Personality and Individual Differences 32 (2002) 707–714

www.elsevier.com/locate/paid

Impulsive and compulsive traits in eating

disordered patients compared with controls
Laurence Claes *, Walter Vandereycken, Hans Vertommen
Katholieke Universiteit Leuven, Department of Psychology, Tiensestraat 102, B-3000 Leuven, Belgium

Received 22 September 2000; received in revised form 27 February 2001; accepted 15 March 2001

Abstract
The question whether bulimia nervosa (BN) patients show more impulsive and less compulsive traits
than anorexia nervosa (AN) patients has been linked to the idea of eating disorders belonging to the so-
called obsessive-compulsive spectrum disorders. In this study we have compared both impulsive and com-
pulsive traits in three subgroups of eating disordered patients (total n=56) and a control group of 102
female students. Information about impulsive and obsessive-compulsive traits were gathered by means of
standardised self-rating scales. BN and bingeing-purging AN patients reported more impulsive and obses-
sive traits than restrictive AN patients and controls without eating disorders, although these traits were
also present in the latter groups. The data support the hypothesis that obsessive-compulsive and impulsive
traits are not mutually exclusive but can be found in groups of individuals with the same diagnosis or even
within the same individual. # 2002 Elsevier Science Ltd. All rights reserved.
Keywords: Obsessive-compulsive traits; Impulsiveness; Eating disorders

1. Introduction

McElroy, Phillips, and Keck (1994) suggested that anorexia nervosa of the restrictive type
(AN-R), anorexia nervosa of the binge-eating/purging type (AN-P) and bulimia nervosa (BN)
might be considered to belong to a spectrum of disorders with varying degrees of obsessive-
compulsive and impulsive traits, the so-called obsessive-compulsive spectrum disorders (OCSDs).
According to Hollander (1998), the compulsive and impulsive disorders are lying at opposite ends
of the dimension risk avoidance but they have two basic characteristics in common: the involve-
ment of repetitive behaviour and a defect in the mechanism to inhibit or delay acting on these

* Tel.: +32-16-32-61-33; fax: +32-16-32-59-16.

E-mail address: laurence.claes@psy.kuleuven.ac.be

0191-8869/02/$ - see front matter # 2002 Elsevier Science Ltd. All rights reserved.
PII: S0191-8869(01)00071-X
708 L. Claes / Personality and Individual Differences 32 (2002) 707–714

behaviours. However, the driving mechanism behind the behaviours appears to be very different:
compulsive individuals may be hypervigilant and attempt to avoid harm and reduce anxiety or
discomfort associated with the rituals; in contrast, impulsive individuals are risk seekers who try
to maximise pleasure, arousal or gratification and who may exhibit antisocial behaviours. Biolo-
gically, there may be two specific mechanisms at work in OCSDs: both serotonin and frontal lobe
activity are increased in those individuals displaying compulsive behaviours, whereas impulsive
behaviours may be associated with decreased serotonin and frontal lobe activity (Hollander,
1998). Instead of the simplistic view that these difficulties are caused by too much or too little
serotonin, Brewerton (1995) hypothesised that a dysregulation of the serotonin system is more
consistent with the existing data that individuals can have both impulsive and compulsive features
simultaneously or at different times in the course of the same disorder.
Much has been written regarding the association between symptoms of the obsessive-compul-
sive disorder (OCD) and AN (e.g. Bastiani, Altemus, Pigott, Rubenstein, Weltzin, & Kaye, 1996;
Kaye, Weltzin, & Hsu, 1993) and the impulsive traits present in BN (e.g. Fahy & Eisler, 1993; Lacey,
& Evans, 1986; Kaye, Bastiani, & Moss, 1995). Some authors (e.g. Sohlberg, Norring, Holmgren, &
Rosemark, 1989) have suggested that the higher impulsivity in BN can be due to an underlying
borderline or another cluster B personality disorder. But several authors have also recognised
impulsive traits in AN subjects (particularly the bingeing-purging subtype) and OCD symptoms
in BN subjects (Aragona & Vella, 1998; Fahy & Eisler, 1993). These traits are of potential interest
for several reasons. First, it has been suggested that the presence of impulsive traits increase the
risk of a poor treatment outcome (Sohlberg et al., 1989) and a worse long-term prognosis (Fichter,
Quadflieg, & Rief, 1994) in BN patients. Secondly, the presence of compulsive traits may be
viewed as an indication for treatment with serotonergic psychotropics. Therefore, understanding
the obsessive-compulsive and impulsive aspects in individuals with eating disorders may help
guiding treatment or allowing for better prediction of outcome (Raymond et al., 1999).
Most studies have focused on either impulsivity or compulsivity, and most of the time they
have only compared subtypes of eating-disordered patients. Our purpose was to study both
impulsive and compulsive characteristics in three subtypes of eating-disordered patients com-
pared with ‘normal’ controls (without an eating disorder) in order to answer the following ques-
tions: (1) are we able to replicate the results of other researchers with respect to differences in
impulsive and compulsive traits in subtypes of eating-disordered patients? (2) If BN patients
indeed appear to be more impulsive than (restricting) AN patients, will these differences remain
after control for personality disorders (especially borderline personality disorder)? (3) Are
impulsivity and compulsivity mutually exclusive traits?

2. Method

2.1. Subjects

2.1.1. Patients
We collected data from 56 female inpatients admitted to a specialised unit for the treatment of
eating disorders. By means of a clinical interview and the Eating Disorder Evaluation Scale
(EDES; Vandereycken, 1993) patients were diagnosed according to DSM-IV criteria (American
 L. Claes / Personality and Individual Differences 32 (2002) 707–714 709

Psychiatric Association, 1994): 30% (n=17) as anorexia nervosa, restrictive subtype (AN-R), 32.1%
(n=18) as anorexia nervosa, bingeing-purging subtype (AN-P) and 37.5% (n=21) as bulimia nervosa
(BN). The mean Body Mass Index (BMI) were, respectively, 15.2 (S.D.=2.6), 17.3 (S.D.=1.2) and
27.4 (S.D.=11.8), and the average ages were 20.2 (S.D.=7.9), 19.2 (S.D.=6.1) and 22.0 (S.D.=5.0).
Questionnaires were completed at admission as a part of the routine assessment.

2.1.2. Controls without eating disorders

Data were also collected in a group of 112 female nursery students. If their score on the EDES
suggested the presence of an eating disorder (n=10), they were excluded from the control group.
The mean BMI of the students was 22.6 (S.D.=3.2) and their average age was 20.6 years
(S.D.=3.2). They filled out the questionnaires on a voluntary basis during a regular course.

2.2. Instruments

The Impulsivity Questionnaire (I7; Eysenck, Pearson, Easting, & Allsopp, 1985) is a 54-item
(yes/no format) questionnaire that measures three personality traits, impulsivity (19 items), ven-
turesomeness (16 items) and empathy (19 filler items). Impulsivity as measured by this instrument
is related to decision making without an awareness of risk, whereas venturesomeness describes
decision making with due consideration of risks and consequences. Impulsivity and venture-
someness are positively correlated. The instrument is known to have good reliability and derived
age norms. The I7 was translated into Dutch and re-translated into English by a native speaker of
English (Braspenning & Vertommen, 1999). Differences between the original version and the re-
translation were discussed in order to improve the quality of the Dutch translation.
The Leiden Impulsiveness Scale (State/Trait; R.J. Verkes, unpublished instrument) consists of
25 items, to be rated on a 4-point scale. Eleven items are supposed to measure impulsivity con-
ceived as a trait and were selected out of the I7 Impulsiveness Scale. On the other hand, 14 items
focus on impulsiveness as a state and ask which of several impulsive behaviours were shown
during the last week. The behaviours of interest are, for example, gambling, drinking too much
alcohol, fighting, self-mutilating, bingeing. The last behaviour has been left out of our analysis
because it already forms a part of the diagnostic criteria of eating disorders. Internal consistency
and test–retest reliability are known to be sufficient.
The Dutch translation of the Padua Inventory (PI; Sanavio, 1988; Van Oppen, 1992; Van
Oppen, Hoekstra, & Emmelkamp, 1995) consists of 60 items describing common obsessional and
compulsive behaviours. All items are rated on a 5-point scale from 0 (not at all) to 4 (very much).
Principal component analysis of the PI revealed two compulsion factors and two obsessional
factors. PI-1 refers to impaired control over mental activities (n=17), i.e. lower ability to remove
undesirable thoughts, difficulties in coping with simple decisions and doubts, ruminative thinking
about low probability dangers, etc. PI-2 assesses fear of becoming contaminated and excessive
handwashing (n=11), i.e. stereotyped cleaning activities, overconcern with dirt, worries about
unrealistic contaminations. PI-3 is about checking behaviours (n=8), i.e. checking doors, gas and
water taps, letters, money, numbers over and over again. PI-4 refers to urges and worries of losing
control over motor behaviours (n=7), i.e. urges of violence against animals or things, impulses to kill
oneself or others without reason, fear of losing control over antisocial or sexual impulses, etc. The
instrument is known to have good reliability and validity.
710 L. Claes / Personality and Individual Differences 32 (2002) 707–714

The Dutch ADP-IV questionnaire (Schotte, De Doncker, Vankerckhoven, Vertommen, &

Cosyns, 1998) consists of 94 Dutch items, which represent the 80 criteria of the 10 DSM-IV per-
sonality disorders and the 14 research criteria of the depressive and passive–aggressive personality
disorders in a randomised order. The ADP-IV produces a dimensional trait score and a catego-
rical personality diagnosis. The dimensional trait scores (which have been used in this study as
covariates) are computed by adding the item scores for each of the personality disorders sepa-
rately, for the three clusters of personality disorders (Cluster A: Paranoid, Schizoid, Schizotypal;
Cluster B: Antisocial, Borderline, Histrionic, Narcissistic; Cluster C: Avoidant, Dependent,
Obsessive-Compulsive) and for a total trait score. Reliability and validity of the instrument are good.

3. Results

Table 1 shows the mean scores and standard deviations on the impulsivity, the compulsivity
and the ADP-IV (sub)scales for the different subtypes of eating-disordered patients and controls.
ANOVAs were used to test the significant differences among the subgroups.

3.1. Impulsivity

Patients with BN showed higher impulsivity (state/trait) scores than patients with AN, but only
the differences between the AN-R and the BN groups are statistically significant, a finding which
is consistent with results of other authors (De Silva & Eysenck, 1987; Toner, Garfinkel, & Gar-
ner, 1987; Piran et al., 1988). Some authors (e.g. Sohlberg et al., 1989) have suggested that the
higher state/trait impulsivity scores of the BN patients can be due to an underlying borderline or
another cluster B personality disorder. Our data also show that BN patients have much higher
scores on the B-cluster Personality Disorders than the AN-R, the AN-P and the control groups.
To find out if the differences in state/trait impulsivity scores for the different subtypes of eating
disordered patients remain significant after controlling for the Cluster B personality disorders, we
performed ANCOVAs in which we used the dimensional Cluster B personality score as a control
variable. The results show that even after controlling for the cluster B personality disorders the
differences in the following impulsivity scores are still significant: I7-Imp (F=4.18, P<0.01), LIS-
state (F=3.62, P<0.05) and LIS-trait (F=4.50, P<0.01). Further, we found that BN patients
had higher impulsivity scores than controls without eating disorders, but that AN patients did
not differ significantly from the controls. With respect to the I7 score for venturesomeness we did
not find any significant difference between the four subgroups. Fahy and Eisler (1993), in con-
trast, found that BN patients had significantly higher I7-venturesomeness scores than the AN
patients. With respect to the I7-impulsivity score, we found the same result as Fahy and Eisler
(1993) indicating that BN patients are more impulsive than restrictive anorectics. However, this
does not mean that AN-R patients do not show any impulsive behaviour.

3.2. Obsessive-compulsive characteristics

The Padua Inventory focussed both on obsessive thoughts and compulsive behaviours. With
respect to obsessions (PI-1 and PI-4), we found significant differences between the different
 L. Claes / Personality and Individual Differences 32 (2002) 707–714 711

subtypes of eating-disordered patients and controls. BN patients reported more complaints about
their impaired control over mental activities (PI-1) and seemed to worry more about losing con-
trol over motor behaviours than AN-R patients and controls. The worries about losing control
over motor activities (e.g. aggressive and sexual behaviour) can probably be due to the fact that
BN patients — compared to AN-R patients — have already experienced themselves to be very
impulsive (as seen in their higher LIS-state scores). Focussing on the compulsive behaviours
‘washing’ and ‘checking’ we did not find significant differences between the different eating-dis-
ordered subgroups. However, the scores of the washing behaviour are in the expected direction,
namely AN-R patients being more compulsive than the AN-P and the BN groups. The fact that
the controls showed the highest scores on the washing subscale is not so surprising, knowing that
the control group comprised nursery students, for whom there is a real danger for contamination
and an obligation to wash their hands regularly (hygiene). With respect to the dimensional score
on the ADP-IV obsessive-compulsive personality disorder scale, only the controls differed sig-
nificantly from the other groups.

Table 1
Comparison of the mean scores (standard deviations) on the impulsivity, the compulsivity and the ADP-IV (sub)scales
for the different subtypes of eating-disordered patients and normalsa

Group 1 Group 2 Group 3 Group 4 F-test Scheffe’s post-hoc tests

AN-R AN-P BN Normals

Impulsivity
I7-Imp 5.7 (2.2) 7.9 (3.0) 8.5 (3.5) 7.0 (2.8) 3.2* 1<3
I7-Vent 8.5 (1.9) 7.5 (2.5) 7.1 (3.5) 8.2 (3.0) 1.1 n.s.
LIS-Trait 16.6 (4.2) 19.7 (6.6) 22.9 (7.4) 19.0 (3.4) 5.9*** 1 < 3, 4 < 3
LIS-State 19.0 (3.7) 23.1 (6.1) 27.1 (6.1) 18.3 (4.8) 19.46*** 1 <3,4 < 2, 4 < 3

Compulsivity
PI-1 19.4 (11.1) 26.0 (17.3) 33.3 (16.1) 15.0 (9.5) 16.2*** 4 < 2, 4 < 3, 1< 3,
PI-2 6.7 (6.9) 6.1 (5.3) 5.7 (5.6) 8.4 (6.9) 1.4 n.s.
PI-3 8.8 (7.6) 9.8 (8.4) 12.7 (10.5) 8.6 (6.8) 1.6 n.s.
PI-4 1.8 (3.0) 4.3 (5.4) 4.0 (4.3) 1.1 (1.8) 9.6*** 4 < 2, 4 < 3

Personality disorder
ADP-Cluster A 55.1 (18.7) 65.8 (24.9) 75.6 (24.8) 41.1 (15.2) 23.7*** 4 <1, 4 < 2, 4 < 3, 1<3
ADP-Cluster B 79.5 (19.9) 85.0 (32.7) 108.3 (29.4) 59.7 (20.5) 26.4*** 4 <1, 4 <2, 4 < 3, 1 < 3, 2<3
ADP-BPD 27.8 (8.1) 33.87 (15.6) 44.6 (13.1) 20.4 (9.1) 32.6*** 1 <3, 2 < 3, 4 < 3, 4<2
ADP-Cluster C 76.7 (29.2) 83.3 (31.1) 88.0 (23.5) 43.6 (16.5) 40.1*** 4 < 1, 4 < 2, 4<3
ADP-OCPD 28.3 (10.6) 29.0 (10.2) 29.3 (8.5) 15.2 (6.4) 35.4*** 4 < 1, 4 < 2, 4<3
a
I7-Imp, I7-Impulsiveness; I7-Vent, I7-Venturesomeness; LIS-Trait, Leiden Impulsivity Scale-Trait; LIS-State, Lei-
den Impulsivity Scale-State (without binge-item); PI-1, Padua Inventory-Impaired control over mental activities; PI-2,
Becoming contaminated; PI-3, Checking behaviours; PI-4, Urges and worries of losing control over motor behaviours;
ADP-BPD, ADP-Borderline Personality Disorder; ADP-OCPD, ADP-Obsessive-compulsive personality disorder.
*P< 0.05.
**P< 0.01.
***P< 0.001.
712 L. Claes / Personality and Individual Differences 32 (2002) 707–714

4. Discussion

Confirming the findings by other researchers (e.g. Sohlberg, 1991), we found impulsivity to be
associated with BN and AN-P. On the whole, these bingeing-purging anorectics seem to have
more in common with BN patients than with restricting anorectics, a finding which is consistent
with the results of other studies. Toner et al. (1987), for example, have reported that formerly
bingeing-purging anorectics made twice as many errors on a test for impulsivity as formerly
restricting anorectics. De Silva and Eysenck (1987) found BN patients to score higher than
restricting anorectics on psychoticism on the Eysenck Personality Questionnaire. Piran et al.
(1988) reported greater impulsivity on the Diagnostic Interview for Borderlines in AN-P than
AN-R patients. Sohlberg et al. (1989) have suggested that the higher impulsivity scores of the BN
patients can be due to an underlying borderline or another cluster B personality disorder. How-
ever, our data suggest that even after controlling for cluster B personality disorders, these results
remain significant; BN patients are more impulsive than restrictive anorectics. Further, our BN
patients and controls showed large differences on both state and trait impulsiveness measures, as
reported by Newton, Freeman, and Munro (1993). They found that impulsivity was increased in
BN patients compared to controls and that BN patients also exhibited more behavioural dys-
control than normal subjects.
With respect to cluster B personality disorders which are characterised by impulsiveness, we
found that normals show much lower scores than AN-R, AN-P and BN patients. Further, AN-P
subjects had significant lower scores than BN patients, a finding that is consistent with those of
Kennedy, Katz, Rockert et al. (1995).
When we focus on OCD symptoms as measured by the Padua Inventory, the results are equi-
vocal. BN patients obtained higher scores on both obsession subscales of the Padua Inventory
compared to AN-R patients and controls. These results were also found by Kaye (1997) who
noticed that AN-R patients, compared to BN, endorse very few sexual and aggressive obsessions
and show more compulsive behaviors related to cleaning activities. Further, Formea and Burns
(1995) showed that BN was more strongly related to obsessions than compulsions as measured by
the Padua Inventory. However, the obsessional subscales of this inventory have raised some
questions, more specifically because they appear to measure worry rather than just assessing
obsessions (Burns, Keortge, Formea, & Sternberger, 1996; Freeston, Ladouceur, Rheaume,
Letarte, Gagnon, & Thibodeau, 1994; Wells & Papageorgiou, 1998). Obsessions are considered
persistent ideas, thoughts, impulses or images that are experienced as intrusive and inappropriate,
and cause marked anxiety and distress (APA, 1994). Worry is considered to involve apprehensive
expectation about real-life concerns such as finances, relations, work, school, household chores,
and so on (APA, 1994). Thus, higher obsession scores in BN than AN patients can either be due
to a higher obsessionality or a higher degree of worry in the BN group or both. The issue of axis 1
comorbidity is far from resolved if one considers the large variety of research findings: 9–69% of
AN patients and 4–43% of BN patients have been found to meet criteria for OCD (e.g. Kaye,
1997; Thiel, Broocks, & Ohlmeier et al., 1995).
Unlike Wonderlich, Swift, Slotnick, and Goodman (1990), we have found no more obsessive-
compulsive personality disorders in AN patients than in BN patients. Again, in the research lit-
erature, the frequency of this axis 2 comorbidity varies greatly: from 3.3–60% in AN patients and
0–13% in BN patients. It is usually thought that the obsessive-compulsive personality disorder is
 L. Claes / Personality and Individual Differences 32 (2002) 707–714 713

more prevalent in AN than in BN patients (Aragona & Vella, 1998). Why the OCPD-subscale of
the ADP-IV in our study did not reveal this difference is not immediately clear; we have to men-
tion here the lack of research on the discriminant validity of this personality questionnaire.
However, the fact that BN and AN-P patients in our study seemed to be more impulsive and
showed more aggression-related obsessions, does not mean that these characteristics are totally
absent in the restricting anorectics. Our data appear to be consistent with the multiple lines of
evidence suggesting that impulsive and obsessional features may coexist in eating-disordered
patients. This supports the concept of the obsessive-compulsive spectrum disorders put forward
by McElroy et al. (1994). Brewerton (1995), in an extensive review of the topic, has proposed a
neurobiochemical mechanism to explain the existence of both types of symptoms in the same
patient. He hypothesised that patients with an eating disorder suffer from dysregulation of the
serotonergic system, instead of a simple increase or decrease in serotonergic activity as assumed
by Hollander (1998).

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