A study of temperament and personality in anorexia and bulimia nervosa

Although temperament and personality traits could influence the development and course of eating disorders, only a few studies examined the similarities and differences in personality between anorexia and bulimia nervosa. We compared 72 patients with DSM-IV eating disorders and 30 healthy controls. Dimensions of personality and personality disorders were evaluated with the Eysenck's EPQ, Cloninger's TCI, and the SCID-II questionnaires. The rates of impulsivity and clinical features were evaluated using specific rating scales. A comorbid personality disorder was found in 61.8% of patients with eating disorder. Avoidant personality disorder appeared was relatively common in anorexia nervosa restricting type; borderline personality disorder was most frequent in bulimia nervosa and the binge eating-purging type of anorexia nervosa. From a dimensional perspective, anorexic patients presented high scores in the dimension of persistence. Higher harm avoidance and impulsivity was found in bulimic patients. The overall eating disorders group presented high scores in neuroticism and low scores in self-directedness. Eating disorder patients have heterogeneous features of temperament and personality traits. Cluster C personality disorders seem more common in anorexia nervosa restricting type and impulsive personality features are associated with bulimic symptoms. Impulsivity seems to be a key aspect of temperament of bulimic patients, whereas anorexic symptoms are linked to persistent temperament traits.     

Developing a model of the treatment for eating disorder: Using neuroscience research to examine the how rather than the what of change

Treatments for eating disorders, in particular for people with anorexia nervosa, have often been adaptations of therapies designed for other conditions. Indeed, there is a move advocating the use of a transdiagnostic treatment approach in which general module based treatments are mixed together as needed rather than using a specific anorexia nervosa targeted strategy. The outcome of treatment is relatively poor, especially for those who for some reason do not have the benefit of an expert form of early intervention for anorexia nervosa. Technological advances in the neurosciences and genetics have radically altered how eating disorders and in particular anorexia nervosa have been conceptualised. In this paper we describe evidence that suggests that key aspects of the social information processing network both the cognitive and affective elements may be anomalous in people with anorexia nervosa. This has implications for models of treatment which can be tailored more directly to these causal and or maintaining factors. We describe the Maudsley method of working with adults with anorexia nervosa which has integrated these elements. This treatment approach includes working with the individual to develop a more flexible and holistic cognitive style with greater emotional intelligence. This is supplemented with work with the families to interrupt interactions that either accommodate to or aggravate the symptoms. Thus we are now in the position to understand and work to change how people with anorexia nervosa think and behave rather than focusing on what people think and say they do. Our prediction is that treatments that focus more directly on aetiology such as the intrapersonal and interpersonal maintaining factors will improve outcome.     

Loneliness and eating disorders

This article examines the link between loneliness and eating disorders. This concept is evaluated through a systematic review of the literature that links loneliness and eating disorders and through a survey of themes connecting the 2 conditions. Eating disorders-including anorexia nervosa, bulimia nervosa, and eating disorders that are not otherwise specified, which include binge eating disorder-are challenging health issues. Each of these diagnoses specifically relates to loneliness. This negative emotion contributes to and fuels eating disorder symptoms. Negative interpersonal relationships, both real experiences and individuals' skewed perceptions, exacerbate eating disorders and feelings of loneliness. Characteristics that have been associated with loneliness clearly relate to eating disorders. Understanding this relationship is vital, so that we can appreciate our patients' struggles and work to target these intense emotions within the treatment setting. We need to be aware of the power of loneliness as it applies to individuals in general and specifically to those struggling with disordered eating.     

Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come

Comparatively little scholarly attention has been given to the question of futility in chronic psychiatric disorders, with the exception of a small body of work on so-called end-stage anorexia nervosa (AN). A review of this literature provides the background for a critical examination of whether the concept of futility has any clinically meaningful, ethically justifiable, and legally defensible application to AN. In this article, the arguments for and against futility judgments in AN are analyzed with special emphasis on determinations of capacity in this serious mental illness. Parallels between the futility disputes in medical and psychiatric disorders, where applicable, will be drawn to further illuminate whether or not the concept that continued psychiatric treatment for AN is ever truly futile.     

Concomitant group therapy with anorectics and their parents as a supplement to family therapy

A study was made of family therapy with anorexia nervosa patients in a child psychiatric outpatient department. Eight families referred in 1984 were offered group therapy and family therapy simultaneously, one group for patients with anorexia nervosa and one group for their parents. The participants of both groups reported that they had learned a lot from the experience but stated that they felt group therapy could not replace family therapy.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

A review of eating disorders research in Mexico

The objective of this paper is to summarize research findings on eating disorders and the current state of the field in Mexico. Papers published in indexed journals and graduate dissertations were retrieved, using “eating disorders,” “anorexia nervosa,” “bulimia nervosa,” “body image,” “binge eating,” “restrained eating,” “weight and shape concern,” and “dieting” as keywords. These were combined with the Boolean operator “AND” with “Mexico” and “Latin America.” Findings are presented for epidemiology, the validity of assessment instruments, comorbidity, and risk factors. A national representative survey found a prevalence of 1.8% for bulimia nervosa, and no cases of anorexia nervosa. However, the lack of studies with confirmatory clinical interview and other national or regional representative samples makes it difficult to reach conclusions about the actual prevalence. A number of instruments for the detection of eating disorders and disordered eating have been validated for the Mexican population. The comorbidity of eating disorders in Mexico includes drug and alcohol abuse, obesity, and borderline personality disorder. Risk factors found included body weight and cultural pressure to be thin. Future lines of research should include epidemiological studies with representative samples and diagnosis confirmation, longitudinal studies, and the exploration of protective and risk factors specific to this population.     

Anorexia nervosa and brain tumor in a 14-year-old girl

A 14-year-old girl with anorexia nervosa (AN) was found to have an intracranial neoplasm. Atypical psychological symptoms prompted further evaluation, including electroencephalogram and neuroimaging, which revealed a sellar and suprasellar mass. This patient had an eating disorder and a brain tumor, which appear to be two unrelated conditions. However, it remains unclear how each affected the other. The diagnosis of AN, like all other psychiatric disorders, requires that possible medical etiologies and coexisting medical problems be excluded. AN and other eating disorders are particularly difficult to diagnose in children and adolescents because they often do not present in the manner typical of adults. Perceptual and cognitive disturbances associated with AN are difficult to evaluate because children and adolescents normally change over time as they progress through different stages of development. Therefore, it is particularly important to evaluate for the presence of medical conditions when a diagnosis of an eating disorder is made in a child or adolescent.     

Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy

The aims of the present review are to apply a recent risk factor approach (H. C. Kraemer et al., 1997) to putative risk factors for eating disorders, to order these along a timeline, and to deduce general taxonomic questions. Putative risk factors were classified according to risk factor type, outcome (anorexia nervosa, bulimia nervosa, binge-eating disorder, full vs. partial syndromes), and additional factor characteristics (specificity, potency, need for replication). Few of the putative risk factors were reported to precede the onset of the disorder. Many factors were general risk factors; only few differentiated between the 3 eating disorder syndromes. Common risk factors from longitudinal and cross-sectional studies were gender, ethnicity, early childhood eating and gastrointestinal problems, elevated weight and shape concerns, negative self-evaluation, sexual abuse and other adverse experiences, and general psychiatric morbidity. Suggestions are made for the conceptualization of future risk factor studies.     

The Role of Cognitive Deficits in the Development of Eating Disorders

Eating disorders (ED), including anorexia and bulimia nervosa, are chronic illnesses with periods of symptom exacerbation and remission. Because symptoms are usually present from 6 to 24 months before a diagnosis is made, aetiological agents are believed to be active well before symptoms appear. It is proposed that neuropsychological deficits in various cognitive domains preexist and underlie the aetiology of ED. This paper provides a comprehensive review of the literature relevant to neuropsychological deficits in ED patients and explores the relationship between cognitive deficits, psychosocial development, and the development of ED. Although the role of neuropsychological deficits in the evolution of ED requires further research, the proposed association has significant implications for clinical practice.     

Belastungen in der Kindheit und in der Jugend Essgestörter

Depending on definition and sample, a minority of varying size of women with eating disorders report to be victims of sexual and/or physical abuse. These stressful experiences are risk factors for mental disorders in general and not specifically for eating disorders. Parental high expectations and pre-morbid negative self-evaluation seem to be specific risk factors for anorexia nervosa and bulimia nervosa. Probably, patients with bulimia nervosa suffered more childhood adversity than those with restrictive anorexia nervosa. Patients with a history of sexual and/or physical abuse may be more severely ill and more difficult to treat than other patients with eating disorders. Careful questioning about childhood adversity seems advisable. In therapy, maintaining factors—like problems of self-esteem—are more important than predisposing or precipitating factors. For prevention, it is recommended to provide for the safety of children when treating their parents with mental illness—particularly substance use disorders—and to avoid parental high expectations.     

Exploring experience of family relations by patients with anorexia nervosa and bulimia nervosa using a projective family test

Elements of family dynamics have been shown to be related to onset, course, as well as prognosis of anorexia nervosa and bulimia nervosa. The goal was to explore the experience of family relations in a group of patients with eating disorders using a projective family test. The Patient group (anorexia=21, bulimia=16), as well as a healthy Control group, were given a projective family test, the Eating Disorder Inventory-2, as well as Karolinska Scales of Personality. The Patient group expressed more discord within the family picture than the Control group, such as cold and loveless relationships and not feeling validated. The group of patients reporting the most family discord did not show more eating disorder pathology or general psychopathology. They did, however, have higher scores on the Eating Disorder Inventory-2 subscale Maturity Fears, as well as higher values on the Karolinska Scales of Personality subscale Socialization. These results are interpreted within the background of methodological challenges in this area of research.     

Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa.

Concurrent verbalisation and a self-report questionnaire were used to investigate self-statements in patients with anorexia nervosa, patients with bulimia nervosa, two groups of dieters and non-dieting controls. Thoughts were collected while subjects performed three behavioural tasks, looking at themselves in a full-length mirror, weighing themselves and eating a chocolate covered mint. Both groups of patients had more negative thoughts related to eating, weight and shape than those in the three control groups. In addition, patients with anorexia nervosa showed a greater concern with eating while patients with bulimia nervosa showed a greater concern with weight and appearance. Differences were found between the patients and non-dieting controls using both methods but the self-report questionnaire was less sensitive than concurrent verbalisation to differences between the patients and dieters. Implications of the findings for cognitive-behavioural treatments of the two disorders are discussed.     

Implicit memory bias for eating- and body appearance-related sentences in eating disorders: an application of Jacoby's white noise task

Jacoby's white noise task and an explicit recognition task were used to investigate whether individuals with eating disorders demonstrate implicit memory bias and explicit memory bias, respectively, for information related to eating and body appearance. Included were 33 women with eating disorders (seven with anorexia nervosa and 26 with bulimia nervosa), 29 with nonclinical eating disorder-related concerns, and 36 healthy controls. Results showed partial support for implicit memory bias but no support for explicit memory bias. These findings suggest that eating disorders may be characterized by relative initial automatic bias for eating disorder-relevant information but not by bias at later stages of information processing. However, previous studies have demonstrated explicit memory bias in eating disorders, which is inconsistent with this interpretation. Future research is required to clarify the precise cognitive biases associated with eating disorders.     

Do Coping Strategies Discriminate Eating Disordered Individuals Better Than Eating Disorder Features? An Explorative Study on Female Inpatients with Anorexia and Bulimia Nervosa

The purpose of this explorative research was to examine how the COPE (Coping Orientation to Problem Experienced Inventory), an established instrument for measuring coping styles, and EDI-2 (Eating Disorder Inventory-2), a widely used questionnaire for assessing psychological and behavioural features of eating disorders (ED), discriminate among healthy individuals, inpatients with anorexia nervosa (AN) and inpatients with bulimia nervosa (BN). A discriminant analysis approach was used. Results showed that coping styles such as positive attitude, planning and social support are even more discriminative variables than eating disorder features. Implications for further studies are discussed.     

From eating disorders to women's situations: Extending the boundaries of psychological inquiry

This paper seeks to extend feminist critiques of the prevalent psychiatric approaches to the eating disorders. It also includes a critique of feminists' writings that make assumptions similar to, and hence suffer from some of the same theoretical weaknesses as, the prevalent clinical literature. The main purpose is to contribute to the development of a social-historical approach to the study of the relentless pursuit of thinness among women. The social-historical approach is contrasted with individualistic psychological, family systems and multidimensional accounts of anorexia nervosa and bulimia. Potential directions suggested by feminist and social-historical analyses of the relentless pursuit of thinness among women are briefly described.     

The role of body image and self‐perception in anorexia nervosa: the neuroimaging perspective

Anorexia nervosa is a severe psychiatric illness characterized by intense fear of gaining weight, relentless pursuit of thinness, deep concerns about food and a pervasive disturbance of body image. Functional magnetic resonance imaging tries to shed light on the neurobiological underpinnings of anorexia nervosa. This review aims to evaluate the empirical neuroimaging literature about self‐perception in anorexia nervosa. This narrative review summarizes a number of task‐based and resting‐state functional magnetic resonance imaging studies in anorexia nervosa about body image and self‐perception. The articles listed in references were searched using electronic databases (PubMed and Google Scholar) from 1990 to February 2016 using specific key words. All studies were reviewed with regard to their quality and eligibility for the review. Differences in brain activity were observed using body image perception and body size estimation tasks showing significant modifications in activity of specific brain areas (extrastriate body area, fusiform body area, inferior parietal lobule). Recent studies highlighted the role of emotions and self‐perception in anorexia nervosa and their neural substrate involving resting‐state networks and particularly frontal and posterior midline cortical structures within default mode network and insula. These findings open new horizons to understand the neural substrate of anorexia nervosa.     

‘It's like there are two people in my head’: A phenomenological exploration of anorexia nervosa and its relationship to the self

This study explores the lived experience of anorexia nervosa from the perspective of those who use pro-recovery websites for eating disorders. Fourteen people participated in an online focus group or an e-interview. Data were analysed using interpretative phenomenological analysis. Participants described their disorder as a functional tool for avoiding and coping with negative emotions, changing their identity and obtaining control. A central theme was the experience of an ‘anorexic voice’ with both demonic and friendly qualities. This voice felt like an external entity that criticised individuals and sometimes dominated their sense of self, particularly as anorexia nervosa got worse. Applying dialogical theory suggests a new model of anorexia nervosa, where the anorexic voice is a self-critical position, which disagrees with and attempts to dominate the more rational self. It is suggested that to move on from anorexia nervosa, the individual needs to address his/her anorexic voice and develop a new dominant position that accepts and values his/her sense of self.