Frederic Atger

Comorbidity of Dependent Personality Disorder and Separation Anxiety Disorder in Addictive Disorders and in Healthy Subjects

The aim of the study was to determine the comorbidity of dependent personality disorder (DPD) and separation anxiety disorder (SAD) in large nonclinical and clinical samples. Using a cross-sectional method, the relationship between these disorders was studied in 784 healthy subjects and in 708 subjects presenting with various addictive behaviors. DPD was significantly associated with SAD in healthy subjects, alcoholics, drug abusers and anorectic and bulimic patients. The comorbidities of SAD and DPD suggest that specific therapeutic strategies could be discussed. Moreover, longitudinal studies are required to determine if SAD constitutes a risk factor for DPD.

Treatment of adolescent patients with eating disorders: Description of a psychodynamic approach in clinical practice

Anorexia nervosa (AN) is now usually considered to be a multifactorial disorder, and there is a consensus among clinicians that its treatment should be aimed at restoring weight, altering anorexic attitudes, treating any medical complications, supporting and treating the family, enhancing autonomy, facilitating identity formation, and increasing self-esteem by means of psychotherapy. The practical aspects of such treatments not only vary from country to country, but sometimes also from one treatment team to another. International meetings dedicate considerable discussion to the subject but, as it seems to be relatively ignored in the published literature, we here describe the main elements of our own method.

Binge eating behaviours, depression and weight control strategies

The aim of this paper was to explore the relationships between depressive symptoms and weight control strategies in DSM-IV eating disordered patients with binge eating behaviours. We hypothesised that weight control strategies characterised by a loss of control, such as vomiting and purging, may be clinically associated with increased levels of depression. The study population consisted of 402 consecutive outpatients: 27 with binge eating/purging anorexia nervosa (AN-BN), 213 with purging bulimia nervosa (BN-P), 73 with non-purging bulimia nervosa (BN-NP), and 89 with binge eating disorder (BED). The severity of depression was measured using the Beck Depression Inventory (BDI), and binge eating behaviours were investigated using the self-report scale for bulimic behaviours. In the sample as a whole, the severity of depression significantly correlated with the severity of binge eating behaviours, but no significant differences were found in the severity of depression by diagnostic sub-types. In order to avoid the confounding erasing effect of time, a smaller sample of patients with a short history of binge eating behaviours was further explored. Furthermore, because weight control strategies and the eating disorder diagnostic sub-types overlapped imperfectly, the patients were compared on the basis of presence or absence of strategies reflecting an active attempt to master the weight gain due to binge-ing behaviours. The patients adopting active control strategies (N=14) had significantly less severe depressive symptoms than those adopting non-active weight control strategies (N=39). Finally, the Authors discuss some hypotheses concerning the defensive role of weight control strategies and the impact of illness duration on the clinical expression of depression in eating disordered patients.

The Quality of Depressive Experience as a Prognostic Factor in Eating Disorders

There is overwhelming evidence that depression is one of the most common experiences of eating disorder patients (Herzog et al., 1992; Touchette et al., 2010). Individuals with anorexia or bulimia nervosa commonly display high levels of dysphoric affects, feelings of emptiness and ineffectiveness and emotions such as loneliness and desperation (Bruch 1973). Self-depreciating emotions associated with pathological eating behaviors may probably trigger depressive episodes (Nolen-Hoesema et al., 2007). However, several authors have suggested that eating behaviors themselves (whether starving, bingeing or purging) may serve as adaptive strategies to regulate negative emotions, such as those associated with identity and interpersonal disturbances, frequently seen in these patients (Heatherton et Baumeister, 1991). For these reasons, it seems worthwhile, in eating disorders, to look for depression not only in a categorical way but also in a dimensional way and to explore the subjective experience of depression of these patients. This is in line with recent conceptualizations on depression from different theoretical perspectives which converge towards the identification of two types of fundamental depressive experiences framed by personality development: the first one focused on concerns associated with disruption in relationships with others (with feelings of loss, abandonment and loneliness) and the second one centered on problems concerning identity (associated with low self-esteem, feelings of failure, culpability, lack of self-confidence) (Blatt and Zuroff 1992). According to Blatt (Blatt, 2004), maladaptive behaviors would emanate directly from an overemphasis and exaggeration of one of the two essential developmental lines of the personality: the Dependent/Anaclitic line, which concerns the establishment of satisfying interpersonal relationships, and the Selfcritical/Introjective line, which focuses on the achievement of a positive and cohesive sense of self (Blatt and Zuroff 1992). Blatt and colleagues have initially developed the Depressive Experience Questionnaire (DEQ) to assess these two dimensions which emerge as independent factors in analytic studies (Blatt et al., 1976). However, subsequent theoretical developments have suggested that different levels could be indentified, each following a developmental trajectory from immature to more mature forms of interpersonal relatedness and self-definition.