reflect obsessive-compulsive personality in adult women with eating disorders and as- sessed the predictive value of the traits for the development of eating ...
Article
Childhood Obsessive-Compulsive Personality Traits in Adult Women With Eating Disorders: Defining a Broader Eating Disorder Phenotype Marija Brecelj Anderluh, M.D. Kate Tchanturia, Ph.D. Sophia Rabe-Hesketh, Ph.D. Janet Treasure, Ph.D., F.R.C.P., F.R.C.Psych.
Objective: The authors retrospectively examined a spectrum of childhood traits that reflect obsessive-compulsive personality in adult women with eating disorders and assessed the predictive value of the traits for the development of eating disorders. Method: In a case-control design, 44 women with anorexia nervosa, 28 women with bulimia nervosa, and 28 healthy female comparison subjects were assessed with an interview instrument that asked them to recall whether they had experienced various types of childhood behavior suggesting traits associated with obsessivecompulsive personality. The subjects also completed a self-report inventory of obsessive-compulsive disorder (OCD) symptoms. Results: Childhood obsessive-compulsive personality traits showed a high predictive
value for development of eating disorders, with the estimated odds ratio for eating disorders increasing by a factor of 6.9 for every additional trait present. Subjects with eating disorders who reported perfectionism and rigidity in childhood had significantly higher rates of obsessive-compulsive personality disorder and OCD comorbidity later in life, compared with eating disorder subjects who did not report those traits. Conclusions: Childhood traits reflecting obsessive-compulsive personality appear to be important risk factors for the development of eating disorders and may represent markers of a broader phenotype for a specific subgroup of patients with anorexia nervosa. (Am J Psychiatry 2003; 160:242–247)
T
he etiology of complex disorders such as anorexia nervosa and bulimia nervosa is likely to involve a dynamic interplay of environmental and genetic factors. New approaches in genetic research provide an opportunity to study associations between a disorder and specific genes but face a well-recognized problem of phenotypic definition. It is likely that diagnostic categories as presented in the DSM-IV do not fully correspond to underlying biological factors. One approach to specifying phenotypes is to use both axis I and axis II dimensions. The restricting subtype of anorexia nervosa is typically linked to personality traits such as perfectionism, sense of ineffectiveness, preoccupation with orderliness, and excessive persistence and compliance (1–7). Bulimia nervosa is often linked with impulsive personality traits (8, 9), but the majority of people with bulimia nervosa are also found to be perfectionistic (4). In a study of obsessive-compulsive disorder (OCD) symptoms in women with bulimia, 39% of the subjects with current bulimia or a history of bulimia were found to have obsessions related to symmetry and exactness (10). Perfectionism and preoccupation with orderliness have been found to persist after recovery from eating disorders (10–13). Perfectionism in childhood is one of the risk factors for both anorexia and bulimia (6, 14). In family studies, persons with a high level
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of perfectionism are overrepresented among healthy firstdegree relatives of patients with eating disorders, suggesting that obsessive-compulsive personality disorder, or its traits, represent a heritable factor contributing to vulnerability for both types of eating disorders (13, 15, 16). The aim of this study was to determine whether retrospectively measured childhood personality traits reflecting obsessive-compulsive personality predicted development of eating disorders. To minimize biases related to retrospective reporting, the study used a newly developed interview instrument with items based on examples of childhood behavior. The study hypothesis was that childhood traits linked to obsessive-compulsive personality are important risk factors for the development of eating disorders. The subsidiary hypothesis was that people with an eating disorder who had a high number of childhood traits reflecting obsessive-compulsive personality have a higher prevalence of this type of personality disorder and have more compulsive symptoms later in life.
Method Participants The participants consisted of three groups: 44 female patients with a DSM-IV diagnosis of anorexia nervosa (26 with the restricting type, 18 with the binge-eating/purging type), 28 female paAm J Psychiatry 160:2, February 2003
ANDERLUH, TCHANTURIA, RABE-HESKETH, ET AL. tients with a DSM-IV diagnosis of bulimia nervosa, and 28 healthy female comparison subjects. The clinical participants were recruited from the inpatient and outpatient programs of the Eating Disorders Unit of the Maudsley Hospital, London, a tertiary referral center. To avoid possible reporting biases related to an acute physical state, patients who fulfilled the diagnostic criteria and were willing to participate were entered in the study 3–4 weeks after the beginning of treatment. Exclusion criteria consisted of a history of psychotic disorder or bipolar disorder assessed according to the ICD-10 criteria. The comparison subjects were administrative staff and students from two universities in different towns in the United Kingdom. They were matched by age, sex, and educational level with the patients and were blind to the study hypothesis. The comparison subjects were of normal weight, had no personal or family history of an eating disorder or any other psychiatric disorder, and had no history of bingeing, vomiting, or abuse of laxatives. All subjects except those recruited as inpatients were reimbursed for their time. All participants were native English speakers. The study was approved by the South London and Maudsley National Health Service Trust and Institute of Psychiatry ethics committee. After complete description of the study to the subjects, written informed consent was obtained.
Procedure Specialists in the Eating Disorders Unit who were blind to the study hypothesis made the initial screening diagnoses of eating disorders using the DSM-IV criteria. Study subjects were interviewed by a trained researcher (one of six postgraduate psychologists and psychiatrists) using a semistructured interview (described in the next section). On the day of the interview, data on demographic characteristics were collected, and the subject’s weight and height were measured. Thirty interviews were recorded on audiotapes and were rerated by one of two assessors who were blind both to the previous scoring and to the subject’s diagnosis.
TABLE 1. Childhood Traits Reflecting Obsessive-Compulsive Personality and Main Areas of the Child’s Life in Which the Traits Are Assessed in the EATATE Interview Assessed Trait Perfectionism: Perfectionism is assessed separately in four areas of child’s life; the trait is regarded as present if reported to have influenced markedly the child’s life in at least two of the assessed areas. Inflexibility: Inflexibility and rule-bound trait both measure rigidity; rigidity is regarded as present if at least one of the two traits was present and markedly influenced the child’s life. Rule-bound trait: Inflexibility and rule-bound trait both measure rigidity; rigidity is regarded as present if at least one of the two traits was present and markedly influenced the child’s life. Excessive doubt and cautiousness: The trait is regarded as present if both excessive doubt and cautiousness were present and markedly influenced the child’s life. Drive for order and symmetry: The trait is regarded as present if reported to have influenced markedly the child’s life in at least two of the assessed areas.
Areas of the Child’s Life Schoolwork Self-care Looking after her room Hobbies, caring for pets, part-time job, or housework
Difficulties in adjusting to changes linked to house moves, school changes, changes in family schedule or structure, changes in planned daily activities Presence of activities to compensate for these difficulties, including written plans, making contingency plans Excessive persistence High degree of compliance with rules set by parents or teachers
Excessive doubt about actions Excessive cautiousness about making a mistake
Looking after her room Housework Appearance (dress, hair style)
Measures The instruments used in the study included the semistructured EATATE interview and the self-report Maudsley Obsessive-Compulsive Inventory. The National Adult Reading Test was used to match patients and comparison subjects in intellectual ability. The EATATE interview. The EATATE interview was developed for the European Healthy Eating Project, which examined genetic and environmental risk factors for eating disorders and obesity. (The instrument is available from the first author.) The first part, which consists of an adaptation of the Eating Disorder Examination (17), is used to identify a lifetime eating disorder diagnosis in subjects and first-degree family members. The first part also is used to assess whether the subject meets the criteria for an ICD10 lifetime diagnosis of OCD. Food and body-related obsessions are excluded as symptoms of OCD. The second part of the EATATE interview, which provided the data that are the focus of this paper, is used to assess whether the subject meets the criteria for current obsessive-compulsive personality disorder, according to the ICD10 International Personality Disorder Examination (18) module for anankastic personality disorder, and to collect data on childhood traits reflecting obsessive-compulsive personality. (An ICD10 diagnosis of anankastic personality disorder corresponds to a DSM-IV diagnosis of obsessive-compulsive personality disorder). The prototype of the assessment of childhood traits was developed in an expert meeting by collaborators on the European Healthy Eating project and other experts with extensive clinical and research experience in the field. After this session, the MEDLINE and PsycINFO databases (1965–2001) were searched for papers describing current and past personality traits linked with eating disorders. The key words used in the search were “personality,” “perfectionism,” “rigidity,” “inflexibility,” “obsessionality,” Am J Psychiatry 160:2, February 2003
“anankastic,” and “childhood.” A focus group of patients with anorexia nervosa was held to identify behavioral examples of childhood traits reflecting obsessive-compulsive personality. The behavioral examples were used in designing the EATATE interview to minimize the problems associated with retrospective reporting and to reduce rationalization. The final instrument is used to assess five childhood traits that reflect obsessive-compulsive personality (Table 1): perfectionism (e.g., Did you spend a long time doing or redoing your hair to make sure it was straight without bumps?), inflexibility (e.g., To what extent were you the sort of person who liked to make written plans/notes or have intricate details about the time ahead?), rule driven (e.g., Were you the kind of person who felt she always had to follow rules? For example, how far did you bend or break rules that were set by your parents or teachers?), drive-for-order and symmetry (e.g., While trying to get your room tidy and organized, were you particularly concerned about making sure that everything was “just so” and in its proper place?), and excessive doubt and cautiousness (e.g., Were your frightened to make a mistake as a child? Can you give an example?). The interviewer used a scoring manual to rate the responses according to predefined criteria. The interviewers were trained in the use of the manual by scoring videotaped interviews and by participating in consensus meetings where ratings were discussed. The presence of each trait was assessed together with its effect on the child’s life in terms of the child’s relationship with the world and with others. Traits were rated 0 for absent, 1 for present but not influencing the child’s life, or 2 for impinging on the child’s life or her relationship with the world or with others. Assessment of interrater reliability was based on the full 3-point scale. In all other analyses, the values 0 and 1 were not discrimihttp://ajp.psychiatryonline.org
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CHILDHOOD TRAITS AND ADULT EATING DISORDERS TABLE 2. Characteristics of Subjects With Eating Disorders and Healthy Comparison Subjects in a Study of Childhood Traits Reflecting Obsessive-Compulsive Personalitya Subjects With Anorexia Nervosa (N=44) Mean SD
Characteristic
Current age (years)b Body mass index (kg/m2) Currentc Lowest ever Highest ever National Adult Reading Test scored Age at onset of eating disorder (years) Maudsley Obsessive-Compulsive Inventory scoree,f
ICD-10 diagnosis Anankastic (obsessive-compulsive) personality disorderf Obsessive-compulsive disorderf,g
Subjects With Bulimia Nervosa (N=28) Mean SD
Healthy Comparison Subjects (N=28) Mean SD
F
Analysis df
p
27.9
9.1
26.7
9.5
25.1
5.1
0.92
2, 97
n.s.
15.9 12.2 20.7 16.4 16.3
2.8 1.8 2.6 5.6 3.6
21.6 17.1 24.2 17.8 16.8
2.0 2.6 2.4 4.0 2.8
22.1 — — 15.1 —
2.4
74.05 87.51 33.58 0.80 0.51
2, 97 1, 70 1, 70 2, 41 1, 70
