Personality disorders in relation to anthropometric, endocrine and metabolic factors

Risk of stroke among patients with borderline personality disorder: A nationwide longitudinal study

BACKGROUND

Previous studies suggested that patients with borderline personality disorder (BPD) had a higher prevalence of stroke-related risk factors, such as hypertension, dyslipidemia, and diabetes mellitus. But, the association between BPD and subsequent stroke has been rarely investigated.

METHODS

Using the Taiwan National Health Insurance Research Database, 5969 borderline patients aged 18 years and older and 23,876 age-and sex-matched controls were enrolled between 2002 and 2009, and followed up to the end of 2011 to identify the development of stroke.

RESULTS

The Cox regression model after adjusting for demographic data, psychiatric comorbidities, and medical comorbidities showed that BPD was associated with an increased risk of developing any stroke (HR: 4.82, 95% CI: 2.77-8.40) and ischemic stroke (HR: 5.67, 95% CI: 2.49-12.93). The findings of sensitivity analysis after excluding the first year of observation were consistent: any stroke (HR: 3.44, 95% CI: 1.83-6.47) and ischemic stroke (HR: 4.75, 95% CI: 1.91-11.77).

DISCUSSION

Patients with BPD had an elevated vulnerability to subsequent stroke and ischemic stroke compared to those without BPD. Further studies would be required to investigate the underlying mechanisms.

Personality disorders and obesity: a systematic review

BACKGROUND

Studies demonstrate an association between personality traits and obesity as well as their prognostic influence on weight course. In contrast, only few studies have investigated the association between personality disorders (PDs) and obesity.

OBJECTIVE

The present review summarizes through a comprehensive and critical evaluation the results of 68 studies identified by database research (PubMed and PsycINFO) covering the last 35 years that investigated the association between PDs, overweight and obesity as well as the predictive value of PDs for the development of obesity and the effectiveness of weight reduction treatments.

RESULTS

Adults with any PD have a higher risk of obesity. In the female general population, there is an association between avoidant or antisocial PD and severe obesity. Further, women with paranoid or schizotypal PD have a higher risk of obesity. Clinical studies including foremost female participants showed a higher comorbidity of PDs, especially borderline PD and avoidant PD, in binge-eating disorder. Regarding both genders, patients with PD show less treatment success in conservative weight-loss treatment programmes for obesity than patients without PD.

CONCLUSIONS

In prevention and conservative weight-loss treatment strategies, more care should be taken to address the special needs of patients with comorbid PDs.

Psychiatric Status across Body Mass Index in a Mediterranean Spanish Population

Background

Mental and body weight disorders are among the major global health challenges, and their comorbidity may play an important role in treatment and prevention of both pathologies. A growing number of studies have examined the relationship between psychiatric status and body weight, but our knowledge is still limited.

Objective

The present study aims to investigate the cross-sectional relationships of psychiatric status and body mass index (BMI) in Málaga, a Mediterranean city in the South of Spain.

Materials and Methods

A total of 563 participants were recruited from those who came to his primary care physician, using a systematic random sampling, non-proportional stratified by BMI categories. Structured clinical interviews were used to assess current Axes-I and II mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). BMI was calculated as weight (Kg) divided by square of height in meters (m²). Logistic regression was used to investigate the association between BMI and the presence of any mental disorder. BMI was introduced in the models using restricted cubic splines.

Results

We found that high BMI values were directly associated with mood and adjustment disorders, and low BMI values were directly associated with avoidant and dependent personality disorders (PDs). We observed an inverse relationship between low BMI values and cluster A PDs. There were not significant relationships between anxiety or substance-related disorders and BMI.

Conclusion

Psychiatric status and BMI are related in a Mediterranean Spanish population. A multidisciplinary approach to both pathologies becomes increasingly more necessary.

Obesity and psychopathology. A study of psychiatric comorbidity among patients attending a specialist obesity unit

Aims – The study aims to evaluate the frequency of association between Axis I and II disorders according to DSMIVTR criteria and obesity, and use of mental health services in a clinical sample of patients attending a centre for the diagnosis and treatment of Obesity. Methods – 150 consecutive patients (32 Males, 118 females, mean age 44.614.3 yrs; mean BMI 35.46.2) were interviewed by means of SCID I and SCID II. Results – Lifetime Prevalence of Axis I disorders was 58% (males 50%; females 61%); the highest prevalence rate was found for Anxiety Disorders (approx 35%), whilst 30% of subjects were affected by Mood disorders, chiefly Major Depression (20%), and 18% by Eating Disorders. 28% of obese patients presented a Personality Disorder, 23% of patients being affected both by an Axis I and Axis II disorder. Mood Disorders, in particular Major Depression, were significantly prevalent among female obese. 50% of females and approx 37% males included in the sample had contacted mental health units for treatment. Conclusion – Data obtained in the present study confirm the high prevalence rates of mental disorders in obese patients seeking treatment. Specialist units should therefore include thorough psychiatric evaluation of patients as a routine practice.

Declaration of Interest: The study was supported by a research grant by University of Cagliari (ex 60% funding, financial year 2006); the authors declare no conflict of interest.

Prenatal origins of hospitalization for personality disorders: the Helsinki birth cohort study

Although a suboptimal prenatal environment has been linked with schizophrenia and depression, possible associations with personality disorders remain unclear. The aim of this study was to examine the associations of body size at birth and length of gestation with hospitalization for personality disorders in a cohort study of 6506 men and 5857 women born in Helsinki, Finland, between 1934 and 1944. International Classification of Diseases (-8, -9, -10) diagnoses of personality disorders were extracted from the national Finnish Hospital Discharge Register since 1969. 102 men and 80 women had been hospitalized due to any personality disorder. 41 men and 30 women had dramatic personality disorders. Among men, head circumference showed an inverse J-shaped, nonlinear association with hospitalization for personality disorders. Men with a small head circumference were at increased risk. Also in men, a smaller head-to-length ratio linearly predicted personality disorders. Among women, a smaller placental area predicted increased risk of hospitalization for dramatic personality disorders. Vulnerability to personality disorders may be programmed during fetal life.

Associations between body weight and personality disorders in a nationally representative sample

OBJECTIVE

To determine whether, in the general population, individuals in numerous abnormal body weight categories had higher odds of having personality disorders (PDs) than normal-weight individuals. Although personality functioning is hypothesized to be associated with body weight, there is a dearth of empirical evaluation of this topic.

METHODS

The association of body weight (five categories: underweight [body mass index [BMI] <18.5]; normal [18.5 <or= BMI <25]; overweight [25 <or= BMI <30]; obese [30 <or= BMI <40]; and extremely obese [BMI >or=40]) with personality disorders was investigated using data from the nationally representative National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (n = 43,093). Lifetime paranoid, schizoid, antisocial, histrionic, avoidant, dependent, and obsessive-compulsive PDs were examined, as assessed by the Alcohol Use Disorders and Associated Disabilities Interview Schedule-DSM-IV version (AUDADIS-IV).

RESULTS

After adjusting for sociodemographics, Axis I disorders, schizophrenia, physical health conditions, and comorbid PDs, extreme obesity was associated with antisocial or avoidant PDs (adjusted odds ratio (AOR) range = 1.66-1.73), whereas underweight was associated with increased odds of schizoid PD (AOR = 1.89). The pattern of associations differed when stratified by gender. Overweight men had lower odds of paranoid PD (AOR = 0.73). Women with higher-than-normal body weights had higher odds of paranoid, antisocial, and avoidant PDs (AOR range = 1.33-2.50), whereas underweight women more often met the criteria for schizoid PD (AOR = 1.95).

CONCLUSIONS

Higher-than-normal body weight is associated with paranoid, antisocial, and avoidant PDs for women, whereas overweight men have lower rates of paranoid PD and underweight women have higher odds of schizoid PD. Possible clinical implications of this research are discussed.

Decision-making in obesity: a study using the Gambling Task

The present study addresses the issue of whether a "decision-making disorder" could account for the behavioral problems of severely obese patients (BMI score >34) who are not classified by traditional psychiatric Eating Disorder tests. The neuropsychological test employed, the Gambling Task (GT), is not directly related to the food domain, but it is sensitive to failure in making long-term advantageous choices. A comparison was made of 20 obese subjects (OS) and 20 normal-weight subjects (NWS) matched in age, education and IQ. The subjects' personalities and food behavior were assessed from psychological questionnaires, and then the Gambling Task was administered. The number of "good" choices made by the two groups during GT performance differed significantly, and the OS did not learn to maximize advantageous choices like the NWS did. OS behavior could be consistent with a prefrontal cortex defect that implies difficulties in inhibition of excessive food intake.

Associations among education, cortisol rhythm, and BMI in blue-collar women

OBJECTIVE

This study sought to test whether a biological measure of chronic stress, Delta cortisol, was related to BMI and whether the relationship between Delta cortisol and BMI varied according to education and positive affect.

RESEARCH METHODS AND PROCEDURES

One hundred fifty-four women from a blue-collar women's health project in 11 industrial sites in rural North Carolina provided saliva for cortisol assays for a substudy on "stress." Delta Cortisol, the difference between awakening and midday cortisol measures representing diurnal decline, was calculated (lower values = greater stress). BMI was regressed on Delta cortisol, education, and positive affect. Analyses were controlled for age, race, and worksite. Standardized beta-coefficients were calculated.

RESULTS

For participants with complete data (n = 129), BMI was greater (beta; 95% confidence interval) for women with less than high school education (0.56; 0.18, 0.94) and those who completed high school (0.26; -0.05, 0.57) relative to women with greater than a high school education (p = 0.009). Delta Cortisol was inversely related to BMI (-0.32; -0.59, -0.05; p = 0.022). Education positively modified the inverse relationship between Delta cortisol and BMI (p = 0.047). Positive affect was negatively associated with BMI (-0.44; -0.82, -0.06; p = 0.026) and positively modified the inverse association between Delta cortisol and BMI (0.33; -0.03, 0.69; p = 0.074).

DISCUSSION

Education and Delta cortisol were inversely related to BMI, and the magnitude of the association between Delta cortisol and BMI was buffered by higher education. Positive affect was inversely related to BMI. Chronic stress is associated with higher BMI, with this relation attenuated by higher education and, possibly, a positive affect.

Aetiology of obesity: a striving after wind?

The current global epidemic of obesity is fuelled by a constant, unidirectional adverse effect on energy balance that exceeds the adaptive capacity of the system. The individual response to this environmental pressure is under the control of a variety of genes, which not only interacts with environmental factors but also with one another. Since the discovery that adipocytes may produce and secrete hormones, the adipose tissue has taken on increasing importance in the regulation of energy balance. Indeed, the pathogenesis of obesity, once regarded as so obvious and simple, is becoming one of the most complex in medical practice. From a clinical perspective, obesity is associated with a remarkably broad spectrum of health complications and, over the years, obesity-related mortality has consistently increased. From a theoretical viewpoint, the growing complexity of factors affecting the liability to obesity, the inconsistency of scientific results, the lack of consensus among scientists, and so forth, obstruct our efforts to unravel the aetiology of obesity. Is the field of obesity research merely a striving after wind, and nothing more?

Personality, manual preference and neuroendocrine reactivity in hirsute subjects

Behavioral and neuroendocrine differences may be postulated in hirsute subjects since central effects of gonadal steroids are well established. We conducted a controlled clinical study with 25 consecutive young hirsute participants compared with 20 consecutive controls. Neuropsychological evaluation included the Minnesota Multiphasic Personality Inventory (MMPI) and the Edinburgh Inventory of Manual Preference (EIMP). Neuroendocrine reactivity was assessed by the adrenocorticotropic hormone (ACTH) and cortisol responses to corticotropin releasing hormone (CRH). Hirsute participants presented a flattened personality profile with lower neurotic triad scores--146 +/- 20 versus 166 +/- 28. Left-hand preference was more common in hirsute participants--4/21 versus 0/20. Decreased ACTH [area under the curve (AUC)--36 +/-2 8 vs. 72 +/- 63 pg/ml h] and cortisol (AUC--18 +/- 4 vs. 25 +/- 10 microg/dl h) responses to CRH were found in the hirsute group. In the hirsute group, higher manual preference scores were associated with lower ACTH responses to CRH, while the opposite association was found in the control group. In the hirsute group, the hyporeactive hypothalamic-pituitary-adrenal (HPA) axis was associated with lower behavior-deviant scores, while in the control group, the hyporeactive HPA axis was associated with more psychopathology. We conclude that personality and HPA axis reactivity are different in hirsute female participants when compared with controls, with a trend for differences regarding handedness. Personality and handedness are differently associated with HPA reactivity. Distinctive features in hirsute participants are probably established very early during ontogenic development.

Obesity, body fat distribution and incidence of sick leave in the Belgian workforce: the Belstress study

OBJECTIVES

In many studies, obesity has been associated with morbidity or mortality, but only a few have studied the relation between obesity and sick leave. Our aim is to analyse the independent effects of both adiposity and body fat distribution in relation to the 1-y incidence of sick leave in a large cohort of male and female workers covering a variety of occupations, taking into account a wide range of socio-demographic, behavioural and bioclinical variables.

DESIGN AND SETTING

The baseline survey of the Belstress study was conducted in 25 companies across Belgium between 1994 and 1998. A cohort of 20 463 workers (15 557 males and 4906 females) aged 35-59 y was followed for absenteeism during 1 y. The 75th percentile of the distribution of the total annual sickness days was used as a cutoff to classify the workers with a high 1-y incidence rate of sick leave. The relation between sick leave and both obesity and body fat distribution assessed by the body mass index (BMI) and the waist circumference, respectively, was analysed by multivariate logistic regression models.

RESULTS

Using a backward procedure based on the likelihood ratio, we found central abdominal fatness to be an independent predictor of sick leave in both genders (high sick-leave incidence and long spells), but not BMI. In men, the odds ratios was 1.31 (99% CI 1.12-1.52, P<0.0001) and in women it ranged from 1.32 (99% CI 1.03-1.70, P=0.005) to 1.47 (99% CI 1.14-1.90, P<0.0001). Two baseline covariables, respiratory problems and perceived health, are confounders or mediators.

CONCLUSIONS

In this study, body fat distribution was associated with a high annual sick-leave incidence and long spells of sickness absence. If this link is reversible, employers may benefit from programs aiming at the prevention and treatment of central obesity.

Associations between repression, general maladjustment, body weight, and body shape in older males: The normative aging study

We examined relationships between repression, general maladjustment, body mass index (BMI), and waist-to-hip ratio (WHR). The participants were 1,081 healthy older men from the Normative Aging Study. Repression and General Maladjustment Scales of the Minnesota Multiphasic Personality Inventory were composite measures of personality. Repression was associated with lower BMI and WHR, and maladjustment with higher BMI and WHR. However, associations between WHR and personality dimensions were no longer significant when controlling for BMI, but associations between BMI and personality dimensions remained significant when controlling for WHR. These effects were explained by differing relationships between WHR, repression, and maladjustment for normal weight, overweight, and obese individuals. Specifically, associations between repression, maladjustment, and body shape were significant for normal weight and overweight individuals, but not for obese individuals. Health behaviors including smoking did not mediate relationships between repression, maladjustment, and body shape, but might be considered in future studies as mechanisms underlying links between personality and body shape.

Polymorphism in exon 6 of the dopamine D(2) receptor gene (DRD2) is associated with elevated blood pressure and personality disorders in men

A deficient dopamine D(2) receptor (DA2) formation or action may contribute to hypertension via an increase of catecholamine release. In addition, Axis II personality disorders that appears odd or eccentric (cluster A) is associated with a low density of DA2. This study sought to examine if a NcoI restriction fragment length polymorphism (C to T transition) in exon 6 of the dopamine D(2) receptor gene (DRD2) was associated with these characteristics. The genotypes (CC, CT and TT) were compared in anthropometric, endocrine, metabolic and haemodynamic variables as well as estimates of personality disorders in 284 randomly selected 51-year-old men. Homozygotes for the C allele constituted 49% of the men and homozygotes for the T allele 9%, while heterozygotes were 41%. The TT genotype was associated with elevated systolic and diastolic blood pressure, independent of obesity and endocrine abnormalities, including the hypothalamic-pituitary-adrenal axis regulation. Moreover, the TT genotype was significantly more frequent among subjects with grade 1 (mild) hypertension (>140/90 mm Hg) compared to normotensive subjects (<130/85 mm Hg). The polymorphism in exon 6 of the DRD2 was also significantly associated with cluster A personality disorders. These results suggest that a polymorphism in exon 6 of the DRD2examined with the restriction enzyme NcoI is associated with an elevated blood pressure, independent of obesity. Paranoid or schizoid personality disorders is also associated with a polymorphism of the DRD2, which might be associated with a previously demonstrated low density of this receptor.

Do stress reactions cause abdominal obesity and comorbidities?

'Stress' embraces the reaction to a multitude of poorly defined factors that disturb homeostasis or allostasis. In this overview, the activation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system have been utilized as objective measurements of stress reactions. Although long-term activation of the sympathetic nervous system is followed by primary hypertension, consequences of similar activation of the HPA axis have not been clearly defined. The focus of this overview is to examine whether or not repeated activation of these two stress centres may be involved in the pathogenesis of abdominal obesity and its comorbidities. In population studies adrenal hormones show strong statistical associations to centralization of body fat as well as to obesity. There is considerable evidence from clinical to cellular and molecular studies that elevated cortisol, particularly when combined with secondary inhibition of sex steroids and growth hormone secretions, is causing accumulation of fat in visceral adipose tissues as well as metabolic abnormalities (The Metabolic Syndrome). Hypertension is probably due to a parallel activation of the central sympathetic nervous system. Depression and 'the small baby syndrome' as well as stress exposure in men and non-human primates are followed with time by similar central and peripheral abnormalities. Glucocorticoid exposure is also followed by increased food intake and 'leptin resistant' obesity, perhaps disrupting the balance between leptin and neuropeptide Y to the advantage of the latter. The consequence might be 'stress-eating', which, however, is a poorly defined entity. Factors activating the stress centres in humans include psychosocial and socioeconomic handicaps, depressive and anxiety traits, alcohol and smoking, with some differences in profile between personalities and genders. Polymorphisms have been defined in several genes associated with the cascade of events along the stress axes. Based on this evidence it is suggested that environmental, perinatal and genetic factors induce neuroendocrine perturbations followed by abdominal obesity with its associated comorbidities.

Relationships between personality disorders and anthropometry, hormones and metabolism in women

This study sought to examine the potential influence of personality disorders (PD) on anthropometry, hormones and metabolism in women. In a population sample of women born in 1956 (no.=270), estimates of PD:s by Structured Clinical Interview for DSM-III-R, Axis II, were correlated with anthropometric, endocrine, and metabolic factors. The PD:s were grouped into three thematic clusters: cluster A (characterized by oddness or eccentricity), cluster B (characterized by self-centeredness, emotionality, and erratic behavior) and cluster C (characterized by anxiety and fear). Subjects with cluster A PD:s had significantly increased body mass index (BMI, kg/m2) and abdominal sagittal diameter (cm) as well as lower salivary cortisol after dexamethasone (DEX) compared to controls. Subjects with cluster B also had a significantly higher abdominal sagittal diameter and significantly lower salivary cortisol levels after DEX than controls. In addition, subjects with cluster B PD:s had decreased levels of ACTH, and significantly higher concentrations of lactate and triglycerides, while high-density lipoprotein (HDL) cholesterol was significantly lower compared to controls. A significantly higher waist/hip ratio was seen among subjects with cluster C PD:s. In addition, these subjects had higher levels of insulin, glucose, lactate, triglycerides, total cholesterol and low-density lipoprotein (LDL) cholesterol than controls. Moreover, IGF-I and HDL cholesterol were significantly decreased in the former group. These results suggest that PD:s are involved in the development of obesity and abdominal fat accumulation in women, with different endocrine and metabolic profiles depending on the type of PD.

Psychoneuroendocrine characteristics of common obesity clinical subtypes

OBJECTIVE

To relate psychological profiles, cerebral asymmetry and the hypothalamus-pituitary-adrenal axis (HPA) reactivity to clinical characteristics of common obesity.

METHODS

Sixty consecutive adult female overweight and obese patients attending the outpatient endocrine department were included in this study. Clinical evaluation specifically selected a priori the following indexes: obesity age of onset, parenthood obesity, carbohydrate craving, binge eating with purging, obesity degree (defined by the body mass index (BMI)--weight (kg)/height (m(2))), body fat distribution (defined by the abdominal--thigh ratio (A/T)) and initial weight loss after medical treatment. Psychological evaluation was performed with the Minnesota Multiphasic Personality Inventory (MMPI). In the last 30 patients, the Edinburgh Inventory of Manual Preference (EIMP) and the corticotrophin-releasing hormone (CRH) test were also performed.

RESULTS

Clinical characteristics defined a priori were independent variables as evaluated by contingency table analysis. Factorial analysis of variance (ANOVA) revealed a significantly different MMPI profile, according to parental obesity, with post-hoc significantly higher scores on the hypochondriasis (Hs), paranoia (Pa), psychasthenia (Pt) and schizophrenia (Sc) scales in patients with obese parents. Obese patients presented significantly higher dichotomized manual preference indexes in relation to overweight patients. Parental obesity, binge eating behaviour with purging, body fat distribution and the dichotomized manual preference index were independent significant factors for the ACTH response in the CRH test, together explaining 41% of the response variability. Age of onset of obesity and the dichotomized manual preference index were independent and significant factors for the cortisol response, together explaining 37% of its variability. A non-normal distribution was found for the ACTH response: high- and low-responders presented significantly different MMPI profiles, with high-responders presenting higher scores on all clinical scales except masculinity/femininity (Mf).

CONCLUSION

Overweight/obese subjects with parental obesity present a distinctive personality profile and a higher ACTH response in the CRH test. Cerebral asymmetry may be a relevant factor for obesity development and is associated with the HPA reactivity. HPA reactivity is a sensitive index integrating clinical, psychological and neural asymmetric factors. International Journal of Obesity (2001) 25, 24-32