**4. Multi-impulsive bulimia nervosa**

The high impulsivity associated with bulimia nervosa leads to a worse prognostic, and patients with different impulsive behaviours linked to bulimic symptoms were said to comprise a subgroup, which was named as multi-impulsive bulimia nervosa. In this concept (Lacey & Evans, 1986) were included some impulsive behaviours as aggressiveness (self/hetero) expressed by suicide attempts, purging behaviours, self mutilations, burns, other forms of self-harm, sexual promiscuity, stealing, substance abuse/dependence, reckless driving or physical aggressions. In addition to the absence of consensus with regards to the reality of this type of bulimia nervosa as a clinical subgroup, there are a lot of methodological problems for its conceptualization, the main being the weak consensus on

Different psychometric studies on impulsivity as a dimension of personality usually (but non always) show that bulimic patients have higher scores on impulsivity than control

Regarding the impulsivity symptoms and bulimic symptoms, may be that both have a common base. On the other hand these symptoms would have a function, which could be the seeking of well-being and/or the avoidance of negative thoughts/emotions. Many times this function reaches a high psychopathological severity due to its self-destructive power. Impulsive behaviours as well as bingeing are usually related to intolerable negative emotions, and many times both people who binge and those with other impulsive behaviours present higher scores on coping strategies focused on emotions (Peñas Lledó,

As it was mentioned above, a neurobiological base of the impulsivity has been proposed, this being based on the serotoninergic regulation. In all disorders with this type of dysregulation, pharmacological treatments which act on serotoninergic receptors has shown

 Some authors state that studies of neurotransmitters in eating disorders suggest that in both the purging type anorexic patients and bulimic patients, as well as in the binge

 The same is referred to some psychopathological disorders whose core seems to be a poor impulse control, such as suicide attempts, hetero-aggressive behaviour, kleptomania, alcohol and other substance abuse/dependence, gambling or sexual

Some authors propose to understand bulimia as a variant of an impulse control

 Some studies propose that impulsivity among bulimic patients would be a specific eating disorder subtype. Another proposal is that impulsivity could be reflecting the

Up to date, the multi-impulsive bulimia is not accepted as a different type of bulimia

The high impulsivity associated with bulimia nervosa leads to a worse prognostic, and patients with different impulsive behaviours linked to bulimic symptoms were said to comprise a subgroup, which was named as multi-impulsive bulimia nervosa. In this concept (Lacey & Evans, 1986) were included some impulsive behaviours as aggressiveness (self/hetero) expressed by suicide attempts, purging behaviours, self mutilations, burns, other forms of self-harm, sexual promiscuity, stealing, substance abuse/dependence, reckless driving or physical aggressions. In addition to the absence of consensus with regards to the reality of this type of bulimia nervosa as a clinical subgroup, there are a lot of methodological problems for its conceptualization, the main being the weak consensus on

association between bulimia nervosa and other psychopathological disorders. Another type of studies (mainly based on psychometric assessments) states that impulsivity and bulimia nervosa would have a common base, which would be a

disorder, which would have its outer manifestation in eating behaviour.

nervosa despite many authors state its undoubted clinical presence.

eating disorder, exist a deficit of the serotonergic function.

participants do.

proved efficacy.

**3.1 Summarising** 

2006; Peñas Lledó & Waller, 2001)

promiscuity among others.

specific type of personality.

**4. Multi-impulsive bulimia nervosa** 

the definition of the different involved behaviours and the heterogeneity of the samples in which the studies have been based on.

Fichter et al. (1994) defined the characteristics of multi-impulsivity, by the fact that bulimic patients should have three or more of the following impulsive behaviours:


Besides these behaviours, patients with multi-impulsive bulimia nervosa show interpersonal relations, which are unstable (fluctuating between idealization and devaluation), selfidentity problems, labile emotions, low frustration tolerance, empty feelings, etc. (Fernández Aranda, 2006).

As it was said, the biological base of the impulsivity highlights the role of the serotoninergic system, and despite the research on candidate genes, there are no relevant conclusions up to date. The prevalence of this multi-impulsive bulimia nervosa ranges from 16%-80%. Such a wide range is due to severe methodological problems, which make it difficult to obtain a clearer conclusion. It seems that after applying the Fichter's criteria we would obtain 18%- 30% of multi-impulsive bulimia nervosa among the bulimic patients (Fernández Aranda, 2006; Fichter, Quadflieg, et al., 1994; Lacey & Evans, 1986). With regards to the personality characteristics of these patients, they show a poorer self-esteem, low level of assertiveness, and high levels of hostility among others less relevant ones. A relevant point with respect to multi-impulsive bulimia nervosa is the fact that these patients show less treatment adherence and, in general, a worse prognostic.

#### **4.1 Summarising**


## **5. Bulimia nervosa and substance abuse/dependence**

Patients with bulimia nervosa and substance abuse/dependence usually show high levels of psychopathology, impulsivity (expressed by the previously commented different behaviours), more physical problems, more hospitalizations, and poorer treatment adherence and prognostic. The risk for substance abuse/dependence among bulimic patients is much higher when bulimia nervosa is associated with other psychopathological

Among causes for death, suicide and medical problems related to the nutritional status are the most relevant in bulimia nervosa. It is said that mortality in bulimia nervosa (mean 0.3%) is lower than in anorexia nervosa. Having bulimia nervosa a shorter course than anorexia nervosa, it is difficult to state clear conclusions about mortality because the rates of mortality increase when the periods of follow-up are longer. The suicide, as cause of death in bulimia nervosa, represents the 20% of mortality. Among the patients with bulimia nervosa, almost 30% commit life-long suicide attempts. These patients seem to be different from the rest of patients with bulimia nervosa with respect to their personality and psychopathological symptoms other than the specific eating disorder symptoms (Bulik,

The relationship between self-harm behaviours and bulimia nervosa shows that the more frequent the presence of self-harms is the higher is the prevalence of bulimic symptoms. Some studies have found increased rates of self-harm associated with bulimia nervosa, but the same rate of self-harm in bulimia nervosa and in binge eating disorder. That could mean that self-harm may be associated with some common symptoms (e.g. bingeing) more than with a specific diagnostic. Among patients who binge, the presence of self-harm seems to be higher in those who have a history of physical or sexual abuse. In fact, different studies have found higher levels of impulsive behaviour (substance abuse, self-harm) in individuals who have been abused, and a high likelihood of physical or sexual abuse in individuals with eating disorders (Mitchell, Hatsukami, et al., 1988; Schmidt, Hodes et al., 1992; Suzuki,

The relationships between eating disorders and suicidal behaviour and non-suicidal selfharm have been examined primarily in eating disorder samples. Some studies suggest that suicide attempts and non-suicidal self-harm are found in more than half of bulimic patients (Franko & Keel, 2006; Svirko & Hawton, 2007). These rates appear higher in bulimia nervosa compared to anorexia nervosa, although it seems that there are similar rates of this behaviour in the anorexia nervosa purging-type as in bulimia nervosa (Favaro & Santonastaso, 2000; Nagata, Kawarada et al., 2000). In binge eating disorder, suicidal behaviour appears higher than that in obese non-binge eating disorder controls (Grucza, Przybeck, et al., 2007). Anorectic and bulimic patients with suicidal behaviour or nonsuicidal self-harm usually report greater numbers of other disorders such as drug or alcohol abuse/dependence, anxiety disorders and depression (Fedorowicz, Falissard, et al., 2007; Franko, Keel, et al., 2004). Other studies with eating disorder patients have found that anorexia and bulimia are associated with major depression (Berkman, Lohr, et al., 2007), and anorexia nervosa purging-type and bulimia nervosa are frequently associated with alcohol

Empirical studies confirm that there is a strong correlation between self-harm and eating disorders despite there are wide variations in prevalence. In fact, the reported incidence of self-harm in eating disorder patients varies in a range of 13%-68%. A higher incidence of self-harm in bulimia nervosa and anorexia nervosa purging-type than in the anorexia nervosa restrictive type has been reported. Possible common factors are impulsivity, obsessive-compulsive traits, dissociation, trauma, conflict in the family environment and sensitivity to cultural factors, among others. Both self-harm and eating disorders may represent failures in emotion regulation, and both forms of body practices could act as an attempt to a more affective coping (Dohm, Striegel-Moore, et al., 2002; Franko & Keel, 2006;

Sullivan, et al., 1999; Corcos, Taieb, et al., 2002; Favaro & Santoanastaso, 1996).

**6. Bulimia nervosa and self-harm** 

Takeda et al., 1995; Welch & Fairburn, 1996).

use disorders (Bulik, Klump, et al., 2004).

Levitt, Sansone, et al., 2004; Svirko & Hawton, 2007).

disorders. Depending on the associated disorder that risk may be increased from 2 (depression) to 7 times (bipolar disorder) (Bulik, Sullivan, et al., 1997; Holderness, Brooks-Gunn, et al., 1994).

In general, the rates of substance abuse/dependence are higher among patients with eating disorders and this association is greater among women with bulimia nervosa and anorexia nervosa purging-type, for both alcohol and illicit drug disorders. With respect to the onset of each disorder, it seems that there is a bidirectional association. Some patients report the onset of a substance abuse/dependence to precede the eating disorder and vice versa (Baker, Mitchell, et al., 2010).

Up to date the reason of such a frequent association remains unclear, and different biological and psychological explanations have been proposed. As a result of families and twin studies, it seems that there are shared genetic influences between bulimia nervosa and substance abuse/dependence. With respect to bulimia nervosa and alcohol abuse/dependence distinct genetic factors have been reported. In addition to the diagnostics, some common genetic factors have been described for the covariance between bulimic symptoms and substance abuse/dependence symptoms, and this relationship could be more relevant than the relation between diagnostics is. In fact, the more severe the eating disorder symptoms, the greater the number of substance types used (Baker, Mitchell, et al., 2010).

Recent literature has shown that patients with bulimia nervosa are two to three times more likely to have an alcohol or illicit drug abuse/dependence. In many cases bulimia nervosa manifests before a substance abuse/dependence, binge eating preceding symptoms of substance abuse/dependence. With respect to specific symptoms, the concern about weight and shape in women with a history of binge eating is usually associated with different substance abuse/dependence (increasing risk by 2). It seems that binge eating, purging behaviours, and body image would be associated with alcohol use disorder and that purging behaviours would be associated with illicit drug use disorders. Some results on the association between symptoms of bulimia nervosa and substance abuse/dependence have lead to the hypothesis of bulimia nervosa as an addictive disorder, and it could be that there is a general vulnerability to bulimia nervosa and substances misuse and that additional factors (e.g., personality) determine which behaviours arise. (Bulik, 1987; Holderness, Brooks-Gunn et al., 1994; Kaye, Lilenfeld, et al., 1996).

#### **5.1 Summarising**


disorders. Depending on the associated disorder that risk may be increased from 2 (depression) to 7 times (bipolar disorder) (Bulik, Sullivan, et al., 1997; Holderness, Brooks-

In general, the rates of substance abuse/dependence are higher among patients with eating disorders and this association is greater among women with bulimia nervosa and anorexia nervosa purging-type, for both alcohol and illicit drug disorders. With respect to the onset of each disorder, it seems that there is a bidirectional association. Some patients report the onset of a substance abuse/dependence to precede the eating disorder and vice versa

Up to date the reason of such a frequent association remains unclear, and different biological and psychological explanations have been proposed. As a result of families and twin studies, it seems that there are shared genetic influences between bulimia nervosa and substance abuse/dependence. With respect to bulimia nervosa and alcohol abuse/dependence distinct genetic factors have been reported. In addition to the diagnostics, some common genetic factors have been described for the covariance between bulimic symptoms and substance abuse/dependence symptoms, and this relationship could be more relevant than the relation between diagnostics is. In fact, the more severe the eating disorder symptoms, the greater the number of substance types used (Baker, Mitchell, et al.,

Recent literature has shown that patients with bulimia nervosa are two to three times more likely to have an alcohol or illicit drug abuse/dependence. In many cases bulimia nervosa manifests before a substance abuse/dependence, binge eating preceding symptoms of substance abuse/dependence. With respect to specific symptoms, the concern about weight and shape in women with a history of binge eating is usually associated with different substance abuse/dependence (increasing risk by 2). It seems that binge eating, purging behaviours, and body image would be associated with alcohol use disorder and that purging behaviours would be associated with illicit drug use disorders. Some results on the association between symptoms of bulimia nervosa and substance abuse/dependence have lead to the hypothesis of bulimia nervosa as an addictive disorder, and it could be that there is a general vulnerability to bulimia nervosa and substances misuse and that additional factors (e.g., personality) determine which behaviours arise. (Bulik, 1987; Holderness,

 Patients with bulimia nervosa and substance abuse/dependence usually show high levels of psychopathology, impulsivity, more physical problems, more hospitalizations,

 The rates of substance abuse/dependence are higher among patients with eating disorders and this association is greater among women with bulimia nervosa and

Up to date the reason of such a frequent association remains unclear, and different

 Some results on the association between symptoms of bulimia nervosa and substance abuse/dependence have lead to the hypothesis of bulimia nervosa as an addictive

Gunn, et al., 1994).

2010).

**5.1 Summarising** 

disorder.

(Baker, Mitchell, et al., 2010).

Brooks-Gunn et al., 1994; Kaye, Lilenfeld, et al., 1996).

and poorer treatment adherence and prognostic.

biological and psychological explanations have been proposed.

anorexia nervosa purging-type.

#### **6. Bulimia nervosa and self-harm**

Among causes for death, suicide and medical problems related to the nutritional status are the most relevant in bulimia nervosa. It is said that mortality in bulimia nervosa (mean 0.3%) is lower than in anorexia nervosa. Having bulimia nervosa a shorter course than anorexia nervosa, it is difficult to state clear conclusions about mortality because the rates of mortality increase when the periods of follow-up are longer. The suicide, as cause of death in bulimia nervosa, represents the 20% of mortality. Among the patients with bulimia nervosa, almost 30% commit life-long suicide attempts. These patients seem to be different from the rest of patients with bulimia nervosa with respect to their personality and psychopathological symptoms other than the specific eating disorder symptoms (Bulik, Sullivan, et al., 1999; Corcos, Taieb, et al., 2002; Favaro & Santoanastaso, 1996).

The relationship between self-harm behaviours and bulimia nervosa shows that the more frequent the presence of self-harms is the higher is the prevalence of bulimic symptoms. Some studies have found increased rates of self-harm associated with bulimia nervosa, but the same rate of self-harm in bulimia nervosa and in binge eating disorder. That could mean that self-harm may be associated with some common symptoms (e.g. bingeing) more than with a specific diagnostic. Among patients who binge, the presence of self-harm seems to be higher in those who have a history of physical or sexual abuse. In fact, different studies have found higher levels of impulsive behaviour (substance abuse, self-harm) in individuals who have been abused, and a high likelihood of physical or sexual abuse in individuals with eating disorders (Mitchell, Hatsukami, et al., 1988; Schmidt, Hodes et al., 1992; Suzuki, Takeda et al., 1995; Welch & Fairburn, 1996).

The relationships between eating disorders and suicidal behaviour and non-suicidal selfharm have been examined primarily in eating disorder samples. Some studies suggest that suicide attempts and non-suicidal self-harm are found in more than half of bulimic patients (Franko & Keel, 2006; Svirko & Hawton, 2007). These rates appear higher in bulimia nervosa compared to anorexia nervosa, although it seems that there are similar rates of this behaviour in the anorexia nervosa purging-type as in bulimia nervosa (Favaro & Santonastaso, 2000; Nagata, Kawarada et al., 2000). In binge eating disorder, suicidal behaviour appears higher than that in obese non-binge eating disorder controls (Grucza, Przybeck, et al., 2007). Anorectic and bulimic patients with suicidal behaviour or nonsuicidal self-harm usually report greater numbers of other disorders such as drug or alcohol abuse/dependence, anxiety disorders and depression (Fedorowicz, Falissard, et al., 2007; Franko, Keel, et al., 2004). Other studies with eating disorder patients have found that anorexia and bulimia are associated with major depression (Berkman, Lohr, et al., 2007), and anorexia nervosa purging-type and bulimia nervosa are frequently associated with alcohol use disorders (Bulik, Klump, et al., 2004).

Empirical studies confirm that there is a strong correlation between self-harm and eating disorders despite there are wide variations in prevalence. In fact, the reported incidence of self-harm in eating disorder patients varies in a range of 13%-68%. A higher incidence of self-harm in bulimia nervosa and anorexia nervosa purging-type than in the anorexia nervosa restrictive type has been reported. Possible common factors are impulsivity, obsessive-compulsive traits, dissociation, trauma, conflict in the family environment and sensitivity to cultural factors, among others. Both self-harm and eating disorders may represent failures in emotion regulation, and both forms of body practices could act as an attempt to a more affective coping (Dohm, Striegel-Moore, et al., 2002; Franko & Keel, 2006; Levitt, Sansone, et al., 2004; Svirko & Hawton, 2007).

The type of personality disorder most frequently observed in patients diagnosed with

 Impulsivity is the most consistent distinguishing finding described in bulimia nervosa. Patients with bulimia nervosa and personality disorders often have an additional Axis I disorder, the most common being major depression and/or substance

In initial studies it was considered that the role played by coping strategies in eating behaviours was not clear (Wolff, Crosby, et al., 2000). Later on, it has been indicated that difficulties on emotion control explain better the occurrence of binge eating than eating restriction or weight and corporal image overestimation do (Whiteside, Chen, et al., 2007), so that in a binge disorder explanatory model emotional vulnerability and deficient strategies for the regulation of emotions would be included. Patients with eating disorders are more inclined to avoid affection than to the acceptance and control of emotions

Coping strategies have been related to the prognostic of eating disorders and it has been observed that impulsiveness, present in some of its forms, is connected to maladaptive

 The specificity of deficient coping strategies found in patients with eating disorders has also been discussed. With respect to bulimia nervosa, it has been observed that the tendency to avoidance, understood as a coping strategy, could be more related to a depressive than to a bulimic symptomatology. However, other strategies such as problem solving or cognitive restructuring do not seem to differ depending on depressive symptoms (Tobin & Griffing,

The problem to be confronted when it´s time to assess how different coping strategies with a determined symptomatology or personality styles relate to each other lies in the fact that interrelations among different strategies are very frequent. (Folkman & Moskovitz, 2004). The studies which have related coping strategies and personality usually conclude that emotionally stable, extrovert and responsible people tend to solve situations or change the meaning of these situations perceiving their coping as efficient, while unstable and introvert people are used to withdraw from society and usually wish the situation had not occurred, perceiving little efficiency in their coping (Bouchard, 2003; Cano, Rodríguez, et al., 2007;

Knowledge about coping strategies in patients with eating disorders is relevant and this relevance does not only lie in a theoretical interest or in its relationship with comorbidity or personality characteristics but also in a therapeutic interest. Hence, learning of new and more adaptive forms of coping with problems and emotions is essential in some treatment

In a recent study (Jáuregui Lobera, Estébanez, et al., 2009), it was observed that patients with eating disorders showed more self-criticism, social withdrawal, inadequate control centred upon emotions and inadequate control in general. On the contrary, a group of students showed bigger scores at problem solving, social support, cognitive restructuring, adequate control centred upon problems, and adequate control in general. Perceived self-efficacy was greater in the student group too. Regarding personality features in the group of patients, punctuation in introversion was significantly greater, while in the group of students

forms for these pathologies (Foa & Wilson, 1991; Peterson, Wonderlich, et al., 2004).

**9. A model of a new approach: Eating disorders and coping strategies** 

bulimia nervosa is the borderline personality disorder.

strategies of emotional regulation (Nagata, Matsuyama, et al., 2000).

abuse/dependence.

(Corstorphine, Mountford, et al., 2007).

1995).

David & Suls, 1999).

#### **6.1 Summarising**

