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

Personality traits, such as perfectionism, impulsivity or 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.

Risk Factors for Eating Disorders

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

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 while others can impact treatment outcomes.

The Link Between Eating Disorders & Specific 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.

Individuals with eating disorders differ significantly from healthy peers, especially in traits like:

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

Perfectionism

Perfectionism is the desire to be or be perceived as perfect. Perfectionism is a common trait in patients with eating disorders, which can exacerbate disordered eating behaviors. Perfectionists often hold themselves to a high standard in terms of their diet, shape and weight and have a drive to achieve perfection in these areas.

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

Perfectionism has also been shown to be both a risk and maintaining factor for anorexia nervosa. Many studies have demonstrated that patients with anorexia nervosa and bulimia nervosa self-report higher levels of perfectionism and score higher on perfectionism scales. Perfectionism is also elevated in eating disorders compared to other conditions.

Perfectionism in eating disorders has been found 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

Impulsivity

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 facets

• 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 highly studied and is found most frequently in patients with binge eating disorder (BED), bulimia nervosa and anorexia nervosa binge eating and purging subtype (AN-BP).

Negative urgency has been found to be greater among those with eating disorders than those without and presents more commonly in those with bulimia nervosa, BED and AN-BP. Positive urgency is also elevated in AN-BP and bulimia.

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 in lack of planning than those with anorexia nervosa restricting subtype (AN-R). 

Levels of sensation seeking vary by diagnosis and individuals, but those with anorexia nervosa tend to score lower, while those with bulimia nervosa score higher.

Those with anorexia nervosa report greater persistence, which 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 and shyness and being fearful, doubtful and easily fatigued. Harm avoidance is elevated in individuals with anorexia nervosa, bulimia nervosa, BED and other specified feeding or eating disorder (OSFED) EDNOS. Those with anorexia nervosa and AN-BP score significantly higher in harm avoidance than those with BED, suggesting individuals with anorexia nervosa tend to be more fearful and worried than healthy controls and other eating disorders.

Signs of harm avoidance:

• Constantly thinking about potential negative events that might happen
• Discomfort in unpredictable situations
• Reluctance and apprehension when interacting with new people
• Focusing more on potential downsides than positive ones

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.

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. Adolescents with eating disorders present with elevated traits of negative affectivity, including interoceptive awareness, fear of maturity, insecurity, borderline tendency and emotional dysregulation.

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.

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).

Between 15-33% of individuals with an eating disorder have OCD.  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:

• 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. Between 30-37% of those with eating disorders also present with a personality disorder, and those with bulimia nervosa are more likely to have a personality disorder than other eating disorders.

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, self-image and affects with marked impulsivity. The prevalence of borderline personality disorder 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

Using personality traits in treatment

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.

Psychotherapy

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.

Personality traits & treatment outcomes

Perfectionism

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. Perfectionism is also associated with poorer outcomes and treatment drop-out.

Impulsivity and negative urgency

Higher levels of impulsivity are also associated with poorer outcomes, and reduced impulsivity may decrease binge eating. 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.

Harm avoidance

Harm avoidance also impacts treatment outcomes and recovery. Those who recover from anorexia nervosa 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.

The importance of relationships in eating disorder recovery

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. Without a support system, self-isolated individuals increase their disordered eating behaviors or delay treatment.

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