Received: 6 December 2019 Revised: 14 April 2020 Accepted: 15 April 2020

DOI: 10.1002/eat.23285

ORIGINAL ARTICLE

Perfectionism and impulsivity based risk profiles

in eating disorders

Kärol Soidla MA | Kirsti Akkermann PhD

Institute of Psychology, University of Tartu,

Näituse, Estonia
Correspondence
Kirsti Akkermann, Institute of Psychology,
University of Tartu, Näituse 2, 50409, Estonia.
Email: kirsti.akkermann@ut.ee
Action Editor: Ruth Weissman
Abstract
Objective: The categorical classification of eating disorders (ED) has several limita-
tions, for example, high symptom variability within the diagnosis and limited predic-
tive validity for treatment response. An alternative is classifying individuals with ED
based on personality traits, which can reflect underlying etiological mechanisms. We
aimed to find latent profiles based on facets of maladaptive and adaptive perfection-
ism, impulsivity and ED symptoms.
Method: The sample comprised of 274 women—164 had an ED diagnosis and
110 were controls. Two separate latent profile analyses were performed—one on the
mixed sample (controls and individuals with ED) and the other on the sample of indi-
viduals with ED only.
Results: We identified a five-class model to be the best fit for the mixed sample. The
classes were: (a) moderately impulsive, (b) high functioning, (c) purely perfectionistic,
(d) emotionally dysregulated, (e) behaviorally dysregulated. Among the individuals
with ED, a four-class solution was found to be the best fit. The classes were very sim-
ilar in their response patterns on indicator variables to response patterns observed in
the mixed sample, except the emotionally and behaviorally dysregulated classes that
formed into one class.
Discussion: In addition to the well-known high-functioning, overcontrolled and
undercontrolled classes, two to three undercontrolled classes (moderately impulsive,
behaviorally, and emotionally dysregulated class) emerged. Those classes differenti-
ated on perfectionism and impulsivity levels as well as on ED symptom severity and
psychiatric comorbidities—all of which may influence maintenance of ED, appropriate
treatment choice and therefore treatment response.

KEYWORDS

eating disorders, impulsivity, latent profile analysis, perfectionism, personality traits

1 | I N T RO DU CT I O N
There is a growing interest in alternative ways to classify eating disor-
ders (ED) (Insel et al., 2010; Wildes & Marcus, 2013) as the current cat-
egorical classification of ED has several limitations, including high
symptom variability within diagnoses, lack of diagnostic stability, and
limited predictive validity for treatment (Insel et al., 2010; Keel, Brown,
Holland, & Bodell, 2012; Peat, Mitchell, Hoek, & Wonderlich, 2009;
Widiger & Samuel, 2005).
According to Wildes and Marcus (2013), two main alternative
models have been proposed. The first model focuses on classifying indi-
viduals on the basis of ED symptoms and the second on the basis of
comorbid psychopathology and associated features, including personal-
ity traits. The second model is particularly promising, as comorbid

Int J Eat Disord. 2020;1–12. wileyonlinelibrary.com/journal/eat © 2020 Wiley Periodicals, Inc. 1

2 SOIDLA AND AKKERMANN
psychopathology and personality traits may reflect distinctive pathways
to disordered eating (Westen & Harnden-Fischer, 2001) and help to
shed light on treatment prognosis, heterogeneity in symptomatic pro-
files and maintenance of ED (Farstad, McGeown, & von Ranson, 2016).
Several studies, regardless of the sample, type of assessment and
statistical analyses used, have identified at least three main latent
classes among EDs: an undercontrolled (high impulsivity, emotional
reactivity, risky behaviors), an overcontrolled (high perfectionism,
rigidity, compulsivity, inhibition), and a high functioning class (for an
overview see Wildes & Marcus, 2013). In most of the studies, three to
six class solutions have been found (Wildes & Marcus, 2013). In stud-
ies which have found more than three classes, the undercontrolled,
overcontrolled and high functioning class are still recognizable (Krug
et al., 2011; Thompson-Brenner et al., 2008; Turner et al., 2014).
1.1 | Perfectionism, impulsivity, and eating
disorders
One possible and promising way to classify individuals with ED is by
using dimensions of perfectionism (associated with overcontrol and
compulsivity) and impulsivity, as both of those traits are central fea-
tures of EDs and may play an important role in influencing treatment
outcome (Bardone-Cone et al., 2007; Egan, Wade, & Shafran, 2011;
Farstad et al., 2016; Waxman, 2009).
Perfectionism is a well-established multidimensional construct, con-
sisting of adaptive (organization, personal standards) and maladaptive
(concern over mistakes, parental criticism) dimensions (Frost, Marten,
Lahart, & Rosenblate, 1990; Lo & Abbott, 2013). Perfectionism has been
associated with disordered eating behaviors like dieting, bulimic symp-
toms, preoccupation with food, weight, shape and compensatory behav-
iors (Bardone-Cone et al., 2007; Egan et al., 2011). Both perfectionistic
concerns (maladaptive perfectionism) and strivings (adaptive perfection-
ism) are strongly associated with EDs (Limburg, Watson, Hagger, &
Egan, 2016). A recent meta-analysis also concluded that individuals with
anorexia nervosa (AN) had both higher adaptive and maladaptive perfec-
tionism compared to controls. However, there were no significant differ-
ences in maladaptive perfectionism between individuals with AN and
bulimia nervosa (BN) (Dahlenburg, Gleaves, & Hutchinson, 2019). A com-
bination of high personal standards and high evaluative concerns is asso-
ciated with the highest level of ED symptoms, such as restrained eating,
concern over eating, weight, and shape (Boone, Soenens, Caroline, &
Goossens, 2010).
Impulsivity as a multidimensional construct can be divided into
negative urgency (tendency to act reckless and without further thought
in stressful situations while experiencing negative affect), positive
urgency (tendency to engage in impulsive behavior when experiencing
strong positive emotions), lack of premeditation, sensation seeking and
lack of perseverance (Whiteside & Lynam, 2001). However, impulsivity
can also be divided into functional (characterized by rapid style of infor-
mation processing resulting in quick thinking and responses, when such
style is optimal) and dysfunctional (failure to inhibit inappropriate
responses, characterized by recklessness and excessive haste) domains
(Brunas-Wagstaff, Bergquist, & Wagstaff, 1994; Dickman, 1990).
Analyzing different aspects of impulsivity Whiteside and Lynam (2001)
found that dysfunctional impulsivity is positively correlated with lack of
premeditation, while functional impulsivity is positively correlated
with sensation seeking and negatively with urgency (Whiteside &
Lynam, 2001). The association between disordered eating behavior and
impulsivity is strongest within EDs characterized by binge eating or
purging behaviors (Waxman, 2009). However, heightened levels of
impulsive behavior have been found in all ED subgroups, including
restricting types (Claes, Robinson, Muehlenkamp, Vandereycken, &
Bijttebier, 2010). Therefore, it has been suggested that impulsivity does
not differentiate well between ED diagnoses, but rather their clinical
presentation (for a review see Waxman, 2009).
Two studies have previously examined the profiles based on
perfectionism and impulsivity and four latent classes have been found.
Boone, Claes, and Luyten (2014) study was conducted on healthy
adolescents and the highest level of ED psychopathology was
reported by individuals who had both high levels of perfectionism and
impulsivity. In Slof-Op't Landt, van Furth, and Claes (2016) study,
which was conducted in a sample of individuals with ED, the highest
level of psychopathology was present in the high adaptive/high mal-
adaptive perfectionism class.
1.2 | The present study
The aim of the current study was to classify individuals based on
dimensions of impulsivity and perfectionism, as well as ED symptoms.
In most of the previous studies, ED symptoms were not included in
the latent profile analysis (LPA) as indicators. Including ED symptoms
as indicators in the latent profile model may reduce statistical bias,
produce stronger relations and therefore reveal possible reciprocal
relationship between symptoms and risk factors in the classes, which
the traditional classify-analyze approach may not account for (more
about the statistical disadvantages about the traditional classify-
analyze approach see Lanza, Tan, & Bray, 2013). Adding the ED
symptoms as indicators in the analysis is also theoretically meaningful.
Widiger (2011) argues in his paper that personality and psychopathol-
ogy both influence each other (pathoplastic relationship). Lilenfield,
Wonderlich, Riso, Crosby, and Mitchell (2006) have proposed a
pathoplastic model explaining the relationship between EDs and per-
sonality traits. The pathoplastic model is also supported by studies
that have shown the effect of starvation and chronic dieting on brain
functioning, including amplification of rigidity and emotion dys-
regulation (for a review see Kaye, Fudge, & Paulus, 2009).
Considering the dimensional nature of personality traits and ED
symptoms, and that disordered eating behavior is prevalent in general
population, we decided to include both individuals with ED and con-
trols in our study. We also did additional LPA including only individ-
uals with ED to control whether the results are affected by using a
mixed sample.
We hypothesized that at least a four-class solution emerges and the
classes resemble the well established overcontrolled, undercontrolled,
SOIDLA AND AKKERMANN
and high functioning classes as well as the previously found combined
high perfectionism and impulsivity class.
2 | METHOD
2.1 | Participants
The sample for the latent profile analysis comprised of 274 women, of
whom 164 where individuals with ED (age 14–48 years, M = 22.4,
SD = 7.03) recruited from the inpatient unit of EDs, and 110 controls
(age 14–47 years, M = 24.4, SD = 8.19) recruited via public advertise-
ments and university lists using chain sampling method. Controls were
screened for any psychiatric disorders. As it is known that impulsivity
decreases with age (Steinberg et al., 2008) we controlled for age
differences. No significant differences between age groups (14–17,
18–25, 26–48-years) were found neither for dysfunctional impulsivity
(DFI) Welch's F(2, 122.34) = 0.45, p = 0.64 nor functional impulsivity
(FI) Welch's F(2,117.57) = 1.72, p = 0.18.
All the patients with ED who were voluntarily hospitalized were
given the opportunity to participate in the study. Individuals with
intellectual disability or current psychotic episode were excluded. The
patients were either diagnosed with AN restricting type (AN-R)
(n = 53), AN binge-eating/purging type (AN-BP) (n = 11), atypical
AN-R (n = 6), BN binge-eating/purging type (BN-BP) (n = 79) or binge-
eating disorder (BED) (n = 13). As all the atypical AN cases were
restricting type and the group was too small for separate analyses,
atypical AN-R cases were merged into one group with AN-R.
2.2 | Measures
Participants were asked about their age, education level, weight
history, duration of ED, and medications taken during the study
2
period. BMI (kg/height m ) was calculated based on participants'
actual weight and height, which was measured by standardized proce-
dures in the hospital.
The Mini-International Neuropsychiatric Interview MINI 5.0.0.
(Sheehan, Lecrubier, Sheehan, & Amorim, 1994) is a short structured
psychiatric interview that was developed to diagnose DSM-IV-R and
ICD-10 mental disorders. Clinical interviews were conducted by a
trained clinical psychologist. In individuals with ED both ED and
comorbid diagnoses were confirmed by a treating psychiatrist.
Frost Multidimensional Perfectionism Scale (FMPS) (Frost et al., 1990).
The Estonian version consists of 28 self-report items, which are
answered on a 5-point Likert scale (from “strongly disagree” to “strongly
agree”). The Estonian version consists of 4 subscales: (a) Organization
(α = 0.81; MacDonald's ω = 0.82), for example, “Neatness is very impor-
tant to me,” (b) Personal standards (α = 0.94; ω = 0.94), for example,
“Other people seem to accept lower standards from themselves than I
do,” (c) Concern over mistakes/doubts about actions (α = 0.92; ω = 0.92),
e.g., “If I fail partly, it is as bad as being a complete failure,” (d) Parental
3
criticism/parental expectations (α = 0.89, ω = 0.89), for example, “I never
feel that I can meet my parents' standards.”
Dickman's Impulsivity Inventory (DII) (Dickman, 1990) is a 24-item
questionnaire, which is answered on a 5-point Likert scale (from
“totally agree” to “do not agree at all”). It consists of two subscales:
functional impulsivity (FI; e.g., “I am able to act quickly in difficult sit-
uations”) (α = 0.76; ω = 0.78) and dysfunctional impulsivity (DFI;
e.g., “I will often say whatever comes into my head without thinking
first”) (α = 0.83; ω = 0.84).
Eating Disorders Assessment Scale (EDAS) (Akkermann, 2010) is a
29-item self-report questionnaire, which assesses ED symptoms.
Items are answered on a 6-point Likert scale (from “never” to
“always”). The scale consists of four subscales (a) Restrained eating
(e.g., “I prefer low-calorie food”) (α = 0.95; ω = 0.95), (b) Binge eating
(e.g., “There have been occasions when I cannot stop eating”)
(α = 0.93; ω = 0.93), (c) Purging (e.g., “When I have been eating a large
amount of food I vomit to alleviate discomfort”) (α = 0.97; ω = 0.97),
(d) Preoccupation with body image and body weight (α = 0.96;
ω = 0.96) (e.g., “I am bothered by the thoughts that people may criti-
cize the way I look”). The latter assesses the cognitive-affective com-
ponent of ED, for example, body dissatisfaction, related negative
emotions, and concerns over one's appearance; subsequently referred
to as preoccupation. EDAS has been used in several studies (Uusberg,
Peet, Uusberg, & Akkermann, 2018; Vainik, Neseliler, Konstabel, Fel-
lows, & Dagher, 2015) and the construct validity of the scale has been
confirmed by strong correlations between Eating Disorders
Inventory-2 (EDI-2; Garner, 1991) and EDAS subscales
(Akkermann, 2010).
2.3 | Procedure
The study was approved by the Research Ethics Committee of the
University of Tartu. Written informed consent was obtained from the
participants, and in the case of adolescents also from their parents.
Participants filled in the questionnaires on the first days of hospitaliza-
tion and controls filled the questionnaires in a laboratory at the uni-
versity setting.
2.4 | Data analysis
The primary purpose of latent profile analysis (LPA) is to use posterior
probabilities to model response pattern heterogeneity in a population,
resulting in classification of individuals into more homogeneous
groups (Gibson, 1959; Oberski, 2016; Vermunt & Magidson, 2002).
FMPS, DII and EDAS subscales were treated as indicator variables
in the model. LPA was performed in Mplus version 6.12. with robust
likelihood maximum method. To avoid converging on a local solution
1000 random sets of starting values were used in the initial stage and
250 optimizations were used in the final stage. Bootstrap draws were
set for 100, each with two sets of random starting values and one
 4

TABLE 1 Descriptive statistics and differences between eating disorder subtypes and controls in age, BMI, duration of eating disorder, FMPS, DII, and EDAS scores

ANOVA
AN-R (n = 59) AN-BP (n = 11) BN-BP (n = 79) BED (n = 13) Controls (n = 110)
Variable M (SD) M (SD) M (SD) M (SD) M (SD) F(4,273) p η2
Age (years) 21.19 (6.39)d,* 22.30 (7.65) 22.15 (5.82)d,* 30.08 (11.32)a,c,* 24.42 (8.19) 5.09 <.001 0.072
c,d,e, d,e, ,c, a,d, ,b,
BMI 15.53 (2.89) ** 16.88 (1.01) ** * 21.69 (4.29) ** * 32.53 (8.88)a,b,c,e,** 22.25 (2.68)a,b,d,** 58.66 <.001 0.468
b,c,d, a, a, a,
Duration of ED (years) 2.79 (3.44) ** 6.35 (7.08) ** 5.91 (4.85) ** 9.77 (8.46) ** — 57.01(4,163) <.001 0.138
EDAS
EDAS total 49.25 (25.55)c,d,e,**,b,* 73.27 (33.26)a,*,e,** 90.51 (23.02)a,e,** 88.77 (15.47)a,e,** 32.36 (16.42)a,b,c,d,** 95.33 <.001 0.588
b,c, ,e, a, ,e, a,e, e,
Restrained eating 19.14 (12.78) * ** 27.91 (11.09) * ** 24.59 (8.81) * 19.54 (6.02) * 11.88 (7.09)a,b,c,*,d,** 25.77 <.001 0.278
c,d, c,d, a,b,e, a,b,e, c,d,
Binge eating 10.86 (7.54) ** 13.73 (8.49) ** 26.84 (8.95) ** 30.92 (10.04) ** 10.90 (6.11) ** 71.12 <.001 0.516
Purging 1.81 (3.19)b,c,** 8.91 (7.09)a,e,**,d,* 12.19 (6.01)a,d,e,** 3.69 (3.59)b,e,*,c,** 0.34 (1.18)b,c,**,d,* 114.33 <.001 0.631
c,d,e, d, ,e, a,e, ,d, a,e, ,b,c, a,b,c,d,
Preoccupation 17.44 (10.99) ** 22.73 (12.69) * ** 26.89 (9.18) ** * 34.62 (5.68) ** * 9.25 (7.49) ** 73.35 <.001 0.461
FMPS
Organization 20.32 (4.50) 22.45 (4.09) 20.27 (4.18) 19.54 (4.58) 19.43 (4.35) 1.56 .186 0.023
Standards 17.95 (8.19)e,** 18.91 (7.33) 17.99 (7.27)e,** 15.77 (9.51) 13.31 (6.26)a,c,** 6.85 <.001 0.093
e, e, e, e, a,c,d, ,b,
Mistakes 11.36 (8.49) ** 12.36 (8.35) * 11.77 (7.52) ** 13.62 (8.70) ** 5.13 (5.01) ** * 15.36 <.001 0.188
Parental criticism 7.92 (7.34) 11.00 (7.96) 10.01 (7.94)e,* 9.92 (7.29) 6.47 (6.18)c,* 3.55 .008 0.051
DII
DFI 15.12 (7.68)c,* 15.64 (7.37) 19.57 (7.71)a,*,e,** 16.46 (9.66) 14.33 (6.79)c,** 6.09 <.001 0.084
e, e, e, a,c,d,
FI 21.29 (8.98) * 22.27 (4.76) 22.22 (7.63) * 17.08 (7.19) * 25.75 (7.84) * 5.97 <.001 0.082

Note: p-values depicted are Sidak's adjusted p-values for multiple comparisons.
Abbreviations: η2, partial eta squared; AN-R, anorexia nervosa restricting; AN-BP, anorexia nervosa binge-eating/purging; BED, binge-eating disorder; BMI, body mass index; BN-BP, bulimia nervosa
binge-eating/purging; DFI, dysfunctional impulsivity; DII, Dickman's Impulsivity Inventory; EDAS, Eating Disorder Assessment Scale; preoccupation, preoccupation with body image and body weight; FI, func-
tional impulsivity; MPS, Multidimensional Perfectionism Scale; mistakes, concern over mistakes.
a
Statistically significant differences from AN-R.
b
Statistically significant differences from AN-BP group.
c
Statistically significant differences from BN group.
d
Statistically significant differences from BED group.
e
Statistically significant differences from control.
*p < .05.
**p < .001.
SOIDLA AND AKKERMANN
SOIDLA AND AKKERMANN 5

final stage optimization for the model with one less class, 50 sets of
random starting values and 15 final stage optimizations for the alter-
native model (for guidelines see: Muthén & Muthén, 1998–2010).
Model selection was based on the following information criteria:
(a) Bayesian Information Criterion (BIC; Schwartz, 1978), (b) Akaike
Information Criterion (AIC; Akaike, 1987), (c) Sample-Size Adjusted
BIC (SSABIC; Sclove, 1987). Lower values of these three fit statistics
indicate better model fit. To estimate the accuracy with which models
classify individuals into classes Entropy was used. Entropy value
ranges from 0 to 1, higher values showing greater accuracy. Bootstrap
Likelihood Ratio test (BLRT; McLachlan & Peel, 2000) and
Lo–Mendell–Rubin test (LMR; Lo, Mendell, & Rubin, 2001) were used
to compare if the improvement in the model was statistically signifi-
cant when one more class was included in the model.
All other analyses were performed in SPSS Statistics version 20.
Classes were compared on the measures which were included in LPA
by one-way ANOVA using Sidak's post-hoc for assessing pairwise dif-
ferences. Chi-square test of independence was used to compare the

TABLE 2 Fit indices for 1 to 7 class solution for two samples—mixed sample (individuals with ED and controls) and individuals with ED only

Free parameters LL AIC BIC Adjusted BIC Entropy BLRT LMR

Number of classes for the mixed sample
1 20 −9560.53 19,161.07 19,233.33 19,169.91 — — —
2 31 −9227.52 18,517.05 18,629.06 18,530.76 0.926 0.00001 0.00001
3 42 −9113.89 18,311.78 18,463.54 18,330.37 0.938 0.00001 0.008
4 53 −9078.19 18,262.38 18,453.88 18,285.83 0.928 0.00001 0.410
5 64 −9031.05 18,190.11 18,421.35 18,218.42 0.946 0.00001 0.320
6 75 −8994.83 18,139.67 18,410.65 18,172.84 0.934 0.00001 0.425
7 86 −8960.72 18,093.44 18,404.17 18,131.48 0.945 0.00001 0.418
Number of classes for the sample of individuals with ED
1 20 −5755.55 11,551.09 11,613.09 11,549.77 — — —
2 31 −5629.10 11,320.17 11,416.29 11,318.15 0.896 0.00001 0.00001
3 42 −5581.08 11,246.16 11,376.35 11,243.38 0.889 0.00001 0.032
4 53 −5556.86 11,219.73 11,384.02 11,216.23 0.867 0.00001 0.343
5 64 −5532.28 11,192.95 11,390.95 11,188.33 0.865 0.00001 0.749
6 75 −5514.38 11,178.76 11,411.25 11,173.80 0.873 0.00001 0.712
7 86 −5497.36 11,166.72 11,433.31 11,161.04 0.873 0.04 0.261

Note: Best fitting model is depicted in bold.

Abbreviations: AIC, Akaike information criterion; BIC, Bayesian information criterion; BLRT, Bootstrap Likelihood Ratio test; LL, log likelihood; LMR,
Lo-Mendell Rubin test.

F I G U R E 1 z-Scores for Frost Multidimensional Perfectionism Scale, Dickman's Impulsivity Inventory and Eating Disorder Assessment Scale in
the five-class (on the left) and four-class (on the right) solution [Color figure can be viewed at wileyonlinelibrary.com]
 6

TABLE 3 Means, SDs and differences in age, BMI, duration of eating disorder, EDAS, FMPS, and DII scores between the five classes in the mixed sample

Moderately High Purely Emotionally Behaviorally

ANOVA
impulsive (n = 23) functioning (n = 142) perfectionistic (n = 53) dysregulated (n = 16) dysregulated (n = 40)
Variables M (SD) M (SD) M (SD) M (SD) M (SD) F(4,273) p η2
Age (years) 22.46 (8.67) 23.95 (7.97) 21.76 (6.69) 23.27 (8.16) 23.03 (6.25) 0.86 .490 0.013
BMI 21.17 (5.62) 20.33 (4.52) 21.07 (8.20) 22.81 (5.11) 21.78 (4.30) 1.14 .339 0.017
Duration of ED (years) 6.35 (8.28) 3.59 (4.23) 3.43 (3.26) 7.54 (4.19) 6.37 (5.24) 103.26(4,163) .004 0.735
EDAS
EDAS total 79.61 (20.92)b,e,**,d,* 30.10 (14.04)a,c,d,e,** 75.36 (16.03)b,d,e,** 98.25 (12.08)b,c,**,a,* 100.53 (16.73)a,b,c,** 247.84 <.001 0.787
b, a,c,d,e, b, b, b,
Restrained eating 23.70 (8.56) ** 10.75 (7.31) ** 25.91 (8.02) ** 29.50 (6.53) ** 26.23 (7.65) ** 71.29 <.001 0.515
Binge eating 22.52 (8.18)b,** 10.44 (5.96)a,c,d,e,** 19.15 (11.34)b,e,** 25.06 (13.66)b,** 28.48 (8.55)b,c,** 47.64 <.001 0.415
b,c,e, a,c,d,e, a,b,d,e, b,c,e, a,b,c,d,
Purging 10.65 (2.23) ** 0.31 (0.81) ** 2.19 (2.09) ** 10.06 (2.14) ** 17.40 (1.97) ** 1116.49 <.001 0.943
Preoccupation 22.74 (8.92)b,d,**,c,e,* 8.61 (5.84)a,c,d,e,** 28.11 (8.13)a,*,b,** 33.63 (6.34)a,b,** 28.43 (8.96)a,*,b,** 130.87 <.001 0.661
FMPS
Organization 18.87 (4.52) 19.42 (4.38) 21.34 (3.76) 21.88 (3.96) 19.95 (4.51) 3.12 .016 0.044
c,d,e, c,d,e, a, ,b, a, ,b, a, ,b,
Personal standards 14.17 (6.06) * 13.32 (7.06) ** 19.21 (6.76) * ** 23.00 (3.95) * ** 19.45 (7.15) * ** 49.25 <.001 0.189
Concern over mistakes 7.14 (4.93)c,d,**,e,* 5.06 (5.06)c,d,e,** 14.40 (7.05)a,b,**,d,* 21.00 (4.41)a,b,e,** 12.88 (7.44)b,d,**,a,* 15.65 <.001 0.424
e, ,d, d,e, ,c, a,b,d, a,b, ,c,e, a,d, ,b,
Parental criticism 5.52 (6.16) * ** 6.10 (6.26) ** * 10.17 (6.83) * 16.69 (7.91) ** * 11.10 (7.26) * ** 14.18 <.001 0.174
DII
DFI 17.78 (5.49) 14.06 (6.80)e,d,** 15.96 (7.35)e,* 21.31 (10.44)b,* 21.20 (7.94)b,**,c,* 10.12 <.001 0.132
c,d, b, b,
FI 24.39 (7.86) 25.00 (7.69) * 20.40 (9.11) * 17.75 (6.59) * 21.83 (7.59) 5.77 <.001 0.079

Note: p-values depicted are Sidak's adjusted p-values for multiple comparisons.
Abbreviations: η2, partial eta squared; AN-R, anorexia nervosa restricting; AN-BP, anorexia nervosa binge-eating/purging; BED, binge-eating disorder; BMI, body mass index; BN-BP, bulimia nervosa
binge-eating/purging; DFI, dysfunctional impulsivity; DII, Dickman's Impulsivity Inventory; EDAS, Eating Disorder Assessment Scale; preoccupation, preoccupation with body image and body weight; FI, func-
tional impulsivity; MPS, Multidimensional Perfectionism Scale; mistakes, concern over mistakes.
a
Statistically significant differences from moderately impulsive class.
b
Statistically significant differences from high functioning class.
c
Statistically significant differences from purely perfectionistic class.
d
Statistically significant differences from emotionally dysregulated class.
e
Statistically significantly differences from behaviorally dysregulated class.
*p < .05.
**p < .001.
SOIDLA AND AKKERMANN
SOIDLA AND AKKERMANN 7

frequency of ED and comorbid disorders between classes. Partial eta
squared (η2) was used as an effect size statistic (rule of thumb for the
effect sizes: 0.01 small, 0.06 medium, 0.14 large).
3 | RESULTS
solution for both the whole sample as well as individuals with ED only
are presented in Table 2. Based on fit indices and considering clinical
and theoretical meaningfulness, a five-class model was selected for
the whole sample and a four-class solution was selected for the indi-
viduals with ED only.

3.1 | Demographics and descriptive statistics 3.3 | Statistical differences on indicator variables:
EDAS, FMPS, and DII
Descriptive statistics (age, BMI, duration of ED, as well as mean scores
of FMPS, DII, and EDAS) of individuals with AN-R, AN-BP, BN-BP, Both the five-class and the four-class solution are depicted in Figure 1.
BED, and controls are presented in Table 1. Table 3 presents the means and SDs for the indicators of profiles
as well as ANOVA results for the five-class solution and Table 4 pre-
sents the same indicators for the four-class solution (only individuals
3.2 | Latent profile analysis with ED).
The five classes were labeled as follows: “moderately impulsive,”
A series of one to seven profile models were estimated based on indi- “high functioning,” “purely perfectionistic,” “emotionally dysregulated,”
cator (FMPS, DII, EDAS) variables. Statistical fit indices of each and “behaviorally dysregulated.”

TABLE 4 Means, SDs and differences in age, BMI, duration of eating disorder, EDAS, FMPS, and DII scores between the four classes of
individuals with ED only sample

Moderately High Purely

impulsive functioning perfectionistic Dysregulated
ANOVA
(n = 37) (n = 40) (n = 55) (n = 32)
Variables M (SD) M (SD) M (SD) M (SD) F(3,163) p η2
Age (years) 22.32 (6.28) 22.45 (7.63) 21.86 (6.65) 23.45 (7.87) 0.33 .805 —
b, a,d, ,c, a, a,
BMI 22.15 (5.32) ** 16.72 (3.59) ** * 20.26 (7.31) * 22.30 (4.45) ** 8.01 <.001 0.128
Duration of ED (years) 5.84 (5.64) 4.01 (6.01) 3.54 (3.28) 7.37 (5.53) 4.40 .005 0.075
EDAS
EDAS total 88.70 (16.45)b,d,**,c,* 32.28 (19.22)a,c,d,** 75.44 (17.03)b,d,**,a,* 106.65 (11.99)a,b,c,** 133.03 <.001 0.710
b, ,d, a,c,d, b, a, ,c,
Restrained eating 23.38 (7.58) ** * 8.87 (8.21) ** 27.35 (7.55) ** 29.20 (6.23) ** * 60.44 <.001 0.527
Binge eating 26.11 (7.74)b,c,** 11.89 (8.69)a,d,**,c,* 17.71 (11.33)a,d,**,b,* 29.41 (9.73)a,b,** 25.32 <.001 0.318
Purging 14.60 (3.60)b,c,** 1.18 (2.41)a,d,**,c,* 3.16 (3.44)a,d,**,b,* 14.50 (4.21)a,b,** 172.21 <.001 0.760
b,c, a,c,d, b, ,d,
Preoccupation 24.62 (8.84) ** 10.35 (6.74) ** 27.22 (8.38) ** * 33.47 (6.32)a,b,**,c,* 60.44 <.001 0.527
FMPS
Organization 18.67 (4.71)c,* 19.28 (4.57)c,* 21.72 (3.55)a,b,* 21.19 (3.87) 5.30 .002 0.089
d, ,c, c,d, b, ,a, a,c,
Personal standards 15.22 (6.82) ** * 13.13 (9.05) ** 19.76 (6.28) ** * 23.22 (4.02) ** 16.19 <.001 0.229
Concern over 8.47 (5.68)c,d,** 5.08 (5.56)c,d,** 14.89 (6.87)b,a,**,d,* 18.69 (5.91)a,c,**,b,* 37.77 <.001 0.411
mistakes
Parental criticism 6.38 (5.69)d,**,c,* 4.82 (5.98)d,**,c,* 10.18 (6.94)d,**,b,a,* 16.94 (6.69)a,b,c,** 24.66 <.001 0.312
DII
DFI 20.38 (5.96)b,**,c,* 12.93 (6.72)a,d,** 15.98 (7.28)d,**,a,* 22.31 (9.23)a,**,b,* 12.56 <.001 0.188
FI 22.81 (7.44) 23.60 (7.94) 19.48 (8.51) 20.53 (7.17) 2.63 .052 0.046

Note: p-values depicted are Sidak's adjusted p-values for multiple comparisons.
Abbreviations: η2, partial eta squared; BMI, body mass index; DFI, dysfunctional impulsivity; DII, Dickman's Impulsivity Inventory; EDAS, Eating Disorder
Assessment Scale; FI, functional impulsivity; MPS, Multidimensional Perfectionism Scale; Preoccupation, preoccupation with body image and body weight.
a
Statistically significant differences from moderately impulsive class.
b
Statistically significant differences from high functioning class.
c
Statistically significant differences from purely perfectionistic class.
d
Statistically signficant differences from dysregulated class.
*p < .05.
**p < .001.
8 SOIDLA AND AKKERMANN

The “moderately impulsive” class was characterized by moderate
level of dysfunctional and functional impulsivity, low levels of adap-
tive and maladaptive perfectionism and moderate to high levels of all
ED symptoms. The “high functioning” class was characterized by the
lowest level of ED symptoms, low level of concern over mistakes,
parental criticism, personal standards, dysfunctional impulsivity, and
high level of functional impulsivity. Individuals in the “purely perfec-
tionistic” class had high levels of both maladaptive and adaptive per-
fectionism and low dysfunctional and functional impulsivity.
Regarding ED symptoms, more restrained eating and preoccupation
with body image and body weight were reported. Individuals in the
“emotionally dysregulated class” had the highest maladaptive perfec-
tionism levels, low functional but high dysfunctional impulsivity and
high levels of all ED symptoms. The “behaviorally dysregulated” class
was characterized by moderate adaptive and maladaptive perfec-
tionism, high dysfunctional impulsivity and the highest level of purg-
ing and binge eating.
Regarding the four-class solution for the individuals with ED only,
three classes strongly resemble the classes described above (i.e., high
functioning, moderately impulsive, purely perfectionistic). The fourth
class encompasses two classes from the five-class solution, namely
the emotionally and the behaviorally dysregulated class. The class was

TABLE 5 Frequency of eating disorder diagnoses and comorbid psychopathology in the five-class and four-class solution

Individuals with ED and controls

Moderately High Purely Emotionally Behaviorally

impulsive functioning perfectionistic dysregulated dysregulated
Measures (n = 23) (n = 142) (n = 53) (n = 16) (n = 40)
ED diagnoses
AN-R n = 2 (8.7%) n = 24 (16.9%) n = 25 (47.2%) n = 1 (6.2%) n = 1 (2.5%)
AN-BP n = 3 (13.0%) n = 4 (2.8%) n=0 n = 2 (12.5%) n = 2 (5.0%)
BN-BP n = 16 n = 4 (2.8%) n = 12 (23.1%) n = 10 (62.5%) n = 37 (92.5%)
(69.9%)
BED n = 1 (4.3%) n = 1 (0.7%) n = 8 (15.5%) n = 3 (18.8%) n=0
Atypical-AN n=0 n = 5 (3.5%) n = 1 (1.9%) n=0 n=0
Controls n = 1 (4.3%) n = 103 (73.0%) n = 6 (11.5%) n=0 n=0
Comorbid psychopathology
Major depression n = 10 n = 11 (7.7%) n = 18 (34.0%) n = 11 (68.8%) n = 21 (52.5%)
(43.5%)
Any anxiety n = 8 (34.8%) n = 12 (8.5%) n = 21 (39.6%) n = 8 (50.0%) n = 14 (35.0%)
disorder
PTSD n=0 n=0 n=0 n = 3 (18.8%) n = 4 (10.0%)
Alcohol use disorder n = 4 (17.4%) n = 4 (2.8%) n = 5 (9.4%) n = 3 (18.8%) n = 13 (32.5%)
OCD n = 1 (4.3%) n = 2 (1.4%) n = 5 (9.4%) n = 1 (6.3%) n = 4 (10.0%)

Individuals with ED

Moderately impulsive (n = 37) High functioning (n = 40) Purely perfectionistic (n = 55) Dysregulated (n = 32)
ED diagnoses
AN-R n = 2 (5.4%) n = 23 (57.5%) n = 28 (52.8%) n=0
AN-BP n = 2 (5.4%) n = 3 (7.5%) n = 3 (5.5%) n = 3 (9.4%)
BN-BP n = 32 (86.5%) n = 6 (15.0%) n = 15 (27.3%) n = 26 (81.2%)
BED n = 1 (2.7%) n = 2 (5.0%) n = 8 (14.5%) n = 3 (9.4%)
Atypical-AN n=0 n = 5 (12.5%) n = 1 (1.8%) n=0
Comorbid psychopathology
Major depression n = 17 (45.9%) n = 12 (30.0%) n = 23 (41.8%) n = 19 (59.4%)
Any anxiety disorder n = 12 (32.4%) n = 13 (32.5%) n = 26 (47.3%) n = 12 (37.5%)
PTSD n = 1 (1.8%) n=0 n = 1 (2.7%) n = 5 (15.6%)
Alcohol use disorder n = 8 (21.6%) n = 4 (10.0%) n = 8 (21.6%) n = 9 (28.1%)
OCD n = 2 (5.4%) n = 2 (5.0%) n = 5 (9.1%) n = 4 (12.5%)

Note: The values given in the parentheses depict percentage of individuals within the same class.
Abbreviations: AN-R, anorexia nervosa restricting; AN-BP, anorexia nervosa binge-eating/purging; BED, binge-eating disorder; BN, bulimia nervosa
binge-eating/purging; OCD, obsessive compulsive disorder; PTSD, post-traumatic stress disorder.
SOIDLA AND AKKERMANN
characterized by moderate to high perfectionism, high dysfunctional
impulsivity and high levels of all ED symptoms, and therefore named
the class “dysregulated.”
3.4 | Clinical features of the five-class and
the four-class solution
Table 5 depicts the relationship between class membership and ED
and comorbid psychopathology for both the five- and the four-class
solutions. A chi-square test of independence was conducted between
ED diagnoses and class membership. Significant differences emerged
among ED diagnostic categories and classes (χ 2[4] = 251.83, p < .001),
the association was moderately strong (Cohen, 1988), Cramer's
V = 0.481. Post-hoc analyses using standardized residuals with (±1.96)
indicating a difference in frequency of ED diagnoses were used. The
majority of BN cases belonged to the moderately impulsive and both
emotionally and behaviorally dysregulated classes. A large proportion
of BED cases belonged to the purely perfectionistic and emotionally
dysregulated class. There were more AN-BP cases in the moderately
impulsive and emotionally dysregulated class, but more AN-R cases in
the high functioning and purely perfectionistic class. Most of the con-
trols, as expected, belonged to the high functioning class.
Significant differences also emerged among ED diagnostic catego-
ries and classes for the individuals with the sample of individuals with
ED (χ 2[3] = 79.90, p < .001, V = 403). The majority of BN cases belonged
to the moderately impulsive and the dysregulated class, most BED cases
were in the purely perfectionistic class, most AN-R cases belonged to
the high functioning and the purely perfectionistic class, while more
atypical-AN cases belonged to the high functioning class. There were no
differences between the classes in frequencies on AN-BP cases.
Statistically significant differences emerged between class member-
ship and frequency of comorbid anxiety disorder (χ 2[4] = 26.89, p < .001,
V = 0.367), depression (χ 2[4] = 59.92, p < .0001, V = 0.468), alcohol use
disorder (χ 2[4] = 31.68, p = .001, V = 0.340) and post-traumatic stress dis-
order (χ 2[4] = 31.48, p < .001, V = 0.339). Post-hoc analyses indicated that
significantly more ED cases with comorbid depression belonged to mod-
erately impulsive, and both emotionally and behaviorally dysregulated
classes. The highest proportion of ED cases with comorbid anxiety disor-
der belonged to the purely perfectionistic and emotionally dysregulated
class. Most ED cases with comorbid alcohol use disorder belonged to the
behaviorally dysregulated class. The highest proportion of comorbid PTSD
cases were in the emotionally and behaviorally dysregulated classes.
For the sample of individuals with ED, significant differences
emerged between class membership and frequency of comorbid PTSD
(χ 2[3] = 12.91, p = .005, V = 0.281) (as expected, more PTSD cases
were in the dysregulated class) (Table 5).
4 | DISCUSSION
The purpose of our study was to find latent profiles based on facets
of perfectionism and impulsivity as well as ED symptoms in both a
9
mixed sample (including individuals with ED and controls) and in a
sample of individuals with ED only.
In the mixed sample, we found support for a five-class solution.
The classes were named as following: high functioning, purely perfec-
tionistic, moderately impulsive, emotionally dysregulated and behavior-
ally dysregulated. In the ED sample, we found support for a four-class
solution (high functioning, purely perfectionistic, moderately impulsive
and dysregulated). The latter classes were very similar in their response
patterns and mean scores on indicator variables to the five-class solu-
tion in the mixed sample. The main difference between the two solu-
tions was the separation of the emotionally and the behaviorally
dysregulated class in the mixed sample.
The four-class solution is consistent with Boone et al. (2014)
study, where similar four classes (resilient, purely impulsive, purely
perfectionistic, and a combined high perfectionism and high impulsiv-
ity class) were found in the sample of healthy adolescents. Another
study conducted among individuals with ED also found support for a
four-class solution, however, the classes were quite different (possibly
due to not including ED symptoms in the LPA), for example, no
combined high perfectionism and high impulsivity class was found
(Slof-Op't Landt et al., 2016).
Studies that have used a variety of personality traits have also
found support for a five-class model, for example, Thompson-Brenner
et al. (2008) found the following five classes: high-functioning, behav-
iorally dysregulated, emotionally dysregulated, avoidant-insecure, and
obsessional-sensitive. Our study also supports the distinction of the
emotionally and the behaviorally dysregulated class. The importance
of this distinction is further discussed below.
In general, the classes revealed important similarities with under-
controlled, overcontrolled and resilient/high-functioning classes
consistently found in several previous studies (Westen & Harnden-
Fischer, 2001; Wonderlich et al., 2005). Three classes, which resem-
bled the undercontrolled classes were identified in the mixed sample
(moderately impulsive, emotionally dysregulated, behaviorally dys-
regulated). The moderately impulsive class had higher dysfunctional
impulsivity, but low levels of perfectionism while the emotionally and
behaviorally dysregulated classes had both high levels of perfection-
ism and dysfunctional impulsivity. The emotionally dysregulated class
had the highest percentage of comorbid anxiety and mood disorders,
which might indicate that individuals in this class do not have adaptive
ways to cope with distress. In concordance with Thompson-Brenner,
Eddy, Franko, et al. (2008), the behaviorally dysregulated class was
characterized by multiple forms of impulsive behavior, evident in
the highest frequency of comorbid substance use disorders and the
highest scores on Purging subscale. Both the emotionally and the
behaviorally dysregulated classes had a higher percentage of PTSD
cases, consistent with the association between PTSD and high levels
of impulsive behavior (Tull, Weiss, & McDermott, 2016).
In the four-class solution, only one dysregulated class was found.
This may be due to lack of power in the sample of individuals with ED
only, which may have influenced LPA results by impeding finding
small but significant classes. Nevertheless, we believe that the distinc-
tion between the two dysregulated classes is important—they differ in
10
levels of maladaptive perfectionism, functional impulsivity, comorbid
psychopathology, and ED symptoms, all of which may influence both
risk and maintaining factors of ED, appropriate treatment choice and
treatment response.
4.1 | Diagnostic distribution in the five classes
Most of the individuals with BN-BP and AN-BP split quite equally
between three classes characterized by higher impulsivity confirming
the higher impulsivity levels of binge-eating/purging type of EDs
(Waxman, 2009). A large proportion of individuals with BN and BED as
well as AN-R belonged to the purely perfectionistic class, indicating that
high levels of perfectionism are not confined to categorical diagnoses.
Interestingly, there was a substantial number of AN-R cases who
belonged to the high functioning class. This rather unexpected finding
is in concordance with Krug et al. (2011), who found that a high number
of individuals with restrictive symptoms belonged to the “adaptive”
profile. This may imply that underweight, particularly purely restrictive
individuals with ED minimize their symptoms (Eddy et al., 2009). Con-
sistent with our hypothesis about the possible underreporting of symp-
toms, Wildes et al. (2011) reported that there was a high rate of
readmission to hospital in the low psychopathology class.
4.2 | Perfectionism, impulsivity and eating disorder
symptoms
Our results are in line with previous findings reporting that personal
standards, concern over mistakes as well as parental criticism are
associated with disordered eating behavior (Dahlenburg et al., 2019;
Limburg et al., 2016). Personal standards, which has previously been
considered as an adaptive dimension (Lo & Abbott, 2013), differenti-
ated the latent profiles, while Organization seems not to be a good
subscale for differentiating between latent profiles.
Division of the concepts of dysfunctional and functional impulsiv-
ity also seems to be important in eating pathology. Functional
impulsivity is related to rapid information processing, being a more
complex process which involves considering alternatives quickly
(Brunas-Wagstaff, Bergquist, Morgan, & Wagstaff, 1996; Smillie &
Jackson, 2006), and is associated with lower neuroticism (Brunas-
Wagstaff, Bergquist, Richardson, & Connor, 1995), whereas dysfunc-
tional impulsivity reflects difficulties of inhibiting competing informa-
tion sources and irrelevant material (Brunas-Wagstaff et al., 1996;
Morgan & Norris, 2010). It seems that dysfunctional impulsivity itself
can be associated with some disordered eating symptoms, but the
severity of those symptoms is influenced by the interplay between
impulsivity and other personality traits—in this case, perfectionism. In
our study, the moderately impulsive class had lower levels of adaptive
and maladaptive perfectionism, but higher functional impulsivity com-
pared to the dysregulated classes. Higher functional impulsivity, but
also lower levels of perfectionism may help those individuals to act
more adaptively in stressful situations.
SOIDLA AND AKKERMANN
The emergence of both high perfectionism and high impulsivity
class found in both solutions is consistent with the finding that both
overcontrolling and undercontrolling traits can characterize ED
patients (Claes, Vandereycken, & Vertommen, 2002). As the duration
of ED was longer in the emotionally and behaviorally dysregulated
class than in the high functioning and the purely perfectionistic class,
it may indicate that some patients might have belonged, in earlier
stages of illness, to the overcontrolled class, but crossed over to the
undercontrolled classes in a later stage of their disorder. Boone
et al. (2014) have proposed that these individuals have developed
high levels of restrained eating to control their impulsivity but over
time this strategy fails.
4.3 | Limitations and future directions
This study also has several limitations to consider. First, though adding
ED symptoms in the analysis has several benefits (reducing bias
associated with classify-analyze approach and accounting for the
pathoplastic relationship between ED symptoms and personality), it
may also bring up two main problems: possibly finding more classes
than could have been found using only personality traits as indicators
and the question of the possible instability of the profiles as ED symp-
toms tend to be more unstable than personality traits. In future stud-
ies, therefore, it would be worthwhile to run the analysis with and
without using ED symptoms in the LPA.
Second, our study has a cross-sectional design, which does not
allow any causal conclusion to be made. Taking into account the two
previously mentioned limitations, the assessment of the stability of
the profiles by longitudinal studies would be needed. In addition, as
we have no prospective information (e.g., treatment response), we
cannot make any clear conclusions about the clinical utility of those
classes. Therefore, future studies are well needed to study response
to treatment in the emerged classes. Previously it has been found,
that compared to individuals in the high-functioning and the over-
controlled class, individuals in the undercontrolled class had a less
successful response to treatment (Wildes et al., 2011). Presumably,
choosing treatments considering differences in multiple domains
(e.g., personality traits and ED symptoms) can lead to improved patient
care by informing the clinicians about the appropriate treatment inten-
sity, setting, and type. For example, it might be that for the purely per-
fectionistic class cognitive-behavioral therapy targeting restrictive
eating and maladaptive perfectionism would suit well, while for the dys-
regulated classes treatments targeting distress tolerance and emotion
regulation (e.g., dialectical-behavioral therapy) would fit better.
Thirdly, we only focused on dimensions of perfectionism, impul-
sivity and ED symptoms for classifying individuals. To address this lim-
itation, future studies would benefit from combining psychological
and biological markers when examining profiles of ED patients to
strengthen the basis and get a more comprehensive picture of the dif-
ferent profiles in EDs.
Lastly, as the class sizes are small to moderate and the sample is
biased toward young females, the replication of the classes is needed
SOIDLA AND AKKERMANN
in larger and more diverse samples (e.g., also in males, children and
teenagers, in different cultural environments, in outpatient settings,
using other measures to assess impulsivity, ED symptoms, etc.).
5 | C O N CL U S I O N S
Our results suggest that profiles based on perfectionism, impulsivity
and ED symptoms can be meaningful for clinicians and researchers by
shedding light on the heterogeneity of possible risk as well as mainte-
nance factors in EDs. Methodologically, our study suggests that both
controls and ED patients can be included in the LPA. Unlike previous
studies, we also included ED symptoms in the LPA and found that in
addition to the well-known high-functioning, overcontrolled and under-
controlled classes, two to three undercontrolled classes emerged—
moderately impulsive, behaviorally dysregulated and emotionally
dysregulated class. Finally, as already stated by Kazdin (2007), individual
differences among the patients need to be acknowledged and dealt
with to improve patient care and as well as the cost-effectiveness of
treatments. Therefore, for advancing the classification of EDs, future
studies need to focus on the clinical utility of those classes by studying
the ability of those classes to predict clinical course of ED and inform
about the most suitable treatment for the patient.
ACKNOWLEDGMENTS
We are grateful to the participants for their time and effort in support
of this study. We thank Dr Anu Järv, Kerttu Petenberg, Sheryl Võsu,
Elis Paasik, and nurses of eating disorder unit for their help in data col-
lection. This research was a part of Kärol Soidla's doctoral thesis and
did not receive any specific grant from funding agencies in the public,
commercial, or nonprofit sectors.
CONF LICT OF IN TE RE ST
The authors declare no potential conflict of interest.
DATA AVAI LAB ILITY S TATEMENT
The data that supports the findings of this study are available on
reasonable request from the corresponding author. The data are not
publicly available due to privacy or ethical restrictions.
ORCID
Kärol Soidla https://orcid.org/0000-0002-9286-760X
Kirsti Akkermann https://orcid.org/0000-0003-1402-8365
RE FE R ENC E S
Akaike, H. (1987). Factor analysis and AIC. Psychometrika, 52, 317–332.
Akkermann, K. (2010). Serotonin-related biomarkers and symptoms of eating
disorders (Doctoral dissertation, University of Tartu, Tartu, Estonia).
Retrieved from http://dspace.ut.ee/handle/10062/15300
Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M.,
Mitchell, J. E., Uppala, S., & Simonich, H. (2007). Perfectionism and
eating disorders: Current status and future directions. Clinical Psychol-
ogy Review, 27, 384–405.
11
Boone, L., Claes, L., & Luyten, P. (2014). Too strict or too loose? Perfec-
tionism and impulsivity: The relation with eating disorder symptoms
using a person-centered approach. Eating Behaviors, 15, 17–23.
Boone, L., Soenens, B., Caroline, B., & Goossens, L. (2010). An empirical
typology of perfectionism in early-to-mid adolescents and its relation
with eating disorder symptoms. Behaviour Research and Therapy, 48,
686–691.
Brunas-Wagstaff, J., Bergquist, A., Morgan, K., & Wagstaff, G. F. (1996).
Impulsivity, interference on perceptual tasks and hypothesis testing.
Personality and Individual Differences, 20, 471–482.
Brunas-Wagstaff, J., Bergquist, A., Richardson, P., & Connor, A. (1995).
The relationships between functional and dysfunctional impulsivity
and the Eysenck personality questionnaire. Personality and Individual
Differences, 5, 681–683.
Brunas-Wagstaff, J., Bergquist, A., & Wagstaff, G. F. (1994). Cognitive cor-
relates of functional and dysfunctional impulsivity. Personality and Indi-
vidual Differences, 17, 289–292.
Claes, L., Robinson, M. D., Muehlenkamp, J. J., Vandereycken, W., &
Bijttebier, P. (2010). Differentiating bingeing/purging and restrictive
eating disorder subtypes: The roles of temperament, effortful control,
and cognitive control. Personality and Individual Differences, 48,
166–170.
Claes, L., Vandereycken, W., & Vertommen, H. (2002). Impulsive and com-
pulsive traits in eating disordered patients compared with controls.
Personality and Individual Differences, 32, 707–714.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. New
York, NY: Routledge Academic.
Dahlenburg, S. C., Gleaves, D. H., & Hutchinson, A. D. (2019). Anorexia
nervosa and perfectionism: A meta-analysis. International Journal of
Eating Disorder, 52, 219–229.
Dickman, S. J. (1990). Functional and dysfunctional impulsivity: Personality
and cognitive correlates. Journal of Personality and Social Psychology,
58, 95–102.
Eddy, K. T., Crosby, R. D., Keel, P. K., Wonderlich, S. A., le Grange, D.,
Hill, P., … Mitchell, J. E. (2009). Empirical identification and validation
of eating disorder phenotypes in a multisite clinical sample. The Journal
of Nervous and Mental Disorders, 197, 41–49.
Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a trans-
diagnostic process: A clinical review. Clinical Psychology Review, 31,
203–212.
Farstad, S. M., McGeown, L. M., & von Ranson, K. M. (2016). Eating disor-
ders and personality, 2004–2016: A systematic review and meta-anal-
ysis. Clinical Psychology Review, 46, 91–105.
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions
of perfectionism. Cognitive Therapy and Research, 14, 449–468.
Garner, D. M. (1991). Eating disorder inventory-2: Professional manual.
Odessa: Psychological Assessment Resources.
Gibson, W. A. (1959). Three multivariate models: Factor analysis, latent
structure analysis, and latent profile analysis. Psychometrika, 24,
229–252.
Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., …
Wang, P. (2010). Research domain criteria (RDoC): Toward a new clas-
sification framework for research on mental disorders. American Jour-
nal of Psychiatry, 167, 748–751.
Kaye, W. H., Fudge, J. L., & Paulus, M. (2009). New insights into symptoms
and neurocircuit function of anorexia nervosa. Nature Reviews Neuro-
science, 10, 573–584.
Kazdin, A. E. (2007). Mediators and mechanism of change in psychother-
apy research. Annual Review of Clinical Psychology, 3, 1–27.
Keel, P. K., Brown, T. A., Holland, L. A., & Bodell, L. P. (2012). Empirical
classification of eating disorders. Annual Review of Clinical Psychology,
8, 381–404.
Krug, I., Root, T., Bulik, C., Granero, R., Penelo, E., Jimenez-Murcia, S., &
Fernandez-Aranda, F. (2011). Redefining phenotypes in eating
12
disorders based on personality: A latent profile analysis. Psychiatry
Research, 188, 439–445.
Lanza, S. T., Tan, X., & Bray, B. C. (2013). Latent class analysis with distal
outcomes: A flexible model-based approach. Structural Equation
Modeling: A Multidisciplinary Journal, 20, 1–26.
Lilenfield, L. R. R., Wonderlich, S., Riso, L., Crosby, R., & Mitchell, J. (2006).
Eating disorders and personality: A methodological and empirical
review. Clinical Psychology Review, 26, 299–320.
Limburg, K., Watson, H. J., Hagger, M. S., & Egan, S. J. (2016). The relation-
ship between perfectionism and psychopathology: A meta-analysis.
Journal of Clinical Psychology, 73, 1301–1326.
Lo, A., & Abbott, M. J. (2013). Review of the theoretical, empirical, and
clinical status of adaptive and maladaptive perfectionism. Behaviour
Change, 30, 96–116.
Lo, Y., Mendell, N., & Rubin, D. (2001). Testing the number of components
in a normal mixture. Biometrika, 88, 767–778.
McLachlan, G., & Peel, D. (2000). Finite mixture models. New York, NY:
Wiley.
Morgan, K., & Norris, G. (2010). An exploration into the relevance of
Dickman's functional and dysfunctional impulsivity dichotomy for
understanding ADHD-type behaviours. Individual Differences Research,
8, 34–44.
Muthén, L. K., & Muthén, B. O. (1998–2010). Mplus user's guide (6th ed.).
Los Angeles, CA: Muthén & Muthén.
Oberski, D. L. (2016). Mixture models: Latent profile and latent class analy-
sis. In J. Robertson & M. Kaptein (Eds.), Modern statistical methods for
HCI: A modern look at data analysis for HCI research. Cham, Switzerland:
Springer.
Peat, C., Mitchell, J. E., Hoek, H., & Wonderlich, S. (2009). Validity and util-
ity of subtyping anorexia nervosa. The International Journal of Eating
Disorders, 42, 590–594.
Schwartz, G. (1978). Estimating the dimension of a model. The Annals of
Statistics, 6, 461–464.
Sclove, L. (1987). Application of model-selection criteria to some problems
in multivariate analysis. Psychometrika, 52, 333–343.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., & Amorim, P. (1994). The
Mini-International Neuropsychiatric Interview (M.I.N.I): The development
and validation of a structured diagnostic psychiatric interview for DSM-IV
and ICD-10. Tampa, FL: University of South Florida College of
Medicine.
Slof-Op't Landt, M. C. T., van Furth, E. F., & Claes, L. (2016). Classifying
eating disorders based on “healthy” and “unhealthy” perfectionism and
impulsivity. International Journal of Eating Disorders, 49, 673–680.
Smillie, L. D., & Jackson, C. J. (2006). Functional impulsivity and reinforce-
ment sensitivity theory. Journal of Personality, 74, 47–83.
Steinberg, L., Albert, D., Caufmann, E., Banich, M., Graham, S., &
Woolard, J. (2008). Age differences in sensation seeking and impulsiv-
ity as indexed by behavior and self-report: Evidence for a dual systems
model. Developmental Psychology, 44, 1764–1778.
Thompson-Brenner, H., Eddy, K., Dorer, D., Franko, D., Vashchenko, M., &
Herzog, D. (2008). A personality classification system for eating
disorders: A longitudinal study. Comprehensive Psychiatry, 49,
551–560.
SOIDLA AND AKKERMANN
Thompson-Brenner, H., Eddy, K. T., Franko, D. L., Dorer, D.,
Vashchenko, M., & Herzog, D. (2008). Personality pathology and sub-
stance abuse in eating disorders: A longitudinal study. International
Journal of Eating Disorders, 41, 203–208.
Tull, M. T., Weiss, N. H., & McDermott, M. J. (2016). Post-traumatic stress dis-
order and impulsive and risky behavior: Overview and discussion of poten-
tial mechanisms. In C. Martin, V. Preedy, & V. Patel (Eds.), Comprehensive
guide to post-traumatic stress disorders. Cham, Switzerland: Springer.
Turner, B. J., Claes, L., Wilderjans, T. F., Pauwels, E., Dierckx, E.,
Chapman, A. L., & Schoevaerts, K. (2014). Personality profiles in eating
disorders: Further evidence of the clinical utility of examining subtypes
based on temperament. Psychiatry Research, 219, 157–165.
Uusberg, H., Peet, K., Uusberg, A., & Akkermann, K. (2018). Attention
biases in preoccupation with body image: An ERP study of the role of
social comparison and automaticity when processing body size. Biolog-
ical Psychology, 135, 136–148.
Vainik, U., Neseliler, S., Konstabel, K., Fellows, L. K., & Dagher, A. (2015).
Eating traits questionnaires as a continuum of a single concept.
Uncontrolled eating. Appetite, 90, 229–239.
Vermunt, J. K., & Magidson, J. (2002). Latent class cluster analysis. In
J. A. Hagenaars & A. L. McCutcheon (Eds.), Applied latent class analysis
(pp. 89–106). Cambridge, England: Cambridge University Press.
Waxman, S. E. (2009). A systematic review of impulsivity in eating disor-
ders. European Eating Disorders Review, 17, 408–425.
Westen, D., & Harnden-Fischer, J. (2001). Personality profiles in eating dis-
orders: Rethinking the distinction between axis I and axis II. American
Journal of Psychiatry, 158, 547–562.
Whiteside, S. P., & Lynam, D. R. (2001). The five factor model and impul-
sivity: Using a structural model of personality to understand impulsiv-
ity. Personality and Individuals Differences, 30, 669–689.
Widiger, T. A. (2011). Personality and psychopathology. World Psychiatry:
Official Journal of the World Psychiatric Association, 10, 103–106.
Widiger, T. A., & Samuel, D. B. (2005). Diagnostic categories or dimensions?
A question for the diagnostic and statistical manual of mental
disorders—Fifth edition. Journal of Abnormal Psychology, 114, 494–504.
Wildes, J. E., & Marcus, M. D. (2013). Alternative methods of classifying
eating disorders: Models incorporating comorbid psychopathology and
associated features. Clinical Psychology Review, 33, 383–394.
Wildes, J. E., Marcus, M. D., Crosby, R. D., Ringham, R. M., Dapelo, M. M.,
Gaskill, J. A., & Forbush, K. T. (2011). The clinical utility of personality
subtypes in patients with anorexia nervosa. Journal of Consulting and
Clinical Psychology, 79, 665–674.
Wonderlich, S. A., Crosby, R. D., Joiner, T., Peterson, C. B., Bardone-
Cone, A., Klein, M., … Vrshek, S. (2005). Personality subtyping and
bulimia nervosa: Psychopathological and genetic correlates. Psychologi-
cal Medicine, 35, 649–657.
How to cite this article: Soidla K, Akkermann K. Perfectionism
and impulsivity based risk profiles in eating disorders. Int J Eat
Disord. 2020;1–12. https://doi.org/10.1002/eat.23285