Eating disorders do not occur in a vacuum. Research has found that 97% of individuals with eating disorders have a co-occurring psychiatric condition, such as a personality disorder, depression, anxiety or substance abuse disorder.1 In our experience, , up to 50 – 70% of patients have comorbid personality disorders.
Personality disorders may typically begin showing signs, patterns and traits by adolescence. Characterized by specific maladaptive patterns of behavior that undermine interpersonal relationships and social functioning, personality disorders affect cognition and self-awareness. Individuals with these disorders have a perception of the world and themselves significantly at odds with others in their society and rigidly hold on to their views and behaviors despite the distress or disability they typically cause.
Individuals with eating disorders most commonly have borderline personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder or obsessive compulsive personality disorder. These personality disorders share common risk factors, including developmental attachment issues, trauma, genetic influences, certain triggering events and stressors.
Professionals who work with patients with eating disorders often find the complex profiles presented by those with personality disorders particularly challenging to treat. They are frequently refractory to treatment and engage in inappropriate behavioral patterns, some of which interfere with therapy. They can be difficult to manage effectively, regularly abandon treatment and often experience suicidal ideation and non-suicidal self-injury. Treating these patients on an outpatient basis can exhaust therapists.
Such patients often require inpatient therapy to address the underlying trauma or other significant stressors, as well as manage behaviors. Programs that treat the whole person rather than specific disorders have a greater likelihood of success. Integrated inpatient and residential programs minimize the chaos patients with personality disorders create in their therapists’ lives, while helping the patients stay committed to recovery from the eating disorder and treatment of their personality disorder.
The symptoms of the eating disorder may abate well before the issues caused by the personality disorder resolve – but it’s complicated. While ensuring the patient achieves medical and nutritional stability must be the first priority, failing to address the issues surrounding identity, trauma, relationships, value and worth will increase the likelihood of relapse.
Patients with borderline and narcissistic personality disorders especially have a high rate of leaving treatment against clinical and/or medical advice. The very nature of the personality issues, including impulsivity, fear of abandonment, incredible fear, internal chaos, pain lead to behaviors of wanting to escape and avoid. Further, often these patients enter treatment because of depression or, for those with narcissism, because they feel they are not being treated as deferentially as they believe is appropriate. Once they stop therapy, they may return to their cycle of self-destructive behaviors, including the eating disorder.
Several types of therapy help break through the resistance to treatment seen in many eating disorder patients with comorbid personality disorders. Dialectical behavior therapy, mindfulness and mentalization-based therapy provide particular benefit when working with patients with borderline personality disorder.2 The time-limited, highly structured interventions help the patient to stay in the moment and focus on making sense of themselves and others in terms of their mental processes. These programs strike a balance that is neither too intense nor too attached. Through them, patients begin to develop better emotional regulation, the absence of which is at the core of many personality disorders. They also begin to rebuild their sense of self-worth on a base more substantial, and healthier, than their looks, weight loss or other’s responses to them.
Patients with avoidant personality, on the other hand, experience social phobias and anxiety. For them, exposure therapy that safely reacclimates them to anxiety-provoking situations can gradually defuse frequently crippling fear. At the same time, cognitive or dialectical behavioral therapy helps these patients get to the core of their negative beliefs and learn how to challenge negative thoughts when they occur.
While understanding the nature of the specific personality disorder involved is critical to effective treatment, therapists should resist labeling and dismissing the disorder. It may be appropriate to share the diagnosis of a personality disorder with a patient so they understand the source of certain behaviors. This awareness may help them commit to treatment and come to grips with both the eating and the personality disorder, as well as have hope that there are effective treatments to address their particular problems. For the therapist, awareness of the personality disorder can lead to greater compassion in the face of often frustrating behaviors, as well as selection of treatments and environments that work more effectively for patients with the specific personality disorder.
Blinder BJ, Cumella EJ, Sanathara VA. Psychiatric comorbidities of female inpatients with eating disorders. Psychosom Med. 2006 May-Jun;68(3):454-62.
Bateman A, Fonagy P. Mentalization based treatment for borderline personality disorder. World Psychiatry. 2010 Feb;9(1):11-15.