**2. Bulimia nervosa and personality**

A lot of studies have found a high prevalence of disorders included in the axis II of DSM among patients with bulimia nervosa, the term co-diagnostic being more appropriate than the concept of comorbidity. This is due to the fact that the latter means the concurrence of two different disorders, which does not respond to the current knowledge about personality and its disturbances. The concept of co-diagnostic also refers to the idea of a cross-sectional and simultaneous evaluation, which could change over time, this highlighting a temporal but no stable association between the two disorders (Ponce de León, 2006).

Studies based on the association between bulimia nervosa and personality styles have been reported a great variability of results due to conceptual and methodological problems (Ponce de León, 2006). The evaluation of personality implies to assess the stability of the traits over time and in different contexts, and to control several variables closely related to the environment. Variables as age, gender, patterns of social relationships, etc., could influence the evaluation of the personality acting as confounders. The usual chronicity of bulimia nervosa may be another factor of confusion, due to the frequent changes that patients display overtime with regards to their symptoms, which could be understood as personality traits. The eating dysregulation showed by bulimic patients has neurobiological consequences and may induce changes in the environment. As a result, the evaluation

cognitive behaviour therapy, and pharmacotherapy. Compared to bulimic patients free of personality disorders, those with cluster B disorders show more general psychopathology, drug and alcohol use, self-destructive behaviour, suicide attempts, histories of sexual/physical abuse, negative appraisals of family functioning, greater hospitalization rates, and higher use of psychotropic medication (Herzog, Keller, et al., 1992; Johnson, Tobin, et al., 1989; Rossiter, Agras, et al, 1993; Steiger & Stotland, 1996; Wonderlich & Swift,

 Clinical observation has long found a link between personality and eating disorders. In case of eating disorders the association with a personality disorder usually makes an early diagnostic difficult, makes the treatment more difficult, and usually is related with

Research has often found bulimic patients to be extroverted, histrionic, and affectively

 It is possible that both, anorexia nervosa and bulimia nervosa may be linked to personality factors heterogeneously. So that, more than one type of personality could

 Patients with purging-type anorexia nervosa and bulimia nervosa usually are more impulsive, and show high levels of sensitivity, emotional instability, and lower self-

 With regards to bulimia nervosa, some researches have focused on the distinction between multi-impulsive versus uni-impulsive patients. In case of uni-impulsive patients, binge eating is the only symptom or behaviour that could be described as impulsive. In case of multi-impulsive patients, there are a lot of symptoms or

A lot of studies have found a high prevalence of disorders included in the axis II of DSM among patients with bulimia nervosa, the term co-diagnostic being more appropriate than the concept of comorbidity. This is due to the fact that the latter means the concurrence of two different disorders, which does not respond to the current knowledge about personality and its disturbances. The concept of co-diagnostic also refers to the idea of a cross-sectional and simultaneous evaluation, which could change over time, this highlighting a temporal

Studies based on the association between bulimia nervosa and personality styles have been reported a great variability of results due to conceptual and methodological problems (Ponce de León, 2006). The evaluation of personality implies to assess the stability of the traits over time and in different contexts, and to control several variables closely related to the environment. Variables as age, gender, patterns of social relationships, etc., could influence the evaluation of the personality acting as confounders. The usual chronicity of bulimia nervosa may be another factor of confusion, due to the frequent changes that patients display overtime with regards to their symptoms, which could be understood as personality traits. The eating dysregulation showed by bulimic patients has neurobiological consequences and may induce changes in the environment. As a result, the evaluation

cause or contribute to the symptoms of the eating disorders.

behaviours related to impulsivity (stealing, substance abuse, etc.).

but no stable association between the two disorders (Ponce de León, 2006).

1990).

**1.2 Summarising** 

unstable.

esteem.

a poor prognostic.

**2. Bulimia nervosa and personality** 

should be difficult. Many times symptoms of the eating disorders and specific symptoms of personality disorders are overlapped, making difficult a proper evaluation of the association between both bulimia nervosa and personality disorder. Another point to take into account is the fact that the majority of the samples of bulimic patients usually comprise only women (or they have a low representation of men), so that is difficult to generalize the results of the evaluations. Finally diagnostic criteria for both bulimia nervosa and personality disorders have been modified in the past years and they are usually under discussion (Ponce de León, 2006; Westen, 1997; Westen & Shedler, 1999a, 1999b; Westen & Westen, 1998).

#### **2.2 How may the results about studies based on the relationship between bulimia nervosa and personality disorders be interpreted?**

As it has been mentioned the prevalence of personality disorders among eating disorder patients shows a wide range of results, and in case of bulimia nervosa ranges from 4% to 84%, despite the majority of studies report prevalence between 20% and 75%. By means of instruments as MMPI, EPQ and other similar scales, it has been reported that bulimic patients have higher scores in extraversion, poor impulse control, novelty seeking or low frustration tolerance, than anorectic patients (Gargallo, Fernández, et al., 2003; Ponce de León, 2006).

Despite the fact that bulimia nervosa seems to be closely related to personality disorders of cluster B of DSM (Jáuregui Lobera, Santiago Fernández, et al., 2009), there are studies finding close links between bulimia nervosa and obsessive syndromes and disorders of cluster C (von Ranson, Kaye, et al., 1999). This seems a surprising result taking into account the dimension impulsivity-compulsivity. This surprising finding is highlighted by the fact that a relatively frequent association between bulimia nervosa and obsessive-compulsive disorder has been found (8%-33%) (von Ranson, Kaye, et al., 1999). In addition, it has been reported that this link between bulimia nervosa and obsessiveness persists after the patients are recovered from their eating disorder or when they are recovered from other associated syndromes as anxiety or depression (von Ranson, Kaye, et al., 1999).

The relationship between bulimia nervosa and borderline personality disorder remains confusing. As opposite of the obsessiveness, borderline traits are present mainly at the beginning of the bulimic symptoms decreasing over time. More over the decrease of the bulimic symptoms usually is associated with a decrease of the borderline thoughts, feelings and behaviours (Ponce de León, 2006).

Despite the fact that the dimension impulsivity-compulsivity seems to be a useful tool to represent the two main eating disorders, it is difficult to explain the concurrence of bulimia nervosa and obsessiveness, or how an eating disorder as anorexia nervosa becomes another one as bulimia nervosa. So that, studies on the association between personality and eating disorders remain controversial. But there is a consensus about the fact that in case of a history of anorexia nervosa and bulimia nervosa, and in case of a purging type-anorexia it is possible to find the highest prevalence of associated personality disorders (mainly of clusters B and C), and the poorest outcome (Bulik, Sullivan et al., 1995; Bussolotti, Fernández-Aranda, et al., 2002; Rossiter, Agras, et al., 1993).

The co-occurrence between bulimia nervosa and personality disorders ranges from 4%-80%, mainly between 20%-75% of cases, and cluster B personality disorders (DSM), especially the borderline personality disorder, is the most frequently reported (Wonderlich & Swift, 1990). It is noted in the literature on eating disorders, that comorbid personality disorders are

studies of neurotransmitters in eating disorders suggest that in both the purging type anorexic patients and bulimic patients, as well as in the binge eating disorder, exist a deficit of the serotonergic function, which, in turn, is observed often in the above-mentioned psychopathological disorders (Diaz Marsá, 1999; Steiger, Young et al., 2001). So that, it seems that impairment (primary or secondary) in the brain function would be common to these disorders, which would explain the frequency with which they appear jointly. Studies of some authors could even pose to understand bulimia as a variant of impulse control disorder that would have its outer manifestation in eating behaviour, as there are several similarities in the structure of both psychopathological disorders: the inclination to carry out a detrimental act to themselves or others, inability to resist the impulsive act, feelings of restlessness or anxiety that increases progressively before the impulsive act, which are relieved when this is done to give way to feelings of shame or guilt (Fahy & Eisler, 1993;

There are different points of view with respect to the relationship between bulimia nervosa and impulsivity. One of them is based on the observed prevalence of the association between bulimia nervosa and impulsivity assessed by clinical interviews. These studies propose that impulsivity among bulimic patients would be a specific eating disorder subtype. Another proposal of these studies is that impulsivity could be reflecting the association between bulimia nervosa and other psychopathological disorders. The second type of studies (mainly based on psychometric assessments) states that impulsivity and bulimia nervosa would have a common base, which would be a specific type of personality. The third group of studies relates symptoms more than diagnostics, in order to explore the possible association between bulimic symptoms and impulsivity based on biological and psychosocial common roots, in both clinical and non-clinical samples (Peñas Lledó, 2006). The relationship between bulimia nervosa and impulsivity leads to two different diagnostics, which are usually involved in bulimic patients. Up to date, the multi-impulsive bulimia (Lacey & Evans, 1986) is not accepted as different type of bulimia nervosa, despite many authors state its undoubted clinical presence (Fichter, Quadflieg, et al., 1994; Welch & Fairburn, 1996). The use of very different criteria to assess this multi-impulsive bulimia leads to great differences of prevalence (Cook Myers, Wonderlich, et al., 2006), ranging from 18% to 80%. Despite the discussion on the real existence of this form of bulimia nervosa, there is a consensus on the fact that the more impulsive the behaviours are the worst is the prognostic of bulimic patients (Fichter, Quadflieg, et al., 1994). Another diagnostic usually involved in this field of study is the borderline personality disorder. In this personality disorder the disordered eating behaviour is only one of the criteria for the diagnostic, the rest being described as different impulse control deficits. The prevalence of this personality disorder among bulimic patients ranges from 2%-50% approximately (Marino & Zanarini, 2001; Peñas Lledó, 2006; Wonderlich & Swift, 1990). Finally a question emerges: How many patients with a borderline personality disorder and bulimia nervosa could really suffer from a multi-impulsive bulimia? (And vice versa). Some facts orientate the possible response: comparing bulimic patients with and without a borderline personality disorder, there are more impulsive behaviours (other than eating-related behaviours) among the patients with the associated personality disorder. On the other hand, comparing multi-impulsive bulimic patients and non-multi-impulsive bulimic patients the first group shows a higher prevalence

Newton, Freeman, et al., 1993; Westen & Harnden-Fischer, 2001).

of borderline personality disorder (63% vs. 13%) (Peñas Lledó, 2006).

generally associated with various factors such as diagnosis, greater impulsivity and selfharm, more substance abuse/dependence, more suicide attempts, more frequent purging behaviours, mood disorders, sexual abuse, greater comorbidity and severity of the disorder. Also, personality disorders have been identified as predictors and worse prognosis associated with a higher frequency of treatment dropout (Herzog, Kelller et al., 1992; Steiger, Leung et al., 1993; Wonderlich & Swift, 1990).

It is possible to interpret the association between bulimia nervosa and personality in different ways as follows:


## **2.3 Summarising**

