Personality Features of Women with Good Outcome from Restricting Anorexia Nervosa REGINA C. CASPER, MD Personality characteristics were assessed in women who had physically and, in the majority, psychologically recovered from restricting anorexia nervosa at an 8- to 10-year follow-up. Personality dimensions were evaluated using the Multidimensional Personality Questionnaire, the California Personality Inventory, and the Reid-Ware Scale. Women who had recovered from anorexia nervosa rated higher on risk avoidance, displayed greater restraint in emotional expression and initiative, and showed greater conformance to authority than age-matched normal women. On comparison with their sisters, the recovered women reported a greater degree of self- and impulse control and less enterprise and spontaneity; sisters, however, endorsed equally high moral standards. The differences in personality characteristics remained significant after statistically controlling for depressive symptoms and eating behavior. The results suggest that a temperamental disposition toward emotional and behavioral restraint combined with a strong sense for traditional values may be psychological risk factors for the development of the restricting type of anorexia nervosa.
INTRODUCTION
The notion that constitution and temperament interact with other factors in the development of psychopathology goes back to antiquity (1). Parallels have been drawn between a person's sanguine or melancholic disposition and the corresponding disorders mania and melancholia by Galen (1), while Kretschmer (2) linked an asthenic leptosomic constitution to introversion and schizoid features. As a hypothesis, however, the association between personality qualities and clinical condition has undergone little empirical testing until recently. Several investiga-
From The University of Chicago and Michael Reese Hospital and Medical Center, Chicago, Illinois. Address reprint requests to: Dr. Regina C. Casper, Department of Psychiatry, Michael Reese Hospital and Medical Center, Lake Shore Drive at 31st Street, Chicago. IL 60616. Received May 31.1989; revision received November 27, 1989.
156 0033-3174/90/5202-0156S02 00/0 Copyright © 1990 by the American Psycho
tors have now examined personality styles in relation to diagnosis and outcome (3-9) by applying either personality scales with established validity and reliability or by designing new inventories (10, 11) to classify adaptive and maladaptive personality traits. In anorexia nervosa, anecdotal reports and past studies have described quite a range of sometimes contradictory personality characteristics, such as compliance coexisting with obstinacy (12-15), obsessive-compulsive features, shyness and introversion along with hysterical traits and impulsivity (16, 17), or interpersonal sensitivity and stoicism (18, 19). Some investigators have claimed that patients with anorexia nervosa have no particular personality structure (20). This diversity in personality features, in part at least, may be a function of the conceptual and methodological limitations of previous studies. Commonly, patients were evaluated during the height of their illness, and as a result some of the recorded features very likely were epiPsychosomatic Medicine 52:156-170 (1990)
PERSONALITY FEATURES IN ANOREXIA NERVOSA
phenomena of the morbid process, whereas others may have been by-products of starvation. Indeed, several studies reported lower neuroticism, fewer obsessional tendencies, and higher extroversion scores with weight gain (21-23). Moreover, since investigators were not cognizant of the differences in the personalities of abstaining and bulimic anorexia nervosa patients (24-27), early reports combined the two groups for data analysis (28-30) and thus increased the chance for discrepant findings. The contribution of the personality to the development of anorexia nervosa is difficult to establish, since there is little opportunity to study children before the onset of the disorder. Furthermore, retrospective reconstruction of the premorbid childhood personality is seldom reliable. An alternate approach would be the study of the personality following recovery from the illness. If certain attributes, such as compliance, exceptional self-control, and greater impulse regulation (2130), were not merely a by-product of the illness, but constituted an integral part of the patients' personality, then one would expect such characteristics to endure. It was this reasoning which led us to study personality variables in anorexia nervosa patients in the course of a long-term follow-up study conducted 8-10 years after illness onset in comparison to normal controls. We also hypothesized that if certain personality features abetted the process of anorexia nervosa, sisters of former patients who had no history of the disorder would not share these qualities. Lastly, in light of past investigations in affective disorders (4-6, 31) and among normal populations (31), which reported an influence of mood on certain personality variables, we examined the influence of concurrent
Psychosomatic Medicine 52:156-170 (1990)
psychiatric symptoms, especially depressive mood, on the personality measures.
METHODS
Subjects All seventy-three patients evaluated and treated for anorexia nervosa between 1975 and 1978 at the Illinois State Psychiatric Institute 9 West Research unit were contacted and invited to participate in the follow-up. Three patients had died. It was possible to trace all former patients. Fifty-one (or 69%) returned in person for a prospective 8- to 10-year psychological and biological assessment (32). Of those who returned, 25% lived outside of the Chicago area and 36% came in from out of state. The sample for this study represents the 25 women from 20 to 32 years old, who were found to qualify for a good outcome from anorexia nervosa according to criteria developed by Morgan and Russell (33). The mean recovery period was 5.9 ± 2.4 years. The original diagnosis of anorexia nervosa was determined independently by two psychiatrists using the diagnostic criteria of Feighner et al.(34). Body weight and height were measured during the evaluation and expressed either as percentage of average weight for height based on Metropolitan Life Insurance Tables (35) or as Quetelet's body mass index (BMI) (36), calculated as weight divided by the square of height or kg/m2. Former patients were rated as having a good outcome if body weight had been maintained within 15% of average weight for height, sex, and age with regular cyclical menstruation. "Good outcome" and physiologically "recovered" are used interchangeably to describe this group. All women had originally presented with the restricting type of anorexia nervosa. Psychological recovery from anorexia nervosa was determined by examining how many in this sample were within the range of or exceeded the Eating Attitudes Test scores for normals by 2 SD. Eighteen women, or 72%, were within the range and called "fully recovered." Seven (18%) former patients exceeded the range; one of these with an EAT score of 85 was considered an outlier and excluded from analysis of the personality measures; she was the only patient who had developed bulimia, albeit without vomiting. The group with abnormal eating attitudes was called "good outcome with weight preoccupation." The first comparison
157
R. C. CASPER group consisted of 15 sisters of recovered patients, whoso ages ranged from 17 to 35 years. Sisters who had ever met criteria for anorexia nervosa as determined by the Diagnostic Interview Schedule (DIS) (39) were excluded. Altogether 18 among the recovered patients had sisters; the remainder had brothers or had no siblings. Two sisters did not participate, and one sister had a history of anorexia nervosa. Comparisons between good outcome patients with and without sisters revealed no significant differences for any of the variables. Another control group consisted of female college students and medical students who ranged in age from 17 to 35 years. They were recruited for the study after being screened with the Diagnostic Interview Schedule for absence of psychiatric disorders. The study was approved by the Institutional Research Committee and all participating subjects gave written informed consent.
Procedures The inventories consisted of three self-report schedules, each designed to test the full range of personality variables characterizing the normal population. Subjects were asked to describe their usual way of acting and feeling. The inventories measure general emotional adjustment and adaptive personality traits. The Multidimensional (formerly Differential) Personality Questionnaire (31, 40) is a 300item factor-analytically developed self-report instrument. Its scales describe 11 primary personality dimensions: well-being, social potency, achievement, social closeness, stress reaction, alienation, aggression, impulsivity (control), danger seeking (harm avoidance), traditionalism, and absorption. Three higher order factors are entitled "positive emotionality" (joy, vigor-calm, disengagement), "negative emotionality" (anger, anxiety-depressive disengagement), and "constraint." Cloninger (41) recently proposed three genetically independent personality dimensions—novelty seeking, harm avoidance, and reward dependence—which can be derived from the MPQ scale (40); these were calculated for all groups. The California Psychological Inventory (42) is a standardized 480-item, true/false self-report scale, describing scale scores for 18 descriptive personality attributes. Factor analysis results in three major dimensions, called person orientation, value orientation, and flexibility (control), respectively. The Reid-Ware scale (43), a 34-item questionnaire of personal beliefs, is a modified version of Rotter's (44)
158
scale of internal versus external control expectancies. The scale has three factors, a factor describing social political influence or social systems control, a factor in which luck or fate is believed to influence one's life or fatalism, and self-control The internal versus external control scale was included to test Bruch's (19) hypothesis that anorexia nervosa patients initiated actions primarily in response to external stimuli rather than in response to their own wishes and needs. The Eating Attitudes Test (45), a 40-item self-report questionnaire, and the Eating Disorders Inventory (46), were used to obtain information concerning the subjects' thinking and behavior regarding weight and eating. For evaluating psychiatric symptoms, the Beck Depression Inventory (47), a 23-item scale with statements describing dimensions of depression on a four-point scale of severity, and the Hopkins Symptom Checklist (HSCL90) (48), comprised of 90 items on a five-point scale of severity yielding scores for nine dimensions of psychopathology, were administered. The scales were given in random sequence to avoid order effects.
Statistical Analysis Recovered women and normal controls were compared by using independent two-tailed t tests with Bonferroni corrections for multiple comparisons. Analyses of covariance were performed to determine whether the differences remained significant when age, total EAT scores, and total Beck Depression scores were introduced into the model. To construct the higher order factor scores we used the loadings reported by Nichols and Schnell (49) and the loadings reported by Tellegen (31). We also used the coefficients reported by Cloninger (41) to construct his three dimensions from the MPQ: harm avoidance, reward dependence, and novelty seeking. The analysis of differences between patients recovered from anorexia nervosa and their sisters was determined by paired t tests. Analysis of covariance was used again to determine whether the differences remained significant when age, total EAT scores, and total Beck Depression scores were introduced in the model. The model in this case was analogous to a repeated measures analysis of variance model (with the recovered patients representing the first level of the repeated measure and the matched sisters as the second level) with the aforementioned covariants.
Psychosomatic Medicine 52:156-170 (1990)
PERSONALITY FEATURES IN ANOREXIA NERVOSA Discriminant function analysis was performed to examine the differences and accuracy of classification of the three groups: recovered anorectic patients, normal controls, and matched sisters of the recovered patients. Because two of these groups could not be considered independent groups (recovered patients and their matched sisters), a threegroup discriminant analysis was not performed. Instead, two separate discriminant analyses were performed, namely, one analysis comparing patients to the normal controls and another analysis comparing the patients with their matched sisters. For both analyses, only variables which significantly differentiated the two groups after covariate adjustment of the Beck depression scores and the EAT score were considered for inclusion into the discriminant function A stepwise method was used to select variables into the equation; this method allowed only variables which improved the fit of the model at the p < 0.05 level to enter the equation.
RESULTS
Age, Body Weight, Attitudes Toward Eating and Body Weight, and Psychiatric Symptoms (see Tables 1 and 2) Comparisons between patients with good outcome from anorexia nervosa and normal controls. The demographic and clinical data for all experimental groups are summarized in Table 1. The first question addressed how physiologically recovered patients compared to healthy control subjects in weight, their attitudes toward weight, and their psychological adjustment. Recovered women and normal controls were closely matched in age. Their body weight was within the normal range, standardized as either percent desirable body weight or as body mass index. Former patients displayed marginally higher Eating Attitudes Test EAT] scores than did controls (t = 2.6; p < 0.03), suggesting weight preoccupation. When we subdivided the former patient group Psychosomatic Medicine 52:156-170 (1990)
on the basis of their EAT scores, the dividing line being drawn at 2 SD above normal values, and excluding one outlier (see Methods), eating attitudes in eighteen women, or 72% of the sample, were not different from normal controls. Six of the women displayed a mean EAT score just below the cut-off point for anorexia nervosa. None of these women qualified for bulimia nervosa. They were restrictive eaters, were diet- and calorie-conscious, described self-control around food, for instance many ate the same foods every day, and reported that they gave too much time and thought to food. Recovered women reported more depressive symptoms than controls. To examine whether the women who had a high EAT score differed in the degree of depression from women with a low EAT score, we subdivided and contrasted the groups (Table 2). Women with a high EAT score were clinically depressed, whereas the depression scores for women with normal eating attitudes were not different from those of controls. On the Eating Disorders Inventory (Table 2), which records feelings about the self aside from eating and weight concerns, recovered patients as a group displayed a greater drive for thinness, a greater sense of ineffectiveness, and less interoceptive awareness than controls. We then examined whether feelings of depression influenced dimensions on the Eating Disorders Inventory (EDI) by conducting an analysis of covariance with the Beck Depression Inventory total score as covariate. Depression significantly affected six of the eight variables: drive for thinness (F = 11.8; p < 0.001), body dissatisfaction (F = 13.7; p < 0.001), interoceptive awareness (F = 73.1; p < 0.000), ineffectiveness (F = 101.0; p < 0.000), maturity fears (F = 28.8; p < 0.000), and 159
R. C. CASPER TABLE 1. Study Population Age (Years)
Body weight (% Ideal)
Body mass index (BMI)
Eating Attitudes Test
Beck Depression Inventory
Good outcome from anorexia nervosa (N = 25) Divided into Fully recovered from anorexia nervosa (N = 18) Good outcome with weight preoccupation (N = 6)
24.7 3.4
101.1 10.9
20.9 2.5
19.0(C)6 17.1
9.8(C) 10.6
24.8 3.1 25.0 4.5
102.1 11.4 99.2 10.8
21.2 2.7 20.5 2.3
11.4 4.9 30.7(C) 9.2
61 9.0 17.1(C) 6.2
Healthy controls (N = 23)
25.6 4.6
103.7 8.1
Sisters of recovered patients (N=15) Paired recovered anorexia nervosa group (N = 15)
26.2 5.2 25.7 3.1
103.9 10.9 98.5 8.6
21.0 1.6 21.4 1.7 20.2 16
9.4 5.4 14.0 9.5 17.5 11.6
2.5 2.8 5.0 5.1 10.1 10.6
J Values are means and SD unless otherwise indicated. '' C = Healthy controls, with group differences at a probability level of p < 0.05 with Bonferroni
interpersonal distrust (F = 9.6; p < 0.004). After covarying for the depressive symptoms, recovered patients did not differ from control subjects on any of the EDI factors. Conversely, eating attitudes (total EAT score) had a significant effect on three of the nine scales of the Hopkins Symptom Checklist (Table 2): depression, hostility, and psychoticism, which distinguished recovered patients from controls (depression F = 19.0, p < 0.000; hostility F = 21.5. p < 0.000; psychoticism F = 3.9, p < 0.05), eliminating the significance of the differences. Comparisons between good outcome patients and their sisters. Fifteen patientsister pairs were studied. If patients had more than one sister they were paired to the sister who was closest in age. We first examined whether sisters who were younger than patients differed on any measure displayed in Tables 1 and 2 from sisters who were older. The only difference observed was greater maturity fears (EDI) in younger sisters (t = 0.3; p < 0.03). 160
Tables 1 and 2 show that patients with good outcome from anorexia nervosa did not differ from their sisters in age, body weight, Eating Attitude Test scores, Beck Depression Inventory scores or psychiatric symptoms. Only on two scales of the Eating Disorder Inventory, ineffectiveness (t = 2.3; p < 0.04) and interpersonal distrust (t = 2.4; p < 0.03), did recovered patients rate slightly higher than sisters. Personality dimensions. The principal hypothesis tested here was that patients who had recovered from the restricting form of anorexia nervosa would continue to show restrictive personality tendencies in areas unrelated to eating when compared with age-matched healthy women or sisters. In Table 3, we present first the results on the 11 primary scales and 3 higher order factors from the Tellegen Multidimensional Personality Questionnaire, MPQ (40), followed by the MPQderived Tridimensional Questionnaire factors (41). In the lower section the 18 scales and 3 higher order factors from the Psychosomatic Medicine 52:156-170 (1990)
PERSONALITY FEATURES IN ANOREXIA NERVOSA
TABLE 2. Comparison of Eating Disorders Inventory and Hopkins Symptom Checklist Scores Good outcome from anorexia nervosa (N = 25) Mean Eating Disorders Inventory Drive for thinness Interoceptive awareness Bulimia Body dissatisfaction Ineffectiveness Maturity fears Perfectionism Interpersonal distrust Hopkins Symptom Checklist (HSCL-90) Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism
SD
Healtny controls (N = 19)
Mean
Sisters of recovered f
P
SD
anorexia nervosa pts. ( N = 15) Mean
SD
10.4
0.5
INTRODUCTION
The notion that constitution and temperament interact with other factors in the development of psychopathology goes back to antiquity (1). Parallels have been drawn between a person's sanguine or melancholic disposition and the corresponding disorders mania and melancholia by Galen (1), while Kretschmer (2) linked an asthenic leptosomic constitution to introversion and schizoid features. As a hypothesis, however, the association between personality qualities and clinical condition has undergone little empirical testing until recently. Several investiga-
From The University of Chicago and Michael Reese Hospital and Medical Center, Chicago, Illinois. Address reprint requests to: Dr. Regina C. Casper, Department of Psychiatry, Michael Reese Hospital and Medical Center, Lake Shore Drive at 31st Street, Chicago. IL 60616. Received May 31.1989; revision received November 27, 1989.
156 0033-3174/90/5202-0156S02 00/0 Copyright © 1990 by the American Psycho
tors have now examined personality styles in relation to diagnosis and outcome (3-9) by applying either personality scales with established validity and reliability or by designing new inventories (10, 11) to classify adaptive and maladaptive personality traits. In anorexia nervosa, anecdotal reports and past studies have described quite a range of sometimes contradictory personality characteristics, such as compliance coexisting with obstinacy (12-15), obsessive-compulsive features, shyness and introversion along with hysterical traits and impulsivity (16, 17), or interpersonal sensitivity and stoicism (18, 19). Some investigators have claimed that patients with anorexia nervosa have no particular personality structure (20). This diversity in personality features, in part at least, may be a function of the conceptual and methodological limitations of previous studies. Commonly, patients were evaluated during the height of their illness, and as a result some of the recorded features very likely were epiPsychosomatic Medicine 52:156-170 (1990)
PERSONALITY FEATURES IN ANOREXIA NERVOSA
phenomena of the morbid process, whereas others may have been by-products of starvation. Indeed, several studies reported lower neuroticism, fewer obsessional tendencies, and higher extroversion scores with weight gain (21-23). Moreover, since investigators were not cognizant of the differences in the personalities of abstaining and bulimic anorexia nervosa patients (24-27), early reports combined the two groups for data analysis (28-30) and thus increased the chance for discrepant findings. The contribution of the personality to the development of anorexia nervosa is difficult to establish, since there is little opportunity to study children before the onset of the disorder. Furthermore, retrospective reconstruction of the premorbid childhood personality is seldom reliable. An alternate approach would be the study of the personality following recovery from the illness. If certain attributes, such as compliance, exceptional self-control, and greater impulse regulation (2130), were not merely a by-product of the illness, but constituted an integral part of the patients' personality, then one would expect such characteristics to endure. It was this reasoning which led us to study personality variables in anorexia nervosa patients in the course of a long-term follow-up study conducted 8-10 years after illness onset in comparison to normal controls. We also hypothesized that if certain personality features abetted the process of anorexia nervosa, sisters of former patients who had no history of the disorder would not share these qualities. Lastly, in light of past investigations in affective disorders (4-6, 31) and among normal populations (31), which reported an influence of mood on certain personality variables, we examined the influence of concurrent
Psychosomatic Medicine 52:156-170 (1990)
psychiatric symptoms, especially depressive mood, on the personality measures.
METHODS
Subjects All seventy-three patients evaluated and treated for anorexia nervosa between 1975 and 1978 at the Illinois State Psychiatric Institute 9 West Research unit were contacted and invited to participate in the follow-up. Three patients had died. It was possible to trace all former patients. Fifty-one (or 69%) returned in person for a prospective 8- to 10-year psychological and biological assessment (32). Of those who returned, 25% lived outside of the Chicago area and 36% came in from out of state. The sample for this study represents the 25 women from 20 to 32 years old, who were found to qualify for a good outcome from anorexia nervosa according to criteria developed by Morgan and Russell (33). The mean recovery period was 5.9 ± 2.4 years. The original diagnosis of anorexia nervosa was determined independently by two psychiatrists using the diagnostic criteria of Feighner et al.(34). Body weight and height were measured during the evaluation and expressed either as percentage of average weight for height based on Metropolitan Life Insurance Tables (35) or as Quetelet's body mass index (BMI) (36), calculated as weight divided by the square of height or kg/m2. Former patients were rated as having a good outcome if body weight had been maintained within 15% of average weight for height, sex, and age with regular cyclical menstruation. "Good outcome" and physiologically "recovered" are used interchangeably to describe this group. All women had originally presented with the restricting type of anorexia nervosa. Psychological recovery from anorexia nervosa was determined by examining how many in this sample were within the range of or exceeded the Eating Attitudes Test scores for normals by 2 SD. Eighteen women, or 72%, were within the range and called "fully recovered." Seven (18%) former patients exceeded the range; one of these with an EAT score of 85 was considered an outlier and excluded from analysis of the personality measures; she was the only patient who had developed bulimia, albeit without vomiting. The group with abnormal eating attitudes was called "good outcome with weight preoccupation." The first comparison
157
R. C. CASPER group consisted of 15 sisters of recovered patients, whoso ages ranged from 17 to 35 years. Sisters who had ever met criteria for anorexia nervosa as determined by the Diagnostic Interview Schedule (DIS) (39) were excluded. Altogether 18 among the recovered patients had sisters; the remainder had brothers or had no siblings. Two sisters did not participate, and one sister had a history of anorexia nervosa. Comparisons between good outcome patients with and without sisters revealed no significant differences for any of the variables. Another control group consisted of female college students and medical students who ranged in age from 17 to 35 years. They were recruited for the study after being screened with the Diagnostic Interview Schedule for absence of psychiatric disorders. The study was approved by the Institutional Research Committee and all participating subjects gave written informed consent.
Procedures The inventories consisted of three self-report schedules, each designed to test the full range of personality variables characterizing the normal population. Subjects were asked to describe their usual way of acting and feeling. The inventories measure general emotional adjustment and adaptive personality traits. The Multidimensional (formerly Differential) Personality Questionnaire (31, 40) is a 300item factor-analytically developed self-report instrument. Its scales describe 11 primary personality dimensions: well-being, social potency, achievement, social closeness, stress reaction, alienation, aggression, impulsivity (control), danger seeking (harm avoidance), traditionalism, and absorption. Three higher order factors are entitled "positive emotionality" (joy, vigor-calm, disengagement), "negative emotionality" (anger, anxiety-depressive disengagement), and "constraint." Cloninger (41) recently proposed three genetically independent personality dimensions—novelty seeking, harm avoidance, and reward dependence—which can be derived from the MPQ scale (40); these were calculated for all groups. The California Psychological Inventory (42) is a standardized 480-item, true/false self-report scale, describing scale scores for 18 descriptive personality attributes. Factor analysis results in three major dimensions, called person orientation, value orientation, and flexibility (control), respectively. The Reid-Ware scale (43), a 34-item questionnaire of personal beliefs, is a modified version of Rotter's (44)
158
scale of internal versus external control expectancies. The scale has three factors, a factor describing social political influence or social systems control, a factor in which luck or fate is believed to influence one's life or fatalism, and self-control The internal versus external control scale was included to test Bruch's (19) hypothesis that anorexia nervosa patients initiated actions primarily in response to external stimuli rather than in response to their own wishes and needs. The Eating Attitudes Test (45), a 40-item self-report questionnaire, and the Eating Disorders Inventory (46), were used to obtain information concerning the subjects' thinking and behavior regarding weight and eating. For evaluating psychiatric symptoms, the Beck Depression Inventory (47), a 23-item scale with statements describing dimensions of depression on a four-point scale of severity, and the Hopkins Symptom Checklist (HSCL90) (48), comprised of 90 items on a five-point scale of severity yielding scores for nine dimensions of psychopathology, were administered. The scales were given in random sequence to avoid order effects.
Statistical Analysis Recovered women and normal controls were compared by using independent two-tailed t tests with Bonferroni corrections for multiple comparisons. Analyses of covariance were performed to determine whether the differences remained significant when age, total EAT scores, and total Beck Depression scores were introduced into the model. To construct the higher order factor scores we used the loadings reported by Nichols and Schnell (49) and the loadings reported by Tellegen (31). We also used the coefficients reported by Cloninger (41) to construct his three dimensions from the MPQ: harm avoidance, reward dependence, and novelty seeking. The analysis of differences between patients recovered from anorexia nervosa and their sisters was determined by paired t tests. Analysis of covariance was used again to determine whether the differences remained significant when age, total EAT scores, and total Beck Depression scores were introduced in the model. The model in this case was analogous to a repeated measures analysis of variance model (with the recovered patients representing the first level of the repeated measure and the matched sisters as the second level) with the aforementioned covariants.
Psychosomatic Medicine 52:156-170 (1990)
PERSONALITY FEATURES IN ANOREXIA NERVOSA Discriminant function analysis was performed to examine the differences and accuracy of classification of the three groups: recovered anorectic patients, normal controls, and matched sisters of the recovered patients. Because two of these groups could not be considered independent groups (recovered patients and their matched sisters), a threegroup discriminant analysis was not performed. Instead, two separate discriminant analyses were performed, namely, one analysis comparing patients to the normal controls and another analysis comparing the patients with their matched sisters. For both analyses, only variables which significantly differentiated the two groups after covariate adjustment of the Beck depression scores and the EAT score were considered for inclusion into the discriminant function A stepwise method was used to select variables into the equation; this method allowed only variables which improved the fit of the model at the p < 0.05 level to enter the equation.
RESULTS
Age, Body Weight, Attitudes Toward Eating and Body Weight, and Psychiatric Symptoms (see Tables 1 and 2) Comparisons between patients with good outcome from anorexia nervosa and normal controls. The demographic and clinical data for all experimental groups are summarized in Table 1. The first question addressed how physiologically recovered patients compared to healthy control subjects in weight, their attitudes toward weight, and their psychological adjustment. Recovered women and normal controls were closely matched in age. Their body weight was within the normal range, standardized as either percent desirable body weight or as body mass index. Former patients displayed marginally higher Eating Attitudes Test EAT] scores than did controls (t = 2.6; p < 0.03), suggesting weight preoccupation. When we subdivided the former patient group Psychosomatic Medicine 52:156-170 (1990)
on the basis of their EAT scores, the dividing line being drawn at 2 SD above normal values, and excluding one outlier (see Methods), eating attitudes in eighteen women, or 72% of the sample, were not different from normal controls. Six of the women displayed a mean EAT score just below the cut-off point for anorexia nervosa. None of these women qualified for bulimia nervosa. They were restrictive eaters, were diet- and calorie-conscious, described self-control around food, for instance many ate the same foods every day, and reported that they gave too much time and thought to food. Recovered women reported more depressive symptoms than controls. To examine whether the women who had a high EAT score differed in the degree of depression from women with a low EAT score, we subdivided and contrasted the groups (Table 2). Women with a high EAT score were clinically depressed, whereas the depression scores for women with normal eating attitudes were not different from those of controls. On the Eating Disorders Inventory (Table 2), which records feelings about the self aside from eating and weight concerns, recovered patients as a group displayed a greater drive for thinness, a greater sense of ineffectiveness, and less interoceptive awareness than controls. We then examined whether feelings of depression influenced dimensions on the Eating Disorders Inventory (EDI) by conducting an analysis of covariance with the Beck Depression Inventory total score as covariate. Depression significantly affected six of the eight variables: drive for thinness (F = 11.8; p < 0.001), body dissatisfaction (F = 13.7; p < 0.001), interoceptive awareness (F = 73.1; p < 0.000), ineffectiveness (F = 101.0; p < 0.000), maturity fears (F = 28.8; p < 0.000), and 159
R. C. CASPER TABLE 1. Study Population Age (Years)
Body weight (% Ideal)
Body mass index (BMI)
Eating Attitudes Test
Beck Depression Inventory
Good outcome from anorexia nervosa (N = 25) Divided into Fully recovered from anorexia nervosa (N = 18) Good outcome with weight preoccupation (N = 6)
24.7 3.4
101.1 10.9
20.9 2.5
19.0(C)6 17.1
9.8(C) 10.6
24.8 3.1 25.0 4.5
102.1 11.4 99.2 10.8
21.2 2.7 20.5 2.3
11.4 4.9 30.7(C) 9.2
61 9.0 17.1(C) 6.2
Healthy controls (N = 23)
25.6 4.6
103.7 8.1
Sisters of recovered patients (N=15) Paired recovered anorexia nervosa group (N = 15)
26.2 5.2 25.7 3.1
103.9 10.9 98.5 8.6
21.0 1.6 21.4 1.7 20.2 16
9.4 5.4 14.0 9.5 17.5 11.6
2.5 2.8 5.0 5.1 10.1 10.6
J Values are means and SD unless otherwise indicated. '' C = Healthy controls, with group differences at a probability level of p < 0.05 with Bonferroni
interpersonal distrust (F = 9.6; p < 0.004). After covarying for the depressive symptoms, recovered patients did not differ from control subjects on any of the EDI factors. Conversely, eating attitudes (total EAT score) had a significant effect on three of the nine scales of the Hopkins Symptom Checklist (Table 2): depression, hostility, and psychoticism, which distinguished recovered patients from controls (depression F = 19.0, p < 0.000; hostility F = 21.5. p < 0.000; psychoticism F = 3.9, p < 0.05), eliminating the significance of the differences. Comparisons between good outcome patients and their sisters. Fifteen patientsister pairs were studied. If patients had more than one sister they were paired to the sister who was closest in age. We first examined whether sisters who were younger than patients differed on any measure displayed in Tables 1 and 2 from sisters who were older. The only difference observed was greater maturity fears (EDI) in younger sisters (t = 0.3; p < 0.03). 160
Tables 1 and 2 show that patients with good outcome from anorexia nervosa did not differ from their sisters in age, body weight, Eating Attitude Test scores, Beck Depression Inventory scores or psychiatric symptoms. Only on two scales of the Eating Disorder Inventory, ineffectiveness (t = 2.3; p < 0.04) and interpersonal distrust (t = 2.4; p < 0.03), did recovered patients rate slightly higher than sisters. Personality dimensions. The principal hypothesis tested here was that patients who had recovered from the restricting form of anorexia nervosa would continue to show restrictive personality tendencies in areas unrelated to eating when compared with age-matched healthy women or sisters. In Table 3, we present first the results on the 11 primary scales and 3 higher order factors from the Tellegen Multidimensional Personality Questionnaire, MPQ (40), followed by the MPQderived Tridimensional Questionnaire factors (41). In the lower section the 18 scales and 3 higher order factors from the Psychosomatic Medicine 52:156-170 (1990)
PERSONALITY FEATURES IN ANOREXIA NERVOSA
TABLE 2. Comparison of Eating Disorders Inventory and Hopkins Symptom Checklist Scores Good outcome from anorexia nervosa (N = 25) Mean Eating Disorders Inventory Drive for thinness Interoceptive awareness Bulimia Body dissatisfaction Ineffectiveness Maturity fears Perfectionism Interpersonal distrust Hopkins Symptom Checklist (HSCL-90) Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism
SD
Healtny controls (N = 19)
Mean
Sisters of recovered f
P
SD
anorexia nervosa pts. ( N = 15) Mean
SD
10.4
0.5
