Cluster B Personality Disorder

Characteristics Predict Outcome

in the Treatment of Bulimia Nervosa

Elise M. Rossiter
W. Stewart Agras
Christy F. Telch
John A. Schneider
(Accepted 25 April 1992)

The Personality Disorders Examination (PDE) was administered to 7 1 bulimia nervosa pa-
tients at baseline assessment in a study comparing the effectiveness of cognitive-behavioral
treatment with desipramine or the combination of both treatments. Personality disorder sub-
scales were combined into single DSM-Ill-R cluster scores. A high cluster B score (consist-
ing of antisocial, borderline, histrionic, and narcissistic features) significantly predicted poor
outcome at 16 weeks and was a better predictor of outcome than borderline personality
characteristics alone or any other DSM-Ill-R cluster score or Combination of cluster scores.
In contrast pretreatment depression level, self-esteem, degree of dietary restraint, frequency
of purging, and history of anorexia nervosa were not significantly related to outcome. At
1-year follow-up there was still a trend toward high cluster B scores predicting poor treat-
ment outcome. Cluster B score was not significantly correlated with percentage of sessions
attended nor did subjects with higher cluster B scores have a better outcome with either
specific treatment. These results suggest that further investigation of alternative treatments is
warranted with high cluster B individuals to determine if treatment effectiveness can be im-
proved. 0 1993 by john Wiley & Sons, lnc.

Relatively few studies have evaluated predictors of outcome in the treatment of bulimia
nervosa. Wilson, Rossiter, Kleifield, and Lindholm (1986) reported that nonresponders
to cognitive-behavioral treatment had significantly lower self-reported past weights than
treatment responders. Similarly, Agras, Dorian, Kirkley, Arnow, and Bachman (1987)
found that in bulimics treated with imipramine, those with lower reported body mass
indices (BMIs) did less well than those with higher BMIs. Fairburn, Kirk, OConnor,
Anastasiades, and Cooper (1987), found that self-esteem, as measured by the Rosen-
berg Self-Esteem Scale (Rosenberg, 1965), was a significant predictor of treatment out-

The authors are affiliated with The Department of Psychiatry, and Laboratory for The Study of Behavioral Medi-
cine, Stanford University School of Medicine. Requests for reprints should be addressed to W Stewart Agros, Stan-
ford University School of Medicine, TD-209, Laboratory for the Study of Behavioral Medicine, Stanford, CA 94305

international journal of €ating Disorders, Vol. 13, No. 4, 349-357 (1993)

0 1993 by John Wiley & Sons, Inc. CCC 0276-03478/93/040349-09
350 Rossiter et al.

come in a study comparing cognitive-behavioral with short-term focal psychotherapy

in bulimia nervosa. These results were not replicated by Garner et al. (1990) in a short-
term psychotherapy trial with bulimia nervosa patients. However, subjects with poor
outcome had significantly higher pretreatment scores on binge frequency, the ineffec-
tiveness scale of the Eating Disorders Inventory, and a trend toward higher scores on
the Borderline Syndrome Index ( p < .06). In a recently published uncontrolled treat-
ment study, Johnson, Tobin, and Dennis (1990) found that 62% of bulimia nervosa pa-
tients with borderline personality disorder (BPD) compared with only 21% of
nonborderline bulimic subjects continued to meet DSM-111-R criteria (American Psychi-
atric Association [APA], 1987) for bulimia nervosa at the end of 1 year of treatment.
Almost 90% of nonborderline subjects compared with 58% of the borderline subjects
achieved significant improvement in bulimic symptoms in 1 year of treatment.
The two latter studies reflect clinical observations suggesting that among patients with
bulimia nervosa, those with concomitant personality disorder diagnoses are the most
challenging cases with the least favorable outcomes (Johnson, Tobin, & Enright, 1989).
BPD appears to coexist in a large number of bulimic patients with prevalence rates rang-
ing from 25% to 48% across the majority of studies (Cooper et al., 1988; Gartner, Mar-
cus, Halmi, & Loranger, 1989; Gwirtsman, Roy-Byrne, Yager, & Gerner, 1983; Johnson
et al., 1989; Levin & Hyler, 1986; Sansone, Seuferer, Fine, & Bovenzi, 1989; Schmidt &
Telch, 1989; Wonderlich, Swift, Slotnick, & Goodman, 1990; Yager, Landsverk, Edet-
stein, & Hyler, 1989; Zanarini et al., 1990). The only dissenting study was by Pope,
Frankenburg, Hudson, Jonas, & Yergelun-Todd (1987) in which only 1.9% of bulimia
nervosa patients met criteria for BPD according to modified strict criteria on the Diag-
nostic Interview for Borderlines (DIB). The majority of studies, however, suggest a high
prevalence of BPD among bulimia nervosa patients and even in the Pope et al. (1987)
study there was a 25% prevalence of BPD if the usual DIB criteria were used. In addi-
tion, the prevalence rates of any Axis I1 diagnosis range from 46-66% of bulimia ner-
vosa patients (Cooper et al., 1988; Gartner et al., 1989; Gwirtsman et al., 1983; Johnson
et al., 1989; Levin & Hyler, 1986; Sansone et al., 1989; Schmidt & Telch, 1989; Wonder-
lich et al., 1990; Yager et al., 1989; Yates, Sieleni, & Bowers, 1989; Zanarini et al., 1990).
Table 1 shows the prevalence rates of BPD and other Axis I1 diagnoses in the published
studies to date. From the literature it is clear that personality disorders coexist in bu-
limia nervosa patients in a substantial number of instances and that many of these pa-
tients have borderline personality characteristics if not the full BPD complex.
Although clinical observation suggests that personality disorders are indicators of
poor prognosis, few empirical studies with the exception of the trend noted by Garner
et al. (1990), and the results of Johnson et al. (1990) have demonstrated this to be true
in bulimia nervosa patients.
In the present study we tested whether several factors of theoretical importance in-
cluding degree of dietary restraint, self-esteem, depression, pretreatment purge fre-
quency, and history of anorexia nervosa would predict treatment outcome in bulimia
nervosa both immediately after and 1year posttreatment. In addition we tested whether
the presence of Axis I1 characteristics in the DSM-111-R (APA, 1987) cluster B spectrum
predicted poor outcome and was a better predictor than BPD alone. Our clinical im-
pression is that bulimic patients may have histrionic, antisocial, borderline, and narcis-
sistic features without clearly meeting diagnostic criteria for any one specific personality
disorder and that the presence of features from any of these diagnoses may be impor-
tant predictors of treatment outcome in bulimia nervosa. As noted in DSM-111-R (APA,
1987) and supported in a study by Hyler et al. (1990), diagnosing a single personality
Cluster B Personality 351

Table 1. Prevalence rates of BPD a n d other personality disorders (I’D) i n published studies
Authors Instrument BPD Any PD

Cooper et al. (1988) BSI + clinician .33 -

Gartner, Marcus, Halmi, PDE .38 .63
& Loranger (1989)
Gwirtsman, Roy-Byrne, clinician .44 .56
Yager, & Gerner (1983)
Johnson, Tobin, & BSI .46 .66
Enright (1989)
Levin & Hyler (1986) PDQ + clinician .25 .46
Pope, Frankenburg, DIB .02/.25* -
Hudson, Jonas, &
Yergelun-Todd (1987)
Sansone, Seuferer, Fine, DIB + MCMI .39
& Bovenzi (1989)
Schmidt & Telch (1989) PDE .35 .61
Wonderlich, Swift, SCID I1 +MCMI .19 .69
Slotnick, & Goodman
(1990)
Yager, Landsverk, PDQ .47 .75
Edelstein, & Hyler
(1989)
Yates, Sieleni, & Bowers - .47
PDQ
(1989)
Zanarini et al. (1990) DIPD .35 .50
Notes: “Pope et al. (1987) study reports two prevalence rates, the first being for extremely stringent criteria
for borderline personality disorder (BPD); BSI = Borderline Syndrome Index; DIB = Diagnostic Interview for
Borderlines; DIPD = diagnostic interview for personality disorders; MCMI = Millon clinical multiaxial inven-
tory; PDE = Personality Disorder Examination; PDQ = personality diagnostic questionnaire; SCID I1 = struc-
tured clinical interview for DSM IIIR personality disorders.

disorder is frequently difficult because people exhibit traits that are not limited to a sin-
gle personality disorder. We grouped together the features of cluster B into a single
composite score, and tested this as a predictor of treatment outcome. We hypothesized
that if personality characteristics affected outcome then the cluster B score would be a
better predictor of outcome than borderline characteristics alone.

METHOD

Participants
Participants in this investigation were 71 females between the ages of 18 and 65 years
who met DSM-111-R (APA, 1987) criteria for bulimia nervosa and were the participants
in a randomized study comparing the efficacy of desipramine, cognitive-behavioral ther-
apy, or their combination (Agras et al., 1992). Exclusion criteria included the presence
of: (1)a concurrent medical condition that would preclude the use of antidepressants
including evidence of conduction disturbance on electrocardiography; (2) current ano-
rexia nervosa; (3) current drug or alcohol abuse; (4)current psychosis; and (5) current
depression with suicidal risk of sufficient severity to preclude the use of antidepres-
sants on an outpatient basis. In the above study both the cognitive-behavioral and com-
bined treatments were significantly superior to medication alone and not different from
each other at the posttreatment assessment. The combined group had reduced purging
by 80.1% with 64% of subjects abstinent, the cognitive-behavioral group had reduced it
352 Rossiter et al.

by 82.6% with 48% abstinent, and the medication group had reduced it by 42.7% with
33% of subjects abstinent from purging. At 1-year follow-up the abstinence rates were:
53%, 38%, and 27% for the combined, cognitive-behavioral, and medication treatments,
respectively.

Sample Description
*
The participants were aged 29.6 8.9 years. Thirty-two percent were married, 56.3%
were single, and the remainder were either divorced (8.5%) or separated (2.8%). Fifty-
six percent had completed college, 36.7% had completed some college, and the remain-
der had either completed high school (5.6%) or some high school (1.4%);83% were
employed at the time of the study. Binge eating had begun at 19.9 5 5.7 years of age
*
and purging a few months later at 20.7 5.9 years of age. The participants reported an
ideal weight of 53.7 2 5.8 kg and their weight as measured at baseline was 59.9 -+ 9.1
*
kg. Frequency of purging at pretreatment was 9.2 6.9 times per week and binge eat-
ing 7.5 & 5.7 times per week. Twenty-two percent had been diagnosed as having an-
orexia nervosa in the past.

Procedures and Measures

All subjects were interviewed by Ph.D. level psychologists experienced in working
with this population. Their DSM-111-R (APA, 1987) Axis I diagnoses were determined
using a semistructured clinical interview. Purge frequency at baseline was carefully as-
sessed using the calendar recall method. In addition, history of anorexia nervosa was
carefully assessed during the clinical interview.
Personality disorder and characteristics were assessed using the Personality Disorder
Examination (PDE; Loranger, Susman, Oldham, & Russakoff, 1987). The PDE, a clini-
cian administered instrument of demonstrated reliability, assesses the presence of per-
sonality disorders and traits. Published interrater reliability data based on joint
interviews with 60 nonpsychotic inpatients revealed Kappas of .70 (antisocial), .77 (his-
trionic), .80 (schizotypal), .88 (compulsive), and .96 (borderline). It contains 328 items
and takes approximately 2 hours for a clinician to administer. Subjects answer ques-
tions such as: Is it hard for you to control your anger?; Are you much more of a per-
fectionist than most people?; Have you ever deliberately cut yourself ?; Has anyone ever
told you that all you care about is yourself? Because binge eating is a feature of both
BPD and bulimia nervosa the question on the PDE concerning binge eating was de-
leted.
In addition subjects completed the following questionnaires that were computer ad-
ministered and scored: (1)the Beck Depression Inventory (BDI; Beck, Ward, Mendel-
son, Mock, & Erbaugh, 1961), a 21-item inventory measuring severity of depression; (2)
the Rosenberg Self-Esteem scale (Rosenberg, 1965), a 10-item questionnaire measuring
level of self-esteem; and (3) the Stunkard and Messick (1985) Three-Factor Eating Ques-
tionnaire, a measure of dietary restraint, hunger, and disinhibition.

Planned Statistical Analyses

A multiple logistic regression was performed using the following independent vari-
ables to predict abstinence from vomiting at the 16-week and 1-year follow-up assess-
ments: (1)pretreatment score on the BDI; (2) pretreatment score on the Rosenberg Self-
Esteem scale; (3) pretreatment score on the Stunkard and Messick (1985) Three-Factor
Cluster B Personality 353

Eating Questionnaire, cognitive restraint factor; (4) purge frequency at baseline; (5) his-
tory of anorexia nervosa; and (6) the PDE cluster B score. The PDE cluster B score was
derived by converting the individual raw scores on the borderline, narcissistic, histri-
onic, and antisocial subscales of the PDE to standard z scores. This was done to com-
pensate for the unequal number of items on the four factors. These four standard scores
were then summed to arrive at the PDE cluster B score. The Bonferroni correction was
applied to interpret significance levels on the multiple logistic regression to compen-
sate for the large number of independent variables. Thus, results were considered sta-
tistically significant at the .008 level or beyond.
The multiple logistic regression was then repeated using the standard score of the bor-
derline scale of the PDE as opposed to the entire cluster B score to see if combining these
factors improved the predictive ability over and above that of the borderline factor alone.
Finally, the prevalence of each type of personality disorder diagnosis identified using
the PDE was calculated as well as the prevalence of at least one Axis I1 diagnosis among
subjects.

RESULTS
The prevalence of each personality disorder diagnosis is presented in Table 2. As seen
in Table 2 nearly 43% of subjects met DSM-111-R (APA, 1987) criteria for at least one
personality disorder. The most prevalent diagnosis was borderline personality, with
21.4% of subjects meeting criteria for this diagnosis. In addition, 28.5% of participants
met criteria for histrionic, narcissistic, and antisocial personality disorders.
The multiple logistic regression revealed that the only significant predictor of out-
come at 16 weeks was the cluster B score of the PDE, x2 = 9.51, p < .002. The odds
ratio was .67 which means that for the first unit increase on the PDE cluster B score
(indicating increased pathology) the odds of successful outcome (i.e., abstinence from
purging) decreased by .67. For the second unit of increase the odds of successful out-
come decreased by an additional .67 squared or .45. The mean PDE cluster B score was
0 (these were summed standard scores) with a standard deviation of 3.2. The minimum
score was -5.86 and the maximum was 8.04. None of the other independent variables,
that is, pretreatment frequency of purging, history of anorexia nervosa, Stunkard and
Messick Dietary Restraint, BDI, or Rosenberg Self-Esteem scales significantly predicted
treatment outcome.

Table 2. Percentage of subjects with personality disorders

Cluster DSM-111-R Diagnosis N % of Subjects

A Paranoid 2 2.9
Schizoid 0 0.00
Schizotypal 1 1.4
B Borderline 15 21.4
Histrionic 5 7.1
Narcissistic 7 10.0
Antisocial 8 11.4
C Compulsive 7 10.0
Dependent 10 14.3
Avoidant 10 14.3
Passive-aggressive 1 1.4
At least one Axis I1 diagnosis 30 42.9
354 Rossiter et al.

Pearson product-moment correlations between the independent variables revealed

significant correlations between the BDI and cluster B score, R2 = .52, p < .0001; the
Rosenberg Self-Esteem scale and cluster B score, R2 = .40,m p < .001; and the BDI and
Rosenberg Self-Esteem scale, R2 = .55, p < .0001. No other significant correlations were
found between cluster B score and any other independent variable. Spearman rank cor-
relation between history of anorexia nervosa and cluster B score was not significant.
The second multiple logistic regression that substituted the borderline standard score
for the PDE cluster B score was not significant once the Bonferroni correction was used
although it approached significance ( p < .03). At l-year posttreatment there was still a
trend toward high cluster B score predicting poor outcome, x2 = 3.43, p < .06. No other
factor predicted outcome at l-year follow-up.

Post-hoc Analyses
A post-hoc analysis was performed to determine whether any of the other personal-
ity clusters, that is, cluster A (dependent, avoidant, passive-aggressive, and obsessive
compulsive) and cluster C (paranoid, schizoid, and schizotypal) either alone or in com-
bination with each other or cluster B, significantly enhanced the prediction of treatment
outcome using the same logistic regression strategy. None of the other clusters or com-
binations of clusters significantly enhanced prediction of abstinence at 16 weeks over
and above the predictive ability of cluster B alone.
A second post-hoc analysis of covariance was performed to determine whether sub-
jects with higher cluster B scores tended to have differential outcomes in either the
cognitive-behavioral or medication treatment conditions. This revealed no significant
advantage for high cluster B subjects in either treatment.
To examine whether cooperation with treatment may have affected the outcome dif-
ferentially for those with high cluster B scores, a third post-hoc analysis was performed.
This analysis revealed that there was no significant correlation between cluster B score
and percentage of sessions attended.

DISCUSSION

The prevalence rates of BPD and any Axis I1 diagnoses found in this study were com-
parable to those of other studies reported in the literature. Our prevalence rates most
closely resembled those of Levin and Hyler (1986) with some 22% of subjects meeting
criteria for BPD and 40% meeting criteria for at least one Axis I1 diagnosis.
The results of this study support clinical observations suggesting that patients with a
higher level of personality disturbance have a poorer outcome in the treatment of bu-
limia nervosa. Of note was the superiority in predicting outcome using a cluster score
rather than relying on a single diagnostic category, that is, BPD per se. When we used
only the BPD score, our results replicated those of Garner et al. (1990) in that they only
approached significant predictive ability. However, the cluster B score was highly sig-
nificant in predicting outcome at 16 weeks. Of particular interest was the specific pre-
dictive ability of cluster B relative to the other personality disorder clusters. Although a
large percentage of subjects received high scores on cluster C (avoidant, dependent,
compulsive, and passive-aggressive), this did not appear to be related to poor treat-
ment outcome. Thus, there appears to be something unique about those characteristics
in the impulse controlldramatic spectrum that lead to poorer outcome in the cognitive-
Cluster B Personality 355

behavioral or pharmacological treatment of bulimia nervosa. Although the 1-year

follow-up data revealed only a trend toward high cluster B scores predicting poorer out-
come it should be noted that 14 subjects had dropped out at 1-year follow-up thereby
reducing the power of the analysis.
One possible explanation of these results is that bulimic subjects who are closer to
normative restrained eaters respond well to a cognitive-behavioral treatment program
aimed at normalizing eating patterns, decreasing unrealistic dieting practices, and chal-
lenging overvalued ideals of slenderness. They also respond better to a pharmacologi-
cal intervention. On the other hand, bulimic subjects with more affective instability and
impulsiveness may require an additional form of treatment. Rossiter, Wilson, and Gold-
stein (1989) found that bulimic subjects differed from their nonbulimic restrained peers
not on degree of dietary restraint or preoccupation with slenderness, but on measures
of disinhibition and affective instability. If one considers bulimia nervosa patients as
existing on a continuum with those who are unrealistically restrained in their eating
but relatively affectively stable on one end, and those who are more affectively unsta-
ble, impulsive, and disinhibited (i.e., high cluster B) at the other end, then one might
hypothesize that different approaches to treatment for the two extremes may be war-
ranted. In addition, those with a higher level of cluster B psychopathology may require
more frequent sessions as suggested by Johnson et al. (1990) who found that success-
fully treated bulimia nervosa patients with BPD had received twice the number of ses-
sions as those who were unsuccessfully treated.
The superiority of the cluster B score confirms the DSM-111-R suggestion that people
exhibit traits not limited to a single personality disorder and that looking at broader
longstanding behavior patterns may be preferable to making specific personality disor-
der diagnoses.
Of interest was the absence of significant findings for history of anorexia nervosa,
pretreatment depression, self-esteem, dietary restraint, and frequency of purging in pre-
dicting treatment outcome given that these have been found to be important predictors
in previous studies. One interpretation of these results is that once cluster B personal-
ity characteristics are taken into account these factors no longer have predictive value.
The significant correlations between the BDI, Rosenberg Self-Esteem scale, and cluster
B score support this interpretation.
One possibility that we tested post-hoc was whether subjects with higher cluster B
scores would have better outcome with either of the treatments because this could have
important practical implications. Our results showed that subjects with higher cluster B
scores had poorer outcome regardless of treatment.
Another possibility that we tested post-hoc was whether poorer outcome is observed
in subjects with higher cluster B scores because they do not receive an equivalent
amount of treatment by attending fewer treatment sessions. This hypothesis was not
borne out by our results. Thus, it appears that both medication and cognitive-behavioral
treatment are simply less effective with these patients.
What then are the clinical implications of these findings? They suggest that the poor
outcome of patients with more severe personality pathology is not due to insufficient
amounts of either the cognitive-behavioral or pharmacological treatment and that more
effort needs to be directed toward developing more effective treatment methods for this
subgroup. Preferable treatment for patients with the longstanding behavioral patterns
characteristic of cluster B personality disorders may require a broader, longer-term, and
more frequent treatment focused on inter and intrapersonal problems. Such programs
have been suggested by Linehan (1987a, 1987b, 1987c) and Turner (1989) for the treat-
356 Rossiter et al.

ment of BPD and by Johnson, Connors, and Tobin (1987) in the treatment of bulimia
nervosa. This broader and more intensive focus of treatment may lead to improvement
in bulimic symptoms by helping such patients control the intense affective instability
and longstanding interpersonal difficulties that are so prevalent in these patients.
This research was supported by NIMH grant 38637 to W. Stewart Agras.

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