Introduction: Clinical and empirical literature has long suggested a link between personality and eating disorders (ED) (Farstad et al., 2016), showing that personality might shape and give meaning to symptomatic presentations of ED. Moreover, there is evidence that personality is an important determinant of ED patients’ response to treatment, as well as of recovery rates or drop-out. For instance, impulsivity and emotional dysregulation have been found to be associated with higher levels of psychiatric and ED symptoms at treatment termination, and then to be possibly related to unfavorable treatment outcomes (Muzi et al., 2021). Even though symptomatic remission is considered a fundamental outcome for a successful therapy, symptom reduction itself is not the only feature to consider with respect to therapeutic change (Oasi et al., 2017). Thus, a possible key aspect is to evaluate changes in more “structural” dimensions of patients’ functioning, such as specific personality features and overall personality functioning. However, to date, personality-based outcome research is still limited, especially in ED populations. Then, the current study aimed at exploring, through a multi-informant and longitudinal perspective, possible changes in a broad spectrum of personality traits and in overall personality functioning in a sample of patients diagnosed with an ED and treated in a residential treatment setting. Furthermore, an additional aim was to examine the predictive value of personality traits and features on treatment outcome at both discharge and two follow-up. Methods: A national sample of cisgender women with an eating disorder (ED) (N= 139) was evaluated at intake and discharge with the Shedler-Westen Assessment Procedure (SWAP-200; Shedler, Westen, & Lingiardi, 2014), a clinician-rated measure of personality disorders and healthy personality functioning. A first subsample of 51 patients was also evaluated at a 6-month follow-up, and a second subsample of 40 patients at a 12-month follow-up after discharge. In all these time points, patients fulfilled the Outcome Questionnaire 45.2 (OQ-45.2) to evaluate overall psychopathological impairment. The inclusion criteria were: (a) aged at least 18 years; (b) a pre-treatment diagnoses of DSM-5 anorexia nervosa (AN) or bulimia nervosa (BN) posed by a licensed staff psychologist or psychiatrist and based on the Structured Clinical Interview for DSM-5 (SCID-5-CV); (c) presenting no organic syndromes, psychotic disorder, or syndrome with psychotic symptoms that could complicate the assessment of any variable in the study. No limits were applied to the body mass index (BMI) at the admission. Treatment was provided in a psychodynamic-oriented multidisciplinary residential setting and consisted in individual weekly psychotherapy sessions, encounters with specialized social workers, and sessions with a nutritional physician. Results: Findings evidenced statistically significant changes in several SWAP-200 Scales and Q-Factors at both discharge and the two follow-up. More specifically, repeated measure ANOVAs showed that there was a significant pre-post increase in the healthy personality functioning scale (ES= .14, p <.001), dysphoric: depressive–high functioning (ES= .08, p=.003) and obsessive (ES= .06, p=.009) Q-factors. For the healthy personality functioning these differences were even more pronounced at the 6-month follow-up (ES= .19, p =.005) and at 12-month follow-up (ES= .20, p=.004). Moreover, findings showed a significant pre-post decrease in the schizoid (ES= .10, p <.001), schizotypal (ES= .09, p=.001) and borderline (ES= .06, p=.01) PD Scales, as well as in the schizoid (ES= .07, p=.005) and dysphoric: emotionally dysregulated (ES= .11, p <.001) Q-factors. These differences also emerged at the 6-month and 12-month follow-up, with the largest effect size in the dysphoric: emotionally dysregulated Q-factor (ES= .20, p=.003, and ES= .16, p=.01). Interestingly, borderline PD Scale showed a significant decrease in the 12-month follow-up (ES= .16, p=.01), but not at the 6-month follow-up. Additional multiple regression analyses also showed that baseline schizoid and borderline PD scales, as well as emotionally dysregulated Q-factor, emerged as significant predictors of higher symptomatic impairment at discharge and at 6-month follow-up. Conclusion: The current study attempted to fill the gap in the literature by applying an empirically grounded, clinician-report, and Q-sort procedure—the SWAP-200 — to assess significant therapeutic changes of a wide range of personality features in ED patients and the predictive value of these features in determining therapy outcomes. Our results have shown significant changes in personality structure throughout treatment and even after treatment termination. Specifically, an increase in healthy personality functioning has been achieved over time, suggesting how residential treatment programs can be considered a viable and convenient intervention to promote therapeutic changes in both symptoms and personality dimensions. Furthermore, these findings showed a significant reduction of borderline and emotionally dysregulated personality features, which have been previously linked to higher symptomatic impairment. However, an important limitation should be noted. There was a low response rate at both at 6-month and 12-month follow-up, suggesting that results cannot be considered as descriptive of all ED patients treated in a residential treatment setting. Despite this shortcoming, to the best of our knowledge this is the first study which systematically explores personality changes in ED patients in a medium- and long-term longitudinal perspective by applying a clinically rich and empirically supported tool, the SWAP-200, above previous single case studies (Lingiardi et al., 2006). From a clinical perspective, these results supported the view that the goals of psychodynamic-oriented therapies include, but extend beyond, alleviation of acute symptoms because psychological health is not merely the absence of symptoms. Then, considering multiple indices of therapeutic change enables a more clinically useful perspective of treatment outcomes in this clinical population.
Personality change after treatment in patients with eating disorders: A longitudinal study with the SWAP-200
Muzi Laura
2022
Abstract
Introduction: Clinical and empirical literature has long suggested a link between personality and eating disorders (ED) (Farstad et al., 2016), showing that personality might shape and give meaning to symptomatic presentations of ED. Moreover, there is evidence that personality is an important determinant of ED patients’ response to treatment, as well as of recovery rates or drop-out. For instance, impulsivity and emotional dysregulation have been found to be associated with higher levels of psychiatric and ED symptoms at treatment termination, and then to be possibly related to unfavorable treatment outcomes (Muzi et al., 2021). Even though symptomatic remission is considered a fundamental outcome for a successful therapy, symptom reduction itself is not the only feature to consider with respect to therapeutic change (Oasi et al., 2017). Thus, a possible key aspect is to evaluate changes in more “structural” dimensions of patients’ functioning, such as specific personality features and overall personality functioning. However, to date, personality-based outcome research is still limited, especially in ED populations. Then, the current study aimed at exploring, through a multi-informant and longitudinal perspective, possible changes in a broad spectrum of personality traits and in overall personality functioning in a sample of patients diagnosed with an ED and treated in a residential treatment setting. Furthermore, an additional aim was to examine the predictive value of personality traits and features on treatment outcome at both discharge and two follow-up. Methods: A national sample of cisgender women with an eating disorder (ED) (N= 139) was evaluated at intake and discharge with the Shedler-Westen Assessment Procedure (SWAP-200; Shedler, Westen, & Lingiardi, 2014), a clinician-rated measure of personality disorders and healthy personality functioning. A first subsample of 51 patients was also evaluated at a 6-month follow-up, and a second subsample of 40 patients at a 12-month follow-up after discharge. In all these time points, patients fulfilled the Outcome Questionnaire 45.2 (OQ-45.2) to evaluate overall psychopathological impairment. The inclusion criteria were: (a) aged at least 18 years; (b) a pre-treatment diagnoses of DSM-5 anorexia nervosa (AN) or bulimia nervosa (BN) posed by a licensed staff psychologist or psychiatrist and based on the Structured Clinical Interview for DSM-5 (SCID-5-CV); (c) presenting no organic syndromes, psychotic disorder, or syndrome with psychotic symptoms that could complicate the assessment of any variable in the study. No limits were applied to the body mass index (BMI) at the admission. Treatment was provided in a psychodynamic-oriented multidisciplinary residential setting and consisted in individual weekly psychotherapy sessions, encounters with specialized social workers, and sessions with a nutritional physician. Results: Findings evidenced statistically significant changes in several SWAP-200 Scales and Q-Factors at both discharge and the two follow-up. More specifically, repeated measure ANOVAs showed that there was a significant pre-post increase in the healthy personality functioning scale (ES= .14, p <.001), dysphoric: depressive–high functioning (ES= .08, p=.003) and obsessive (ES= .06, p=.009) Q-factors. For the healthy personality functioning these differences were even more pronounced at the 6-month follow-up (ES= .19, p =.005) and at 12-month follow-up (ES= .20, p=.004). Moreover, findings showed a significant pre-post decrease in the schizoid (ES= .10, p <.001), schizotypal (ES= .09, p=.001) and borderline (ES= .06, p=.01) PD Scales, as well as in the schizoid (ES= .07, p=.005) and dysphoric: emotionally dysregulated (ES= .11, p <.001) Q-factors. These differences also emerged at the 6-month and 12-month follow-up, with the largest effect size in the dysphoric: emotionally dysregulated Q-factor (ES= .20, p=.003, and ES= .16, p=.01). Interestingly, borderline PD Scale showed a significant decrease in the 12-month follow-up (ES= .16, p=.01), but not at the 6-month follow-up. Additional multiple regression analyses also showed that baseline schizoid and borderline PD scales, as well as emotionally dysregulated Q-factor, emerged as significant predictors of higher symptomatic impairment at discharge and at 6-month follow-up. Conclusion: The current study attempted to fill the gap in the literature by applying an empirically grounded, clinician-report, and Q-sort procedure—the SWAP-200 — to assess significant therapeutic changes of a wide range of personality features in ED patients and the predictive value of these features in determining therapy outcomes. Our results have shown significant changes in personality structure throughout treatment and even after treatment termination. Specifically, an increase in healthy personality functioning has been achieved over time, suggesting how residential treatment programs can be considered a viable and convenient intervention to promote therapeutic changes in both symptoms and personality dimensions. Furthermore, these findings showed a significant reduction of borderline and emotionally dysregulated personality features, which have been previously linked to higher symptomatic impairment. However, an important limitation should be noted. There was a low response rate at both at 6-month and 12-month follow-up, suggesting that results cannot be considered as descriptive of all ED patients treated in a residential treatment setting. Despite this shortcoming, to the best of our knowledge this is the first study which systematically explores personality changes in ED patients in a medium- and long-term longitudinal perspective by applying a clinically rich and empirically supported tool, the SWAP-200, above previous single case studies (Lingiardi et al., 2006). From a clinical perspective, these results supported the view that the goals of psychodynamic-oriented therapies include, but extend beyond, alleviation of acute symptoms because psychological health is not merely the absence of symptoms. Then, considering multiple indices of therapeutic change enables a more clinically useful perspective of treatment outcomes in this clinical population.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
