The Tridimensional Personality

Questionnaire in Eating Disorder Patients

Timothy D. Brewerton
Lisa D. Hand
Emmett R. Bishop, Jr.
(Accepted 21January1993)

The Tridimensional l'ersonality Questionnaire (TPQ! was developed to measure a variety of

personality variants on three biosoual dimensions, harm avoidance (HA), novelty seeking
(NS), and reward dependence (RO), which ,ire thought to be related to serotonin (5-HTJ,
dopamine (DA), and norepinephrinc> (NE! function, respectively. Patients with eating disorders have been reported to have abnormalities in all of these systems, as well as personality
variants described by these dimensions. We therefore administered the TPQ to 147 patients
with DSM-111-R defined eating disorders (110 bulimia nervosa [BNJ, 27 with anorexia nervosa /AN], and 10 with BN+AN) and compared their scores to those of 350 female controls. When significant, post hoc Bonferroni t tests were performed using alpha ~ 0.05. All
subtypes of eating disorder patients scored significantly higher on HA than controls (p -s
.0001, analysis of variance. Only patients with BN (AN! had significantly higher degrees
of NS (p -s .0001 ), particularly on the impulsiveness subscale (N52), although this may, in
part, be due to age. No significant dillerence.1 in total RO were found, although BN patients
scored lower on R03 (attachment vs. detachment) and higher on RD4 (dependence vs. independence) than controls. In addition, AN patients had significantly higher RD2 (persistence vs. irresoluteness) subscale scores. These data support a theory of 5-HT dysregulation
in both types of eating disorders and suggest that further research be done on the role of DA
and NE in BN. 1993 hy John Wiley & Sons. Inc.

Psychiatrists and psychologists have long sought a tool that would not only characterize behavioral aspects of personality in certain diagnostic groups but also provide leads
to the neurobiological system involved. One such tool is the Tridimensional Personality Questionnaire (TPQ) that was developed to measure three fundamental dimensions
of personality suggested to correlate with specific neurotransmitter functions. These di-

Ti~othy 0. Brewerton, M.D., is Associate Professor of 1-'sychiatry and Behavioral Sciences and Director, Eating
D_1sorder.s Program, Institute of P~ychiatry, MPdiral University of South C.:irolina. Lisa D. Hand, M.D., 1s Instructor
ot Psy(.h1atry ilnd Behavioral Sciences, MedKdl Univf'rsity of South Carolina, Charleston, South Carolina. Emmett
R. Bishop, Jr., M.D., ts Director, the Clark Center Eating Disorders Program, Memorial Medical Center Savannah
Ceorgia. Ad_dress reprint requests to Dr. 13rewt'rlon at l\1USC!lnstitute of Psychiatry, 171 Ashley Avpn~e, Charles~

ton, South Carolina 29425-0742.

International Journal of taring Disonlers, Vol. 14, No. 2, 211-218 (1993)

1993 by John Wiley & Sons, Inc

CCC 0276-3478/93/020211-06

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Brewerton et al.

mensions are defined in terms of the basic response characteristics of novelty seeking
(NS), harm avoidance (HA), and reward dependence (RD) with extreme variants of tridimensional combinations reflecting traditional descriptions of personality disorders
(Cloninger, 1986, 1987a, 1987b). Cloninger details these personality dimensions as well
as the neurochemical and psychopharmacological studies that support their correlation
with specific neurotransmitter systems in his proposal. He suggests that individuals
with high scores on NS tend to be impulsive, excitable, extravagant, quickly bored, and
ready to engage in new activities. This dimension is thought to be associated with low
dopaminergic (DA) activity. Those who score high on the HA dimension are characterized as cautious, tense, inhibited, shy, and easily fatigable and are theorized to have
increased activity in the serotonin (5-HT) system. High scores on RD are suggested to
be sensitive to social cues, persistent, sentimental, and prone to delay gratification if
eventual reward is expected. These traits are associated with low activity in the noradrenergic system (NE) (Cloninger, 1978b).
When integrated, these dimensions would reflect a constellation of personality traits
and their neurotransmitter correlates that should be able to delineate characteristic behavioral differences between a defined patient population and normal controls. If this
theory is valid, results of the TPQ might aid in both clarifying personality characteristics of certain diagnostic groups as well as suggesting the potential involvement of specific neurotransmitter systems.
Pfohl's work (Pfohl, Black, Noyes, Kelley, & Blum, 1990) using the TPQ in comparing patients with obsessive compulsive disorder (OCD) and controls suggested moderate validity in identifying behavioral differences that were consistent with clinical
experience and the tridimensional personality theory with OCD patients scoring high
on HA and RD.
Waller et al. (1991) noted high NS and HA and low RD scores in a group of 27 bulimic women. We extended these observations to a larger sample of bulimic and anorexic patients as well as women with both disorders in order to further determine the
relationship between eating disorder subgroups and TPQ scores.

METHODS
We administered the TPQ to a consecutive group of female Caucasian patients evaluated at either the Medical University of South Carolina Institute of Psychiatry Eating
Disorders Program (N = 40), or the Clarke Center Eating Disorders Program (N = 107)
with the DSM-III-R (American Psychiatric Association, 1987) defined eating disorders,
anorexia nervosa (AN) and/or bulimia nervosa (BN). The TPQ is a 100-item, selfadministered, true-false questionnaire that measures three higher-order personality dimensions as described above, including HA, NS, and RD. Each of these dimensions
has four subscales that are shown in Table 1. No demographic differences were seen
between the two groups, so they were combined into one group. One hundred ten
had BN, 27 had AN, and 10 had both disorders. The demographic characteristics are
shown in Table 1. For a comparison group we used TPQ scores from 350 Caucasian
female controls provided by Cloninger and reported in detail elsewhere (Cloninger, Przybeck, & Svrakic, 1991).
The scores for each parameter and its subscale were compared by diagnosis using an
analysis of variance (AN OVA) when appropriate. Post hoc comparisons were performed
using Bonferroni t tests. Given the significant difference in age between patients and

Tridimensional Personality

215

Table 1. The Tridimensional Personality

Questionnaire Scales and Subscales
Novelty seeking (NS)
NSl: exploratory excitability vs. stoic rigidity
NS2: impulsiveness vs. reflection
NS3: extravagance vs. reserve
NS4: disorderliness vs. regimentation
Harm avoidance (HA)
HAI: anticipatory worry vs. uninhibited optimism
HA2: fear of uncertainty vs. confidence
HA3: shyness with strangers vs. gregariousness
HA4: fatigability and asthenia vs. vigor
Reward dependence (RD)
RDl: sentimentality vs. insensitiveness
RD2: persistence vs. irresoluteness
RD3: attachment vs. detachment
RD4: dependence vs. independence

controls, an analysis of covariance (ANCOV A) using age as a dependent variable would

have been appropriate. However, this could not be done because the individual data
points for the controls were not available. Correlations between age and TPQ scales are
reported for the patients.

RESULTS
The results for all groups are shown in Table 2. Normal controls were significantly
older than the patients, regardless of diagnosis. All eating disorder groups scored significantly higher on the total score for the HA dimension than controls (p < .001),
whereas only those with BN (with or without AN) had significant elevations in their
total scores for the NS dimension (p < .0001). The RD scores were not significantly different between the eating disorder groups and the controls with the exception of the
subscales RD3 and RD4 on which bulimics scored significantly lower (RD3) and higher
(RD4) than controls (p < .0001), respectively. In addition, AN patients scored significantly higher than controls on RD2 subscale scores. Other differences in TPQ subscale
scores are shown in Table 2. Pearson correlation coefficients (r) between age and the
TPQ scales are as follows: NS (-0.14, p < .01), HA (0.13, p < .08,), RD (-0.07, p < .1).

DISCUSSION
In interpretating our results certain limitations must be taken into account. Most notably, the significantly greater age of the controls is problematic given that the three
dimensions, especially NS, correlate with age (Cloninger et al., 1991). In addition, data
were collected at intake and could be influenced by acute illness. Repeat assessments
at weight restoration and at clinical recovery is necessary to determine state vs. trait
characteristics.
Patients with AN, BN, or both disorders appear to differ significantly from the control population and from each other on the major dimensions of the TPQ. This is consistent with clinical presentation in which the disorders have some shared

Brewerton et al.

216
Table 2.

Mean TPQ Scores.

Bulimia Nervosa Anorexia Nervosa Bulimia + Anorexia
(BN)
(AN)
(BN +AN)
Normal Controls

Sample Size

110

27

10

350

Comments

Mean Age (SD)

25.4 8

24.6 11

29.5 7

45.3 18

Novelty seeking
Total
NS 1
NS2
NS3
NS4
Harm avoidance
Total
HS 1
HS 2
HS3
HS4
Reward dependence
Total
RD 1
RD2
RD3
RD4

18.1
5.1
3.8
4.2
4.9

5.6
2.1
2.2
2.1
2.1

12.9
4.0
2.5
3.2
3.2

5.6
2.2
2.3
2.0
1.9

18.3
4.5
4.5
4.6
4.7

5.2
2.0
2.5
1.0
2.2

13.0
4.3
2.2
3.2
3.2

4.9
2.0
1.7
1.7
1.8

b,c,d,e,f
g
b,d,e,f
b
b,c

20.0
5.8
5.1
4.2
4.9

7.5
2.8
1.8
2.3
2.9

21.3
6.3
5.3
4.6
5.1

7.5
3.0
1.8
2.5
3.0

19.6
5.3
4.9
4.4
5.0

6.8
2.3
1.6
2.0
3.1

12.9
2.6
4.7
3.0
2.5

6.1
2.1
1.7
2.1
2.4

b,c,d
b,c,d

20.4
4.2
6.1
6.5
3.6

3.9
1.1
2.1
2.8
1.2

19.7
4.4
6.7
5.6
3.0

5.0
0.8
1.5
3.1
1.2

18.9
4.2
5.4
6.1
3.2

4.1
1.1
2.0
2.5
0.8

20.1
4.3
5.6
7.2
3.0

3.8
0.9
2.0
2.2
1.2

b,c
b,c,d

i
g,h
b

Note. a = normal controls significantly higher than patients (p :5 .001); b = BN patients significantly higher
than controls (p :5 .0001); c = AN patients significantly higher than controls (p < .0001); d = BN + AN patients significantly higher than controls (p < .0001); e = BN patients significantly higher than AN patients
(p < .0001); f = AN patients significantly higher than BN + AN patients (p :5 .0001); g = BN patients significantly lower than controls (p :5 .004); h = AN patients significantly lower than controls (p :5 .001); i = AN
patients significantly higher than controls (p :5 .01).

characteristics, such as a gross disturbance in eating behaviors and overconcem with

body shape and weight, but also other distinctly different pathological features.
Our finding of high HA scores in all eating disorder patients is interesting, given that
they often appear to have clinical features suggestive of OCD (George et al., 1990; Kaye,
Gwirtman, George, & Ebert, 1991). High HA scores have been reported in OCD patients (Pfohl et al., 1990), and patients with AN have been noted to have high YaleBrown OCD Scale (Y-BOCS) scores (Kaye et al., 1991). Both disorders have been shown
to involve dysregulation of 5-HT function (Brewerton, Brandt, Lesem, Murphy, & Jimerson, 1990a; Brewerton, Murphy, Lesem, Brandt, & Jimerson 1990b; Brewerton et
al., 1992; Jimerson, Lesem, Kaye, & Brewerton, 1992; Zohar & Insel, 1987) and to respond to specific serotonergic agents (George et al., 1990a; Hollander, Mullen, Carrasco,
DeCaria, & Stein, 1992). Given that HA scale scores slightly increase with age, the difference in age between patients and controls is inconsequential. Taken together, these
data are consistent with Cloninger's theory that high HA is associated with altered 5-HT
function.
The patients with BN alone are characterized by high total NS scores, which theoretically may contribute to tendencies toward binge eating, purging, and perhaps other
impulsive behaviors. These findings are consistent with reports of NE abnormalities in
bulimic patients (George et al., 1990b; Kaye et al., 1990), although other studies suggest that impulsivity may also be related to 5-HT dysfunction (Brewerton et al., 1992;
Jimerson et al., 1992; Kaye et al., 1991; Asberg, Schalling, Traskman-Bendz, & Wagner,

Tridimensional Personality

217

1987; Linnoila et al., 1983). The age difference between patients and controls is more
likely to have influenced this difference in NS. However, NS scores decrease on the
average by only 1 point per decade (Cloninger et al., 1991). Therefore, age alone is unlikely to account for group differences.
Our results support Waller et al.'s (1991) finding of high HA scores and high NS scores
in bulimic patients. Although we did not find a significantly different total RD score in
BN, RD3 scores were significantly lower and RD4 scores were significantly higher in
BN patients compared to controls. In addition, AN patients had significantly higher RD2
scores than controls. Using a related instrument, Casper (1990) reported high HA scores
and low NS scores in a group of recovered restrictor AN patients at 8-year follow-up,
which is what Strober (1991) predicted in his theoretical discussion of neuroadaptive
traits. The reasons for these apparent differences following weight restoration are unknown but may reflect starvation-induced changes in personality, possibly mediated
via the NE system and others. It would be interesting to study other diagnostic groups
such as affective and anxiety disorders and compulsive overeaters in order to compare
these personality dimensions with those of anorexic and bulimic patients.
The authors would like to gratefully thank Dr. C.R. Cloninger for providing normative data and
Lou Frye for performing the statistical analyses.

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