Psychiatry Research 225 (2015) 452–457

Contents lists available at ScienceDirect

Psychiatry Research journal homepage: www.elsevier.com/locate/psychres

Temperament and emotional eating: A crucial relationship in eating disorders Francesco Rotella a,n, Giulia Fioravanti b, Lucia Godini a, Edoardo Mannucci c, Carlo Faravelli b, Valdo Ricca a a

Psychiatric Unit, Careggi Teaching Hospital, Florence University School of Medicine, Largo Brambilla 3, 50134 Florence, Italy Department of Health Sciences, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy c Diabetes Agency, Careggi Teaching Hospital, Via delle Oblate 4, 50141 Florence, Italy b

art ic l e i nf o

a b s t r a c t

Article history: Received 20 March 2014 Received in revised form 28 August 2014 Accepted 29 November 2014 Available online 11 December 2014

Specific personality traits are related to Eating Disorders (EDs) specific and general psychopathology. Recent studies suggested that Emotional Eating (EE) is a common dimension in all EDs, irrespective of binge eating. The present study was aimed to explore the relationship of temperamental features with EE and eating symptomatology in a sample of EDs patients, adjusting for general psychopathology. One hundred and sixty six female patients were enrolled at the Eating Disorders Outpatient Clinic of the Careggi Teaching-Hospital of Florence. Participants completed the emotional eating scale, the temperament and character inventory, the eating disorder examination questionnaire and the symptom checklist 90-revised. Novelty seeking and self directedness showed significant correlations with EE after adjustment for general psychopathology. Patients with binge eating displayed significant associations between EE and novelty seeking and self directedness. Among patients without binge eating, no significant correlation between EE and temperamental features was observed. Specific temperamental features are associated to EE in EDs. A clear, different pattern of association in patients with different eating attitudes and behavior was found. Considering that treatments of EDs are largely based on psychotherapeutic interventions, focused on emotions and cognitions, the present data provide some hints which could be helpful for the development of more appropriate psychotherapeutic strategies. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Temperament Emotional eating Binge eating Eating disorder Psychopathology

1. Introduction Temperament has been defined as the individual differences in emotional, motor, and attentional reactivity measured by latency, intensity, and recovery of response, and self-regulation processes such as effortful control that modulate reactivity (Rothbart and Derryberry, 1981), or, more briefly, as the individual differences in a person's emotional reactivity and regulation (Goldsmith et al., 1987). Cloninger et al. (1993) proposed a distinction between temperament and character. In his view, temperament refers to emotional responses that are moderately heritable, stable throughout life, and mediated by neurotransmitter functioning, whereas character refers to self-concepts and individual differences in goals and values that develop through experience (Cloninger et al., 1993). The Temperament and Character Inventory (TCI; Cloninger, 1994) was developed within this conceptual framework.

n

Corresponding author. Tel./fax: þ 39 55 794 74 87. E-mail addresses: francesco.rotella@unifi.it (F. Rotella), giulia.fioravanti@unifi.it (G. Fioravanti), [email protected] (L. Godini), edoardo.mannucci@unifi.it (E. Mannucci), carlo.faravelli@unifi.it (C. Faravelli), valdo.ricca@unifi.it (V. Ricca). http://dx.doi.org/10.1016/j.psychres.2014.11.068 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

Temperamental features seem to have an important role in the development, clinical expression, course, and treatment response in psychiatric disorders (e.g. Fassino et al., 2013; Miettunen and Raevuori, 2012). A recent meta-analysis using Cloninger temperamental dimensions (Miettunen and Raevuori, 2012) showed that patients with psychiatric disorders have elevated harm avoidance scores compared with control subjects, suggesting a heightened tendency to worry, to be fearful, to be shy, and to be easily fatigable, among people with mental illness. Furthermore, compared with controls, novelty seeking was significantly lower in individuals with major depression, whereas in those with schizophrenia, reward dependence was significantly lower and persistence was significantly higher. However, Fassino et al. (2013) recently suggested that high harm avoidance and low self directedness scores are recurrent in all psychiatric disorders and can be considered as a “personality core”, regardless of diagnosis. These temperamental features may be risk factors and relapse-related; they can indicate incomplete remission or chronic course of mental disorders, consistently influencing patients' functioning; furthermore, they may even represent predictors of treatment outcome (Fassino et al., 2013). In accordance with this perspective, several studies indicated that these specific personality traits (mainly elevated

F. Rotella et al. / Psychiatry Research 225 (2015) 452–457

harm avoidance and low self directedness and cooperativeness) are also related to Eating Disorders (EDs) (Fassino et al., 2002a, 2002b; Klump et al., 2000). A recent survey on a large sample of patients with EDs showed that different temperamental profiles are associated with specific eating attitudes and behaviors (Krug et al., 2011), such as binge eating, restrained eating, and severe concerns over body weight and shape. Other studies suggested that engaging in binge eating or vomiting seems in general explained by high levels of novelty seeking and low levels of self directedness (Peñas-Lledó et al., 2010; Reba et al., 2005). Emotional Eating (EE) has been defined as “the tendency to eat in response to a range of negative emotions such as anxiety, depression, anger and loneliness, to cope with negative affect” (Arnow et al., 1995). This construct is not merely focused on eating behavior and overeating, but it specifically addresses the feelings that lead persons to experience an urge to eat and the desire to assume food in response to different emotions. EE has been identified as a possible trigger for binge eating in Bulimia Nervosa (BN) (Engelberg et al., 2007) and Binge Eating Disorder (BED) (Masheb and Grilo, 2006; Ricca et al., 2009; Stein et al., 2007; Zeeck et al., 2011 ). Recent studies suggested that EE is a common dimension in all EDs, irrespective of binge eating (Courbasson et al., 2008; Torres et al., 2011; Ricca et al., 2012). In summary, available evidences suggest that at least two temperamental features (high harm avoidance and low self directedness) are recurrent in all EDs, as well as in almost all psychiatric disorders (e.g. Fassino et al., 2013). Moreover, some studies reported an association between temperamental traits and eating psychopathological features/behaviors (Peñas-Lledó et al., 2010; Reba et al., 2005). However, despite the fact that EE is present and clinically significant in all EDs diagnostic groups, the association between temperamental features and EE has not been investigated to date. Given the exploratory nature of this study, no specific hypothesis could be formulated. The present study is therefore aimed at exploring the relationship of temperamental features with emotional eating and eating symptomatology in a sample of patients with EDs, adjusting for general psychopathology.

2. Methods

453

2.3. Measures Sociodemographic data, as well as anthropometric measures and main medical comorbidities, were evaluated by a psychiatrist, who also performed the categorical diagnoses of EDs (AN Restricter – ANR; AN Binge/Purge – ANBP; BN; BED) with DSM-IV criteria. Anthropometric measurements (height and weight) were assessed using standard calibrated instruments. In order to collect data on eating and general psychopathology, participants completed the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn and Beglin, 1994) and the Symptom Checklist 90-Revised (SCL-90-R; Derogatis et al., 1973). The self-reported EDE-Q consists of 38 items, assessing the core psychopathological features of eating disorders, and contains 4 subscales: dietary restraint, eating concern, weight concern, and shape concern. The dietary restraint subscale is a combination of cognitions and behaviors pertaining to dietary restriction. The three other subscales evaluate the dysfunctional attitudes with respect to eating, and overvalued thoughts on weight and shape. The global score represents the mean of the four subscale scores (Fairburn and Beglin, 1994). The EDE-Q has good concurrent validity (Mond et al., 2004) and reliability (Berg et al., 2012). The SCL90-R (Derogatis et al., 1973) is a psychometric instrument devoted to the identification of the psychopathologic distress. In addition, participants completed the TCI (Cloninger, 1994) and the Emotional Eating Scale (EES) (Arnow et al., 1995). The TCI is a self-report questionnaire used to evaluate the individual differences on each of the seven independent dimensions of personality (Cloninger, 1994) and it is composed by 240 items with true-false answer (0/1). The inventory specifies four dimensions of temperament: novelty seeking, which reflects the tendency to respond with intense excitement to a novel stimulus; harm avoidance, which is the tendency to respond intensively to signals of aversive stimuli, thereby inhibiting behavior; reward dependence, which represents the tendency to respond intensely to signals of reward, thus maintaining rewarded behaviors; and persistence which is the perseverance in behaviors associated with reward or relief from punishment. The character dimensions are cooperativeness, which refers to the degree to which the self is viewed as a part of society; self directedness, which is the degree to which the self is viewed as autonomous and integrated; and self transcendence, which reflects the degree to which the self is viewed as an integral part of the universe. The score is calculated for each temperamental or character trait by combining of the relative subscale scores. The TCI has good internal consistency, inter-tester reliability and test-retest reliability (Cloninger, 1994). The Emotional Eating Scale (EES) (Arnow et al., 1995) is a 25-item-self-report questionnaire that evaluates the extent to which specific feelings lead a subject to feel an urge to eat. Each item consists of an emotion term (e.g., loneliness, angry, helpless), and the individual is asked to indicate the level to which experiencing that emotion makes her/him likely to eat using the 5-point scale: “no desire to eat”, “a small desire to eat,” “a moderate desire to eat,” and “a strong desire to eat,” “an overwhelming urge to eat”. The 25 items form 3 subscales, reflecting eating in response to anger (anger/frustration), anxiety (anxiety), and depressed mood (depression). The EES has demonstrated good internal consistency, construct validity, discriminant validity, and criterion-related validity (Arnow et al., 1995). The questionnaires were considered valid when at least 85% of the answers were completed.

2.1. Procedures 2.4. Data analysis The study was performed at the Eating Disorders Outpatient Clinic of the Psychiatric Unit of Careggi teaching hospital of Florence, Italy. The diagnostic procedures and the psychometric questionnaires were part of the routine clinical assessment for patients with EDs, conducted at the clinic. The protocol was approved by the Ethics Committee of the Institution. During the first routine visit, a written informed consent was obtained from each patient after the procedures of the study were fully explained.

2.2. Participants The participants were 200 female patients with EDs who consecutively attended the Outpatient Clinic between March 1st, 2012 and June 30th, 2013. Inclusion criteria were the diagnosis of full blown Anorexia Nervosa (AN), BN, or BED and age Z 18 years. Exclusion criteria were illiteracy, comorbidity with schizophrenia or bipolar disorder, mental retardation, and refusal of consent. Patients enrolled attended a specialist Outpatient Clinic, based in a University hospital, for the diagnosis and treatment of EDs. In this clinic, after the completion of the assessment during the first visit, patients with AN and BN follow a nine-month multidisciplinary treatment program. This program includes: visits with a dietician (every week for the first month, then once per month); individual cognitivebehavioral therapy, consisting of about 40 h-long manual-based sessions conducted over a minimum of 40 weeks; and control visits with a psychiatrist (after 1, 3, 6 and 9 months form the first contact). Patients with BED follow a six-month multidisciplinary program consisting of 16 h-long manual-based group sessions, conducted by a dietician, a psychologist and a psychiatrist.

The values of normally distributed variables were expressed as mean 7 SD, whereas the values of skewed variables were expressed as median values [quartiles]. The relationship between temperament and character traits and EE, EDE-Q and SCL-90 scores was assessed with Spearman bivariate correlations. Multiple linear regression models, with TCI subscales as predictors, and EES and EDE-Q scores as dependent variables, adjusting for general psychopathology (SCL-90 global severity index), were performed in the whole sample. Separate analyses were performed in patients with binge eating behaviors (binge; i.e., those with BED, BN, or ANBP), and in those without such behaviors (non-binge; i.e., those with ANR). The Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, IL) for windows 18.0 was used for data analysis.

3. Results Of the 200 patients invited, 34 (17.0%) denied participation or failed to complete the questionnaires; the final sample therefore consisted of 166 patients (37, 11, 36 and 82 – 22.3%, 6.6%, 21.7%, and 49.4%, with ANR, ANBP, BN and BED, respectively). All the patients included in the study were at their first contact with the clinic. The mean age of the sample was (mean 7SD) 37.9 714.4 years, and years of education were (median [quartiles]) 13 [9.5; 14.0]. As far as the previous use of psychotropic drugs are

454

F. Rotella et al. / Psychiatry Research 225 (2015) 452–457

concerned, 16 (9.6%) patients were taking low doses of benzodiazepines and 6 (3.6%) patients (all with BED) were taking a selective serotonin reuptake inhibitor (sertraline, fluoxetine or escitalopram). Descriptive statistics and the correlation coefficients for TCI dimensions and EES, EDE-Q and SCL-90-R scores in the whole sample are summarized in Table 1. Novelty seeking and harm avoidance showed a significant positive correlation with EDE-Q total and all subscale scores except restraint, and with EE total and subscale scores. Harm Avoidance, but not novelty seeking, also showed a significant correlation with SCL-90 Global Severity Index (GSI) and subscales scores. Reward dependence displayed a significant negative correlation only with EDE-Q restraint subscale and with SCL-90 anger/hostility subscale. Persistence was positively associated to anxiety and paranoid ideation SCL-90 subscales scores. Self directedness showed a negative correlation with all the scores of EDE-Q, EES, and SCL-90 scores. Cooperativeness was negatively correlated with general psychopathology (SCL-90 GSI) and with all SCL-90 subscales scores, with the exception of Positive Symptom Distress Index and Somatization. Finally, self transcendence displayed a positive correlation with EE total and subscales scores. For those temperamental/character features (i.e. harm avoidance and self directedness) which showed a significant correlation with both general and EDs psychopathology and/or emotional eating, multiple linear regression analyses were performed, in order to assess the relationship of TCI scores with EDE-Q and EES, adjusting for SCL-90 GSI. Since harm avoidance did not show significant correlations with EE, the multiple linear regression analysis with harm avoidance as predictor and EE as dependent variable was not performed (Table 2, panel A). The correlation of harm avoidance with EDE-Q total and subscale scores did not retain statistical significance after adjusting for SCL-90 GSI (Table 2, panel B). When self directedness and SCL-90 GSI were imputed as covariates in a multiple linear regression, self directedness, but not SCL-90 GSI retained a significant association with EE total and subscale scores (Table 2, panel C). On the other hand, both self directedness and SCL-90

GSI were significantly associated with EDE-Q total and subscale scores, with the exception of EDE-Q restraint, in multivariate models (Table 2, panel D). Separate analyses were performed in patients with (“Binge” group; N¼ 129 patients) and without binge eating behaviors (“Non-Binge” group, N¼37 patients). Correlation coefficients between TCI dimensions and EE scores are summarized in Table 3. In “Binge” group, Table 2 Multiple linear regression analyses for the relationships of temperament and character inventory scores with eating disorder examination – questionnaire and emotional eating scale, adjusted for general psychopathology.

A EES total score EES anger/ frustration EES anxiety EES depression B EDE-Q total score EDE-Q restriction EDE-Q eating behaviors EDE-Q weight EDE-Q shape

SCL GSI

HA

Adjusted R2

SCL GSI

– –

– –

– –

C 0.10 0.10

 0.29nn 0.11  0.24nn 0.08

– –

– –

– –

0.08 0.07

 0.28nn 0.09  0.24nn 0.07

0.58nn  0.06 0.30 – – – 0.52nn  0.05 0.24

D 0.45nn 0.28nn 0.37nn

 0.23nn 0.34  0.07 0.09  0.27nn 0.29

0.52nn 0.50nn

0.40nn 0.41nn

 0.21nn 0.27  0.20n 0.27

 0.05 0.24  0.01 0.24

SD

Adjusted R2

SCL GSI ¼symptom checklist global severity index; HA ¼ harm avoidance; SD ¼ self directedness; EES ¼ emotional eating scale; EDE-Q ¼eating disorder examinationquestionnaire. Each panel (A,B,C,D) includes multiple linear regression models with the predictors (TCI dimensions and SCL-90 GSI) reported in columns and the dependent variables (EE scores and EDE-Q scores) reported in rows. Panel A is empty because HA did not show statistically significant correlations with any EES dimensions. Data are expressed as beta coefficients. All models are significant with a p o0.01. n

p o 0.05. p o 0.01.

nn

Table 1 Descriptive statistics and correlation coefficients for temperamental and character inventory, emotional eating scale, eating disorder examination – questionnaire and symptom checklist 90-R.

Median [quartiles] EDE-Q total score EDE-Q restriction EDE-Q eating behaviors EDE-Q weight EDE-Q shape EES total score EES anger/frustration EES anxiety EES depression SCL GSI SCL PST SCL PSDI SCL somatization SCL obssesive compulsive SCL interpersonal sensitivity SCL depression SCL anxiety SCL anger/hostility SCL phobic anxiety SCL paranoid ideation SCL psychoticism

Median [quartiles]

NS

HA

RD

P

SD

C

ST

3.0 [2.0;3.9] 2.4 [1.1;3.6] 2.4 [1.4;3.6] 3.2 [2.2;4.0] 3.7 [2.5;5.0] 1.4 [0.8;2.2] 1.4 [0.8;2.3] 1.2 [0.7;2.0] 1.7 [1.0;2.5] 1.3 [0.8;1.6] 57.5 [41.2;68.7] 1.9 [1.7;2.4] 1.3 [0.7;1.9] 1.4 [0.9;2.1] 1.3 [0.7;2.0] 1.5 [0.9;2.3] 1.1 [0.6;1.7] 1.0 [0.5;1.5] 0.4 [0.1;0.8] 1.2 [0.6;2.0] 0.8 [0.4;1.3]

18.5 [14;23.2] 0.18* 0.05 0.17* 0.21** 0.18* 0.28** 0.22** 0.27** 0.25** 0.07 0.09 0.03 0.04 0.02 0.08 0.08  0.03 0.16 0.03 0.07 0.11

22 [17;27] 0.21** 0.10 0.22** 0.19* 0.23** 0.04 0.02 0.02 0.02 0.45** 0.42** 0.38** 0.28** 0.48** 0.47** 0.47** 0.35** 0.17* 0.39** 0.31** 0.34**

15 [12;18]  0.04  0.17* 0.01 0.02 0.02 0.08 0.06 0.01 0.12  0.06  0.07  0.07 0.02  0.06  0.07  0.09  0.12  0.21*  0.06  0.08  0.05

5 [3;6]  0.05  0.08  0.01  0.05 0.01  0.01 0.01  0.02  0.02 0.01 0.12 0.07 0.06 0.08 0.04 0.10 0.19* 0.07 0.05 0.17* 0.13

23 [18;29]  0.44**  0.21**  0.45**  0.39**  0.41**  0.32**  0.26**  0.32**  0.24**  0.50**  0.41**  0.47**  0.30**  0.55**  0.45**  0.49**  0.32**  0.32**  0.28**  0.46**  0.41**

31 [27;35]  0.09  0.10  0.12  0.04  0.03  0.06  0.04  0.12 0.01  0.26**  0.29**  0.15  0.13  0.23**  0.24**  0.26**  0.24**  0.30**  0.19*  0.25**  0.27**

13 [9;18] 0.14 0.03 0.13 0.13 0.12 0.17* 0.17* 0.18* 0.18* 0.08 0.05 0.09 0.06 0.08  0.06 0.04 0.02 0.04 0.14 0.10 0.15

NS¼ novelty seeking; HA¼ harm avoidance; RD ¼reward dependence; P ¼persistence; SD ¼ self directedness; C ¼cooperativeness; ST¼ self transcendence; EDE-Q ¼eating disorder examination-questionnaire; EES ¼emotional eating scale; SCL GSI ¼ symptom checklist global severity index; SCL PST¼ symptom checklist positive symptom total; SCL PSDI: symptom checklist positive symptom distress index. n

po 0.05. p o0.01.

nn

F. Rotella et al. / Psychiatry Research 225 (2015) 452–457

novelty seeking showed a positive correlation with EE total score and with all the EE subscales, whereas self directedness displayed a negative correlation with EE scores. Cooperativeness negatively correlated to EE anxiety subscale. In the “Non-Binge” group, no significant correlation between TCI dimensions and EE scores was observed.

4. Discussion The present study shows that emotional eating is associated with specific temperamental/character features. Previous surveys had shown that EDs are often associated with a temperamental profile, characterized by elevated harm avoidance and low selfdirectedness (Fassino et al., 2002a, 2002b, 2013). The present study confirms that low self-directedness is inversely associated with eating psychopathology, as assessed with EDE-Q, as well as with emotional eating. In addition, EE scores are also associated with higher novelty seeking and self-transcendence. Conversely, harm avoidance is associated with EDE-Q, but not with EE scores. These results suggest that specific eating attitudes and behaviors in eating disordered patients may be characterized by different temperamental profiles. In fact, novelty seeking is correlated with eating psychopathology in patients with binge eating behaviors, but not in those with restriction only. Higher harm avoidance and lower self directedness scores were associated with general psychopathology (i.e. SCL-90 GSI). This is in line with other recent studies (Fassino et al., 2013; Miettunen and Raevuori, 2012) and the result that also lower cooperativeness scores are associated with general psychopathology may be due to the fact that our sample is fully composed of ED patients (Fassino et al., 2013). In fact SCL-90 scores are significantly associated to both EDE-Q and EES scores, and, in addition, ED psychopathology and EES scores are closely correlated (except in patients with restriction only). Multivariate analyses show that at least some temperamental/ character features are associated with disordered eating behaviors even after adjustment for general psychopathology. More in detail, lower self directedness scores retain the association with EDE-Q scores after correction for SCL-90 GSI scores, suggesting the specificity of this association. Conversely, harm avoidance loses its significant association with EDE-Q scores, after correction for general psychopathology. This result suggests that harm avoidance is a temperamental trait not specifically associated to EDs psychopathology, as previously reported (Fassino et al., 2013). A negative association between EE and Self Directedness scores was found, also after adjustment for general psychopathology. Furthermore,

455

we observed an association of EE with higher novelty seeking scores, at least in subjects with binge eating behaviors. This is in line with the previously reported association between novelty seeking and the frequency of binge eating behaviors (Peñas-Lledó et al., 2010). Indeed, it may be hypothesized that this association could be at least partly explained by EE. As already mentioned, Cloninger's view of temperament and character suggests that temperamental traits are, to a certain extent, heritable and more stable throughout life, whereas character is more referred to experience and individual goals (Cloninger et al., 1993). However, this sharp distinction has been often criticized, suggesting that much of personality is flexible and dynamic (e.g., Mischel and Shoda, 1995), and that it changes over the life span and it is shaped by experience (e.g., Roberts et al., 2006). For EDs, a multi-factorial etiology has been proposed, with the bio-psycho-social model taking into account genetics, early and recent life events, personality, and environmental factors as the consensual approach (for a review see: Polivy and Herman, 2002). However, our data suggest that psychotherapeutic interventions, focused on temperamental and character features, may be crucial for treatment of EE in EDs. More in detail, the specific association between EE and novelty seeking and self directedness, and the observation that EDs patients with specific eating behaviors (i.e. binge or restriction) display different temperament features, suggest the need for a more accurate tailoring of psychotherapeutic interventions. Furthermore, subjects with EDs that do not display the above mentioned temperamental/character profiles may be treated for other aspects, different from temperament (e.g. general psychopathology). Some limitations of the present study should be recognized. First of all, depression and anxiety have been assessed only through self-report measures, the reliability of which is questionable. The limited sample size could have prevented the detection of some relevant associations, especially when separate analyses for “Binge” and “Non-Binge” groups were performed (e.g. the negative association between EE and self transcendence, observed in the total sample, was no longer statistically significant in the two subgroups). For the same reason multiple linear regression has not been conducted separately for patients with binge eating. It should be highlighted that patients enrolled in the study were entirely composed by women and all referred to a single unit. This means that results cannot be extended to male gender. In addition, the possibility that the characteristics of the clinic in which patients were enrolled affects the clinical features of the patients should be considered. Furthermore, the relationship between EE and temperament in non-clinical settings (i.e., patients with ED not seeking care,

Table 3 Correlation coefficients between temperament and character inventory scores and emotional eating scale scores among patients with (binge) and without (non-binge) binge eating behaviors. Binge (N ¼ 129)

EDE-Q total score EDE-Q restriction EDE-Q eating behaviors EDE-Q weight EDE-Q shape EES total score EES anger/frustration EES anxiety EES depression

Non-binge (N ¼ 37)

NS

HA

RD

P

SD

C

ST

NS

HA

RD

P

SD

C

ST

0.15 0.02 0.18n 0.15 0.13 0.28nn 0.23n 0.33nn 0.25nn

0.18n 0.03 0.18n 0.16 0.21n 0.05 0.01 0.05 0.03

0.01  0.16 0.08 0.05 0.06 0.05 0.04  0.03 0.13

0.01  0.10  0.06 0.04 0.08 0.09 0.11 0.02 0.06

 0.41nn  0.13  0.42nn  0.35nn  0.41nn  0.34nn  0.28nn  0.39nn  0.27nn

 0.04  0.06  0.10 0.01  0.01  0.12  0.11  0.20n  0.02

0.16 0.06 0.20n 0.12 0.11 0.16 0.14 0.17 0.14

0.18 0.15 0.09 0.20 0.18 0.13  0.05  0.01 0.02

0.36n 0.36n 0.35n 0.29 0.26  0.12  0.15  0.23  0.22

 0.19  0.25  0.25  0.07  0.16 0.12 0.05 0.07 0.04

0.01 0.03  0.05 0.03 0.10 0.22 0.16 0.22 0.22

 0.55nn  0.47nn  0.48nn  0.54nn  0.41n  0.20  0.10  0.03  0.08

 0.22  0.23  0.21  0.20  0.08 0.11 0.16 0.08 0.06

 0.05  0.08  0.19 0.01 0.03 0.11 0.14 0.15 0.15

NS¼ novelty seeking; HA¼ harm avoidance; RD ¼ reward dependence; P ¼persistence; SD ¼ self directedness; C ¼ cooperativeness; ST¼ self transcendence; EDE-Q ¼ eating disorder examination-questionnaire; EES ¼emotional eating scale. n

po 0.05. p o0.01.

nn

456

F. Rotella et al. / Psychiatry Research 225 (2015) 452–457

or subjects without full-blown ED) could be very different from that of patients referring to a specialist clinic for ED treatment. For these reasons the sample of the present study cannot be considered representative of all the patients with EDs. Another important limitation is the cross-sectional design of the study that does not allow speculations on causal relationship. From one side, is conceivable that temperament should precede EDs symptoms. On the other hand, as character (and perhaps also temperament) may change during the lifespan (Roberts et al., 2006), general and specific psychopathology may have modified the personality profiles of the patients. Finally, our choice to divide patients on the basis of psychopathology/behavior rather than DSM-IV diagnosis (American Psychiatric Association, 2000), although supported by several data (Mitchell et al., 2007; Olatunji et al., 2012), is not completely in line with the suggested dimensional approach on EDs (Fairburn et al., 2003). However, given the limitations of current DSM diagnostic categories, the use of a categorization based on psychopathologic/behavioral features could be considered a strength, rather than a weakness, of this study. In some patients with ED, binge eating is associated with purging behaviors. Previous studies have shown that temperamental features can moderate purging in patients with AN (e.g., Hoffman et al., 2012). It is possible that some of the relationships between binge eating and temperament are moderated by concomitant purging. However, in our study the correlation between emotional eating in bingeing individuals and TCI scales was observed in a sample mainly composed by patients with BED, without purging behaviors. This suggests that temperament specifically modulates emotional eating in patients with binge eating, independent of purging. This result may seem partly at variance with that of a previous study in AN, in which correlations with TCI scales were reported for purging, but not bingeing (Hoffman et al., 2012); however, it should be observed that, in the previous study, only patients with AN were included, whereas the present study enrolled a broader range of patients with EDs, with a majority of individuals in whom binge eating was the principal pathological behavior. The treatment of EDs is, to date, largely based on psychotherapeutic interventions (Fairburn et al., 2003, 2009; Shapiro et al., 2007; Hay et al., 2009; Treasure et al., 2010), which is focused on emotions and cognitions. Different studies showed that emotions affect eating behavior in a relevant manner (Ricca et al., 2012; Abbate-Daga et al., 2012), and temperamental traits can moderate this relationship. Despite these facts, the studies exploring the relationships between temperament and EE are still scarce. The present data provide some hints for the therapeutic approach of EE in EDs patients and suggest that psychotherapeutic intervention in subjects with EE should clearly distinguish between patients with different eating behaviors (i.e. binge and eating restriction), take under control general psychopathology, and perform a specific intervention on novelty seeking and self directedness. Further research in this area could be of help for the development of more focused and appropriate psychotherapeutic strategies for EE in EDs.

References Abbate-Daga, G., Marzola, E., Gramaglia, C., Brustolin, A., Campisi, S., De-Bacco, C., Aminato, F., Fassino, S., 2012. Emotions in eating disorders: changes of anger control after an emotion-focused day hospital treatment. European Eating Disorders Review 20, 496–501. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th revised American Psychiatric Association, Washington. Arnow, B., Kenardy, J., Agras, W.S., 1995. The Emotional Eating Scale: the development of a measure to assess coping with negative affect by eating. International Journal of Eating Disorders 18, 79–90. Berg, K.C., Peterson, C.B., Frazier, P., Crow, S.J., 2012. Psychometric evaluation of the eating disorder examination and eating disorder examination-questionnaire: a systematic review of the literature. International Journal of Eating Disorders 45, 428–438.

Cloninger, C.R., Švrakić, D.M., Przybeck, T.R., 1993. A psychobiological model of temperament and character. Archives of General Psychiatry 50, 975–990. Cloninger, C.R., 1994. The Temperament and Character Inventory (TCI): A Guide to its Development and Use. Center for Psychobiology of Personality, Washington University, St. Louis. Courbasson, C.M., Rizea, C., Weiskopf, N., 2008. Emotional eating among individuals with concurrent eating and substance use disorders. International Journal of Mental Health and Addiction 6, 378–388. Derogatis, L.R., Lipman, R.S., Covi, L., 1973. SCL-90: an outpatient psychiatric rating scale – preliminary report. Psychopharmacology Bulletin 9, 13–28. Engelberg, M.J., Steiger, H., Gauvin, L., Wonderlich, S.A., 2007. Binge antecedents in bulimic syndromes: an examination of dissociation and negative affect. International Journal of Eating Disorders 40, 531–536. Fairburn, C., Cooper, Z., Shafran, R., 2003. Cognitive behavior therapy for eating disorders: a “transdiagnostic” theory and treatment. Behavior Research and Therapy 41, 509–528. Fairburn, C.G., Cooper, Z., Doll, H.A., 2009. Transdiagnostic cognitive behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. American Journal of Psychiatry 166, 311–319. Fairburn, C.G., Beglin, S.J., 1994. Assessment of eating disorders: interview or selfreport questionnaire? International Journal of Eating Disorders 16, 363–370. Fassino, S., Abbate-Daga, G., Amianto, F., Leombruni, P., Boggio, S., Rovera, G.G., 2002a. Temperament and character profile of eating disorders: a controlled study with the temperament and character inventory. International Journal of Eating Disorders 32, 412–425. Fassino, S., Leombruni, P., Pierò, A., Abbate-Daga, G., Amianto, F., Rovera, G., Rovera, G.G., 2002b. Temperament and character in obese women with and without binge eating disorder. Comprehensive Psychiatry 43, 431–437. Fassino, S., Amianto, F., Sobrero, C., Abbate Daga, G., 2013. Does it exist a personality core of mental illness? A systematic review on core psychobiological personality traits in mental disorders. Panminerva Medica 55, 397–413. Goldsmith, H., Buss, A., Plomin, R., Rothbart, M., Thomas, A., Chess, S., Hinde, R.A., McCall, R.B., 1987. Roundtable: what is temperament? Four approaches. Child Development 58, 504–529. Hay, P.P.J., Bacaltchuk, J., Stefano, S., 2009. Psychological treatments for bulimia nervosa and binging. Cochrane Database System Review, 4 (CD000562). Hoffman, E.R., Gagne, D.A., Thornton, L.M., Klump, K.L., Brandt, H., Crawford, S., Fichter, M.M., Halmi, K.A., Johnson, C., Jones, I., Kaplan, A.S., Mitchell, J.E., Strober, M., Treasure, J., Woodside, D.B., Berrettini, W.H., Kaye, W.H., Bulik, C.M., 2012. Understanding the association of impulsivity, obsessions, and compulsions with binge eating and purging behaviours in anorexia nervosa. European Eating Disorders Review 20 (3), e129–e136. Klump, K.L., Bulik, C.M., Pollice, C., Halmi, K.A., Fichter, M.M., Berrettini, W.H., Devlin, B., Strober, M., Kaplan, A., Woodside, D.B., Treasure, J., Shabbout, M., Lilenfeld, L.R., Plotnicov, K.H., Kaye, W.H., 2000. Temperament and character in women with anorexia nervosa. Journal of Nervous and Mental Disease 188, 559–567. Krug, I., Root, T., Bulik, C., Granero, R., Penelo, E., Jiménez-Murcia, S., FernándezAranda, F., 2011. Redefining phenotypes in eating disorders based on personality: a latent profile analysis. Psychiatry Research 188, 439–445. Masheb, R.M., Grilo, C.M., 2006. Emotional overeating and its associations with eating disorder psychopathology among overweight patients with binge eating disorder. International Journal of Eating Disorders 39, 141–146. Miettunen, J., Raevuori, A., 2012. A meta-analysis of temperament in axis I psychiatric disorders. Comprehensive Psychiatry 53, 152–166. Mischel, W., Shoda, Y., 1995. A cognitive-affective systems theory of personality: reconceptualizing the invariances in personality and the role of situations. Psychological Review 102, 246–268. Mitchell, J.E., Crosby, R.D., Wonderlich, S.A., Hill, L., Ie Grange, D., Powers, P., Eddy, K., 2007. Latent profile analysis of a cohort of patients with eating disorders not otherwise specified. International Journal of Eating Disorders 40, S95–S98. Mond, J.M., Hay, P.J., Rodgers, B., Owen, C., Beumont, P.J., 2004. Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behaviour Research and Therapy 42, 551–567. Olatunji, B.O., Broman-Fulks, J.J., Ciesielski, B.G., Zawilinski, L.L., Shewmaker, S., Wall, D., 2012. A taxometric investigation of the latent structure of eating disorders. Psychiatry Research 197, 97–102. Peñas-Lledó, E., Jiménez-Murcia, S., Granero, R., Penelo, E., Agüera, Z., Alvarez-Moya, E., Fernández-Aranda, F., 2010. Specific eating disorder clusters based on social anxiety and novelty seeking. Journal of Anxiety Disorders 24, 767–773. Polivy, J., Herman, P., 2002. Causes of eating disorders. Annual Review of Psychology 53, 187–213. Reba, L., Thornton, L., Tozzi, F., Klump, K.L., Brandt, H., Crawford, S., Crow, S., Fichter, M.M., Halmi, K.A., Johnson, C., Kaplan, A.S., Keel, P., LaVia, M., Mitchell, J., Strober, M., Woodside, D.B., Rotondo, A., Berrettini, W.H., Kaye, W.H., Bulik, C.M., 2005. Relationships between features associated with vomiting in purging-type eating disorders. International Journal of Eating Disorders 38, 287–294. Ricca, V., Castellini, G., Fioravanti, G., Lo Sauro, C., Rotella, F., Ravaldi, C., Lazzeretti, L., Faravelli, C., 2012. Emotional eating in anorexia nervosa and bulimia nervosa. Comprehensive Psychiatry 53, 245–251. Ricca, V., Castellini, G., Lo Sauro, C., Ravaldi, C., Lapi, F., Mannucci, E., Rotella, C.M., Faravelli, C., 2009. Correlations between binge eating and emotional eating in a sample of overweight subjects. Appetite 53, 418–421. Roberts, B.W., Walton, K.E., Viechtbauer, W., 2006. Patterns of mean-level change in personality traits across the life course: a meta-analysis of longitudinal studies. Psychological Bulletin 132, 1–25.

F. Rotella et al. / Psychiatry Research 225 (2015) 452–457

Rothbart, M.K., Derryberry, D., 1981. Development of individual differences in temperament. In: Lamb, M.E., Brown, A.L. (Eds.), Advances in Developmental Psychology, vol. l. Erlbaum, Hillsdale, NJ, pp. 37–86. Shapiro, J.R., Berkamn, N.D., Brownley, K.A., 2007. Bulimia nervosa treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders 40, 321–336. Stein, R.I., Kenardy, J., Wiseman, C.V., Dounchism, J.Z., Arnow, B.A., Wilfley, D.E., 2007. What's driving the binge in binge eating disorder? A prospective examination of precursors and consequences. International Journal of Eating Disorders 40, 195–203.

457

Torres, S., Guerra, M.P., Lencastre, L., Roma-Torres, A., Brandão, I., Queirós, C., Vieira, F., 2011. Cognitive processing of emotions in anorexia nervosa. European Eating Disorders Review 19, 100–111. Treasure, J., Claudino, A.M., Zucker, N., 2010. Eating disorders. Lancet 375, 583–593. Zeeck, A., Stelzer, N., Linster, H.W., Joos, A., Hartmann, A., 2011. Emotion and eating in binge eating disorder and obesity. European Eating Disorders Review 19, 426–437.

Temperament and emotional eating: a crucial relationship in eating disorders.

Specific personality traits are related to Eating Disorders (EDs) specific and general psychopathology. Recent studies suggested that Emotional Eating...
271KB Sizes 0 Downloads 9 Views