Eating-Related Concerns, Mood, and Personality Traits in Recovered Bulimia Nervosa Subjects: A Replication Study

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1 Eating-Related Concerns, Mood, and Personality Traits in Recovered Bulimia Nervosa Subjects: A Replication Study D. Stein, 1,2 W. H. Kaye, 2 * H. Matsunaga, 2,3 I. Orbach, 4 D. Har-Even, 4 G. Frank, 2 C. W. McConaha, 2 and R. Rao 2 1 Sheba Medical Center, Tel Hashomer, Israel, af liated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel 2 Western Psychiatric Institute and Clinic, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania 3 Department of Neuropsychiatry, Osaka City University Medical School, Osaka, Japan 4 Department of Psychology, Bar Ilan University, Ramat Gan, Israel Accepted 28 October 2001 Abstract: Objective: Limited data suggest that eating-related concerns and behaviors, disturbances in mood, and altered temperament persist following recovery from bulimia nervosa (BN). Method: In order to replicate and extend such ndings, 11 women who were long-term recovered from BN (>1 year with no binging, purging, or restricting behaviors, normal weight, and regular menstrual cycles) were compared with 15 healthy volunteer women on the Eating Disorders Invertory-2 (EDI-2), the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Multidimensional Personality Questionnaire (MPQ). Results: Compared with the control women, the recovered BN women showed elevated levels of the EDI-2 subscales of Drive for Thinness, Body Dissatisfaction, Ineffectiveness, Perfectionism, and Social Insecurity, greater depression and anxiety, elevated levels of the MPQ Stress Reaction dimension and the higher-order factor of Negative Emotionality, and lower levels of the MPQ Well Being and Closeness dimensions. Discussion: Core eating and weight-related concerns, dysphoric affect, social discomfort, and personality traits indicative of perfectionism persist following long-term recovery from BN. Ó 2002 by Wiley Periodicals, Inc. Int J Eat Disord 32: , Key words: bulimia nervosa; personality; dysphoric affect; eating-related concerns INTRODUCTION The investigation of the psychological profile of individuals recovered from anorexia nervosa (AN) and bulimia nervosa (BN) is still limited. Few studies have compared Correspondence to: Walter H. Kaye, M.D., University of Pittsburgh, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA KayeWH@MSX.UPMC.EDU Published online in Wiley InterScience ( DOI: /eat Ó 2002 by Wiley Periodicals, Inc.

2 226 Stein et al. recovered AN subjects, whether of the restricting (Casper, 1990) or the combined restricting and binging/purging subtypes (Pollice, Kaye, Greeno, & Weltzin, 1997; Srinivasagam et al., 1995), with non eating-disordered (ED) controls. These studies found that after no less than 1 year of recovery, former AN subjects still continue to have elevated levels of weight preoccupation, pursuit of thinness, ineffectiveness, and a decreased awareness of interoceptive stimuli. In addition, they report greater eating-related and general obsessionality, particularly symptoms involving symmetry, ordering, and exactness. These individuals also demonstrate lower feelings of well-being and overall positive emotionality, as well as elevated levels of depression, anxiety, and stress. Several personality features have been found to be elevated in recovered AN subjects compared with controls, including perfectionism, compliance with conventional and moral standards, a greater disposition toward rigidity, preference for a safe routine, and restraint in emotional expression and initiative. We are aware of only one study that compared long-term recovered BN subjects with non-ed controls (Kaye et al., 1998). This study has shown that former BN subjects demonstrate elevated levels of pathological eating behaviors, body dissatisfaction, and ineffectiveness, decreased interoceptive awareness, greater eating-related and general obsessionality, and elevated levels of perfectionism, depression, and anxiety. The aim of this study was to replicate the previous findings in a new cohort of recovered BN subjects. We hypothesized that recovered BN subjects would be similar to recovered AN subjects in that they would demonstrate personality traits indicative of the inhibitedperfectionistic spectrum and heightened social anxiety. METHODS Subjects Subjects were 11 recovered BN female subjects (RBN) and 15 healthy matched volunteer women. The inclusion and exclusion criteria of these subjects were described in Kaye et al. (1998). All RBN subjects had a previous lifetime diagnosis of BN as outlined in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) and were required to have no history of AN. These subjects also reported that in the past year they maintained a stable and normal weight (85% 115% of ideal body weight [IBW]; Metropolitan Life Insurance Company, 1959). They had not binged, purged (both vomiting and use of laxatives or diuretics), or engaged in restrictive eating patterns. They also had regular menstrual cycles. In addition, the RBN subjects had no evidence of a DSM-IV Axis I disorder, substance abuse, or psychoactive medication use in the past year, and no present or past medical and neurological illness. These subjects had been treated previously in the eating disorders treatment program at the Western Psychiatric Institute and Clinic (WPIC; Pittsburgh, PA). Healthy volunteers were 15 age-matched women whose weight has been between 90% and 120% of IBW (Metropolitan Life Insurance Company, 1959) since menarche. These volunteers had no evidence of present or past psychiatric, medical, or neurological illness, and no symptoms suggestive of an ED. The volunteers came from the staff of the WPIC. Of the 15 controls, 3 were studied previously (Kaye et al., 1998). All subjects gave informed consent to participate in the study according to institutional guidelines and were paid for their participation in the study.

3 Eating-Related and Personality Traits in Bulimia Nervosa 227 Instruments Psychiatric diagnosis according to the DSM-IV criteria was assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P; First, Spitzer, Gibbon, & Williams, 1995). Recovery from past BN, or lack of an ED diagnosis in the controls, was assessed with a modified version of the structured Eating Disorders Family History Interview (Strober, 1987). This interview has been used extensively in studies of currently ill and recovered ED subjects (Kaye et al., 1998). Eating-related concerns were evaluated with the Eating Disorders Inventory-2 (EDI-2; Garner, 1991). Depression was assessed with the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Anxiety was assessed with the State Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1970). The STAI evaluates anxiety at the time of examination (state anxiety) and the general tendency to display anxiety (trait anxiety). Relevant personality traits were assessed with the Multidimensional Personality Questionnaire (MPQ; Tellegen, 1982). The scales of the MPQ represent 11 primary personality dimensions and three higher-order factors, Positive Emotionality, Negative Emotionality, and Constraint. The EDI, BDI, and STAI discriminate between subjects with and without AN or BN and between recovered AN and BN subjects and non-ed controls (Casper, 1990; Kaye et al., 1998; Srinivasagam et al., 1995). Similar findings were reported for the MPQ in AN patients (Casper, 1990). Procedure A screening interview was conducted by a psychiatrist (D.S.). If subjects were screened positively, they received the SCID-I/P, the Eating Disorders Family History Interview, and a thorough evaluation of medical and neurological condition, including measurement of weight and height. If they fulfilled all inclusion and exclusion criteria, they received the psychometric assessment. Statistical Analysis Multivariate analysis of variance (MANOVA) was used for the between-group comparison of multiple variables. Univariate analysis of variance (ANOVA) was then used for individual scale comparisons after the overall multivariate test for mean differences was determined to be significant at the p <.05 level. Separate MANOVAs were run for dysphoric emotions (anxiety and depression), EDI-2, and the MPQ personality scale. Results are presented as mean SD. RESULTS The mean age of the RBN subjects was years and of the controls was years, t (df = 24) = 1.80; NS. The mean IBWs for the RBN subjects and controls were and %, respectively, t (24) =.70; NS. The mean body mass indexes were and , respectively, t (24) =.76; NS. MANOVA analysis showed overall significant between-group differences for depression and anxiety, F (3,22) = 7.20; p <.01. Separate univariate ANOVAs showed that compared with the controls, the RBN subjects had elevated BDI ( vs ), F (1,24) = 5.54; p <.03, and STAI trait scores ( vs ), F (1,24) = 18.39; p <.0001.

4 228 Stein et al. MANOVA analysis also showed significant between-group differences for the EDI-2, F (10,15) = 4.93; p <.01. Speci cally, univariate ANOVAs showed that for the following EDI-2 subscales, the RBN subjects fared signi cantly worse compared with the controls: Drive for Thinness ( vs ), F (1,24) = 16.14; p <.001; Body Dissatisfaction ( vs ), F (1,24) = 20.42; p <.0001; Ineffectiveness ( vs ), F (1,24) = 11.31; p <.003; Perfectionism ( vs ), F (1,24) = 11.44; p <.002; and Social Insecurity ( vs ), F (1,24) = 7.70; p <.01. MANOVA analysis showed a trend for between-group differences for the primary dimensions of the MPQ, F (11,14) = 2.34; p <.07, and signi cant between-group differences for the higher-order MPQ factors, F (3,22) = 6.441; p <.003. Univariate ANOVAs showed that compared with the controls, the RBN subjects had lower levels of the MPQ primary dimensions of Well Being ( vs ), F (1,24) = 8.22; p <.0008, and Social Closeness ( vs ), F (1,24) = 5.10; p <.03, and elevated levels of Stress Reaction ( vs ), F (1,24) = 17.62; p <.0001, and the higher-order factor of Negative Emotionality ( vs ), F (1,24) = 12.56; p <.002. DISCUSSION These data replicate previous findings (Kaye et al., 1998) that showed persistent elevations of eating and weight-related concerns, ineffectiveness, perfectionism, depression, and trait anxiety in women who were long-term RBN. Moreover, these results showed RBN subjects had reduced social security, social closeness, and well-being, as well as elevated stress reaction and negative emotionality compared with healthy control women. Although the sample size was small, the between-group differences were robust. It is not known whether the persistence of core ED concerns and related personality traits following recovery from BN is a premorbid vulnerability for, or a consequence of, having an ED (Casper, 1990; Srinivasagam et al., 1995). Perfectionism has been implicated as a risk factor for AN (Bruch, 1973) and BN (Fairburn, Welch, Doll, Davies, & O'Connor, 31997) and predicts bulimic symptoms in women who perceive themselves as overweight (Joiner, Heatherton, Rudd, & Schmidt, 1997). Two dimensions reflecting oversensitivity in social relationshipsðthe EDI-2 Social Insecurity and the MPQ Social ClosenessÐwere more disturbed among the RBN subjects compared with the controls. Social discomfort is believed to contribute to the development of an ED (Bruch, 1973), although the secrecy involved in having long-standing BN might aggravate this factor (Fairburn, Marcus, & Wilson, 1993). Importantly, welladapted social capacities predict a favorable outcome from an ED (Strober, Freeman, & Morrell, 1997). It is worthwhile noting that reduced MPQ Well Being and elevated MPQ Stress Reaction correlate with the Tridimensional Personality Questionnaire (Cloninger, 1987) Harm Avoidance subscale (Waller, Lilienfeld, Tellegen, & Lykken, 1991). This scale represents not only a preference for safe routine and risk avoidance, but also a tendency toward anticipatory anxiety, shyness, and fatigability (Cloninger, 1987). It also reflects a persistent disposition toward thinking and behaving in ways that foster negative affective experiences (Waller et al., 1991). These data suggest that elevated harm avoidance persists after recovery from both BN and AN (Casper, 1990). In conclusion, these data show that core eating and weight-related concerns, dysphoric affect, social discomfort, and personality traits indicative of perfectionism and ineffec-

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