Eating psychopathology and personality in eating disorders

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.

Lifetime and recent DSM and ICD psychiatric comorbidity of inpatients engaging in different eating disorder behaviours

OBJECTIVE

Previous studies investigating psychiatric comorbidity in eating disorder (ED) patients compared groups according to ED diagnoses. The current paper compared groups according to ED behaviours: self-induced vomiting, objective binge eating, excessive exercising, and to body mass index (BMI, kg/m(2)) for selected psychiatric comorbidity using two systems: Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) and International Classification of Diseases - Tenth Revision (ICD-10) diagnoses.

METHOD

Two hundred and twenty-six patients admitted for treatment in a specialised Eating Disorders Unit completed the Composite International Diagnostic Interview (CIDI). Lifetime and recent (12 months) psychiatric diagnoses were produced according to DSM-IV and ICD-10. Associations between presence of ED behaviours or BMI and psychiatric comorbidity were investigated.

RESULTS

Eighty-eight percent of patients had a lifetime history (72% recent history) of at least one comorbid diagnosis (regardless of diagnostic system). Agreement between the systems was high for mood (affective) disorders and moderate for anxiety/somatoform disorders. Significantly more patients who vomit had lifetime and recent mood (affective) disorders (DSM-IV and ICD-10). Significantly more 'vomiters' had recent anxiety disorders (DSM-IV) and neurotic, stress-related and somatoform disorders (ICD-10) including post-traumatic stress disorder (PTSD; DSM-IV and ICD-10). More patients with BMI >17.5 kg/m(2) had lifetime and recent mood (affective) disorders and lifetime PTSD (DSM-IV and ICD-10). The results for 'excessive exercisers' varied and appeared inconsistent. There were no differences in any disorders for objective binge eaters.

DISCUSSION

Patients who induce vomiting have more psychiatric comorbidity than 'non-vomiters', both lifetime and recent, and may benefit from diagnostic recognition as a separate group, for example 'vomiting' or 'purging' ED, who can then receive specialist treatment for their comorbidity and associated problems.

Overt and covert aggression in college women with bulimia nervosa

OBJECTIVE

This study examines the prevalence of overt and covert aggression in women with bulimia nervosa (BN) as well as the relationship between the severity of BN and the frequency of aggressive acts.

PATIENTS AND METHODS

20 female college students with BN and 20 control subjects completed self-report measures of aggressive behavior and eating disorder pathology. They also completed the Juvenile Health and Wellness Survey-76 to assess general risk taking and indices of sexual behavior and mental health.

RESULTS

BN subjects reported higher levels of both overt and covert aggression (p < .001). Overt aggression tended to be more premeditated, while the self-report of covert aggression behavior was more impulsive. Levels of aggressive behavior were significantly correlated with severity of BN (p < .01). Subjects with BN reported higher levels of risk-taking and sexual behaviors.

CONCLUSIONS

Aggression is an important clinical issue in BN. Subtypes of aggression suggest different pathways for overt and covert aggressive acts with impulsive covert aggression being more closely related to the binge-purge cycle. Awareness of subtypes of aggression in BN may have important clinical and treatment implications.

Parental bonding and eating psychopathology in bulimia nervosa: personality traits as possible mediators

Aims– The relationship between eating disorders, attachment, personality traits and eating psychopathology remains unexplored. This study tested the mediating role of temperament and character between parental bonding and psy-chopathology in bulimic women.Methods– 154 bulimic subjects and 154 healthy controls were compared using Parental Bonding Instrument (PBI), Temperament and Character Inventory (TCI), Eating Disorder Inventory-2 (EDI-2), and Beck Depression Inventory (BDI). Multiple regression analysis tested the mediation of personality traits between parenting and eating psy-chopathology.Results– Bulimic subjects displayed low maternal and paternal care and low self-directedness, and high novelty seeking and eating psychopathology. Maternal care was negatively related to social insecurity, inadequacy and impulsiveness. Paternal care predicted novelty seeking, self-directedness, interoceptive awareness, impulsiveness, and asceticism. The mediation effect of self-directedness between paternal care and psychopathology was significant, not the one of novelty seeking. Conclusions – Parental care is lower in bulimic than in control women even when controlled for possible confounding variables. Some eating psychopathology traits are related to maternal and paternal care, but not the bulimia subscale. Paternal care is also related to temperament and character traits which are related to eating psychopathology. Self-directedness mediates with different degrees between parenting and eating psychopathology. Clinical implications are discussed.

Declaration of Interest:The first author received financing from Compagnia di San Paolo Foundation for the research on eating disorders (3989 IT/FA 2005.1797). The National Eating Disorder Association (NEDA) awarded a Charron Family Grant to the second author to sustain research about the families of subjects affected by eating disorders. The third author received a grant from “Regione Piemonte” for research on Eating Disorders for the years 2008 and 2009. The authors have not received any other financing for the present research, including pharmaceutical company support or any honoraria for consultancies for interventions during the last two years. The authors are not involved in any conflict of interest in connection to the submitted article.

Promotion of Well-Being in Person-Centered Mental Health Care

An understanding of the mechanisms of personality development provides a systematic way to promote health as an integrated state of physical, mental, social, and spiritual well-being. Individual differences in personality are causal antecedents of the full range of psychopathology. The maturation with integration of personality appears to be an important mechanism by which diverse modalities of treatment promote wellness and reduce illness. First, the authors review the relationship between personality and a wide range of psychiatric disorders. Second, the authors evaluate the impact of character structure on a wide range of measures of well-being, including positive emotions, negative emotions, life satisfaction, perceived social support, and perceived health. Third, the authors describe a practical and inexpensive clinical method for facilitating the maturation and integration of personality based on an understanding of the processes of human thought, which underlie changes in personality and well-being.

The dynamic relationship of parental personality traits with the personality and psychopathology traits of anorectic and bulimic daughters

OBJECTIVE

Parenting and family dynamics influence the emergence, development, and maintenance of eating disorders (EDs). Although family interventions are relevant for therapeutic programs, knowledge of the relationship between parental personality traits and the eating psychopathology of daughters is scarce. This study explored the personality and psychopathology of women with EDs and correlated them with parental personality traits.

METHOD

The personality and eating psychopathology traits of 38 restricter anorectics, 30 bingeing/purging anorectics, 37 bulimics, and their parents' personality traits (87 fathers and 97 mothers) were measured with the Temperament and Character Inventory, the Clinical Global Impression Scale, the Eating Disorders Inventory-2, and the Beck Depression Inventory. The results were compared with matched controls (54 women, 50 fathers, 54 mothers). Personality and psychopathology were correlated with multiple regression.

RESULTS

Women with ED displayed high harm avoidance and low self-directedness, whereas restricter anorectic women had high persistence. Low persistence was common in fathers of daughters across all EDs. Fathers of restricter anorectics were highly harm avoidant. Fathers of both anorectic subtypes and mothers of bulimic women displayed low self-directedness. Parental personality traits were linearly correlated with their daughter's personality and psychopathology, but the correlation differed among EDs.

CONCLUSION

Parents of eating-disordered participants displayed personality characteristics that differed from controls and, among ED subgroups, these differences were related to their daughter's personality and psychopathology. The linear correlation did not fully explain the relationship of the parental personality traits to the presence of their daughter's ED, suggesting that a more complex personality-based family dynamic is involved. A Temperament and Character Inventory profile of the entire family may be used in the planning of family treatment.

Deficient activity in the neural systems that mediate self-regulatory control in bulimia nervosa

CONTEXT

Disturbances in neural systems that mediate voluntary self-regulatory processes may contribute to bulimia nervosa (BN) by releasing feeding behaviors from regulatory control.

OBJECTIVE

To study the functional activity in neural circuits that subserve self-regulatory control in women with BN.

DESIGN

We compared functional magnetic resonance imaging blood oxygenation level-dependent responses in patients with BN with healthy controls during performance of the Simon Spatial Incompatibility task.

SETTING

University research institute.

PARTICIPANTS

Forty women: 20 patients with BN and 20 healthy control participants. Main Outcome Measure We used general linear modeling of Simon Spatial Incompatibility task-related activations to compare groups on their patterns of brain activation associated with the successful or unsuccessful engagement of self-regulatory control.

RESULTS

Patients with BN responded more impulsively and made more errors on the task than did healthy controls; patients with the most severe symptoms made the most errors. During correct responding on incongruent trials, patients failed to activate frontostriatal circuits to the same degree as healthy controls in the left inferolateral prefrontal cortex (Brodmann area [BA] 45), bilateral inferior frontal gyrus (BA 44), lenticular and caudate nuclei, and anterior cingulate cortex (BA 24/32). Patients activated the dorsal anterior cingulate cortex (BA 32) more when making errors than when responding correctly. In contrast, healthy participants activated the anterior cingulate cortex more during correct than incorrect responses, and they activated the striatum more when responding incorrectly, likely reflecting an automatic response tendency that, in the absence of concomitant anterior cingulate cortex activity, produced incorrect responses.

CONCLUSIONS

Self-regulatory processes are impaired in women with BN, likely because of their failure to engage frontostriatal circuits appropriately. These findings enhance our understanding of the pathogenesis of BN by pointing to functional abnormalities within a neural system that subserves self-regulatory control, which may contribute to binge eating and other impulsive behaviors in women with BN.

Anger expression in eating disorders: clinical, psychopathological and personality correlates

The goals of the study were to compare anger expressions in individuals with eating disorders and healthy controls, and to explore the relation among eating disorder symptoms, comorbid psychopathology, personality traits, and impulsive behaviours. Participants comprised 135 eating disorder patients consecutively admitted to our unit and 103 healthy controls. Assessment measures included the Eating Disorders Inventory 2 (EDI-2), Bulimic Investigatory Test Edinburgh (BITE), Symptom Checklist-Revised (SCL-90-R), Social Avoidance Distress Scale (SAD), Temperament and Character Inventory-Revised (TCI-R), State-Trait Anger Expression Inventory 2 (STAXI-2), and other clinical and psychopathological indices. In the control group also the General Health Questionnaire-28 (GHQ-28) was also used. Women with eating disorders obtained significantly higher mean scores than controls on all STAXI-2 scales except for Anger Control. When various purging methods were assessed independently, the frequency of laxative use was associated with anger suppression. Eating disorder symptoms and specific personality traits were positively associated with different forms of anger expression. Finally, patients with higher scores on anger suppression were more likely to report self-harming behaviors. Eating disorder patients may have inadequate anger expression and deficits in coping with anger and frustration. Furthermore, different purging methods may be related to different facets of anger.