Studying the impact of personality traits in people with eating disorders
From a clinical and research perspective, Eating Disorders (EDs) are interesting, almost unique, in that despite not wanting to have an ED, many people continue to engage in behaviour that can be dangerous and even deadly. More concerning is that people with an ED can often have a poor prognosis, with limited evidence of effective treatment options (Scherr, Ferraro, & Weatherly, 2010). This is particularly true for those with anorexia (Zeeck et al., 2018), but also for groups of people with bulimia or binge eating disorder (Eddy et al., 2007). This leaves researchers with a difficult question: how can we improve outcomes for people living with the deadliest of psychiatric disorders (APA, 2013; Scherr et al., 2010)?
An interesting question that has been raised in the search for interventions to improve treatment outcomes is, can EDs be conceptualised differently? Can we look at them in a different, more helpful, way? Researchers at Swinburne University have called for EDs to be renamed “body image disorders,” while other researchers have argued that classifying EDs according to personality factors may be more effective (Thompson-Brenner et al., 2008; Wildes et al., 2011). Research dating back to the early 1980s has suggested that people can be classified along a spectrum ranging from “Over-Control” (OC) to “Under-Control” (UC) with a group of “resilient” people in the middle of the two poles. Those in the middle are able to respond flexibly to challenges when they arise (Chapman & Goldberg, 2011; Eisenberg, Fabes, Guthrie, & Reiser, 2000; Steca, Alessandri, & Caprara, 2010).
When this theory has been applied to people with EDs, it has been identified that most people with anorexia are either OC or resilient, and those with bulimia tend to be resilient or UC. However, there are many exceptions to these findings (Bohane, Maguire, & Richardson, 2017; Farstad, McGeown, & von Ranson, 2016). Research has also found that when using diagnostic criteria to classify people with EDs, researchers have not been able to predict treatment outcomes. However, when the same group of people were classified based on personality type (i.e. OC, UC or resilient) researchers have been able to predict who would achieve positive treatment outcomes and who would not (Thompson-Brenner et al., 2008; Wildes et al., 2011). This suggests that regardless of the eating behaviour a person engages in when they present to treatment, their underlying personality style may dictate treatment outcomes.
Targeting personality traits as part of ED treatment is not a new idea. Enhanced Cognitive Behaviour Therapy (CBT-E) has included interventions to target personality style (Fairburn, 2008), while Dialectical Behaviour Therapy (DBT) has been widely researched for individuals presenting with personality disorders in addition to EDs (Linardon, Fairburn, Fitzsimmons-Craft, Wilfley & Brennan, 2017). An area that is still in its infancy is how to understand and treat OC EDs. While Radically Open Dialectical Behaviour Therapy (RO-DBT) is a treatment that has been designed for individuals with OC presentations, and outcome trials have indicated positive outcomes using RO-DBT for those with anorexia, the research is limited, and the treatment is not widely offered. Additionally, there is no easy way to classify someone as OC or UC. The assessment procedure outlined as part of RO-DBT includes several steps and requires intensive training and experience to understand (Bohane et al., 2017; Lynch, 2018). This obviously creates a barrier to more widespread use of this theory and treatment.
The two big questions as a clinician and researcher that arise for me are:
- Can we conceptualise EDs differently, in a way that can lead to more effective treatment selection and completion?
- How can we simplify this way of conceptualisation so that doctors and clinicians from a range of backgrounds can understand and communicate diagnosis and treatment needs to other medical professionals, clients and carers?
This area of research interests me because I have found that many people with EDs are being misdiagnosed because of common misconceptions in the medical field. For example, it is frequently assumed that Borderline Personality Disorder is very prevalent among people with EDs, when Avoidant Personality Disorder and Obsessive Compulsive Personality Disorder are in fact more prevalent (Farstad et al., 2016). This leads people with ED symptoms to feel as if treatment does not “fit” for them, and they miss out on the help that they need. Additionally, other professionals had difficulty understanding how OC differs from UC and how this could be relevant, further removing people from treatment that may helpful.
A research team at Monash University is exploring how to conceptualise people with EDs by personality presentation. The team is currently seeking Australian research participants with or without a history of an ED, aged between 16-30, to complete an online survey by 30 June 2021 (which may take up to 30 minutes). Access the survey here.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 ed.). Washington, DC: American Psychiatric Association.
Bohane, L., Maguire, N., & Richardson, T. (2017). Resilients, overcontrollers and undercontrollers: A systematic review of the utility of a personality typology method in understanding adult mental health problems. Clinical Psychology Review, 57, 75-92. doi:http://dx.doi.org/10.1016/j.cpr.2017.07.005
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Wildes, J. E., Marcus, M. D., Crosby, R. D., Ringham, R. M., Dapelo, M. M., Gaskill, J. A., & Forbush, K. T. (2011). The clinical utility of personality subtypes in patients with anorexia nervosa. Journal of Consulting and Clinical Psychology, 79(5), 665-674. doi:10.1037/a0024597
Zeeck, A., Herpertz-Dahlmann, B., Friederich, H. C., Brockmeyer, T., Resmark, G., Hagenah, U., . . . Hartmann, A. (2018). Psychotherapeutic treatment for anorexia nervosa: A systematic review and network meta-analysis. Frontiers in Psychiatry, 9, 158. doi:10.3389/fpsyt.2018.00158