Personality subtypes in adolescents with eating disorders: validation of a classification approach

Borderline personality disorder traits in adolescents with anorexia nervosa

OBJECTIVE

To examine the correlation between eating disorder (ED) symptoms and borderline personality disorder (BPD) traits in a sample of adolescents with eating disorders.

METHOD

There were 168 participants (M_age  = 16.0 years; SD = 1.16) with a diagnosis of anorexia nervosa (AN) or Eating Disorder Not Otherwise Specified-AN type. Eating Disorder Examination (EDE) and the Borderline Personality Questionnaire (BPQ) were used to assess ED symptoms and BPD traits.

RESULTS

A total of 10 participants (6.6%) scored above the clinical cut-off for a likely diagnosis of BPD. A positive correlation was observed between BPQ total score and EDE global (r_s  = 0.64, p < .001). There were also positive correlations between the BPQ self-image and emptiness subscales and all EDE subscales. Similarly, the EDE eating concern subscale was correlated with all BPQ subscales.

DISCUSSION

Previous studies have demonstrated that some BPD traits (i.e., suicidality, impulsivity, anger) are co-morbid with ED but the link with other BPD traits has been poorly studied in adolescents and those with AN. These findings indicate that while the prevalence of BPD in adolescents with AN may be relatively low, ED symptom severity is closely related to severity of BPD traits, particularly identity disturbance and feelings of emptiness.

Suggestive Evidence for Causal Effect of Leptin Levels on Risk for Anorexia Nervosa: Results of a Mendelian Randomization Study

Genetic correlations suggest a coexisting genetic predisposition to both low leptin levels and risk for anorexia nervosa (AN). To investigate the causality and direction of these associations, we performed bidirectional two-sample Mendelian randomization (MR) analyses using data of the most recent genome-wide association study (GWAS) for AN and both a GWAS and an exome-wide-association-study (EWAS) for leptin levels. Most MR methods with genetic instruments from GWAS showed a causal effect of lower leptin levels on higher risk of AN (e.g. IVW b = -0.923, p = 1.5 × 10^-4). Because most patients with AN are female, we additionally performed analyses using leptin GWAS data of females only. Again, there was a significant effect of leptin levels on the risk of AN (e.g. IVW b = -0.826, p = 1.1 × 10^-04). MR with genetic instruments from EWAS showed no overall effect of leptin levels on the risk for AN. For the opposite direction, MR revealed no causal effect of AN on leptin levels. If our results are confirmed in extended GWAS data sets, a low endogenous leptin synthesis represents a risk factor for developing AN.

The Mediator Effect of Personality on the Relationship Between Symptomatic Impairment and Treatment Outcome in Eating Disorders

Features of personality disorders (PDs) have been found to explain meaningful variance in the onset, maintenance, and symptomatic presentation of eating disorders (EDs), and a co-occurent personality pathology is commonly associated with poorer response to ED treatment. The "pathoplasty model" of the relationship between personality and EDs implies that, once both conditions are established, they are likely to interact in ways that modify therapy outcome; however, to date, no studies have explored overall personality functioning, and especially PD clusters, as a mediator of treatment outcome. The present study aimed at conjointly exploring the associations between personality functioning and PDs, respectively, with pre-treatment ED symptomatic impairment and therapy outcome; and the mediating role of personality variables. At treatment onset, a sample of 107 women with ED problems were evaluated using both the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Shedler-Westen Assessment Procedure-200 (SWAP-200)-a clinician-rated procedure to dimensionally assess personality. Participants were also asked to complete self-report questionnaires on overall ED symptomatology, symptoms of binge eating and purging behaviors, and therapy outcome. The findings showed that, over and above the categorical ED diagnosis, the SWAP-200 healthy personality functioning score mediated the relationship between baseline ED symptom severity and therapy outcome, as well as the association between baseline bulimic symptoms and treatment outcome; furthermore, SWAP-200 Cluster B PD scores mediated the link between baseline binge eating and purging symptoms and therapy outcome, whereas scores in Clusters A and C showed no significant effects. The findings suggest that personality-based outcome research may improve treatment effectiveness in this difficult-to-treat population.

Personality as a predictor of symptomatic change in a residential treatment setting for anorexia nervosa and bulimia nervosa

PURPOSE

Although personality has been widely researched in patients with anorexia nervosa (AN) and bulimia nervosa (BN), the nature of this relationship has not yet been clearly articulated. The pathoplasty model theorizes that personality might shape symptomatic presentation and thus affect therapeutic outcomes, but more research is needed. The present study aimed at investigating the predictive value of a broad spectrum of personality traits in determining AN and BN treatment outcomes, considering both the statistical and clinical significance of the therapeutic change.

METHODS

Eighty-four female patients with AN and BN treated in a residential program were evaluated at treatment onset using the Shedler-Westen Assessment Procedure-200-a clinician-rated measure of personality disorders and healthy personality functioning. At both intake and discharge, patients completed the Eating Disorder Inventory-3 to assess eating symptoms and the Outcome Questionnaire-45.2 to evaluate overall impairment.

RESULTS

Considering overall ED symptomatic change, multiple regression analyses showed that, even when controlling for baseline symptoms and DSM-5 categories, schizoid (B = 0.41, p ≤ 0.01), avoidant (B = 0.31, p ≤ 0.05), and paranoid (B = 0.25, p ≤ 0.05) personality features predicted worse therapeutic outcomes. Similar results were found when applying the clinical significance approach, with the emotionally dysregulated factor as an additional negative predictor of significant/reliable change (B =  - 0.09; p < 0.01). Healthy personality functioning predicted better therapeutic outcomes (B =  - 0.34, p ≤ 0.001).

CONCLUSIONS

Pathoplastic models and personality-based research in this clinical population have the potential to inform effective treatment strategies by targeting relevant individual factors.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

The Risk of Substance Use Among Adolescents and Adults With Eating Disorders

Eating disorders (EDs) are negative eating habits that have harmful mental and physical effects. EDs primarily affect young women. Most cases are diagnosed in adolescence. The most common EDs are bulimia nervosa (BN), anorexia nervosa (AN), and binge eating disorder (BED). There is a strong association between EDs and substance use disorder (SUD) in adolescence. Bulimia nervosa and alcohol use disorder (AUD) are the most common co-occurrence. There is a high behavioral association between EDs and AUD. Alcohol consumption could be a primary trigger for binge eating in women with BN. Alcohol can be used as an appetite suppressor and as a compensatory behavior to avoid food.

The objective of this literature review was to explore the relation between EDs and SUD. The results of the study showed SUD is common with EDs. There are many reasons for this association such as shared neurobiological mechanisms, personality features, environmental and genetic factors. 

Personality Heterogeneity in Adolescents With Disruptive Behavior Disorders1

We first confirmed adolescents diagnosed with disruptive behavior disorders (oppositional defiant, conduct disorder; n = 158) had lower constraint and higher negative emotionality, and greater psychiatric comorbidity and psychosocial dysfunction, relative to adolescents without (n = 755), in a population-based sample enriched for externalizing psychopathology (mean age = 17.90 years; 52% female). We then explored whether different personality types, defined by patterns of personality identified via latent profile analysis, were differently associated with clinical features in adolescents with a disruptive behavior disorder diagnosis. Four distinct personality types ("disinhibited," "high distress," "low distress," "positive") were meaningfully different from one another. Results highlight personality heterogeneity as a means of identifying individuals at greatest risk for the most deleterious forms of externalizing psychopathology.

Pilot study of a personality-based approach to assessing eating disorder and Obsessive Compulsive Disorder symptom risk in college men and women

Objective: To conduct a pilot test of the validity of using empirically derived personality types to characterize eating disorder (ED) risk in college students and resolve discrepancies regarding the role of perfectionism and obsessive-compulsive disorder (OCD) symptoms.Participants: Man and woman undergraduate students (N = 169) at a small, private university. Data were collected from February to May 2016 and 2018. Methods: Participants completed self-report measures of personality (perfectionism, impulsivity, and effortful control) and psychopathology (EDs, OCD). Results: Our analyses replicated three validated personality types: overcontrolled, undercontrolled, and resilient. Analysis of variances demonstrated perfectionism, ED, and OCD symptoms were significantly elevated in the overcontrolled subtype. There was no interaction by sex. Conclusions: These findings suggest that personality types may be useful for classifying ED risk and OCD symptoms in college students across sexes. Further study and relevance to prevention and intervention efforts to reduce the burden of EDs on college campuses will be discussed.

Clinician Reactions When Working with Adolescent Patients: The Therapist Response Questionnaire for Adolescents

This study examined the factor structure and psychometric properties of the Therapist Response Questionnaire for Adolescents (TRQ-A), an 86-item clinician-report instrument measuring a wide range of thoughts, feelings, and behaviors expressed by therapists toward their adolescent patients. A sample of psychodynamic and cognitive-behavioral clinicians (N = 192) filled in the TRQ-A and the latest version of the Shedler-Westen Assessment Procedure for Adolescents (SWAP-II-A) in order to assess the personality styles/disorders of a randomly selected adolescent patient in their care. Factor analysis identified six conceptually coherent and internally consistent countertransference patterns: warm/attuned, angry/criticized, disorganized/frightened, overinvolved/worried, disengaged/hopeless, and sexualized. These patterns were significantly related to patients' personality styles/disorders in a clinically meaningful and systematically predictable manner. The results support the TRQ-A's validity and internal reliability in evaluating the complex portrait of multifaceted reactions that clinicians typically experience toward adolescent patients, and its potential to improve diagnostic accuracy and guide clinicians in planning effective therapeutic interventions. The TRQ-A promises to significantly contribute to this less explored research area and encourage systematic studies of youth treatment, promoting best practice for successful therapeutic outcomes.

The behavioral and affective profile of inpatient adolescent girls with restrictive anorexia nervosa

BACKGROUND

A better understanding of the individual difficulties reported by adolescents presenting with anorexia nervosa seems like an interesting avenue to refine our understanding of their psychological functioning.

OBJECTIVE

This study aimed to: (1) describe the behavioral and affective profile of difficulties of inpatient adolescent girls presenting a restricting type of anorexia (ANR); and (2) investigate the presence of a relationship between behavioral and affective problems and severity of the disorder.

METHODS

The sample consisted of 52 inpatient adolescent girls presenting an ANR. The youth self report assessed the behavioral and emotional profile of difficulties of participants while the Eating Disorder Risk Composite of the Eating Disorder Inventory measured the symptomatology of the disorder. A ratio between body mass index at admission and at the end of the treatment served as an indicator of weight gain.

RESULTS

The sample presented an internalized profile of problems. Individual differences were found and three profiles of difficulties were present in the sample: normative, pure internalizing and mixed (clinical on the internalizing and externalizing clusters).

CONCLUSION

This study provides information on the heterogeneity of this specific population otherwise quite similar and demonstrates how severity of the disorder can be associated with a wide range of other behavioral and affective difficulties.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Family profiles in eating disorders: family functioning and psychopathology

Research has studied family functioning in families of patients suffering from eating disorders (EDs), particularly investigating the associations between mothers’ and daughters’ psychopathological symptoms, but limited studies have examined whether there are specific maladaptive psychological profiles characterizing the family as a whole when it includes adolescents with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Through the collaboration of a network of public and private consultants, we recruited n=181 adolescents diagnosed for EDs (n=61 with AN, n=60 with BN, and n=60 with BEDs) and their parents. Mothers, fathers, and youths were assessed through a self-report measure evaluating family functioning, and adolescents completed a self-report questionnaire assessing psycho-pathological symptoms. Results showed specific family functioning and psychopathological profiles based on adolescents’ diagnosis. Regression analyses also showed that family functioning characterized by rigidity predicted higher psychopathological symptoms. Our study underlines the importance of involving all members of the family in assessment and intervention programs when adolescent offspring suffer from EDs.

Personality and Attachment in Transsexual Adults

The main aim of this study was to investigate the associations between personality features and attachment patterns in transsexual adults. We explored mental representations of attachment, assessed personality traits, and possible personality disorders. Forty-four individuals diagnosed with gender identity disorder (now gender dysphoria), 28 male-to-female and 16 female-to-male, were evaluated using the Shedler-Westen assessment procedure-200 (SWAP-200) to assess personality traits and disorders; the adult attachment interview was used to evaluate their attachment state-of-mind. With respect to attachment, our sample differed both from normative samples because of the high percentage of disorganized states of mind (50% of the sample), and from clinical samples for the conspicuous percentage of secure states of mind (37%). Furthermore, we found that only 16% of our sample presented a personality disorder, while 50% showed a high level of functioning according to the SWAP-200 scales. In order to find latent subgroups that shared personality characteristics, we performed a Q-factor analysis. Three personality clusters then emerged: Healthy Functioning (54% of the sample); Depressive/Introverted (32%) and Histrionic/Extroverted (14%). These data indicate that in terms of personality and attachment, GD individuals are a heterogeneous sample and show articulate and diverse types with regard to these constructs.

Empirically derived personality subtyping for predicting clinical symptoms and treatment response in bulimia nervosa

OBJECTIVE

Evidence suggests that eating disorder subtypes reflecting under-controlled, over-controlled, and low psychopathology personality traits constitute reliable phenotypes that differentiate treatment response. This study is the first to use statistical analyses to identify these subtypes within treatment-seeking individuals with bulimia nervosa (BN) and to use these statistically derived clusters to predict clinical outcomes.

METHODS

Using variables from the Dimensional Assessment of Personality Pathology-Basic Questionnaire, K-means cluster analyses identified under-controlled, over-controlled, and low psychopathology subtypes within BN patients (n = 80) enrolled in a treatment trial. Generalized linear models examined the impact of personality subtypes on Eating Disorder Examination global score, binge eating frequency, and purging frequency cross-sectionally at baseline and longitudinally at end of treatment (EOT) and follow-up. In the longitudinal models, secondary analyses were conducted to examine personality subtype as a potential moderator of response to Cognitive Behavioral Therapy-Enhanced (CBT-E) or Integrative Cognitive-Affective Therapy for BN (ICAT-BN).

RESULTS

There were no baseline clinical differences between groups. In the longitudinal models, personality subtype predicted binge eating (p = 0.03) and purging (p = 0.01) frequency at EOT and binge eating frequency at follow-up (p = 0.045). The over-controlled group demonstrated the best outcomes on these variables. In secondary analyses, there was a treatment by subtype interaction for purging at follow-up (p = 0.04), which indicated a superiority of CBT-E over ICAT-BN for reducing purging among the over-controlled group.

DISCUSSION

Empirically derived personality subtyping appears to be a valid classification system with potential to guide eating disorder treatment decisions. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:506-514).

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.

Nothing Tastes as Good as Thin Feels: Low Positive Emotion Differentiation and Weight Loss Activities in Anorexia Nervosa

Positive emotion (PE) has not been well studied in anorexia nervosa. Low positive emotion differentiation (PED), which involves a diminished ability to distinguish between discrete positive emotions, may contribute to positive emotion dysregulation in anorexia. Specifically, low PED may interact with elevated PE intensity to both motivate and reinforce weight loss and evaluation behaviors. Using ecological momentary assessment, we examined PE and weight loss behaviors reported over two weeks. As hypothesized, low PED predicted more vomiting, laxative-use, exercising, weighing, checking for fat, and restricting. Furthermore, those with low PED who experienced elevated average PE intensity reported even more frequent behaviors. Within-person analyses indicated that, for those with low PED, more weight loss behaviors at one recording predicted elevated PE at the subsequent recording. Similarly, for those with low PED higher momentary PE predicted more subsequent weight loss behaviors. Thus, low PED in anorexia may reinforce and motivate weight loss behavior.

Genetic and environmental factors underlying comorbid bulimic behaviours and alcohol use disorders: a moderating role for the dysregulated personality cluster?

Women with bulimia nervosa (BN) frequently have co-occurring alcohol use disorders (AUDs). Studies of shared genetic transmission of these disorders have been mixed. Personality heterogeneity among individuals with BN may explain discrepant findings. Cluster analysis has characterized women with BN in groups on the basis of personality profiles. One group, the Dysregulated cluster, characterized largely by behavioural disinhibition and emotional dysregulation may be more closely linked etiologically to AUDs. This study examined whether genetic associations between BN and AUDs are the strongest among the Dysregulated cluster. Symptoms of BN and AUDs were assessed in female twins at ages 17 and 25 years from the Minnesota Twin Family Study. Personality clusters were defined using the Multidimensional Personality Questionnaire. Twin moderation models suggested small-to-moderate common genetic transmission between BN and AUDs. However, shared genetic effects did not differ by personality cluster. Findings suggest that personality clusters are unlikely to account for inconsistent findings regarding their shared aetiology.

Personality disorder cognitions in the eating disorders

Patients with eating disorder have relatively high rates of comorbid personality disorder diagnoses, including both anxiety-based personality disorders (obsessive-compulsive and avoidant) and borderline personality disorder. However, there is preliminary evidence that the core cognitions underlying personality pathology in the eating disorders are those related specifically to anxiety. This article builds on that evidence, replicating and extending the findings with a large sample of patients with eating disorder (N = 374). There were no differences in personality disorder cognitions between eating disorder diagnoses. This study also examines the possibility that there are clusters of patients, differentiated by patterns of personality disorder cognition. Affect-related personality disorder cognitions were key to understanding the role of personality pathology in the eating disorders. It is suggested that those cognitions should be considered when planning psychological treatments.

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.

Too strict or too loose? Perfectionism and impulsivity: the relation with eating disorder symptoms using a person-centered approach

Although both perfectionism (i.e. personal standards perfectionism and evaluative concerns perfectionism) and impulsivity have been shown to be implicated in eating disorders, no previous studies have examined the interplay between both personality dimensions in their association with eating disorder symptoms. This is the first study to investigate the relationship between empirically derived personality subtypes based on perfectionism and impulsivity and eating disorder symptoms (i.e., dietary restraint, and concerns over eating, weight and shape). Cluster analysis was used to establish naturally occurring combinations of perfectionism and impulsivity in adolescent boys and girls (N=460; M age=14.2 years, SD=.90). Evidence was obtained for four personality profiles: (1) a resilient subtype (low on perfectionism and impulsivity), (2) pure impulsivity subtype (high on impulsivity only), (3) pure perfectionism subtype (high on perfectionism only), and (4) combined perfectionism/impulsivity subtype (high on both perfectionism and impulsivity). Participants in these four clusters showed differences in terms of eating disorder symptoms in that participants with a combination of high perfectionism and high impulsivity (rather than the presence of one of these two characteristics alone) had the highest levels of ED symptoms. These findings shed new light on extant theories concerning ED.

Prevalence and severity of categorical and dimensional personality disorders in adolescents with eating disorders

OBJECTIVE

The objective of this study is to explore and compare the prevalence of categorical and dimensional personality disorders (PDs) and their severity in Spanish adolescents with Eating Disorders (EDs).

METHOD

Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and International Classification of Diseases, Tenth Revision-10 modules of the International Personality Disorder Examination were administered to a sample of 100 female adolescents with EDs (mean age=15.8 years, SD=0.9).

RESULTS

'Thirty-three per cent of the sample had at least one PD, in most cases a simple PD. The rate of PDs was 64-76% in bulimia patients, 22-28% in anorexia and 25% in EDs not otherwise specified. The highest dimensional scores were observed in bulimia, [corrected] mainly in borderline and histrionic PDs, and higher scores for anankastic PD in anorexia than in the other ED diagnoses. Overall, purging type EDs had higher cluster B personality pathology scores than restrictive type.' [corrected] The Publisher would like to apologize for this error and any confusion it may have caused. [corrected].

DISCUSSION

Adolescent female patients with ED have a risk of presenting a comorbid PD, especially patients with bulimia and purging type EDs.

A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders

INTRODUCTION

Research has shown that eating disorder (ED) patients who abuse substances demonstrate worse ED symptomatology and poorer outcomes than those with EDs alone, including increased general medical complications and psychopathology, longer recovery times, poorer functional outcomes and higher relapse rates. This article provides a broad overview of the prevalence, aetiology, assessment and management of co-morbid EDs and substance use disorders (SUDs).

REVIEW

The co-occurrence of EDs and SUDs is high. The functional relationship between EDs and SUDs vary within and across ED subtypes, depends on the class of substance, and needs to be carefully assessed for each patient. Substances such as caffeine, tobacco, insulin, thyroid medications, stimulants or over the counter medications (laxatives, diuretics) may be used to aid weight loss and/or provide energy, and alcohol or psychoactive substances could be used for emotional regulation or as part of a pattern of impulsive behaviour. A key message conveyed in the current literature is the importance of screening and assessment for co-morbid SUDs and EDs in patients presenting with either disorder. There is a paucity of treatment studies on the management of co-occurring EDs and SUDs. Overall, the literature indicates that the ED and SUD should be addressed simultaneously using a multi-disciplinary approach. The need for medical stabilization, hospitalization or inpatient treatment needs to be assessed based on general medical and psychiatric considerations. Common features across therapeutic interventions include psycho-education about the aetiological commonalities, risks and sequelae of concurrent ED behaviours and substance abuse, dietary education and planning, cognitive challenging of eating disordered attitudes and beliefs, building of skills and coping mechanisms, addressing obstacles to improvement and the prevention of relapse. Emphasis should be placed on building a collaborative therapeutic relationship and avoiding power struggles. Cognitive behavioural therapy has been frequently used in the treatment of co-morbid EDs and SUDs, however there are no randomized controlled trials. More recently evidence has been found for the efficacy of dialectical behavioural therapy in reducing both ED and substance use behaviours.

CONCLUSION

Future research would benefit from a meta-analysis of the current research in order to better understand the relationships between these two commonly co-occurring disorders.

Sintomas internalizantes na adolescência e as relações familiares: uma revisão sistemática da literatura

Este artigo teve como objetivo realizar uma revisão sistemática de literatura, nacional e internacional, no período de 2005 a 2010, sobre os sintomas internalizantes na adolescência e as relações familiares. Inicialmente, foi realizado um levantamento dos artigos indexados nas bases de dados Academic Search Premier, Education Resources Information Center (ERIC), ISI Web of Knowledge, Lilacs, MEDLINEwith Full Text e SciELO (Scientific Electronic Library Online), utilizando-se os descritores, em português, "problemas internalizantes" ou "sintomas internalizantes" e "adolescência ou adolescente ou jovem" e "família"; e, em inglês, "internalizing problems or internalizing symptoms" and "adolescence or adolescent or teenager" and "family". Os artigos foram classificados de acordo com o ano de publicação, o país, a metodologia, o instrumento de mensuração para comportamentos internalizantes e, ainda, quanto à temática principal. Na literatura internacional, constatou-se um predomínio de estudos empíricos e de caráter quantitativo, realizados preponderantemente pelos Estados Unidos. No Brasil, observou-se uma grande escassez de estudos integrando as temáticas da sintomatologia internalizante na adolescência e as relações familiares. Foram encontrados somente dois artigos, o que indica a necessidade de realização de mais pesquisas nesta área em nosso país.

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.

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.

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.

Out of control? Inhibition processes in eating disorders from a personality and cognitive perspective

OBJECTIVE

The present study examined the role of "a breakdown in inhibition" as a mechanism to explain differences in impulsivity between restrictive and bingeing/purging eating disorders (ED). Two types of inhibition (i.e., executive and reactive inhibition) were assessed by means of personality and neuropsychological tests.

METHOD

Forty-eight female in patients with ED completed the Effortful Control Scale, the BISBAS scales, and a set of neuropsychological tests.

RESULTS

The results showed that executive inhibition measures were able to differentiate restrictive from bingeing/purging ED subtypes. Patients with ED and bingeing/purging behavior scored significantly lower on the Effortful Control Scale, needed more time to finish the Trail Making Test/STROOP, and showed more reaction time variability on the Go No-Go task. We did not find significant associations between personality and neuropsychological measures of executive/reactive inhibition.

DISCUSSION

Insight in the breakdown of inhibition in bingeing/purging patients can increase our understanding of impulse-control disorders and guide the development of tools to improve effortful control.

Personality subtypes of adolescents who attempt suicide

Research suggests that personality pathology is shared among a considerable portion of adolescents presenting suicidal behavior. Furthermore, heterogeneity of personality within this population suggests a need to tease apart different types of attempters. The goal of this study was to identify the personality subtypes of adolescents who attempt suicide. We analyzed data on 266 adolescents, ages 13 to 18 years, with a history of at least one suicide attempt who were selected by treating clinicians for having at least some degree of personality problems. We used a Q-factor analysis to identify subtypes based on the Shedler-Westen Assessment Procedure-II for Adolescents (a 200-item measure of personality pathology used by clinically experienced observers). We derived six subtypes: Externalizing, Internalizing, Emotionally dysregulated, High functioning, Narcissistic, and Immature. The subtypes differed on measures of adaptive functioning, axis I and II pathology, and etiology. Adolescents who attempt suicide constitute a heterogeneous group, and they vary meaningfully on a measure of personality pathology. Interventions targeting suicidal behaviors in adolescents should consider individual differences.

Eating disorder symptoms and borderline personality symptomatology

According to the empirical literature, there are high rates of borderline personality disorder (BPD) among individuals with formal diagnoses of eating disorders, and high rates of eating disorders among individuals with BPD. In this study, we examined relationships between three eating disorder symptoms (i.e., binge eating, starving oneself, abusing laxatives) and borderline personality symptomatology according to two self-report measures (the borderline personality scale of the Personality Diagnostic Questionnaire-4 and the Self- Harm Inventory) in a sample of psychiatric inpatients (N=126) and in a sample of internal medicine outpatients (N=419). Each individual eating disorder item, as well as a composite score of all three items, demonstrated statistically significant correlations with both measures of borderline personality symptomatology in both samples. In addition, endorsement of all three symptoms was invariably associated with borderline personality symptomatology on both measures. Specific eating disorder symptoms, alone, may predict for borderline personality symptomatology.

Emotion dysregulation and negative affect: association with psychiatric symptoms

OBJECTIVE

A growing body of research focuses on the development and correlates of emotion dysregulation, or deficits in the ability to regulate intense and shifting emotional states. Current models of psychopathology have incorporated the construct of emotion dysregulation, suggesting its unique and interactive contributions, along with childhood disruptive experiences and negative affect, in producing symptomatic distress. Some researchers have suggested that emotion dysregulation is simply a variant of high negative affect. The aim of this study was to assess the construct and incremental validity of self-reported emotion dysregulation over and above childhood trauma and negative affect in predicting a range of psychopathology.

METHOD

Five hundred thirty individuals aged 18 to 77 years (62% female) were recruited from the waiting areas of the general medical and obstetric/gynecologic clinics in an urban public hospital in Atlanta, Georgia. Participants completed a battery of self-report measures obtained by interview, including the Childhood Trauma Questionnaire, the Positive and Negative Affect Schedule, and the Emotion Dysregulation Scale. Regression analyses examined the unique and incremental associations of these self-report measurements of childhood traumatic experiences, negative affect, and emotion dysregulation with concurrent structured interview-based measurements of psychiatric distress and history of self-destructive behaviors. These measures included the Clinician-Administered PTSD Scale, the Alcohol Use Disorders Identification Test, the Short Drug Abuse Screening Test, the Beck Depression Inventory, and the Global Adaptive Functioning Scale from the Longitudinal Interval Follow-Up Evaluation. The presented data were collected between 2005 and 2009.

RESULTS

Regression models including age, gender, childhood trauma, negative affect, and emotion dysregulation were significantly (P ≤ .001) associated with each of the study's criterion variables, accounting for large portions of the variance in posttraumatic stress symptoms (R² = 0.21), alcohol and drug abuse (R² = 0.28 and 0.21, respectively), depression (R² = 0.55), adaptive functioning (R² = 0.14), and suicide history (omnibus χ² = 74.80, P < .001). Emotion dysregulation added statistically significant (P < .01) incremental validity to each regression model (β = 0.25, 0.34, 0.35, 0.34, and -0.18, and Wald = 24.43, respectively).

CONCLUSIONS

Results support the conceptualization of emotion dysregulation as a distinct and clinically meaningful construct associated with psychiatric distress that is not reducible to negative affect. Emotion dysregulation is a key component in a range of psychiatric symptoms and disorders and a core target for psychopharmacologic and psychosocial treatment interventions.

Eating disorders and major depression: role of anger and personality

This study aimed to evaluate comorbidity for MD in a large ED sample and both personality and anger as clinical characteristics of patients with ED and MD. We assessed 838 ED patients with psychiatric evaluations and psychometric questionnaires: Temperament and Character Inventory, Eating Disorder Inventory-2, Beck Depression Inventory, and State-Trait Anger Expression Inventory. 19.5% of ED patients were found to suffer from comorbid MD and 48.7% reported clinically significant depressive symptomatology: patients with Anorexia Binge-Purging and Bulimia Nervosa were more likely to be diagnosed with MD. Irritable mood was found in the 73% of patients with MD. High Harm Avoidance (HA) and low Self-Directedness (SD) predicted MD independently of severity of the ED symptomatology, several clinical variables, and ED diagnosis. Assessing both personality and depressive symptoms could be useful to provide effective treatments. Longitudinal studies are needed to investigate the pathogenetic role of HA and SD for ED and MD.

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.

Adolescent eating disorders: treatment and response in a naturalistic study

This naturalistic study investigated the treatment and outcome of adolescents with eating disorders (EDs) in the community. Clinicians from a practice-research network provided data on ED symptoms, global functioning, comorbidity, treatment, and outcome for 120 adolescents with EDs. ED "not otherwise specified" was the most common ED diagnosed. After an average of 8 months of treatment, about one third of patients had recovered, with patients with anorexia nervosa showing the most improvement. Clinicians utilized a range of psychotherapy interventions and two thirds of the patients had received adjunct psychoactive medication. Although CBT showed the strongest association with outcome in a subsample characterized by poor relational/personality functioning, dynamic therapy was associated with better global outcome in the overall sample.

Personality and temperament

The assessment of personality and temperament in the context of eating disorders (EDs) poses unique challenges because of the physiological symptoms and sequelae of these illnesses. Four models of the relationship between personality and EDs are presented, along with a discussion of the different methodological designs which can evaluate these models. Current data support the likelihood that neuroticism and perfectionism are risk factors for EDs. Perfectionism and the related obsessive-compulsive personality disorder may also share a common cause with anorexia nervosa. High harm avoidance and low self-directedness also characterize all EDs, though more data are needed to confirm their role as risk factors; importantly however, this combination of traits may diminish one's ability to cope with stressful life events. At the other end of the spectrum, considering impulsivity multidimensionally may be important to understanding the role of this personality trait in EDs, though existing data do not yet allow for conclusions regarding its role as a risk factor versus a consequence of the ED. All of the identified traits that may be risk factors are also exacerbated as a consequence of having, or having had, an ED. Finally, the role of personality disorders in influencing the course and outcome of EDs is still unclear. A fruitful avenue for future research in this area is to utilize personality and temperament to classify individuals in a way that allows for the best chance of identifying genetic loci that confer increased risk for EDs.

Personality subtypes of suicidal adults

Research into personality factors related to suicidality suggests substantial variability among suicide attempters. A potentially useful approach that accounts for this complexity is personality subtyping. As part of a large sample looking at personality pathology, this study used Q-factor analysis to identify subtypes of 311 adult suicide attempters using Shedler-Westen Assessment Procedure-II personality profiles. Identified subtypes included internalizing, emotionally dysregulated, dependent, hostile-isolated, psychopathic, and anxious somatizing. Subtypes differed in hypothesized ways on criterion variables that address their construct validity, including adaptive functioning, Axis I and II comorbidity, and etiology-related variables (e.g., history of abuse). Furthermore, dimensional ratings of the subtypes predicted adaptive functioning above DSM-based diagnoses and symptoms.

Countertransference reactions to adolescents with eating disorders: relationships to clinician and patient factors

OBJECTIVE

Clinical report suggests that therapists have strong and sometimes difficult-to-manage reactions to patients with eating disorders (EDs); however, systematic research is largely absent. The purpose of this study was to explore the emotional responses, or countertransference (CT) reactions, clinicians experience when working with patients with EDs, and to identify clinician, patient, and therapy variables associated with these responses.

METHOD

One hundred twenty clinicians reported on multiple variables related to an adolescent female patient they were treating for an ED.

RESULTS

Six patterns of reactions were identified: angry/frustrated, warm/competent, aggressive/sexual, failing/incompetent, bored/angry at parents and overinvested/worried feelings. The factors showed meaningful relationships across clinician demographics, patient characteristics, and treatment techniques.

DISCUSSION

Overall, clinician's reactions were most frequently associated with the clinician's gender, patient's level of functioning and improvement during treatment, and patient personality style. These issues have important implications for treatment, training and supervision.

Impulsivity and personality variables in adolescents with eating disorders

Impulsivity among individuals with eating disorders (EDs) is associated with severe comorbidities and poor treatment outcome. However, research investigating the construct of impulsivity in EDs is limited. The objectives of the present study were to characterize multiple dimensions of impulsivity in adolescents with EDs; determine if differences in impulsivity were associated with ED diagnosis and/or broader personality traits; and explore the relationship between impulsivity and etiologically significant variables. Experienced clinicians from a practice-research network provided data on ED symptoms, impulsive characteristics, personality pathology, The Diagnostic and Statistical Manual of Mental Disorders comorbidity, and family and developmental history for 120 adolescent patients with EDs. Three distinct types of impulsivity were identified: general, acting out, and aggressive/destructive. The impulsivity types showed specific relationships to ED diagnosis, broader personality factors, individual histories of adverse (traumatic) events, and family histories of externalizing disorders, supporting the importance of taking, assessing, and addressing impulsivity in ED research and treatment.

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.