by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (civilian) and Medical Director, Family Health Clinic, Wright-Patterson Medical Center in WPAFB, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US government.
Innov Clin Neurosci. 2011;8(3):14–18
Funding: There was no funding for the development and writing of this article.
Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.
Key Words: Anorexia nervosa, binge eating, borderline personality disorder, bulimia nervosa, eating disorders, laxative abuse, obsessive compulsive personality disorder, personality disorders
Abstract: Personality disorders appear to be present in a significant minority of individuals with eating disorders. For example, in contrast to reported rates in the general population of eight percent, obsessive compulsive personality is present in approximately 22 percent of individuals with anorexia, restricting type. Likewise, in contrast to rates in the general population of six percent, borderline personality is present in approximately 25 percent of individuals with anorexia nervosa, binge-eating purging type, and in 28 percent of individuals with bulimia nervosa. Could these high rates of comorbidity indicate a partially causal relationship? At the very least, these specific personality disorders may be shaping corresponding styles of eating pathology, with obsessive compulsive personality disorder partially accounting for restrictive eating pathology and borderline personality disorder partially accounting for impulsive eating pathology. These potential associations are explored.
Introduction
In the empirical literature, there are a number of identified risk factors for the development of eating disorders. Among these various psychological and biological risk factors, the potential role of personality dysfunction has received little scrutiny beyond the perspective of comorbidity. It may be that personality pathology not only partially contributes to the development of eating disorders, but may also shape the specific type of expressed eating pathology. In this edition of The Interface, we explore these two potential associations. See Table 1.
Eating Disorders: Psychiatric Disorders with Multiple Psychological Risk Factors
Eating disorders have long been conceptualized as multidetermined disorders that develop in the context of a number of potential contributory factors.[1] Identified contributory factors are numerous and include both biological and psychological variables.
While biological variables are beyond our present scope, a number of psychological risk factors for eating disorders have been described in the literature. For example, Mazzeo and Bulik[2] described parents who model eating-disordered behavior by overemphasizing the child’s weight and shape, adverse life events, the child’s distress tolerance, exposure to teasing and/or criticism about weight, and the media’s perpetuation of thin stereotypes. Striegel-Moore and Bulik[3] discuss several broad cultural factors (e.g., the social pressure in Westernized societies to be thin, upper-socioeconomic-strata dictations on body weight, and the shrinking ideal female body size since the 1950s) as well as the role of race/ethnicity (i.e., the observation that the classic eating disorders, anorexia and bulimia nervosa, predominantly affect Caucasian individuals, whereas individuals with binge eating disorder tend to demonstrate a broader racial/ethnic diversity). These influences all potentially contribute to an individual’s psychological attitudes around an acceptable body shape/weight.[3] We have also discussed several psychological variables for risk as they relate to adolescence (i.e., age of onset), being female, being exposed to sports and professional influences, suffering from specific medical disorders, such as diabetes mellitus, and experiencing negative life events.[4] While these are but a sampling of the numerous psychological risk factors identified in the literature, they provide a sense of the broad range of the potential factors associated with the development of eating disorders. In addition to this list of possibilities, there is the role of personality pathology.
The Prevalence of Personality Disorders in Eating Disorders
In 2006, we reviewed the extensive available literature regarding the prevalence of various personality disorders in individuals with the classic types of eating disorders: anorexia nervosa, restricting type; anorexia nervosa, binge-eating purging type; and bulimia nervosa.[5] Through combining data from multiple studies, we found that the most common personality disorder in anorexia nervosa, restricting type, was obsessive compulsive personality disorder, with a prevalence rate of 22 percent. For anorexia nervosa, binge-eating purging type, the most common personality disorder was borderline personality disorder, with a prevalence rate of about 25 percent. Finally, the most common personality disorder in bulimia nervosa was borderline personality disorder, with a prevalence rate of about 28 percent. Note that these rates for personality pathology are considerably higher than the overall rate of personality disorders encountered in the general population, which is estimated to be 5 to 10 percent.[6]
Our prevalence findings are in line with additional data, which indicate that anywhere from 30 to 38 percent7,8 (i.e., roughly one-third) of patients with eating disorders have a diagnosable axis II disorder—a finding that does not include individuals with subthreshold or subsyndromal symptoms (i.e., personality disorder traits). To restate this clarification, none of these data account for individuals with personality disorder traits—only individuals with bona fide personality disorders. According to Hong et al,[9] as in full-blown personality disorder symptomatology, personality disorder traits may also have a long-term effect on functioning.[9]
The Temporal Relationship between Personality Disorders and Eating Disorders
In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, personality disorders are described as becoming, “…recognizable during adolescence or early adult life.”[10] In terms of development, inherited temperamental characteristics are believed to be the raw antecedents of subsequent personality disorders. These temperamental characteristics are consequently influenced and shaped by a number of factors, including caretaking style and life stressors. Therefore, the roots of personality disorders may be conceptualized as consisting of genetic influences and early life experiences. This indicates that personality disorders, in all likelihood, precede the development of eating disorders. The critical question for our discussion is whether a pre-existing personality disorder 1) heightens the risk for the development of an eating disorder and/or 2) shapes or contours, to any degree, the subsequent pattern of eating pathology.
Personality Pathology and its Effects on Eating Pathology
Given that obsessive compulsive and borderline personality disorders appear to be the most predominant comorbid disorders in individuals with eating disorders, we will focus on these two specific axis II disorders. However, this is not to imply that other types of personality disorders have no influence or shaping characteristics.
Obsessive compulsive personality disorder and restrictive eating pathology. Risk predisposition. Note that the prevalence of obsessive compulsive personality disorder in anorexia nervosa, restricting subtype (22%) is far above the expected rate of eight percent[11] in the general population. While not necessarily a causal association, the impressive disparity in prevalence between the two suggests the possibility of a partially causal relationship. In support of this impression, perfectionism has long been described as fundamentally overlapping with anorexia nervosa.[12]
Personality pathology and symptom shaping. Obsessive compulsive personality disorder is characterized by an intense preoccupation with details, rules, lists, order, organization, and/or schedules; perfectionism that interferes with task completion; excessive devotion to work and productivity to the exclusion of social experiences; over-conscientiousness and/or inflexibility about matters of morality, ethics, or values; and rigidity and stubbornness. While a patient with obsessive compulsive disorder may also exhibit a reluctance to discard worn out items, resistance to delegating tasks, and miserly spending, the former qualities are more likely to contribute to shaping and influencing the style of eating pathology.
With regard to this axis II disorder shaping the symptom presentation encountered in anorexia nervosa, restricting type, the characteristics of obsessive compulsive personality disorder are clearly mirrored in this type of eating pathology. The characterological need to center on details, assemble personal rules of conduct (in this case, rules for eating), achieve order and organization, and adhere to schedules melds easily into the eating disorder symptoms of extreme and precise dieting, faithful calorie counting, precision weighings, the development of rigid and unwavering menu plans, and the strict monitoring of grams of fat and fiber. Likewise, the characterological feature of perfectionism predictably complements the need to achieve a culturally ideal body weight/shape, maintain a precise and complex eating and exercise regimen, and dutifully starve oneself. The characterological feature of excessive devotion to work to the exclusion of social activities complements the eating disorder symptoms of intense and unwavering focus on weight loss (i.e., the “work”) as well as the observed social withdrawal and isolation, and an aversion to wasteful pastimes (i.e., social diversions). The need for a higher moral ground complements the ascetic idealization of weight loss or low body weight in the service of a dramatized cultural ideal. Finally, the characterological features of rigidity and stubbornness likely reflect the unyielding and unquestioning pursuit of weight loss by these individuals, despite realistic psychological and potentially life-threatening biological consequences. Overall, the underlying character pathology manifests in identical themes in food/body/weight issues. Given this unfolding, it is patently clear how a pre-existing personality structure like obsessive compulsive personality disorder might easily be one of the shaping forces for restrictive eating pathology.
Borderline personality disorder and impulsive eating pathology. Risk predisposition. The prevalence of borderline personality disorder in anorexia nervosa, binge-eating purging type (25%), and bulimia nervosa (28%) is far above the expected rate of six percent[13] in the general population. While not necessarily a causal association, again, the impressive disparity between the two suggests the possibility of a partially causal relationship.
Personality pathology and symptom shaping. Borderline personality disorder is characterized by impulsivity, self-harm behavior (e.g., suicidal gestures, self-mutilating behavior), affective instability, chronic feelings of emptiness, and inappropriate anger. While borderline personality disorder is also characterized by intense fears of abandonment, unstable interpersonal relationships, identity disturbance, and stress-induced quasipsychotic symptoms, the preceding characterological features are more likely to shape eating pathology.
Like the complementary relationship portrayed between obsessive compulsive personality disorder and restrictive eating pathology, note that the characteristics of borderline personality disorder are easily reflected in impulsive eating pathology. Specifically, characterological impulsivity is evidenced in binge eating episodes and various reflexive counter-regulatory responses, such as self-induced vomiting and/or the abuse of laxatives or diuretics. Self-harm behavior is evident in the undertaking of potentially destructive behaviors, such as self-induced vomiting, high levels of laxative misuse, and/or diuretic abuse (i.e., self-injury equivalents). In keeping with the theme of self harm, many eating-disordered behaviors in individuals with borderline personality disorder may be simultaneously viewed from the following two perspectives: 1) as a behavior to modify food intake/body/shape and 2) as a self-harm behavior (i.e., a self-injury equivalent in which these individuals appear to be acting out their self-destructive behavior through the venue of food/body/weight issues).[14] As for the characterological features of affective instability, chronic feelings of emptiness, and inappropriate anger, binging behavior literally fills one up (i.e., it addresses the chronic feelings of emptiness) whereas purging behavior, particularly self-induced vomiting, results in exhaustion and fatigue, thereby effectively containing affective crests and anger. Given this unfolding, it is fairly evident how a pre-existing personality structure, such as borderline personality disorder, might easily manifest in impulsive eating pathology.
Conclusion
Eating disorders are multidetermined psychiatric disorders that may also be influenced by personality pathology. Among individuals with eating disorders, the two most prevalent personality disorders appear to be obsessive compulsive personality disorder (anorexia nervosa, restricting type) and borderline personality disorder (anorexia nervosa, binge-eating purging type; bulimia nervosa). In comparing the prevalence of these two personality disorders in the general population versus their much higher prevalence in these respective eating disorders, the possibility of a partially causal relationship presents itself. In addition, once established, it appears that personality pathology may significantly influence and shape the general style of eating pathology, with obsessive compulsive personality disorder forging restrictive eating patterns and borderline personality disorder forging impulsive eating pathology. Both in psychiatric and primary care settings, these associations are clinically meaningful in terms of anticipating comorbidities and their influences on treatment and outcome.
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