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Psychosocial variables of eating disordered women : assertiveness, intimate relationships, interpersonal… Silverton, Toby Irene 1988

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PSYCHOSOCIAL VARIABLES OF EATING DISORDERED WOMEN ASSERTIVENESS, INTIMATE RELATIONSHIPS, INTERPERSONAL DISTRUST, AND SOCIAL SELF-ESTEEM by TOBY IRENE SILVERTON B.A., University of B r i t i s h Columbia, 1985 A THESIS SUBMITTED IN THE REQUIREMENTS MASTER PARTIAL FULFILMENT OF FOR THE DEGREE OF OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept t h i s thesis as conforming to the reguired standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1988 © TOBY IRENE SILVERTON, 1988 In p resen t ing this thesis in part ial f u l f i lmen t o f t he requ i remen ts fo r an a d v a n c e d d e g r e e at t h e Univers i ty o f Bri t ish C o l u m b i a , I agree that t h e Library shall m a k e it f ree ly avai lable fo r re fe rence a n d s tudy . I f u r the r agree that permiss ion fo r ex tens ive c o p y i n g o f th is thesis fo r scholar ly p u r p o s e s may be g r a n t e d by the h e a d o f m y d e p a r t m e n t o r b y his o r her representa t ives . It is u n d e r s t o o d tha t c o p y i n g o r pub l i ca t i on o f th is thesis f o r f inancia l ga in shall n o t b e a l l o w e d w i t h o u t m y w r i t t e n pe rm iss ion . D e p a r t m e n t o f C o u n s e l l i n g P s y c h o l o g y T h e Univers i ty o f Brit ish C o l u m b i a 1956 M a i n M a l l Vancouve r , Canada V 6 T 1Y3 Date August, 1988 i i Abstract This study examined the psychosocial variables of assertiveness, intimate relationships, interpersonal d i s t r u s t , , and s o c i a l self-esteem in eating disordered and non-eating disordered women. Assertiveness was examined between three eating disordered subgroups, namely, r e s t r i c t i n g anorexics, previously anorexic bulimics, and never anorexic bulimics, in an attempt to answer the question: Are there differences in assertiveness between these subgroups? Intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem were examined between the o v e r a l l eating disordered group and the non-eating disordered group. It was expected that eating disordered women, as compared to non-eating disordered women would report more d i f f i c u l t y in establishing and maintaining intimate relationships, higher interpersonal d i s t r u s t , and lower s o c i a l self-esteem. The subjects were 82 females (41 eating disordered and 41 non-eating disordered), aged 19 to 40 years. Eating disordered subjects were recruited from a l o c a l support group for women with eating disorders. None of the eating disordered subjects were hospitalized at the time of test i n g . Eating disordered subjects were c l a s s i f i e d using the DSM-III (1980) c r i t e r i a for anorexia nervosa and Russell's (1979) c r i t e r i a for bulimia nervosa. Non-eating disordered subjects were nursing students at a l o c a l community college. Non-eating disordered subjects were screened using the Eating Attitudes Test in order to prevent the inclusion of women with mild eating disorders into the comparison group. A l l subjects completed a battery of tests including: The Eating Attitudes Test; The Assertion Inventory; The Adult Self-Perception P r o f i l e ; The Eating Disorder Inventory; T h e S o c i a l Self-Esteem Inventory; arid a demographic information sheet. A l l subjects were weighed and their height measured. A one-way multivariate analysis of variance was computed for the assertiveness measures of discomfort and response prob a b i l i t y , examining differences between the three eating disordered subgroups. No s i g n i f i c a n t differences were found. Post hoc analysis between the overall eating disordered group and the non-eating disordered group revealed highly s i g n i f i c a n t differences between the two groups on both assertiveness measures ( J D < . 0 0 1 ) . An examination of the means revealed that the eating disordered group experiences more discomfort in situations requiring assertiveness, and are less l i k e l y to respond asse r t i v e l y in those sit u a t i o n s . Intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem were tested using a one-way multivariate analysis of variance. Differences were tested between the eating disordered and non-eating disordered groups. Highly s i g n i f i c a n t differences were found between the groups on a l l three measures ( J D < £ . 0 0 1 ) . An examination of the means revealed that the eating disordered group have more d i f f i c u l t y in forming and maintaining intimate relationships, a greater degree of interpersonal d i s t r u s t , and less s o c i a l s e l f -esteem. Implications of these results and suggestions for future research are discussed. i v Table of Contents ABSTRACT i i LIST OF TABLES v i i ACKNOWLEDGEMENTS,,......... ^  ............. ....... . . ... • .. v i i i INTRODUCTION .1 METHOD . . 9 Subjects 9 Eating Disordered Group... 9 Restricting Anorexics 10 Previously Anorexic Bulimics 10 Never Anorexic Bulimics 11 Non-Eating Disordered Group . 11 Measures 12 Dependent Measures 12 The Assertion Inventory 12 Adult Self-Perception P r o f i l e 13 Eating Disorder Inventory 14 The Social Self-Esteem Inventory 15 Apparatus 15 Procedure . . 15 Data Analysis 17 Procedures for Handling Missing Values.. 17 RESULTS 18 Demographic and Weight Related Characteristics... 18 V Eating Disordered Group 18 Restricting Anorexics 18 Previously Anorexic Bulimics 19 Never Anorexic Bulimics . 20 Non-Eating Disordered Group 24 MANOVA Analysis.. 31 Assert iveness 31 Intimate Relationships, Interpersonal Distrust, and Social Self-Esteem 34 Post Hoc Analysis ^ 37 Correlation Matrix 37 DISCUSSION 39 REFERENCES 54 APPENDIX A 63 Review of the Literature 64 Social Adjustment 64 Assert iveness 68 Intimate Relationships 72 Interpersonal Distrust 77 Social Self-Esteem 78 Summary 81 APPENDIX B 82 Review of Measures and Selection C r i t e r i a 83 Eating Attitudes Test 83 The Assertion Inventory 84 Normative Data 85 v i F a c t o r i a l A n a l y s i s 85 R e l i a b i l i t y and V a l i d i t y 86 Adul t S e l f - P e r c e p t i o n P r o f i l e 87 Normative Data...... 88 I n t e r n a l Consistency R e l i a b i l i t y 88 F a c t o r i a l A n a l y s i s 88 E a t i n g Disorder Inventory 89 V a l i d i t y and R e l i a b i l i t y 89 Response Bias 90 C r i t e r i o n Related V a l i d i t y . 9 0 Convergent and D i s c r i m i n a n t V a l i d i t y 90 The S o c i a l Self-Esteem Inventory 91 V a l i d i t y 92 R e l i a b i l i t y 93 S e l e c t i o n and D i a g n o s t i c C r i t e r i a 93 APPENDIX C 99 I n t r o d u c t i o n L e t t e r 100 Informed Consent 101 APPENDIX D 102 E a t i n g A t t i t u d e s Test 103 The A s s e r t i o n Inventory 105 Adul t . S e l f - P e r c e p t i o n P r o f i l e . . 107 E a t i n g Disorder Inventory I l l The S o c i a l Self-Esteem Inventory 113 Demographic Information Sheet 115 v i i L i s t of Tables I I l l n e s s and Treatment C h a r a c t e r i s t i c s of E a t i n g Disordered Groups 22 •.II. Demographics of E a t i n g Disordered and Non-E a t i n g Disordered Groups 25 I I I Weight Related C h a r a c t e r i s t i c s of E a t i n g Disordered and Non-Eating Disordered Groups 28 IV D i e t i n g Information f o r E a t i n g Disordered and Non-Eating Disordered Groups 30 V Means and Standard D e v i a t i o n s by Group and Measure. . . ...... . . ..... ... : 32 VI D i s t r i b u t i o n of E a t i n g Disordered Subgroups and Non-Eating Disordered group i n t o Four A s s e r t i o n P r o f i l e s 35 VII C o r r e l a t i o n M a t r i x of Dependent Measures, Age, and Weight f o r a l l Subjects 38 VIII S e l e c t i o n C r i t e r i a f o r Subjects 94 IX DSM-III D i a g n o s t i c C r i t e r i a f o r Anorexia Nervosa 96 X R u s s e l l ' s (1979) C r i t e r i a f o r Bulimia Nervosa.... 97 XI Sample Questions f o r Determining Subgroup Placement of E a t i n g Disordered Subjects 98 Acknowledgements I would l i k e to express my deep appreciation to my committee members for sharing their time / ; support,, and wisdom.. In pa r t i c u l a r , I wish to thank my chairperson, Dr. Sharon Kahn, for her i n s p i r a t i o n , patience, and motivation from inception to completion of my thesis. Her words of encouragement were, and continue to be, a source of strength. I would also l i k e to thank Dr. Bonita Long for her invaluable direction on s t a t i s t i c a l matters, not to mention her support and enthusiasm for thi s project. Thanks also to Dr. E l l i o t Goldner for sharing his expertise in eating disorders during the planning and execution phases of this research, and for always taking time from his very busy schedule for consultation and to attend my thesis defence. In addition to my committee, I would also l i k e to thank Dr. Ronald Manley for his i n s i g h t f u l suggestions when f i r s t planning my research, and for his continuing friendship. And, I want to express my appreciation to a l l of the women from the support group who, amidst th e i r own struggles, took the time to share of themselves in order that I could complete my research. Last, but not least, I want to thank my family for their unending understanding, and for always believing in me. Introduction 1 Several authors have hypothesized that women with anorexia nervosa and/or bulimia are unable to identif y or trust their own feelings as a result of early childhood experiences (Bruch, 1973, 1977; Goodsitt, 1969, 1977, 1985; S e l v i n i - P a l a z z o l i , 1978). D i f f i c u l t y in recognizing thoughts and feelings may be central to the so c i a l problems of women with eating disorders. According to Goodsitt (1977, 1985) and s e l f - d e f i c i t theory, the anorexic i s "arrested in self-development and deficient or incomplete in self-regulatory structure" (1985, p. 80). The lack of self-regulatory structure (the a b i l i t y to provide and maintain one's own sense of well-being, s e l f -esteem, cohesiveness, and tension and mood regulation) renders the individual unable to successfully separate from the parents. Thus the c h i l d feels l i k e an extension of the parents, not experienced as, or allowed to be a person in her own right. Without a well-integrated s e l f , the anorexic is unable to fee l in control. She often feels dependent upon external contingencies to define and "translate" her thoughts, feelings, needs, and basic well-being. The anorexic, or potentially anorexic c h i l d , i s vulnerable to feeling l i k e an empty receptacle that can be e a s i l y influenced, exploited, distorted, or invaded by external forces, leading to a mistrust of interpersonal experiences. 2 Bruch (1970) described the etiology of eating disorders s i m i l a r l y . She states that the incomplete personality .structure of the anorexic i s "the outcome of childhood experiences lacking in appropriate confirming responses to c h i l d - i n i t i a t e d clues" (p. 51). Bruch (1973) maintains that in order to develop a r e l i a b l e sense of i d e n t i t y and capacity for expression i t i s necessary that clues coming from the infant or c h i l d , whether b i o l o g i c a l , emotional, or s o c i a l , are correctly recognized and responded to in an appropriate way. Without confirmation of needs, the c h i l d grows-up perplexed by, and mistrusting of, bodily sensations, emotional, and interpersonal experiences. The i n a b i l i t y to id e n t i f y and trust their own identity and emotions causes interpersonal relationships to be problematic for anorexic women (Bruch, 1978). In agreement with Bruch, S e l v i n i - P a l a z z o l i (1978) also believes that the lack of trust in internal experiences results from "...an insensitive parent [who] constantly interferes, c r i t i c i z e s , suggests, takes over v i t a l experiences and prevents the c h i l d from developing feelings of [her] own" (p. 88). The majority of the early theoretical writing done in the f i e l d of eating disorders by such individuals as Bruch, Goodsitt, and S e l v i n i - P a l a z z o l i addressed only anorexia nervosa. Bulimia was not discussed at length in these early 3 writings although these authors occasionally mentioned binging episodes combined with anorexia nervosa. Phenomena such as lack of s e l f - i d e n t i f y , feelings of emptiness, and a sense of being alienated from themselves and th e i r feelings described by these authors in their discussions of anorexia nervosa are also freguently observed in bulimic women. The lack of a complete self-structure, suggested by Bruch (1973, 1977), Goodsitt (1969, 1977, 1985) and Se l v i n i - P a l a z z o l i (1978), may cause a l l eating disordered women, regardless of..the type of eating disorder, d i f f i c u l t y in recognizing and trusting thoughts and feelings, emotional, b i o l o g i c a l , or so c i a l needs. Tyhurst (1986) observed that "Most [eating disordered] patients...are not w i l l i n g to,... also not able to view themselves as participants in s o c i a l environment.... The s o c i a l space which surrounds them appears to be genuinely unexplored t e r r i t o r y " (p. 51). The lack of awareness of, and pa r t i c i p a t i o n in, a s o c i a l milieu i s understandable within the conceptual framework of a s e l f - d e f i c i t theory. S e l f - d e f i c i t theory applied to eating disordered women would suggest that these women have d i f f i c u l t y in s p e c i f i c s o c i a l areas such as assertiveness, intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem. Assertion d e f i c i t s have been observed to be a central component in both anorexia nervosa and bulimia (Boskind-White, 1976; Boskind-White & White, 1983; Bruch, 1973, 1978; Neuman & Halvorson, 1983). Research has begun to examine these assertion d e f i c i t s in women with eating 'disorders. The results are s t i l l non-conclusive although the evidence seems to be supportive of a lack of assertiveness in women with bulimia. For example, during development of a scale to measure behavioural and a t t i t u d i n a l parameters of bulimia, Hawkins and Clement (1980) found that increased binge eating was associated with low assertiveness. To date, no studies have been found that examine assertion d e f i c i t s in anorexic women.. .• In addition to assertiveness problems, interpersonal relationships have been noted to be profoundly d i f f i c u l t for eating disordered women (Boskind- White, 1976; Boskind-White & White, 1983; Neuman & Halvorson, 1983). Research suggests that the majority of women with eating disorders, regardless of the type of eating disorder, have problematic relationships. M i t c h e l l , Hatsukami, Eckert, and Pyle (1985) studied 275 women with bulimia. They found that the majority had never married, and that intimate or interpersonal relationships were most commonly reported to have been affected by bulimia. Thompson and Schwartz (1982) studied a sample of anorexic women as compared to "anorexic-like" and non-anorexic women. They found that the majority of anorexic women li v e d at home, and l i v e d l i v e s of extreme s o c i a l deprivation with few friends and d i f f i c u l t i e s with r e l a t i v e s and co-workers. In contrast, the "anorexic-like" women led s o c i a l l i v e s as f u l l as the problem-free group. Numerous authors have discussed eating disordered women's i n a b i l i t y to trust in the r e l i a b i l i t y and v a l i d i t y of their own i d e n t i t y , thoughts, feelings, perceptions, and behaviours (Bruch, 1973, 1978; Garner, Garfinkel, & Bemis, 1982; Goodsitt, 1977; S e l v i n i - P a l a z z o l i , 1978; Story, 1976). The lack of intrapersonal trust contributes to what Garner and Olmstead (1984) described as interpersonal d i s t r u s t or a "sense of alienation and a general reluctance to form close relationships" (p. 5). To date, l i t t l e empirical research has been undertaken on the construct of interpersonal d i s t r u s t . A study by Johnson and Connors (1987) found that interpersonal d i s t r u s t distinguished r e s t r i c t i n g anorexics and bulimic anorexics from normal weight bulimics, obese, and normal controls. In addition to other s o c i a l problems, eating disordered women also appear to suffer from low s o c i a l self-esteem. Social self-esteem i s defined as one's perception of one's self-worth, competence, and a b i l i t y to be s o c i a l as reflected by habitual attitudes and responses in dealing with people in interpersonal situations (Lawson, Marshall, & McGrath, 1979). The lack of self-esteem in interpersonal experiences i s understandable seen in the context of the woman with an. eating disorder who grows-up feeling unable to c l e a r l y i d e n t i f y 6 her•own -intrapersonal experiences, fearing engulfment or rejection from others, and feel i n g unable to assert herself. Family pressures and her own feelings of v u l n e r a b i l i t y keep the g i r l apart from s o c i a l experiences, and the lack of s o c i a l contact further reinforces her view of herself as a s o c i a l f a i l u r e . C l i n i c a l observation and research studies suggest that most eating disordered women report that they are in e f f e c t i v e and lack confidence in s o c i a l situations. Garner and Bemis (1985) state" that, "The t y p i c a l patient with anorexia nervosa is highly s e l f - c r i t i c a l and experiences herself as inadequate in most areas of personal or s o c i a l functioning" (p. 128). As with the other psychosocial variables, l i t t l e research exists on so c i a l self-esteem in eating disordered women. Much of the research on psychosocial variables of eating disordered women has been c r i t i c i z e d for being based on unsystematic observations and/or methodologically weak studies (Allerdissen, F l o r i n , & Rost, 1981; Kubistant, 1982; Mizes, 1985; Rost, Neuhaus, & F l o r i n , 1982). In addition, i t has generally been assumed that a l l eating disordered women suffer similar s o c i a l problems. Research has primarily focused only on one diagnostic category or another, but has f a i l e d to examine, to any great extent, whether differences exist between anorexic and bulimic women. "Research in the area of psychosocial c h a r a c t e r i s t i c s of. eating disordered women has been limited, and that which exists precludes d e f i n i t i v e conclusions. For a more detailed review of the literature,see Appendix A. The purpose of the present study i s to examine the variables of assertiveness, intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem in an attempt to further understand the s o c i a l world of anorexic and bulimic women. Given the lack of trust in intrapersonal and interpersonal experiences suggested by s e l f - d e f i c i t theory (Goodsitt, 1969, 1977, 1985), i t i s expected that eating disordered women w i l l have d i f f i c u l t i e s in a l l of these so c i a l areas. The eating disordered population has t y p i c a l l y been broken down into subcategories, usually based on the behaviours of abstaining, binging, and purging. Recent research has used the categories of r e s t r i c t i n g anorexics, previously anorexic bulimics, and never anorexic bulimics (Freeman, Thomas, Solyom, & Koopman, 1985). This study also u t i l i z e d the categories of r e s t r i c t i n g anorexics, previously anorexic bulimics, and never anorexic bulimics. By u t i l i z i n g only behaviours for c l a s s i f i c a t i o n ( i . e . binging or abstaining) information regarding the dynamics of an individual's disorder, such as the progression from r i g i d starvation to binging behavour, and the impact that such movement may have on various psychosocial variables,. i s l o s t . . With regard to a s s e r t i v e n e s s , i t has been p r e v i o u s l y noted t h a t the m a j o r i t y of women with e a t i n g d i s o r d e r s are expected to have a s s e r t i o n d i f f i c u l t i e s . . This study w i l l ask the ques t i o n : Are there d i f f e r e n c e s i n a s s e r t i v e n e s s between the e a t i n g d i s o r d e r e d subgroups of r e s t r i c t i n g a n o r e x i c s , p r e v i o u s l y anorexic b u l i m i c s , and never an o r e x i c b u l i m i c s ? With regard to in t i m a t e r e l a t i o n s h i p s , i n t e r p e r s o n a l d i s t r u s t , and s o c i a l s e l f - e s t e e m , i t i s expected that women with e a t i n g d i s o r d e r s , i n comparison to women without e a t i n g d i s o r d e r s : 1) w i l l f e e l l e s s able to e s t a b l i s h and maintain intimate r e l a t i o n s h i p s , 2) w i l l experience more i n t e r p e r s o n a l d i s t r u s t , and f i n a l l y , 3) w i l l have lower s o c i a l s e l f - e s t e e m . 9 Method Sub j ects A t o t a l of 82 female subjects (41 eating disordered and 41 non-eating disordered) between the ages of 19 and 40 years participated in th i s study. Eating Disordered Group Eating disordered subjects were recruited from a l o c a l eating disorders support group. One additional subject, a past member of the eating disorders support group, was referred to the study by a private practitioner who specializes in the treatment of eating disorders. Over a period of four bi-weekly meetings approximately 60 potential volunteers were given a l e t t e r outlining the purpose of the study, arid what their p a r t i c i p a t i o n would e n t a i l (see Appendix C). The one subject referred from the private pra c t i t i o n e r was given the same information l e t t e r . Volunteers then contacted the researcher i f they were interested in p a r t i c i p a t i n g . Forty women from the eating disorders support group volunteered to participate, as well as the one subject recruited from the private p r a c t i t i o n e r . A l l 41 eating disordered volunteers completed the study. These subjects were categorized into three subgroups based on diagnostic c r i t e r i a (see Tables 8, 9, & 10 in Appendix B). None of the eating disordered subjects were hospitalized at the time of testing. 10 Restri c t i n g anorexics. Thirteen subjects were c l a s s i f i e d as r e s t r i c t i n g anorexics (RA) based on the DSM-III (American Psychiatric Association, 1980) c r i t e r i a for anorexia nervosa (see Table 9 in Appendix B) with the modification of 20% weight loss rather than 25% loss of o r i g i n a l body weight within the last two years. The weight loss modification was made since clear cut cases of anorexia nervosa have been i d e n t i f i e d in which weight loss did not approach 25% of o r i g i n a l body weight (Dally & Gomez, 1979; Garfinkel, Moldofsky, & Garner., 1980) . . The same, modified c r i t e r i a has been used previously in eating disorders research (Freeman, Thomas, Solyom, & Koopman, 1985; Garner, Olmstead, & Polivy, 1983; McLaughlin, Karp, & Herzog, 1985). Subjects included in the RA group achieve and maintain a low body weight through severe c a l o r i c r e s t r i c t i o n . These subjects may also use self-induced vomiting or abuse purgatives in order to prevent absorption of an already reduced intake of food. They d i f f e r from other eating disordered groups who use evacuation methods after episodes of overeating (Russell, 1979). Previously anorexic bulimics. Thirteen subjects met Russell's (1979) c r i t e r i a for bulimia nervosa (see Table 10 in Appendix B). Previously anorexic bulimics (PAB) i n i t i a l l y experienced a .period of c a l o r i c r e s t r i c t i o n and extreme weight loss replaced by increasingly frequent eating binges and 11 reliance on food evacuation methods to prevent weight gain. Never anorexic bulimics. Fifteen subjects met Russell's (1979) c r i t e r i a for bulimia nervosa. None had experienced an episode of anorexia nervosa in the past. Non-Eating Disordered Comparison Group Subjects in this group were female undergraduate nursing students recruited from a l o c a l community college. During a two-week period the researcher addressed f i v e classes of nursing students regarding their possible p a r t i c i p a t i o n in.the research. A brief 10-minute presentation was given outlining the purpose of the study and what their p a r t i c i p a t i o n would e n t a i l . Students who were interested in p a r t i c i p a t i n g signed up at the end of the presentation. Out of a possible t o t a l number of 136 students, 70 volunteered to par t i c i p a t e . Of these, 20 subjects (28.6%) withdrew c i t i n g lack of time to complete the study. F i f t y non-eating disordered subjects completed the test packages. Of these, nine subjects (18%) scored above normal on a screening index of anorexic symptomatology and were thus eliminated. The remaining 41 non-eating disordered volunteers comprised the normal comparison group. Non-eating disordered subjects met the following c r i t e r i a . They (a) were 18 years and over, (b) had no history of an eating disorder, (c) were not currently in treatment for a psychiatric problem, and (d) had a score of 15 or below on the Eating Attitudes Test. Measures The Eating Attitudes Test (Garner & Garfinkel, 1979) was used as a screening device in order to prevent the inclusion of women with mild eating disorders into the comparison group.. The Eating Attitudes Test (EAT) i s a 40-item, self-report inventory with a 6-point Like r t response format ranging from always to never. Responses are summed res u l t i n g in one overall score. The scale was designed as an index of anorexic symptomatology. Garner and Garfinkel report an alpha r e l i a b i l i t y c o e f f i c i e n t of r = .79 for anorexia nervosa patients and r_ = .94 for pooled anorexic and normal controls, indicating a high degree of internal r e l i a b i l i t y . Garner and Garfinkel suggest a cutoff score of 30 to determine potential eating disordered women. The authors report a mean EAT score of 15.6 for normal controls. Accordingly, a conservative score of 15 or below was required for inclusion in the comparison group. Dependent Measures The Assertion Inventory. The Assertion Inventory (Gambrill & Richey, 1975) i s a 40-item, self-report questionnaire sampling a range of situations requiring assertive behaviour. The scale allows c o l l e c t i o n of two types of information for each item; (a) the degree of discomfort in re l a t i o n to a s p e c i f i c s i t u a t i o n requiring assertive behaviour, and (b) the probability of engaging in an assertive behaviour. A 5-point L i k e r t response format i s employed. Responses range from none to very much f o r discomfort, and from always do i t to never do i t f o r response p r o b a b i l i t y . Responses to dis c o m f o r t and response p r o b a b i l i t y are summed s e p a r a t e l y r e s u l t i n g i n two scores f o r each s u b j e c t . Based on discomfort and response p r o b a b i l i t y s c o r e s , s u b j e c t s can be de s c r i b e d as u n a s s e r t i v e , anxious performer, doesn't care, or a s s e r t i v e . The authors reported t e s t - r e t e s t r e l i a b i l i t y of r_ = .87 f o r disc o m f o r t and r_ = .81 f o r response p r o b a b i l i t y . A d u l t S e l f - P e r c e p t i o n P r o f i l e (ASPP). The Adult S e l f -P e r c e p t i o n P r o f i l e (Messer & Harter, 1986) i s a 50-item s e l f - r e p o r t , m u l t i d i m e n s i o n a l measure of s e l f - e s t e e m . The s c a l e i s d i v i d e d i n t o 11 su b s c a l e s , each c o n s i s t i n g of four items. In a d d i t i o n , there i s a g l o b a l s e l f - w o r t h s c a l e c o n s i s t i n g of s i x items. The questions are f o r c e d choice on a 4-point s c a l e . H a l f of the questions begin with a p o s i t i v e statement and h a l f with a negative statement. The s t r u c t u r e d a l t e r n a t i v e s were designed to minimize s o c i a l l y d e s i r a b l e responses. Subscale scores are obtained by averaging responses to subscale items. The subscale of i n t e r e s t to t h i s study was in t i m a t e r e l a t i o n s h i p s , implying c l o s e , meaningful i n t e r a c t i o n s or r e l a t i o n s h i p s with one's mate, l o v e r , and/or very s p e c i a l f r i e n d . I t i s d e s c r i b e d i n the items as seeking out c l o s e , i n t i m a t e r e l a t i o n s h i p s and f e e l i n g f r e e to communicate openly 14 in a close relationship. Based on data obtained from two norming samples, Messer and Harter reported int e r n a l consistency r e l i a b i l i t i e s of r = .85 and r_ = .82 for the intimate relationships subscale. Eating Disorder Inventory (EDI). The Eating Disorder Inventory (Garner & Olmstead, 1984) i s a 64-item, multi-scale, self-report inventory with a 6-point L i k e r t response format ranging from always to never. It was designed for the assessment of psychological and behavioural t r a i t s common in anorexia nervosa and bulimia. The EDI consists of eight subscales. Three measure behavoural and symptomatic patterns of anorexia nervosa and bulimia, and f i v e measure psychological factors related to these disorders. Each subscale i s scored separately by summing the responses to subscale items. Although this scale u t i l i z e s a 6-point response format, three of the six responses, never, rarely, and sometimes, receive a numerical value of zero, with the remaining responses, always, usually, and often receiving scores of three, two, and one, respectively. In the case of negatively scored items, the reverse scoring pattern is used, with always, usually, and often receiving zeros, and never, rarely, and sometimes receiving scores of three, two, and one, respectively. The subscale of interest to this study was interpersonal d i s t r u s t . The seven items in this subscale r e f l e c t a sense of alienation and a general reluctance to form close relationships. It i s to be distinguished from paranoid thinking and relates to an i n a b i l i t y to form attachments or f e e l comfortable expressing emotions toward others. Garner and Olmstead reported internal consistency r e l i a b i l i t y for the interpersonal d i s t r u s t subscale of r = .85 for the anorexia nervosa sample and r = .76 for the female comparison group. The Social Self-Esteem Inventory (SSEI). The Social Self-Esteem Inventory (Lawson, Marshall, & McGrath, 1979) i s a 30-item, self-report inventory with a 6-point Likert response format'ranging from' completely unlike me to exactly l i k e me. Fifteen of the items are negatively phrased and are scored by subtracting the number placed against them from seven. A l l responses are then summed to obtain one overall score. The inventory i s intended to assess self-esteem in s o c i a l situations. The authors reported t o t a l retest r e l i a b i l i t y of r_ = .88, with individual items ranging from r = .33 to r_ = .70. Apparatus Subjects were weighed on a Seca personal scale, Model 760, weighing capacity up to 320 lbs. (150 kg.). Procedure A l l subjects were told that they were p a r t i c i p a t i n g in a study of personality c h a r a c t e r i s t i c s of women with eating disorders. Non-eating disordered volunteers were told that they were pa r t i c i p a t i n g as part of a normal comparison group. Subjects signed a consent form (see Appendix C) and were 16 given test packages to complete independently. Instructions for completing the test packages were given and any questions were answered. The test package included the following scales with relevant instructions: (a) Eating Attitudes Test, (b) Social Self-Esteem Inventory, (c) Adult Self-Perception P r o f i l e , (d) The Assertion Inventory, (e) Eating Disorder Inventory, and (f) a demographic information sheet (see Appendix D for complete scales). A second meeting was arranged to c o l l e c t the test package. During the second interview subjects were weighed and t h e i r height measured. A l l subjects were weighed standing backwards on the scale. This position was adopted as the majority of the eating disordered subjects agreed to participate in the study only i f they did not have to know their actual weight. Standing backwards thus ensured c o n f i d e n t i a l i t y of weight and uniformity of standing position on the scale for a l l subjects. As subjects were weighed while f u l l y dressed, a constant of three pounds was subtracted from the obtained weight. Eating disordered subjects were asked several questions pertinent to the selection c r i t e r i a in order to determine which eating disordered subgroup they would be assigned to (see Table 11 in Appendix B). Subjects were debriefed and any questions were answered. These subjects were p a r t i c i p a t i n g in two separate studies being conducted conjointly.. Therefore, at the second meeting ... 17 subjects also completed two other procedures not relevant to the present study. Data Analysis Two multivariate analysis of variance (MANOVA) were conducted. Differences between r e s t r i c t i n g anorexic, previously anorexic bulimic, and never anorexic bulimic groups were tested with the dependent measures of assertiveness-discomfort and assertiveness-response probability. Differences between eating disordered and non-eating disordered groups were also tested with the dependent measures of intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem. Procedures for Handling Missing Values Test booklets were examined for any missing data, and such data were collected at the beginning of the second interview. Missing data consisted only of demographic information ( i . e . i f onset age was given as "childhood", subjects were asked to report a s p e c i f i c age). No missing values were found in the actual inventories. Results Demographic and Weight Related Characteristics  Eating Disordered Group Restrict i n g anorexics. The 13 r e s t r i c t i n g anorexics (RA) ranged in age from 19 to 40 years, with a mean age of 27.7 years (SD = 5.8 years). The majority of these subjects were Euro-Canadian (92.3%), had some college or university education (61.5%), were single (53.8%), l i v e d alone (53.8%), and worked fewer than 20 hours per week (53.8%). The average height of RA subjects was 64.8 inches (SD = 2.6 inches), and the mean weight of these subjects was 101.2 pounds (SD = 16.5 pounds). Weight for four subjects (30.8%) was within ^10% of the standard weight range for height, as derived from the Metropolitan L i f e Insurance Co. norms (Society of Actuaries, 1959). Their average weight, expressed as a percentage of standard weight for height, was 96.3% (SD = 3.3 %) . Weight for four subjects (30.8%) was between 10% and 19% below the lower l i m i t of the standard weight range. Their average weight, expressed as a percentage of standard weight, was 84.0% (SD = 3.6%). Weight for the remaining f i v e subjects (38.5%) was >20% below the lower l i m i t of the standard weight range. Their average weight, expressed as a percentage of standard weight, was 72.2% (SD = 7.5%). The average onset age of the eating disorder was 18.1 years (SD -4.8 years)., and the average duration 19 of i l l n e s s was 9.6 years (SD =5.1 years). At the time of testing, 69.2% were currently receiving some form of psychological treatment. Over the course of th e i r i l l n e s s , RA subjects had received an average of 33.8 months (SD = 39.0 months) of treatment. Only two of the RA subjects had never received any form of psychological treatment. Of these, one had received a formal diagnosis of anorexia nervosa and the other had not. The average Eating Attitudes Test score for RA subjects was 57.9 (SD = 24.2). Previously anorexic bulimics., The 13 previously anorexic bulimics (PAB) ranged in age from 19 to 34 years, with a mean age of 27.9 years (SD = 3.8 years). A l l PAB subjects were Euro-Canadian. The majority had some college or university education (69.2%), were single (61.5%), and worked over 30 hours a week (53.8%). Their l i v i n g arrangements were varied, with 23.1% l i v i n g in some type of supportive care f a c i l i t y . The average height of PAB subjects was 64.8 inches (SD = 2.8 inches), and their mean weight was 129.7 pounds (SD = 27.2 pounds). Weight for 10 of these subjects (77.0%) was within -10% of the standard weight range for height. Their average weight, expressed as a percentage of standard weight, was 98.9% (SD = 1.8%). Weight for one subject (7.7%) was ^10% below the lower l i m i t of the standard weight range. This weight, expressed as a percentage of standard weight, was 80%. Weight for two subjects (15.0%) was }10% above the upper l i m i t of the standard.weight range. These subjects' average weight, expressed as a percentage of standard weight, was .125.5% (SD = ,16.3%). The average age of onset was 15.1 years (SD' = 2.0 years) and the average duration of i l l n e s s was 12.8 years (SD = 3.5 years). At the time of testing, 76.9% were currently receiving some form of psychological treatment. Over the course of their i l l n e s s , PAB subjects had received an average of 14.7 months (SD = 19.1 months) of treatment. One PAB subject had received a formal diagnosis of an eating disorder but had never received any psychological treatment. The average Eating Attitudes Test score for PAB subjects was 53.8 (SD = 17.2). Never anorexic bulimics. The 15 never anorexic bulimic (NAB) subjects ranged in age from 20 to 34 years, with a mean age of 25.4 years (SD = 4.7 years). A l l of these subjects were Euro-Canadian. Over half (53.3%) had some college or university education, and 53.3% worked fewer than 20 hours per week. The majority (80.0%) were single, with varied l i v i n g arrangements. The average height of NAB subjects was 64.9 inches (SD = 1.9 inches), and their mean weight was 131.9 pounds (SD = 16.2 pounds). Weight for 13 of the subjects (86.7%) was within i l O % of the standard weight range for height. Their average weight, expressed as a percentage of standard weight, was 100.2% (SD = 4.6%). None of the subjects had a weight that was >10% below the lower l i m i t of the standard weight range. Weight for two of the subjects (13.3%) was ^10% above the upper l i m i t of the standard weight range. Their average weight, expressed as a percentage of standard weight was 120.0% (SD = 9.9%). For this group, the average onset age was 15.3 years (SD = 3.7 years), and the average duration of i l l n e s s was 10.1 years (SD = 5.7 years). At the time of testing, 53.3% were receiving some form of psychological treatment. Over the course of their i l l n e s s , NAB subjects had received an average of 21.9 months (SD = 24.4 months) of treatment. Two NAB subjects had never received any form of psychological treatment, although both had received a formal diagnosis of an eating disorder. The average Eating Attitudes Test score for NAB subjects was 32.2 (SD = 15.2). See Table 1 for i l l n e s s and treatment ch a r a c t e r i s t i c s of a l l symptomatic groups. T a b l e 1 I l l n e s s and Tre a t m e n t C h a r a c t e r i s t i c s o f E a t i n g D i s o r d e r e d G roups *RA PAB NAB n=13 n=13 n=15 M SD M SD M SD Onset age o f i l l n e s s ( y r s . ) 18.1 4 . 8 15. 1 2 . 0 15. 3 3.7 D u r a t i o n o f i l l n e s s ( y r s . ) 9.6 5.1 12. 8 3.5 10. 1 5.7 L e n g t h - o f t r e a t m e n t (mos.) 33.8 39.0 14. 7 19.1 21 . 9 24.4 % C u r r e n t l y i n t r e a t m e n t 69. 2 76 .9 53. 3 * R A = r e s t r i c t i n g a n o r e x i c s ; P A B = p r e v i o u s l y a n o r e x i c b u l i m i c s ; NAB=never a n o r e x i c b u l i m i c s to 23 In general, the three eating disordered subgroups were similar in age and height. With regard to weight, 69.2% of RA subject's weight was ^10% below the lower l i m i t of the standard weight range for height. The majority of PAB (77.0%) and NAB (86.7%) subjects' weight f e l l within ^10% of the standard weight range for height. A Chi square analysis revealed no s i g n i f i c a n t differences in education l e v e l between the three eating disordered subgroups, OC^ 2, N = 41) = 3.19, £ }.20. Collapsing categories of marital status to eithe r married or single revealed that 92.3% of RA subjects, 76.9% of PAB subjects, and 93.3% of NAB subjects were single. Living arrangement categories were collapsed to either l i v i n g alone or l i v i n g with others. A Chi square analysis of these categories revealed no s i g n i f i c a n t differences in l i v i n g arrangements between the three eating disordered subgroups, y?\ 2, N = 41) = 1.78, £ ^.41. However, when examined des c r i p t i v e l y , i t can be seen that approximately half (53.3%) of RA subjects l i v e d alone, while approximately one-third of PAB (30.8%) and NAB (33.3%) subjects l i v e d alone. In the PAB group, 23.1% of subjects l i v e d in some type of supportive care f a c i l i t y ( i . e . , psychiatric group home). Only 6.7% of NAB subjects, and no RA subject, l i v e d in a supportive care f a c i l i t y . 24 Non-Eating Disordered Group Subjects in the non-eating disordered group (NED) ranged in age from 19 to 37 years, with a mean age of 25.4 years (SD = 5.5 years). The majority of these subjects (78.0%) were Euro-Canadian and single (75.6%). Their l i v i n g arrangements were varied, with close to half (41.5%) l i v i n g with their parents. The fact that the non-eating disordered group were full-time nursing students recruited from a college accounts for 97.6% of these students working fewer than 20 hours per week. The average height of NED subjects was 64.7 inches (SD = 2.6 inches), and the i r mean weight was 127.3 pounds (SD =21.1 pounds). Weight for 32 subjects (78.0%) was within ^10% of the standard weight range for height. Their average weight, expressed as a percentage of standard weight, was 98.3% (SD = 4.5%). Weight for three subjects (7.3%) f e l l ^10% below the lower l i m i t of the standard weight range for height. Their average weight, expressed as a percentage of standard weight, was 85.7% (SD = 4.2%). Weight for six subjects (14.6%) was >10% above the upper l i m i t of the standard weight range for height. Their average weight, expressed as a percentage of standard weight, was 123.8% (SD = 10.3%). The average Eating Attitudes Test score for NED subjects was 8.6 (SD = 3.6). The mean score reported for women.-without eating disorders f o r . t h i s inventory i s Table 2 Demographics of Eating Disordered and Non-Eating Disordered Groups *RA n = 13 PAB n = 13 NAB n = 15 NED n=41 Age: Ethnic group: Education: Euro Canadian Asian Canadian Indo Canadian High school College/university Graduate school M SD M SD H SD M SD 27.7 5.8 27.9 3.8 25.4 4.7 25.4 5.5 92. 3 7.7 0.0 38.5 61 . 5 0.0 100.0 0.0 0.0 15.4 69. 2 15.4 % 100. 0 0.0 0.0 46. 7 53.3 0.0 78.0 9.8 12.2 0.0 100.0 0.0 (Table continues) RA n=13 Occupation: Unemployed 30.8 Professional 15.4 Worker 30.8 Student 23.1 Health related f i e l d 0.0 Hours worked per week: <20 hours 53.8 20-30 hours 30.8 >30 hours 15.4 Marital status: Single 53.8 Married/common law 15.4 Separated/divorced 38.5 Widowed 0.0 PAB NAB N E D n=13 n=15 n=41 % 23.1 20.0 0.0 23.1 0.0 .0.0 15.4 20.0 0.0 23.1 46.7 100.0. 15.4 13.3 0.0 30.8 53.3 97.6 15.4 0.0 2.4 53.8 46.7 0.0 61.5 80.0 75.6 23.1 6.7 21.9 15.4 13.3 2.4 0.0 0.0 0.0 (Table continues) RA PAB NAB NED n=13 n=l3 n=l5 n=41 % Living arrangement: Alone 53.8 30.8 33.3 12.2 Husband (including common law); husband & children; boyfriend 23.1 23.1 13.3 36.6 Parents; parents & siblings 23.1 15.4 26.7 .41.5 Roommates (male & female) 7.7 0,0 20.0 9.8 Children only 7.7 7.7 0.0 0.0 Supportive care (group home) 0.0 23.1 6.7 0.0 *RA=restricting anorexic; PAB=previously anorexic bulimic; NAB=never anorexic bulimic; NED=non-eating disordered Table 3 Weight Related Characteristics of Eating Disordered and Non-Eating Disordered Groups *RA PAB. NAB NED n= 13 n = 13 n = 15 ri = 41 M SD M SD M SD M SD Height (inches): 64. 8 2.6 64. 8 2. 8 64. 9 1 . 9 64. 7 2 . 6 Current weight ( l b s . ) : 101 . 2 16.5 129. 7 27.2 131 . 9 16.2 127. 3 21 . 1 Highest past weight (l b s . ) : 130. 2 15.2 152. 7 39.0 148. 7 17.6 140. 7 24.9 Lowest past weight (l b s . ) : 86. 9 8.9 94. 4 15.6 I l l . 3 11.5 118. 0 17.2 Ideal weight (l b s . ) : 101 . 9 10.4 112. 3 14.2 118. 7 8.4 120. 8 13.5 Actual weight as % of standard weight: % Underweight (<90%) 69 .2 7 . 7 0 .0 7 .*3 Average weight (%) 77. 4 8.4 80. 0 0.0 85. 7 4.2 % Normal (90-110%) 30 .8 77 .0 86 . 7 78 .0 Average weight (%) 96. 3 3.3 98. 9 1.8 100. 2 4.6 98. 3 4.5 (Table continues) oo RA n = 13 PAB n = 13 NAB n = 15 NED n=41 M SD M SD M SD M SD % Overweight ( >110%) Average weight (%) 0.0 15.0 13.3 14.6 125.5 16.3 120.0 9.9 123.8 10.3 * RA=restricting anorexics; PAB=previously anorexic bulimics; NAB=never anorexic bulimics; NED-non-eating disordered 30 Table 4 Dieting Information for Eating Disordered  and Non-Eating Disordered Groups *RA PAB NAB NED n=13 n=13 n=15 n=41 Currently on diet: Yes 46. 2 38. 9 5 O 33. 3 7. 3 No 53. 8 61 . 5 66. 7 92. 7 Daily c a l o r i e consumption: 0 - 500 calories 15. 4 7. 7 0. 0 0. 0 500 - 1000 38. 5 15. 4 6. 7 7. 3 1000 - 1500 30. 8 30. 8 46. 7 31. 7 over 1500 15. 4 46. 2 46. 7 61 . 0 Frequency of weighing behaviour: ^.once a month 23. 1 46. 2 40. 0 46. 3 1 - 2 times a month 23. 1 0. 0 40. 0 26. 8 1 - 2 times a week 23. 1 30. 8 6. 7 19. 5 once a day 15. 4 7. 7 6. 7 7. 3 >once a day 15. 4 15. 4 6. 7 0. 0 Eating Attitudes Test Score : M 57 . 9 53. 8 32 . 3 8-6 SD 24. 2 17. 2 15. 2 3. 6 * RA=restricting anorexics; PAB=previously anorexic bulimics; NAB=never anorexic bulimics; NED=non-eating disordered 15.6 (SD = 9.3). For further demographic, weight related c h a r a c t e r i s t i c s , and dieting information of eating disordered and non-eating disordered subjects, see Tables 2, 3, and 4 respectively. A one-way multivariate analysis of variance (MANOVA) was computed for the two major groups, eating disordered and non-eating disordered, on the variables of age, weight, and height. A nonsignificant overall group main eff e c t was found, F(3, 78) = 1.11, £^ . 3 5 , indicating no differences between the groups on these variables. A Chi square analysis was computed for marital status. No s i g n i f i c a n t differences were found between the eating disordered and non-eating disordered groups,X*(l^ N = 82) = .78, £ ^ >.38. MANOVA Analyses Assertiveness A one-way multivariate analysis of variance (MANOVA) was computed for the assertiveness measures of discomfort and response probability, examining differences between the three eating disordered sub-groups. A nonsignificant overal l group main effect was found, F(4, 74) = 1.36, £^.25, indicating that there were no differences between the groups on assertiveness scores. Although the analysis of assertiveness was not s i g n i f i c a n t , inspection of Table 5 (means and standard deviations) reveals that for both discomfort and. response Table 5 Means and Standard Deviations by Group and Measure Assertiveness Social Interpersonal Intimate Self-Esteem Distrust Relationships Response Discomfort Probability M SD M SD M SD M SD M SD ED Group (n=41) 136. 1 26.0 . 123. 3 17.5 97.5 32. 1 7.2 4.2 1 . 8 . 7 Restricting anorexics (n=13) 147.5 21 . 5 131.2 16.0 88.7 31.0 9.2 3.0 1.6 .4 Previously anorexic bulimics (n=13) 134. 3 29.2 120.0 17.7 107.2 37.9 6.4 4.8 2.0 .8 Never anorexic bulimics (n=15) 127. 7 24.6 119.2 17.3 96.4 26.9 6.1 4.3 1.9 .7 NED Group (n=41) 94.4 21 . 5 103 .4 14.9 136.7 24.9 1.6 2.3 3.2 •8 (Table continues) CO NJ Note. ED Group = eating disordered group, NED Group = non-eating disordered group. For assertiveness - discomfort, higher scores indicate more discomfort. For assertiveness response probability, higher scores indicate less probability of responding as s e r t i v e l y . For s o c i a l self-esteem, higher scores indicate more soc i a l self-esteem. For interpersonal di s t r u s t , higher scores indicate more interpersonal d i s t r u s t . For intimate relationships, higher scores indicate a more positive judgement of one's a b i l i t y to form and maintain intimate relationships. 34 probability, r e s t r i c t i n g anorexics scored the highest, indicating the most discomfort and least p r obability of responding assertively; previously anorexic bulimics were in the middle; and never anorexic bulimics scored the lowest, indicating the least discomfort and highest probability of responding assertively. Combining the discomfort and response probability scores of the assertiveness scale generates four p r o f i l e s ; (1) unassertive, (2) anxious performer, (3) doesn't care, and (4) assertive. Table 6 shows the d i s t r i b u t i o n of the eating disordered subgroups and the non-eating disordered group into the four p r o f i l e s . Intimate Relationships, Interpersonal Distrust,  and Social Self-Esteem Intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem were tested by computing a one-way multivariate analysis of variance (MANOVA). Differences were examined between the eating disordered and non-eating disordered groups. The multivariate group ef f e c t was s i g n i f i c a n t , F(3, 78) = 26.70, £<.001. Follow-up univariate tests revealed s i g n i f i c a n t differences on measures of intimate relationships, F ( l , 80) = 71.66, £<.001; interpersonal d i s t r u s t , F ( l , 80) = 54.33, £ <.001; and s o c i a l self-esteem, F ( l , 80) = 38.32, £ <.001. An examination of the means revealed that the eating disordered group, as compared to 35 Table 6 Distribution of Eating Disordered Subgroups and the Non-Eating Disordered Group into Four Assertion P r o f i l e s Response Probability Discomfort Low (105+) High (104-) Totals Restri c t i n g Anorexics High Unassertive Anxious Performer (96+) 13 (100%) 13 (100%) Low Doesn't Care Assertive (95-) Totals 13 (100%) -Previously Anorexic Bulimics High Unassertive Anxious Performer (96+) 10 (76.9%) 2 (15.4%) 12 (92.3%) Low Doesn't Care Assertive (95-) 1 ( 7.7%) 1 ( 7.7%) Totals 10 (76.9%) 3 (23.1%) (Table continues) 36 Response Probability-Discomfort Low (105+) High (104-) Totals Never Anorexic Bulimics High Unassertive Anxious Performer (96+) 11 (73.3%) 3 (20.0%) 14 (93.3%) Low Doesn't Care Assertive (95-) 1 ( 6.7%) 1 ( 6.7%) Totals 11 (73.3%) 4 (26.7%) Non-Eating Disordered Group High Unassertive Anxious Performer (96+) 11 (26.8%) 7 (17.1%) 18 (43.9%) Low Doesn't Care Assertive (95-) 5 (12.2%) 18 (43.9%) 23 (56.1%) Totals 16 (39.0%) 25 (61.0%) 37 the non-eating disordered group, have more d i f f i c u l t y in forming and maintaining intimate relationships, a greater degree of interpersonal d i s t r u s t , and less s o c i a l self-esteem. Post Hoc Analysis No s i g n i f i c a n t differences were found on assertiveness between the three eating disordered subgroups. These subgroups were subsequently collapsed and a post hoc one-way multivariate analysis of variance (MANOVA) was conducted on assertiveness between the eating disordered and non-eating disordered groups. The multivariate group ef f e c t was s i g n i f i c a n t , F(2, 79) = 26.60, p_<.001. Follow-up univariate tests revealed s i g n i f i c a n t differences on the measures of assertiveness-discomf ort, F ( l , 80) = 53.77, p_<.001 and assertiveness-response probability, F_(l, 80) = 30.67, £<.001. An examination of the means revealed that the eating disordered group, as compared to the non-eating disordered group, experience more discomfort in situations reguiring assertiveness and are less l i k e l y to respond as s e r t i v e l y in those situations. Correlation Matrix A correlation matrix for a l l dependent measures, as well as age and weight, was used to examine relationships between the measures. See Table 7. 38 Table 7 Correlation Matrix of Dependent Measures, Age,  and Weight for a l l Subjects (N = 82) age actualwt sses AssDis AssRP EDIid 1 2 3 4 5 6 age 1 1 .0000 actualwt 2 -0 .0089 1 .0000 sses 3 -0 .0946 0. . 1157 1 . ,0000 AssDis 4 0 .0856 -0, .0611 -0. 7331 1 . .0000 AssRP 5 0. .0867 -0. .2083 -0. 7170 0. .8108 1 . .0000 EDIid 6 0 .0834 -0, . 1581 -0. 7287 0. . 7247 0 .6908 1.0000 ASPPIr 7 -0 . 1615 0. . 1173 0. 7271 -0, .6870 -0 .6487 -0.7496 ASPPir 1.0000 Note. Actualwt = current weight of subjects in pounds; SSES = Social Self-Esteem Inventory; AssDis = Assertion Inventory - discomfort subscale; AssRP = Assertion Inventory - response probability subscale; EDIid = Eating Disorder Inventory - interpersonal di s t r u s t subscale; ASPPir = Adult Self-Perception P r o f i l e - intimate relationships subscale. C r i t i c a l r Values. r .05; 82 = .1829. r .01; 82 = .2565. 39 Discussion Women with eating disorders as compared to women without eating disorders reported more d i f f i c u l t y in the areas of intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem. No s i g n i f i c a n t differences in assertiveness were found between the groups of women with eating disorders. Despite the absence of s i g n i f i c a n t differences in assertiveness among r e s t r i c t i n g anorexics, previously anorexic bulimics, and never anorexic bulimics, a further examination of the results reveals that assertiveness i s a sal i e n t problem area for women with eating disorders. On average, eating disordered women, regardless of the subcategory, scored high in discomfort in situations requiring assertiveness and scored low in probability of responding in those situations. Division of the eating disordered group into three subcategories further emphasized an already small sample size which may have contributed to the nonsignificant findings. However, on both dimensions, namely discomfort and response probability, a trend was evident. On average, r e s t r i c t i n g anorexics reported the highest degree of discomfort in situations requiring assertiveness and the least probability of responding in those situations, previously anorexic bulimics were in the middle, and never anorexic bulimics reported the 40 least discomfort and highest probability of responding assertively. Post hoc analysis revealed that the eating disordered women scored s i g n i f i c a n t l y less assertive than women without eating disorders on both discomfort and response probability. Furthermore, the means for the eating disordered women (M = 136.1, SD = 26.0 for discomfort; M = 123.3, SD = 17.5 for response.probability) were much higher than the means reported by Gambrill and Richey (1975) for the c l i n i c a l norming sample of women seeking assertiveness training (M = 107.7, SD = 22.37 for discomfort; M = 104.8, SD = 22.55 for response p r o b a b i l i t y ) . This i s consistent with the findings of Fisher-McCanne (1985) who found that bulimic women reported s i g n i f i c a n t l y more assertion d i f f i c u l t i e s than a c l i n i c a l sample of women seeking therapy for various general issues. C l a s s i f i c a t i o n of subjects into the four p r o f i l e s generated by the discomfort and response pr o b a b i l i t y scores (see Table 6) resulted in the majority of the eating disordered women being c l a s s i f i e d as unassertive and approximately one-eighth as assertive. Only one-quarter of the women without eating disorders were c l a s s i f i e d as unassertive and close to one-half as assertive. C l a s s i f i c a t i o n of the eating disordered women resulted in almost twice as many eating disordered subjects c l a s s i f i e d as unassertive and approximately o n e - f i f t h as many c l a s s i f i e d as. assertive as compared to the o r i g i n a l c l i n i c a l norming sample (Gambrill & Richey, 1975). The act of assertiveness presupposes an internal s e l f -knowledge of wants or needs. S e l f - d e f i c i t theory suggests that eating disordered women lack an organized and cohesive core s e l f . U n t i l the formation of a core s e l f - identity begins, the internal knowledge required to be assertive may not be available to eating disordered women. Clearly the findings of thi s study, while not supporting the hypothesis of differences within eating disordered c l a s s i f i c a t i o n s , confirm assertion d i f f i c u l t i e s as one of the important symptom constellations associated with eating disorders. The findings in the area of intimate relationships are consistent with both c l i n i c a l descriptions and empirical findings which suggest that a l l eating disordered women, regardless of the type of eating disorder, have d i f f i c u l t y in forming and maintaining intimate relationships (Boskind-White & White, 1983; Bruch, 1978; Johnson & Connors, 1987; Johnson, Stuckey, Lewis, & Schwartz, 1982; Neuman & Halvorson, 1983; Norman & Herzog, 1983). In the present study, eating disordered women reported that they had s i g n i f i c a n t l y less a b i l i t y to develop, and more d i f f i c u l t y in maintaining, intimate relationships than women without eating disorders. Eating disordered women also reported avoiding close relationships and finding i t hard to communicate openly in close relationships. These types of d i f f i c u l t i e s within relationships are understandable within the context of s e l f - d e f i c i t theory. The lack of s e l f - i d e n t i t y , and the i n a b i l i t y to identif y emotions and even b i o l o g i c a l states a r i s i n g from the incomplete self-structure would appear to make i t extremely d i f f i c u l t , i f not impossible at times, for the eating disordered woman to seek a relationship with another. How can she be honest about her wants, needs, and feelings in interpersonal situations when unable to ide n t i f y them herself? In short, how can she have relationships with others while lacking a relationship with s e l f ? The Adult Self-Perception P r o f i l e (Messer & Harter, 1986) has not been normed on a c l i n i c a l population, but the items contained in the intimate relationships subscale appear to accurately r e f l e c t the c l i n i c a l l y observed relationship d i f f i c u l t i e s of women with eating disorders. In addition, the intimate relationship subscale correlated negatively (r = -.75, p_<^ .01) with the interpersonal d i s t r u s t subscale of the Eating Disorder Inventory (Garner & Olmstead, 1984) implying that high interpersonal distrust i s related to poor intimate relationships. This suggests that the intimate relationships subscale r e f l e c t s concerns that may be relevant to an eating disordered population. The intimate relationships subscale also correlated negatively with the Assertion Inventory (_r = -.69, £ <.01 for discomfort; r_ = -.65, £ <.01 for response probability) and p o s i t i v e l y with the Social Self-Esteem Inventory (_r = .73, £ ^ .01) suggesting the usefulness of the Adult Self-perception P r o f i l e in research. Research has usually focused on the intimate, close, and sexual relationships of eating disordered women. Future research may y i e l d more understanding of the relationship issue by studying, not intimate relationships which appear to be beyond the scope of most eating disordered women, but casual friendship patterns of thi s group. Understanding the means by which women with eating disorders .establish, maintain, and succeed or f a i l at the l e v e l of acquaintanceship may add insight into the various elements that a s s i s t or impede them in developing close, intimate relationships. The findings of s i g n i f i c a n t differences on the interpersonal distrust subscale between the women with eating disorders and the women without eating disorders were similar to those found in previous studies (Garner & Olmstead, 1984;.Johnson & Connors, 1987; Toner, Garfinkel, & Garner, 1987). Means:and standard deviations for the eating disordered group (M = 7.2, SD = 4.2) and the non-eating disordered group (M = 1.6, SD = 2.3) were comparable to the interpersonal d i s t r u s t norms of the Eating Disorder Inventory (to t a l anorexic sample; M = 6.4, SD = 4.9: female comparison sample M = 2.4, S_D ~ 3.0). Eating disordered women reported more d i f f i c u l t y in being open with their feelings, in talking about personal thoughts, and in expressing emotions to others. They also reported d i f f i c u l t y in trusting others, and f e e l i n g a need to keep people at a distance, feeling uncomfortable when someone t r i e s to get too close. The phenomenon of interpersonal d i s t r u s t has been widely observed (Bruch, 1973, 1978; Goodsitt, 1969, 1977; Se l v i n i - P a l a z z o l i , 1978; Story, 1977; Strober, 1980). Theoretically the i n a b i l i t y to trust the r e l i a b i l i t y and v a l i d i t y of one's own thoughts and feelings could lead to interpersonal d i s t r u s t in a wide variety of situations. Interpersonal d i s t r u s t may be one of the most important psychosocial factors for c l i n i c i a n s and researchers to understand when working with, or studying, women with eating disorders. In addition to interpersonal distrust a f f e c t i n g most areas of the s o c i a l experience of eating disordered women, Johnson and Connors (1987) suggest that interpersonal distrust can negatively impact the counselling process as i t results in a mistrust of any perceived caretaker. Research e f f o r t s are needed to understand more about the s p e c i f i c dynamics of interpersonal d i s t r u s t and 45 whether the dynamics of interpersonal di s t r u s t may d i f f e r between anorexic and bulimic women as suggested by Johnson and Connors (1987). The f i n a l psychosocial variable of interest in this study was s o c i a l self-esteem. C l i n i c a l observations have suggested that eating disordered women f e e l i n e f f e c t i v e s o c i a l l y and lack confidence in their s o c i a l a b i l i t i e s . It has been suggested that the arrested self-development of these women may lead to s o c i a l alienation (Goodsitt, 1969, 1977, 1985). Eating disordered,women's sense of alienation and perceived f a i l u r e in s o c i a l areas may increase the probability of avoiding s o c i a l contact. The avoidance of so c i a l experiences reinforces feelings of s o c i a l inadequacy and thus perpetuates the cycle of so c i a l avoidance. To date, s o c i a l self-esteem in eating disordered women has not been d i r e c t l y studied. The present study confirms that eating disordered women suffer s i g n i f i c a n t l y lower s o c i a l self-esteem than women without eating disorders. Eating disordered women rated themselves negatively on such factors as being s o c i a l l y e f f e c t i v e , f e e l i n g confidence in so c i a l situations, getting along well with people, and being popular with people of their own age. Women with eating" disorders also reported lacking confidence with people, being no good at a l l from a s o c i a l standpoint, being awkward in soc i a l situations, and being a bore with most people. The mean and standard deviation of the women without eating disorders (M = 136.7, SD = 24.9) were comparable to the mean and standard deviation of the norming sample (M = 132, SD = 21) for the Social Self-Esteem Inventory (Lawson, Marshall, & McGrath, 1979). This scale has not been normed on a c l i n i c a l population, so a sim i l a r comparison for the eating disordered women was not possible. The Social Self-Esteem Inventory was devised, however, from c l i n i c a l l y observed s o c i a l d i f f i c u l t i e s of psychiatric c l i e n t s and appears to adequately r e f l e c t the s o c i a l concerns of eating disordered women. The mean of the eating disordered women f e l l at the eighth percentile of the norming sample, where the mean of the women without eating disorders f e l l at approximately the 55th percentile. Comparable studies do not exist that have used the Social Self-Esteem Inventory with eating disordered women. Nevertheless, the concept tapped by this scale (one's s e l f -worth, competence, and a b i l i t y to be s o c i a l as reflected by habitual attitudes and responses in dealing with people in interpersonal situations) may be comparable to concepts studied in other research. For example, Strober (1980) found that anorexics reported s i g n i f i c a n t l y less interpersonal confidence, adaptability of s o c i a l behaviours, soc i a l i n i t i a t i v e , outgoing s o c i a l temperament, and a b i l i t y to create favourable interpersonal impressions. Leon, Lucas, Colligan, Ferdinande, and Kamp (1985) found similar results in both anorexic and bulimic sub-types of eating disorders. It has been suggested that there are differences in s o c i a l ineffectiveness, e f f i c a c y , and confidence between anorexic and normal-weight bulimic subjects (Wagner, Halmi, & Maguire, 1987) and this d i s t i n c t i o n requires further attention. When a l l of the above c h a r a c t e r i s t i c s , lack of assertiveness, poor intimate relationships, interpersonal d i s t r u s t , and low s o c i a l self-esteem, are present in an indiv i d u a l , especially to the degree that is found in eating disordered women, i t can be concluded that every facet of the eating disordered woman's s o c i a l world becomes affected. Such interpersonal d i f f i c u l t i e s may have served i n i t i a l l y to predispose the individual to develop an eating disorder and/or may play an integral part in i t s maintenance. One problematic area in eating disorders research has been the heterogeneity of the samples. The present eating disordered sample, in general, was comparable to other samples studied on factors such as age; ethnic group; educational l e v e l ; marital status; current, highest past, lowest past, and ideal weights; and onset age of i l l n e s s (Johnson, Stuckey, Lewis, & Schwartz, 1982; M i t c h e l l , Hatsukami, Eckert, & Pyle, 1985; Rost, Neuhaus, & F l o r i n , 1982). In addition, in 1983 the National Association of Anorexia Nervosa and Associated Disorders surveyed over 1,400 individuals with anorexia nervosa and/or bulimia. 48 Their results are comparable to the above mentioned studies and to the present study (National Association of Anorexia Nervosa and Associated Disorders/ 1983). By c l a s s i f y i n g the eating disordered subjects as r e s t r i c t i n g anorexics, previously anorexic bulimics and never anorexic bulimics, an interesting finding with regard to l i v i n g arrangements was observed. Approximately 23% of previously anorexic bulimic subjects were l i v i n g in some type of supportive care f a c i l i t y ( i . e . , psychiatric group home), while only 6.7% of never anorexic bulimic subjects, and no r e s t r i c t i n g anorexic subject, l i v e d in a supportive care f a c i l i t y . If these subjects had been c l a s s i f i e d s t r i c t l y by abstaining or binging behaviours, this difference between the previously anorexic bulimic and never anorexic bulimic subjects would have not been evident. Progression from starvation to binging/purging may r e f l e c t an increasing breakdown of impulse control and, therefore, the necessity of some type of residential/supportive care. This finding supports the u t i l i t y of this c l a s s i f i c a t i o n system. Important differences in the dynamics of eating disordered subgroups may be further revealed with the use of these c l a s s i f i c a t i o n s in future research. 49 Social areas may have been overlooked as one of the most important symptom constellations in terms of therapeutic goal-setting and assessing treatment outcome. T r a d i t i o n a l l y , much of therapy has focused on restoration of weight and diminishing of disordered eating behaviours as treatment goals. Also, weight and eating behaviours have usually been the factors used to assess treatment outcome. According to Bruch (1977), "By whatever method this is achieved, weight gain alone i s an unreliable sign of r e h a b i l i t a t i o n " (p. 298). S i m i l a r l y , Tyhurst (1986) stated that, "eating-related behaviour can not be evaluated as an index of i l l health in i s o l a t i o n from other behaviours in the s o c i o - c u l t u r a l and interpersonal environment of a person" (p. 5 5 ) . Counsellors may find i t more advantageous to focus on s p e c i f i c s o c i a l problems, such as expectations of s o c i a l situations, friendships, basic s o c i a l s k i l l s building, and communication s k i l l s with an aim to increasing s o c i a l self-esteem rather than d i r e c t l y focusing on changing eating aptterns. When teaching communication s k i l l s to individuals, counsellors usually assume that the trainee can ident i f y her thoughts, feelings, wants and needs and requires the s k i l l s to communicate her 50 ideas or desires. However, with eating disordered women, the counsellor should not assume that these c l i e n t s have knowledge of their internal feeling world. During recovery, the eating disordered woman experiences an adolescent stage of s o c i a l development. She w i l l experience many of the same issues as adolescents such as forming peer relationships, the need for love and belonging, and distinguishing her own s o c i a l needs as d i s t i n c t from'her parents' needs. An understanding of this developmental stage w i l l aid counsellors in their work with eating disordered women. Counsellors also need to explore how the actual eating disorder i s connected to the individual's current s o c i a l milieu. One assumption is that the c o n f l i c t r e s u l t i n g from an i n a b i l i t y to navigate interpersonal relationships and situations may be a source of considerable distress which may in turn trigger further disordered eating in a wide range of situations. Pushing a c l i e n t to engage in s o c i a l a c t i v i t i e s beyond her current a b i l i t i e s could result in an increase in disordered eating behaviours. On the other hand, the eating disorder may be used as a way of avoiding s o c i a l situations which are already feared. Working with the c l i e n t , the counsellor must determine the appropriate balance between avoidance of, and engagement i n , new s o c i a l a c t i v i t i e s . This study employed some instruments that have not been widely used in eating disorders research such as the Social Self-Esteem Inventory (Lawson, Marshall, & McGrath, 1979), the Adult Self-Perception P r o f i l e (Messer & Harter, 1986), and the Assertion Inventory (Gambrill & Richey, 1975) These scales more than adequately address the concerns of eating disordered women. During administration high face v a l i d i t y was noted. It i s believed that these measures are useful tools, not only in eating disorders research, but also in the counselling process. For example, the Social Self-Esteem Inventory i s a short, e a s i l y administered and scored scale. It would provide a useful counselling tool to aid in discussion of some of the core issues encompassed in the concept of s o c i a l self-esteem. The Assertion Inventory also provides opportunities for discussion. The d i v i s i o n of assertion into discomfort and response probability, plus the many different situations and dimensions of proximity covered by the inventory provides a wealth of opportunity for exploration of a very complex problem. In addition, the Assertion Inventory has been used to measure change pre and post treatment (Gambrill & Richey, 1975) and could be used as a valuable ongoing tool for assessment and discussion of change. The present study suffers from some of the same limit a t i o n s experienced by much of the research in the area of eating disorders, namely, the use of sel f - r e p o r t measures 52 small sample size further emphasized by d i v i s i o n into subgroups, and limited g e n e r a l i z a b i l i t y . Concerning g e n e r a l i z a b i l i t y , this study i n i t i a l l y sought a normal comparison group consisting of women without eating disorders who were employed in c l e r i c a l positions. One of the consistent c r i t i c i s m s of eating disorder research i s the use of college or university students as comparison subjects. It has been shown that high rates of "anorexic-like" behaviour exist among otherwise normal university students (Thompson & Schwartz, 1982). In addition, i t has been suggested that certain environments, such as university settings, increase the r i s k of eating disorders (Striegel-Moore, S i l b e r s t e i n , & Rodin, 1986). For these reasons, i t was deemed desirable to go outside of the usual university setting to re c r u i t a comparison group. It was also hoped that the move away from university students as comparisons would y i e l d new information and increase the g e n e r a l i z a b i l i t y of the f indings. Although permission was obtained from two corporations to test their female employees, a combined potential sample of approximately 200 female employees, only two women volunteered to part i c i p a t e . Feedback from those who wanted to participate indicated that their co-workers did not wish to answer, questions, regarding, their eating, behaviours, some • 53 feared that they may discover that they had an eating problem, and some f e l t that their eating habits were already problematic ( i . e . , problems with binging or f a s t i n g ) . Of course, numerous other general factors may have contributed, to the very low volunteer rate, such as lack of time or interest, or job d i s s a t i s f a c t i o n resulting in low motivation. Taking into consideration a l l other possible reasons for not p a r t i c i p a t i n g , i t appeared that these women were very sensitive about issues surrounding food and eating, and the fact that they had very r e a l concerns about eating warrants further attention. Our understanding of eating disorders such as anorexia nervosa and bulimia w i l l be enhanced and enlarged by studying related attitudes and phenomenon with those other than the eating disordered individuals themselves. At this point in time, further research into the underlying dynamics of observed so c i a l d e f i c i t s of eating disordered women, as well as research into the s o c i a l functioning of eating disordered women i s greatly needed. In addition, evaluation of differences between sub-types of eating disorders could y i e l d important diagnostic and prognostic information, and could be taken into consideration when planning therapeutic programmes. References Abraham, S., & Beumont, P.J.V. (1982). 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(1986). Bulimia as a manifestation of the stress process: A LISREL causal modeling analysis. International Journal of Eating Disorders, 5_(3), 451-473. 61 Society of Actuaries. (1959). Build and blood pressure study. Chicago, IL: Author. Story, I. (1976).- Caricature and impersonating the other: ' O b s e r v a t i o n s from the psychotherapy" of a n o r e x i a nervosa. Psychiatry, 39, 176-188. Striegel-Moore, R.H., S i l b e r s t e i n , L.R., & Rodin, J. (1986). Toward an understanding of r i s k factors for bulimia. American Psychologist, 4_1(3), 246-263. Strober, M. (1980). Personality and symptomatological features in young, nonchronic anorexia nervosa patients. Journal of Psychosomatic Research, 24, 353-359. Thompson, M.G., & Schwartz, D.M. (1982). L i f e adjustment of women with anorexia nervosa and anorexic-like behavior. International Journal of Eating Disorders, 2 , 47-60. Toner, B.B., Garfinkel, P.E., & Garner, D.M. (1987). Measurement of psychometric features and their relationship to c l i n i c a l outcome in the long term course of anorexia nervosa. International Journal of Eating Disorders, 6^(1), 17-27. Tyhurst, L. (1986). Eating and psychotherapy. International Journal of Social Psychiatry, 3211, 48-57. Wagner, S., Halmi, K.A., & Maguire, T.V. (1987). The sense of personal ineffectiveness in patients with eating disorders: one construct or several. International Journal of Eating Disorders, 6(4), 495-505. 62 Weissman, M.M., Prusoff , B . A. , Thompson, W.D., Hardin, P.S., & Myers, J.K. (1978). Social adjustment by s e l f report in a community sample and in. psychiatric outpatients. Journal of  Nervous and. Mental Disease, 166, 317-326 . APPENDIX A Review of the L i t e r a t u r e 64 Review of the Literature Research in the area of so c i a l adjustment of women with anorexia nervosa and bulimia i s limited. The consensus appears to be that eating disordered women experience s i g n i f i c a n t s o c i a l impairment. However, l i t t l e e f f o r t has been made to delineate more concisely the various elements that contribute to these women's poor overall s o c i a l adjustment. Appendix A w i l l review research in the area of the general s o c i a l adjustment of women with eating disorders. Also reviewed w i l l be the s p e c i f i c areas of interest, namely assertiveness, intimate relationships, interpersonal d i s t r u s t , and s o c i a l self-esteem. Social Adjustment In terms of general s o c i a l adjustment, Johnson and Berndt (1983) investigated the functioning of 80 normal-weight bulimic women in the areas of work, s o c i a l / l e i s u r e , and f a m i l i a l relations using the Social Adjustment Scale (Weissman, Prusoff, Thompson, Harding, & Myers, 1978). Subjects were self-selected volunteers who wrote to a medical centre to obtain information regarding bulimia. Subjects were sent the questionnaires with the reguest for their assistance in investigating eating disorders. No other incentive was offered. These subjects met the DSM-III c r i t e r i a for bulimia, and had no history of anorexia nervosa. 65 A comparison of the means of bulimic women to those of the community sample described by Weissman et a l . (1978) revealed that bulimic women had s i g n i f i c a n t l y poorer s o c i a l adjustment in a l l areas as compared to the community sample. Johnson and Berndt suggest, from their c l i n i c a l observations, that deterioration in s o c i a l functioning i s a resul t of progressive chaotic eating. Norman and Herzog (1984) also administered the Social Adjustment Scale to 40 bulimic women, who met the DSM-III c r i t e r i a for bulimia, at th e i r i n i t i a l evaluation at an outpatient eating disorders c l i n i c in a large metropolitan h o s p i t a l . These subjects were also tested again an average of one year l a t e r . At the i n i t i a l evaluation, the bulimic women were found to be s i g n i f i c a n t l y less well-adjusted s o c i a l l y than the normal women reported by Weissman and associates, and were similar to those described by Johnson and Berndt (1983). A comparison of the means of the bulimic subjects at the time of i n i t i a l evaluation and at follow-up revealed no marked changes except for a s i g n i f i c a n t drop in mean score on the work scale, although the follow-up work score was s t i l l s i g n i f i c a n t l y higher than that of Weissman's normal group. It i s of interest to note that 81% of the subjects had received some form of treatment during the one-year in t e r v a l between testings. Unlike Johnson and Berndt ( 1983) , who 66 suggest that the s o c i a l impairment develops as a result of the bulimia, Norman and Herzog (1984) note the persistence of so c i a l impairment even after treatment. Herzog, Pepose, Norman, and Rigotti (1985) surveyed by mail, 212 female medical students in order to assess the frequency of eating disorders in this population, and i t s association with s o c i a l functioning using the Social Adjustment Scale (Weissman et al.., 1978). One hundred and twenty-one' surveys were completed. These subjects, ranging in age from 19 to 36 years, were divided, into four groups. Five subjects were c l a s s i f i e d as currently bulimic, 10 had a history of bulimia, four had a history of anorexia nervosa, and the rest (102) were normal. Results were compared to the normal community sample described by Weissman et al. and to the sample of 40 bulimic women presenting to an eating disorders outpatient c l i n i c (see Norman & Herzog, 1983). The mean subscale scores for bulimic medical students and medical students with a previous history of bulimia were higher than those reported for the normal community sample, and similar to those reported for the sample of 40 bulimic women from the outpatient c l i n i c . The mean subscale scores for medical students with a history of anorexia nervosa did not d i f f e r s i g n i f i c a n t l y from the normal community sample. There were s i g n i f i c a n t differences between groups on the work, so c i a l and lei s u r e , and ov e r a l l subscales of the Social 67 Adjustment S c a l e . For the b u l i m i c and h i s t o r y of b u l i m i a groups, f i v e items were i d e n t i f i e d as the most freguent source of impairment.. .. The 40 b u l i m i c s u b j e c t s from, the o u t p a t i e n t c l i n i c i d e n t i f i e d the same f i v e items as the most frequent areas of maladjustment. These f i v e items were: (a) being unable to t a l k about one's f e e l i n g s and problems with a f r i e n d , (b) having spare time f o r hobbies, (c) coping with having one's f e e l i n g s h urt or offended, (d) f e e l i n g shy or uncomfortable with people, and (e) f e e l i n g l o n e l y . Herzog, et a l . conclude that the s e v e r i t y of the e a t i n g d i s o r d e r i s not c o r r e l a t e d to the s e v e r i t y of maladjustment due to the f a c t that medical students with b u l i m i a , or a h i s t o r y of b u l i m i a , show s i m i l a r maladjustment to o u t p a t i e n t c l i n i c b u l i m i c s . They suggest t h a t a lower frequency of b i n g i n g and purging may not be a s i g n of the l e s s e n i n g of the psychopathology, which b r i n g s i n t o question the u s e f u l n e s s of b e h a v i o u r a l l y o r i e n t e d outcome measures as the s o l e measure of success. Herzog, et a l . note that t h e i r data should be viewed with c a u t i o n as i t rep r e s e n t s only 57% of the female medical students e n r o l l e d . In a d d i t i o n , the small sample s i z e was f u r t h e r emphasized by i t s d i v i s i o n i n t o d i a g n o s t i c s u b c a t e g o r i e s . 68 Assertiveness The assertion d e f i c i t observed in women with eating disorders has been conceptually related to various causes. In the Introduction, d i f f i c u l t i e s in .early childhood experiences were proposed as a major factor in the development of problems in assertiveness, as well as other interpersonal d i f f i c u l t i e s . Boskind-White (1976) suggests that overly i d e n t i f y i n g with the stereotypic female sex-role orientation leads to problems with assertiveness. She states that "far from rejecting the stereotype of f e m i n i n i t y — t h a t of the accommodating, passive, dependent woman—these young women... not only...[accept] this ideal but [represent] an exaggerated s t r i v i n g to achieve i t " (p. 438). Rost, Neuhaus, and F l o r i n (1982) compared sex-role attitudes and sex-role behaviour in 34 bulimarexic women and 34 women without eating disorders. Comparison of means revealed that the bulimic women were s i g n i f i c a n t l y less liberated than normals in both sex-role attitudes and behaviours. Bulimic women also showed a s i g n i f i c a n t attitude-behaviour gap with sex-role behaviour less liberated than sex-role attitudes. Rost et a l . suggest that although bulimic women may have liberated attitudes, their actual sex-role behaviour more closely resembles that of the t r a d i t i o n a l female role concept of passivity, dependency, 69 and under-assertiveness. The authors also suggest that this gap may be a s i g n i f i c a n t source of c o n f l i c t to these women leading to s e l f - c r i t i c i s m for f a i l i n g to l i v e up to their sex-role i d e a l , .and may,act as a trigger to binge- .. eating. Cultural pressure on women to respond in stereotypic non-assertive ways has also been proposed as a cause of assertion d e f i c i t s observed in eating disordered women. According to Leon and Finn (1984), "cu l t u r a l stereotypes of appropriate emotional expression can function to reinforce noneffective responses to interpersonal situations requiring assertive behaviors" (p. 329). Like Leon and Finn, Gandour (1984) suggests that bulimic women have learned a "passive and accommodating approach to l i f e , which i s reinforced by parents and society. Assertiveness and independence are discouraged and submissive 'goodness' i s rewarded" (p. 22). Likewise, Boskind-White(1976) reports that most of the women in her study had f e l t punished by parents, grandparents, teachers, and peers for displaying such c h a r a c t e r i s t i c s as independence, s e l f - r e l i a n c e , and assertiveness. Although the lack of assertiveness has become an accepted concomitant of anorexia nervosa and bulimia, research has only recently begun to examine this p a r t i c u l a r aspect of so c i a l functioning. The few studies that have^examined 70 assertiveness in bulimic women using normal comparison groups have generally found bulimic women to be less assertive than women without eating disorders. Hawkins and Clement.(1980) found support for an assertion d e f i c i t in bulimic women. they surveyed two samples t o t a l i n g 255 female and 110 male undergraduates, a l l normal weight, and a t h i r d c l i n i c a l sample of 26 overweight females. Included in their measures was the College Self-Expression Scale (Galassi, Delo, Galassi, & Bastien, 1974). Hawkins and Clement found that low assertiveness on the College Self-Expression Scale tended to be associated with higher binge eating concern in females, but not in males. Fisher-McCanne (1985) examined assertiveness, also using the College Self-Expression Scale, across 23 bulimic women, 15 women in a general therapy group, and 18 undergraduate normal controls. Analysis of variance revealed highly s i g n i f i c a n t differences among the groups on assertiveness. The bulimic group showed less assertiveness than either the general therapy group or the control group. The bulimic group scored the least assertive, therapy group members were in the middle, and the comparison group scored the most assertive. 71 Shatford and Evans (1986) conducted a cross-validation study of the stress process in bulimic behaviour in 144 female undergraduates of whom 34 could be c l a s s i f i e d as bulimic. Lack of assertiveness was included as a source . of stress and was measured using the Rathus Assertiveness Schedule (Rathus, 1973). The model used (linear structural relations analysis), and the results found, do not show a direct linear relationship between assertiveness as a psychological status variable and bulimia as a mediator of stress. Howeverthe authors suggest that these factors may have a reciprocal influence. They concluded that i t i s more l i k e l y than not for bulimic women to show a lack of assertiveness. Al l e r d i s s e n , F l o r i n , and Rost (1981) compared 28 bulimic women, ranging in age from 18 to 39 years, to 28 women without eating disorders matched to the bulimic group. They measured the tendency to blame frustrations on s e l f or others, using the Picture Frustration Test. Analysis u t i l i z i n g Mann-Whitney's U Test showed that the bulimarexic group showed a s i g n i f i c a n t l y higher tendency not to blame others for f r u s t r a t i n g them. The authors interpreted this finding as support for an assertion d e f i c i t , however, the relationship between the tendency to blame frustrations on se l f or others and assertion i s not clear. 72 Dorman (1984) assessed the relationship between dif f e r e n t patterns of eating behaviours and body morphology on various psychological dimensions using standard personality questionnaires and. a structured interview. Eighty female subjects were divided into four groups: anorexic, bulimic, obese, and asymptomatic. The results suggest that anorexic and bulimic women are def i c i e n t in sel f - a s s e r t i o n s k i l l s , where obese and asymptomatic controls appeared similar on a l l psychological dimensions except physical self-regard. Katzman and Wolchik (1984) conducted the one study that reports no s i g n i f i c a n t differences in assertion between 30 bulimic female undergraduates, 22 female undergraduates who reported binge eating tendencies, and a control group of 28 female undergraduates. However, i t has been suggested (Mizes, 1985) that the questionnaire used, Levenson and Gottman Dating and Assertion Questionnaire (Levenson & Gottman, 1978) may not have been a v a l i d measure of assertion d e f i c i t s relevant to bulimics. Intimate Relationships Another aspect of the s o c i a l experience of eating disordered women i s d i f f i c u l t y with interpersonal relationships. Bruch (1978) suggests that relationship problems stem from the same source as d i f f i c u l t i e s with s e l f - a s s e r t i o n , namely an i n a b i l i t y to ide n t i f y and trust one's own ide n t i t y and emotions. Bruch observed that "friendship patterns reveal similar overcompliant adaptation to others that characterizes the whole l i f e .of these children" (p. 51). Bruch reported that each time the anorexic found a new friend she would fe e l the need to develop d i f f e r e n t interests and a diff e r e n t personality. According to Bruch, "They conceive of themselves as blanks who just go along with what friends enjoy and want to do. The idea that they have their own i n d i v i d u a l i t y to contribute to a friendship never occurs to them" (p. 51). Neuman and Halvorson (1983) also observed that intimacy issues were problematic for anorexics. Neuman and Halvorson suggest that anorexics are f e a r f u l of being rejected or of making a mistake within the relationship. These authors noted that, "even those anorexics who are sexually active are not t y p i c a l l y 'intimate' with their partners. A lack of honesty and assertiveness characterizes the relationships" (p. 22). Bulimic women also have d i f f i c u l t y with relationships. Boskind-White and White (1983) note that women with bulimia describe themselves as never having had genuine intimate relationships with men, and only having s u p e r f i c i a l relationships with women. Although they appeared to want friendships, their preoccupation with food, shyness, and lack of assertiveness impedes their development of close, intimate relationships. Neuman and Halvorson ( 1983) observed that while on. the whole bulimics tend to be more extroverted than anorexics, their relationships appear to be s u p e r f i c i a l and that women with bulimia are "adept at distancing themselves from people even while seeming to be very f r i e n d l y and sociable" (p. 58). Johnson and Connors (1987) observed that some women with bulimia have interpersonal d i f f i c u l t i e s due to so c i a l s k i l l s d e f i c i t s , but most are knowledgeable about proper interpersonal responses. Johnson and Connors noted that most bulimics appear to be extremely sensitive to the reactions of others so i n h i b i t their s o c i a l responses in order not to r i s k rejection or anger. Rather than r i s k assertiveness, which may bring a negative reaction, the bu-limic woman may avoid other people, f e e l d i s s a t i s f i e d with her relationships, and s e t t l e for poor relationships. There is not much empirical data on the relationships of eating disordered women. However, the data that .exists appears to confirm that relationships are problematic to eating disordered women. Johnson and Larson (1982) compared 15 bulimic women with 25 normal controls. Bulimic subjects ranged in age from 19 to 33 years. Using beepers, the researchers had subjects f i l l out self-report questionnaires about the situ a t i o n and subjective state they were experiencing at random signals over a one-week period. The average bulimic woman reported being s i g n i f i c a n t l y l o n e l i e r , weaker, passive, and spent s i g n i f i c a n t l y more time alone (49%) than the time spent alone by normal controls (32%). A number of the bulimic women reported that as their involvement with food increased, so did their s o c i a l withdrawal, and as time went on they were more l i k e l y to stay home and binge instead of partaking in s o c i a l a c t i v i t i e s . Johnson, Stuckey, Lewis, and Schwartz (1982) surveyed by mail, 316 women with bulimia. They found that 70% had never married. The majority (68.4%) reported that eating problems had t o t a l l y or very much influenced t h e i r interpersonal relationships. Norman and Herzog (1983) compared the Minnesota Multiphasic Personality Inventory (MMPI) p r o f i l e s of 14 normal weight bulimics to 10 r e s t r i c t i n g anorexics and 15 bulimic anorexics. Overall, the bulimic anorexics reported the most symptomatology; the r e s t r i c t i n g anorexics reported the least. The peak p r o f i l e code of the r e s t r i c t i n g anorexics (287) indicated, among other problems, s o c i a l withdrawal, alienation, and avoidance of close interpersonal r e l a t i o n s h i p s . The peak p r o f i l e code of b u l i m i c a n o r e x i c s (248) i n d i c a t e d a l i e n a t i o n , s e x u a l c o n f l i c t s , and o v e r a l l poor adjustment. The b u l i m i c a n o r e x i c group tended t o be s u s p i c i o u s and d i s t r u s t f u l , but c o n c o m i t a n t l y had h i g h , needs f o r a f f e c t i o n . The peak p r o f i l e code of normal weight b u l i m i c s (428) i n d i c a t e d t r o u b l e d f a m i l y r e l a t i o n s and s h a l l o w i n t e r p e r s o n a l r e l a t i o n s h i p s . In a f u r t h e r attempt t o understand the i n t i m a t e r e l a t i o n s h i p s of e a t i n g d i s o r d e r e d women, Abraham and Beumont (1982) examined the s e x u a l h i s t o r i e s of 31 a n o r e x i c p a t i e n t s ( i n c l u d i n g a n o r e x i c s who bin g e d and p u r g e d ) . S u b j e c t s ranged i n age from 17 t o 24 y e a r s . The r e s e a r c h e r s d i s t i n g u i s h e d f o u r groups from the i n f o r m a t i o n they r e c e i v e d . Group 1. s u b j e c t s were r e s t r i c t o r s . They had m i n i m a l p s y c h o s e x u a l development. The a u t h o r s suggest t h a t t h e i r e a t i n g b e h a v i o u r a l l o w e d them t o a v o i d c l o s e r e l a t i o n s h i p s . Group 2 s u b j e c t s m a i n t a i n e d low (but not se v e r e ) weight f o r y e a r s . A l t h o u g h s u b j e c t s i n t h i s group may have m a r r i e d , they t y p i c a l l y found i t d i f f i c u l t t o form mature r e l a t i o n s h i p s . The a u t h o r s h y p o t h e s i z e t h a t the low weight h e l p e d l i m i t any s e x u a l exposure or c h a l l e n g e s t o poor i n t e r - p e r s o n a l s k i l l s . Groups 1 and 2 accounted f o r 56% of the s u b j e c t s s t u d i e d . Group 3 s u b j e c t s purged and a l s o had b u l i m i c e p i s o d e s c o u n t e r e d by f a s t i n g . The a u t h o r s found t h a t s u b j e c t s i n t h i s group were s e x u a l l y a c t i v e , but u n r e s p o n s i v e . T h e i r 77 disturbed eating often led to termination of relationships. Group 3 accounted for 30% of the subjects. For subjects in Group 4 bulimia and vomiting were prominent. Subjects in this group were sexually assertive, but also seemed unable to' form long-term relationships, instead they had casual sexual encounters. They were s o c i a l l y active but lonely. Group 4 accounted for the remaining 14% of subjects studied. Although there were differences between the four groups, i t appeared that a l l subjects had d i f f i c u l t y in forming long-term.relationships with the- opposite sex. Interpersonal Distrust Interpersonal d i s t r u s t has been c l i n i c a l l y observed in eating disordered women, and refers to a "sense of alienation and a general reluctance to form close relationships" (Garner & Olmstead, 1984, p. 5). Johnson and Connors (1987) observed anorexic patients to be highly defensive and resistant to therapeutic intervention. These authors suggest that "potential caretakers [are] experienced as h o s t i l e and malevolent intruders" (p. 68), and interpersonal d i s t r u s t , for the anorexic, may r e f l e c t a fear of intrusive over-involvement from others. Johnson and Connors observed, that in contrast to the anorexic patients, bulimic patients often sought help w i l l i n g l y , but were sensitive to rejection. For the bulimic patient, Johnson and Connors suggest that interpersonal distrust might r e f l e c t a fear of under-involvement or rejection. L i t t l e empirical research has been undertaken on this construct. Toner, Garf inkel, and Garner (198.7) examined interpersonal d i s t r u s t , among other variables, in 55 former anorexic patients and 26 normal comparisons. The c l i n i c a l group was divided into asymptomatic, improved, symptomatic, and deceased. The authors found that the symptomatic group had s i g n i f i c a n t l y higher interpersonal d i s t r u s t scores than the asymptomatic and comparison groups. Social Self-Esteem Women with eating disorders have usually had limited s o c i a l experiences during childhood and adolescence. Bruch (1978) and Boskind-White and White (1983) note that these g i r l s are often overprotected, and their families appear to be self-contained units with a minimum of outside s o c i a l i z i n g encouraged. Lack of so c i a l experience leaves adolescents unprepared to meet new s o c i a l demands and can result in their feeling isolated and s o c i a l l y insecure. Anxiety and fearfulness of s o c i a l situations further increases the probability of avoiding s o c i a l contact. The lack of s o c i a l contact reinforces a lack of confidence in so c i a l situations, and the resu l t i s often low s o c i a l s e l f -esteem. Although s o c i a l self-esteem has not been studied d i r e c t l y in eating disordered women, some research has reported d i f f i c u l t i e s with interpersonal confidence and s o c i a l efficacy., Problems in these areas may r e f l e c t lowered s o c i a l self-esteem. Strober (1980) compared personality and symptom variables in 22 young (age range 13 to 16 years), nonchronic anorexics (abstainers and.bingers) and 44 non-anorexic controls with other forms of psychiatric problems. In the s o c i a l areas, he found that anorexics exhibited s i g n i f i c a n t l y less interpersonal confidence, adaptability of s o c i a l behaviours, s o c i a l i n i t i a t i v e , outgoing s o c i a l temperament, and a b i l i t y to create favourable interpersonal impressions. Strober also noted that in comparing the abstaining anorexics with the binging anorexics, binging anorexics had a greater degree of adaptability and f l e x i b i l i t y in s o c i a l behaviour and were less inhibited in the s o c i a l sphere. Strober's study i s interesting due to the fact that he used subjects who were experiencing their f i r s t episode of i l l n e s s and who had been referred for treatment within nine months (average 6.7 months) after the onset of noticeable weight loss or s i g n i f i c a n t change in dietary patterns. This study presents various s o c i a l factors that have not been confounded by chronici ty. Leon, Lucas, Colligan, Ferdinande, and Kamp (1985) also studied s o c i a l factors in 31 young (mean age 15 years) female anorexics as compared to 37 normal weight females. The anorexic, group was divided into restricting.and bulimic subtypes. The researchers found s i g n i f i c a n t differences between the two groups with the anorexics reporting unfavourable evaluations of their s o c i a l a b i l i t i e s , and a lack of confidence and comfort in so c i a l s i t u a t i o n s . The anorexic group also showed a lack of interest in sexual relationships. There were no s i g n i f i c a n t differences between the bulimic and r e s t r i c t o r subtypes on these variables. Wagner, Halmi, and Maguire (1987) studied ineffectiveness, including s o c i a l e f f i c a c y , in 18 eating disordered women and 18 normal controls. The eating disordered sample was divided into r e s t r i c t i n g anorexics, bulimic anorexics, and normal weight bulimics. The researchers found that the so c i a l e f f i c a c y subscale could s i g n i f i c a n t l y discriminate between the eating disordered and the control groups. Social e f f i c a c y also c l e a r l y separated the subgroups indicating that r e s t r i c t i n g anorexics and those with mixed symptomatology experienced much more d i f f i c u l t y in this area than normal weight bulimics. Normal weight bulimics were indistinguishable from controls. The normal weight bulimics, who had moderate d i f f i c u l t y in c o n t r o l l i n g eating and purging, exhibited as much s o c i a l confidence as controls.- R e s t r i c t i n g anorexics 81 and anorexic bulimics reported the greatest d e f i c i t s in s o c i a l areas. Summary There appears to be both c l i n i c a l and empirical evidence that women with eating disorders, regardless of the type of eating disorder, are not s o c i a l l y well-adjusted. They experience a lack of confidence in their s o c i a l a b i l i t i e s , have d i f f i c u l t i e s in establishing and maintaining relationships, often appear to distrust interpersonal experiences, and suffer a marked lack of assertiveness. APPENDIX B Review of Measures and S e l e c t i o n C r i t e r i a Review of Measures and  Selection C r i t e r i a Appendix B w i l l review the scales u t i l i z e d in this study, and the subject selection c r i t e r i a . Eating Attitudes Test (EAT) The Eating Attitudes Test (Garner & Garfinkel, 1979) was used as a screening device to prevent the inclusion of women with mild eating disorders in the comparison group. Garner and Garfinkel (1979) report an alpha r e l i a b i l i t y c o e f f i c i e n t of .79 for anorexia nervosa patients and .94 for pooled anorexic and normal controls, indicating a high degree of internal r e l i a b i l i t y . The EAT is reported to discriminate between anorexic and female control subjects, with a t o t a l EAT score s i g n i f i c a n t l y correlated with c r i t e r i o n group membership (_r = .87, p_<.001). L i t t l e overlap in the freguency dist r i b u t i o n s of the two groups was found, with only 1% of the normal controls scoring as high as the lowest anorexic patient. A subseguent study by R a c i t i and Norcross (1987) found an alpha r e l i a b i l i t y c o e f f i c i e n t of .86 for the t o t a l EAT, r e f l e c t i n g adequate internal consistency. R a c i t i and Norcross compared the EAT and the Eating Disorder Inventory (Garner & Olmstead, 1984) on c l a s s i f i c a t i o n and found high agreement in ident i f y i n g approximately 85% of the women as not weight-preoccupied. They i d e n t i f i e d a . trend for the Eating Disorder Inventory to be more conservative than the EAT (2.6% versus 7.2%) in c l a s s i f y i n g women as weight-preoccupied. However, i t should be noted that Ra c i t i and Norcross used the o r i g i n a l cutoff score of 30 to determine p o t e n t i a l l y eating disordered subjects, while the present study used a much more conservative cutoff score of 15. The Assertion Inventory (Al) The Assertion Inventory (Gambrill & Richey, 1975) separates assertiveness into two dimensions, degree of discomfort and response probability. In addition, items in the scale r e f l e c t numerous categories such as: (a) turning down reguests, (b) expressing personal limitations such as admitting ignorance in some areas, (c) i n i t i a t i n g s o c i a l contracts, (d) expressing positive feelings, (e) handling c r i t i c i s m , (f) d i f f e r i n g with others, (g) assertion in service situations, and (h) giving negative feedback. Since assertive behaviour may vary according to the relationship between the people involved, this dimension is b u i l t into many of the items. Normative data. The A l was administered to four samples f o r normative purposes. Sample 1, conducted i n 1973, c o n s i s t e d of 197°female and 116 male u n i v e r s i t y undergraduates, with a mean age . of 22.1 years. Sample 2, i n 1974, c o n s i s t e d of 158 female and 137 male u n i v e r s i t y undergraduates, with a mean age of 21.6 years. The age range f o r these f i r s t two samples was 18 to 27 years. Sample 3 c o n s i s t e d of 33 female and 16 male u n i v e r s i t y undergraduates. The mean age of t h i s group was 23.1 years, with an age range of 18 to 53 years. T h i s t h i r d sample was r e t e s t e d a f t e r f i v e weeks. Sample 4 was an a s s e r t i v e n e s s t r a i n i n g ( c l i n i c a l ) sample c o n s i s t i n g of 19 females ranging i n age from 22 to 48 years. The mean age f o r t h i s group was 32.1 years. The c l i n i c a l sample was te s t e d before and a f t e r a s s e r t i v e n e s s t r a i n i n g , a six-week i n t e r v a l . F a c t o r i a l a n a l y s i s . F a c t o r a n a l y s i s of the discomfort scores f o r the 1973 sample generated 11 f a c t o r s accounting f o r 61% of the v a r i a n c e . The emergence of a number of r e l a t i v e l y e q u a l l y weighted f a c t o r s supported the s i t u a t i o n a l s p e c i f i c i t y of u n a s s e r t i v e behaviour. Items were in c l u d e d i n a f a c t o r i f they had a l o a d i n g g r e a t e r than .40 on that f a c t o r , and l e s s than .40 on a l l other f a c t o r s . Using these c r i t e r i a , 37 of the 40 items on the inventory were in c l u d e d i n one of the 11 f a c t o r s . 86 R e l i a b i l i t y and v a l i d i t y . In a review of assertiveness scales, the Assertion Inventory was cited to have one of the most extensive va l i d a t i o n studies of the top f i v e assertiveness scales (Galassi & Galassi, 1978). Norms are reported for three samples of undergraduates t o t a l l i n g 269 males and 388 females. Gambrill and Richey reported test-retest r e l i a b i l i t y (5-week interval) of r_ = .87 for discomfort and r_ = .81 for response pro b a b i l i t y . The inventory was also administered to a c l i n i c a l sample, and there i s evidence that the scale i s able to d i f f e r e n t i a t e between a c l i n i c a l , and a normal population. The assertiveness t r a i n i n g ( c l i n i c a l ) sample obtained a s i g n i f i c a n t l y higher mean discomfort score (107.7) before training than both the mean discomfort score (95.6) of the 1973 sample (_t(330) = 2.55, p_<.02), and for the mean discomfort score (96.0) for the pretest of Sample 3 (t(66) = 2.02, p_<.05). The c l i n i c a l population before training was sim i l a r to a l l undergraduates in mean response probability. In addition, based on discomfort and response probability scores, more individuals in the c l i n i c a l sample could be categorized as unassertive and anxious performer as compared to the normal populations. Also, the c l i n i c a l groups' discomfort and response probability scores decreased s i g n i f i c a n t l y following training when no change occurred during the 5-week inte r v a l in the r e l i a b i l i t y sample (Sample 3). The post mean 87 discomfort scores for the c l i n i c a l sample and r e l i a b i l i t y sample were 82.0 and 95.2 respectively (_t(66) = 2.27, £ <^.05). The post mean response probability scores for the c l i n i c a l and r e l i a b i l i t y samples were 97.9 and 105.0 respectively (t(56) = 3.67, £ <.002). The inventory also re f l e c t e d s i g n i f i c a n t differences within the c l i n i c a l sample before and after t r a i n i n g . The mean discomfort scores pre and post t r a i n i n g were 107.7 and 82.0 respectively (t(36) = 2.39, £ <.05). Adult Self-Perception P r o f i l e (ASPP) The Adult Self-Perception P r o f i l e (Messer & Harter, 1986) was devised in response to the need for a psychometrically sound instrument which adequately reflected the complexity of a multidimensional adult self-concept. The ASPP measures 12 domains of self-esteem, namely (a) s o c i a b i l i t y , (b) job competence, (c) nurturance, (d) a t h l e t i c a b i l i t i e s , (e) physical appearance, (f) adequate provider, (g) morality, (h) household management, (i ) intimate relationships, (j) i n t e l l i g e n c e , (k) sense of humour, and (1) global self-worth. The domain u t i l i z e d in the present study was intimate relationships. Normative data. The ASPP was administered to two samples for normative purposes. Sample A consisted of 141 parents (male and female) with the following c h a r a c t e r i s t i c s : age range was 30 to 50 years, upper middle class families, 100% had completed high school and the majority had completed college, and 95% were Caucasian. Sample A was divided into four groups: fulltime homemakers/ mothers (N = 41), part-time working women/mothers (N = 26), f u l l - t i m e working mothers (N = 29), and f u l l - t i m e working fathers (N = 44).. Sample B consisted of 215 mothers with the following c h a r a c t e r i s t i c s : a l l had children under the age of three years, some were middle class with an average age of 26 years, some were lower class with an average age of 22 years, over 90% were married, 90% had completed high school, 50% had attended college, and 95% were Caucasian. Sample B mothers were divided into two groups, working mothers and homemakers. Internal consistency r e l i a b i l i t y . The authors reported internal consistency r e l i a b i l i t i e s of r = .85 (Sample A) and r_ = .82 (Sample B) for the intimate relationships subscale. F a c t o r i a l analysis. Factor analysis, employing an oblique solution was performed on Sample B (N=215). A l l of the s p e c i f i c domains were included in the analysis. General self-worth items were not included since they do not 89 systematically load on pa r t i c u l a r factors for an entire sample. Factor analysis demonstrated that the average loadings for items defining each subscale are high, and cross loadings n e g l i g i b l e . The average loading for the intimate relationships subscale i s .78, with a cross loading of .06. Eating Disorder Inventory (EDI) The Eating Disorder Inventory (Garner & Olmstead, 1984) consists of eight subscales, namely (a) drive for thinness, (b) bulimia, (c) body,dissatisfaction, (d) ineffectiveness, (e) perfectionism, (f) interpersonal d i s t r u s t , (g) interoceptive awareness, and (h) maturity fears. For the purposes of this study only one subscale, interpersonal d i s t r u s t , was u t i l i z e d . V a l i d i t y and r e l i a b i l i t y . Cross-validation of the EDI was carried out on two subject groups. The c r i t e r i o n group was comprised of three subsamples of female anorexia nervosa patients (N s 113), with a mean age of 21.8 years. Approximately 50% of the c r i t e r i o n group were r e s t r i c t o r anorexics (n = 48) with a mean age of 21.0 years, and the remainder (n = 65) exhibited some bulimic symptoms. The bulimic group had a mean age of 22.4 years. The comparison group was comprised of three independent subsamples t o t a l l i n g 577 female university students with a mean age of 19.9 years. Internal consistency c o e f f i c i e n t s , using Standardized Cronbach's Alpha, for the subscales were required to be above .80 for the anorexic samples. For the interpersonal d i s t r u s t subscale, internal consistency is reported to be .85 for the anorexia nervosa sample, and .76 for the female comparison sample. Response bias. The possible effects of response bias were examined by comparing the mean subtotal score of a l l p o s i t i v e l y keyed items to that of a l l negatively keyed items. Correlations showed no s i g n i f i c a n t differences between either the anorexic group (r_ = .74, £ <.001) or the comparison group (r = .67, p_ <.001) suggesting minimal response set bias. C r i t e r i o n related v a l i d i t y . C r i t e r i o n related v a l i d i t y was examined, in part? by.use of therapist-consultants rating "the relevancy of each of these t r a i t s or c h a r a c t e r i s t i c s for this patient compared to other anorexics that you have treated" in accordance with descriptions of the content of each subscale (Garner & Olmstead, 1984, p. 6). Correlations between therapist-consultant ratings and the anorexic subjects self-report subscale scores were a l l s i g n i f i c a n t (p_ <.001). Convergent and discriminant v a l i d i t y . Convergent and discriminant v a l i d i t y of the subscales were demonstrated. An alpha l e v e l of p_ <.001 was chosen for each co r r e l a t i o n . Interpersonal d i s t r u s t was related to low self-esteem and depression. Congruence between c l i n i c i a n s ' ratings and subjects' subscale scores provides some evidence of construct v a l i d i t y . The demonstration of convergent and discriminant v a l i d i t y for 91 subscales, as well as their a b i l i t y to d i f f e r e n t i a t e between anorexic and the female comparison groups contribute to the construct v a l i d i t y of the subscales of the EDI. A study by Raciti,and Norcross (1987) reported a Cronbach's alpha c o e f f i c i e n t for the t o t a l EDI, for a female college sample (N = 283), of .93, with an alpha c o e f f i c i e n t of .81 for the interpersonal d i s t r u s t subscale. These authors report that, "the EDI appears to be an i n t e r n a l l y consistent, multi-dimensional instrument with a r e l a t i v e l y stable factor structure that accounts for a high percentage of the t o t a l variance" (p. 585). The authors conclude that the EDI i s a valuable research scale for eating disorders. The Social Self-Esteem Inventory (SSEI) Most measures of self-esteem are global estimates based on the assumption that individuals are characterized by a consistent disposition toward self-evaluation that i s uniform across situations. Lawson, Marshall, and McGrath (1979) suggest that a more useful estimate of self-esteem could be provided by a scale with a r e l a t i v e l y homogeneous item pool that would measure self-worth in the s i t u a t i o n for which performance is to be predicted. Based on c l i n i c a l experience Lawson et a l . determined that a measure of s o c i a l self-esteem would be a valuable tool for c l i n i c i a n s , since many psychiatric patients have d i f f i c u l t i e s with self-esteem in s o c i a l situations. V a l i d i t y . The preliminary scale was made up of 76 items culled from existing l i t e r a t u r e and from the authors' c l i n i c a l experience. The items are in the form of statements about habitual, attitudes and responses. Half of the items affirm high s o c i a l self-esteem and the rest affirm low s o c i a l self-esteem. The i n i t i a l scale was administered to a sample of 256 f i r s t year psychology students (142 females and 123 males). F a c t o r i a l analysis was employed in order to develop a shorter, more economical, and more homogeneous scale. F a c t o r i a l p u r i f i c a t i o n was performed u n t i l 31 items remained. The median item-total correlation was increased from 147 for 76 items to 160 for 31 items. These 31 items exhibited a general factor variance of approximately 40%. The f i n a l 31 items consisted of 16 p o s i t i v e l y and 15 negatively keyed statements. By discarding the p o s i t i v e l y keyed item with the lowest item-total c o r r e l a t i o n , the f i n a l 30 item format was arrived at. The general factor variance of the f i n a l 30 items is 39.7%, the remaining variance being largely item s p e c i f i c . Lawson et al.suggest that the construct of s o c i a l self-esteem i s necessarily somewhat "noisy" as there are no situations in which behaviour or attitude would exemplify pure s o c i a l self-esteem uncontaminated by si t u a t i o n s p e c i f i c 93 variance. The authors argue, however, that t h i s "in no way c a l l s in guestion the usefulness of the construct of s o c i a l self-esteem" (p. 806). R e l i a b i l i t y . The 30-item scale was administered to a d i f f e r e n t group of f i r s t year psychology students (64 males and 64 females), and readministered four weeks l a t e r . Retest r e l i a b i l i t i e s were assessed for each item as well as for the t o t a l score. The t o t a l retest r e l i a b i l i t y score was r_ = .88, with individual items ranging from r_ = .33 to r_ = .70. The standard error of measurement of the t o t a l score was estimated to be 7.29. Selection and Diagnostic C r i t e r i a Subjects were categorized into two major groups, eating disordered and non-eating disordered. The eating disordered group was further divided into three subgroups, r e s t r i c t i n g anorexics, previously anorexic bulimics, and never anorexic bulimics. The following tables outline the selection and diagnostic c r i t e r i a used. Table 8 i s an overview of the selection c r i t e r i a used for a l l groups. Table 9 contains the DSM-III diagnostic c r i t e r i a for anorexia nervosa. Table 10 contains Russell's (1979) diagnostic c r i t e r i a for bulimia nervosa. Table 11 contains sample interview questions used to assist with subgroup placement of eating disordered subjects. Table 8 Selection C r i t e r i a for Subjects 94 Eating Disordered Group (a) female (b) 18 years and over (c) not presently an inpatient in hospital Restricting anorexics (RA) (a) meet the DSM-III (1980) c r i t e r i a with weight modification (see Table 9), (b) low body weight achieved and maintained through severe c a l o r i c r e s t r i c t i o n , (c) no impulsive eating binges present, (d) food evacuation methods may be used to prevent food absorption. Previously anorexic bulimics (PAB) (a) meet Russell's c r i t e r i a for bulimia nervosa (see Table 10), (b) i n i t i a l l y experienced a period of c a l o r i c r e s t r i c t i o n and extreme weight loss, replaced by increasingly freguent eating binges and reliance on food evacuation methods to prevent weight gain. Never anorexic bulimics (NAB) (a) meet Russell's c r i t e r i a for bulimia nervosa, (b) no previous history of anorexia nervosa, as defined by the DSM-III c r i t e r i a (Table continues) Non-Eating Disordered Group (a) female (b) 18 years and over (c) no history of an eating disorder (d) a score of 15 and below on the Eating Attitudes Test (e) not currently in treatment for a psychiatric problem Table .9 DSM-III Diagnostic C r i t e r i a for Anorexia Nervosa (a) Intense fear of becoming obese, which does not diminish as weight loss progresses. (b) Disturbance of body image, e.g. claiming to " f e e l " fat even when emaciated. (c) Weight loss of at least 25%* of o r i g i n a l body weight or, i f under 18 years of age, weight loss from o r i g i n a l body weight plus projected weight gain expected from growth charts may be combined to make the 25%. (d) Refusal to maintain body weight over a minimal normal weight for age and height. (e) No known physical i l l n e s s that would account for the weight loss. * A modification of 20% weight loss was used. Table 10 Russell's (1979) C r i t e r i a for Bulimia Nervosa (a) A powerful and i n t r a c t i b l e urge to overeat resulting in episodes of overeating. (b) Avoidance of "fattening" effects of food by inducing vomiting or abusing purgatives or both. (c) A morbid fear of becoming f a t . T a b l e 11 Sample Q u e s t i o n s f o r D e t e r m i n i n g Subgroup  P l a c e m e n t o f E a t i n g D i s o r d e r e d S u b j e c t s (a) When you f i r s t d e v e l o p e d an e a t i n g d i s o r d e r was t h e r e a p e r i o d o f t i m e when you s e v e r e l y r e s t r i c t e d y o u r c a l o r i e s and g o t down t o a v e r y low w e i g h t ? (b) D i d you e v e r e x p e r i e n c e e a t i n g b i n g e s , where you maybe a t e as much as two o r t h r e e d i n n e r s a t one t i m e ? (c) D i d you b i n g e a t a l l d u r i n g t h e p e r i o d o f r e s t r i c t i o n , o r d i d t h e b i n g i n g b e g i n l a t e r and i n c r e a s e i n f r e q u e n c y as t i m e went on? (d) Do you s t i l l r e a l l y w a t c h what you e a t o r how many t i m e s a day you e a t ? (e) Do you s t i l l e x p e r i e n c e d i f f i c u l t y w i t h b i n g i n g ? ( f ) Do you f e e l c o m f o r t a b l e w i t h g a i n i n g w e i g h t , o r does t h a t t h o u g h t s t i l l s c a r e you? (g) Do you s t i l l r e a l l y s ee y o u r s e l f as r e a l l y f a t , o r f e e l l i k e you a r e f a t ? (h) Can you b r i e f l y d e s c r i b e t h e c o u r s e y o u r e a t i n g p r o b l e m s have t a k e n o v e r t h e y e a r s ? , APPENDIX C Introduction Letter Informed Consent APPENDIX D Eating Attitudes Test The Assertion Inventory Adult Self-Perception P r o f i l e Eating Disorder Inventory Social Self-Esteem Inventory Demographic Information Sheet EATING ATTITUDES TEST 103 Please place an "X" under the column which applies best to each of the numbered statements. Most of the questions d i r e c t l y r e l a t e to food or eating, although other types of questions have been included. There are NO righ t or wrong answers so t r y very hard to be completely honest in your answers. Results are completely c o n f i d e n t i a l . Please answer each question c a r e f u l l y . a 0) cn d> CM B-o •H >, fi +J r-l u to CU CU CU CU s u +J £ U > cu cw o (0 CU < > O <*> « z 1. Like eating with other people. 2. Prepare foods for others but do not eat what I cook. 3. Become anxious p r i o r to eating. 4. Am t e r r i f i e d about being overweight. 5. Avoid eating when I am hungry. 6. Find myself preoccupied with food. 7. Have gone on eating binges where I f e e l that I may not be able to stop. 8. Cut my food into small pieces. 9. Aware of the c a l o r i e content of foods that I eat. 10. P a r t i c u l a r l y avoid foods with a high carbohydrate content (e.g. bread, potatoes, r i c e , e t c . ) . 11. Feel bloated a f t e r meals. 12. Feel that others would prefer i f I ate more. 13. Vomit after I have eaten. 14. Feel extremely g u i l t y a f t e r eating. 15. Am preoccupied with a desire to be thin. 16. Exercise strenuously to burn o f f c a l o r i e s . 17. Weight myself several times a day. 18. Like my clothes to f i t t i g h t l y . 19. Enjoy eating meats. 20. Wake up early in the morning. 21. Eat the same foods day a f t e r day. 22. Think about burning up c a l o r i e s when I exercise. 23. Have regular menstrual periods. 24. Other people think that I am too t h i n . 25. Am preoccupied with the thought of having f a t on my body. 26. Take longer than others to eat my meals. 27. Enjoy eating at restaurants. 28. Take laxatives. 29. Avoid foods with sugar in them. 30. Eat diet foods. 31. Feel that food controls my l i f e . 32. Display s e l f - c o n t r o l around food. 33. Feel that others pressure me to eat. 34. Give too much time and thought to food. c 104 0) tn •p e o •H C +-> r-l M >> 0) (U 0) 3 +J e u > 4-1 O < > O C/5 3 5 . S u f f e r f r om c o n s t i p a t i o n . 3 6 . F e e l u n c o m f o r t a b l e a f t e r e a t i n g s w e e t s . 3 7 . Engage i n d i e t i n g b e h a v i o u r . 3 8 . L i k e my s tomach t o be empty . 3 9 . E n j o y t r y i n g hew r i c h f o o d s . 4 0 . Have the i m p u l s e t o v o m i t a f t e r m e a l s . 105 ASSERTION INVENTORY Many people experience d i f f i c u l t y in situations requiring them to assert themselves i n some way. Please indicate your degree of discomfort or anxiety in the space provided before each s i t u a t i o n l i s t e d below. Use the following scale to indicate your degree of discomfort: l=none 2=a l i t t l e 3=a f a i r amount 4=much 5=very much then, go over the l i s t a second time and indicate a f t e r each item the p r o b a b i l i t y or l i k e l i h o o d of your engaging in the behaviour i f a c t u a l l y faced with the s i t u a t i o n . " For example, i f you r a r e l y apologize when you are at f a u l t , mark a "4" a f t e r that item. Use the following scale to indicate response p r o b a b i l i t y : l=always do i t 2=usually do i t 3=do i t about ha l f the time 4=rarely do i t 5=never do i t -NOTE: I t i s important to cover your discomfort ratings (located i n front of the items) while i n d i c a t i n g response p r o b a b i l i t y . Otherwise, one r a t i n g may e f f e c t the other and a r e a l i s t i c assessment of your behaviour i s u n l i k e l y To correct f o r t h i s , place a piece of paper over your discomfort ratings while responding to the situations a second time f o r response p r o b a b i l i t y Degree of Response Discomfort SITUATIONS P r o b a b i l i t y 1. Turn down a request to borrow your car 2. Compliment a f r i e n d 3. Ask a favour of someone 4. Resist sales pressure 5. Apologize when you are at f a u l t 6. Turn down a request for a meeting or date 7. Admit fear and request consideration 8. T e l l a person you are intimately involved with when he/she says or does something that bothers you 9. Ask for a r a i s e 10. Admit ignorance i n some area 11. Turn down a request to borrow money 12. Ask personal questions 13. Turn o ff a t a l k a t i v e friend 14. Ask for constructive c r i t i c i s m 15. I n i t i a t e a conversation with a stranger 16. Compliment a person you are romantically involved with or interested i n 17. Request a meeting or a date with a person 18. Your i n i t i a l request for a meeting i s turned down and you ask the person again at a l a t e r time.. 19. Admit confusion about a point under discussion and ask for c l a r i f i c a t i o n . . . . . . . . . . . . . . . . . . . . . . . 20. Apply f o r a job 21. Ask whether you have offended someone Degree of Discomfort SITUATION 106 Response Pr o b a b i l i t y 22. T e l l someone that you l i k e them 23. Request expected service when such i s not forthcoming, e.g., in a restaurang... 24. Discuss openly with the person his/her c r i t i c i s m of your behaviour 25. Return defective items, e.g. store or restaurant 26. Express an opinion that d i f f e r s from that of the person you are talking to 27. Resist sexual overtures when you are not interested 28. T e l l the person when you f e e l he/she has done something that i s unfair to you 29. Accept a date 30. T e l l someone good news about yourself.... 31. Resist pressure to drink 32. Resist a s i g n i f i c a n t person's unfair demands 33. Quit a job 34. Resist pressure to "turn on" 35. Discuss openly with the person his/her c r i t i c i s m of your work 36. Request the return of borrowed items 37. Receive compliments 38. Continue to converse with someone who disagrees with you 39. T e l l a f r i e n d or someone with whom you work when he/she says or does something that bothers you 40. Ask a person who i s annoying you in a public s i t u a t i o n to stop Lastly, please indicate the situa t i o n s you would l i k e to handle more a s s e r t i v e l y by placing a c i r c l e around the item number. You can c i r c l e as many items as you please. Gambrill, E.D. & Richey, C.A., 1975 (c) WHAT I AM LIKE T h e s e a r e s t a t e m e n t s w h i c h a l l o w p e o p l e t o d e s c r i b e t h e m s e l v e s . T h e r e a r e n o r i g h t o r w r o n g a n s w e r s s i n c e p e o p l e d i f f e r m a r k e d l y . P l e a s e r e a d t h e e n t i r e s e n t e n c e a c r o s s . First d e c i d e w h i c h o n e o f t h e t w o p a r t s o f e a c h s t a t e m e n t b e s t describes you; t h e n g o t o t h a t s i d e o f t h e s t a t e m e n t a n d c h e c k w h e t h e r t h a t is j u s t s o r t o f t r u e f o r y o u o r r e a / / y t r u e f o r YOU. Y o u w i l l j u s t c h e c k O N E o f t h e f o u r b o x e s f o r e a c h s t a t e m e n t . R e a l l y S o r t o f T r u e T r u e f o r M e f o r M e ( ) ( ) S o m e a d u l t s l i k e t h e w a y t h e y a r e l e a d i n g t h e i r l i v e s B U T O t h e r a d u l t s d o n ' t l i k e t h e w a y t h e y a r e l e a d i n g t h e i r l i v e s . S o r t o f R e a l l y T r u e T r u e f o r M e f o r M e ( ) ( 0 ( ) ( ) ( ) ( ) S o m e a d u l t s f e e l t h a t t h e y a r e e n j o y a b l e t o b e w i t h ( ) S o m e a d u l t s a r e n o t s a t i s f i e d w i t h t h e w a y t h e y d o t h e i r w o r k ( ) S o m e a d u l t s s e e c a r i n g o r n u r t u r i n g o t h e r s as a c o n t r i -b u t i o n t o t h e f u t u r e B U T O t h e r a d u l t s o f t e n q u e s t i o n ( ) w h e t h e r t h e y a r e e n i o y a b l e t o b e w i t h . B U T O t h e r a d u l t s a r e s a t i s f i e d t h e ( ) w a y t h e y d o t h e i r w o r k . B U T O t h e r a d u l t s d o n o t g a i n a ( ' ) s e n s e o f c o n t r i b u t i o n t o t h e f u t u r e t h r o u g h n u r t u r i n g o t h e r s . ( ) ( ) ( ) ( ) ( ) I n g a m e s a n d s p o r t s s o m e a d u l t s u s u a l l y w a t c h i n s t e a d o f p l a y B U T O t h e r a d u l t s u s u a l l y p l a y r a t h e r t h a n j u s t w a t c h . ' ( ) ( ) ( ) ( ) S o m e a d u l t s a r e h a p p y w i t h t h e w a y t h e y l o o k ( ) ( ) S o m e a d u l t s f e e l t h e y a r e n o t a d e q u a t e l y s u p p o r t i n g t h e m -s e l v e s a n d t h o s e w h o a r e i m p o r t a n t t o t h e m ( ) ( ) S o m e a d u l t s l i v e u p t o t h e i r o w n m o r a l s t a n d a r d s B U T O t h e r a d u l t s a r e n o t h a p p y ( ) w i t h t h e w a y t h e y l o o k B U T O t h e r a d u l t s f e e l t h e y a r e ( ) p r o v i d i n g a d e q u a t e s u p p o r t f o r t h e m s e l v e s a n d o t h e r s . ( ) ( ) B U T O t h e r a d u l t s h a v e t r o u b l e ( ) ( ) l i v i n g u p t o t h e i r m o r a l s t a n d a r d s ( ) ( ) S o m e a d u l t s a r e v e r y h a p p y b e i n g t h e w a y t h e y a r e 1 0 . ( ) ( ) S o m e a d u l t s a r e n o t v e r y o r g a n i z e d i n c o m p l e t i n g h o u s e h o l d t a s k s B U T O t h e r a d u l t s w o u l d l i k e ( ) t o b e d i f f e r e n t . B U T O t h e r a d u l t s a r e o r g a n i z e d i n c o m p l e t i n g h o u s e h o l d t a s k s . ( ) ( ) ( ) 1 1 . ( ) ( ) S o m e a d u l t s h a v e t h e a b i l i t y t o d e v e l o p i n t i m a t e r e l a t i o n s h i p s B U T O t h e r a d u l t s d o n o t f i n d i t e a s y t o d e v e l o p i n t i m a t e r e l a t i o n s h i p s . ( ) ( ) 1 2 . ( ) ( ) w h e n s o m e a d u l t s d o n ' t u n d e r s t a n d s o m e t h i n g , i t m a k e s t h e m f e e l s t u p i d 8 U T O t h e r a d u l t s d o n ' t n e c e s s a r i l y f e e l s t u p i d w h e n t h e y d o n ' t u n d e r s t a n d . ( ) ( ) 1 3 . 1 4 . ( ) ( ) S o m e a d u l t s c a n r e a l l y l a u g h a t t h e m s e l v e s B U T O t h e r a d u l t s h a v e a h a r d t i m e ( ) l a u g h i n g a t t h e m s e l v e s . ( ) ( ) S o m e a d u l t s f e e l u n c o m f o r t a b l e B U T O t h e r a d u l t s l i k e t o m e e t w h e n t h e y h a v e t o m e e t n e w p e o p l e n e w p e o p l e . ( ) ( ) ( ) 1 5 . ( ) ( ) S o m e a d u l t s f e e l t h e y a r e v e r y B U T O t h e r a d u l t s w o r r y a b o u t ( ) ( ) g o o d a t t h e i r w o r k w h e t h e r t h e y c a n d o t h e i r w o r k M « w r and Harter. Adu l t Self-Perception Profile. University of Oenver. 1984 (Rl - 2 - 108 1 6 . ( : ) 1 7 . ' ( ) ( • ) S o m e a d u l t s d o n o t e n j o y f o s t e r i n g t h e g r o w t h o f o t h e r s ( ) S o m e a d u l t s s o m e t i m e s q u e s t i o n w h e t h e r t h e y a r e a w o r t h w h i l e p e r s o n B U T O t h e r a d u l t s e n j o y f o s t e r i n g t h e g r o w t h o f o t h e r s B U T O t h e r a d u l t s f e e l t h a t t h e y a r e a w o r t h w h i l e p e r s o n . ( ) ( ) ( ) ( ) 1 8 . ( ) ( ) S o m e a d u l t s t h i n k t h e y c o u l d d o w e l l a t j u s t a b o u t a n y n e w p h y s i c a l a c t i v i t y t h e y h a v e n ' t t r i e d b e f o r e B U T O t h e r a d u l t s a r e a f r a i d t h e y ( ) m i g h t n o t d o w e l l a t p h y s i c a l a c t i v i t i e s - h e y h a v e n ' t e v e r t r i e d . ( ) 19- ( ) ( ) S o m e a d u l t s t h i n k t h a t t h e y a r e n o t v e r y a t t r a c t i v e o r g o o d l o o k i n g B U T O t h e r a d u l t s t h i n k t h a t t h e v a r e a t t r a c t i v e o r g o o d l o o k i n g ( ) ( ) 2 0 . u : ( ) S o m e a d u l t s a r e s a t i s f i e d w i t h h o w t h e y p r o v i d e f o r t h e i m p o r t a n t p e o p l e i n t h e i r l i v e s B U T O t h e r a d u l t s a r e d i s s a t i s f i e d w i t h h o w t h e v p r o v i d e f o r t h e s e p e o p l e ( ) ( ) 2 1 . ( ) 2 2 . ( ) ( ) S o m e a d u l t s w o u l d l i k e t o b e a B U T O t h e r a d u l t s t h i n k t h a t t h e y b e t t e r p e r s o n m o r a l l y a r e q u i t e m o r a l ( ) S o m e a d u l t s c a n k e e p t h e i r h o u s e h o l d r u n n i n g s m o o t h l y B U T O t h e r a d u l t s h a v e t r o u b l e k e e p i n g t h e i r h o u s e h o l d r u n n i n g s m o o t h l y . ( ) ( ) ( ) 2 3 . ( ) ( ) S o m e a d u l t s f i n d i t h a r d t o e s t a b l i s h i n t i m a t e r e l a t i o n s h i p s B U T O t h e r a d u l t s d o n o t h a v e d i f f i c u l t y e s t a b l i s h i n g i n t i m a t e r e l a t i o n s h i p s . ( ) ( ) 2 4 . ( ) ( ) S o m e a d u l t s f e e l t h a t t h e y a r e i n t e l l i g e n t B U T O t h e r a d u l t s q u e s t i o n w h e t h e r ( ) t h e y a r e v e r y i n t e l l i g e n t . ( ) 25- ( ) ( ' ) S o m e a d u l t s a r e d i s a p p o i n t e d B U T O t h e r a d u l t s a r e q u i t e p l e a s e d ( ) ( ) w i t h t h e m s e l v e s w i t h t h e m s e l v e s 2 6 - ( ) ( ) S o m e a d u l t s f i n d i t h a r d t o a c t i n a j o k i n g o r k i d d i n g m a n n e r w i t h f r i e n d s o r c o l l e a g u e s B U T O t h e r a d u l t s f i n d i t v e r y e a s y ( ) t o j o k e o r k i d a r o u n d w i t h f r i e n d s a n d c o l l e a g u e s . ( ) 2 7 . ( ) ( ) S o m e a d u l t s f e e l a t e a s e w i t h o t h e r p e o p l e B U T O t h e r a d u l t s a r e q u i t e s h y . ( ) ( ) 2 8 . ( ) ( ) S o m e a d u l t s a r e n o t v e r y p r o d u c t i v e i n t h e i r w o r k B U T O t h e r a d u l t s a r e v e r y p r o d u c t i v e i n t h e i r w o r k . ( ) ( ) 2 9 . 3 0 . ( ) ( ) ( ) S o m e a d u l t s f e e l t h e y a r e g o o d a t n u r t u r i n g o t h e r s ( ) S o m e a d u l t s d o n o t f e e l t h a t t h e v a r e v e r y g o o d w h e n i t c o m e s t o s p o r t s B U T O t h e r a d u l t s a r e n o t v e r y n u r t u r a n t ( ) B U T O t h e r a d u l t s f e e l t h e y d o ( ) v e r y w e l l a t a l l k i n d s o f s p o r t s . ( ) ( ) 3 1 . ( ) ( ) S o m e a d u l t s l i k e t h e i r p h y s i c a l B U T O t h e r a d u l t s d o n o t l i k e t h e i r ( ) ( ) a p p e a r a n c e t h e w a y i t is p h y s i c a l a p p e a r a n c e 3 2 - ( ) ( ) S o m e a d u l t s f e e l t h e v c a n n o t p r o v i d e f o r t h e m a t e r i a l n e c e s s i t i e s o f l i f e B U T O t h e r a d u l t s f e e l t h e v d o ( ) a d e q u a t e l y p r o v i d e f o r t h e m a t e r i a l n e c e s s i t i e s o f l i f e . ( ) 3 3 . ( ) ( ) S o m e a d u l t s a r e d i s s a t i s f i e d w i t h t h e m s e l v e s B U T O t h e r a d u l t s a r e s a t i s f i e d w i t h t h e m s e l v e s . ( ) ( ) 109 3 4 . ( ) ( ) S o m e a d u l t s u s u a l l y d o w h a t t h e y k n o w is m o r a l l y r i g h t B U T O t h e r a d u l t s o f t e n d o n ' t d o w h a t t h e y k n o w is m o r a l l y r i g h t . ( ) ( ) 3 S . ( ) ( ) S o m e a d u l t s a r e n o t v e r y e f f i c i e n t i n m a n a g i n g a c t i v i t i e s a t h o m e ' B U T O t h e r a d u l t s a r e e f f i c i e n t i n m a n a g i n g a c t i v i t i e s a t h o m e . ( ) ( ) 3 6 . ( ) ( ) S o m e p e o p l e s e e k o u t c l o s e r e l a t i o n s h i p s B U T O t h e r p e r s o n s s h y a w a y f r o m c l o s e r e l a t i o n s h i p s . ( ) ( ) 3 7 . ( ) ( ) S o m e a d u l t s d o n o t f e e ) t h a t t h e y a r e v e r y i n t e l l e c t u a l l y c a p a b l e B U T O t h e r a d u l t s f e e l t h a t t h e y a r e ( ) ( ) i n t e l l e c t u a l l y c a p a b l e . 3 8 . ( ) ( ) S o m e a d u l t s f e e l t h e y h a v e a g o o d s e n s e o f h u m o r 3 9 . ( ) ( ) S o m e a d u l t s a r e n o t v e r y s o c i a b l e B U T O t h e r a d u l t s w i s h t h e i r s e n s e o f h u m o r w a s b e t t e r . B U T O t h e r a d u l t s a r e s o c i a b l e . ( ) ( ) ( ) ( ) 4 0 . ( ) ( ) S o m e a d u l t s a r e p r o u d o f t h e i r w o r k 8 U T O t h e r a d u l t s a r e n o t v e r y p r o u d o f w h a t t h e y d o ( ) ( ) 4 1 . ( ) ( ) S o m e a d u l t s l i k e t h e k i n d o f p e r s o n t h e y a r e B U T O t h e r a d u l t s w o u l d l i k e t o b e s o m e o n e e l s e ( ) ( ) 4 2 . ( ) ( ) S o m e a d u l t s d o n o t e n j o y n u r t u r i n g o t h e r s B U T O t h e r a d u l t s e n j o y b e i n g n u r t u r a n t . ( ) ( ) 4 3 . ( ) ( ) S o m e a d u l t s f e e l t h e y a r e b e t t e r t h a n o t h e r s t h e i r a g e a t s p o r t s B U T O t h e r a d u l t s d o n ' t f e e l t h e y c a n p l a y as w e l l . ( ) . ( ) 4 4 . ( ) ( ) S o m e a d u l t s a r e u n s a t i s f i e d w i t h s o m e t h i n g a b o u t t h e i r f a c e o r h a i r B U T O t h e r a d u l t s l i k e t h e i r f a c e a n d h a i r t h e w a y t h e y a r e . ( ) ( ) 4 5 . ( ) ( ) S o m e a d u l t s f e e l t h a t t h e y p r o v i d e a d e q u a t e l y f o r t h e n e e d s o f t h o s e w h o a r e i m p o r t a n t t o t h e m B U T O t h e r a d u l t s f e e l t h e y d o n o t p r o v i d e a d e q u a t e l y f o r t h e s e n e e d s . ( ) ( ) 4 6 . 4 7 . ( ) ( ) S o m e a d u l t s o f t e n q u e s t i o n t h e m o r a l i t y o f t h e i r b e h a v i o r ( ) ( ) S o m e a d u l t s u s e t h e i r t i m e e f f i c i e n t l y a t h o u s e h o l d a c t i v i t i e s B U T O t h e r a d u l t s f e e l t h a t t h e i r b e h a v i o r is u s u a l l y m o r a l . B U T O t h e r a d u l t s d o n o t u s e t h e i r t i m e e f f i c i e n t l y ( ) ( ) ( ) ( ) 4 8 . ( ) . - ( . ) . . S o m e a d u l t s i n c l o s e . r e l a t i o n s h i p s h a v e a h a r d t i m e c o m m u n i c a t i n g o p e n l y 8 U T O t h e r a d u l t s i n c l o s e r e l a t i o n s h i p s f e e l t h a t i t is e a s y t o c o m m u n i c a t e o p e n l y (. ) ( ) 4 9 . ( ) ( ) S o m e a d u l t s f e e l l i k e t h e y a r e j u s t as s m a r t as o t h e r a d u l t s B U T O t h e r a d u l t s w o n d e r i f t h e y a r e as s m a r t . ( ) ( ) 5 0 . ( ) ( ) S o m e a d u l t s f e e l t h a t t h e y B U T O t h e r a d u l t s a r e a b l e t o f i n d ( ) ( ) a r e o f t e n t o o s e r i o u s a b o u t h u m o r i n t h e i r l i f e , t h e i r l i f e - L i -110 When you have completed the "What I Am Like" form, please f i l l out this "Importance Rating" form which asks about the importance of various areas i n your l i f e . For each area, choose how important this statement i s to your sense of self-worth. Place an "X" under the column which best applies to you. Lastly, on the lines below, l i s t the 3 statements which are most important and the 2 or 3 statements which are least important to you.. Very Pretty Only sort of Not very Ho" important i s i t to you? Important Important Important Important 1 . To be sociable/at ease with others. 2. To be good at your work, (hnw did you define '-rork: job homemaking) 3- To care for others. t^-. To be good at physical a c t i v i t i e s . 5. To be good looking. 6. To be an adequate provider. 7. To be moral. 8. To be good at household management. 9. To have intimate relationships. 1 0 . To be i n t e l l i g e n t . 1 1 . To have a sense of humor. On the l i n e s below l i s t the 3 areas from above which are most important to you and l i s t the 2 or 3 areas which are least important to you: Most Important Least Important I l l EDI This i s a scale which measures a va r i e t y of attitudes, f e e l i n g s , and behaviours. Some of the items re l a t e to food and eating. Others ask you about your fee l i n g s . about yourself. There are no r i g h t or wrong answers, so tr y very hard to be completely honest i n your answers. Results are completely c o n f i d e n t i a l . Read each question and place an "X" under the column which applies best to you. Please answer each question very c a r e f u l l y . 1. I eat sweets and carbohydrates without f e e l i n g nervous. 2. I think that my stomach i s too big. 3. I wish that I could return to the security of childhood. 4. I eat when I am upset. 5. I s t u f f myself with food. 6. I wish that I could be younger. 7. I think about d i e t i n g . 8. I get frightened when my feeli n g s are too strong. 9. I think that my thighs are too large. 10. I - f e e l i n e f f e c t i v e as a person. 11. I f e e l extremely g u i l t y a f t e r overeating. 12. I think that my stomach i s ju s t the right s i z e . 13. Only outstanding performance i s good enough in my family. 14. The happiest time in l i f e i s when you are a c h i l d . 15. I am open about my f e e l i n g s . 16. I am t e r r i f i e d of gaining weight. 17. I tr u s t others. 18. I f e e l alone i n the world. 19. I f e e l s a t i s f i e d with the shape of my body. 20. I f e e l generally i n control of things in my l i f e . 21. I get cofused about what emotion I am f e e l i n g . 22. I would rather be an adult than a c h i l d . 23. I can communicate with others e a s i l y . 24. I wish I were someone else. 25. I exaggerate or magnify the importance of weight. 26. I can c l e a r l y i d e n t i f y what emotion I am f e e l i n g . 27. I f e e l inadequate. 28. I have gone on eating binges where I have f e l t that I could not stop. 29. As a c h i l d , I t r i e d very hard to avoid disappointing my parents and teachers. 30. I have close r e l a t i o n s h i p s . 31. I l i k e the shape of my buttocks. 32. I am preoccupied with the desire to be thinner. 33. I don't know what i s going on inside of me. 34. I have trouble expressing my emotions to others. 35. The demands of adulthood are too great. 36. I hate being less than best at things. 37. I f e e l secure about myself. co CD e CO I - I •H >. f-l C +-> I - I M m nj CD CD CD 3 3 •P E f-l > I - I CO 4-1 o aj CD < O C/) 05 3 38. I think about binging (over-eating). 39. I f e e l happy that I am not a c h i l d anymore. 40. I get confused as to whether or not I am hungry. 41. I^have a low opinion of myself. 42. I f e e l that I can achieve my standards. 43. My parents have expected excellence of me. 44. I worry that my feelings w i l l get out of control. 45. I think that my hips are too big. 46. I eat moderately in front of others and s t u f f myself when they are gone. 47. I f e e l bloated a f t e r eating a normal meal. 48. I f e e l that people are happiest when they are c h i l d r e n . 49. If I gain a pound, I worry that I w i l l keep gaining. 50. I f e e l that I am a worthwhile person. 51. When I am upset, I don't know i f I am sad, frightened, or angry. 52. I f e e l that I must do things p e r f e c t l y , or not do them at a l l . 53. I have the thought of t r y i n g to vomit in order to lose weight. 54. I need to keep people at a c e r t a i n distance ( f e e l uncomfortable i f someone t r i e s to get too close). 55. I think that my thighs are j u s t the rig h t s i z e . 56. I f e e l empty inside (emotionally). 57. I can talk about personal thoughts or f e e l i n g s . 58. The best years of your l i f e are when you become an adult, 59. I think that my buttocks are too large. 60. I have feelings that I can't quite i d e n t i f y . 61. I eat or drink in secrecy. 62. I think that my hips are j u s t the rig h t s i z e . 63. I have extremely high goals. 64. When I am upset, I worry that I w i l l s t a r t eating. 112 co CU >> e r-i .1-1 >> >, r-i C +J 1-1 M rfl td cu CU cu CU 3 4-> 6 u > co 4-1 • o cu < 3 O « z Adapted and reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16102 North F l o r i d a Avenue, Lutz, F l o r i d a , 33549, from the Eating Disorder Inventory, by D. Garner, M.P. OLmstead, J. Polivy, Copyright, 1984. Further reproduction i s prohibited without permission from PAR, Inc. 113 SSES Please place a number in the space provided beside each of the statements below according to the following scale: Completely unlike me 1 2 3 4 5 6 Exactly l i k e me Please choose the number that best describes how much the statement i s " l i k e you". For example, i f you f e e l that a statement describes you exactly, place a 6 beside that statement. If the statement is completely unlike you, place a 1 against that statement. The numbers 2 through 5 represent varying degrees of how much each statement is " l i k e you". Please answer each question c a r e f u l l y . 1. I f i n d i t hard to t a l k to strangers. 2. I lack confidence with people. 3. I am s o c i a l l y e f f e c t i v e . 4. I f e e l confident i n s o c i a l s i t u a t i o n s . 5. I am easy to l i k e . 6. I get along well with other people. 7. I make friends e a s i l y . 8. I am l i v e l y and witty in s o c i a l s i t u a t i o n s . 9. When I am with other people I lose self-confidence. 10. I f i n d i t d i f f i c u l t to make friends. 11. I am no good at a l l from a s o c i a l standpoint. 12. I am a reasonably good conversationalist. 13. I am popular with people my own age. 14. I am a f r a i d of large p a r t i e s . 15. I t r u l y enjoy myself at s o c i a l functionings. 16. I usually say the wrong thing when I talk with people. 17. I am confident at p a r t i e s . 18. I am usually unable to think of anything i n t e r e s t i n g to say to people 19. I am a bore with most people. 20. People do not f i n d me i n t e r e s t i n g . 21. I am nervous with people who are not close f r i e n d s . 22. I am quite good at making people f e e l at ease with me. 23. I am more shy than most people. 24. I am a f r i e n d l y person. 25. I can hold people's i n t e r e s t easily.. 26. I don't have much "personality". 114 27. I am a l o t of fun to be with. 28. I am quite content with myself as a person. 29. I am quite awkward in s o c i a l s i t u a t i o n s . 30. I do not f e e l at ease with other people. BACKGROUND INFORMATION 115 1. Age 2. Occupation 3. How many hours per week do you work? (Check one) Less than 20 hrs/wk. ( ) 20-30 hrs/wk. ( ) Over 30 hrs/wk. ( ) 4. Highest l e v e l of education achieved? (Check one) Grade school ( ) College/University ( ) High school ( ) Graduate school ( ) 5. L i v i n g arrangements: Single ( ) Separated/Divorced ( ) Married ( ) Widowed ( ) 6. Who else l i v e s in your household with you? (State t h e i r r e l a t i o n s h i p to you) Highest past weight (excluding pregnancy)? How long ago? (years or months) How long did you stay at t h i s weight? (years or months) 8. Lowest past adult weight? How long ago? (years or months) How long did you stay at t h i s weight? (years or months) i What do you consider your id e a l weight? 10. Age at which weight problems began ( i f any)? 11. How often do you weight yourself? (Check one) Less than once a month ( ) Once a day ( ) Once or twice a month ( ) More than once a day ( ) Once or twice a week ( ) 12. Are you currently on a diet to lose weight? yes ( ) no ( ) Approximately how many c a l o r i e s do you eat daily? (Check one) 0-500 calo r i e s ( ) 500-1000 ( ) 1000-1500 ( ) 1500 & over ( ) 13. Have you ever been previously diagnosed as having an eating disorder? yes ( ) no ( ) I f yes, how long ago? (years or months) "  Did you receive treatment? yes ( ) no ( ) If yes, for how long? (years or months) 14. Are you currently in therapy for any problems? yes ( ) no ( ) 

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