Individual Psychological Traits and Personality Features

A reliable assessment of pre-illness personality traits is difficult to make without prospective studies. As it is, most personality research has been done retrospectively and some studies have relied on the patient's memory alone, with its subjective bias, instead of obtaining information from independent interviews of parents or other relatives. It is also difficult to judge personality features during the acute stage of the disorder, since the starvation state tends to reinforce rigidity and controlling tendencies [25]. Other manifest features may be a consequence of a comorbid psychiatric disorder: for instance, depressive symptoms affect self-esteem [25]. On the other hand, the overall stability of personality traits into adulthood makes it possible to obtain valid information from patients after full recovery [26,27].

These methodological problems notwithstanding, studies have consistently identified childhood personality traits of high self-expectations and high moral standards along with rigidity as precursors [27].

Research which led to the suggestion to subtype AN based on eating patterns noted early on differences in the patient's childhood personality [20,28]. Restricting AN patients were more often described by their parents as introverted and perfectionistic than binge-eating/purging patients, who tended to be more outgoing as children. Rastam [29] reported a high frequency of premorbid obsessive-compulsive personality disorder in a population-based sample. The existence of traits of obsessionality and social avoidance in AN patients were confirmed by Wentz et al. [30] in a follow-up study of the same sample. In two other follow-up studies, women who had recovered from the restricting type of AN and were assessed along normal personality dimensions [31] displayed higher moral standards and rigidity, along with greater emotional, cognitive and behavioural control, than sisters or healthy controls [26], and more obsessive-compulsive personality traits, such as perfectionism, rigidity and preference for order and symmetry [27].

More recently, studies have focused on personality traits reflecting ''perfectionism'' as a risk factor, albeit different studies have measured different components of perfectionism. Fairburn et al. [24] found that negative self-evaluation and perfectionism (''high personal standards'') as a childhood characteristic distinguished AN patients from healthy and psychiatric controls. Bulik et al. [32] found ''concern over mistakes'' but not ''personal standards'' to increase the odds ratio of AN, yet in her study neither characteristic was a predictor for AN. Perfectionism defined in Webster as ''a disposition to regard anything short of perfection as unacceptable'' tends to coexist with low self-esteem in AN. In a population-based female twin sample, Walters and Kendler [3] found low self-esteem and a higher level of neuroticism to be associated with AN. Low self-esteem also occurred in those without a history of depression. Confirmatory evidence for a poor self-concept comes from three independent studies which described very low (self-critical) self-image scores in adolescents with acute AN by comparison with healthy and depressed adolescents [33-35].

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