Personality traits among currently eating disordered, recovered and never ill first-degree female relatives of bulimic and control women

Treatment implications of Axis-II comorbidity in eating disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies--the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)--both include the concept that "trait-oriented" interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.

Eating disorders: clinical features and pathophysiology

Anorexia nervosa (AN) and bulimia nervosa (BN) are disorders of eating and weight-related behavior that together afflict some 1-3% of women in the United States. One of the remarkable features about each of the eating disorders is how persistent the disordered eating behavior becomes once it has begun. Substantial psychological, social, and physiological disturbances are associated with eating disorders, and it has been very difficult to disentangle those factors that may result from the disturbed behavior from the factors that may have predisposed individuals to, or precipitated the development of, the disorder. This article will briefly review the definitions, phenomenology, and identified risk factors for development of each of the major eating disorders. Pathophysiology will be discussed, with a particular focus on candidate factors that might sustain disordered eating behavior, as informed by clinical and basic science research. Future research directions will be suggested.

Athletics, perfectionism, and disordered eating

OBJECTIVES

To determine the effects of sex, perfectionism, level of athletic participation (varsity vs. recreational), and type of sport (swimming, running, or soccer) on disordered eating.

METHOD

Male and female swimmers, runners, and soccer players at Stanford University were recruited at both the recreational and varsity level. Athletes were given the Multidimensional Perfectionism Scale (MPS), the Eating Attitudes Test-26 (EAT-26), the Eating Disorders Examination Questionnaire (EDE-Q), and a survey on demographics and level of athletic competition. Of 257 athletes identified, 250 (97.3%) returned the questionnaires.

RESULTS

A Multivariate Analysis of Variance (MANOVA) was used to assess the variables' effects on disordered eating attitudes. Significant main effects were found for Sex (F5,199=25.7, p<0.001), Level (F5,199=2.5, p<0.05), and Perfectionism (F10,400=3.0, p<0.001). Only two of the ten interaction terms were significant: Sex by Level of athletic participation (F5,199=3.2, p<0.01) and Sex by Perfectionism (F10,400=2.1, p<0.05). Females displayed higher disordered eating than males. Disordered eating attitudes increased with perfectionism and were greater for recreational athletes than varsity, but this trend was significant for females only. Type of sport showed no significant effects. When examining physiological data a higher percentage of varsity females had irregular periods (42.9%) or amenorrhea (14.3%) than recreational females (13.4% and 2.9%, respectively).

DISCUSSION

Males showed little variability in their data due to low disordered eating scores overall, thus demonstrated few significant results. The greatest risk factor for disordered eating attitudes for females was perfectionism, which crossed all athletic divisions. Although recreational athletes seemed more at risk psychologically, the varsity athletes had more physiological risk.

Stability of personality traits in patients who received intensive treatment for a severe eating disorder

A longitudinal prospective design with four assessments was used to examine the stability of personality traits and their relation to recovery in patients with restrictive anorexia nervosa (N=35), bingeing/purging anorexia nervosa (N=37), bulimia nervosa (N=47), and eating disorder not otherwise specified (N=27). Recovery is associated with changes in personality traits in the direction of healthy control women. Recovered patients still show higher harm avoidance and higher persistence than healthy control women. These temperament factors seem to be a vulnerability factor for developing an eating disorder. Novelty seeking seems to define the type of eating disorder one is prone to develop. The character dimensions contribute the most to recovery. High self-directedness contributes to a favorable prognosis of bulimic symptomatology, whereas high cooperativeness contributes to an unfavorable prognosis in patients with anorexia nervosa.

Factor structure of DSM-IV criteria for obsessive compulsive personality disorder in patients with binge eating disorder

OBJECTIVE

To examine the factor structure of DSM-IV criteria for obsessive compulsive personality disorder (OCPD) in patients with binge eating disorder (BED).

METHOD

Two hundred and eleven consecutive out-patients with axis I diagnoses of BED were reliably assessed with semi-structured diagnostic interviews. The eight criteria for the OCPD diagnosis were examined with reliability and correlational analyses. Exploratory factor analysis was performed to identify potential components.

RESULTS

Cronbach's coefficient alpha for the OCPD criteria was 0.77. Principal components factor analysis with varimax rotation revealed a three-factor solution (rigidity, perfectionism, and miserliness), which accounted for 65% of variance.

CONCLUSION

The DSM-IV criteria for OCPD showed good internal consistency. Exploratory factor analysis, however, revealed three components that may reflect distinct interpersonal, intrapersonal (cognitive), and behavioral features.

Comparison of patients with bulimia nervosa, obese patients with binge eating disorder, and nonobese patients with binge eating disorder

This study compared patients with bulimia nervosa (BN), obese patients with binge eating disorder (BED), and nonobese patients with BED. One hundred sixty-two adult women consecutively evaluated for outpatient clinical trials who met DSM-IV criteria for BN, purging type (N = 46) or for BED (N = 79 obese and N = 37 nonobese) were compared using the Eating Disorder Inventory (EDI). The three groups differed significantly on two (drive for thinness and body dissatisfaction) of the three eating-related scales and on all five of the general personality scales of the EDI. When age and depression level were controlled, findings for the eating-related scales did not change, whereas four of the five general personality scales were no longer significant. Post hoc analyses revealed that the BN group and the nonobese BED group had significantly higher drive for thinness than the obese BED group. The nonobese and the obese BED groups did not differ from each other in any area (other than drive for thinness), including body dissatisfaction. The nonobese and the obese BED groups had significantly lower maturity features than the BN group. Our findings suggest that when the effects of age and depression levels are controlled, treatment-seeking women with BN and BED are generally similar. Certain differences that do exist between women with BN and BED are associated with obesity status (drive for thinness), whereas others are associated with diagnosis (body dissatisfaction, maturity fears).

Association of the 5-HT2c gene with susceptibility and minimum body mass index in anorexia nervosa

The association between a non-conservative Cys23Ser in the 5-HT2c gene and anorexia nervosa in females was examined. We used case-controls and family based association analysis in a sample of 118 patients with DSMIV anorexia nervosa, 244 controls and 47 family trios. There was a significant increase in the frequency of the Ser23 allele in the patients by allele (18.8% vs 12.8%; p = 0.026; OR 1.58, 95% CI 1.0-2.4) and genotype (32.2% vs 19.9%; genotype-wise p = 0.027). There was significant correlation between genotype and minimum BMI (r2 = 0.056; p = 0.01), indicating that the Ser23 allele has an effect on severity of illness. We performed TDT analysis using a sub-sample of the cases (58) for whom both parents were available and we found an excess transmission of the Ser23 allele (p = 0.05). Our findings are consistent a role for the Ser23 allele of 5-HT2c in mediating susceptibility to and increasing severity of anorexia nervosa.

Neuroticism and low self-esteem as risk factors for incident eating disorders in a prospective cohort study

OBJECTIVE

To assess the role of neuroticism and low self-esteem as risk factors for eating disorders (ED).

METHOD

A representative sample of girls 12-21 years old from Navarre, Spain. Girls free from any ED in 1997 were followed up for 18 months and reevaluated using DSM-IV criteria. Multivariable logistic models were used to examine associations between neuroticism (Eysenck Inventory) or low self-esteem (36-item scale) and incident ED.

RESULTS

Higher levels of neurotic personality increased the risk of ED (adjusted odds ratio [OR] for the highest quartile, 3.3; 95% Cl; 1.6-4.8). High levels of self-esteem were protective (OR, 0.32; 95% CI, 0.16-0.66). Neuroticism was a more powerful predictor than low self-esteem.

DISCUSSION

Our results provide prospective evidence supporting the role of neuroticism and low self-esteem as major determinants of ED.

Do eating disorders co-occur with personality disorders? Comparison groups matter

OBJECTIVE

To assess and compare lifetime rates of occurrence of eating disorders (ED) with four Axis II personality disorders (PD) and with major depressive disorder (MDD) without PD. The eating disorders met criteria outlined in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

METHOD

Six hundred sixty-eight patients recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were reliably assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders and the Diagnostic Interview for DSM-IV Personality Disorders. The distribution of ED diagnoses was compared among four PD study groups (schizotypal, borderline, avoidant, obsessive-compulsive) and a fifth study group with MDD without any PD.

RESULTS

The distribution of lifetime diagnoses of anorexia nervosa (N = 40), bulimia nervosa (N = 56), and eating disorder not otherwise specified (N = 118) did not differ significantly across the five study groups, between the MDD group versus all PD groups, and among the four PD study groups.

CONCLUSIONS

ED diagnoses did not differentially co-occur significantly across common Axis I and II disorders. The pattern of ED lifetime co-occurrence rates demonstrates the powerful influence of base rates and highlights that declarations of comorbidity demand significant variations from base-rate patterns.

Temperament and character of Japanese eating disorder patients

Previous studies consistently reported a link between bulimic behaviors and high Novelty Seeking (NS), as measured by the Temperament and Character Inventory (TCI). However, it remains unclear whether this relationship is universal and occurs in different environments. Subjects of the present study consisted of 66 patients with anorexia nervosa restricting type (AN-R), 59 patients with anorexia nervosa binge eating/ purging type (AN-BP), 101 patients with bulimia nervosa purging type (BN), and 75 controls. NS score in AN-R patients was significantly lower than that in controls, although NS in BN patients did not differ from that in controls. The temperament of AN-R patients seems to be universal, even in different environments. Conversely, something other than temperament might be important in the development of bulimia nervosa in Japan.

Clinical perfectionism: a cognitive-behavioural analysis

This paper reviews the characteristics of clinical perfectionism and proposes a new definition of the phenomenon. It is suggested that the defining feature of clinically significant perfectionism is the overdependence of self-evaluation on the determined pursuit (and achievement) of self-imposed personally demanding standards of performance in at least one salient domain, despite the occurrence of adverse consequences. It is suggested that such clinical perfectionism is maintained by the biased evaluation of the pursuit and achievement of personally demanding standards. Specifically, it is suggested that people with perfectionism react to failure to meet their standards with self-criticism. If they do meet their standards, the standards are re-evaluated as being insufficiently demanding. Anorexia nervosa and bulimia nervosa are considered to have a particular relationship to perfectionism, with both disorders often being direct expressions of perfectionism. Under these circumstances self-evaluation is dependent on the pursuit and attainment of personally demanding standards in the domain of control over eating, shape and weight. The implications of this analysis for research and practice are considered.

Genetic relationships between personality and eating attitudes and behaviors

Genetic and environmental factors underlying relationships between personality traits and disordered eating were examined in 256 female adolescent twin pairs (166 monozygotic, 90 dizygotic). Eating behaviors were assessed with the Total Score, Body Dissatisfaction, Weight Preoccupation, Binge Eating, and Compensatory Behavior subscales from the Minnesota Eating Disorders Inventory (M-EDI; K. L. Klump, M. McGue, & W. G. Iacono, 2000). Personality characteristics were assessed with the Negative Emotionality, Positive Emotionality, and Constraint scales from the Multidimensional Personality Questionnaire (MPQ; A. Tellegen, 1982). Model-fitting analyses indicated that although genetic factors were more likely to contribute to MPQ and M-EDI phenotypic associations than environmental factors, shared genetic variance between the 2 phenotypes was limited. MPQ personality characteristics may represent only some of several genetic risk factors for eating pathology.

Personality, perfectionism, and attitudes toward eating in parents of individuals with eating disorders

OBJECTIVE

This study compares personality and eating-related traits in parents of probands with eating disorders, with age-band matched healthy normal controls.

METHOD

Data were abstracted from an international genetic study of anorexia nervosa. Information was available for the Multidimensional Perfectionism Scale (MPS), the Eating Disorders Inventory (EDI), and the Temperament and Character Inventory (TCI). Comparisons were done by multivariate analysis of variance.

RESULTS

Mothers of probands showed elevated levels of perfectionism on the MPS and more concerns about weight and shape on the EDI compared with controls. Mothers who had daughters with diagnoses other than the restricting subtype of anorexia nervosa showed elevated levels of perfectionism on the MPS.

CONCLUSION

These data are compatible with the notion that some personality traits, such as perfectionism, and weight and shape concerns may cluster in families of probands with eating disorders.

Bulimia in children and adolescents

Although there have been many recent advances in research, much work remains to be done in the area of child and adolescent eating disorders. More data are needed regarding the normal development of eating behavior, resilience and risk factors for eating pathology, and treatment studies in children and adolescents. The best studied areas include epidemiology, short-term treatment for bulimia nervosa (BN), and outcome in anorexia nervosa. A case report of the single blind use of repetitive transcranial magnetic stimulation in a patient with BN has been reported, but its safe use in children and adolescents remains to be established.

Recent research of relationships among eating disorders and personality disorders

This review focuses on recent research examining the relationships among eating disorders (ED) and personality disorders (PD). Studies that have examined rates of PD in patients with ED and rates of ED in patients with PD have generally reported high rates of diagnostic co-occurrence, although the marked inconsistency and variability in rates across studies is striking. Methodologic limitations and conceptual problems make interpretation of the existing literature ambiguous. Overall, circumspect review suggests that anorexia nervosa may be associated with obsessional and perfectionistic forms of personality disturbances, bulimia nervosa with impulsive and unstable personality disturbances, and binge eating disorder with avoidant and anxious forms of personality disturbances. In terms of longitudinal associations, PD may be more closely associated with the course of general psychiatric or psychosocial functioning than with fluctuations in the course of ED. The significance (and more precise nature) of these associations, however, is unclear and will require sophisticated longitudinal studies to arrive at more definitive answers.

Evolution of symptom severity during residential treatment of females with eating disorders

OBJECTIVES

The overall objective of this study was to measure the evolution of symptom severity in a residential programme based on a multidimensional approach to treatment that includes cognitive-behavioural, interpersonal, experiential and family therapies. The specific aims of the study were: 1) to evaluate changes in symptom severity in bulimic and anorexic patients between admission and discharge; 2) to compare the severity of these symptoms with those of non-patient college females (control group); and 3) to monitor the progression of symptom changes six months after discharge.

METHODS

The evolution of symptom severity was measured by comparing the mean raw scores of the Eating Disorder Inventory (EDI original inventory, 1983 version), which was administered at the beginning and end of the residential treatment. A subgroup of patients was also administered the EDI six months after discharge. The study involved 99 females: 47 with bulimia and 52 with anorexia as diagnosed by means of a clinical interview using DSM-IV criteria. The mean raw EDI scores in the control group (FC1, female college students) were obtained from the EDI manual. The population means were compared using the t-test for paired data (Microsoft Excel, version 2000).

RESULTS

The overall results for the population as a whole show that the eight subscales of the EDI improved significantly with treatment (<0.001). The subscales with the largest numerical improvements were drive for thinness, ineffectiveness and interoceptive awareness. When divided on the basis of diagnosis, the mean feelings of perfectionism score of the bulimic patients was less than that of the control female college sample; the symptoms of bulimia in the anorexic patients were similar to those found in the control group. The fact that the mean follow-up scores for a number of the ED1 subscales remained similar to those recorded at the time of discharge suggests that some of the improvements in symptoms remained for at least six months.

CONCLUSIONS

The results of our study show that multidimensional residential treatment leads to statistically significant changes in the severity of the symptoms manifested by females with eating disorders.

Perfectionism and psychopathology: a review of research and treatment

Clinical experience suggests that perfectionism can impede the successful treatment of psychological disorders. This review examines the concept of perfectionism, critically evaluates its assessment, reviews the association between existing measures of perfectionism and psychopathology, and considers the impact of perfectionism on treatment. It is concluded that existing measures do not reflect the original construct of perfectionism and that, consequently, new measures are needed. The evidence reviewed indicates that high personal standards are specifically elevated in patients with eating disorders and beliefs about others' high standards for the self are associated with a broad range of psychopathology. The importance of examining mean scares across studies (as well as associations between variables within studies) is emphasized. There has been no systematic evaluation of the treatment of perfectionism despite existing cognitive-behavioral treatment protocols.

The role of personality in the onset of eating disorders and treatment implications

The relationship of personality and eating disorders is largely unclear. The development of well-specified conceptual models of this relationship, developments in family history, behavior genetic and prospective longitudinal research methodology, and careful consideration of how trait constructs may interact with state variables to produce or maintain eating disorders all will help to advance this area of research.

The evolving genetic foundations of eating disorders

Data described earlier are clear in establishing a role for genes in the development of eating abnormalities. Estimates from the most rigorous studies suggest that more than 50% of the variance in eating disorders and disordered eating behaviors can be accounted for by genetic effects. These high estimates indicate a need for studies identifying the specific genes contributing to this large proportion of variance. Twin and family studies suggest that several heritable characteristics that are commonly comorbid with AN and BN may share genetic transmission with these disorders, including anxiety disorders or traits, body weight, and possibly major depression. Moreover, some developmental research suggests that the genes involved in ovarian hormones or the genes that these steroids affect also may be genetically linked to eating abnormalities. Molecular genetic research of these disorders is in its infant stages. However, promising areas for future research have already been identified (e.g., 5-HT2A receptor gene, UCP-2/UCP-3 gene, and estrogen receptor beta gene), and several large-scale linkage and association studies are underway. These studies likely will provide invaluable information regarding the appropriate phenotypes to be included in genetic studies and the genes with the most influence on the development of these disorders.