PREDISPOSITION: Does Temperament Play a Role in Eating Disorders?
This is a rather long writing, but I consider it very enlightening in several aspects.
Many thanks to Dr. Emmett Bishop.
Temperament refers to those aspects of an individual's personality, such as introversion or extroversion, which are often regarded as innate rather than learned. Differences in temperament are determined by individual variations in perception of physical sensations as well as variations in processes of selective attention and emotional salience. This means that, in a sense, individuals with different temperaments see the world through a different lens.
These innate personality traits can play a significant role not only in an individuals' predisposition to an eating disorder, but also in their maintenance of an eating disorder. By understanding the specific temperamental traits that are common among individuals with eating disorders, clinicians can form a more targeted, informed approach to treatment and look to newer psychotherapies for guidance.
Adapted from C. Robert Cloninger's Temperament Character Inventory, the four key temperament dimensions associated with eating disorders and the characteristics of high and low scorers on each dimension are described below.
1. HARM AVOIDANCE
The harm avoidance dimension of temperament, often intense in eating disordered persons, is an expression of the behavioral inhibition system of the brain. Those who are high in this temperament trait tend to overestimate the risk of hurt. They feel the somatic aspects of anxiety more intensely than the average person. Consequently, they are more cautious, fearful, tense, timid, apprehensive, doubtful, passive, negative or pessimistic in situations which do not worry other people. They tend to be inhibited and shy in social situations. Their cautious nature has an adaptive advantage when there are real risks but can be an impediment to healthy change in treatment due to their excessive avoidance of new experiences.
High harm avoidance contributes to a life centered on anxiety management with an eating disorder. Eating disordered patients often report that they spend a major portion of their waking existence thinking about controlling their anxiety about eating, shape and weight. The eating disorder becomes the main tactic for mentally avoiding life's anxieties.
2. NOVELTY SEEKING
Novelty seeking is a pre-conceptual bias in the brain which relates to behavioral activation. Those with high novelty seeking are drawn to the new and stimulating. Such individuals are quick-tempered, excitable, exploratory, enthusiastic, exuberant, curious, easily bored, impulsive and disorderly. It is not surprising that high novelty seeking is associated with binge/purge behavior. Higher novelty seeking is seen in bulimia nervosa cases, anorexia nervosa cases with binge/purge behaviors, and is also associated with diagnostic cross-over from anorexia to bulimia.
On the other hand, individuals with low novelty seeking temperaments are slow tempered, non-inquisitive, unenthusiastic, stoical, reflective, frugal, reserved, tolerant of monotony, systematic and orderly. In eating disordered patients, low novelty seeking is seen in restricting anorexic patients. Such individuals tend to be slaves to routines and rituals because they like things to be orderly.
3. REWARD DEPENDENCE
The behavioral maintenance system of the brain is represented by the temperament trait of reward dependence. The reward dependence trait is manifested by individual differences in response to social reward. Those who are high in this trait are tender-hearted, sensitive, socially dependent, warm and sociable. They easily form emotional attachments. High reward dependence can be advantageous when sensitivity to social cues is needed and the capacity to understand the feelings of others is beneficial. A disadvantage of high reward dependence ensues from being easily influenced by emotional appeals. Reward dependence is not consistently associated with diagnosis but can significantly impact treatment issues such as therapeutic alliance.
Persistence is a bias in the brain which concerns maintenance of behavior in the face of frustration, punishment, fatigue and intermittent reward. Highly persistent individuals tend to be hard-working and ambitious overachievers. High persistence is associated with anorexia nervosa and consistent with their well-known perfectionism and inability to shift mental sets to a more healthy orientation.
As we comprehend the structure of temperament and how it relates to the intuitive senses, we can grasp the limitations of many current treatments for eating disorders. We can then begin to make the case for many of the strategies employed by some of the newer psychotherapies, which focus on building mindfulness skills, acceptance strategies and transcendent sense of self; targeting experiential or emotional avoidance; building awareness of rule governance; understanding valued-life direction;and focusing on coherence seeking and connection.
Emmett R. Bishop, Jr., MD, CEDS