G.G. Rovera

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.

Evidence for a positive correlation between serum cortisol levels and IL-1β production by peripheral mononuclear cells in anorexia nervosa

A hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis has been reported in anorexia nervosa (AN), together with some immunological abnormalities, involving citokine — and particularly Tumor Necrosis-Factor-α (TNF-α) — production by polymorphonuclear cells. The ability of pro-inflammatory cytokines to activate the HPA axis is well known; however, there are no data demonstrating an interdependence between immunological and endocrine response in AN. To investigate the presence of a correlation between immune response and pituitary-adrenal function, plasma ACTH and serum cortisol concentrations were measured in 13 AN patients and in the same number of controls. TNF-α and interleukin (IL)-1β production by ex-vivo unstimulated and LPS-stimulated peripheral mononuclear cells was also assessed. Circulating cortisol concentrations were higher (p<0.01) in AN (156.7±45.1 μg/l, mean±SD) than in controls (105.9±25.7 μg/l). Unstimulated IL-1β release in supernatants of mononuclear cell cultures was slightly but not significantly higher in AN than in controls, while TNF-α release was similar in the two groups. A positive correlation was found between IL-1β concentrations in unstimulated culture supranatants and serum cortisol levels in AN (r=0.782, p=0.002), while in normal subjects there was a trend toward a negative correlation; a slight positive correlation, while not significant, between IL-1β and plasma ACTH, as well as between TNF-α and serum cortisol was also found in AN. These data suggest that the normal relationship between pro-inflammatory cytokines release, particularly IL-1β and cortisol secretion is deranged in AN.

Temperament and character in Italian men with anorexia nervosa: A controlled study with the temperament and character inventory

This study compares personality traits of men and women with anorexia nervosa and matched controls. The Temperament and Character Inventory was used to assess personality traits of 15 male and 50 female anorectics and 28 male and 58 female controls matched for age and education. Male anorectic patients displayed overall lower reward dependence and cooperativeness. Male and female anorectics displayed higher persistence and lower self-directedness than controls. Anorectic men had lower harm avoidance than anorectic women. Discriminating analysis revealed the anorectic male group as the most clearly defined. Anorectic men shared more traits with anorectic women than with male controls. Temperament and character of anorectic men reflect features partly similar to those of women with anorexia. Personal history and discriminating analysis led to interesting inferences about the gender identity of anorectic men. These results should be helpful in directing pharmacologic and psychotherapeutic approaches that consider the specific personality traits of these patients.

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.

Combining the Rorschach test and the Temperament Character Inventory: a new perspective on personality assessment.

Background: The numerous reports on research involving the clinical assessment of personality in axis I disorders highlight the importance of temperament features in the current approach to all mental disorders. However, the available instruments of personality assessment have many limits. Self-administered questionnaires depend on the patient’s insight, and projective instruments (i.e. the Rorschach test) often lack objectivity. This study compared the results of personality assessment with the Temperament and Character Inventory (TCI) and the Rorschach test to verify their validity. Patients and Methods: TCI and Rorschach tests were administered to a wide sample of patients (n = 180) in a short period. The most common Rorschach siglatures were correlated with the TCI raw scores using the Pearson correlation test. Results: All TCI temperament dimensions and facets displayed at least two correlations with Rorschach siglatures. The description of each dimension and facet of the TCI obtained with the interpretation of Rorschach siglatures was consistent with its original meaning. Conclusions: The TCI and Rorschach tests adequately validated each other. In the future, the administration and integration of these tests will overcome the biases of both. Further, the theoretical bases of the TCI could facilitate the study of psychological functions, whereas the psychodynamic bases of the Rorschach test provide an in-depth insight into temperament traits.

Prolonged treatment with glycerophosphocholine, an acetylcholine precursor, does not disclose the potentiating effect of cholinesterase inhibitors on GHRH-induced somatotroph secretion in anorexia nervosa

Unlike normal subjects, in patients with anorexia nervosa (AN) the GH response to GHRH is refractory to the increasing and inhibitory effect of cholinergic agonists and antagonists, respectively. This cholinergic impairment could reflect malnutrition-induced exhaustion of acetylcholine (Ach) precursors. We studied whether treatment with glycerophosphocholine (GLY), an Ach precursor, could disclose the potentiating effect of pyridostigmine (PD) on the GH response to GHRH in AN. In 6 young women with AN (AW) we studied the GH response to iv GHRH (1.0 μg/kg) alone and combined with oral PD (120 mg) before and after 1 month of oral treatment with GLY (400 mg thrice daily). Eight age-matched normal women (NW) were studied as controls. Before GLY, basal GH levels in AW were higher (p<0.05) than in NW. The GH response to GHRH in AW was higher (p<0.05) than in NW. PD failed to modify the GHRH-induced GH rise in AW, while it enhanced it in NW (p<0.05). One month treatment with GLY in AW did not modify the GH response to GHRH either alone or combined with PD. This study shows the existence of a derangement in the cholinergic control of somatotroph function in AN and indicates that treatment with Ach precursors does not exert any effect on this impairment. This could reflect primary alterations of cholinergic neurons, though the effectiveness of more prolonged treatment and/or higher doses of cholinergic precursors needs to be verified.

Earliest recollections in anorexia and bulimia

Earliest Recollections (ER) are very useful as they reveal information about a person’s main aims and lifestyle, according to the Individual Psychology assumption of the inner coherence of the personality. This paper looks at the utility of analyzing ER in psychopathological research, diagnosis and therapy. Its purpose is to compare particular ER in a group of anorectic outpatients, a group of bulimic outpatients and in a control group. The results provide further evidence that ER are a useful instrument to identify various aspects o family dynamics, particular pathological nuclei which are often of the borderline type. They can also help to overcome the initial hostility towards any therapy that is often present in anorectic and assist the therapist early on in drawing a mental picture of the premisses for understanding the lifestyle of the subject both as a child, and now as a patient.