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 behaviors 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.
That last paragraph was not just obscure, but really opaque! 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 a diagnosable 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 [Caspi et al., 2005], people generally become more dominant, agreeable, conscientious and emotionally stable over the course of adult life (measured up to late middle-age) [D.P. Adams, B.D. Olson; 2010].
“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.” [ibid: Donnellan et al.; 2007, Johnson et al.; 2007, Lonnqvist et al., 2008].
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 Lawrence 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.
Although in other studies anorexics cluster in the second category and bulimics cluster in the third category, Lawrence found that cluster membership was not associated with specific eating disorder subtypes.
So clearly, the correlations between particular personality traits and specific facets of restrictive eating disorders are non-existent. Nonetheless generalizations still persist in the mainstream that link anorexia with perfectionism and bulimia with impulsivity.
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.” [K.A. Halmi et al., 2000].
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.” [C.G. Fairburn, K.D. Bronwell (ed.), Eating Disorders and Obesity: a comprehensive handbook, Guildford Press, 2002, pp. 204]
Of course, because bulimia nervosa is considered a distinct mental disorder within the DSM-IV, studies looking at personality traits and eating disorders distinguish between the facets of the restrictive 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 [S. Fischer et al., 2003].
Despite numerous attempts to classify self-harming, drug-abusing bulimics as a distinct subtype of the restrictive eating disorder spectrum (multi-impulsivity bulimia), studies have failed to corroborate the theory that these behaviors will co-exist with any dependability in those with bulimia [L. Claes et al., 2004].
We also have to remember that almost two-thirds of all patients who begin their experience on the restrictive eating disorder spectrum with anorexia nervosa, develop bulimia nervosa within eight years of the onset of the condition [K. Eddy et al., 2002]. Given that fact, obviously personality trait clusters are not a dependable way to identify particular facets of the restrictive 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.
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 (behavior), agency (striving) and authoring (narrating), may help explain how ostensibly immoveable personality traits can moderate over time.
Heavily borrowing from the work of Adams and Olson , our innate temperaments at birth correlate to the development of the Big Five personality traits. These are our behaviors. 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 behaviors that will help us achieve goals and hence create a life story that is consistent with our own view of ourselves.
By the time he 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 he is eight years old, he has decided he wants to learn gymnastics. His agency now pushes back on his personality traits. He moderates his anxiety and distaste of new experiences so that he might become a gymnast. In college he determines that he would like to have a girlfriend so he moderates his social anxiety and reserved nature to get out and meet new people.
By the time he is 40, we find him with a career in the United Nations involved in the logistics of supporting various refugee camps around the world. He has lived abroad with his wife and two children in various developing nations for long periods of time thanks to his job. Tested on the Big Five yet again at age 42, he is now more open to new experience than he was at age four; he has stayed highly conscientious; while still preferring solitary pursuits over social ones, he scores lower now than he once did; he is now neutrally neither reserved nor friendly; and he is 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.
Any circumstance that inhibits or hinders a child’s ability to develop both agency and authorship of his or her 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.
As just one example of many, higher neurosis at diagnosis for diabetes mellitus Type I resulted in poorer self-reported quality of life at 4 months and 12 months after diagnosis [M.D. Taylor et al., 2003].
If we take several hundred average teenagers who all naturally score higher on neuroticism and lower on conscientiousness than they will 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.
Little Miss Me
I am going to talk about me simply as an example of these principles in action: one story of how personality traits can define the onset and shape the progression of certain chronic conditions.
I am a firstborn. However, my mother had suffered several miscarriages prior to my arrival and I was not planned. She spent the first six months of the pregnancy bed-ridden as she threatened to lose me. My start in life was essentially a nine-month bath of amniotic fear, anxiety and an aggressive quashing of all hope as it could “tempt the Fates”. Showing up with all my fingers and toes was actually a bit of a shock and my father had to frantically rush around to get all the baby gear that they had avoided getting, as it was naturally assumed I might not arrive at all.
I was a perfect baby. My mother has said I only cried when I was hungry. I was quiet and cuddly. Awww.
A year and a half later my brother arrived—a study in contradictions. He was fussy and ill. Asthma runs in the family but the family doctor at the time encouraged my parents not to even consider that as a possibility; naturally, it was asthma. My brother was acutely ill with asthma throughout childhood. I remember waking up in the middle of the night and heading down the hall to see my Dad sitting side by side with my brother on the edge of his bed as my brother struggled to breathe. Lots of emergency visits. Lots of hospitals. I can still remember the framed picture of flowers in the waiting room at the children’s hospital.
My brother outgrew his asthma at puberty and I developed asthma as I entered puberty. Thankfully my asthma was and is mild.
The Eight Facets of Me
I was a high-achiever. I studied ballet throughout childhood, played the piano, the cello and the flute.
Here is a desperate diary entry from me, age 12–– I was taking a sewing course:
“I’m hopeless at sewing. I became really downcast and I still am. I can never seem to do everything. I feel so horribly feeble and stupid. I’ve had millions of dreams about becoming an interpreter or teacher. I’ll probably end up a drop-out at the age of sixteen.”
Eek. I still don’t sew to this day.
“I think I’m going to lose marks on my French exam because we were only supposed to write a ten line paragraph, and I did about twice as many lines as needed.”
Half the diary entries are written in French that year for some reason. There’s even one entry with some indecipherable code that was used (likely referring the boy next door).
There are descriptions of me regularly making family breakfasts on weekends at age 12 (I don’t recall doing this, but it’s there in the diary!). I did all my chores. I kept my room tidy at all times. In fact, often I would remove everything from my room, pile it into the hall and then clean everything, putting all the furniture back in the room in a new configuration as I went. That was an all-day event on weekends. Even the handwriting in my diaries is insipidly neat. What twelve-year-old actually writes that she is “downcast”? Obviously me.
I graduated at age 17 with an international baccalaureate and scholarships for university. My mother recalls how she just naturally expected a lot of me because I seemed so mature.
I may have seemed mature, but the conscientiousness was very deceiving.
Phobia at Eight
Apart from being a sensitive, overachieving girl, I had one event that likely derailed my train-track-straight path through personality trait development.
At the age of eight, I had a nasty bout of cystitis (likely in hindsight an early occurrence of Reiter’s Syndrome) and it galvanized our GP of the day to want to investigate the possibility of bladder cancer.
I recall everything about that day of tests. I was put in a fuzzy white bathrobe, my extremely worried looking mother was parked in the waiting room while the multiple x-rays, barium drinks, injected dyes and the like were prescribed. After the dye injection I was told to stand behind a full-length x-ray machine and instructed to urinate while standing. With an audience of one male technician and two female nurses, I couldn’t cope. I burst into tears at the sheer embarrassment of such an overwhelming request. They let me go home. I knew nothing of why I was having the tests, other than my mother’s serious and frightening expression.
Within the next day or so, I got a cold. I have a hair-trigger vasovagal response like my father and would (and did) pass out when I am sick. As the kitchen radio buzzed on about some medical topic, I felt dizzy, stood up, passed out and hit my head on the way down.
Et Voilà: massive medical phobia.
The phobia developed really around the fear of passing out. That I could somehow stitch together the trauma of medical tests, a random radio show, passing out, and hitting my head due to a cold, is all a marvel of phobia development in the brain.
I studied for my international baccalaureate exam in biology by reading the textbook until I felt faint, then I would lie down until I could get up and do it again. I received a perfect mark on that final.
Not knowing then what is known now, I didn’t receive any intervention or therapy and it has been a lifelong slog to get to where I am now, especially given my vocation. To this day, you still cannot tie off my arm to draw blood—but you would have to drag me away from an afternoon of watching open heart surgery.
As a girl it appears I was a textbook study in industriousness, perfectionism (both internal and external facets), tidiness, control, cautiousness, task planning, perseverance with perhaps less intensity on the procrastination refrainment side and definitely highly neurotic.
When Narratives Are Wrong
All in all, I entered adulthood intellectually well prepared, yet I was socially and emotionally far behind my peers.
Perfect little boys and perfect little girls seem highly capable of developing agency (striving to achieve goals), but appear to struggle with the authorship of their lives.
And when I refer to perfect little boys and girls, obviously they are not “perfect”—but they want to be.
How exactly does a 12-year-old girl determine that she will end up a dropout at age 16 because she cannot sew?
The answer to that is where my perfect little life and lives of many who struggle with eating disorders diverge.
Such A Disappointment
Until I was in my 30s, I had assumed that the narrative of my childhood was a happy one. We had parents who loved each other and their children. We wanted for nothing. We lived in a peaceful part of the world and were provided with safety, love, nourishment and care.
I assumed that I was a failure despite such a wonderful childhood. My inability to feel at peace, my restlessness, my lack of success when compared to my entire overachieving family and, in my mind, to all of my peers—these were all personality flaws, inherent and mine.
Not so. While indeed my parents were loving and caring, they were also burdened with their own issues of anxiety and depression. I was a sensitive kid and able to absorb it all. I likely inherited those dispositions as well. How could I, at 12, assume that being a dropout was likely? Because my parents feared such an eventuality.
And in my 30s, family skeletons revealed themselves and hammered at the foundation upon which I had carefully built the deeply held, yet deeply flawed, narrative of my life. They are not my skeletons but because they impacted my family, they impacted me.
And so I built a new narrative from the ground up—a healthy one developed on the maturity principle. And although I haven’t gone through the exercise, I am going to guess I would test a lot closer to my peers on the Big Five now than I did at age 12!
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 restrictive 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 his or her natural course towards maturity.
I was, from a family-of-origin and personality trait perspective, supposedly a walking time bomb for developing a restrictive eating disorder. Yet I did not develop one. And apart from a rather persistent phobia, my trajectory as I have aged is to be less neurotic (infectious disease specialist’s opinions aside) and hopefully more agreeable!
If I had developed a restrictive eating disorder, I suspect I would to this day think that my childhood had been blissful and that I was simply a failure and to blame for anything and everything including my abysmal sewing skills.
If my asthma had become debilitating in my teen years, then I also suspect I would be equally well off course when it comes to maturity levels today.
As it is, because I was not born mature (oh, and we all know those ones who are—how I wanted to be like them!) I came to a more socially acceptable version of the Big Five Personality Traits later than most and perhaps sooner than just a few.
The point is that 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 restrictive 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 behaviors as a way to achieve “true healing”, has everything to do with eating disorders being classified within the DSM-IV (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 behaviors. There appear to be some real physiological changes in the brains of those who suffer from restrictive eating behaviors, 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 restrictive 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 restricted 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 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 and never underweight 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.