Impact of comorbid borderline personality disorder on the outcome of inpatient treatment for anorexia nervosa: a retrospective chart review.
11 Mar 2021-Vol. 8, Iss: 1, pp 1-12
TL;DR: In this paper, the authors investigated whether patients with anorexia nervosa and comorbid Borderline personality disorder (AN+BPD) differ in characteristics related to admission to, discharge from, and course of specialized inpatient eating disorder treatment.
Abstract: Data on patients with anorexia nervosa (AN) and comorbid Borderline personality disorder (AN+BPD) are scarce. Therefore, we investigated (1) whether patients with AN and AN+BPD differ in characteristics related to admission to, discharge from, and course of specialized inpatient eating disorder treatment and (2) how comorbid BPD affects treatment outcome. One-thousand one-hundred and sixty inpatients with AN (97.2% female, 5.9% with comorbid BPD; mean age = 26.15, SD = 9.41) were administered the Brief Symptom Inventory (BSI), the Eating Disorder Inventory 2 (EDI-2), and the Global Assessment of Functioning (GAF) at admission and discharge. Data were extracted by a retrospective chart review of naturalistic treatment data. Age, sex, weekly weight gain, length of stay, and discharge characteristics were compared with independent t-tests and χ2-tests. Changes in outcome variables, including body mass index (BMI), were analyzed with longitudinal multilevel mixed-effects models. No differences in age or sex were found between patients with AN and AN+BPD, but groups differed in previous inpatient treatments, BMI at admission, and frequency of at least one additional comorbidity with higher values for AN+BPD. Higher levels of disorder-specific and general psychopathology at admission were found for AN+BPD. Patients with AN showed statistically significant improvement in all examined variables, patients with AN+BPD improved in all variables except EDI-2 body dissatisfaction. Strongest improvements in patients with AN+BPD occurred in BMI (Cohen’s d = 1.08), EDI-2 total score (Cohen’s d = 0.99), EDI-2 interpersonal distrust (d = 0.84). Significant Group x Time Interactions were observed for BSI GSI, GAF, and EDI-2 body dissatisfaction, indicating a reduced benefit from inpatient treatment in AN+BPD. At discharge, no differences were found in weekly weight gain, BMI, length of stay, or discharge characteristics (e.g., ability to work, reason for discharge), however, patients with AN+BPD were more frequently treated with medication. Patients with AN+BPD differ from patients with AN in that they show higher general and specific eating disorder psychopathology and only partially improve under specialized inpatient treatment. In particular, aspects of emotion regulation and core AN symptoms like body dissatisfaction and perfectionism need to be even more targeted in comorbid patients.
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TL;DR: In this article, the authors explored the associations between personality functioning and personality disorders, respectively, with pre-treatment ED symptomatic impairment and therapy outcome; and the mediating role of personality variables.
Abstract: Features of personality disorders (PDs) have been found to explain meaningful variance in the onset, maintenance, and symptomatic presentation of eating disorders (EDs), and a co-occurent personality pathology is commonly associated with poorer response to ED treatment. The "pathoplasty model" of the relationship between personality and EDs implies that, once both conditions are established, they are likely to interact in ways that modify therapy outcome; however, to date, no studies have explored overall personality functioning, and especially PD clusters, as a mediator of treatment outcome. The present study aimed at conjointly exploring the associations between personality functioning and PDs, respectively, with pre-treatment ED symptomatic impairment and therapy outcome; and the mediating role of personality variables. At treatment onset, a sample of 107 women with ED problems were evaluated using both the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Shedler-Westen Assessment Procedure-200 (SWAP-200)-a clinician-rated procedure to dimensionally assess personality. Participants were also asked to complete self-report questionnaires on overall ED symptomatology, symptoms of binge eating and purging behaviors, and therapy outcome. The findings showed that, over and above the categorical ED diagnosis, the SWAP-200 healthy personality functioning score mediated the relationship between baseline ED symptom severity and therapy outcome, as well as the association between baseline bulimic symptoms and treatment outcome; furthermore, SWAP-200 Cluster B PD scores mediated the link between baseline binge eating and purging symptoms and therapy outcome, whereas scores in Clusters A and C showed no significant effects. The findings suggest that personality-based outcome research may improve treatment effectiveness in this difficult-to-treat population.
3 citations
TL;DR: While personality disorders were highly prevalent in the sample of patients with longstanding eating disorders, both disorders were significantly reduced at the 17-year follow-up.
Abstract: Abstract Objective This study aimed to report the presence of categorical and dimensional personality disorders (PD) in adults with longstanding eating disorders (ED) over a period of 17 years and to investigate whether changes in PD predict changes in ED symptoms or vice versa. Methods In total, 62 of the 80 living patients (78% response rate) with anorexia nervosa (n = 23), bulimia nervosa (n = 25), or other specified feeding or ED (n = 14) at baseline were evaluated during hospital treatment and at 1‐year, 2‐year, 5‐year, and 17‐year follow‐up. PD were assessed using the Structured Clinical Interview for DSM‐IV Axis II disorders, and the eating disorder examination (EDE) interview was used to assess ED. Data were analyzed using multilevel modeling. Results From baseline to the 17‐year follow‐up, the number of patients with any PD decreased significantly from 74.2% to 24.2%, and the total number of PD diagnoses declined from 80 to 22. Mean EDE score was significantly reduced from 4.2 (SD: 1.1) to 2.0 (SD: 1.6). There was a positive association between ED and PD where the initial level of either disorder was followed by similar levels of the other disorder throughout the entire follow‐up period. High baseline levels of borderline PD predicted less decrease in ED symptoms. No significant within‐person effects were found. Conclusions Both ED and PD significantly declined over time. As the severity of either disorder seems to be associated with the other, thorough assessment and treatment that incorporates both the ED psychopathology and the personality disturbances are advisable. Public Significance Statement While personality disorders were highly prevalent in the sample of patients with longstanding eating disorders, both disorders were significantly reduced at the 17‐year follow‐up. The disorders are related in the sense that an initial high level of either disorder is associated with a high level of the other over time. A thorough assessment and attention to both illnesses are advisable in therapy. Clinical Trial Identifier NCT03968705.
1 citations
TL;DR: The course of weight gain during inpatient treatment was hampered in adolescent AN patients who have difficulties developing a stable identity, unlike other aspects of psychopathology, this was independent of the initial weight.
Abstract: Background Anorexia Nervosa (AN) typically begins during early adolescence, an important phase of personality development. A substantial proportion of adolescent AN patients shows impaired personality functioning, which might be a relevant but understudied aspect of illness severity. The developmental status of identity as key element of personality is suggested to influence inpatient treatment outcome in adolescents with AN. Methods This study analyzed existing data of N = 60 adolescents with AN. Multilevel models assessed the influence of identity functioning, measured by the Assessment of Identity Development in Adolescence (AIDA) at admission, on weight gain [BMI (body mass index), BMI-SDS (BMI standard deviation score)] during 10 weeks of inpatient treatment. Moreover, the influence of other indicators of illness severity, i.e., eating disorders and comorbid psychopathologies, was explored. Results As expected, higher AIDA scores negatively influenced the course of weight gain. A similar effect was observed for other psychopathology measures, especially body image distortion. In general, higher weight at admission was associated with less weight gain. Higher weight at admission was also predicted by higher other psychopathology measures, but not AIDA scores. Conclusion The course of weight gain during inpatient treatment was hampered in adolescent AN patients who have difficulties developing a stable identity. Unlike other aspects of psychopathology, this was independent of the initial weight. Thus, in addition to the level of underweight and other aspects of psychopathology, difficulties in identity development constitute a relevant aspect of illness severity in AN. This recommends consideration of identity development during treatment.
1 citations
TL;DR: In this paper , the prevalence of borderline personality disorder (BPD) symptoms in a sample of eating disorder (ED) outpatients and assess how BPD symptoms correlate with severity, distress, and function.
Abstract: We aimed to determine the prevalence of borderline personality disorder (BPD) symptoms in a sample of eating disorder (ED) outpatients and assess how BPD symptoms correlate with severity, distress, and function. A total of 119 individuals were assessed and divided into high BPD symptoms (H-BPD) and low BPD symptoms (L-BPD) using a cut-off score of seven on the McLean Screening for Borderline Personality Disorder (MSI-BPD). Groups were compared on ED diagnosis, age at ED onset, age at assessment, illness duration, body mass index (BMI), ED symptomatology, psychological distress, and psychosocial function. Correlation analyses were performed to assess the relationship between BPD symptoms and these variables. The 45.4% of the participants scored ≥7 on the MSI-BPD, indicating a diagnosis of BPD. There were no differences between the H-BPD (N = 54) and L-BPD (N = 65) groups on age at onset, age at assessment, duration of illness, BMI, or proportion of ED diagnosis. The H-BPD group reported significantly higher ED symptomatology, psychological distress, and poorer psychosocial functioning. MSI-BPD scores were positively associated with these variables. This study suggests a high prevalence of BPD symptoms within outpatients seeking ED treatment, and use of a brief screening instrument for BPD in this group may contribute to a greater understanding of the patient.
1 citations
TL;DR: In this paper , the authors outline data-driven strategies for treating eating disorders and the accompanying comorbid conditions and a research program that can test the usefulness of the different approaches suggested.
Abstract: OBJECTIVE
While co-occurring mental health conditions are the norm in eating disorders, no testable protocol addresses management of these in psychotherapy.
METHOD
The literature on managing mental health conditions that co-occur with eating disorders is outlined and reviewed.
RESULTS
In the absence of clear evidence to inform managing co-occurring mental health conditions, we advocate for use of an iterative, session-by-session measurement to guide practice and research. We identify three data-driven treatment approaches (focus solely on the eating disorder; multiple sequential interventions either before or after the eating disorder is addressed; integrated interventions), and the indications for their use. Where a co-occurring mental health condition/s impede effective treatment of the eating disorder, and an integrated intervention is required, we outline a four-step protocol for three broad intervention approaches (alternate, modular, transdiagnostic). A research program is suggested to test the usefulness of the protocol.
DISCUSSION
Guidelines that provide a starting point to improving outcomes for people with eating disorders that can be evaluated/researched are offered in the current paper. These guidelines require further elaboration with reference to: (1) whether any difference in approach is required where the co-occurring mental health condition is a comorbid symptom or condition; (2) the place of biological treatments within these guidelines; (3) precise guidelines for selecting among the three broad intervention approaches when adapting care for co-occurring conditions; (4) optimal approaches to involving consumer input into identifying the most relevant co-occurring conditions; (5) detailed specification on how to determine which adjuncts to add.
PUBLIC SIGNIFICANCE
Most people with an eating disorder also have another diagnosis or an underlying trait (e.g., perfectionism). Currently no clear guidelines exist to guide treatment in this situation, which often results in a drift away from evidence-based techniques. This paper outlines data-driven strategies for treating eating disorders and the accompanying comorbid conditions and a research program that can test the usefulness of the different approaches suggested.
References
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TL;DR: The DSM-IV: Diagnostic and Statistical Manual of Mental Disorders , fourth edition, was developed with a great deal of input from mental health professionals and professional organizations and is a great improvement over thethird edition (DSM-III) and the third edition, revised (DSS-III-R).
Abstract: Diagnostic Criteria From DSM-IV, by the American Psychiatric Association, 358 pp, spiral-bound, $22.50, ISBN 0-89042-064-5, Washington, DC, American Psychiatric Press Inc, 1994. DSM-IV Sourcebook , vol 1, edited by Thomas A. Widiger, Allen J. Frances, Harold Alan Pincus, Michael B. First, Ruth Ross, and Wendy Davis, 768 pp, $112.50, ISBN 0-89042-065-3, Washington, DC, American Psychiatric Association, 1994. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders , fourth edition, was developed with a great deal of input from mental health professionals and professional organizations. In addition, there was a significant collaboration between the American Psychiatric Association (APA) and the World Health Organization, as it developed the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) . As a result, DSM-IV is a great improvement over the third edition (DSM-III) and the third edition, revised (DSM-III-R) . The Task Force on DSM-IV and 13 work groups (each responsible for a section
2,630 citations
01 Jan 2010
TL;DR: The Brief Symptom Inventory consists of 53 items covering nine symptom dimensions: Somatization, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation and Psychoticism; and three global indices of distress.
Abstract: Conceptual Organization The Brief Symptom Inventory (BSI) consists of 53 items covering nine symptom dimensions: Somatization, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation and Psychoticism; and three global indices of distress: Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total. The global indices measure current or past level of symptomatology, intensity of symptoms, and number of reported symptoms, respectively.
340 citations
TL;DR: Recovery is still possible for anorexic patients after a period of 21 years, but patients can relapse, becoming symptomatic again despite previously achieving recovery status, therefore, it is recommended that these patients should be monitored regularly and offered treatment whenever possible.
Abstract: Background. Given our poor understanding of the very long-term course of anorexia nervosa, many questions remain regarding the potential for recovery and relapse. The purpose of the present study was to investigate long-term outcome and prognosis in an anorexic sample 21 years after the initial treatment. Method. A multidimensional and prospective design was used to assess outcome in 84 patients 9 years after a previous follow-up and 21 years after admission. Among the 70 living patients, the follow-up rate was 90%. Causes of death for the deceased patients were obtained through the attending physician. Predictors of a poor outcome at the 21-year follow-up were selected based on the results of a previous 12-year follow-up of these patients. Results. Fifty-one per cent of the patients were found to be fully recovered at follow-up, 21% were partially recovered and 10% still met full diagnostic criteria for anorexia nervosa. Sixteen per cent were deceased, due to causes related to anorexia nervosa. The standardized mortality rate was 9·8. The three groups also showed significant differences in psychosocial outcome. A low body mass index and a greater severity of social and psychological problems were identified as predictors of a poor outcome. Conclusions. Recovery is still possible for anorexic patients after a period of 21 years. On the other hand, patients can relapse, becoming symptomatic again despite previously achieving recovery status. Only a few patients classified as having a poor outcome were found to seek any form of treatment, therefore, it is recommended that these patients should be monitored regularly and offered treatment whenever possible.
335 citations
TL;DR: The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment, and drop-out was predicted by more binge/purge behaviors and lower motivation to recover.
Abstract: OBJECTIVE
Understanding the factors that predict a favourable outcome following specialist treatment for an eating disorder may assist in improving treatment efficacy, and in developing novel interventions. This review and meta-analysis examined predictors of treatment outcome and drop-out.
METHOD
A literature search was conducted to identify research investigating predictors of outcome in individuals treated for an eating disorder. We organized predictors first by statistical type (simple, meditational, and moderational), and then by category. Average weighted mean effect sizes (r) were calculated for each category of predictor.
RESULTS
The most robust predictor of outcome at both end of treatment (EoT) and follow-up was the meditational mechanism of greater symptom change early during treatment. Simple baseline predictors associated with better outcomes at both EoT and follow-up included higher BMI, fewer binge/purge behaviors, greater motivation to recover, lower depression, lower shape/weight concern, fewer comorbidities, better interpersonal functioning and fewer familial problems. Drop-out was predicted by more binge/purge behaviors and lower motivation to recover. For most predictors, there was large interstudy variability in effect sizes, and outcomes were operationalized in different ways. There were generally insufficient studies to allow analysis of predictors by eating disorder subtype or treatment type.
DISCUSSION
To ensure that this area continues to develop with robust and clinically relevant findings, future studies should adopt a consistent definition of outcome and continue to examine complex multivariate predictor models. Growth in this area will allow for stronger conclusions to be drawn about the prediction of outcome for specific diagnoses and treatment types.
330 citations