Impulse Regulation in Anorexia Nervosa and Bulimia Nervosa: Some Formulations

Abstract

Empirical observations imply that impulsivity is specifically associated with poor prognosis in eating disorders. The present paper cites studies suggesting that this factor is predominantly associated with the bulimic pattern of eating disturbance, while "restriction" may be associated rather with hypercontrol of behaviour. Further evidence is cited suggesting that the relationship between hyper-and hypocontrol is actually very intimate, both on a behavioural and biochemical level. Rather than bulimics being generally impulsive and "restrictors" generally hypercontrolled, future studies may reveal impulse regulation difficulties of both kinds in both groups. Single-minded preoccupation with dieting may be an ill-equipped individual's effort to simplify life in periods of change and environmental challenge that demand capacity for flexible impulse regulation. IntroductionContrary to impressions of both professionals and the lay public, recent evidence suggests that the incidence of anorexia nervosa may not be greater today than during previous decades (Lucas et Nielsen, 1990). Still, this disorder and related patterns of weight-shape preoccupation, body image disturbance and severely disordered eating (bulimia nervosa and atypical or subclinical variants) continue to present significant health problems. Thus, beyond the risks directly associated with starvation, binge eating and purging, there are often significant and long-lasting psychological and social sequelae.Some 90-95% of patients are women and there is a fair amount of consensus that the disorders begin with dieting, often starting in the context of separation (e.g. going to boarding school, au pair work in another country, loss of a love relationship). For some, dieting escalates into frankly anorexic food refusal and emaciation. For others dieting is interrupted by periods of binge eating in which huge amounts of food are consumed in a short time, only to be purged immediately afterwards. When the afflicted individual eventually seeks help, her condition is a mixture of basic psychopathology and the effects of acute malnutrition (e.g. Woell et at., 1989). No firm conclusions have been drawn concerning why some dieters go on to have clinical eating disorders. In the present paper I will discuss how investigation of impulse regulation could shed some light on this issue.

Restrained eaters act on impulse

“…Multi-impulsivity is related to worse treatment outcomes in bulimic patients (Sohlberg, 1991), and an important question is whether impulsivity or deficits in response inhibition, which is a hard-wired, biological based trait, can ever be changed. Therapy, or even drugs, which can im-prove response inhibition, should also improve eating disordered behaviour and might prevent the development of eating disorders.…”

“…The fact that the impulsive behaviour of bulimic patients is not restricted to their eating behaviour, but stretches out to a broad-spectrum of behaviours, suggests that they have rather fundamental deficits in their impulse control. Considering the fact that multi-impulsivity is related to worse treatment outcomes in bulimic patients (Sohlberg, 1991), it might be fruitful to know whether a basically deficient impulse control system underlies the disorder.…”

Impulsivity and dyscontrol in bulimia nervosa: is impulsivity an independent phenomenon or a marker of severity?

“…These dyscontrol disorders clearly bear strong resemblances to OCD (30). Sohlberg (31) hypothesizes that the problem in BN is one of brittle hypercontrol, so that obsessional hyper-and hypocontrol are present in the same individual. He suggests that the underlying abnormality is an incapacity to regulate impulses flexibly.…”

Personality in Anorexia nervosa: An update and a theoretical integration

“…Obsessive and inhibited tendencies ar evi dent in both Casper's and Strober's studies,,and cannot be explained as entirely due to starvation. If it is assumed that obsessive traits and inhibition can be a way of dealing with problems concerning impulse regulation (22), the MMPI results obtained in two different samples by Skoog et al fit the pattern: depression was less evident after treatment, consistent with less introversion, but 5 -having anorexia nervosa could alter aspects of someone's personality could be hypothesized, but the most obvious one is not genuine changes, but apparent ones due to acute starvation. That starvation could produce deviant personality profiles or at least significantly influence them has been a cause for concern ever since the field began appreciating the findings reported by Keys et al in the Fifties (see 17).…”