Cooccurrence de troubles de la personnalité et d’accès hyperphagiques : enjeux cliniques et pistes d’intervention psychothérapeutique

Les troubles de la personnalité (TP) sont associés à de nombreuses comorbidités physiques et psychologiques, l’une d’entre elles étant la présence récurrente d’accès hyperphagiques (AH). En effet, la prévalence des AH chez les personnes ayant un TP serait jusqu’à 15 fois plus élevée que dans la population générale. Chez les personnes présentant un TP, une fréquence et une sévérité plus importantes des AH sont observées. Le présent article vise à exposer l’état des connaissances actuelles quant à la cooccurrence de TP et d’AH ainsi qu’à explorer des pistes d’intervention psychothérapeutique prometteuses pouvant contribuer à améliorer la qualité de vie chez cette patientèle. La cooccurrence élevée entre TP et AH pourrait s’expliquer notamment par les nombreuses caractéristiques communes partagées par les deux problématiques, telles que l’impulsivité, les problèmes de régulation émotionnelle et les difficultés variées dans les relations interpersonnelles. Néanmoins, les TP et les AH sont typiquement traités séparément avec des approches distinctes. Des taux d’efficacité moindre des psychothérapies habituelles pour les AH sont par ailleurs documentés lorsque la personne présente également un TP. Toutefois, un nombre croissant d’approches thérapeutiques développées à l’origine pour les troubles de la personnalité ont été adaptées aux problématiques alimentaires. La thérapie des schémas serait ainsi un traitement prometteur, alors que la thérapie basée sur la mentalisation et la thérapie dialectique-comportementale, qui offrent des adaptations spécifiques aux AH, sont maintenant dûment validées et leur efficacité a été appuyée empiriquement. En présence d’une comorbidité TP-AH, il apparaît crucial de miser sur les traitements permettant d’aborder les difficultés communes aux deux conditions. Heureusement, de plus en plus d’options sont disponibles puisque certaines psychothérapies développées pour traiter les TP offrent maintenant des adaptations spécifiques et manualisées pour les AH. Personality disorders (PDs) are often associated with numerous physical and psychological comorbidities, one of which is the recurrent presence of binge eating (BE). While the causes of BE are multiple and complex, well-known triggers of BE include the so-called binge-restrict cycle and the presence of a high negative emotional load (e.g. sadness, anxiety, loneliness), which may sometimes lead to a dissociative state during the BE episode. The prevalence of BE in people with PDs is reported to be up to 15 times greater than in community samples. The presence of PDs is also associated with a greater frequency and severity of BE, as well as a higher preoccupation towards weight and body appearance. The aim of this article is to present the current state of knowledge regarding the co-occurrence of PDs and BE, and to explore promising avenues for psychotherapies that could help improve quality of life with this clientele. The high degree of co-occurrence between PDs and BE may be due to the many characteristics shared by both, such as greater impulsivity, emotional regulation problems, and various difficulties in interpersonal relationships. They are also both associated with a traumatic history (e.g., abuse, neglect, bullying) that transforms into insecure attachment styles in adulthood. The PDs most frequently observed in people with recurrent BE are, in order of importance, avoidant PD, borderline PD and obsessive-compulsive PD. However, PDs and BE are typically treated separately by distinct approaches. Unfortunately, the usual treatments for BE appear less effective when the person also has a PD, leading to more previous treatments, as well as greater residual eating pathology and negative affect at the end of therapy. Instead, it seems preferable to turn to treatments that aim to address the common features of both BE and PDs (i.e. impulsivity, emotional regulation, interpersonal relationships). Fortunately, a growing number of psychotherapies originally developed for PDs (aimed precisely at working those common difficulties) have now been adapted to address eating disorders as well. Schema therapy appears to be a promising treatment, but the small number of studies necessitates cautious interpretation of the results. Mentalization-based therapy (MBT), an evidence-based treatment for PDs, also offers a recent manualised adaptation for eating disorders (MBT-ED) which makes it more easily applicable to treat BE. Dialectical-behavioural therapy (DBT) is well validated and empirically supported, even offering two specific adaptations for BE. The first adaptation, the Stanford Model, was created specifically to treat cases of bulimia and BE. It views BE as an ineffective and inappropriate way to regulate emotions and aims to replace it with less harmful strategies. The second adaptation, the Multidiagnostic Complex Eating Disorders for DBT Model, was designed to treat complex cases of eating disorders with comorbidities requiring additional care. This adaptation combines the principles of cognitive-behavioural therapy to treat eating disorder behaviours and the principles of original DBT to manage risk behaviours and improve emotional regulation skills. Both adaptations have been associated with multiples benefits (e.g. reduction of BE and hospitalizations, improved emotional regulation). In the presence of a PD and BE comorbidity, it seems crucial to focus on treatments that address the difficulties common to both conditions. Fortunately, more and more options are available, as some psychotherapies originally developed to treat PDs now offer specific and manualised adaptations for BE.

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