Impulsivity-related traits in eating disorder patients

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Abstract

Whiteside and Lynam (2001) have proposed a new model for understanding personality pathways to impulsive behavior. In this model four personality dimensions (UPPS) are related differentially to impulsive behaviors: Urgency, Sensation Seeking, (Lack of) Premeditation, and (Lack of) Perseverance. Furthermore, the UPPS model suggests very specific ways in which the dimensions might be related to psychopathology and other problematic behaviors. In the present study, we have assessed 146 eating-disordered patients with respect to the four impulsivity-related personality traits in the purpose of testing the specific hypotheses offered by the UPPS model. The diagnostic subtypes of eating-disordered patients did differ on the four impulsivity-related traits, and these traits were differentially related to various behaviors and forms of psychopathology confirming many of Whiteside and Lynam’s (2001) predictions. Bulimia nervosa patients showed consistently more Urgency and Sensation Seeking and less Premeditation and Perseverance than restrictive anorexia nervosa patients, with the bingeing-purging anorexics being situated in between. Both in assessment and treatment of eating-disordered patients specific attention should be paid to impulsivity-related personality traits.

Introduction

In a review of obsessive–compulsive spectrum disorders, McElroy, Phillips, and Keck (1994) suggested that the various eating disorders (ED)—anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED)—could be situated on a spectrum with varying degrees of obsessive–compulsive and impulsive traits. Much has been written regarding the more obsessional nature of AN versus the more impulsive traits in BN (for reviews see: Grilo, 2002, Serpell et al., 2002, Yaryura-Obias et al., 2001). But obsessional traits have also been found in BN patients and impulsive traits in AN subjects, in particular the bingeing-purging subtype (see Claes, Vandereycken, & Vertommen, 2002). The interpretation of the many studies is seriously hampered by methodological differences reflecting different concepts especially with regard to impulsivity or impulsiveness. Many overlapping and sometimes contradictory definitions have been used (McCown et al., 1993, Webster and Jackson, 1997). Various researchers have described impulsivity-related constructs using terms such as lack of control, lack of deliberation, excitement seeking, novelty seeking, lack of self-discipline, and venturesomeness. Although these impulsivity constructs show some conceptual and content overlap, there may also be real and important distinctions among them (Miller, Flory, Lynam, & Leukefeld, 2003).

Whiteside and Lynam (2001) have suggested that the Five Factor Model (FFM) of personality, as assessed by the NEO-PI-R (Costa & McCrae, 1992), may provide a way of parsing impulsivity into its different forms. They argued that the FFM model includes four personality traits that represent distinct pathways to impulsive behavior. These four traits exist on the separate higher-order factors of personality, clearly described by Miller et al. (2003): (1) The first trait Whiteside and Lynam have identified was the NEO-PI-R trait of impulsiveness, which is situated on the Neuroticism factor and assesses an individual’s tendency to give in to strong impulses, specifically when accompanied by negative emotions such as depression, anxiety, or anger. (2) Excitement seeking, a specific trait on the higher-order factor of Extraversion, which measures an individual’s preference for excitement and stimulation, is another route to impulsive behavior. The third and fourth traits, self-discipline and deliberation, both exist on the broader factor of Conscientiousness, and a lack of these traits is hypothesized to lead to impulsive behavior. (3) Self-discipline measures an individual’s ability to persist in completing jobs or obligations despite boredom and/or fatigue. (4) Deliberation assesses an individual’s ability to think through the potential consequences of his or her behavior before acting. Whiteside and Lynam (2001) have argued that these four personality dimensions actually subsume the major conceptualizations of impulsivity and that they are best understood as four personality pathways to impulsive behavior. In order to test these hypotheses, they conducted factor analyses with the most widely-used impulsivity scales and the four selected scales from the FFM. On this basis they developed the UPPS Impulsive Behavior Scale including four new scales to assess each of the underlying dimensions. Although defined by the FFM scales, Whiteside and Lynam (2001) have relabeled the new dimensions: (1) Urgency (FFM-impulsiveness), (2) Perseverance (FFM-self-discipline), (3) Premeditation (FFM-deliberation), and (4) Sensation Seeking (FFM-excitement seeking).

Furthermore, Whiteside and Lynam (2001) suggested very specific ways in which the dimensions might be related to psychopathology and other problematic behaviors. For example, they assumed that Urgency would be related to borderline personality disorder, (para)suicidal behavior and bulimia, while Sensation Seeking would be associated to exciting but dangerous behavior, such as substance use. In addition, they postulated that a Lack of Perseverance would be related specifically to difficulties in children with attention deficit disorder, and that a Lack of Premeditation would be related to antisocial personality disorder and psychopathy. Miller et al. (2003) have studied a sample of 481 young adults (20–21 year-old students) in order to provide validation for this model and to test some of the specific hypotheses offered by Whiteside and Lynam (2001). The results revealed that all four traits were significantly related to almost all of the externalizing disorders and even several of the internalizing ones. Lack of Premeditation was consistently the strongest correlate of the externalizing problems, whereas Urgency appeared to be more strongly related to several other forms of psychopathology, such as personality disorders, ED, and depression. In the same line, Fischer, Smith, and Anderson (2003) have shown that Lack of Premeditation was not significantly associated with bulimic symptoms. However, the tendency to act rashly when experiencing negative affect (Urgency) was positively correlated with bulimic symptoms in two independent student samples. According to these authors, future researchers should measure urgency, not lack of planning, when assessing impulsivity as a risk factor for BN.

Faced with a confusing literature on impulsivity in ED, we found the UPPS model quite clarifying and wanted to test the hypotheses offered by Whiteside and Lynam (2001) and compare our results with those of Miller et al. (2003). Inspired by the idea of obsessive–compulsive spectrum disorders, we hypothesized a gradual increase of the four impulsivity-related personality traits: starting from AN-restrictive type, over AN-bingeing/purging type to BN. Furthermore, we expected Urgence to be positively related to borderline personality disorder, parasuicidal behavior and bulimic behavior; while Sensation Seeking would be related to substance abuse. In addition, we hypothesized that a Lack of Perseverance would be linked to inattention difficulties, and that a Lack of Premeditation would be associated with antisocial personality disorder and psychopathy. In ED patients, these traits are of potential interest for several reasons. It has been suggested that the presence of impulsive traits increase the risk of a poor treatment outcome and a worse long-term prognosis in BN patients (Keel & Mitchell, 1997). Additionally, the presence of compulsive traits may be viewed as an indication for a treatment trial with serotonergic psychotropics. Therefore, understanding the obsessive–compulsive and impulsive aspects in individuals with ED may guide treatment choices aimed at a better long-term outcome (Raymond et al., 1999).

Section snippets

Participants

We gathered data from 146 white female ED patients admitted to a specialized inpatient unit. By means of a diagnostic interview conducted by an experienced psychiatrist (second author) supplemented with the Eating Disorder Evaluation Scale (EDES; Vandereycken, 1993) patients were diagnosed according to DSM-IV criteria (American Psychiatric Association, 1994): 31.5% (N = 46) as anorexia nervosa, restrictive type (AN-R); 34.2% (N = 50) as anorexia nervosa, bingeing-purging type (AN-P); 34.2% (N = 50)

Results

As shown in Table 1, we found significant differences between the subtypes of ED patients with respect to ED symptoms (EDES; Wilks’λ = 0.31, p < 0.001), psychopathological symptoms (SCL-90; Wilks’λ = 1.92, p < 0.05), alcohol abuse (MALT; F(2, 130) = 6.07, p < 0.01), DSM-IV personality disorder traits (ADP-IV; Wilks’λ = 0.59, p < 0.001), and all four personality traits (Wilks’λ = 0.71, p < 0.001) of the UPPS model. As expected, AN patients showed more pathological scores on the EDES anorectic preoccupation scale and

Discussion

Confirming the general findings in the literature (see Section 1), we found that restrictive AN patients are less impulsive than the bingeing-purging AN and BN patients on the four impulsivity-related traits. On the whole, these bingeing-purging anorexics seem to have more in common with BN patients than with restricting AN patients, as suggested in other studies (see Claes et al., 2002). Compared to normative data of a female age-related group, the ED subtypes can be situated in a diminishing

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