Abstract
Background: Previous research suggests a high prevalence of eating disorders and personality disorders amongst women in secure care. Objectives: The present study sought to extend this research by establishing a prevalence estimate of anorexia nervosa and bulimia nervosa (using DSM-IV criteria), as well as subclinical disordered eating styles amongst all women patients in a maximum security hospital. A further purpose of the study was to investigate the relationship between personality characteristics such as self-esteem and perfectionism with eating disorder symptomatology and to examine the overlap of obsessive-compulsive personality disorder and borderline personality disorder with eating disorder symptomatology, as both of these links were suggested in the literature. Design: A correlational design was used. Method: From the total of 83 women patients in the Special Hospital, 50 (60%) were screened for anorexia nervosa, bulimia nervosa, borderline personality disorder and obsessive-compulsive disorder, using the Structured Clinical Interview for DSM-IV (SCID). Ratings of self-esteem and perfectionism were obtained using the Culture-Free Self-Esteem Inventory (CFSEI) and the Setting Conditions for Anorexia Nervosa Scale (SCANS). Information on the presence of eating disorder symptomatology and personality disorder symptomatology was obtained from the clinical files for those women (N = 33) who were unable to participate in the interview. Results: The results provided a conservative overall prevalence estimate of 18.1% of diagnosable eating disorders currently present amongst women in the maximum security hospital (combined data from interviewed women and case note information). However, specific data on currently diagnosable eating disorders from the interviewed sample (24%) and data on currently subclinical disordered eating styles (33.7%) from the combined sample provided estimates which are similar to those obtained in other forensic settings for women patients. Bulimia nervosa was significantly more common than anorexia nervosa. Regarding the examined personality characteristics, significant negative correlations were found between self-esteem and bulimia nervosa, as well as between perfectionism and bulimia nervosa. No significant correlations were obtained for anorexia nervosa. With respect to the examined personality disorders, a significant positive correlation was found between borderline. personality disorder and bulimia nervosa, but none was found between anorexia nervosa and obsessive-compulsive personality disorder. The obtained correlation between borderline personality disorder and bulimia nervosa resulted partly from an overlap of diagnostic symptoms and thus highlighted an association between the two conditions with regard to symptoms including affective instability and general impulsivity. Conclusions: The results suggested that eating disorders (past, present and at subclinical level) are under-detected in women in this setting, confirming clinical impressions and previous research. This highlighted an important area of pathology that characterises some of the problems experienced by women in maximum security care. The nature and degree of personality characteristics associated with the presenting eating disorders was partly different to that obtained from community studies, emphasising that general findings are not simply transferable to extraordinary populations, such as women in conditions of maximum security. Thus, the functional analysis of eating disorders, suggesting these personality characteristics to constitute the setting conditions for eating disorders, received only limited support when applied in this setting. The observed comorbidity of bulimia nervosa and borderline personality disorder, independent of its theoretical interpretation, highlighted the shared variance between symptoms relating to affective instability, often underlying the impulsive behaviours seen in both conditions. Thus, within the context of previous research, it appears that once triggered, these impulsive behaviours characterising bulimia nervosa as well as borderline personality disorder might serve as a maladaptive psychological coping mechanism. This mechanism often occurs in relation to trauma and might facilitate an escape from conscious awareness when an individual is confronted with negative emotional states.