ابراز خشم در اختلالات تغذیه ای: ارتباط بالینی، روانشناختی و شخصیت

The goals of the study were to compare anger expressions in individuals with eating disorders and healthy controls, and to explore the relation among eating disorder symptoms, comorbid psychopathology, personality traits, and impulsive behaviours. Participants comprised 135 eating disorder patients consecutively admitted to our unit and 103 healthy controls. Assessment measures included the Eating Disorders Inventory 2 (EDI-2), Bulimic Investigatory Test Edinburgh (BITE), Symptom Checklist-Revised (SCL-90-R), Social Avoidance Distress Scale (SAD), Temperament and Character Inventory-Revised (TCI-R), State-Trait Anger Expression Inventory 2 (STAXI-2), and other clinical and psychopathological indices. In the control group also the General Health Questionnaire-28 (GHQ-28) was also used. Women with eating disorders obtained significantly higher mean scores than controls on all STAXI-2 scales except for Anger Control. When various purging methods were assessed independently, the frequency of laxative use was associated with anger suppression. Eating disorder symptoms and specific personality traits were positively associated with different forms of anger expression. Finally, patients with higher scores on anger suppression were more likely to report self-harming behaviors. Eating disorder patients may have inadequate anger expression and deficits in coping with anger and frustration. Furthermore, different purging methods may be related to different facets of anger.

In eating disorders, anger and aggression are important psychopathologic traits (Fassino et al., 2001), which have been found to be associated with eating disorder subtype (Fassino et al., 2001), severity of eating disorder symptoms (Abbate-Daga et al., 2005), comorbidity (Fassino et al., 2003a), altered biochemical functioning (Coccaro et al., 1989), endocrinologic dysfunction (Bartolomucci et al., 2004 and Coste et al., 2006) and poorer treatment outcome (Fava et al., 1995 and Fassino et al., 2003b). Marked impulse dysregulation has also been related to difficulties in expressing anger (Tiller et al., 1995 and Truglia et al., 2006). The present study explores the manner in which various facets of anger are linked to eating disorder symptoms, comorbid psychopathology, personality traits, and impulsive behaviors. Aggressiveness can be defined as any behavior that is intended to harm. (Truglia et al., 2006). Research into the role of anger in eating disorders has been somewhat inconsistent and imprecise, which may in part be due to limits in the current conceptualization of this emotion. Anger has generally been considered as a unitary construct (Arnow et al., 1995). However, Spielberger (1996) suggested that anger should be conceptualized as a multifaceted construct, comprising anger states (a changeable emotional condition consisting of subjective feelings of tension, annoyance, irritation, fury, or rage, frequently accompanied by the activation of the autonomic nervous system) and anger traits (an enduring personality feature, displaying individual differences in the incidence with which state anger is experienced over time). In addition, Spielberger remarked that individuals can differ in the ways in which they express or suppress their anger (Spielberger, 1996). 1.1. Anger and eating disorders Little is known about the role that anger plays in eating disorders. The few studies assessing anger in eating disorders have generally revealed that individuals with eating disorders, especially bulimia nervosa (BN) patients, report higher anger levels than healthy controls (Fava et al., 1995, Tiller et al., 1995, Milligan and Waller, 2000, Fassino et al., 2001 and Zaitsoff et al., 2002). Independent of diagnosis, elevated levels of unexpressed anger have been revealed in individuals with eating disorders (Milligan and Waller, 2000). More specifically, Arnow et al. (1995) outlined that anger plays a very important role in affect-driven overeating and bingeing. In relation to this, one unanswered question is whether severity of bulimic behaviors is related to higher levels of unexpressed anger, independent of diagnosis. The few studies that have addressed this topic have yielded contradictory findings with some studies indicating that anger outbursts were associated with greater severity of bulimic symptoms (Fava et al., 1995), while others found that individuals who vomited did not show more anger than those who did not vomit (Fassino et al., 2001 and Abbate-Daga et al., 2005). Further research is needed to clarify these inconsistencies. 1.2. Anger and personality An important dimension to consider when studying anger in eating disorders is the underlying personality traits (Fassino et al., 2001 and Fassino et al., 2002). Contrasting personality profiles reveal high harm avoidance, reward dependence, and low novelty seeking in individuals with anorexia nervosa (AN) and high impulsivity, sensation seeking and novelty seeking in individuals with bulimic presentations (Klump et al., 2000). To date, the few studies that have assessed anger and personality concurrently have not revealed replicable patterns of association between particular personality profiles and anger expression (Fassino et al., 2003a, Fassino et al., 2003c and Abbate-Daga et al., 2005); however; considerable room for further work in this area exists. 1.3. Anger and impulsivity Impulsivity is the only trait that has consistently been found to be associated with anger and eating disorder symptoms. Various researchers have suggested that negative affective states (particularly anger) are strongly related to impulsive behaviors in eating disordered patients (Favaro and Santonastaso, 1999) such as suicidal and parasuicidal gestures (Rodriguez-Cano et al., 2006), self-injurious behavior (Grant et al., 2005), drug or alcohol abuse (Bulik et al., 2004), stealing (Grant and Kim, 2002), and sexual promiscuity (Wiederman et al., 1996 and Matsunaga et al., 2000). Further validation of the relation between impulsivity and anger is required. In sum, further research on anger in individuals with eating disorders is potentially useful, since anger may have some etiological role and therefore could be a premorbid personality characteristic and/or a risk factor for developing eating disorders. Furthermore, high levels of anger may also be a barrier to treatment by maintaining psychopathology and should therefore be addressed in treatment (Fassino et al., 2002 and Fassino et al., 2003b). The present study extends previous research on the association between eating disorders and anger by assessing whether the severity of bulimic features is related to anger expression. Taking a transdiagnostic approach rather than relying exclusively on diagnostic categories might allow us to understand why treatment outcome is not always directly related to the severity of bulimic symptoms and might also enable us to tailor treatment modules to specific needs of patients with deficits in particular areas. Furthermore, the detection of particular character and temperament traits and psychopathologic and impulsive cores in relation to anger expressions has not been assessed previously and is of great interest, as it may allow us to identify individuals who are at greater risk of developing severe clinical eating disorder symptoms. 1.4. Aims of the study Given the current gaps in the literature, the goals of the present study were fourfold: (1) to compare various facets of anger expression in individuals with eating disorders and healthy controls; (2) to explore the specific relation between anger and bulimic behaviors; (3) to explore the relation of anger expression to eating disorder symptoms, general psychopathological features, and personality traits; (4) to determine the relation between anger expressions and self-damaging impulsive behaviors. We hypothesized that there would be higher scores on general anger expression in patients with eating disorders than controls and that patients with bulimic behaviors would score significantly higher on Anger-In (a measure of anger suppression). Moreover, we hypothesized that individuals with intense urges to express anger would also display a variety of impulsive self-destructive behaviors.