Personality and Eating Disorders
Theory and evidence suggest that personality characteristics explain important variability in the onset, course, symptoms, and treatment outcome of eating disorders. Personality is individuals’ characteristic ways of feeling, thinking, and behaving, whereas personality disorders are extreme, inflexible, or maladaptive personality traits which cause difficulties in functioning or distress. In addition to considering normal-range personality traits and personality disorders, we also consider personality pathology, or dysfunctional personality traits.
The most common eating disorders are anorexia nervosa, which is a syndrome of self-starvation; bulimia nervosa, which involves recurrent binge eating (i.e., episodes of eating an unusually large amount of food while feeling out of control) and inappropriate compensatory behaviors such as self-induced vomiting, laxative abuse, or excessive exercise; and binge-eating disorder, which involves recurrent and distressing binge eating without recurrent compensatory behaviors. In addition to considering eating disorder diagnoses, we also consider eating pathology, or dysfunctional eating behaviors and eating disorder symptoms.
The role of personality in eating disorders has been considered from three general perspectives, around which we organize this entry. First, individual differences in normal-range personality dimensions have been considered, which involves measuring an individual’s (or a group’s, e.g., those with a particular eating disorder) constellation of personality traits and comparing the pattern to that of others. This approach identifies relatively high and low levels of traits and makes an effort to describe broadly the personality of a person or group. Also, specific personality traits that are theorized to play a role in the etiology or maintenance of an eating disorder have been examined individually. Second, research has focused on the co-occurrence of personality disorders among individuals with eating disorders or eating pathology. Third, researchers have identified personality pathology patterns that cut across diagnoses of anorexia nervosa and bulimia nervosa.
The three consistent findings with respect to personality traits in eating disorders are, first, that women with eating disorders, especially those who purge (i.e., self-induce vomiting or misuse laxatives), tend to report experiencing more negative emotions than women without eating disorders. However, these reports may be influenced by symptoms of depression and anxiety, which commonly co-occur with eating disorders. Second, women with eating disorders often report they are less self-directed – in other words, less responsible, reliable, resourceful, and self-confident – than women without eating disorders. Third, women with eating disorders tend to be less extraverted than other women, and those who binge eat tend to experience fewer positive emotions.
Several specific personality traits have been a particular focus of attention among those with eating disorders. Perfectionism has been widely studied, for example. Individuals with eating disorders, especially anorexia nervosa and bulimia nervosa, tend to report elevated perfectionism relative to others. Perfectionism also tends to be stable among those with eating disorders and often persists after eating disorder symptom recovery. Another commonly studied personality trait is impulsiveness, which is generally understood to be multifaceted. In particular, negative urgency, or the propensity to act impulsively when experiencing negative emotions, appears to be elevated among individuals with all eating disorders, particularly among those with bulimia nervosa. Findings on other facets of impulsiveness have been mixed. In addition, individuals who are highly compulsive – that is, who engage in repetitive behaviors they feel driven to perform – as well as impulsive tend to report relatively high rates of eating pathology. Finally, individuals with eating disorders tend to approach socially rewarding situations but avoid taking risks in their daily lives, particularly risks that might involve a loss of face.
Personality Pathology and Personality Disorders
Personality disorders, which describe extreme, maladaptive versions of personality characteristics, affect a minority of people with eating disorders, and tend to be more common in samples of those receiving inpatient treatment for an eating disorder. The highest rates of personality disorders (ranging from 0% to 30% across studies) occur among women with eating disorders characterized by binge eating, purging, or both. The lowest rates of personality disorders (0%–14%) occur among women with anorexia nervosa.
Anorexia nervosa is often linked with personality disorders associated with perfectionism, interpersonal control, social anxiety, and sensitivity to negative evaluation by others. By contrast, eating disorders that include binge eating and compensatory behaviors are often associated with personality disorders involving emotion dysregulation, impulsivity, and suspiciousness of others.
Personality Pathology Types
Another way of conceptualizing relationships between eating disorders and personality looks for patterns in personality pathology across eating disorder diagnoses. Women with anorexia nervosa or bulimia nervosa have been found to fall into one of three types: underregulated (i.e., impulsive, emotionally and behaviorally dysregulated); overregulated (i.e., compulsive, inhibited); and normative (i.e., low levels of personality pathology). The specific proportion of women included in each category has tended to vary depending on the type of eating disorder that was predominant in the sample (i.e., anorexia nervosa, bulimia nervosa, or mixed eating disorder); however, across all samples, a large proportion of women tended to fall in the normative group (e.g., 21%–51%). This three-class typology has been widely replicated by a variety of researchers using different assessment approaches and populations.
In general, those with eating disorders tend to report greater perfectionism and neuroticism and lower extraversion and self-directedness than those without eating disorders. Those with eating disorders also report greater risk aversion and sensitivity to social rewards, such as praise, affection, and social standing. In addition, those who binge eat or purge consistently report greater impulsiveness than those who do not.
Generally, most women with eating disorders do not have co-occurring personality disorders. However, personality disorder rates are highest among those who binge eat or purge, and among inpatient samples, and rates are lowest among those with anorexia nervosa who do not binge eat or purge. When they have personality disorders, women with anorexia nervosa emphasizing dietary restriction alone tend to exhibit personality disorder symptoms of overcontrol and perfectionism. By contrast, women with eating disorders characterized by binge eating, purging, or both behaviors tend to exhibit personality disorder symptoms of impulsivity and undercontrolled emotion. When women with anorexia nervosa and bulimia nervosa are evaluated altogether, the following three personality types tend to be identified: underregulated, overregulated, and absent significant pathology.
In summary, personality traits and pathology are important theoretically and may help us better understand the etiology, maintenance, symptom expression, and effective treatment of eating disorders. The precise relationship between personality characteristics and eating disorders remains under study. Personality variables may serve as risk factors for the development of an eating disorder, but other possibilities include that eating disorder symptoms (such as semi-starvation) may affect personality, personality traits or disorders may be complications of eating disorders, personality and eating disorders may be phenomena that interact once established, or both personality and eating disorders may result from a common cause. Further research will help elucidate the role of personality in eating disorders.
- Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research review: What we have learned about the causes of eating disorders: A synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry, 56, 1141–1164. https://doi.org/10.1111/jcpp.12441.