Eating Disorders

European Eating Disorders Review
Eur. Eat. Disorders Rev. 16, 451462 (2008)
The Development of the Childhood

Retrospective Perfectionism
Questionnaire (CHIRP) in an
Eating Disorder Sample
Laura Southgate 1*, Kate Tchanturia 1,
David Collier 1 and Janet Treasure 2
1
Division of Psychological Medicine, Institute of Psychiatry, Kings College

London, UK
2
Department of Academic Psychiatry, Guys, Kings and St. Thomas Medical
School, London, UK
This investigation explored the prevalence and predictive value of

childhood obsessive-compulsive personality traits (OCPTs) in the
development of eating disorders (EDs) using a novel retrospective
questionnaire. To reduce bias associated with retrospective selfreport data, an identical informant version of the questionnaire was
also utilised. Substantial testretest and inter-rater reliabilities
were found for the questionnaire, as well as concordant validity
with the semi-structured interview from which it was derived.
Participants with an ED (n 246) endorsed more childhood behaviours reflecting OCPTs than the control group (n 89). This was
mirrored in the informant report data (n 93). The prevalence rate
for each OCPT in childhood was significantly higher in the total ED
sample compared to the control group. Both proband and informant reports of childhood traits predict the later development of an
ED according to a strong doseresponse relationship. The potential
utility of this measure in future retrospective and prospective
research studies is highlighted. Copyright # 2008 John Wiley &
Sons, Ltd and Eating Disorders Association.
Keywords:
eating disorders; risk factors; questionnaire development; perfectionism; inflexibility
INTRODUCTION
Distinct from obsessive-compulsive disorder
(OCD), obsessive-compulsive personality disorder
* Correspondence to: Dr Laura Southgate, PhD, Eating Disorders Research Unit (PO59), Institute of Psychiatry, Kings
College London, De Crespigny Park, SE5 8AF, UK. Tel: 0207
8480134. Fax: 0207 8480181.
E-mail: l.southgate@iop.kcl.ac.uk
(OCPD) is defined in DSM-IV as a pervasive

pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control (APA,
1994). The reported presence of such traits in
individuals with eating disorders (EDs) both
premorbidly and following recovery suggests these
are stable traits (Anderluh, Tchanturia, RabeHesketh, & Treasure, 2003; Kaye et al., 1998;
Lilenfeld et al., 2000; Srinivasagam, Kaye, Plotnicov,
Greeno, Weltzin, & Rao, 1995). The increased
Copyright # 2008 John Wiley & Sons, Ltd and Eating Disorders Association.
Published online 28 April 2008 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.870
L. Southgate et al.
452
prevalence of obsessive-compulsive personality
traits (OCPTs) amongst first-degree relatives of
individuals with EDs and their pattern of transmission highlights their potential aetiological significance (Lilenfeld et al., 1998; 2000).
It is generally accepted that premorbid personality can be involved in the development
and expression of psychiatric disorders (Duggan,
Milton, Egan, McCarthy, Palmer, & Lee, 2003). In a
systematic review of risk factor research in ED
(Jacobi, Hayward, de Zwaan, Kraemer, & Agras,
2004) OCPTs that developed in childhood were
identified as medium potency risk factors. The
importance of these premorbid features emphasises the need for a reliable measurement tool
that could be used to screen for phenotypic
traits in childhood and for use in prospective
longitudinal research. With this goal in mind,
we developed a short retrospective self-report
measure of childhood OCPT, utilising items
from the EATATE semi-structured interview
assessment of these traits (Anderluh et al., 2003).
To minimise the biases associated with retrospective self-report data and also to test methodology suitable for informant reports in childhood,
we also developed an informant report version of
the questionnaire.
The aims of the current study were to investigate
the psychometric properties of this novel retrospective questionnaire; to explore the prevalence
and predictive validity of premorbid traits suggestive of obsessive-compulsive personality, in a large
sample of females with a lifetime history of either
anorexia nervosa (AN) or bulimia nervosa (BN)
based upon both self and informant report data; and
to retrospectively examine the relationship between
childhood OCPTs and the development of an ED.
The construct validity of this measure relied on the
involvement of ED experts, including individuals
with a personal experience of an ED, in its development (see Anderluh et al., 2003). The reliability of
the questionnaire was explored through the
measurement of testretest and inter-rater reliability. The informant report questionnaire consisted of
identical items to the proband version that related to
clearly observable behaviours. Concurrent validity
was evaluated by comparing the data obtained from
the questionnaire with that elicited in the EATATE
semi-structured interview, from which the questionnaire was derived.
In line with prior studies of childhood OCPTs
in women with EDs (Anderluh et al., 2003;
Gillberg, Rastam, & Gillberg, 1995; Karwautz,
Rabe-Hesketh, Collier, & Treasure, 2002), our
hypotheses were that participants with a history

of an ED would report a greater endorsement of
behaviours associated with OCPTs in childhood
than a sample of non-clinical control participants
and that these traits would be apparent to
informants.
METHOD
Participants
Two hundred and forty-six female participants with
a lifetime history (thus including individuals at
acute and recovered illness states) of AN (n 170)
or BN (n 76) were recruited from clinical settings
(inpatient and outpatient services) and the community, by way of a volunteer database maintained
by the eating disorder research unit at the Institute
of Psychiatry, London. In order to join the database,
individuals are required to provide baseline information with regards to their current and lifetime
symptom history, taking into account duration and
severity. Lifetime diagnoses were determined for
each participant based upon knowledge of current
and past diagnoses and were assigned according to
a formal diagnostic hierarchy, ensuring that their
full range of pathology was taken into account
(Kaye et al., 2000; Lilenfeld et al., 1998). For example
if participants had pure histories of AN (incorporating all sub-types) or BN (bingepurge behaviour
with no history of low weight) they were given that
lifetime diagnosis as appropriate. If a participant
had a symptom history containing discrete episodes
of AN and BN, they were given the lifetime
diagnosis of BN.
The control group consisted of 89 females who did
not have a history of an ED, recruited from the local
community.
Ninety-three informants also took part in this
study, limited to one informant per proband. They
consisted of family members or close friends of the
probands recruited into the study, who were invited
by the proband to complete (independently) an
informant version of the CHIRP questionnaire.
This study was approved by the South London
and Maudsley NHS Trust and the Central and
North West London NHS Trust Research Ethics
Committees. Information sheets describing the
study were provided along with freepost envelopes
with which to return the questionnaires. The return
of questionnaires was taken to imply participant
consent in the study.

DOI: 10.1002/erv
Childhood Personality Traits in EDs
Materials
Diagnostic measures As participants were recruited
by different means, two diagnostic instruments were
used to assign diagnoses. A common factor for each
measure was that they assessed and allocated ED
diagnoses according to DSM-IV criteria.
The EATATE interview, part 1 (Anderluh et al.,
2003). Participants who had completed the questionnaire as part of another ongoing study in the
research unit had their current and lifetime
diagnoses determined using the EATATE interview. This is a semi-structured clinical interview
based upon the Eating Disorders Examination
(Fairburn & Cooper, 1993) but adapted to assess
lifetime symptoms of ED following the Longitudinal Interval Follow-up Evaluation (Keller, Lavori, &
Friedman, 1987).
The eating disorder diagnostic scale (EDDS; Stice,
Telch, & Rizvi, 2000). The EDDS is a one page
self-report questionnaire that can distinguish
between full and sub-threshold diagnoses of AN
and BN, (Stice et al., 2000; Stice, Fisher, & Martinez,
2004). This diagnostic screen was sent to members
of the volunteer database along with the retrospective childhood OCPTs questionnaire.
453
the use of pronouns to denote the proband as the
reference for the responses. The informant had to be
someone who had good knowledge of the proband
in childhood (e.g. parent, sibling, good friend). This
was determined by eliciting the relationship
between the informant and the proband and the
number of childhood years (up to 12) that they had
known the proband. Informants are also asked to
rate as a percentage, how reliable they would
consider their answers to be.
The EATATE interview, part 2 to explore concordant

validity (Anderluh et al., 2003). This section of the
EATATE interview (from which the CHIRP questionnaire was derived), was developed by academics, clinicians and personal experts (service
users) in the area of EDs, to assess five childhood
traits that reflect obsessive-compulsive personality;
perfectionism, inflexibility, rule driven, excessive doubt and cautiousness and drive for order
and symmetry. The presence of each trait and its
effect on the childs life in terms of relationships
with the world and others, was assessed and rated
according to a manualised scoring system; 0 for
absent, 1 for present but not influencing the childs
life or 2 for the presence of a trait that impinges on
the childs life.
Procedure
Childhood obsessive-compulsive personality traits

The childhood retrospective perfectionism questionnaire (CHIRP)self-report version. This 20-item
questionnaire requires a yes/no answer to assess
the presence of variety of behaviours in childhood
believed to be typical of OCPTs. Childhood is
explicitly defined as being up to 12 years of age to
ensure that the behaviours assessed were present
during a time preceding the onset of an ED for the
vast majority of the clinical population (Fairburn &
Harrison, 2003). Questionnaire items refer to
perfectionist tendencies (with regards to school
work, self-care/appearance, order/tidiness and
hobbies), childhood caution, rule bound behaviour
and rigidity, in order to screen for the childhood
traits of global perfectionism, inflexibility and
need for order and symmetry.
The childhood retrospective perfectionism questionnaire (CHIRP)informant report version. The
informant questionnaire consists of identical items
as found in the proband version, differing only in
Members of the volunteer database were sent a copy

of the self- and informant report CHIRP questionnaire, along with instructions on how to
complete them. Participants taking part in ongoing
studies in the department were also asked to fill out
a questionnaire and were invited to take home
an informant version to give to an appropriate
informant. To maintain participant confidentiality,
investigators did not have any direct contact with
the informants, hence the recruitment of informants
was reliant on the proband. Within the study
instructions, probands and their informants were
asked to ensure that they complete their questionnaires individually and separately to minimise
any influence in their responses. Separate freepost
return envelopes were provided to emphasise this
point.
Scoring the CHIRP Questionnaire

Each questionnaire was scored according to the
following dimensional and categorical scoring
procedures.

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L. Southgate et al.
454
Proband questionnaire
A scoring system was designed to provide an
overall dimensional questionnaire score and to
obtain categorical childhood trait scores. The
dimensional score represented the number of
behaviours that each participant endorsed as being
relevant to them in childhood. Simply, every yes
response received a score of 1 and the total summed
(question 6c reversed scored). The endorsement of
particular behaviours was taken to reflect the
presence of specific traits. Table 1 details the
childhood traits assessed, the behaviours measured
to determine the presence or absence of these traits
and the scoring protocol. The scoring procedure
was kept as close as possible to that of the interview
used by Anderluh et al. (2003). The nature and the
quantity of traits present (03) was determined in
this way for each participant.
Informant questionnaire
The same scoring systems as used for the proband
questionnaire, were employed with the informant
questionnaire to (a) derive a dimensional score to
represent the number of behaviours relating to
obsessive-compulsive personality that was relevant
each proband and (b) produce an overall OCPT
score (03).
behaviours endorsed). Cohens k analyses investigated the inter-rater and testretest reliabilities based
on the presence/absence of each individual trait
assessed (perfectionism, inflexibility and symmetry), with weighted ks to determine the reliability
for the total number of childhood traits endorsed.
Between group analyses for normally distributed
continuous variables were conducted using oneway ANOVA with Bonferroni post-hoc analyses
where appropriate. Where the assumptions of
parametric testing were violated, non-parametric
tests were used; Kruskal Wallis to test for main
effects and MannWhitney U-tests for pairwise
analyses, applying Bonferroni correction procedure
to correct for multiple testing. x2 analyses explored
the prevalence of the childhood traits across the ED
and control participants. The association between
childhood personality features and the development of an ED was determined using logistic
regression analyses, with ED status as the dependent variable and (1) total CHIRP questionnaire
score as the independent (predictor) variable, (2)
total number of childhood traits present (03) as the
independent variable. Analyses were performed on
both the self-report and witness data, using
two-tailed tests with a 5% level of significance.
Analyses were conducted using SPSS version 12
and STATA 8.0.
Statistical Analysis
The psychometric properties of the CHIRP questionnaire were determined using intra-class correlation coefficients to explore testretest reliability
and inter-rater reliability, based upon the total
questionnaire score (representing the number of
RESULTS
Psychometric Properties of the Questionnaire
Complete reports were collected from 77 proband
informant participant pairs. The majority of
Table 1. Childhood traits reflecting obsessive-compulsive personality as measured by the CHIRP questionnaire
OCP trait
Behaviour assessed relevant to trait
Questionnaire scoring protocol
Perfectionism
Perfectionism is assessed separately in

four areas of the childs life:
School work
Self care (appearance)
Looking after room
Hobbies (including caring for pets)
Inflexibility is assessed by exploring
the presence of:
Rigid behaviours (i.e. finding periods
of transition difficult, making
detailed plans)
Rule-bound behaviours (excessively
careful to obey rules)
Drive for order and symmetry is assessed in
two areas of the childs life:
Appearance (clothes or hair)
Looking after room
The trait was regarded to have been present

if at least one behaviour was endorsed in any
two of the four perfection domains
Inflexibility
Drive for order

and symmetry

if any behaviour relating to childhood rigidity
and any childhood rule-bound behaviour was
endorsed. At least one behaviour had to be
endorsed in both the rigidity and rule
bound domains
if relevant behaviours were endorsed in both
the areas of life investigated

DOI: 10.1002/erv
455
Table 2. Reliability and validity analyses based upon the dimensional scoring procedure
Psychometric property
Testretest reliability
Inter-rater reliability
Concurrent validity
Sample size
Intra-class correlation
coefficient
95% CI
59
77y
81
0.73
0.60
0.60
0.580.83
0.440.73
0.450.73
Agreement rating
Substantial
Substantial
Substantial

y
Landis and Koch (1977).

Probandinformant pairs.
informants were parents (77%) with the remaining

being siblings (12.7%), other relatives (4.8%) and
friends (4.8%). Informants knew the proband well
throughout the whole of childhood (median 12
years, mode 12 years) and estimated their reports
to be highly reliable (median reliability as a
percentage 92%, inter-quartile range 20%).
Fifty-nine probands completed the questionnaire
at two separate time points in order to investigate
testretest reliability. The mean duration between
questionnaire completions was 5.99 months (2.35).
In order to assess concurrent validity 81 probands
had taken part in the semi-structured EATATE
interview (part 2; Anderluh et al., 2003) prior to
completing the CHIRP questionnaire. Having been
audio taped, 30 interviews were randomly picked to
be re-rated by an assessor blind to participant
diagnosis and the previous scores provided by the
interviewer. A very high correlation between the
two raters scoring was found (r 0.96, 95% CI:
0.920.98), highlighting the reliability and consistency of the interview data used in this current
study.
Table 2 displays the results of the reliability and
validity analyses based upon the dimensional
scoring procedure, conducted using intra-class
correlation coefficients. The substantial to large
(Landis & Koch, 1977) correlation coefficients
reported support the utility of this questionnaire.
Table 3 displays the results of the reliability and

validity analyses based upon the categorical scoring
procedure, conducted using Cohens k analyses
(weighted and unweighted). Fair to substantial
agreement between scores derived from differing
time points (testretest reliability), informants
(inter-rater reliability) and data collection formats
(concurrent validity) were found.
Prevalence of Childhood OCPT

Total questionnaire score (dimensional analyses)
based on self- and informant report data
Complete reports were collected from 93 informants (related proband diagnostic category: control
n 28, AN n 45, BN n 20). The majority of
informants were parents (72.8%) with the remaining
being siblings (18.5%), other relatives (3.3%) and
friends (4.3%). Informants knew the proband well
throughout the whole of childhood (median
12 years, mode 12 years) and estimated their
reports to be highly reliable (median reliability as a
percentage 95%, IQR 15%).
Table 4 displays participant descriptive statistics
according to lifetime ED group, thus containing
individuals in acute and recovered illness states.
Age differences were found, the participants with
lifetime BN being significantly older than the
control and AN groups. Correlational analyses
Table 3. Reliability and validity analyses for the total data set based upon the categorical (trait) scoring procedure
Trait
Child Perfectionismy
Inflexibilityy
Drive for order and symmetryy
Total number of traits (03)z

y
z
Testretest
reliability (n 59)
0.46
0.67
0.49
0.54
p < 0.001
p < 0.001
p < 0.001
p < 0.001
Inter-rater
reliability (n 77)
Concurrent
validity (n 81)
0.28 p < 0.01

0.43 p < 0.001
0.35 p < 0.001
0.34 p < 0.001
0.30 p < 0.001

0.38 p < 0.001
0.61 p < 0.001
Probandinformant pairs.
Unweighted k analysis.
Weighted k analysis.

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456
Table 4. Participant characteristics and total CHIRP questionnaire score (based on self- and informant report data)
Self-report
Age
BMI
CHIRP total
Informant report
CHIRP total
Control
n 89
AN
n 170
BN
n 76
F
(df 2, 332)
Pair-wise
comparisons
29.13 (9.40)
22.23 (2.47)
30.87 (11.47)
17.33 (2.80)
33.71 (11.99)
21.06 (3.64)
3.42
88.87
<0.05
<0.001
3.64 (3.48)
9.54 (4.57)
9.57 (5.12)
57.75
<0.001
C<BN p < 0.05

AN < C p < 0.001
BN < C p < 0.05
AN < BN p < 0.001
C < AN p < 0.01
C < BN p < 0.01
Control
n 28
AN
n 45
BN
n 20
F
(df 2, 90)
Pair-wise
comparisons
4.04 (3.69)
9.31 (4.48)
9.25 (4.48)
9.91 (df 2, 90)
<0.001
C < AN p < 0.01

C < BN p < 0.01
Bonferroni post-hoc tests. Results confirmed with non-parametric MannWhitney analyses with Bonferroni adjustment of the a level
( p < 0.017).
(Spearmans and Pearsons) were performed to

determine the relationship between age and CHIRP
questionnaire total score. No significant relationship was found; hence this variable was not
required to be entered into the subsequent analyses
as a covariate. As expected, lifetime AN participants
had significantly lower current BMIs than the other
participant groups. According to the self-report
data, control participants had significantly lower
total scores on the CHIRP questionnaire compared
to those with a lifetime history of AN or BN, sharing
similar scores. The pattern of results using the
informant reports mirrored that of the self-report
scores.
The presence of childhood traits (categorical analyses)

based upon self- and informant report data
The prevalence of OCPTs in childhood determined by self- and informant reports and the odds
ratios comparing the total ED group and the control
participants are displayed in Table 5. The proportion of participants endorsing the presence of
each of the three childhood traits was significantly
higher in the ED group compared to the control
group. A significantly higher proportion of informants for the ED participants endorsed the
presence perfectionism and inflexibility in their
subjects during childhood compared to the control
informants.
The relationship between OCPTs in childhood and
the development of an eating disorder
Based upon proband self-report (n 335) and
informant report (n 93) data, logistic regression
analyses were conducted to determine the discriminant validity of the CHIRP questionnaire. With
participant diagnostic category (lifetime ED or
control participant) as the dependent variable and
total questionnaire score (dimensional analyses) as
the predictor variable, both proband questionnaire
scores (l2 (1) 63.76, p < 0.001, OR 1.38, 95% CI
1.271.49) and witness questionnaire scores (l2
(1) 13.53, p < 0.001, OR 1.28, 95% CI 1.121.47)
could accurately predict participant diagnostic
category.
Similarly with the number of OCPTs endorsed
(03) as the predictor variable, both the proband
reports (l2 (1) 63.64, p < 0.001, OR 3.93, 95% CI
2.815.49) and witness reports (l2 (1) 12.05,
p 0.001, OR 2.79, 95% CI 1.564.97) were found
to be significant predictors of ED status. Thus the
strongest doseresponse relationships for the development of an ED were found when using the
questionnaire data categorically.
DISCUSSION
The aims of the current study were threefold; (1) to
investigate the psychometric properties of a novel
retrospective questionnaire measure of childhood
personality traits; (2) to investigate the prevalence of
childhood OCPTs in adults with a lifetime history of
an ED, measured by self- and informant report
questionnaires and (3) to determine the strength of
the relationship between OCPTs in childhood and
the development of an ED.

DOI: 10.1002/erv
457
Table 5. Prevalence of childhood traits reflecting obsessive-compulsive personality among participants with a history
of an ED and controls
x2 statistic
(ED vs. C)
Participant group
(lifetime diagnoses)
Self-report
Perfectionism
Inflexibility
Symmetry
Informant report
Perfectionism
Inflexibility
Symmetry
p-value
Odds ratio
(95% CI)
AN (n)
BN (n)
ED (n)
Control (n)
df 1
78.20% (129)
71.30% (117)
18.25% (31)
71.20% (52)
73.00% (54)
22.40% (17)
76.10% (181)
71.80% (171)
19.50% (48)
34.80% (31)
18.00% (16)
2.20% (2)
48.27
76.78
15.34
<0.001
<0.001
<0.001
6.00 (3.5010.07)
11.59 (6.3221.44)
12.00 (2.5144.37)
68.90% (31)
55.60% (25)
11.10% (5)
70.00% (14)
55.00% (11)
10.00% (2)
69.20% (45)
55.40% (36)
10.80% (7)
35.70% (10)
14.30% (4)
3.60% (1)
9.10
13.49
1.29
0.003
<0.001
>0.05
4.02 (1.6010.32)
7.29 (2.3223.90)
3.00 (0.3827.82)
Assumption of x2 violated therefore significance value determined using fishers exact test. 95% CI 95% confidence interval.
By comparing retrospective self-report data

obtained by questionnaire to that obtained by
interview and witness reports, our exploration
highlighted adequate testretest and inter-rater
reliability and concurrent validity. The foremost
limitation in retrospective research is the potential
for memory bias, calling into question the reliability
of self-report measures in particular. As a consequence, informant reports and semi-structured
interviews are considered to be the most valid
methods of such data collection. Therefore when
judged against these quality standards, this novel
measure of childhood personality appears to have
some utility.
The results of the between group analyses were in
accordance with the hypotheses that (a) participants
with a history of an ED would report a greater
endorsement of OCPT related behaviours in childhood than a sample of healthy control participants
and (b) these traits would be apparent to informants. Participants with an ED had a significantly
greater experience of OCPT in childhood than the
control participants and a doseresponse relationship was found with the three traits (perfectionism,
inflexibility and need for order and symmetry) and
the development of an ED. The informant report
data generally mirrored the findings of the selfreport data; the only difference being the reduced
prevalence of the trait drive for order and
symmetry as reported by the informants of the
ED probands. Behaviour related to this trait may be
less observable to others than perfectionism and
inflexibility. The majority of informants who
completed the witness questionnaire were parents,
the second most frequent probandinformant
relationship being siblings. This close relationship
enhances the likelihood that the informant provided
a reliable account of the proband during childhood

(Ready, Clarke, Watson, & Westerhouse, 2000).
Informants reported close contact with the proband
for all of their childhood years, allowing responses
to be based on a longitudinal perspective of the
individuals behaviour in a variety of different
contexts, thus providing confidence in the results of
this study (Zimmerman, 1994).
In comparison to our previous findings using a
semi-structured interview (Anderluh et al., 2003)
the prevalence of OCPTs in childhood did not differ
between the AN and BN participants and the
magnitude of increased risk associated with the
presence of each childhood trait found was smaller.
Two explanations may account for these discrepancies. Firstly, the use of an interview has the
advantage of eliciting greater detail, allowing
superior diagnostic sensitivity and specificity.
Secondly, compared to the exclusively clinical
sample recruited in the former study, the participants in the current study were recruited from both
clinical settings and from our volunteer database,
potentially representing individuals with less
severe EDs and associated personality pathology.
The results from this study concord with the overall
literature. Childhood personality traits relating to
perfectionism, inflexibility/rigidity and the drive for
order and symmetry were associated with the
development of both AN and BN (Anderluh et al.,
2003; Fairburn, Welch, Doll, Davies, & OConnor,
1997; Fairburn, Cooper, Doll, & Welch, 1999;
Rastam, 1992). Thus OCPTs are reflective of
vulnerability factors for both disorders, the similarity of premorbid features being in line with the
similarity in enduring traits found in individuals
upon recovery (Matsunaga, Kaye, McConaha,
Plotnicov, Pollice, & Rao, 1998; Srinivasagam

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L. Southgate et al.
458
et al., 1995). The fact that the findings reported here
were comparable with the consensus in the
literature, endorses the criterion validity of this
novel measure.
The inter-rater reliability based upon the presence/absence of each individual trait was smaller
than the agreement found when utilising the
dimensional score. These findings are typical
(Kraemer, Noda, & OHara, 2004), being found in
previous literature investigating self-informant
concordance regarding the presence of personality
traits and disorders (Bernstein et al., 1997; Riso,
Klein, Anderson, Ouimette, & Lizardi, 1994). Overall, the inter-rater concordance reflects an absence of
self-presentation biases in the ED participants,
defending the reliability of self-report data with
this clinical group.
The concordance of the data obtained from the
retrospective questionnaire with that determined
from the EATATE semi-structured interview,
confirmed the utility of this questionnaire as a
quick and easy measure of childhood personality
traits, allowing a large participant sample to be
tested. Whilst the use of the EATATE interview has
the advantage of eliciting greater detail and thus
allowing superior diagnostic sensitivity and specificity, its limitations lie in the time and costs
associated with interviewer training and administration. Literature suggests that OCPTs increase
individual vulnerability towards the development
of an ED. To confirm this, longitudinal prospective
risk factor studies are required (Jacobi et al., 2004),
research which is difficult and costly to conduct,
especially in EDs due to the relatively low incidence
of disorder. The potential for such research is made
increasingly possible with this quick and simple
questionnaire that reliably measures the construct
under study.
The instability of the ED diagnostic categories
poses a problem for research. This study utilised a
trait approach to diagnostic classification, following
a symptom hierarchy to derive lifetime diagnoses
for each ED participant. This methodology makes a
substantial attempt to overcome some of the short
comings associated with the conceptualisation of
current diagnoses, including their temporal
instability, the problem of state versus trait and
the heterogeneous nature of the phenotypes. Thus,
whilst the diagnosis of eating disorder not otherwise specified (EDNOS) is commonly found in the
clinical setting (Fairburn & Bohn, 2005) and may
have been a relevant current diagnosis for some
participants included in this study, EDNOS as a
lifetime diagnostic category was not relevant as
each participant had previously met DSM-IV

diagnostic criteria (APA, 1994) for either AN or
BN at some point in their lifetime. Following the
lifetime diagnostic approach (taking an individuals
full symptom profile into account), a diagnosis of
AN or BN trumps that of EDNOS. Further research
is required to explore the prevalence of OCPTs in
individuals with subthreshold EDs or EDNOS.
A limitation of this instrument was that the
reliability of the categorical subscales was low
compared to that of the dimensional score. There is
always a tension between increasing the reliability
of factors by expanding the number of items and the
burden this imposes on subjects. We opted to
minimise the burden as we wanted an instrument
that could be used broadly in longitudinal studies.
Furthermore, it is not clear as to the extent to which
the data obtained may be generalised to the ED
population as a whole. Members of the volunteer
database cannot be considered a true community
sample due to the self-selected nature of such
individuals. Participants recruited from adult
treatment settings have undergone a different
selection process. Participants from the volunteer
database were tested approximately 15 years
following the onset of the illness. Two limitations
arise from this. First, a large proportion of
cases may have had a long duration of illness.
OCPTs have been recognised to be a factor
maintaining the illness, (Carter, Blackmore, Sutandar-Pinnock, & Woodside, 2004; Skodol et al., 2004;
Steinhausen, 2002; Wentz-Nilsson, Gillberg, Gillberg, & Rastam, 1999) and so these traits may be
over represented. Second, the longer time elapsed
between these distant events may make it less easy
to distinguish premorbid traits from those that arise
secondary to the ED. It will be interesting to use this
measure in adolescent cases and to examine
whether it does predict prognosis. It is acknowledged that the use of two different diagnostic
screening methods is not ideal, however this
enabled the recruitment of a large clinical and
control participant sample.
Whilst the current study identified childhood
OCPTs to be retrospective correlates of EDs in
general (as no significant differences were found
between AN and BN participants) a psychiatric
control group was not included thus it is still to be
determined as to whether the traits explored here
reflect specific vulnerability towards ED psychopathology or generic factors involved in a variety of
psychiatric disorders. The current results need be
confirmed in prospective longitudinal studies, the
gold standard for risk factor research (Kazdin,

DOI: 10.1002/erv

Kraemer, Kessler, Kupfer, & Offord, 1997). However, the association between these premorbid traits
and the later development of an ED highlight
features of psychopathology that would benefit from
therapeutic intervention. The use of this questionnaire as a brief screen in clinical settings would aid
the development of individualised treatment
packages, potentially enhancing treatment efficacy.
In conclusion, this study represents an important
and necessary step in the exploration of OCPTs as
endophenotypes of EDs. These traits warrant future
study in a longitudinal design to establish definitive
risk factor status. The fact that our novel measure
yielded consistent results with existing literature
regarding the presence and importance of premorbid OCPTs in EDs, endorses its use in future
retrospective and prospective research studies and
its potential in clinical settings.
ACKNOWLEDGEMENTS
The authors would like to acknowledge Sara Morgan for her help in re-rating the EATATE interviews
used in the assessment of concordant validity and
thank all those who participated in this research.
Support for this work has been received from the
Nina Jackson Research Into Eating Disorders (RIED)
in conjunction with the Psychiatry Research Trust
(registered charity no. 284286), The Wellcome Trust,
BIAL foundation (grant nos. 88/02: 61/04) and the
European Commission Framework 5 Project Factors in Healthy Eating QLK1-1999-916.
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APPENDIX A: THE CHILDHOOD

RETROSPECTIVE PERFECTIONISM
QUESTIONNAIRE (CHIRP) PROBAND
VERSION
Permission is given for the questionnaire to be used
but it should not be modified without written
permission from the authors.
Name . . .. . .. . .. . .. . .. . .. . .. . .. . .. Date . . .. . .. . .. . .. . .
Please think back to the time when you were a
child, up to the age of 12 years. Then judge if the
following behaviours described you at that time.
461
However only judge if a behaviour was present if
you:
EITHER took longer than others doing things
because of attention to detail or high standards
and if in your judgement this interfered with
other activities (e.g. leisure time, school or hobbies)
OR this behaviour was so extreme that other
people (e.g. siblings, relatives, friends, teachers)
commented on it
I estimate that my account is . . .. . .. . .. . .. . ..% reliable (where 0% is not at all reliable and 100% is perfect).

DOI: 10.1002/erv
L. Southgate et al.
462
APPENDIX B: THE CHILDHOOD

RETROSPECTIVE PERFECTIONISM
QUESTIONNAIRE (CHIRP)
INFORMANT VERSION
Permission is given for the questionnaire to be used
but it should not be modified without written
permission from the authors.
Subject/Childs Name...........................Completed
by. . .. . .. . .. . .. . .. . .. . ..Date.........................
In the following questions we are interested in
certain behaviours that may have been relevant to
your child up to the age of 12. We ask you to only

judge a behaviour as being present in your child if
they:
EITHER took longer than others doing things
because of attention to detail or high standards
and if in your judgement this interfered with
other activities (e.g. leisure time, school or hobbies)
OR this behaviour was so extreme that other
people (e.g. siblings, relatives, friends, teachers)
commented on it
I estimate that my account is . . .. . .. . .. . .. . ..% reliable (where 0% is not at all reliable and 100% is perfect).

DOI: 10.1002/erv

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European Eating Disorders Review

Eur. Eat. Disorders Rev. 16, 451462 (2008)

The Development of the Childhood

Division of Psychological Medicine, Institute of Psychiatry, Kings College

This investigation explored the prevalence and predictive value of