Personality profiles in eating disorders: rethinking the distinction between axis I and axis II

Exaggerated frontoparietal control over cognitive effort-based decision-making in young women with anorexia nervosa

Effortful tasks are generally experienced as costly, but the value of work varies greatly across individuals and populations. While most mental health conditions are characterized by amotivation and effort avoidance, individuals with anorexia nervosa (AN) persistently engage in effortful behaviors that most people find unrewarding (food restriction, excessive exercise). Current models of AN differentially attribute such extreme weight-control behavior to altered reward responding and exaggerated cognitive control. In a novel test of these theoretical accounts, we employed an established cognitive effort discounting paradigm in combination with fMRI in young acutely underweight female patients with AN (n = 48) and age-matched healthy controls (HC; n = 48). Contrary to the hypothesis that individuals with AN would experience cognitive effort (operationalized as N-back task performance) as less costly than HC participants, groups did not differ in the subjective value (SV) of discounted rewards or in SV-related activation of brain regions involved in reward valuation. Rather, all group differences in both behavior (superior N-back performance in AN and associated effort ratings) and fMRI activation (increased SV-related frontoparietal activation during decision-making in AN even for easier choices) were more indicative of increased control. These findings suggest that while effort discounting may be relatively intact in AN, effort investment is high both when performing demanding tasks and during effort-based decision-making; highlighting cognitive overcontrol as an important therapeutic target. Future research should establish whether exaggerated control during effort-based decision-making persists after weight-recovery and explore learning the value of effort in AN with tasks involving disorder-relevant effort demands and rewards.

The current clinical approach to feeding and eating disorders aimed to increase personalization of management

Feeding and eating disorders (FEDs) are a heterogeneous grouping of disorders at the mind-body interface, with typical onset from childhood into emerging adulthood. They occur along a spectrum of disordered eating and compensatory weight management behaviors, and from low to high body weight. Psychiatric comorbidities are the norm. In contrast to other major psychiatric disorders, first-line treatments for FEDs are mainly psychological and/or nutrition-focused, with medications playing a minor adjunctive role. Patients, carers and clinicians all have identified personalization of treatment as a priority. Yet, for all FEDs, the evidence base supporting this personalization is limited. Importantly, disordered eating and related behaviors can have serious physical consequences and may put the patient's life at risk. In these cases, immediate safety and risk management considerations may at least for a period need to be prioritized over other efforts at personalization of care. This paper systematically reviews several key domains that may be relevant to the characterization of the individual patient with a FED aimed at personalization of management. These domains include symptom profile, clinical subtypes, severity, clinical staging, physical complications and consequences, antecedent and concomitant psychiatric conditions, social functioning and quality of life, neurocognition, social cognition and emotion, dysfunctional cognitive schemata, personality traits, family history, early environmental exposures, recent environmental exposures, stigma, and protective factors. Where possible, validated assessment measures for use in clinical practice are identified. The limitations of the current evidence are pointed out, and possible directions for future research are highlighted. These also include novel and emerging approaches aimed at providing more fine-grained and sophisticated ways to personalize treatment of FEDs, such as those that utilize neurobiological markers. We additionally outline remote measurement technologies designed to delineate patients' illness and recovery trajectories and facilitate development of novel intervention approaches.

Do empirically-derived personality subtypes relate to cognitive inflexibility in anorexia nervosa and bulimia nervosa?

BACKGROUND

Accruing evidence suggests that personality-based approaches to eating disorder classification may offer several advantages over current diagnostic models, with prior research consistently identifying three personality-based groups characterized by either (1) high levels of impulsivity and dysregulation (termed the "undercontrolled" group), (2) high levels of rigidity and avoidance (termed the "overcontrolled" group), or (3) relatively normative levels of personality functioning (termed the "low psychopathology" group). Cognitive inflexibility (i.e., difficulty adjusting thoughts or behaviors) has theorized relevance to eating disorders. However, prior research has frequently failed to observe differences in cognitive inflexibility across eating disorder diagnostic groups. The present study aimed to identify personality-based groups in an eating disorder sample, and then to examine the relations between these groups and behavioral measures of cognitive inflexibility.

METHOD

83 men and women who met DSM-5 criteria for anorexia nervosa or bulimia nervosa completed self-report questionnaires to assess trait-level approach/avoidance behaviors and impulsivity, as well as behavioral tasks assessing attentional set-shifting and reversal learning, two facets of cognitive inflexibility.

RESULTS

Latent profile analysis of measures assessing approach/avoidance behaviors and impulsivity supported a three-class model replicating the undercontrolled, overcontrolled, and low psychopathology groups. Notably, the low psychopathology group was characterized by elevated reward responding. One-way ANOVAs indicated that the low psychopathology group demonstrated heightened perseverative errors (an indicator of impaired reversal learning) relative to the other groups. No group differences were observed for attentional set-shifting errors or probabilistic switch errors.

DISCUSSION

Findings from the present study provide additional support for personality-based classification approaches identifying undercontrolled, overcontrolled, and low psychopathology eating disorder groups. Results also suggest that reward-related processes may contribute to disorder maintenance in the low psychopathology group, indicating potentially meaningful targets for intervention.

A Qualitative Exploration of Prominent Factors Contributing to the Aetiology of Child and Adolescent Eating Disorder Presentations during the COVID-19 Pandemic: The Perspectives of Patients, Parents and Clinicians

AIM

The aim of this study was to explore the prominent factors that contributed to the development of child and adolescent eating disorder presentations during the COVID-19 pandemic.

METHODS

This was achieved through a qualitative analysis of interviews gathered from (1) adolescent patients diagnosed with an eating disorder (ED) during the COVID-19 pandemic (aged 13-18) (n = 4), (2) parents of patients attending an ED service (n = 7) and (3) clinicians working within a specialist child and adolescent ED support service (n = 7). Reflexive thematic analysis was used to analyse the data and establish the most prominent aetiological factors reported.

RESULTS

The most prominent aetiological factors reported were (1) the accumulation of risk factors; (2) seeking control amid increased anxiety, stress and uncertainty; (3) social isolation; (4) an increased focus on exercise and "healthy eating"; (5) increased social media use promoting unhelpful attention towards ED triggers; and (6) a lack of both awareness and support services.

CONCLUSION

During the COVID-19 pandemic, the quantity and severity of ED presentations increased. The current study uncovered six themes perceived by patients, parents and clinical staff that contributed to the aetiology of ED presentations during the COVID-19 pandemic. It is hoped that the insight gained through this research study into ED aetiology may act as a basis for further research and support ED awareness, prevention and intervention in the future.

Psychometric properties of the Pride in Eating Pathology Scale in a Spanish population

BACKGROUND

In its relation to eating disorders, pride is one of the self-conscious emotions least analyzed, and requires valid and reliable instruments for its measurement. This study aimed to examine the factor structure and the psychometric properties of the Pride in Eating Pathology Scale (PEP-S), in the Spanish general population, as well as between-sex differences in PEP-S scores.

METHODS

Of the 1483 participants aged 18 to 34 (M = 21.99; SD = 3.09), 954 were women (65.2%) and the majority were university students (78.8%). Psychometric properties of the scale were tested in a cross-sectional design using cross-validation, i.e., exploratory and confirmatory factor analysis, and estimation of invariance (sex).

RESULTS

The four-factor structure found was similar to the original scale with invariance across sex and internal consistency (ordinal alpha .99) and stability (.85). Evidence of convergent validity and differences between sexes were found. Specifically, women scored higher on all the factors, including the healthier sense of pride.

CONCLUSIONS

The PEP-S scale is an instrument with evidence of validity and reliability in the Spanish population. Although it still has to be tested in a clinical population, it constitutes a promising instrument for the evaluation of the self-conscious emotion, pride.

Five-Factor Model and DSM-5 Alternative Model of Personality Disorder Profile Construction: Associations with Cognitive Ability and Clinical Symptoms

Although numerous studies have explored latent profiles using the Five-Factor Model (FFM) of normative personality, no studies have investigated how broad personality traits (i.e., FFM) and pathological personality traits using the alternative model of personality disorder (AMPD) may combine for latent personality profiles. The present study recruited outpatients (N = 201) who completed the Big Five Aspects Scales (BFAS), Personality Inventory for DSM-5 (PID-5), Structured Clinical Interview for DSM-IV (SCID-I/P), gambling and alcohol use measures, and the Weschler Intelligence subtests. When FFM and AMPD measures were combined, latent profile analyses revealed four profiles, Internalizing-Thought disorder, Externalizing, Average-Detached, and Adaptive. Detachment and openness to experience were the most and least essential traits for profile distinction, respectively. No associations between group membership and cognitive ability measures were found. Internalizing-Thought disorder membership was linked with a current mood and anxiety disorder diagnosis. Externalizing profile membership was associated with younger age, problematic gambling, alcohol use, and a current substance use disorder diagnosis. The four FFM-AMPD profiles overlapped with the four FFM-only and three AMPD-only profiles. Overall, the FFM-AMPD profiles appeared to have better convergent and discriminant validity with DSM-relevant psychopathology.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

Investigating Functioning Profile of Adolescents with Anorexia before and during the COVID-19 Pandemic: A Cross-Sectional Study on Mentalizing, Alexithymia, and Impulsiveness

Anorexia nervosa (AN) usually emerges in adolescence when important changes occur in cognitive, emotional, and social processes. Mentalizing, alexithymia, and impulsiveness represent key dimensions for the understanding and interpretation of psychological difficulties in AN. The outbreak of the COVID-19 pandemic has impacted adolescents with AN, showing a worsening of the disease. The main aims of the present paper are (1) to compare adolescents with AN before and during the COVID-19 pandemic and (2) to explore the relationship between mentalizing, alexithymia, impulsiveness, and psychological difficulties related to eating disorders in adolescents with AN during the COVID-19 pandemic. One hundred and ninety-six AN female adolescents (N = 94 before COVID-19; N = 102 during COVID-19) participated in this study. The results show that adolescents with AN during the COVID-19 pandemic had a more impaired functioning profile than the before COVID-19 group. Mentalizing, alexithymia, and impulsiveness had a predictive role on psychological difficulties related to eating disorders in adolescents with AN during the COVID-19 pandemic. In conclusion, our data reveal that the COVID-19 pandemic has likely represented a stress condition that affects mental health; worsening the severity of adolescents with AN clinical condition. Lastly, predictive patterns suggest the existence of a link between difficulties in the ability to face the problems of the present time using effective strategies and the severity of psychological symptoms.

The relationship between self-control and symptoms of anxiety and depression in patients with eating disorders: a cross-sectional study including exploratory longitudinal data

BACKGROUND

Personality style can partly be described as the way an individual controls and regulates emotions and can be divided into over- and undercontrol. Studies have indicated that personality style may impact the onset, clinical presentation, and recovery from an eating disorder (ED). Furthermore, symptoms of anxiety and depression are common in patients with EDs. However, the association between self-control levels and anxiety/depression symptoms in patients with EDs remains unknown. The main aim of this study was to assess how levels of self-control relate to anxiety/depression symptoms in patients with EDs, with a secondary, exploratory aim to assess the stability of self-control during treatment.

METHODS

Patients were recruited from the outpatient ED clinic at the Uppsala University Hospital, between October 2014 and December 2019. In total, 227 patients (age: 25.4, SD: 7.1) were included at the start of their treatment, with 14 participants also completing post-treatment measurements. Self-control was assessed with the Ego Undercontrol scale (EUC-13), anxiety/depression symptoms with the Hopkins Symptoms Checklist (HSCL-25), and ED diagnosis and symptoms with the Eating Disorder Examination Interview (EDE-I) and Questionnaire (EDE-Q), respectively.

RESULTS

A quadratic regression (n = 227) showed that levels of self-control accounted for about four percent of the variance in degree of global anxiety/depressive symptoms. Anxiety/depression symptoms were better explained by ED symptoms (R² = 0.24). Visualizations in boxplots revealed a tendency for extreme values of both over- and undercontrol to be associated with higher levels of depression, whereas symptoms of anxiety increased with increasing undercontrol. In the exploratory analyses (n = 14) levels of self-control remained more stable than symptoms of anxiety and depression, which decreased significantly during ED treatment.

CONCLUSIONS

Our results indicated that anxiety/depression symptoms, in patients with EDs, were not strongly correlated with levels of self-control, but rather with ED symptoms. However, extreme values of both over- and undercontrol showed a tendency to be associated with higher levels of depression symptoms, whereas anxiety symptoms increased with increasing levels of undercontrol. Future studies could benefit from considering both over- and undercontrol as potentially dysfunctional.

One size does not fit all: Exploring how the five-factor model facets predict disordered eating behaviours among adolescent and young adult males and females

There is a wealth of research that has highlighted the relationship between personality and eating disorders. It has been suggested that understanding how subclinical disordered eating behaviours are uniquely associated with personality can help to improve the conceptualization of individuals with eating disorders. This study aimed to explore how the facets of the Five-Factor Model (FFM) predicted restrictive eating, binge eating, purging, chewing and spitting, excessive exercising and muscle building among males and females. An online survey assessing disordered eating behaviours, FFM and general psychopathology was completed by 394 females and 167 males aged between 16 and 30 years. Simultaneous equations path models were systematically generated for each disordered eating behaviour to identify how the FFM facets, body dissatisfaction and age predicted behaviour. The results indicated that each of the six disordered behaviours were predicted by a unique pattern of thinking, feeling and behaving. Considerable differences between males and females were found for each path model, suggesting differences between males and females in the personality traits that drive disordered eating behaviours. It was concluded that it is important to take personality into account when treating males and females who engage in disordered eating behaviours.

Bottom-up transdiagnostic personality subtypes are associated with state psychopathology: A latent profile analysis

Introduction

Personality-based profiling helps elucidate associations between psychopathology symptoms and address shortcomings of current nosologies. The objective of this study was to bracket the assumption of a priori diagnostic class borders and apply the profiling approach to a transdiagnostic sample. Profiles resembling high-functioning, undercontrolled, and overcontrolled phenotypes were expected to emerge.

Methods

We used latent profile analysis on data from a sample of women with mental disorders (n = 313) and healthy controls (n = 114). 3-5 profile solutions were compared based on impulsivity, perfectionism, anxiety, stress susceptibility, mistrust, detachment, irritability, and embitterment. The best-fitting solution was then related to measures of depression, state anxiety, disordered eating, and emotion regulation difficulties to establish clinical significance.

Results

A 5-profile solution proved best-fitting. Extracted profiles included a high-functioning, a well-adapted, an impulsive and interpersonally dysregulated, an anxious and perfectionistic, and an emotionally and behaviorally dysregulated class. Significant differences were found in all outcome state measures, with the emotionally and behaviorally dysregulated class exhibiting the most severe psychopathology.

Discussion

These results serve as preliminary evidence of the predictive nature and clinical utility of personality-based profiles. Selected personality traits should be considered in case formulation and treatment planning. Further research is warranted to replicate the profiles and assess classification stability and profiles' association with treatment outcome longitudinally.

The impact of personality disorders and personality traits on psychotherapy treatment outcome of eating disorders: A systematic review

A significant proportion of those with eating disorders (EDs) do not respond to first-line treatments. This systematic review was conducted to identify whether personality disorders (PDs)/traits predict or moderate ED treatment outcomes and whether these outcomes were differentially influenced by ED or PD diagnostic subtypes, or treatment approach. A comprehensive systematic literature search was conducted using the PRISMA guidelines. A total of seven randomised controlled trials (RCTs) plus four follow-up studies were reviewed investigating the impact of PD and PD traits on treatment outcomes for EDs. The majority indicated that PD had some impact on treatment outcomes. Outcome measures and time-point measurements varied across studies. Included studies suggested that bulimia nervosa treatment outcomes were not hindered by co-morbidity of borderline PD; however, psychiatric impairment remained high at post-treatment and follow-up. Cluster C PDs were found to negatively impact treatment outcomes for binge ED and attrition rates for anorexia nervosa. Included studies suggested that interventions that addressed aspects of personality pathology showed greater main effects for ED treatment outcomes. There is an urgent need for future RCTs on ED treatments to include routine measures of core personality features to allow their impacts to be more thoroughly examined and for psychotherapies to be tailored accordingly.

The relationship between disordered eating behaviour and the five factor model personality dimensions: A systematic review

The relationship between personality and eating disorders has received significant research attention. This review aimed to synthesize research regarding the Five Factor Model (FFM) and disordered eating behaviors, to gain an improved understanding of the relationship between normal-range personality and subclinical eating disorders. Electronic Databases were used to identify studies published in English that utilized self-report measures of disordered eating and the FFM. A qualitative synthesis of 45 papers was then conducted. High scores on Neuroticism were associated with increased disordered eating behavior. Different disordered eating behaviors were found to have unique relationships with personality dimensions. Facets within domains varied in direction of correlation with disordered eating behaviors, particularly in the Agreeableness, Contentiousness, and Openness domains. The results indicate that, further research is needed before generalizing treatment approaches for eating disorders for females, males, and gender diverse populations.

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.

Emotional reactivity to binge food and erotic cues in women with bulimia nervosa symptoms

BACKGROUND

Studies on food cue reactivity have documented that altered responses to high-calorie food are associated with bulimic symptomatology, however, alterations in sexual motivations and behaviors are also associated clinical features in this population, which justify their inclusion as a research target. Here, we study responses to erotic cues-alongside food, neutral and aversive cues-to gain an understanding of specificity to food versus a generalized sensitivity to primary reinforcers.

METHODS

We recorded peripheral psychophysiological indices -the startle reflex, zygomaticus, and corrugator responses-and self-reported emotional responses (valence, arousal, and dominance) in 75 women completing the Bulimia Test-Revised (BULIT-R). Multiple regression analysis tested whether BULIT-R symptoms were predicted by self-reported and psychophysiological responses to food versus neutral and erotic versus neutral images.

RESULTS

The results showed that individuals with higher bulimic symptoms were characterized by potentiated eye blink startle response during binge food (vs. neutral images) and more positive valence ratings during erotic (vs. neutral) cues.

CONCLUSIONS

The results highlight the negative emotional reactivity of individuals with elevated bulimic symptoms toward food cues, which could be related to the risk of progression to full bulimia nervosa and thereby addressed in prevention efforts. Results also point to the potential role of reactivity to erotic content, at least on a subjective level. Theoretical models of eating disorders should widen their conceptual scope to consider reactivity to a broader spectrum of primary reinforcers, which would have implications for cue exposure-based treatments. We examined appetitive and aversive cue responses in college women to investigate how bulimic symptoms relate to primary reinforcers such as food and erotic images. We recorded peripheral psychophysiological indices (the startle reflex, zygomaticus, and corrugator responses) and self-reported emotional responses (valence, arousal, and dominance) in 75 college women that were presented with the Spanish version of the Bulimia Test-Revised. The results showed that bulimic symptoms increase both psychophysiological defensiveness toward food cues and subjective pleasure toward erotic cues. The findings suggest a generalized sensitivity to primary reinforcers in the presence of bulimic symptoms, and emphasize the relevance of adopting a wider framework in research and treatment on bulimia nervosa.

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.

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

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

Radically open dialectical behavior therapy for anorexia nervosa: A multiple baseline single-case experimental design study across 13 cases

BACKGROUND AND OBJECTIVES

No treatment for adult anorexia nervosa (AN) has shown sufficient effectiveness or superiority to other treatments. Overcontrol has been suggested as a viable mechanism to target in the treatment of patients with AN. Radically open dialectical behavior therapy (RO DBT) is developed for disorders related to maladaptive overcontrol. Our objective was to evaluate the outcome of RO DBT for AN in a clinical outpatient setting.

METHODS

Thirteen adult female patients with mild to moderate AN provided written consent and entered a multiple baseline single-case experimental design study. Median age at eating disorder (ED) onset was 15 years and the median duration of the ED was 10 years. Individual changes were assessed weekly during a baseline phase (A) of four to six weeks, and during the subsequent 40-week RO DBT phase (B). Additional assessments were conducted before and after treatment, and at a six-month follow-up. Primary outcome was ED psychopathology. Secondary outcomes were psychosocial impairment, quality of life, social connectedness, and adaptive control strategies.

RESULTS

Eight patients (62%) completed treatment. All completers were in full remission after treatment, with BMI ≥18.5 kg/m² and ED psychopathology within one standard deviation of the community mean. Improvements occurred after introducing RO DBT, not during baseline.

LIMITATIONS

Participants were female with mild to moderate AN, limiting generalizability to severe AN or males.

CONCLUSIONS

The study provides preliminary support for using RO DBT in adult outpatients with AN and overcontrol. Further studies should replicate these findings.

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.

Overcontrolled, undercontrolled, and resilient personality styles among patients with eating disorders

BACKGROUND

Personality has been suggested to be an important factor in understanding onset, maintenance, and recovery from eating disorders (ED). The objective of the current study was to evaluate personality style in different ED diagnostic groups as classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5).

METHODS

The overcontrolled, undercontrolled, and resilient personality styles were compared in four groups of patients with EDs: anorexia nervosa restricting (ANr) (n = 34), anorexia nervosa binge eating/purging (ANbp) (n = 31), atypical anorexia nervosa (AAN) (n = 29), and bulimia nervosa (BN) (n = 76). These groups were compared with a group of patients with borderline personality disorder (BPD) (n = 108), and a non-clinical group (NC) (n = 444). Patient data were collected at two outpatient clinics in Uppsala, Sweden. NC control data were collected through convenience sampling. Participants filled out questionnaires assessing personality style.

RESULTS

The main findings were more pronounced overcontrol reported by the ANr and AAN groups compared with the BN, BPD, and NC groups, and no significant difference in resilience between the ED and the NC groups. Considerable variability of over- and undercontrol was also found within each group.

CONCLUSIONS

The results replicate previous findings when EDs are classified according to current diagnostic criteria (DSM-5). Taking personality styles into account may improve our understanding of certain characteristics in EDs, such as social deficits and rigidity that are attributed to poor treatment outcome.

Associations Between Trauma, Early Maladaptive Schemas, Personality Traits, and Clinical Severity in Eating Disorder Patients: A Clinical Presentation and Mediation Analysis

Background: The literature has shown a significant association between traumatic experiences and eating psychopathology, showing a greater symptomatology in patients with trauma history. Less is known about the associations between trauma and cognitive schemas, and personality traits and the differences between childhood and adulthood trauma experiences. Thus, this paper aims to assess the clinical and psychological characteristics of eating disorder (ED) patients, looking for differences between patients without a history of trauma and patients with trauma experiences, as well as at possible differences between exposure in childhood, adulthood, or repeated events. Another aim of the paper is to evaluate the possible mediation role of cognitive schemas and personality traits in the relationship between early trauma and eating psychopathology.

Methods: From January to November 2020, 115 consecutive inpatients admitted for a specific multidisciplinary ED treatment in a dedicated Unit were evaluated for trauma, differentiating between trauma occurring in childhood and adulthood. The subjects were evaluated for early maladaptive schemas (EMS), personality traits, trauma symptomatology, quality of life, and specific psychopathologies linked to EDs. Mediation analyses between childhood and adulthood trauma and eating psychopathology were performed, with EMS and personality traits as mediators.

Results: Patients with a history of trauma showed higher physical and psychological symptomatology scores, with a more impaired clinical profile in patients with both childhood and adulthood trauma exposure. The mediation analysis showed a specific mediator role for the “disconnection and rejection (DR)” EMS factor in the relationship between childhood trauma (cT) and eating psychopathology.

Conclusion: Trauma experiences are associated with more severe clinical symptomatology in EDs and may need a specific assessment in patients with failed outpatient standard treatments. Specific cognitive schemas linked to DR domain should be evaluated in treatments for ED patients with history of trauma due to the mediation role between trauma and eating psychopathology. The need for outcome studies about treatment approaches for ED patients with history of trauma is discussed.

Sharing and connecting with others - patient experiences of radically open dialectical behavior therapy for anorexia nervosa and overcontrol: a qualitative study

BACKGROUND

Recovery rates after psychological treatments for anorexia nervosa are low to moderate, and in adults, no treatment outperforms any other. The aim of this study was to evaluate patient experiences of Radically open dialectical behavior therapy (RO DBT), a treatment developed for disorders related to maladaptive overcontrol.

METHODS

Eleven female patients with anorexia nervosa were interviewed after either treatment completion (eight patients) or drop-out (three patients) from RO DBT. Interviews were transcribed and analyzed with inductive thematic analysis.

RESULTS

The analysis yielded five main themes: 1) a comprehensive treatment, 2) the benefits of sharing and connecting with others, 3) growing trust, 4) moving toward valued goals - but some remain, and 5) doing well in treatment.

CONCLUSION

Patients appreciated what they described as a comprehensive treatment and holistic view of their problems, which helped them reduce both maladaptive overcontrol and eating disorder symptoms. Gradually sharing personal experiences both in- and outside therapy was described as essential and led to enhanced social connectedness.

TRIAL REGISTRATION

The intervention study (Isaksson M, et al. J Behav Ther Exp Psychiatry. 71, 2021) that preceded this interview study was performed by the first, second, third, and fifth author, preregistered in the ISRCTN registry (no: ISRCTN47156042 ).

Evaluating empirically valid and clinically meaningful change in intensive residential treatment for severe eating disorders at discharge and at a 6-month follow-up

PURPOSE

The present study evaluated the statistical and clinical significance of symptomatic change at discharge and after 6 months of an intensive residential treatment for patients with eating disorders (ED), and explored the individual factors that may affect therapeutic outcomes.

METHODS

A sample of 118 female ED patients were assessed at intake and discharge on the following dimensions: BMI, ED-specific symptoms, depressive features, and overall symptomatic distress. A subsample of 59 patients filled out the same questionnaires at a 6-month follow-up after discharge.

RESULTS

Findings evidenced statistically significant changes in all outcome measures at both discharge and follow-up. Between 30.1 and 38.6% of patients at discharge and 35.2-54.2% at the 6-month follow-up showed clinically significant symptomatic change; additionally, 19.8-29.1% of patients at discharge and 22.9-38.3% at follow-up improved reliably. However, 34.9-39.8% remained unchanged and 2-4.8% worsened. At the 6-month follow-up, 21.3-25.9% showed no symptomatic change and 0-3.7% had deteriorated. Unchanged and deteriorated patients had an earlier age of ED onset and were more likely to suffer a comorbid personality pathology and to be following concurrent pharmacological treatment.

CONCLUSIONS

Results suggested that intensive and multimodal residential treatment may be effective for the majority of ED patients, and that therapeutic outcomes tend to improve over time. Prevention strategies should focus on early onset subjects and those with concurrent personality pathology.

LEVEL OF EVIDENCE

Level III, evidence obtained from a longitudinal cohort study.

Mentalizing Subtypes in Eating Disorders: A Latent Profile Analysis

Background: Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in several mental disorders. Some studies have suggested that eating disorders (EDs) may also be associated with impairments in mentalizing. The aim of this work is to investigate the possible presence of mentalizing subtypes in a sample of patients with EDs.

Method: A sample of patients with eating disorders (N = 157) completed a battery of measures assessing mentalization and related variables, including the Reflective Functioning Questionnaire (RFQ), the Difficulties in Emotion Regulation Strategies (DERS), the Interpersonal Reactivity Index (IRI). Clinicians rated patients in relation to imbalances in different dimensions of mentalization to prementalizing modes and attachment style by using the Mentalization Imbalances Scale, the Modes of Mentalization Scale (MMS), and the Adult Attachment Questionnaire. A latent profile analysis was conducted to test the possible presence of different subgroups. MANOVA was used to test the possible differences between the four mentalizing profiles in relation to emotion dysregulation (DERS), empathy (IRI), and adequate and impairments in mentalizing (MMS and RFQ).

Results: The latent profile analysis suggested the presence of four different profiles in relation to impairments in the dimensions of mentalization: (1) affective/self/automatic imbalances, (2) external imbalance, (3) cognitive/self/automatic imbalances, and (4) cognitive/other/automatic imbalances. Patients belonging to profile 1 are characterized by the prevalence of affective mentalization that overwhelms the capacity to reflect on mental states with an imbalance on the self-dimension; profile 2 patients are excessively focused on the external cues of mentalization; profile 3 patients are characterized by an over-involvement on the cognitive and self-facets of mentalization, with an impairment in adopting the other mind perspective; and profile 4 patients have similar impairments compared to profile 3 patients but with an excessive focus on others and deficits in self-reflection. These profiles were heterogeneous in terms of EDs represented in each group and presented significant differences on various variables such as attachment style, emotion dysregulation, empathy, interpersonal reactivity, and reflective function. This study represents, so far, the first work that confirms the presence of different mentalizing patterns in ED patients.

Conclusions: ED patients can be classified in relation to impairments in different dimensions of mentalization above and beyond ED diagnosis.

An evolutionary life history approach to understanding mental health

In recent years, evolutionary life history theory has been used as a heuristic framework to understand mental health. This article reviews the life history theory and its integration with mental disorders and then introduces representative research methods and related empirical studies in the field of evolutionary psychopathology. In the end, this article concludes with future directions for further research examining and developing the evolutionary psychopathological framework.

Drive for thinness provides an alternative, more meaningful, severity indicator than the DSM-5 severity indices for eating disorders

OBJECTIVE

To assess an alternative trans-diagnostic indicator for severity based on drive for thinness (DT) for anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and other specified feeding or eating disorder (OSFED), and to compare this new approach to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) severity categories for EDs.

METHOD

A total of 2,811 ED [428 AN-restrictive (AN-R), 313 AN-binge purging (AN-BP), 1,340 BN, 329 BED, 154 OSFED/atypical AN (AT), and 223 OSFED/purging disorder (PD)] patients were classified using: (a) The DSM-5 severity categories and (b) a DT categorisation. These severity classifications were then compared based on ED symptoms, general psychopathology, personality, and impulsive behaviours.

RESULTS

For the DSM-5 categories, most ED patients fell into the 'mild' to 'moderate' categories. Using the DT categories, AN patients were mainly represented in the 'low' DT category, and BN, OSFED/AT, and PD in the 'high' DT category. The clinically significant findings were stronger for the DT than the DSM-5 severity approach (medium-to-large effect sizes). AN-BP and AN-R provided the most pronounced effects.

CONCLUSION

Our findings question the clinical value of the DSM-5 severity categorisation, and provide initial support for an alternative DT severity approach for AN. HIGHLIGHTS : This study assessed an alternative trans-diagnostic drive for thinness (DT) severity. Category for all eating disorder (ED) sub-types, and then compared this to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) severity indices for EDs. ED symptoms, general psychopathology, personality, and impulsive behaviours were assessed using both classifications in a total of 2,811 female patients diagnosed with EDs. Clinically significant findings were stronger for the DT than the DSM-5 severity category (medium-to-large effect sizes); there was differentiation of the anorexia nervosa (AN) patients into mainly 'low' DT, and bulimia nervosa (BN) spectrum patients into mainly 'high' DT, vs. most patients were clustered in the 'mild-to-moderate' DSM-5 categories. Our findings provide initial support for an alternative trans-diagnostic DT severity category that may be more clinically meaningful than the DSM-5 severity indices for EDs.

Differences in Affective Dynamics Among Eating Disorder Diagnostic Groups

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

Perfectionism and impulsivity based risk profiles in eating disorders

OBJECTIVE

The categorical classification of eating disorders (ED) has several limitations, for example, high symptom variability within the diagnosis and limited predictive validity for treatment response. An alternative is classifying individuals with ED based on personality traits, which can reflect underlying etiological mechanisms. We aimed to find latent profiles based on facets of maladaptive and adaptive perfectionism, impulsivity and ED symptoms.

METHOD

The sample comprised of 274 women-164 had an ED diagnosis and 110 were controls. Two separate latent profile analyses were performed-one on the mixed sample (controls and individuals with ED) and the other on the sample of individuals with ED only.

RESULTS

We identified a five-class model to be the best fit for the mixed sample. The classes were: (a) moderately impulsive, (b) high functioning, (c) purely perfectionistic, (d) emotionally dysregulated, (e) behaviorally dysregulated. Among the individuals with ED, a four-class solution was found to be the best fit. The classes were very similar in their response patterns on indicator variables to response patterns observed in the mixed sample, except the emotionally and behaviorally dysregulated classes that formed into one class.

DISCUSSION

In addition to the well-known high-functioning, overcontrolled and undercontrolled classes, two to three undercontrolled classes (moderately impulsive, behaviorally, and emotionally dysregulated class) emerged. Those classes differentiated on perfectionism and impulsivity levels as well as on ED symptom severity and psychiatric comorbidities-all of which may influence maintenance of ED, appropriate treatment choice and therefore treatment response.

Personality trait risk factors for attempted suicide among young women with eating disorders

Objective

Clinical observations and a review of the literature led us to hypothesize that certain personality and character traits could provide improved understanding, and thus improved prevention, of suicidal behaviour among young women with eating disorders.

Method

The clinical group consisted of 152 women aged between 18 and 24 years, with DSM-IV anorexia nervosa/restrictive type (AN-R = 66), anorexia nervosa/purging type (AN-P = 37), bulimia nervosa/non-purging type (BN-NP = 9), or bulimia nervosa/purging type (BN-P = 40). The control group consisted of 140 subjects. The assessment measures were the Minnesota Multiphasic Personality Inventory—second version (MMPI-2) scales and subscales, the Beck Depression Inventory (BDI) used to control for current depressive symptoms, plus a specific questionnaire concerning suicide attempts.

Results

Suicide attempts were most frequent in subjects with purging behaviour (30.0% for BN-P and 29.7% for AN-P). Those attempting suicide among subjects with eating disorders were mostly students (67.8%). For women with AN-R the scales for ‘Depression’ and ‘Antisocial practices’ represented significant suicidal risk, for women with AN-P the scales for ‘Hysteria’, ‘Psychopathic deviate’, ‘Shyness/Self-consciousness’, ‘Antisocial Practices’, ‘Obsessiveness’ and ‘Low self-esteem’ were risk indicators and for women with BN-P the ‘Psychasthenia’, ‘Anger’ and ‘Fears’ scales were risk indicators.

Conclusion

This study provides interesting results concerning the personality traits of young women with both eating disorders and suicidal behaviour. Students and those with purging behaviour are most at risk. Young women should be given more attention with regard to the risk of suicide attempts if they: (a) have AN-R with a tendency to self-punishment and antisocial conduct, (b) have AN-P with multiple physical complaints, are not at ease in social situations and have antisocial behaviour, or (c) if they have BN-P and tend to be easily angered with obsessive behaviour and phobic worries. The MMPI-2 is an interesting assessment method for the study of traits indicating a risk of suicidal behaviour in young subjects, after controlling for current depressive pathology.

Family environment of eating disordered patients with and without self-injurious behaviors

Objective.

– The family environment is known to be an important contributor to the course of psychiatric disorders. In this study, we examined the family context of eating disordered (ED) patients with and without self-injurious behaviors (SIB).

Method.

– A Dutch adaptation of the Family Environment Scale ‘Sci Eng 57(9-B):1997;5927’ was completed by 131 ED patients of whom 47% showed at least one form of SIB (e.g., cutting, burning, hair pulling, etc.).

Results

– Results showed a significant difference in family environment between patients with and without SIB. The family environment of self-injuring ED patients was less cohesive, expressive and socially oriented, and more conflictual and disorganized than the family environment of those without SIB. No significant differences in perceived family environment were found with respect to the number or form of SIB and the subtype of ED. Neither did we find a significant interaction effect between ED subtype and presence/absence of SIB.

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.

Measurement of Personality Structure by the OPD Structure Questionnaire Can Help to Discriminate Between Subtypes of Eating-Disorders

Background

Differentiation between purging type (AN-P) and restricting type (AN-R) is common in anorexia nervosa (AN) and relevant for clinical practice. However, differences of personality pathology in eating disorders (ED) and their subtypes, which can be captured by the operationalized psychodynamic diagnosis (OPD) system, have not been systematically investigated to date.

Objectives

The aim of this study was to explore differences in personality structure between the subtypes of AN and bulimia nervosa (BN) using the OPD structure questionnaire (OPD-SQ). In addition, the ability of the instrument to support the classification of eating disorders was examined.

Materials and Methods

We conducted a retrospective, exploratory study in a subset sample of a larger validation study. The OPD-SQ had been collected from n = 60 patients with AN or BN. Patients were assigned to the ED groups by clinical assessment. Statistical analyses included multivariate analysis of variance (MANOVA) and discriminant analysis.

Results

Differences between ED groups were observed on 5 OPD-SQ main scales and 9 subscales, as well as on the global scale. AN-P patients demonstrated the lowest personality structure on most of the main scales and subscales, whereas AN-R patients showed a higher personality structure level as compared to both BN and AN-P patients. The OPD-SQ scales with the largest differences include self-perception, object perception, and attachment to internal objects. Discriminant analysis resulted in satisfactory assignment to ED groups by OPD-SQ subscales.

Conclusions

Personality structure was found to be less developed in patients with BN and AN-P as compared to patients with AN-R. Although the results have to be proven in larger prospective studies, these results suggest that the OPD-SQ may be used to support the clinical assessment and classification in patients with EDs.

Reduced mentalizing in patients with bulimia nervosa and features of borderline personality disorder: A case-control study

BACKGROUND

Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in some mental disorders such as Borderline Personality Disorder (BPD). Some studies have suggested that Eating Disorders (EDs) may also be associated with impairments in mentalizing, but studies have not always yielded consistent results. This is the first study to systematically investigate mentalizing impairments in patients with Bulimia Nervosa (BN) compared with controls. In addition, we investigated whether impairments in mentalizing were related to BPD features, rather than BN per se, given the high comorbidity between BPD and BN.

METHODS

Patients with BN (n = 53) and healthy controls (HCs; n = 87) completed a battery of measures assessing mentalizing including the Reflective Function Questionnaires (RFQ), the Object Relations Inventory (ORI; Differentiation-Relatedness Scales) and the Reading The Mind in The Eyes Test (RMET).

RESULTS

Patients with BN scored significantly lower than HCs on all tests of mentalizing, with moderate to large between-group effect sizes. These differences were partially accounted for by BPD features as assessed with the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and partially by bulimic symptoms measured with the Eating Disorder Examination Questionnaire (EDE-Q).

CONCLUSIONS

Patients with BN have significantly lower levels of mentalizing as assessed with a broad range of tests compared to HCs. These differences were related to both bulimic symptoms and BPD features. Although further research in larger samples is needed, if replicated, these findings suggest that poor mentalizing may be a significant factor in BN patients and should be addressed in treatment, regardless of the presence of BPD features.

Personality Variables and Eating Pathology

Personality variables have long been implicated in the onset and maintenance of eating disorders, as well as in symptom divergence between anorexia nervosa and bulimia nervosa. Clinical observations are broadly supported by the data, with restricting anorexia nervosa associated with higher levels of constraint and Persistence, and binge-purge behaviors linked to the tendency to take impulsive action when emotionally distressed. Considerable heterogeneity is found within diagnostic categories, however, suggesting that different personality structures may predispose individuals to develop disordered eating through alternative pathways.

Eating Pathology Among Patients With Anorexia Nervosa and Bulimia Nervosa: The Role of Narcissism and Self-Esteem

We sought to deepen our understanding of the relationship between pathological narcissism and eating disorders (ED) by examining specific facets that composed grandiose and vulnerable narcissism while taking into account self-esteem, a well-known and consistent risk factor for ED. Twenty-seven women diagnosed with anorexia nervosa (AN) and 23 women diagnosed with bulimia nervosa (BN) completed standardized measures of pathological narcissism, self-esteem, and dysfunctional eating attitudes and behaviors. Different patterns of associations between the facets of pathological narcissism and eating pathology arose between AN and BN diagnoses. Closer examination of the facets of pathological narcissism revealed that hiding the self, a vulnerable narcissistic facet, contributed significantly to dysfunctional eating attitudes and behaviors over and above self-esteem for women with AN. Hiding the self should continue to be explored in regard to treatment of ED.

Longitudinal Associations Among Bullying by Peers, Disordered Eating Behavior, and Symptoms of Depression During Adolescence

Importance

Bullying by peers has been associated with disordered eating behavior and symptoms of depression among adolescents as both an antecedent and an outcome. Identification of the temporal pattern of associations among bullying by peers, disordered eating behavior, and depression in adolescence is needed for the optimal targeting of intervention and prevention.

Objective

To assess the concurrent and longitudinal associations among bullying by peers, disordered eating behavior, and symptoms of depression using a cascade model that controlled for within-time and across-time (ie, stability paths) associations while examining cross-lag effects.

Design, Setting, and Participants

In this 5-year longitudinal cohort study, 612 participants of the McMaster Teen Study were included. This ongoing Canadian study examines the associations among bullying, mental health, and educational outcomes. Data collection began in 2008 when students were in grade 5 (10 years of age) and have since been collected annually. Data analysis was performed between August 20 and October 18, 2017.

Exposures

Bullying by peers was assessed in grades 7 to 11 using a composite measure of 5 items.

Main Outcomes and Measures

Disordered eating behavior was assessed in grades 7 to 11 using the Short Screen for Eating Disorders, and depressive symptoms were assessed in grades 7 to 11 using the Behavior Assessment System for Children-Second Edition.

Results

The 612 students included in the analytic sample had a mean age (SD) of 13.03 (0.38) years in grade 7; 331 (54.1%) were girls and 392 (71.1%) were white. Bullying by peers was concurrently associated with disordered eating behavior and depressive symptoms at every time point during the 5-year period (r range [SE], 0.15-0.48 [0.04-0.08]; P < .01). Disordered eating behavior was associated longitudinally with depressive symptoms at every time point (β range [SE], 0.14-0.19 [0.06-0.08]; P < .02) and bullying by peers at 2 time points (β range [SE], 0.12-0.22 [0.06-0.07]; P < .04) in girls and boys.

Conclusions and Relevance

Bullying by peers was proximally associated with multiple psychopathologic symptoms, whereas symptoms of disordered eating behavior were a key risk factor for future depressive symptoms and bullying by peers. Interventions aimed at reducing problematic eating behavior in adolescents may attenuate the risk of future depressive symptoms and relational problems.

Transdiagnostic vs. disorder-focused perspective in children and adolescents with eating disorders: Findings from a large multisite exploratory study

BACKGROUND

The transdiagnostic model of eating disorders (ED) proposes common cognitive mechanisms in patients with ED psychopathology. Little is known about their role in the maintenance of ED in children and adolescents. This study aimed to determine whether the relationships between key factors (low self-esteem, weight and shape control, clinical perfectionism, interpersonal problems, distress and mood instability) and core maintaining mechanisms (binge-eating and restraint) would support a transdiagnostic theory in young patients.

METHODS

A total of 419 patients (mean age 14.7 ± 2.14 years; age range: 7-18 years; males 13.8%) diagnosed with an ED were assessed in six Italian clinical centers in 2013. Multiple comparisons between ED diagnosis, correlation analysis and principal component analysis (PCA) were performed.

RESULTS

Of the entire collective, 51.5% of patients were diagnosed with Anorexia Nervosa (AN), 12.3% were diagnosed with Bulimia Nervosa (BN) and 36.2% with Eating Disorder Not Otherwise Specified (EDNOS). In PCA, the core ED mechanisms, dietary restraint and binge eating, acted as poles of attraction of the other variables. The AN group was particularly linked to restraint and the BN group was particularly related to "Bulimia". Considering the diagnostic subtypes, there were no significant differences between the anorexic binge-purging group, bulimic purging group and bulimic non-purging group, which constituted a unique cluster related to affective, interpersonal problems and to perfectionism, indicating a very homogeneous subgroup. Restricting anorexic group (AN-R), related to shape concern and anxious-depressed mood, was not linked to the other subtypes. EDNOS appeared to be opposed to the AN-R group; the binge eating disorder group appeared to be independent from others.

CONCLUSION

Our results suggest the presence of both specific and transdiagnostic mechanisms in ED subtypes, whose knowledge is of relevance for clinical practice.

Affect-based profiles of bulimia nervosa: The utility and validity of indicators assessed in the natural environment

Theoretical conceptualizations of bulimia nervosa (BN) emphasize the role of emotion dysregulation in the development and maintenance of symptoms, which has been supported by ecological momentary assessment studies. Given the importance of affective disturbances in BN, this study aimed to classify a sample of adult women with BN (N = 130) based on primarily momentary affective indicators, including negative and positive affect, negative and positive affective lability, and depression. Participants completed baseline assessments followed by a two-week ecological momentary assessment protocol. Latent profile analysis revealed four groups: (1) a "stable normal" group characterized by low affective lability and intensity; (2) a "stable depressed" group characterized by low affective lability and higher affect intensity; (3) an "unstable normal" group characterized by higher affective lability but lower affect intensity; and (4) an "unstable depressed" group characterized by higher affective lability and intensity. The stable depressed group evidenced the highest levels of eating psychopathology, borderline personality traits, and childhood trauma history, while the stable normal group generally evidenced the lowest levels of psychopathology. The findings demonstrate significant heterogeneity in the topography of affect experienced by individuals with BN, and suggest that chronic, intense negative affect may be particularly important to address in treatment.

Predicting intolerance of uncertainty in individuals with eating disorder symptoms

BACKGROUND

Intolerance of Uncertainty (IU) is recognized for its contribution to various psychopathologies, in particular anxiety and depression. Studies highlight the relevance of IU for Eating Disorders (EDs) however, potential factors contributing to IU in EDs remain unstudied.

METHODS

Three hundred and forty-nine women with ED symptoms and 214 individuals without ED symptoms were recruited and compared on levels of IU, insecure (anxious and avoidant) attachment styles, extraversion and openness. Secondly, the contribution of these factors to IU were tested.

RESULTS

Compared to the non-ED group, the ED group scored higher on IU, insecure attachment, and lower on extraversion and openness. Regression analyses confirmed that higher insecure attachment, and lower extraversion predicted higher IU scores in the ED group, and that insecure attachment predicted higher IU scores in the non-ED group.

CONCLUSIONS

Results confirm the relevance of IU to ED, and demonstrate that personality traits and insecure attachment styles contribute to IU in ED. Findings add to the growing literature on IU in ED and suggest that people with EDs may benefit from clinical interventions targeting IU.

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).

Neuroticism and clinical course of weight restoration in a meal-based, rapid-weight gain, inpatient-partial hospitalization program for eating disorders

We evaluated the impact of personality on weight restoration in 211 underweight (BMI ≤ 19 kg/m²) females admitted to an inpatient-partial hospitalization program for eating disorders. Symptomatology and personality were assessed by questionnaires, and clinical and demographic variables were assessed by chart review. Neuroticism, a personality trait associated with reactivity to stress, was correlated with higher symptomatology, chronicity, length of stay, and income source. Contrary to our hypothesis, neuroticism was positively associated with weight restoration. Length of stay mediated this relationship such that longer length of stay in patients with high neuroticism explained their higher likelihood of weight restoration prior to program discharge. Higher neuroticism is therefore associated with better weight restoration outcomes but may also indicate greater difficulty transitioning out of intensive treatment.

A comprehensive review of psychodynamic treatments for eating disorders

PURPOSE

To comprehensively review the existing literature on the effectiveness of psychodynamic psychotherapies in eating disorders (EDs) and to stimulate both debate and research on this topic.

METHODS

Online and hand searches were conducted to identify papers published between 1980 and 2015 on psychodynamic treatments delivered to adults with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

RESULTS

A total of 47 studies were finally included in this review. Fifteen studies were available for AN, 9 for BN, 12 for BED, and 11 for samples with mixed diagnoses. Several methodological flaws emerged, but overall psychodynamic interventions showed promising results at the end of treatment and follow-up, when available.

CONCLUSIONS

The body of literature on psychodynamic treatments is sparse and sometimes methodologically questionable; nevertheless, current data provide support to the effectiveness of these interventions, particularly for AN. However, both a defined approach (focus, themes, and techniques) and randomized controlled trials (RCTs) are warranted to clarify the effectiveness of psychodynamic psychotherapies.

Associations between adverse childhood experiences and clinical characteristics of eating disorders

Patients with eating disorders (EDs) frequently report a history of childhood trauma (CT). We investigated whether certain subtypes of CT are associated with more severe features of EDs, independently of psychiatric comorbidity, and whether they act additively. One hundred and ninety-two patients with DSM-V-defined EDs were consecutively recruited. Five clinical characteristics were assessed: restraint, eating, shape and weight concerns on the EDE-Q, and daily functioning. CT was assessed by the childhood traumatism questionnaire. The clinical features were associated with at least one CT subtype (emotional, sexual or physical abuse, emotional neglect). Multivariate analyses adjusted for lifetime comorbid psychiatric disorders revealed that emotional abuse independently predicted higher eating, shape and weight concerns and lower daily functioning, whereas sexual and physical abuse independently predicted higher eating concern. A dose-effect relationship characterised the number of CT subtypes and the severity of the clinical features, suggesting a consistent and partly independent association between CT and more severe clinical and functional characteristics in EDs. Emotional abuse seems to have the most specific impact on ED symptoms. Last, not all CT subtypes have the same impact but they do act additively.

Dimensions of impulsivity in relation to eating disorder recovery

OBJECTIVE

Impulsivity is associated with eating pathology, but different dimensions of impulsivity have not been extensively studied in the eating disorders. The current study examined the relationship between four facets of impulsivity and eating disorder recovery status.

METHOD

Females formerly seen for an eating disorder were categorized as having an eating disorder (n = 53), partially recovered (n = 15), or fully recovered (n = 20) based on a diagnostic interview and physical, behavioral, and psychological indices. These groups and non-eating disorder controls were compared on impulsivity facets from the UPPS Impulsive Behavior Scale (UPPS): Urgency (negative urgency), Premeditation (lack of), Perseverance (lack of), and Sensation Seeking.

RESULTS

Negative urgency (the tendency to engage in impulsive behavior to alleviate negative affect) was related to recovery. The fully recovered group and controls experienced significantly less negative urgency than those with a current eating disorder; the partially recovered group did not differ from the eating disorder group.

DISCUSSION

Findings suggest that negative urgency may be a particularly important facet of impulsivity to target in therapeutic intervention for eating disorders, especially among those with a history of binge eating and/or purging. Future longitudinal work is needed to test a potential causal relationship between negative urgency and eating disorder recovery. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1027-1031).