Sociodemographic characteristics.

Sociodemographic characteristics were collected: age, sex, marital status, educational level, and employment status.

Disorder-related characteristics.

Damage. Patients were asked about the extent to which their disorder had caused negative consequences to their life, using a 6-point Likert-type scale. Three different areas were explored: health, work/school and relationships.

Disorder course. The age of initiation of the problematic behavior, the age at which the behavior became problematic, and the age at which the patient first pursued treatment were collected. The patients were asked whether they were able to completely stop the problematic behavior for at least one month, and if so, the maximum abstinence duration was collected.

Addiction severity. Goodman’s addictive disorder criteria were used to assess the addiction’s severity for all of the BAs and the EDs [8]. The use of Goodman’s criteria in EDs have been demonstrated as relevant in previous research [5], except for the restrictive form of anorexia nervosa, for which Goodman’s criteria were considered to be inappropriate (difficulty identifying the beginning and the end of the behavior). In the present study, we used responses to item E as a dimensional score of the addiction’s severity, which can range from 0 to 9.

Psychiatric comorbidities.

The French version of the MINI 5.0 [21] was used to explore the main axis-I psychiatric disorders at T1 and T3: anxiety disorders, mood disorders (plus the current risk of suicide), addictive disorders and psychotic disorders.

The French version [35] of the Wender-Utah Rating Scale-Child (WURS-C) [26] was used to perform a retrospective diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in childhood and was supplemented by the French version [36] of the Adult ADHD Self-report Scale (ASRS-v1.1) [27], which screens for ADHD in adulthood.

Psychological characteristics.

Personality. The Temperament and Character Inventory (TCI-125) [37]was used to rapidly explore four temperament traits (novelty seeking, harm avoidance, reward dependence and persistence) and three character traits (self-directedness, cooperation and self-transcendence). We used the 125-item French version [38].

Impulsivity. The French version [39] of the Impulsivity Behavior Scale (UPPS) [29] was used to measure impulsivity. During the data collection, we moved to the UPPS-P French short version of the scale [30]. To standardize the results, we have reconstructed the four available scores of the new UPPS-P (“negative urgency,” (lack of) “premeditation,” (lack of) “perseverance” and “sensation seeking”) based on the initial UPPS for the first patients.

Self-esteem. The Rosenberg Self-Esteem Scale (RSES) [31] is a 10-item self-report questionnaire that explores the global self-esteem of a person. A validated French version of this scale was used for our study [40].

Locus of control. The French-Canadian version [41] of the Levenson’s questionnaire (IPAH) [32]was used to explore locus of control in three dimensions: internally, powerful others and chance.

Defense mechanisms. The Defense Style Questionnaire (DSQ) [33] explores the predominant defense style for each participant: mature, neurotic or immature. We used the French 40-items version [42].

Negative life events. We used a revised version of the French Life Events questionnaire (EVE) [34], which was previously used in another study on the EVALADD cohort [16]. The revised EVE questionnaire explores 6 areas (family, professional life, social life, marital and emotional life, health, other traumatic events) and allows to compute a total cumulative score of traumatic events by summing the intensity of trauma experienced for each of the 40 items.

Step 1: Identification of trajectories for each variable.

We focused only on variables that can evolve over time: (i) scores from the UPPS and the ASRS, the character dimensions of the TCI, and the intensity of damage for continuous variables and (ii) psychiatric comorbidities (MINI) for categorical variables.

For continuous variables, we used Growth Mixture Models (GMMs) through a structural equation modeling framework [44] to identify different patterns of change among a potentially heterogeneous population. For each variable, several models were tested with a varying number of different trajectories (1 to 4), various shape of each trajectory (quadratic, linear, constant), the application of a random effect on the intercept only or on the intercept and slope, and equal or different residuals’ variances. We then followed a backward procedure, going from the most complex model (quadratic shape, different residuals’ variances and random effect on intercept and slope) to the simplest. Step by step, we excluded the trajectories which were not statistically significant according to the Wald test (with type I error fixed at 0.05). We finally obtained a set of several models composed of 1 to 4 trajectories for each variable. To select the most appropriate model for each variable, we used 4 main criteria: the lowest Sample-Size Adjusted Bayesian Information Criteria (SABIC) [45], the sample size of the less represented trajectory of more than 4% of the total sample (n = 13); at least 8 out of 10 models that converged to consider a model to be stable [46] and clinical interpretability and relevance [47, 48]. Outcomes of GMMs are assignment probabilities, which represent the probabilities that a patient will belong to each trajectory composing the model (rather than the assignment of a patient to a unique trajectory). For example, with a model composed of 3 types of trajectories (trajectory A: constant, trajectory B: decreasing and trajectory C: increasing) for a variable X, a patient will be characterized by 3 probabilities of following either trajectory A, B or C. This procedure is particularly interesting for avoiding a loss of information when assigning a patient to a single trajectory while he may transit from one trajectory to another.

For categorical variables (only MINI diagnosis), because it was impossible to apply GMMs, we created a change indicator, making it possible to reflect changes over time. The change indicator was constructed as a categorical variable, which could take 4 different values depending on the 4 possible evolutions between the beginning (T1) and the end (T3) of the follow-up, i.e.: absent at T1 and T3, present only at T1, present only at T3 and present at T1 and T3.

Step 2: Classification of patients.

We used latent class analysis (LCA) to classify patients within the final typology. We applied the LCA to assignment probabilities obtained from GMMs and change indicators. We tested several models whose number of classes ranged from 2 to 7. To determine the best number of classes, we used the same 4 criteria as for the GMMs. We used assignment probabilities as outcomes for the LCA.

Descriptions of classes.

We used all of the variables collected, both those used in the trajectory analysis (evolving over time) and the others, to describe the classes. To compare each class to the total sample, we performed analyses of variance (ANOVAs) or non-parametric tests for continuous variables and chi-square or Fisher exact tests for categorical variables. The conventional 5% value was used for significance.

Patients with complex psychological functioning.

This class contained 92 patients (30%), and significantly emerged from the others, with the majority of the variables being significantly different from the entire sample. The sociodemographic characteristics and distribution of disorders did not differ from the entire sample.

This class displayed the highest rate of inability stopping the problematic behavior for at least one month (61%), largely over the other classes. The age of problematic behavior onset was lower (15 years), with no other difference in the problematic behavior course.

This class was characterized by a more severe symptomatology, with a higher addiction severity and a higher level of disorder-related damage in all domains. This high-severity profile was associated with multiple comorbidities (mood disorders, anxiety disorders, substance use disorders and ADHD) and numerous psychopathological personality traits (low self-esteem, high neurotic and immature defense mechanisms, a high external locus of control, high impulsivity, high novelty seeking and harm avoidance temperaments, a low persistence temperament, low self-directedness and cooperation character traits, and a high transcendence character trait). They experienced a very high rate of suicidal risk (two-thirds of the class) and displayed a higher negative life events score.

All of these arguments led us to define these patients as patients with complex psychological functioning to illustrate their high level of severity in all psychopathological domains explored.

After the exclusion of patients with complex psychological functioning, the corrected sample used for the comparative analyses of the other four classes was reduced to 210 patients.

Patients with impulsive psychological functioning.

This class was the smallest, with only 13 patients (4%). These patients presented mostly with PG and SA, and ED were largely underrepresented compared to the other classes.

Men were overrepresented, and the average age of initiation was low. Their internal locus of control score was lower, but the difference did not reach clinical relevance (one-point difference).

We identified an impulsive profile because of three arguments: a higher novelty seeking score, three higher impulsivity scores (lack of premeditation, negative urgency and sensation seeking) and more frequent histories of ADHD. Despite having the highest experimentation of abstinence, patients with impulsive psychological functioning appeared to be less able to durably stop their problematic behavior, with a significantly lower maximum duration of abstinence (half of the entire sample). An unexpected result was that the problematic behavior had less impact on relationships.

Patients with cooperative psychological functioning.

This class was composed of 53 patients (18%). The sociodemographic characteristics, distribution of disorders, problematic behavior course and comorbid psychiatric disorders within this class did not differ from the corrected sample. Patients with cooperative psychological functioning were found to have a higher addiction severity than the corrected sample, although this difference was very small (0.6 points out of 9). They displayed a lower childhood ADHD score, a lower immature defense style score and a lower novelty seeking score. They were also characterized by a low level of impulsivity, particularly on the negative urgency and lack of premeditation dimensions. The attribute that best characterized this class was a significantly higher cooperation score. Finally, they declared a higher impact of the problematic behavior, although to a lower extent than for complex patients.

Patients with immature psychological functioning.

This class was the most represented, with 127 patients (42%). There were no differences in the sociodemographic characteristics, distribution of disorders, problematic behavior course and comorbid psychiatric disorders. This class had the lowest addiction severity. These patients displayed a lower self-esteem score, a lower cooperation score and a higher transcendence score. They also presented a high impulsive profile, particularly on the negative urgency dimension. The levels of reported damage were lower for the work/school domain and higher for health and relationships domains, but the difference was clinically relevant only for relationships. We identified this class as being patients with immature psychological functioning because of a higher external locus of control, a lower self-directedness score and a higher immature defense style score.

Patients with resilient psychological functioning.

This class was the second smallest class, with 17 patients (6%). There were no differences for the sociodemographic characteristics, distribution of disorders, problematic behavior course and comorbid psychiatric disorders. Patients with resilient psychological functioning were high novelty seekers and displayed high levels of impulsivity on the negative urgency and sensation seeking dimensions. They experienced a lower maximum duration of abstinence, although higher than for impulsive patients. We identified the patients from this class as having a resilient psychological functioning because it seemed that they were more efficiently able to cope with problems. One illustration of this point is the low reported level of negative consequences, despite an equivalent or even higher (although not significant) level of addiction severity. Another illustration is the fact that the negative life events score was three times lower than for the other classes, despite an equivalent number of experienced life events and no difference in age.

Fig 2 is an attempt to summarize the main characteristics of each class.

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Fig 2. Schematic representation of the five types of patients with behavioral addictions or eating disorders.

(+) High level of the characteristic (relative to the other classes). (-) Low level of the characteristic (relative to the other classes). The (+) and (-) have been positioned to indicate a high level of psychopathology on the right column and a low level on the left column. For example, patients with impulsive psychological functioning have a high capacity to achieve a one-month period of abstinence, which was associated with a low level of psychopathology, but a low capacity to maintain abstinence (low duration), which was associated with a high level of psychopathology. Patients with complex psychological functioning presented with the highest severity, the highest disorder-related damage, the highest level of psychiatric and addictive comorbidity, the highest suicidal risk, the highest level of impulsivity, and the lowest capacity to achieve a one-month period of abstinence, giving a multiple-psychopathological profile.

https://doi.org/10.1371/journal.pone.0207398.g002

General implications.

As stated in the introduction, given that we obtained different trajectories not linked to the type of disorder but, rather, based on patient profiles (profiles of personality, psychiatric comorbidities, etc.), it is possible to envisage the use of common therapeutic tracks independently of the disorder, targeted on individual vulnerabilities (personalized medicine), rather than care only centered on the problematic behavior. This may allow achieving a subject-centered rather than an object-centered clinical approach. Care management of BAs and EDs may benefit from a dual-approach based on the use of therapies that has demonstrated relatively good efficiency for the various addictive and eating disorders (motivational interviewing and cognitive-behavioral therapies (CBT), for example), supplemented by specific approaches focusing on the individual vulnerabilities of each profile from the typology. This may allow patients to partly distance themselves from their problematic behavior and to work on the mechanisms underlying their addictive vulnerability. Consequently, addiction care providers should feel legitimate in managing the various addictive and eating disorders, and addictology departments receiving patients suffering from all types of addictions or eating disorders should be promoted.

Clinical implications of the five-class typology.

Patients with complex psychological functioning were deeply affected in various domains. Such patients may demonstrate poorer responses to care and less compliance. The complexity of patients in health care has received increasingly more attention from care providers [54, 55]. Achieving congruence between the patient and the care provider is of crucial importance for effective, patient-centered care [54]. The difficulty lies in the management of the multiplicity of associated disorders, together with psychopathological personality traits and negative life events. A possible approach would be to first direct the therapeutic work more to the psychiatric comorbidities, which seem to be very pregnant in this class, rather than to the problematic behavior itself. Indeed, psychiatric comorbidities have been found to increase the risk of relapse and to worsen the prognosis in other substance-related addictive disorders [56], so that appropriate treatment of such comorbidities can significantly improve long-term prognosis and functioning in multiple domains. As a consequence, treating psychiatric comorbidities in patients with complex psychological functioning should be considered a key goal andmay secondarily improve the other psychopathological characteristics (self-esteem, abstinence capacity) and their intrinsic motivation to change, and help the patient be more receptive to addictive care in a second time, in a virtuous cycle of recovery. Because they display a very high rate of suicidal risk and a high level of disorder-related damage, harm reduction should also be provided to limit the negative consequences of the behavior. Finally, mental health providers should keep in mind that access to addiction treatment for these patients with multiple comorbidities may be done through the co-occurring disorders. A systematic screening of addictions (substance-related or not) and EDs should be promoted for all patients presenting for a mental health problem.

Patients with impulsive psychological functioning unexpectedly reported lower damage from the disorder. This finding may be due to a low addiction severity or the fact that they have less awareness of the negative impacts on their lives (lower insight). This class was the smallest one, which may indirectly indicate that they have more difficulty accessing specialized care, especially due to a lower awareness of disorder-related damage. Such a profile of patients does not seek for care easily but may benefit from impulsivity-centered care, focused on the reduction of stress reactivity or the enhancement of coping strategies with psychotherapies and/or the regulation of their biologically-based impulsivity with psychotropic medications [53]. This would be the first step toward favoring care compliance and the durability of abstinence.

In contrast, patients with cooperative psychological functioning reported a slightly higher severity of the addiction, which could reflect a higher awareness of the negative impacts on their lives (higher insight). This could represent a therapeutic lever for these patients because their high cooperativeness may lead them to attempt to solve their problems. Solution-oriented therapies focused on the experienced damage may thus represent an efficient care strategy for these patients.

Patients with immature psychological functioning displayed global weak maturity characterized by a lower ability to appropriately adapt behavior to the situation and the attribution of the causality of events to external causes. Care should focus on the correction of external attribution with the reinforcement of self-esteem and personal skills and on the enhancement of coping strategies.

Finally, patients with resilient psychological functioning were characterized by presumed good coping skills, with a low level of reported damage and negative impact from traumatic events. Such patients may benefit from shorter interventions such as support groups (such as Gamblers Anonymous) or CBT, supplemented by relapse prevention programs.