulated type was positively associated with substance abuse at baseline. Longitudinal associations were observed, suggesting that obsessional-sensitive personality type was protective against the development of substance abuse. Longitudinal associations between the other personality types and substance abuse were nonsignificant after baseline substance abuse history was included as a covariate in the model.

CONCLUSION

Substance use demonstrates cross-sectional associations with personality style, but substance abuse history appears to be the most important predictor of future substance abuse in women with eating disorders.

Links between eating disorder symptom severity and psychiatric comorbidity

Patients with eating disorders (ED) frequently exhibit additional psychiatric disorders. This study aimed to examine whether psychiatric comorbidity in ED patients is associated with increased severity of ED symptoms in a sample of 277 women with a current ED (84 anorexia nervosa, 152 bulimia nervosa, 41 eating disorders not otherwise specified). Psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview (SCID) for DSM-IV. Severity of ED-related symptoms was assessed using interviewer-rated scales from the Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Affective and anxiety-related disorders of both axes were linked with increased intensity of weight- and appearance-related fears and concerns. Frequency of binge-eating and frequency of purging both were associated with Axis I anxiety disorders, substance-related disorders, and Cluster B personality disorders. Frequency of dieting was related to anxiety disorders on both axes. Multivariate analyses revealed that Axis I anxiety disorders were more closely linked with severity of ED symptoms than affective or substance-related disorders. The results showed that psychiatric comorbidity of both axes is linked with increased severity of ED symptoms and that there are associations between specific ED symptoms and specific forms of comorbidity.

The relationship of momentary anger and impulsivity to bulimic behavior

Past research has suggested that negative affect may be a causal factor for eating disordered behaviors. More specifically, research has shown that anger appears to be one aspect of negative affect that is particularly relevant in bulimic patients. Previous studies have also shown that the relationship between negative affect and eating disordered behaviors may partially depend upon personality variables such as impulsivity. The present study examined whether the relationship between anger and eating disordered behaviors is moderated by impulsivity. Subjects completed an ecological momentary assessment (EMA) protocol for an average of 2 weeks. Findings revealed that overall antecedent anger level and the variability of antecedent anger predicted binge-eating episodes and that these relationships were moderated by participants' level of impulsivity. These findings suggest that personality variables impact the way that anger and eating behaviors relate. They also suggest that the variability of antecedent anger may be a fruitful avenue for future research for those interested in causal variables associated with bulimia nervosa.

Is multi-impulsive bulimia a distinct type of bulimia nervosa: Psychopathology and EMA findings

OBJECTIVE

To determine if clinically defined multi-impulsive bulimia (MIB) can be validated using an empirical classification approach.

METHOD

One hundred and twenty-five women who met DSM-IV criteria for bulimia nervosa were interviewed and completed a two-week EMA protocol. Participants who reported at least three highly impulsive behaviors were compared to participants who did not report such impulsive behavior. Also, Latent Class Analysis (LCA) was conducted to determine if the MIB classification could be replicated empirically.

RESULTS

LCA produced a two-class solution consistent with the traditional clinical approach to MIB classification. In both approaches, MIB was associated with higher levels of anxiety disorders, child abuse, and daily self-damaging behaviors than the non-MIB class.

CONCLUSION

Clinical classification of MIB was empirically supported through LCA. Although the classes failed to differ in bulimic behavior, MIB appears to represent a group of bulimic individuals with significant trauma histories and associated psychopathology.

Personality traits after recovery from eating disorders: do subtypes differ?

OBJECTIVE

We compared individuals recovered from anorexia (AN) and bulimia nervosa (BN) to determine characteristics that are shared by or distinguish eating disorder (ED) subtypes.

METHOD

Sixty women recovered for > or = 1 year from AN or BN were compared with 47 control women (CW). Assessments included the Yale-Brown-Cornell Eating Disorder Scale, the Spielberger State-Trait Anxiety Inventory, the Beck Depression Inventory, the Yale-Brown Obsessive Compulsive Scale, the Temperament and Character Inventory, and Structured Clinical Interviews for DSM-IV.

RESULTS

Individuals recovered from an ED had similar scores for mood and personality variables that were significantly higher than the scores for CW. Few recovered subjects had Cluster B personality disorder. Most individuals recovered within 6 years of their ED onset. A latent profile analysis identified an "inhibited" and "disinhibited" cluster based on personality traits.

CONCLUSION

A wide range of symptoms persist after recovery and do not differ between subtypes of ED. These findings may aid in identifying traits that create vulnerabilities for developing an ED.

A naturalistic study of psychotherapy for bulimia nervosa, part 2: therapeutic interventions in the community

Data from naturalistic samples provide an important complement to findings from randomized trials of psychotherapy. A random national sample of US clinicians provided data on 145 completed treatments of patients with bulimic symptoms. We attempted to characterize the nature of treatments in the community and to examine the relation between treatment variables and outcome. Clinicians of all theoretical orientations report using interventions with polysymptomatic cases designed to address clinically significant personality characteristics and interpersonal patterns. Whereas cognitive-behavioral therapy is associated with more rapid remission of eating symptoms, psychodynamic interventions and increased treatment length predict better global outcome across treatment modalities, suggesting the importance of integrative treatments for the broad range of pathology seen in patients with bulimic symptoms.

Personality and anorexia nervosa

We provided a selective review of the relationship between anorexia nervosa (AN) and personality. They reviewed the existing empirical literature examining the relationship between AN and personality. In spite of continued methodologic challenges related to personality assessment, there appears to be a relatively common phenotype in restricting-type AN characterized by high degrees of obsessionality, restraint, and perfectionism. However, there is also evidence of variability within the AN diagnostic category that is related to personality variables. Importantly, personality variables may significantly predict the course and outcome of AN. Personality variables may be risk factors for AN, consequences of AN, share a common cause with AN, or affect the course and outcome of AN. This literature would be enhanced by the articulation of conceptual models of these relationships that can be empirically tested.