Article

Childhood Obsessive-Compulsive Personality Traits

in Adult Women With Eating Disorders:
Defining a Broader Eating Disorder Phenotype

Marija Brecelj Anderluh, M.D.
Kate Tchanturia, Ph.D.
Sophia Rabe-Hesketh, Ph.D.
Janet Treasure, Ph.D., F.R.C.P.,
F.R.C.Psych.
Objective: The authors retrospectively ex-
amined a spectrum of childhood traits that
reflect obsessive-compulsive personality in
adult women with eating disorders and as-
sessed the predictive value of the traits for
the development of eating disorders.
Method: In a case-control design, 44
women with anorexia nervosa, 28 women
with bulimia nervosa, and 28 healthy fe-
male comparison subjects were assessed
with an interview instrument that asked
them to recall whether they had experi-
enced various types of childhood behavior
suggesting traits associated with obsessive-
compulsive personality. The subjects also
completed a self-report inventory of obses-
sive-compulsive disorder (OCD) symptoms.
Results: Childhood obsessive-compulsive
personality traits showed a high predictive
value for development of eating disorders,
with the estimated odds ratio for eating
disorders increasing by a factor of 6.9 for
every additional trait present. Subjects
with eating disorders who reported perfec-
tionism and rigidity in childhood had sig-
nificantly higher rates of obsessive-com-
pulsive personality disorder and OCD
comorbidity later in life, compared with
eating disorder subjects who did not re-
port those traits.
Conclusions: Childhood traits reflecting
obsessive-compulsive personality appear
to be important risk factors for the devel-
opment of eating disorders and may rep-
resent markers of a broader phenotype
for a specific subgroup of patients with
anorexia nervosa.

(Am J Psychiatry 2003; 160:242–247)

T he etiology of complex disorders such as anorexia

nervosa and bulimia nervosa is likely to involve a dynamic
interplay of environmental and genetic factors. New ap-
proaches in genetic research provide an opportunity to
study associations between a disorder and specific genes
but face a well-recognized problem of phenotypic defini-
tion. It is likely that diagnostic categories as presented in
the DSM-IV do not fully correspond to underlying biologi-
cal factors.
One approach to specifying phenotypes is to use both
axis I and axis II dimensions. The restricting subtype of an-
orexia nervosa is typically linked to personality traits such
as perfectionism, sense of ineffectiveness, preoccupation
with orderliness, and excessive persistence and compliance
(1–7). Bulimia nervosa is often linked with impulsive per-
sonality traits (8, 9), but the majority of people with bulimia
nervosa are also found to be perfectionistic (4). In a study of
obsessive-compulsive disorder (OCD) symptoms in
women with bulimia, 39% of the subjects with current bu-
limia or a history of bulimia were found to have obsessions
related to symmetry and exactness (10). Perfectionism and
preoccupation with orderliness have been found to persist
after recovery from eating disorders (10–13). Perfectionism
in childhood is one of the risk factors for both anorexia and
bulimia (6, 14). In family studies, persons with a high level
of perfectionism are overrepresented among healthy first-
degree relatives of patients with eating disorders, suggest-
ing that obsessive-compulsive personality disorder, or its
traits, represent a heritable factor contributing to vulnera-
bility for both types of eating disorders (13, 15, 16).
The aim of this study was to determine whether retro-
spectively measured childhood personality traits reflect-
ing obsessive-compulsive personality predicted develop-
ment of eating disorders. To minimize biases related to
retrospective reporting, the study used a newly developed
interview instrument with items based on examples of
childhood behavior. The study hypothesis was that child-
hood traits linked to obsessive-compulsive personality are
important risk factors for the development of eating disor-
ders. The subsidiary hypothesis was that people with an
eating disorder who had a high number of childhood traits
reflecting obsessive-compulsive personality have a higher
prevalence of this type of personality disorder and have
more compulsive symptoms later in life.
Method
Participants
The participants consisted of three groups: 44 female patients
with a DSM-IV diagnosis of anorexia nervosa (26 with the restrict-
ing type, 18 with the binge-eating/purging type), 28 female pa-

242 http://ajp.psychiatryonline.org Am J Psychiatry 160:2, February 2003

 ANDERLUH, TCHANTURIA, RABE-HESKETH, ET AL.

tients with a DSM-IV diagnosis of bulimia nervosa, and 28 healthy TABLE 1. Childhood Traits Reflecting Obsessive-Compulsive
female comparison subjects. The clinical participants were re- Personality and Main Areas of the Child’s Life in Which the
cruited from the inpatient and outpatient programs of the Eating Traits Are Assessed in the EATATE Interview
Disorders Unit of the Maudsley Hospital, London, a tertiary refer- Assessed Trait Areas of the Child’s Life
ral center. To avoid possible reporting biases related to an acute Perfectionism: Perfectionism is Schoolwork
physical state, patients who fulfilled the diagnostic criteria and assessed separately in four Self-care
were willing to participate were entered in the study 3–4 weeks af- areas of child’s life; the trait is Looking after her room
ter the beginning of treatment. Exclusion criteria consisted of a regarded as present if reported Hobbies, caring for pets,
history of psychotic disorder or bipolar disorder assessed accord- to have influenced markedly part-time job, or housework
ing to the ICD-10 criteria. The comparison subjects were admin- the child’s life in at least two of
istrative staff and students from two universities in different the assessed areas.
Inflexibility: Inflexibility and Difficulties in adjusting to changes
towns in the United Kingdom. They were matched by age, sex,
rule-bound trait both measure linked to house moves, school
and educational level with the patients and were blind to the rigidity; rigidity is regarded as changes, changes in family
study hypothesis. The comparison subjects were of normal present if at least one of the schedule or structure, changes
weight, had no personal or family history of an eating disorder or two traits was present and in planned daily activities
any other psychiatric disorder, and had no history of bingeing, markedly influenced the Presence of activities to
vomiting, or abuse of laxatives. All subjects except those recruited child’s life. compensate for these
as inpatients were reimbursed for their time. All participants were difficulties, including written
native English speakers. The study was approved by the South plans, making contingency plans
London and Maudsley National Health Service Trust and Institute Rule-bound trait: Inflexibility Excessive persistence
and rule-bound trait both High degree of compliance with
of Psychiatry ethics committee. After complete description of the
measure rigidity; rigidity is rules set by parents or teachers
study to the subjects, written informed consent was obtained. regarded as present if at least
one of the two traits was
Procedure present and markedly
Specialists in the Eating Disorders Unit who were blind to the influenced the child’s life.
study hypothesis made the initial screening diagnoses of eating Excessive doubt and Excessive doubt about actions
disorders using the DSM-IV criteria. Study subjects were inter- cautiousness: The trait is Excessive cautiousness about
viewed by a trained researcher (one of six postgraduate psycholo- regarded as present if both making a mistake
excessive doubt and
gists and psychiatrists) using a semistructured interview (de-
cautiousness were present and
scribed in the next section). On the day of the interview, data on markedly influenced the
demographic characteristics were collected, and the subject’s child’s life.
weight and height were measured. Thirty interviews were re- Drive for order and symmetry: Looking after her room
corded on audiotapes and were rerated by one of two assessors The trait is regarded as present Housework
who were blind both to the previous scoring and to the subject’s if reported to have influenced Appearance (dress, hair style)
diagnosis. markedly the child’s life in at
least two of the assessed areas.
Measures
The instruments used in the study included the semistructured “anankastic,” and “childhood.” A focus group of patients with an-
EATATE interview and the self-report Maudsley Obsessive-Com- orexia nervosa was held to identify behavioral examples of child-
pulsive Inventory. The National Adult Reading Test was used to hood traits reflecting obsessive-compulsive personality. The be-
match patients and comparison subjects in intellectual ability. havioral examples were used in designing the EATATE interview
The EATATE interview. The EATATE interview was developed to minimize the problems associated with retrospective reporting
for the European Healthy Eating Project, which examined genetic and to reduce rationalization. The final instrument is used to as-
and environmental risk factors for eating disorders and obesity. sess five childhood traits that reflect obsessive-compulsive per-
(The instrument is available from the first author.) The first part, sonality (Table 1): perfectionism (e.g., Did you spend a long time
which consists of an adaptation of the Eating Disorder Examina- doing or redoing your hair to make sure it was straight without
tion (17), is used to identify a lifetime eating disorder diagnosis in bumps?), inflexibility (e.g., To what extent were you the sort of
subjects and first-degree family members. The first part also is person who liked to make written plans/notes or have intricate
used to assess whether the subject meets the criteria for an ICD- details about the time ahead?), rule driven (e.g., Were you the kind
10 lifetime diagnosis of OCD. Food and body-related obsessions of person who felt she always had to follow rules? For example,
are excluded as symptoms of OCD. The second part of the EATATE how far did you bend or break rules that were set by your parents
interview, which provided the data that are the focus of this paper, or teachers?), drive-for-order and symmetry (e.g., While trying to
is used to assess whether the subject meets the criteria for current get your room tidy and organized, were you particularly con-
obsessive-compulsive personality disorder, according to the ICD- cerned about making sure that everything was “just so” and in its
10 International Personality Disorder Examination (18) module proper place?), and excessive doubt and cautiousness (e.g., Were
for anankastic personality disorder, and to collect data on child- your frightened to make a mistake as a child? Can you give an ex-
hood traits reflecting obsessive-compulsive personality. (An ICD- ample?). The interviewer used a scoring manual to rate the re-
10 diagnosis of anankastic personality disorder corresponds to a sponses according to predefined criteria. The interviewers were
DSM-IV diagnosis of obsessive-compulsive personality disorder). trained in the use of the manual by scoring videotaped interviews
The prototype of the assessment of childhood traits was devel- and by participating in consensus meetings where ratings were
oped in an expert meeting by collaborators on the European discussed. The presence of each trait was assessed together with
Healthy Eating project and other experts with extensive clinical its effect on the child’s life in terms of the child’s relationship with
and research experience in the field. After this session, the MED- the world and with others. Traits were rated 0 for absent, 1 for
LINE and PsycINFO databases (1965–2001) were searched for pa- present but not influencing the child’s life, or 2 for impinging on
pers describing current and past personality traits linked with the child’s life or her relationship with the world or with others.
eating disorders. The key words used in the search were “person- Assessment of interrater reliability was based on the full 3-point
ality,” “perfectionism,” “rigidity,” “inflexibility,” “obsessionality,” scale. In all other analyses, the values 0 and 1 were not discrimi-

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CHILDHOOD TRAITS AND ADULT EATING DISORDERS

TABLE 2. Characteristics of Subjects With Eating Disorders and Healthy Comparison Subjects in a Study of Childhood Traits
Reflecting Obsessive-Compulsive Personalitya
Subjects With Anorexia Subjects With Bulimia Healthy Comparison
Characteristic Nervosa (N=44) Nervosa (N=28) Subjects (N=28) Analysis
Mean SD Mean SD Mean SD F df p

Current age (years)b 27.9 9.1 26.7 9.5 25.1 5.1 0.92 2, 97 n.s.
Body mass index (kg/m2)
Currentc 15.9 2.8 21.6 2.0 22.1 2.4 74.05 2, 97 <0.001
Lowest ever 12.2 1.8 17.1 2.6 — 87.51 1, 70 <0.001
Highest ever 20.7 2.6 24.2 2.4 — 33.58 1, 70 <0.001
National Adult Reading Test scored 16.4 5.6 17.8 4.0 15.1 5.4 0.80 2, 41 n.s.
Age at onset of eating disorder (years) 16.3 3.6 16.8 2.8 — 0.51 1, 70 n.s.
Maudsley Obsessive-Compulsive
Inventory scoree,f 12.6 6.1 11.0 6.1 3.8 3.1 22.70 2, 72 <0.001

N % N % N % χ2 df p
ICD-10 diagnosis
Anankastic (obsessive-compulsive)
personality disorderf 27 61 13 46 1 4 24.10 2 <0.001
Obsessive-compulsive disorderf,g 18 45 5 20 0 0 18.33 2 <0.001
a Patients with eating disorders were recruited from the inpatient and outpatient programs of the Eating Disorders Unit of the Maudsley
Hospital, London. Comparison subjects were recruited among students and administrative staff at two universities in the United Kingdom.
b Age range=15–52 years for the subjects with anorexia nervosa, 15–61 for the subjects with bulimia nervosa, and 18–45 for the healthy
comparison subjects.
c Significant difference between subjects with anorexia nervosa and subjects with bulimia nervosa (p<0.001, Tukey).
d N=18 for patients with anorexia nervosa, N=9 for patients with bulimia nervosa, N=16 for comparison subjects.
e N=26 for patients with anorexia nervosa, N=19 for patients with bulimia nervosa, N=20 for comparison subjects.
f No significant difference between subjects with anorexia nervosa and subjects with bulimia nervosa (Tukey).
g N=40 for patients with anorexia nervosa, N=25 for patients with bulimia nervosa, N=28 for comparison subjects.

nated, and only traits that were reported to impinge on the child’s
life (a rating of 2) were regarded as present. Any problems with the
ratings were discussed at consensus meetings.
Maudsley Obsessive-Compulsive Inventory. The Maudsley
Obsessive-Compulsive Inventory (19) is a 30-item self-report
scale that assesses four types of obsessive-compulsive com-
plaints: checking, washing, doubting, and slowness. Alpha coeffi-
cients of 0.7, 0.8, 0.7, and 0.7 for the four subscales, respectively,
were found. Good test-retest reliability has been reported for the
instrument (Kendall’s tau=0.8) (19).
The National Adult Reading Test. The National Adult Read-
ing Test (20) was used to match the participant groups in terms
of approximate intellectual ability. The National Adult Reading
Test requires the participant to read aloud 50 phonetically ir-
regular words, and the number of mistakes is recorded. The test
results have been found to correlate significantly with level of
education (20).
Analysis
The clinical and demographic data were compared across
groups by using chi-square tests and one-way analysis of vari-
ance, with the Tukey test for post hoc comparisons of group dif-
ferences. Interrater reliability for the childhood trait scale of the
EATATE interview was assessed with weighted kappa coefficients
calculated for individual items (rated as 0–2) and an unweighted
kappa coefficient for the diagnosis of obsessive-compulsive per-
sonality disorder. Cronbach’s alpha was calculated to measure the
internal consistency of the childhood trait scale. Linear regres-
sion analysis was used to examine the relationship of childhood
and adult obsessive-compulsive personality traits within the eat-
ing disorder and the comparison groups. Logistic regression was
used to measure the association of childhood obsessive-compul-
sive personality traits with the presence of an eating disorder and
obsessive-compulsive personality disorder later in life. T tests for
independent samples (with Bonferroni corrections) and chi-
square tests (with Yates’s corrections) were used to compare the
subjects with eating disorders who did and did not report child-
hood perfectionism and rigidity. Two-tailed tests with a 5% level
of significance were used throughout the analyses. No significant
differences were found between the subjects with the restricting
type of anorexia nervosa and those with the binge-eating/purging
type. Thus, the data for those subgroups were analyzed together.
All analysis were carried out by using SPSS-PC (21).
Results
Subject Characteristics
Table 2 summarizes the subjects’ demographic and clin-
ical characteristics. The groups did not differ significantly
in age, and the eating disorder groups had similar mean
ages at onset of the illness. As expected, the body mass in-
dex at assessment differed significantly across the groups
(F=74.05, df=2, 97, p<0.001). The two clinical groups dif-
fered significantly on the lowest past body mass index (F=
87.51, df=1, 70, p<0.001). National Adult Reading Test
scores were assessed in about half of the subjects, and the
availability of data was consistent across the groups. No
significant differences were observed in National Adult
Reading Test score across the groups. The three groups dif-
fered significantly in the prevalence of obsessive-compul-
sive personality disorder (χ2=24.10, df=2, p<0.001), but the
difference in prevalence between the two patients groups
was not significant. The prevalence of OCD comorbidity
was higher in the bulimia nervosa group than in the anor-
exic group, although the difference did not reach signifi-
cance. Although every effort was made to collect complete
data for all subjects, data from the Maudsley Obsessive-
Compulsive Inventory were available for only 62% of the

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TABLE 3. Prevalence of Childhood Traits Reflecting Obsessive-Compulsive Personality Among Subjects With Eating Disor-
ders and Healthy Comparison Subjects
Subjects With Anorexia Subjects With Anorexia
Nervosa, Restricting Nervosa, Binge-Eating/ Subjects With Bulimia
Type (N=26) Purging Type (N=18)
Traita N % N %
Perfectionism 17 65.4 13 72.2
Inflexibility 20 76.9 11 61.1
Rule-bound trait 16 61.5 14 77.8
Doubt and cautiousnessb 6 27.3 7 46.7
Drive for order and
symmetryc 10 38.5 5 31.3
a Kappa coefficients measuring interrater reliability were 0.79 for perfectionism, 0.89 for inflexibility, 0.76 for rule-bound trait, 0.73 for doubt
and cautiousness, and 0.65 for drive for order and symmetry.
b N=22 for subjects with anorexia nervosa, restricting type; N=15 for subjects with anorexia nervosa, binge-eating/purging type; N=65 for all
eating disorder subjects.
c N=16 for subjects with anorexia nervosa, binge-eating/purging type; N=70 for all eating disorder subjects.
subjects. The loss of data was consistent across the groups,
and subjects with a completed Maudsley Obsessive-Com-
pulsive Inventory did not differ from those without a com-
pleted inventory on any of the clinical parameters. The
eating disorder groups reported higher total Maudsley Ob-
sessive-Compulsive Inventory scores than the compari-
son group (F=22.70, df=2, 72, p<0.001), but no significant
difference was found between the patients with anorexia
nervosa and those with bulimia.
Interrater Reliability and Consistency
of the Childhood Trait Scale
The weighted kappa was estimated from 30 interviews
that were recorded on audiotapes and rerated by an asses-
sor who was blind to the previous scorings. Good inter-
rater reliability of the instrument was observed, with
mean weighted kappa coefficients of 0.74 and 0.80 for the
ratings of childhood traits and for the diagnosis of adult
obsessive-compulsive personality disorder, respectively.
The weighted kappas for the individual items are shown in
Table 3. The childhood scale also showed good internal
consistency (Cronbach’s alpha=0.74).
Childhood Traits
Robust differences between groups were observed in
the frequency of the reported childhood traits reflecting
obsessive-compulsive personality (Table 3). In an analysis
that controlled for eating disorder diagnoses, adult obses-
sive-compulsive personality disorder traits were signifi-
cantly related to childhood traits reflecting obsessive-
compulsive personality (regression coefficient=0.73, 95%
confidence interval [CI]=0.47–0.99, p<0.001). In a logistic
regression analysis with adult obsessive-compulsive per-
sonality disorder diagnosis as the dependent variable and
childhood traits as the independent variables, every addi-
tional reported trait increased the estimated odds ratio for
development of adult obsessive-compulsive personality
disorder by 2.1 (95% CI=1.4–3.2, p<0.001).
To test the predictive value of the childhood obsessive-
compulsive personality traits for the development of an
eating disorder, a logistic regression analysis was per-
Am J Psychiatry 160:2, February 2003
ANDERLUH, TCHANTURIA, RABE-HESKETH, ET AL.
All Eating Disorder Healthy Comparison
Nervosa (N=28) Subjects (N=72) Subjects (N=28)
N % N % N %
14 50.0 44 61.1 0 0.0
7 25.0 38 52.8 0 0.0
14 50.0 44 61.1 5 17.9
6 21.4 19 29.2 0 0
3 10.7 18 25.7 1 3.6
formed with the presence of an eating disorder as the de-
pendent variable and the number of childhood traits as the
independent variable. With every additional trait reported,
the estimated odds ratio for development of an eating dis-
order increased by 6.9 (95% CI=2.9–16.4, p<0.001), suggest-
ing a strong dose-response relationship.
Childhood Perfectionism and Rigidity
and Adult Clinical Variables
The patients with eating disorders were grouped ac-
cording to whether childhood perfectionism and rigidity
traits were reported. (These dimensions showed the high-
est difference in prevalence between the clinical and the
comparison groups). Two-thirds of the patients with anor-
exia nervosa and approximately one-third of the patients
with bulimia nervosa reported perfectionism and at least
one of the two traits reflecting rigidity in childhood; the
difference in the prevalence of the traits between the two
groups was significant (χ2=7.1, df=2, p<0.03). People with
eating disorders who reported perfectionism and rigidity
in childhood did not differ significantly in their age at on-
set of illness or in their lowest-ever body mass index from
those who did not report these traits, but they did have sig-
nificantly higher dimensional scores on the assessment of
obsessive-compulsive personality disorder in adulthood
(t=4.67, df=70, p<0.001). However, the prevalence of life-
time OCD comorbidity and the total Maudsley Obsessive-
Compulsive Inventory score at assessment did not differ
significantly between the two groups (Table 4).
Discussion
The results of this study confirm our hypothesis that
women with eating disorders show high levels of obses-
sive-compulsive personality traits in childhood, relative to
healthy comparison subjects. There was a strong increas-
ing relationship between the number of reported child-
hood traits and the odds of developing an eating disorder,
with each extra reported trait increasing the odds of devel-
oping an eating disorder nearly sevenfold. We also con-
firmed our subsidiary hypothesis of developmental conti-
http://ajp.psychiatryonline.org 245
CHILDHOOD TRAITS AND ADULT EATING DISORDERS

TABLE 4. Characteristics of Subjects With Anorexia Nervosa or Bulimia Nervosa With and Without Childhood Traits of
Perfectionism and Rigiditya
Childhood Perfectionism and Rigidity
Characteristic Yes (N=37) No (N=35) Analysis
Mean SD Mean SD t df p

Age at onset (years) 16.8 3.7 16.1 2.9 0.83 70 n.s.

Lowest-ever body mass index (kg/m2) 13.6 2.9 14.7 3.4 1.60 70 n.s.
EATATE dimensional score for obsessive-compulsive
personality disorder 10.8 3.0 7.3 3.4 4.67 70 <0.01b
Maudsley Obsessive-Compulsive Inventory scorec 13.5 6.1 10.0 5.6 2.06 45 n.s.

N % N % χ2 (Yates’s Correction) df p
ICD-10 diagnosis
Anankastic (obsessive-compulsive) personality disorder 28 75.7 12 34.3 10.86 1 <0.001
Obsessive-compulsive disorderd 11 33.3 12 37.5 0.01 1 n.s.
a Rigidity was considered present if either inflexibility or the rule-bound trait was present and markedly influenced the child’s life.
b With Bonferroni correction.
c N=26 for subjects with childhood perfectionism and rigidity; N=21 for subjects without childhood perfectionism and rigidity.
d N=33 for subjects with childhood perfectionism and rigidity; N=32 for subjects without childhood perfectionism and rigidity.

nuity in that the presence of childhood perfectionism and
rigidity identified a subgroup of people with eating disor-
ders with a significantly higher prevalence of obsessive-
compulsive personality disorder later in life.
Our results confirm and extend findings from previous
studies. Fairburn et al. (14) assessed perfectionism in
childhood with a single item (high personal standards)
and identified it as a risk factor for anorexia and bulimia in
eating disorder patients, compared with healthy subjects
(odds ratio=3.9, 95% CI=2.1–7.4, and odds ratio=2.6, 95%
CI=1.5–4.6, respectively). The instrument we developed
retrospectively examined a broader spectrum of obses-
sive-compulsive personality traits, including perfection-
ism, by using a range of behavioral examples.
Approximately two-thirds of the subjects with anorexia
nervosa reported perfectionism and rigidity in childhood.
This prevalence is consistent with that reported by Rastam
(22) for premorbid obsessive-compulsive (or anankastic)
personality disorder in anorexia nervosa. We are not aware
of any similar studies conducted for patients with bulimia
nervosa. However, previous findings that perfectionism,
obsessionality, excessive concern about mistakes, and
doubt about actions persist after recovery from both disor-
ders suggest that they represent persistent traits (10, 13, 16).
The prevalence of comorbidity of anorexia and bulimia
with OCD in this study was congruent with the published
rates of 25%–69% in women with anorexia nervosa (23–25)
and 25%–36% in women with bulimia nervosa (8, 26).
The prevalence of cluster C personality disorders, which
include obsessive-compulsive personality disorder, has
been reported to range between 5% and 80% in people
with anorexia nervosa (4, 27–29) and to be as high as 25%
in people with bulimia nervosa (8, 28). These figures are
congruent with our findings.
This study had several limitations. The retrospective as-
sessment was subject to inaccuracies of memory and sub-
jectivity in reporting. Although the instrument used in this
study was based on simple behavioral examples and used
interviewer-based ratings (according to predefined crite-
ria) to optimize the precision of the assessment, further
studies with other informants or with a prospective design
are needed to confirm the findings. It was impossible for
the assessor to be blind to the primary diagnosis in assess-
ing severely emaciated subjects with anorexia nervosa.
This source of bias was minimized by rerating audiotaped
interviews. Indeed, for the interviews that were audio-
taped, we found a high level of agreement between the two
raters, one of whom scored the taped interview and was
blind to the subject’s appearance. The subjects with eating
disorders were recruited from a tertiary referral center and
were taking medication while participating in the study.
Thus, their medication status may have influenced report-
ing accuracy.
The findings suggest that childhood obsessive-compul-
sive personality traits are important risk factors for later
development of eating disorders, particularly anorexia
nervosa. Furthermore, the findings suggest that childhood
perfectionism and rigidity may offer a more specific and
homogenous phenotypic determination for genetic stud-
ies. Further studies are needed to determine whether
these traits are specific for eating disorders or are also
linked to other psychiatric disorders, such as depression
or OCD. Personality traits may also act as maintaining fac-
tors and as such may have an important influence on the
prognosis of the disorder. Studies of people who have re-
covered from an eating disorder would be needed to ex-
plore the influence of childhood obsessive-compulsive-
personality traits on the length of illness and its severity.
Female subjects were included in this study because the
prevalence of eating disorders is approximately nine times
higher in women than in men. However, further studies
that include male subjects are needed to better under-
stand the role of the assessed traits. To our knowledge, the
interview scale described here is the first to measure these
personality trait risk factors in a broad and comprehensive
way. The finding that perfectionism and rigidity represent

246 http://ajp.psychiatryonline.org Am J Psychiatry 160:2, February 2003


strong risk factors suggests that these items might also be
also used to identify people at high risk for developing an
eating disorder later in life. Prospective studies are needed
to replicate these findings.
Received Sept. 4, 2001; revisions received March 6 and Aug. 6,
2002; accepted Aug. 27, 2002. From the Institute of Psychiatry, King
College London, De Crespigny Park; and the University Psychiatric
Hospital Ljubljana, Ljubljana-Polje, Slovenia. Address reprint re-
quests to Dr. Anderluh, Eating Disorders Unit, Institute of Psychiatry,
De Crespigny Park, London SE5 8AD; marija.brecelj@guest.arnes.si
(e-mail).
Supported by grant QLK1-1999-916 from the European Commis-
sion Framework V program.
The authors thank Prof. C. Fairburn, Prof. P. McGuffin, Prof. R. Plo-
min, Dr. I. Hayman, Dr. D. Nicholls, and the European Consortium for
advice provided at the expert meeting to develop the EATATE inter-
view and Prof. I. Campbell and Dr. N. Troop for comments on the
manuscript.
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