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Temperament in Juvenile Eating Disorders
Temperament in Juvenile Eating Disorders RICHARD J. SHAW M.B., B.S. HANs STEINER, M.D.
Previous studies have suggested an association between temperament and eating disorder pathology. The purpose of this study was to differentiate on the basis oftemperament among patients with anorexia, bulimia, and major depression. In this study, 101 adolescent girls completed the Revised Dimensions of Temperament Survey (Self), a self-report measure that identifies nine dimensions oftemperament. Significant differences were found between the diagnostic groups while controlling for disturbances in mood and defensiveness. Specific subscales differentiated the subjects with anorexia from those with bulimia. These data support the concept ofusing temperament to differentiate patients with related psychiatric syndromes. (Psychosomatics 1997; 38:126-131)
A
relationshi P between temperament and psychopathology was first suggested in the New York Longitudinal Study, I in which nine dimensions of temperament were identified. These dimensions have been widely adopted in scales used to assess temperament and have been found to remain relatively stable over time. 2 Three constellations of temperament were described: easy, difficult, and slow-towarm-up, and each constellation appeared to be associated with characteristic patterns ofbehavior in response to environmental stimuli. The concept of "goodness of fit" between the temperament of parent and child has been offered to explain how temperament interacts with family and other environmental experiences to contribute to the development of psychopathology. 3 Later studies4-S have supported the Received February 7, 1996; revised March 20, 1996; accepted May 10, 1996. From the Deparunent of Psychiatry and Behavioral Sciences, Division of Child Psychiatry and Child Development, Stanford University School of Medicine, Palo Alto, California. Address reprint requests to Dr. Shaw, 401 Quarry Road, Stanford, CA 94305-5540. Copyright C 1997 The Academy of Psychosomatic Medicine.
126
original assertions that infants with a "difficult temperament" profile are more likely to manifest behavioral problems and psychiatric disordersduringadolescence. Similarly, adolescents assessed with "difficult temperament" are reported to have a higher incidence of childhood behavior problems, including conduct disorder, substance abuse, delinquent activity, and depression, particularly when associated with lower perceived family emotional support. 6 In addition, attempts have been made to identify a relationship between specific profiles of temperament and eating disorder pathology.7-8 Studies of temperament in patients with eating disorders have suggested that patients with anorexia nervosa and bulimia nervosa may be differentiated on the basis of temperament. Brewerton et al. 9 used the Tridimensional Personality Questionnaire (TPQ)IO to show that patients with eating disorders were more likely to rate themselves as being cautious, tense, inhibited, shy, and easily fatigued. The patients with bulimia rated themselves as being impulsive, excitable, extravagant, quickly bored, and ready to engage in new activities. Bulik et al. 1I used the same instrument to show that women PSYCHOSOMATICS
Shaw and Steiner
with anorexia rated themselves highly on the TPQ subscale of "reward dependence," indicating a need for signs of praise and reward, and persistence in previously rewarded behavior. These findings parallel clinical observations of women with eating disorders. Patients with anorexia nervosa have been described as hypersensitive to rejection and disapproval,12 while women with bulimia are often described as having labile affect, poor impulse control, and cluster B personality traits. 13.14 This study, conducted in 1991, examines temperament in a group of adolescent girls with anorexia nervosa (AN), bulimia nervosa (BN), and major depression (DEP). Temperament is assessed using the Revised Dimensions of Temperament Survey (DOTS-R [Self]), IS a selfreport instrument used to derive nine dimensions of temperament, corresponding with those originally described in the New York Longitudinal Study. In general, high scores on the subscales indicate adaptability, flexibility, persistence, and features indicative of an "easy" temperament profile. Windle 16 has used a second-order factor analysis of eight of the firstorder factors to create three higher order dimensions of temperament, which are used in the
TABLE 1.
statistical analysis (Table 1). We hypothesized that significant differences in temperament would be found between each diagnostic group. Based on clinical observations of patients with these disorders, we further hypothesized that specific dimensions of temperament obtained from the DOTS-R (Self) would be helpful in distinguishing patients with AN from those with BN, as indicated in Table 2. METHODS The subjects were 101 female adolescent patients referred to a well-established eating disorders clinic or hospitalized directly in the inpatient psychiatric unit specializing in the treatment of eating disorders at Children's Hospital at Stanford. All eligible subjects were asked to participate in research, and they completed several questionnaires as part of the routine evaluation process. No one refused to participate in the study. The subjects were diagnosed according to DSM-Ill-R criteria following a semistructured interview by two clinicians. On the basis of primary Axis I diagnosis, the subjects were divided into three groups: AN (n =37, mean ± SD age = 15.1 ± 2.8); BN (n =
Revised Dimensions of Temperament Survey (SeIO (DOTS·R [Self}) Thmperament Factor
Slgnilkance of High Score
fLEX
Activity level-general Activity level-sleep Approach-withdrawal Flexibility-rigidity
MOOD RHY-S RHY-E RHY-DP TASK
Mood quality Rhythmicity-sleep Rhythmicity-eating Rhythmicity-daily patterns Task orientation
High level of energy and vigor High level of physical activity during sleep Tendency to approach new situations and people Tendency to respond flexibly to changes in the environment Characteristic display of positive effect Regular sleep-wake cycle Regular pattern of eating habits Regular pattern of diurnal activities Ability to concentrate and persist with activities
DOTS-R First·Order ACf-G ACf-S
APPR
Second-order ADAPT
Adaptability/positive affect
RHY-G
General rhythmicity
TASK
Task orientation
Tendency to approach new situations, respond flexibly to changes, and display positive affect Regular patterns of diurnal activities. including sleep and eating patterns Ability to concentrate and persist with activities
Note: Table adapted from Windle. 17
VOLUME 38 • NUMBER 2. MARCH - APRIL 1m
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Juvenile Eating Disorders
=
=
28, mean ± SD age 16.6 ± 1.2); and DEP (n 36, mean ± SD age = 15.1 ± 1.7). The subjects with more than one diagnosis were excluded from the study. Half of the sample were inpatient and half outpatient. The ethnic distribution of the sample was as follows: 78% Caucasian, 15% Hispanic, I % African-American, 1% Asian, and 5% other. The age, ethnicity, and distribution of diagnoses of the sample are representative of this particular clinic and inpatient population, whose demographic characteristics have been reported in a previous study. 18 During the initial evaluation, each subject completed a battery of self-report measures that included the DOTS-R (Self), the Beck Depression Inventory (BDI), and the Marlowe-Crowne Social Desirability Scale (MCSDS). The BDI I9 consists of 21 items rated by self-report on a 3-point scale measuring severity of depression. The MCSDS 20 is a 33-item self-report questionnaire that measures defensiveness. It has high test-retest and internal consistency and concurrent validity with other measures of defensiveness. Data reduction was carried out on the subscales of the DOTS-R (Self) by principal components analysis. The three second-order factors described by Windle l7 were used to test multivariate analysis of covariance (MANCOVA) with the BDI and MCSDS scores as covariates. Follow-up analyses consisted of analysis of covariance (ANCOVA) and Scheffe. A two-tailed I-test of significance was used for all analyses.
TABLE 2.
PredIcted dilrerences In subsalles or the the Dimensions or Temperament Survey (Self)
DOTS·R Thmperament Factor APPR RHY-S RHY-E RHY-DP TASK
128
Approach-withdrawal Rhythmicity-sleep Rhythmicity--eating Rhythmicitydaily patterns Task orientation
AN
BN
Decreased Increased Increased Decreased Increased Decreased Increased Increased
Decreased Decreased
RESULTS Table 3 shows the nine first-order and three second-order temperament subscales derived from the DOTS-R (Self) for the three groups of girls with a psychiatric diagnosis, compared with a group of 517 age-matched healthy control subjects, using data published by Windle. 17 MANCOVA was significant for a diagnosis effect (Wilk's A. =0.741, F[6.188) =5.1, P =0.001); BDI effect (Wilk's A. 0.862, F(3.94) 5.02, P 0.003); and MCSDS effect (Wilk's A. 0.898, F[3.94) 3.56, P 0.02). Adaptability/positive affect was significantly different in the three groups (ANCOVA: F(4.96) 4.71, P 0.002), but these differences were attributable to the subjects' BDI scores (F[2.96) 8.82, P 0.004) and MCSDS scores (F[2.96) 8.91, P 0.004), whereas diagnostic grouping had no significant effect. General rhythmicity was also significantly different in the three groups (ANCOVA: F[4.96) 5.39, P 0.0006), and with this factor, diagnosis was significant as a distinguishing factor (F[2.961 10.34, P 0.00021). Attentional focus was also significantly different in the three groups (ANCOVA: F[4.96) = 6.14, P = 0.0002), and with this factor, both diagnosis (F[2.96) = 6.88, P = 0.002) and BDI (F(2.96) = 13.11, P =0.0005) were significant as distinguishing factors. Follow-up analysis by Scheffe indicated that the patients with AN could be differentiated from both the BN and DEP groups on the basis of general rhythmicity, and from the BN group on the basis of attentional focus. The patients with BN could be differentiated from the AN group on the basis of these two factors, but not from the DEP group. To explore these differences further, we contrasted the patients with AN and BN on all nine DOTS-R (Self) subscales by Students' 1test and Wilcoxon. Significant differences were found on three of the nine subscales: The patients with AN showed increased rhythmicity-sleep (P 0.005), increased rhythmicity-eating (P =0.000 I), and increased task orientation (P =0.005) compared with the patients with BN. Patients with AN also showed
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=
= = =
=
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=
= = =
=
=
=
=
PSYCHOSOMATICS
Shaw and Steiner
TABLE 3.
Comparisoa of four adolescent croups on measures or temperament usessed usiDg the Revised DlmeDSIODS or Temperament Survey (Self) (DOTS-R [Sclf)
DOTS·R
(Mean ± SD) Anorexia Bulimia
DepressioD (II = 36)
'Iemperament Factor
Normal (II = 517)
Activity level-general Activity level-sleep Approach-withdrawal Flexibility-rigidity Mood quality Rhythmicity-sleep Rhythmicity--eating Rhythmicity--4iaily panerns Task orientation
19.2±4.6 10.9± 3.7 20.1 ±3.5 14.9 ± 2.7 24.4±4.0 14.4± 3.7 12.9± 3.7 12.1 ± 2.7 19.0±4.7
19.7±4.9 9.6±4.3 IS.I ± 5.1 13.6±4.2 IS.9±6.3 16.S±4.6 15.0±3.7 10.5 ±3.3 2 \.6 ± 5.3
19.6±5.2 9.4 ±4.S 20.4±5.4 14.3±2.3 19.7 ±5.2 13.3±5.2 1O.6±4.2 9.1 ± 3.5 18.2±4.2
19.9 ± 4.4 10.7 ±4.4 17.5±3.6 13.6±2.7 19.1 ± 5.2 13.4 ± 4.1 12.7±4.0 1O.4±2.7 19.0±4.7
Adaptability/positive affect General rhythmicity Task orientation
59.4 ± S.O 39.5 ±s.o 19.0±4.7
50.6 ± 11.3 42.3 ±9.2 2 \.6 ± 5.3
54.4±9.3 33.0 ± 9.0 IS.2 ±4.2
50.1 ± 7.9 36.5 ± S.4 19.0±4.7
(II
= 37)
(II
= 28)
FIrst-<>nler ACf-G ACf-S APPR FLEX MOOD RHY-S RHY-E RHY-DP TASK
Second-Order
ADAPT RHY-G TASK Note:
Normal data derived from Windle. 17
trends toward increased rhythmicity-daily habits and decreased approach, although these findings do not reach statistical significance. These findings support all of the initial hypotheses (Table 2), with the exception of decreased flexibility in the AN group, which was not found. DISCUSSION In general, this study supports the hypothesis that temperament, assessed with the DOTS-R (Self), can differentiate three groups of adolescent girls with different psychiatric diagnoses: AN, BN, and DEP. These findings remain statistically significant while controlling for the confounding effects of depression and defensiveness on measures of self-report. In addition, the results of the study show that two dimensions of temperament, general rhythmicity and attentional focus, are particularly useful in differentiating patients with AN from those with BN. Further comparison of individual subscales of the DOTS-R (Self) shows that patients with AN are more likely to show trends toward regular patterns of eating, sleeping and diurnal VOLUME38.NUMBER2.MARCH-APmL1~7
activities, and persistence with activities, which distinguishes them from patients with BN and also supports general clinical observations of eating disorder populations as previously described. 12- 14 This study supports findings from prior studies that examined differences in temperament in women with eating disorders by using the TPQ.9-11 The finding is important since it suggests that specific constellations of temperament may be associated with specific psychiatric syndromes. Previous research has established the relevance of multiple factors in the etiology of eating disorders, which include family genetic studies/I psychosocial factors,'2.22-24 and, of particular relevance to this report, studies of personality and temperament. 2S It is generally accepted that temperament, which is biologically determined, interacts with environmental variables, both to influence personality development and to contribute to the development of psychiatric symptoms. 3 Steiner et al. 26 have proposed a model specific for the pathogenesis of AN, in which the interaction of infant temperament with differences in early feeding experiences is believed to lead to symptoms of anorexia. In addition, Cloninge~7.28 has proposed 129
Juvenile Eating Disorders
a biological model to explain how temperament may predispose an individual to develop specific psychiatric symptoms, based on the association of dimensions of personality with neurotransmitter activity. Although many of the hypotheses predicted in this study were substantiated by the findings, there are several important limitations. First, the sample size is small and is limited to adolescent female subjects. Second, the study relies on a self-report instrument, which is vulnerable to distortion, although the inclusion of measures of depression and defensiveness in the analysis does reduce interference from these two items. Moreover, this study supports fmdings from other studies that have used a different self-report instrument to assess temperament.9.11 A third limitation is that this study examined patients with current diagnoses of AN, BN, and DEP, without ratings of symptom severity, and it is not known to what extent acute state disturbances influence self-assessment of temperament. In
particular, starvation associated with AN may affect subscales of the DOTS-R (Self).29 Nonetheless, the study raises some interesting questions about the role of temperament in the etiology of eating disorders, and our findings may have implications for both treatment and prognosis. Our study also suggests the importance of including measures of temperament in future prospective studies that assess persons at risk for eating disorders.
Initial portions ofthis study were presented at the 143rd Annual Meeting of the American Psychiatric Association, May 1990, and at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry, January 1991. The authors thank Ying-Yao Lee. M.D.Jor help with data management and Beth Steinberg. Ph.D.• for editorial assistance. The authors would also like to thank Dr. Michael Windle for providing normative data.
References 1. Thomas A. Chess S. Birch HG. et al: Behavior Individuality in Early Childhood. New York. New York University Press. 1963 2. Thomas A. Chess S: Genesis and evolution of behavior disorders: from infancy to early adult life. Am J Psychiatry 1984; 141:1-9 3. Chess S: Studies in temperament: a paradigm in psychosocial research. Yale J Bioi Med 1990; 63:313-324 4. Rutter M. Birch HG. Thomas A. et al: Temperamental characteristics in infancy and the later development of behavioral disorders. Br J Psychiatry 1964; II 0:651 ~ 1 5. Maziade M. Caperaa P. Laplante B. et al: Value of difficult temperament among 7 year olds in general population for predicting psychiatric diagnosis at age 12. Am J Psychiatry 1985; 142:943-945 6. Windle M: The difficult temperament in adolescenceassociations with substance use. family support, and problem behaviors. J Clin Psycholl99l; 47:310-315 7. Casper RC: Personality features of women with good outcome from restricting anorexia nervosa. Psychosom Med 1990; 52:156-170 8. Strober M: Disorders of the self in anorexia nervosa: an organismic developmental paradigm, in Psychodynamic Treatment of Anorexia Nervosa and Bulimia. edited by Johnson CL. New York. Guilford. 1991. pp. 3~373 9. Brewenon TD. Hand LO. Bishop ER: The Tridimensional Personality Questionnaire in eating disorder pa130
tients. Int J Eat Disord 1993; 2:213-218 10. Cloninger CR: The Tridimensional Personality Questionnaire (Version IV). St Louis. MO. Department of Psychiatry. Washington School of Medicine. 1987 11. Bulik CM. Sullivan PF. Weltzin TE. el al: Temperament in eating disorders. Int J Eat Disord 1995; 3:251-261 12. Bruch H: Eating Disorders. New York. Basic Books. 1973 13. Garfinkel PE, Garner OM: Anorexia Nervosa: A Multidimensional Perspective. New York, BrunerlMazel. 1982 14. Rossiter EM. Stewan Agras W. Teich CF. et al: Cluster B personality disorder characteristics predict outcome in the treatment of bulimia nervosa. Int J Eat Disord 1993; 4:349-357 15. Windle M. Lerner RM: Reassessing the dimensions of temperamental individuality across the life span: the Revised Dimensions of Temperament Survey (DOTSR). Journal of Adolescent Research 1986; I: 213-230 16. Windle M: Revised Dimensions of Temperament Survey (OOTS-R): simultaneous group confirmatory factor analysis for adolescent gender groups. Psychological Assessment 1992; 4:228-234 17. Windle M: Temperament and personality: an exploratory interinventory study of the DOTS-R, BASI-D. and EPI. J Pers Assess 1989; 53:487-501 18. Thienemann M. Steiner H: Family environment ofeating disordered and depressed adolescents. Int J Eat Disord 1993; 14:43-48 PSYCHOSOMATICS
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19. Beck AT, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-571 20. Crowne OP, Marlowe 0: A new scale of social desirability independent of psychopathology. J Clio Consult Psycholl960; 24:349-354 21. Strober M: Family-genetic studies of eating disorders. J Clin Psychiatry 1991; 52:9-12 22. Selvini Palazzoli M: Self-Starvation: From Individual to Family Therapy in the Treatment of Anorexia Nervosa. New York, Aronson, 1978 23. Minuchin S, Baker L, Rosman BL, et al: A conceptual model of psychosomatic illness in children. Arch Oen Psychiatry 1975; 32:1031-1038 24. Crisp AH: Let Me Be. London, England, Academic
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Press,1980,pp.84-87 25. Sohlberg S, Strober M: Personality in anorexia nervosa: an update and a theoretical integration. Acta Psychiatr Scand 1994; 378:1-15 26. Steiner H, Smith C, Rosenkranz RT, et al: The early care and feeding of anorexics. Child Psychiatry Hum Dev 1991; 21:163-167 27. Cloninger CR: A unified biosocial theory of personality and its role in the development of anxiety states. Psychiatric Development 1986; 4:167-226 28. Cloninger CR, Svrakic OM, Pryzbeck TR: A biopsychosocial model of temperament and character. Arch Oen Psychiatry 1993; 50:975-990 29. Brown NW: Anorexia nervosa visited and revisited: weight is the issue. JAmMed Wom Assoc 1993; 48:23-26
13\
Previous studies have suggested an association between temperament and eating disorder pathology. The purpose of this study was to differentiate on the basis oftemperament among patients with anorexia, bulimia, and major depression. In this study, 101 adolescent girls completed the Revised Dimensions of Temperament Survey (Self), a self-report measure that identifies nine dimensions oftemperament. Significant differences were found between the diagnostic groups while controlling for disturbances in mood and defensiveness. Specific subscales differentiated the subjects with anorexia from those with bulimia. These data support the concept ofusing temperament to differentiate patients with related psychiatric syndromes. (Psychosomatics 1997; 38:126-131)
A
relationshi P between temperament and psychopathology was first suggested in the New York Longitudinal Study, I in which nine dimensions of temperament were identified. These dimensions have been widely adopted in scales used to assess temperament and have been found to remain relatively stable over time. 2 Three constellations of temperament were described: easy, difficult, and slow-towarm-up, and each constellation appeared to be associated with characteristic patterns ofbehavior in response to environmental stimuli. The concept of "goodness of fit" between the temperament of parent and child has been offered to explain how temperament interacts with family and other environmental experiences to contribute to the development of psychopathology. 3 Later studies4-S have supported the Received February 7, 1996; revised March 20, 1996; accepted May 10, 1996. From the Deparunent of Psychiatry and Behavioral Sciences, Division of Child Psychiatry and Child Development, Stanford University School of Medicine, Palo Alto, California. Address reprint requests to Dr. Shaw, 401 Quarry Road, Stanford, CA 94305-5540. Copyright C 1997 The Academy of Psychosomatic Medicine.
126
original assertions that infants with a "difficult temperament" profile are more likely to manifest behavioral problems and psychiatric disordersduringadolescence. Similarly, adolescents assessed with "difficult temperament" are reported to have a higher incidence of childhood behavior problems, including conduct disorder, substance abuse, delinquent activity, and depression, particularly when associated with lower perceived family emotional support. 6 In addition, attempts have been made to identify a relationship between specific profiles of temperament and eating disorder pathology.7-8 Studies of temperament in patients with eating disorders have suggested that patients with anorexia nervosa and bulimia nervosa may be differentiated on the basis of temperament. Brewerton et al. 9 used the Tridimensional Personality Questionnaire (TPQ)IO to show that patients with eating disorders were more likely to rate themselves as being cautious, tense, inhibited, shy, and easily fatigued. The patients with bulimia rated themselves as being impulsive, excitable, extravagant, quickly bored, and ready to engage in new activities. Bulik et al. 1I used the same instrument to show that women PSYCHOSOMATICS
Shaw and Steiner
with anorexia rated themselves highly on the TPQ subscale of "reward dependence," indicating a need for signs of praise and reward, and persistence in previously rewarded behavior. These findings parallel clinical observations of women with eating disorders. Patients with anorexia nervosa have been described as hypersensitive to rejection and disapproval,12 while women with bulimia are often described as having labile affect, poor impulse control, and cluster B personality traits. 13.14 This study, conducted in 1991, examines temperament in a group of adolescent girls with anorexia nervosa (AN), bulimia nervosa (BN), and major depression (DEP). Temperament is assessed using the Revised Dimensions of Temperament Survey (DOTS-R [Self]), IS a selfreport instrument used to derive nine dimensions of temperament, corresponding with those originally described in the New York Longitudinal Study. In general, high scores on the subscales indicate adaptability, flexibility, persistence, and features indicative of an "easy" temperament profile. Windle 16 has used a second-order factor analysis of eight of the firstorder factors to create three higher order dimensions of temperament, which are used in the
TABLE 1.
statistical analysis (Table 1). We hypothesized that significant differences in temperament would be found between each diagnostic group. Based on clinical observations of patients with these disorders, we further hypothesized that specific dimensions of temperament obtained from the DOTS-R (Self) would be helpful in distinguishing patients with AN from those with BN, as indicated in Table 2. METHODS The subjects were 101 female adolescent patients referred to a well-established eating disorders clinic or hospitalized directly in the inpatient psychiatric unit specializing in the treatment of eating disorders at Children's Hospital at Stanford. All eligible subjects were asked to participate in research, and they completed several questionnaires as part of the routine evaluation process. No one refused to participate in the study. The subjects were diagnosed according to DSM-Ill-R criteria following a semistructured interview by two clinicians. On the basis of primary Axis I diagnosis, the subjects were divided into three groups: AN (n =37, mean ± SD age = 15.1 ± 2.8); BN (n =
Revised Dimensions of Temperament Survey (SeIO (DOTS·R [Self}) Thmperament Factor
Slgnilkance of High Score
fLEX
Activity level-general Activity level-sleep Approach-withdrawal Flexibility-rigidity
MOOD RHY-S RHY-E RHY-DP TASK
Mood quality Rhythmicity-sleep Rhythmicity-eating Rhythmicity-daily patterns Task orientation
High level of energy and vigor High level of physical activity during sleep Tendency to approach new situations and people Tendency to respond flexibly to changes in the environment Characteristic display of positive effect Regular sleep-wake cycle Regular pattern of eating habits Regular pattern of diurnal activities Ability to concentrate and persist with activities
DOTS-R First·Order ACf-G ACf-S
APPR
Second-order ADAPT
Adaptability/positive affect
RHY-G
General rhythmicity
TASK
Task orientation
Tendency to approach new situations, respond flexibly to changes, and display positive affect Regular patterns of diurnal activities. including sleep and eating patterns Ability to concentrate and persist with activities
Note: Table adapted from Windle. 17
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Juvenile Eating Disorders
=
=
28, mean ± SD age 16.6 ± 1.2); and DEP (n 36, mean ± SD age = 15.1 ± 1.7). The subjects with more than one diagnosis were excluded from the study. Half of the sample were inpatient and half outpatient. The ethnic distribution of the sample was as follows: 78% Caucasian, 15% Hispanic, I % African-American, 1% Asian, and 5% other. The age, ethnicity, and distribution of diagnoses of the sample are representative of this particular clinic and inpatient population, whose demographic characteristics have been reported in a previous study. 18 During the initial evaluation, each subject completed a battery of self-report measures that included the DOTS-R (Self), the Beck Depression Inventory (BDI), and the Marlowe-Crowne Social Desirability Scale (MCSDS). The BDI I9 consists of 21 items rated by self-report on a 3-point scale measuring severity of depression. The MCSDS 20 is a 33-item self-report questionnaire that measures defensiveness. It has high test-retest and internal consistency and concurrent validity with other measures of defensiveness. Data reduction was carried out on the subscales of the DOTS-R (Self) by principal components analysis. The three second-order factors described by Windle l7 were used to test multivariate analysis of covariance (MANCOVA) with the BDI and MCSDS scores as covariates. Follow-up analyses consisted of analysis of covariance (ANCOVA) and Scheffe. A two-tailed I-test of significance was used for all analyses.
TABLE 2.
PredIcted dilrerences In subsalles or the the Dimensions or Temperament Survey (Self)
DOTS·R Thmperament Factor APPR RHY-S RHY-E RHY-DP TASK
128
Approach-withdrawal Rhythmicity-sleep Rhythmicity--eating Rhythmicitydaily patterns Task orientation
AN
BN
Decreased Increased Increased Decreased Increased Decreased Increased Increased
Decreased Decreased
RESULTS Table 3 shows the nine first-order and three second-order temperament subscales derived from the DOTS-R (Self) for the three groups of girls with a psychiatric diagnosis, compared with a group of 517 age-matched healthy control subjects, using data published by Windle. 17 MANCOVA was significant for a diagnosis effect (Wilk's A. =0.741, F[6.188) =5.1, P =0.001); BDI effect (Wilk's A. 0.862, F(3.94) 5.02, P 0.003); and MCSDS effect (Wilk's A. 0.898, F[3.94) 3.56, P 0.02). Adaptability/positive affect was significantly different in the three groups (ANCOVA: F(4.96) 4.71, P 0.002), but these differences were attributable to the subjects' BDI scores (F[2.96) 8.82, P 0.004) and MCSDS scores (F[2.96) 8.91, P 0.004), whereas diagnostic grouping had no significant effect. General rhythmicity was also significantly different in the three groups (ANCOVA: F[4.96) 5.39, P 0.0006), and with this factor, diagnosis was significant as a distinguishing factor (F[2.961 10.34, P 0.00021). Attentional focus was also significantly different in the three groups (ANCOVA: F[4.96) = 6.14, P = 0.0002), and with this factor, both diagnosis (F[2.96) = 6.88, P = 0.002) and BDI (F(2.96) = 13.11, P =0.0005) were significant as distinguishing factors. Follow-up analysis by Scheffe indicated that the patients with AN could be differentiated from both the BN and DEP groups on the basis of general rhythmicity, and from the BN group on the basis of attentional focus. The patients with BN could be differentiated from the AN group on the basis of these two factors, but not from the DEP group. To explore these differences further, we contrasted the patients with AN and BN on all nine DOTS-R (Self) subscales by Students' 1test and Wilcoxon. Significant differences were found on three of the nine subscales: The patients with AN showed increased rhythmicity-sleep (P 0.005), increased rhythmicity-eating (P =0.000 I), and increased task orientation (P =0.005) compared with the patients with BN. Patients with AN also showed
=
=
=
=
= = =
=
=
=
= = =
=
=
=
=
PSYCHOSOMATICS
Shaw and Steiner
TABLE 3.
Comparisoa of four adolescent croups on measures or temperament usessed usiDg the Revised DlmeDSIODS or Temperament Survey (Self) (DOTS-R [Sclf)
DOTS·R
(Mean ± SD) Anorexia Bulimia
DepressioD (II = 36)
'Iemperament Factor
Normal (II = 517)
Activity level-general Activity level-sleep Approach-withdrawal Flexibility-rigidity Mood quality Rhythmicity-sleep Rhythmicity--eating Rhythmicity--4iaily panerns Task orientation
19.2±4.6 10.9± 3.7 20.1 ±3.5 14.9 ± 2.7 24.4±4.0 14.4± 3.7 12.9± 3.7 12.1 ± 2.7 19.0±4.7
19.7±4.9 9.6±4.3 IS.I ± 5.1 13.6±4.2 IS.9±6.3 16.S±4.6 15.0±3.7 10.5 ±3.3 2 \.6 ± 5.3
19.6±5.2 9.4 ±4.S 20.4±5.4 14.3±2.3 19.7 ±5.2 13.3±5.2 1O.6±4.2 9.1 ± 3.5 18.2±4.2
19.9 ± 4.4 10.7 ±4.4 17.5±3.6 13.6±2.7 19.1 ± 5.2 13.4 ± 4.1 12.7±4.0 1O.4±2.7 19.0±4.7
Adaptability/positive affect General rhythmicity Task orientation
59.4 ± S.O 39.5 ±s.o 19.0±4.7
50.6 ± 11.3 42.3 ±9.2 2 \.6 ± 5.3
54.4±9.3 33.0 ± 9.0 IS.2 ±4.2
50.1 ± 7.9 36.5 ± S.4 19.0±4.7
(II
= 37)
(II
= 28)
FIrst-<>nler ACf-G ACf-S APPR FLEX MOOD RHY-S RHY-E RHY-DP TASK
Second-Order
ADAPT RHY-G TASK Note:
Normal data derived from Windle. 17
trends toward increased rhythmicity-daily habits and decreased approach, although these findings do not reach statistical significance. These findings support all of the initial hypotheses (Table 2), with the exception of decreased flexibility in the AN group, which was not found. DISCUSSION In general, this study supports the hypothesis that temperament, assessed with the DOTS-R (Self), can differentiate three groups of adolescent girls with different psychiatric diagnoses: AN, BN, and DEP. These findings remain statistically significant while controlling for the confounding effects of depression and defensiveness on measures of self-report. In addition, the results of the study show that two dimensions of temperament, general rhythmicity and attentional focus, are particularly useful in differentiating patients with AN from those with BN. Further comparison of individual subscales of the DOTS-R (Self) shows that patients with AN are more likely to show trends toward regular patterns of eating, sleeping and diurnal VOLUME38.NUMBER2.MARCH-APmL1~7
activities, and persistence with activities, which distinguishes them from patients with BN and also supports general clinical observations of eating disorder populations as previously described. 12- 14 This study supports findings from prior studies that examined differences in temperament in women with eating disorders by using the TPQ.9-11 The finding is important since it suggests that specific constellations of temperament may be associated with specific psychiatric syndromes. Previous research has established the relevance of multiple factors in the etiology of eating disorders, which include family genetic studies/I psychosocial factors,'2.22-24 and, of particular relevance to this report, studies of personality and temperament. 2S It is generally accepted that temperament, which is biologically determined, interacts with environmental variables, both to influence personality development and to contribute to the development of psychiatric symptoms. 3 Steiner et al. 26 have proposed a model specific for the pathogenesis of AN, in which the interaction of infant temperament with differences in early feeding experiences is believed to lead to symptoms of anorexia. In addition, Cloninge~7.28 has proposed 129
Juvenile Eating Disorders
a biological model to explain how temperament may predispose an individual to develop specific psychiatric symptoms, based on the association of dimensions of personality with neurotransmitter activity. Although many of the hypotheses predicted in this study were substantiated by the findings, there are several important limitations. First, the sample size is small and is limited to adolescent female subjects. Second, the study relies on a self-report instrument, which is vulnerable to distortion, although the inclusion of measures of depression and defensiveness in the analysis does reduce interference from these two items. Moreover, this study supports fmdings from other studies that have used a different self-report instrument to assess temperament.9.11 A third limitation is that this study examined patients with current diagnoses of AN, BN, and DEP, without ratings of symptom severity, and it is not known to what extent acute state disturbances influence self-assessment of temperament. In
particular, starvation associated with AN may affect subscales of the DOTS-R (Self).29 Nonetheless, the study raises some interesting questions about the role of temperament in the etiology of eating disorders, and our findings may have implications for both treatment and prognosis. Our study also suggests the importance of including measures of temperament in future prospective studies that assess persons at risk for eating disorders.
Initial portions ofthis study were presented at the 143rd Annual Meeting of the American Psychiatric Association, May 1990, and at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry, January 1991. The authors thank Ying-Yao Lee. M.D.Jor help with data management and Beth Steinberg. Ph.D.• for editorial assistance. The authors would also like to thank Dr. Michael Windle for providing normative data.
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Press,1980,pp.84-87 25. Sohlberg S, Strober M: Personality in anorexia nervosa: an update and a theoretical integration. Acta Psychiatr Scand 1994; 378:1-15 26. Steiner H, Smith C, Rosenkranz RT, et al: The early care and feeding of anorexics. Child Psychiatry Hum Dev 1991; 21:163-167 27. Cloninger CR: A unified biosocial theory of personality and its role in the development of anxiety states. Psychiatric Development 1986; 4:167-226 28. Cloninger CR, Svrakic OM, Pryzbeck TR: A biopsychosocial model of temperament and character. Arch Oen Psychiatry 1993; 50:975-990 29. Brown NW: Anorexia nervosa visited and revisited: weight is the issue. JAmMed Wom Assoc 1993; 48:23-26
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