Multi-impulsive Eating Disorders:
another slant on
Borderline Personality
Jane Morris & Vicky Hay
 What
is the relationship between
eating disorders and personality
 Why does it matter?
 What is it like to experience ‘multiimpulsive eating disorder?
 How can we help?
What is the relationship between
disorders and personality?
 Personality
patterns may make people more
vulnerable to a particular range of illnesses
– ‘type A’ personality and heart disease,
perfectionists and anxiety disorders etc
 Particular disorders may shape personality –
people with chronic illnesses often become
carers, children with dyslexia may develop
rule-breaking or highly creative
What is the relationship between
eating disorders and personality?
Do particular personality patterns predipose
a person to develop an ED?
 Does the experience of suffering from an
ED influence the development of
 Do particular personality structures
determine the nature of the eating disorder
experienced by the sufferer?
Eating disorders ?
Anorexia nervosa (since 15th century)
Low weight obsessively achieved because of fear
of fatness. 2 subtypes AN-R and AN-BN
Bulimia nervosa (since 1970s –
Russell et al) Attempted weight loss by
starvation leads to vicious cycle of
restriction/binge/purge at normal weight
Binge eating disorder (since 1980s
and 1990s) Binges and periods of attempted
restriction but without other compensatory
behaviours – often overweight
Co-morbidity with eating disorders
Anorexia often found in individuals – and
families – who also show OCD, anxiety
disorders, ASD
 Bulimia often seen with depression,
substance abuse
 So-called ‘axis II disorders’ also tend to
cluster in similar ways – obsessivecompulsive PD with AN, impulsive PD
with Bulimic type illnesses
DSM-IV personality disorders
 Cluster
A – ‘odd’ eg schizotypal
B – flamboyant,
histrionic, narcissistic,
Cluster C – avoidant, rigid,
DSM–IV (APA, 1994
Diagnostic criteria for borderline personality disorder
At least five of:
 Intense and unstable personal relationships
 Frantic efforts to avoid real or imagined abandonment
 Identity disturbance or problems with sense of self
 Impulsivity that is potentially self-damaging
 Recurrent suicidal or parasuicidal behaviour
 Affective instability
 Chronic feelings of emptiness
 Inappropriate intense or uncontrollable anger
 Transient stress-related paranoid ideation or severe
dissociative symptoms
Research on Eating Disorders
and personality disorders:
1988 Powers et al 77% BN patients
 1989 Garner et al 61% BN patients
 1990 Schmidt & Telch 43% BN patients
 1994 Steiger et al 28% BN patients
...met diagnostic criteria for at least one
personality disorder (DSM IV, APA 1994)
Research on Eating Disorders
and personality disorders:
Braun et al, 1994 found that
 69% all ED patients had at least one PD
 Of those with bulimic subtypes, 31% had a
Cluster B Personality Disorder – mostly
borderline type
 NONE of the purely restricting anorexic patients
had a cluster B personality Disorder
 Cluster C personality disorders spread evenly
across all types of ED
Research on Eating Disorders
and personality disorders:
 1992
Hertzog (210 patients) found that
the commonest PD to be associated with
an ED is borderline type
 2000 Matsunya studied patients
recovered from EDs. 26% had at least
one PD. Cluster B strongly associated
with bulimic subtypes
Two extremes of eating disorders and
broadly two ‘groups’ in our service
1- ‘STABILITY’ Those who relieve anxiety
and guilt by means of avoidance and rituals
of sameness (obsessive compulsive
behaviours). Strong attachment to the
disorder – other people seen as obstacles to or
protectors of the disorder
2 - ‘INSTABILITY’Those who relieve
intolerable emotions – anxiety, boredom,
shame – by means of ‘acting out’ behaviours
often involving risk-taking (impulsive or
borderline). Strong but insecure attachments
to other people – disorder serves to
communicate perceived needs, albeit
(Lacey, 1993)
Bulimia nervosa + at least 3 of the
Heroin, LSD, amphetamines,
street tranquillisers
 Abuse of alcohol
 Stealing/ shop lifting
 self harm – Overdoses, selfcutting or burning
And frequently ‘promiscuous sexual
behaviours’, inability to be truthful
Why does this matter?
Attempts to work therapeutically with people with
EDs depend crucially on development of a
respectful therapeutic relationship
Understanding attachment styles and personality
profiles is helpful in formulating reasonable
expectations of people in treatment
Those working to help people with personality
disorders need to be aware of the effects of
starvation and the results of other eating
disordered behaviours on the capacity to learn
Why does this matter?
People engaging in weight-losing
behaviours display many more behaviours
than food restriction
 Paradoxically, whilst these attempts to
control weight are attempts at control and
stability, in fact they lead to increasing
amplifications of instability
 and make it harder and harder for people to
learn ordinary skills for coping with life or
attracting help from other people
Chewing & spitting out
Medication abuse - Appetite suppressants – including gum,
cigarettes - alternative, OTC & www medications – laxatives,
ipecac, pain killers to allow exercise despite damage
Overexercise – often secret, obsessive housework
Overactivity – ‘fidgetting, twitching, never sitting down,
fetching one item at a time
Cooling – inadequate dress, open windows etc
‘Body-checking’– both when alone and in terms of
comparisons with others - and body image avoidance
Spoiling or messing of food, bizarre combinations
Cruising ‘pro-ana’ websites/emailing fellow sufferers
Effects of eating disorders on the brain
Hypoglycemia – chronic ‘restrictors’ show
adaptation – not so for those who bingepurge, where rapid swings in glu levels act
like drug highs and withdrawal
 Hypoglycemia mimics symptoms of anxiety,
and loss of K+ and Mg++ makes people even
more nervous and twitchy
 Starvation makes us aggressive – difference
between hunger and anger often hard to
discriminate – and utterly preoccupied with
Eating disorders and self harm
DSH as primary? For some patients self-starving is a
form of self-harm and may replace the ‘need’ for cutting,
overdosing etc. Body image gratification may then
ensue and become a perpetuating factor
ED as primary? Others resort to these other forms of
self-harm for the first time if their anorexia is ‘taken away
from them’ or if they ‘break the rules’ themselves. For
some patients this is ‘neutralising’ behaviour, whilst for
others it is a communication of protest
Some patients remain natural restrictors all their lives,
unable to achieve any peace of mind unless they take
constant control But for the majority, with age and the
passage of time, ‘graduation’ is from restricting anorexia
to bulimic type anorexia, to normal weight bulimia and
also then to other forms of self-harm
Auto/biographical literature
 Alice
in the Looking Glass
 The Best Little Girl in the World
 Stick Figure
 My Hungry Hell
 Wasted
 Wounded: Fighting my Demons
What does it feel like to
experience a multi-impulsive
eating disorder?
Vicky Hay, author of
‘Wounded: Fighting my Demons’
What might be helpful?
CBT? Formulates binge-purge episodes in
terms of a vicious cycle of restraint > binge
>purge +further restraint> bigger binge>
purge etc etc
 IPT-BN? Formulates binge-purge episodes
in terms of failure to cope with
interpersonal incidents
 DBT? Formulates DSH and eating
disordered behaviour in terms of failure of
emotional regulation and distress tolerance
What can help?
Importance of  Physiological stability
 intrapsychic and
 interpersonal aspects
 and of the therapeutic relationship
CBT Beck, 1979, Fairburn, Waller
Links physical, emotional and cognitive aspects of
 Psychoeducation – what is going wrong at present
and what will be expected during the course of
 Establishing of stable pattern of 3 meals & 3
snacks daily, weekly weight recorded on graph
 Getting rid of binge-purge behaviours and using
problem solving, thought challenging and other
cognitive techniques to cope with emotional and
interpersonal difficulties
But 50% patients not helped by CBT-BN alone
IPT Klerman & Weissman, Fairburn
Fairburn’s model of IPT actually turns its
back on the eating disorder behaviours!
 Interpersonal inventory
 Grief, conflict and disputes, transitions
 Identifying and tolerating emotion and
 Role play and creative development of
interpersonal skills for getting the best out
of relationships and protecting self from
destructive patterns of relating
 Coping with endings and goodbyes
DBT Linnehan, 1993, Palmer
 Intense,
irreverent therapeutic relationship,
exploitation of the attachment
 Individual and group therapies in parallel
 Focus on not unwittingly reinforcing selfdestructive behaviour
 Skills: mindfulness, distress tolerance,
emotional regulation, interpersonal skills
 Chain analysis of painful incidents
DBT for eating disorders
Palmer et al 2003 (n=7) fewer days in
hospital, reduced DSH ‘eatingness’
 Maltheus, Allen, Reid & Linehan 2008
(n=8) BN and BED
 Stanford model of DBT for BN (1RCT) &
BED (2RCTs) – similar results to CBT and
IPT trials
- Mindful vs mindless eating
- Urge surfing vs capitulation
- ‘apparently irrelevent behaviours’
Sometimes things don't go, after all,
from bad to worse. Some years, muscadel
faces down frost; green thrives; the crops don't fail.
Sometimes a man aims high, and all goes well.
A people sometimes will step back from war,
elect an honest man, decide they care
enough, that they can't leave some stranger poor.
Some men become what they were born for.
Sometimes our best intentions do not go
amiss; sometimes we do as we meant to.
The sun will sometimes melt a field of sorrow
that seemed hard frozen; may it happen for you.
Sheenagh Pugh

Multi-impulsive Eating Disorders