Simulating Eating Disorder Patients with LLMs: Evaluating Psychological Persona Stability in Multi-Turn Conversations
For researchers using LLM patient simulations, this reveals a critical validity gap: models lack a 'missing middle' of moderate pathology, limiting their use for clinical training and research.
LLM-based simulations of eating disorder patients show high persona stability but systematically overshoot ground-truth severity by 12-30% of the scale range, failing to represent moderate clinical presentations due to selective stereotyping.
Large language model (LLM)-based simulations of clinical patients are increasingly used for research and training, yet their validity requires persona stability: coherent maintenance of an assigned psychological profile across and within conversations. We evaluate this prerequisite using eating disorder personas grounded in five published case vignettes, a dual-assessment framework (self-report + independent observer ratings), and validated psychometric instruments (EDE-Q) with known ground-truth scores. Across six LLMs and two experiments (between-conversation stability (Exp. I) and within-conversation stability (Exp. II)), we find that LLMs are paradoxically too stable and too inaccurate: variability is negligible, yet all models systematically overshoot ground-truth severity by 12-30% of the scale range (0.7-1.8 points on a 0-6 scale). The mechanism is selective stereotyping: models differentiate cases on behavioural items (dietary restraint) but maximise cognitive-affective items (body dissatisfaction, weight preoccupation) at ceiling regardless of case severity. Additional conversational context does not improve accuracy; it compounds the overshoot. LLMs can portray severe eating pathology but lack a representation of moderate clinical presentations, a "missing middle".