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Doi:10.1016/j.pnpbp.2006.06.025

Progress in Neuro-Psychopharmacology & Biological Psychiatry xx (2006) xxx – xxx Psychological traits and platelet monoamine oxidase activity in eating disorder patients: Their relationship and stability Iris Podar a,⁎, Maiken Jaanisk a,b, Jüri Allik a, Jaanus Harro a,b a Department of Psychology, University of Tartu, Tiigi 78, Tartu 50410, Estonia b The Estonian Centre of Behavioral and Health Sciences, University of Tartu, Tartu 50410, Estonia Self-reported behavior and attitudes towards eating [Eating Disorder Invetory-2; Garner DM (1991). Eating Disorder Inventory-2: Professional Manual. Odessa, Fl.: Psychological Assessment Resources; Estonian version Podar I, Hannus A, Allik J (1999). Personality and AffectivityCharacteristics Associated With Eating Disorders: a Comparison of Eating Disordered, Weight-Preoccupied, and Normal Samples. J Pers Assess;73(1), 133–147] and the activity of platelet monoamine oxidase (MAO) was studied in 11 patients with anorexia nervosa (AN), 43 patients withbulimia nervosa (BN) and a healthy control group (n = 138). Nineteen patients filled in the EDI-2 questionnaire and donated blood samples threetimes with three month intervals in order to determine platelet MAO activity. Eating disordered (ED) patients scored higher on all EDI-2 subscalesand had lower MAO activity compared to the control group. They also scored higher than the control group on the Neuroticism domain but loweron the Extraversion, Openness, and Conscientiousness domains of the NEO-PI-R questionnaire. The average stability of MAO on differentoccasions (r = .56) was slightly smaller than the stability of the EDI-2 scores (r = .70). The lack of correlations between personality dispositions andMAO activity indicates that they have independent influence on eating disorders. A possible relationship between neurochemical mechanisms andpsychological symptoms of eating disordered behavior is discussed.
2006 Elsevier Inc. All rights reserved.
Keywords: Anorexia nervosa; Bulimia; Eating disorders; EDI-2; NEO-PI-R; Platelet MAO; Stability syndromes are far more common among females than males andthey have become more common among younger females Since eating disordered behavior is more prevalent in during the latter half of the twentieth century it is believed that industrialized and Western societies, culture has been identified they are reflecting current cultural beauty ideals for women as one of the major etiological factors leading to the development of anorexia nervosa (AN) and bulimia nervosa eating disorders have socio-cultural (e.g., family influences and cultural pressures for thinness) risk factors there are also psycho-logical (e.g., personality dispositions) Abbreviations: 5-HT, 5-hydroxytryptamine; A, agreeableness; A, asceti- cism; AN, anorexia nervosa; B, bulimia; BD, body dissatisfaction; BMI, body involved in the development of eating disordered behavior mass index; BN, bulimia nervosa; C, conscientiousness; DT, drive for thinness; E, extraversion; EDI-2, Eating Disorder Inventory 2; F 50.0, anorexia nervosa Like many other obsessive compulsive behaviors, eating (International Classification of Diseases-10); F 50.2, bulimia nervosa (Interna- disorders demonstrate a high degree of stability over time ( tional Classification of Diseases-10); I, ineffectiveness; IA, interoceptiveawareness; ID, interpersonal distrust; IR, impulse regulation; MAO, monoamine oxidase; MAO-B, monoamine oxidase B isoenzyme; MF, maturity fears; N, neuroticism; NEO-PI-R, Revised NEO Personality Inventory; O, openness to is associated with a 9-fold increase in risk for late adolescent experience; P, perfectionism; SI, social insecurity.
bulimia nervosa and a 20-fold increase in risk for adult bulimia nervosa. Late adolescent bulimia nervosa is associated with a 35- (M. Jaanisk), (J. Allik), (J. Harro).
fold increase in risk for adult bulimia nervosa. Presence of eating 0278-5846/$ - see front matter 2006 Elsevier Inc. All rights reserved.
I. Podar et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry xx (2006) xxx–xxx problems in early childhood or an eating disorder in adolescence confers a strong risk for an eating disorder over a 17-year interval The role of serotonin dysregulation in the devel- Disorder Inventory (EDI-2; administered 10 years opment of eating disorders is also demonstrated by a significant improvement of AN and BN patients who have been treated with the serotonin reuptake inhibitor citalopram that disturbed eating attitudes decline with age, the mean scores on eating disorder attitude scales tended to increase with age Although both, personality dispositions and serotonin sys- (). Therefore it is not surprising that different tem dysfunction, contribute to the eating disorders, there are instruments like Eating Disorder Inventory (EDI, relatively few studies in which these two groups of factors are also demonstrate a good test–retest stability. For example, in a jointly studied in the clinical and normal samples. Existing data, non-clinical sample EDI demonstrated a substantial stability however, demonstrate that there may be a covariation between over a 1 year period ). Although developed personality traits and neurochemical activity in the brain. For for adults, EDI-2 scales demonstrated considerable test–retest stability also in a sample of adolescents over a 3 year period tween personality traits and 5-HT indices in bulimic patients.
(An acceptable test–retest stability was These findings suggest a multidimensional model of eating also observed in samples of eating disordered patients disorders according to which biological and personality dispo- sitions jointly interact in the development of eating disorders “drive for thinness” were found to change significantly over of attempts to study in parallel the influence of personality Although the stability of eating disordered behaviors and dispositions and the activity of the serotonin system on the attitudes suggests the enduring role of personality dispositions in eating behavior and attitudes. Another novelty of this study is a the development of eating disorders, it is not entirely clear what longitudinal observation of self-reported behavior and attitudes combination of personality traits contribute as a risk factor ( towards eating in parallel with MAO activity three times with The best documented link exists betweenneuroticism and eating disorders ). However, the role of other personality dispositions in theetiology of eating disorders is less clear. Increasing evidence Altogether one hundred and ninety two subjects from two indicates that normal and abnormal personality can be treated different groups participated in this study.
within a single hierarchical structure in which the level of fivefactors is the most comprehensive Unfor- tunately, the number of studies of eating disorders in the frame- Fifty four patients with eating disorders who were consec- work of the Big Five personality factors is limited utively admitted to the Psychiatric Clinic of Tartu University Hospitals between March 2000 and March 2003 took part in this study, among them 11 cases met the criteria for anorexia nervosa ). Nevertheless, findings seem to suggest that (F 50.0) and 43 cases for bulimia nervosa (F 50.2). The patients eating disorder symptomatology is correlated with high neurot- were diagnosed based on the criteria of the Classification of icism and openness to experience and low conscientiousness and Mental and Behavioural Disorders (International Classification of Diseases-10; World Health Organization, 1992). The patients were diagnosed by experienced psychiatrists. Twenty one complete agreement between different studies. For example, patients were diagnosed having co-morbidity symptoms, most frequently depression (F 32) in 15 cases. However, only in domly selected from the general population a high level of open- 2 cases depressive episodes were severe (F 32.2). Two patients ness, not closeness, was significantly associated with self- were diagnosed with recurrent depressive disorder (F 33.1). In reported lifetime history of eating disorder.
2 cases, both bulimics, a harmful use or dependence on alcohol Besides phenotypical personality traits, that can be conceptu- was recorded (F 10). In one case social phobias (F 40.1) were alized as biologically rooted endogenous dispositions ( reported. Forty patients (74%) received antidepressant treat- the disturbances in the underlying neuro- ment. In most cases (30 patients) Fluoxetin (20 mg/day) or some chemical systems may be another risk factor for eating disorders.
other antidepressants like Paroxetin or Citalopram (9 cases) were In particular, patients with eating disorders exhibit serotonin (5- prescribed from one to twelve months. In 1 case anxiolytic Xanax was prescribed. All patients received at least once psy- ). Several studies have confirmed that patients with chiatric consultation concerning eating disorders, dieting, and AN or BN demonstrate reduced activity of platelet monoamine nutrition and were encouraged to start treatment. Three patients oxidase (MAO) activity which is a reliable peripheral indicator of attended sessions of cognitive-behavioral therapy (at least 10 I. Podar et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry xx (2006) xxx–xxx sessions). All participants were females aged 16–37 years activity was measured as previously described ( (Mean = 20.1; S.D. = 4.5) and their mean body mass index (BMI; ) and expressed as nanomoles of β-phenylethylamine the body weight in kilograms divided by the squared height in oxidized per 1010 platelets/min. On the first time all the patients meters) was 19.77 (S.D. = 2.8). Eleven patients were smokers.
participating in the research were tested for MAO activity(n = 54), blood samples from 34 and 26 patients, respectively, were available at follow-up three months or six months later.
The control group (n = 138) was also entirely comprised of females aged 16–37 years (Mean = 20.14; S.D. = 3.33) and their BMI was 20.47 (S.D. = 2.45). The control group was selected fromthe students of Tartu University and other schools, employees of Patients who volunteered to participate were asked to fill in the Psychiatric Clinic and others, who volunteered to participate in the EDI-2 Estonian version and have their blood tested for the the research project. The control group was selected to match the activity of monoamine oxidase three times with an interval of eating disordered patients by their sex, age, and education.
three months. Forty eight filled EDI-2 questionnaires were Thirteen participants from the control group were smokers.
returned on the first time, 26 on the second and 19 on the third.
Nineteen patients returned the filled questionnaires and had MAO activity tested all three times.
The Estonian version (of the Eating Disorder Inventory- 2 (EDI-2; ) consists of 91 items and 11 Internal consistency of the EDI-2, both in clinical and control subscales measuring psychological characteristics and behaviors samples, was similar and in the range of reliabilities reported in associated with eating disorders. The items are evaluated on a 6- the EDI-2 manual ). In the control group (n = 138) point scale (from “never” to “always”) which for the analysis is alpha was .84 and in the patient group (n = 54) alpha was .88.
transformed into a 4-point scale. Like its predecessor, EDI-2 shows the mean values on EDI-2 scales for the three consists of 8 primary scales: DT — Drive for Thinness, B — categories of participants: AN and BN patients and the control Bulimia, BD — Body Dissatisfaction, I — Ineffectiveness, P — group. When treated as a single category, ED patients scored Perfectionism, ID — Interpersonal Distrust, IA — Interoceptive significantly higher on all EDI-2 scales compared to the control Awareness, and MF — Maturity Fears. In the second revision group (F values in ANOVA varied from F(1,182) = 8.08 to 79.90 EDI-2 consisted of 3 additional scales were developed: A — for the Perfectionism and Ineffectiveness subscales respectively, Asceticism, IR — Impulse Regulation, and SI — Social p always higher than .003). In comparison with each other, ano- Insecurity. The first 3 subscales are concerning eating, weight rexia and bulimia patients differed significantly only on the B and body shape (DT, B, BD), and eight subscales concerning subscale (F(1,44) = 11.64, p b .001) where bulimia patients scored psychological traits thought to be clinically relevant to eatingdisorders (I, P, ID, IA, MF, A, IR, SI). The diagnostic validity ofthe Estonian EDI-2 has been previously demonstrated NEO Personality Inventory (NEO-PI-R) is a 240-item measureof the Five Factor Model of personality (It contains 30 8-item facet scales, six for each of the fivebasic personality factors, Neuroticism (N), Extraversion (E),Openness to Experience (O), Agreeableness (A), and Consci-entiousness (C). The factors can be estimated by domain scores,which sum the relevant six facets. The original NEO-PI-R wastranslated and adapted into Estonian with all psychometricallysignificant parameters similar to the original instrument ). In the previous report of Estonian EDI-2() an older version of the NEO-PI was used(Estonian NEO-PI-R data have repeatedlybeen reported in different publications and demonstrate anacceptable validity ).
Fig. 1. The mean scores of EDI-2 subscales for controls (n = 138), anorexiapatients (AN) (n = 11) and bulimia patients (BN) (n = 37). EDI-2 subscales: DT =Drive for Thinness; B = Bulimia; BD = Body Dissatisfaction; IE = Ineffectiveness; P = Perfectionism; ID = Interpersonal Distrust; IA = One hundred and six individuals from the control group gave Interoceptive Awareness; MF = Maturity Fears; A = Asceticism; IR = Impulse blood samples for determining their MAO-B activity. MAO I. Podar et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry xx (2006) xxx–xxx higher than anorexia patients. The difference on the BD subscale EDI-2 stability proved to be statistically significant on all the was only marginally significant (F(1,45) = 4.08; p = .049).
subscales as well as in the total score. The average stability of The average profile of ED patients was very similar to what MAO on different occasions (r = .56) was slightly smaller than the was obtained in other countries. When the correlations were stability of self-reported eating disorders (r = .70).
computed between the EDI-2 subscale profile obtained in thisstudy and profiles of ED patients reported in the literature, they were typically in the range from .90 to .98 compared with Canada(Germany Italy The results of this study clearly indicate that self-reported behaviors and attitudes distinguish clinical samples from a healthy control group. Both AN and BN patients scored signi- When ED patients completed EDI-2 the second and the third ficantly higher than normal individuals on all 11 EDI-2 sub- time after three months and six months, respectively, only Ma- scales. The obtained profiles of eating disordered patients are turity Fears had decreased significantly, F(2,36) = 5.02. These very similar to those that were obtained previously in Estonian changes were not related to the treatment outcome. The same samples (and various other countries such as tendency of decrease can be seen in B, BD, IE, ID, IA and IR Japan, Sweden and Italy. This seems to indicate that symptoms subscales as well as the EDI-2 total score, but the difference did and behaviors characterizing ED are rather universal and tran- not reach a level of significance. These results are both quali- scend from one culture to another. Although EDI-2 differenti- tatively and quantitatively similar to previous Estonian data ated ED samples from norm rather well, it was rather insensitive to discriminate AN patients from BN patients. Like in previous As expected, ED patients scored higher than the control group on the Neuroticism domain [F(1,153) = 42.8, p b .0001] subscale the BN group did not score higher than the AN group but lower on the Extraversion [F(1,152) = 14.7, p = .0002], Openness [F(1,153) = 6.27, p = .013], and Conscientiousness The current study supports previous studies that have revealed a [F(1,151) = 9.57, p = .002] domains.
considerable personality disposition towards ED. As expected, In the patient group, the activity of MAO was slightly lower neuroticism was the strongest predictor of ED. Many previous 9.76 (n = 54, S.D. = 2.91) than in the control group 10.79 (n = 106, studies have demonstrated that individuals who are not able to SD = 3.28). ANOVA revealed that this difference was marginally control their emotional reactions are more inclined towards ED significant F(1,158) = 3.76, p = 0.054. There was a statistically significant correlation between the activity of MAO and two EDI subscales, DT (r = −.169, p = .036) and B (r = −.190, p = .018).
). Besides neuroticism, other personality traits also These correlations, however, were reduced and became insignif- join a cluster of traits that is typical to ED patients characterized icant when the division into the patient and control group was besides neurotic tendencies by high introversion, closeness to taken into account. When controlled for smoking correlations experience, and low conscientiousness. It is understandable that between the activity of MAO and all EDI subscales became individuals who have not learned to manage their desires (low conscientiousness), who tend to be conventional in their behavior The correlations or stability in time of test–retest on EDI-2 (closeness), and who are more shy (introversion) are more prone to subscale scores in eating disordered patients are shown in developing eating problems. It is an open question whether lowagreeableness is also an etiological risk factor for the developmentof ED or not (It seems, however, that AN patients have somewhat higher scores than BN patients on the Test–retest correlations of EDI-2 subscales and MAO in eating disordered Like many previous studies, results of this study indicated that self-reported symptoms and problems are very stable in time despite psychological and pharmacological intervention.
The average test–retest correlation of the EDI-2 total scores was .70 which is surprisingly higher than the MAO test–retest correlation (r = .56). It is also remarkable that the six-month stability indices were not significantly lower than the three- Platelet MAO activity tended to be lower among the patients, in line with previous findings that eating disordered patients have described a considerably larger difference in platelet MAO activity between patients and healthy controls. Platelet MAOactivity is considered to be individually highly stable, but indeed Note: All correlations are significant at least p b .05. T the second, and the third time of testing.
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