Impulsivity and personality variables in adolescents with eating disorders

Testing associations between assessments of cognitive flexibility and eating disorder symptoms in adolescent bulimia nervosa

OBJECTIVE

Cognitive rigidity, or difficulty adapting to changing demands, is commonly observed in anorexia nervosa. Less is known, however, about cognitive flexibility (CF) in bulimia nervosa (BN) and, particularly, adolescence. Clarifying this relation and best assessment practices may guide informed clinical decision-making. The current study compared how two measures of CF (i.e., Wisconsin Card Sort Task [WCST] and Trail Making Task [TMT]) relate to BN symptoms among adolescents.

METHODS

Data from a subsample (n = 78) of adolescents with BN were analyzed. Linear and hurdle regressions were used to compare the effects of WCST perseverative errors and TMT performance on Eating Disorder Examination Global Scores, objective binge episodes, and self-induced vomiting episodes (SVEs) at baseline and end-of-treatment (EOT).

RESULTS

Neither CF measure associated with baseline BN symptoms. TMT performance positively associated with the likelihood of engaging in SVEs at EOT (𝛽 = 0.47, p = 0.01, 95% confidence interval [CI] = [0.11-0.84]) and, among adolescents who endorsed ≥1 SVE at EOT, WCST perseverative errors (𝛽 = 0.05, p = 0.005, 95% CI = [0.01-0.08]) positively associated with SVE frequency at EOT.

DISCUSSION

The overall lack of associations between CF and outcomes suggests that cognitive rigidity may not be as relevant to the clinical profile of adolescent BN as for anorexia nervosa. In the few significant associations that emerged, the WCST and TMT uniquely predicted the severity of vomiting at EOT in this sample. Given the lack of CF deficits, future work should aim to test the role of other executive functions (e.g., impulsivity), in addition to CF, to determine which deficits are present in adolescent BN and may predict outcomes.

PUBLIC SIGNIFICANCE

Patients with eating disorders often have difficulties thinking flexibly, which may interfere with their recovery. We tested two ways of measuring flexible thinking in adolescents with BN. Overall, flexible thinking was not associated with symptom-level outcomes. However, less flexible thinking at the start of treatment predicted self-induced vomiting at EOT. If findings are replicable, then assessing and addressing flexible thinking could improve outcomes for adolescents with BN.

Relationship of self-reported pica and avoidant restrictive food intake disorder symptomology with dimensions of impulsivity, perceived stress among Pakistani University students

INTRODUCTION

Pica and avoidant/restrictive food intake disorder are two of the three new eating and feeding disorders introduced in the DSM-5, this inclusion has drawn attention to the immediate need for research into their prevalence, diagnostic assessment, underlying risk factors and optimal treatment. There are very few studies available that explored the predictors or causes of these eating disorders specifically in Pakistani context.

OBJECTIVES

The objectives of the current study include (a) to estimate the presence of pica and avoidant/restrictive food intake disorder symptomology among young adults in Pakistan, (b) to examine the relationship between dimensions of impulsivity, stress and presence of pica and avoidant/restrictive food intake disorder, (c) to explore the mediation role of stress.

METHODS

The sample consisted of 660 young adults with age range 18-25 years, recruited through convenient sampling. The respondents were provided with a questionnaire comprising of an informed consent, a demographic information sheet and self-report measures including PARDI-AR-Q to assess symptomology of pica and avoidant/restrictive food intake disorder, UPPS-P Impulsive Behaviour Scale to assess dimensions of impulsivity and Perceived Stress Scale to measure perceived stress.

RESULTS

The findings show that 28 participants (4.2%) reported Pica symptomology, of which eleven participants indicated that they currently consume more than one non-food item. 19 respondents (2.8%) reported avoidant/restrictive food intake disorder symptomology. 13 respondents reported varying degrees of all three symptom clusters namely sensory based food avoidance, lack of interest in food, and fear of negative consequences of eating. Additionally, each of the dimensions of impulsivity was found to be positively correlated to the presence of pica and avoidant/restrictive food intake disorder. Perceived stress was identified as a mediating factor between each of the dimensions of impulsivity and presence of pica and avoidant/restrictive food intake disorder.

CONCLUSION

Although current study focused on a particular age range, it has drawn attention to the necessity of screening and investigating other strata of Pakistani population for pica and avoidant/restrictive food intake disorder. The clinical utility of the present research resided in the identification of factors associated with pica and avoidant/restrictive food intake disorder, an information which can be used to tailor psychological interventions, modify existing ones, and inform the future research on evidence-based treatment.

Potential applications of Schema Therapy in the treatment of adolescents with anorexia nervosa: a theoretical analysis

Purpose

The main purpose of the article is to present basic theoretical assumptions on Schema Therapy and its hypothetical application among adolescents suffering with anorexia nervosa.

Views

Anorexia nervosa is a very deadly mental disease, more frequently suffered by females than males, with the mean age of onset at approximately 14-15. Studies underline the relatively poor effectiveness of currently applied treatment methods and the need for new approaches that could be recommended for adolescent patients suffering with this disease. The results of studies conducted to date lead to the conclusion that Schema Therapy is a promising approach for this group. It is a transdiagnostic method of work that compiles elements known in other therapeutic approaches, aiming at an increase in the individual's awareness of their feelings and emotional needs, applied both in adolescent and adult groups of patients. Since the symptoms of eating disorders observed in adolescents are strongly connected with family systems it seems reasonable to use treatment techniques that rigorously address the unmet needs and rejected emotions of the individual.

Conclusions

Based on the data published so far it might be hypothesized that the techniques characteristic for Schema Therapy (e.g. imagery rescripting, chairwork, limited reparenting) could be eligible for use with adolescent patients with anorexia nervosa.They address unmet needs, rejected emotions, and early maladaptive schemas that are very frequent in patients with AN. Since the analysis presented provides only hypotheses and the discussion of theoretical aspects, empirical research in this area is needed.

Association between impulsivity and healthy orthorexia: any moderating role of personality traits?

The study objectives were to investigate correlates of healthy orthorexia (HeOr), its relation with impulsivity, and the moderating role of adaptive personality traits among a Lebanese adult sample. The sample was recruited from seven community pharmacies, from the five districts in Lebanon, chosen from a list provided by the Lebanese Order of Pharmacists in a convenient way. The questionnaire included the Teruel Orthorexia Scale (TOS) to measure HeOr, Big Five Inventory (BFI) to assess adaptive personality traits, and the I-8 scale for impulsivity. Higher extraversion (B = -4.31) was significantly associated with lower healthy orthorexia. The interaction perseverance by extraversion was associated with higher healthy orthorexia; in those with higher perseverance, higher extraversion was associated with more healthy orthorexia. Our study presents findings that could be of significant clinical relevance in the future, especially with the interest increase in Orthorexia Nervosa prevalence, which subsequently prompts more research and intrigue about HeOr. Furthermore, it places healthy eating and consistent commitment to a healthy diet within a clearly defined scientific frame, on which further investigation can be based.

Is personality the key in cognitive-behavioural therapy for eating disorders? A review

The efficacy of individual cognitive-behavioural therapy (CBT) for eating disorders can be assessed by investigating the potential predictors, mediators and moderators of treatment. The present review focused on personality since its crucial role has been emphasized both by research and practice. Sixteen studies were collected, and data were extracted through a highly operationalized coding system. Overall, personality disorders were the most investigated construct; however, their influence was somewhat contradictory. A more cogent result occurred for borderline personality disorder (BPD) when considered as a moderator (not a predictor nor a mediator). Patients with a more disturbed borderline personality benefited to a greater extent from treatments including booster modules on affects, interpersonal relationships and mood intolerance, rather than symptoms exclusively. Nine additional personality dimensions, beyond BPD, were investigated sparsely, and results regarding them were barely indicative in this review. However, some of these dimensions (e.g., affective lability and stimulus-seeking behaviours) could be traced back to BPD, thereby strengthening evidence of the role of borderline disorder as a moderator. Although research on the relationship between personality and eating disorders needs to be increased and methodologically improved, personality, taken as a whole, emerged as a promising variable for enhancing the efficacy of CBT.

Impulsivity and compulsivity in anorexia and bulimia nervosa: A systematic review

This study aimed to systematically appraise cross-sectional research that compared the cognitive performance of individuals in the acute phase of BN and/or AN to HCs on measures of impulsivity and compulsivity. The results of the systematic review showed support for the trans-diagnostic approach to eating disorders. There was no strong evidence to support the characterisation of AN as high in compulsivity (and low in impulsivity), nor to support the characterisation of BN as high in impulsivity (and low in compulsivity). There appeared to be mixed findings for both impulsivity and compulsivity across AN and BN. Results were highly variable due to the heterogeneous tasks used, and lack of replication across studies. There was no consensus amongst the included studies on the most appropriate task and/or outcome measures that should be used to study the constructs of impulsivity and compulsivity.

Personality traits in adolescents with eating disorder: A meta-analytic review

OBJECTIVE

Given the growing interest in personality traits among the young population with eating disorders (EDs) and the recognition that a better understanding of personality can facilitate clinical management, this meta-analytic study reviewed evidence concerning the relationship between personality traits and the presence of an ED during adolescence.

METHOD

We conducted a systematic literature search to identify studies that examined personality traits among adolescents with an ED (anorexia nervosa, bulimia nervosa, binge-eating disorder, eating disorder not otherwise specified) and that compared these traits with a normative group without an ED. The personality traits investigated in the selected studies were organized according to the personality trait domains presented in the Diagnostic and Statistical Manual of Mental Disorders (fifth ed.). Effect sizes of the mean differences were calculated for each domain. We performed meta-regressions to assess the moderating effect of ED subtype and age on the combined effect sizes.

RESULTS

Twenty-six studies met our inclusion criteria, containing a total of 63 effect sizes. Adolescents with EDs differed from the non-ED group according to traits related to negative affectivity (g = 0.78), detachment (g = 0.69), and conscientiousness (g = -0.53). The presence of an anorexia nervosa diagnosis moderated the relationship between an ED and personality traits; this diagnosis was more strongly associated with conscientious traits compared to other EDs.

DISCUSSION

Our findings provide evidence that personality traits are related to EDs in adolescents. Thus, considering personality traits could lead to a better understanding of etiological and maintenance factors for EDs.

Identification and management of eating disorders in gynecology: menstrual health as an underutilized screening tool

Eating disorders are life-threatening conditions that disproportionately affect females, often during child-bearing years. Although the endocrinological and reproductive sequelae of these conditions often fall within the treatment purview of obstetrician-gynecologists, the assessment of eating pathology is challenging and often not part of routine clinical care. This commentary focuses on one of the common presenting symptoms of eating disorders in women, menstrual dysfunction, and discusses considerations for its clinical management in gynecology. Assessment of menstrual status provides a natural starting point for provider-patient discussion of disordered eating and weight behavior. Routine screening for eating disorders is critical and must be universal given the serious long-term consequences of these disorders.

Relationships of personality dimensions with impulsivity in alcohol-dependent inpatient men

BACKGROUND

Impulsivity is closely related to substance use and abuse, both as a contributor to use and as a consequence of use. Particular dimensions of temperament and character were reported to be associated with trait impulsivity in different populations.

AIM

The aim of the present study was to evaluate the relationship of personality dimensions with impulsivity among men with alcohol dependence. Also we wanted to control the effect of depression and anxiety symptoms on this relationship.

METHODS

Participants were consecutively admitted male alcohol-dependent inpatients (n = 94) and healthy controls (n = 63). Patients were investigated with the Barratt Impulsiveness Scale, version 11 (BIS-11), the Temperament and Character Inventory (TCI) and the Symptom Checklist-Revised (SCL-90-R).

RESULTS

Severity of impulsivity and dimensions of impulsivity were higher in alcohol-dependent inpatients than in healthy controls. Impulsivity was negatively correlated with reward dependence, persistence, self-directedness and cooperativeness, but positively correlated with novelty seeking, harm avoidance, depression and anxiety. Although high depression and temperament dimensions (high novelty seeking, harm avoidance and low reward dependence) predicted impulsivity, combinations of personality dimensions that predict dimensions of impulsivity differed.

CONCLUSIONS

RESULTS may suggest that together with depression when impulsivity is the problem, both dimensions of impulsivity and personality must be evaluated and the treatment should be shaped accordingly for alcohol-dependent inpatients.

Annual research review: The neurobehavioral development of multiple memory systems--implications for childhood and adolescent psychiatric disorders

Extensive evidence indicates that mammalian memory is organized into multiple brains systems, including a 'cognitive' memory system that depends on the hippocampus and a stimulus-response 'habit' memory system that depends on the dorsolateral striatum. Dorsal striatal-dependent habit memory may in part influence the development and expression of some human psychopathologies, particularly those characterized by strong habit-like behavioral features. The present review considers this hypothesis as it pertains to psychopathologies that typically emerge during childhood and adolescence. These disorders include Tourette syndrome, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, eating disorders, and autism spectrum disorders. Human and nonhuman animal research shows that the typical development of memory systems comprises the early maturation of striatal-dependent habit memory and the relatively late maturation of hippocampal-dependent cognitive memory. We speculate that the differing rates of development of these memory systems may in part contribute to the early emergence of habit-like symptoms in childhood and adolescence. In addition, abnormalities in hippocampal and striatal brain regions have been observed consistently in youth with these disorders, suggesting that the aberrant development of memory systems may also contribute to the emergence of habit-like symptoms as core pathological features of these illnesses. Considering these disorders within the context of multiple memory systems may help elucidate the pathogenesis of habit-like symptoms in childhood and adolescence, and lead to novel treatments that lessen the habit-like behavioral features of these disorders.

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.

The severity of ADHD and eating disorder symptoms: a correlational study

BACKGROUND

Attention deficit/hyperactivity disorders (ADHD) and eating disorders (ED) share several clinical features. Research on the association between ADHD and ED is still quite sparse and findings are ambiguous.

METHODS

Correlations between the severity of ADHD key features (Barratt Impulsiveness Scale, and Attention Deficit/Hyperactivity Disorder-Self-Rating questionnaire) and the severity of specific ED symptoms (Structured Interview for Anorexia and Bulimia Nervosa) were examined in 32 female patients diagnosed with ED.

RESULTS

Most correlations between the severity of ADHD features and the severity of ED symptoms were low (r<0.30) and did not reach statistical significance. The only exception was a statistically significant, but counterintuitive association between impulsivity and the avoidance of fattening food.

CONCLUSIONS

The findings in this small sample suggest a weak link between the severity of ADHD key features and the severity of single ED symptoms in female patients with ED. The role of ADHD features for the development, maintenance, and treatment of EDs seems to be intricate and requires further study.

Behavioral and cognitive impulsivity in obsessive-compulsive disorder and eating disorders

This study compared self-reported impulsivity and neurocognitively assessed response inhibition in obsessive-compulsive disorder (OCD), eating disorder (ED), and healthy control participants. Participants completed the Barratt Impulsiveness Scale (BIS-11), stop-signal reaction time task, and measures of OCD and ED symptomatology (Yale-Brown Obsessive-Compulsive Scale and Eating Disorders Examination-Questionnaire). Compared to controls, both clinical groups reported higher levels of impulsivity on the BIS-11 however; only the OCD demonstrated increased stop-signal reaction time. Heightened levels of self-reported impulsivity may reflect the experience of anxiety in both OCD and ED populations whereas a lack of inhibitory control may represent a specific behavioral deficit in OCD.

Personality traits in patients with juvenile myoclonic epilepsy

There is evidence of personality disorders in patients with juvenile myoclonic epilepsy (JME). To date, there have been no published quantitative studies on personality traits in JME. The aim of the work described here was to study a group of patients with JME and quantitatively measure personality traits. We evaluated 42 patients (mean age: 26.57 years, SD: 8.38) and 42 controls (mean age: 26.96, SD: 8.48) using a validated personality inventory, the Temperament and Character Inventory (TCI). We applied two scores, one for the Beck Depression Inventory and one for the State-Trait-Anxiety Inventory, as depression and anxiety may impact the performance of these patients on the TCI. We compared both groups on TCI scales using analysis of covariance with Beck Depression Inventory and State-Trait-Anxiety Inventory scores as covariates. Patients with JME obtained significantly higher scores on Novelty Seeking (P=0.001) and Harm Avoidance (P=0.002) and significantly lower scores on Self-Directedness (P=0.001). Patients with JME have a higher expression of impulsive personality traits that demand early recognition to avoid further consequences and facilitate social insertion, consequently avoiding future stigma.

Personality correlates of impulsivity in subjects with generalized anxiety disorders

BACKGROUND

As yet, the relation between personality traits and impulsiveness has not been investigated in subjects affected by generalized anxiety disorder (GAD).

METHOD

A sample of 79 subjects with a diagnosis of GAD has been assessed at intake with Clinical Global Impression (CGI), Barratt Impulsiveness Scale (BIS-11), and with Temperament and Character Inventory. Comorbidity with cluster A or B personality disorders was excluded.

RESULTS

A multiple linear regression has identified 3 variables as independent predictors of impulsiveness: novelty seeking (NS) and reward dependence (RD) as for temperament and self-directedness (SD) as for character. Predictor analysis of the 3 subscales of BIS-11 showed that a higher NS is a predictor of all 3 subscales of BIS-11, whereas a higher RD is a protective factor for the attentive impulsiveness, and a low SD is predictive of a greater nonplanned impulsiveness. The CGI severity index is directly related to motor impulsiveness.

DISCUSSION

Preliminary results showed that in subjects with GAD only the motor component of impulsivity seems directly related to clinical severity, whereas impulsiveness is predicted by higher levels of 2 temperamental dimensions that are influenced by dopamine and norepinephrine systems and by weakness of character.

CONCLUSION

Subjects with GAD showed an interesting variability in NS. Differences in levels of NS and of other temperament (RD) and character (SD) dimensions seem related to different degrees of behavioral inhibition and to a different impact of the cognitive components of impulsiveness. Clinical implications are discussed.