Week 4 (Integration & projective material)
Learning Goals
1. Report the associations between personality and eating disorders
2. Discuss the role of motivation in the treatment of eating disorders
3. Discuss the effects of (pharmacological treatment for) psychiatric disorders on
sexuality
4. Discuss the role of sleep (deprivation) in the context of psychiatric disorders
5. Understand the (suspected) working mechanisms behind projective material.
6. List the advantages and disadvantages of different projective psycho-diagnostic
material (word association methods, inkblots, storytelling tests, and drawing tests)
Source: Personality and eating disorders: A decade in review Stephanie E. Cassin, Kristin
M. von Ranson
Abstract
o The present article reviews literature examining the link between personality and
EDs published within the past decade, and presents a meta-analysis evaluating the
prevalence of personality disorders (PDs) in anorexia nervosa (AN), bulimia nervosa
(BN), and binge eating disorder (BED) as assessed by self-report instruments versus
diagnostic interviews.
o AN and BN are both consistently characterized by perfectionism, obsessive-
compulsiveness, neuroticism, negative emotionality, harm avoidance, low self-
directedness, low cooperativeness, and traits associated with avoidant PD.
o Consistent differences that emerge between ED groups are high constraint and
persistence and low novelty seeking in AN and high impulsivity, sensation seeking,
novelty seeking, and traits associated with borderline PD in BN.
o The meta-analysis, which found PD rates of 0 to 58% among individuals with AN and
BN, documented that self-report instruments greatly overestimate the prevalence of
every PD.
Introduction
Integrating knowledge gained from disparate studies has clinical implications because
personality may make an important contribution to the prediction of general functioning,
clinical phenomenology, prognosis, and treatment outcome.
The present review had three purposes.
1. The first purpose was to update our understanding of associations between
personality and EDs by reviewing studies that have been published within the past
decade.
2. The second purpose was to incorporate information regarding binge eating disorder
(BED), a disorder only recently defined.
3. The third purpose was to conduct a meta-analysis of the comorbidity of PDs among
individuals with EDs, including an examination of the relative utility of self-report
instruments and interviews in estimating the prevalence of PDs.
This review examines the association between personality and ED diagnoses (i.e., ANR,
ANB, BN, BED), which is the most common approach taken by researchers in examining
associations between personality and EDs.
Studies exploring personality and EDs have examined the contribution of both
personality traits and PDs to disordered eating using the following four methods: (1) self-
,report measures of specific, dimensional personality traits; (2) omnibus self-report
measures of dimensional personality traits; (3) self-report measures of categorical PDs; and
(4) diagnostic interviews of categorical PDs.
Personality traits and eating disorders
1.1 Perfectionism
Perfectionism is characterized by the tendency to set and pursue unrealistically high
standards, despite the occurrence of adverse consequences (e.g., food and weight
preoccupation, persistent hunger).
One multidimensional perspective considers adaptive and maladaptive aspects of
perfectionism.
Individuals with EDs show significantly greater neurotic perfectionism (e.g.,
overconcern with mistakes, anxiety about performance) and similar levels of normal
perfectionism (e.g., high personal standards, need for order) compared to university
controls.
The Multidimensional Perfectionism Scale assesses three dimensions of
perfectionism: self- oriented, other-oriented, and socially prescribed perfectionism.
Self-oriented and socially prescribed perfectionism tend to be associated with ANR
and BED.
Taken together, studies using this instrument suggest that individuals with EDs set
unrealistic personal standards for themselves and believe that others evaluate them
harshly and exert excessive demands for perfection.
Using a similar instrument that measured different aspects of perfectionism,
specifically concern over mistakes, doubts about actions, personal standards,
parental expectations, and parental criticism, it was found that individuals with EDs
doubt the quality of their performance and react negatively to mistakes,
interpreting them as equivalent to failure.
The concern over mistakes and doubts about actions subscales seem to overlap
more with obsessive-compulsive traits than with perfectionism.
Collectively, findings suggest that multidimensional perfectionism may prospectively
predict the onset of AN symptoms and that it is a salient correlate of AN, BN, and
BED in acutely ill women as well as after ED recovery.
However, certain elements of perfectionism, such as socially prescribed
perfectionism, may diminish with ED remission. While findings consistently support
the association between perfectionism and EDs, it is uncertain whether
perfectionism is associated specifically with disordered eating, or more generally
with maladjustment.
1.2 Obsessive-compulsive traits
Obsessive-compulsive traits have been associated with disordered eating in both
university and clinical samples and are more common among individuals with EDs
than psychiatric control groups.
According to retrospective reports, childhood obsessive-compulsive traits tend to
precede and predict the development of Eds.
Anderluh et al. (2003) reported a strong dose–response relationship such that each
additional obsessive-compulsive trait increased the estimated odds of developing an
ED by nearly sevenfold. However, these findings should be interpreted with caution
due to possible recall bias.
, Recent studies suggest that individuals with ANR and BN do not differ
systematically in obsessive-compulsive traits, and that obsessional traits persist
after recovery both from AN and BN.
1.3 Impulsivity
Impulsivity is characterized by lack of forethought and failure to contemplate risks
and consequences before acting (e.g., sudden decision to binge and purge, without
considering the associated dysphoria and physical risks).
Studies examining impulsivity in ANR suggest that they are less impulsive than non-
psychiatric controls. In contrast, BN patients and outpatients are more impulsive
than individuals with ANR and non-psychiatric controls.
However, rather than reflecting an enduring personality trait, impulsivity may be
attributed to the erratic dietary patterns and emotional instability associated with
BN. In support of such claims, emotional lability and other indices of behavioral
disinhibition generally decrease following reductions in binge eating and purging.
(Longitudinal assessment of impulsivity before and after recovery from BN would
help clarify this issue).
1.4 Sensation seeking
Sensation seeking is defined as “a need for varied, novel, and complex sensations
and experiences and the willingness to take physical and social risks for the sake of
such experiences”.
Individuals with EDs characterized by bingeing behavior, purging behavior, or both
(i.e., ANB, BN, BED) tend to score higher on measures of sensation seeking than
individuals with ANR and controls.
Individuals with ANR score lower than community controls but similar to psychiatric
controls on measures of sensation seeking.
Results thus far suggest that sensation seeking is most salient among ANB, BN, and
BED individuals.
1.5 Narcissism
Narcissism reflects pathological concern with physical appearance and presentation,
need for external validation from the social environment, intense interpersonal
sensitivity, and proneness to deflation of self-esteem.
Narcissism is more characteristic of individuals with AN or BN than those with other
psychiatric disturbances (i.e., anxiety, affective, and adjustment disorders),
suggesting that it may be a unique risk factor for Eds.
Narcissism may persist after remission from BN, suggesting that it may be a trait
characteristic.
1.6 Sociotropy–autonomy
Sociotropy is a personality style characterized by concern with acceptance and
approval from others, whereas autonomy is a personality style oriented towards
independence, control, and achievement. Cross-sectional studies suggest that
disordered eating is associated with both sociotropy and autonomy in clinical
samples and university samples, however, findings should be considered preliminary
because these studies are so few in number.
Heightened vulnerability for an ED may be associated with a sociotropy–autonomy
conflict. That is, individuals with EDs may strive to maintain independence, but also
rely on interpersonal relationships for validation and self-esteem.
, Low self-esteem may mediate the relationship between autonomy and disordered
eating, whereas ambivalence over emotional expression may mediate the
relationship between sociotropy and disordered eating.
That is, women characterized by high sociotropy may be reluctant to express
emotions that may threaten their interpersonal relationships (e.g., anger), but
suppression of these emotions may make them vulnerable to ED symptomatology.
In sum, correlational research suggests that AN and BN are both characterized by
perfectionism, obsessive-compulsiveness, narcissism, sociotropy, and autonomy, whereas
impulsivity and sensation seeking are more typical of disorders characterized by bingeing.
The relationship between EDs and self-reported personality traits has also been examined
using a variety of omnibus measures of personality, including the NEO Personality Inventory,
Eysenck Personality Questionnaire, Multidimensional Personality Questionnaire, Minnesota
Multiphasic Personality Inventory, Tridimensional Personality Questionnaire, and the
Temperament and Character Inventory.
1.7 NEO Personality inventory and Eysenck Personality Questionnaire
Similar in that both instruments assess neuroticism and extraversion; however,
the NEO-PI measures the additional dimensions of conscientiousness, agreeableness,
and openness to experience whereas the EPQ measures psychoticism.
Neuroticism is characterized by a predisposition towards emotionality,
hypersensitivity, anxiety, worry, moodiness, and depression. Individuals with EDs
score higher on neuroticism than controls.
Neuroticism is also positively correlated with eating disorder symptomatology in
female university samples, and community samples and with bulimic
symptomatology in a small male university sample. These studies consistently
associate neuroticism with ED symptomatology.
The EPQ psychoticism subscale assesses characteristics such as nonconformity,
impulsivity, paranoia, and lack of empathy. Weak to nonexistent associations
between psychoticism and ED symptomatology have been found in university
samples.
High extraversion is characterized by sociability and liveliness whereas low
extraversion is characterized by introspection and reservation.
Weak to nonexistent associations between extraversion and ED symptomatology
have been found in both clinical and non-clinical samples.
The study by Gual et al. (2002), which did not support the association between
extraversion and ED symptomatology, is most persuasive because its large sample
was randomly recruited from the community.
Individuals with EDs tend to be less conscientious, less agreeable, and more open
to experience, than community controls.
However, openness to experience may only be a risk factor for EDs when combined
with high neuroticism and low agreeableness. These three traits were
characteristic of individuals with a lifetime ED, as well as those who developed an ED
in a large, community-based, prospective study.
ED symptomatology is correlated with high neuroticism and openness to
experience and low conscientiousness and agreeableness. Most studies grouped
together individuals with various EDs and compared them with non-psychiatric
