انواع شخصیت در نوجوانان مبتلا به بی اشتهایی عصبی

The aims of this study are to (1) empirically identify the personality subtypes of adolescents with anorexic disorders and (2) investigate the personality disorders, identity disturbances, and affective features associated with the different subtypes. We assessed 102 adolescent patients with Eating Disorders (anorexia nervosa and eating disorder not otherwise specified) using three clinical instruments: the Shedler-Westen Assessment Procedure for Adolescents (SWAP-200-A) (Westen D, Shedler J, Durrett C, Glass S, Martens A. Personality diagnoses in adolescence: DSM-IV Axis II diagnoses and an empirically derived alternative. Am J Psychiatry 2003;160:952–966), the Affective Regulation and Experience Questionnaire (AREQ) (Zittel Conklin C, Bradley R, Westen D. Affect regulation in borderline personality disorder. J Nerv Ment Dis 2006;194:69–77), and the Identity Disorder Questionnaire (IDQ) (Wilkinson-Ryan T, Westen D. Identity disturbance in borderline personality disorder: An empirical investigation. Am J Psychiatry 2000;157:528–541). We performed a Q factor analysis of the SWAP-200-A descriptions of our sample to identify personality subtypes. We correlated these personality styles with AREQ and IDQ factors and explored the personality differences among individuals with the different types of ED. The Q factor analysis identified three personality subtypes: high-functioning/perfectionist, emotionally dysregulated, and overcontrolled/constricted. Each subtype showed specific identity and affective features, comorbidities with different personality disorders, and clinical implications. These results contribute to the understanding of adolescents with ED and seem to be relevant for treatment planning.

Eating disorders (EDs) are severe psychiatric disorders that usually onset in adolescence [1], [2] and [3]. In population aged 13 to 18, anorexia nervosa (AN) and bulimia nervosa (BN) have an average prevalence rate of 0.3% and 0.9%, respectively [4], and about 50–60% of cases of EDs in adolescence fall into the category of Eating Disorder Not Otherwise Specified (EDNOS) [5] and [6]. The clinical and social relevance of these disorders, especially in adolescence, raises the need for a deeper understanding of the psychological features underlying them. A large number of clinical observations of patients with EDs focused on patient personality features, and empirical research on personality disorders (PDs) in patients with EDs is considerable, but its results are discordant. Studies have identified highly variable rates of overall comorbidity between EDs and PDs, ranging from 27% to 93% [7], [8], [9], [10], [11], [12], [13] and [14]. Most of the research, however, has focused on patients aged 16 years or more [13] and [15], and although the DSM-IV recommends caution in the diagnosis of PD before age 18, there is increasing evidence that PDs are already identifiable in adolescence and show stability similar to that seen in adults. Moreover, empirical research of the last twenty years suggests that adolescent personality disorders are associated with a high risk of substance use and conduct disorder in adolescence and Axis I and Axis II diagnoses in adulthood, and that underlying personality pathology is crucial in understanding the prognosis of adolescent symptomatology [16], [17], [18], [19], [20] and [21]. A recent study examined PD comorbidity in outpatient adolescents with AN and found an overall 24.8% prevalence for one or more PDs and an association between the presence of a PD and a greater severity of AN [22]. Several studies and meta-analyses suggest that PDs are less frequent in subjects with AN-R than in other patients with EDs and cluster C PDs as the more common Axis II disorders associated with AN-R [12], [23], [24], [25] and [26], followed by cluster B disorders [8], [13], [22] and [27]. Instead, patients with binge-eating/purging type of anorexia nervosa (AN-BP) and those with bulimia nervosa (BN) tend to show a more severe and pervasive personality pathology, in general, with a high prevalence of borderline PD or other cluster B PDs [7], [8], [12], [22] and [26]. Less is known about the prevalence and distribution of PDs in patients with EDNOS. Striving to improve the understanding of personality pathology in patients with EDs, several researchers have used different statistical techniques for empirically identifying subgroups of adult patients with EDs and similar personality traits. With the exception of Thompson-Brenner and colleagues [28], these studies have identified the presence of three different personality subtypes: high-functioning/perfectionist (or low psychopathology), characterized by several features of healthy functioning and traits of perfectionism, self-criticism, and negative affectivity; overcontrolled (or rigid or constricted/overcontrolled or overcontrolled/avoidant), characterized by a general inhibition and passivity, with constricted affectivity, thinking, and interpersonal relations; and dysregulated/undercontrolled, characterized by emotional dysregulation, impulsivity, and relationship craving [29], [30], [31], [32], [33] and [34]. The high-functioning/perfectionist subtype has shown the mildest personality pathology, the dysregulated/undercontrolled subtype has revealed the most severe personality pathology and poorest prognosis, and the constricted/overcontrolled subtype has shown an intermediate level of personality pathology. Some of these studies [29], [31] and [33] seem to suggest that the constricted/overcontrolled subtype is mostly made up of patients with AN, while the dysregulated/undercontrolled subtype is mostly made up of patients with BN. To our knowledge, the first of the two existing personality subtyping studies on samples of adolescents with EDs has been conducted by Thompson-Brenner and colleagues [35]. Even in this adolescent population, three personality subtypes were identified: high-functioning/perfectionist, dysregulated, and avoidant/depressed. The first two subtypes substantially resembled the corresponding subtypes seen in adult samples, while the third subtype was different from the constricted/overcontrolled subtype of adult studies because of the greater weight of depressive and avoidant features. There were no statistically significant correlations between personality subtypes and ED diagnoses, with the exception of a negative association between AN and the dysregulated subtype. This study has demonstrated the validity and utility of identifying personality subtypes of EDs in adolescence; however, its sample consists only of outpatients and is characterized by a small percentage of patients with AN (15%). The second study [36], conducted on adolescent patients with ED features hospitalized for a variety of severe mental health problems, identified three subgroups: high functioning, characterized by lower levels of psychopathology; internalizing, characterized by negative affects and inability to experience and express pleasure; and externalizing, characterized by emotional and behavioral dysregulation. These subgroups, according to the authors, are similar to those described in previous research on adults with EDs. Thus, the two studies conducted on adolescent patients with EDs have confirmed a tripartite classification of personality similar to the one identified in adult samples, with some differences. Most of the empirically derived personality subtypes associated with EDs, both in adulthood and adolescence, seem characterized by peculiarities in affective experience and regulation, both of a dysregulated and of a constricted type; these domains also seem to play an important role in vulnerability and maintenance of EDs. There is substantial empirical evidence of a link between negative or dysphoric emotions and eating behaviors in women with binge-eating disorder and bulimia nervosa [37], [38] and [39], suggesting affect regulation difficulties in these disorders [40]. Some studies have highlighted the importance of emotional avoidance in EDs in terms of both negative [41] and positive affects [42] and [43]; studies on facial and verbal expression of emotions, for example, have recently emphasized emotional inhibition [44], [45] and [46] in adult patients with AN. Inhibition of emotion, described as a key feature of AN [47], has been proposed as a maintenance factor of the disorder, connected with obsessive-compulsive and avoidant traits [48] and with emotion regulation difficulties [42]. The study of the relationship between affectivity and EDs, as well as the correlation between EDs and personality traits, seems to be even more interesting in adolescence. In fact, some prospective studies have found an increased risk of ED in children and adolescents with negative emotionality and poor interoceptive awareness [49]. From a psychodynamic perspective, it seems relevant to study how the affective features of patients with EDs are correlated to their specific personality styles: affective regulation ad expression is in fact one of the main personality functions and can be better understood in the context of the different personality styles [50]. Both in the organization of personality and in the psychopathology and maintenance of EDs, also identity and identity impairments play an important role [51], [52], [53] and [54], especially in adolescence [55]. However, most of the empirical research on identity in EDs has focused mainly on disturbances of body image [56], which is only one identity dimension relevant for understanding and treating patients with ED. In fact, Stein and Corte [57], studying a sample of 111 subjects with EDs, found that oversimplified and rigid self-schemas and negative attitudes toward themselves were typical of patients with EDs, supporting the hypothesis that overall identity impairments may contribute to the disorder. Cozzi and Ostuzzi [58], studying a sample of 90 women with EDs, highlighted the difficulty among the participants in developing an autonomous personal identity, in particular in patients with AN. Schupak-Neuberg and Nemeroff [59] found that women with BN, compared with women with BED and controls, had greater disturbances in identity, including identity confusion, a sense of enmeshment with others, and instability in self-concept; the authors proposed that binge eating behavior in these patients was an escape from self-awareness. Some authors have suggested that an eating disorder may serve to create an identity [52] or achieve a new identity [43]. However, to our knowledge, there is no empirical study on identity and identity disorders in adolescent patients with EDs. The aim of this study is to explore the personality subtypes of an Italian sample of adolescent inpatients and outpatients with AN and EDNOS with restrictive and binge-eating/purging behaviors. We have tried to empirically identify the personality subtypes of our sample and have explored the features of these different subtypes in terms of prevalent affects, emotional regulation styles, identity disturbances, and personality disorders. More specifically, we hypothesized the following: 1) It is possible to identify also in Italian adolescents with EDs three main personality subtypes: a high-functioning/perfectionist subtype, an emotionally dysregulated subtype and an overcontrolled/constricted subtype. We expect to find this third personality style, rather than an avoidant/depressed subtype, because of the high rate of subjects with AN-R in our sample; clinical observation and previous research have suggested an association between constricted/overcontrolled subtype and anorexia nervosa [29], [31] and [33]. 2) The high-functioning/perfectionist subtype is associated with healthier coping strategies and no identity disorders; the emotionally dysregulated subtype is associated with emotional dysregulation, negative affects, and identity incoherence [60]; and the overcontrolled/constricted subtype is associated with the avoidance of emotional experiences. 3) The high-functioning/perfectionist subtype is more common in outpatients and in patients with restrictive behaviors, the dysregulated subtype is more common in inpatients and in patients with binge-eating/purging behaviors, and the overcontrolled/constricted subtype is more common in patients with restrictive behaviors. 4) Finally, we expect to find that the high-functioning personality subtype is associated with the SWAP-200-A index of personality health, the inhibited/self-critical personality style, a better capacity to perceive the severity of one's own pathological conditions, and less severe EDs; the emotionally dysregulated subtype is associated with cluster B personality disorders, more severe EDs, and the worst capacity to perceive the severity of one's own clinical conditions; and the overcontrolled/constricted personality subtype is associated with avoidant/constricted personality disorder and a low degree of personality pathology.