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. Rao2
1
3
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
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: 225 229, 2002.
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 15213. E-mail: KayeWH@MSX.UPMC.EDU
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.10025
Ó 2002 by Wiley Periodicals, Inc.
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.
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 28.8 ‹ 5.5 years and of the controls was 25.1 ‹
4.8 years, t (df = 24) = 1.80; NS. The mean IBWs for the RBN subjects and controls were
107.8 ‹ 12.1 and 104.6 ‹ 10.6%, respectively, t (24) = .70; NS. The mean body mass indexes
were 22.4 ‹ 2.5 and 21.7 ‹ 2.3, 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 (2.91 ‹ 3.4 vs. 0.67 ‹ 1.3), F (1,24)
= 5.54; p < .03, and STAI trait scores (33.18 ‹ 7.5 vs. 24.20 ‹ 2.8), F (1,24) = 18.39; p < .0001.
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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 (4.91 ‹ 4.5 vs. 0.20 ‹ 0.6), F (1,24) = 16.14; p < .001; Body Dissatisfaction
(15.00 ‹ 7.4 vs. 3.27 ‹ 5.8), F (1,24) = 20.42; p < .0001; Ineffectiveness (1.72 ‹ 2.0 vs. 0.00 ‹
0.0), F (1,24) = 11.31; p < .003; Perfectionism (6.36 ‹ 3.4 vs. 2.27 ‹ 2.7), F (1,24) = 11.44; p <
.002; and Social Insecurity (2.82 ‹ 2.9 vs. 0.47 ‹ 1.3), 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 (17.91 ‹ 5.5 vs. 22.27 ‹ 1.8), F (1,24) = 8.22; p < .0008,
and Social Closeness (16.00 ‹ 3.8 vs. 19.07 ‹ 3.1), F (1,24) = 5.10; p < .03, and elevated
levels of Stress Reaction (11.73 ‹ 6.9 vs. 3.00 ‹ 3.5), F (1,24) = 17.62; p < .0001, and the
higher-order factor of Negative Emotionality (122.98 ‹ 10.9 vs. 109.89 ‹ 8.0), 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,
3 1997) 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-
Eating-Related and Personality Traits in Bulimia Nervosa
229
tiveness may be found not only during the active phase of BN, but also following longterm recovery.
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