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The effects of depression and treatment on the tridimensional personality questionnaire
The Effects of Depression and Treatment on the Tridimensional Personality Questionnaire Erin I. Kleifield, Suzanne Sunday, Stephen Hurt, and Katherine A. Halmi
K e y W o r d s : Tridimensional Personality Questionnaire, eating disorders, Beck Depression Inventory
Introduction
Methods
A dimensional approach to assessing peasonality was _rece__ntly developed as an alternative to traditional categorical assessment techniques (Cloninger 1987). The dimensional approach differs from categorical methods in that it attempts to measure personality features as continuous rather than discrete entities. The Tridimensional Personality Questionnaire (TPQ) was developed to operationalize and measure behaviors associated with four personality dimensions: novelty seeking, harm avoidance, reward dependence, and pmsistence (for details of Clouinger's dimensional ~ and tbe TPQ, see Cloninger 1987). Recently, the TFQ was applied to four subgroups of eating disonter patients and normal controls (Kleifield et ai 1993, EI Kleifield et al, in press). The ~ was found to be effective in illuminating personality differences among the eating disorder subgroups, and between patients and controls. Consistent differz t ~ t ~ ~'oups, a,.'A between anorectics and controls, on the novelty seeking and persistence dimensions. The harm avoidance and reward dependence dimensions were found to be significantly affected by level of depression. Given the success of the T I ~ in delineating personality characteristics of eating disorder patients, the present investigation was designed to evaln_a~ the stability of TPQ scores. This was done by examining the effects of depression on TPQ scores before and after treatment in eating disorder patients and normal controls.
Subjects
.
.
.
.
.
Ft~omthe Department of Psychiatry, Comell University Medical College, Westcheste~ Div~on. White plains, NY. Address n~'int requests to Dr. Erin !. Kleifield, DepL of Psychiatry, CorneH University Medical Center, 2 ! Bloomingdale Road. White Plains, NY 10605. ReccivedJuly26,1993; revised Januazy 14,1994.
O ! 994 Society of Biohigical Psychiatry
Eating disorder subjects were 88 women hospitalized fur an eating disorder on the Eating Disorders unit at the Comell Medical Center-W~tchester Division. The patients were divided into four subgroups according to DSM-III-R: anorectic-reslrictors, those with a present diagnosis of anorexia and no history of bulimia (AN-R; n = 30), anorectic-hafimics, those with a present diagnosis of anorexia and bulimia (AN-B; n = 14), bulimics with no history of anorexia (BN; n = 25), and bulimics with a history of anorexia (B-AN;n= 19). Control subjects were recruited from a local college. They were included in the study if they did not have a current or past history of an eating disorder or obesity, substance abuse, or psychiatric illness, and were currently at a normal weight. Thirty-four subjects met fl!ese c~'i.'teri.aand w ~ included in the study.
Measures The Tridimensional Personahrty Questionnaire (TI'Q, Cloninger 1987) is a 100-item questionnaire comprised of true/false questions designed to assess dimensions of personality: Novelty Seeking (NS), the tendency toward intense exhilaration and excitement; Harm Avoidance (HA), the tendency toward intense avoidance of aversive stimuli; Reward Dependence (RD), the tendency toward intense response to rewards, particularly interpersonal rewards; and Persistence (P), the tendency to persist at nonsocially mediated tasks. The Beck Depression Inventory (BDI) (Beck et al 1961) consists of 21 items reflecting symptoms and cognitions associated with depression. A score of 11-16 indicates mild mood disturbance, 17-20 borderline clinical depression, and 21-30 moderate depression. Scores over 30 indicate severe depression. 0006-3223/94/$07.00
Brief Ruports
BIOLPSYCIflATItY 1994~..~j~dJ-'m
69
Table 1. Clinical Demographics (SD in parentheses) n~tricwrs Mean age Mean pereentage of i d e a l weight at current weight Beck score
pretreatment posmeatment pretreatment posttrealment
24.6(9.1) 74.2(13.9) 95.7 (4.6) 22.3 (13.1) 8.4 (6.8)
Bulimics
bulimies (n=14)
(n=29)
23.7 (5.6) 80.9(11.8) 98.1 (5.0) 26.9 (16.7) 9.8 (13.5)
Belimies-~ m~exia
(n = 25)
(It= 19)
(n=34)
24.7 (SA) 109.0(13.6)
24.7 (7_5)
26.3 (t2.5)
23.7 (6.1) 113.9(13.9) I08.2 (6.9) 30.7 (14.0)
10.5 (10.2)
16.9(13.8)
!06.0 0.7)
3.9 (4.0) 3.6(4,3)
Table 2. TPQ Means and Adjusted Means (SD in parentheses) Anorectie-
restrictms (n = 29)
Novelty seeking
Harm avoidance
Reward dependence
Persistence
pretreatment posare~tment adjusted pretmument adjusted posureaunem prelreaunent posttreatment adjusted prelreatment adjusted posttreatment prelreatment posttreatment adjusted pretreatment adjusted posmeaunem pretreatment posnreatment adjusted pretreatmem adjusted posnreatment
! 3.0 (5.8) 13A (5.7) 12.9 13.3 18.3 (7.6) 15.9 (6.7) 17.6 ! 6.3 i 4.0 (2.9) 16.4 (2.6) 14.2 16.2 6.8 (1`3) 6.6 (1.7) 6.9 6.6
Anorccficbulimics (n= 14)
Bulimics
Bnlin,k~,I~ anmem
Controls
(n-- 25)
(n= 19)
(n=51)
15.1 (5.6)
17.1 (4.9)
18.1 (5.2)
16.1 (4.7)
12.7 (4.0)
17.1 (4.5)
17.2 (4.9)
16.6 (4,3)
15.0
17.1
18.0
16.2
12.7
17.2
17.4
16.5
22.2 (7.8)
22.3 (7.4)
20.5 (5.6)
12.7(5.9)
16.7 (7.9)
18.8 (7.3)
17.8 (7.3)
I i.6 (4.7)
20.1 16.4
20.4 18,3
17A 15.1
17,3 13.4
13.8 (2.6)
! 3.2 (3.3)
! !.7 (4.5)
15.8 (3.4)
14.6 (2.9) 14.4 14.6 5.8 ( i .7) 5.6(2.1) 5.9 5.6
15.3(3.0) 13.7 15.3
15.3 (1.9) 12.5 15.7
16.2(2.8) 14.6 15.9
5.8 (1.7)
6.0 (1.9)
5.4 (2.0)
5.6(1.5) 5.9 5.9
6.1 (!.7) 6.2 6.2
5.7(1.9) 5.1 5.1
Procedure
Results and Discussion
All subjects completed the TPQ and BDI questionnaires within 2 weeks of hospital admission and again at discharge. Control subjects completed the questionnaires at time points comparable to the patients (at approximately 3-month intervals).
Table 1 shows the mean age and level of depression for each diagnostic group, and weight (i.e., percentage of ideal weight at current weight) for the eating disorder subgroups. Before treatment, the bulimics with a past history of anorexia were the most dewessed group with a mean Beck score (33) i n , caring severe dep_~siono All eating disorder groups, with mean Beck scores placing them in the range of moderate to severe depression, were significantly more depressed than the conlrol group [F(l,ll6) = 86.56] whose mean Beck score (3.9) indicated that this group was not at all depressed. All eating disorder groups showed a siL,nificant reduction in depression across treatment. The anoreclic-restrictors and anoreclie bulimics moved from moderate depression (Beck 22 and 26, respectively) to levels at posttreatment which were below the threshold for mild mood disturbance (Beck 8 and 9, respectively). In contrast, the bulimics with a past history of anorexia continued to show some depression at posttreatment (Beck 16) and fed just below the cutoff for borderline clinical depression, whereas the bulimic group without a past history of anorexia fell just below the cutoff for mild mood disturbance (Beck l I) with a Beck score of 10.5. There were no significant differences in age between diagnostic
Inpatient Treatment Program The treatment at New York Hospital is a cognitive-behavioral program consisting of nutritional stabilization, and individual, group, and family therapies. The program is designed to ensure that patients who are anoreclic gain weight steadily, and that palients who are bulimic are prevented from bingeing and purging.
Analyses To control for the effects of depression on ~e TPQ, residual scores were obtained by performing regressions between the TPQ and BDI scores. Analyses of Variance (ANOVAs) were then conducted on residuals. A priori single-degree of freedom simple pairwise contrasts were conducted following the ANOVAs to invesligate how subgroups of patients and controls differ from each other. For all results reported as significant, p < 0.05.
70
040#PS~ATft ; .
groups. As erpacted, there were significant differences in weight ~nnthccPringdisonlcrsubgroupsbefolerrecrtment[91,84)= 127.771, with both anorectic groups more than 15% below ideal weight and both bulimic groups above ideal weight. These groups also differed after treatment [F(1,84) = 54.931, even though all eating disorder groups showed significant changes in weight with aeatment and the anomctic groups were within normal weight ranges at posttmatment (although often at the lower end of the range)* The various eating disorder subgroups showed significant differences in their Novelty Seeking and Persistence tendencies, and these diffetences were not affected by mood or tmatment (see Tabk 2). The anorectic-restrictorsand anorectic-bulimics had low Novelty Seeking scores both before and atter tteatment and scored significantly lower than the two bulimic groups P(2.115) = 8.261 and controls 192. I 15) = 4.971. On the Persistence scale, the anorectic-resuictors had scores that were significantly elevated relative to all other groups. This dimensional analysis highlights basic character features associated with anorexia and supports the clinical literature in depicting anorcctics as overly reflective, stoical, slow-tempemd and orderly, as well as extremely determined and resolute. The Harm Avoidance scale was strongly affected by mood. Any group differences and treatment effects on this scale were traceable to levels of and changes in levels of depression. Mood affected Reward Dependence scores in much the same way; but treatment did affect the adjusted scores of the anomctic-bulimics and bulimics with a past history of anorexia afterchanges in level of depression were removed. Specifically, the anomctic-bulimics
Brief Reports
lowered [fl1.116) = 4.891. and the bulimics with a past history of anomxia increased (0 I,1 16) = 4.161, their teward dependence scoresacrosstreatment. Together, results of the pmscnt study indicate that the TFQ effectively caphues key personality features associated with eating disotder pathology and illuminates differences in personality structurebetween theeating disorder subgmups. Most noteworthy was the extteme ptopensity of anorectic patients to be reflective, slow-tempered and orderly (low Novelty Seeking), and to seek-out and persist at tasks that provide minimal social interaction (high Persistence). Furthermore, these character traits were tesilient to the effects of treatment and depression; as such, they may be considered to be enduring characteristics of the personality organization of patients with anorexia nervosa. In contrast the traits associated with Hatm Avoidance (shyness, apprehension. worry) and Reward Dependence (sentimentality, attachment, dependence) were significantly affected by depression, suggesting that the behaviors associated with these dimensions wets artificially changed by levels of depression. Tbe implications of these findings for understanding the personality sttuctum and treatment of eating disorders are twofold. First, these data undctscore the importance of considering state variables such as depression before drawing conclusions about steadfast personality traits when the eating disorder patient is acutely ill. Second treatment of the eating disorder produces a reduction in depression and a concsponding reduction in the expressed intensity of behaviors associated with the dimensions of Harm AvoidanceandRewardDependence.
References Beck AT, Ward CH, Mendelson M, Mock J, ErbaughJ (1961): An invenmty for measuring depression. Arch Gen Psychkzrty 4:53-f& Cloninger CR ( 1987): A systematic method of clinical description and classification of personality varktnts.Arch Gen Psychiatry 44: 573-588. Rleifield RI, Sunday S, Hurt S, Hahni KA (1993): Psychometric
validation of the tridimensional personality questionnaire: Application to subgroups of eating disorders. Comp Psychiatry 34: 249-253. Kleifield EI, Sunday S, Hurt S, Halmi RA (1994): The tridimensional personality questionnaire: An exploration of personality traits in eating disorders. Psychiatric Res. in press.
K e y W o r d s : Tridimensional Personality Questionnaire, eating disorders, Beck Depression Inventory
Introduction
Methods
A dimensional approach to assessing peasonality was _rece__ntly developed as an alternative to traditional categorical assessment techniques (Cloninger 1987). The dimensional approach differs from categorical methods in that it attempts to measure personality features as continuous rather than discrete entities. The Tridimensional Personality Questionnaire (TPQ) was developed to operationalize and measure behaviors associated with four personality dimensions: novelty seeking, harm avoidance, reward dependence, and pmsistence (for details of Clouinger's dimensional ~ and tbe TPQ, see Cloninger 1987). Recently, the TFQ was applied to four subgroups of eating disonter patients and normal controls (Kleifield et ai 1993, EI Kleifield et al, in press). The ~ was found to be effective in illuminating personality differences among the eating disorder subgroups, and between patients and controls. Consistent differz t ~ t ~ ~'oups, a,.'A between anorectics and controls, on the novelty seeking and persistence dimensions. The harm avoidance and reward dependence dimensions were found to be significantly affected by level of depression. Given the success of the T I ~ in delineating personality characteristics of eating disorder patients, the present investigation was designed to evaln_a~ the stability of TPQ scores. This was done by examining the effects of depression on TPQ scores before and after treatment in eating disorder patients and normal controls.
Subjects
.
.
.
.
.
Ft~omthe Department of Psychiatry, Comell University Medical College, Westcheste~ Div~on. White plains, NY. Address n~'int requests to Dr. Erin !. Kleifield, DepL of Psychiatry, CorneH University Medical Center, 2 ! Bloomingdale Road. White Plains, NY 10605. ReccivedJuly26,1993; revised Januazy 14,1994.
O ! 994 Society of Biohigical Psychiatry
Eating disorder subjects were 88 women hospitalized fur an eating disorder on the Eating Disorders unit at the Comell Medical Center-W~tchester Division. The patients were divided into four subgroups according to DSM-III-R: anorectic-reslrictors, those with a present diagnosis of anorexia and no history of bulimia (AN-R; n = 30), anorectic-hafimics, those with a present diagnosis of anorexia and bulimia (AN-B; n = 14), bulimics with no history of anorexia (BN; n = 25), and bulimics with a history of anorexia (B-AN;n= 19). Control subjects were recruited from a local college. They were included in the study if they did not have a current or past history of an eating disorder or obesity, substance abuse, or psychiatric illness, and were currently at a normal weight. Thirty-four subjects met fl!ese c~'i.'teri.aand w ~ included in the study.
Measures The Tridimensional Personahrty Questionnaire (TI'Q, Cloninger 1987) is a 100-item questionnaire comprised of true/false questions designed to assess dimensions of personality: Novelty Seeking (NS), the tendency toward intense exhilaration and excitement; Harm Avoidance (HA), the tendency toward intense avoidance of aversive stimuli; Reward Dependence (RD), the tendency toward intense response to rewards, particularly interpersonal rewards; and Persistence (P), the tendency to persist at nonsocially mediated tasks. The Beck Depression Inventory (BDI) (Beck et al 1961) consists of 21 items reflecting symptoms and cognitions associated with depression. A score of 11-16 indicates mild mood disturbance, 17-20 borderline clinical depression, and 21-30 moderate depression. Scores over 30 indicate severe depression. 0006-3223/94/$07.00
Brief Ruports
BIOLPSYCIflATItY 1994~..~j~dJ-'m
69
Table 1. Clinical Demographics (SD in parentheses) n~tricwrs Mean age Mean pereentage of i d e a l weight at current weight Beck score
pretreatment posmeatment pretreatment posttrealment
24.6(9.1) 74.2(13.9) 95.7 (4.6) 22.3 (13.1) 8.4 (6.8)
Bulimics
bulimies (n=14)
(n=29)
23.7 (5.6) 80.9(11.8) 98.1 (5.0) 26.9 (16.7) 9.8 (13.5)
Belimies-~ m~exia
(n = 25)
(It= 19)
(n=34)
24.7 (SA) 109.0(13.6)
24.7 (7_5)
26.3 (t2.5)
23.7 (6.1) 113.9(13.9) I08.2 (6.9) 30.7 (14.0)
10.5 (10.2)
16.9(13.8)
!06.0 0.7)
3.9 (4.0) 3.6(4,3)
Table 2. TPQ Means and Adjusted Means (SD in parentheses) Anorectie-
restrictms (n = 29)
Novelty seeking
Harm avoidance
Reward dependence
Persistence
pretreatment posare~tment adjusted pretmument adjusted posureaunem prelreaunent posttreatment adjusted prelreatment adjusted posttreatment prelreatment posttreatment adjusted pretreatment adjusted posmeaunem pretreatment posnreatment adjusted pretreatmem adjusted posnreatment
! 3.0 (5.8) 13A (5.7) 12.9 13.3 18.3 (7.6) 15.9 (6.7) 17.6 ! 6.3 i 4.0 (2.9) 16.4 (2.6) 14.2 16.2 6.8 (1`3) 6.6 (1.7) 6.9 6.6
Anorccficbulimics (n= 14)
Bulimics
Bnlin,k~,I~ anmem
Controls
(n-- 25)
(n= 19)
(n=51)
15.1 (5.6)
17.1 (4.9)
18.1 (5.2)
16.1 (4.7)
12.7 (4.0)
17.1 (4.5)
17.2 (4.9)
16.6 (4,3)
15.0
17.1
18.0
16.2
12.7
17.2
17.4
16.5
22.2 (7.8)
22.3 (7.4)
20.5 (5.6)
12.7(5.9)
16.7 (7.9)
18.8 (7.3)
17.8 (7.3)
I i.6 (4.7)
20.1 16.4
20.4 18,3
17A 15.1
17,3 13.4
13.8 (2.6)
! 3.2 (3.3)
! !.7 (4.5)
15.8 (3.4)
14.6 (2.9) 14.4 14.6 5.8 ( i .7) 5.6(2.1) 5.9 5.6
15.3(3.0) 13.7 15.3
15.3 (1.9) 12.5 15.7
16.2(2.8) 14.6 15.9
5.8 (1.7)
6.0 (1.9)
5.4 (2.0)
5.6(1.5) 5.9 5.9
6.1 (!.7) 6.2 6.2
5.7(1.9) 5.1 5.1
Procedure
Results and Discussion
All subjects completed the TPQ and BDI questionnaires within 2 weeks of hospital admission and again at discharge. Control subjects completed the questionnaires at time points comparable to the patients (at approximately 3-month intervals).
Table 1 shows the mean age and level of depression for each diagnostic group, and weight (i.e., percentage of ideal weight at current weight) for the eating disorder subgroups. Before treatment, the bulimics with a past history of anorexia were the most dewessed group with a mean Beck score (33) i n , caring severe dep_~siono All eating disorder groups, with mean Beck scores placing them in the range of moderate to severe depression, were significantly more depressed than the conlrol group [F(l,ll6) = 86.56] whose mean Beck score (3.9) indicated that this group was not at all depressed. All eating disorder groups showed a siL,nificant reduction in depression across treatment. The anoreclic-restrictors and anoreclie bulimics moved from moderate depression (Beck 22 and 26, respectively) to levels at posttreatment which were below the threshold for mild mood disturbance (Beck 8 and 9, respectively). In contrast, the bulimics with a past history of anorexia continued to show some depression at posttreatment (Beck 16) and fed just below the cutoff for borderline clinical depression, whereas the bulimic group without a past history of anorexia fell just below the cutoff for mild mood disturbance (Beck l I) with a Beck score of 10.5. There were no significant differences in age between diagnostic
Inpatient Treatment Program The treatment at New York Hospital is a cognitive-behavioral program consisting of nutritional stabilization, and individual, group, and family therapies. The program is designed to ensure that patients who are anoreclic gain weight steadily, and that palients who are bulimic are prevented from bingeing and purging.
Analyses To control for the effects of depression on ~e TPQ, residual scores were obtained by performing regressions between the TPQ and BDI scores. Analyses of Variance (ANOVAs) were then conducted on residuals. A priori single-degree of freedom simple pairwise contrasts were conducted following the ANOVAs to invesligate how subgroups of patients and controls differ from each other. For all results reported as significant, p < 0.05.
70
040#PS~ATft ; .
groups. As erpacted, there were significant differences in weight ~nnthccPringdisonlcrsubgroupsbefolerrecrtment[91,84)= 127.771, with both anorectic groups more than 15% below ideal weight and both bulimic groups above ideal weight. These groups also differed after treatment [F(1,84) = 54.931, even though all eating disorder groups showed significant changes in weight with aeatment and the anomctic groups were within normal weight ranges at posttmatment (although often at the lower end of the range)* The various eating disorder subgroups showed significant differences in their Novelty Seeking and Persistence tendencies, and these diffetences were not affected by mood or tmatment (see Tabk 2). The anorectic-restrictorsand anorectic-bulimics had low Novelty Seeking scores both before and atter tteatment and scored significantly lower than the two bulimic groups P(2.115) = 8.261 and controls 192. I 15) = 4.971. On the Persistence scale, the anorectic-resuictors had scores that were significantly elevated relative to all other groups. This dimensional analysis highlights basic character features associated with anorexia and supports the clinical literature in depicting anorcctics as overly reflective, stoical, slow-tempemd and orderly, as well as extremely determined and resolute. The Harm Avoidance scale was strongly affected by mood. Any group differences and treatment effects on this scale were traceable to levels of and changes in levels of depression. Mood affected Reward Dependence scores in much the same way; but treatment did affect the adjusted scores of the anomctic-bulimics and bulimics with a past history of anorexia afterchanges in level of depression were removed. Specifically, the anomctic-bulimics
Brief Reports
lowered [fl1.116) = 4.891. and the bulimics with a past history of anomxia increased (0 I,1 16) = 4.161, their teward dependence scoresacrosstreatment. Together, results of the pmscnt study indicate that the TFQ effectively caphues key personality features associated with eating disotder pathology and illuminates differences in personality structurebetween theeating disorder subgmups. Most noteworthy was the extteme ptopensity of anorectic patients to be reflective, slow-tempered and orderly (low Novelty Seeking), and to seek-out and persist at tasks that provide minimal social interaction (high Persistence). Furthermore, these character traits were tesilient to the effects of treatment and depression; as such, they may be considered to be enduring characteristics of the personality organization of patients with anorexia nervosa. In contrast the traits associated with Hatm Avoidance (shyness, apprehension. worry) and Reward Dependence (sentimentality, attachment, dependence) were significantly affected by depression, suggesting that the behaviors associated with these dimensions wets artificially changed by levels of depression. Tbe implications of these findings for understanding the personality sttuctum and treatment of eating disorders are twofold. First, these data undctscore the importance of considering state variables such as depression before drawing conclusions about steadfast personality traits when the eating disorder patient is acutely ill. Second treatment of the eating disorder produces a reduction in depression and a concsponding reduction in the expressed intensity of behaviors associated with the dimensions of Harm AvoidanceandRewardDependence.
References Beck AT, Ward CH, Mendelson M, Mock J, ErbaughJ (1961): An invenmty for measuring depression. Arch Gen Psychkzrty 4:53-f& Cloninger CR ( 1987): A systematic method of clinical description and classification of personality varktnts.Arch Gen Psychiatry 44: 573-588. Rleifield RI, Sunday S, Hurt S, Hahni KA (1993): Psychometric
validation of the tridimensional personality questionnaire: Application to subgroups of eating disorders. Comp Psychiatry 34: 249-253. Kleifield EI, Sunday S, Hurt S, Halmi RA (1994): The tridimensional personality questionnaire: An exploration of personality traits in eating disorders. Psychiatric Res. in press.