Personality as a predictor of symptomatic change in a residential treatment setting for anorexia nervosa and bulimia nervosa

Abstract

Purpose Although personality has been widely researched in patients with anorexia nervosa (AN) and bulimia nervosa (BN), the nature of this relationship has not yet been clearly articulated. The pathoplasty model theorizes that personality might shape symptomatic presentation and thus affect therapeutic outcomes, but more research is needed. The present study aimed at investigating the predictive value of a broad spectrum of personality traits in determining AN and BN treatment outcomes, considering both the statistical and clinical significance of the therapeutic change. Methods Eighty-four female patients with AN and BN treated in a residential program were evaluated at treatment onset using the Shedler-Westen Assessment Procedure-200—a clinician-rated measure of personality disorders and healthy personality functioning. At both intake and discharge, patients completed the Eating Disorder Inventory-3 to assess eating symptoms and the Outcome Questionnaire-45.2 to evaluate overall impairment. Results Considering overall ED symptomatic change, multiple regression analyses showed that, even when controlling for baseline symptoms and DSM-5 categories, schizoid (B = 0.41, p ≤ 0.01), avoidant (B = 0.31, p ≤ 0.05), and paranoid (B = 0.25, p ≤ 0.05) personality features predicted worse therapeutic outcomes. Similar results were found when applying the clinical significance approach, with the emotionally dysregulated factor as an additional negative predictor of significant/reliable change (B = − 0.09; p < 0.01). Healthy personality functioning predicted better therapeutic outcomes (B = − 0.34, p ≤ 0.001). Conclusions Pathoplastic models and personality-based research in this clinical population have the potential to inform effective treatment strategies by targeting relevant individual factors. Level of evidence Level III, longitudinal cohort study.

The Mediator Effect of Personality on the Relationship Between Symptomatic Impairment and Treatment Outcome in Eating Disorders

“…(a) There would be significant positive associations of moderate magnitude (Cohen, 1988) between PDs in Clusters A, B, and C, more severe pre-treatment ED symptomatic impairment, and worse therapy outcome (e.g., Farstad et al, 2016), as well as a significant association between healthy personality functioning (see the SWAP-200 description in the "Measures" section), lower severity of ED symptoms at treatment intake, and better therapy outcome; (b) There would be no significant differences between the main DSM-5 ED diagnoses (AN and BN) in terms of baseline ED symptomatic impairment and therapy outcome, in line with studies supporting the overall lack of discriminant validity of ED categorical diagnoses (e.g., Westen and Harnden-Fischer, 2001;Raykos et al, 2018); and (c) Overall healthy personality functioning and PD clusters would mediate the association between the severity of ED symptomatic impairment at baseline and therapy outcome, in line with previous theoretical contributions (e.g., Lilenfeld et al, 2006) and empirical evidence showing that personality may influence both the severity or pattern of symptomatology and the course of the illness (e.g., Thompson-Brenner and Westen, 2005;Muzi et al, 2020).…”

“…Although research on personality as a predictor of ED outcome is sparse, some relevant studies, drawing on the pathoplasty model, have found that PDs are commonly associated with poorer response to treatment (Steinhausen, 2002(Steinhausen, , 2009Thompson-Brenner and Westen, 2005;Wildes et al, 2011;Muzi et al, 2020Muzi et al, , 2021. Further research has suggested that high attrition, low compliance, dropout, symptom chronicity, low recovery rates, and low efficacy of therapeutic interventions relate to the personality characteristics of individual patients (Pham-Scottez et al, 2012;Martinez and Craighead, 2015;Levallius et al, 2016).…”

“…A systematic review also suggested that this variable may moderate or mediate the outcome of ED treatment, especially in patients with AN (Crane et al, 2007). Despite these findings, there is very scarce evidence with respect to other PDs, within Clusters A, B, or C. However, some authors have argued that the presence of suspiciousness, paranoid features, and interpersonal distrust or detachment may interacted with other patient variables to predict ED symptoms over the long term (Dingemans et al, 2016), and a recent study also found that paranoid and schizoid personality traits may predict therapy outcome in residential treatment for ED patients (Muzi et al, 2020). Moreover, avoidant-insecure personality features and a diagnosis of avoidant personality disorder have been found to be associated with more severe symptomatic impairment, lower ED symptom improvement, and higher treatment utilization (Thompson-Brenner et al, 2008a;Vrabel et al, 2010).…”

“…More specifically, with respect to treatment outcomes, some studies have found that categorical DSM-5 ED diagnoses do not predict patients' responses to therapeutic interventions or future clinical courses (Westen and Harnden-Fischer, 2001;Raykos et al, 2018;Muzi et al, 2021), and that DSM-5 severity specifiers are not related to ED psychopathology, overall impairment, health status, comorbid conditions (e.g., depressive symptoms), or therapy outcomes (Gianini et al, 2017;Machado et al, 2017;Dalle Grave et al, 2018). Conversely, studies employing more dimensional and empirically derived approaches, such as the Shedler-Westen Assessment Procedure-200 (SWAP-200;Westen and Shedler, 1999a,b), have shown promising results in the identification of personality constellations in ED patients (Westen and Harnden-Fischer, 2001;Thompson-Brenner and Westen, 2005;Gazzillo et al, 2013), including healthy personality features and psychological resources (e.g., Muzi et al, 2020), as well as their predictive value in determining therapeutic outcomes (Thompson-Brenner et al, 2008a,b).…”

Weight Gain in a Sample of Patients Affected by Overweight/Obesity with and without a Psychiatric Diagnosis during the Covid-19 Lockdown

“…The results showed higher levels of stress and depression in patients affected by overweight/obesity with a psychiatric diagnosis compared with those with no psychiatric diagnosis. However, despite this significant difference between groups, levels of psychological distress (relating to depression, stress, and anxiety) in the psychiatric patients affected by overweight/obesity were lower than the averages reported for the clinical population [ 19 , 31 , 32 ]. Furthermore, increased psychological distress during the COVID-19 lockdown did not seem to predict weight gain for these patients; instead, they were more likely to gain weight as a result of binge eating behaviors, which preceded the lockdown situation and were frequently a symptom of their psychiatric diagnosis.…”