Temperament, character and suicide attempts in anorexia nervosa, bulimia nervosa and major depression

Personality and psychopathology in children with and without loss of control over eating

BACKGROUND

In children with loss of control (LOC) over eating, recent research has revealed evidence for distinct personality features, such as more impulsivity. The aim of this study was to assess parent- and child-report personality profiles in children with and without LOC over eating and to relate these profiles to general and eating-disorder psychopathology.

METHOD

A total of 120 children (60 with LOC over eating; 68 girls) aged 8 to 13 years were recruited from the community. Clinical interview, self-report, and parent-report questionnaires were administered to assess personality as well as both general and eating-disorder psychopathology.

RESULTS

The group with LOC over eating showed lower self-directedness and cooperativeness compared to the group without LOC. The children with LOC were significantly more impulsive. Personality dimensions were significantly correlated with greater general but not eating-disorder psychopathology and frequency of LOC over eating.

CONCLUSION

A distinct pattern of personality traits in children with LOC over eating was found that is partly in line with research on binge-eating disorder, bulimia nervosa, and obesity in adulthood. The findings suggest that longitudinal studies should examine whether certain patterns of personality in children with LOC over eating account for differences in psychopathology later in life.

Suicidal behavior and depression in adolescents with eating disorders

BACKGROUND

Eating disorders are associated with an increased risk of suicide.

AIM OF THE STUDY

To examine suicidal behavior and depression in adolescents with eating disorders, and to identify risk factors associated with suicidal ideation and attempted suicide.

METHODS

Forty-six Israeli adolescent girls with anorexia nervosa or bulimia nervosa completed a self-report battery at the time of assessment or treatment. Suicide attempts and suicidal ideation were investigated in relation to clinical (e.g. body mass index, purging) and psychological (e.g. body dissatisfaction) features of the eating disorders, as well as depression. Twenty-four percent of the subjects had attempted suicide, and 65% reported suicidal thoughts. Fifty-eight percent were moderately to severely depressed.

FINDINGS

The risk of attempted suicide was associated with depression, a history of sexual abuse and longer duration of illness, but it was moderated by hospital treatment. Suicidal ideation was related only to depression.

CONCLUSIONS

The results of this study emphasize the importance of treating aggressively depression in adolescents with eating disorders. Depression seems to amplify illness severity. Currently, strategies for treating eating disorders focus more on the eating disorder behaviors and less on depression. We suggest investing more resources in detecting and treating the co-morbid depression.

Temperament and character personality profile in relation to suicidal ideation and suicide attempts in major depressed patients

To prevent suicidal behaviour, it is important to better understand those personality traits associated with suicidal ideation and suicide attempts. A sample of 394 consecutive major depressed outpatients admitted to Bonn University Hospital was subdivided into three groups: Lifetime suicide attempters (N=32; 8.1%), suicide ideators (N=133) and patients without suicide ideation (N=229). Psychodiagnostic measures embraced the Temperament and Character Inventory (TCI), the Symptom Checklist-90-R and the Hamilton Depression Rating Scale. Suicide attempters and ideators showed higher scores on emotional distress and depression. Analysis of covariance (covariates: age, gender, depression) revealed that suicide attempters score higher on the temperament dimension harm avoidance compared with non-attempters. Suicide ideators could be distinguished from non-ideators by character dimensions in terms of lower self-directedness and higher self-transcendence. Our findings suggest that high harm avoidance is a personality trait associated with suicide attempt in major depression, whereas low self-directedness and high self-transcendence are related to suicidal ideation. As temperament dimensions represent the "emotional core" and character dimensions the "cognitive core" of personality, we discuss whether Cloninger's psychobiological model might be helpful to distinguish between non-suicide ideators, patients who do think about suicide, and patients initiating suicidal behaviour.

Personality and attempted suicide. Analysis of anger, aggression and impulsivity

Suicide is one of the leading causes of death worldwide, mortality from suicide being approximately 2%. Attempted suicide appears to be a major risk factor for suicide completion. Anger, aggression and impulsivity are personality traits associated with suicide attempt. In this study we analysed a part of a previously reported sample in order to test anger, impulsivity and temperament/character scales as predictors of aggression and self-aggression in suicide attempters and to compare anger- and aggression-related traits between impulsive and premeditated suicide attempts as well as between violent and non-violent suicide methods. One-hundred-eleven consecutively admitted inpatients with a lifetime history of attempted suicide were assessed for anger (State-Trait Anger Expression Inventory, STAXI), aggression (Questionnaire for Measuring Factors of Aggression, FAF) and temperament/character (Temperament and Character Inventory, TCI). Higher aggression scores, as measured by FAF, were predicted by being male, meeting criteria for borderline personality disorder and having higher angry temperament scores as assessed by STAXI; low cooperativeness was also associated with aggression but not after controlling for STAXI scales. TCI dimensions associated with self-aggression were high harm avoidance, high impulsivity and low self-directedness; state anger, inwardly directed anger and inhibition of aggression were also predictors of self-aggression. In conclusion, impulsivity and harm avoidance have emerged as temperament dimensions independently associated with self-aggressive tendencies in personality. Such interactions could explain the correlation between temperament and suicidality but further research is needed. Anger and self-directedness appear to have some effects on suicide attempt.

A comparison of borderline personality disorder with and without eating disorders

This study examines the degree to which an eating disorder (ED) is associated with the recurrence and severity of suicide attempts, non-suicidal self-injury, rates of co-occurring Axis I and II disorders, and psychosocial functioning among Borderline Personality Disorder (BPD) outpatients. A group of 135 treatment-seeking women with BPD were assessed using structured clinical interviews. BPD was assessed using the International Personality Disorders Examination, confirmed by the Structured Clinical Interview for DSM-IV (SCID)-II, and Axis I disorders were assessed with the SCID I. A total of 17.8% of the sample met criteria for a current ED, with 6.7% meeting criteria for Anorexia Nervosa (AN), 5.9% for Bulimia Nervosa (BN), and 5.2% for Binge-Eating Disorder (BED). In this BPD sample, in the last year, current BN was associated with a significantly greater risk of recurrent suicide attempts while current AN was associated with increased risk of recurrent non-suicidal self-injury. BPD with current AN or BED was associated with a greater number of non-ED current Axis I disorders. Further replication of these results is needed. Women with BPD must be assessed for AN and BN as these diagnoses may confer greater risk for suicidal and self-injurious behavior and may have to be prioritized in treatment.

Development and validation of a culturally appropriate HIV/AIDS Stigma Scale for Puerto Rican health professionals in training

HIV/AIDS stigma continues to be an obstacle for primary and secondary HIV prevention. Its consequences for the lives of people living with the disease have been well documented and continue to be of great concern for health care providers and researchers in the field. These consequences are worsened when such stigma emanates from health professionals, as this can limit access to services. One of the main obstacles for HIV/AIDS stigma research in Puerto Rico is the absence of quantitative measures to assess HIV/AIDS stigma manifestations among health professionals. In light of this gap in the scientific literature, the main objective of this study was to develop and test the psychometric properties of a culturally appropriate HIV/AIDS Stigma Scale for Puerto Rican health care providers and to develop a reduced form of the scale suitable for use in time-limited clinical settings. The developed measure was based on previous qualitative evidence gathered from Puerto Rican health professionals (Varas-Diaz, Serrano-Garcia, & Toro-Alfonso, 2005) and administered to a sample of 421 health professionals in training. The scale addresses 12 HIV/AIDS stigma dimensions. In quantitative analyses 11 of these dimensions demonstrated satisfactory validity and reliability. These dimensions in turn were subcomponents of a higher-order general stigma factor. Implications and limitations of these findings are discussed.

[Eating behaviour disorders and personality. A study using MCMI-II]

OBJECTIVE

To study the personality characteristics in patients with eating behaviour disorders and the influence of these characteristics, and certain clinical syndromes on the progress of these disorders, particularly when they have lasted more than seven years.

DESIGN

Study of comorbidity using a diagnostic test.

SETTING

Eating behaviour disorders unit outpatients.

PARTICIPANTS

A total of 147 patients with eating behaviour disorders being treated as outpatients. They were of normal weight, with a mean age of 22.24 years.

INTERVENTIONS

Assessment of personality and clinical syndromes using the Millon Clinical Multiaxial Inventory (MCMI-II).

MAIN MEASUREMENTS

Means of the personality and clinical syndromes scales and determination of prevalence using a rate-base>84.

RESULTS

At least one personality disorder was detected in 25.33% of patients with anorexia, 30.44% with bulimia nervosa and 32.13% with binge-eating disorder. In the purgative and non-purgative forms the prevalence was 31.07% and 24.75%, respectively. An obsessive disorder is more common in anorexia (39.77%); a histrionic disorder in bulimia (46.66%); a dependent disorder in the purgative forms (46.15%), and an obsessive one in the no-purgative forms (35.36%). As regards the mean scores, they were significantly higher in patients with bulimia for the histrionic disorder (P<.05). More hysterical type symptoms and hypomania were also observed in these patients (P<.01 and P<.05, respectively). Finally, the patients who had suffered the disorder for more than seven years registered more anxiety (P<.05), depressive neurosis (P<.05) and alcohol abuse (P<.01).

CONCLUSIONS

To assess personality styles and clinical syndromes associated with eating behaviour disorders can be an important therapeutic and prognostic tool.

Temperament and character of suicide attempters

Temperamental features are strongly associated with suicidal behaviors both in general population and clinical samples. In the present study we considered the association between personality traits, measured by Temperament and Character Inventory (TCI), and suicidal behavior. We analyzed five samples: a German control sample of 1148 healthy individuals; 144 German suicide attempters affected by Mood (n=101), Schizophrenia spectrum (n=20) and Borderline Personality (n=23) Disorders; 46 Italian suicide attempters affected by Mood Disorders (UP=15; BP=31); 76 German non-suicide Mood Disorder patients; 147 Italian non-suicide Mood Disorder patients. Suicide attempters showed higher scores in Harm Avoidance (HA) and lower scores in Self-Directedness (SD) and Cooperativeness (C), when compared to controls. Nevertheless, comparing the German and the Italian suicide attempter groups with the non-suicide Mood Disorder patient groups, no differences were detected. This could be due to the effect of Mood Disorder on personality. In conclusion, the present study reveals the difficulty to disentangle the personality profile of suicide attempters from their psychopathology. Those findings may be useful for cautions in further dissecting this complex phenotype.

Shyness, sociability, and eating problems in a non-clinical sample of female undergraduates

Previous empirical studies have shown that the personality trait of shyness, either alone or in combination with varying levels of sociability (i.e., a socially-conflicted profile--high shyness with high sociability) to be a reliable predictor of various psychopathologies, including substance abuse and mood disorders. Extending these findings to other forms of dysregulated behaviours, we examined multiple measures of eating problems in relation to self-reported shyness and sociability in a sample of 520 undergraduate females (M = 20.7 years). Analyses revealed a consistent significant main effect for shyness across all measures of disordered eating. These findings extend earlier work on shyness to another form of psychopathology (i.e., eating problems) not previously examined in a non-clinical sample.

Suicide attempts in anorexia nervosa

OBJECTIVE

To explore prevalence and patterns of suicidal attempts in persons with anorexia nervosa (AN).

METHODS

Participants were the first 432 persons (22 male, 410 female) enrolled in the NIH funded Genetics of Anorexia Nervosa Collaborative Study. All participants had current or lifetime AN. The participants ranged in age from 16 to 76 (mean = 30.4, SD = 11.3). Suicidal behavior and intent was assessed via the Diagnostic Interview for Genetic Studies. We compared frequency and severity of attempts across diagnostic subtypes and comorbidity, and personality features associated with the presence of suicide attempts in persons with AN.

RESULTS

About 16.9% of those with AN attempted suicide. Significantly fewer persons with the restricting subtype (7.4%) reported at least one attempt than those with purging AN (26.1%), AN with binge eating (29.3%), and a mixed picture of AN and bulimia nervosa (21.2%). After controlling for major depression, suicide attempts were associated with substance abuse, impulsive behaviors and traits, Cluster B personality disorders, panic disorder, and post-traumatic stress disorder as well as low self-directedness and eating disorder severity.

CONCLUSIONS

Suicide attempts in AN are not uncommon, are frequently associated with the intention to die, occur less frequently in persons with the restricting subtype of the illness, and after controlling for depression are associated with a constellation of behaviors and traits associated with behavioral and affective dyscontrol.

Deaths by suicide among individuals with anorexia as arbiters between competing explanations of the anorexia-suicide link

BACKGROUND

Suicide is a leading cause of death among individuals with anorexia nervosa (AN). In this paper, we examined competing explanations of the high rate of death by suicide among individuals with anorexia nervosa (AN).

METHODS

Nine case reports of individuals with AN who died by suicide were evaluated to determine whether death by suicide occurred a) because physical health was so compromised that what would be a non-lethal suicide attempt in a healthy adult became a fatal suicide attempt, or b) because highly lethal suicide attempts that would have killed any adult, healthy or medically compromised, were made.

RESULTS

The findings converged with the latter hypothesis, as predicted by Joiner's [Joiner, T., 2006. Why People Die By Suicide. Harvard University Press, Cambridge, MA] theory of suicide, which suggests individuals with AN may habituate to the experience of pain during the course of their illness and accordingly die by suicide using methods that are highly lethal.

LIMITATIONS

This study utilized case reports instead of an experimental design, which impedes its ability to comment on whether there is a causal relationship between Joiner's theory and death by suicide among individuals with AN.

CONCLUSIONS

Clinicians are encouraged to carefully assess suicidality in AN patients, paying particular attention to issues related to lethality.

Self-injurious behavior and attempted suicide in purging bulimia nervosa: associations with psychiatric comorbidity

BACKGROUND

Few studies, to date, have investigated the relationship between self-damaging behavior and the presence of comorbid psychiatric diagnoses in eating disorders. The aim of the present study was to investigate the axis I and II comorbidity in subjects with bulimia nervosa who report self-injurious behavior and/or suicide attempt.

METHODS

The subjects were 95 patients with purging type bulimia nervosa who underwent a clinical evaluation assessing the presence of self-injurious behavior and suicide attempts, comorbidity for axis I and II psychiatric disorders and temperament.

RESULTS

No axis I diagnosis was associated with any type of self-injurious behavior, whereas social phobia and bipolar disorder were linked to attempted suicide. Significant independent predictors of impulsive self-injurious behavior were the presence of childhood sexual abuse, high harm avoidance scores, and high self-transcendence scores, whereas childhood sexual abuse, the presence of a cluster B personality disorder, and a low self-directedness were predictors of suicide attempts. Compulsive self-injurious behavior was significantly associated with harm avoidance and cluster C personality disorders. Harm avoidance was also associated with skin picking.

CONCLUSIONS

Personality disorders are a frequent correlate of the presence of SIB in purging bulimia nervosa. However, temperament seems to play a more important role. Further studies on larger samples are necessary to confirm our findings in bulimia nervosa and to extend them to other patient populations.

Comparison of personality risk factors in bulimia nervosa and pathological gambling

OBJECTIVE

The objective of the study was to assess the predictive value of personality profiles to classify individuals with bulimia nervosa (BN), pathological gambling (PG), and a nonpsychiatric comparison group while controlling for sex.

METHODS

The sample comprised 270 BN (241 women, 29 men), 429 PG (42 women, 387 men), and 96 comparison (nonpsychiatric) subjects (35 women, 61 men). All patients were consecutively admitted to our Psychiatry Department and were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. We administered the Temperament and Character Inventory-Revised as well as other clinical indices. Multinomial and binary logistic regression models adjusted for age and stratified by sex were used to assess the predictive value of personality in relation to group status.

RESULTS

In comparison to controls, high Novelty Seeking (P < .001) was specifically associated with a diagnosis of PG. Independently of sex, low Self-Directedness was associated with both BN (P < .001) and PG (P < .001). Some sex-specific differences were also observed; namely, women with BN and PG displayed higher Harm Avoidance and Cooperativeness than control women, whereas men with PG reported higher Reward Dependence and Persistence than control men.

CONCLUSIONS

Our results suggested that, whereas there are some shared personality traits between BN and PG when compared with healthy controls, there are also some sex- and diagnostic-specific personality traits that weigh against the consideration of BN as an impulse control disorder.

The relations of temperament and emotion self-regulation with suicidal behaviors in a clinical sample of depressed children in Hungary

Although major depressive disorder (MDD) is associated with suicidal behaviors, some depressed individuals are not suicidal and others evidence various forms of suicidality. We thus investigated whether aspects of temperament and self-regulation of dysphoria represent risk factors for DSM-IV suicidality (recurrent thoughts of death, recurrent suicidal ideation, suicidal plan, and suicide attempt) in depressed youths. Using a sample of children with MDD (N = 407; ages 7-14 years), recruited from clinical sites across Hungary, we tested the hypotheses that: (a) suicidality is related to higher levels of trait negative emotionality as well as more maladaptive and fewer adaptive regulatory responses to dysphoria and (b) as the severity of suicidal behavior increases, levels of trait negative emotionality and dysfunctional emotion regulation also increase. We also explored if other aspects of temperament relate to suicidality. Children's DSM-IV diagnoses were based on semi-structured interviews and best-estimate psychiatric consensus. Parents independently provided ratings of their children's temperament, and children separately completed an inventory of emotion regulation (ER). Using multivariate models, we failed to confirm the hypothesized relations of negative trait emotionality and suicidality, but confirmed that high maladaptive and low adaptive ER response tendencies increase the odds of suicidal behaviors, above and beyond the risk posed by depressive illness severity. Unplanned interaction terms between temperament dimensions (other than negative emotionality) and ER suggested that at some high-extremes of temperament, ER has no impact on suicidality but in their absence, adaptive ER lowers the risk of suicidality. The practical implications of the findings are discussed.

Switching to the bingeing/purging subtype of anorexia nervosa is frequently associated with suicidal attempts

OBJECTIVE

Anorexia nervosa has the highest suicide mortality ratio of psychiatric disorders, suicide being associated with many factors. We assessed the first lifetime occurrence of these factors taking into account their possible overlap.

METHOD

Three hundred and four in- and out-patients with anorexia nervosa (DSM-IV) were systematically recruited in three hospitals of Paris suburbs, between December 1999 and January 2003. Patients were assessed by a face-to-face interview (DIGS). Current eating disorder dimensions were measured, and patients interviewed by a trained clinician to assess minimal BMI and, retrospectively, the age at which anorexia nervosa, major depressive disorder, anxiety disorders and switch to bingeing/purging type occurred for the first time, if applicable.

RESULTS

Major depressive disorder (p<0.001) and subtype switch from the restrictive to the bingeing/purging type (p<0.001) were the two factors significantly more frequently occurring before suicidal attempts, and remained involved when a multivariate analysis is performed, whether syndromic or dimensional measures are being used. Taking into account lifetime occurrence with a survival analysis, the switch to bingeing/purging type of anorexia appears as a major predictive factor, with a large increase of the frequency of suicidal attempts (OR=15) when compared to patients with neither major depressive disorder nor bingeing/purging type.

CONCLUSIONS

Bingeing/purging type of anorexia nervosa is largely associated with suicidal attempts, and may deserve specific attention. If confirmed on a prospectively designed study, these results would argue for early detection and/or more intensive and specific therapeutic intervention on this aspect of bingeing and purging behaviors.

Early identification and treatment of eating disorders: prodrome to syndrome

The onset of eating disorder psychopathology is most common in the adolescent age group. Acute psychopathology or subsyndromal eating disorders are perhaps less intractable in these young patients. Subsyndromal eating disorders in children and adolescents are not only clinically significant in their present state, but may represent legitimate candidates for preventive efforts in light of: (i) a risk of progression from subthreshold anorexia nervosa (SAN) to AN or subthreshold bulimia nervosa (SBN) to BN; (ii) the detrimental effects on outcome of delaying treatment; and (iii) the refractory, severe nature of eating disorders once the diagnostic threshold is crossed. Moreover, children and adolescents with SAN and SBN may in fact be exhibiting early 'caseness' of these disorders. Given that AN is notoriously difficult to treat, and there are limited efficacy data for adolescent BN, attempts to disrupt these disorders in what is arguably their early phases is an important goal in preventing more chronic and treatment-resistant forms of these disorders. Future research should address whether the best interventions for SAN and SBN should be derived from the prevention or intervention fields.

Symptom profile of major depressive disorder in women with eating disorders

OBJECTIVE

Based on the well-documented association between eating disorders (EDs) and affective disorders, the patterns of comorbidity of EDs and major depressive disorder (MDD) were investigated. The temporal relation between EDs and MDD onset was analyzed to determine differences in the course and nature of MDD when experienced prior to versus after the onset of the ED.

METHOD

Lifetime MDD and depressive symptoms were assessed in 1371 women with a history of ED. The prevalence of MDD was first explored across ED subtypes, and ages of onset of MDD and EDs were compared. Depressive symptoms were examined in individuals who developed MDD before and after ED onset.

RESULTS

The lifetime prevalence of MDD was 72.9%. Among those with lifetime MDD (n =963), 34.5% reported MDD onset before the onset of ED. Those who experienced MDD first reported greater psychomotor agitation (OR =1.53; 95%CI =1.14-2.06), and thoughts of own death (but not suicide attempts or ideation; OR =1.73; 95%CI =1.31-2.30). Among individuals who had MDD before ED, 26.5% had the MDD onset during the year before the onset of ED; 67% of individuals had the onset of both disorders within the same 3 year window.

CONCLUSION

Clinicians treating individuals with new-onset ED or MDD should remain vigilant for the emergence of additional psychopathology, especially during the initial 3 year window following the onset of the first disorder.

Depression and Internet addiction in adolescents

BACKGROUND

The aim of the study was to evaluate the relationship between depression and Internet addiction among adolescents.

SAMPLING AND METHOD

A total of 452 Korean adolescents were studied. First, they were evaluated for their severity of Internet addiction with consideration of their behavioral characteristics and their primary purpose for computer use. Second, we investigated correlations between Internet addiction and depression, alcohol dependence and obsessive-compulsive symptoms. Third, the relationship between Internet addiction and biogenetic temperament as assessed by the Temperament and Character Inventory was evaluated.

RESULTS

Internet addiction was significantly associated with depressive symptoms and obsessive-compulsive symptoms. Regarding biogenetic temperament and character patterns, high harm avoidance, low self-directedness, low cooperativeness and high self-transcendence were correlated with Internet addiction. In multivariate analysis, among clinical symptoms depression was most closely related to Internet addiction, even after controlling for differences in biogenetic temperament.

CONCLUSIONS

This study reveals a significant association between Internet addiction and depressive symptoms in adolescents. This association is supported by temperament profiles of the Internet addiction group. The data suggest the necessity of the evaluation of the potential underlying depression in the treatment of Internet-addicted adolescents.

Suicide and attempted suicide in eating disorders, obesity and weight-image concern

Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Meta-analyses have shown that individuals suffering from anorexia nervosa and bulimia nervosa commit suicide more often than their counterparts in the general population; also a few studies have suggested that suicide is the major cause of death among patients with anorexia nervosa, refuting the assumption that inanition generally threatens the life of these patients. Data concerning suicide in bulimia nervosa, on the other hand, are still scarce but suicide attempts are easily found among cohorts of patients with bulimia nervosa, which constitutes a risk factor for completed suicide. Suicidality in obesity and individuals with disturbed weight status has been reported. Both in the case of bulimia nervosa and obesity more long-term follow-up studies need to be completed before the risk of suicide for such disorders may be compared with that for anorexia nervosa.

Suicidality in eating disorders: Occurrence, correlates, and clinical implications

This review summarizes the published studies on suicide and suicide attempts in individuals with eating disorders, highlighting rates of occurrence, clinical correlates, and implications for practitioners. Multiple studies find high rates of suicide in patients with anorexia nervosa (AN) [Standardized Mortality Ratio (SMR) for suicide range from 1.0 to 5.3], whereas suicide rates do not appear to be elevated in bulimia nervosa (BN). In contrast, suicide attempts occur in approximately 3-20% of patients with anorexia nervosa and in 25-35% of patients with bulimia nervosa. Clinical correlates of suicidality in eating disorders include purging behaviors, depression, substance abuse, and a history of childhood physical and/or sexual abuse. Patients with eating disorders, particularly those with comorbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of eating disorder or depressive symptoms.

Soluble interleukin 2 receptor levels, temperament and character in formerly depressed suicide attempters compared with normal controls

An imbalance of the immune system and mixed personality profiles in suicide attempters have been reported. As suicidal behavior is common in patients with psychiatric disorders within the spectrum of depressive features, in this study we measured soluble interleukin-2 receptor concentrations in plasma (sIL-2R) and investigated temperament and character profile and their potential correlation in formerly depressed patients with a history of suicide attempt. We studied sIL-2R levels in plasma and personality characteristics (using Cloninger's Temperament and Character Inventory [TCI]) of formerly depressed patients who had attempted suicide a mean of 3 years previously (n = 25), and age and gender matched normal controls (n = 25). There was no significant difference in sIL-2R levels between formerly depressed suicide attempters and age and gender matched normal controls (0.23 ng/ml +/- 0.25 vs. 0.19 ng/ml +/- 0.16). When compared to normal controls, suicide attempt patients had a significantly higher score on the temperament dimension "harm avoidance" and a lower score on the character dimension "self-directedness." No significant correlation was found between sIL-2R values and TCI dimensions. We propose that the liability to suicidal behavior among suicide attempters susceptible to depressive symptomatology may be related to high harm avoidance and low self-directedness.

Familial and sociopsychopathological risk factors for suicide attempt in bulimic and in depressed women: prospective study

OBJECTIVE

This study was carried out to examine sociopsychopathological predictors of prospective observed suicide attempts in bulimic women purging type without comorbid major depression (BNG) at the time of study entry and in woman with major depression without comorbid eating disorder at the time of study entry (MDG).

METHODS

Data from 28 BNG (age 23.5 +/- 3.6) and 126 MDG women (age 33.4 +/- 5.1) who had attempted suicide during 12 months' monitoring were compared.

RESULTS

A univariate comparison of the two groups revealed various differences. Analysis of risk factors for suicide attempts using stepwise logistic regression was conducted separately for each group. The derived logistic models showed that patients from the BNG group had a history of higher incidence of sexual abuse in childhood, as well as abuse of laxatives and illicit drugs; they also lacked orientation in life, felt lonely despite family and friends, tended to direct their anger outward, and were unable to relax.

CONCLUSIONS

Sociopsychopathological risk factors for suicide attempts in the BNG and MDG appear to vary.

The relationship of suicide attempt history with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality in substance dependents

The aim of this study was to evaluate the prevalence of suicide in Turkish male substance dependents, and to investigate the relationship of suicide attempt history with childhood abuse and neglect, alexithymia, and temperament and character dimensions of personality. Participants were 154 consecutively admitted male substance dependents. Patients were investigated with the Childhood Abuse and Neglect Questionnaire, Toronto Alexithymia Scale (TAS-20) and Temperament and Character Inventory (TCI). Among substance-dependent patients, 28.6% was considered a group with suicide attempt history (SAH). Current age was lower and rate of being single was higher in the group with SAH. There were no significant differences between groups in terms of employment, educational status and duration of education. Rates of physical, emotional abuse and neglect, self-mutilation and being alexithymic were higher and ages at first substance use and regular substance use were lower in the group with SAH. Mean scores of "difficulty in identifying feelings" (DIF) and "difficulty in describing feelings" (DDF) subscale EOT of the TAS-20 were higher in the SAH group. Among temperament and character dimensions of the TCI, only "Self-directedness" and "Cooperativeness" were lower in SAH and there were no significant differences between groups in terms of other subscales. Age and Self-directedness score of TCI were determinants for suicide attempt. In particular, young drug users with low Self-directedness scores could be the target population in order to prevent suicidal behavior. This study also suggests that in substance-dependent patients, in the background of all suicidal behavior, childhood abuse and neglect must be evaluated.

Eating disorders and emotional and physical well-being: associations between student self-reports of eating disorders and quality of life as measured by the SF-36

OBJECTIVE

To assess health-related quality of life (HRQoL) in subjects with eating disorders in terms of eating disorder type and in relation to self-reports of longstanding illness, depression and self-harming behaviours.

METHOD

Data on eating disorder history, SF-36 health status, longstanding illness, and self-reported frequencies of depression, self-harming behaviour, and suicidal thoughts or acts were collected during 1996 as part of a UK postal survey of students' health. Completed questionnaires were returned by 1439 of 3750 students (response rate 42%).

RESULTS

Eighty-three respondents (5.8%; 8.9% of females) reported a probable eating disorder history: 54 (3.8%) bulimia nervosa, 22 (1.6%) binge eating disorder, and 7 (0.5%) anorexia nervosa. Eating disorder subjects reported more impairment in SF-36 emotional than physical well-being, with significantly lower mental (p < 0.001) but not physical (p = 0.21) component summary scores. This was most evident in bulimia nervosa and binge eating disorder subjects. Anorexia nervosa subjects reported fewer SF-36 emotional limitations although they were significantly more likely to report depression, self-harming behaviour, and suicidal ideation.

DISCUSSION

An eating disorder history is accompanied by HRQoL impairment primarily in emotional well-being. Anorexia nervosa subjects perceive fewer limitations than subjects with other eating disorders. While this is consistent with previous reports of better SF-36 emotional well-being in those with restrictive eating behaviours, it may also suggest that the SF-36 is insensitive to emotional distress in anorexia nervosa.

Psychopathological distress predicts suicidal ideation and self-harm in adolescent eating disorder outpatients

OBJECTIVE

This study evaluated the differences in suicidal behaviour between adolescent anorexia nervosa (AN) and bulimia nervosa (BN), and the association of age, menarche timing, duration of eating disorder (ED), depression and general psychopathological symptoms (GSI) with suicidal behaviour in adolescent ED.

METHODS

The study group comprised 57 adolescent outpatients (girls) attending for assessment because of eating disorders. Suicidal ideation, deliberate self-harm and suicidal attempts were assessed in self-report questionnaires.

RESULTS

In both ED groups, one adolescent had attempted suicide before assessment. Suicidal ideation and/or deliberate self-harm were reported in over half of the cases. Bulimics had significantly more suicidal ideation and deliberate self-harm than anorectics. In multivariate analysis, BN and depression predicted suicidal ideation, but only GSI persisted as predicting deliberate self-harm.

CONCLUSIONS

Suicidal behaviour is common in adolescent ED. Type of ED (BN), depression and higher GSI are strongly associated with suicidal ideation and deliberate self-harm. Our results point to the need to evaluate psychopathological symptoms in adolescent ED, especially in BN, in the initial assessment to prevent severe suicidal behaviour.

Psychometric Properties of the Temperament and Character Inventory–Revised (TCI–R) in a Belgian Sample

The Temperament and Character Inventory (TCI; Cloninger, Przybeck, Svrakic, & Wetzel, 1994) is a self-questionnaire developed to assess the 7 dimensions of personality described by Cloninger et al. (1994) with a total of 29 subscales. In 1999, a revised version was proposed by Cloninger (TCI-R). In this study, we present psychometric properties of the TCI-R from 958 French-speaking participants of Belgium. Women exhibited higher scores for harm avoidance, reward dependence, and cooperativeness dimensions. The proposed factorial structure of 4 temperament dimensions and 3 character dimensions was confirmed. The TCI-R inventory had good test-retest reliabilities as well as good alpha coefficients. The addition of 3 new subscales to the original scale for Persistence has produced a very reliable dimension in the TCI-R.

Factors related to severity of vomiting behaviors in bulimia nervosa

Assessments of the severity of vomiting (weekly frequency), depressive and eating-related psychopathology, anger level and management, and personality dimensions were used to characterize patients with bulimia nervosa binge purging type (BN-BP). The sample comprised 130 outpatients with BN and 130 control women. The Eating Disorder Inventory-2 (EDI-2), the State-Trait Anger Expression Inventory, the Beck Depression Inventory, and the Temperament and Character Inventory (TCI) were administered to all patients. The Self-Directedness dimension of the TCI and the Bulimia subscale of the EDI-2 were the strongest predictors of the severity of bulimic behavior; anger levels and anger expression were not so strongly related to illness severity. A more severe form of bulimic symptomatology probably has substrata in specific character deficits (low Self-Directedness on the TCI) and particular psychopathological features (high bulimia on the EDI-2). Patients with a high frequency of vomiting need specific therapeutic interventions to enhance the character dimension of Self-Directedness.

The relationship between temperament and impulsive behaviors in eating disordered subjects

To date, few studies have examined the personality characteristics and clinical predictors of impulsive behaviors in eating disorders (ED). The aim of this work was to study the prevalence of a wide range of impulsive behaviors in a sample of 554 ED subjects and to examine the predictors of these behaviors. Subjects were diagnosed according to DSM-IV criteria as having anorexia nervosa restricting type (ANR; n = 183), anorexia nervosa binge eating/purging type (ANBP; n = 65), bulimia nervosa purging type (BNP; n = 244), and bulimia nervosa nonpurging type (BNNP; n = 62). Nine different types of impulsive behaviors were assessed in these groups. About 55% of the whole sample reported at least one type of impulsive behavior, 35% more than one, and about 13% more than three. According to findings, impulsive and multi-impulsive subjects are characterized by the presence of purging behavior and by specific temperamental features such as high levels of novelty seeking and low persistence. The prediction of impulsive behavior is further improved by considering the presence of a history of childhood abuse, maternal psychiatric morbidity, and some specific psychological symptoms such as maturity fears, perfectionism, depression, and obsessive-compulsive symptoms. The presence of impulsive behavior appears to be associated with overall higher levels of psychiatric symptomatology and eating psychopathology, thus indicating that they are an important feature to be considered in the assessment and treatment of ED.

Purging behaviors and comorbidity as predictive factors of quality of life in anorexia nervosa

OBJECTIVE

This study examined the predictive factors for the physical and mental summary components (PCS and MCS) of quality of life (SF-36) in patients with anorexia nervosa.

METHOD

Forty-seven patients with anorexia nervosa were studied. Assessment comprised psychiatric diagnosis by a clinical structured interview for Axis I disorders (SCID-I) and personality disorders (SCID-II), Clinical Global Impression (CGI), and Quality of Life (SF-36).

RESULTS

Anorexia nervosa, restrictive type, was diagnosed in 73.9% of the patients and 51% of the patients presented with comorbidity on Axis I or Axis II or both. The predictive variables for the PCS were poor outcome in previous year, comorbidity on Axes I and II, and female gender. The predictive variables for the MCS were the presence of comorbidity in one or the other of the Axis I or II disorders and purging behaviors.

DISCUSSION

The current study suggests the importance of comorbidity and purging behaviors in the quality of life of these patients with anorexia nervosa.

Psychiatric disorders in pregnancy

This review, although not exhaustive, provides information on the potential impact of psychiatric illness on obstetric outcome. There is clear evidence that psychiatric illness poses a risk to pregnancy outcome. There productive safety data on many of the available treatments fail to demonstrate a clear risk from treatment. The medications with clear teratogenic, neonatal, and developmental risks are, not surprisingly, those used to treat some of the most severe and debilitating psychiatric illnesses. Even the amount of information available is inadequate without some straightforward clinical guidelines. A model of risk for illness and treatments of illnesses during pregnancy developed by the authors' group reminds clinicians that nonexposure does not exist. Rather, the decision is which type of exposure is in the best interest of the patient and family-exposure to illness or exposure to treatment. Regardless of the choice, clinicians are encouraged to think in terms of reducing the total number of exposures; that is, if choosing to treat, patients should be kept well by adjusting and monitoring medications-partial treatment simply provides exposure to illness and treatment. Guidelines to accomplish the goal of minimizing exposures include: 1. Treating women of reproductive capacity from the first visit as if they are pregnant: choosing treatments with reproductive safety information (eg, new and improved = no data) and providing supplemental folic acid for all women (800 microg), with higher doses for those treated with anticonvulsants (3 to 4 mg).2. For women who conceive while taking a medication, and if it was efficacious for them, then the majority of decisions for medication selection should be considered already made for pregnancy and lactation (eg, do not switch medications once pregnant or for breastfeeding, as that simply exposes the baby to a second medication and the data previously discussed do not apply). 3. Because the serum concentration of most medications decreases during pregnancy, establishing criteria a priori for increasing the maternal daily dose; as a general rule, sleep patterns are good markers of psychiatric illnesses. 4. Always preferring monotherapy to two medications. 5. Obtaining up-to-date information at www.emorywomensprogram.org (a website with links to many support groups, reproductive safety registries) or other women's health websites. These basic guidelines can help decrease the number of exposures and aid in conducting clinical care with at least some reproductive safety data.

Attempted suicide and self-injury in patients diagnosed with eating disorders

Eating disorders (ED) patients are at high risk for developing suicidal behavior. The aim of the present study was to investigate factors associated with suicidal behavior in ED patients. One hundred fifty patients at an outpatient ED clinic were included in the study. Data were gathered by retrospective chart analysis. We found that 48 patients (32%) had a history of parasuicide (i.e., suicide attempts, self-injury, or both). A significantly greater percentage of parasuicidal patients than nonparasuicidal patients had EDs with bingeing/pursing symptomatology, used more than one type of purging method, and had a lifetime history of a drug use disorder, impulse control problems, and bipolar disorder, as well as a more extensive outpatient and inpatient treatment history. The findings of this study support an increased tendency toward impulsivity among parasuicidal ED outpatients.

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.

Suicide attempts and suicidal ideation: links with psychiatric comorbidity in eating disorder subjects

Additional psychiatric disorders in eating disorders patients may contribute to the risk of suicide and suicide attempts. The aim of this study was to examine associations between Axes I and II comorbidity and suicidality in a large sample of women currently suffering from an eating disorder (ED). In a sample of 288 women (87 anorexia nervosa, 158 bulimia nervosa, 43 eating disorders not otherwise specified) psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview for DSM-IV. Histories of attempted suicide were explored in a structured interview. Suicidal ideation was determined by means of the SCL-90. Past suicide attempts were reported by 26%. Subjects with a purging type ED more frequently had a history of attempted suicide than subjects with a nonpurging type ED. A history of suicide attempts was associated with higher levels of Axes I and II comorbidity, in particular with affective disorders and Cluster B personality disorders. Current suicidal ideation was generally linked with higher levels of all types of Axes I and II comorbidity. Eating disorders are serious psychiatric disorders associated with high levels of comorbidity and suicidality. Incorporating a comprehensive psychiatric evaluation into the clinical assessment of ED patients is important for the assessment of suicidality and for the provision of adequate treatments.

Causes and recovery in anorexia nervosa: the patient's perspective

OBJECTIVE

We explored anorexic patients' subjective accounts of the causes of their anorexia and of the factors that fostered recovery. Subjective accounts could assist in understanding this complicated and often intractable disorder.

METHOD

All female new referrals to an eating disorders service underwent extensive interviews including open-ended questions about their beliefs concerning the causes of their anorexia nervosa and factors that led to recovery. Responses were categorized by two independent raters.

RESULTS

The most commonly mentioned perceived causes were dysfunctional families, weight loss and dieting, and stressful experiences and perceived pressure. The three most commonly cited factors contributing to recovery were supportive nonfamilial relationships, therapy, and maturation.

DISCUSSION

Individuals with anorexia nervosa perceive both external (family environment) and personal factors (dieting and stress) as contributory to their disorders. The results underscore the importance of interpersonal factors in recovery from anorexia nervosa and suggest that attention to this area in treatment may be beneficial.

Suicide attempts in women with bulimia nervosa: frequency and characteristics

OBJECTIVE

This study aimed to estimate the lifetime frequency of suicide attempts in a large referred population of women with DSM-IV bulimia nervosa (BN), and to compare demographic and clinical characteristics of those who had attempted suicide and those who had not.

METHOD

A total of 295 women (202 with BN purging type, 68 with BN non-purging type and 25 with anorexia nervosa binge/eating purging type) were assessed using a semi-structured interview and self-rated questionnaires.

RESULTS

Suicide attempts were frequent (27.8% of women), often serious and/or multiple. Women who had attempted suicide differed significantly from those who had not for earlier onset of psychopathology, higher severity of depressive and general symptoms, and more impulsive disordered conducts, but not for the core symptoms or severity of BN.

CONCLUSION

Interventions targeting depressive and impulsive features associated with BN are essential to reduce the risk of suicide attempt in women with this disorder.

Analysis of Crisis Intervention Processes

Summary: The remediation processes in psychosocial crisis intervention were modeled focusing on cognitive orientation. Frequent observations and subsequent process modeling constitute a novel approach to process research and reveal process-outcome associations. A sample of 40 inpatients who were assigned to treatment in a crisis intervention unit was monitored in order to study the process of crisis intervention. The process data consisted of patients' self-ratings of the variables mood, tension, and cognitive orientation, which were assessed three times a day throughout hospitalization (M = 22.6 days). Linear time series models (vector autoregression) of the process data were computed to describe the prototypical dynamic patterns of the sample. Additionally, the outcome of crisis intervention was evaluated by pre-post questionnaires. Linear trends were found pointing to an improvement of mood, a reduction of tension, and an increase of outward cognitive orientation. Time series modeling showed that, on average, outward cognitive orientation preceded improved mood. The time series models partially predicted the treatment effect, notably the outcome domain “reduction of social anxiety,” yet did not predict the domain of symptom reduction. In conclusion, crisis intervention should focus on having patients increasingly engage in outward cognitive orientation in order to stabilize mood, reduce anxiety, and activate their resources.

Self-harm and suicide attempts in individuals with bulimia nervosa

Self-harm has been identified as a clinical feature in at least a subgroup of women with bulimia nervosa. We explored how women with bulimia who engage in self-harming behaviors differ from women with bulimia without self-harming behaviors and from women with bulimia who attempt suicide with lethal intent. We compared features of the eating disorder, Axis I and II comorbidity, and Eating Disorder Inventory and Temperament and Character Inventory (TCI) scores across 19 women with bulimia who engaged in self-harming behaviors, 28 women with bulimia who reported suicide attempts with lethal intent, and 105 women with bulimia with no self-harming or suicidal behaviors. Women with bulimia nervosa and self-harm behaviors reported significantly more laxative abuse and drug abuse in general. Bulimic women with suicide attempts had the highest rates of overall comorbidity across the three groups. Individuals with self-harm scored significantly higher on the self-transcendence scale of the TCI. Bulimic women with self-harming behaviors appear to engage in more drug taking behavior--both associated with the eating disorder (laxatives) and in terms of illicit drug use. Overall, the highest rates of Axis I and Axis II comorbidity were associated with individuals with suicide attempts. High scores on self-transcendence may signal a greater sense of dissociation and disconnectedness in bulimic women who self-harm.

Rejection of life in anorexic and bulimic patients

OBJECTIVES

To investigate eating- disordered (ED) patients' attraction to life and death.

METHOD

Thirty-two anorexic and 37 bulimic patients were matched by age, sex, and socioeconomic status to 37 matched normal controls. Participants were administered the Eating Attitudes Test (EAT-26), the Beck Depression Inventory (BDI), the Multiattitude Suicidal Tendency Scale (MASS), and the Selflessness Scale.

RESULTS

ED patients scored significantly higher on the Selflessness Scale than normal controls. They are less attracted to and more repulsed by life than normal controls. In death variables, attraction to or repulsion by, no significant differences were found. These results were not influenced by depression. The higher the tendency of ED patients to ignore their needs and serve other's needs (high Selflessness scores), the higher their tendency to be attracted to death and to be less attracted to life.

DISCUSSION

ED patients, rather than dwelling on death, reject life. Theoretically, the findings support differentiation of death preoccupation to several components. Clinically, the findings might direct clinicians to help patients reduce their "self-guilt," that is, guilt of promoting their own interests.

Anger and personality in eating disorders

OBJECTIVE

This study was designed to examine how anger, temperament and character profiles differ across subtypes of eating disorders (EDs) in comparison to healthy controls and to analyze the relationship between anger expression, eating attitudes and personality dimensions.

METHOD

One hundred and thirty-five outpatients (50 of whom suffered from anorexia nervosa restrictor type [AN-R], 40 from anorexia nervosa binge/purging [AN-BP] and 45 from bulimia nervosa [BN]) and 50 control subjects were recruited and administered State-Trait Anger Expression Inventory (STAXI), Temperament and Character Inventory (TCI) and Eating Disorder Inventory II (EDI-II).

RESULTS

STAXI showed greater levels of anger in patients with BN than in those with AN. TCI showed different personality profiles, in accordance with previous studies. Correlations were found between the management of anger feelings and psychological and personality traits typical of patients with EDs.

CONCLUSIONS

Clinically, impulsivity seems to be the psychopathologic element most strongly correlated to anger. Moreover, it appears clear that anger is better managed by individuals with greater character strength.

Normative data and factor structure of the Temperament and Character Inventory (TCI) in the French version

We explored the psychometric features of the French Temperament and Character Inventory (TCI) in a 602-subject community sample (263 men and 339 women), representative of the French population. The factor structures of the temperament and character dimensions, explored separately, were in agreement with the hypothesized constructs, except for the scales Novelty Seeking NS1 (exploratory excitability), Persistence, and Self-Directedness SD4 (self-acceptance). The internal consistency of the main dimensions was good (Cronbach alpha coefficients between 0.68 and 0.82), but weak for Persistence (0.49). The mean scores of the temperament dimensions were notably different from those published in other normative data - especially lower for Novelty Seeking (16.4+/-5.6) and higher for Harm Avoidance (16.1+/-7.2) when compared with US data - suggesting cross-cultural differences in personality assessment, and the necessity to use specific normative values with each translated instrument.