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Body image perception and preference in anorexia nervosa Buree, Barbara Ursula 1981

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B O D Y I M A G E P E R C E P T I O N A N D P R E F E R E N C E I N A N O R E X I A N E R V O S A b y B a r b a r a U r s u l a B u r e e B . A . h o n . , T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1 9 7 7 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T OF T H E R E Q U I R E M E N T S 1 F O R T H E D E G R E E OF M A S T E R OF A R T S i n T H E F A C U L T Y OF G R A D U A T E S T U D I E S ( C l i n i c a l / C o m m u n i t y P s y c h o l o g y ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A M a y 1981 (c) B a r b a r a U r s u l a B u r e e , 1 9 8 1 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l m a k e i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s m a y b e g r a n t e d b y t h e h e a d o f my d e p a r t m e n t o r b y h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f ^Ps^dLrji^)^  T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a 2 0 7 5 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V 6 T 1W5 ABSTRACT Nineteen female anorexic p a t i e n t s (10 a n o r e x i c - a b s t a i n e r s and 9 a n o r e x i c s w i t h episodes of bulimia) and 19 matched normal weight females p a r t i c i p a t e d i n a study designed to i n v e s t i g a t e u n d e r l y i n g dimensions of body image p e r c e p t i o n and body image p r e f e r e n c e s . The t e s t m a t e r i a l s c o n s i s t e d of a s e r i e s of s i l -h ouettes which v a r i e d s y s t e m a t i c a l l y i n the s i z e s of four body p a r t s : b r e a s t s , abdomen, b u t t o c k s , and l e g s . F i r s t , the s u b j e c t s s o r t e d the s i l h o u e t t e s i n t o c a t e g o r i e s , Subjects then ordered the s i l h o u e t t e s along a 100-unit s c a l e r e f l e c t i n g t h e i r p r e f e r -ence f o r each s i l h o u e t t e . F i n a l l y , the s u b j e c t s s e l e c t e d the s i l h o u e t t e which resembled themselves most and completed a seman-t i c d i f f e r e n t i a l f o r t h i s and the most and l e a s t p r e f e r r e d s i l h o u e t t e s . M u l t i d i m e n s i o n a l s c a l i n g analyses (INDSCAL & PREFMAP) were performed. F i v e u n d e r l y i n g dimensions o f percep-t i o n were i n t e r p r e t e d : four of those dealt with s i z e of buttocks and abdomen and one with b r e a s t s i z e . The dimensions were s i m i l a r f o r both groups. Contrary to e x p e c t a t i o n , no group d i f f e r e n c e s were found r e g a r d i n g body image p r e f e r e n c e s . Sub-j e c t s w i t h i n each group were heterogeneous. Pr e f e r e n c e r a t i n g s of own body s i l h o u e t t e were s i g n i f i c a n t l y lower f o r a n o r e x i c a b s t a i n e r s than f o r b u l i m i c a n o r e x i c s (p < .05) and normal c o n t r o l s (p < .01). The semantic d i f f e r e n t i a l s c a l e s y i e l d e d no group d i f f e r e n c e s . I t was concluded t h a t v a r i a b l e s other than a d i s t o r t e d body image and a thin), body image i d e a l are important t o the e t i o l o g y of anorexia nervosa; f u t u r e r e s e a r c h should i n v e s t i g a t e a l t e r n a t i v e e t i o l o g i c a l concepts such as weight phobia and fear of losing control. The d i s t i n c t i o n be-tween anorexic abstainers and bulimic anorexics appears to be useful and the c h a r a c t e r i s t i c s of these subgroups need to be investigated further. i v Table o f Contents PAGE ABSTRACT i i LIST OF TABLES v LIST OF FIGURES v i PREFACE 1 INTRODUCTION 3 METHOD 26 RESULTS 31 DISCUSSION 60 CONCLUDING REMARKS 69 REFERENCES 71 APPENDICES Appendix 1: C r i t e r i a f o r Diagnosis of Anorexia Nervosa (Feigher e t a l . ) 75 Appendix 2: D i a g n o s t i c C r i t e r i a f o r Anorexia Nervosa (DSM-III) 76 Appendix 3: Semantic D i f f e r e n t i a l S c a l e s 78 Appendix 4: Case H i s t o r i e s 79 Appendix 5: Background C h a r a c t e r i s t i c s of Anorexics 88 Appendix 6: Background C h a r a c t e r i s t i c s o f C o n t r o l s 90 Appendix 7: Scores on the R e s t r a i n t Q u e s t i o n n a i r e by C o n t r o l Subjects 91 Appendix 8: S i l h o u e t t e s 92 Appendix 9: E a t i n g A t t i t u d e s Test 9 7 Appendix 10: R e s t r a i n t Q u e s t i o n n a i r e 100 Appendix 11: P e r c e p t u a l A b e r r a t i o n S c a l e 101 V L i s t o f T a b l e s PAGE Tab l e 1. Average S a l i e n c e s p e r Group on Each Dimension 34 Table 2. P e r c e n t a g e s o f Agreement f o r 15 S u b j e c t s T a b l e 3. Average P r e f e r e n c e R a t i n g s and Rankings f o r a l l S i l h o u e t t e s T a ble 4. Spearman's p P r e f e r e n c e R a t i n g s Comparison T a b l e 5. Root Mean Squares T a b l e 6. Average S i z e o f D i r e c t i o n C o s i n e s f o r Each Group Table 7. Average P r e f e r e n c e R a t i n g s o f S i l h o u e t t e s Chosen as B e s t R e p r e s e n t a t i o n . o f O n e s e l f T a b l e 8. Means o f Semantic D i f f e r e n t i a l S c a l e s T able 9. S c o r e s on the R e s t r a i n t Q u e s t i o n n a i r e and t h e E a t i n g A t t i t u d e s T e s t Tablel.10. Means o f P e r c e p t u a l A b e r r a t i o n S c o r e s f o r Each Group T a b l e 11. Means and S t a n d a r d D e v i a t i o n s o f the E x t r a v e r s i o n and N e u r o t i c i s m S c a l e s f o r Each Group 35 37 38 39 52 53 56 57 58 59 L i s t o f F i g u r e s F i g u r e 1. V a r i a n c e A c c o u n t e d F o r ( V A F ) f o r A l l D i m e n s i o n s F i g u r e 2. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 1 a n d D i m e n s i o n 2 F i g u r e 3. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 2 : a n d D i m e n s i o n 3 F i g u r e 4. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 3 a n d D i m e n s i o n 4 F i g u r e 5. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 4 a n d D i m e n s i o n 5 F i g u r e 6. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 1 a n d 3 F i g u r e 7. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 1 a n d 4 F i g u r e 8. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 1 a n d 5 F i g u r e 9. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 2 a n d 4 F i g u r e 10. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 2 a n d 5 F i g u r e 11. P o s i t i o n s o f S t i m u l i a n d P r e f e r e n c e V e c t o r s w i t h r e s p e c t t o D i m e n s i o n 3 a n d 5 A C K N O W L E D G E M E N T S I l i k e t o t h a n k D r . D e m e t r i o s P a p a g e o r g i s f o r h i s g u i d a n c e t h r o u g h o u t t h e p r e p a r a t i o n o f t h i s t h e s i s . F u r t h e r , I l i k e t o e x t e n d my t h a n k s t o D r . L e s l i e S o l y o m f o r l e t t i n g me s e e h i s a n o r e x i c p a t i e n t s a n d f o r p r o v i d i n g h e l p f u l s u g g e s t i o n s . D r . J e r r y W i g g i n s h e l p e d w i t h t h e c l a r i f i c a t i o n o f s e v e r a l p o i n t s . L a s t b u t n o t l e a s t , I t h a n k my h u s b a n d P e t e r f o r h i s c o n t i n u a l s u p p o r t . 1 Preface Patients with anorexia nervosa present a s t r i k i n g appear-ance: emaciated, they look l i k e 'skeletons clad i n skin'. Anorexia nervosa occurs mostly i n women and t y p i c a l l y starts during puberty. Most patients are of normal weight or a l i t t l e over when they f i r s t s t a r t to d i e t . After reaching the target weight, however, they continue to die t and can become emaciated. Central to the disorder i s the patients' denial of i l l n e s s , t h e i r insistence that they are just f i n e . Some adopt bizarre food handling habits, and many are overactive subjecting themselves to physical stresses. Presence of bulimia i s common and the eating binges are often followed by vomiting or use of laxatives. Physical symptoms i n anorexia include amenorrhea which i s almost always present, lanugo, and bradycardia. If the anorexic r e l i e s heavily on vomiting or laxatives, metabolic balance might be seriously disturbed. Only about two-thirds of anorexics recover or improve, and though mortality rate i s lower now than i t had been i n the past, many anorexics continue to lead marginal l i v e s . Although true anorexia nervosa i s not very common, incidence appears to be r i s i n g , probably due to society's emphasis on slimness. Studies of anorexia nervosa appear to be warranted. Several e t i o l o g i c a l theories have been proposed, including one which focusses on body image d i s t o r t i o n . If the anorexic g i r l overestimates her body size she w i l l con-tinue to d i e t i n order to look slim. There i s some experimental evidence that some anorexics d i s t o r t body size perception. Another body image issue deals with body image i d e a l ; the 2 assumption i s made that anorexics have adopted an extremely thin body i d e a l and constantly s t r i v e to achieve and maintain t h i s i d e a l . I t i s implied that normal females have a much more r e a l i s t i c and healthy body i d e a l . Variables influencing such body image ideals have not yet been studied systematically. The present study investigated underlying dimensions of percep-t i o n i n anorexic and normal females and how body image prefer-ences d i f f e r among these groups. In the introductory chapter, the f i r s t section deals with methods of testing body size percep-ti o n and summarizes results of studies on body size perception by normal subjects. In the following section, the anorexic syndrome i s described i n more d e t a i l and e t i o l o g i c a l theories are presented. Research on body size perception and preference by anorexic subjects i s then reviewed. The f i n a l section pre-sents the purposes and hypotheses of the present study. The remaining chapters present i n d e t a i l the methods and results of the present study and discuss and summarize t h e i r implications. 3 Chapter 1 Introduction Perception of Body Size The c l a s s i c d e f i n i t i o n of body image i s 'the picture of our own body which we form i n our mind, that i s to say the way in which the body appears to ourselves' (Schilder, 1935, c i t e d i n Shontz, 1969). A vague and all-encompassing d e f i n i t i o n , Schilder's body image includes body schemata and emotional and evaluative components attached to the body schemata. His-t o r i c a l l y , body image disturbances were studied by neurologists. After brain damage and/or loss of limb patients often f a i l to perceive t h e i r body accurately and to adapt to t h e i r impairment. For example, pain might be experienced from a phantom limb some time a f t e r amputation. Paralysis of limbs or body s i t e s re-sul t s i n disuse of the affected body part and the patient might adopt a distorted attitude to t h i s part of the body. Body image disturbances have also been observed i n p s y c h i a t r i c pa-t i e n t s . For example, schizophrenics might experience that parts of t h e i r body are shrinking, expanding, or r o t t i n g away. A loss of body image boundaries might also be present. One component of body image concerns s p a t i a l properties of body image perception. Studies have attempted to determine accuracy of body image perception and factors that influence possible inaccuracies. Four methods of s p a t i a l estimation have been developed. The l i n e a r method has been used extensively. The subject estimates body distances with a c a l i p e r device, i . e . , by moving markers on a rod so that the required distance i s indicated. 4 One distance (e.g. shoulder width, hand length) at a time i s estimated. This standard condition may be varied; the subject may a c t u a l l y view his or her own body, the c a l i p e r device can be manipulated by the experimenter, and the markers may be moved in an ascending or descending manner ( i . e . , the markers are set i n i t i a l l y next to each other or very far apart). E f f e c t s of such manipulations w i l l be summarized below. In the configurational method, complex body s t i m u l i , rather than i n d i v i d u a l body parts, are presented, and the sub-ject makes a single global judgment as to which stimulus i s the appropriate one. The stimuli can be body silhouettes of varying size or actual pictures of the subject. These pictures are distorted e i t h e r by mirrors (Traub &'Orbach, 1964) or by an anamorphic lens (Garner, Garfinkel, Stancer, & Moldofsky, 1976). The subject's task i s to eliminate the d i s t o r t i o n . The d i s c r e -pancy between the subject's judged undistorted picture and the size of the actual picture can then be calculated. The r a r e l y used p i c t o r i a l method requires the subject to draw himself or herself. The drawing can be l i f e - s i z e , e.g., the subject stands i n front of a wall and draws the body boundary as accurately as possible. A l t e r n a t i v e l y , the drawing i s made to scale. The dimensions are then measured. This procedure i s s i m i l a r to the Draw-a-Person Test, except that i n the l a t t e r accuracy of body distances are not scored. . One l a s t method i s simply a verbal report. The subject i s asked to respond verbally, i . e . , to give estimations i n actual numbers. In one study (Shontz, 196 9) subjects expressed t h e i r 5 estimates of body distances as proportions of t h e i r height. Shontz (1969) reported a series of studies investigating body image perception. The c a l i p e r device was used i n most studies. In the standard condition the subjects were required to make estimations by moving markers on a rod, without being able to view t h e i r own body. The subjects were verbally i n -structed to estimate f i v e body distances; head width, waist, arm length (elbow to w r i s t ) , hand length, and foot length. Comparison non-body objects were also estimated with subjects allowed to touch but not to view them. Comparison stimuli were mostly wooden dowels. Under such "standard" conditions patterns of estimation errors were consistent. Overall, body stimuli were overestimated whereas comparison non-body objects were underestimated. Among body stimuli head width and arm length were overestimated, and hand length and foot length were under-estimated. Estimation of waist width was intermediate; some studies have found sex differences with women overestimating waist width when compared with men (Shontz, 1969), while others f a i l e d to f i n d such differences (Fuhrer & Cowen, 1967). Varia-b i l i t y of estimation scores was larger for body st i m u l i than for comparison objects. Some experimental variations influenced the magnitude of the estimation scores. For example, under-estimation of distances was more l i k e l y to occur i n a dark rather than i n a lighted room (Fuhrer & Cowen, 1967), or when l i t t l e v i s u a l feedback to the responses was given, or under ascending marker conditions (Shontz, 1969). The presence of projected images on a screen and descending marker conditions 6 i n i t i a l l y produced overestimation. Other manipulations such as t a c t i l e vs. verbal descriptions of body stimuli to be estimated or v i s u a l cues from the body did not influence the magnitude of estimation (Shontz, 1969). Comparison objects were judged larger i f they could be seen i n addition to being touched. In one study (Shontz, 1969), when comparison objects were matched with body st i m u l i i n terms of complexity, i . e . , they looked more l i k e body parts, subjects produced more estimation errors. These errors, however, did not resemble the pattern found con-s i s t e n t l y with estimation of body s t i m u l i . The higher v a r i a b i -l i t y of error scores of the comparison objects might have re-f l e c t e d i n part complexity of contour. Orbach, Traub and Olson (1966, c i t e d i n Shontz, 1969) used a d i s t o r t i n g mirror apparatus for body size estimation. Their subjects accepted a wide range of images as good representations of t h e i r bodies. Subjects were, however, able to discriminate among the degrees of d i s t o r t i o n . Practice e f f e c t s were ob-served. Subjects often complained that they did not know what they looked l i k e . In a similar study (Schneidermann, 1957, c i t e d i n Shontz, 1969) subjects' estimations of t h e i r faces were more accurate i f they had seen t h e i r face p r i o r to the task. The observation that subjects appear to need a reference point when making estimations with the configurational method con-trasts with Shontz's finding that estimation scores were not more accurate when subjects actually viewed t h e i r body. In fact, Shontz noted that many subjects did not look at t h e i r bodies p r i o r to the estimation asserting that they knew what they looked l i k e . This seeming confidence contrasts with the 7 consistent pattern of estimation errors. Two points are r e l e -vant i n t h i s connection: i n the f i r s t place, body size and body distances change throughout l i f e i n the course of develop-ment, growth, weight change, pregnancy, and even changes of clothing. People become used to accepting a larger range of body sizes as r e a l i s t i c . Secondly, although subjects did show a clear pattern of estimation errors when tested with the c a l i p e r device, differences between subjects are easier to observe when a configurational method i s used. The l a t t e r pro-vides a more r e a l i s t i c image of the subject, and thus probably also e l i c i t s a f f e c t i v e and evaluative components of the body image. According to Shontz, such research does not deal s t r i c t -l y with perceptual a b i l i t y to estimate accurately one's body size but also r e f l e c t s the influence of personality character-i s t i c s on body size estimation and the interplay between person-a l i t y and estimation. Schonbuch and Shell (1967) were i n t e r -ested i n the relationship between weight and body size estima-t i o n . Underweight, normal weight, and overweight male students selected from a series of graded silhouettes the one that resembled t h e i r own body. This silhouette was also chosen by two independeant observers i n order to assess estimation errors. Both the underweight and the overweight groups made more errors than the normal weight group: Errors were made more often by overestimation than underestimation. This study was the f i r s t to suggest that body weight might influence body size perception. Body size d i s t o r t i o n has also been associated with anorexia nervosa. 8 Anorexia Nervosa Anorexia nervosa i s most probably a psychosomatic d i s -order: psychological disturbances lead to a deterioration of physical health which i n turn produces additional problems. The f i r s t account of an anorexic woman was given by Morton, an English physician, i n 1689, (cited i n Bruch, 1973). A young woman had severely reduced her food intake, becoming quite emaciated. Despite progressive weakening, she continued to be very active and denied that she was i l l . Like a 'good1 anorexic she refused a l l help and eventually died during a fa i n t i n g s p e l l . Description of the anorexic syndrome has changed l i t t l e since that time. Anorexia nervosa occurs mostly i n young females (only about 10% of anorexics are males). Age of onset had been generally associated with adolescence, a l - ' though late onset ( i . e . , a f t e r age 25) anorexia i s now more widely recognized. Although mild forms of the disorder are probably widespread, true anorexia nervosa i s rare. Incidence varies with studies (.24 to 1.6 per 100,000 population; see Bemis, 1978), although some investigators report an increasing number of cases. This increase can be attributed to more ac-curate diagnoses and to society's continuing and increasing emphasis on slimness. Prognosis i s not very encouraging, with at best only about three-quarters reported improved or recov-ered (see Hsu, 19 80). The reduced mortality rate (with some studies reporting as few as 2%, see Bemis, 1978; Hsu, 1980), can be i n part credited to e a r l i e r recognition. Many anorexics become chronic patients, alternately gaining weight i n a hospital and promptly losing i t afte r discharge. The central 9 feature of anorexia nervosa - voluntary s e l f - s t a r v a t i o n - i s accompanied by other symptoms. Overactivity i s frequently ob-served; the patient exercises strenuously u n t i l exhausted i n order to burn o f f c a l o r i e s . Bizarre food handling habits are often present. Only a few, so-called 'healthy' foods are per-mitted and those might be spiced excessively. Food fads such as vegetarianism are common. Others eat secretly, cut up the food i n small pieces, or look for food i n garbage p a i l s . Many spend much time reading cookbooks and preparing n u t r i t i o u s meals for others and i n s i s t that a l l food be eaten. Anorexics might experience bouts of bulimia when foods r i c h i n carbohy-drates are consumed. This binge eating i s followed by fast i n g , vomiting, or laxative use. Vomiting i f induced repeatedly can become involuntary. Excessive use of laxatives and reliance on. vomiting can cause severe metabolic disturbances which can re-s u l t i n admission to h o s p i t a l . Strong feelings of g u i l t , shame, and depression usually follow a binge. Presence of bulimia has been linked to poor prognosis (Russell, 1979). Denial of i l l n e s s i s probably u n i v e r s a l l y present. Anorexics refuse to admit that they are too thin and i l l , and generally f a i l to recognize required n u t r i t i o n a l needs. A die t of, say 600 cal o r i e s a day i s considered to be adequate. Behaviours i n -volving food and weight loss become obsessive. For example, a perfect record of number of ca l o r i e s eaten d a i l y i s kept (though not necessarily shown to the ther a p i s t ) ; when food i s presented c a l o r i e s are added automatically; the goals of exercise are adhered to s t r i c t l y . Anorexics are often perfee-10 t i o n i s t s . In school they are conscientious, studious, and com-p l i a n t . Although t h i s trend appears to be changing, many families of anorexics belong to the middle or upper s o c i a l classes. Achievement and ambition are valued: thus, when the g i r l decides to d i e t she i s determined to succeed. Anorexics r e l y on external information regarding weight los s : a scale, smaller size of clothes, l o o s e - f i t t i n g clothes, l i t t l e f a t on bones. Many complain that they are fat and f e e l f a t even when they see t h e i r body i n a mirror. This apparent i n a b i l i t y to perceive accurately body size (overestimation), has led to corresponding e t i o l o g i c a l formulations (Bruch, 1973). As weight loss progresses, t h i s d i s t o r t i o n of body size seemingly in-^: creases. A desire for extreme thinness i s often expressed a-long with a r e a l fear of becoming obese. This fear can become phobic (Crisp, 1967). In order to eliminate any r i s k of be-coming obese the anorexic loses even more weight. The safety margin increases but gives no reassurance. One aspect of the weight phobia i s the fear of losing control, of not being able to stop eating. As one anorexic put i t when i t became apparent that her intake was less than 800 calo r i e s d a i l y : 'I know . that we agreed to 1,500 calo r i e s per day. But i f I have less than 800 then there i s no danger that I ' l l go over the 1,500.' Physical symptoms include amenorrhea, lanugo, and brady-cardia. Amenorrhea i s almost always present and often appears before s i g n i f i c a n t amounts of weight are l o s t . Menstruation often does not resume immediately aft e r weight gain. Stress can only i n part account for the early and persistent ameno-11 rrhea; e.g., i t has been shown that women i n concentration camps were only amenorrheic for an i n i t i a l period of t h e i r imprisonment (Bemis, 1978). Lanugo and bradycardia are symp-toms of emaciation. Two sets of diagnostic c r i t e r i a for anorexia are cur-ren t l y i n use. Diagnosis i s based frequently upon the Feigh-ner, Robins, Guze, Woodruff, Winokur and Munoz (1972, see Appendix 1) c r i t e r i a . Denial of i l l n e s s , a desire for extreme thinnness, unusual food handling habits, and symptoms such as amenorrhea, lanugo, and bulimia are required for t h i s diagnosis. The c r i t e r i a for anorexia nervosa contained i n the Diagnostic and S t a t i s t i c a l Manual (DSM-III, American Psych i a t r i c Associa-t i o n , 19 80, see Appendix 2) include intense fear of becoming obese, disturbance of body image, and refusal to maintain appro-priate body weight. Anorexia nervosa i s c l a s s i f i e d on Axis I. Both sets of c r i t e r i a r e f e r to the presence of body image d i s -turbance. Although obsessive and depressive symptoms are often present, absence of other p s y c h i a t r i c or physical i l l n e s s e s which could cause the weight loss i s required for a po s i t i v e diagnosis: of anorexia nervosa. One further comment regarding anorexic symptomatology i s in order. Though the symptoms described above characterize anorexia nervosa, i t i s by no means clear which symptoms con-s t i t u t e anorexia nervosa per se and which ones r e s u l t from emaciation. Studies on starvation (Keys, Brozek, Henschel, Mickelson, Taylor, 1950) have reported s i m i l a r behaviours, e.g., an increase i n preoccupation with food, bizarre food handling habits, excessive use of spices, etc. Interests 12 become centered almost exclusively on food. To date, no physiological causes of anorexia have been found. Research has focussed on hypothalmic centers that ap-pear to regulate eating behaviour and on hormonal l e v e l s , e s p e c i a l l y with respect to amenorrhea. There have been r e l a -t i v e l y few psychological theories advanced to explain the etiology of the disorder (for a review, see Bemis, 1978). Since anorexia frequently starts i n puberty when sexual maturation occurs, psychoanalytic interpretations have been suggested. When the adolescent feels unable to accept mature sexuality she regresses to an early stage of development where the sexual i n s t i n c t i s expressed i n terms of o r a l g r a t i f i c a -t i o n . Consequent fear of o r a l impregnation leads to food re-f u s a l , while bouts of bulimia r e f l e c t strong sexual i n s t i n c t s , and amenorrhea i s viewed simultaneously as a symbol of preg-nancy and a r e j e c t i o n of femininity. There i s , however, l i t t l e evidence of, e.g., widespread fantasies of o r a l impregnation. T r a d i t i o n a l psychoanalytic psychotherapy has had very limited success because anorexics do not e a s i l y form transference r e l a -tionships . Ego psychologists have focussed instead on a disturbed mother-child r e l a t i o n s h i p . A dominant mother prevents strong ego formation i n the g i r l . Demands for independence such as going to college cannot be met e a s i l y by the anorexic, and food r e j e c t i o n symbolizes r e j e c t i o n of mother and femininity and allows a return to childhood. P r e c i p i t a t i n g factors of t h i s kind are often observed. 13 Family i n t e r a c t i o n a l approaches emphasize family func-tioning at the time of onset of anorexia. Proponents of t h i s theory such as Minuchin (cited i n Bemis, 1978) have found that family disturbances become displaced on the anorexic c h i l d . Therapy emphasizes treatment of the family, and some follow-up studies are encouraging. Behavioural approaches do not address themselves d i r e c t l y to e t i o l o g i c a l questions but focus on treatment. By removing any secondary gain and rewarding eating behaviour many anor-exics gain weight. This weight gain, however, i s not always l a s t i n g . Behavioural treatment has been severely c r i t i c i z e d because i t does not encourage anorexics to exercise control over t h e i r eating behaviour (Bruch, 1974). Hilda Bruch (1962) has described three areas of psycholo-g i c a l disturbance underlying the etiology and maintenance of anorexia nervosa. A disturbance of body image int e r f e r e s with the anorexic's perception of severe weight loss and leads to denial of i l l n e s s . A fear of being ugly, of becoming obese, and a thin body i d e a l reinforce anorexic behaviour. A second disturbance causes interference with the accurate perception of bodily s t i m u l i . Hunger awareness appears to be very con-fused, ranging from denial of need for food to bulimia. Com-pl a i n t s of stomach pains are frequent aft e r ingestion of only small amounts of food. Overactivity i s often present, but fatique and exhaustion are not perceived and are not attributed to malnutrition. F i n a l l y , a pervasive sense of ineffectiveness i s seen as central to the disorder. Anorexics s a t i s f y demands of others such as parents but have few s k i l l s i n expressing 14 t h e i r own wishes. The fear of losing control and not being able to stop eating r e f l e c t s t h i s sense of ineffectiveness. So when puberty o f f e r s new challenges the anorexic feels unable to cope and attempts to return to childhood. Bruch considers resolution of those disturbances central to the recovery from anorexia nervosa. Thus two related aspects of body image disturbance - d i s -t o r t i o n of body size and an extremely t h i n body i d e a l - can be linked to the etiology of anorexia nervosa. Most research has dealt with distorted perceptions of body s i z e . One of the e a r l i e s t reports (Gottheil, Backup & Cornelison, 1969) i n d i -cated that body size perception becomes more accurate as the patient's weight increases. In t h i s case study (n = 1) an anorexic patient i n i t i a l l y claimed that she was unable to see how thin she was when she viewed herself on videotape. Concur-rent with psychotherapy she was also regularly confronted with videotape recordings of interviews with her and she was asked to comment on the tapes. As the patient gained weight and recuperated she remarked increasingly that she looked too thin and unhealthy. Eventually, she accepted how thin and emaciated she was and viewing pictures of her thin body became abhorrent to her. The f i r s t researchers to experimentally test for body size d i s t o r t i o n s i n anorexia nervosa were Slade and Russell (1973). Using the c a l i p e r device described e a r l i e r , 14 anorexics and 20 normal controls estimated the widths of t h e i r faces, chests, waists, and hips. Slade and Russell found that i n contrast to 15 „ normal controls who judged those body parts accurately, the anorexics overestimated the size of a l l four body regions. This overestimation did not extend to non-body physical objects. In a second study (also reported i n Slade and Russell, 1973), 10 anorexics estimated t h e i r height and the widths of the face, chest, waist, and hips of a model. The results showed that anorexics estimated t h e i r height accurately,but o v e r e s t i -mated the size of the model although to a lesser degree than t h e i r own s i z e . In a t h i r d , longitudinal study (also i n Slade and Russell, 1973) body image d i s t o r t i o n was correlated with weight gain. As weight increased, body image d i s t o r t i o n de-creased. Weight loss a f t e r discharge from hospital was found to be correlated with magnitude of body image d i s t o r t i o n at admission. The investigators concluded that body image d i s t o r -t i o n can be a prognostic indicator. Crisp and Kalucy (1974) continued t h i s l i n e of research, also using the c a l i p e r device. /Anorexics overestimated t h e i r body widths when they had l o s t s i g n i f i c a n t amounts of weight and t h e i r estimations became more r e a l i s t i c a f t e r weight was restored. The two anorexics who were most accurate continued to do very well aft e r discharge from h o s p i t a l . Interestingly, when afte r making estimations subjects were asked to repeat t h e i r estimations and to be very r e a l i s t i c , they a l l were more accurate and overestimated l e s s . Crisp and Kalucy also found that anorexics (n = 6) overestimated more afte r ingestion of a seemingly high-calorie meal than a f t e r a seemingly low-caloried meal although both meals contained the same amount of c a l o r i e s . This was not 16 observed with normal controls. Recovered anorexics were more l i k e normals i n making estimations under such conditions. In t h i s study, however, normals also tended to overestimate t h e i r body widths though less so than the anorexics. The authors found some evidence that the normal controls who were within 10% of average weight at time of te s t i n g had had a his t o r y of weight l o s s . Russell, Campbell, and Slade (1975) investigated factors of body image perception i n anorexia nervosa. They demonstrated that anorexics respond to external information about t h e i r body weight; e.g., t h e i r weight increased i f they believed that they had l o s t some weight. They also repeated e a r l i e r work. Again using the c a l i p e r device, they showed that anorexics o v e r e s t i -mated t h e i r widths of face, chest, waist, and hips, and that normals were accurate i n t h e i r estimation. Anorexics also overestimated the body widths of a model but to a lesser degree ( s i g n i f i c a n t only for bust and waist). Again i t was shown that aft e r weight gain (especially i f slow) patients d i s t o r t e d t h e i r body size l e s s . Russell et a l . concluded that restoration of weight i s c r u c i a l i n the treatment of anorexia nervosa. Garner, Garfinkel, Stancer, and Moldofsky (1976) studied body image disturbances i n anorexia nervosa. A l l groups (anorexics, obese, p s y c h i a t r i c controls, normal controls, and thin con-trol s ) were tested with two procedures: the c a l i p e r device and the anamorphic lens. Results obtained from the ca l i p e r device, f a i l e d to di s t i n g u i s h between the groups, i . e . , a l l groups overestimated t h e i r s i z e s . However, when the groups 17 used the anamorphic lens to make t h e i r estimations, anorexic and obese subjects d i f f e r e d from a l l control groups. Whereas a l l control groups underestimated t h e i r body sizes, one-half of the anorexic and one-half of the obese subjects o v e r e s t i -mated; the remaining subjects, l i k e the controls, underesti-mated t h e i r s i z e s . Overestimation i n anorexics was linked to neuroticism (measured by the Eysenck Personality Inventory) and to lack of s e l f - c o n t r o l (as measured by Rotter's Locus of Control Scale). There were no differences between groups on size estimations of a model and an inanimate object. Garner et a l . also obtained i d e a l size estimations. Except for anor-exics and thin control subjects, a l l groups wanted to be s i g n i -f i c a n t l y thinner than t h e i r perceived body s i z e . Such a tend-ency could explain why normal weight females underestimate t h e i r s i z e . Garner et a l . concluded that body image disturbances are related to eating disorders but not to weight l o s s . Such disturbances, however, are found only i n half of the subjects. Goldberg, Halmi, Casper, Eckart, and Davis (1977) attempted to i d e n t i f y pretreatment predictors of weight change. Part of t h e i r assessment was the body width estimation task developed by Slade and Russell. In a sample of 44 patients they confirmed e a r l i e r work that anorexics overestimate body sizes but not the sizes of inanimate objects. Overestimation was correlated with low appetite and denia l . Weight gain was associated with a lesser degree of overestimation. In a study investigating anorexia and secondary amenorrhea, Fries (1977) compared anorexics with a clear diagnosis with women whose 18 symptoms included secondary amenorrhea associated with weight loss but who did not f u l f i l l a l l c r i t e r i a for true anorexia nervosa. Both groups overestimated on the Slade and Russell task, whereas a group of normal controls was. more accurate. Patient groups did not d i f f e r from each other on other measures. Fries noted that some normal controls overestimated themselves just as anorexics did. Overestimation, thus, could not be associated s o l e l y with anorexia nervosa: i t also occurred i n normals and i n women with only some anorexic features. Button, Fransella, and Slade (1977) compared anorexics at various stages of treatment with controls. Using the c a l i -per device, they f a i l e d to f i n d any differences between anor-exic patients and controls: both groups overestimated. In-ter e s t i n g l y , they found the anorexic patients to be quite a heterogeneous group. When data were analyzed separately for anorexics who were non-vomiters and anorexics who were vomiters, results showed that overestimation was associated with vomiters; the non-vomiters were accurate. For the entire anorexic sample there was a high p o s i t i v e c o r r e l a t i o n between overestimation and amount of weight gained since admission. The study i s , however, flawed with methodological problems. As the authors noted, they had switched from the manual c a l i p e r device to an automated one midway through the study. This change was not recorded. They also found correlations between amount of overestimation and d i f f e r e n t treatment settings. I t i s , therefore, quite d i f f i c u l t to interpret the findings. 19 Garfinkel, Moldofsky, Garner, Stancer, and Coscina (1978) attempted to demonstrate that body image d i s t o r t i o n s can be modified by external cues and that they are related to sa t i e t y aversion to sucrose tastes. /Anorexic and control subjects estimated themselves and the size of a vase with the anamorphic lens technique. Body image and i d e a l image measurements were obtained before and afte r looking i n a mirror and before and after high and low c a l o r i e connotation meals. Garfinkel et a l . found body image perceptions to be stable over time (one week), p a r t i c u l a r l y for anorexics. Body image perception was not modified by external cues. Again, some anorexics overestim^ ated whereas controls were accurate i n t h e i r perceptions. The Garner et a l . (19 76) finding that normals want to be thinner than they are was confirmed. Only those anorexics who were overestimators f a i l e d to develop an aversion to sucrose, i n d i -cating lack of responsiveness to interoceptive s t i m u l i . A year l a t e r , Garfinkel, Moldofsky, and Garner (1979) retested the same subjects. S t a b i l i t y of body size perception was c l e a r l y demonstrated for anorexic women. Controls tended to be less stable i n body size perception. Ideal size perception was very stable for both groups. Anorexics who had gained weight were more s i m i l a r to normals i n t h e i r i d e a l size percep-t i o n . Five anorexics were at average weight at the time of the second testing; t h e i r body size estimates were, however, very s i m i l a r to t h e i r e a r l i e r ones. This r e s u l t contrasts with other studies which associated a decrease i n overestimation with weight gain. Again, overestimation i n anorexics was asso-20 ciated with an absence of aversion to sucrose tastes. Strober, Goldenberg, Green, and Saxon (1979) f a i l e d to di s t i n g u i s h between anorexics and controls using the Image Marking Procedure, a p i c t o r i a l method. Both groups o v e r e s t i -mated at both times of testing six months apart. Anorexics endorsed more items on the Fisher Body Dis t o r t i o n Questionnaire than did normals. These differences persisted at the time of re-testing during the recuperative phase. Within the anorexic group body image di s t o r t i o n s as measured by the questionnaire were associated with the presence of vomiting, a finding con-s i s t e n t with the Button et a l . (1977) study. The results of the studies reviewed above can be summarized i n the following way: 1) There appears to be some body image d i s t o r t i o n among some anorexics. Variables influencing the d i s t o r t i o n cannot be s p e c i f i e d c l e a r l y . 2) Anorexics appear to be a very heterogeneous group. The presence or absence of vomiting might d i f f e r e n t i a t e true subgroups. 3) Normal controls can exhibit body image d i s t o r t i o n s . Their body image perception appears to be less stable over time. Factors associated with overestimation i n normals are presently not c l e a r l y i d e n t i f i e d . 4) Ideal size estimations are stable over time. Normals, prefer to be thinner than they perceive themselves. 5) None of the methods of measuring body image appears to be e n t i r e l y s a t i s f a c t o r y . For example, studies using the 21 c a l i p e r device report more overestimation than studies using the anamorphic lens. With the c a l i p e r device, the subject makes one judgment at a time; however, t h i s task might be quite d i f f i c u l t because no reference point i s given. With the anamorphic lens, subjects use a picture of t h e i r own body as a reference point, and thus the task appears to be more r e a l i s t i c . S t i l l , subjects might not be very f a m i l i a r with t h e i r own body, since people do not spend much time looking at t h e i r own bodies. Furthermore, when adjusting the lens, the amount of d i s t o r t i o n i s iden-t i c a l for a l l body parts and any possible differences between parts cannot be assessed. Gross d i s t o r t i o n of any one body part might anchor the o v e r a l l judgment. One variant of the p i c t o r i a l method ( l i f e - s i z e drawing of one's body) has not been used extensively; t h i s task probably requires drawing s k i l l . In a l l methods comparison objects were usually not matched on complexity with the body s t i m u l i . The presence of overestimation i n some studies must be interpreted with caution. As Shontz (1969) already noted, head width i s always overestimated. He also found evidence that women overestimate the widths of waist and hips (Shontz, 1969). Unfortunately, Shontz did not obtain estimates of chest width; normative standards are, therefore, not yet a v a i l a b l e . Overall, subjects i n Shontz's studies overestimated body widths although magnitude of overestimation was influenced by experimental procedure. Shontz concluded that patterns of 22 estimation errors (e.g., head width was much more overestimated than hand length) are more important than magnitude of p a r t i c u -l a r errors. A more complete design would also include estima-tions of other body regions such as hand length where normative standards are known. Normal subjects have been shown to exhibit a clear pattern.of estimation; i t would be of i n t e r e s t to know whether anorexics d i f f e r . Overall, the findings suggest that some anorexics show more body size d i s t o r t i o n than others although variables underlying those d i s t o r t i o n s cannot be i d e n t i f i e d yet. The Present Study Although i t i s accepted c l i n i c a l lore that anorexics express a preference for extremely thin body image, only two studies included estimations of body image i d e a l s . As noted above, both studies found that normals want to be thinner than they are. Ideal size estimations by anorexics did not d i f f e r much from actual s i z e . None of the studies, however, s p e c i f i e d how body image preferences d i f f e r between anorexic and normal females. The present study addresses t h i s issue. Because of demonstrated success i n distinguishing between c l i n i c a l and normal groups, a configurational method was chosen. Rather than using an anamorphic lens, a series of female s i l -houettes varying i n sizes of breast, abdomen, buttocks, and legs were used. I t was hoped that through the use of standard stimuli any differences between groups would become more d i s -t i n c t . Based upon s i m i l a r i t y and preference judgments, multi-dimensional scaling techniques were employed i n order to specify 23 underlying dimensions of body image perception and body image preference by anorexic and non-anorexic females. The INDSCAL model, developed by C a r r o l l and Chang (1970), determines underlying dimensions of perception which are common to a l l i n d i v i d u a l s . A common space for a l l stimuli i s assumed and stimulus coordinates are calculated i n t h i s space for a speci-f i e d number of dimensions. The program then solves for each subject matrix and determines the weights of every subject on the dimensions. Thus, i n d i v i d u a l differences can be accommo-dated by, f o r example, giving a weight of 0 on one dimension, and a weight close to 1 on another. The solution i s unique and cannot be transformed. Preference judgments were analyzed with the PREFMAP model ( C a r r o l l , ~::1972) . This model, requires a stimulus space (e.g., from the INDSCAL solution) and deter-mines an i d e a l point i n t h i s space for each subject. The more preferred a stimulus i s , the closer i t approaches the i d e a l point. The PREFMAP analysis takes into account any group d i f -ferences regarding underlying dimensions of perception. The model i s h i e r a r c h i c a l ; four le v e l s are possible. At l e v e l 1 subjects may d i f f e r e n t i a l l y rotate the dimensions whereas i n l e v e l 2 only d i f f e r e n t i a l weighting i s allowed. In l e v e l 3 a l l subjects have a common space, and i n l e v e l 4 the preferences are expressed as vectors. Thus, both procedures allow for i n d i v i - , dual and group differences. Although no s p e c i f i c hypothesis was formulated, a finding that anorexics d i f f e r from normals i n t h e i r underlying dimen-sions of body image perception would not be suprising. Anorex-24 i c s might focus exclusively upon one body region such as abdomen when viewing body silhouettes. I t was hypothesized that anorex-i c s would prefer thinner body images than normals. Subjects were also asked to choose a silhouette that best represented t h e i r own body. Anorexics' preference ratings for t h i s s i l -houette were expected to be lower. Although no objective evalu-ation of the accuracy of this silhouette choice could be made, the number of anorexics who chose fat silhouettes and who were c l e a r l y inaccurate was determined. Previous findings suggested that about one-half might do so. Subjects were asked to complete several semantic d i f f e r e n -t i a l scales (Osgood, Suci, & Tannenbaum, 1957) measuring evalua-t i o n , potency, and a c t i v i t y with respect to the silhouette that was judged to represent themselves and with respect to t h e i r most and least preferred silhouettes (see Appendix 3). I t was expected that evaluation would be more negative for the least preferred silhouette and become po s i t i v e for the most preferred silhouette. The silhouette representing one's own body should be evaluated less p o s i t i v e l y by anorexic than normal females. Also, the potency rating should be lower for t h i s silhouette i n anorexic women r e f l e c t i n g perhaps a sense of ineffectiveness (Bruch, 1977). Since o v e r a c t i v i t y i s a common symptom in anorexia nervosa, anorexics might rate themselves more active than normals do. Subjects also completed the Perceptual Aber-ration Scale (Chapman, Chapman, & Raulin, 1978). This scale was designed to t e s t for deviant body experiences i n c l i n i c a l , p a r t i c u l a r l y schizophrenic groups. The Strober et a l . (1979) findings predict that anorexics may endorse more items than normals. In addition, subjects were asked to complete the Maudsley Personality Inventory (Eysenck, 1959) which i s a measure of neuroticism and extroversion. I t was expected that anorexics would score higher on the neuroticism scale and lower on the extroversion scale than normals. 26 Chapter 2 Method Subjects Nineteen anorexic females and 19 matched normal control subjects participated i n the study. A l l anorexics were i n treatment at the time of t e s t i n g . One of the anorexic females was an inpatient; a l l other anorexics were being treated on an outpatient basis. The diagnosis of anorexia nervosa was based on the c r i t e r i a of the DSM-III (1980) and on the c r i t e r i a pro-posed by Feighner et a l . (19 72). The anorexics met both sets of c r i t e r i a with the exception of eight subjects. Seven of these subjects did not show a weight loss exceeding 25% of previous or expected body weight. Their range, however, was s t i l l underweight and i n any event a weight loss i n excess of 25% was not deemed necessary for a pos i t i v e diagnosis when an otherwise clear c l i n i c a l picture was present. The eighth sub-ject was unable to remember her premorbid body weight. Only one anorexic subject f a i l e d to meet the c r i t e r i o n of onset before 25 years of age. The 19 anorexics were subdivided into two subgroups: anorexics who were mainly abstainers from eating . (n = 10) and anorexics who described binge-eating as a s i g n i f i c a n t additional problem (n = 9). The l a t t e r group generally f u l f i l l e d the DSM-III c r i t e r i a for bulimia as wel l . Short c l i n i c a l descriptions of a l l patients are presented i n Appendix 4. Detailed data concerning height, weight, age, age at onset, and other relevant variables for each patient are contained i n Appendix 5. It i s s u f f i c i e n t to note here that 2 7 a g e r a n g e d f r o m 1 3 t o 3 4 y e a r s (M = 2 2 . 8 9 ) , a n d t h a t a g e a t o n -s e t r a n g e d b e t w e e n 1 1 a n d 2 9 y e a r s (M = 1 7 . 8 6 ) . P a t i e n t s i n t h e B A g r o u p w e i g h e d s i g n i f i c a n t l y m o r e (M = 5 2 . 0 3 k g ) t h a n p a t i e n t s i n t h e A A g r o u p (M = 4 6 . 1 0 k g ) , t ( 1 7 ) = 2 . 1 9 , p < . 0 5 . O t h e r d i f f e r e n c e s w e r e n o t s i g n i f i c a n t , t h o u g h t h e f o l l o w i n g t r e n d s w e r e o b s e r v e d : a g e a t o n s e t w a s g e n e r a l l y l o w e r f o r t h e A A g r o u p (M = 1 6 . 8 5 ) t h a n f o r t h e B A g r o u p (M = 1 9 . 0 0 ) . M o r e B A t h a n A A s u b j e c t s (56% v s . 20%) h a d b e e n h o s p i t a l i z e d . D u r a -t i o n o f a n o r e x i a w a s l o n g e r i n t h e B A g r o u p ( w i t h o n e n o t a b l e e x c e p t i o n : s u b j e c t # 9 ) . O n l y f o u r o f t h e n i n e B A p a t i e n t s w e r e c u r r e n t l y a m e n o r r h e i c , a l t h o u g h a l l e x c e p t o n e h a d h a d e a r l i e r e p i s o d e s o f a m e n o r r h e a ; a l l A A s u b j e c t s , o n t h e o t h e r h a n d , w e r e c u r r e n t l y a m e n o r r h e i c . T h e 1 9 a n o r e x i c p a t i e n t s w e r e m a t c h e d w i t h 1 9 n o r m a l f e -m a l e s o f a v e r a g e w e i g h t f o r t h e i r h e i g h t a s d e t e r m i n e d b y t h e M e t r o p o l i t a n L i f e T a b l e s ( M e t r o p o l i t a n L i f e , 1 9 6 9 ) . E a c h a n o r e x i c s u b j e c t w a s c l o s e l y m a t c h e d w i t h a c o n t r o l s u b j e c t o n ' a g e , e d u c a t i o n a l b a c k g r o u n d , a n d s o c i o - e c o n o m i c s t a t u s . T h e B l i s h e n S c a l e ( B l i s h e n , 1 9 5 2 ) w a s u s e d t o d e t e r m i n e s o c i a l c l a s s o f t h e s u b j e c t o r h e r f a m i l y . A p p e n d i x 6 p r e s e n t s t h e r e l e v a n t c h a r a c t e r i s t i c s o f a l l c o n t r o l s u b j e c t s . I t h a d b e e n h o p e d t h a t c o n t r o l s u b j e c t s c o u l d b e d i v i d e d i n t o t w o g r o u p s , d i e t e r s a n d n o n - d i e t e r s o n t h e b a s i s o f t h e i r r e s p o n s e s t o t h e R e s t r a i n t Q u e s t i o n n a i r e ( H e r m a n & P o l i v y , 1 9 7 5 ) . I t w a s f o u n d , h o w e v e r , t h a t t h e R e s t r a i n t Q u e s t i o n n a i r e f a i l e d t o s e p a r a t e c l e a r l y d i e t e r s f r o m n o n - d i e t e r s . T h e r e f o r e , c o n t r o l s u b j e c t s w e r e c o n s i d e r e d a s a s i n g l e g r o u p t h r o u g h o u t t h e a n a l y s i s ( s e e 2 8 Appendix 7). Permission to carry out the research was obtained from the h o s p i t a l research committee p r i o r to the s t a r t of the study. In addition, informed consent was obtained from a l l patients and control subjects. Materials A series of 19 female s i l h o u e t t e s 1 varying i n sizes of body parts was constructed. Four body parts were allowed to vary i n s i z e : breasts, abdomen, buttocks, and legs. Five variations were used: +2 (large), +1 (moderately large), 0 (standard), -1 (moderately small), -2 (small). For 16 silhouettes three of the four parts assumed the standard size and the fourth part varied from i t . The remaining silhouettes represented +2, 0, and -2 respectively on a l l four parts. Each silhouette was printed i n black on a 8 x 20.5 cm white card (see Appendix 8). Other materials included an Eating Attitude Test (Garner & Gaffinkel, 19 79, see Appendix 9) and a Restraint Questionnaire (see Appendix 10). A Background Information Sheet provided demographic and menstrual history information for each subject. In addition, a b r i e f p s y c h i a t r i c history was obtained from the anorexics. A l l subjects also completed the Maudsley Personality Inventory (Eysenck, 1959), the Perceptual Aberration Scale (Chapman, Chapman, & Raulin, 1978, see Appendix 11), and several Semantic D i f f e r e n t i a l scales (Osgood, Suci, & Tannenbaum, 1957). "'"The silhouettes were obtained from a study by Wiggins, Wiggins, and Conger (196 8) by permission of the senior author. 29 P r o c e d u r e T h e s t u d y c o n s i s t e d o f t h r e e p a r t s . A l l s u b j e c t s w e r e t e s t e d i n d i v i d u a l l y . P a r t 1: T h e s u b j e c t s w e r e s h o w n a l l s i l h o u e t t e s i n a r a n d o m a r r a y a n d w e r e a s k e d t o s o r t - i t h e m i n t o 2, 5, 8, 11 a n d 14 d i f -f e r e n t c a t e g o r i e s . T h e o r d e r i n w h i c h t h e s o r t i n g s w e r e c a r r i e d o u t w a s d e t e r m i n e d b y m e a n s o f a l a t i n s q u a r e t o c o n t r o l f o r o r d e r e f f e c t s . T h u s s o m e s u b j e c t s b e g a n w i t h e i g h t c a t e g o r i e s , o t h e r s b e g a n w i t h t w o c a t e g o r i e s , a n d s o o n . S u b j e c t s w e r e t o l d t o s o r t t h o s e s i l h o u e t t e s w h i c h t h e y f e l t b e l o n g e d t o g e t h e r i n t o t h e s a m e c a t e g o r y ; h o w e v e r , s o r t i n g w a s u n s p e c i f i e d , i . e . , s u b j e c t s c h o s e t h e i r o w n c r i t e r i a f o r t h e c a t e g o r i e s . S o r t i n g w a s a l s o u n r e s t r i c t e d , i . e . , i t e m s t h a t w e r e s o r t e d i n t o d i f f e r -e n t c a t e g o r i e s c o u l d b e c o m b i n e d a g a i n a t a l a t e r s o r t . A f t e r e a c h s o r t t h e s i l h o u e t t e s w e r e m i x e d a n d a g a i n p r e s e n t e d ' i n r a n -d o m a r r a y t o e n c o u r a g e u n r e s t r i c t e d s o r t i n g . T h e r e s u l t s f r o m e a c h s o r t w e r e r e c o r d e d b y t h e e x p e r i m e n t e r . A l t h o u g h u s u a l l y s i m i l a r i t y j u d g m e n t s a r e b a s e d o n p a i r w i s e c o m p a r i s o n s o f s t i m -u l i , t h e p r o c e d u r e e m p l o y e d i n t h e p r e s e n t s t u d y y i e l d s e q u i v a -l e n t r e s u l t s ( W a r d , 1977) a n d i s f a s t e r t o c o m p l e t e . P a r t 2: T h e s i l h o u e t t e s w e r e p r e s e n t e d i n a r a n d o m a r r a y o n a l o n g t a b l e . A l o n g t h e t a b l e a t a p e m e a s u r e i n d i c a t e d 100 u n i t s e a c h 20.5 c m w i d e . S u b j e c t s w e r e a s k e d t o o r d e r t h e s i l h o u e t t e s a l o n g t h i s 1 0 0 - u n i t s c a l e a c c o r d i n g t o t h e i r p r e f e r e n c e . T h e m o s t a n d l e a s t p r e f e r r e d s i l h o u e t t e s w e r e c h o s e n f i r s t a n d a s s i g n e d t o t h e e n d p o i n t s o f t h e s c a l e . T h e r e m a i n i n g s i l h o u -e t t e s w e r e t h e n o r d e r e d a l o n g t h e s c a l e s o t h a t t h e d i s t a n c e s 30 between them r e f l e c t e d distances i n preference. Again, the experimenter recorded the r e s u l t s . Part-3: Subjects selected from the randomly arrayed silhouettes the silhouette that resembled most c l o s e l y t h e i r own body. Following t h i s , they completed the semantic d i f f e r e n t i a l scales for t h i s silhouette and for the most and le a s t preferred silhouettes. Subjects then completed the Background Information Sheet, the Restraint Questionnaire, the Eating Attitude Test, the Maudsley Personality Inventory, and the Perceptual Aberration Scale. Items of the l a s t scale were presented interspersed with .items from the MMPI. F i n a l l y , height and weight data were determined from each subject. In order to assess the r e l i a b i l i t y of the silhouette judgments, 15 subjects were asked to repeat t h e i r selections of the le a s t and most preferred silhouettes and of the s i l -houette that resembled them most. 31 Chapter 3 Results S i m i l a r i t y Judgments It w i l l be re c a l l e d that subjects were asked to sort the 19 silhouettes into two, f i v e , eight, eleven, and fourteen d i f f e r e n t groups. Silhouettes that were placed i n the same group were assumed to have been judged by the subject as more similar than silhouettes that were placed i n d i f f e r e n t groups. Furthermore, silhouettes that were sorted together at higher sorts (e.g., i n one of 14 d i f f e r e n t categories) were assumed to have been judged more s i m i l a r than silhouettes sorted together at lower sorts (e.g., i n one of two d i f f e r e n t categories). In th i s fashion, a s i m i l a r i t y matrix was generated for each of the 38 subjects. For example, a pa i r of silhouettes that occurred at the 2, 5, and 11 category sorts received a s i m i l a r -i t y r a t ing of 2+5+11 = 18. The maximum possible s i m i l a r i t y r a ting for any pair was 2+5+8+11+14 = 40. The 38 s i m i l a r i t y matrices were then subjected to the INDSCAL (C a r r o l l & Chang, 1970) computer program. Solutions for one up to six dimensions were computed. The 5-dimensional (5-D) solution was chosen as a workable solution. Although no strong elbow was apparent, l i t t l e seemed to be gained in terms of variance accounted for (VAF) by going beyond f i v e dimensions (see Figure 1). The choice of the 5-D solution was supported by other-. 1 considerations. The number of stimuli should be twice the number' of dimensions and the VAF/degrees of freedom r a t i o should be as large as possible, and c e r t a i n l y greater than f i v e . Since 32 Dimensions Figure 1. Variance Accounted For (VAF) for A l l Dimensions the study used 19 stimuli and the VAF/degrees of freedom r a t i o was 12.05, the 5-D solution e a s i l y met both c r i t e r i a . The o v e r a l l c o r r e l a t i o n of the solution with the data was .717. The average correlations for the three groups ranged from .700 (control group) to .721 (AA group) to .735 (BA group). The solution seemed to f i t subjects equally well i n a l l three groups. One additional important c r i t e r i o n was i n t e r p r e t a b i l i t y of data. Unlike the 2-D, 3-D, and 4-D solutions which a l l con-tained one dimension that was not readi l y interpreted, a l l dimensions i n the 5-D solution could be interpreted. Dimension 5 was not prominent i n e a r l i e r solutions. I n t e r p r e t a b i l i t y of the data was arrived at by examining the stimuli that had the largest p o s i t i v e and negative weights on any dimension. Those sti m u l i characterized the.poles of each dimension. Since the ch a r a c t e r i s t i c s of every stimulus were known, i t was possible to see d i r e c t l y which c h a r a c t e r i s t i c s defined each dimension. The p o s i t i o n of every stimulus on a l l dimensions can be seen i n Figures 2 to 11 which are presented i n the next section. The f i v e dimensions can be polarized i n the following way: D-1 buttock, large vs. buttock and abdomen, small D-2 standard silhouette vs. buttock, extreme sizes D-3 buttock, somewhat large vs. abdomen, large D-4 abdomen, small vs. buttock, small D-5 breasts, small vs. breasts, large D-1 i s s i m i l a r to the f i r s t dimension obtained i n the previous solutions (i.e ., 1D-4D) a l l of which contrasted large and small buttocks and abdomen. A l l subjects' weights were^positive, 34 2 another i n d i c a t i o n of a good solution. The average salience for each group on each dimension was calculated (Table 1). Table 1 Average Saliences per Group on Each Dimension AA BA C Combined D-l .350 .320 .360 .345 D-2 .296 .315 .280 .292 D-3 .281 .296 .249 .268 D-4 .253 .317 .217 .250 D-5 .219 .238 .262 .245 Although average saliences showed some var i a t i o n between groups on dimensions 3 and 4, the differences are quite small. In order to t e s t further for possible group differences, the s i m i l a r i t y matrices were averaged for each group and analyzed for f i v e dimensions with the INDSCAL program. VAF was .73; a l l saliences were quite s i m i l a r for each group on a l l dimen-sions. In a t h i r d analysis, a separate 5-dimension INDSCAL solution was calculated for each group. The dimensions were s i m i l a r to the o r i g i n a l solution with the possible exception of two dimensions i n the BA group. Those two dimensions were unipolar and referred to size of abdomen. Overall, a l l three analyses f a i l e d to show any consistent and clear differences i n underlying dimensions of perception between the AA, BA, and control groups. 2 Salience refers to the subjects' weights. 35 Preference Analysis R e l i a b i l i t y : F i f t e e n of the 38 subjects (two from the BA group, f i v e from the AA group, and eight from the C group) were able to repeat t h e i r selections of the least preferred and the most preferred silhouettes and the silhouette that best repre-sented them. Test-retest r e l i a b i l i t y was determined for these 15 subjects by computing percentages of agreement between f i r s t and second choice. Three leve l s of agreement were distinguished: exact agreement, i . e . , the same silhouettes were chosen both times; agreement within two ranks, e.g., the most preferred silhouette ranked number 19 and the silhouette chosen the second time had ranked number 17 or 18 previously; and, f i n a l l y , difference of ranks between the two choices was greater than two, i n d i c a t i n g disagreement. Because the number of retested subjects was small i n every group, only the combined data from a l l subjects are shown (See Table 2) . Table 2 Percentages of Agreement for 15 Subjects (Number of Subjects i n Parentheses) Within More than Exact 2 Ranks 2 Ranks Least Preferred 93.33 0.00 6.66 Silhouette (14) (0) (1) Most Preferred 40.00 40.00 20.00 Silhouette (6) (6) (3) Silhouette Repre- 66 .66 13.33 20.00 senting Oneself (10) (2) (3) R e l i a b i l i t y was c l e a r l y highest for the least preferred silhouette, and lowest for the most preferred silhouette. Preference Ratings: The average preference rating for each stimulus was calculated for the following f i v e groups: AA, BA, a l l anorexics, control group, a l l subjects. A higher rating indicated greater preference. The stimuli were also ranked from lowest (1) to highest (19). A l l average ratings and rankings are shown i n Table 3. The silhouettes were coded i n the following manner. As described e a r l i e r , silhouettes varied i n four dimensions, breast (br), abdomen (a), buttock (b), and legs (1). Five sizes were possible: +2, +1, 0 (standard), -1, -2. For 16 silhouettes one of the four body parts varied from the standard and the other three parts assumed the standard s i z e . So a +lbr silhouette refers to the silhouette with a +1 breast and 0 abdomen, 0 buttock, and 0 legs. Three silhouettes represented the two extremes and the standard on a l l body parts and are referred to as -2, *2,.and 0. This coding system appears i n Table 3 and i s used through-out the remainder of t h i s thesis. Contrary to expectation, preference ratings were very s i m i l a r for a l l groups. In fa c t , the silhouettes which ranked 1, 2, 3, and 4 were i d e n t i c a l for a l l groups. A l l subjects d i s l i k e d the same silhouettes. Though not i d e n t i c a l , ratings and rankings for more preferred silhouettes were also very sim i l a r in a l l groups. The three silhouettes most preferred by the AA group were characterized by one body part being small; -1 buttocks, -2 breast, and -a abdomen. Subjects i n \ Table 3 Average Preference Ratings and Rankings (in Parenthesis) for a l l Silhouettes Code of Silhou-ettes +2 0 -2 +2br +lbr -lbr -2br +2b +lb -lb -2b +21 +11 -11 -21 +2a +la - l a -2a AA (1) (16) (6) (7) (15) 12) (18) (3) (5) (19) (8) (11) (13) (9.5) (9.5) (2) (4) (17) (14) Group 1.3 69.7 45.5 59.0 65.4 63.2 73.2 18. 8 38.7 80.5 59.9 62. 8 64.7 60.7 60.7 7.9 22.3 71.6 64.8 BA (1) (15) (10) (5) (13) (14) (7) (3) (6) (19) (17) (8) (12) (9) (11) (2) (4) (18) (16) Group 1.1 72.7 59.2 40.5 68.3 71.8 53.0 20.4 42.1 81.7 76.5 54.0 66.6 56.5 62.0 8.5 29.4 78.3 : 74.3 A l l (1) (17) (7) (6) (13) (14) (11) (3) (5) (19) (15) (8) (12) (9) (10) (2) (4) (18) (16) anor-' exics 1.2 71.1 51.9 50.2 66.7 67.3 63.6 19.5 40.3 81.1 67.7 58.6 65.6 58.7 61.3 8.2 25.6 74.7 69.3 Controls (1) (17) (5) (6) (ID (15) (8) (3) (7) (16) (10) (18) (19) (12) (13) (2) (4) (14) (9) 1.4 82.3 35.0 41.2 62.3 74.7 57.2 13.0 46.8 81.4 58.7 82.5 84.3 64.3 67.0 9.8 25.6 73.0 57.8 A l l (1) (18) (5) (7) (13) (15) (8) (3) (6) (19) (10) (14) (17) (9) (12) (2) (4) (16) (11) Sub-jects 1.3 76.7 43.4 45.7 64.5 71.0 60.4 16.2 43.6 81.2 63.2 70.5 74.9 61.3 64.1 9.0 25.8 73.9 63.6 3.8 the BA group also preferred most -1 buttocks, followed by -1 abdomen, and -2 buttocks. Control subjects preferred most +1 legs, then +2 legs, and 0, the standard. The standard s i l h o u -ette was also w e l l - l i k e d by the anorexic subjects. The most d i s l i k e d silhouettes for a l l subjects were +2, +2 abdomen, +2 buttocks, +1 abdomen. Preference ratings for the thinnest silhouette, -2, ranged from 1 to 100 i n each group but o v e r a l l t h i s silhouette was not rated highly by any group. Preference ratings for the +1 legs silhouette ranged from 11 to 10 0 i n the AA and BA group, and from 54 to 99 i n the control group. Ratings for the -1 buttocks silhouette ranged from 25 to 100 i n the anorexic group and from 11 to 100 i n the control group. Clearly, there are subjects i n every group who l i k e and d i s l i k e those silhouettes. Correlation c o e f f i c i e n t s of rank orders (Spearman's p ) were large and highly s i g n i f i c a n t for the following group comparisons: AA with BA, AA with C, BA with C, and a l l anorexics with C, c l e a r l y i n d i c a t i n g an absence of group differences (Table 4). Table 4 A l l Anorexics with C .7474 AA with BA .7723 AA with C .7521 BA with C .7167 Note: A l l ps < .01 39 PREFMAP analysis; The preference ratings were also anal-yzed with the PREFMAP algorithms. Using the 5-dimensional space obtained from the INDSCAL analysis, the program establishes the id e a l space for the s t i m u l i . Results for phase 2 - 4 were com-puted. Inspection of the root mean squares showed that phase 4 had a s u f f i c i e n t l y large root mean square and that l i t t l e was to be gained by going to a higher phase (See Table 5). Table 5 Root Mean Squares Phase Root Mean Square 2 .9313 3 .8948 4 .8805 The F-ratios between phases allow one to choose the most . appropriate model for the data. Only for one subject was the F-rati o between phases 3 and 4 greater than 9.33 (p < .01), ind i c a t i n g a poor f i t of phase 4 for t h i s subject's data. Because phase 4 f i t well a l l other subjects' data, i t was de-cided to include t h i s subject i n the vector model. Subjects' preferences were represented as vectors in the 5-dimensional space where stimuli project onto the vectors so that they cor-relate with the preference data. The o v e r a l l c o r r e l a t i o n be-tween the o r i g i n a l preference ratings and phase 4, the vector model, of the PREFMAP analysis was r = 0.938. 4 0 The preference vectors of a l l subjects were plotted for a l l pairs of dimensions. The plots are shown i n Figures 2 - 1 1 . The dimensions are * i d e n t i c a l to the ones obtained from the INDSCAL solution and, consequently, the positions of the stim-u l i also remained the same. The preference vectors were coded by subject number and group membership as indicated on the bottom of the figures. Inspection of a l l plots showed that the preference vectors are d i s t r i b u t e d over a large area but s t i l l form a c l u s t e r . Supporting previous analysis, group differences did not emerge: the preference vectors of each group were not arranged i n separate clusters but appear to belong to a single group. Vectors of subjects from a l l groups are scattered throughout the cl u s t e r . Inspection of the actual positions of the preference vectors along the dimensions revealed a consis-tent pattern. On dimension 1 most vectors are situated along the --buttocks, -abdomen rather than the tbuttocks side. Quite a few of the d i r e c t i o n cosines are large, e.g., 0.89 for subject 9 i n group BA. On dimension 2, almost a l l vectors (except for subjects 1, 4, 5, and 6 of group AA, and subjects 1, 2 of group BA) are on the po s i t i v e side which represents the standard and moderate s t i m u l i . Again, the d i r e c t i o n cosines of several subjects are quite large. The six subjects whose vectors f e l l on the negative side of the dimensions w i l l be discussed i n more d e t a i l i n a l a t e r section. On dimension 3, the vectors are located on the -.+buttocks stimulus rather than the +abdomen side, though many vectors are quite distant to the +buttocks stimulus which characterizes t h i s dimension 41 A * • 3 42 x5 x l l JO.X"* - I b r O e A3 X16 10 * l •1 o*it oO -lbr o-lC -T>4 I F '-lb 4 6 A5 A l O-lb O-lOL 0+X o 4 l b Figure 2 Note: 0 br b a Positions of Stimuli and Preference Vectors with respect to Dimension 1 and Dimension 2 s t i m u l i breast buttocks abdomen 1 = legs X - C group ^ - AA group • - BA group 42 •1 A t o+lb AS o-Zb o*2b x*o lb •lfer o»2br °o0 • 5 15 x l *1H A 10 x-5 • 3 A l *1 * l b A l A*X* At *5 »-lbr o*lt A A A . .•la Figure 3. Positions of Stimuli and Preference Vectors with respect to Dimension 2 and Dimension 3. Note: o br b a 1 st i m u l i breast buttocks abdomen legs X - c group A - AA group • - BA group 43 -Hi » b o - l x8 *5 eO K i t *1 •s -J>-3 -ibr --at^  WAb -tie o * t b r e-lb • 3 A « Figure 4. Note: O br b a 1 Positions of Stimuli and Preference Vectors with respect to Dimension 3 and Dimension 4. s t i m u l i breast buttocks abdomen legs X - c group A - AA group • - BA group 44 * 5 * C t i l •1 19 x • 3 - l b r • ©-lbr • b o-lb A O A I C M l b r © • l b r xS •1 A H x!5 x* A ) A 5 -It 0 oo * l o A l x H OA o-Z •2. A l O -D-H l+la x i Figure 5. Note: O br b a 1 Positions of Stimuli and Preference Vectors with respect to Dimension 4 and Dimension 5. st i m u l i breast buttocks abdomen legs X - c group A - AA group • - BA group 4 5 A l • 5 * i 5 * x l 4 5 xlH A * • 1 • 5 A * A* o-2b o - l b ^ e - l b r o-lC •6 AS o*lb l b x* Q 4 l t o-te o«tb 0*1 Figure 6. Positions of Stimuli and Preference Vectors with respect to Dimension 1 and Dimension 3 Note; O br b a 1 s t i m u l i breast buttocks abdomen legs * - C group 4 - AA group • - BA group 46 D-4 4 6 I,"' x*0 *n xl% -la oo-lo o - l 4 5 x i 4H «5 x « x* eO a t * -D-l 4 2 M i l O 2b o*lbr o + l a •ft A * 41 4B a * Figure 7 Note: O b a 1 Positions of Stimuli and Preference Ratings with respect to Dimension 1 and Dimension 4 s t i m u l i breast buttocks abdomen legs X - c group A - AA group • - BA group 47 V r 5 5X A t 1 xb*4B xl5 A5 x l l x l A b A l - l b , J -1 "-la • a t x l * X* . X h» «b * 1 0 hi Al© o+ta lb • l b r -abr e Figure 8. Note: O br = b = a : 1 : Positions of Stimuli and Preference Vectors with respect to Dimension 1 and Dimension 5. sti m u l i breast buttocks abdomen legs * - C group A - AA group • - BA group 48 •1 4H • 5 x l * x ° x 5 x $ o 0 o - l t • *> x l t Al© ©•lb ©•lb S-tbr •lbr © - l b r x l l x l b o-ib xl» x t t A ? <4-lb • S 4*1 4 8 • H Figure 9. Note: O br b a 1 Positions.of Stimuli and Preference Vectors with respect to Dimension 2 and Dimension 4 st i m u l i breast buttocks abdomen legs X - c group • - AA group • - BA group 49 4H 4 5 -ibd 4" "lb 8 x S x i i 18 ***** H o - l b r S-lbr a , • - ^ o + l t 4 * , Q kb *1 X » X * ab • 3 Xi 4>-2 10 «H 4 * . M *3 **b ©•1. a«lbr OVLbr Figure 10. Positions of Stimuli and Preference Vectors with respect to Dimension 2 and Dimension 5 Note: O br b a 1 s t i m u l i breast buttocks abdomen legs X - C group A - AA group 81 - BA group 50 x D-5 8 -U»r e • I t o - I t o xS • i x l l x i i , * b * m 8 18 a t .15 x ? A l © o-lk * * A 5 , x l ab x l k i t o : l b • 5 e«U» AB -D-3 o«la 1 «n O+lb *10 A i O x i b x3 o«lbr o+lbr Figure 11. Positions of Stimuli and Preference Vectors with respect to Dimension 3 and Dimension 5. Note: 0 br b a 1 s t i m u l i breast buttocks abdomen legs X - C group A - A A group 81 - B A group 51 (see F i g u r e 3). G e n e r a l l y , the d i r e c t i o n c o s i n e s are not very l a r g e . Along dimension 4, which c o n t r a s t s s m a l l abdomen wit h s m a l l b u t t o c k s , the p r e f e r e n c e v e c t o r s do not c l u s t e r at one end o f the dimension but are d i s t r i b u t e d q u i t e evenly. The d i r e c t i o n c o s i n e s are o v e r a l l not very l a r g e . On dimension 5 (lar g e b r e a s t s v s . s m a l l b r e a s t s ) , the p o s i t i o n of the v e c t o r s i n d i c a t e s a s t r o n g p r e f e r e n c e f o r s m a l l b r e a s t s . A few of the d i r e c t i o n c o s i n e s are l a r g e . O v e r a l l , e a r l i e r analyses are confirmed. S u b j e c t s p r e f e r s m a l l abdomen and buttocks over l a r g e ones. H i g h l y p r e f e r r e d s t i m u l i are the standard s i l h o u -e t t e and the moderate s i l h o u e t t e s such as +1 and -1. Subjects p r e f e r both s m a l l abdomen and s m a l l b u t t o c k s . Moderately l a r g e buttocks are p r e f e r r e d over l a r g e abdomen. On the l a s t dimen-' s i o n s u b j e c t s expressed a p r e f e r e n c e f o r s m a l l b r e a s t s . No group d i f f e r e n c e s were found. S i z e o f the d i r e c t i o n c o s i n e s i s b e l i e v e d ' t o show the impor-tance o f p a r t i c u l a r dimensions of p r e f e r e n c e judgments, because l a r g e d i r e c t i o n c o s i n e s on a dimension i n d i c a t e t h a t t h i s dimension accounts f o r most o f the v a r i a n c e . The a n a l y s i s showed t h a t dimension 1 ( l a r g e buttock v s . s m a l l buttock and s m a l l abdomen) and dimension 2 (standard vs. buttock extremes) i n f l u e n c e most p r e f e r e n c e judgments, though dimension 5 ( s i z e o f b r e a s t s ) i s a l s o important f o r some c o n t r o l s u b j e c t s . The average d i r e c t i o n c o s i n e s f o r each dimension are shown f o r each group i n Table 6 on page 52. Table 6 Average Size of Direction Cosines for Each Group D-1 D-2 D-3 D-4 D-5 AA .4612 .4895 .3541 .2647 .1856 BA .4947 .3484 .3873 .3798 .2548 C .4113 .5434 .3210 .1810 .3714 Choice of Silhouette Most Like Oneself Though no independent assessment was made i n order to v e r i f y whether subjects' choice of the silhouette that best represented them was objectively accurate, i t was expected that anorexics would choose a thin silhouette because generally they were thinner than control subjects. Nonetheless, four of the anorexics i n the AA group and two i n the BA group chose c l e a r l y inaccurate silhouettes, i . e . , silhouettes that were +2, +2 abdomen, and +1 abdomen. Three control subjects chose the +1 abdomen silhouette, possibly r e a l i s t i c a l l y . None of the anorexic subjects chose a +1 buttock silhouette, though two of the controls did so. A l l other anorexic subjects chose, however, thin s i l h o u -ettes as best representations of themselves. Of the remaining si x subjects i n the AA group three chose the -2 silhouette and the other three selected the -2 buttocks silhouette. The silhouette chosen by the remaining BA group subjects were -2 buttocks (three subjects), -2 breasts (three subjects), and -1 breast (one subject). Thirteen of the remaining 16 control sub-jects chose a +1 -1 silhouette or the standard as the best 53 representation of themselves. Preference ratings of the silhouettes that were l a t e r selected as best representations of oneself had been -obtained e a r l i e r . T h e o r e t i c a l l y , these preference ratings could range from 1 to 100. The obtained ranges i n each group were 1 to 99 for AA subjects, 4 to 99 for BA subjects, and 2 to 100 for controls. As can be seen the preference ratings ranged from very low to very high i n a l l groups; however, only i n the AA group did two subjects choose the least preferred silhouette as the one that represented them best whereas only i n the control group did three subjects choose the most preferred silhouette as the one that best represented them. The mean preference ratings of these silhouettes i n each group are shown in Table 7. Table 7 Average Preference Ratings of Silhouettes Chosen As  Best Representations of Oneself AA BA C M 24.90 59.88 a SD 33.75 31.52 35.38 f*;p< .05 compared with AA group. p^.01 compared with AA group. Preference ratings of the silhouette that was chosen as best representation of oneself are lowest i n the AA group whereas 54 such r a t i n g s are s i g n i f i c a n t l y higher (t(17) = 2.201, p < .05) i n the BA group. The s i l h o u e t t e s s e l e c t e d by the C group have the highest preference r a t i n g s , which are s i g n i f i c a n t l y higher than the r a t i n g s by the AA group (t(27) = 2.921, p < .01), but only s l i g h t l y ( n o n - s i g n i f i c a n t l y ) higher than the r a t i n g s by the BA group. These d i f f e r e n c e s are not the r e s u l t of d i f f e r -e n t i a l s e l e c t i o n of +abdomen s i l h o u e t t e s by the AA group. The tabdomen s i l h o u e t t e s had r e c e i v e d c o n s i s t e n t l y low r a t i n g s . When the +abdomen subjects are excluded, the new means of pre-ference r a t i n g s are 33.83 i n the AA group (n = 6) , 73.00 i n the BA group (n = 7), and 77.81 i n the C group (n = 16). A l l means were higher but the same ord e r i n g of group means was ob-served and the distances between the means were a l s o q u i t e s i m i -l a r ; however, because of the small number of subjects i n the AA and BA groups, no s i g n i f i c a n c e t e s t s were performed. Three of the f o u r subjects i n the AA group and one of the two subjects i n the BA group whose preference vectors were d i f f e r e n t on dimension 2 than a l l other s u b j e c t s ' preference vectors chose the +abdomen s i l h o u e t t e as best r e p r e s e n t a t i o n of themselves. Those subjects gave a l s o high preference r a t i n g s to the -2, -l^abdomen, and-2 abdomen s i l h o u e t t e s . However, no other v a r i a b l e s ; could be observed which would d i s t i n g u i s h f u r t h e r these subjects from others. Thus, the r e s u l t s show t h a t o v e r a l l the preference r a t i n g s ranged from very low to very high i n each group. Anorexics who are a b s t a i n e r s do not s e l e c t h i g h l y p r e f e r r e d s i l h o u e t t e s as best representations of themselves whereas anorexics who 55 are also bingers are more l i k e normals, i . e . , they choose more preferred silhouettes as best representations of themselves. In addition, the low preference ratings i n the AA group were not caused by the four anorexics who saw themselves with a tabdomen. Semantic D i f f e r e n t i a l Scales After the subjects had selected the silhouettes that best represented them, they completed semantic d i f f e r e n t i a l scales for t h i s silhouette and for the most and least preferred s i l -houettes. Table 8 shows the means for each group of the three sets of semantic d i f f e r e n t i a l scales that measure evaluation, potency, and a c t i v i t y . Theoretically, these means could have a range between -3 and +3. Overall, the least preferred silhouette was evaluated negatively and the most preferred silhouette p o s i t i v e l y . Ratings of potency and a c t i v i t y followed a s i m i l a r pattern. No s i g n i f i c a n t differences between groups were found, though some expected trends were noted. For example, anorexic ab-stainers saw the self-representing silhouette as more active, less potent, and more negative. Control subjects evaluated t h i s silhouette more p o s i t i v e l y . Subjects i n the BA group also saw t h i s silhouette as less potent, quite i n a c t i v e , and evaluated i t neutrally. Restraint Questionnaire and Eating Attitude Test The Restraint Questionnaire : assesses d i e t i n g behaviour, whereas the Eating Attitude Test i s designed to diagnose anorexia nervosa. Table 9 shows group means and standard 56 Table 8 Means of Semantic D i f f e r e n t i a l Scales Measuring E v a l u a t i o n ( E ) , Potency (P), and A c t i v i t y (A) Groups E P A AA M -1.725 -.533 -.900 SD 1.232 1.156 1.149 Least P r e f e r r e d BA M:. -1.555 -.185 -.861 S i l h o u e t t e SD 1. 762 1.081 .985 C M -1.236 -.280 -.605 SD 1.608 1.436 1.410 AA M 1. 025 .721 . 825 SD 1. 386 .799 .957 Most P r e f e r r e d S i l h o u e t t e BA M SD 1. I l l 1.193 .147 . 819 .694 .982 C M 1. 36 .108 .631 SD .958 . 840 . 813 AA M -.175 -.341 .550 SD 1.716 1.540 • 1.466 S i l h o u e t t e Most L i k e Oneself BA M SD .072 1.188 -.296 .965 -.305 1.102 C M .638 .021 .236 SD 1.125 .958 . 765 57 deviations. Table 9 Scores on the Restraint Questionnaire and Eating Attitudes Test AA BA A l l Anorexics C Restraint M 19 . 30 29 .66 24. 21 14. .36 Questionnaire SD 5 .90 6 .89 8. 17 4. . 89 Eating Attitude M 58 .10 51 .77 55. 10 14. .15 Test SD 27 .59 18 .38 23. 26 8. .90 Restraint C vs A. P< .001 t(36) = 4. ,571 Questionnaire C vs A C O t d l P < .050 t(27) = 2. . 413 C vs B P< .001 t(26) = 6. .852 A vs B P< .010 t(17) = 3. .605 The scores for controls ranged from 5-26 on the Restraint Questionnaire and from 4-35 on the Eating Attitude Test and, as mentioned e a r l i e r , most control subjects described some dieting behaviour. Anorexics scored s i g n i f i c a n t l y higher i n d i c a t i n g t h e i r concern with d i e t i n g . The scores for the AA group ranged from 11 to 2 9 on the Restraint Questionnaire and from 16 to 106 on the Eating Attitude Test. Subjects i n the BA group had the highest scores on the Restraint Questionnaire (with a range from 20-43), and th e i r scores on the Eating Attitude Test (with a range from 27-73) were sim i l a r to the AA subjects' scores. As expected, anorexics scored much higher than controls on the Eating Attitude Test (t(36) = 7.266, p < .001). The o v e r a l l c o r r e l a t i o n between the Restraint Questionnaire and the Eating Attitude Test was r = 0.64. The co r r e l a t i o n for the control group was r = 0.62. The correlations among the anorexic groups were very inconsistent: r = 0.88 i n the AA group and r = 0.01 in the BA group. Group membership (AA vs. 58 BA) appears to be a moderator v a r i a b l e t h a t i n f l u e n c e s the c o r r e l a t i o n between the two qu e s t i o n n a i r e s . Perceptual A b e r r a t i o n Scale Means and standard d e v i a t i o n s of the number of items en-dorsed which i n d i c a t e s body image abe r r a t i o n s are presented i n Table 10. Table 10 Means of Perceptual A b e r r a t i o n Scores f o r Each Group (Standard Deviations i n Parentheses) AA BA C 7.400 6.880 4.315 (7.089) (3.620) (4.781) None of the group mean comparisons were s i g n i f i c a n t . Scores ranged from 1 to 24 i n the AA group, from 1-12 i n the BA group, and from 0 to 14 i n the c o n t r o l group. The highest score (24 i n the AA group) was the only high score (> 14). Maudsley P e r s o n a l i t y Inventory The Maudsley P e r s o n a l i t y Inventory i s designed to measure degrees of n e u r o t i c i s m and e x t r a v e r s i o n . The maximum score t h a t can be obtained on each s c a l e i s 48, a high score i n d i -c a t i n g a greater degree of n e u r o t i c i s m or e x t r a v e r s i o n . On the e x t r a v e r s i o n s c a l e , the scores ranged from 8 — 44 i n the c o n t r o l group, from 8 -33 i n the AA group, and from 12 -36 i n the BA group. The scores of three anorexic subjects were 59 excluded from the analyses because those subjects used f r e -quently (more than ten times) the option '?', in d i c a t i n g that they could not answer the question. Such frequent endorsement decreases the value of the results (Eysenck, 1959). The means and standard deviations for the extraversion scale and the neuroticism scale by each group are presented i n Table 11. Table 11 Means and Standard Deviations of the Extraversion (E)  and Neuroticism (N) Scales for Each Group E N C M 30.47 25.73 SD (8.40) (12.8) AA M 20.22 37.22 SD (10.03) (6.99) BA MD 27.00 38.71 SD (8.34) (5.96) A l l Anorexics 23.18 37.87 (9.67) (6.39) Anorexics were s i g n i f i c a n t l y more neurotic than normal controls, t(33) = 3.43, p < .01'''. The l a t t e r group was, however, more extraverted, t(33) = 2.39, p < .05. The results of the study do not permit an assessment of a possible relationship between degrees of overestimation and neuroticism. 60 Chapter 4 Discussion Dimensions of Body Image Perception The INDSCAL analyses based on the s i m i l a r i t y judgments suggest that f i v e dimensions can be described that underlie the perception of female body images. Though no s p e c i f i c hypothesis had been formulated, c l i n i c a l observations suggest that anorexics may focus on s p e c i f i c dimensions such as size of abdomen or thighs to, e.g., ascertain weight loss. I t was expected that such d i f f e r e n t i a l emphasis would be r e f l e c t e d i n the test r e s u l t s . This, however, was not the case: no group differences were found. Both normal weight females and anorex-i c s u t i l i z e the same dimensions i n a s i m i l a r fashion. Of p a r t i -cular i n t e r e s t are the f i v e dimensions that characterize the common space of s t i m u l i . Although the silhouettes varied i n size on four body parts (breasts, abdomen, buttocks, and legs), only three of those are recovered i n the f i v e dimensions. Size of legs appears to be i r r e l e v a n t to body image perception. Sizes of buttocks and abdomen are important variables under-lyi n g body image perception: four of the f i v e dimensions deal with one or both of these variables. Dimension 1 suggests that females notice f i r s t whether abdomen and buttocks are large or small. A second variable i n body image perception distinguishes between figures of average size and those which deviate from the average i n terms of buttock s i z e . The next two dimensions contrast the extreme sizes of buttocks and abdomen. The re-maining dimension deals with breast s i z e . In e a r l i e r solutions 61 (1D-4D) breast size did not appear as a d i s t i n c t dimension and, although t h i s dimension i s important for some subjects, i t i s the size of buttocks and abdomen that c l e a r l y guides body image perception. Body Image Preferences Although the r e l i a b i l i t y of preference choices i s far from perfect, i t appears to be adequate. Studies (Orbach, Traub & Olson, 1966, c i t e d i n Shontz, 1969) indicate that normal females accept a wide range of d i s t o r t i o n s as acceptable s e l f - r e p r e -sentations. Regression to the mean might account f o r the lower r e l i a b i l i t y of the most preferred silhouettes. Subjects possibly prefer highly several silhouettes and use them i n t e r -changeably. The hypothesis that anorexics (both abstainers and bingers) prefer thinner body images than normals was not supported. There was exact agreement as to which silhouettes were d i s l i k e d . Moreover, subjects l i k e d the same silhouettes, with few excep-tio n s . Generally, moderate silhouettes were preferred, a finding consistent with other research (Minahan, 19 71) that found that tenth and twelfth grade females rated medium silh o u -ettes as most a t t r a c t i v e ; (Minahan, 1971) reported that the most preferred silhouette had large breasts, medium buttocks, medium thighs, and medium calves. Although anorexics showed a tendency to prefer more of the smaller figures (e.g., -2 abdomen, -2 buttocks, or-2:breasts), the differences were not s i g n i f i c a n t . The thinnest silhouette was both l i k e d and d i s -l i k e d by subjects i n a l l groups, and also f a i l e d to distinguish 62 anorexic from non-anorexic subjects. The positions of the vectors i n the PREFMAP analysis confirm the absence of group differences and the presence of much va r i a t i o n among a l l sub-j e c t s . Again, small abdomen and buttocks are preferred over large ones, and most subjects l i k e medium size body s t i m u l i . Given a choice, the lesser e v i l seems to be a tbuttock rather than a tabdomen silhouette; the mean preference ratings confirm t h i s i n t e r p r e t a t i o n . Nonetheless, small buttocks are preferred equally to small abdomen. A few control subjects whose pre-ference i s influenced by the breast dimension strongly prefer small breasts, a finding that contradicts Minahan 1s r e s u l t (1971) who observed that large breasts were found to be a t t r a c t i v e . This change may r e f l e c t the increasing i d e a l of slimness during the l a s t decade and perhaps the r e a l i z a t i o n that small breasts are common. The?disliked figures were fat and, again, buttock and abdomen sizes predominate. Surprising i s the r e j e c t i o n of the+1.'abdomen silhouette (over, e.g., the+1 bottocks silhouette); presence or absence of a f l a t tummy appears to influence prefer-ence ratings considerably. Since most of the subjects were rather young, i t would be of i n t e r e s t to compare preference ratings of older women, who presumably have not a l l retained a youthful figure. Two implications follow. Although some anorexics apparently prefer moderate, average looking silhouettes as body i d e a l they nevertheless remain anorexic. On the other hand, some normal weight females express a strong preference for thin body ideals but do not show any signs of an eating disorder. The large 63 range of preference ratings for some of the more preferred silhouettes indicates a large v a r i a t i o n of body image ideals among females. I t can be concluded that such v a r i a t i o n i s not by i t s e l f e i t h e r a symptom or a cause of eating disorders. Choice of Silhouette that Best Represents Oneself I t should be kept i n mind that the choice of the sil h o u -ette that was the best representation of oneself was not objec-t i v e l y v e r i f i e d as to accuracy i n any way and that studies have shown that such choices are not necessarily accurate (Shontz, 1969). Nonetheless, the results are s t i l l meaningful i n terms of subjects' self-perceptions. Overall, anorexic abstainers gave the lowest preference ratings for the self-representing silhouette and controls the highest. This finding had been pre-dicted. Bulimic anorexics, unexpectedly, were more l i k e controls and unlike anorexic abstainers, in d i c a t i n g greater preference for t h e i r own body silhouette. This observation persisted even af t e r subjects who chose a tabdomen silhouette were excluded from the analysis. Six subjects chose c l e a r l y inaccurate silhouettes. Such subjects tend to be c a l l e d overestimators. In the present study only 31.5% of the anorexics could be des-cribed i n such a manner, fewer than would be expected from the results of previous studies (Garner et a l . , 1976; Garfinkel et a l . , 1978). Contrary to the findings by Button et a l . (1977) more 'overestimators 1 were found i n AA group than the BA group. Thus, overestimation was not associated with vomiting. I t i s not clear, however, whether such overestimation i s a true per-ceptual phenomen or i f i t r e f l e c t s evaluative components of the 64 body image. Remarks made by some of these subjects such as 'that's what I f e e l l i k e ' tend to support the l a t t e r specula-t i o n . One bulimic subject implied that such choice would depend on whether she had binged recently. The remaining anorexics selected very thin (mostly -2) silhouettes, and t h e i r body size perception i s c l e a r l y accurate. There i s a paradox here: anorexic abstainers who see them-selves as thin appear not to l i k e t h e i r thin bodies; though i t i s p r e c i s e l y t h e i r overt wish to be t h i n . Bulimic anorexics, on the other hand, also see themselves as thin but seem to pre-fer more those body images. Although t h e i r preference ratings are s i m i l a r to those of normal females, they continue to suffer from an eating disorder. Normal weight females see themselves of average size and prefer average sizes. Postulations that some anorexics see themselves as grossly distorted on some body parts and suffer from dysmorphophobia were generally not supported by t h i s study. There i s i n s u f f i -c ient evidence to interpret the overestimators as being dysmorpho-phobic regarding abdomen siz e . Overall then, the findings cast doubt on the importance of body image perception and ideals i n the etiology of anorexia nervosa. Abstainers vs. Bingers Bulimic anorexics d i f f e r e d from anorexic abstainers i n several ways. Their average weight was higher, amenorrhea was not always present, and they expressed a higher preference for silhouettes chosen as best representations of themselves. 65 The very inconsistent correlations between the Restraint Questionnaire and the Eating Attitude Test which were obtained from the AA group and the BA group support further the concept of v a l i d subgroups i n anorexia nervosa. Russell (1979) coined the term 'bulimia nervosa' for bulimic anorexics and described three central c h a r a c t e r i s t i c s : an uncontrollable urge to overeat, avoidance of the consequences of binges by vomiting or the use of laxatives, and a morbid fear of becoming f a t . This l a s t symptom i s also present i n anorexia nervosa proper. Two other features present i n anorexia nervosa are severe weight loss and persistent amenorrhea. Most of Russell's bulimic patients had experienced episodes of true anorexia nervosa. Bulimia nervosa i s not described as a d i s t i n c t syndrome but rather as a h e u r i s t i c category for the study of two groups of patients who share a common diagnostic feature, i . e . , a morbid fear of becoming fat but who also d i f f e r on other important variables. Beaumont, George, and Smart (1976) also separated e a s i l y two subgroups: dieters vs. vomiters and found them d i f f e r e n t along s i m i l a r l i n e s . The d i f f e r e n t i a t i o n of two subgroups according to the presence of bulimia has been advo-cated also by other investigators (Casper, Eckert, Halmi, Gold-berg & Davis, 19 80; Garfinkel, Moldofsky & Garner, 19 80). They found that bulimic anorexics d i f f e r e d from fas t i n g anorexics on several variables, e.g., bulimic anorexics weighed more, were more impulsive and extraverted. The usefulness of t h e i r d i s t i n c t i o n s between anorexic-abstainers and bulimic anorexics i s supported by the findings of the present study. 66 Results of Psychological Tests The c l i n i c a l diagnosis of anorexia nervosa was supported by the Restraint Questionnaire and the Eating Attitude Test. Results of the f i r s t t e s t confirm that anorexics are dieters and show much concern with food and eating. The very high scores of the bulimic anorexics r e f l e c t t h e i r large weight fluctuations. Such fluctuations are viewed as part of di e t i n g behaviour. It was, however, impossible to separate control subjects into high and low r e s t r a i n t eaters. A l l controls i n d i -cated some concern with dieting r e f l e c t i n g current c u l t u r a l ideals for slimness. The Eating Attitude Test discriminated well among anorexic and non-anorexic subjects. The means ob-tained i n the anorexic and control groups were s i m i l a r to those found i n the o r i g i n a l v a l i d a t i o n sample. Garner and Garfinkel • (1979) used a cut-off score of 30 to eliminate fa l s e negatives and found a fa l s e p o s i t i v e rate of 13%. If the lowest scoring anorexic of the present study i s excluded (her behaviour was very much characterized by denial) the cut-off score would be 27 with no false negatives and only 10% false p o s i t i v e s . The Eating Attitude Test appears to be a useful s e l f - r e p o r t measure of anorexia nervosa. There were no s i g n i f i c a n t differences of group means on the Perceptual Aberration Scores. The Strober et a l . findings that anorexics experience more body image d i s t o r t i o n were not supported. The means of both anorexic groups were very s i m i l a r to the mean of 1,367 female college students tested by Chapman, E d e l l , and Chapman (1980). The mean for control subjects in 67 the present study was lower than the one found by Chapman et a l . Only one subject had a high score that could be suggestive of body image d i s t o r t i o n s , and t h i s subject, moreover, was quite young. Chapman et a l . found that t h e i r scale was successful i n i d e n t i f y i n g subjects who had psychotic-like experiences. Re-sults of the present study do not lend support to a hypothesis that anorexics experience such d i s t o r t i o n s i n perception of t h e i r own body. As expected, controls were more extraverted and less neurotic than anorexics. The mean scores of the anor-exics were sim i l a r to those obtained by Solyom, Freeman & Miles (19 81). The mean extraversion score of the controls i s compar-able to the American college students test norms (Eysenck, 1959) group; the mean neuroticism score i s s l i g h t l y higher than the one obtained by the standardization group (25.73 vs. 20.91). Limitations The major l i m i t a t i o n of t h i s study concerns the method of data c o l l e c t i o n . As already noted i n the introductory chapter, research findings have been influenced by the method that was used; e.g., subjects tested with a l i n e a r method may respond d i f f e r e n t l y than subjects tested with a configurational method. The present study used a configurational method. In addition, subjects used a series of standard silhouettes (not t h e i r own body representations) to make s i m i l a r i t y and preference judg-ments. I t i s possible that d i f f e r e n t results w i l l be obtained i f an alternative testing method and/or stimuli are used. Only future research can e s t a b l i s h the g e n e r a l i z a b i l i t y of the pre-sent r e s u l t s . 68 Some Speculations Overall, the findings suggest that body image d i s t o r t i o n s are not central to the anorexic disorder and that the s i g n i f i -cance of other symptoms should be investigated. Diagnostic c r i t e r i a describe two related symptoms: a fear of obesity and a fear of losing control (not being able to stop eating). These symptoms are common to a l l anorexics, both abstainers and bingers. Crisp (1967) discussed anorexia nervosa i n terms of weight phobia, i . e . , the anorexic i s phobic of normal weight. The present author suggests that body image research be put aside and that investigations focus on the formulation of anorexia nervosa within a framework of phobias. The feared st i m u l i could be the weight (normal or obese)or, more immediately, the food i t s e l f . Related i s the fear of losing control. Anor-exic abstainers are often characterized by r i g i d overcontrol. Overcontrol has been described as a symptom of the obsessive-compulsive style (Shapiro, 1965), and other investigators (Solyom et al., 1981) have found obsessive symptoms i n anorexics. Bulimic anorexics, on the other hand, exhibit lack of impulse control. Investigation of these two aspects - overcontrol and lack of impulse control - w i l l increase our understanding of the anorexic disorder i n general and may provide a basis for distinguishing two subgroups. If such conceptualizations can be substantiated experimentally, then anorexia nervosa should be treated with therapies that have been found to be e f f e c t i v e i n those disorders: e.g., behavioural techniques (systematic desensitization and flooding). 69 Concluding Remarks The present study investigated underlying dimensions of body image perception of anorexic and normal weight females and how such dimensions influence preference judgments. Sub-jects sorted repeatedly a series of female silhouettes (to e s t a b l i s h s i m i l a r i t y judgments) and then ordered the silhouettes on a 100 unit scale according to t h e i r preference. Results were analyzed with multidimensional scaling analyses. Five dimensions underlying body image perception could be i d e n t i f i e d . Four of these dealt with sizes of buttocks and abdomen, and the remaining one referred to breast s i z e . Anorexic and control subjects did not d i f f e r on those dimensions. Unexpectedly, subjects also l i k e d and d i s l i k e d s i m i l a r silhouettes and no group differences were observed. Moderate st i m u l i were generally preferred, as were small abdomen and small buttocks. The thinnest silhouette was generally not rated highly by any group. A large v a r i a t i o n of preferences was observed among subjects i n a l l groups. For example, some normal weight subjects tended to prefer thin silhouettes without showing signs of an eating disorder. When choosing a silhouette most l i k e oneself, some anorexics seem-ing l y overestimated and chose large abdomen silhouettes. Most anorexics, however, saw themselves as very thin . S t i l l , anor-exic abstainers, who are objectively the thinnest group of subjects, do not give high preference ratings to thin s i l h o u -ettes. Bulimic anorexics, l i k e controls, tend to l i k e the silhouettes which represent them. Within the l i m i t s imposed by the perceptual task, the results do not support the hypo-70 thesis that anorexics experience body image d i s t o r t i o n s . The findings suggest that there might be a small group of anorexics who experience body image problems as part of t h e i r anorexic symptoms. However, a thin body i d e a l i s not s p e c i f i c to anorexic subjects but i s also found among normal females. 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Metropolitan L i f e Tables, Metropolitan L i f e Insurance Company, 1969. Osgood, C , Suci, G., and Tannenbaum, P. The Measurement of  Meaning. Urbana, 111.: University of I l l i n o i s , 1957. Russell, G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychological Medicine, 1979, 9_, 429-448. Schonbuch, S.S. and S c h e l l , R.E. Judgments of body appearance by f a t and skinny male college students. Perceptual and  Motor S k i l l s , 1967, 24, 999-1002. Shapiro, D. Neurotic Styles.. New York. Basic Books Inc., 1965. . . • .• . Slade, P. and Russell, G. Awareness of body dimensions i n anorexia nervosa: cross-sectional and longitudinal studies. Psychological Medicine, 1973, 3_, 188-199. Solyom, L., Freeman, R., and Miles, J. Comparative studies of anorexia nervosa and obsessive neurosis. Canadian Psychia-t r i c Association Journal, to be published, 19 81. Spencer, J.A. and Fremoure, W.J. Binge eating as a function of r e s t r a i n t and weight c l a s s i f i c a t i o n . Journal of Abnormal  Psychology, 1979, £8, 362-367. 74 Strober, M., Goldenberg, I., Green, J., and Saxorz, J. Body image disturbance i n anorexia nervosa during the acute and recuperative phase. Psychological Medicine, 1979 , 9_, 695-701. Traub, A.C. and Orbach, J. Psychophysical studies of body image. Archives of General Psychiatry, 1964, 11_, 53-66. Ward, L.M. Multidimensional scaling of the molar physical environment. Multivariate Behavioural Research, 1977, 12 23-42. Wiggins, J.S., Wiggins, N., and Conger, J.C. Correlates of heterosexual somatic preference. Journal of Personality  and S o c i a l Psychology, 1968, 10, 82-90. A P P E N D I X 1 C r i t e r i a f o r D i a g n o s i s o f A n o r e x i a N e r v o s a ( F e i g h n e r e t a l , 1 9 7 2 ) A g e o f o n s e t p r i o r t o a g e 2 5 . A n o r e x i a w i t h a c c o m p a n y i n g w e i g h t l o s s o f a t l e a s t 25% o f o r i g i n a l b o d y w e i g h t . A d i s t o r t e d , i m p l a c a b l e a t t i t u d e t o w a r d s e a t i n g , f o o d , o r w e i g h t t h a t o v e r r i d e s h u n g e r , a d m o n i t i o n , r e a s s u r a n c e a n d t h r e a t s , e . g . : 1 . D e n i a l o f i l l n e s s w i t h a f a i l u r e t o r e c o g n i z e n u t r i t i o n a l h e e d s . 2 . A p p a r e n t e n j o y m e n t i n l o s i n g w e i g h t w i t h o v e r t m a n i f e s t a t i o n s t h a t f o o d r e f u s a l i s a p l e a s u r a b l e i n d u l g e n c e . 3 . A d e s i r e d b o d y i m a g e o f e x t r e m e t h i n n e s s w i t h o v e r t e v i d e n c e t h a t i t i s r e w a r d i n g t o t h e p a t i e n t t o a c h i e v e a n d m a i n t a i n t h i s s t a t e . 4 . U n u s u a l h o a r d i n g o r h a n d l i n g o f f o o d . N o k n o w n m e d i c a l i l l n e s s t h a t c o u l d a c c o u n t f o r t h e a n o r e x i a a n d w e i g h t l o s s . N o o t h e r k n o w n p s y c h i a t r i c d i s o r d e r , w i t h p a r t i c u l a r r e f e r e n c e t o p r i m a r y a f f e c t i v e d i s o r d e r s , s c h i z o p h r e n i a , o b s e s s i v e - c o m p u l s i v e a n d p h o b i c n e u r o s i s . ( T h e a s s u m p -t i o n i s m a d e t h a t e v e n t h o u g h i t m a y a p p e a r p h o b i c o r o b s e s s i o n a l , f o o d r e f u s a l a l o n e i s n o t s u f f i c i e n t t o q u a l i f y f o r o b s e s s i v e - c o m p u l s i v e o r p h o b i c d i s e a s e . ) A t l e a s t t w o o f t h e f o l l o w i n g m a n i f e s t a t i o n s : 1 . a m e n o r r h e a 2 . l a n u g o 3 . b r a d y c a r d i a ( p e r s i s t e n t r e s t i n g p u l s e o f 60 o r l e s s ) 4 . p e r i o d s o f o v e r a c t i v i t y 5 . e p i s o d e s o f b u l i m i a 6 . v o m i t i n g ( m a y b e s e l f - i n d u c e d ) . APPENDIX 2 Diagnostic C r i t e r i a for Anorexia Nervosa (DSM-III, 1980) Intense fear of becoming obese, which does not diminish as weight loss progresses. Disturbance of body image, e.g., claiming to " f e e l good" even when emaciated. 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 combined to make the 2 5%. Refusal to maintain body weight over a minimal normal weight for age and height. No known physical i l l n e s s that would account for the weight loss. 77 APPENDIX 2 (cont'd) Diagnostic C r i t e r i a for Bulimia (DSM-III, 1980) A. Recurrent episodes of binge eating (rapid consumption of a large amount of food i n a discrete period of time, usually less than two hours). B. At least three of the following: 1. Consumption of h i g h - c a l o r i c , e a s i l y ingested food during a binge. 2. Inconspicuous eating during a binge. 3. Termination of such eating episodes by abdominal pain, sleep, s o c i a l interruptions, or self-induced vomiting. 4. Repeated attempts to lose weight by severely r e s t r i c -t i v e d i e t s , self-induced vomiting, or use of cathartics or d i u r e t i c s . 5. Frequent weight fluctuations greater than ten pounds due to alternating binges and fasts. C. Awareness that;the eating pattern i s abnormal and fear of not being able to stop eating v o l u n t a r i l y . D. Depressed mood and self-deprecating thoughts following eating binges. E. The bulimic episodes are not due to Anorexia Nervosa or any known physical disorder. 78 APPENDIX 3 Semantic D i f f e r e n t i a l Scales Evaluation: successful : • • • . . . . . . — unsuccessful f o o l i s h : :  — — — " — " — • —• — • — wise negative : : . . — • — • — po s i t i v e good : : . . . — — — — — b a d Potency: hard • — - soft weak . . . . — strong severe : : : , — lenient A c t i v i t y : f a s t : • . . . . . . . — —"—"—*—"—" —*_*_"_*_ :_ :_ :_ slow passive : . . —" — * — •—" — " — "—• — active cautious : : • - . . — —" — " — " — * — * — • — r a s h excitable : :  : : calm APPENDIX 4 Case Histories 79 Patient #1 This 30 year old patient has a long history of anorexia nervosa. Although she remembers being concerned about her weight since she was seven years old, her food intake pattern did not become e r r a t i c u n t i l she was 24 years old. At that time she was overweight and f e l t very ugly. She abandoned her studies, i s o l a t e d herself i n an apartment, and l i v e d on tea and bran muffins losing 10 pounds i n three weeks. Her weight then decreased to about 100 pounds. Shortly a f t e r , she started to binge, followed by vomiting. Since that time her eating behaviour can be characterized as an alternation of binges and vomiting. She has kept her weight around 105 pounds. She was amenorrheic for f i v e years, then resumed menstruation, but i s currently amenorrheic again. Unusual food handling habits are present. She has reported compulsive behaviours such as r i t u a l s i n the past and, generally, i s quite obsessive. Patient #2 Patient #2 became anorexic at age 17 (she i s now 20). She was a l i t t l e heavy at that time, and when i t was suggested to her that she lose a few pounds she went on a starvation diet (less than 800 calories/day) and exercised excessively. She l o s t about 25 pounds of weight and became amenorrheic. Bulimia was a problem from the beginning. Binge eating was always followed by vomiting. This pattern of bulimia and . 80 vomiting was interrupted once by a period of starvation. Char-a c t e r i s t i c a l l y , she l i k e s to cook for others. The patient complains that her buttocks and thighs are too f a t , and she i s very self-conscious about i t . Her choice of silhouettes showed a strong desire for extreme thinness. Patient #3 This 13 year old patient became anorexic at the beginning of puberty. Although her weight was average for her height she f e l t too chubby and l o s t weight through di e t i n g and exer-c i s e . She became very preoccupied with food and her weight, and worried that she would become too muscular from the exercises. Some body image disturbance might be present as she chose the +1 abdomen silhouette as representing herself though she i s obviously quite slim. She has few friends and i s quite shy and insecure. Her parents i n s i s t e d on treatment when she had l o s t about ten pounds and her periods had stopped. Her anorexia i s not chronic and she i s responding well to therapy v Patient #4 This patient i s 25 years o l d . Her weight i s currently i n the average range due to bulimia. I n i t i a l l y she l o s t much weight and was amenorrheic for over a year. Her weight i n -creased when she started to binge. Binge eating episodes are followed by fas t i n g , but recently her periods of fas t i n g have shortened. Her weight has had a range of 60 pounds during APPENDIX 4 (cont'd) 81 the past f i v e years. Currently, she has l i t t l e control over her binge eating. Patient #5 This 22 year old patient who has been anorexic for 2 1/2 years was hospitalized at the time of t e s t i n g . H o s p i t a l i z a t i o n (duration of three months) became necessary because of her low weight. She has been gaining weight and has resumed menstrua-t i o n . Episodes of bulimia are frequent and are usually followed by vomiting. Although she i s s t i l l underweight she selected the +1 abdomen silhouette as the best representation of h e r s e l f . Patient #6 This 2 4 year old patient began to d i e t at age 16 although her weight was normal. At that time, her parents were going through a divorce and the patient might have blamed her mother's obesity for the marital problems. The patient has been on many diets since then as she has been concerned about being overweight. She became anorexic 2 1/2 'years ago. For the past two years she has binged almost d a i l y , usually during the evening. Binge eating i s always followed by vomiting. Most of her thoughts centre around food. Presently she i s motivated to change because of pressures from her boyfriend. Patient #7 This 24 year old patient's eating disorder began at age APPENDIX 4 (cont'd) 14. She was a very good a t h l e t e , p a r t i c u l a r l y a good swimmer, and wanted to l o s e weight i n order to perform b e t t e r . When she was 16 1/2 she had l o s t much weight, was amenorrheic, and stopped swimming. Since t h a t time her., weight has been i r r e - • g u l a r . Menstruation resumed f o r awhile (she has two c h i l d r e n ) , but c u r r e n t l y she i s amenorrheic. She had gained o n l y ten pounds d u r i n g one pregnancy, but 25 d u r i n g the o t h e r . Pre-s e n t l y her food i n t a k e i s very low, on some days o n l y 200-300 c a l o r i e s , and she continues to e x e r c i s e s t r e n u o u s l y . Although she now o n l y wants to be s l i m , not t h i n , she i s a f r a i d o f becoming overweight because d e s p i t e her d i e t i n g and e x e r c i s i n g she l o s e s weight s l o w l y . G e n e r a l l y , she i s q u i t e anxious and o b s e s s i v e . P a t i e n t #8 T h i s 19 year o l d p a t i e n t i s c u r r e n t l y of very low weight. She l o s e s weight by d i e t i n g and e x e r c i s i n g c o m p u l s i v e l y . She r e c o g n i z e s t h a t some of her h a b i t s and behaviours are compul-s i v e . She expresses a very t h i n body image i d e a l and a c c u r a t e l y p e r c e i v e s h e r s e l f ; as t h i n . She has been amenorrheic s i n c e she became a n o r e x i c three years ago. P a t i e n t #9 T h i s 31 year o l d p a t i e n t was overweight when she s t a r t e d t o d i e t two years ago. However, when she reached, her t a r g e t weight (somewhat low f o r her height) she continued to d i e t . C u r r e n t l y she i s amenorrheic and g a i n i n g weight very s l o w l y . APPENDIX 4 (cont'd) 83 Test responses showed that she does not see herself as very t h i n : she selected the +1 abdomen silhouette as the best representation of herself. Overactivity i s present. Thera-peutic progress i s very slow as the patient has devised many good.arguments favouring her starvation d i e t and refuses to agree to any contracting based on weight gain. Patient #10 This 16 year old patient professes to have much ins i g h t . She admits that she i s an anorexic but at the same time attempts to show that she has recovered. She c a r e f u l l y t r i e s to give non-anorexic responses and emphasizes a preference for average size body image. Her weight remains, however, low and she i s s t i l l amenorrheic. She i s not p a r t i c u l a r l y worried about other people's concerns regarding her weight. She admits that at times she i s a f r a i d of losing control. She i s quite a t h l e t i c and generally, ambitious and competetive. Patient #11 This 32 year old patient i s a t r u l y chronic anorexic (17 years). She became anorexic at the beginning of puberty and has maintained a very low weight throughout the years. She could describe a two year period during her teens when she put on some weight though she s t i l l remained underweight and amenorrheic. Many c l a s s i c anorexic behaviours can be observed: she only eats health foods, she i s very active, does volunteer work (Including cooking f o r others), and exercises strenuously APPENDIX 4 (cont'd) (e.g., rides a bicycle i n cold weather). Currently she i s motivated for therapy and feels she w i l l improve as she has just gained half a pound without being i n panic about i t . Prognosis, however, i s poor. Patient #12 This i s the second episode of anorexia nervosa for thi s 23 year old patient. The f i r s t one lasted half a year and the patient made a good recovery. The current episode started less than a year ago. The patient could i d e n t i f y two p r e c i -p i t a t i n g factors. During vacation with another couple she f e l t inadequate, not thin enough, and thought that the other woman looked gorgeous. Some time l a t e r at a party she li s t e n e d to some friends who were talking about someone else who was a l i t t l e overweight. She became a f r a i d that people would talk about her the same way. She reduced her weight by low c a l o r i e intake and vomiting which has become automatic. Soon afterward she became amenorrheic again. She has recently gained some weight but feels i t i s too much. In the tes t she preferred the very thin silhouette and saw herself as f a t with a +2 abdomen. However, she i s now w i l l i n g to stay at a three - d i g i t number ( i . e . , over 100 pounds) weight. Patient #13 This 15 year old patient has been anorexic for a year. She l o s t about 20 pounds to a low of 83 pounds. Weight loss was achieved mainly by reduced c a l o r i e intake. The patient APPENDIX 4 (cont'd) 0 3 complains of f e e l i n g f u l l a f t e r a few bites of food and having l i t t l e appetite. Her parents reported that she eats very slowly. About eight months ago the patient became amenorrheic. No p r e c i p i t a t i n g factors can be i d e n t i f i e d . The mother re c a l l e d , however, that her own s i s t e r had been anorexic at about 14 years of age. Patient #14 This 15 year old patient f i r s t l o s t weight two years ago when she was 170 pounds and overweight. After that her weight showed fluctuations. Currently she weighs about 119 pounds though her i d e a l weight for her height should be between 130 and 140 pounds. She became amenorrheic one year ago. She i s an emphatic vegetarian, e.g., she c a r e f u l l y supervises the cleaning of a l l u t e n s i l s that are used f o r preparing her food to ensure that no traces of meat or fat are l e f t on them. She i s a good student and quite active i n sports. Once a week or. so s h e ' l l binge on cookies, though her actual c a l o r i e intake during a binge i s not very high. She feels that she i s fat and claims that she sees herself so. She chose the f a t t e s t silhouette (+2) as an accurate representation of herself. She selected the thinnest silhouette (-2) as her body image i d e a l . Patient #15 This patient has been anorexic for two years and ameno-rrh e i c for one year. I n i t i a l l y she l o s t weight u n t i l she reached 90 pounds (her height i s 1.71 m). Now she i s s t i l l APPENDIX 4 (cont'd) 86 underweight at about 112 pounds. Weight loss was achieved through d i e t i n g and use of laxatives. Obsessive and h y s t e r i -c a l features are also present. She had been hosp i t a l i z e d twice because of her low weight. She perceives how thin she i s but considers her weight normal and i s a f r a i d of becoming average weight which she now considers overweight. Currently she i s binging about three times a week, although bulimia was not present i n i t i a l l y . C h a r a c t e r i s t i c a l l y , at the beginning of her anorexic career she worked as a cook. Patient #16 This patient became anorexic at age 19. Her c l i n i c a l picture i s a mixture of anorexia and bulimia. Her weight has ranged from 45 to 170 pounds i n the past four years. When her weight i s low she i s amenorrheic. Fear of obesity i s present, and she i s overactive. She binges regularly and uses large amounts of laxatives (e.g., 60 Exlax) to r i d her body of the food that she had consumed during the binge. This excessive use of laxatives had led to two h o s p i t a l i z a t i o n s . She prefers a very t h i n body image i d e a l , but perceives her body size quite accurately. Patient #17 This 21 year old patient has a six year history of anor-exia. Bulimia i s an important symptom. Regular binge eating i s followed by vomiting and periods of severe d i e t i n g . She prefers health foods and avoids sugar (except when she binges). Her weight has ranged from 100 to 145 pounds. She has been APPENDIX 4 (cont'd) 87 amenorrheic for the past year. Patient #18 This 27 year old patient l o s t weight gradually over a period of four years. Although she was s l i g h t l y overweight i n i t i a l l y , when she reached her goal she continued to d i e t . She became amenorrheic p r i o r to any s i g n i f i c a n t weight loss. She went to a low of 88 pounds (height 1.63 m) but denies the seriousness of her weight los s . She i s continually preoccupied with food and has begun to exercise. She l o s t i n t e r e s t i n s o c i a l relationships and broke up with her boyfriend. During the interview she expressed a wish to gain some weight..and selected the thinnest silhouette (-2) as the least preferred one. This silhouette was also chosen as the one that best represented h e r s e l f . Patient #19 This 34 year old patient has a 18 year history of anor-exia. Episodes of bulimia are frequent and usually are followed by vomiting. Her weight has ranged from 6 8 to 95 pounds (height 1.60 m) during the past 18 years. However, she has never been amenorrheic, even at her lowest weight. She accurately perceived herself as t h i n , and ;also selected a thin body image silhouette (-2b) as her body i d e a l . Currently, she i s making a sincere attempt to change her anorexic way of l i f e . APPENDIX 5 Background Characteristics of Anorexics-Bingers , „ a +. A a e =t Highest Lowest Duration Duration # / Duration Subject / Tsel of / Testing / Height / Weight / Weight / Weight / of A.eno-7 of jnor- / of Ho.pxtala^xon Anorexia m " k g Before After rrhea exia Onset of Onset of (Years) (Years) Anorexia Anorexia 1 19.5 22 1,68 48.4 63.6 43.6 ep^spdes) 2.5 2 .35 2 19 23 1,69 55.3 77.3 43.2 .5 4 2 1.5 3 21 24 1,63 54 61.4 49.1 - 2.5 - -4 16 34 1,60 40.5 45.5 30.9 - 18 2 2.5 5 15 21 1,66 52.2 45.5 1 6 - -6 24 30 1,65 46.3 73.2 44.1 .16 6 1 2 7 17 20 1,70 57.5 64.1 52.7 2 3 - -8 20 25 1,68 61.5 53.6 47.8 epfis rides) 6 - -9 19.5 21 1,71 52.6 58.6 40.5 ep^ socles) 1.5 2 4.5 M 19.00 24.4 1,66 52.03 62.1 44.1 5.5 SD 2.7 4.6 .03 6.2 10.2 6.1 4.9 APPENDIX 5 (cont'd) Background Characteristics of Anorexics-Abstainers Age at Age at Highest Lowest Duration Duration # / Duration Subject / Onset of/ Testing / Height / Weight / Weight / Weight /of Ameno- / of Anor- / of Hospitalization Anorexia Before After rrhea exia (Months) (m) (kg) Onset of Anorexia Onset of Anorexia (Years) (Years) 1 13 13 1,61 48.2 52.3 46.4 .16 .67 - -2 29 31 1,52 44.3 64.5 39.5 2 2 - -3 15 16 1,65 48.7 59.1 41,8 3 1 -4 16 19 1,68 39.3 54.5 37.7 3 3 - -5 18 23 1,65 54.5 61.4 48.6 .58 .67 1 2 6 14 15 1,73 54.5 77.3 53.2 1 1 - -7 14 15 1,65 44.2 46.8 36.4 .67 1 - -8 16 24 1,68 48 63.2 48.6 .25 8 - • -9 11 32 1,55 35.9 31.4 13.6 never men-struated aeLtuEaXty 17 4+ -10 22.5 27 1,63 43 61.4 40 5 5 - -M 16.85 21.5 1,63 46.06 57.2 40.5 3.4 SD 5.3 6.9 .1 5.9 12.2 10.9 5.2 APPENDIX 6 Background Characteristics of Control Subjects: Matched with Anorexic Subjects on Age, Educational Background, and Socio-Economic Status CONTROLS ANOREXICS' Educational Educational Background Socio- Background Socio-Subject Height Weight Age (Years of Economic (Years of Economic Number (m) (kg) (years) Schooling) Status 3 Age Schooling) Status 3 1 1,67 60. 4 20 12 3 22 11 5 2 1,55 55.9 20 12 5 23 10 5 3 1,65 50.4 24 14 or more 2 24 14 or more 2 4 1,57 49.5 34 12 2 34 12 2 5 1,52 47.7 21 12 2 21 12 2 6 1,62 47.5 29 14 or more 1 30 14 or more 2 7 1,64 56.7 20 13 2 20 13 2 8 1,68 61.2 25 14 or more 2 25 14 or more 2 9 1,72 64.7 21 14 or more 4 21 14 or more 5 10 1,62 50.7 32 14 or more 2 32 13 2 11 1,62 5 5 - 5 K 25 14 or more 3 24 13 2 12 1,65 45.5b 15 9 5 15 10 3 13 1,57 48.2 15 9 3 15 9 3 14 1,65 56.8 23 12 5 23 12 5; 15 1,71 57.0 19 13 2 19 13 2 16 1,72 67.3 16 11 3 16 11 3 17 1,55 47.7 30 12 c 31 12 2 18 1,57 50.5 14 8 3 13 8 3 19 1,70 60.5 27 12 4 27 12 4 M 1,63 54.40 22.63 2.94 22.89 2.94 SD .06 6.39 5.86 1.21 5.99 1.22 ^Occupation of self; father or husband where appropriate Subject has gained weight since testing cHousewife 91 APPENDIX 7 Scores on the R e s t r a i n t Q u e s t i o n n a i r e by C o n t r o l S u b j e c t s Although the scores on the R e s t r a i n t Q u e s t i o n n a i r e ranged from 5 t o 26 wit h a mean of 14.36 (median 14.5, mode 15) and a standard d e v i a t i o n of 4.84, c l o s e r i n s p e c t i o n showed t h a t 78.9%: of the c o n t r o l s u b j e c t s ' responses f e l l w i t h i n one standard d e v i a t i o n of the mean. Although o t h e r s t u d i e s have used a median s p l i t t o form subgroups (Herman & P o l i v y , 1975, Spencer & Fremouw, 1979), t h i s procedure was not deemed a p p r o p r i a t e g i v e n the d i s t r i b u t i o n of the pr e s e n t s c o r e s . APPENDIX 8 A P P E N D I X 8 ( c o n f b r e a s t s APPENDIX 8 (cont'd) abdomen APPENDIX 8 (cont APPENDIX 8 (cont'd) +1 legs 97 APPENDIX 9 Eating Attitudes Test Instructions: Please place an (X) under the column which applies best to each of the numbered statements. A l l of the results w i l l be s t r i c t l y c o n f i d e n t i a l . Most of the questions d i r e c t l y relate to food or eating, although other types of questions have been included. Please answer each question c a r e f u l l y . Thank you. 53 W CQ EH EH £ cn o H 53 EH < » W Cijj EH § l-H w EH O < > O CO l-H OH EH 53 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 over-weight . 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 aft 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 thinner. A P P E N D I X 9 ( c o n t ' d ) 98 < 53 W CO EH Cn O M EH X w rt En W CM o > O CO >H rt ( ) (':) ( ) ( ) ( ) ( ) 16. E x e r c i s e s t r e n u o u s l y t o b u r n o f f c a l o r i e s . 17. W e i g h m y s e l f s e v e r a l t i m e s a d a y . 18. L i k e my c l o t h e s t o f i t t i g h t l y . 19. E n j o y e a t i n g m e a t . 20. W a k e u p e a r l y i n t h e m o r n i n g . 21. E a t t h e s a m e f o o d s d a y a f t e r d a y . 22. T h i n k a b o u t b u r n i n g u p c a l o r i e s w h e n I e x e r c i s e . 23. H a v e r e g u l a r m e n s t r u a l p e r i o d s . 24. O t h e r p e o p l e t h i n k t h a t I am t o o t h i n . 25. Am p r e o c c u p i e d w i t h t h e t h o u g h t o f h a v i n g f a t o n my b o d y . 26. T a k e l o n g e r t h a n o t h e r s t o e a t my m e a l s . 27. E n j o y e a t i n g a t r e s t a u r a n t s . 28. T a k e l a x a t i v e s . 29. A v o i d f o o d s w i t h s u g a r i n t h e m . 30. E a t d i e t f o o d s . 31. F e e l t h a t f o o d c o n t r o l s my l i f e . 32. D i s p l a y s e l f c o n t r o l a r o u n d f o o d . 33. F e e l t h a t o t h e r s p r e s s u r e me t o e a t . 34. G i v e t o o m u c h t i m e a n d t h o u g h t t o f o o d . 35. S u f f e r f r o m c o n s t i p a t i o n . 99 APPENDIX 9 (cont'd) W CO EH W fa g CO O H >H >H 2 EH KH « <! >H W W H W IS « EH g « > i-H W fa O <5 W < > O CO K 13 ( ) ( ) ( ) ( ) ( ) ( ) 36. F e e l uncomfortable a f t e r e a t i n g sweets. ( ) ( ) ( ) ( ) ( ) ( ) 37. Engage i n d i e t i n g behaviour. ( ) ( ) ( ) ( ) ( ) ( ) 38. L i k e my stomach to be empty. ( ) ( ) ( ) ( ) ( ) ( ) 39. Enjoy t r y i n g new r i c h foods. ( ) ( ) ( ) ( ) ( ) ( ) 40. Have the impulse to vomit a f t e r meals. 100 APPENDIX 10 •'- Restraint .Questionnaire 1. How many pounds over your desired weight were you at your maximum weight? pounds 2. How often are you dieting? r a r e l y . . *\ sometimes_ usually always Which describes best your behaviour a f t e r you have eaten a 'not-allowed' food while on your diet? return to diet stop eating for an extended period of time i n order to compensate continue on a splurge, eating other "not-allowed 1 foods 4. What i s the maximum amount of weight that you have ever l o s t within 1 month? - pounds 5. What i s your maximum weight gain within a week? pounds 6. In a t y p i c a l week, how much does your weight fluctuate? pounds 7. Would a weight fl u c t u a t i o n of 5 pounds a f f e c t the way you l i v e your l i f e ? Not at a l l s l i g h t l y moderately very much 8. Do you eat sensibly before others and make up for i t alone? never rarely_ often always 9. Do you give too much time and thought to food? never ra r e l y often always 10. Do you have feelings of g u i l t a f t e r overeating? never rarely often always 11. How conscious are you of what you are eating? not at a l l s l i g h t l y moderately extremely 12.. Are you currently dieting? yes - no 13. What i s your desired weight? pounds 101 APPENDIX 11 Perceptual Aberration Scale 1. True 2. True 3. True 4. True 5. True 6. True 7. True 8. True 9. True 10. True 11. False 12. False 13. True 14. True 15. True 16. True Sometimes I have had feelings that I am united with an object near me. I have sometimes had the f e e l i n g that one of my arms or legs i s disconnected from the rest of my body. I sometimes have to touch myself to make sure I ' m ' s t i l l there. Sometimes I have had the f e e l i n g that a part of my body i s larger than i t usually i s . At times I have wondered i f my body was r e a l l y my own. Parts of my body occasionally seem dead or unreal. Sometimes I have had a passing thought that some part of my body was r o t t i n g away. Occasionally I have f e l t as though my body did not e x i s t . Sometimes I have f e l t that I could not d i s t i n -guish my body from other objects around me. I t has seemed at times as i f my body was melting into my surroundings. I have never f e l t that my arms or legs have momentarily grown i n s i z e . The boundaries of my body always seem clear. I can remeber when i t seemed as though one of my limbs took on an unusual shape. I sometimes have had the f e e l i n g that my body i s abnormal. I have sometimes had the f e e l i n g that my body i s decaying inside. I have had the momentary f e e l i n g that the things I touch remain attached to my body. 102 APPENDIX 11 (cont'd) 17. True Occasionally i t has seemed as i f my body had taken on the appearance of another person's body. 18. True Sometimes I f e e l l i k e everything around me i s t i l t i n g . 19. True Ordinary colors sometimes seem much too bright to me (without taking drugs). 20. False My hands or feet have never seemed far away. 21. True I have sometimes f e l t that some part of my body no longer belonged to me. 22. True I have f e l t that something outside my body was a part of my body. 23. True I have f e l t that my body and another person's body were one and the same. 24. True Now and then when I look i n the mirror, my face seems quite d i f f e r e n t than usual. 25. True I have f e l t as though my head or limbs were somehow not my own. 26. True Sometimes when I look at things l i k e tables and chairs, they seem strange. 27. False I have never had the passing f e e l i n g that my arms or legs had become longer than usual. 28. True I sometimes have had the f e e l i n g that some parts of my body are not attached to the same person. 29. True I have had the momentary fe e l i n g that my body has become misshapen. 30. True Sometimes part of my body has seemed smaller than i t usually i s . 31. True My hearing i s sometimes so sensitive that ordinary sounds become uncomfortable. 32. True Sometimes people whom I know well begin to look l i k e strangers. 103 APPENDIX 11 (cont'd) 33. True I have sometimes f e l t confused as to whether my body was r e a l l y my own. 34. True Often I have a day when indoor l i g h t s seem so bright that they bother my eyes. 35. True For several days at a time I have had such a heightened awareness of sights and sounds that I cannot shut them out. 

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