G. Abbate Daga

Temperament and character in eating disorders: Ten years of studies

In recent years a number of studies of personality have been performed in subjects with Eating Disorders (EDs) to investigate the clinical differences between controls and ED patients and among EDs subtypes, and its role in the development and course of symptoms. The Tridimensional Personality Questionnaire (TPQ) and the Temperament and Character Inventory (TCI) have been widely used at this purpose, allowing the description of specific temperament and character profiles for EDs. High Harm Avoidance (HA) and low Self-Directedness (SD) are shared by all EDs. Slight differences on some facets have been found among ED subgroups. Nevertheless, HA is influenced by mood and both high HA and low SD are personality traits shared by many mental disorders, whose specificity is rather low. Restrictor anorectics are characterized by high Persistence (P) and a relatively higher SD, and bulimics by higher Novelty Seeking (NS) and the lowest SD, while binge/purging and purging anorectics share some traits with anorexia and some with bulimia. Though current data justify the discrimination among anorexia subtypes, they are not in contrast with the thesis of a continuum in ED personality traits. Since some personality traits display a prognostic value with regard to therapy and clinical outcome, further studies are needed on treatments and prognostic factors in EDs. Moreover, studies attempting to define the neurobiological and genetic correlates of temperament should be supported by clinical pharmacological trials.

Dropout from Brief Psychotherapy in Anorexia nervosa

Background: Dropout from psychotherapy is an important issue that has received little systematic attention. This study investigated the phenomenon of dropout from brief psychotherapy for anorexia nervosa (AN). Methods: 99 outpatients suffering from AN of the restrictor type (n = 53) or binge/purging type (n = 46) were evaluated. Their clinical and personal characteristics were recorded, and body mass index was calculated for participants. They were administered the Eating Disorder Inventory-II (EDI-II), the State-Trait Anger Expression Inventory (STAXI) and the Temperament and Character Inventory (TCI). Results: Significant differences in some baseline psychopathologic (EDI-II, STAXI) and personality (TCI) variables emerged from the comparison between dropouts and completers. Patients who dropped out of the treatment showed higher levels of anger temperament, anger expression-in and expression-out and lower scores for the dimensions of character (low self-directedness and low cooperativeness). No differences were found between the two groups regarding sociodemographic and clinical variables. Conclusions: Dropout from brief psychotherapy seems to be related to either psychopathologic or personality aspects, such as the tendency to repress anger, which is encountered also in psychosomatic disorders, and the presence of more compromised dimensions of character, typical of subjects with personality disorders. This study of dropout from brief psychotherapy in AN provided interesting results that will need further confirmation. Possible implications for treatment are addressed.

Outcome predictors in anorectic patients after 6 months of multimodal treatment.

Background: Anorexia nervosa is asevere disorder that often responds poorly to treatment. At this time, little is known about pretreatment predictors of response. Methods: A sample of 42 restrictor type anorectics was tested at the assessment phase and after 180 days retested using the Temperament and Character Inventory and Eating Disorder Inventory 2 along with other clinical evaluation instruments. After 180 days of treatment with multimodal ‘network’ therapy, the patients were divided into two groups. The first group included patients who showed relevant clinical improvement; the second group included patients considered ‘not yet responding’. Data collected from the not-yet-responding group were compared by the t test with the other group’s data to evaluate prognostic indexes. Results: Diagnosis of personality disorder, which afflicted about 50% of patients, seemed not to be a relevant prognostic factor. However, a lower novelty seeking was characteristic of the nonresponder group. Higher levels of asceticism and maturity fears also characterized the nonresponder group. Conclusion: Present data suggest some elements that could be useful to focus pharmacotherapy, psychotherapy and family counseling on the current psychopathology of each patient.

The Temperament and Character Inventory in women with migraine

The purpose of this work was to investigate: (1) the differences in temperament and character between 49 women with migraine and 49 controls using the Temperament and Character Inventory (TCI), and (2) the extent to which these differences were related to migraine or to the presence of comorbid depression. The migraine patients scored significantly higher than the controls in two temperament dimensions—Harm Avoidance (HA) and Persistence (P)—and significantly lower in one character dimension—Self-Directedness (SDir) (Student’s t). After multiple logistic regression, the TCI P and HA dimensions were significantly associated with the presence of migraine. The HA dimension was also related to the presence of depression. Our results show that in migraine the higher HA score could be partly associated to comorbid depression while the high P dimension seems to be solely related to the presence of migraine.

Baseline personality characteristics of responders to 6-month psychotherapy in eating disorders: Preliminary data

Objective.The Karolinska Psychodynamic Profile (KAPP) was used for the assessment of the six-month outcome of Brief Adlerian Psychodynamic Psychotherapy (B-APP). Method.Fifty-seven eating disordered women (28 with anorexia nervosa, 29 with bulimia nervosa), were included in the study. The sample was evaluated at baseline (time 0) and after six months (T6) with a clinical assessment and with Temperament and Character Inventory (TCI), Eating Disorder Inventory (EDI-2), State-Trait Anger Expression Inventory (STAXI), and KAPP. Results.Based on symptomatologic improvement, two sub-groups were obtained: responders (66.6%) and non-responders (33.3%). Significantly higher baseline scores emerged in the responders group on Ineffectiveness and Impulsivity (EDI-2) and on Harm Avoidance (TCI). Several KAPP items and areas improved in both groups at T6. Conclusion.Multimodal treatment centered on B-APP lead to both a global clinical improvement and an improvement in several psychological and psychopathological features as assessed by EDI-2, STAXI and KAPP. The results suggest interesting clinical implications, though outcome predictors are quite weak.

Nonresponder anorectic patients after 6 months of multimodal treatment: predictors of outcome

Currently the therapy of anorexia nervosa is a relevant clinical problem. The percentage of patients who respond to short-term pharmacotherapy and psychotherapy is still low and the condition often leads to chronic pathology or death. The present study aims to determine outcome predictors beyond personality traits, eating psychopathology, or particular clinical features. Forty patients with restricter type anorexia nervosa were tested, at T0 and after 180 days, with psychometric tests and clinical evaluation instruments. Patients were then divided into two groups. One group included patients who showed relevant clinical improvement; the other included not-yet-improved patients. A lower Novelty Seeking, higher levels of Ascetism and Maturity Fears characterised the not-yet-improved group. Correlation showed evidence of diverse bonds between personality and psychopathology in the improved and not-yet-improved groups. The psychopathology of non-yet-improved patients seemed to be more linked to their temperamental features, whereas improved patients seemed to be more influenced by their character. Different levels of psychological functioning can be expressed. The present data suggest focusing pharmacotherapy and psychotherapy, even family counseling, with a progression more strictly related to the current personality functioning level and psychopathology of each patient.

Eating disorders and the Internet: cure and curse

OBJECTIVE: The role of culture and the mass-media in relation to eating disorders (EDs) is widely acknowledged, and the Internet has become an important part of this over the last few years. The aim of this report is to suggest the general features and potential clinical implications of “pro-Ana” websites and those concerning the treatment of EDs. METHOD: We conducted a Google search using the key words “anorexia nervosa (AN) and treatment”, “AN and psychotherapy”, “AN and pharmacotherapy”, and then “pro-anorexia”, “pro-ana sites”, “thinspiration” and “anorexicnation”. RESULTS: The first group of queries gave respectively 546,000, 212,000 and 39,100 results; the second 257,000, 18,600, 14,200 and 577. Forty-seven of 100 randomly selected pro-ana websites were thoroughly visited. CONCLUSIONS: Internet websites may increase the accessibility of treatments but also strengthen some of the core psychopathological and symptomatological issues of AN, such as asceticism, competition, purging behaviours and obsession for control. Greater attention should be paid to the health policy of countries in which pro-ana websites flourish, and the clinical implications of the websites themselves.

Hormonal and metabolic responses to acute ghrelin administration in patients with bulimia nervosa

Ghrelin is generally influenced by energy balance status and is inversely associated with body mass index (BMI), being reduced in simple obesity, notable exception being Prader Willi syndrome, and elevated in several conditions of undernutrition, including anorexia nervosa (AN). Interestingly, ghrelin levels have also been found elevated in patients with bulimia nervosa (BN) in spite of normal BMI. In humans, intravenous (iv) ghrelin administration induces endocrine (increase in GH, PRL, ACTH and cortisol) and metabolic (increase in glucose and decrease in insulin) effects as well as an increase in appetite and food intake. In AN, ghrelin administration surprisingly leads to a decreased GH response and absence of glycemic variations but normal PRL, ACTH and insulin response. This pattern would reflect a decrease in sensitivity to ghrelin or, alternatively, the metabolic status of AN. To further clarify the function of ghrelin in eating disorders, the endocrine and metabolic response to acute iv ghrelin (1.0 microg/kg) was studied in seven young women with purging BN (BW, BMI, mean+/-SEM: 20.3+/-0.5 kg/m2). Circulating total ghrelin levels were also measured. The results in BW were compared to those recorded in a group of nine healthy women (HW; BMI 22.3+/-2.5 kg/m2). The GH response to ghrelin in BW overlapped with that in HW. Ghrelin administration also led to a similar increase in PRL, ACTH, cortisol and glucose levels in the two groups. Insulin levels were not significantly modified by ghrelin administration in either group. The overlapping endocrine and metabolic response to ghrelin in the two groups occurred with regard to circulating total ghrelin levels which were higher in BW than in HW. In conclusion, BN, a condition of ghrelin hypersecretion, is connoted by a normal endocrine and metabolic response to exogenous ghrelin administration.

Major Depression and Avoidant Personality Traits in Eating Disorders

Statistical analyses were carried out using SPSS software, version 13.0 for Windows. Categorical data were compared using the 2 test, and continuous data were analyzed using a two-tailed independent t test. Subjects with MD represented 17.4% (n = 121) of the sample, with the following ED subtypes: 13.2% restricting type of AN (n = 20), 24% binge-eating/purging type of AN (n = 18), 21.2% BN (n = 40) and 15.4% ED not otherwise specified (n = 43). No significant differences were found among ED subtypes ( 2 : 7.162; p ! 0.067), but patients with MD reported more frequent episodes of binge eating than patients without MD (5.6 8 8.2 vs. 3.51 8 5.9 episodes/week; F: 8.46; p ! 0.004) after controlling for BMI (based on investigators’ measurements), age, duration of the disorder and ED diagnosis (clinical variables). Moreover, subjects with MD more often reported self-induced vomiting (5.1 8 8.8 vs. 3.3 8 6.2; F: 5.89; p ! 0.015), after controlling for age and clinical variables. Patients with MD did not differ from those without MD with regard to age, age of onset of the disorder, duration of the disorder and BMI (data not shown). The BMI in the binge-eating/purging AN subgroup was lower in patients with MD than in those without MD (data not shown). The BDI scores of subjects with MD were significantly different from those without MD (35.1 8 3.3 vs. 10.9 8 5.8; F: 550.5; p ! 0.001), after controlling for age and clinical variables. In addition, the BDI scores of 306 patients (44.1% of the sample) who were not diagnosed with MD were The lifetime prevalence of mood disorders in anorexia nervosa (AN) varies between 64.1 and 96%, and between 50 and 90% in bulimia nervosa (BN). Moreover, the prevalence of comorbid mood disorders among patients diagnosed with eating disorders (ED) is also high, between 12.7 and 68% among those with AN and 40% among those with BN [1] . The severity of depressive symptomatology seems to correlate with the severity of the ED [2–4] . Unfortunately, previous studies showed several limitations. Other factors that should be addressed are depressive personality traits. Instability and emotional liability, avoidant behaviors and depressive traits have been frequently found in ED patients [5, 6] . Some studies [7–9] have identified groups of patients with comorbid avoidant behaviors, depressed mood and constricted affect. This study aimed to (a) assess the prevalence of current major depression (MD) in a clinical sample of female patients with ED, (b) confirm the correlation between ED severity and diagnosis of MD, and (c) assess the differences in personality traits between ED patients with and without MD. The sample consisted of 693 patients admitted to the outpatient service of the ED Program of Turin University between January 1, 2003, and October 30, 2007. All subjects were diagnosed with an ED: AN, restricting type, n = 151; AN, binge-eating/purging type, n = 75; BN, purging type, n = 188; ED not otherwise specified, n = 279. Diagnoses of ED and MD were based on the Structured Clinical Interview for DSM-IV [10] . Exclusion criteria were (a) severe medical comorbidity (e.g. epilepsy or diabetes), (b) current drug abuse and (c) male gender. The first two assessment interviews were conducted by psychiatrists experienced in the diagnosis and treatment of ED. Between the first and the second interviews, patients completed some self-report questionnaires: Eating Disorder Inventory 2 [11] , Beck Depression Inventory (BDI) [12] and Temperament and Character Inventory [13] . After complete description of the study to the subjects, written informed consent was obtained. Received: February 3, 2009 Accepted after revision: February 1, 2011 Published online: June 30, 2011

The adrenal sensitivity to ACTH stimulation is preserved in anorexia nervosa

Hyperactivity of hypothalamus-pituitary-adrenal (HPA) axis in anorexia nervosa (AN) has been demonstrated and is likely to reflect a central nervous system (CNS)-mediated effect of starvation. Alterations in the adrenal response to ACTH in AN have also been reported by some authors. In order to define the adrenal sensitivity to ACTH in this condition, we studied cortisol (F), aldosterone (A) and DHEA responses to the sequential administration of low and supramaximal ACTH 1–24 doses (0.06 μg/m2 ACTH 1–24 iv at 0 min and 250 μg ACTH 1–24 iv at +60 min, respectively) in 10 young women with AN [ANW, age 21.2±0.9 yr, body mass index (BMI) 15.7±0.6 kg/m2]. The results in this group were compared with those recorded in 10 healthy normal women (HW, 23.4±1.1 yr, 21.9±0.9 kg/m2).In ANW urinary F levels were similar to those in HW. Basal serum F, A and DHEA levels in ANW were not significantly different from those in HW. In HW the lowest ACTH dose induced a significant (p<0.05) increase of F, A and DHEA. The maximal ACTH dose induced F, A and DHEA increases greater (p<0.05) than those induced by the lowest ACTH dose. In ANW both ACTH doses induced significant (p<0.05) F and DHEA increases which were not significantly different from those in HW, though a trend toward a lower cortisol response after ACTH 0.06 μg/m2 in ANW was present. Like in HW, in ANW the maximal ACTH dose induced F and DHEA increases greater (p<0.01) than those induced by the lowest dose. Unlike HW, in ANW A levels did not increase after the lowest ACTH dose while they increased after the maximal one overlapping the response in HW.In conclusion, the cortisol and DHEA responses to a very low and a supra-maximal ACTH dose in patients with AN were similar to those in healthy subjects, indicating that the sensitivity to ACTH of the fasciculata and reticularis adrenal zones is preserved in this condition.On the other hand, a reduced sensitivity to ACTH of the glomerularis adrenal zone in patients with AN is suggested by the lack of aldosterone response to the lowest corticotropin dose.