**7. References**

APA. (2000). *Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.* (American Psychiatric Association, Washington, DC).

APA. (2011).

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=397

by the young age at inclusion and the duration of the study. However, we made the choice of directly collecting data and retaining only patients with complete files to ensure a good

Aside from these limitations, the results of our study indicate that an immature development of interpersonal relatedness can act as a negative prognostic factor of the longterm outcome of patients with eating disorders. This result implies that relational issues should deserve specific attention in eating disorders and indirectly supports the interest of family approaches for these patients. More generally, this study highlights the interest of a person-centered approach focusing on the subjective experience of patients. As Fonagy and Target (Fonagy and Target 2002) have outlined, the majority of studies do not explore the subjective experience and the psychological distress of patients, although this may be critically different among subjects. The investigation of the subjective experience can deepen our understanding of psychiatric disturbances as categorized by the DSM-IV and refine our prediction about treatment outcomes for a variety of different types of psychological disturbances (Fonagy 2004). This approach is also in line with the recommendations issued by the working group on personality disorders for the future DSM-V. The working group, arguing that personality psychopathology fundamentally emanates from disturbances in thinking about self and others, and that these features influence treatment strategies, has proposed to include an assessment of the levels of self (including identity and self-direction) and interpersonal functioning (including empathy and intimacy) to describe the personality characteristics of all patients, independently from the presence of a personality disorder (APA 2011). Professionals should carefully monitor interpersonal concerns when assessing eating disorder patients and should develop specific therapeutic strategies to handle the negative relational expectancies frequently experienced by these patients (Goodsit 1997).

This work was conducted within the clinical research project "Dependence Network 1994- 2000". The Network received the support of the Institut National de la Santé et de la Recherche Médicale (Réseau Inserm n° 494013) and of the Fondation de France. The promoter of the project is the Institut Mutualiste Montsouris. All the centres participating in the project should be acknowledged: Department of Adolescent and Young Adult Psychiatry, Institut Mutualiste Montsouris, Paris, France ; Department of Psychiatry, Hôpital Pinel, Amiens, France ; Department of Psychiatry, Hôpital Saint-Jacques, Nantes, France ; Department of Psychiatry Hôpital Universitaire, Besançon, France ; Department of

APA. (2000). *Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text* 

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=397

*Revision.* (American Psychiatric Association, Washington, DC).

Child and Adolescent Psychiatry, SUPEA, Lausanne, Switzerland.

quality of the sample.

**6. Acknowledgments** 

**7. References** 

APA. (2011).

**5. Conclusions** 


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A relatively new approach, which tends to be applied in order to subtype eating disorders, is based on the study of personality and its disturbances. A well-known statement is that anorexia nervosa and bulimia nervosa are disorders with a high level of heterogeneity in terms of personality variables. Clinical observation has long found a link between personality and eating disorders. Despite the fact that a lot of personality profiles have been described among eating disorder patients, in case of anorexia nervosa and bulimia nervosa the personality traits tend to be described within a dimension of impulsivity-compulsivity. The study of personality in eating disorder patients seems to be useful as a subtyping strategy, this being more effective than the traditional symptoms-based categorization (diagnostic criteria), mainly in order to predict the psychosocial functioning and different clinical features (Abbott, Wonderlich, et al., 2001; Steiger & Stotland, 1996; Westen &

The association between eating disorders and personality disorders has been studying mainly from the moment in which the personality disorders were included in the axis II of DSM. An improvement with regards to the study of personality disorders was the development of specific structured interviews and self-reported questionnaires in order to assess personality traits and its disturbances (Echeburúa & Marañón, 2001; Loranger, 1995;

Personality disorders constitute rigid and maladaptive thoughts, feelings and behaviours, all related with poor learning of effective coping strategies. As a result, patients suffering from personality disorders usually have interpersonal conflicts and severe psychosocial limitations. Moreover, these disorders imply a psychological distress and they are stable throughout life (Echeburúa & Corral, 1999; Sarason & Sarason, 1996; Vázquez, Ring, et

There is a shortage of reliable studies on epidemiology of personality disorders due to several facts, as the heterogeneity of the studied populations and the scarce of valid and reliable instruments. Nevertheless, all the studies usually show a common conclusion, this being the high prevalence of personality disorders (ranging from 6% in general population to 20%-40% among psychiatric outpatients) and a slightly higher prevalence among women

The frequent comorbidity between personality disorders and other pathologies of the DSM axis I may be explained by different facts: a) personality disorders may be a risk factor for suffering from mental disorders; b) personality disorders may be a consequence of any mental disorders, and c) both, personality disorders and other mental disorders may follow

Matsunaga, Kiriike, et al., 1998; Millon & Ávila, 1998; Spitzer, Williams, et al., 1992).

**1. Introduction** 

al., 1990).

(Echeburúa & Corral, 1999).

Harnden-Fischer, 2001; Wonderlich & Mitchell, 2001).

Ignacio Jáuregui Lobera

*Spain* 

*Pablo de Olavide University, Seville,* 

Zuroff DC, Moskowitz DS, Cote S. (1999b). Dependency, self-criticism, interpersonal behaviour and affect: evolutionary perspectives. Br J Clin Psychol 38 ( Pt 3),231-50. **9** 

Ignacio Jáuregui Lobera

*Pablo de Olavide University, Seville, Spain* 

#### **1. Introduction**

126 New Insights into the Prevention and Treatment of Bulimia Nervosa

Zuroff DC, Moskowitz DS, Cote S. (1999b). Dependency, self-criticism, interpersonal

A relatively new approach, which tends to be applied in order to subtype eating disorders, is based on the study of personality and its disturbances. A well-known statement is that anorexia nervosa and bulimia nervosa are disorders with a high level of heterogeneity in terms of personality variables. Clinical observation has long found a link between personality and eating disorders. Despite the fact that a lot of personality profiles have been described among eating disorder patients, in case of anorexia nervosa and bulimia nervosa the personality traits tend to be described within a dimension of impulsivity-compulsivity. The study of personality in eating disorder patients seems to be useful as a subtyping strategy, this being more effective than the traditional symptoms-based categorization (diagnostic criteria), mainly in order to predict the psychosocial functioning and different clinical features (Abbott, Wonderlich, et al., 2001; Steiger & Stotland, 1996; Westen & Harnden-Fischer, 2001; Wonderlich & Mitchell, 2001).

The association between eating disorders and personality disorders has been studying mainly from the moment in which the personality disorders were included in the axis II of DSM. An improvement with regards to the study of personality disorders was the development of specific structured interviews and self-reported questionnaires in order to assess personality traits and its disturbances (Echeburúa & Marañón, 2001; Loranger, 1995; Matsunaga, Kiriike, et al., 1998; Millon & Ávila, 1998; Spitzer, Williams, et al., 1992).

Personality disorders constitute rigid and maladaptive thoughts, feelings and behaviours, all related with poor learning of effective coping strategies. As a result, patients suffering from personality disorders usually have interpersonal conflicts and severe psychosocial limitations. Moreover, these disorders imply a psychological distress and they are stable throughout life (Echeburúa & Corral, 1999; Sarason & Sarason, 1996; Vázquez, Ring, et al., 1990).

There is a shortage of reliable studies on epidemiology of personality disorders due to several facts, as the heterogeneity of the studied populations and the scarce of valid and reliable instruments. Nevertheless, all the studies usually show a common conclusion, this being the high prevalence of personality disorders (ranging from 6% in general population to 20%-40% among psychiatric outpatients) and a slightly higher prevalence among women (Echeburúa & Corral, 1999).

The frequent comorbidity between personality disorders and other pathologies of the DSM axis I may be explained by different facts: a) personality disorders may be a risk factor for suffering from mental disorders; b) personality disorders may be a consequence of any mental disorders, and c) both, personality disorders and other mental disorders may follow

Fig. 1. Comorbidity of anorexic and bulimic symptoms with each other, and core personality

Despite the inconsistencies across different studies, the understanding of the relation between eating disorders and personality disorders is relevant, because patients with comorbid personality pathology have a worse course, greater psychological distress, greater mood disturbances, and a slower recovery than those without comorbid personality disorders (Herzog, Keller, et al., 1992; Herzog, Keller, et al., 1992; Steiger, Leung, et al., 1993;

The presence of obsessiveness, rigidity, perfectionism, dependency, social inhibition or low self-sufficiency is usual among patients with anorexia nervosa, while patients with purgingtype anorexia nervosa and bulimia nervosa usually are more impulsive, and show high levels of sensitivity, emotional instability, and lower self-esteem. The association of bulimia nervosa and other disturbances (i.e., poor impulse control, self-injuries, aggressive behaviour, kleptomania, substance abuse, gambling, stealing or sexual promiscuity) is highly frequent (Braun, Sunday, et al., 1994; Gartner, Marcus, et al., 1989; Matsunaga,

With regards to bulimia nervosa, some researches have focused on the distinction between multi-impulsive versus uni-impulsive patients (Lacey & Evans, 1986). In case of uniimpulsive 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 behaviours related to impulsivity (stealing, substance abuse, etc.). Multi-impulsive bulimic patients usually have significantly greater rates of borderline personality disorder and mood disorders than uni-impulsive bulimic patients (Lacey & Evans, 1986). These two groups of bulimic patients may represent very different kinds of patients, despite the fact that they have the same eating disorder symptoms. These two types of bulimic patients constitute an example of two possible subtypes within the general classification of bulimia nervosa that may not be easily differentiated by the eating symptoms. Nevertheless, they may differ in

personality, aetiology, or function of symptoms (Westen & Harnden-Fischer, 2001).

The differences in personality style are related to clinical variables. Bulimic patients with borderline personality disorder (or any cluster B personality disorder of the DSM), display a poorer outcome across a wide range of treatments, including individual and group therapy,

Kiriike, et al*.,* 1998; Steiger & Stotland, 1996; Wonderlich & Swift, 1990).

traits in anorexia and bulimia.

Wonderlich & Swift, 1990).

an independent course (Medina & Moreno, 1998). 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 a poor prognostic (Díaz, Carrasco, et al., 1999).

Research has consistently linked anorexia (particularly restrictive type) to personality traits such as introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features (Casper, 1990). The picture for bulimia is less clear and somehow mixed. Traits such as perfectionism, shyness, and compliance have consistently emerged in studies of individuals with bulimia or with anorexia, although research has often found bulimic patients to be extroverted, histrionic, and affectively unstable (Vitousek & Manke, 1994).

Different studies have been developed based on two points of view. As a result the focus may be on how many patients suffering from eating disorders have any personality disorders, or the focus could be how many patients with personality disorders suffer from any eating disorders. In the first case there is a wide range of comorbidity, from 21% to 97% (Dolan, Evans, et al., 1994; Skodol, Oldham, et al., 1993). Following Westen & Harnden-Fischer (2001), the comorbidity between eating disorders and personality disorders could reflect the possibility a) that many patients have the random misfortune of having two or more disorders, at least one of which is on axis I and another on axis II; b) that anorexic and bulimic behaviours are symptomatic expressions of personality pathology and hence distinctions regarding syndromes, states and traits embodied in the distinction between DSM axis I and axis II may be problematic with respect to eating disorders; or c) that some common genetic or environmental diathesis underlies both eating disorders and personality disorders.

With regards to the above-mentioned dimension of impulsivity-compulsivity, personality pathology in eating disorders is related with specific forms of neurotransmitter dysregulation, anorexia and bulimia lying at opposite ends of a personality continuum defined by compulsivity at the anorexic end and impulsivity at the bulimic (Skodol, Oldham, et al., 1993). Following this theory, patients with anorexia are most frequently diagnosed with cluster C (anxious/avoidant) personality disorders, whereas bulimic patients are more likely to receive cluster B (dramatic/erratic) diagnoses. Another usual finding refers to the association between bulimia and borderline personality disorder (Herzog, Keller, et al., 1992; Kennedy, McVey, et al., 1990; Skodol, Oldham, et al., 1993). Despite these findings, above and beyond there are a lot of studies, which fail to find a clear relationship between personality variables and eating disorders. So that, the research based on the relationships between eating disorders and personality is highly inconsistent (Gartner, Marcus, et al., 1989; Steiger, Liquornik, et al., 1991).

It is well known, that there is an extensive comorbidity of anorexic and bulimic symptoms with each other. If certain core personality traits are associated with, or contribute to, specific eating disordered behaviour, and these personality traits are in many respects polar opposites, how could one individual display both classes of symptoms, as it is represented in Figure 1? (Westen & Harnden-Fischer, 2001). In fact, patients who have a lifetime history of both disorders or who simultaneously have symptoms of both disorders more often receive a personality disorder diagnosis than patients with either bulimia or anorexia (restricting type). In addition, their personality disorder diagnoses are equally distributed in cluster B or cluster C. What could explain the inconsistency of the studies? 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 cause or contribute to the symptoms of the eating disorders (Sohlberg & Strober, 1994).

an independent course (Medina & Moreno, 1998). 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 a poor prognostic (Díaz, Carrasco, et al., 1999). Research has consistently linked anorexia (particularly restrictive type) to personality traits such as introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features (Casper, 1990). The picture for bulimia is less clear and somehow mixed. Traits such as perfectionism, shyness, and compliance have consistently emerged in studies of individuals with bulimia or with anorexia, although research has often found bulimic patients to be

Different studies have been developed based on two points of view. As a result the focus may be on how many patients suffering from eating disorders have any personality disorders, or the focus could be how many patients with personality disorders suffer from any eating disorders. In the first case there is a wide range of comorbidity, from 21% to 97% (Dolan, Evans, et al., 1994; Skodol, Oldham, et al., 1993). Following Westen & Harnden-Fischer (2001), the comorbidity between eating disorders and personality disorders could reflect the possibility a) that many patients have the random misfortune of having two or more disorders, at least one of which is on axis I and another on axis II; b) that anorexic and bulimic behaviours are symptomatic expressions of personality pathology and hence distinctions regarding syndromes, states and traits embodied in the distinction between DSM axis I and axis II may be problematic with respect to eating disorders; or c) that some common genetic or environmental diathesis underlies both eating disorders and personality

With regards to the above-mentioned dimension of impulsivity-compulsivity, personality pathology in eating disorders is related with specific forms of neurotransmitter dysregulation, anorexia and bulimia lying at opposite ends of a personality continuum defined by compulsivity at the anorexic end and impulsivity at the bulimic (Skodol, Oldham, et al., 1993). Following this theory, patients with anorexia are most frequently diagnosed with cluster C (anxious/avoidant) personality disorders, whereas bulimic patients are more likely to receive cluster B (dramatic/erratic) diagnoses. Another usual finding refers to the association between bulimia and borderline personality disorder (Herzog, Keller, et al., 1992; Kennedy, McVey, et al., 1990; Skodol, Oldham, et al., 1993). Despite these findings, above and beyond there are a lot of studies, which fail to find a clear relationship between personality variables and eating disorders. So that, the research based on the relationships between eating disorders and personality is highly inconsistent

It is well known, that there is an extensive comorbidity of anorexic and bulimic symptoms with each other. If certain core personality traits are associated with, or contribute to, specific eating disordered behaviour, and these personality traits are in many respects polar opposites, how could one individual display both classes of symptoms, as it is represented in Figure 1? (Westen & Harnden-Fischer, 2001). In fact, patients who have a lifetime history of both disorders or who simultaneously have symptoms of both disorders more often receive a personality disorder diagnosis than patients with either bulimia or anorexia (restricting type). In addition, their personality disorder diagnoses are equally distributed in cluster B or cluster C. What could explain the inconsistency of the studies? 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 cause or contribute to the

extroverted, histrionic, and affectively unstable (Vitousek & Manke, 1994).

(Gartner, Marcus, et al., 1989; Steiger, Liquornik, et al., 1991).

symptoms of the eating disorders (Sohlberg & Strober, 1994).

disorders.

Fig. 1. Comorbidity of anorexic and bulimic symptoms with each other, and core personality traits in anorexia and bulimia.

Despite the inconsistencies across different studies, the understanding of the relation between eating disorders and personality disorders is relevant, because patients with comorbid personality pathology have a worse course, greater psychological distress, greater mood disturbances, and a slower recovery than those without comorbid personality disorders (Herzog, Keller, et al., 1992; Herzog, Keller, et al., 1992; Steiger, Leung, et al., 1993; Wonderlich & Swift, 1990).

The presence of obsessiveness, rigidity, perfectionism, dependency, social inhibition or low self-sufficiency is usual among patients with anorexia nervosa, while patients with purgingtype anorexia nervosa and bulimia nervosa usually are more impulsive, and show high levels of sensitivity, emotional instability, and lower self-esteem. The association of bulimia nervosa and other disturbances (i.e., poor impulse control, self-injuries, aggressive behaviour, kleptomania, substance abuse, gambling, stealing or sexual promiscuity) is highly frequent (Braun, Sunday, et al., 1994; Gartner, Marcus, et al., 1989; Matsunaga, Kiriike, et al*.,* 1998; Steiger & Stotland, 1996; Wonderlich & Swift, 1990).

With regards to bulimia nervosa, some researches have focused on the distinction between multi-impulsive versus uni-impulsive patients (Lacey & Evans, 1986). In case of uniimpulsive 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 behaviours related to impulsivity (stealing, substance abuse, etc.). Multi-impulsive bulimic patients usually have significantly greater rates of borderline personality disorder and mood disorders than uni-impulsive bulimic patients (Lacey & Evans, 1986). These two groups of bulimic patients may represent very different kinds of patients, despite the fact that they have the same eating disorder symptoms. These two types of bulimic patients constitute an example of two possible subtypes within the general classification of bulimia nervosa that may not be easily differentiated by the eating symptoms. Nevertheless, they may differ in personality, aetiology, or function of symptoms (Westen & Harnden-Fischer, 2001).

The differences in personality style are related to clinical variables. Bulimic patients with borderline personality disorder (or any cluster B personality disorder of the DSM), display a poorer outcome across a wide range of treatments, including individual and group therapy,

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).

syndromes as anxiety or depression (von Ranson, Kaye, et al., 1999).

Fernández-Aranda, et al., 2002; Rossiter, Agras, et al., 1993).

and behaviours (Ponce de León, 2006).

**nervosa and personality disorders be interpreted?** 

León, 2006).

**2.2 How may the results about studies based on the relationship between bulimia** 

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

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

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

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,

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

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, 1990).
