The “atypical” subgroup of women with anorexia nervosa not characterized by drive for thinness (DT) was studied. The study group comprised 151 anorectic patients (restrictor anorectics [AN-R], n = 74; binge-purging anorectics [AN-BP], n = 77). Subjects completed the following self-administered questionnaires: Eating Disorder Inventory-2 (EDI-2), Temperament and Character Inventory (TCI), State-Trait Anger Expression Inventory (STAXI), and Beck Depression Inventory (BDI). Patients were subdivided into three groups on the basis of body mass index (BMI) and DT score: AN-I with a BMI < 15 and DT < 7 (n = 24); AN-II with a BMI > 15 and DT < 7 (n = 34); and AN-III with a BMI < 17.5 and DT > 7 (n = 93). Patients belonging to the AN-III group had a more severe disorder and form of psychopathology based on their scores on several scales. No association emerged between personality disorders and any single subgroup. Three hypotheses emerge: (1) some patients (about 38%) deny DT and provide negative answers on the questionnaires; (2) patients without DT (even when malnourished) seem to show less severe psychopathologic and personality traits; and (3) patients without DT answer questions honestly, but they have developed a character structure that enables them to feel negative and ego-dystonic emotions regarding their condition. Implications for treatment are discussed.
About 50% of persons with eating disorders (EDs) have partial-syndrome EDs or “atypical” EDs; therefore the study of these forms is a relevant and often neglected field of research (Fairburn and Harrison, 2003). In the research literature, the term “atypical” (or partial-syndrome) EDs refers to those patients who do not meet all the criteria required for a DSM-IV diagnosis (Strober et al., 1999) but also to those full-syndrome cases of anorexia nervosa (AN) who meet DSM-IV criteria but do not show some of the core psychological features of AN from a dimensional point of view (atypical anorexia nervosa). For example, a key psychopathological role in AN is played by a morbid and strong fear of fatness (American Psychiatric Association, 2000) and by the consequent drive for and pursuit of thinness. This fear/drive is often measured by self-report questionnaires as a drive for thinness (DT; Garner, 1984), which is a psychological variable implicated in the etiology and course of EDs (Striegel-Moore et al., 1995 and Bizeul et al., 2001).
Recent investigations found a subgroup of anorectic patients with full-syndrome AN, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), but without a significant DT ( Ramaciotti et al., 2002). The percentage of patients within this subgroup is variable, ranging from 0% to 20% in clinical samples ( Ramaciotti et al., 2002 and Garfinkel and Dorian, 2001). This subgroup of patients is difficult to define and has received little attention in the literature ( Crow et al., 2002), although such patients display a clinical severity that requires treatment. Indeed, people with full-syndrome and partial-syndrome EDs usually do not differ with respect to DT ( Dancyger and Garfinkel, 1995).
Interest in “atypical” anorectic patients increased after reports that patients with a low DT at baseline assessment have a more favorable outcome (Bizeul et al., 2001) and a less severe course (Strober et al., 1999). Some authors who investigated this subgroup did not distinguish between severely (body mass index < 15) and less severely (body mass index > 15) malnourished anorectic patients and did not focus on the personality characteristics of these subjects. Subjects with a body mass index (BMI) < 15 are so severely ill that an inpatient program is often necessary (American Psychiatric Association, 2000). Therefore, it seems a paradox that these patients do not have a high DT. This feature could be related to the difficulties in treating patients with AN associated with an ego-syntonic functioning of personality (Kaplan and Garfinkel, 1999).
The a priori hypothesis of this study was that AN patients with low DT deny their DT and their fat phobia when their physical condition is severe (BMI < 15), whereas the so-called “atypical anorectics” could be those with low DT but a BMI > 15. The study explored differences in personality and psychological functioning subgroups of AN women with low BMI (< 15) with low DT, anorectic women with BMI > 15 with low DT, and anorectic women with high DT.
