The Eating Disorder Personality: Personality as a Risk Factor
Eating Disorders & Personality
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 genetic predisposition, circumstances, environment, existing mental health struggles and personality.
While 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, and some traits impact treatment outcomes.
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.1
The Five Factor Model of Personality
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
- Openness to experience
Each factor is defined by adjectives, Q-sort items (a research method used in psychology and in social sciences to study a person’s or persons' subjective viewpoint) and questionnaire scales.2
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, four temperaments:
- Novelty seeking
- Harm avoidance
- Reward Dependence
and three characters:
Each dimension is measured on four subscales which are measured through true-false statements. In the revised TCI (TCI-R) the true-false statements were replaced with a five-point scale.
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
Each facet is measured on a four-point scale, and the asset scores are then used to determine the domain scores.
Eating Disorder Personality Traits
Individuals with eating disorders differ significantly from healthy peers, especially in traits like perfectionism, impulsivity, neuroticism, obsessive-compulsivity and detachment.
Perfectionism is the desire to be or appear or be perfect. Patients with eating disorders may hold themselves to a high standard in regards control their diet, shape and weight and may have a drive to achieve perfection in these areas, maintaining their eating disorder.3 It is not uncommon for compensatory behaviors to be used to cope with excessive concerns about mistakes, self-doubt and high levels of perceived parental criticism.21 Perfectionism has also been shown to be both a risk and maintaining factor for anorexia nervosa.4,5,6,7
Many studies have demonstrated that patients with anorexia nervosa and bulimia nervosa self-report higher levels of perfectionism and score higher on perfectionism scales.19 Perfectionism is also elevated in eating disorders compared to other disorders.6 Those with anorexia nervosa were also found to take longer performing tasks, spend more time checking their work, and produce higher quality results.2 Those with anorexia nervosa and bulimia both express excessive concerns about their mistakes and doubts on the quality of their actions, and individuals with anorexia nervosa tend to endorse high personal.8,9
Impulsiveness in eating disorders patients has been highly studied. Impulsivity is understood to be a multifaceted construct with at least five different facets:
- Negative urgency: tendency to engage in impulsive behavior when experiencing strong negative emotions
- Positive urgency: tendency to engage in impulsive behavior when experiencing strong positive emotions
- Lack of planning: inability to consider the consequences of one's behavior
- Sensation seeking: tendency to desire thrills and excitement
- Difficulty persisting on tasks: inability to persist on tasks when bored and/or fatigued
Negative injury is the tendency to behave impulsively when experiencing strong negative emotions (negative affect). An example of negative urgency in eating disorders is the cycle of bingeing and/or purging in people with bulimia nervosa, anorexia nervosa binge-eating/purging subtype (AN-BP), and binge-eating disorder (BED). Individuals may binge to cope with feelings of anxiety, depression or loneliness. For those with bulimia nervosa and AN-BP, they may subsequently purge to cope with guilt, disappointment, anger or anxiety they feel after purging.
Negative urgency is greater among those with eating disorders than those without.10,11,12 It also presents more commonly in binge-eating/purging eating disorders than restrictive eating disorders. Individuals with bulimia tend to score higher in negative urgency than those with anorexia nervosa, and those with AN-BP score higher than those with anorexia nervosa restricting subtype (AN-R).13,14
Individuals with binge eating disorder (BED), bulimia nervosa and the anorexia nervosa binge/purge subtype (AN-BP), tend to binge and/or purge to cope with or alleviate overwhelming emotions. The link between negative urgency is stronger for bulimia nervosa and AN-BP than it is for the anorexia nervosa restricting subtype (AN-R).15 Binge/purge subtypes also tend to present with other impulse control disorders and experience increased difficulties with emotional regulation.16,17
Positive urgency is the tendency to behave impulsively when experiencing strong positive emotions (positive affect). Positive urgency in individuals with eating disorders is understudied, most likely due to higher levels of negative emotionality in eating disorder populations. There has been one study that’s examined positive urgency among those with eating disorders, showing positive urgency was elevated in AN-BP, bulimia nervosa and eating disorder not otherwise specified (EDNOS) relative to AN-R and healthy controls.18
Lack of Planning
Lack of planning is the inability to consider the consequences of one’s actions. Those with bulimia nervosa tend to score higher in lack of planning compared to those with anorexia nervosa, and those with AN-BP score higher than those with AN-R.19
However, when using measures that assess cognitive aspects of planning, rather than behavior, there are no significant differences between those with eating disorders and those without.25
Sensation seeking, also known as thrill-seeking, is the tendency to pursue new and different sensations and experiences. For those with eating disorders this may lead to high-risk behavior outside of their disorder, or manifest within their eating disorders as a disregard for the risks of overexercise, malnutrition or purging. Levels of sensation seeking vary by diagnosis. Individuals with anorexia nervosa tend to score lower, while those with bulimia nervosa score higher and those with BED score similar to controls.25
Lack of Persistence
Lack of persistence is the inability to persistent when a task is boring, difficult or tiring. Like sensation seeking, lack of persistence also varies by diagnosis. Those with anorexia nervosa report greater persistence, while those with bulimia nervosa score similar to controls.20,23,24 This may be partially explained by increased rigidity found in those with anorexia nervosa, particularly AN-R.
Harm Avoidance & Avoidance Motivation
Harm avoidance is a personality trait characterized by excessive worrying, pessimism, shyness, and being fearful, doubtful, and easily fatigued. Harm avoidance is elevated in individuals with anorexia nervosa, bulimia nervosa, BED and EDNOS. Those with anorexia nervosa and AN-BP have significantly the higher scores in harm avoidance than those with BED and EDNOS, suggesting individuals with AN tend to be more fearful and worried than healthy controls and other eating disorders.21
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, dietary restriction, and emotional eating.32
Negative affectivity (sometimes referred to as negative emotionality or neuroticism) is the tendency to experience negative emotional states, including anger, anxiety, self‐consciousness, irritability, emotional instability and depression. Negative affectivity is more prevalent in females and typically presents in adolescents.
High negative affectivity is also linked to disordered eating behaviors in adolescents.22 Adolescents with eating disorders present with elevated traits of negative affectivity, including interoceptive awareness, fear of maturity, insecurity, borderline tendency and emotional dysregulation.23,24,25
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 (BN) show lower emotional stability.22
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 and OCD.26
Between 15-33% of individuals with an eating disorder also have obsessive-compulsive disorder (OCD).27 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 & Extraversion
Detachment, which exists opposite of extraversion, 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 inhibition, introversion, interpersonal distrust, personal and social alienation and feelings of inefficiency, and they may have lower novelty seeking and extraversion.21,22,23
Combined with higher scores of neuroticism, this may explain why individuals with eating disorders struggle with emotional and interpersonal relationships.28,29 Undergraduate women who scored high on neuroticism and low on extraversion were also at the greatest risk for symptoms of eating problems.21
Eating Disorders & Personality Disorders
Personality disorders are one of the most common psychiatric comorbidities in those with eating disorders. Between 30-37% of those with eating disorders also present with a personality disorder, and those with bulimia are more likely to have a personality disorder than other eating disorders.30,31
Obsessive-Compulsive Personality Disorder
Obsessive Compulsive Personality Disorder (OCPD) is a pattern of preoccupation with perfectionism, order control at the expense of flexibility, openness and efficiency. The prevalence of obsessive-compulsive personality disorder is significantly higher in patients 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.32
Borderline Personality Disorder
Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image and affects with marked impulsivity. The prevalence of borderline personality disorder is more common in patients with anorexia nervosa binge-eating/purging subtype (AN-BP) and bulimia nervosa.31 This may be explained by the greater prevalence of impulsive facets found in binge-eating/purging eating disorders than restrictive ones.
Personality Traits & Implications in Treatment
Certain personality traits, including perfectionism, impulsivity, harm avoidance and detachment can all impact treatment outcomes.
Personality & Treatment Outcomes
Personality facets play are important for understanding eating disorders and their treatment. The ability to identify and work on certain personality traits may enhance treatment alliance, address underlying problems and improve outcomes for patients.33
Although some studies have shown that scores on perfectionism can improve with treatment and possibly return to normal levels at discharge, the bulk of research suggests that perfectionism does not improve with treatment among women with anorexia nervosa or bulimia nervosa.22 Perfectionism is also associated with poorer outcomes and treatment drop-out.34
Higher levels of impulsivity are also associated with poorer outcomes, and reduced impulsivity may decrease binge eating.35,36 People considered fully recovered from their eating disorder experienced significantly less negative urgency than those partially recovered or with an active eating disorder. 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.37
Harm avoidance also impact treatment outcomes and recovery. Those who recover from AN scored lower in harm avoidance than those not recovered. 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.20
Detachment traits like personal and social alienation and interpersonal distrust can impact recovery. Women in recovery note that relationships with loved ones were an essential part of their recovery because they provided love, support, trust and hope.38 Without a support system, self-isolated individuals increase their disordered eating behaviors or delay treatment.
Treatment & Interventions for Eating Disorders & Personality Traits
Personality can’t be changed, instead 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 and treatment-based therapy with supports.
Providers should utilize strategies that help patients learn how to use their strengths and temperament-based traits to maintain their recovery or learn new skills that help them cope with overwhelming feelings.
For overcontrolled temperamental eating disorders such as AN-R, providers should focus on developing cognitive flexibility (as opposed to rigidity) and managing negative affectivity or emotional states through coping skills. It’s also helpful for patients to learn to how to more accurately evaluate “threat” and not over-evaluate threat in food choices.
For undercontrolled temperamental eating disorders such as bulimia nervosa or AN-BP, providers should focus on cultivating healthy coping skills that can help patients manage emotional dysregulation and impulsivity.
Dialectical Behavioral Therapy
Dialectical behavioral therapies can be used to address eating disorders, personality traits and/or co-occuring eating disorder and personality disorder. Dialectical behavioral therapy (DBT) is a form of talk therapy that focuses on mindfulness, interpersonal relationships, distress tolerance and emotional regulation and has been used to treat borderline personality disorder, substance use disorder and eating disorders.39 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.40
Temperament-based Therapy with Supports
Temperament-based therapy with supports (TBT-S) is a neurobiological-based treatment that addresses the underlying factors that lead to the development of an eating disorder, including biology, brain functionality, genetics and personality traits.
The main attribute of TBT-S is taking existing personality traits, that largely cannot be changed, reworking them to benefit an individual’s recovery instead of their eating disorder. Those with anorexia nervosa and bulimia nervosa showed significant reductions in eating disorder pathology through TBT-S.41,42
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- Temperament Based Therapy with Support for Anorexia Nervosa By Laura L. Hill, Stephanie Knatz Peck, and Christina E. Wierenga (Cambridge University Press