Dropout from brief psychotherapy within a combination treatment in bulimia nervosa: role of personality and anger

The Impact of High Levels of Compensatory Exercise on Treatment Outcomes in Threshold and Subthreshold Bulimia Nervosa

Bulimia nervosa (BN) and other specific feeding or eating disorders with subthreshold BN symptoms (OSFED-BN) are characterized by recurrent binge eating episodes accompanied by compensatory behaviors, including excessive exercise. We aimed to examine the role of compensatory exercise on several clinical disorder-related variables and the treatment outcomes. The sample included 478 patients diagnosed with either BN or OSFED-BN admitted for a 16-week eating disorder-specific treatment program. A battery of questionnaires was administered to evaluate eating and general psychopathology, and personality traits. Other clinical disorder-related data, including levels of compensatory exercise, were assessed through a semi-structured clinical interview. Between-group comparisons of compensatory exercise levels were analyzed, as a predictive model of risk of poor treatment outcomes. Path analysis was conducted using structural equation models to estimate the direct and indirect effects between the main variables. Higher levels of self-reported compensatory exercise were associated with greater eating psychopathology, general psychopathology, and more dysfunctional personality traits and were a predictor of poor treatment outcomes. Additionally, these levels achieved a mediating role in several paths contributing to a higher likelihood of a poor outcome. Further research is required to determine how psychotherapeutic approaches can be optimized to adequately include adaptive exercise for these patients.

Using classification trees to identify psychotherapy patients at risk for poor treatment adherence

To determine the relative importance of a wide variety of personality and psychopathology variables in influencing patients' adherence to psychotherapy treatment.

Two classification trees were trained to predict patients' (1) treatment utilization (i.e., their likelihood of missing a given appointment) and (2) termination status (i.e., their likelihood of dropping out of therapy prematurely). Each tree was then validated in an external dataset to examine performance accuracy.

Patients' social detachment was most influential in predicting their treatment utilization, followed by affective instability and activity/energy levels. Patients' interpersonal warmth was most influential in predicting their termination status, followed by levels of disordered thought and resentment. The overall accuracy rating for the tree for termination status was 71.4%, while the tree for treatment utilization had a 38.7% accuracy rating.

Classification trees are a practical tool for clinicians to determine patients at risk of premature termination. More research is needed to develop trees that predict treatment utilization with high accuracy across different types of patients and settings.

Impact of Impulsivity and Therapy Response in Eating Disorders from a Neurophysiological, Personality and Cognitive Perspective

Impulsivity, as a multidimensional construct, has been linked to eating disorders (EDs) and may negatively impact treatment response. The study aimed to identify the dimensions of impulsivity predicting poor remission of ED symptoms. A total of 37 ED patients underwent a baseline assessment of impulsive personality traits and inhibitory control, including the Stroop task and the emotional go/no-go task with event-related potentials (ERPs) analysis. The remission of EDs symptomatology was evaluated after 3 months of cognitive-behavioral therapy (CBT) and at a 2-year follow-up. Poor remission after CBT was predicted by poor inhibitory control, as measured by the Stroop task. At 2 years, the risk of poor remission was higher in patients with higher novelty seeking, lower inhibitory control in the Stroop and in ERPs indices (N2 amplitudes) during the emotional go/no-go task. The present results highlight inhibitory control negatively impacting both short- and long-term symptomatology remission in ED patients. On the other hand, high novelty seeking and ERPs indices of poor inhibition seem to be more specifically related to long-term remission. Therefore, a comprehensive assessment of the impulsivity dimension in patients with ED is recommended to tailor treatments and improve their efficacy.

Using network analysis to explore the association between eating disorders symptoms and aggressiveness in Bulimia nervosa

Aggressive behaviors have been reported to be more frequent in people with eating disorders (ED), especially bulimia nervosa (BN). Network Analysis (NA) is particularly useful or examining the interactions among symptoms of comorbid conditions through the identification of "bridge symptoms," defined as those symptoms playing a key role in the connection between two syndromic clusters. The aim of the present study was to investigate the association of ED core symptoms and ED-related psychopathology with aggressiveness in a clinical sample of women with BN through NA. Two hundred and seventy-nine women with BN completed the Eating Disorder Inventory-2 and the Buss-Durkee Hostility Inventory. A NA was conducted, including ED symptoms and aggressiveness measures. The bridge function was implied to identify symptoms bridging ED symptoms and aggressiveness. The most connected nodes among communities were asceticism and impulsivity from ED-related psychopathology, drive for thinness from ED-core psychopathology and guilt and suspicion from aggressiveness domain. In particular, drive for thinness connected ED-core community to verbal hostility, while impulsivity connected ED-related symptoms to guilt and suspicion of aggressiveness community. In conclusion the present study showed that in people with BN guilt is the specific negative emotion of the hostile dimensions that may be bidirectionally associated with ED symptoms.

Hunger games: Associations between core eating disorder symptoms and responses to rejection by peers during competition

OBJECTIVE

Individuals with eating disorder (ED) symptoms are sensitive to social threat and report maladaptive interpersonal styles that may contribute to and exacerbate negative evaluation from others. Research in this area has relied primarily on self-report. The current study examined associations between behavioral responses to social threat and core ED symptoms using a behavioral paradigm. Based on previous findings that individuals with binge-eating report being more reactive and confrontational, whereas individuals with dietary restriction tend to be more submissive and avoidant of conflict, we hypothesized that binge eating would be associated with a greater tendency to retaliate against rejection perpetrators, whereas dietary restriction would be associated with a lower tendency to retaliate when rejected.

METHOD

Undergraduate women (N = 132) completed a self-report measure of ED symptoms and participated in an online "Survivor"-type game in which they voted to either accept or reject computerized coplayers, while also receiving acceptance or rejection feedback from others.

RESULTS

Neither ED symptom was associated with how often participants retaliated against coplayers who rejected them. However, dietary restriction was related to more rejection votes overall (i.e., the tendency to reject others regardless of how others voted).

DISCUSSION

Findings suggest that individuals with dietary restriction may rely on a maladaptive defensive strategy aimed at pre-empting rejection, or alternatively, have difficulty shifting from habitual self-isolating behavior that results from over-involvement with restricting symptoms. Interventions targeting hypersensitivity to social threat or interpersonal flexibility may help reduce interpersonal stress and mitigate its impact on restricting symptoms.

Naturalistic follow-up of subjects affected with anorexia nervosa 8 years after multimodal treatment: Personality and psychopathology changes and predictors of outcome

Background:

Eating disorders (EDs) are serious mental illnesses of growing clinical and social impact. Despite their severity, there is still no satisfactory evidence-based treatment. Follow-up investigations are the most reliable studies to enlighten long-term outcome predictors and modifiers.

Methods:

In total, 59 subjects affected with anorexia nervosa were assessed 8 years after their admission into an outpatient multimodal treatment program for eating disorders. The follow-up changes in diagnostic criteria were compared with Chi-square test. Improved and not-improved subjects were compared. Clinical, personality and psychopathology features between T0 and T1 were compared with t-test for repeated measures. Correlation between T0 features and changes at T1 in personality and psychopathology features were assessed.

Results:

The rate of complete remission was 42%, an overall rate of 67.8% improved, a rate of 18.6% worsened. Concerning personality, a significant decrease of harm avoidance and increase in self-directedness were evidenced. Interoceptive awareness, drive for thinness, bulimia were significantly reduced at follow-up. Many T0 personality facets were related to personality and psychopathology improvement at follow-up.

Conclusion:

Multimodal treatment encompassing psychiatric, nutritional and psychological approaches is at the moment the most reliable approach for the treatment of moderate to severe anorexia nervosa with a discrete rate of improvement. Some personality and psychopathology characteristics may represent specific factors which favor resistance and impair improvement. Future approaches should consider the personalization of therapeutic approach according to these features.

Characteristics of patients in an eating disorder sample who dropped out: 2-year follow-up

OBJECTIVE

This manuscript explores the characteristics of individuals diagnosed with an eating disorder who dropped out of treatment, compared with those who completed it.

METHOD

The participants were 196 patients diagnosed with eating disorders (according to DSM-IV-TR criteria) who consecutively began treatment for the first time in an eating disorders unit. They were assessed at baseline with a set of questionnaires evaluating eating habits, temperament, and general psychopathology. During the follow-up period, patients who dropped out were re-assessed via a telephone interview.

RESULTS

In the course of a 2-year follow-up, a total of 80 (40.8%) patients were labeled as dropouts, and 116 (59.2%) remaining subjects were considered completers. High TCI scores in the character dimensions of Disorderliness (NS4) (p < .01) and total Novelty Seeking (NST), along with low scores in Dependency (RD4), were significantly associated with dropout in the course of 2 years. Once the results were submitted to logistic regression analysis, dropout only remained associated with high scores in Disorderliness (NS4) and, inversely, with an initial Anorexia Nervosa (AN) diagnosis (p < .05). Reasons for dropout stated by the patients included logistic difficulties, subjective improvement of their condition, and lack of motivation.

DISCUSSION

Clinicians should handle the first therapeutic intervention with particular care in order to enhance their understanding of clients and their ability to rapidly identify those who are at risk of dropping out of treatment.

LEVEL OF EVIDENCE

Level III: Cohort Study.

DSM-5 severity specifiers for anorexia nervosa and treatment outcomes in adult females

OBJECTIVE

The aim of this study was to evaluate treatment outcomes across the BMI (body mass index)-based DSM-5 severity specifiers in a sample of adult females with anorexia nervosa (AN) treated with enhanced cognitive behavioural therapy (CBT-E).

METHOD

One hundred and twenty-eight participants with AN (64 outpatients and 64 inpatients) were sub-categorised using DSM-5 severity specifiers and compared by baseline clinical characteristics and treatment outcomes at the end of treatment and at 6- and 12-month follow-ups.

RESULTS

No significant differences were found across the four severity groups for 'weight recovery' (i.e., BMI ≥ 18.5 kg/m²) or 'good outcome' (i.e., BMI ≥ 18.5 kg/m² and minimal accompanying eating disorder psychopathology).

DISCUSSION

Our data suggest that the DSM-5 severity specifiers for anorexia nervosa may have limited clinical utility in predicting treatment outcomes of CBT-E.

Intermittent explosive disorder and eating disorders: Analysis of national comorbidity and research samples

OBJECTIVE

Clinical studies suggest comorbidity between eating disorders and aggressive behaviors. This study examined the pattern of comorbidity between intermittent explosive disorder (IED) and eating disorders (ED).

METHODS

Data were analyzed from both the adult and adolescent samples of the National Comorbidity Survey-Replication (n = 19,430) and a clinical research sample (n = 1,642).

RESULTS

Lifetime prevalence of Any ED was elevated in IED vs. non-IED for both the community and clinical research samples. Though anorexia nervosa displayed no relationship with IED in either sample, bulimia nervosa was associated with IED in the community sample and binge eating disorder was associated with IED in both the community and clinical research samples. Onset of IED preceded onset of Any ED in at least 70% of comorbid IED/ED cases in both community and clinical research samples. Associations of IED with Any ED and bulimia nervosa in the community sample, and associations of IED with binge eating disorder in the clinical research sample, remained significant after controlling for other psychiatric disorders.

CONCLUSIONS

Individuals with IED are more likely to report lifetime prevalence of ED, particularly bulimic spectrum disorders. This finding, and the observation that the onset of IED occurs prior to the onset of ED in the majority of individuals, suggests that longitudinal studies are needed to clarify this relationship and determine whether IED is a risk factor for the development of ED. Early identification of individuals with IED or impulsive aggression may provide clinically useful information to determine most effective treatment interventions.

Predicting Dropout from Intensive Outpatient Cognitive Behavioural Therapy for Binge Eating Disorder Using Pre-treatment Characteristics: A Naturalistic Study

BACKGROUND

Dropout rates in binge eating disorder (BED) treatment are high (17-30%), and predictors of dropout are unknown.

METHOD

Participants were 376 patients following an intensive outpatient cognitive behavioural therapy programme for BED, 82 of whom (21.8%) dropped out of treatment. An exploratory logistic regression was performed using eating disorder variables, general psychopathology, personality and demographics to identify predictors of dropout.

RESULTS

Binge eating pathology, preoccupations with eating, shape and weight, social adjustment, agreeableness, and social embedding appeared to be significant predictors of dropout. Also, education showed an association to dropout.

DISCUSSION

This is one of the first studies investigating pre-treatment predictors for dropout in BED treatment. The total explained variance of the prediction model was low, yet the model correctly classified 80.6% of cases, which is comparable to other dropout studies in eating disorders. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Can an intervention based on a serious videogame prior to cognitive behavioral therapy be helpful in bulimia nervosa? A clinical case study

BACKGROUND

Several studies have highlighted the implications of impulsivity and novelty seeking for both the maintenance and the process of recovery from bulimia nervosa (BN). Cognitive behavioral therapy (CBT) is the treatment of choice for BN, but for some cases, this treatment alone might not be sufficient for reducing the high levels of impulsivity. The paper presents a case report of a patient with BN, examining the effectiveness of using a videogame (VG; Playmancer) as an additional intervention designed to address impulsivity.

DESIGN

Psychometric and neuropsychological measures were collected at baseline. After this assessment, Playmancer was applied prior to CBT, following an "A-B-A-C-A" single case experimental design. Impulsivity levels were assessed with the Conner's Continuous Performance Test II (CPT-II). After the Playmancer treatment, the patient started CBT, and the levels of impulsivity were recorded again. Finally, psychometric and neuropsychological measures were collected after treatment. Weekly frequency of binges and vomiting were also recorded during the entire procedure.

RESULTS

After the VG intervention, psychometric measures such as anxiety levels, impulsivity and novelty seeking decreased. Regarding the neuropsychological measures, impulsivity levels (measured with the CPT-II) progressively decreased throughout the intervention, and an improvement in decision making capacities was observed. Furthermore, the frequency of binges also decreased during and after the VG intervention.

DISCUSSION

This case report suggests that using the Playmancer VG to reduce impulsivity prior to CBT may enhance the final results of the treatment for BN.

The effects of aggression on symptom severity and treatment response in a trial of cognitive behavioral therapy for panic disorder

BACKGROUND

Previous research suggests that patients with panic disorder exhibit higher levels of aggression than patients with other anxiety disorders. This aggression is associated with more severe symptomatology and interpersonal problems. However, few studies have examined whether higher levels of aggression are associated with a worse treatment response in this population.

METHODS

The present study sought to examine the association of aggression with panic disorder symptom severity in a sample of 379 patients who participated in a trial examining long-term strategies for the treatment of panic disorder.

RESULTS

We found that aggression was significantly associated with higher baseline levels of panic disorder symptoms, anxiety, depression, and functional impairment. Further, we found that patients higher in aggression did not achieve the same level of improvement in general anxiety symptoms during treatment compared to patients lower in aggression, even when controlling for baseline anxiety symptom severity.

CONCLUSION

These results suggest that more research is needed concerning patients with anxiety disorders with higher aggression, as they may be a group in need of additional treatment considerations.

[Dropout behavior during inpatient psychotherapy ]

OBJECTIVES

Dropouts result in far-reaching consequences for the individual patient, fellow patients, therapists, and the clinic. This study was aimed at early identification of patients with a dropout risk.

METHODS

Data from patients of the Department of Psychosomatic Medicine and Psychotherapy of the Medical University Clinic of Tübingen (Germany) were analyzed retrospectively in a case-control study (matched). Differences in the results of various questionnaires (SCL-90-R, IIP-D, SF-36) regarding reasons for dropout and sociodemographic data were analyzed. A total of 59 dropouts, 50 females and 9 males, were included. They were split into 28 early dropouts and 31 late dropouts. The data were compared between early and late dropouts and control group.

RESULTS

Early dropouts were significantly younger than late dropouts; they tended to live with their parents or on their own, and suffered more frequently from eating disorders. Late dropouts lived together with partners and suffered from somatoform disorders more frequently than early dropouts. The reasons given for dropout did not differ between the groups. No differences between dropouts and the controls were found with respect to psychopathology (SCL- 90-R) and quality of life (SF-36). Late dropouts did show significantly lower scores on the scale "autocracy/dominance" than the controls (IIP).

CONCLUSIONS

Therapy dropout is a multifactorial occurrence. It is generally not predictable, though it may be predicted with different instruments on the basis of a diagnosis, especially with respect to interpersonal behavior patterns. In further studies, targeted interventions should be developed and tested which enable procedures to minimize the risk of dropout and to achieve complete treatment according to patients' intentions.

Systems Training for Emotional Predictability and Problem Solving (STEPPS): program efficacy and personality features as predictors of drop-out -- an Italian study

In this study we present a clinical application of the STEPPS model in an Italian sample of severely affected patients with borderline personality disorder (BPD) or personality disorder (PD) with prominent borderline features in comorbidity with a mood disorder. The aims of this work are: 1) to confirm our preliminary results in a larger sample and at a 12-month follow-up, and 2) to identify predictors of drop-out vs completion of STEPPS in order to understand which characteristics of patients make them suitable or not for this treatment. The sample is composed of 32 subjects recruited from a population of inpatients of the Mood Disorders Center, Department of Clinical Neurosciences, Hospital San Raffaele-Turro, Milan. To confirm STEPPS efficacy at 12-month follow-up, we selected the following outcome criteria: reduction in the number of hospitalizations related to self-harm acts; reduction in the number of suicidal attempts; reduction of perceived emotional intensity levels; changes in cognitive filter scores; changes in the scores on self-report questionnaires. To identify predictors of drop-out vs completion, we analysed the following variables: demographic features (sex, marital status, school level achieved, and job status); Axis-I diagnosis; Axis-II categorical and dimensional diagnosis; and personality features. Seventeen (53%) subjects completed the treatment successfully. The drop-out rate was 47%. Patients who completed the program show a significant decrease in the number of hospitalizations, both at the end of the treatment and at 12-month follow-up. Friedman ANOVA test shows a significant decrease in suicidal attempts during and after STEPPS, and at 12-month follow-up. Analysis of drop-outs showed no significant differences with regard to sex, marital status, school level and job status between the two groups. Axis-I and Axis-II categorical diagnoses did not discriminate between the two groups. Those patients who dropped differ significantly from completers in histrionic personality traits and magical thinking index, given by the interaction between low scores in Self-Directedness and high scores in Self-Transcendence.

Personality Traits in Obesity Associated with Binge Eating and/or Night Eating

Specific personality traits, as assessed by the Temperament and Character Inventory (TCI), have been identified in individuals with obesity, but their association with binge and/or night eating has scarcely been reported. Indeed, our systematic search of Medline (1987 to 2013) yielded only five studies on the issue. Taken together, they suggest that personality traits do not have any significant role in determining body mass index, and therefore obesity class. However, obese individuals, in comparison with normal weight individuals, do seem to have a distinctive personality profile, characterized by low self-directedness and cooperativeness, and obese individuals with binge eating show lower self-directedness than those without. Moreover obese individuals with binge eating and/or night eating share a temperament profile characterized by high novelty-seeking and harm-avoidance, two traits also observed in other eating disorder categories and in clinical depression. Future longitudinal studies are needed to investigate the role of personality traits in the onset of binge eating and night eating in obese individuals, and to clarify their influence, if any, on treatment outcomes. Such information will enable us to determine whether the evaluation of personality traits should be included in the comprehensive assessment of obese individuals.

Impulsivity, anxiety, and alcohol misuse in bipolar disorder comorbid with eating disorders

Background

Eating disorders (ED) are noted to occur with bipolar disorder (BD), but relationships between additional comorbidities, clinical correlates, and personality factors common to both remain largely unknown.

Methods

Using data from the Prechter Longitudinal Study of Bipolar Disorder, we measured the prevalence and demographic factors of comorbid ED with BD, presence of additional comorbidity of anxiety and substance use disorders, psychosis, suicide attempts, mixed symptoms, childhood abuse, impact of NEO-Personality Inventory (NEO-PI) personality factors, and mood outcome in 354 patients with BD. We analyzed the prevalence of ED using both broad and narrow criteria.

Results and discussion

ED was more common in the Prechter BD sample than the general population, with the majority of those with ED being female. Anxiety disorders, alcohol abuse/dependence, and NEO-PI N5 impulsiveness were independently associated with ED in a multivariable linear regression analysis. BD age at onset was earlier in the ED group than that in the non-ED group and was earlier than the average onset of ED. Anxiety occurred before ED and alcohol use disorders after both BD and ED. Childhood trauma was associated with ED. Impulsivity and anxiety associated with BD may fuel ED and put patients at risk for other impulsivity-related disorders such as alcohol use disorders. ED was associated with more severe and variable moods and more frequent depression. Patients with BD should be regularly screened for ED, anxiety disorders, and alcohol use disorders, and comorbidity should be promptly addressed.

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

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

Predictors of dropout from in-patient treatment of eating disorders: an Italian experience

INTRODUCTION

The aim of the study was to examine possible risk factors for dropout from in-patient treatment for eating disorders (ED).

MATERIALS AND METHODS

The present study consisted of a retrospective analysis of clinical and non-clinical available information about 186 patients suffering from ED consecutively admitted into the Villa Maria Luigia Private Hospital (Parma, Italy) in a three-year period (01/01/2006 - 31/12/2009). Sociodemographics, clinical history and current features, and results to the following psychometric instruments were analysed: Eating Disorder Questionnaire (EDQ), Predisposing, On-set and Maintaining risk factors list for Eating Disorders, Eating Disorders Inventory-II, Body Uneasiness Test and SCL-90.

RESULTS

Of the 186 patients, 46 (24.7%) voluntarily left the treatment program prematurely. Predictive factors included poor educational and professional achievements, parents' divorcing, parents' history of substance abuse and difficulties in interpersonal relationships.

DISCUSSION

Dropout is a multifactorial phenomenon with deep clinical consequences: the recognition of possible risk factors may support the choice of specific therapeutic strategies to improve the treatment of ED and its outcomes.

Longstanding underweight eating disorder: associated features and treatment outcome

The clinical features and the response to inpatient cognitive-behavior treatment (I-CBT) of underweight individuals with either longstanding or more recent-onset eating disorder have rarely been compared. We compared the psychopathological profile and the response to I-CBT of 37 female patients with longstanding eating disorder (≥10 years, L-ED) and 58 with shorter disease duration. Individuals with L-ED had higher age, baseline BMI, higher frequency of self-induced vomiting, laxative and diuretic misuse, but not different personality traits at baseline and not different psychopathological changes, outcome, and dropout rates in response to I-CBT. This study provides preliminary evidence that I-CBT may be useful to treat L-ED and improve their eating disorder psychopathology.

Predictors of dropout among personality disorders in a specialist outpatients psychosocial treatment: a preliminary study

AIM

The aim of this study was to identify factors that may affect treatment retention in a 1-year psychosocial program for adult personality disorders.

METHODS

The sample consists of patients admitted to the Adult Personality Disorder Outpatient Programme of the Bologna Community Mental Health Centre in the period 2003-2008. At the beginning of the program, patients were evaluated through a comprehensive assessment including sociodemographic form, diagnostic interviews and self-report questionnaires. Patients who dropped out from treatment were retrospectively compared with patients who completed the program.

RESULTS

Out of 39 patients enrolled in the program, 20 (51.3%) dropped out and 19 (48.7%) completed the treatment. Out of 20 patients who dropped out, 14 terminated the treatment within the first 2 months. The dropout group and the group which remained showed significant differences in diagnosis (borderline personality disorder [BPD]), demographic data (age, time from first contact with psychiatric services), clinical variable (impulsiveness) and subjective experience (motivation, treatment expectation, therapeutic relation perception and barriers to access). BPD and subjective evaluation were found to be predictors of premature termination in the sample. In detail, BPD patients who experienced a less satisfactory therapeutic relationship and reported many external problems were more likely to drop out of the program.

CONCLUSION

Important factors contributing to dropout were identified, with potential implication for clinical practice. Further efforts need to be made to find ways to retain BPD patients who find the first subjective experience of the service more problematic.

Influence of attitudes towards change and self-directness on dropout in eating disorders: a 2-year follow-up study

OBJECTIVE

This study examined dropout-related factors at the Outpatient Eating Disorders Treatment Programme.

METHOD

One hundred ninety-six eating disorders patients following DSM-IV diagnostic criteria that consecutively commenced treatment were recruited and followed up for a 2-year period. A total of 151 patients completed the whole assessment with a set of questionnaires evaluating eating and general psychopathology. The Attitudes towards Change in Eating Disorders questionnaire was used, and personality was evaluated using the Temperament and Character Inventory. During the follow-up period, patients were re-assessed. Two years later, 102 patients continued on treatment.

RESULTS

Scores on Precontemplation at the beginning were predictors for dropout at 2-year follow-up. Character variables, as Responsibility, Integrity and Self-acceptance were protective factors to be at Precontemplation stage.

DISCUSSION

The clinician's challenge is to help eating disorders patients to develop an unyielding sense of responsibility and self-acceptance, aimed to integrate the therapeutic choice into their own intrapersonal frame of goals.

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.

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 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.

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.

Factors associated with dropout from treatment for eating disorders: a comprehensive literature review

BACKGROUND

Dropout (DO) is common in the treatment of eating disorders (EDs), but the reasons for this phenomenon remain unclear. This study is an extensive review of the literature regarding DO predictors in EDs.

METHODS

All papers in PubMed, PsycINFO and Cochrane Library (1980-2009) were considered. Methodological issues and detailed results were analysed for each paper. After selection according to inclusion criteria, 26 studies were reviewed.

RESULTS

The dropout rates ranged from 20.2% to 51% (inpatient) and from 29% to 73% (outpatient). Predictors of dropout were inconsistent due to methodological flaws and limited sample sizes. There is no evidence that baseline ED clinical severity, psychiatric comorbidity or treatment issues affect dropout. The most consistent predictor is the binge-purging subtype of anorexia nervosa. Good evidence exists that two psychological traits (high maturity fear and impulsivity) and two personality dimensions (low self-directedness, low cooperativeness) are related to dropout.

CONCLUSION

Implications for clinical practice and areas for further research are discussed. Particularly, these results highlight the need for a shared definition of dropout in the treatment of eating disorders for both inpatient and outpatient settings. Moreover, the assessment of personality dimensions (impulse control, self-efficacy, maturity fear and others) as liability factors for dropout seems an important issue for creating specific strategies to reduce the dropout phenomenon in eating disorders.

Let eating disorder patients decide: Providing choice may reduce early drop-out from inpatient treatment

Premature drop-out from treatment is a highly prevalent phenomenon among eating disorder (ED) patients. In a specialized inpatient treatment unit a major change was made in the admission strategy in 2001, giving a maximum of personal choice to the patients. A quasi-experimental research was carried out comparing 87 patients treated till 2000 ('old' strategy) with 87 patients treated from 2001 on ('new' strategy). The results indicate that the provision of choice at the beginning of treatment significantly reduced drop-out during the first weeks of inpatient treatment. No differences between both strategies on later drop-out and weight change (in anorexia nervosa patients) during inpatient treatment were found. The results are discussed in the light of the importance placed on dynamics of personal choice, autonomy and volition within the framework of the self-determination theory (SDT).

The impact of narcissism on drop-out from cognitive-behavioral therapy for the eating disorders: a pilot study

This study examined the relationship between narcissism and drop-out from the early stage of cognitive behavioral therapy (CBT) for the eating disorders. Narcissism was defined in terms of both its core elements and the narcissistic defense styles. The participants were 41 patients presenting for CBT at a specialist eating disorders service. Each completed measures of narcissism and eating disorder psychopathology. Attendance at sessions was also recorded. The presence of the narcissistically abused personality defense style was associated with a higher likelihood of dropping out of outpatient CBT. This "martyred" form of narcissism appears to have a significant role in the adherence to treatment for the eating disorders. The limitations and the clinical implications of this preliminary research are discussed, and future directions for research are suggested.

Predictors of early change in bulimia nervosa after a brief psychoeducational therapy

We aimed to examine baseline predictors of treatment response in bulimic patients. 241 seeking-treatment females with bulimia nervosa completed an exhaustive assessment and were referred to a six-session psychoeducational group. Regression analyses of treatment response were performed. Childhood obesity, lower frequency of eating symptomatology, lower body mass index, older age, and lower family's and patient's concern about the disorder were predictors of poor abstinence. Suicidal ideation, alcohol abuse, higher maximum BMI, higher novelty seeking and lower baseline purging frequency predicted dropouts. Predictors of early symptom changes and dropouts were similar to those identified in longer CBT interventions.

Predictors of dropout from inpatient dialectical behavior therapy among women with borderline personality disorder

Inpatient dialectical behavior therapy (DBT) is an effective treatment for borderline personality disorder (BPD), but often treatment is ended prematurely and predictors of dropout are poorly understood. We, therefore, studied predictors of dropout among 60 women with BPD during inpatient DBT. Non-completers had higher experiential avoidance and trait anxiety at baseline, but fewer life-time suicide attempts than completers. There was a trend for more anger-hostility and perceived stigma among non-completers. Experiential avoidance and anxiety may be associated with dropout in inpatient DBT. Low life-time suicidality and high anger could reflect a subtype at risk for discontinuation of inpatient treatment.

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.

Personality dimensions and treatment drop-outs among eating disorder patients treated with cognitive behavior therapy

Premature, unilateral interruption of inpatient treatment of eating disorders (ED) is a key factor limiting success. We evaluated the role of personality dimensions (temperament and character) in predicting drop-out in 145 consecutive ED inpatients (133 females) who entered cognitive behavior therapy. Baseline assessment included anthropometry, the Eating Disorder Examination, the Beck Depression Inventory, the State-Trait Anxiety Inventory, and the Temperament and Character Inventory (TCI). Treatment was based on the new transdiagnostic cognitive behavior theory of ED, adapted for an inpatient setting; it was manual-based and lasted 20 weeks (13, inpatients; 7, residential day hospital). Thirty-four patients (23.4%) discontinued treatment. Drop-outs had a lower level of education, a higher prevalence of separation or divorce in the family, and lower scores on the TCI Persistence scale. After correction for age, gender and body-mass index, scores on the Persistence scale continued to be significantly related to drop-out, and the association was confirmed by Kaplan-Meier analysis. Eating disorder patients with low Persistence scores are significantly less likely to complete inpatient treatment.

Self-image and treatment drop-out in eating disorders

INTRODUCTION

Drop-out from treatment is a serious problem in eating disorders which remains poorly understood. The present study investigated whether self-image and interpersonal theory could help to explain why eating disorder patients drop out of treatment.

METHOD

Intake data on eating disorder patients who terminated treatment prematurely (N=54) were compared with patients who had completed treatment (N=54) and those who were still in treatment after 12 months (N=54). Self-image was assessed using the structural analysis of social behaviour (SASB), and comparisons were made on demographic and clinical variables.

RESULTS

Patients who dropped out had initially presented with less negative self-image and fewer psychological problems compared with remainers. Low levels of SASB self-blame discriminated drop-outs from completers and remainers and significantly predicted treatment drop-out.

DISCUSSION

Drop-out in eating disorders appears to be a complex phenomenon, not necessarily as pathological as often assumed. There may be important differences in the treatment goals of drop-outs and therapists; patients who drop out may be choosing to disengage at a time when symptom improvement creates space for closer examination of interpersonal issues.

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

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

The effect of inpatient cognitive-behavioral therapy for eating disorders on temperament and character

Personality traits seem to have an important role in the development, clinical expression, course, and treatment response in eating disorders (EDs). We investigated the effects of an inpatient cognitive-behavioral treatment (CBT) on the measures of temperament and character (Temperament and Character Inventory (TCI)) in 149 consecutive patients with EDs. Baseline assessment included anthropometry, the Eating Disorder Examination (EDE), the Beck Depression Inventory (BDI), and the TCI. Treatment was based on the transdiagnostic cognitive behavior theory and treatment of ED, adapted for an inpatient setting. Treatment effects were tested by paired ANOVA, adjusted for covariates. No effects were found on Novelty Seeking, Reward Dependence, and Cooperativeness. Harm Avoidance (F=18.17, p<0.001), Persistence (F=7.71, p=0.006), Self-Directedness (F=27.55, p<0.001), and Self Transcendence (F=16.38, p<0.001) significantly changed after treatment. Changes in TCI scores were wholly dependent on the changes in BDI and EDE, and independent of ED diagnosis and behavior and of BMI changes. We conclude that in ED, a few scales of both temperament and character are significantly modified by CBT, in relation to changes in psychopathology and depression, independently of nutrition. These results are relevant for future studies based on TCI.

Anger, depression and personality dimensions in patients with migraine without aura

BACKGROUND

Migraine without aura causes acute and chronic pain and partially compromises patients' social functioning and work performance. Over the past years, psychiatric comorbidities were frequently observed in these patients, together with coping difficulties and typical personality traits. The aim of this study was to identify whether migraine patients and controls share distinctive personality traits.

METHODS

105 consecutive patients suffering from migraine without aura referred to the Headache Center of Turin University were enrolled in the study and compared to a control group of 79 healthy subjects. Patients and controls completed several psychometric questionnaires, including the Temperament and Character Inventory, the Beck Depression Inventory and the State-Trait Anger Expression Inventory.

RESULTS

Patients suffering from migraine show more depressive symptoms, difficult anger management with a tendency to hypercontrol, and a distinctive personality profile with high harm avoidance, high persistence and low self-directedness. When a logistic regression was performed, the only significant predictors of migraine were temperament variables.

CONCLUSIONS

The results suggest that the personality traits and psychosomatic mechanisms of migraine patients may make them vulnerable to stress and less skilled in coping with pain. These traits correlate with dysregulated neurotransmitter systems which may also be part of the psychobiological components of personality, depressive disorders and migraine itself.