Journal of Psychosomatic Research 57 (2004) 273–278

Personality in men with eating disorders

D. Blake Woodsidea,b,*, Cynthia M. Bulikc, Laura Thorntond, Kelly L. Klumpe, Federica Tozzif, Manfred M. Fichterg, Katherine A. Halmih, Allan S. Kaplana,b, Michael Stroberi, Bernie Devlind, Silviu-Alin Bacanud, Kelly Ganjeij, Scott Crowk, James Mitchelll, Alessandro Rotondom, Mauro Maurim, Giovanni Cassanon, Pamela Keelo, Wade H. Berrettinip, Walter H. Kayed

a Program for Eating Disorders, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada M5G 2C4 b Department of Psychiatry, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada M5G 2C4 c Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA 23298-0126, USA d Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213-2593, USA e Department of , Michigan State University, East Lansing, MI 48824, USA f University of Rome Tor Vergata, Rome, Italy g Roseneck Hospital for Behavioural Medicine affiliated with the University of Munich, Prien, Germany h New York Presbyterian Hospital, Weill Medical College of Cornell University, White Plains, NY 10605, USA i Department of Psychiatry and Behavioral Science, University of California at Los Angeles, Los Angeles, CA 90024-1759, USA j Core Genotyping Facility, Advanced Technology Center, National Cancer Institute, Gaithersburg, MD 20877, USA k Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA l Neuropsychiatric Research Institute, Fargo, ND, USA m Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies, University of Pisa, Pisa, Italy n University of Pisa, Pisa, Italy o Department of Psychology, Harvard University, Cambridge, MA, USA p Center of Neurobiology and Behavior, University of Pennsylvania, Philadelphia, PA 19104, USA

Received 9 July 2003; accepted 3 February 2004

Abstract

Objective: This study compares personality variables of men to be slightly less at risk for perfectionism, , with eating disorders to women with eating disorders. Method: reward dependence, and cooperativeness than females. Few Data were obtained from an international study of the genetics of differences were found when diagnostic subgroup was considered. eating disorders. Forty-two male participants were age-band Conclusion: Observed differences in personality variables may matched at 1:2 ratio to females from the same study. Personality help explain the difference in incidence and prevalence of eating features were compared between males and females controlling for disorders in men and women. diagnostic subgroup. Results: Males with eating disorders appear D 2004 Elsevier Inc. All rights reserved.

Keywords: Eating disorders; Men; Personality

Introduction prevalence of both (AN) and (BN) between the two genders [1,2]. Recent work Eating disorders in males continue to be an area of upholds the existence of this gender imbalance, although to interest, primarily because of the marked difference in a lesser extent than previously believed [3]. In addition to examining prevalence, research in this area * Corresponding authors. D.B. Woodside is to be contacted at Inpatient has focused on the clinical characteristics, psychometric Eating Disorders Program, Toronto General Hospital, 8EN-219, 200 profiles, and comorbidity patterns in men with eating disor- Elizabeth Street, Toronto, Ontario, Canada M5G 2C4. Fax: +1-416-340- ders compared to women. In general, there are more similar- 4198. W.H. Kaye, Anorexia and Bulimia Nervosa Research Module, ities than differences across genders on these dimensions [4]. Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Suite 600 Iroquois Building, Pittsburgh, PA 15213, USA. Fax: +1-412-647-3507. Little research has been done in the area of personality E-mail addresses: [email protected] (D.B. Woodside), kayewh@ in men with eating disorders. Joiner et al. [5] compared msx.upmc.edu (W.H. Kaye). 14 males to 97 females, showing that men chronically ill

0022-3999/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2004.02.011 274 D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 with BN had higher levels of perfectionism and interper- disorder diagnoses were confirmed by trained raters using the sonal distrust than the female comparison group. Research Structured Interview for Anorexia Nervosa and Bulimic into Axis II comorbidity has some relevance to this ques- disorders (SIAB) [13]. Informed consent was obtained from tion, as the presence of personality disorders may reflect all study participants, and all sites received approval from underlying dimensional personality characteristics. Striegel- their local Institutional Review Board. Moore et al. [6] showed elevated rates of personality For the AN study, probands were required to meet disorders, substance use, and mood disorders in males with modified (criterion D, amenorrhea, not required) lifetime ED in comparison to a sample of men without [7] ED. DSM-IV criteria for AN, and had never met criteria for BN. Fassino et al. [7] compared a small group of male anorectic Probands from the BN study were required to meet the patients to a control group of anorectic women and a sample following criteria: (1) a DSM-IV lifetime diagnosis of BN of nonclinical men and women using the and purging type (purging must have included regular vomiting, Character Inventory (TCI) [8] and showed that male ano- with other means of purging also allowed, and bingeing and rectics had lower scores on harm avoidance, reward depen- vomiting must have occurred at least twice a week for a dence, and cooperativeness and higher scores on novelty duration of at least 6 months); and (2) age between 13 and seeking compared to women with AN. 65 years. A current or lifetime history of AN was acceptable. As we advance our understanding of the genetic under- Exclusion criteria for all probands included mental retarda- pinnings of AN and BN, it becomes increasingly important tion (IQ < 70); dementia; organic brain syndromes; psychot- to refine our phenotypic definitions. In a series of linkage ic disorders including , schizophreniform analyses, we have optimized our linkage information by disorder, delusional disorder, and schizoaffective disorder; incorporating behavioral phenotypes into the genetic link- Turner’s syndrome; any medical condition that could age analysis [9]. As the relative risk for AN appears to be appetite, body weight, or eating (e.g., diabetes and thyroid highest in female relatives of males with AN [10], male conditions were excluded if the onset of the disease preced- eating disorders cases may be particularly valuable to ed the onset of the ED). Bipolar I and bipolar II were genetic studies. The purpose of this study is to examine excluded only if symptoms of BN occurred exclusively personality factors in a sample of males with ED derived during manic or hypomanic episodes. Probands with neuro- from a large-scale study of the genetics of ED, and compare logical problems were excluded with the exception of those these factors to a matched sample of females with ED from diagnosed with a seizure disorder resulting from trauma the same study. following the onset of the ED. Probands whose premorbid weight exceeded the BMI for the 95th percentile for gender and age on the Hebebrand index [14] or whose high lifetime Methods and materials BMI was greater than 35 kg/m2 were also excluded. Affected relatives were biologically related to the proband Participants (e.g., siblings, half siblings, cousins). Inclusion criteria for affected relatives required they be 13–65 years of age and All participants were from the multisite Price Foundation received at least one of the following lifetime eating disorder Genetic Study of AN [11] or the Price Foundation Genetic diagnoses: (1) DSM-IV BN, purging type or nonpurging Study of BN [12], both of which used similar methodologies. type; (2) DSM-IV AN, restricting type or binge eating/ Males and females affected with AN, BN or eating disorder purging type; (3) EDNOS-1, defined as subthreshold AN not otherwise specified (ED-NOS) were recruited from 11 with the presence of two of three criteria A through C of sites in North America and Europe including Pittsburgh, New DSM-IV AN, no lifetime bingeing, and a lifetime BMI York, Los Angeles, Toronto, London, Munich, Philadelphia, < 125% of expected for height and weight; (4) EDNOS-2, Pisa, Fargo, Minneapolis, and Boston. defined as subthreshold BN with the presence of criteria A, Details of sample ascertainment and recruitment strategies B, D, and E of DSM-IV BN and the presence of binge eating are described elsewhere (Ref.[11]; Kaye et al., submitted) and and purging, which must have occurred ‘‘more than just will only be described briefly here. Full assessments were experimentally’’ but may have occurred for less than 3 completed on the proband and affected relative(s). Eating months or at a lower frequency than twice a week; (5)

Table 1 Age and weight-related variables for males and female comparison group AN ANBN, BN, EDNOS Males (n = 21) Females (n = 40) HR v2 P Males (n = 21) Females (n = 40) HR v2 Age (years) 29.43 (9.3) 28.20 (6.2) 0.88 0.43 .51 28.52 (11.6) 26.23 (9.6) 1.45 3.60 BMI (kg/m2) 20.37 (2.5) 19.00 (1.9) 1.42 4.36 .04 22.31 (2.6) 20.41 (2.8) 1.42 4.36 Lowest past BMI 15.98 (1.8) 14.88 (2.2) 1.28 2.71 .10 19.66 (2.8) 17.50 (2.6) 1.28 2.71 Highest past BMI 22.28 (3.1) 21.04 (2.7) 1.15 1.60 .21 24.24 (3.2) 23.48 (3.1) 1.15 1.60 Values represent means (S.D.). HR = hazard ratio. D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 275

EDNOS-3, defined as the presence of purging or other dence, persistence, self-directedness, cooperativeness, and clearly excessive compensatory behaviors, in the absence self-transcendence. of objective binge eating, in individuals of normal weight who have either an intense fear of gaining weight or STAI becoming fat or an undue influence of body weight or shape Subjects completed the STAI (Form Y-1), a 40-item on self evaluation. Exclusion criteria for affected relatives instrument used to assess states of anxiety both ‘‘at this included all exclusion criteria listed for the probands, with moment’’ and how the individual ‘‘generally feels’’. the following additional criteria: (1) monozygotic twin of the proband; (2) biological parent with an ED, unless there was Statistical analysis another affected family member with whom the parent could be paired; (3) a diagnosis of binge eating disorder as the only Our goal was to identify characteristics that differentiate lifetime eating disorder diagnosis. males and females with eating disorder diagnoses. The data All males (n = 42) with an ED were included in this set was designed as a case–control study, with each male study. Each male was matched to two females by ED being matched with two females, except in the cases noted diagnosis, 5-year age band (age at the time of interview), above. To account for the double representation of the males and proband status (proband or affected relative). In addi- and to take advantage of the increased sample size of the tion, the females included in the comparison group were not females, conditional logistic regression was conducted using related to any of the males. Two of the males were only able SAS (SAS Institute, 1996). This type of statistical analysis is to be matched to one female on the basis of our matching used to investigate the relationship between the outcome criteria and we were unable to identify an appropriate match for one male (total number of females = 80).

Assessment instruments Table 2 Predicting the likelihood of being male from symptom and personality variables, combined eating disorders diagnoses All participants were assessed with the SIAB [13], the Scale/Variable Hazard ratio CI P value Yale–Brown–Cornell Eating Disorder Scale (YBC-EDS) YBC-EDS [15], and the Yale–Brown Obsessive Compulsive Scale Current to change 1.17 (0.79, 1.71) .434 (Y-BOCS) [16]. Participants completed self-report ques- Current period preoccupation 0.57 (0.35, 0.93) .026 tionnaires including the TCI [8], Multidimensional Perfec- Current rituals 0.86 (0.58, 1.27) .441 tionism Scale (MPS) [17], and State-Trait Anxiety Inventory Current period total score 0.71 (0.46, 1.10) .124 (STAI) [18]. Worst motivation to change 0.67 (0.45, 1.00) .052 Worst period of preoccupation 0.53 (0.32, 0.88) .014 Worst period ritual score 0.62 (0.38, 1.01) .056 SIAB Worst period total score 0.54 (0.32, 0.92) .022 A modified version of the SIAB was used to assess the lifetime histories and phenotype diagnoses of eating disor- TCI ders of the subjects in both studies. Harm avoidance 0.58 (0.37, 0.92) .021 Novelty seeking 1.37 (0.91, 2.08) .133 Persistence 0.91 (0.61, 1.36) .633 YBC-EDS Reward dependence 0.34 (0.19, 0.61) .0004 The YBC-EDS was used to assess the severity and types of Self-directedness 1.04 (0.67, 1.61) .867 core obsessions and compulsions specific to eating disorders. Cooperativeness 0.54 (0.35, 0.84) .006 Self-transcendence 1.03 (0.71, 1.50) .870

Y-BOCS MPS Y-BOCS is a semistructured interview designed to rate Concern over mistakes 0.55 (0.35, 0.87) .010 the presence and severity of obsessive thoughts and com- Doubts about actions 0.85 (0.58, 1.25) .402 pulsive behaviors typically found among individuals with Organization 0.41 (0.24, 0.70) .001 obsessive–compulsive disorder. Parental criticism 1.15 (0.77, 1.71) .500 Parental expectations 1.17 (0.80, 1.72) .410 Personal standards 0.72 (0.46, 1.12) .148 MPS Overall 0.77 (0.51, 1.16) .211 The MPS assesses six specific dimensions of perfection- ism, including concern over mistakes, personal standards, STAI perceived parental expectations, perceived parental criti- State anxiety 0.88 (0.59, 0.32) .540 Trait anxiety 0.86 (0.57, 1.28) .447 cism, doubts about actions, and organization. Y-BOCS TCI Compulsions 0.84 (0.56, 1.27) .407 The TCI measures seven dimensions of personality, Obsessions 1.09 (0.73, 1.62) .676 including novelty seeking, harm avoidance, reward depen- Total 0.96 (0.64, 1.43) .822 276 D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278

(whether the subject is a case or a control, in this study, a lowest past BMI. Males did report higher current BMI as male or a female) and one or more predictive factors. would be expected based on gender. Significant findings suggest that males and females differ Table 2 presents hazard ratios, confidence intervals, for those factors with hazard ratios greater than 1 indicating and P values. If the hazard ratio of a personality trait is that males have higher scores on the variable of interest, and greater than 1, an increment in the trait increases the hazard ratios less than 1 indicating that females have higher hazard rate for males. If the hazard ratio is less than 1, an scores. Analysis was performed first on the whole sample increment in the trait decreases the hazard rate. The and then on two different diagnostic groups [group 1 = AN; hazard ratios were also significantly lower for males for group 2 = ANBN (lifetime diagnosis of both AN and BN), the following eating disorder symptoms as measured by BN and EDNOS (a residual diagnostic group composed the YBC-EDS such as preoccupation with weight and primarily of partial syndrome eating disorders: all three types shape (HR 0.57, CI 0.35–0.93, P = .026), level of preoc- of EDNOS were combined for this analysis)]. As the study is cupation with eating disorder symptoms overall (HR 0.53, exploratory, and there is very limited other literature, P = .05 CI 0.32–0.88, P = .014), and overall score at the period was set as the significance level for this report. of worst symptoms (HR 0.54, CI 0.32–0.92, P = .022). On the TCI, men reported lower reward dependence (HR 0.34, CI 0.19–0.61, P = .0004), cooperativeness (HR 0.54, Results CI 0.35–0.84, P = .006), and harm avoidance (HR 0.58, CI 0.37–0.92, P = .021) as compared to females. On the MPS, As indicated in Table 1, there were no significant differ- men reported lower organization (HR 0.41, CI 0.24–0.70, ences between males and females on age, or highest past or P = .001) and fewer concerns about mistakes (HR 0.55, CI

Table 3 Predicting the likelihood of being male from symptom and personality variables by eating disorders subgroup AN BN, ANBN, NOS1, NOS2, NOS3 Variable Hazard ratio CI P value Hazard ratio CI P value YBC-EDS Current motivation to change 1.11 (0.57, 2.16) .763 1.20 (0.75, 1.91) .456 Current preoccupations 0.48 (0.19, 1.21) .122 0.61 (0.34, 1.10) .099 Current rituals 0.85 (0.44, 1.67) .645 0.86 (0.53, 1.39) .536 Current period total score 0.65 (0.29, 1.45) .293 0.74 (0.44, 1.24) .250 Worst period motivation to change 0.83 (0.49, 1.40) .487 0.50 (0.26, 0.97) .042 Worst period preoccupations 0.63 (0.32, 1.26) .192 0.43 (0.20, 0.96) .033 Worst period rituals 0.74 (0.38, 1.44) .377 0.50 (0.23, 1.08) .076 Worst period total 0.67 (0.34, 1.34) .255 0.42 (0.18, 0.96) .040

TCI Harm avoidance 0.55 (0.29, 1.06) .072 0.61 (0.32, 1.18) .144 Novelty seeking 1.25 (0.71, 2.18) .439 1.54 (0.83, 2.86) .174 Persistence 0.82 (0.47, 1.42) .478 1.03 (0.56, 1.88) .934 Reward dependence 0.23 (0.08, 0.66) .006 0.44 (0.02, 0.90) .025 Self-directedness 1.11 (0.57, 2.16) .753 0.98 (0.55, 1.76) .953 Cooperativeness 0.48 (0.24, 0.96) .038 0.59 (0.34, 1.05) .071 Self-transcendence 1.06 (0.68, 1.67) .790 0.96 (0.50, 1.87) .920

MPS Concern over mistakes 0.47 (0.22, 0.98) .045 0.61 (0.34, 1.10) .100 Doubts about actions 0.74 (0.41, 1.36) .337 0.93 (0.56, 1.54) .785 Organization 0.49 (0.24, 1.02) .056 0.34 (0.15, 0.78) .011 Parental criticism 0.74 (0.41, 1.35) .327 1.98 (0.98, 4.02) .058 Parental expectations 0.83 (0.48, 1.42) .486 1.90 (0.98, 3.67) .057 Personal standards 0.61 (0.30, 1.23) .166 0.82 (0.45, 1.48) .505 MPS overall 0.55 (0.27, 1.11) .093 1.00 (0.56, 1.80) .990

STAI State anxiety 0.87 (0.48, 1.57) .635 0.89 (0.51, 1.56) .694 Trait anxiety 0.71 (0.40, 1.27) .252 1.03 (0.58, 1.81) .926

YBOCS Compulsions 0.60 (0.32, 1.13) .113 1.22 (0.66, 2.25) .522 Obsessions 0.75 (0.40, 1.38) .349 1.49 (0.85, 2.62) .169 Total YBOCS 0.65 (0.35, 1.22) .180 1.37 (0.77, 2.45) .285 D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 277

0.35–0.87, P = .010) compared to the female sample. Men comparisons to nonclinical males showed a reduced risk for did not differ from women on measures of anxiety-related reward dependence and cooperativeness, possibly identify- symptoms from the STAI and Y-BOCS. ing these two variables as especially interesting as potential Table 3 presents data examining hazard ratios by gender trait markers for eating disorders. for specific diagnostic subgroups. For AN, men are distin- There are relatively few differences between men and guished from women by lower levels of reward dependence women when diagnostic subgroup is considered. This may be on the TCI (HR 0.23, CI 0.08–0.66, P = .006), lower body at least partially due to the way in which cases were image disturbance as measured by the SIAB (HR = 0.30, CI ascertained, specifically that probands with BN could have 0.11–0.080, P = .016), and lower cooperativeness as mea- a lifetime history of AN. Cooperativeness, reward depen- sured by the TCI (HR = 0.48, CI 0.24–0.96, P = .038) and dence, and concern over mistakes were less characteristic of concern over mistakes as measured by the MPS (HR = 0.47, males than females with AN. Likewise, motivation to change, CI 0.22–0.98, P = .045). reward dependence, and organization were less characteristic For EDNOS, males were significantly distinguishable of males with EDNOS and BN than females with the same from women by reporting lesser influence of weight and diagnoses. Although there are few studies of treatment shape on self-esteem (HR = 0.41, CI 0.19–0.85, P = .017), response in men compared to women [22], it might be of less motivation to change (HR = 0.50, CI 0.26–0.97, interest to evaluate the impact of reduced motivation to P = .042), fewer preoccupations about wei ght and shape change, and lower cooperativeness and reward dependence (HR = 0.43, CI 0.20–0.96, P = .033), lower reward depen- on treatment outcome. Reduced levels of motivation to dence (HR = 0.44, CI 0.02–0.90, P = .025), and lower change in the EDNOS group might partially explain the organization (HR = 0.34, CI0.15–0.78, P = .011). findings of Woodside et al. [3] showing a relatively high prevalence of EDNOS in males in the community that was not reflected in terms of those attending treatment Discussion These findings diverge from those of Joiner et al. [5] that showed higher rates of perfectionism in late adolescent This study represents one of a very few attempts to males with BN compared to late adolescent females with systematically compare personality factors in men and BN. This difference could be a result of the age differences women with eating disorders. The measures used in this between the samples, with our sample being older. Alter- study assess a reasonable cross section of personality factors nately, the inclusion of ANBN and EDNOS diagnoses in that have been thought to be important in ED, including this part of the analysis may have obscured a difference that perfectionism, obsessionality, obsessive–compulsive disor- would otherwise have been present. There may also be some der, harm avoidance, novelty seeking, and anxiety [19,20]. complex interaction between genetic loading and underlying The primary findings of the study suggest that men with personality that could result in the established gender ED are less perfectionistic as measured by the MPS than difference in the prevalence of eating disorders. Further women with ED, and their personality profile as measured work on the genetics of eating disorders may allow for more by the TCI is also marked by lower harm avoidance, reward precise examinations of the contribution of underlying dependence, and cooperativeness. There is relatively little personality to the development of the illnesses. literature comparing men and women on the MPS and the The constellation of differences reported on the TCI and TCI. Cloninger et al.’s initial report on the TCI [8] showed MPS may be a reflection of an underlying personality women to have higher levels of cooperativeness and spiri- structure associated with a higher risk of personality disor- tual acceptance, while a 1994 paper [21] showed lower der, as reported by other investigators [6]. It is possible that scores by men on cooperativeness. We are not aware of any there is a protective effect of this constellation of personality literature comparing men and women on the MPS. Frost variables that accounts for some of the reduction in inci- et al.’s original research characterizing the measure was dence of these illnesses in men compared to women. The performed entirely on women [17]. presence of increased levels of perfectionism and reward Our results are compatible with but extend the only other dependence in women compared to men may be a mediating comparable study, that of Fassino et al. [7]. The limitations factor that sensitizes women preferentially to the societal in comparing the two papers are that our sample included pressures to be thin and to be excessively aware of body men with a variety of eating disorder subtypes, and that not shape. If men experience reduced levels of perfectionism, all of our samples were acutely ill at the time of assessment. they may as a group be less prone to develop the weight and However, both studies showed less risk for harm avoidance, shape concerns that appear to be a pathway into the illness reward dependence, and cooperativeness in anorexic males in Western society. Alternately, given that all the subjects in compared to anorexic females. While Fassino’s group were this study had an ED, these personality features may all acutely ill, only a minority of our AN subjects were represent gender-specific mediating pathways in the devel- underweight at the time of assessment, suggesting that these opment of eating disorders. observed differences are not entirely state dependent, and The strengths of this study lie in its sophisticated and may in fact represent trait abnormalities. Fassino et al.’s comprehensive assessment protocols, and the inclusion of a 278 D.B. Woodside et al. / Journal of Psychosomatic Research 57 (2004) 273–278 fairly large sample of men with ED. The limitations include KA, Kaplan AS, Strober M, Treasure J, Woodside DB, Berrettini the small numbers of men in the various diagnostic sub- WH, Kaye WH. Linkage analysis of anorexia nervosa incorporating behavioral covariates. Hum Mol Genet 2002;11:689–96. groups, making subgroup analysis tentative. As well, the [10] Strober M, Freeman R, Lampert C, Diamond J, Kaye W. Males with lack of control data makes it difficult to conclude that any anorexia nervosa: a controlled study of eating disorders in first-degree findings are specific to the illness rather than being a feature relatives. Int J Eat Disord 2001;29:263–9. of gender per se. The similarity of some of the TCI findings [11] Kaye WH, Lilenfeld LR, Berrettini WH, Strober M, Devlin B, to those of Fassino et al. [7] is, however, encouraging. This Klump KL, Goldman D, Bulik CM, Halmi KA, Fichter MM, Kaplan A, Woodside DB, Treasure J, Plotnicov KH, Pollice C, study does not shed much light on the gender imbalance in Rao R, McConaha CW. A genome-wide search for susceptibility the prevalence of the conditions in men compared to loci in anorexia nervosa: methods and sample description. Biol women, nor does it add anything to our body of information Psychiatry 2000;47:794–803. about the treatment of the conditions. 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