**3. Impulsivity and bulimia nervosa**

In bulimic patients, the association between the specific eating disorder symptoms and many psychopathological disorders whose core seems to be the poor impulse control, such as suicide attempts, hetero-aggressive behaviour, kleptomania, alcohol abuse/dependence, substance abuse/dependence, gambling or sexual promiscuity, has long been described. The study of Clinton & Glant (1992) may be illustrative due to the fact that it reports the presence of alcohol abuse in 22.2%, drug abuse in 14.4%, and suicide attempts in 21.4% (7.1 % having performed more than one attempt) of bulimic patients. Some authors state that

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,

It is possible to interpret the association between bulimia nervosa and personality in

a. The association could be the result of an overlap between symptoms-traits, the result of methodological errors, or the concurrence of different syndromes (i.e., anxiety,

b. Bulimia nervosa and some personality disorders could have links with regards to biology and/or environment. In this case it would be appropriate to take into account

c. It could be admitted that there are two different patients, from a clinical point of view: Those who hardly fit criteria of personality disorders (these being more closely related to compulsivity), and those more closely related to impulsivity and usually suffering

 Studies based on the association between bulimia nervosa and personality styles have reported a great variability of results due to conceptual and methodological problems. Many times symptoms of the eating disorder and specific symptoms of personality disorders are overlapped, making difficult a proper evaluation of the association

 The prevalence of personality disorders among eating disorder patients shows a wide range of results, and in case of bulimia nervosa the majority of studies report

 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

 Comorbid personality disorders are generally associated with various factors such as diagnosis, greater impulsivity and self-harm, more substance abuse/dependence, more suicide attempts, more frequent purging behaviours, mood disorders, sexual abuse,

In bulimic patients, the association between the specific eating disorder symptoms and many psychopathological disorders whose core seems to be the poor impulse control, such as suicide attempts, hetero-aggressive behaviour, kleptomania, alcohol abuse/dependence, substance abuse/dependence, gambling or sexual promiscuity, has long been described. The study of Clinton & Glant (1992) may be illustrative due to the fact that it reports the presence of alcohol abuse in 22.2%, drug abuse in 14.4%, and suicide attempts in 21.4% (7.1 % having performed more than one attempt) of bulimic patients. Some authors state that

Leung et al., 1993; Wonderlich & Swift, 1990).

depression) in bulimia nervosa.

prevalence between 20% and 75%.

**3. Impulsivity and bulimia nervosa** 

becomes another one as bulimia nervosa.

the dimension impulsivity-compulsivity.

from personality disorders (mainly of cluster B).

between both bulimia nervosa and personality disorder.

greater comorbidity and severity of the eating disorder.

different ways as follows:

**2.3 Summarising** 

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

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

the definition of the different involved behaviours and the heterogeneity of the samples in

Fichter et al. (1994) defined the characteristics of multi-impulsivity, by the fact that bulimic

f. Sexual promiscuity (having sexual relations with five or more different partners in the

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

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

With regards to the reality of this type of bulimia nervosa as a clinical subgroup, there

 Besides impulsive behaviours, patients with multi-impulsive bulimia nervosa show interpersonal relationships, which are unstable (fluctuating between idealization and devaluation), self-identity problems, labile emotions, low frustration tolerance, and

It is accepted that applying the Fichter's criteria we would obtain 18%-30% of multi-

Patients with multi-impulsive bulimia nervosa usually show less treatment adherence

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

impulsive bulimia nervosa among the bulimic patients.

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

patients should have three or more of the following impulsive behaviours:

c. One or more stealing episodes (other than those related to food)

two last years, or ten or more since the puberty)

adherence and, in general, a worse prognostic.

is no consensus up to the date.

and, in general, a worse prognostic.

which the studies have been based on.

a. One or more suicide attempts b. One or more self-harm episodes

d. Alcohol abuse/dependence e. Substance abuse/dependence

Aranda, 2006).

**4.1 Summarising** 

empty feelings.

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 participants do.

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, 2006; Peñas Lledó & Waller, 2001)

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 proved efficacy.
