Received: 25 January 2019 Revised: 12 September 2019 Accepted: 17 September 2019

DOI: 10.1002/eat.23183

REVIEW

Personality traits in adolescents with eating disorder:

A meta-analytic review

Laurie Dufresne BA1 | Eve-Line Bussières PhD2 | Alexandra Bédard PhD3 |

Nathalie Gingras MD FRCP MSc4 | Agathe Blanchette-Sarrasin BA1 |
Catherine Bégin PhD1

1
School of Psychology, Laval University,
Québec, Québec, Canada
2
Department of Psychology, University of
Quebec at Trois-Rivières, Trois-Rivières,
Québec, Canada
3
Faculty of Agricultural and Food Sciences,
Institute of Nutrition and Functional Food,
Laval University, Québec, Québec, Canada
4
Department of Psychiatry, Laval University,
Québec, Québec, Canada
Correspondence
*Catherine Bégin, École de Psychologie,
Pavillon Félix-Antoine Savard, Université Laval,
2325 rue des Bibliothèques, Québec, Québec
G1V 0A6, Canada.
Email: catherine.begin@psy.ulaval.ca
Associate Editor: Kelly Klump
Abstract
Objective: Given the growing interest in personality traits among the young popula-
tion with eating disorders (EDs) and the recognition that a better understanding of
personality can facilitate clinical management, this meta-analytic study reviewed
evidence concerning the relationship between personality traits and the presence of
an ED during adolescence.
Method: We conducted a systematic literature search to identify studies that exam-
ined personality traits among adolescents with an ED (anorexia nervosa, bulimia
nervosa, binge-eating disorder, eating disorder not otherwise specified) and that
compared these traits with a normative group without an ED. The personality traits
investigated in the selected studies were organized according to the personality trait
domains presented in the Diagnostic and Statistical Manual of Mental Disorders
(fifth ed.). Effect sizes of the mean differences were calculated for each domain. We
performed meta-regressions to assess the moderating effect of ED subtype and age
on the combined effect sizes.
Results: Twenty-six studies met our inclusion criteria, containing a total of
63 effect sizes. Adolescents with EDs differed from the non-ED group
according to traits related to negative affectivity ( g = 0.78), detachment
( g = 0.69), and conscientiousness ( g = −0.53). The presence of an anorexia
nervosa diagnosis moderated the relationship between an ED and personality
traits; this diagnosis was more strongly associated with conscientious traits
compared to other EDs.
Discussion: Our findings provide evidence that personality traits are related to EDs
in adolescents. Thus, considering personality traits could lead to a better understand-
ing of etiological and maintenance factors for EDs.

KEYWORDS
adolescents, anorexia nervosa, bulimia nervosa, eating disorders, meta-analysis, personality

Int J Eat Disord. 2019;1–17. wileyonlinelibrary.com/journal/eat © 2019 Wiley Periodicals, Inc. 1

2 DUFRESNE ET AL.
1 | I N T RO D UC T I O N
Personality refers to a set of psychological characteristics that are rel-
atively stable and widespread in every life domain; they allow an indi-
vidual to behave, think, and feel in certain ways (Pervin & Cervone,
2010; Shiner & Caspi, 2003). Personality traits, which are determined
by biological and contingent components during development, reflect
interindividual differences (Caspi, Roberts, & Shiner, 2005; Schaffer,
2006; Shiner & Caspi, 2003). The relationship between personality
and eating disorders (EDs) has long been a subject of interest and
remains so. According to previous studies, personality traits could
either represent risk factors for the ED, modulating factors in the evo-
lution of the disorder, collateral effects of the ED or a different mani-
festation of the same underlying causal factor (Krueger & Eaton,
2010; Lilenfeld, Wonderlich, Riso, Crosby, & Mitchell, 2006). There-
fore, it is now acknowledged that a better understanding of personal-
ity traits in EDs can lead to several clinical advantages. This can help
identify at-risk populations and adopt prevention-oriented solutions,
for example, by sensitizing the clinician to investigate harmful eating
behaviors when knowing that a patient presents a personality profile
predisposing him or her to an ED (von Ranson, 2008). It also allows cli-
nicians to adapt treatment by working on the key factors underlying
ED symptomatology and to predict symptom fluctuations and treat-
ment outcomes according to specific personality traits (Cassin & von
Ranson, 2005; Farstad, McGeown, & von Ranson, 2016; Martinez &
Craighead, 2015; Tasca et al., 2009). For example, we now know that
impulsive traits are linked to a poorer response to ED treatment and
an unfavorable prognosis and that psychotherapeutic interventions
that address personality characteristics associated with EDs such as
perfectionism, mood intolerance, or low self-esteem can be effective
in reducing ED symptoms (Fairburn, Cooper, & Shafran, 2003;
Fairburn, Jones, Peveler, Hope, & O'connor, 1993; von Ranson, 2008).
Until now, two systematic reviews have revealed that differences in
personality traits may be observed between individuals suffering from
an ED and nonclinical populations. Individuals with EDs tend to be
characterized by elevated negative emotionality, harm avoidance, nov-
elty seeking, perfectionism and persistence, and low extraversion and
self-directedness (Atiye, Miettunen, & Raevuori-Helkamaa, 2015;
Farstad et al., 2016). According to the meta-analysis by Atiye et al.
(2015), low-to-moderate effect sizes were reported for novelty seeking
(d = 0.41), persistence (d = 0.29), and harm avoidance (d = 0.55) traits.
Those reviews also suggested that associations between EDs and per-
sonality traits may differ according to the ED subtype. Individuals with
anorexia nervosa (AN) tend to display more persistence whereas those
with bulimia nervosa (BN) tend to be more inclined to impulsivity and
novelty seeking (Atiye et al., 2015; Farstad et al., 2016).
Considering the potential reciprocal influence between personality
and psychopathology in adolescence and the predictive value of per-
sonality traits in the explanation of psychological and physical health
status among adolescents, there has recently been increased interest
in studying personality in younger ED patients (Caspi, 2000; Krueger,
1999; Soto & Tackett, 2015; Tackett, 2006; Tackett et al., 2013).
Indeed, pathological personality traits may contribute to the mainte-
nance of ED symptoms; moreover, the persistence of EDs may exac-
erbate certain pathological traits (e.g., Krueger & Eaton, 2010;
Lilenfeld et al., 2006). Some studies have proposed that the clinical
course of EDs and the neurobiological long-term effects of eating
symptoms may contribute to the development of pathological person-
ality traits (e.g., Holliday, Uher, Landau, Collier, & Treasure, 2006;
Klump et al., 2004; Lewinsohn, Striegel-Moore, & Seeley, 2000;
Steiger, Stotland, & Houle, 1994). This is in line with studies that have
previously shown a link between acute starvation and behavioral and
personality changes (Keys et al., 1950). Based on the knowledge that
most EDs begin during adolescence (Hudson, Hiripi, Pope, & Kessler,
2007), it appears highly relevant to document personality traits during
this developmental period, with an attempt to reduce the chronicity
of eating symptoms and the exacerbation of a bidirectional effect
between personality traits and ED symptoms.
In recent years, studies have suggested that adolescents with EDs
tend to differ from those of the nonclinical population in their propen-
sities toward neuroticism (Aloi & Segura-Garcia, 2016; Cervera et al.,
2003; Gual et al., 2002; Liu, Tseng, Chang, Fang, & Lee, 2016), self-
criticism (Abbate-Daga, Gramaglia, Malfi, Pierò, & Fassino, 2007;
Aloi & Segura-Garcia, 2016; Grylli, Hafferl-Gattermayer, Wagner,
Schober, & Karwautz, 2005), anxiety-related traits, and borderline
traits (Abbate-Daga et al., 2007; Aloi & Segura-Garcia, 2016; Grylli
et al., 2005; Liley, Watson, Seah, Priddis, & Kane, 2013). Regarding
the variation of personality traits according to ED diagnostic subtypes,
some studies have also highlighted the presence of elevated impulsive
traits in adolescents with BN compared to other types of EDs
(Boisseau, Thompson-Brenner, Eddy, & Satir, 2009; Sancho, Arija, &
Canals, 2008). Youth with AN tend to display more trait-anxiety, emo-
tional inhibition, and social isolation compared to other subtypes of
EDs or the nonclinical population (Calderoni et al., 2015; Damiano,
Reece, Reid, Atkins, & Patton, 2015; Fornasari et al., 2014; Lachish
et al., 2009; Sancho et al., 2008). However, the differences observed
in personality traits in ED adolescents compared to the nonclinical
population and between adolescents presenting with different ED
subtypes have not been replicated in many other studies (Buhren
et al., 2012; Fornasari et al., 2014; Gila, Castro, Cesena, & Toro, 2005;
Grylli et al., 2005; Maïano, Morin, Monthuy-Blanc, Garbarino, & Ninot,
2016; Sancho et al., 2008). These inconsistencies emphasize the rele-
vance of a quantitative synthesis to obtain an accurate portrait of the
situation and to clarify the relationship observed between EDs and
personality traits in adolescents. To date, although the two system-
atical reviews that have examined personality traits in ED included
individuals of all age, they did not focus on finding adolescent specific
personality measures. These measures often differ from those used in
adults and this may explain why adolescents with EDs have not yet
been represented in quantitative synthesis (e.g., the Millon Adolescent
Clinical Inventory, Junior Temperament, and Character Inventory). It is
thus important to document whether those results found in adults can
apply to a population of adolescents with EDs mainly in the context
where ED symptoms and clinical course can have a long-term effect
DUFRESNE ET AL. 3

on personality. Considering the above discussion, we cannot assume
that the results obtained in adults are generalizable to adolescents.
Recently, the Work Group for Personality and Personality Disor-
ders has proposed a dimensional trait assessment in Section III of the
fifth edition of the Diagnostic and Statistical Manual of Mental Disor-
ders (DSM-5; American Psychiatric Association, 2013), which has
received considerable attention in clinical research. The DSM-5
dimensional model of personality traits integrates several previous
personality conceptualizations interested in both maladaptive and
normal traits, which offers many benefits in clinical and research con-
texts (Hopwood, Zimmermann, Pincus, & Krueger, 2015; Stepp et al.,
2012). The integrative model suggested by Widiger and Simonsen
(2005), which was based on 18 existing dimensional personality mea-
sures and models, was the premise for the DSM-5 model conceptuali-
zation. This research highlighted four domains of personality traits
with opposite poles (i.e., negative affect vs. Emotional Stability, Extra-
version vs. Introversion, Antagonism vs. Compliance, and Constraint
vs. Impulsivity). Taking these results into account, a dimensional
trait assessment model was proposed in the DSM-5 that includes
five higher-order and continuous domains: (a) Negative Affectivity
versus Emotional Stability (e.g., emotional lability, anxiousness, sub-
missiveness), (b) Detachment versus Extraversion (e.g., withdrawal,
intimacy avoidance, anhedonia), (c) Antagonism versus Agreeableness
(e.g., manipulativeness, deceitfulness, grandiosity), (d) Disinhibition
versus Conscientiousness (e.g., impulsivity, irresponsibility, lack of
rigid perfectionism), and (e) Psychoticism versus Lucidity (e.g., unusual
beliefs and experiences, eccentricity), in which were grouped 26 per-
sonality lower-order traits or “facets.” For each domain, both opposite
and extreme poles represent maladaptive traits and may be associated
with psychopathology (American Psychiatric Association, 2013;
Krueger & Markon, 2014). A more detailed description of the DSM-5
domains and traits is provided in Table 1.
This dimensional conceptualization then conceives personality
traits on a continuum of severity, as opposed to the categorical
approach that is based on the presence versus absence of criteria that
overlap from one personality disorder diagnosis to another. It provides

TABLE 1 DSM-5 description of personality domains and associated traits (facets; APA, 2013)

Domain Definition Associated traits (facets)

1. Negative affectivity
(vs. emotional stability)
2. Detachment
(vs. extraversion)
3. Antagonism
(vs. agreeableness)
4. Disinhibition
(vs. conscientiousness)
5. Psychoticism
(vs. lucidity)
Frequent and intense experiences of high levels of a wide range of Emotional lability
negative emotions (e.g., anxiety, depression, guilt/shame, worry, anger), Anxiousness
and their behavioral (e.g., self-harm) and interpersonal (e.g.,
dependency) manifestations. Separation insecurity
Submissiveness
Hostility
Perseveration
Depressivity
Suspiciousness
Restricted affectivity (lack of)
Avoidance of socioemotional experience, including both withdrawal from Withdrawal
interpersonal interactions (ranging from casual, daily interactions to Intimacy avoidance
friendships to intimate relationships) and restricted affective
experience and expression, particularly limited hedonic capacity. Anhedonia
Depressivity
Restricted affectivity
Suspiciousness
Behaviors that put the individual at odds with other people, including an Manipulativeness
exaggerated sense of self-importance and a concomitant expectation Deceitfulness
of special treatment, as well as a callous antipathy toward others,
encompassing both an unawareness of others' needs and feelings and a Grandiosity
readiness to use others in the service of self-enhancement. Attention seeking
Callousness
Hostility
Orientation toward immediate gratification, leading to impulsive behavior Irresponsibility
driven by current thoughts, feelings, and external stimuli, without Impulsivity
regard for past learning or consideration of future consequences.
Distractibility
Risk taking
Rigid perfectionism (lack of)
Exhibiting a wide range of culturally incongruent odd, eccentric, or Unusual beliefs and experiences
unusual behaviors and cognitions, including both process Eccentricity
(e.g., perception, dissociation) and content (e.g., beliefs).
Cognitive and perceptual dysregulation
4 DUFRESNE ET AL.
several clinical and research benefits, such as clarifying the level of
functioning of various personality domains by capturing individual
heterogeneity and allowing a deeper understanding of related psycho-
pathologies and their treatment responses. The DSM-5 traits and
domains and its corresponding assessment measure (i.e., Personality
Inventory for DSM-5) have demonstrated empirical validity in many
populations (e.g., Krueger, Derringer, Markon, Watson, & Skodol,
2012; Thomas et al., 2013; Wright et al., 2012), including adolescents
(Soto & John, 2014; Verbeke, De Caluwé, & De Clercq, 2017; Ver-
beke & De Clercq, 2014).
In summary, considering the mounting evidence suggesting the
role of personality traits in the development and/or maintenance of
EDs, and the inconsistent results about personality traits in adoles-
cents suffering from EDs, there is a clear need to synthesize past sci-
entific evidence about the relationship between personality traits and
EDs in adolescents, taking into consideration some moderating vari-
ables such as the ED subtype and the participants' age. Moreover, the
need to regroup different measures used in the literature on personal-
ity and EDs under theoretical and empirical constructs has been
highlighted to consolidate findings (von Ranson, 2008). A synthesis of
the data in light of the integrative and dimensional model of the
DSM-5, which has a strong empirical basis and represents a common
language in the study of personality, is then of highest relevance.
1.1 | Objectives
The aim of the present study was to synthesize the available literature
on personality traits in adolescents suffering from an ED (AN, BN,
binge-eating disorder [BED], and eating disorder not otherwise speci-
fied [EDNOS]) from the standpoint of the dimensional conceptualiza-
tion of personality traits proposed in the DSM-5 and other relevant
studies (e.g., American Psychiatric Association, 2013; Krueger &
Eaton, 2010; Stepp et al., 2012; Widiger, Livesley, & Clark, 2009;
Widiger & Simonsen, 2005). More precisely, the first objective was to
compare adolescents suffering from EDs to adolescents without an
ED, in light of the five personality trait domains (Negative Affectivity
vs. Emotional Stability, Detachment vs. Extraversion, Antagonism
vs. Agreeableness, Disinhibition vs. Conscientiousness, and Psy-
choticism vs. Lucidity). The second objective was to explore whether
the associations between EDs and personality trait domains were
moderated by the ED subtype and the participants' age.
The ED group was hypothesized to have higher scores on Negative
Affectivity based on previous studies showing elevated neuroticism, anx-
iety, and borderline-related traits in ED samples (e.g., Aloi & Segura-Gar-
cia, 2016; Farstad et al., 2016; Gual et al., 2002; Liu et al., 2016). The ED
group was also hypothesized to present more Detachment-related traits
since less extraversion and more social isolation were previously
reported in ED samples (e.g., Calderoni et al., 2015; Farstad et al., 2016;
Fornasari et al., 2014). No formal hypothesis regarding Disinhibition-
related traits was proposed due to inconsistencies in previous studies
(Boisseau et al., 2009; Farstad et al., 2016; Sancho et al., 2008). The cur-
rent literature also does not enable us to hypothesize on the direction of
the effect for the Psychoticism versus Lucidity domain. Regarding the
moderating effect according to ED subtype, we expected that adoles-
cents with AN would present lower Disinhibition-related traits, based on
previous studies that showed more obsessiveness and persistence
among individuals with AN (Atiye et al., 2015; Farstad et al., 2016).
2 | METHODS
2.1 | Literature search
We searched for studies published between January 1990 and May
2018 in PsycNet, Medline, Embase, and Psychology and Behavioral Sci-
ences Collection databases. Unpublished studies were searched for on
the ProQuest database. We applied a publication time limitation to tar-
get studies that focused on modern personality and ED constructs. The
following ED keywords were used: eating disorder, feeding disorder,
anorexia, anorexia nervosa, bulimia, bulimia nervosa, binge-eating disor-
der, and EDNOS. Personality keywords included personality* and
temperament*. This last keyword was used to be as inclusive as possi-
ble, although studies using exclusively measures of temperament were
not retained afterward. We also included keywords according to per-
sonality inventories adapted for or validated in adolescent populations:
Eysenck Personality Questionnaire, EPQ; Minnesota Multiphasic Per-
sonality Inventory, MMPI; Temperament and Character Inventory, TCI;
Millon Adolescent Clinical Inventory, MACI; NEO PI-R; NEO PI-3; Big
Five; Personality Assessment Schedule, PAS; Shedler-Westen Assess-
ment Procedure, SWAP; Dimensional Assessment of Personality
Pathology, DAPP; PSY-5; Zuckerman Personality Questionnaire, ZPQ;
Multidimensional Personality Questionnaire, MPQ; Symptom Checklist
90 Revised, SCL-90-R; and the Eating Disorder Inventory, EDI. The Eat-
ing Disorder Inventory was retained in the search criteria since this
instrument includes subscales that evaluate traits relevant to EDs. The
following keywords specified the age group: adolescent*, adolescence,
teen*, youth, or juvenile. The reference section of each selected article
was reviewed to identify other relevant studies.
After excluding duplicated studies, 1,379 abstracts were reviewed
by two independent readers according to the inclusion and exclusion
criteria (Figure 1 for the PRISMA flowchart). Studies were removed
when there was an agreement between the two readers for the fol-
lowing reasons: off-topic subject (ED or personality not studied), no
ED diagnosis, no comparison group, did not match the age criteria,
research reviews, theoretical or qualitative papers, case studies, or
measurement time. In cases of disagreement about eligibility between
the reviewers, the study was included for full-text assessment. This
broad screening identified 640 potentially eligible studies that were
fully assessed. A significant number (n = 614) were excluded for the
following reasons: did not match the age criteria, no formal ED diag-
nosis (e.g., based on a self-reported instrument), no measure on per-
sonality traits, no comparison group, nontranslatable article, research
design, full text not retrievable, off-topic subject (no interest in ED),
case studies, research reviews or duplicated samples. Finally, 26 stud-
ies were extracted for quantitative synthesis.
DUFRESNE ET AL.
F I G U R E 1 PRISMA diagram
illustrating the selection of studies for the
meta-analysis
2.2 | Eligibility criteria
We included studies examining self-reported personality traits among
adolescents with ED diagnoses that had compared these traits with a
normative group without EDs. To avoid selection bias by the authors,
the studies had to include personality inventories; studies using mea-
sures about specific personality traits were excluded (e.g., a question-
naire on perfectionism or impulsivity exclusively). The participants had
to be formally diagnosed with AN, BN, BED or EDNOS by a profes-
sional or through a clinical interview, which excluded studies that
exclusively measured personality traits pre- or post-ED. Studies that
included participants with disordered eating symptoms or participants
at risk of an ED were excluded. The ED group had to include adoles-
cents with a mean age under or equal to 18 years old and, when age
ranges were specified, the minimum age required was 10 years. Stud-
ies written in languages other than English or French were excluded.
Studies that exclusively included a clinical comparison group
(e.g., individuals with depressive disorder) and those measuring only
psychophysiological temperament without personality traits were
excluded. It is worth mentioning that, in some cases, statistics were
unusable for the meta-analysis since the means of each group for per-
sonality scales were not reported (i.e., Boyadjieva & Steinhausen,
1996; Schecklmann et al., 2012). We contacted the authors to obtain
the additional data necessary to calculate an effect size, but we were
unable to obtain this information. These studies were therefore
5
excluded from the meta-analysis. Finally, studies were excluded when
the sample was duplicated in another study. In that case, we selected
the study that reported more outcomes (means and SD) on personality
traits or the study with a larger clinical group sample size.
2.3 | Data extraction and coding of study features
Each personality measure and subscale used in the selected studies
was identified to code them according to the five-domain model pres-
ented above (Table 1). The integrative model of personality constructs
developed by Widiger and Simonsen (2005) and validated by Stepp
et al. (2012) served as the framework to build the coding scheme. The
review by Widiger and Simonsen (2005) provided a pantheoretical inte-
grative model that categorizes dimensional personality measures into
five trait dimensions, which correspond to the actual DSM-5 classifica-
tions: Emotional Instability (Negative Affectivity vs. Emotional Stability),
Extraversion (Detachment vs. Extraversion), Antagonism (Antagonism
vs. Agreeableness), Constraint (Disinhibition vs. Conscientiousness),
and Unconventionality (Psychoticism vs. Lucidity); the psychometric
study from Stepp et al. (2012) has validated this model. Two authors
with clinical and research expertise in personality independently cate-
gorized the measures that were not identified in these latest studies
according to the five-domain and facets model proposed in the DSM-5
(American Psychiatric Association, 2013). Coding manuals of the
6 DUFRESNE ET AL.

TABLE 2 Overview of the personality domains and the assigned personality scales for the included studies

Personality domain Personality trait/subscale Effect direction Measure Effect sizes (k)a
Negative affectivity (vs. emotional stability) Borderline tendency Positive MACI 1
Negative affect Positive MACI 1
Depression Positive MMPI 2
Hysteria Positive MMPI 1
Psychasthenia Positive MMPI 2
Harm avoidance Positive TCI 8
Self-directedness Negative TCI 4
Neuroticism Positive EPI 1
Obsessiveness Positive SCL-90-R 1
Affective problems composite Positive EDI 1
Emotional dysregulation Positive EDI 1
Interoceptive awareness and deficits Positive EDI 12
Maturity fears Positive EDI 9
Social insecurity/inadequacy Positive EDI 4
Detachment (vs. extraversion) Inhibition Positive MACI 1
Self-demeaning Positive MACI 1
Social introversion Positive MMPI 1
Extroversion Negative EPI 1
General dissatisfaction Positive SCANS 1
Ineffectiveness Positive EDI 9
Interpersonal alienation Positive EDI 1
Interpersonal distrust Positive EDI 9
Interpersonal problems composite Positive EDI 1
Low self-esteem Positive EDI 1
Personal alienation Positive EDI 1
Antagonism (vs. agreeableness) Hypomania Positive MMPI 1
Psychopathic deviate Positive MMPI 1
Cooperativeness Negative TCI 4
Reward dependence Negative TCI 4
Disinhibition (vs. conscientiousness) Persistence Negative TCI 4
Novelty seeking Positive TCI 5
Asceticism Negative EDI 5
Impulsivity Positive EDI 4
Perfectionism Negative EDI 14
Overcontrol composite Negative EDI 1

Abbreviations: EDI, Eating Disorder Inventory; EPI, Eysenck Personality Inventory; MACI, Millon Adolescent Clinical Inventory; MMPI, Minnesota
Multiphasic Personality Inventory; SCANS, Setting Conditions for Anorexia Nervosa and Bulimia Nervosa Scale; SCL-90-R, symptom checklist-90-revised;
TCI, Temperament and Character Inventory.
a
The same study may include more than one effect sizes for each domain, which explains why k in the present table is higher than that indicated in the
subsequent tables in which the study is the unit of analysis.

questionnaires were used to classify the trait subscales to the
corresponding domains. After independent classification by each
author, consensus was achieved through discussion and by referring to
the DSM-5 model description (American Psychiatric Association, 2013).
Table 2 provides an overview of the five personality trait domains and
the assigned personality measures and subscales. In the next sections
and tables, we used the personality trait domain labels proposed in the
DSM-5 (American Psychiatric Association, 2013) to simplify the text;
we also referred to the typology proposed by Widiger and Simonsen
(2005) to build the coding scheme. Notably, according to the DSM-5,
the depressivity and suspiciousness traits are integrated in both Nega-
tive Affectivity and Detachment domains, whereas the hostility trait is
integrated into both the Negative Affect and Antagonism domains
(American Psychiatric Association, 2013). For the analysis, these
DUFRESNE ET AL.
traits were associated with a single domain. It was then determined
after consensus between the two authors that in the present meta-
analysis, depressivity was part of the Negative Affectivity domain,
suspiciousness was part of the Detachment domain and hostility was
part of the Antagonism domain.
Using a pre-established grid, data were then extracted from each
article to compute the effect sizes; the sample sizes of the clinical and
control groups; personality measures and subscales (see Table 2 for
coding scheme); and the mean and SD of the personality trait subscales
for each group. Characteristics hypothesized to moderate associations
were also extracted, including the average (and SD) participant age and
the proportion of each type of ED (AN, BN, BED, and EDNOS) in the
clinical group. One study did not include the mean age of the sample. In
that case, the median age was extracted and considered in the analysis.
Other methodological variables were also recorded to limit the risk of
bias, including publication year, country in which the study was con-
ducted, recruitment site, and number of matching variables included in
the primary study.
In the computation of effect size, a positive effect size indicates
that the ED group is elevated on the problematic pole of the trait and
its associated personality trait domain.
2.4 | Risk of bias in primary studies
To limit the risk of bias in the selected studies, certain quality criteria
had to be met for study inclusion. First, only studies that assessed an
ED diagnostic using a formal evaluation method were included (either
confirmed by a professional or by a clinical interview), which limited het-
erogeneity among studies. The effect of methodological variables was
also assessed to control for between-study variability: (a) publication
year; (b) country where the recruitment occurred; (c) recruitment site
(i.e., hospital/ED treatment program, mental health/psychiatric center,
schools/community); and (d) analysis of potential confounders (i.e., age,
gender, weight and height, race, education, socioeconomic status and
intelligence quotient).
2.5 | Effect size calculation
Data were analyzed using the Comprehensive Meta-analysis software
(Borenstein, Hedges, Higgins, & Rothstein, 2007). The pooled effect
sizes of the group differences (ED vs. control) were calculated using
Hedges's g with 95% CIs around the point estimate (Hedges & Olkin,
1985). Hedges's g offers an unbiased effect size corrected for small
sample sizes (Hedges & Olkin, 1985). The magnitude of Hedges'
g coefficient was interpreted according to Cohen (1988): values of
0.2–0.5 correspond to a small effect, 0.5–0.8 to a medium effect and
0.8 or more to a large effect. In the current meta-analysis, positive
d values indicate that ED groups presented more problematic traits
for a certain domain whereas negative d values indicate that the con-
trol groups had higher scores on problematic traits. Two studies had
more than one independent ED group, so under these conditions, the
sample size of the control group was divided in half to calculate the
effect sizes to limit duplication of the control group (A vs. C; B vs. C).
7
2.6 | Analytic plan
Four meta-analyses were performed to estimate the effect size of the
mean differences (ED vs. control) for each personality trait domain,
according to the theoretical framework explained above: Negative
Affectivity versus Emotional Stability, Detachment versus Extraversion,
Antagonism versus Agreeableness, and Disinhibition versus Conscien-
tiousness. The analyses could not be performed for the Psychoticism-
Lucidity domain since it did not meet the minimum criteria of four
studies per cell (Bakermans-Kranenburg, Van Ijzendoorn, & Juffer,
2003; Fu et al., 2011). Only one study reported results relative to this
domain. We further performed subgroup analyses to estimate whether
personality trait domains differed significantly between subgroups.
The first screening of our data revealed that most studies used a clin-
ical group that included different ED subtypes. More specifically, 9 of the
26 studies (34.6%) used a clinical group that included various ED diagno-
ses (e.g., AN, BN, EDNOS) without distinguishing them in their analyses.
Nine studies (34.6%) used a mixed clinical group of both subtypes of AN
without distinguishing them in their analyses. Five studies (19.2%)
included patients with restrictive AN exclusively, two studies (7.7%) per-
formed comparative analyses that included separate groups of AN-R or
AN-binge/purge subtype (BP) and one study (3.8%) included patients
with BN exclusively. Therefore, there were insufficient studies reporting
outcomes separately for participants with AN-BP, BN and EDNOS,
which prevented us from performing a formal subgroup analysis to inves-
tigate the moderation effect of ED subtype. The moderating effect of
the proportion of AN diagnoses (number of AN/number of all other EDs)
was then tested via a meta-regression for each personality domain.
Meta-regressions were also performed to test the moderating effects of
other continuous theoretical and methodological variables including age,
publication year, and number of matching variables included in the pri-
mary study. To analyze the categorical moderating variables (i.e., country
and recruitment site), subgroup analyses were performed. Because
the heterogeneity of effects between samples was assumed, we used
the random-effects method when performing the significance tests
of the effect size of the mean differences for each personality trait
domain and when performing meta-regression analyses. This computa-
tional method allows the effect sizes to be adjusted when the studies
present methodological variations (Borenstein, Hedges, Higgins, &
Rothstein, 2009). Moderation analyses using categorical variables
(i.e., recruitment site) were performed by comparing groups with a mixed
effects analysis, which uses random-effects weights within subgroups
and a fixed-effect model across subgroups (Borenstein et al., 2009).
To quantify the heterogeneity in effect sizes, the Q and I2 statis-
tics were calculated with 95% confidence intervals. The Q significance
test indicates whether the variation in effect sizes is explained by
within-study variability (sampling error) or by both within- and
between-study variabilities (Huedo-Medina, Sánchez-Meca, Marín-
Martínez, & Botella, 2006). The I2 index represents the percentage of
variation in effect sizes that is caused by between-study variability
(Huedo-Medina et al., 2006). According to Higgins, Thompson, Deeks,
and Altman (2003), a percentage of 25–50% indicates low heteroge-
neity, 50–75% indicates moderate heterogeneity and 75% or more
8 DUFRESNE ET AL.
indicates high heterogeneity. Asterisks for Q indicate heterogeneity of
a specific set of effect sizes.
The effect sizes of the differences between the ED and normative
groups were calculated with the z-test whereas meta-regressions
were tested using the method of moments and the Knapp and Har-
tung adjustment. This last method is recommended when there is
uncertainty in the between-study variance or when there are rela-
tively few studies; it provides adequate control of the Type I error rate
in these conditions (IntHout, Ioannidis, & Borm, 2014).
When there was more than one outcome (i.e., personality traits) in
a study for the same domain analyzed, the mean of these selected
outcomes was used to avoid overestimation of the summary effect
(Borenstein et al., 2009). The size of the combined effect was then
treated as the data for this study. Moreover, to avoid participant
duplication, we used the study as the unit of analysis for the analyses
performed on the four domains and moderator analyses.
2.7 | Risk of bias across studies
A gray literature search of unpublished theses was performed to mini-
mize publication bias. However, none of the unpublished studies met
the inclusion criteria. In addition, for each personality trait domain, the
publication bias across studies was assessed with the Egger test of fun-
nel plot asymmetry (Sterne & Egger, 2001) and was confirmed with the
Trim-and-Fill Procedure (Duval & Tweedie, 2000). To assess the pres-
ence of outliers in our data, a Fisher's Z was computed for each study,
as a normally distributed equivalent to Cohen's d. The presence of out-
liers was confirmed by a value lower than −3.29 or greater than 3.29.
3 | RESULTS
3.1 | Study selection
Sixty-three effect sizes based on 26 studies were available, including a
total of 986 adolescents suffering from an ED (Figure 1 for the
PRISMA flowchart). Generally, more than one domain of data were
available in each study, which explains why the total number of effect
sizes is greater than the number of studies. Twenty-five effect sizes
were available for Negative Affectivity, 14 for Detachment, 5 for
Antagonism, and 19 for Disinhibition. The meta-analysis of the
Psychoticism-Lucidity domain could not be performed since only one
study reported data on these personality traits. Analyses within each
personality domain were performed using study as the unit of analysis
to avoid participant duplication.
Of the 26 included studies, four were performed in North Amer-
ica, nine in Southern Europe, six in Western Europe, three in Northern
Europe, two in Eastern Europe, one in Australia and one in Asia. The
publication years ranged between 1999 and 2018. Girls represented
98% of the ED groups, and the mean age was 15.74 years old. The
associated sample size for the analysis of each of the personality
trait domains ranged from 159 to 967 adolescents with an ED,
corresponding to a total of 986 unique participants (3,724 in norma-
tive groups). Of the selected studies, 12 did not report data on the
presence of comorbid disorders. Among those that reported this infor-
mation (n = 14), 10 included anxiety and/or depressive disorders.
Regarding comorbid disorders excluded from primary studies, nine
studies excluded psychotic disorders, eight excluded substance abuse
or dependence disorders, six excluded bipolar disorders, and two
excluded personality disorders. A detailed description of the included
studies is presented in Table 3.
The analysis of the Fisher's Z values revealed an outlier that had
been excluded. Furthermore, a visual inspection of the funnel plot and
the Trim-and-Fill procedure confirmed that there was no publication
bias in the included studies.
3.2 | Main analysis
The pooled effect sizes for the differences between ED groups and nor-
mative groups for the four-personality trait domains studied (Negative
Affectivity vs. Emotional Stability, Detachment vs. Extraversion, Antago-
nism vs. Agreeableness, and Disinhibition vs. Conscientiousness) are
presented in Tables 4–7. The results showed that personality traits asso-
ciated with Negative Affectivity (g = 0.78; k = 25; 95% confidence inter-
val [CI] = 0.59–0.96; p < .001) and Detachment (g = 0.69; k = 14; 95%
CI = 0.59–1.08; p < .001) were significantly higher in ED adolescents
compared with normative adolescents. In the Disinhibition domain, per-
sonality traits were significantly lower in ED adolescents compared with
normative adolescents (g = −0.53; k = 19; 95% CI = −0.72 to −0.34;
p < .001). ED adolescents did not differ from nonclinical adolescents
regarding the personality traits relative to Antagonism (g = 0.18; k = 5;
95% CI = −0.21 to 0.58; p = .107). According to Cohen's criteria, the
effect size was large for the Detachment personality domain and
medium for the Negative Affectivity and Disinhibition domains.
Medium heterogeneity in effect sizes was found for the Negative
Affectivity (I2 = 74.74; Q0 = 95.02; p < .001) and Disinhibition
(I2 = 71.69; Q0 = 63.59; p < .001) domains, and a high heterogeneity
was found for the Detachment domain (I2 = 78.96; Q0 = 61.79;
p < .001). These results confirm the relevance of moderating variables
in the analysis. No heterogeneity in effect size was observed for the
Antagonism personality domain. In addition, inspection of the funnel
plot and the Trim-and-Fill analysis revealed a potential publication bias
for the Detachment domain because three studies were identified as
not being symmetrically paired. An adjusted effect size was then calcu-
lated with the Trim-and-Fill procedure with a reported value of 0.69
(95% CI = 0.59–1.08). The effect size for the Detachment domain
would then be medium rather than large, as previously estimated. No
potential publication bias was found for the other personality trait
domains (Negative Affectivity, Antagonism, and Disinhibition).
3.3 | Moderator analysis
The moderating effect was tested for each of the four domains
(Tables 4–7). Two theoretical moderators were considered: the pro-
portion of participants with an AN diagnosis in the sample and the
participants' age. The methodological moderators included publication
year, country in which the study was performed, recruitment site and
TABLE 3 Studies included in the meta-analysis

Comparative
Study ED group group Mean age (SD) [age range) Measure of personality traits ED diagnosis Cohen's d (95% CI)
Bentz et al. (2017) 43 AN females 41 females AN = 16.1 (1.5) [14.1–21.5] EDI-3: interoceptive deficits ICD-10 criteria 1.64 [1.15, 2.14]
DUFRESNE ET AL.

CG = 17.7 (2.2) [14–22.5]

Bernardoni et al. 32 AN-R 32 and 3 AN- 35 females AN = 16 (2.6) [12–23] J-TCI: harm avoidance SIAB-EX (DSM-IV −0.20 [−0.54, 0.14]
(2018) BP females CG = 16.3 (2.6) [12–24] EDI-2: perfectionism criteria)
Bischoff-Grethe 10 AN-R females 12 females AN = 16.2 (1.8) [12–18] TCI: harm avoidance MINI-KID and SCID 0.17 [−0.49, 0.84]
et al. (2013) CG = 15.4 (1.6) [12–18] EDI-2: perfectionism (DSM-IV criteria)
Bomba et al. (2014) 60 AN-R females 60 females AN = 15.43 (1.63) [11–18] EDI-3: affective problems, interpersonal problems, overcontrol, ICD-10 criteria 0.37 [0.15, 0.59]
CG = 15.73 (1.88) [11–18] maladjustment, and ineffectiveness (composites)
Boschi et al. (2003) 16 EDNOS, 2 BED, and 136 females ED = 16.25 [14–18] EDI-2: interoceptive awareness, maturity fears, social inadequacy, DSM-IV criteria 0.49 [0.21, 0.76]
2 BN females CG = 16.25 [14–18] interpersonal disrupt, ineffectiveness, perfectionism, asceticism,
and impulse regulation
Brytek-Matera and 35 AN females 57 females AN = 17.7 (1.3) EDI (version not specified): interoceptive awareness, maturity DSM-IV-R criteria 0.32 [0.07, 0.57]
Schiltz (2009) CG = 19.6 (1) fears, interpersonal distrust, ineffectiveness, and perfectionism
Buhren et al. (2012) 28 AN females 27 females AN = 15.6 (1.5) [12.2–17.8] SCL-90-R: obsessiveness SIAB-EX (DSM-IV −0.20 [−0.58, 0.18]
CG = 15 (1.7) [12.3–18.8] EDI-2: perfectionism criteria)
Dacey, Nelson, and 12 BN females 14 females [14–18] MMPI: depression, psychasthenia, social introversion, Russell's diagnostic 0.64 [0.19, 1.10]
Aikman (1990) psychopathic deviate, and hypomania criteria for BN
Dmitrzak-Weglarz 46 AN-R and 15 AN-BP 45 females AN = 15.9 (2.16) TCI: harm avoidance, novelty seeking, reward dependence, DSM-IV criteria −0.08 [−0.42, 0.27]
et al. (2013) females CG = 37.7 (13.9) cooperativeness, persistence, and self-directedness
Frank, Shott, 17 AN-R and 2 AN-BP 22 females AN = 15.4 (1.4) TCI: harm avoidance and novelty seeking C-DISC (DSM-IV 0.02 [−0.46, 0.51]
Hagman, and CG = 14.8 (1.8) criteria)
Yang (2013)
Garcia-Alba (2004) 50 AN-R females 50 AN = 14.84 (1.13) MMPI (version not specified): depression and psychasthenia DSM-III-R criteria 0.70 [0.29, 1.11]
CG = 14.90 (0.95) [13–16]
Gaudio et al. (2017) 14 AN-R females 15 females AN = 15.7 (1.6) [13–18] TCI: harm avoidance DSM-IV criteria 2.69 [1.68, 3.69]
CG = 16.3 (1.5) [13–18]
Gila et al. (2005) 19 AN males 200 males AN = 14.7 (1.7) [11–18] EDI (version not specified): interoceptive awareness, maturity DSM-IV criteria 0.16 [−0.11, 0.43]
CG = 14.3 (2.3) [11–18] fears, interpersonal distrust, ineffectiveness, and perfectionism
Grylli et al. (2005) 2 BN and 9 EDNOS 175 (gender not ED = 14.8 (2.3) TCI: harm avoidance, novelty seeking, reward dependence, EDE (DSM-IV 0.47 [0.11, 0.82]
females specified) CG = 14 (2.0) cooperativeness, persistence, and self-directedness criteria)
Laghi et al. (2015) 40 AN-R females 40 females AN = 14.93 (1.48) EDI-3: interoceptive deficits, maturity fears, emotional K-SADS-PL (DSM- 0.29 [0.03, 0.55]
CG = 14.88 (0.56) dysregulation, interpersonal alienation, personal alienation, IV-TR criteria)
interpersonal insecurity, low self-esteem, perfectionism, and
asceticism
Liley et al. (2013) 9 AN-R, 1 AN-B, 1 BN, 25 females ED = 15 (1.27) [13–17] MACI: borderline tendency, negative affect, inhibition, and self- EDE (DSM-IV 1.34 [0.90, 1.78]
9 EDNOS-AN, and CG = 15 (1.15) [13–17] demeaning criteria)
3 EDNOS-BN
females
9

(Continues)
TABLE 3 (Continued)
10

Comparative
Study ED group group Mean age (SD) [age range) Measure of personality traits ED diagnosis Cohen's d (95% CI)
Liu et al. (2016) 42 EDNOS, 19 BN, and 374 females ED = 16.3 (0.6) EPI: neuroticism and extroversion SCID (DSM-IV-TR 0.08 [−0.07, 0.23]
7 AN females CG = 16.4 (0.6) EDI-1: perfectionism criteria)
Maïano et al. 19 AN females 19 females 15.68 (total sample) EDI-VS: interoceptive awareness, maturity fears, interpersonal MINI 0.34 [−0.08, 0.76]
(2016) distrust, ineffectiveness, and perfectionism
Mele et al. (2016) 16 AN-R and 4 AN-BP 20 females AN = 15.45 (1.75) [12–18] EDI-3: interoceptive awareness K-SADS-PL (DSM- 0.64 [0.00, 1.27]
females CG = 15.3 (1.92) [12–18] IV-TR criteria)
Rosenvinge, 7 BED, 5 BN, 73 females 15.4 (0.31) [15–16] (total sample) SCANS: general dissatisfaction and perfectionism Diagnostic survey 0.75 [0.37, 1.12]
Sundgot Borgen, 5 EDNOS-BN, and for eating
and Börresen 2 AN-BP females disorders (DSM-
(1999) IV criteria)
Rybakowski, 36 AN-R and 25 AN-BP 60 females AN-R = 17.1 (1.8) TCI: harm avoidance, novelty seeking, reward dependence, ICD-10 and DSM- −0.30 [−0.59, 0.00]
Slopien, females AN-BP = 17.5 (2) cooperativeness, persistence, and self-directedness IV criteria
Zakrzewska, CG = 17.7 (1.8)
Hornowska, and
Rajewski (2004)
Salbach, 58 AN females 56 females AN = 15.5 (1.5) [12–18] EDI-2: interoceptive awareness, maturity fears, interpersonal SIAB-EX (DSM-IV 0.23 [0.01, 0.45]
Klinkowski, CG = 14.9 (1.7) [12–18] distrust, ineffectiveness, and perfectionism criteria)
Pfeiffer,
Lehmkuhl, and
Korte (2007)
Sancho, Arija, 37 AN and 14 BN 149 females and (Total sample) EDI-2: interoceptive awareness, maturity fears, social insecurity, DICA (DSM-IV 0.03 [−0.24, 0.29]
Asorey, and females and males males Boys = 13.78 (0.75) interpersonal distrust, ineffectiveness, perfectionism, criteria)
Canals (2007) Girls = 13.79 (0.71) asceticism, and impulse regulation
[13–15]
Sim and Zeman 13 BN and 6 EDNOS 19 females ED = 16.67 (1.5) [14.17–19.42] EDI (version not specified): interoceptive awareness Clinical interview 2.73 [1.85, 3.62]
(2004) BN CG = 16.67 (1.33) [13.67–19.58] (DSM-IV criteria)
Thurfjell, Edlund, 89 EDNOS, 87 AN, and 2,046 females ED = 15.5 (1.3) [13–17] EDI-2: interoceptive awareness, maturity fears, social insecurity, Semi-structured 0.42 [0.33, 0.50]
Arinell, Hägglöf, 25 BN females CG = 15.7 (1.6) [13–17] interpersonal distrust, ineffectiveness, perfectionism, interview (DSM-
and Engström asceticism, and impulse regulation IV criteria)
(2003)
Urgesi et al. (2012) 10 AN-R, 4 EDNOS, 15 females ED = 15.5 (1.2) [13–17] EDI-2: interoceptive awareness, maturity fears, social insecurity, K-SADS-PL (DSM- 0.41 [0.04, 0.78]
and 1 AN-BP females CG = 15.4 (1.2) [13–17] interpersonal distrust, ineffectiveness, perfectionism, IV criteria)
asceticism, and impulse regulation

Abbreviations: AN, anorexia nervosa; AN-R, anorexia nervosa, restrictive subtype; AN-BP, anorexia nervosa, binge/purge subtype; BED, binge-eating disorder; BN, bulimia nervosa; C-DISC, Computerized
Diagnostic Interview Schedule for Children; CG, control group; CI, confidence interval; DICA, Diagnostic Interview for Children and Adolescents; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders; ED,
eating disorder; EDE, Eating Disorder Examination; EDI, Eating Disorder Inventory; EDI-VS, Eating Disorder Inventory (Very Short Form); EDNOS, eating disorder not otherwise specified; EPI, Eysenck Personality
Inventory; ICD, International Classification of Diseases; J-TCI, Junior Temperament and Character Inventory; K-SADS-PL, Kiddie-Sads-Present and Lifetime Version; LL, lower limit; MACI, Millon Adolescent Clinical
Inventory; MINI, Mini International Neuropsychiatric Interview; MINI-KID, Mini International Neuropsychiatric Interview (for Children and Adolescents); MMPI, Minnesota Multiphasic Personality Inventory; SCANS,
Setting Conditions for Anorexia Nervosa Scale; SCID, Structural Clinical Interview for DSM-IV Axis I Disorders; SCL-90-R, Symptoms Checklist-90-Revised; SIAB-EX, Structured Interview of Anorexic and Bulimic
Disorders; TCI, Temperament and Character Inventory; UL, upper limit.
DUFRESNE ET AL.
DUFRESNE ET AL. 11

TABLE 4 Summary statistics for total sample meta-analysis and for moderating variables according to negative affectivity personality domain

95% CI

k Hedge's g (p) SE LL UL Contrast Q0 (p) β (p)

Total sample 25 0.78*** 0.09 0.59 0.96 95.02***
% AN 24 0.00 −0.01 0.00 −0.00 (.669)
Age of participants 25 0.14 −0.22 0.38 0.08 (.591)
Year of publication 25 0.02 −0.04 0.05 0.01 (.772)
Recruitment site 24 5.14 (.162)
Hospital/ED treatment program 15 0.94 0.15 0.64 1.24
Psychiatric/mental health center 5 0.67 0.23 0.22 1.13
School/community 4 0.49 0.14 0.23 0.76
Matching variables 25 0.07 −0.16 0.13 −0.01 (.862)

Abbreviations: AN, anorexia nervosa; β, beta (slope); CI, confidence interval; ED, eating disorder; k, number of samples; LL, lower limit; Q0 , Cochran's
measure of heterogeneity; SE, standard error; UL, upper limit.
***p < .001.

TABLE 5 Summary statistics for total sample meta-analysis and for moderating variables according to detachment personality domain

95% CI

k Hedge's g (p) SE LL UL Contrast Q0 (p) β (p)

Total sample 14 0.69 *** a
0.12 0.59 1.08 61.79***
% AN 14 0.00 −0.00 0.01 0.00 (.307)
Age of participants 14 0.14 −0.23 0.40 0.08 (.578)
Year of publication 14 0.02 −0.04 0.04 0.00 (.934)
Matching variables 14 0.08 −0.17 0.16 −0.00 (.941)

Abbreviations: AN, anorexia nervosa; β, beta (slope); CI, confidence interval; k, number of samples; LL, lower limit; Q0 , Cochran's measure of heterogeneity;
SE, standard error; UL, upper limit.
a
Adjusted value for the publication bias (“Trim and Fill procedure”).
***p < .001.

TABLE 6 Summary statistics for total sample meta-analysis and for moderating variables according to antagonism personality domain

95% CI

k Hedge's g (p) SE LL UL Contrast Q0 (p) β (p)

Total sample 5 0.18 0.20 −0.21 0.58 7.60 (.107)
% AN 5 0.00 −0.02 0.00 −0.01 (.174)
Age of participants 5 0.16 −0.79 0.25 −0.27 (.200)
Year of publication 5 0.03 −0.07 0.04 −0.02 (.579)
Matching variables 5 0.08 −0.13 0.35 0.11 (.228)
0
Abbreviations: AN, anorexia nervosa; β, beta (slope); CI, confidence interval; k, number of samples; LL, lower limit; Q , Cochran's measure of heterogeneity;
SE, standard error; UL, upper limit.

the number of matching variables that have been considered in pri-
mary studies.
3.3.1 | Theoretical variables
Meta-regressions revealed that the proportion of adolescents with
AN in the samples significantly moderated the association between
Disinhibition personality traits and ED (k = 19, β = −0.01, p = .01),
which indicates that Disinhibition personality traits decline with the
proportion of participants with an AN diagnosis in studies. The
corresponding analyses for Negative Affectivity, Detachment, and
Antagonism were not significant. In addition, the moderating analyses
of the age of participants were not significant for all personality trait
domains.
12 DUFRESNE ET AL.

TABLE 7 Summary statistics for total sample meta-analysis and for moderating variables according to disinhibition personality domain

95% CI

k Hedge's g (p) SE LL UL Contrast Q0 (p) β (p)

Total sample 19 −0.53*** 0.10 −0.72 −0.34 63.59***
% AN 19 0.00 −0.01 −0.00 −0.01*
Age of participants 19 0.12 −0.36 0.16 −0.10 (.439)
Year of publication 19 0.02 −0.08 0.00 −0.04 (.069)
a
Recruitment site 18 8.14*
Hospital/ED treatment program 10 −0.72*** 0.18 −1.07 −0.37
Psychiatric/mental health center 4 −0.31*** 0.07 −0.45 −0.18
School/community 4 −0.21* 0.11 −0.42 −0.00
Matching variables 19 0.09 −0.21 0.16 −0.03 (.760)

Abbreviations: AN, anorexia nervosa; β, beta (slope); CI, confidence interval; ED, eating disorder; k, number of samples; LL, lower limit; Q0 , Cochran's
measure of heterogeneity; SE, standard error; UL, upper limit.
a
One missing value for recruitment site.
*p < .05; ***p < .001.

3.3.2 | Methodological variables period. However, no review had synthesized previous results on this
topic. Thus, the aim of the present study was to provide a synthesis of
Coefficients of the meta-regressions incorporating the year of publi-
the literature about personality traits in adolescents with EDs and to
cation as an independent variable were found to be nonsignificant for
quantify the associations between personality traits and EDs by refer-
each of the personality trait domains.
ring to a widely validated dimensional model of personality traits
However, the subgroup analyses revealed that the recruitment
(American Psychiatric Association, 2013; Krueger & Eaton, 2010;
site moderated the association between ED and Disinhibition traits
Stepp et al., 2012; Widiger et al., 2009; Widiger & Simonsen, 2005).
(Q0 = 8.14, p = .043). Subsequent comparative analyses revealed that
The present study first provides evidence that personality traits are
the effect size for studies performed in Hospital/ED treatment pro-
associated with EDs in adolescents. We found that compared to ado-
grams was significantly higher than that for studies performed in Psy-
lescents without an ED, those with an ED presented a greater propen-
chiatric/Mental health centers (Q0 = 4.61, p = .03) or in Schools/
sity for personality traits related to Negative Affectivity, Detachment,
Communities (Q0 = 6.07, p = .014), which indicates that elevated Con-
and Conscientiousness (opposite pole of Disinhibition). Negative Affec-
scientiousness traits are greater when adolescents are recruited in
tivity and Detachment-related traits were the most strongly associated
hospitals or ED treatment programs compared with those who are
with EDs, followed by Conscientiousness-related traits. The only
recruited from psychiatric centers and from communities and schools.
domain of personality traits that did not appear to differ in ED versus
No significant difference was found between Psychiatric/Mental
nonclinical adolescents was Antagonism.
Health Center and School/Community (Q0 = 0.63, p = .428). The mod-
According to our results, adolescents suffering from an ED pres-
erating effect of recruitment site was not significant for the Negative
ented elevated Negative Affectivity-related traits (as opposed to
Affectivity domain. There were too few studies per cell to perform
Emotional Stability), such as neuroticism, interoceptive awareness, fear
analyses for the Detachment and Antagonism domains. Finally, the
of maturity, insecurity, borderline tendency, and emotional dys-
number of matching variables included in the primary studies did not
regulation. These results are in line with those found in previous
influence the effect sizes for any of the domains studied. Subgroup
reviews including people of all ages, which showed that higher negative
analyses could not be performed for the moderating effect of country
emotionality (e.g., disposition to experience emotional tension, depres-
since each cell did not include a minimum of four studies as rec-
sion, anger, or anxiety) was associated with AN, BN, and problematic
ommended (Bakermans-Kranenburg et al., 2003; Fu et al., 2011).
eating behaviors (Farstad et al., 2016; Vitousek & Manke, 1994).
According to the DSM-5 model, personality traits related to Negative
4 | DISCUSSION Affectivity could be manifested by self-harm behaviors and interper-
sonal insecurity and dependence (American Psychiatric Association,
The association between personality traits and psychopathologies in 2013). From this perspective, ED symptoms could be conceived as a
adolescence has already been confirmed in previous studies (Caspi, self-harm behavior in response to an experience of negative affectivity
2000; Krueger, 1999; Soto & Tackett, 2015; Tackett, 2006; Tackett and/or a way of maintaining a relationship of dependence on others.
et al., 2013). Because ED symptoms often appear during adolescence, However, the concomitant effects of depressive or anxiety disorders
there has been an increased interest in the last decade in studying the were not controlled, which could also explain some of the variance
relationship between EDs and personality during this developmental found. It is also possible that EDs worsen depressive traits or state. The
DUFRESNE ET AL.
moderation analysis taking into account the proportion of AN diagno-
ses was not significant for this domain, which supports several previous
studies reporting that negative affectivity traits are not correlated with
ED subtype (Farstad et al., 2016). From a clinical point of view, negative
affectivity could be treated as a transdiagnostic indicator of severity
considering that past studies have shown an association between affec-
tive lability and impulsive behaviors such as self-harm behaviors and
higher levels of compulsivity (see Farstad et al., 2016). Therefore, emo-
tion regulation must be a treatment priority.
Our results also revealed that adolescents with EDs were more
likely to present Detachment-related personality traits (as opposed to
Extraversion) compared with non-ED adolescents. According to our
coding scheme, adolescents suffering from EDs may then show more
traits such as inhibition, introversion, interpersonal distrust, personal
and social alienation, and feelings of inefficiency, and they may have
lower novelty seeking and extraversion. These results are consistent
with the reviews of Farstad et al. (2016) and Vitousek and Manke
(1994), which reported lower extraversion traits in people of all ages
suffering from EDs (Farstad et al., 2016; Vitousek & Manke, 1994). Our
results then suggest that young people with EDs may have more diffi-
culty entering into relationships and may be more insecure. However,
we cannot rule out that other variables associated with the ED condi-
tion created interpersonal distance and greater insecurity with others.
Moreover, the proportion of AN diagnoses did not moderate the effect
size for this domain, which is consistent with previous studies con-
ducted in samples of all ages that reported that individuals with AN-R,
AN-BP, and BN consistently reported lower levels of extraversion than
non-ED controls (Farstad et al., 2016; Tasca et al., 2009). The fact that
adolescents with EDs are more inhibited and suspicious in relationships,
despite relational needs, could make them more vulnerable to eating
control/compulsion and body image concerns in order to fulfill these
relational needs, thus highlighting the intrinsic relationship between
personality and ED symptoms. In addition, the tendency towards inhibi-
tion and social isolation may limit access to social support that can help
the adolescent to cope with eating or body image concerns.
Adolescents with ED were also less likely to present personality
traits associated with Disinhibition compared with non-ED youth. They
may display more traits related to Conscientiousness (i.e., the opposite
pole of Disinhibition), such as persistence, asceticism, overcontrol, per-
fectionism, and self-directedness. For this domain, our hypothesis
regarding the moderating effect of the proportion of participants with
an AN diagnosis was confirmed. The association between ED and
Conscientiousness-related traits was stronger when there was an ele-
vated proportion of AN in the samples. These results suggest a greater
tendency for impulse control among adolescents suffering from AN
compared with other types of ED (e.g., BN, BED, EDNOS), which cor-
roborates previous narrative reviews that showed fewer impulsive
traits in people with AN compared to those with BN or BED (Farstad
et al., 2016) and higher constraint and persistence in those with AN
(Cassin & von Ranson, 2005). Some studies have already proposed that
eating symptomatology (and ED) could be represented along a contin-
uum of impulse control, which could explain why AN moderates dis-
inhibited traits in adolescents with ED (Wildes & Marcus, 2013). Again,
13
it would be very interesting to take into account the degree of
conscientiousness-disinhibition that characterizes the ED pathology to
design a more specific treatment. More precisely, along the impulse
control continuum, if conscientiousness is the core factor of the ED
pathology, treatment could focus more specifically on this factor,
whereas if disinhibition is part of the clinical picture, then the treatment
program should specifically address disinhibition.
The meta-analysis related to the Antagonism domain did not
reveal significant associations with ED in adolescents. These findings
are in line with those from previous reviews which revealed that indi-
viduals with ED in comparison to non-ED individuals were similar for
traits related to Antagonism (vs. agreeableness; e.g., cooperativeness,
reward dependence; Farstad et al., 2016). However, there were fewer
effect sizes for this personality domain, which may have limited the
statistical power. This raises the relevance of including traits related
to Antagonism (vs. Agreeableness) in the personality analysis of ED
adolescents in future research. The same suggestion can be applied to
the study of traits associated with Psychoticism (vs. Lucidity) because
there were not sufficient data to perform a meta-analysis for this
domain.
The age of the participants did not appear to significantly contrib-
ute to the effect size for any of the personality domains studied. This
result indicates that in older adolescents with ED, there is no eleva-
tion of problematic personality traits compared to the normative
group. However, these results should be interpreted in light of the
low variability of age groups in the studies that were included (i.e., the
mean ages were rarely below 14 years).
With regard to methodological moderator variables, our results rev-
ealed that recruitment site moderates the effect size of the relationship
between Disinhibition-Conscientiousness traits and ED. The association
between ED and elevated Conscientiousness traits then appears to be
greater when adolescents were recruited in hospitals or ED treatment
programs compared with those who were recruited from psychiatric
centers and from community and schools. These findings indicate that
Conscientiousness personality traits (e.g., persistence, asceticism, per-
fectionism) would be more prevalent among young people who seek
treatment in hospitals and may suggest that these types of personality
traits are related to more severe malnutrition and poorer physical
health status (which may be representative of those who consult in
hospitals or ED treatment programs). These results are in line with
Berkson's selection bias, which postulates that individuals with more
than one psychiatric condition and those with a more acute ED or per-
sonality pathology would be more likely to be hospitalized or seen at a
hospital (Berkson, 1946). In that sense, recruitment site may be a proxy
for ED severity. Moreover, it can be argued that these Conscientious-
ness personality traits would have been exacerbated or even induced
by starvation and nutritional imbalance, as suggested by the findings of
Keys et al. (1950) on the effects of starvation on personality manifesta-
tions (Williamson et al., 2004; Keys et al., 1950). Finally, the fact that
the Disinhibition-Conscientiousness traits were moderated by both the
ED diagnosis and the recruitment site highlights that these traits may
be associated with more heterogeneity and can explain the inconsis-
tencies found in the literature.
14
A few methodological constraints were encountered, namely, the
heterogeneity of instruments used to measure personality traits (out-
comes), the lack of data pertaining to specific subtypes of ED and the
high proportion of AN diagnosis compared to low rates of other diag-
noses such as BN and BED. First, variability among personality invento-
ries used in the selected studies may explain the high heterogeneity
indices (Q, I2) found for Negative Affectivity and Disinhibition personal-
ity domains. A significant proportion of variation in effect sizes for
these domains could then be explained by between-study variability
(Huedo-Medina et al., 2006). Moreover, the lack of data (means and
SD) pertaining to specific subtypes of ED in the actual literature had
prevented us from performing moderation analyses by subgroups using
a categorical variable (e.g., AN vs. BN vs. BED), which limited the gener-
alization of results to specific subtypes of ED. Nevertheless, we cannot
ignore that there is a high prevalence of diagnostic crossover among
ED subtypes over time (Rastam, Gillberg, & Wentz, 2003; Wentz,
Gillberg, Anckarsäter, Gillberg, & Råstam, 2009; Wilfley, Bishop, Wil-
son, & Agras, 2007). The analysis according to the ED subtypes would
not have prevented us from avoiding this migration problem. Personal-
ity traits seem more consistently related to ED symptoms rather than
to the ED diagnosis. For example, some previous studies revealed a
greater association between restrictive eating behaviors and avoidant
traits and between purging eating behaviors and negative affectivity
traits (e.g., borderline tendency, affective lability; Farstad et al., 2016).
These latter methodological limitations highlight the relevance for
future studies to more systematically document personality traits in
relation to ED symptomatology. In addition, since a majority of selected
studies included adolescents with AN, the results are less generalizable
to adolescents with BN or BED. Other limitations must be considered
in the interpretation of the present findings. First, the inclusion of self-
reported personality inventories may present some limitations. Indeed,
it can be hypothesized that mentalization deficits reported in young
people with ED (Jewell et al., 2016) and the effect of starvation at the
active phase of the illness (Vitousek & Stumpf, 2004) could have intro-
duced a bias in the self-report measurement of personality traits. There
remains an uncertainty about whether the dysfunctions reported are
related to the personality itself or to the symptoms of the psychopa-
thology (Mulder, Joyce, Sullivan, Bulik, & Carter, 1999), and the direc-
tion of effects between personality and ED cannot be analyzed with
cross-sectional studies. The comorbidities that were included or
excluded in the primary studies may also influence reported data and
effect sizes. Since the number of selected studies was limited and a sig-
nificant proportion of those did not report data on comorbidities, there
was not enough data per cell to conduct a categorical moderation anal-
ysis related to this potentially confounding variable. The findings must
then be interpreted in the light of these limitations.
5 | CO NC LUSIO N
In summary, this study offers a better comprehension of personality
traits in adolescents suffering from EDs and on the influence of the
ED subtype on this association. The results from the present meta-
DUFRESNE ET AL.
analysis revealed that adolescents with EDs present personality traits
characterized by elevated Negative Affectivity, Detachment, and Con-
scientiousness. Our findings underline the relevance of considering
personality traits to offer a better understanding of etiological and
maintenance factors for ED and to develop treatments more adapted
to adolescents with EDs while taking into account personality traits.
Personality traits such as elevated Negative Affectivity or Detachment
or Conscientiousness, which may predispose, exacerbate or maintain
dysfunctional eating behaviors, should be considered. The present
meta-analytic review also highlighted the limitations of previous stud-
ies in this research area. According to our findings, there is a need to
document the symptomatology effects among AN (restrictive and
binge-purge behaviors) in future studies investigating the relationships
between EDs and personality. Moreover, prospective studies would
allow a clearer understanding of the temporal relationships between
personality and EDs to better distinguishing what belongs to personal-
ity from what belongs to symptomatology. In future work, the use of
a theoretical integrative personality framework such as the one used
in this study may be relevant to benefit research and clinical advance-
ment regarding personality traits and eating behaviors.
DATA AVAILABILITY STAT EMEN T
Data sharing is not applicable to this article as no new data were
created or analyzed in this study.
OR CID
Laurie Dufresne https://orcid.org/0000-0002-6104-5291
Catherine Bégin PhD https://orcid.org/0000-0003-0554-4181
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How to cite this article: Dufresne L, Bussières E-L, Bédard A,
Gingras N, Blanchette-Sarrasin A, Bégin PhD C. Personality
traits in adolescents with eating disorder: A meta-analytic
review. Int J Eat Disord. 2019;1–17. https://doi.org/10.1002/
eat.23183