Journal of Psychosomatic Research 57 (2004) 273 – 278 Personality in men with eating disorders D. Blake Woodside a,b,*, Cynthia M. Bulik c, Laura Thornton d, Kelly L. Klump e, Federica Tozzi f, Manfred M. Fichter g, Katherine A. Halmi h, Allan S. Kaplan a,b, Michael Strober i, Bernie Devlin d, Silviu-Alin Bacanu d, Kelly Ganjei j, Scott Crow k, James Mitchell l, Alessandro Rotondo m, Mauro Mauri m, Giovanni Cassano n, Pamela Keel o, Wade H. Berrettini p, Walter H. Kaye d a Program for Eating Disorders, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada M5G 2C4 b Department of Psychiatry, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada M5G 2C4 c Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA 23298-0126, USA d Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213-2593, USA e Department of Psychology, Michigan State University, East Lansing, MI 48824, USA f University of Rome Tor Vergata, Rome, Italy g Roseneck Hospital for Behavioural Medicine affiliated with the University of Munich, Prien, Germany h New York Presbyterian Hospital, Weill Medical College of Cornell University, White Plains, NY 10605, USA i Department of Psychiatry and Behavioral Science, University of California at Los Angeles, Los Angeles, CA 90024-1759, USA j Core Genotyping Facility, Advanced Technology Center, National Cancer Institute, Gaithersburg, MD 20877, USA k Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA l Neuropsychiatric Research Institute, Fargo, ND, USA m Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies, University of Pisa, Pisa, Italy n University of Pisa, Pisa, Italy o Department of Psychology, Harvard University, Cambridge, MA, USA p Center of Neurobiology and Behavior, University of Pennsylvania, Philadelphia, PA 19104, USA Received 9 July 2003; accepted 3 February 2004 Abstract Objective: This study compares personality variables of men with eating disorders to women with eating disorders. Method: Data were obtained from an international study of the genetics of eating disorders. Forty-two male participants were age-band matched at 1:2 ratio to females from the same study. Personality features were compared between males and females controlling for diagnostic subgroup. Results: Males with eating disorders appear to be slightly less at risk for perfectionism, harm avoidance, reward dependence, and cooperativeness than females. Few differences were found when diagnostic subgroup was considered. Conclusion: Observed differences in personality variables may help explain the difference in incidence and prevalence of eating disorders in men and women. D 2004 Elsevier Inc. All rights reserved. Keywords: Eating disorders; Men; Personality Introduction Eating disorders in males continue to be an area of interest, primarily because of the marked difference in * Corresponding authors. D.B. Woodside is to be contacted at Inpatient Eating Disorders Program, Toronto General Hospital, 8EN-219, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4. Fax: +1-416-3404198. W.H. Kaye, Anorexia and Bulimia Nervosa Research Module, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Suite 600 Iroquois Building, Pittsburgh, PA 15213, USA. Fax: +1-412-647-3507. E-mail addresses: b.woodside@utoronto.ca (D.B. Woodside), kayewh@ msx.upmc.edu (W.H. Kaye). 0022-3999/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2004.02.011 prevalence of both anorexia nervosa (AN) and bulimia nervosa (BN) between the two genders [1,2]. Recent work upholds the existence of this gender imbalance, although to a lesser extent than previously believed [3]. In addition to examining prevalence, research in this area has focused on the clinical characteristics, psychometric profiles, and comorbidity patterns in men with eating disorders compared to women. In general, there are more similarities than differences across genders on these dimensions [4]. Little research has been done in the area of personality in men with eating disorders. Joiner et al. [5] compared 14 males to 97 females, showing that men chronically ill D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 274 disorder diagnoses were confirmed by trained raters using the Structured Interview for Anorexia Nervosa and Bulimic disorders (SIAB) [13]. Informed consent was obtained from all study participants, and all sites received approval from their local Institutional Review Board. For the AN study, probands were required to meet modified (criterion D, amenorrhea, not required) lifetime DSM-IV criteria for AN, and had never met criteria for BN. Probands from the BN study were required to meet the following criteria: (1) a DSM-IV lifetime diagnosis of BN purging type (purging must have included regular vomiting, with other means of purging also allowed, and bingeing and vomiting must have occurred at least twice a week for a duration of at least 6 months); and (2) age between 13 and 65 years. A current or lifetime history of AN was acceptable. Exclusion criteria for all probands included mental retardation (IQ < 70); dementia; organic brain syndromes; psychotic disorders including schizophrenia, schizophreniform disorder, delusional disorder, and schizoaffective disorder; Turner’s syndrome; any medical condition that could affect appetite, body weight, or eating (e.g., diabetes and thyroid conditions were excluded if the onset of the disease preceded the onset of the ED). Bipolar I and bipolar II were excluded only if symptoms of BN occurred exclusively during manic or hypomanic episodes. Probands with neurological problems were excluded with the exception of those diagnosed with a seizure disorder resulting from trauma following the onset of the ED. Probands whose premorbid weight exceeded the BMI for the 95th percentile for gender and age on the Hebebrand index [14] or whose high lifetime BMI was greater than 35 kg/m2 were also excluded. Affected relatives were biologically related to the proband (e.g., siblings, half siblings, cousins). Inclusion criteria for affected relatives required they be 13 –65 years of age and received at least one of the following lifetime eating disorder diagnoses: (1) DSM-IV BN, purging type or nonpurging type; (2) DSM-IV AN, restricting type or binge eating/ purging type; (3) EDNOS-1, defined as subthreshold AN with the presence of two of three criteria A through C of DSM-IV AN, no lifetime bingeing, and a lifetime BMI < 125% of expected for height and weight; (4) EDNOS-2, defined as subthreshold BN with the presence of criteria A, B, D, and E of DSM-IV BN and the presence of binge eating and purging, which must have occurred ‘‘more than just experimentally’’ but may have occurred for less than 3 months or at a lower frequency than twice a week; (5) with BN had higher levels of perfectionism and interpersonal distrust than the female comparison group. Research into Axis II comorbidity has some relevance to this question, as the presence of personality disorders may reflect underlying dimensional personality characteristics. StriegelMoore et al. [6] showed elevated rates of personality disorders, substance use, and mood disorders in males with ED in comparison to a sample of men without [7] ED. Fassino et al. [7] compared a small group of male anorectic patients to a control group of anorectic women and a sample of nonclinical men and women using the Temperament and Character Inventory (TCI) [8] and showed that male anorectics had lower scores on harm avoidance, reward dependence, and cooperativeness and higher scores on novelty seeking compared to women with AN. As we advance our understanding of the genetic underpinnings of AN and BN, it becomes increasingly important to refine our phenotypic definitions. In a series of linkage analyses, we have optimized our linkage information by incorporating behavioral phenotypes into the genetic linkage analysis [9]. As the relative risk for AN appears to be highest in female relatives of males with AN [10], male eating disorders cases may be particularly valuable to genetic studies. The purpose of this study is to examine personality factors in a sample of males with ED derived from a large-scale study of the genetics of ED, and compare these factors to a matched sample of females with ED from the same study. Methods and materials Participants All participants were from the multisite Price Foundation Genetic Study of AN [11] or the Price Foundation Genetic Study of BN [12], both of which used similar methodologies. Males and females affected with AN, BN or eating disorder not otherwise specified (ED-NOS) were recruited from 11 sites in North America and Europe including Pittsburgh, New York, Los Angeles, Toronto, London, Munich, Philadelphia, Pisa, Fargo, Minneapolis, and Boston. Details of sample ascertainment and recruitment strategies are described elsewhere (Ref.[11]; Kaye et al., submitted) and will only be described briefly here. Full assessments were completed on the proband and affected relative(s). Eating Table 1 Age and weight-related variables for males and female comparison group AN Age (years) BMI (kg/m2) Lowest past BMI Highest past BMI ANBN, BN, EDNOS Males (n = 21) Females (n = 40) HR v2 P Males (n = 21) Females (n = 40) HR v2 29.43 20.37 15.98 22.28 28.20 19.00 14.88 21.04 0.88 1.42 1.28 1.15 0.43 4.36 2.71 1.60 .51 .04 .10 .21 28.52 22.31 19.66 24.24 26.23 20.41 17.50 23.48 1.45 1.42 1.28 1.15 3.60 4.36 2.71 1.60 (9.3) (2.5) (1.8) (3.1) Values represent means (S.D.). HR = hazard ratio. (6.2) (1.9) (2.2) (2.7) (11.6) (2.6) (2.8) (3.2) (9.6) (2.8) (2.6) (3.1) D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 EDNOS-3, defined as the presence of purging or other clearly excessive compensatory behaviors, in the absence of objective binge eating, in individuals of normal weight who have either an intense fear of gaining weight or becoming fat or an undue influence of body weight or shape on self evaluation. Exclusion criteria for affected relatives included all exclusion criteria listed for the probands, with the following additional criteria: (1) monozygotic twin of the proband; (2) biological parent with an ED, unless there was another affected family member with whom the parent could be paired; (3) a diagnosis of binge eating disorder as the only lifetime eating disorder diagnosis. All males (n = 42) with an ED were included in this study. Each male was matched to two females by ED diagnosis, 5-year age band (age at the time of interview), and proband status (proband or affected relative). In addition, the females included in the comparison group were not related to any of the males. Two of the males were only able to be matched to one female on the basis of our matching criteria and we were unable to identify an appropriate match for one male (total number of females = 80). Assessment instruments All participants were assessed with the SIAB [13], the Yale –Brown – Cornell Eating Disorder Scale (YBC-EDS) [15], and the Yale –Brown Obsessive Compulsive Scale (Y-BOCS) [16]. Participants completed self-report questionnaires including the TCI [8], Multidimensional Perfectionism Scale (MPS) [17], and State-Trait Anxiety Inventory (STAI) [18]. SIAB A modified version of the SIAB was used to assess the lifetime histories and phenotype diagnoses of eating disorders of the subjects in both studies. YBC-EDS The YBC-EDS was used to assess the severity and types of core obsessions and compulsions specific to eating disorders. Y-BOCS Y-BOCS is a semistructured interview designed to rate the presence and severity of obsessive thoughts and compulsive behaviors typically found among individuals with obsessive – compulsive disorder. MPS The MPS assesses six specific dimensions of perfectionism, including concern over mistakes, personal standards, perceived parental expectations, perceived parental criticism, doubts about actions, and organization. TCI The TCI measures seven dimensions of personality, including novelty seeking, harm avoidance, reward depen- 275 dence, persistence, self-directedness, cooperativeness, and self-transcendence. STAI Subjects completed the STAI (Form Y-1), a 40-item instrument used to assess states of anxiety both ‘‘at this moment’’ and how the individual ‘‘generally feels’’. Statistical analysis Our goal was to identify characteristics that differentiate males and females with eating disorder diagnoses. The data set was designed as a case – control study, with each male being matched with two females, except in the cases noted above. To account for the double representation of the males and to take advantage of the increased sample size of the females, conditional logistic regression was conducted using SAS (SAS Institute, 1996). This type of statistical analysis is used to investigate the relationship between the outcome Table 2 Predicting the likelihood of being male from symptom and personality variables, combined eating disorders diagnoses P value Scale/Variable Hazard ratio CI YBC-EDS Current motivation to change Current period preoccupation Current rituals Current period total score Worst motivation to change Worst period of preoccupation Worst period ritual score Worst period total score 1.17 0.57 0.86 0.71 0.67 0.53 0.62 0.54 (0.79, (0.35, (0.58, (0.46, (0.45, (0.32, (0.38, (0.32, 1.71) 0.93) 1.27) 1.10) 1.00) 0.88) 1.01) 0.92) .434 .026 .441 .124 .052 .014 .056 .022 TCI Harm avoidance Novelty seeking Persistence Reward dependence Self-directedness Cooperativeness Self-transcendence 0.58 1.37 0.91 0.34 1.04 0.54 1.03 (0.37, (0.91, (0.61, (0.19, (0.67, (0.35, (0.71, 0.92) 2.08) 1.36) 0.61) 1.61) 0.84) 1.50) .021 .133 .633 .0004 .867 .006 .870 MPS Concern over mistakes Doubts about actions Organization Parental criticism Parental expectations Personal standards Overall 0.55 0.85 0.41 1.15 1.17 0.72 0.77 (0.35, (0.58, (0.24, (0.77, (0.80, (0.46, (0.51, 0.87) 1.25) 0.70) 1.71) 1.72) 1.12) 1.16) .010 .402 .001 .500 .410 .148 .211 STAI State anxiety Trait anxiety 0.88 0.86 (0.59, 0.32) (0.57, 1.28) .540 .447 Y-BOCS Compulsions Obsessions Total 0.84 1.09 0.96 (0.56, 1.27) (0.73, 1.62) (0.64, 1.43) .407 .676 .822 276 D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 (whether the subject is a case or a control, in this study, a male or a female) and one or more predictive factors. Significant findings suggest that males and females differ for those factors with hazard ratios greater than 1 indicating that males have higher scores on the variable of interest, and hazard ratios less than 1 indicating that females have higher scores. Analysis was performed first on the whole sample and then on two different diagnostic groups [group 1 = AN; group 2 = ANBN (lifetime diagnosis of both AN and BN), BN and EDNOS (a residual diagnostic group composed primarily of partial syndrome eating disorders: all three types of EDNOS were combined for this analysis)]. As the study is exploratory, and there is very limited other literature, P = .05 was set as the significance level for this report. Results As indicated in Table 1, there were no significant differences between males and females on age, or highest past or lowest past BMI. Males did report higher current BMI as would be expected based on gender. Table 2 presents hazard ratios, confidence intervals, and P values. If the hazard ratio of a personality trait is greater than 1, an increment in the trait increases the hazard rate for males. If the hazard ratio is less than 1, an increment in the trait decreases the hazard rate. The hazard ratios were also significantly lower for males for the following eating disorder symptoms as measured by the YBC-EDS such as preoccupation with weight and shape (HR 0.57, CI 0.35– 0.93, P = .026), level of preoccupation with eating disorder symptoms overall (HR 0.53, CI 0.32– 0.88, P = .014), and overall score at the period of worst symptoms (HR 0.54, CI 0.32– 0.92, P = .022). On the TCI, men reported lower reward dependence (HR 0.34, CI 0.19– 0.61, P = .0004), cooperativeness (HR 0.54, CI 0.35 –0.84, P = .006), and harm avoidance (HR 0.58, CI 0.37 – 0.92, P = .021) as compared to females. On the MPS, men reported lower organization (HR 0.41, CI 0.24 – 0.70, P = .001) and fewer concerns about mistakes (HR 0.55, CI Table 3 Predicting the likelihood of being male from symptom and personality variables by eating disorders subgroup AN BN, ANBN, NOS1, NOS2, NOS3 P value Hazard ratio CI 2.16) 1.21) 1.67) 1.45) 1.40) 1.26) 1.44) 1.34) .763 .122 .645 .293 .487 .192 .377 .255 1.20 0.61 0.86 0.74 0.50 0.43 0.50 0.42 (0.75, (0.34, (0.53, (0.44, (0.26, (0.20, (0.23, (0.18, 1.91) 1.10) 1.39) 1.24) 0.97) 0.96) 1.08) 0.96) .456 .099 .536 .250 .042 .033 .076 .040 (0.29, (0.71, (0.47, (0.08, (0.57, (0.24, (0.68, 1.06) 2.18) 1.42) 0.66) 2.16) 0.96) 1.67) .072 .439 .478 .006 .753 .038 .790 0.61 1.54 1.03 0.44 0.98 0.59 0.96 (0.32, (0.83, (0.56, (0.02, (0.55, (0.34, (0.50, 1.18) 2.86) 1.88) 0.90) 1.76) 1.05) 1.87) .144 .174 .934 .025 .953 .071 .920 0.47 0.74 0.49 0.74 0.83 0.61 0.55 (0.22, (0.41, (0.24, (0.41, (0.48, (0.30, (0.27, 0.98) 1.36) 1.02) 1.35) 1.42) 1.23) 1.11) .045 .337 .056 .327 .486 .166 .093 0.61 0.93 0.34 1.98 1.90 0.82 1.00 (0.34, (0.56, (0.15, (0.98, (0.98, (0.45, (0.56, 1.10) 1.54) 0.78) 4.02) 3.67) 1.48) 1.80) .100 .785 .011 .058 .057 .505 .990 STAI State anxiety Trait anxiety 0.87 0.71 (0.48, 1.57) (0.40, 1.27) .635 .252 0.89 1.03 (0.51, 1.56) (0.58, 1.81) .694 .926 YBOCS Compulsions Obsessions Total YBOCS 0.60 0.75 0.65 (0.32, 1.13) (0.40, 1.38) (0.35, 1.22) .113 .349 .180 1.22 1.49 1.37 (0.66, 2.25) (0.85, 2.62) (0.77, 2.45) .522 .169 .285 Variable Hazard ratio CI YBC-EDS Current motivation to change Current preoccupations Current rituals Current period total score Worst period motivation to change Worst period preoccupations Worst period rituals Worst period total 1.11 0.48 0.85 0.65 0.83 0.63 0.74 0.67 (0.57, (0.19, (0.44, (0.29, (0.49, (0.32, (0.38, (0.34, TCI Harm avoidance Novelty seeking Persistence Reward dependence Self-directedness Cooperativeness Self-transcendence 0.55 1.25 0.82 0.23 1.11 0.48 1.06 MPS Concern over mistakes Doubts about actions Organization Parental criticism Parental expectations Personal standards MPS overall P value D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 0.35 –0.87, P = .010) compared to the female sample. Men did not differ from women on measures of anxiety-related symptoms from the STAI and Y-BOCS. Table 3 presents data examining hazard ratios by gender for specific diagnostic subgroups. For AN, men are distinguished from women by lower levels of reward dependence on the TCI (HR 0.23, CI 0.08 – 0.66, P = .006), lower body image disturbance as measured by the SIAB (HR = 0.30, CI 0.11 –0.080, P = .016), and lower cooperativeness as measured by the TCI (HR = 0.48, CI 0.24 – 0.96, P = .038) and concern over mistakes as measured by the MPS (HR = 0.47, CI 0.22 –0.98, P = .045). For EDNOS, males were significantly distinguishable from women by reporting lesser influence of weight and shape on self-esteem (HR = 0.41, CI 0.19 – 0.85, P = .017), less motivation to change (HR = 0.50, CI 0.26 – 0.97, P = .042), fewer preoccupations about wei ght and shape (HR = 0.43, CI 0.20– 0.96, P = .033), lower reward dependence (HR = 0.44, CI 0.02 – 0.90, P = .025), and lower organization (HR = 0.34, CI0.15 – 0.78, P = .011). Discussion This study represents one of a very few attempts to systematically compare personality factors in men and women with eating disorders. The measures used in this study assess a reasonable cross section of personality factors that have been thought to be important in ED, including perfectionism, obsessionality, obsessive –compulsive disorder, harm avoidance, novelty seeking, and anxiety [19,20]. The primary findings of the study suggest that men with ED are less perfectionistic as measured by the MPS than women with ED, and their personality profile as measured by the TCI is also marked by lower harm avoidance, reward dependence, and cooperativeness. There is relatively little literature comparing men and women on the MPS and the TCI. Cloninger et al.’s initial report on the TCI [8] showed women to have higher levels of cooperativeness and spiritual acceptance, while a 1994 paper [21] showed lower scores by men on cooperativeness. We are not aware of any literature comparing men and women on the MPS. Frost et al.’s original research characterizing the measure was performed entirely on women [17]. Our results are compatible with but extend the only other comparable study, that of Fassino et al. [7]. The limitations in comparing the two papers are that our sample included men with a variety of eating disorder subtypes, and that not all of our samples were acutely ill at the time of assessment. However, both studies showed less risk for harm avoidance, reward dependence, and cooperativeness in anorexic males compared to anorexic females. While Fassino’s group were all acutely ill, only a minority of our AN subjects were underweight at the time of assessment, suggesting that these observed differences are not entirely state dependent, and may in fact represent trait abnormalities. Fassino et al.’s 277 comparisons to nonclinical males showed a reduced risk for reward dependence and cooperativeness, possibly identifying these two variables as especially interesting as potential trait markers for eating disorders. There are relatively few differences between men and women when diagnostic subgroup is considered. This may be at least partially due to the way in which cases were ascertained, specifically that probands with BN could have a lifetime history of AN. Cooperativeness, reward dependence, and concern over mistakes were less characteristic of males than females with AN. Likewise, motivation to change, reward dependence, and organization were less characteristic of males with EDNOS and BN than females with the same diagnoses. Although there are few studies of treatment response in men compared to women [22], it might be of interest to evaluate the impact of reduced motivation to change, and lower cooperativeness and reward dependence on treatment outcome. Reduced levels of motivation to change in the EDNOS group might partially explain the findings of Woodside et al. [3] showing a relatively high prevalence of EDNOS in males in the community that was not reflected in terms of those attending treatment These findings diverge from those of Joiner et al. [5] that showed higher rates of perfectionism in late adolescent males with BN compared to late adolescent females with BN. This difference could be a result of the age differences between the samples, with our sample being older. Alternately, the inclusion of ANBN and EDNOS diagnoses in this part of the analysis may have obscured a difference that would otherwise have been present. There may also be some complex interaction between genetic loading and underlying personality that could result in the established gender difference in the prevalence of eating disorders. Further work on the genetics of eating disorders may allow for more precise examinations of the contribution of underlying personality to the development of the illnesses. The constellation of differences reported on the TCI and MPS may be a reflection of an underlying personality structure associated with a higher risk of personality disorder, as reported by other investigators [6]. It is possible that there is a protective effect of this constellation of personality variables that accounts for some of the reduction in incidence of these illnesses in men compared to women. The presence of increased levels of perfectionism and reward dependence in women compared to men may be a mediating factor that sensitizes women preferentially to the societal pressures to be thin and to be excessively aware of body shape. If men experience reduced levels of perfectionism, they may as a group be less prone to develop the weight and shape concerns that appear to be a pathway into the illness in Western society. Alternately, given that all the subjects in this study had an ED, these personality features may represent gender-specific mediating pathways in the development of eating disorders. The strengths of this study lie in its sophisticated and comprehensive assessment protocols, and the inclusion of a 278 D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 fairly large sample of men with ED. The limitations include the small numbers of men in the various diagnostic subgroups, making subgroup analysis tentative. As well, the lack of control data makes it difficult to conclude that any findings are specific to the illness rather than being a feature of gender per se. The similarity of some of the TCI findings to those of Fassino et al. [7] is, however, encouraging. This study does not shed much light on the gender imbalance in the prevalence of the conditions in men compared to women, nor does it add anything to our body of information about the treatment of the conditions. Further research would include a larger sample of men in the various subgroups of eating disorder diagnoses to allow for a more precise identification of possible vulnerability and protective factors in this subset of the eating disorder population. [10] [11] [12] [13] [14] References [1] Lucas AR, Beard CM, O’Fallon WM, Kurland LT. 50-Year trends in the incidence of anorexia nervosa in Rochester, Minnesota: a population-based study. Am J Psychiatry 1991;148:917 – 22. [2] Soundy T, Lucas A, Suman V, Melton L. Bulimia nervosa in Rochester, Minnesota from 1980 to 1990. Psychol Med 1995;25:1065 – 71. [3] Woodside DB, Garfinkel PE, Lin E, Goering P, Kaplan AS, Goldbloom DS, Kennedy SH. Men with full and partial syndrome eating disorders: community comparisons with non-eating disordered men and eating disordered women. Am J Psychiatry 2001;158:582 – 6. [4] Braun DL, Sunday SR, Huang A, Halmi KA. More males seek treatment for eating disorders. Int J Eat Disord 1999;25(4):415 – 24. [5] Joiner TE, Katz J, Heatherton TF. Personality features differentiate late adolescent females and males with chronic bulimic symptoms. Int J Eat Disord 2000;27:191 – 7. [6] Striegel-Moore RH, Garvin V, Dohm FA, Rosenbeck RA. Psychiatric comorbidity of eating disorders in men: a national study of hospitalized veterans. Int J Eat Disord 1999;25:399 – 404. [7] Fassino S, Abbate-Daga G, Leombruni P, Amianto F, Rovera G, Rovera GG. Temperament and character in Italian men with anorexia nervosa: a controlled study with the temperament and character inventory. J Nerv Ment Disease 2001;189(11):788 – 94. [8] Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry 1993; 50:975 – 90. [9] Devlin B, Bacanu SA, Klump KL, Bulik CM, Fichter MM, Halmi [15] [16] [17] [18] [19] [20] [21] [22] KA, Kaplan AS, Strober M, Treasure J, Woodside DB, Berrettini WH, Kaye WH. Linkage analysis of anorexia nervosa incorporating behavioral covariates. Hum Mol Genet 2002;11:689 – 96. Strober M, Freeman R, Lampert C, Diamond J, Kaye W. Males with anorexia nervosa: a controlled study of eating disorders in first-degree relatives. Int J Eat Disord 2001;29:263 – 9. Kaye WH, Lilenfeld LR, Berrettini WH, Strober M, Devlin B, Klump KL, Goldman D, Bulik CM, Halmi KA, Fichter MM, Kaplan A, Woodside DB, Treasure J, Plotnicov KH, Pollice C, Rao R, McConaha CW. A genome-wide search for susceptibility loci in anorexia nervosa: methods and sample description. Biol Psychiatry 2000;47:794 – 803. Kaye WH, Devlin B, Barbarich N, Bulik CM, Thornton L, Bacanu SA, Fichter MM, Halmi KA, Kaplan AS, Strober M, Woodside DB, Bergen AW, Crow S, Mitchell J, Rotondo A, Mauri M, Cassano G, Keel P, Plotnicov K, Pollice C, Klump KL, Lilenfeld LR, Ganjei JK, Quadflieg R, Berrettini WH. Genetic analysis of bulimia nervosa: methods and sample description. Int J Eat Disord (In press) Fichter MM, Herpertz S, Quadflieg N, Herpertz-Dahlmann B. Structured interview for anorexic and bulimic disorders for DSM-IV and ICD-10: update (third) revision. Int J Eat Disord 1998;24:227 – 57. Hebebrand J, Remschmidt H. Anorexia nervosa viewed as an extreme weight condition: genetic implications. Hum Genet 1995;95(1):1 – 11. Sunday SR, Halmi KA, Einhorn A. The Yale – Brown – Cornell Eating Disorder Scale: a new scale to assess eating disorder symptomatology. Int J Eat Disord 1995;18:237 – 45. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Heninger GR, Chamey DS. The Yale – Brown Obsessive – Compulsive Scale (Y-BOCS): 1. Development, use and reliability. Arch Gen Psychiatry 1989;46:1006 – 11. Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism. Cogn Ther Res 1990;14:449 – 68. Spielberg CD, Gorsuch RL, Lushene RE. STAI manual for the State Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press, 1970. Sutandar-Pinnock K, Woodside DB, Carter J, Olmsted MP, Kaplan AS. Perfectionism in anorexia nervosa: a 6 – 24 month follow-up study. Int J Eat Disord 2002;31:290 – 9. Lilenfeld L, Kaye W, Greeno C, Merikangas K, Plotnikov K, Pollice C, Rao R, Strober M, Bulik CM, Nagy L. A controlled family study of restricting anorexia and bulimia nervosa: comorbidity in probands and disorders in first-degree relatives. Arch Gen Psychiatry 1998;55: 603 – 10. Cloninger CR, Przybeck TR, Svrakic DM, Wetzel RD. The Temperament and Character Inventory (TCI): a guide to its development and use. St. Louis (MO): Center for Psychobiology of Personality, Washington University, 1994. Woodside DB, Kaplan AS. Day hospital treatment in males with eating disorders—response and comparison to females. J Psychosom Res 1994;38(5):471 – 5.