Personality as a Risk Factor for Eating Disorders: How Therapy Can Help

Personality traits, such as perfectionism, impulsivity and negative affect, can contribute to the development of eating disorders. These traits may drive unhealthy behaviors like restriction, binge eating or purging. Addressing these personality patterns in therapy is key to treating eating disorders, helping individuals develop healthier coping mechanisms and improve self-image.

Is There an Eating Disorder Personality?

Even though personality is not the sole factor in the development of an eating disorder, certain personality traits can make one more likely to develop an eating disorder, while others can impact treatment outcomes. Some personality traits are elevated in individuals with eating disorders, such as:^1,2

• Perfectionism
• Impulsivity
• Negative affect
• Avoidance motivation
• Obsessive-compulsivity
• Detachment

Eating disorders are considered a perfect storm illness, where multiple components intermingle to create the perfect opportunity for an eating disorder to develop. Eating disorders develop through a combination of different factors, including:

• Personality
• Genetic predisposition
• Co-occurring psychiatric diagnoses
• Circumstances and life events
• Environment

Understanding the role of personality traits in the development of an eating disorder can help not only facilitate recovery but also help individuals learn how to utilize some of those same personality traits to achieve their treatment goals.

Eating Disorders & Personality Traits

Personality is the enduring configuration of characteristics and behavior that comprises an individual’s unique adjustment to life, including major traits, interests, drives, values, self-concept, abilities and emotional patterns. Various theories explain the structure and development of personality in different ways, but all agree that personality helps determine behavior.

Perfectionism

Perfectionism – the desire to be or be perceived as perfect – is a common trait among patients with eating disorders that can worsen disordered eating behaviors. Perfectionists often set high standards for their diet, shape and weight and are driven to attain perfection in these areas.

Perfectionism has been identified as both a risk factor and a maintaining factor, or anything that keeps the cycle of symptoms going, for anorexia nervosa.³

Many studies have shown that patients with anorexia nervosa and bulimia nervosa report higher levels of perfectionism and score higher on perfectionism scales.^2,4

Perfectionism in eating disorders has been shown to manifest through:

• Taking longer performing tasks
• Spending more time checking work
• Producing higher quality results
• Expressing excessive concern about mistakes
• Doubting the quality of their action
• Endorsing high personal standards

Compensatory behaviors, like purging, can be used to cope with excessive concerns about mistakes, self-doubt and high levels of perceived criticism. 

Impulsivity

Impulsivity is elevated in patients with eating disorders, particularly those with bulimia nervosa, anorexia nervosa binge eating and purging subtype (AN-BP) and binge eating disorder (BED).

Impulsivity is the tendency to act without thinking or with little to no consideration of the consequences. Impulsivity is understood to be a multifaceted construct with at least five different dimensions:

• Negative urgency: :the tendency to engage in impulsive behavior when experiencing strong negative emotions
• Positive urgency: the tendency to engage in impulsive behavior when experiencing strong positive emotions
• Lack of planning: the inability to consider the consequences of one's behavior
• Sensation seeking: the tendency to desire thrills and excitement
• Difficulty persisting on tasks: the inability to persist when a task is boring, difficult or tiring

Impulsivity in patients with eating disorders has been extensively studied and is most commonly observed in those with binge eating disorder (BED), bulimia nervosa and anorexia nervosa binge eating and purging subtype (AN-BP).

Negative urgency is greater among those with eating disorders than those without and presents more commonly in those with bulimia nervosa, BED and AN-BP, and is also the most strongly correlated to disordered eating behavior.⁵

Positive urgency, lack of planning, and sensation seeking are all higher in individuals with eating disorders, especially those who binge and purge.⁴

The exception is persistence; individuals with bulimia nervosa, AN-BP and BED score similar to controls, whereas those with anorexia nervosa restricting type (AN-R) report higher persistence.⁴

Negative affectivity

Negative affectivity (sometimes referred to as negative emotionality and in older literature as “neuroticism”) is the tendency to experience negative emotional states, including:

• Anger
• Anxiety
• Self‐consciousness
• Irritability
• Emotional instability
• Depression

High negative affectivity is linked to disordered eating behaviors in adolescents.⁶ Adolescents with eating disorders present with elevated traits of negative affectivity, including interoceptive awareness, fear of maturity, insecurity, borderline tendency and emotional dysregulation.⁶

Individuals with anorexia nervosa, bulimia nervosa and BED consistently report significantly higher levels of negative affectivity than those without. Before onset of illness individuals with anorexia display higher neuroticism than controls and those with bulimia nervosa show lower emotional stability.¹

Avoidance motivation

Avoidance motivation is a tendency to avoid distressing problems and undesirable outcomes. Avoidance motivation has been positively associated with bingeing, purging and restriction behaviors like binge episodes, laxative abuse, diet pill use, food restriction and emotional eating.

Avoidance motivation is elevated in individuals with anorexia nervosa, bulimia nervosa, BED and other specified feeding or eating disorder (OSFED).¹

Signs of avoidance motivation include:

• Discomfort in unpredictable situations
• Reluctance and apprehension when interacting with new people
• Focusing more on potential downsides than positive ones
• Procrastination or last-minute withdrawals from commitments

Obsessive-compulsivity

Childhood obsessive-compulsive personality traits are a predictor for eating disorders. These traits can include preoccupation with perfection, orderliness and control. Additionally, individuals with eating disorders who reported perfectionism and rigidity in childhood were significantly more likely to develop obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD).⁷

Up to 44% of those with anorexia nervosa and atypical anorexia nervosa and up to 33% of those with bulimia nervosa also have OCD.^8,9  OCD is the presence of obsessions, compulsions or both. Obsessions or compulsions are either time consuming or cause clinically significant distress or impairment. Repetitive behaviors to perform certain acts, obsessive and persistent thoughts and compulsive behavior to reduce stress are present in both OCD and eating disorders.

Detachment

Detachment involves depressive affect and interpersonal withdrawal and mistrust. Adolescents with eating disorders are more likely to present detachment-related personality traits compared to their peers, including:⁶

• Inhibition
• Introversion
• Interpersonal distrust
• Personal and social alienation
• Feelings of inefficiency

Combined with higher scores of negative affect, this may explain why individuals with eating disorders struggle with emotional and interpersonal relationships. Undergraduate women who scored high on negative affect and low on extraversion were also at the greatest risk for disordered eating behaviors.

Eating Disorders & Personality Disorders

Personality disorders are one of the most common psychiatric comorbidities in those with eating disorders, with up to 37% of those with eating disorders also present with a personality disorder.¹⁰

Obsessive-compulsive personality disorder

OCPD is a pattern of preoccupation with perfectionism, order and control at the expense of flexibility, openness and efficiency. The prevalence of obsessive-compulsive personality disorder is significantly higher in patients with AN-R. The rigidity and relentless pursuit of a particular weight or shape through strict calorie counting, exercise schedules and precision dieting is reflected in OCPD.

Borderline personality disorder

Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships. It is more common in patients with AN-BP and bulimia nervosa. This may be explained by the greater prevalence of impulsive facets found in binge-eating/purging eating disorders than restrictive ones.

Assessing Personality Traits

There are several ways to assess personality traits in patients, including the five factor model, temperament and character inventory and the personality inventory for the DSM-5.

The Five Factor Model

There are many research articles that use the Five Factor Model of Personality (FFM), which is a hierarchical organization of personality traits in terms of five basic dimensions:

• Extraversion
• Agreeableness
• Conscientiousness
• Neuroticism
• Openness to experience

Temperament and Character Inventory

In addition to the FFM, there is also the Temperament and Character Inventory (TCI). The TCI is a psychobiological model with seven dimensions of personality traits, including four temperaments:

• Novelty seeking
• Harm avoidance
• Reward dependence
• Persistence

Alongside the four temperaments are three character traits:

• Self-directedness
• Cooperativeness
• Self-transcendence

The Personality Inventory for the DSM-5

The personality inventory for the DSM-V (PID-5) is an assessment tool of personality disorder traits developed for the DSM-V. The PID-5 consists of 25 hierarchal facets organized into 5 domains:

• Negative affect
• Detachment
• Antagonism
• Disinhibition
• Psychoticism

Psychotherapy for Eating Disorders

Personality can’t be changed, and instead of focusing on changing personality traits, providers should help their patients learn how to work with these traits to achieve their desired treatment outcomes, whether through general strategies or through treatment models that address personality traits in patients with eating disorders, like dialectical behavioral therapy (DBT) and temperament-based therapy with supports.

Dialectical behavioral therapy

Dialectical behavioral therapy (DBT) can be used to address eating disorders, personality traits and/or a co-occurring eating disorder and personality disorder. DBT is a form of talk therapy that focuses on mindfulness, interpersonal relationships, distress tolerance and emotional regulation and is also used to treat borderline personality disorder and substance use disorder. 

Radically open dialectical behavioral therapy (RO-DBT) is a form of DBT designed to address a spectrum of difficult-to-treat disorders with features associated with maladaptive over-control, like anorexia nervosa, chronic depression and OCPD.

Temperament-based therapy with supports

Temperament-based therapy with supports (TBT-S) is a neurobiological-based treatment that addresses the underlying mechanisms – like biology, brain functionality, genetics and personality traits – that contribute to the development and maintenance of an eating disorder.

The main attribute of TBT-S is acknowledging and working with a person’s temperament to manage the symptoms of an eating disorder. Those with anorexia nervosa and bulimia nervosa showed significant reductions in eating disorder pathology through TBT-S.

Does Personality Affect Treatment Outcomes?

Some personality traits, like perfectionism, impulsivity and harm avoidance can impact treatment outcomes.

Perfectionism

Some studies have shown that scores on perfectionism can improve with treatment and possibly return to normal levels at discharge with targeted approached.^11,12 However, the bulk of research suggests that perfectionism does not improve with treatment among women with anorexia nervosa or bulimia nervosa.^13,14 Perfectionism is also associated with poorer outcomes and treatment drop-out.¹⁵

Impulsivity & negative urgency

People considered fully recovered from their eating disorder experienced significantly less negative urgency than those partially recovered or with an active eating disorder.¹⁶ They are also similar in negative urgency to healthy controls, suggesting negative urgency may be one of the most important facets of impulsivity to target in therapeutic intervention.¹⁶

Harm avoidance

Harm avoidance, a form of avoidance motivation, impacts treatment outcomes and recovery. Those who recover from anorexia nervosa scored lower in avoidance motivation than those not recovered.¹ Lower harm avoidance is also found in those in recovery from depressive disorders, which may suggest either reduced harm avoidance is a consequence of recovery or that those with lower scores of harm avoidance have a better prognosis.¹⁷

Getting Help for a Severe Eating Disorder

Personality traits like perfectionism and impulsivity can play a big role in eating disorders, sometimes making recovery feel even more challenging. But these traits don’t have to hold you back. With the right support and treatment, it’s possible to understand these patterns and build healthier coping strategies.

References

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