RESEARCH ARTICLE
Prevalence and Severity of Categorical and Dimensional Personality Disorders in Adolescents with Eating Disorders Ernesto Magallón-Neri1,2*, Esther González1, Gloria Canalda1*, Maria Forns2, J. Eugenio De La Fuente1, Estebán Martínez1, Raquel García1, Anais Lara1, Antoni Vallès4 & Josefina Castro-Fornieles1,3,5 1
Department of Child and Adolescent Psychiatry and Psychology, Institute of Neurosciences, Hospital Clinic Universitari of Barcelona, and Biomedical Research Center in Mental Health Network CIBERSAM, Barcelona, Spain 2 Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Barcelona, Barcelona, Spain 3 Institut d’Investigacions Biomediques August Pi Sunyer (IDIBAPS), Barcelona, Spain 4 Department of Public Health, University of Barcelona, Barcelona, Spain 5 Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain
Abstract Objective: The objective of this study is to explore and compare the prevalence of categorical and dimensional personality disorders (PDs) and their severity in Spanish adolescents with Eating Disorders (EDs). Method: Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and International Classification of Diseases, Tenth Revision-10 modules of the International Personality Disorder Examination were administered to a sample of 100 female adolescents with EDs (mean age = 15.8 years, SD = 0.9). Results: Thirty-three per cent of the sample had at least one PD, in most cases a simple PD. The rate of PDs was 64–28% in anorexia and 25% in EDs not otherwise specified. The highest dimensional scores were observed in bulimia, mainly in borderline and histrionic PDs, and higher scores for anankastic PD in anorexia than in the other ED diagnoses. Overall, purging type EDs had higher cluster B personality pathology scores than restrictive type. Discussion: Adolescent female patients with ED have a risk of presenting a comorbid PD, especially patients with bulimia and purging type EDs. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association. Received 12 July 2013; Revised 10 October 2013; Accepted 14 October 2013 Keywords personality disorders; adolescents; Eating Disorders; categorical–dimensional; severity *Correspondence Ernesto Magallón-Neri, PhD, University of Barcelona, Department of Personality Assessment and Psychological Treatment, Barcelona, Spain. Tel: +34 93 403 11 54 Gloria Canalda, PhD, Hospital Clinic Universitari of Barcelona, Barcelona, Spain. Email: [email protected] Published online 14 November 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2268
Introduction Adolescents with Eating Disorders (EDs) have a high risk of developing a wide spectrum of physical and mental disturbances (Johnson, Cohen, Kasen, & Brook, 2002). Given the significant differences observed in symptomatology, comorbidity, aetiology and clinical response, clinicians should pay particular attention to the personality characteristics of adolescent patients with EDs (Thompson-Brenner, Eddy, Satir, Boisseau, & Westen, 2008). Personality disorders (PDs) are among the problems most frequently associated with EDs in clinical settings (Cassin & von Ranson, 2005; Godt, 2008; von Lojewski, Fisher, & Abraham, 2013; Marañon, Echeburúa, & Grijalvo, 2007; Van Hanswijck de Jonge, Van Furth, Hubert, & Waller, 2003). This comorbidity tends to complicate clinical care and increases the use of mental health services (Bender et al., 2006; Cassin & von Ranson, 2005). Given that PD diagnoses rarely seem to occur singly, it is very important to identify patterns of overlap and severity and comorbidity (Waller, Ormonde, &
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Kuteyi, 2013). Moreover, people with PDs frequently receive insufficient psychiatric treatment and social support, and their PD significantly complicates functional impairments in Axis I comorbidity (Lenzenweger, Lane, Loranger, & Kessler, 2007). Clinical diagnostic manuals [Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and International Classification of Diseases (ICD-10)] suggest caution in diagnosing PDs in adolescents, because it has been argued that the personality is not fully formed until early adulthood (Adshead, Brodrick, Preston, & Deshpande, 2012; Freeman & Reinecke, 2007; Westen, Shedler, Durrett, Glass, & Martens, 2003). Other theorists, however, hold that some personality traits are present and stable from early childhood onwards. Many clinicians are reluctant to diagnose PD during youth (Guilé & Greenfield, 2004), because an inaccurate diagnosis of PD in young people may focus attention away from interventions that improve their treatment and may stigmatize them (Adshead et al., 2012; Magallón-Neri et al., 2012). However, a growing body of research suggests that personality
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pathology constitutes a major form of psychopathology in adolescents, just as it does in adults (Feenstra, Busschbach, Verheul, & Hutsebaut, 2011; Magallón-Neri et al., 2012; Westen & Chang, 2000). Moreover, late identification of these disorders prevents timely treatment and potentially increases morbidity (Guilé & Greenfield, 2004). PDs in adolescent patients may be unstable, especially when they are assessed at categorical level (Freeman & Reinecke, 2007; Grilo, Becker, Edell, & McGlashan, 2001; Jucksch, SalbachAndrae, & Lehmkuhl, 2009). However, enduring maladaptative personality features are not limited to Axis I disorders and show predictive value above and beyond Axis I diagnoses (Westen & Chang, 2000). For this reason, it is important to conceptualise the potential utility of understanding personality pathology in terms of dimensional scores, and thus to clarify the differentiation between ED groups. The dimensional markers of personality pathology can be used to provide information about the underlying diagnosis (Marañon et al., 2007); indeed, these dimensional models are being increasingly used in empirical studies (De Bolle et al., 2011; Skodol, 2012; Van Hanswijck De Jonge et al., 2003). The rates of comorbidity with PDs in adult patients with EDs vary widely, from 0% to 58% (Cassin & von Ranson, 2005). These discrepancies may be because of methodological differences in the type of recruitment, assessment methods or clinical characteristics of each sample. Regarding the type of PD, clinical studies have mainly found relationships with cluster C disorders in patients with restrictive type EDs and with cluster B disorders in purging type (Godt, 2008). Associations between anorexia nervosa (AN) and avoidant, dependent and obsessive–compulsive PDs have been reported (Karwautz, Troop, Rabe-Hesketh, Collier, & Treasure, 2003), and associations between bulimic or binge ED with borderline or histrionic PDs (Cassin & von Ranson, 2005; Marañon et al., 2007; Sansone & Sansone, 2011; Van Hanswijck De Jonge et al., 2003). The presence of comorbid PDs imposes a significant additional burden on mental health clinical services (Bender et al., 2006; Magallón-Neri et al., 2012). Although a substantial amount of research has been carried out in adults with EDs (Cassin & von Ranson, 2005; De Bolle et al., 2011; Godt, 2008; von Lojewski et al., 2013; Marañon et al., 2007; Sansone & Sansone, 2011; Van Hanswijck De Jonge et al., 2003), few studies have analysed the relationship between personality and eating pathology; fewer still have assessed the prevalence of PDs in adolescents with EDs (Bottin et al., 2010; Gaudio & Di Ciommo, 2011; Nilsson, Gillberg, Gillberg, & Rastam, 1999); and hardly any have introduced categorical, dimensional and severity approaches to PDs into their analysis. For this reason, this study aims to explore the prevalence of categorical and dimensional PDs and their severity in Spanish adolescents with ED based on scores derived from a semistructured interview for PDs. Two nosological taxonomies (DSM-IV and ICD-10) were used for their identification and their results compared.
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Universitari, Barcelona, which includes a specific reference unit for ED. The following inclusion criteria were established: female, 15–18 years old and first visit at our department. Patients were consecutively attended during periods between 2009 and 2011. They were recruited from different therapeutic settings, which follow a similar base therapy with a cognitive–behavioural orientation, and a therapeutic plan according to their status (inpatient, day hospital or outpatient). Subjects with anorexia nervosa, bulimia nervosa (BN) or ED not otherwise specified (EDNOS)were selected for analysis of the prevalence of PDs. Exclusion criteria were the presence of mental retardation and severe acute psychopathological disturbances (severe psychotic state or severe depression). One hundred and twenty-eight patients met these criteria, of whom 21 declined to participate. Written informed consent was obtained from the remaining 107 patients and from their parents or legal guardians prior to inclusion in the study. Seven patients who did not complete the assessment protocol were subsequently excluded. The final analysis was based on the remaining 100 adolescent psychiatric patients (mean age = 15.8 years, SD = 0.8, range 15–17; 100% female). Instruments Assessment of ED Each ED was diagnosed using our department’s clinical interview (not standarised interview) according to DSM-IV and ICD-10 criteria. The clinical divisions used in this study were AN, BN and EDNOS. EDs were also divided into restrictive and purging subtypes.
Methods
Assessment of Axis II disorders The official Spanish version of the International Personality Disorder Examination (IPDE; López-Ibor, Pérez, & Rubio, 1996), developed by Loranger et al. (1994) and adjusted for international use by the World Health Organization, is a semistructured clinical interview for the examination of ICD-10 and DSM-IV PD criteria. The version of the ICD-10 consists of 67 semi-structured questions assessing the presence or absence of the ten ICD-10 PDs. The version of the DSM-IV consists of 99 semi-structured questions covering all the criteria for the 11 PDs in the module. The IPDE has been reported to have good inter-rater reliability (median kappa = 0.73), good retest reliability (median kappa = 0.87) and temporal stability across nations, cultures and languages (Loranger et al., 1994). There are three possible diagnostic decisions (positive, probable or negative). The IPDE manual developed by Loranger et al. (1994) and the Spanish language adaptation by López-Ibor et al. (1996) note that it was not designed for subjects younger than 18 years, but, with a few modifications, its utility has been demonstrated in adolescents aged 15 years and older (López-Ibor et al., 1996). The criterion in the adolescent population is that a PD can be considered positive if it has been pervasive and persistent for at least three years (López-Ibor et al., 1996; Loranger et al., 1997).
Participants Patients were recruited at the Child and Adolescent Psychiatry and Psychology Department of the General Hospital Clinic
Procedure This study was approved by the hospital’s Institutional Review Board. After a full explanation of the study procedures, written
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informed consent was obtained from all subjects and their parents or legal guardians. The assessment was administered within the first three months of referral to the department. Axis I disorders were assessed independently by clinicians from the department. The psychiatrist or clinical psychologist who interviewed and assessed the patient established ED diagnosis on the basis of the information given by the patient and his/her parents and using DSM-IV and ICD-10 diagnostic criteria. This assessment of clinical disorders of Axis I was performed independently from the assessment of Axis II disorders (PDs), which was performed by the authors of the article. IPDE interviews were conducted and monitored by the research evaluation team which comprised at least three senior specialists with over 20 years of clinical experience. Discrepancies were resolved after expert discussion, giving more strength to the final diagnosis. Data analysis The sample was divided into three subdiagnoses for ED (AN, BN and EDNOS). The overall sample was divided further into two subtypes (restrictive and purging). Sociodemographic and clinical data were assessed with the chi-squared proportion test and Fisher’s exact test for categorical distributions, whereas the Student’s t-test, the Kruskal-Wallis test and the Mann–Whitney ‘U’ test were used to assess dimensional scores in each subgroup. Because of the great variability in each median dimensional score, nonparametric tests were required to analyse the sample divided according to subdiagnosis. All statistical analyses were performed using SPSS 16.0 (SPSS Inc, Chicago, IL, USA),the level of significance was set at p < 0.05, and in order to be more cautious analysing the results on this study also p < 0.01 was informed.
Results Clinical and sociodemographic issues All participants had at least one ED: 32% AN (25% restrictive vs 7% purging), 17% BN (15% purging vs 2% non-purging) and 51% EDNOS (26% restrictive vs 25% purging). The mean age of the anorexia nervosa group was 15.5 years (SD = 0.8), and their mean body mass index (BMI) was 16.1 (SD = 1.6). The mean age of the BN group was 16.1 years (SD = 0.9) and their mean BMI was 21.7 (SD = 2.1). The EDNOS group had a mean age of 15.8 years (SD = 0.9) and a mean BMI of 19.4 (SD = 3.2). The mean age of the restrictive group was 15.7 years (SD = 0.9) and their mean BMI was 18.0 (SD = 4.1). Finally, the mean age of the purging group was 15.9 years (SD = 0.8) and their mean BMI was 19.5 (SD = 2.4). The prevalence of intra-individual comorbid Axis I disorders (at least two coexisting Axis I disorders in the same patient) was 25%, with 17 patients having two comorbid psychiatric diagnoses (including ED), seven patients having three, and one patient having four Axis I clinical disorders. The distribution of comorbid clinical diagnoses was as follows: 12% anxiety disorder, 7% mood disorders, 5% disruptive disorders, 3% substance use disorder, 2% adjustment disorder and 3% other disorders. Prevalence and severity of personality disorders Table 1 presents the frequencies and percentages of PDs by subjects detected using the IPDE and the severity levels of 178
personality pathology. PD severity is classified as follows: simple PD is defined as one or more PDs from one cluster; complex PD is defined as one or more PDs from at least two different clusters; and probable PD is defined as one criterion below the threshold for PD. One third (33%) of the sample had at least one PD. Focusing on the severity of the disturbance in the PD subgroup, a large proportion presented simple PDs in both modules (ICD-10 and DSM-IV) and only 2–3% presented complex PDs. A small subgroup of the subjects without PD disturbances presented probable PD: around 15% in ICD-10 and 8% in DSM-IV. Significant inter-diagnostic differences were presented, with a stronger relationship between simple PDs and BN in both modules. Categorical personality disorder diagnoses Table 2 shows the prevalence of positive and probable categorical PD diagnoses taking into account that subjects may have more than one positive and/or probable PD diagnosis. Although the ICD-10 does not divide PDs into clusters for comparative purposes, they were assigned as follows: paranoid and schizoid PDs were classified under cluster A; emotionally unstable (impulsive and borderline subtype), histrionic, narcissistic and dissocial PDs under cluster B; and anankastic, anxious and dependent PDs under cluster C. Significant intra-diagnostic differences (vertical comparisons) for each ED (AN, BN and EDNOS) were found. In anorexia, cluster C PDs were the most prevalent in the ICD-10 module. In BN and in EDNOS, cluster B PDs were the most prevalent in both modules (ICD-10 and DSM-IV). Regarding inter-diagnostic differences (horizontal comparisons), cluster B PDs were most prevalent in bulimia patients in both modules. The high number of probable PD diagnoses in the overall sample should also be noted: 54 (13 diagnoses for AN, 17 for BN and 24 for EDNOS) in the ICD-10 module, and 42 (10 diagnoses for AN, 13 for BN and 19 for EDNOS) in the DSM-IV. Finally, BN had the highest overall prevalence of positive PDs. Table 3 shows the prevalence of categorical PDs divided by subtype in the overall sample (restrictive 51% vs purging 47%; two patients with non-purging BN were excluded). Cluster C PDs were the most frequent in the restrictive subtype in the ICD-10 and DSM-IV modules. Cluster B PDs were the most frequent in the purging subtype. Regarding inter-subtype differences, the purging type had more cluster B PDs (both positive and probable) in both modules; the differences were mainly observed for positive impulsive and borderline PDs and probable histrionic PD. The purging type group had a higher overall rate of PD diagnoses than the restrictive type. Only two significant inter-module differences were detected: more cluster B PDs in the module ICD-10, and more PDs not otherwise specified in DSM-IV. Dimensional PD scores Table 4 shows the dimensional scores for each PD for each ED. Significant differences were detected in inter-diagnostic comparisons after post hoc analysis. Paranoid PD was higher in BN than in AN patients in the ICD-10 module. Bulimia patients presented higher rates of impulsive PD in the ICD-10 than anorexia and EDNOS patients, and higher rates of borderline and histrionic PDs in both modules. Finally, anankastic PD scores were higher
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52 15 31 2
Severity No PD disturbances Probable PDs Simple PDs Complex PDs 59 8 30 3
33 67 i
19 (.59) 4 (.13) m 8 (.25) 1 (.03)
9 (.28) * e 23 (.72)
a
j
23 (.72) 2 (.06) n 7 (.22) * 0 (.00)
b
7 (.22) f 25 (.78) *
AN (N = 32) ICD-10 DSM-IV N (%) N (%)
i
3 (.18) 3 (.18) m 11 (.64) * 0 (.00)
a
11 (.64) * e 6 (.36) * j
3 (.18) 1 (.06) n 12 (.70) * 1 (.06)
b
13 (.76) f 4 (.24) *
BN (N = 17) ICD-10 DSM-IV N (%) N (%)
i
30 (.59) 8 (.16) m 12 (.23) * 1 (.02)
a
13 (.25) e 38 (.75) * j
33(.65) 5 (.10) n 11(.21) * 2 (.04)
b
13(.25) f 38 (.75) *
EDNOS (N = 51) ICD-10 DSM-IV N (%) N (%)
k
c
32 (.63) 8 (.16) o 10 (.19) 1(.02)
11 (.22) g 40(.78)
l
38 (.75) 2 (.04) p 10 (.19) 1 (.02)
d
11 (.22) h 40 (.78)
Restrictive (N = 51) ICD-10 DSM-IV N (%) N (%)
k
19 (.40) 7 (.15) o 20 (.43) 1 (.02)
c
21 (.45) g 26 (.55)
l
21 (.44) 5 (.11) p 20 (.43) 1 (.02)
d
21 (.45) h 26 (.55)
Purging (N = 47) ICD-10 DSM-IV N (%) N (%)
m,n,o.p
i,j,k,l
a,b,c,d e,f,g,h
Summary of significant differences
Note: DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; N, number of subjects; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, Eating Disorder not otherwise specified; R, restrictive type; P, purging type. Simple PDs, one or more PDs from one cluster; complex PDs, one or more PDs from at least two different clusters; probable PDs, one criterion below the threshold for PD; %, percentage corresponding by each disorder or subtype. Two patients with non-purging BN subtype were not included in the restrictive versus purging comparisons Significant differences at p < .050: inter-diagnostic [a = BN > EDNOS, AN in ICD-10 module; b = BN > EDNOS, AN in DSM-IV module]; inter-subtypes [c = P > R in ICD-10 module; d = P > R in DSM-IV module]; inter-diagnostic [e = EDNOS, AN > BN in ICD-10 module; f = EDNOS, AN > BN in DSM-IV module]; inter-subtypes [ g = R > P In ICD-10 module; h = R > P In DSM-IV module]; inter-diagnostic [i = EDNOS, AN > BN in ICD-10 module; j = EDNOS, AN > BN in DSM-IV module]; inter-subtypes [ k = R > P In ICD-10 module; l = R > P In DSM-IV module]; inter-diagnostic [m = BN > EDNOS, AN in ICD-10 module; n = BN > EDNOS, AN in DSM-IV module]; inter-subtypes [o = P > R in ICD-10 module; p = P > R in DSM-IV module]. *Significant differences two-tailed p < .010
33 67
Total sample (N = 100) ICD-10 DSM-IV N N
Positive PDs No PDs
Prevalence
Table 1 Prevalence and severity of personality pathology measured by the International Personality Disorder Examination in adolescents with Eating Disorders
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180
C>A (C > A) ns (ns)
8 (10)
15 (13)
— 4 (3) 2 (3) 1 (1) 2 (5) 0 (3) 1 (0) 1 (2) 6 (0)
0 (0)
0 (1) 0 (1) 0 (0) 0 (0) 7 (7)
B > A, C, PDNOS* B > A* (ns) (B > PDNOS)*
15 (17)
6 (2) 3 (1) 4 (4) — 0 (6) 0 (3) 0 (2) 0 (1) 1 (2)
— 1 (0) 0 (1) 0 (1) 5 (6) 4 (3) 1 (2) 0 (1) 1 (1)
2 (0) 0 (2) 2 (0) — 7 (8) 1 (5) 5 (2) 1 (1) 1 (2)
13 (13)
0 (0)
1 (2) 1 (2) 0 (0) — 13 (7)
1 (0)
0 (1) 0 (0) 0 (1) 0 (0) 2 (2)
BN (N = 17) ICD-10 DSM-IV N + (Np) N + (Np)
1 (0)
0 (1) 0 (0) 0 (1) — 5 (2)
AN (N = 32) ICD-10 DSM-IV N + (Np) N + (Np)
20 (24) B > A, PDNOS* (B, C > A)*
6 (2) 3 (3) 2 (6) — 6 (10) 3 (7) 2 (1) 1 (2) 0 (2)
1 (0)
2 (1) 1 (0) 1 (1) — 12 (11) BN > AN, EDNOS* (BN > AN) *
ICD-10 N + (Np)
BN > AN* (BN > AN)*
DSM-IV N + (Np)
BN > AN, EDNOS* (BN > AN)*
Inter-diagnostic differences
16 (19) BN > AN, EDNOS (BN > AN, EDNOS) B > A* (ns)
— 6 (1) 1 (5) 1 (1) 4 (6) 4 (5) 0 (1) 0 (0) 4 (2)
0 (1)
0 (3) 0 (3) 0 (0) 0 (0) 8 (8)
EDNOS (N = 51) ICD-10 DSM-IV N + (Np) N + (Np)
Inter-module differences AN BN EDNOS N + (Np) N + (Np) N + (Np)
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; N+, number of positive diagnoses; Np, number of probable diagnoses; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, Eating Disorder not otherwise specified; PDNOS, personality disorder not otherwise specified; O–C, obsessive–compulsive; ns, not significant. Clusters (A, B, C); Significantly different scores in brackets are related to probable PD diagnosis. *Fisher’s exact test with significant differences two-tailed p < .010.
Intra-diagnostic differences
Dissocial/ antisocial Impulsive Borderline Histrionic Narcissistic Cluster C Anxious/avoidant Anankastic/O–C Dependent Not otherwise specified Overall
Cluster A Paranoid Schizoid Schizotypal Cluster B
PD diagnosis
Table 2 Categorical personality disorder diagnoses calculated by the International Personality Disorder Examination in adolescents according to Eating Disorder
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Table 3 Categorical personality disorders diagnoses calculated by the International Personality Disorder Examination in adolescents according to eating subtype
PDs diagnosis
Restrictive (N = 51) ICD-10 DSM-IV N + (Np) N + (Np)
Purging (N = 47) ICD-10 N + (Np)
DSM-IV N + (Np)
Cluster A Paranoid Schizoid Schizotypal Cluster B
0 (1) 0 (0) 0 (1) — 4 (5)
0 (2) 0 (1) 0 (1) 0 (0) 2 (4)
3 (3) 2 (2) 1 (1) — 25 (15)
0 (3) 0 (3) 0 (0) 0 (0) 14 (12)
Dissocial/antisocial Impulsive Borderline Histrionic Narcissistic Cluster C Anxious/avoidant Anankastic /O–C Dependent Not otherwise specified Overall
1 2 0 1
(0) (2) (2) (1) — 8 (11) 4 (6) 4 (3) 0 (2) 1 (4)
0 (1) — 2 (1) 0 (1) 0 (1) 7 (5) 7 (3) 0 (2) 0 (0) 3 (1)
1 (0) 12 (2) 6 (4) 6 (9) — 5 (12) 0 (8) 3 (2) 2 (2) 1 (2)
1 (0) — 9 (3) 2 (8) 2 (1) 3 (11) 1 (8) 1 (1) 1 (2) 8 (2)
13 (21)
12 (12)
34 (32)
25 (28)
Intra-subtype differences
C > A* : C > PDNOS (C > A)*C > A (ns)B > C,A,PDNOS* (B > A, PDNOS)*
Inter modules Inter-subtype differences differences ICD-10 DSM-IV R Type P Type N + (Np) N + (Np) N + (Np) N + (Np)
P > R* (P > R)
P > R* (P > R)
ICD > DSM
P > R* (P > R)*
P>R (P > R)
DSM > ICD P > R* (P > R)
P>R (P > R)
B > C,A* (B > PDNOS)*
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; N+, number of positive diagnoses; Np, number of probable diagnoses; R, restrictive type; P, purging type; PDNOS, personality disorder not otherwise specified; ns, not significant. Clusters (A, B, C); Significant differences scores between parenthesis are related to probable PD diagnosis. *Fisher’s exact test with significant differences two-tailed p < .010.
in anorexia than EDNOS patients in the ICD-10. Inter-module and intra-diagnostic differences were not calculated; these dimensional scores are not comparable as they have a different number of criteria and different overall dimensional scores in each taxonomy or PD. Table 5 shows dimensional scores of personality pathology for the two subtypes, restrictive and purging. Significant inter-subtype differences were found in cluster B PDs (antisocial, borderline and histrionic). In both modules, the purging type showed higher scores than restrictive type, and also for impulsive PD in ICD-10.
Discussion This study aimed to explore the prevalence of personality pathology in a sample of adolescents with EDs. Thirty-three per cent of the sample met the criteria for at least one PD. This result corroborates those of another study in a European adolescent clinical sample with EDs, which reported a prevalence of 30.3% by using the SCID-II (Bottin et al., 2010). These rates for the overall mean prevalence of PDs are similar to or slightly lower than those found in the adult clinical population (Cassin & von Ranson, 2005; De Bolle et al., 2011; Godt, 2008; Karwautz et al., 2003; Marañon et al., 2007), However, using a highly structured interview administered by trained interviewers, von Lojewski et al. (2013) found a PD prevalence of 21%, somewhat lower than previous studies of inpatients with an ED. As regards the severity of personality pathology, the majority of our
sample presented a simple PD, a relatively small group a probable PD and very few subjects, a complex PD. The analysis of categorical perspective data for each diagnosis of ED studied (AN, BN and EDNOS) reveals some interesting findings. First, the clusters associated with ED diagnoses were similar to those found in previous studies in adult populations (Cassin & von Ranson, 2005; Godt, 2008; Karwautz et al., 2003; Marañon et al., 2007; Van Hanswijck De Jonge et al., 2003): cluster B PDs were the most prevalent in bulimia (Godt, 2008), cluster C in anorexia in the ICD-10 and a mixed combination of clusters B and C was the most prevalent in EDNOS. The results for adolescent patients with anorexia corroborate in part those obtained by Nilsson et al. (1999), that is, a higher prevalence of cluster C than cluster A or B PDs. Second, the number of probable PD diagnoses in the overall sample was high in both ICD-10 and DSM-IV modules. This personality subthreshold has not been recorded in detail in the literature, but it is particularly important (Balsis, Lowmaster, Cooper, & Benge, 2011; Magallón-Neri et al., 2013) because it may represent a precursor for the full PD syndrome and may therefore have predictive validity. Its potential impact has been suggested in other childhood disorders (Shankman et al., 2009), but is often concealed (Elliott, Tyrer, Horwood, & Fergusson, 2011). The evaluation by categorical subtypes of ED (purging vs. restrictive) presented similar results (Table 3). The restrictive type
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DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; M, mean score; , standard deviation; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, Eating Disorder not otherwise specified; U-M–W, U-Mann–Whitney; O–C, obsessive–compulsive; ns, not significant. Data in bold text are significant.
BN > AN : ns ns :ns — : ns ns : ns BN > AN, EDNOS : — BN > AN, EDNOS : BN > AN, EDNOS BN > AN, EDNOS : BN > AN, EDNOS ns : — ns : ns AN > EDNOS : ns ns : ns .196 .812 .256 .889 — R P>R:— P>R:P>R P>R:P>R — : ns ns : ns ns : ns ns : ns
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; M, mean score; SD, standard deviation; R, restrictive type; P, purging type; O–C, obsessive–compulsive; ns, not significant. Data in bold text are significant.
PD severity (Tyrer et al., 2011), in adolescents with EDs from two taxonomies (ICD-10 and DSM-IV). The results also corroborate those of previous studies and contribute to the development of a more global perspective of personality pathology in EDs (Cassin & von Ranson, 2005; Marañon et al., 2007; Van Hanswijck De Jonge et al., 2003). A longitudinal assessment would be necessary for identifying patterns of stability and change in personality pathology in samples of this kind.
Conclusions One third of adolescents with EDs meet criteria for a PD. The purging subtype presents a higher degree of personality pathology (mainly associated with cluster B PDs) than the restrictive group. Many probable PD diagnoses have been identified and may play an important role in the assessment of psychopathological status of personality. Finally, the severity assessment system strengthens REFERENCES
the estimation of the categorical–dimensional models by considering the degree of personality pathology as a whole along a continuum. From a clinical point of view, the results stress the importance of PD assessment in adolescents with EDs, in order to treat not only the ED but the PD as well. This will help to increase the efficacy and the efficiency of treatment, improve the evolution and prognosis of the disorder, and reduce the use and cost of mental health services.
Acknowledgements This study was supported in part by a grant for fellowship research to the first author from the Commission for Universities and Research of the Department of Innovation of the Generalitat of Catalunya and European Social Fund (2009FI-EX00016), PSI2009-11542 from MICINN Feder Funds, and SGR1199.
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Prevalence and Severity of Categorical and Dimensional Personality Disorders in Adolescents with Eating Disorders Ernesto Magallón-Neri1,2*, Esther González1, Gloria Canalda1*, Maria Forns2, J. Eugenio De La Fuente1, Estebán Martínez1, Raquel García1, Anais Lara1, Antoni Vallès4 & Josefina Castro-Fornieles1,3,5 1
Department of Child and Adolescent Psychiatry and Psychology, Institute of Neurosciences, Hospital Clinic Universitari of Barcelona, and Biomedical Research Center in Mental Health Network CIBERSAM, Barcelona, Spain 2 Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Barcelona, Barcelona, Spain 3 Institut d’Investigacions Biomediques August Pi Sunyer (IDIBAPS), Barcelona, Spain 4 Department of Public Health, University of Barcelona, Barcelona, Spain 5 Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain
Abstract Objective: The objective of this study is to explore and compare the prevalence of categorical and dimensional personality disorders (PDs) and their severity in Spanish adolescents with Eating Disorders (EDs). Method: Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and International Classification of Diseases, Tenth Revision-10 modules of the International Personality Disorder Examination were administered to a sample of 100 female adolescents with EDs (mean age = 15.8 years, SD = 0.9). Results: Thirty-three per cent of the sample had at least one PD, in most cases a simple PD. The rate of PDs was 64–28% in anorexia and 25% in EDs not otherwise specified. The highest dimensional scores were observed in bulimia, mainly in borderline and histrionic PDs, and higher scores for anankastic PD in anorexia than in the other ED diagnoses. Overall, purging type EDs had higher cluster B personality pathology scores than restrictive type. Discussion: Adolescent female patients with ED have a risk of presenting a comorbid PD, especially patients with bulimia and purging type EDs. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association. Received 12 July 2013; Revised 10 October 2013; Accepted 14 October 2013 Keywords personality disorders; adolescents; Eating Disorders; categorical–dimensional; severity *Correspondence Ernesto Magallón-Neri, PhD, University of Barcelona, Department of Personality Assessment and Psychological Treatment, Barcelona, Spain. Tel: +34 93 403 11 54 Gloria Canalda, PhD, Hospital Clinic Universitari of Barcelona, Barcelona, Spain. Email: [email protected] Published online 14 November 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2268
Introduction Adolescents with Eating Disorders (EDs) have a high risk of developing a wide spectrum of physical and mental disturbances (Johnson, Cohen, Kasen, & Brook, 2002). Given the significant differences observed in symptomatology, comorbidity, aetiology and clinical response, clinicians should pay particular attention to the personality characteristics of adolescent patients with EDs (Thompson-Brenner, Eddy, Satir, Boisseau, & Westen, 2008). Personality disorders (PDs) are among the problems most frequently associated with EDs in clinical settings (Cassin & von Ranson, 2005; Godt, 2008; von Lojewski, Fisher, & Abraham, 2013; Marañon, Echeburúa, & Grijalvo, 2007; Van Hanswijck de Jonge, Van Furth, Hubert, & Waller, 2003). This comorbidity tends to complicate clinical care and increases the use of mental health services (Bender et al., 2006; Cassin & von Ranson, 2005). Given that PD diagnoses rarely seem to occur singly, it is very important to identify patterns of overlap and severity and comorbidity (Waller, Ormonde, &
176
Kuteyi, 2013). Moreover, people with PDs frequently receive insufficient psychiatric treatment and social support, and their PD significantly complicates functional impairments in Axis I comorbidity (Lenzenweger, Lane, Loranger, & Kessler, 2007). Clinical diagnostic manuals [Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and International Classification of Diseases (ICD-10)] suggest caution in diagnosing PDs in adolescents, because it has been argued that the personality is not fully formed until early adulthood (Adshead, Brodrick, Preston, & Deshpande, 2012; Freeman & Reinecke, 2007; Westen, Shedler, Durrett, Glass, & Martens, 2003). Other theorists, however, hold that some personality traits are present and stable from early childhood onwards. Many clinicians are reluctant to diagnose PD during youth (Guilé & Greenfield, 2004), because an inaccurate diagnosis of PD in young people may focus attention away from interventions that improve their treatment and may stigmatize them (Adshead et al., 2012; Magallón-Neri et al., 2012). However, a growing body of research suggests that personality
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pathology constitutes a major form of psychopathology in adolescents, just as it does in adults (Feenstra, Busschbach, Verheul, & Hutsebaut, 2011; Magallón-Neri et al., 2012; Westen & Chang, 2000). Moreover, late identification of these disorders prevents timely treatment and potentially increases morbidity (Guilé & Greenfield, 2004). PDs in adolescent patients may be unstable, especially when they are assessed at categorical level (Freeman & Reinecke, 2007; Grilo, Becker, Edell, & McGlashan, 2001; Jucksch, SalbachAndrae, & Lehmkuhl, 2009). However, enduring maladaptative personality features are not limited to Axis I disorders and show predictive value above and beyond Axis I diagnoses (Westen & Chang, 2000). For this reason, it is important to conceptualise the potential utility of understanding personality pathology in terms of dimensional scores, and thus to clarify the differentiation between ED groups. The dimensional markers of personality pathology can be used to provide information about the underlying diagnosis (Marañon et al., 2007); indeed, these dimensional models are being increasingly used in empirical studies (De Bolle et al., 2011; Skodol, 2012; Van Hanswijck De Jonge et al., 2003). The rates of comorbidity with PDs in adult patients with EDs vary widely, from 0% to 58% (Cassin & von Ranson, 2005). These discrepancies may be because of methodological differences in the type of recruitment, assessment methods or clinical characteristics of each sample. Regarding the type of PD, clinical studies have mainly found relationships with cluster C disorders in patients with restrictive type EDs and with cluster B disorders in purging type (Godt, 2008). Associations between anorexia nervosa (AN) and avoidant, dependent and obsessive–compulsive PDs have been reported (Karwautz, Troop, Rabe-Hesketh, Collier, & Treasure, 2003), and associations between bulimic or binge ED with borderline or histrionic PDs (Cassin & von Ranson, 2005; Marañon et al., 2007; Sansone & Sansone, 2011; Van Hanswijck De Jonge et al., 2003). The presence of comorbid PDs imposes a significant additional burden on mental health clinical services (Bender et al., 2006; Magallón-Neri et al., 2012). Although a substantial amount of research has been carried out in adults with EDs (Cassin & von Ranson, 2005; De Bolle et al., 2011; Godt, 2008; von Lojewski et al., 2013; Marañon et al., 2007; Sansone & Sansone, 2011; Van Hanswijck De Jonge et al., 2003), few studies have analysed the relationship between personality and eating pathology; fewer still have assessed the prevalence of PDs in adolescents with EDs (Bottin et al., 2010; Gaudio & Di Ciommo, 2011; Nilsson, Gillberg, Gillberg, & Rastam, 1999); and hardly any have introduced categorical, dimensional and severity approaches to PDs into their analysis. For this reason, this study aims to explore the prevalence of categorical and dimensional PDs and their severity in Spanish adolescents with ED based on scores derived from a semistructured interview for PDs. Two nosological taxonomies (DSM-IV and ICD-10) were used for their identification and their results compared.
Personality Disorders Adolescence
Universitari, Barcelona, which includes a specific reference unit for ED. The following inclusion criteria were established: female, 15–18 years old and first visit at our department. Patients were consecutively attended during periods between 2009 and 2011. They were recruited from different therapeutic settings, which follow a similar base therapy with a cognitive–behavioural orientation, and a therapeutic plan according to their status (inpatient, day hospital or outpatient). Subjects with anorexia nervosa, bulimia nervosa (BN) or ED not otherwise specified (EDNOS)were selected for analysis of the prevalence of PDs. Exclusion criteria were the presence of mental retardation and severe acute psychopathological disturbances (severe psychotic state or severe depression). One hundred and twenty-eight patients met these criteria, of whom 21 declined to participate. Written informed consent was obtained from the remaining 107 patients and from their parents or legal guardians prior to inclusion in the study. Seven patients who did not complete the assessment protocol were subsequently excluded. The final analysis was based on the remaining 100 adolescent psychiatric patients (mean age = 15.8 years, SD = 0.8, range 15–17; 100% female). Instruments Assessment of ED Each ED was diagnosed using our department’s clinical interview (not standarised interview) according to DSM-IV and ICD-10 criteria. The clinical divisions used in this study were AN, BN and EDNOS. EDs were also divided into restrictive and purging subtypes.
Methods
Assessment of Axis II disorders The official Spanish version of the International Personality Disorder Examination (IPDE; López-Ibor, Pérez, & Rubio, 1996), developed by Loranger et al. (1994) and adjusted for international use by the World Health Organization, is a semistructured clinical interview for the examination of ICD-10 and DSM-IV PD criteria. The version of the ICD-10 consists of 67 semi-structured questions assessing the presence or absence of the ten ICD-10 PDs. The version of the DSM-IV consists of 99 semi-structured questions covering all the criteria for the 11 PDs in the module. The IPDE has been reported to have good inter-rater reliability (median kappa = 0.73), good retest reliability (median kappa = 0.87) and temporal stability across nations, cultures and languages (Loranger et al., 1994). There are three possible diagnostic decisions (positive, probable or negative). The IPDE manual developed by Loranger et al. (1994) and the Spanish language adaptation by López-Ibor et al. (1996) note that it was not designed for subjects younger than 18 years, but, with a few modifications, its utility has been demonstrated in adolescents aged 15 years and older (López-Ibor et al., 1996). The criterion in the adolescent population is that a PD can be considered positive if it has been pervasive and persistent for at least three years (López-Ibor et al., 1996; Loranger et al., 1997).
Participants Patients were recruited at the Child and Adolescent Psychiatry and Psychology Department of the General Hospital Clinic
Procedure This study was approved by the hospital’s Institutional Review Board. After a full explanation of the study procedures, written
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informed consent was obtained from all subjects and their parents or legal guardians. The assessment was administered within the first three months of referral to the department. Axis I disorders were assessed independently by clinicians from the department. The psychiatrist or clinical psychologist who interviewed and assessed the patient established ED diagnosis on the basis of the information given by the patient and his/her parents and using DSM-IV and ICD-10 diagnostic criteria. This assessment of clinical disorders of Axis I was performed independently from the assessment of Axis II disorders (PDs), which was performed by the authors of the article. IPDE interviews were conducted and monitored by the research evaluation team which comprised at least three senior specialists with over 20 years of clinical experience. Discrepancies were resolved after expert discussion, giving more strength to the final diagnosis. Data analysis The sample was divided into three subdiagnoses for ED (AN, BN and EDNOS). The overall sample was divided further into two subtypes (restrictive and purging). Sociodemographic and clinical data were assessed with the chi-squared proportion test and Fisher’s exact test for categorical distributions, whereas the Student’s t-test, the Kruskal-Wallis test and the Mann–Whitney ‘U’ test were used to assess dimensional scores in each subgroup. Because of the great variability in each median dimensional score, nonparametric tests were required to analyse the sample divided according to subdiagnosis. All statistical analyses were performed using SPSS 16.0 (SPSS Inc, Chicago, IL, USA),the level of significance was set at p < 0.05, and in order to be more cautious analysing the results on this study also p < 0.01 was informed.
Results Clinical and sociodemographic issues All participants had at least one ED: 32% AN (25% restrictive vs 7% purging), 17% BN (15% purging vs 2% non-purging) and 51% EDNOS (26% restrictive vs 25% purging). The mean age of the anorexia nervosa group was 15.5 years (SD = 0.8), and their mean body mass index (BMI) was 16.1 (SD = 1.6). The mean age of the BN group was 16.1 years (SD = 0.9) and their mean BMI was 21.7 (SD = 2.1). The EDNOS group had a mean age of 15.8 years (SD = 0.9) and a mean BMI of 19.4 (SD = 3.2). The mean age of the restrictive group was 15.7 years (SD = 0.9) and their mean BMI was 18.0 (SD = 4.1). Finally, the mean age of the purging group was 15.9 years (SD = 0.8) and their mean BMI was 19.5 (SD = 2.4). The prevalence of intra-individual comorbid Axis I disorders (at least two coexisting Axis I disorders in the same patient) was 25%, with 17 patients having two comorbid psychiatric diagnoses (including ED), seven patients having three, and one patient having four Axis I clinical disorders. The distribution of comorbid clinical diagnoses was as follows: 12% anxiety disorder, 7% mood disorders, 5% disruptive disorders, 3% substance use disorder, 2% adjustment disorder and 3% other disorders. Prevalence and severity of personality disorders Table 1 presents the frequencies and percentages of PDs by subjects detected using the IPDE and the severity levels of 178
personality pathology. PD severity is classified as follows: simple PD is defined as one or more PDs from one cluster; complex PD is defined as one or more PDs from at least two different clusters; and probable PD is defined as one criterion below the threshold for PD. One third (33%) of the sample had at least one PD. Focusing on the severity of the disturbance in the PD subgroup, a large proportion presented simple PDs in both modules (ICD-10 and DSM-IV) and only 2–3% presented complex PDs. A small subgroup of the subjects without PD disturbances presented probable PD: around 15% in ICD-10 and 8% in DSM-IV. Significant inter-diagnostic differences were presented, with a stronger relationship between simple PDs and BN in both modules. Categorical personality disorder diagnoses Table 2 shows the prevalence of positive and probable categorical PD diagnoses taking into account that subjects may have more than one positive and/or probable PD diagnosis. Although the ICD-10 does not divide PDs into clusters for comparative purposes, they were assigned as follows: paranoid and schizoid PDs were classified under cluster A; emotionally unstable (impulsive and borderline subtype), histrionic, narcissistic and dissocial PDs under cluster B; and anankastic, anxious and dependent PDs under cluster C. Significant intra-diagnostic differences (vertical comparisons) for each ED (AN, BN and EDNOS) were found. In anorexia, cluster C PDs were the most prevalent in the ICD-10 module. In BN and in EDNOS, cluster B PDs were the most prevalent in both modules (ICD-10 and DSM-IV). Regarding inter-diagnostic differences (horizontal comparisons), cluster B PDs were most prevalent in bulimia patients in both modules. The high number of probable PD diagnoses in the overall sample should also be noted: 54 (13 diagnoses for AN, 17 for BN and 24 for EDNOS) in the ICD-10 module, and 42 (10 diagnoses for AN, 13 for BN and 19 for EDNOS) in the DSM-IV. Finally, BN had the highest overall prevalence of positive PDs. Table 3 shows the prevalence of categorical PDs divided by subtype in the overall sample (restrictive 51% vs purging 47%; two patients with non-purging BN were excluded). Cluster C PDs were the most frequent in the restrictive subtype in the ICD-10 and DSM-IV modules. Cluster B PDs were the most frequent in the purging subtype. Regarding inter-subtype differences, the purging type had more cluster B PDs (both positive and probable) in both modules; the differences were mainly observed for positive impulsive and borderline PDs and probable histrionic PD. The purging type group had a higher overall rate of PD diagnoses than the restrictive type. Only two significant inter-module differences were detected: more cluster B PDs in the module ICD-10, and more PDs not otherwise specified in DSM-IV. Dimensional PD scores Table 4 shows the dimensional scores for each PD for each ED. Significant differences were detected in inter-diagnostic comparisons after post hoc analysis. Paranoid PD was higher in BN than in AN patients in the ICD-10 module. Bulimia patients presented higher rates of impulsive PD in the ICD-10 than anorexia and EDNOS patients, and higher rates of borderline and histrionic PDs in both modules. Finally, anankastic PD scores were higher
Eur. Eat. Disorders Rev. 22 (2014) 176–184 © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.
52 15 31 2
Severity No PD disturbances Probable PDs Simple PDs Complex PDs 59 8 30 3
33 67 i
19 (.59) 4 (.13) m 8 (.25) 1 (.03)
9 (.28) * e 23 (.72)
a
j
23 (.72) 2 (.06) n 7 (.22) * 0 (.00)
b
7 (.22) f 25 (.78) *
AN (N = 32) ICD-10 DSM-IV N (%) N (%)
i
3 (.18) 3 (.18) m 11 (.64) * 0 (.00)
a
11 (.64) * e 6 (.36) * j
3 (.18) 1 (.06) n 12 (.70) * 1 (.06)
b
13 (.76) f 4 (.24) *
BN (N = 17) ICD-10 DSM-IV N (%) N (%)
i
30 (.59) 8 (.16) m 12 (.23) * 1 (.02)
a
13 (.25) e 38 (.75) * j
33(.65) 5 (.10) n 11(.21) * 2 (.04)
b
13(.25) f 38 (.75) *
EDNOS (N = 51) ICD-10 DSM-IV N (%) N (%)
k
c
32 (.63) 8 (.16) o 10 (.19) 1(.02)
11 (.22) g 40(.78)
l
38 (.75) 2 (.04) p 10 (.19) 1 (.02)
d
11 (.22) h 40 (.78)
Restrictive (N = 51) ICD-10 DSM-IV N (%) N (%)
k
19 (.40) 7 (.15) o 20 (.43) 1 (.02)
c
21 (.45) g 26 (.55)
l
21 (.44) 5 (.11) p 20 (.43) 1 (.02)
d
21 (.45) h 26 (.55)
Purging (N = 47) ICD-10 DSM-IV N (%) N (%)
m,n,o.p
i,j,k,l
a,b,c,d e,f,g,h
Summary of significant differences
Note: DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; N, number of subjects; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, Eating Disorder not otherwise specified; R, restrictive type; P, purging type. Simple PDs, one or more PDs from one cluster; complex PDs, one or more PDs from at least two different clusters; probable PDs, one criterion below the threshold for PD; %, percentage corresponding by each disorder or subtype. Two patients with non-purging BN subtype were not included in the restrictive versus purging comparisons Significant differences at p < .050: inter-diagnostic [a = BN > EDNOS, AN in ICD-10 module; b = BN > EDNOS, AN in DSM-IV module]; inter-subtypes [c = P > R in ICD-10 module; d = P > R in DSM-IV module]; inter-diagnostic [e = EDNOS, AN > BN in ICD-10 module; f = EDNOS, AN > BN in DSM-IV module]; inter-subtypes [ g = R > P In ICD-10 module; h = R > P In DSM-IV module]; inter-diagnostic [i = EDNOS, AN > BN in ICD-10 module; j = EDNOS, AN > BN in DSM-IV module]; inter-subtypes [ k = R > P In ICD-10 module; l = R > P In DSM-IV module]; inter-diagnostic [m = BN > EDNOS, AN in ICD-10 module; n = BN > EDNOS, AN in DSM-IV module]; inter-subtypes [o = P > R in ICD-10 module; p = P > R in DSM-IV module]. *Significant differences two-tailed p < .010
33 67
Total sample (N = 100) ICD-10 DSM-IV N N
Positive PDs No PDs
Prevalence
Table 1 Prevalence and severity of personality pathology measured by the International Personality Disorder Examination in adolescents with Eating Disorders
E. Magallon-Neri et al. Personality Disorders Adolescence
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180
C>A (C > A) ns (ns)
8 (10)
15 (13)
— 4 (3) 2 (3) 1 (1) 2 (5) 0 (3) 1 (0) 1 (2) 6 (0)
0 (0)
0 (1) 0 (1) 0 (0) 0 (0) 7 (7)
B > A, C, PDNOS* B > A* (ns) (B > PDNOS)*
15 (17)
6 (2) 3 (1) 4 (4) — 0 (6) 0 (3) 0 (2) 0 (1) 1 (2)
— 1 (0) 0 (1) 0 (1) 5 (6) 4 (3) 1 (2) 0 (1) 1 (1)
2 (0) 0 (2) 2 (0) — 7 (8) 1 (5) 5 (2) 1 (1) 1 (2)
13 (13)
0 (0)
1 (2) 1 (2) 0 (0) — 13 (7)
1 (0)
0 (1) 0 (0) 0 (1) 0 (0) 2 (2)
BN (N = 17) ICD-10 DSM-IV N + (Np) N + (Np)
1 (0)
0 (1) 0 (0) 0 (1) — 5 (2)
AN (N = 32) ICD-10 DSM-IV N + (Np) N + (Np)
20 (24) B > A, PDNOS* (B, C > A)*
6 (2) 3 (3) 2 (6) — 6 (10) 3 (7) 2 (1) 1 (2) 0 (2)
1 (0)
2 (1) 1 (0) 1 (1) — 12 (11) BN > AN, EDNOS* (BN > AN) *
ICD-10 N + (Np)
BN > AN* (BN > AN)*
DSM-IV N + (Np)
BN > AN, EDNOS* (BN > AN)*
Inter-diagnostic differences
16 (19) BN > AN, EDNOS (BN > AN, EDNOS) B > A* (ns)
— 6 (1) 1 (5) 1 (1) 4 (6) 4 (5) 0 (1) 0 (0) 4 (2)
0 (1)
0 (3) 0 (3) 0 (0) 0 (0) 8 (8)
EDNOS (N = 51) ICD-10 DSM-IV N + (Np) N + (Np)
Inter-module differences AN BN EDNOS N + (Np) N + (Np) N + (Np)
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; N+, number of positive diagnoses; Np, number of probable diagnoses; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, Eating Disorder not otherwise specified; PDNOS, personality disorder not otherwise specified; O–C, obsessive–compulsive; ns, not significant. Clusters (A, B, C); Significantly different scores in brackets are related to probable PD diagnosis. *Fisher’s exact test with significant differences two-tailed p < .010.
Intra-diagnostic differences
Dissocial/ antisocial Impulsive Borderline Histrionic Narcissistic Cluster C Anxious/avoidant Anankastic/O–C Dependent Not otherwise specified Overall
Cluster A Paranoid Schizoid Schizotypal Cluster B
PD diagnosis
Table 2 Categorical personality disorder diagnoses calculated by the International Personality Disorder Examination in adolescents according to Eating Disorder
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Table 3 Categorical personality disorders diagnoses calculated by the International Personality Disorder Examination in adolescents according to eating subtype
PDs diagnosis
Restrictive (N = 51) ICD-10 DSM-IV N + (Np) N + (Np)
Purging (N = 47) ICD-10 N + (Np)
DSM-IV N + (Np)
Cluster A Paranoid Schizoid Schizotypal Cluster B
0 (1) 0 (0) 0 (1) — 4 (5)
0 (2) 0 (1) 0 (1) 0 (0) 2 (4)
3 (3) 2 (2) 1 (1) — 25 (15)
0 (3) 0 (3) 0 (0) 0 (0) 14 (12)
Dissocial/antisocial Impulsive Borderline Histrionic Narcissistic Cluster C Anxious/avoidant Anankastic /O–C Dependent Not otherwise specified Overall
1 2 0 1
(0) (2) (2) (1) — 8 (11) 4 (6) 4 (3) 0 (2) 1 (4)
0 (1) — 2 (1) 0 (1) 0 (1) 7 (5) 7 (3) 0 (2) 0 (0) 3 (1)
1 (0) 12 (2) 6 (4) 6 (9) — 5 (12) 0 (8) 3 (2) 2 (2) 1 (2)
1 (0) — 9 (3) 2 (8) 2 (1) 3 (11) 1 (8) 1 (1) 1 (2) 8 (2)
13 (21)
12 (12)
34 (32)
25 (28)
Intra-subtype differences
C > A* : C > PDNOS (C > A)*C > A (ns)B > C,A,PDNOS* (B > A, PDNOS)*
Inter modules Inter-subtype differences differences ICD-10 DSM-IV R Type P Type N + (Np) N + (Np) N + (Np) N + (Np)
P > R* (P > R)
P > R* (P > R)
ICD > DSM
P > R* (P > R)*
P>R (P > R)
DSM > ICD P > R* (P > R)
P>R (P > R)
B > C,A* (B > PDNOS)*
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; N+, number of positive diagnoses; Np, number of probable diagnoses; R, restrictive type; P, purging type; PDNOS, personality disorder not otherwise specified; ns, not significant. Clusters (A, B, C); Significant differences scores between parenthesis are related to probable PD diagnosis. *Fisher’s exact test with significant differences two-tailed p < .010.
in anorexia than EDNOS patients in the ICD-10. Inter-module and intra-diagnostic differences were not calculated; these dimensional scores are not comparable as they have a different number of criteria and different overall dimensional scores in each taxonomy or PD. Table 5 shows dimensional scores of personality pathology for the two subtypes, restrictive and purging. Significant inter-subtype differences were found in cluster B PDs (antisocial, borderline and histrionic). In both modules, the purging type showed higher scores than restrictive type, and also for impulsive PD in ICD-10.
Discussion This study aimed to explore the prevalence of personality pathology in a sample of adolescents with EDs. Thirty-three per cent of the sample met the criteria for at least one PD. This result corroborates those of another study in a European adolescent clinical sample with EDs, which reported a prevalence of 30.3% by using the SCID-II (Bottin et al., 2010). These rates for the overall mean prevalence of PDs are similar to or slightly lower than those found in the adult clinical population (Cassin & von Ranson, 2005; De Bolle et al., 2011; Godt, 2008; Karwautz et al., 2003; Marañon et al., 2007), However, using a highly structured interview administered by trained interviewers, von Lojewski et al. (2013) found a PD prevalence of 21%, somewhat lower than previous studies of inpatients with an ED. As regards the severity of personality pathology, the majority of our
sample presented a simple PD, a relatively small group a probable PD and very few subjects, a complex PD. The analysis of categorical perspective data for each diagnosis of ED studied (AN, BN and EDNOS) reveals some interesting findings. First, the clusters associated with ED diagnoses were similar to those found in previous studies in adult populations (Cassin & von Ranson, 2005; Godt, 2008; Karwautz et al., 2003; Marañon et al., 2007; Van Hanswijck De Jonge et al., 2003): cluster B PDs were the most prevalent in bulimia (Godt, 2008), cluster C in anorexia in the ICD-10 and a mixed combination of clusters B and C was the most prevalent in EDNOS. The results for adolescent patients with anorexia corroborate in part those obtained by Nilsson et al. (1999), that is, a higher prevalence of cluster C than cluster A or B PDs. Second, the number of probable PD diagnoses in the overall sample was high in both ICD-10 and DSM-IV modules. This personality subthreshold has not been recorded in detail in the literature, but it is particularly important (Balsis, Lowmaster, Cooper, & Benge, 2011; Magallón-Neri et al., 2013) because it may represent a precursor for the full PD syndrome and may therefore have predictive validity. Its potential impact has been suggested in other childhood disorders (Shankman et al., 2009), but is often concealed (Elliott, Tyrer, Horwood, & Fergusson, 2011). The evaluation by categorical subtypes of ED (purging vs. restrictive) presented similar results (Table 3). The restrictive type
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DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; M, mean score; , standard deviation; AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, Eating Disorder not otherwise specified; U-M–W, U-Mann–Whitney; O–C, obsessive–compulsive; ns, not significant. Data in bold text are significant.
BN > AN : ns ns :ns — : ns ns : ns BN > AN, EDNOS : — BN > AN, EDNOS : BN > AN, EDNOS BN > AN, EDNOS : BN > AN, EDNOS ns : — ns : ns AN > EDNOS : ns ns : ns .196 .812 .256 .889 — R P>R:— P>R:P>R P>R:P>R — : ns ns : ns ns : ns ns : ns
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ICD-10, International Classification of Diseases; PDs, personality disorders; M, mean score; SD, standard deviation; R, restrictive type; P, purging type; O–C, obsessive–compulsive; ns, not significant. Data in bold text are significant.
PD severity (Tyrer et al., 2011), in adolescents with EDs from two taxonomies (ICD-10 and DSM-IV). The results also corroborate those of previous studies and contribute to the development of a more global perspective of personality pathology in EDs (Cassin & von Ranson, 2005; Marañon et al., 2007; Van Hanswijck De Jonge et al., 2003). A longitudinal assessment would be necessary for identifying patterns of stability and change in personality pathology in samples of this kind.
Conclusions One third of adolescents with EDs meet criteria for a PD. The purging subtype presents a higher degree of personality pathology (mainly associated with cluster B PDs) than the restrictive group. Many probable PD diagnoses have been identified and may play an important role in the assessment of psychopathological status of personality. Finally, the severity assessment system strengthens REFERENCES
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Acknowledgements This study was supported in part by a grant for fellowship research to the first author from the Commission for Universities and Research of the Department of Innovation of the Generalitat of Catalunya and European Social Fund (2009FI-EX00016), PSI2009-11542 from MICINN Feder Funds, and SGR1199.
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