Eating Disorder Personality
Is there One?
Is there such a thing as personality traits that can predict the development of an eating disorder? I don’t think so.
I do think that different cultures preferentially judge some personality traits as being more attractive than others and that these judgments subsequently frame the experience of social exclusion or inclusion for individuals in those respective cultures.
Also, personality traits are not uniformly expressed as specific behaviours across all cultures, and that fact provides further evidence that we are not limited to the inviolate traits vs. malleable states, but rather there is variable expression of both traits and states based on social and environmental pressures.
I’ll try to unravel it all to make more sense.
First of all, a personality trait is considered a persevering and reasonably unwavering element of a person. A state is a changeable and variable expression of the person’s mood. For example if you have a frustrating day and are subsequently short-tempered, your ill temper is a state and not an inherent personality trait. Conversely, if you usually find large social gatherings tiring and would prefer not to attend them, then that will likely be an inherent personality trait of yours, namely introversion.
In societies where introversion is more highly prized as an inherent trait, for example in China, then the expression of the trait is less moderated over time than it is for someone who is introverted and lives in the United States, where introversion is frowned upon.
Big Five Personality Traits
For any of you with an introductory psychology course under your belt, you were inducted into the School of Personality and were shown the amazing evidence that all human beings have five basic personality traits that remain fairly constant throughout life.
Each trait is a spectrum:
Openness to experience: inventive and curious at one end of the spectrum, and consistent and cautious at the other.
Conscientiousness: efficient and organized vs. easy going/careless
Extraversion: outgoing and energetic vs. solitary and reserved
Agreeableness: friendly and compassionate vs. cold and reserved
Neuroticism: sensitive and nervous vs. secure and confident.
Where you fall out in each of the five traits is supposedly highly consistent throughout your life. Each trait has heritability ratings of approximately 50%—suggesting that half of the expression of the trait is due to environmental inputs and the remaining half is genetic in origin.
The trait definitions are so subjective that you can already define what would be considered an attractive set of traits to have in our western cultures (where the Big Five were developed): open, conscientious, extraverted, agreeable and emotionally stable.
The least attractive personality would be: closed, careless, reserved, cold and neurotic.
When personality traits are loaded in this way then obviously the application of the traits is greatly impacted by cultural pressures. Seriously, who would ever want to be labeled as “neurotic”?
I had an infectious disease specialist once tell me I was neurotic. My husband had a wonderful rejoinder to that dismissive statement: “Well we know that, but that’s not actually why we are here.” I brought my husband into the consult precisely because I know all too well that I am “only a woman” when I am a patient. Naturally, I fired the guy and got appropriate treatment elsewhere (and in case you’re wondering, I did have an infection that was fully treated!).
While the Big Five Personality Traits may have value in the labs of psychologists in the developed nations, they have infiltrated completely inappropriate areas of application. You can use the self-report questionnaire for the Big Five to determine if an ex-pat is more or less likely to leave a foreign post early? Really?
Test-retest correlations for the Big Five tend to decay as the time intervals between assessments get longer. Far from being stable traits over a lifetime, there are in fact vanishingly small coefficients obtained for agreeableness and neuroticism over a 40-year span. Furthermore, in what has been identified as the maturity principle, people generally become more dominant, agreeable, conscientious and emotionally stable over the course of adult life (measured up to late middle-age). [1]
“Those individuals who tend to change the least over time are often those who already show the dispositional signature associated with maturity—low neuroticism and high agreeableness, conscientiousness and extraversion.”
That the maturity principle leads all of us to eventually develop an open, conscientious, extraverted, agreeable and emotionally stable set of personality traits is a critical point I will return to later in this post.
Clusters of Personalities Traits for Eating Disorder Subtypes
Researcher Laurence Claes and his colleagues were able to show that eating disordered patients (N=335) tended to fall into three basic groups when assessed using the Big Five Personality Traits: 1) a resilient, high-functioning cluster with no clinical elevations on the NEO-Five Factor Inventory, 2) a cluster scoring high on neuroticism and conscientiousness, low on openness to experience and 3) an under-controlled dysregulated group with elevated scores for neuroticism and low scores for conscientiousness and agreeableness. [3]
Although in other studies anorexics cluster in the second category and bulimics cluster in the third category, Claes found that cluster membership was not associated with specific eating disorder subtypes.
So clearly, the correlations between particular personality traits and specific facets of eating disorders are non-existent. The traits arre spread across clusters that you would see in the population at large. Nonetheless generalizations still persist in the mainstream that link anorexia with perfectionism and bulimia with impulsivity.
Perfectionism
Perfectionism is one of eight facets that have been identified for one of the five personality traits called conscientiousness (see above section on the Big Five Personality Traits). The eight facets of conscientiousness are: industriousness, perfectionism, tidiness, procrastination refrainment, control, cautiousness, task planning, and perseverance.
In broad brush strokes, perfectionism can be said to be expressed in both internal and external ways. You can be driven to always best yourself (internal) and/or be driven to ensure others perceive you as perfect (external).
“…perfectionism is a robust, discriminating characteristic of anorexia nervosa. Perfectionism is likely to be one of a cluster of phenotypic trait variables associated with a genetic diathesis for anorexia nervosa.”
Numerous studies link anorexia nervosa to anxiety disorders, obsessive-compulsive disorder and perfectionism. But, as we all know, links do not reveal causation.
“…inspite of the impressive clinical convergence over the personality traits characteristic of patients with anorexia nervosa, it is proven difficult to determine if such a constellation reflects a cause or effect of the eating disorder.”
And that merits repeating: perfectionism may very well be the result of the neurobiological impacts of an active eating disorder.
Impulsiveness
Of course, because bulimia nervosa is considered a distinct mental disorder within the DSM, studies looking at personality traits and eating disorders distinguish between the facets of the eating disorder as they relate to dominant personality traits. The dominant personality trait often highlighted for bulimia is the mirror image of anorexia: instead of high-conscientiousness, there is low conscientiousness. Or, instead of perfectionism, there is impulsivity.
Specifically, bulimic patients supposedly do not suffer from lack of planning, but rather a marked increase in urgency and a tendency to act rashly when experiencing negative affect. [6]
Despite numerous attempts to classify self-harming, drug-abusing bulimics as a distinct subtype of the eating disorder spectrum (multi-impulsivity bulimia), studies have failed to corroborate the theory that these behaviours will co-exist with any dependability in those with bulimia. [7]
We also have to remember that almost two-thirds of all patients who begin their experience on the eating disorder spectrum with anorexia nervosa, develop bulimia nervosa within eight years of the onset of the condition. [8] Given that fact, obviously personality trait clusters are not a dependable way to identify particular facets of the eating disorder spectrum, given that those facets are changeable over time.
And as with the studies of anorexia nervosa and perfectionism, bulimia nervosa and impulsivity may correlate at times, but data provide us with no causative agents.
Acting, Agent and Author—the Trinity of Personality
Returning yet again to the Big Five Personality Traits and the maturity principle, how do these supposedly stable traits actually modify over time for the population at large?
The three faces of personality: acting (behaviour), agency (striving) and authoring (narrating), may help explain how ostensibly immovable personality traits can moderate over time.
Heavily borrowing from the work of McAdams and Olson, our innate temperaments at birth correlate to the development of the Big Five personality traits. [9] These are our behaviours. However, by age seven or eight, we have developed full-fledged agency: we can identify our goals and strive to achieve them. By the time we are in adolescence we begin to imagine our own trajectories and life stories in relation to our peers and the cultures in which we live (authoring our lives). Both agency and authoring greatly impact how we apply the traits we have. Essentially, we become adept at selectively applying behaviours that will help us achieve goals and hence create a life story that is consistent with our own view of ourselves.
By the time a child is four years old, a child born with an introverted and cautious temperament may develop the following Big Five Personality traits: more closed than open to new experience, more conscientious than easy going, more solitary than social, more reserved than friendly and more anxious than calm.
However, by the time this child is eight years old, they have decided they want to learn gymnastics. Their agency now pushes back on those personality traits. They moderate their anxiety and distaste for new experiences so that they might become a gymnast. In college they determine that they would like an intimate partner so they further moderate any social anxiety and reserved nature to get out and meet new people.
By the time that child is now 40, we find them with a career in the United Nations involved in the logistics of supporting various refugee camps around the world. They have lived abroad with their partner and two children in various developing nations for long periods of time thanks to the job. Tested on the Big Five yet again at age 42, they are now more open to new experience than they were at age four; they have stayed highly conscientious; while still preferring solitary pursuits over social ones, they now score lower now than they once did on introversion and they are now neutrally neither reserved nor friendly; and finally, they are more calm than anxious.
I would argue that the maturity principle is meant to be the natural trajectory of all our lives and that while we may all begin at different points along the maturity scale, we do essentially even out by mid-life.
Yet that natural progression is not always the case for everyone. I believe the primary reason for the persistence of personality traits that are disjointed from cultural norms and remain unchanged as a person ages, is that there is an unwanted introduction of illness during that maturation process.
Arrested Development
Any circumstance that inhibits or hinders a child’s ability to develop both agency and authorship of their life, will obviously suspend the complex interplay of personality trait expression and maturation.
If you are not one of the lucky ones essentially born mature, then the personality traits you have at the age of onset of an illness or chronic disease state will not only become self-reinforcing, but will also generate a poor overall prognosis for the illness itself. [10],[11],[12],[13]
If we take several hundred average teenagers who all naturally score higher on neuroticism and lower on conscientiousness than they will be when they reach mid-life, and then we arbitrarily assign half of them to a chronic illness and the others to general good health, then how do those environments impact the innate personality traits?
How many everyday circumstances will generate anxiety for you if you have asthma, Type I diabetes, or rheumatoid arthritis? If you have ever forgotten your inhaler or insulin kit, then increasing neuroticism and anxiety will obviously be reinforced.
Within fairly short order, the teens with chronic illness look to have personality traits that separate them from their healthy peers. By their mid-twenties, their personality trait development towards lower neuroticism and higher agreeableness has been arrested while their peers continue along the maturation scale unimpeded.
About the Food
“It’s About the Food” is an extremely controversial statement, even in this day and age, when it comes to discussions about the eating disorder spectrum.
It is a foundational concept of child psychology to assume that human beings naturally develop using the maturity principle: we all achieve development milestones with some variation in time frames, but nonetheless progress sequentially as expected. A child in crisis is one for whom circumstances, environmental and/or genetic, have intervened to move the child off of their natural course towards maturity.
A chronic condition or illness will put you in suspended maturation. And unless and until you can have a manageable remission of the condition or illness, then you do not have the resources to mature.
For eating disorders there is a kind of triple hit as well: 1) your brain cannot think when you are starving, so you are less likely to have the neural capability to moderate your agentic-self or develop sophisticated authorship; 2) you are really ill and so your dependency on your parents increases rather than naturally decreases (and usually exactly at the time when you would be developing your independence from them); and 3) everyone increasingly expects you to mature and so you experience more rejection and fear of abandonment that only entrenches less mature personality traits.
Without proper nourishment, weight restoration and physical repair to achieve complete remission, how exactly can you apply the maturity principle in your life? You cannot.
On the one hand, you need to re-assess your childhood; see your parents as the lovely but ultimately very flawed and equal-to-you human beings they are; reassign goals to suit your personality and environment (a more mature application of agency); and rewrite a more realistic and less rose-tinted-spectacled (or black-tinted as the case may be) version of the narrative of your life.
On the other hand you cannot get any traction when you still need to believe parents are superhuman; no goal is unreasonable; and any failure is yours and not your parents’ because the alternate possibility threatens your belief in their ability to save you.
Eat first, mature second.
Persistence of “It’s NOT About the Food”
That there are still many treatment programs that reinforce the necessity of patients with eating disorders coming to terms with the underlying “reasons” for their restrictive eating behaviours as a way to achieve “true healing”, has everything to do with eating disorders being classified within the DSM (diagnostic and statistical manual of mental disorders).
Of course, there was a time when asthma was in the DSM. Thank goodness for progress.
Understandably in the time of Hilde Bruch, the woman who wrote the seminal book on anorexia nervosa in 1978 (The Golden Cage: the Enigma of Anorexia Nervosa) not much was known about the brain as a social organ.
Now, however, there is no excuse for continuing to confuse correlations with causation.
We don’t know what causes any patient to persist with restricted eating behaviours. There appear to be some real physiological changes in the brains of those who suffer from restrictive eating behaviours, but those physiological changes are not due to cold and distant mothers or overly protective fathers or any other correlative environmental concoction you care to name.
If certain personalities are prone to eating disorders then I should have an eating disorder given my history with neuroticism and perfectionism. It’s not about neuroticism or perfectionism, although certainly those traits are exacerbated when an eating disorder hits.
The basic drive to self-administer starvation is beyond our cognitive connections to the brain structures impacted by the physiological shifts that mark the eating disorder spectrum. Somewhere within those physiological shifts in older parts of our brain is the real cause of the drive to restrict, but we may never be able to explain it or frame it in a cognitive sense.
Instead, we resort to scanning the environment to place meaning on that drive after the fact. But that meaning we assign is not the cause of the condition.
What if we stopped trying to assign meaning? What if we just accepted that those who are on the restrictive eating disorder spectrum have a drive to starve that defies explanation, but nonetheless we have to somehow wrestle it all into remission?
In a way, this is what the Maudsley (now Family Based Treatment) treatment approach attempts to address—re-feed first and then determine if developmental issues persist. Of course the Maudsley approach is specifically targeted at young patients (children and adolescents).
But I believe the same priorities exist for adult patients, whether they have shuffled through rounds of treatment programs; have been sub-clinical the entire time; or have had relapses and remissions in cyclical fashion.
Eat first, mature second.
If I use myself as some kind of a parallel marker, I can tell you that maturation happens under its own steam. I can also tell you that maturation is definitely suspended for young patients struggling with other medical chronic conditions. If the illness or condition is unmanageable and not in remission, then maturation will remain out of reach, no matter the patient involved.
You have to create an environment that is conducive to your efforts to mature, and starvation is definitely not an enabling environment.
Eat first, mature second.
McAdams, Dan P., and Bradley D. Olson. "Personality development: Continuity and change over the life course." Annual review of psychology 61 (2010): 517-542.
ibid.
Claes, Laurence, Walter Vandereycken, Patrick Luyten, Bart Soenens, Guido Pieters, and Hans Vertommen. "Personality prototypes in eating disorders based on the Big Five model." Journal of Personality Disorders 20, no. 4 (2006): 401-416.
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