Abstract
Features of personality disorders (PDs) have been found to explain meaningful variance in the onset, maintenance, and symptomatic presentation of eating disorders (EDs), and a co-occurent personality pathology is commonly associated with poorer response to ED treatment. The “pathoplasty model” of the relationship between personality and EDs implies that, once both conditions are established, they are likely to interact in ways that modify therapy outcome; however, to date, no studies have explored overall personality functioning, and especially PD clusters, as a mediator of treatment outcome. The present study aimed at conjointly exploring the associations between personality functioning and PDs, respectively, with pre-treatment ED symptomatic impairment and therapy outcome; and the mediating role of personality variables. At treatment onset, a sample of 107 women with ED problems were evaluated using both the Structured Clinical Interview for DSM-5 (SCID-5-CV) and the Shedler-Westen Assessment Procedure-200 (SWAP-200)—a clinician-rated procedure to dimensionally assess personality. Participants were also asked to complete self-report questionnaires on overall ED symptomatology, symptoms of binge eating and purging behaviors, and therapy outcome. The findings showed that, over and above the categorical ED diagnosis, the SWAP-200 healthy personality functioning score mediated the relationship between baseline ED symptom severity and therapy outcome, as well as the association between baseline bulimic symptoms and treatment outcome; furthermore, SWAP-200 Cluster B PD scores mediated the link between baseline binge eating and purging symptoms and therapy outcome, whereas scores in Clusters A and C showed no significant effects. The findings suggest that personality-based outcome research may improve treatment effectiveness in this difficult-to-treat population.
Highlights
Eating disorders (EDs), including anorexia nervosa (AN), and bulimia nervosa (BN), are commonly ranked amongst the most complex and pernicious of all psychiatric illnesses to treat
The results showed that Clusters A and B of the SWAP-200 personality disorders (PDs) scales were positively associated with higher levels of overall ED symptomatic impairment at treatment intake and worse therapy outcome, with Cluster B showing an additional association with more severe baseline bulimic symptoms
SWAP-200 healthy personality functioning was negatively associated with more severe baseline ED and bulimic symptoms, as well as to worse therapy outcome
Summary
Eating disorders (EDs), including anorexia nervosa (AN), and bulimia nervosa (BN), are commonly ranked amongst the most complex and pernicious of all psychiatric illnesses to treat. “Personality” describes a set of relatively stable ways of thinking, feeling, behaving, and relating to others, resulting from the convergence of constitutional factors, development, and social and cultural experiences (Lingiardi and McWilliams, 2017; McWilliams et al, 2018) This variable has been found to influence a wide range of psychiatric disorders, as well as patients’ motivation, compliance, and response to treatment (Ramos-Grille et al, 2013; Steinert et al, 2015; Bagby et al, 2016; Huber et al, 2017). The so-called pathoplasty model implies that, once personality traits or disorders and EDs are established, they may influence each other in ways that modify the presentation and course of each condition, including ED symptomatic impairment and treatment outcome. This model is in line with the perspective that patients’ personality is a relevant “context” (Westen et al, 2006) in which ED symptoms serve different functions and provide alternative meanings
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