European Eating Disorders ReviewEur. Eat. Disorders Rev. 12, 375–379 (2004)

Is Drive for Thinness in AnorecticPatients Associated withPersonality Characteristics?

M. Vervaet1*, C. van Heeringen2 and K. Audenaert21Outpatient Unit, Centre for Eating Disorders,University Hospital Gent, Belgium2Department of Psychiatry, University Hospital Gent, Belgium

Objective: The objective was to compare clinical and personalityfeatures in anorectic patients (AN) with a high and low drive forthinness (DT).Method: The samples comprised 244 AN in- and outpatients atthe Department of Psychiatry andMedical Psychology (Universityof Gent) in Belgium. Subjects were assessed on clinical andpsychometric parameters.Results: 27 per cent (N¼ 62) of the subjects had low DT asmeasured by the Eating Disorder Inventory (EDI) of whom 48were restricting anorectic patients (ANR). This atypical anorecticgroup appeared to have less severe psychopathology with a lowerharm avoidance and higher self-directedness as subscales of theTemperament and Character Inventory (TCI).Discussion: Weight concerns is an important diagnosticcriterion, but may have other motivations than a culture-bounddrive for thinness. This differentiation may have therapeuticconsequences. Copyright # 2004 John Wiley & Sons, Ltd andEating Disorders Association.

Keywords: personality; anorexia nervosa; weight concerns

INTRODUCTION

Weight phobia is a main criterion to distinguishpatients suffering from eating disorders (EDs) fromthose with other psychiatric diagnoses andfrom non-clinical populations (Russell, 1970, 1979;American Psychiatric Association, 1994). In anorexianervosa (AN), this intense fear of fatness perseveresin the face of emaciation and remains present evenafter weight restoration (Bastiani, Rao, Weltzin, &Kaye, 1995). The morbid fear of fat is often measuredby clinical means and self-report as the drive for thin-

ness (DT; Ramacciotti et al., 2002). Thus, while thisfeature is considered an important element in thediagnosis of eating disorders, it is surprising to notethat fat phobia or a drive for thinness is absent in asubstantial proportion of non-western (Lee, Ho, &Hsu, 1993) and western (Ramacciotti et al., 2002;Strober, Freeman, & Morell, 1999) patients. Theabsence of fat phobia in AN patients has beenexplained by the comorbid presence of a conversiondisorder (Garfinkel, Kaplan, Garner, & Darby, 1983),by the egosyntonic nature of emaciation (Theander,1995; Lasegue, 1997), as a consequence of the denialof illness, and even as a feature of grandiosity(Orimoto & Vitousek, 1992). Furthermore, Lee et al.(2001) explained the diversity of rationales for foodrefusal in AN patients as congruous with historical,clinical and community studies showing that attribu-tions regarding weight and shape were not static.

Copyright # 2004 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.586

* Correspondence to: Prof. Dr M. Vervaet, Department ofPsychiatry, University Hospital Gent, De Pintelaan 185, 9000Gent, Belgium. Tel: þ32 9 240 43 95. Fax: þ32 9 240 49 89.E-mail: myriam.vervaet@Ugent.be

Instead, they varied with situations (Lee, 1995), acrossthe lifespan (Tiggemann & Stevens, 1999), and withthe body weight (Fairburn, Shafran, & Cooper, 1998).

We recently showed an association between a sub-stantial number of cognitive and behavioural char-acteristics and personality traits in ED patients(Vervaet, Audenaert, & van Heeringen, 2003). Itcan be questioned whether DT is also associatedwith particular personality characteristics. Recentstudies of the personality of ED patients have com-monly used Cloninger’s Temperament and Charac-ter Inventory (TCI; Cloninger, Przybeck, Svrakic, &Wetzel, 1994), showing a comparatively high scoreon harm avoidance and low score on novelty seekingand reward dependence, the data concerning thelast dimension not being equivocal (Brewerton,Hand, & Bishop, 1993; Bulik, Sullivan, Weltzin, &Kay, 1995; Cloninger et al., 1994; Klump et al.,2000), and by low scores on self-directedness andhigh scores on persistence (Diaz-Marsa, Carrasco,Hollander, Cesar, & Saiz-Ruiz, 2000).

The present study aimed at investigating whetherthe presence or absence of DT is associated with per-sonality characteristics in patients with anorexianervosa.

METHODS

Subjects

The study group consisted of patients who were con-secutively referred to the in- and out-patient units ofthe Centre for Eating Disorders at the Department ofPsychiatry of the University Hospital Gent betweenDecember 1998 and March 2003, and who met theDSM-IV criteria for eating disorders. All patientsgave informed consent compliant with the Code ofEthics of the World Medical Association (Declara-tion of Helsinki) and the study was conducted fol-lowing the approval of the local ethics committee.

Assessments

Weight and height were measured during the firstconsultation, while highest and lowest adult weightever and duration of illness were assessed by self-report. The current body mass index (BMI) was cal-culated, as well the highest and lowest lifetime BMI(HBMI, LBMI), based on the highest and lowestadult weight ever. Age of onset was defined as theage at which eating behaviour changed. Patientswere asked to report the presence (i.e. two or moretimes per week) or absence of bingeing and/or pur-ging behaviours.

The Dutch version of the SCAN (WHO—Sche-dules for Clinical Assessment in Neuropsychiatry)was used to assign diagnoses according to DSM-IVcriteria (Giel & Nienhuis, 1996). Patients also com-pleted the Eating Disorder Inventory (EDI; Garner,Olmstead, & Polivy, 1983), the Dutch EatingBehaviour Questionnaire (DEBQ; Van Strien, 1986)and the validated Dutch version of the TCI(Duijsens, Spinhoven, Goekoop, Spermon, &Eurelings-Bontekoe, 2000).

On the basis of the score obtained on the EDI sub-scale ‘Drive for thinness’ and calculated usingGarner’s (1991) item-transformation, we dividedthe sample in two groups. The first group comprisedpatients with a DT higher than 7 (the ‘typical’ group)and the second group consisted of patients with a DTup to 7 (the ‘atypical’ group). The cutoff score of 7was similar to that in previous studies (e.g.Ramacciotti et al., 2002) in order to allow for compar-ison of our results. The six-point Likert scale wasrecalculated in a score of 0–3 with a range of the totalscore between 0 and 21.

RESULTS

Among the total group of referred patients(N¼ 531), 244 (46.0 per cent) were diagnosedwith anorexia nervosa, including 167 restrictors(68 per cent of the AN patients). Assessment datawere available for 226 AN patients (93 per cent).Using the above-mentioned EDI–DT cutoff score,the ‘atypical’ group comprised 62 (27 per cent) ANpatients, while 164 (73 per cent) AN patients consti-tuted the ‘typical’ group.

The atypical group was significantly larger amongrestricting AN patients (N¼ 48) than amongbingeing/purging anorexics (N¼ 14; Pearson�2¼ 20; p< 0.001). No significant difference in theproportion of atypical patients was found betweeninpatients (N¼ 34) and outpatients (N¼ 28; Pearson�2¼ 0.025; p¼ 0.874).

Further statistical analysis pursued the compari-son between atypical and typical AN patients. Asshown in Table 1, no significant differences werefound for the characteristics age, BMI, highest life-time BMI and duration of illness. Atypical patientsreported a later age of onset of their eating disorderand a lower lifetime BMI.

Atypical AN patients were also found to scorelower on the ‘restrained eating’ subscale of theDutch Eating Behaviour Questionnaire. No signifi-cant differences were found for scores on the ‘exter-nal eating’ and ‘emotional eating’ subscales. With

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Copyright # 2004 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 12, 375–379 (2004)

regard to personality characteristics, atypicalpatients scored significantly lower on the tempera-ment dimension ‘harm avoidance’ and significantlyhigher on the character dimension ‘self-directed-ness’ (Table 1).

While no significant difference was found withregard to the occurrence of bingeing behaviour,there were comparatively fewer atypical patients(N¼ 29; 47 per cent) than typical patients (103;63 per cent) who reported purging (Pearson �2¼4.759; p< 0.05).

DISCUSSION

This study aimed at investigating the occurrence andpersonality-related correlates of a low drive for thin-ness among anorexia nervosa patients by comparingtheir characteristics with those of anorexia nervosapatients with a high drive for thinness. The findingsindicate that a low drive for thinness is present inmore than one-quarter of these patients, and particu-larly common among those of the restricting type.The findings also demonstrate that a low drive forthinness is associated with a higher age of onset ofthe eating disorder and with less severe behaviouralmanifestations such as purging and restrained eating.Also, with regard to their personality profile, anorexicpatients with a low drive for thinness showed com-

paratively less severe disturbances, i.e. a relativelyless increased harm avoidance and a relatively lessdecreased self-directedness, than anorexic patientswith a high drive for thinness.

With regard to the occurrence of a low drive forthinness, the current findings are in keeping withthose from previous studies using the same diagnos-tic criteria for drive for thinness (Ramacciotti et al.,2002; Strober, Freeman, & Morrell, 1999). In accor-dance with the findings of Lee and colleagues (Lee,Lee, Ngai, Lee, & Wing, 2001), no differencesbetween the two groups were found regardingBMI, age at referral and duration of illness. We couldnot demonstrate a significantly lower premorbidBMI in association with a low drive for thinness.

It thus appears that a low drive for thinness amonganorexia nervosa patients is associated with less eat-ing-related pathology (lower frequency of purgingand less restrained eating) and less severe psycho-pathology (lower harm avoidance and higher self-directedness). Strober, Freeman and Morrell (1999)have stated in a similar way that atypical anorexicshave a comparatively smaller chance of progressingto chronic morbidity, a faster rate of full clinicalrecovery and a lower risk of developing a first onsetof binge eating. According to current cognitive beha-vioural theory, an extreme need to control eating isthe central feature of AN, with a superimposed ten-dency to judge self-worth in terms of shape and

Table 1. Clinical characteristics, DEBQ and TCI variables between atypical and typical ANs

Atypical AN (N¼ 62) Typical AN (N¼ 164)Mean (SD) Mean (SD) t-test statistics

Clinical characteristicsAge 23.7 (7.3) 21.9 (7.7) 1.6BMI 15 (1.5) 15.1 (1.5) �0.5HBMI 20.7 (3.1) 21.2 (3.7) �1.1LBMI 13.9 (1.8) 14.5 (1.7) �2.4*Duration of illness 4.0 (5.0) 3.9 (6.1) 0.1Age of onset 19.6 (4.8) 18.0 (4.5) 2.3*

Dutch Eating Behaviour Questionnaire (DEBQ)Restrained eating 3.1 (0.9) 4.3 (0.9) �9.3***External eating 3.2 (0.7) 2.9 (1.1) 0.1Emotional eating 2.4 (0.9) 2.6 (1.2) 0.2

Temperament and Character Inventory (TCI)Novelty seeking (NS) 15.9 (6.3) 16.2 (6.9) 0.8Harm avoidance (HA) 21.8 (6.8) 24.8 (6.6) �3.0**Reward dependence (RD) 16.6 (3.6) 16.2 (3.8) 0.5Persistence (P) 5.9 (2.0) 5.6 (1.9) 0.4Self-directedness (SD) 25.3 (7.0) 21.1 (7.4) 3.8***Cooperativeness (C) 33.4 (4.5) 31.8 (6.7) 0.1Self-transcendence (ST) 12.3 (6.6) 12.7 (6.4) 0.7

*p< 0.05; **p< 0.005; ***p< 0.001.BMI, body mass index; HBMI, highest adult (�16 years) BMI ever; LBMI, lowest adult (�16 years) BMI ever.

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Copyright # 2004 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 12, 375–379 (2004)

weight in western societies (Fairburn, Shafran, &Cooper, 1998; Fairburn, Cooper, & Shafran, 2003).This need to control eating has been attributed tofat phobia, but recent research findings suggest thatreinforcing effects of food restriction per se play acrucial role. Kaye et al. (2003) hypothesize that star-vation in anorexia nervosa patients serves to reduce5-HT neuronal activity in response to their trait-related (i.e. premorbid and persisting after recovery)increase in serotonergic (5-HT) neuronal transmis-sion. This increased 5-HT signal transmission doesnot respond to normal regulatory mechanisms,and thus contributes to uncomfortable core symp-toms such as obsessionality, perfectionism, harmavoidance and anxiety. Starvation is associated witha dietary-induced reduction of tryptophan (TRP;the precursor of 5-HT), and thus may temporarilyreduce this dysphoric behavioural state. The influ-ence of bingeing or purging on the anxiolytic effectof starvation in anorexia nervosa patients is cur-rently not known. Our present findings indicate anassociation between a low drive for thinness andrestricting rather than bingeing/purging behaviourin anorexia nervosa patients.

The drive for thinness in anorexia nervosa patientsmay in general thus reflect a drive for food restric-tion as a compensatory mechanism for increasedanxiety. In view of the comparatively less severe eat-ing disorder-related symptoms, this mechanismappears to be relatively effective in patients with alow drive for thinness. Our findings suggest that thisrelative effectiveness is associated with a compara-tively lower harm avoidance and a higher self-directedness. Low self-directedness is indeed asso-ciated with an external locus of control, and thuswith a more outspoken susceptibility to externalinfluences. Knowing that individuals with charactertraits denoting low self-directedness and high self-transcendence may be particularly reactive and sus-ceptible to societal messages referring to the ideol-ogy of slenderness (Gendall, Joyce, Sullivan, &Bulik, 1998), it can be hypothesized that typical anor-exia nervosa patients translate their food phobia intoa weight phobia, characterized by behavioural com-pensatory mechanisms such as more restrained eat-ing and purging.

Ramacciotti et al. (2002) suggest that the treatmentof the non-fat phobic group of anorexia nervosapatients should be less cognitively based and lessfocused on cultural tyranny and fat. However, thereare several reasons to include cognitive strategies inthe treatment of anorexia nervosa patients with alow drive for thinness. The important interactionbetween an extreme need for control and the use of

food restriction to judge self-worth in order to copewith anxiety in anorexia nervosa patients (Fairburnet al., 1998, 2003) requires cognitive restructuringprocedures. Such strategies should be added tobehavioural interventions aiming at increasing bodyweight, perhaps through in vivo exposure to food toattain the extinction of the anxiety–food connection.In order to prevent relapse, and in keeping with pre-vious findings (see e.g. Kaye et al., 2003), the currentstudy indicates that trait-dependent anxiety regula-tion should also be addressed. In view of the well-documented role of 5-HT in the modulation of harmavoidance (Cloninger, 2000), serotonergic drugsmay be particularly indicated (Frank et al., 2001;Kaye et al., 1998).

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