An investigation of indirect effects of personality features on anorexia nervosa severity through interoceptive dysfunction in individuals with lifetime anorexia nervosa diagnoses.

OBJECTIVE: This study examined a hypothesized pathway by which interoceptive dysfunction accounted for associations between personality features (harm avoidance, self-directedness, and perfectionism) and anorexia nervosa (AN) severity (indicated by drive for thinness, eating disorder-related preoccupations and rituals, and body mass index). METHOD: The study sample (n = 270, mean age = 28.47, 95.2% female, 98% White/Caucasian) consisted of probands and biological relatives who met DSM-IV criteria for lifetime diagnoses of AN (omitting criterion D, amenorrhea) drawn from the Price Foundation Anorexia Nervosa Affected Relative Pairs Study (AN-ARP). Participants completed measures assessing personality, interoceptive dysfunction, and eating pathology. RESULTS: Associations between personality features of low self-directedness and high perfectionism and indicators of AN severity (drive for thinness and eating disorder-related preoccupations and rituals) were significant, as were the hypothesized indirect pathways through interoceptive dysfunction. Neither harm avoidance nor body mass index was significantly related to other study variables, and the proposed indirect pathways involving these variables were not significant. DISCUSSION: Findings suggest that certain personality features may relate to AN severity, in part, through their associations with interoceptive dysfunction. Future research should examine prospective associations and the value of interventions targeting interoceptive dysfunction for interrupting the link between personality and AN severity.

Parent Traumatic Stress After Minor Pediatric Burn Injury.

Parents are at increased risk for psychological sequelae following their child's burn injury which has demonstrated negative impacts on the child. The current study sought to address gaps in the literature on risk factors for parental distress by examining the relationships among demographic variables, burn characteristics, and child functioning after burn injury, with parent post-traumatic stress symptoms (PTSS). Participants included parents of 660 pediatric burn patients from a regional burn clinic. Parents completed measures during their initial visit to the burn clinic. Additional demographic and burn data were retrospectively collected by medical chart review. Fifteen percent of parents reported at-risk levels of parent PTSS. Parent PTSS was independently associated with child burn characteristics of total body surface area (TBSA) affected by the burn, required hospitalization, number of nights hospitalized, and number of ambulatory burn appointments attended. Minority race was associated with higher parent PTSS than non-minority race status, with Asian parents endorsing the highest scores. Furthermore, when considered simultaneously, impaired child quality of life (QOL), a higher number of ambulatory burn appointments attended, and racial minority status were associated with higher parent PTSS. These findings highlight the need for routine parent trauma screening in pediatric burn clinics, while additionally identifying a feasible screening measure.

A prospective study of obsessive-compulsive and borderline personality traits, race and disordered eating.

Most previous investigations of the relationship between personality and disordered eating have been cross-sectional and have utilised relatively homogeneous samples. The current study sought to prospectively explore two specific putative personality risk factors for disordered eating in an ethnically diverse sample of women (n = 58). During the initial and 2-year follow-up assessments, semi-structured diagnostic interviews were administered. Analyses revealed that borderline personality disorder symptoms, as well as an interaction between obsessive-compulsive personality disorder symptoms and race, significantly predicted disordered eating over a 2-year period. Obsessive-compulsive personality pathology was most strongly predictive of disordered eating for the African American women, specifically. These data supported both borderline and obsessive-compulsive personality pathology as predictors of the development of eating disorder symptoms among women over a 2-year period in college. In addition, race may be an important consideration in understanding the role of personality in the aetiology of disordered eating.

Features associated with laxative abuse in individuals with eating disorders.

OBJECTIVE: Laxative abuse is common in patients with anorexia and bulimia nervosa and has been associated with longer duration of illness, suicide attempts, impulsivity, and greater eating and general psychopathology. We explored the extent to which laxative abuse was associated with specific psychopathological features across eating disorder subtypes. METHODS: Participants were 1021 individuals from the multisite, International Price Foundation Genetic Studies. Axis I disorders, personality disorders and traits, and obsessive compulsive features were assessed. RESULTS: Laxative abuse was associated with worse eating disorder and general psychopathology and higher prevalence of borderline personality disorder (BPD). Symptom level analyses revealed that specific features of BPD, including suicidality and self-harm, feelings of emptiness, and anger, were most strongly associated with laxative abuse. CONCLUSIONS: The function of laxative abuse may differ across individuals with eating disorders, alternatively serving as a method of purging and a form of self-harm.

Eating disorders and personality: a methodological and empirical review.

Methodological approaches utilized to evaluate models of the relationship between personality and eating disorders, as well as empirical support for each model, are reviewed. Limited prospective research suggests that negative emotionality, perfectionism, drive for thinness, poor interoceptive awareness, ineffectiveness, and obsessive-compulsive personality traits are likely predisposing factors. Limited family study research suggests that obsessive-compulsive personality disorder (OCPD) and anorexia nervosa share a common familial liability. Potential pathoplastic personality factors include Cluster B personality disorders and OCPD, which predict a poorer course and/or outcome, and histrionic personality traits and self-directedness, which predict a more favorable course and/or outcome. Future research should focus upon sophisticated prospective and family study research in order to best evaluate competing models of the eating disorder-personality relationship.

Symptom fluctuation in eating disorders: correlates of diagnostic crossover.

OBJECTIVE: The course of anorexia nervosa often includes the emergence of bulimic symptoms and a crossover to the full syndrome of bulimia nervosa. However, clinicians' ability to predict who will develop bulimia nervosa is limited. The converse phenomenon, crossover from bulimia nervosa to anorexia nervosa, has not been investigated as thoroughly. The authors identified factors that are associated with crossover from anorexia nervosa to bulimia nervosa and from bulimia nervosa to anorexia nervosa. METHOD: All participants were from the International Price Foundation Genetic Study. Two groups were studied. The first comprised 88 individuals with an initial diagnosis of anorexia nervosa, of whom 32 developed bulimia nervosa. The second included 350 individuals with bulimia nervosa, of whom 93 developed anorexia nervosa. Several variables, including DSM-IV axis I and II disorders and personality traits, were evaluated as potential predictors of crossover. RESULTS: For the majority of affected individuals, crossover occurred by the fifth year of illness. A low level of self-directedness was associated with crossover in both directions. Other factors differed by diagnosis: high parental criticism was associated with crossover from anorexia nervosa to bulimia nervosa, whereas alcohol abuse/dependence and a low level of novelty seeking were associated with crossover from bulimia nervosa to anorexia nervosa. CONCLUSIONS: Low self-directedness may be associated with diagnostic instability in general, whereas other specific factors are related to the direction of diagnostic crossover. These results indicate that personality and family characteristics may influence the course of eating disorders and may be informative for planning interventions.

Influence of heredity on dietary restraint, disinhibition, and perceived hunger in humans.

OBJECTIVE: Dietary restraint, disinhibition, and perceived hunger have been shown to affect food intake and body weight and are thought to be risk factors for eating disorders, but little is known about their origins. We investigated the influence of heredity, shared (familial) environment, and individual environment on dietary restraint disinhibition, perceived hunger and their relation to body size and food intake. METHODS: Scores on the Three Factor Eating Questionnaire and the Restraint Scale in addition to height, weight, body mass index, and 7-d diary reported nutrient intakes were obtained from 39 identical, 60 fraternal same-sex, and 50 fraternal opposite-sex adult twin pairs who were living independently. Linear structural modeling was applied to investigate the nature and degree of genetic and environmental influences. RESULTS: Analysis showed significant genetic and individual environmental, but not shared (familial) environmental, influences on cognitive restraint, perceived hunger, and Restraint Scale scores, with genes accounting for 44%, 24%, and 58% of the variance, respectively. In contrast, disinhibition was found to be significantly influenced by the shared (familial) environment, accounting for 40% of the variance. Further analysis showed that cognitive restraint and perceived hunger heritabilities could not be accounted for by significant heritabilities of body weight, height, or body mass index. In contrast, the heritability of Restraint Scale scores was found to be related to body size. Cognitive restraint was negatively correlated with nutrient intake, and differences in cognitive restraint were found to be related to differences in the body sizes of identical twin pairs. CONCLUSIONS: Dietary restraint appears to be another component in a package of genetically determined physiologic, sociocultural, and psychological processes that regulate energy balance, whereas dietary disinhibition may be the intermediary between upbringing and the development of overweight and/or eating disorders.

The Link Between Alcoholism and Eating Disorders.

The comorbidity between alcoholism and eating disorders, especially in young women, is well documented. Alcohol and other drug (AOD)-use disorders are particularly common in women with bulimia nervosa. Although the mechanisms underlying the coexistence of these disorders remain unknown, recent family epidemiology studies suggest that bulimia nervosa and AOD dependence are transmitted independently in families. Furthermore, bulimia nervosa generally develops before the onset of AOD dependence. Thus, factors other than addictive behavior may contribute to the development of bulimia nervosa in a substantial proportion of women. The comorbidity of AOD-use disorders with eating disorders has implications for the treatment of the affected patients.

Personality and temperament.

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

A family history study of binge-eating disorder.

Family studies of anorexia nervosa and bulimia nervosa have yielded important information about the etiologies of these eating disorders. By contrast, little is known about familial factors of etiologic importance for binge-eating disorder (BED). The purpose of the current family history study was to assess the prevalence of comorbid psychopathology in a non-treatment seeking female sample of 31 probands with BED, 32 control probands without BED, and their 283 first-degree relatives. In-person semistructured clinical interviews were conducted with the probands, who also served as informants for all of their first-degree relatives. Significantly higher lifetime rates of major depressive disorder, dysthymic disorder, and social phobia were found among women with BED compared with control women. Significantly higher lifetime rates of bipolar (I or II) disorder, any depressive disorder, nearly all anxiety disorders, anorexia nervosa, and BED were reported among the first-degree relatives of women with BED compared with the first-degree relatives of control women. Furthermore, female relatives of women with BED were reported to have higher rates of substance use disorders and dysthymic disorder compared with female relatives of control women without BED. Nearly all disorders that were elevated in relatives of women with BED followed a pattern of independent transmission from BED. The primary exception was substance use disorder among female relatives, whose transmission pattern was consistent with that of a shared etiology with BED. Thus, BED and substance use disorder may share a common mechanism of familial transmission among women.

Placebo response in binge eating disorder.

OBJECTIVE: Placebo response in studies of binge eating disorder (BED) has raised concern about its diagnostic stability. The aims of this study were (1) to compare placebo responders (PRs) with nonresponders (NRs); (2) to investigate the course of BED following placebo response; and (3) to examine attributions regarding placebo response. METHOD: The baseline placebo run-in phase (BL) was part of a RCT investigating sibutramine hydrochloride for BED; it included 451 participants, ages 19-63, diagnosed with BED. Follow-up (FU) included 33 PRs. RESULTS: : In this study, 32.6% of participants responded to placebo (PRs = 147; NRs = 304). PRs exhibited significantly less symptom severity. At FU (n = 33), many PRs reported continued symptoms. CONCLUSION: PRs exhibited significantly less severe pathology than NRs. Placebo response in BED may transitory or incomplete. The results of this study suggest variable stability in the BED diagnosis.

Personality and anorexia nervosa.

We provided a selective review of the relationship between anorexia nervosa (AN) and personality. They reviewed the existing empirical literature examining the relationship between AN and personality. In spite of continued methodologic challenges related to personality assessment, there appears to be a relatively common phenotype in restricting-type AN characterized by high degrees of obsessionality, restraint, and perfectionism. However, there is also evidence of variability within the AN diagnostic category that is related to personality variables. Importantly, personality variables may significantly predict the course and outcome of AN. Personality variables may be risk factors for AN, consequences of AN, share a common cause with AN, or affect the course and outcome of AN. This literature would be enhanced by the articulation of conceptual models of these relationships that can be empirically tested.

The relation among perfectionism, obsessive-compulsive personality disorder and obsessive-compulsive disorder in individuals with eating disorders.

OBJECTIVE: Perfectionism and obsessionality are core features of eating disorders (ED), yet the nature of their relation remains unknown. Understanding the relation between these traits may enhance our ability to identify relevant behavioral endophenotypes for ED. METHOD: Six-hundred seven individuals with anorexia and bulimia nervosa from the International Price Foundation Genetic Study were assessed for perfectionism, obsessive-compulsive personality disorder (OCPD), and obsessive-compulsive disorder (OCD). RESULTS: No differences were found across ED subtypes in the prevalence of OCPD and OCD, nor with the association between OCD and OCPD. Perfectionism scores were highest in individuals with OCPD whether alone or in combination with OCD. CONCLUSION: Perfectionism appears to be more closely associated with obsessive-compulsive personality symptoms rather than OCD. The pairing of perfectionism with OCPD may be a relevant core behavioral feature underlying vulnerability to ED.

Axis I comorbidity onset and parasuicide in women with eating disorders.

OBJECTIVE: We examined differences in the onset pattern of comorbid disorders in eating-disordered women with and without a history of parasuicide to elucidate potential etiologic differences between the two groups. METHODS: Fifty-four women with a current or past eating disorder partcipated. Of these women, 27 had a history of suicide attempts and self-injury and 27 had no history of suicide attempts or self-injury. The age and pattern of onset for the eating disorder relative to comorbid major depression, anxiety disorder, and substance use disorder were compared between the groups. RESULTS: The onset of major depression and anxiety disorders occurred at a younger age in the parasuicidal group. In addition, the onset of major depression in the parasuicidal group occurred significantly more often before the onset of the eating disorder. DISCUSSION: The eating disorder may be secondary to a mood disturbance in women with parasuicidal histories.

The relationship among binge severity, personality psychopathology, and body mass index.

OBJECTIVE: To determine the relationship among binge severity, personality psychopathology, and body mass index (BMI) among individuals with binge eating disorder (BED). METHOD: Participants were 50 individuals from the community who responded to advertisements for a medication treatment study of compulsive overeating and met BED criteria. Participants completed the Eating Disorder Examination and the Structured Clinical Interview for DSM-IV Personality Disorders. RESULTS: Binge eating severity was significantly and positively correlated with BMI and personality disorder symptomatology. The frequency of binge eating episodes, but not binge size, was associated with greater levels of personality psychopathology. BMI and personality psychopathology were unrelated. Twelve percent of the participants met full criteria for avoidant personality disorder (APD) and 10% met full criteria for obsessive-compulsive personality disorder (OCPD). DISCUSSION: Findings suggest that eating pathology, rather than weight, is related to personality psychopathology. APD and OCPD traits may be of particular relevance when considering treatment interventions for individuals with BED.

Attempted suicide and self-injury in patients diagnosed with eating disorders.

Eating disorders (ED) patients are at high risk for developing suicidal behavior. The aim of the present study was to investigate factors associated with suicidal behavior in ED patients. One hundred fifty patients at an outpatient ED clinic were included in the study. Data were gathered by retrospective chart analysis. We found that 48 patients (32%) had a history of parasuicide (i.e., suicide attempts, self-injury, or both). A significantly greater percentage of parasuicidal patients than nonparasuicidal patients had EDs with bingeing/pursing symptomatology, used more than one type of purging method, and had a lifetime history of a drug use disorder, impulse control problems, and bipolar disorder, as well as a more extensive outpatient and inpatient treatment history. The findings of this study support an increased tendency toward impulsivity among parasuicidal ED outpatients.

Does environment matter? A review of nonshared environment and eating disorders.

OBJECTIVE: Nonshared environmental influences are experiences that are unique to siblings reared in the same family. We review studies highlighting the importance of nonshared factors for the development of eating disorders and suggest areas for future research. METHODS: Findings from behavioral genetic studies of eating disorders as well as methodological issues are reviewed. RESULTS: Twin studies suggest that approximately 17%-46% of the variance in both anorexia nervosa (AN) and bulimia nervosa (BN) can be accounted for by nonshared environmental factors. Studies directly examining these influences are scarce, although initial data indicate that differential paternal relationships, body weight teasing, peer group experiences, and life events may account for the development of eating pathology in one sibling versus another. DISCUSSION: Additional research is needed to identify specific nonshared environmental influences on eating disorders such as differential parental and sibling treatment, disparate peer group characteristics, and differential experience of life events such as physical and sexual abuse.

Personality, perfectionism, and attitudes toward eating in parents of individuals with eating disorders.

OBJECTIVE: This study compares personality and eating-related traits in parents of probands with eating disorders, with age-band matched healthy normal controls. METHOD: Data were abstracted from an international genetic study of anorexia nervosa. Information was available for the Multidimensional Perfectionism Scale (MPS), the Eating Disorders Inventory (EDI), and the Temperament and Character Inventory (TCI). Comparisons were done by multivariate analysis of variance. RESULTS: Mothers of probands showed elevated levels of perfectionism on the MPS and more concerns about weight and shape on the EDI compared with controls. Mothers who had daughters with diagnoses other than the restricting subtype of anorexia nervosa showed elevated levels of perfectionism on the MPS. CONCLUSION: These data are compatible with the notion that some personality traits, such as perfectionism, and weight and shape concerns may cluster in families of probands with eating disorders.

Personality characteristics of women before and after recovery from an eating disorder.

BACKGROUND: Previous studies of personality characteristics in women with eating disorders primarily have focused on women who are acutely ill. This study compares personality characteristics among women who are ill with eating disorders, recovered from eating disorders, and those without eating or other Axis I disorder pathology. METHOD: Female participants were assessed for personality characteristics using the Temperament and Character Inventory (TCI): 122 with anorexia nervosa (AN; 77 ill, 45 recovered), 279 with bulimia nervosa (BN; 194 ill, 85 recovered), 267 with lifetime histories of both anorexia and bulimia nervosa (AN + BN; 194 ill, 73 recovered), 63 with eating disorder not otherwise specified (EDNOS; 31 ill, 32 recovered), and 507 without eating or Axis I disorder pathology. RESULTS: Women ill with all types of eating disorders exhibited several TCI score differences from control women, particularly in the areas of novelty-seeking, harm avoidance, self-directedness, and cooperativeness. Interestingly, women recovered from eating disorders reported higher levels of harm avoidance and lower self-directedness and cooperativeness scores than did normal control women. CONCLUSIONS: Women with eating disorders in both the ill and recovered state show higher levels of harm avoidance and lower self-directedness and cooperativeness scores than normal control women. Although findings suggest that disturbances may be trait-related and contribute to the disorders' pathogenesis, additional research with more representative community controls, rather than our pre-screened, normal controls, is needed to confirm these impressions.