The Relationship Between Body Image and Fear of Weight Gain in Women with Varying Levels of Disturbed Eating

THE RELATIONSHIP BETWEEN BODY IMAGE AND FEAR OF WEIGHT GAIN IN WOMEN WITH VARYING LEVELS OF DISTURBED EATING

Sandra L. Newes

A Thesis Presented to The Faculty of Humboldt State University

In Partial Fulfillment of the Requirements for the Degree Master of Arts In Psychology

August, 1996 THE RELATIONSHIP BETWEEN BODY IMAGE AND FEAR OF WEIGHT GAIN IN WOMEN WITH VARYING LEVELS OF DISTURBED EATING

Sandra L. Newes

Approved by:

Alane L. Wiener-Osborn, Thesis Chair

Warren J. Carlson, Committee Member

Senqi Hu, Committee Member

Alane L. Wiener-Osborn, Academic Research Program Coordinator

John . Turner, Dean for Research and Graduate Studies Abstract The Relationship Between Body Image and Fear of Fat in Women with Varying Levels of Disturbed eating

Sandra L. Newes

This study explored the relationship between the constructs of body image concern and fear of weight gain.

It was hypothesized that participants with varying levels of eating disturbance would show a differential pattern of indicators related to these constructs.

Female college students were screened for eating disturbance using the BULIT-R and 41 participants were placed into either a Normal eating (NOR), an Abnormal eating

(AB), or an At Risk (AR) group. Participants completed the

Eating Disorders Examination, the Goldfarb Fear of Fat

Scale, the Body Image Avoidance Questionnaire, and a size estimation task using the Video Distortion Technique.

Differences were found between the NOR group and the AB and AR group on all measures. There were no differences between the AB and the AR group, with the exception of the

"Real" body image distortion measure which indicated a trend toward differences. Correlations were found between all body image and fear measures. Results were discussed in terms of the two-component model of eating disorder development and the eating disorders continuum model.

iii Acknowledgments I would like to acknowledge Dr. Alane Wiener-Osborn for all of her support and guidance throughout the course of this project. I would like to thank Dr. Osborn for all of the tremendous extra effort involved with helping me to finish from 3000 miles away. Dr. Osborn truly went beyond that which might be expected from a thesis chair, both personally and professionally.

I would like to thank Elizabeth Brill for her dedicated work on this project; for her problem solving abilities, so very necessary in this undertaking; and for her sense of humor, her acceptance, and her friendship. I would also like to thank Lisa Brown for both her efforts on this project and her personal support; as well as the other members of the Eating Disorders Laboratory.

I would also like to thank members of my committee, Dr.

Warren Carlson and Dr. Senqi Hu, and George Bailey for his technical support and his patience.

In addition, I would like to thank Dr. Aaron Pincus, both for his excellent suggestions and for his personal encouragement.

I would also like to send unique thanks to the Penn

State Outing Club for helping me to maintain focus; and

Daniel Nicholson in particular- for helping me to realize a dream, for motivating me, for believing in me, and for being there.

iv Most of all though, I would like to thank my family. Their complete love and support is what has made everything possible, and their confidence has been unwavering. A most heartfelt "thank you" goes to them.

v Table of Contents

Page Abstract iii Acknowledgements iv List of Tables xi Introduction 1 Body Image Distortion 3 Fear of Weight Gain 10 Statement of Purpose 15 Hypotheses 16 Method 19 Participants 19 Apparatus 20 Screening measures 20 Weight and height measures 21 Body image measures 21 Fear measures 23 Procedure 24 Evaluation screening 24 Body distortion measurement 25 Self-report questionnaires 26 Results 27 Analysis of Selection Criteria 27 Selection criteria follow-up analyses 27 Analysis of Body Image 29

vi Body image follow-up analyses 29 Analysis of Fear of Weight Gain 32 Fear follow-up analyses 33 Analysis of Body Image and Fear of Weight Gain

Relationships 35 Discussion 39 Summary of findings 39 Continuum of eating disorders 43 Two-Component model of eating disorder development 44 Conclusions and implications 54 References 56 Appendices 73 A Consent Form #1 73 B The Bulimia Test-Revised (BULIT-R) 76 C The Eating Disorders Examination 84 D Schematic Representation of Eating Disorders Laboratory 109 E The Body Image Avoidance Questionnaire 111 F The Goldfarb Fear of Fat Scale 113 G Consent Form #2 115 H Real Body Image Instructions 116 I Ideal Body Image Instructions 118 J Human Subjects: Letter of Approval 120

vii List of Tables

Table Page

1 Means and Standard Deviation of Selection Criteria by Group 28

2 Means and Standard Deviation of Body Image Measures by Group 31

3 Means and Standard Deviation of Fear measures by Group 34

4 Correlations of Body Image Self-Report Measures with Body Image Distortion Measures Across Combined Groups 36

5 Correlations of All Body Image Measures with Fear Measures Across Combined Groups 37

viii Introduction Scientific interest in the area of eating disorders has increased over the past twenty five years (Cash & Brown, 1987; Fairburn & Garner, 1986; Kerr, Skok, & McLaughlin, 1991; Russell, 1979). Through this increase in research, investigators have identified several characteristics commonly associated with eating disorders. Two major characteristics in particular have been found to be associated with anorexia nervosa and bulimia nervosa: 1) an abnormal concern with body size and weight and 2) a morbid fear of becoming fat (Cash, Wood, Phelps, & Boyd, 1991; Clinton & Glant, 1993; Cooper & Fairburn, 1983; Fairburn, 1980; Fairburn & Cooper, 1982; Fairburn & Garner, 1986; Garner & Garfinkel, 1982; Kerr et al., 1991; Pyle, Mitchell, & Eckert, 1981; Russell, 1979). In a review of the bulimia research, Schlesier-Stropp (1984) stated "clearly, the one characteristic found...was an abnormal concern with body size -- a concern of becoming fat without a realistic perspective of what constitutes normal size" (p. 250). Subsequently, the Diagnostic and Statistical Manual- IV .(APA,1994) lists both the overconcern with weight and shape and fear of weight gain as defining characteristics of eating disorders. In addition to these defining characteristics, DSM-IV includes an "an undue influence of body weight and shape on self-evaluation" (pp.545,550) as a diagnostic criteria for both bulimia and anorexia nervosa.

1 2 Generally, researchers have approached these diagnostic features by attempting to validate the constructs of body image and fear of weight gain. Body image has been conceptualized and measured from many different points of view and results have been mixed and inconclusive. Both anorexics and bulimics have been found to overestimate body size (Garner & Garfinkel, 1982; Willmuth, Leitenburg, Rosen, Fondacaro, & Gross, 1985) and it has been suggested that bulimics overestimate to a greater extent than do anorexics (Thompson, Berland, Linton, & Weinsier, 1986). However, body size overestimation has often been found in normal control groups as well (Thompson & Thompson, 1986; Willmuth et al., 1985), leading some to question the inclusion of this feature as a defining characteristic. In addition to body image distortion, numerous studies have attempted to measure the fear construct (Rosen & Leitenburg, 1982; Leitenburg, Gross, Peterson, & Rosen, 1984; Giles, Young, & Young, 1985). A number of descriptions have been applied to the construct, including "overconcern with body shape and weight," "feelings of fatness," "fear of fatness," "sensitivity to weight gain," "dissatisfaction with weight," "dissatisfaction with shape," "pursuit of weight loss," or "pursuit of thinness" (Fairburn, 1987), but there still appears to be no consensus on the operational definition of this construct. 3 As is suggested by the above descriptions, terms indicating "fear of fatness" have been used interchangeably with terms indicating body image distortion. One purpose of the present study is to approach these issues with distinct conceptualizations of body image distortion and fear of fat. Following is a brief review of the body image distortion literature, proceded by a brief review of the fear of weight gain literature. Body Image Distortion Hilde Bruch (1962) was the first researcher to postulate distortion of body image as a pathognomonic indicator of anorexia nervosa (1962). As a result, there have been a number of investigations into the body image distortion construct as it relates to eating disorders. Thompson (1990) defines body image as "an evaluation of one's size, weight, or any other aspect of the body that determines physical appearance" (p. 1). As a psychological construct, body image has been described and measured from many points of view. The physical appearance aspect of body image is commonly subdivided into two components: (a) perceptual, indicating body size perception accuracy and (b) subjective or attitudinal, indicating satisfaction, concern, cognitive evaluation and anxiety. Much of the research has focused on the perceptual component. 4 Interest in the perceptual aspect of body image emerged after Slade and Russell (1973) originally observed greater size overestimation in anorexics than in controls. According to Cash and Brown (1987), the variety of instruments designed to measure size perception (or estimation) accuracy fall under two broad categories: 1) body-part procedures, and 2) whole-body procedures. Body-part procedures require that the participants estimate the width of discrete body parts, e.g., hips and waist. For instance, in the first empirical investigation of the perceptual aspects of body image distortion, Slade and Russell (1973) developed the movable caliper technique (or visual size estimation task, VSE), adapted from Reitman and Cleveland (1964). The VSE consists of a horizontal bar with tracks onto which two lights are mounted. Using a pulley, participants are able to adjust the light beams to indicate a perceived width of a body part. Perceived widths are then compared to actual widths to create a body perception index. Results of Slade and Russell's (1973) study indicated that anorexics significantly overestimated the widths of their specific body parts as compared to normal controls. Following the development of the VSE, a number of investigations of eating disordered individuals using this technique attempted to replicate Slade and Russell's indings. Some were successful in finding similar results 5 (Fries, 1977; Pierloot & Houben, 1978), while others were not (Button, Fransella, & Slade, 1977; Casper, Halmi, Goldberg, Eckert, & Davis, 1979; Crisp & Kalucy, 1974; Garner, Garfinkel, Stancer, & Moldofsky, 1976). Inconsistency in results has also been common among the studies comparing bulimics with normal controls. Birchnell, Lacey, and Harte (1985) found no overestimation differences, while Willmuth et al. (1985) found that bulimics overestimated significantly more than controls. A simpler and less popular body-part procedure is the image marking procedure (IMP) which was introduced by Askevold (1975). Size estimations are obtained by simply having the participant stand before a paper-lined wall and with a pencil in each hand indicate the width of a given body part. This method has also produced mixed results as some studies have found significant differences between anorexics and controls (Pierloot & Houben, 1978; Wingate & Christie, 1978) while others have not (Strober, Goldenberg, Green, & Saxon, 1979). Ruff and Barrios (1986) developed the body image detection device (BIDD) which was introduced as an inexpensive as well as uncomplicated technique. Using a standard overhead projector and black poster board templates with wooden guides, a beam of light is projected onto the wall and the participant is required to match the width of the beam to the width of various body sites. Thompson and 6 Spana (1988) created a modified version of the BIDD called the adjustable light beam apparatus (ALBA) utilizing four light beams allowing for estimates of several body parts a once. A number of studies using these techniques (i.e., Ruff & Barrios, 1986; Thompson et al., 1986; Thompson & Thompson, 1986) have reported overestimation among both eating disordered and control groups. However, Norris (1984) reported that while bulimics, anorexics, and emotionally disturbed participants overestimated their body size, the normal controls were extremely accurate. Whole body procedures require the participant to estimate whole body size rather than distinct body parts. There have been three techniques most widely used. The first investigation of this type was conducted by Traub and Orbach (1964) in which they used the distorting mirror technique (DMT). The DMT consists of a mirror that can be bent to distort to size of the image. Participants are asked to adjust the image to the size which most closely matches their own body size. More widely used than the DMT has been the distorting photograph technique (DPT) developed by Glucksman and Hirsch (1969) in which a variable anamorphic lens allows the participant to view a slide of themselves at plus or minus 20% of actual size. The participant is required to adjust the image to both their perceived real and ideal sizes. 7 The video distortion technique (VDT) is similar to the DPT and was first developed by Allenback, Halberg, and Epsmark (1976). It has been modified by Freeman et al., (1983) and by Wiener, Seime, and Goetsch (1989). Rather than using a slide as in the DPT, the VDT utilizes a modified video camera that electronically distorts the image, allowing the participant to view and adjust his/her image on a television monitor by increasing the size up to 80% and decreasing the size by up to 40%. Silhouettes have also been used to measure body distortion (Counts & Adams, 1985; Williamson et al., 1985; Williamson et al.,1993). The participant is asked to select a silhouette most closely representing her actual and ideal body sizes from a series of silhouettes ranging from very thin to very obese. As with the body-part investigations, research into whole body distortion has also produced inconsistent findings. In a comprehensive review, Cash and Brown (1987) reported that anorexics overestimated significantly more than controls in some studies (Freeman et al. 1983; Garfinkel et al., 1978) with other studies reporting no differences (e.g., Garfinkel, Moldofsky & Garner, 1979; Touyz et al., 1984). Studies comparing bulimics to other groups (Freeman et al., 1984; Freeman et al., 1983; Seime, Wiener, Larkin, & Fremouw, 1989; Wiener, 1990) have found greater overestimation in bulimics. Silhouette studies have 8 reported greater overestimation in bulimics (Williamson et al., 1985; Williamson, Goreczny, & Blouin, 1989), with one study reporting no difference (Counts & Adams, 1985). Most recently, a new technique called the Body Image Testing System (BITS) combines the body part procedure and the whole body procedure in a microcomputer program for assessing body image (Schlundt & Bell, 1993). The BITS accomplishes this task by presenting the participant with a computer image which has nine adjustable body parts. The participant is able to adjust each body part by interacting with a menu accompanied by a judgment task in which the participant provides satisfaction ratings for each of the nine body parts. This particular study utilized a nonclinical population of over 500 participants in order to validate the BITS. Using a variety of body image and eating disturbance measures, a factor analysis resulted in five orthogonal factors: 1) body weight discrepancy, 2) body weight distortion, 3) neck-face factor, 4) shoulder factor, and 5) breast factor. These five factors were strongly associated with actual body size, body fat percentage, and circumference of specific body parts. The results of this study indicate that the BITS may be a promising tool for assessing body image distortion. Given the mixed results of the perceptual body image research, it is apparent that the concept of distorted body image among eating disordered groups has not been 9 unequivocally supported. A number of possible explanations have been offered as to the rationale behind these mixed results. In a review body image techniques, McCrea, Summerfield and Rosen (1982) assert that a major obstacle to progress in the field of body image is the differing methods employed for measuring body image variables. These differing techniques have led to conflicting findings, therefore, comparison across studies becomes less meaningful. (p. 231). Garner et al. (1976) suggested the-two types of techniques may be measuring two different aspects of body image; i.e., the distortion techniques involve a more direct confrontation with the whole body whereas discrete body-part techniques do not involve a visual reference to one's entire body. Therefore, differences in perception based on technique may require different interpretations of seemingly similar results. Cash and Brown (1987) stated, "certain variations in participant characteristics, measurement techniques, and experimental setting can significantly influence the results of the study it is virtually impossible to determine whether the inconsistencies across studies are due to differences in methodology or due to the heterogeneity of the samples utilized" (p. 507-508). They suggest using multiple measures of body image, especially across modalities (i.e., perceptual and attitudinal measures). 10 Thompson, Allabe, Johnson, & Stormer (1994) conducted factor analysis of five self-report measures of body image commonly used as indicators of multiple aspects of body image disturbance. Only one factor was found for adult participants, and one strong factor with another significantly weaker factor was found for adolescents. The results of this study suggest that perhaps all of these measures are tapping into the same concept. Researchers (Hsu, 1991; Wiener, 1990) have proposed that body image distortion is not a prognostically valid construct, adding that we perhaps should return to the original terms of fear of fatness, weight phobia and pursuit of thinness. Cash and Brown (1987)and Wiener (1990) hypothesize that eating disordered individual's size estimations may actually reflect their aversion to weight gain, or fear of fat. Fear of Weight Gain The "fear of fat" construct has been the least systematically examined area within eating disorders. Initial evidence was primarily anecdotal in nature. In 1970, Crisp stressed the importance of fear in anorexia nervosa, stating that one immediate diagnostic problem is clearly to try and understand more fully the basis or bases

of this fear. Since then, it was suggested by Fairburn and Cooper (1984) that the most prominent psychological feature of bulimia nervosa is a morbid fear of fatness. 11 Vanderheyden and Boland (1987) are cited in a recent review of the characteristics of bulimia and anorexia (Kerr et el., 1991) as referring to the combined fear of fatness and striving for thinness as being central to the anorexic's drive. Numerous studies have referred to bulimics having extremely high anxiety levels (Halmi, 1987; Leon, Chernyk,& Finn, 1984; Mizes, 1988a, 1988b; Prather & Williamson, 1988), and it has been found that among bulimics, anxiety levels increased as bingeing and purging behavior increased (Williamson et al., 1987). Additionally, the anxiety model of bulimia (Rosen & Leitenburg, 1982) proposes that eating evokes anxiety about weight and that binge eating increases this anxiety dramatically. Vomiting is an escape response which reduces weight gain anxiety, and thus this behavior is negatively reinforced. A vicious circle is created where eating and self-induced vomiting are tied together by fear of weight gain. In support of the mediational role of fear of fatness, Rosen and Leitenberg (1982) tested an exposure plus response prevention model of treatment for bulimia (e.g., not allowing vomiting after ingestion of frightening foods) and found that the amount of food eaten without vomiting and the subjective discomfort after eating decreased following treatment. Similarly, Goldfarb, et al. (1987) conducted a treatment study which viewed anorexia as weight phobia. Systematic desensitization and relaxation were employed as 12 methods of treatment and were shown to be effective treatments for reducing fear of fat. Wiener (1990) conducted the most rigorous assessment of the fear of weight gain construct to date. Using the Video Distortion Technique (Freeman, et al., 1984), 17 bulimic participants and 16 normal controls were filmed in a black leotard, and their images made progressively larger. Participants then viewed this "phobic" condition and a neutral weight gain condition, utilizing a mannequin. Cognitive/verbal, behavioral/motoric escape responses, and physiological responses were recorded. Bulimic participants had significantly greater behavioral and cognitive responses than normal controls in both the neutral and phobic weight gain conditions. Bulimics also scored significantly higher in the phobic condition than the neutral condition. No group differences were found between conditions on the physiological measures. This study supports both the fear of weight gain construct and the anxiety model of bulimia. Although the fear of weight gain construct has permeated the eating disorders literature, only a few self report instruments address it. Among standard self-report measures, The Eating Disorders Inventory (EDI; Garner, Olmstead, & Polivy, 1983), the Eating Attitude Test (EAT; Garner & Garfinkel, 1979),. the Bulimic Investigatory Test, Edinburgh (BITE; Henderson & Freeman, 1987), and the Body- 13 Self Relations Questionnaire (BSRQ; Cash, 1990) all contain only one item directly related to fear. The Body Shape Questionnaire(BSQ; Cooper, Taylor, Cooper, & Fairburn, 1987)and the Body Image Avoidance Questionnaire (BIAQ; Rosen, Srebnik, Saltzberg, & Wendt, 1993) both assess fear, but indirectly. The BSQ is a self- report instrument emphasizing body shape and weight gain, as well as fears pertaining to these areas and the consequences of such fears. Whereas other instruments have inferred the presence of fear of weight gain through eating and/or purging behaviors, the BSQ focuses more on this construct. Wiener (1990) found participants showing higher levels of body shape concern as measured by the BSQ were more likely to report increased levels of anxiety when viewing the phobic weight gain condition of themselves. The Body Image Avoidance Questionnaire (BIAQ; Rosen et al, 1993) is 19-item semantic differential scale which assesses avoidant behaviors associated with negative body image. Fear is implied from the degree to which an individual engages in these behaviors. Rosen, et al. (1993) administered the BIAQ to 353 participants and found avoidance to be strongly associated with fear of fatness, body dissatisfaction, and greater importance placed on shape and weight for self-evaluation. Only two scales to date directly assess the fear of fat construct. The Goldfarb Fear of Fat Scale (GFFS; Goldfarb 14 et al., 1985) is a 10-item self-report measure created for the purpose of identifying individuals extremely fearful of becoming fat. Bulimics, repeat dieters, and normal controls were administered the GFFS along with other measures previously shown to differentiate bulimic from non-bulimic women. The GFFS was shown to be the strongest differentiating measure, as well as being significantly correlated with a number of other differentiating variables (Goldfarb et al., 1985). The Fat Phobia scale (F Scale; Robinson, Bacon, & O'Reilly, 1993) is a 50-item scale designed to identify fat phobic attitudes. It measures the degree to which someone has internalized popular societal stereotypes regarding fat people. Fear is determined through the level of fat phobic attitudes an individual exhibits. Robinson et al. (1993) found higher levels of fat phobic attitudes among participants who were younger (i.e., below 55), female, average weight, and with above a high school education. The most common stereotypes held by those with high fat phobic attitudes were that fat people were undisciplined, inactive, and unappealing (Robinson et al., 1993). These differing methodologies for measuring the fear of weight gain construct have led to confusion regarding its operationalization. In addition, the relationship between methods of measuring the fear and the body image disturbance 15 constructs is unclear, and thus the association is not well delineated. One method for resolving these discrepant findings was the inclusion in the present study of additional groups with more variant levels of eating-related pathology. It has been suggested that these discrepancies may relate to the fact that the typical comparison groups in eating disorders research involve the extremes on dimensions of beahviors and attituudes; i.e., those individuals diagnosed with bulima nervosa (Dolan, Evans, & Lacey; 1992). All of the studies in the above literature review employ groups with clear distinctions between those individuals with high levels of disordered eating (i.e., bulimics, anorexics) and those with low levels (i.e., normal controls). Given that body dissatisfaction, the pursuit of thinness, and compulsive dieting have become "normative" behaviors for women in our society (Rodin, Silberstein, & Striegel-Moore; 1985), the inclusion of participants with abnormal, but not clinically diagnosable levels of eating-related pathological behaviors was an attempt to resolve some of these discrepancies. It was hypothesized in the present study that participants with intermediate levels of eating severity would show a differential pattern of indicators related to the fear and body image disturbance constructs, thus providing suggestions as to what may be the issues underlying these inconsistent findings. 16 Statement of Purpose This study explored the relationship between the construct of body image disturbance and the fear of weight gain among female college students with varying levels of eating disturbance; i.e., At Risk eating behaviors, Abnormal eating behaviors, and Normal eating behaviors. The study compared perceptual and attitudinal measures of body image and also compared both measures of body image with self- report measures of fear. Hypotheses: It was predicted that: I. Body image 1. The At Risk participants would have greater "Real" body size estimates than both the Abnormal and the Normal Eating participants as measured by the video distortion camera. 2. The Abnormal Eating participants would have greater "Real" body size estimates than the Normal Eating participants as measured by the video distortion camera, but smaller than the At Risk participants. 3. The At Risk participants would have smaller "Ideal" body size estimates than both the Abnormal and the Normal Eating participants as measured by the video distortion camera. 4. The Abnormal Eating participants would have smaller "Ideal" body size estimates than the Normal Eating 17 participants as measured by the video distortion camera, but larger than the At Risk participants. 5. The At Risk participants would have a greater discrepancy between the "Real" and "Ideal" body image measures than do both the Abnormal and the Normal Eating participants. 6. The Abnormal Eating participants would have a greater discrepancy between the "Real" and "Ideal" body image measures than the Normal Eating participants, but less discrepancy than the At Risk participants. 7. The At Risk participants would have greater body concern than both the Abnormal and the Normal Eating participants as measured by the Shape Concern subscale of the Eating Disorders Examination (EDE; Fairburn & Cooper, 1987) and the Weight Concern subscale of the EDE. 8. The Abnormal Eating participants would have greater body concern than the Normal participants as measured by the shape concern subscale of the Eating Disorders Examination (EDE; Fairburn & Cooper, 1987), and the Weight Concern subscale of the EDE; but less body concern than the At Risk participants. 9. There would be a significant positive correlation between attitudinal (i.e., EDE subscales) and perceptual (i.e., "Real", "Ideal", "Discrepancy") measures of body image for all three groups. 18 II. Fear of Weight Gain 1. The At Risk participants would have higher levels of fear than both the Abnormal and the Normal Eating participants as measured by the Goldfarb Fear of Fat Scale (GFFS; Goldfarb et al., 1985). 2. The Abnormal Eating participants would have higher levels of fear than Normal Eating participants as measured by the Goldfarb Fear of Fat Scale (GFFS; Goldfarb et al., 1985); but lower levels than the At Risk participants. 3. The At Risk participants would engage in higher levels of avoidance behaviors than both the Abnormal and the Normal Eating participants as measured by the Body Image Avoidance Questionnaire (BIAQ; Rosen et al., 1991). 4. The Abnormal Eating participants would engage in higher levels of avoidance behaviors than Normal Eating participants as measured by the Body Image Avoidance Questionnaire (BIAQ; Rosen et al.,1991), but lower levels than the At Risk participants. 5. There would be significant positive correlations between the measures of body image and the measures of fear. Method Participants Potential At Risk, Abnormal, and Normal eating female participants, ages 18-35, were recruited from undergraduate psychology courses at Humboldt State University for participation in this study. With prior permission from the acting professor, a brief consent form (see Appendix A) and one screening questionnaire (BULIT-R) were administered during the last fifteen minutes of class. Based on scores to the BULIT-R, participants were grouped in the following manner: 1) Normal eating patterns (N=14), 2)Abnormal eating patterns (N=10), 3) At Risk for disordered eating (N=17). Eligibility of Normal Eating participants for invitation to participate in the study was determined by the following inclusionary criteria: 1) A Body Mass Index (BMI) that was between 20 and 27; which, according to Canadian Guidelines, has been deemed normal (Obesity and Health, p. 93, 1993), and 2)absence of a clinical eating disorder or history of diagnosis or treatment for an eating disorder, and 3)normal eating patterns as were determined by participants' responses to the Bulimia Test-Revised Version (BULIT-R) (score <61) (see Appendix B). Participants in the At Risk group were determined by 1)BMI criteria and 2) presence of at risk for disordered eating behaviors as were determined by responses to the

19 20 BULIT-R(i.e., BULIT-R score >80). Participants in the Abnormal eating patterns group were determined by 1)BMI criteria and 2) presence of abnormal eating patterns as were determined by responses to the BULIT-R (i.e., BULIT-R score>61 and <80). Apparatus This study was conducted in the Eating Disorders Lab located in Room 133 and in Room 112, the equipment and computing room for the laboratory in Harry Griffith Hall at Humboldt State University. Screening measures. During the group screening procedure (i.e., initial screening) of the study, the Bulimia Test-Revised Version (BULIT-R, Thelen, Farmer, Wondrich, & Smith; 1991) were used. The BULIT-R is a 35-item forced choice scale which uses a 5-point Likert format. It is designed to discriminate between bulimic individuals and individuals with no eating problems with scores >80 considered to be highly at risk for eating disorders, and <61 considered to be non-eating disordered. Test-retest reliability was found to be .95. The validity of the BULIT-R was established by comparing scores obtained on the BULIT-R with scores obtained on other eating disorder measures such as the Bulimia Test (BULIT; Smith & Thelan, 1984) and the Binge 21 Scale (Hawkins & Clements, 1980). Correlations ranged from .99 to .85. Weight and height measures. A pre-calibrating Detecto balance beam scale (RE-250) and a pre-calibrated Stadi-O-Meter (Novel Products, Inc.) height measure mounted on the wall near the scale was used to obtain body weight and height. Body Mass Index (BMI; i.e., weight divided by height squared - W/H2 (kg/m2) will be obtained by referring to the Body Mass Index table (See Appendix C) in which a normal BMI is considered to be between 20 and 27 according to Canadian Guidelines (Obesity and Health, p. 93, 1993). Body image measures. To meaure Real, Ideal, and body image Discrepanacy, a modified RCA black and white 750 line camera (Model TC7012U) was used which utilized the Video Distotion Technique. The degree of distortion ranges from 40% smaller to 80% larger than actual size. Specifications for the camera modifications can be found in Freeman et al., (1983). Next to each television monitor was a suspended hanging fluorescent light (each light has two 2-foot fluorescent bulbs). Directly in front of the modified TV camera behind the platform was a visually neutral wall. The fluorescent lighting and neutral background eliminated shadows and other potential visual cues. Appendix D provides a schematic illustration of the video distortion apparatus placement. 22 Internal consistency for the video distortion apparatus has been established by Freeman et al. (1983) by examining the frontal and profile body image scores of eating disordered, psychiatric controls, and normal women. Test-retest reliability coefficients for normal and eating disordered women were .90 for the frontal estimates and .86 for profile estimates with a time lapse of between 7 and 22 days. The validity of this measurement procedure has been established two ways: 1) body image scores have been shown to be moderately correlated (r=.56) with scores of the Eating Attitudes Test (Garner & Garfinkel, 1979) and 2) the Discrepancy between Real and Ideal body image scores has been found to significantly correlate with measures of depression (r=.45) (Freeman et al., 1983). The Eating Disorders Examination (EDE; Fairburn & Cooper, 1987) was also used to assess participants' levels of body image concern (See Appendix E). The EDE is a semi- structured clinical interview designed to assess a broad range of the specific psychopathology of anorexia and bulimia nervosa and their variants. The EDE contains four subscales: 1) shape concern 2) weight concern 3) eating concern and 4) restraint. The shape and weight concern subscales will be utilized in this study. Several studies have supported the interrater reliability of the EDE (Cooper & Fairburn, 1987; Beglin, 1990; Wilson & Smith, 1989; Rosen 23 et al., 1990), with correlation coefficients have ranged from .83-.99. There have been no studies of test-retest reliability. Internal consistency has been reported to be satisfactory (Cooper, Cooper, & Fairburn, 1989). Four studies of the discriminant validity of the EDE have shown it to discriminate well between groups (e.g., eating disordered, non-eating disordered, restrained eaters)(Cooper et al., 1989; Wilson & Smith, 1989; Rosen et al., 1990; Fairburn & Cooper, 1992). Fear measures. Participants were also asked to complete the Body Image Avoidance Questionnaire (BIAQ; Rosen et al., 1991)(See Appendix F) and the Goldfarb Fear of Fat Scale (GFFS; Goldfarb et al.,1985)(See Appendix G). The BIAQ is a 19-item self-report questionnaire that deals with avoidance of situations which provoke concern about physical appearance such as avoidance of tight fitting clothes, social outings, and physical intimacy. The BIAQ has good internal consistency with a Cronbach's Alpha = .89. Test-retest reliability coefficients were equal to .87. The validity of the BIAQ has been established through correlations with other self-report measures, including the Body Shape Questionnaire (BSQ; Cooper et al.,1987)(r(df=351) =.78, 2<.0001), the body size estimation test (r(df=111 =.22, 2<.01), and the Shape Concern and Weight Concern subscales for 86 participants (r(df=84) =.68, 2<.0001 and r(df=84) =.63, 2<.0001). 24 The GFFS is a 10-item self-report scale which assesses individuals' level of fear of fat. The GFFS was found to have high internal reliability (Cronbach's Alpha= .85). Test-retest reliability was established by readministering the scale to 23 out of the 73 original participants one week after and initial testing (r=.88). The GFFS was reported to have high internal reliability and high test-retest reliability, and to discriminate between anorexic and normal women.

Procedure Evaluation screening. This study consisted of three phases. In phase one, individuals were screened from undergraduate classes using the BULIT-R, and an acceptable BMI between 20 and 27. Those participants meeting the inclusionary criteria for the At Risk, Abnormal, and Normal eating groups were contacted by telephone to schedule interested individuals for laboratory time for phase two of the study. Upon arrival to the eating disorders laboratory, each participant was greeted and the basic procedure was immediately explained. They were then be instructed to read a consent form and sign it if they had no objections (see Appendix H). A semi-structured interview using the Eating Disorder Examination (EDE; Fairburn & Cooper, 1987) was conducted by 25 advanced research and counseling students to insure absence of a clinical eating disorder. Body distortion measurement. Once the interview was completed, the participant was asked to change into a freshly laundered black leotard and full length lab coat, at which time the researcher exited the room. The participant had been instructed to tap lightly on the door to indicate when she was finished changing. The researcher re-entered the room and measured the participant's weight and height. After the weight and height measurement, the researcher and the participant entered the lab and the researcher went immediately behind the screen, out of view of the participant, to perform the body measurement procedure. The participant was then asked to step up onto the platform (see Appendix D), remove the lab coat, and face the frontal monitor. The experimenter read the instructions for the "Real" body image estimates (see Appendix I) and used the distortion control box to vary this frontal TV image throughout the range of distortion from large to small and small to large. Four frontal estimates and four profile estimates were obtained. The experimenter then read the instructions for the "Ideal" body estimates (see Appendix J). Following the same procedure, four frontal ideal estimates and four profile ideal estimates were taken. 26 Upon completion of the body measurement procedure, the researcher left the room and allowed the participant to change into her own clothing. When the participant indicated that she was finished changing by lightly tapping on the door, the researcher then entered the room and answered any questions which the participant may have had. Additionally, the participant was thanked, given $5, and inquiries were made as to whether the participant was willing to participate in the final phase of the study. Self-report questionnaires. 41 participants (17 At Risk, 10 Abnormal Eating, and 14 Normal Eating) who had indicated willingness to participate in the study, and who met all inclusionary criteria described above were contacted again by telephone to schedule laboratory time for phase three of the study. In this final phase, participants completed the fear of fat and the body image questionnaires. Participants were greeted upon arriving to the lab and asked to complete the BIAQ and the GFFS. Completion of the self-report instruments was counterbalanced to control for order effects. After the completion of the questionnaires, the participant were debriefed and any questions were answered. The participant was thanked and given $5. Following the final phase of the experiment, all identifying information was destroyed and each participant's data was assigned a number. Results I. Analysis of Selection Criteria A univariate analysis of variance (ANOVA) was used in determining whether individuals assigned to the three groups (At Risk, Abnormal, and Normal controls)differed on their scores to the self-report measure of bulimic symptoms; The Bulimia Test-Revised (BULIT). Age and BMI were also used as selection criteria, but were not included in this ANOVA, as the relationship between bulimia symptoms and an individuals age or body mass has not gained empirical demonstration. Univariate analyses for age and BMI will be presented with the univariate analysis of the BULIT. Using the F approximation test for the Wilks' Lambda Criterion, a significant effect for group, F(6,72) 26.45, 2< .001, was found for the measures of bulimic symptoms. Given the criteria for group assignment, this significant group effect was expected. Selection criteria follow-up analyses. Three analyses of variance (ANOVA) were conducted for the selection criteria (i.e., Age, BMI, and BULIT scores). The mean values and standard deviations on these measures for each group are presented in Table 1. The BULIT showed a significant effect for group (F(2,38)=135.55, 2<.001), and there were no group differences found for age or BMI.

27 28 Table 1 Means and Standard Deviations of Selection Criteria by Group

Group

Selection Normal Abnormal At Risk Criteria (n=14) (n=10) (n=17)

AGE M 22.00 21.70 20.88 D 2.45 4.9 2.27

BMI - M 22.91 23.81 22.82 SD 2.67 2.25 2.90 BULIT-R M 41.50a 69.10b 95.82c D 8.98 4.72 10.98

Note. BMI=Body Mass Index [weight (kg)/height (m2) ]; BULIT-R= Bulimia Test-Revised. 29 Post hoc comparisons for the BULIT were conducted using Tukey's Honestly Significant Differences Test for Unequal Sample Sizes at p<.01. Results showed significant differences between all three groups with the At Risk group scoring the highest on both measures, the Abnormal Eating group scoring in the middle, and the Normal Eating group scoring the lowest. II. Analysis of Body Image Scores obtained on the five Body Image measures: (a)Real body image (Real), (b)Ideal body image (Ideal), (c)body image Discrepancy (DIS), (d)the Eating Disorders Examination Shape subscale (EDE Shape) and (e)the Eating Disorders Examination Weight subscale (EDE Weight) were analyzed using a multivariate analysis of variance (MANOVA) to determine whether participants from the three groups differed in their responses. Analysis of the scores using the F approximation test for the Wilks' Lambda Criterion yielded a significant effect for group, F(8,70)=8.97, p<.001. Body image follow-up analyses. Univariate analyses of variance (ANOVA) for each of the five body image measures (Real, Ideal, Discrepancy, EDE-Shape, EDE-Weight) were performed. As predicted, significant group effects were found on both the self report measures; i.e., EDE-Shape and EDE-Weight (F(2,38)=42.77, p<.001; F(2,38)=16.56, p<.001) and the Body Image Distortion measures; i.e., Real, Ideal, 30 and Discrepancy (F(2,38)=7.54, p<.01; F(2,38)=11.76, p<.001; F(2,38)=22.46, p<.001 respectively). Mean scores and standard deviations are presented in Table 2. Post hoc comparisons using Tukey's Honestly Significant Differences Test for Unequal Sample Sizes at 2<.01 were conducted on both the self-report body image measures, (i.e., EDE-Shape and EDE-Weight) and the body image distortion measures, (i.e., Real, Ideal, and Discrepancy) to further investigate group differences. On the two self-report measures, significant differences were found between the Normal group and both the At Risk and the Abnormal Eating group. The At Risk and Abnormal Eating group scored higher than the Normal Eating controls on both of the self-report measures; however, there were no significant differences on these measures between the At Risk and the Abnormal Eating group. The results indicate that women with disturbed eating patterns report greater shape and weight concerns than do their normal eating counterparts. On the Body Image Distortion measures, significant differences were also found as predicted between the Normal eating group and both the At Risk and the Abnormal Eating 31 Table 2 Means and Standard Deviations of Body Image Measures by Group

Group

Body Image Normal Abnormal At Risk Measures (n=14) (n=10) (n=17) EDE-SHAPE M 1.18a 4.09b 4.47b SD 1.20 1.15 .80 EDE-WEIGHT M .91a 3.54b 3.64b SD 1.26 1.27 1.61 Video Distortion Cameral REAL M 1.29a 4.60ab 12.83b D 7.94 6.02 9.54 IDEAL M -9.71A -2.56B -2.23B SD 9.22 6.92 9.41 DISCREPANCY M 11.00A 30.20B 34.82B D 7.97 8.07 12.54

Note. EDESHAPE=Eating Disorders Examination, Shape Concern subscale; EDEWEIGHT=Eating Disorders Examination, Weight Concern subscale; DISCREPANCY=(REAL-IDEAL).

1Scores expressed as a percent. 32 group on the Ideal and Discrepancy measures. Again, there were no significant differences between the At Risk and the Abnormal group on these measures. The Abnormal and At Risk groups both desired a smaller ideal body size and had a larger discrepancy between how they actually saw themselves and how they would like to look than did the Normal Eating group. On the Real body image distortion measure, however, there were significant differences between the Normal Eating and the At Risk group, but there were no significant differences between either the Normal Eating group and the Abnormal Eating group, or the At Risk and the Abnormal Eating group. The At Risk group viewed themselves as significantly larger than the Normal group. The Normal group essentially viewed their body size quite accurately, while the At Risk group viewed themselves as larger than they actually were. Overall, the results appear to suggest that the At Risk and Abnormal Eating group are more similar than different on measures relating to body image, despite the differences in original selection criteria. III. Analysis of Fear of Weight Gain Scores obtained on the two self-report measures of fear: (a) the Body Image Avoidance Questionnaire (BIAQ), and (b) the Goldfarb Fear of Fat Scale (GFFS) were analyzed using a multivariate analysis of variance (MANOVA) to 33 determine whether participants from the three groups differed in their responses. Analysis of the scores using the F approximation test for the Wilks' Lambda Criterion yielded a significant effect for group, F(4,72)=10.58, p<.001. Fear follow-up analyses. Univariate analyses of variance (ANOVA) were conducted for the two self-report fear measures (BIAQ, GFFS). Significant group effects were found for the BIAQ and the GFFS (F(2,37)=9.94, p<.001; F(2,38)=26.83, p<.001 respectively). Means and standard deviations are presented in table 3. Post hoc comparisons using Tukey's Honestly Significant Differences for Unequal Sample Sizes at p<.01 were conducted to further examine these differences. As predicted, significant differences were found between the Normal Eating group and both the At Risk and the Abnormal on the BIAQ, with the At Risk group showing the highest levels of avoidant behavior and the Normal Eating group showing the lowest. However, there were no significant differences between the At Risk group and the Abnormal Eating group. Also as predicted, there were again significant differences between the Normal Eating group and both the At Risk group and the Abnormal Eating group on the GFFS, with the At Risk group showing the highest levels of fear and the Normal Eating group showing the lowest levels. Again, there were 34 Table 3

Means and Standard Deviations of Fear Measures by Group

Group

Fear Normal Abnormal At Risk Measures (n=14) (n=10) (n=17)

BIAQ M 24.86a 38.67b 42.47b SD 9.41 9.67 13.12

Goldfarb M 16.5a 25.11' 31.23b SD 4.67 7.29 5.31

Note. BIAQ=Body Image Avoidance Questionnaire; Goldfarb=Goldfarb Fear of Fat Scale 35 no significant differences between the At Risk and the Abnormal Eating group on the GFFS. IV. Analysis of Body Image and Fear of Weight Gain Relationships To examine the relationship between the Body Image measures (i.e., Real body image (Real), Ideal body image (Ideal), body image Discrepancy (DIS), the Eating Disorders Examination Shape subscale (EDE-Shape), and the Eating Disorders Examination Weight subscale (EDE-Weight)), a Pearson Product-Moment Correlation Coefficient (r)was computed for each of the three Body Image Distortion measures across the two self-report measures of Body Image. Additionally, correlation coefficients were also computed for the five Body Image measures measures across the two self-report measures of Fear. The summary intercorrelation matrices can be found in tables 4 and 5. Inspection of the body image correlation matrix showed the Body Image Distortion measures (i.e., Real, Ideal, DIS) correlated significantly with the self-report measures of Body Image (i.e., EDE-Shape, EDE-Weight). The results indicate that as perceptual body image distortion increases, attitudinal body image concerns also increase. The body image by fear correlation matrix also indicated that all of the Body Image measures correlated significantly with the self-reported fear measures; 36 Table 4

Correlations of Body Image Self-Report Measures with Body

Image Distortion Measures Across Combined Groups

Measure1 Real Ideal Discrepancy EDE-WEIGHT .45** .57*** .72*** EDE-SHAPE .49** .61*** .78***

Note. EDE-WEIGHT=Eating Disorder Examination, weight Concern subscale. EDE-SHAPE=Eating Disorder Examination, Shape Concern subscale.

1n=41

**p<.01***p<.001 37 Table 5 Correlations of All Body Image Measures with Fear Measures Across Combined Groups

Note. EDE-SHAPE=Eating Disorders Examination, Shape Concern suscale; EDE-WEIGHT=Eating Disorders Examination, Weight Concern subscale; Discrepancy=(Real-Ideal);Goldfarb=Goldfarb Fear of Fat Scale; BIAQ=Body Image Avoidance Questionnaire. 38 showing that as body image concerns increase, fear of weight gain also increases. Results suggest that women with greater body image distortion were also more likely to report both higher levels of body image concern and higher levels of fear. Discussion Summary of Findings As predicted, the Normal eating group differed significantly from the Abnormal Eating group and the At Risk group on both the "Ideal" and the "Discrepancy" measures of body image distortion. These latter groups both desired a smaller body size and had a larger discrepancy between what they thought they looked like and what they wished to look like than did the Normal group. The finding that increasing levels of eating disturbance is related to increasing discrepancy scores is especially important in light of the fact that the Discrepancy score has been conceptualized as the best measure of body image dissatisfaction (Keeton, Cash, & Brown, 1990; Williamson et al., 1993). Differences on these body image distortion measures between Normal controls and groups with increased levels of pathological eating-related behavior replicates the work of other researchers utilizing the same techniques (Freeman et al., 1985; Gardner, Martinez, & Sandoval, 1987; Seime et al., 1989; Wiener, 1990. In light of this prior research, the additional finding in this study of no difference between the Abnormal and the At Risk group on these measures was surprising and will be discussed later in more depth. On the "Real" Body Image Distortion measure, the At Risk group saw themselves as significantly larger than the Normal group; also replicating the previously reviewed

39 40 studies. Of particular interest, however, is the finding that there were no significant differences between the Abnormal group and either the Normal or the At Risk group on this measure. Unlike the "Ideal" and the Discrepancy scores, however, the data do indicate a trend toward the Abnormal group seeing themselves more accurately than the At Risk group. Further examination of the mean percentages of size overestimation indicate that the Normal group overestimated by 1% (essentially viewing themselves accurately), and the Abnormal group viewed themselves as 5% larger than they actually were. However, the At Risk group saw themselves as 13% larger than they actually were. This particular finding related to the "Real" body image distortion measure, although not significant, may be a key indicator of the progression from disturbed eating to disordered eating and will also be further discussed. On the self-report measures of body image, as predicted, the Normal group had significantly less body image disturbance than both the Abnormal and the At Risk group. This finding has been commonly demonstrated in the literature (Cash & Brown, 1987; Dolan et al., 1991; Keeton et al., 1990; Slade, 1985; ). Again, contrary to prediction, there were no significant differences between the Abnormal and the At Risk group. A similar pattern of results for the At Risk and the Abnormal group continues with the self-report measures of 41 fear. The Normal group showed significantly lower levels of both fear of fat and avoidant behaviors related to body image than did both the Abnormal and the At Risk group, consistent with previous findings in the literature (Rosen, 1993; Cash, 1990). Similar levels of fear between the two disturbed eating groups, i.e., Abnormal and At Risk, supports the contention that fear is a motivating factor in disturbed eating patterns (Goldfarb et al., 1985). Again, however, there were no significant differences between the At Risk and the Abnormal group on the fear measures. The findings of significant correlations between the Body Image distortion measures and the self-report measures of body image are also consistent with the predictions of this study. As an individual's level of body image distortion increases, so does her level of self-reported body image dissatisfaction. This finding is to be expected given previous research (Williamson et al., 1993) and lends support to the model suggested by Garner and Garfinkel (1981) that body image is composed of both a perceptual and an attitudinal component. Also as predicted, correlations were significant for all body image measures across the measures of fear. A highly convergent relationship was shown between the Goldfarb Fear of Fat Scale and all body image measures. Relationships were also demonstrated between the Body Image Avoidance Questionnaire and the self-report body image 42 measures. These findings indicate that as levels of both body image distortion and body image dissatisfaction increase, so do levels of fear and avoidant behaviors related to weight gain. The results of this study support body image dissatisfaction and fear of weight gain as being core features in eating disordered syndromes. Based on this data, it appears that an increase in eating disturbance is accompanied by an increase in levels of fear and body image disturbance. Individuals with higher levels of eating- related symptomatology have higher levels of body distortion and body dissatisfaction, as well as higher levels of fear of weight gain and avoidant behaviors related to this fear. These findings uphold the contention that body image dissatisfaction and fear of fat are strongly related constructs (Wiener, 1990) and further support the inclusion of both of these constructs as primary diagnostic indicators within DSM-IV. Based on the data, however, we cannot conclude that differences based on eating symptomatology alone are enough to differentiate between those with intermediate levels of eating disturbance and those with high levels of eating disturbance. The At Risk and the Abnormal group were significantly different on the original selection criteria related to bulimic symptoms. If fear of weight gain and body image disturbance are both diagnostic characteristics of 43 bulimia nervosa, as defined by DSM-IV, one would expect these two groups with differing levels of eating disturbance to show differing levels of fear and body image disturbance as well. However, the results of this study consistently failed to demonstrate differences between the Abnormal and the At Risk group on any of the fear and body image measures, with the exception of a possible difference on the "Real" body image distortion measure. This suggests that the two disturbed eating groups appear to be more similar than dissimilar on measures of fear and body image, and may indicate that weight concerns and body dissatisfaction are necessary but not sufficient predictors of eating disorders (Leon, Fulkerson, Perry, & Cudeck; 1993).

Continuum of Eating Disorders One potential explanation for the similarities found between the two groups relates to the possibility suggested in the literature that eating disorders lie on a continuum; with full-blown eating disorder syndromes on one end, and normal eating on the other end (Button & Whitehouse, 1981; Garfinkel, 1983; Garner et al., 1984). In support of this, several studies comparing dieters to eating disordered individuals found dieters to have the same preoccupations with food and the same dissatisfaction with body shape and weight, but differed in that they did not manifest the same degree of non-eating related psychopathology as the eating 44 disordered individuals (Dykens & Gerrard, 1986). The data from the present study support the above findings in that the only differences found between the Abnormal and the At Risk group were based on eating symptomatology; i.e., selection criteria, and levels of body distortion; i.e., "Real" size estimation. The continuum model, however, also would suggest that one would find differences on eating-related constructs, such as fear and body image. If a continuum does indeed exist, the fact that there are no differences between the two groups on the fear and body image measures may suggest an additional unmeasured differentiating factor which underlies the two groups. Two-Component Model of Eating Disorder Development According to Garner, Olmstead, Polivy, and Garfinkel (1984), eating disorder development is based on two components. They assert that maladaptive eating patterns result from intense concerns with body image; but that fully diagnosable eating disorders result when body image disturbance coexists with generalized; i.e., nonspecific, non-eating related psychopathology. According to this model, individuals with disturbed eating patterns should manifest body image concerns without the non-eating related psychopathology which accompanies fully disordered eating behavior. Also according to the model, eating disorders may indeed lie on a continuum, but 45 movement along the continuum may be propelled by increasing levels of non-eating related psychopathology rather than increases in body image concerns (Garner et al., 1984). Steiger, Leung, Puentes-Neuman, and Gottheil (1992) conducted a study which supports this model. Utilizing a between groups design, 715 female participants were assessed via self-report on measures of eating disturbance and general mood disturbance. In line with the two-component model (Garner et al., 1984), the general mood disturbance measure was an attempt to assess non-specific, non-eating related psychopathology. Participants were assigned to one of four groups based on the results of this assessment: (1) individuals with high levels of eating disturbance concurrent with high levels of mood disturbance; (2) individuals with high levels of eating disturbance only; (3)individuals with high levels of mood disturbance only; and (4) individuals with neither mood or eating disturbance. The four groups were then compared on measures of body dissatisfaction (i.e., concerns about body areas and weight), self-criticism, impulsivity, and family incohesion. These particular measures were chosen for their relation to the common psychological profiles associated with eating disorders and as an attempt to assess general psychological disturbance(Steiger et al., 1992). The results of this study demonstrated that participants with concurrent eating and mood symptoms did, 46 in fact, have profiles similar to eating disordered patients based on these measures (Steiger et al., 1992). The eating and mood disturbed group showed significantly more psychological disturbance, higher body image concerns, and rated their families as more incohesive than did the group with no eating or mood disturbance. In comparison, those participants with eating disturbance alone were similar to the eating and mood disturbed group in levels of body dissatisfaction and perfectionism, but showed less self- criticism, impulsivity, and family incohesion. Additionally, the mood disturbed participants had levels of psychological disturbance similar to the eating and mood disturbed participants, but showed significantly lower levels of body dissatisfaction. According to Steiger et al., (1992), their results showed the eating disturbed only participants had much more intact psychological profiles than did the eating and mood disturbed participants. The authors assert that the profiles of the eating disturbed only individuals bear little resemblance to that of a typical clinically diagnosed eating disordered individual. They contend that their results support the two-component model and assert that an "eating/mood" syndrome represents an index of risk for movement along the continuum towards clinical eating disorders. 47 In a follow-up study, Steiger, Leung, Ross, and Gulko (1992) used clinical interviews to assess the relationship between actual eating disordered symptomatology and self- reported eating and mood disturbance. Participants were screened for eating and mood disturbance and grouped according to the earlier study (Steiger et al., 1991), with the omission of the mood disturbed only group. Participants were interviewed using the anorexia nervosa, bulimia nervosa, major depression, and dysthymia modules of the Structured Clinical Interview for DSM-ILI-R Outpatient Version. Results of this study showed that those individuals with high levels of eating and mood disturbance showed more clinically diagnosable symptoms of anorexia and bulimia nervosa, and that the eating disturbed only group was no different than the group with no eating or mood disturbance on eating disordered symptomatology. Additionally, the majority of subjects who were then diagnosed with either a clinical or subclinical eating disorder fell into the mood disturbed group. The results from this second study add further support to the two-component model of eating disorder development (Garner et al., 1984), demonstrating that mood disturbance along with eating disturbance is related to increasingly eating disordered symptomatology. Steiger et al. (1992) contend that eating disturbance alone is not enough to identify "clinical-spectrum" eating 48 disturbance, and suggest that a screening based on concurrent eating and mood symptoms may be necessary to identify such individuals. Also in support of the two-component model (Garner et al., 1984), researchers have consistently found overall levels of disturbed eating to correlate with numerous measures of non-eating related psychopathology including depression, ineffectiveness, paranoia, borderline symptomatology, self-esteem, self-criticism, and perfectionism (Bunnell, Shenker, Nussbaum, Jacobson, & Cooper, 1990; Steiger et al., 1992). Additionally, dietary restriction, bingeing, and purging behaviors have been found to be highly correlated with poor psychological and social adjustment (Brown, Cash, & Lewis, 1989; Kishchuk, Gagnon, Belisle, & Laurendeau, 1992). Body image concerns have also been found to be linked to non-eating related psychopathology. Body dissatisfaction, concerns with weight and shape, and discrepancy scores are all related to increased levels of eating disturbance, and individuals with high levels of these constructs show increased levels of non-eating related psychopathology (Altabe & Thompson, 1991; Cash & Brown, 1987; Fabian & Thompson, 1989; Keeton et al., 1990; Thompson & Thompson, 1986). Additionally, high levels of body dissatisfaction have been found to be associated with depression (Noles, 49 Cash, & Winstead, 1985) and poor social adjustment (Kishchuk et al., 1992). In addition to measures of general psychopathology, clinically diagnosable eating disorders have also been found to be highly comorbid with specific Axis I and Axis II disorders. Depression, generalized anxiety disorder, and obsessive-compulsive disorder have been found to have increased comorbidity with eating disorders; as well as dependent, avoidant, and borderline personality disorders (Head, Williamson, Duchman, & Bennett, 1988; Pope, Hudson, & Yurgelen-Todd, 1984; Prather & Williamson, 1988). It is clear that a relationship exists between eating disorders, eating disturbance, and body image variables with non-eating related psychopathology. In the present study, there were no differences on levels of fear and body image concerns between the two disturbed eating groups. Based on the two-component model of eating disorder development (Garner et al., 1984) and the findings of Steiger et al.(1992), however, it could be hypothesized that what actually differentiated between the two disturbed eating groups may have been an increased level of psychopathology rather than fear of fat or body image concerns. Non-eating related psychopathology of participants was not specifically addressed. Differences between the groups based on levels of psychopathology is only conjecture and more concrete evidence is necessary to draw further 50 conclusions regarding this possibility. One clue to these differences, however, may be the differences in the percentages of "Real" body size estimation scores between the groups. As previously reported, the "Real" body image data indicate a trend toward the Abnormal group as seeing themselves more accurately than do their At Risk counterparts. Specifically, the mean percentage scores of overestimation indicate that the At Risk group saw themselves as 13% larger than they actually were, while the Abnormal group saw themselves as only 5% larger than they actually were. This is compared to the Normal group, who essentially saw themselves accurately; i.e., 1% larger. These results may suggest that the "Real" variable may be a key factor differentiating the two disturbed eating groups. In support of this, several recent large-scale studies have found that individuals with "partial syndrome eating disorders" are differentiated from full-syndrome eating disordered individuals by a lower frequency and severity of compensatory behaviors; i.e., vomiting, laxative use, excessive exercise (Garfinkel et al., 1994; Kendler et al., 1991); and little evidence of body image distortion (Shisslack, Crago, & Yates; 1989). Additionally, the literature suggests a relationship between size estimation and non-eating related psychopathology. Keeton et al.(1990) compared multiple 51 measures of both perceptual and attitudinal measures of body image with measures related to eating disturbance and psychological functioning. They found positive correlations between body image distortion and psychopathology; asserting that in a non-clinical sample, perceptual body-image distortion may be linked to psychological maladjustment in general. Other researchers have specifically noted body size overestimation to be related to higher levels of depression (Fabian & Thompson, 1989), and lower levels of self-esteem (Thompson & Thompson, 1986). Additionally, Garner and Garfinkel (1981) suggest that size estimation accuracy may be affected by the level of general psychopathology present. If indeed higher levels of body distortion are related to higher levels of non-eating related psychopathology, the lower percentage of size overestimation in the Abnormal group could be interpreted as suggesting lower levels of non-eating related psychopathology in the Abnormal group as compared to the At Risk group. The results of the present study lend support for the two-component model of eating disorder development (Garner et al., 1984). The two disturbed eating groups had similar levels of fear and body image concerns. According to the two-component model, similar levels of body image concerns would be expected because eating disturbance results from body image concerns; i.e., the first component of the model. 52 Furthermore, lower levels of body size overestimation in the Abnormal group as compared to the At Risk group lends support for the second component, the coexistence of body image concerns and non-eating related general psychopathology. The correlational data from the present study may also be interpreted as showing support for the continuum model of disordered eating (Button & Whitehouse, 1981; Garner et al, 1983; Garner et al., 1983; Garner et al., 1984), with increases in levels of eating disturbance being related to increases in constructs related to eating disorders; i.e., fear and body image concerns. There are two cautionary notes, however, which must be applied to any conclusions drawn based on the "Real" size estimation. The first relates to the lack of statistical significance. While the Normal group differed from the At Risk group, and the mean scores of the Abnormal group show their percentage of overestimation to lie in between the Normal and the At Risk group, the statistical results show only a trend for differences between the At Risk and the Abnormal group. The Abnormal group was not found to differ significantly from either the At Risk or the Normal group on the "Real" body image measure. However, it is possible that the trend towards differences between the two groups, based on a sample size of 10, could become significant in a study utilizing a larger sample size. 53 Additionally, there are inconsistencies in the literature regarding the relationship between size estimation and bulimic symptoms. To date, no study has utilized the Video Distortion Technique (VDT)and a three group design, so there are no comparisons that can be made with other groups of Abnormal eating participants on this measure. Researchers using other body size estimation techniques specifically with a nonclinical population have found a relationship between eating disturbance and body size overestimation (Thompson, 1991) while others have not (Coovert, Thompson, & Kinder; 1995). Additionally, inconsistencies have also been found in the literature with clinical populations. In studies with clinically diagnosable eating disordered samples, results have been mixed; with some studies showing size overestimation(Freeman et al., 1984; Touyz et al., 1985; Wiener, 1990), some showing underestimation (Meerman, 1983), and others showing no size overestimation (Fernandez, Probst, Meerman, & Vandereycken, 1994). Given these inconsistencies, caution is warranted as to conclusions that can be drawn based on this measure. In addition to the cautions applied to the "Real" size estimation variable, there are also restrictions to the overall conclusions that can be drawn based on limitations within the design of the study. The first involves the grouping of the participants, which is less than precise. 54 The cut-off scores were somewhat arbitrary, and may not have resulted in three distinct categories of eating behavior. While the scores on the selection criteria (BULIT-R) related to bulimic symptoms theoretically support the groupings, there is no clear-cut clinically determined separation between the individual groups. Future research should utilize more clearly determined groups. Additionally, future research should include a clinical sample along with groups with varying levels of eating disturbance. Conclusions and Implications In summary, the results of this study clearly support body image disturbance and fear of fat as being strongly related constructs (Wiener, 1990), as well as core features of disturbed eating. It is also clear from these results that fear and body image concerns alone are not enough to differentiate between those individuals with intermediate levels of eating disturbance from those with higher levels of eating disturbance. The one measure that came close to differentiating between the two disturbed eating groups was "Real" body size estimation. If, as has been suggested, body size overestimation more accurately reflects non-eating related psychopathology, it could be maintained that the feature which differentiates disturbed eating individuals may not be fear and body image concerns, but rather differing levels of non-eating related psychopathology as reflected by greater 55 body size overestimation. Accordingly, the data lend support for the two-component model of eating disorder development; as well as an eating disordered continuum model which is propelled by underlying psychopathology. A large question pertaining to both of the models remains unanswered, however. If increasing levels of psychopathology are indeed related to diagnosable eating disorders, it is impossible at the present time to determine whether the psychopathology is a predisposing factor for an eating disorder, or whether the increase in psychopathology is related to the disordered eating behavior. Future longitudinal research examining levels of psychopathology among individuals with varying levels of eating disturbance is necessary in order to further examine this model. Future longitudinal research is also necessary to determine what factors predict the progression from disturbed eating to eating disordered. If in fact there does exist an eating disorders continuum, it is necessary to determine specific factors which may facilitate movement along this continuum, with prevention of this movement as a central goal. References Allenback, P., Hallberg, D., & Epsmark, S. (1976). Body image- an apparatus for measuring disturbances in estimation of size and shape. Journal of Psychosomatic Research, 20, 583-589. Altabe, M., & Thompson, J.K. (1992). Size estimation versus figural ratings of body image disturbance: Relation to body dissatisfaction and eating dysfunction. International Journal of Eating Disorders, 11, 397-402. American Psychiatric Association, (1994). Diagnostic and Statistical Manual Fourth Edition: Washington, DC: American Psychiatric Association. Askevold., F. (1975). Measuring body image. Psychotherapy and Psychosomatics, 26, 71-77. Birtchnell, S.A., Lacey, J.H., &_Harte, A. (1985). Body image distortion in bulimia nervosa. British Journal of Psychiatry, 147, 408-412. Boskind-Lodahl, M. (1976). Cinderella's stepsisters: A feminist perspective on anorexia and bulimia nervosa. Signs: Journal of Women in Culture and Society, 2, 342-356. Brown, T.A., Cash, T.F., & Lewis, R.J. (1989). Body image disturbances in adolescent female binge purgers: A brief report of the results of a national survey in the U.S.A.. Journal of Child Psychology and Psychiatry and Allied Disciplines, 30, 605-613. Brown, T.A., Cash, T.F., & Mikulka, P.J. (1990). Attitudinal body image assessment: Factor analysis of the Body-Self Relations Questionnaire. Journal of Personality Assessment, 55(1-2), 135-144. Bunnell, D.W., Shenker, I.R., Nussbaum, M.P., Jacobson, M.S., & Cooper, P. (1990). Subclinical versus formal eating disorders: Differentiating psychological features. International Journal of Eating Disorders, 9, 357-362. Button, E.J., Fransella, F., & Slade, P.D. (1977). A reappraisal of body perception disturbance in anorexia nervosa. Psychological Medicine, 7, 235-243. Button, E.J., & Whitehouse, A. (1981). Subclinical anorexia nervosa. Psychological Medicine, 11, 509-516.

56 57 Bruch, H. (1962). Perceptual and conceptual disturbances in anorexia and bulimia nervosa. Psychosomatic Medicine, 24, 187-194. Cash, T.F. (1990). The psychology of physical appearance: Aesthetics, attributes, and images. In T.F. Cash & T. Pruzinsky (Eds.), Body images: Development, deviance, and change. New York: Guilford Press. Cash, T.F. & Brown, T.A. (1987). Body image in anorexia nervosa and bulimia nervosa: A review of the literature. Behavior Modification, 11, 487-521. Cash, T.F., Counts, B., & Huffine, C.E. (1990). Current and vestigial effects of overweight among women: Fear of fat, attitudinal body image, and eating behaviors. Journal of Psychopathology and Beahvioral Assessment, 12, 157-167. Cash, T.F., Winstead, B.A., & Janda, L.H. (1986). The great American shape-up. Psychology Today, 20, 30-37. Cash, T.F., Wood, C.C., Phelps, K.D., & Boyd, K. (1991). New assessments of weight-related body image derived from extant instruments. Perceptual and Motor Skills, 73, 235-241. Casper, R.C., Halmi, K.A., Goldberg, S.C., Eckert, E.D., & Davis, J.M. (1979). Disturbances in body image estimation as related to other characteristics and outcome in anorexia nervosa. British Journal of Psychiatry, 134, 60-66. Cooper, P.J., & Fairburn, C.G. (1983). Binge-eating and self-induced vomiting in the community: A preliminary study. British Journal of Psychiatry, 134, 60-66. Cooper, M.J. & Fairburn, C.G. (1992). Selective processing of eating, weight, and shape related variables in patients with eating disorders and dieters. British Journal of Clinical Psychology, 31, 363-365. Cooper, P.J., Taylor, M.J., Cooper, Z., & Fairburn, C.G. (1987). The development and validation of the body shape questionnaire. International Journal of Eating Disorders, 6, 485-494. Counts, C.R., & Adams, H.E. (1985). Body image in bulimic, dieting, and normal females. Journal of Psychopathology and Behavioral Assessment, 7, 289-300. 58 Crisp, A.H. (1970). Anorexia nervosa: "feeding disorder", "nervous malnutrition", or "weight phobia"? World Review of Nutrition and Dietetics, 12, 452-504. Cutts, T.F., & Barrios, B.A. (1986). Fear of weight gain among bulimic and nondisturbed females. Behavior Therapy, 17, 626-636. Dolan, B., Evans, C.,. & Lacey, J.H. (1992). The natural history of disordered eating behavior and attitudes in adult women. International Journal of Eating Disorders, 12, 241-248. Dykens, E.M, & Gerrard, M. (1986). Psychological profiles of purging bulimics, repeat dieters, and controls. Journal of Consulting and Clinical Psychology, 54, 283-288. Fabian, L.J., & Thompson, J.K. (1989). Body image and eating disturbance in young females. - International Journal of Eating Disorders, 8, 63-74. Fairburn, C.G. (1980). Self-induced vomiting. Journal of Psychosomatic Research, 24, 193-197. Fairburn, C.G. (1987). The definition of bulimia nervosa: Guidelines for clinicians and research workers. Annals of Behavioral Medicine, 9, 3-7. Fairburn, C.G. & Beglin, S.J. (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16, 363-370. Fairburn, C.G. & Cooper, P.J. (1982). Self-induced vomiting and bulimia nervosa: An undetected problem. British Medical Journal, 284, 1153-1155. Fairburn, C.G., & Cooper, P.J. (1984). The clinical features of bulimia nervosa. British Journal of Psychiatry, 144, 238-246. Fernandez, F., Probst, M., Meerman, R., & Vandereycken, W. (1994). Body size estimation and body dissatisfaction in eating disorder patients and normal controls. International Journal of Eating Disorders, 16, 307-310. Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20-35. Freeman, R.J., Beach, B., Davis, R., & Solyom, L. (1985). The prediction of relapse in bulimia nervosa. Journal of Psychiatric Research, 19, 349-353. 59 Freeman, R.J., Thomas, C.D., Solyom, L., & Hunter, M.A. (1984). A modified video camera for measuring body image distortion: Technical description and Reliability. Psychological Medicine, 14, 411-416. Fremouw, W., Seime, R., Damer, D., Weltzin, T., & Kaye, W. (1993). Anorexia and bulimia. In V.B. VanHasselt & M. Hersen (Eds.), Handbook of behavior therapy and pharmocotherapy for children: A comparative analysis. Boston: Allyn & Bacon, Inc. Fremouw, W., Wiener, A., & Seime, R.J. (1987). Self- monitoring forms for bulimia. In P.A. Keller & S.R. Heyman (Eds.), Innovations in clinical practice: A sourcebook, Vol. 6. Sarasota, FL: Professional Resource Exchange. Fries, H. (1977). Studies on secondary amenorrhea, anorectic behavior, and the body image perception: Importance of early recognition of anorexia nervosa. In R. Vigersky (Ed.), Anorexia nervosa. New York: Raven Press. Gardner, R.M., Martinez, R., & Sandoval, Y. (1987). Obesity and body image: An evaluation of sensory components. Psychological Medicine, 17, 927-932. Garfinkel, P.E. (1992). Evidence in support of attitudes to shape and weight as a diagnostic criterion of bulimia nervosa. International Journal of Eating Disorders, 11, 321-325. Garfinkel, P.E., Moldofsky, H., & Garner, D.M. (1979). The stability of perceptual disturbances in anorexia nervosa. Psychological Medicine, 9, 703-708. Garner, D.M.; Fairburn, C.G.; & Davis, R. (1987). Cognitive-behavioral treatment of bulima nervosa: A critical appraisal. Special Issue: Behavioral and cognitive-behavioral treatment of anorexia nervosa and bulimia nervosa. Behavior Modification, 11, 398-431. Garner, D.M., & Garfinkel, P.E. (1979). The Eating Attitudes test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273-279. Garner, D.M, & Garfinkel, P.E. (1981). Body image in anorexia nervosa: Measurement, theory, and clinical implications. International Journal of Psychiatry in Medicine, 11, 263-294. Garner, D.M. & Garfinkel, P.E. (1982). Anorexia nervosa: A multidimensional perspective. New York: Brunner Mazel. 60 Garner, D.M., Garfinkel, P.E., Stancer, H.C., & Moldofsky, H. (1976). Body image disturbance in anorexia nervosa and obesity. Psychosomatic Medicine, 38, 217-336. Garner, D.M., Olmstead, M.P., & Garfinkel. P.E. (1983). Does anorexia nervosa occur on a continuum? International Journal of Eating Disorders, 2, 11-20. Garner, D.M., Olmstead, M.A., & Polivy, J. (1983). Development and validation of a multidimensional eating disorder inventory for anorexia and bulimia nervosa. International Journal of Psychiatry in Medicine, 11, 263- 285. Garner, D.M., Olmstead, M.A., Polivy, J., & Garfinkel, P.E. (1984). Comparisons between weight preoccupied women and anorexia nervosa. Psychosomatic Medicine, 46, 255-266. Garner, D.M., & Garfinkel, P.E. (1981). Body image in anorexia nervosa: Measurement, theory, and clinical implications. International Journal of Psychiatry in Medicine, 11, 263-285. Garner, D.M. & Garfinkel, P.E. (1982). Anorexia nervosa: A multidimensional perspective. New York: Brunner Mazel. Giles, T.R., Young, R.R., & Young, D.E. (1985). Case studies and clinical replication series: Behavioral treatment of severe bulimia. Behavior Therapy, 16, 393-405. Glucksman, M.L., & Hirsh, J. (1969). The response of obese patients to weight reduction: III. The perception of body size. Psychosomatic Medicine, 31, 1-7. Goldfarb, Lori A.; Dykens, Elisabeth M.; & Gerrard, Meg (1985). The Goldfarb Fear of Fat Scale. Journal of Personality Assessment, 19, 329-332. Goldfarb, Lori A.; Fuhr, Robert; Tsujimoto, Richard M.; & Fischman, Stanley E. (1987). Systematic desensitization and relaxaton as adjuncts in the treatment of anorexia nervosa: A preliminary study. Psychological Reports, 60, 511-518. Halmi, K.A., & Falk, J.R. (1981). Common physiological changes in anorexia nervosa. International Journal of Eating Disorders, 1, 16-27. Hawkins, R.C., & Clements, P.F. (1980). Development and construct validation of a self-report measure of binge eating tendencies. Addictive Behaviors, 5, 219-226. 61 Head, S., Williamson. D.A., Duchman, E.G., & Bennett, R. (1988). Bulima nervosa: Association with Axis I and Axis II disorders. Poster presented at the annual meeting for the Association for the Advancement of Behavior Therapy, New York. Henderson, M., & Freeman, C.P.L. (1987). A self-rating scale for bulimia- The BITE. British Journal of Psychiatry, 150, 18-24. Hsu, L.K.G. (1982). Is there a disturbance in body image in anorexia nervosa? Journal of Nervous and Mental Diseases, 170, 305-307. Jackson, Linda A.; Sullivan, Linda A.; Rostker, Ronald (1988). Gender, gender-role, and body image. Sex Roles, 19(7-8), 429-443. Keeton, W.P., Cash, T.F., & Brown, T.A. (1990). Body image or body images?: Comparative, multidimensional assessment among college students. Journal of Personality Assessment, 54(1-2), 213-230. Kennedy, S.H., Kaplan, A.S., Garfinkel, P.E., & Rockert, W. (1994). Depression in anorexia nervosa and bulimia nervosa: Discriminating depressive symptoms and episodes. Journal of Pasychosomatic Research, 38, 773-782. Kerr, J.K, Skok, R.L., & McLaughlin, T.F. (1991). Characteristics common to females who exhibit anorexic or bulimic behavior: A review of current literature. Journal of Clinical Psychology, 47, 846-853. Kishchuk, N., Gagnon, G., Belisle, D., & Laurendeau, M. (1992). Sociodemographic and psychological correlates of actual and desired weight insufficiency in the general population. International Journal of Eating Disorders, 12, 73-81. Lang, P.J. (1968). Fear reduction and fear behavior: Problems in treating a construct. In J.M. Shilen (Ed), Research in Psychotherapy (Vol. 3), 90-103. Washington, DC: American Psychological Association. Leitenburg, H., Gross, H., Peterson, H., & Rosen, J.C. (1984). Analysis of an anxiety model in the process of change during exposure plus response prevention treatment of bulimia nervosa. Behavior Therapy, 15, 3-20. 62 Leon, G.R., Fulkerson, J.A., Perry, C.L., & Cudeck, R. (1993). Personality and behavioral vulnerabilities associated with risk status for eating disorders in adolescent girls. Journal of Abnormal Psychology, 102, 438- 444. McCrea, C.W., Summerfield, A.B., & Rosen, B. (1982). Body image: A selective review of existing measurement techniques. British Journal of Medical Psychology, 55, 225- 233. Mizes, J. Scott (1988). Controlled comparisons of bulimics and non-eating-disordered controls on the MMPI-168. International Journal of Eating Diorders, 7(3), 425-428. Mizes, J. Scott (1988). Personality characteristics of bulimc and non-eating-disordered female contols: A cognitive behavioral perspective. International Journal of Eating Disorders, 7(4), 541-550. Morris, D.L. (1984). The effects of mirror confrontation on self-estimation of body dimensions in anorexia nervosa, bulimia, and two control groups. Psychological Medicine, 14, 835-842. Noles, Steven W.; Cash, Thomas F.; & Winstead, Barbara A. (1985). Body image, physical attractiveness, and depression. Journal of Consulting and Clinical Psychology, 53, 88-94. Pierloot, R.A., & Houben, M.E. (1978). Estimation of body dimensions in anorexia nervosa. Psychological Medicine, 8, 317-324. Pope, H.G., Hudson, J.I., & Yurgelun-Yodd, D. (1984). Anorexia nervosa and bulimia among 300 suburban women shoppers. American Journal of Psychiatry, 141, 292-294. Prather, R.C. & Williamson, D.A. (1988). Psychopathology associated with bulima, binge eating, and obesity. International Journal of Eating Disorders, 7(2), 177-184. Probst, M., Van Coppenolle, H., Vandereycken, W., & Goris, M. (1991). Body image assessment in anorexia nervosa patients and university students by means of video distortion: A reliability study. Journal of Psychosomatic Research, 36, 89-97. Pyle, R.L., Mitchell, J.E., and Eckert, E.D. (1981). Bulimia: A report of 34 case. Journal of Clinical Psychiatry, 42, 60-64. 63 Reitman, E.E., & Cleveland, S.E. (1964). Changes in body image following sensory deprivation in schizophrenic and control groups. Journal of Abnormal and Social Psychology, 68, 168-176. Robinson, B.E.; Bacon, J.G.; & O'Reilly, J.(1993). Fat phobia: Measuring, understanding, and changing anti-fat attitudes. International Journal of Eating Disorders, 14, 467-480. Rosen, J.C., & Leitenburg, H. (1982). Bulimia nervosa: Treatment with exposure and response prevention. Behavior Therapy, 13, 117-124. Rosen, J.C., Leitenburg, H., Gross, J., & Willmuth, M. (1985). Standardized test meals in the assessment of bulimia nervosa. Advances in Behaviour Research and Therapy, 7, 181-197. Rosen, J.C., & Srebnik, D. (1990). The assessment of eating disorders. In P. Reynolds, J.C. Rosen, & G.J. Chelune (Eds), Advances in psychological assessment, Vol. 7. New York: Plenum Press. Rosen, J.C., Srebnik, D., Saltzberg, E., & Wendt, S.(1991). Development of a body image questionnaire. Psychological Assessment, 3, 32-37. Ruff, G.A., & Barrios, B.A. (1986). Realistic assessment of body image. Behavioral Assessment, 8, 237- 251. Russell, G. (1979). Bulimia nervosa: an ominous variant of anorexia nervosa. Psychological Medicine, 9, 429-451. Schlesier-Stropp, B. (1984). Bulimia: A review of the literature. Psychological Bulletin, 95, 247-257. Schlundt, David G. & Bell, Crystal (1993). Body image testing system: A microcomputer program for assessing body image. Journal of Psychopathology and Behavioral Assessment, 15, 267-285. Seime, R.J., Wiener, A.L., Larkin, K.T., & Fremouw, W.. A comparison of bulimic patients and individuals at high and low risk for bulimia on multiple measures of body image. Manuscript in Progress. Shisslack, C.M., Crago, M., & Estes, L., (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18, 209-219. 64 Slade, P.D. (1977). A review of body image studies in anorexia nervosa and bulimia nervosa. Journal of Psychiatric Research, 19, 255-265. Slade. P.D. (1985). A review of the body image studies in anorexia nervosa and bulima nervosa. Journal of Psychiatric Research, 19, 255-265. Slade, P.D., & Russell, G.F.M. (1973). Awareness of body dimensions in anorexia nervosa: Cross sectional and longitudinal studies. Psychological Medicine, 3, 188-199. Smith, M.C., & Thelan, M.H. (1984). Development and validation of a test for bulimia. Journal of Consulting and Clinical Psychology, 52, 863-872. Steiger, H., Leung, F.Y.K., Puentes-Neuman, G., & Gottheil, N. (1992). Psychosocial profiles of adolescent girls with varying degrees of eating and mood disturbance. International Journal of Eating Disorders, 11, 121-131. Steiger, H., Leung, F.Y.K., Ross, D., & Gulko, J. (1992). Signs of anorexia and bulimia nervosa in high school girls reporting combinations of eating and mood symptoms: Relevance of self-report to interview based findings. International Journal of Eating Disorders, 12, 143-149. Stormer, S.M., & Thompson, J.K. (1996). Explanations of body image disturbance: A Test of maturational status, negative verbal commentary, social comparison, and sociocultural hypotheses. International Journal of Eating Disorders, 19, 193-202. Streigel-Moore, R., Silberstein, L., & Rodin, J. (1986). Toward an understanding of risk factors for bulimia. American Psychologist, 41, 246-263. Strober, M., Goldenberg, I., Green, J., & Saxon, J. (1979). Body image disturbance in anorexia nervosa during the acute and recuperative phase. Psychological Medicine, 9, 695-701. Thompson, J. Kevin (1990). Body image disturbance: Assessment and treament. New York: Pergamon Press, Inc. Thompson, J.K. (1991). Body shape preferences: Effects of instructional protocol and levels of eating disturbance. International Journal of Eating Disorders, 10, 193-198. 65 Thompson, J.K., Altabe, M., Johnson, S., & Stomer, S.M. (1994). Factor analysis of multiple measures of body image disturbance: Are we all measuring the same construct? International Journal of Eating Disorders, 16(3), 311-315. Thompson, J.K., Berland, N.W., Linton, P.H., & Weinsler, R.L. (1986). Utilization of a self-adjusting light beam in the objective assessment of body distortion in seven eating disorder groups. International Journal of Eating Disorders, 5, 133-120. Thompson, J.K. & Psaltis, K. (1988). Multiple aspects and correlates of body figure ratings: A replication and extension of Fallon & Rozin (1985). International Journal of Eating Disorders, 7, 813-817. Thompson, J.K. & Thompson, C.M. (1986). Body size distortion and self-esteem in asymptomatic, normal weight males and females. International Journal of Eating Disorders, 5, 1061-1068. Touyz, S.W., Beumont, P.V.J., Collins, J.K., McCabe, M., & Jupp, J. (1984). Body shape perception and its disturbance in anorexia nervosa. British Journal of Psychiatry, 144, 167-171. Traub, A.C., & Orbach, J. (1964). Psychophysiological studies of body-image. Archives of General Psychiatry, 11, 53-66. Vanderheyden, D.A. & Boland, F.J. (1987). A comparison of normals, mild, moderate, and severe binge eaters, and binge vomiters using discriminant function analysis. International Journal of Eating Disorders, 6, 331-337. Wiener, A.(1990). A multimethod investigation of body image and weight gain concerns in bulimic and non-eating disordered women (Doctoral dissertation, West Virginia University, 1990). Dissertation Abstracts International, 51(5-B),2639. Williamson, D.A., Cubic, B.A., & Gleaves, D.H. (1993). Equivalence of body image disturbances in anorexia and bulima nervosa. Journal of Abnormal Psychology, 102, 177- 180. Williamson, D.A., Gleaves, D.H., Watkins, P.C., & Schlundt, D.G. (1993). Validation of self-ideal body size discrepancy as a measure of body dissatisfaction. Journal of Psychopathology ad Behavioral Asessment, 15, 57-68. 66 Williamson, D.A., Goreczny, A.J., Davis, C.J., Ruggiero, L., & McKenzie, S.J. (1988). Psychophysiological analysis of the anxiety model of bulimia nervosa. Behavior Therapy, 19, 1-9. Williamson, D.A., Kelley, M.L., Davis, C.J., Ruggiero, L., & Blouin, D.C. (1985). Psychopathology of eating disorders: A controlled comparison of bulimic, obese, and normal subjects. Journal of Consulting and Clinical Psychology, 53, 161-166. Willmuth, M.E., Leitenburg, H, Rosen, J.C., Fondacaro, K.M., & Gross, J. (1985). Body size distortion in bulimia nervosa. International Journal of Eating Disorders, 4, 71- 78. Wingate, B.A., & Christie, M.J. (1978). Ego strength and body image in anorexia nervosa. Journal of Psychosomatic Research, 22, 201-204. Appendix A Consent Form #1

67 An Investigation of Women's Self Image 68

Informed Consent

This research project is designed to explore issues related to women's self image. The project consists of three separate phases. I understand that I am being asked to participate in the first phase. This phase entails completing two questionnaires examining eating behaviors. Completion of these questionnaires should take approximately 10-15 minutes. I understand that there are no physical risks or monetary costs involved in this procedure, but that I may experience mild emotional discomfort when answering the questionnaires due to the personal nature of the questions. I understand that if I find the questions to be too upsetting for me, I may choose to discontinue participation at any time. I understand that my responses to the questionnaires will be assigned a number code so my identity will remain confidential, however, I will be asked to provide my name and phone number, for the purposes of contacting me, if I am willing to participate in the second phase of this study. I understand that due to the limited number of participants required, I may or may not be selected and contacted for the second phase. I understand that if I am not contacted for the second and third phase of the study, my name, and phone number will be removed from this consent form and be destroyed. If I do participate after phase I of this study, my name and phone number will be destroyed when my participation in this study is complete. The second and third phases of this study will involve filming two short videotapes of me, estimating the size of my body, and measuring my physiological and subjective responses to the videotape. The two videotapes of me will be erased in my presence at the conclusion of the study. I understand that separate consent forms detailing these procedures will be provided should I be involved in these phases of the study. I understand that my participation in this study is completely voluntary. Additionally, I may choose to discontinue my participation at any time without consequence. I understand that a potential benefit of my participation in this study is knowing that I have contributed to a better understanding of body image concerns among women. Additionally upon request, I may receive a summary of the findings of this study. I understand that if I have any questions regarding this study, I may contact the following individuals:

I) Dr. Mane Osborn, Department of Psychology, 826-5265 2) Elizabeth Brill, graduate student/Department of Psychology/Academic Research Program, 826-5265 3) Sandra Newes, graduate student/Department of Psychology/ 69 Academic Research Program, 826-5265

In signing this consent form, I state that I have read and understand the description of the assessment procedure and I have volunteered to participate as a subject. I have been given a chance to ask questions and these have been answered to my satisfaction. I enter into the assessment procedure willingly. I may withdraw at any time without fear of retribution and my data will be destroyed if I ask that it not be used in this study.

Subject's Signature Date

I would be interested in participating in Phase H and HI.

NAME

CONTACT PHONE #

BEST TIME TO CALL Appendix B The Bulima Test-Revised (BULIT-R)

70 71

THE BULIT-R

Answer each question by circling the appropriate response. Please respond to each item as honestly as possible; remember all of the information you provide will be kept strictly confidential. 1. I am satisfied with my eating patterns. 1. agree 2. neutral 3. disagree a little 4. disagree 5. disagree strongly 2. Would you presently call yourself a "binge eater"? 1. yes, absolutely 2. yes 3. yes, probably 4. yes, possibly 5. no, probably not 3. Do you feel you have control over the amount of food you consume? 1. most or all of the time 2. a lot Of the time 3. occasionally 4. rarely 5. never

4. I am satisfied with the shape and size of my body. 1. frequently or always 2. sometimes 3. occasionally 4. rarely 5. seldom or never

5. When I feel that my eating behavior is out of control, I try to take rather extreme measures to get back on course (strict dieting, fasting, laxatives, diuretics, self-induced vomiting, or vigorous exercise). 1. always 2. almost always 3. frequently 4. sometimes 5. never or my eating behavior is never out of control 72

6. I use laxatives or suppositories to help control my weight. 1. once a day or more 2. 3-6 times a week 3. once or twice a week 4. 2-3 times a month 5. once a month or less (or never)

7. I am obsessed about the size and shape of my body. 1. always 2. almost always 3. frequently 4. sometimes 5. seldom or never

8. There are times when I rapidly eat a very large amount of food. 1. more than twice a week 2. twice a week 3. once a week 4. 2-3 times a month 5. once a month or less (or never)

9. How long have you been binge eating (eating uncontrollably to the point of stuffing yourself)? 1. not applicable; I don't binge eat 2. less than 3 months 3. 3 months - 1 year 4. 1 - 3 years 5. 3 or more years

10. Most people I know would be amazed if they knew how much food I can consume at one sitting. 1. without a doubt 2. very probably 3. probably 4. possibly 5. no

11. I exercise in order to burn calories. 1. more than 2 hours per day 2. about 2 hours per day 3. more than 1 but less than 2 hours per day 4. one hour or less per day 5. I exercise but not to burn calories or I don't exercise 73

12. Compared with women your age, how preoccupied are you about your weight and body shape? 1. a great deal more than average 2. much more than average 3. more than average 4. a little more than average 5. average or less than average

13. I am afraid to eat anything for fear that I won't be able to stop. 1. always 2. almost always 3. frequently 4. sometimes 5. seldom or never

14. I feel tormented by the idea that I am fat or might gain weight. 1. always 2. almost always 3. frequently 4. sometimes 5. seldom or never

15. How often do you intentionally vomit after eating? 1. 2 or more times a week 2. once a week 3. 2-3 times a month 4. once a month 5. less than once a month or never

16. I eat a lot of food when I'm not even hungry. 1. very frequently 2. frequently 3. occasionally 4. sometimes 5. seldom or never

17. My eating patterns are different from the eating patterns of most people. 1. always 2. almost always 3. frequently 4. sometimes 5. seldom or never 74

18. After I binge eat I turn to one of several strict methods to try to keep from gaining weight (vigorous exercise, strict dieting, fasting, self-induced vomiting, laxatives, or diuretics). 1. never or I don't binge eat 2. rarely 3. occasionally 4. a lot of the time 5. most or all of the time

19. I have tried to lose weight by fasting or going on strict diets. 1. not in the past year 2. once in the past year 3. 2-3 times in the past year 4. 4-5 times in the past year 5. more than 5 times in the past year

20. I exercise vigorously and for long periods of time in order to burn calories. 1. average or less than average 2. a little more than average 3. more than average 4. much more than average 5. a great deal more than average

21. When engaged in an eating binge, I tend to eat foods that are high in carbohydrates (sweets and starches). 1. always 2. almost always 3. frequently 4. sometimes 5. seldom, or I don't binge

22. Compared to most people, my ability to control my eating behavior seems to be: 1. greater than others' ability 2. about the same 3. less 4. much less 5. I have absolutely no control

23. I would presently label myself a 'compulsive eater', (one who engages in episodes of uncontrolled eating). 1. absolutely 2. yes 3. yes, probably 4. yes, possibly 5. no, probably not 75

24. I hate the way my body looks after I eat too much. 1. seldom or never 2. sometimes 3. frequently 4. almost always 5. always 25. When I am trying to keep from gaining weight, I feel that I have to resort to vigorous exercise, strict dieting, fasting, self-induced vomiting, laxatives, or diuretics. 1. never 2. rarely 3. occasionally 4. a lot of the time 5. most or all of the time

26. Do you believe that it is easier for you to vomit than it is for most people? 1. yes, it's no problem at all for me 2. yes, it's easier 3. yes, it's a little easier 4. about the same 5. no, it's less easy

27. I use diuretics (water pills) to help control my weight. 1. never 2. seldom 3. sometimes 4. frequently 5. very frequently 28. I feel that food controls my life. 1. always 2. almost always 3. frequently 4. sometimes 5. seldom or never 29. I try to control my weight by eating little or no food for a day or longer. 1. never 2. seldom 3. sometimes 4. frequently 5. very frequently 76

30. When consuming a large quantity of food, at what rate of speed do you usually eat? 1. more rapidly than most people have ever eaten in their lives 2. a lot more rapidly than most people 3. a little more rapidly than most people 4. about the same rate as most people 5. more slowly than most people (or not applicable)

31. I use laxatives or suppositories to help control my weight. 1. never 2. seldom 3. sometimes 4. frequently 5. very frequently

32. Right after I binge eat I feel: 1. so fat and bloated I can't stand it 2. extremely fat 3. fat 4. a little fat 5. OK about how my body looks or I never binge eat

33. Compared to other people of my sex, my ability to always feel in control of how much I eat is: 1. about the same or greater 2. a little less 3. less 4. much less 5. a great deal less

34. In the last 3 months, on the average how often did you binge eat (eat uncontrollably to the point of stuffing yourself)? 1. once a month or less (or never) 2. 2-3 times a month 3. once a week 4. twice a week 5. more than twice a week

35. Most people I know would be surprised at how fat I look after I eat a lot of food. 1. yes, definitely 2. yes 3. yes, probably 4. yes, possibly 5. no, probably not or I never eat a lot of food 77

36. I use diuretics (water pills) to help control my weight. 1. 3 times a week or more 2. once or twice a week 3. 2-3 times a month 4. once a month 5. never Appendix C Eating Disorders Examination

78 80

The Eating Disorder Examination (12.0D)

Interview Schedule

INTRODUCTION

[Having oriented the subject to the specific time period being assessed, it is best to open the interview by asking a number of introductory questions designed to obtain a general picture of the subject's eating habits. Suitable questions are suggested below.]

To begin with I should like to get a general picture of your eating habits over the last 4 weeks.

Have your eating habits varied much from day to day? Have weekdays differed from weekends? Have there been any days when you haven't eaten anything?

What about the previous 2 months?

Appendix D Schematic Representation of Eating Disorders Laboratory, Room #113, HGH

104 105

Schematic of the body image distortion apparatus. A, camera; B, screen; C, experimenter; D, distortion meter, VCR, and portable TV; E, frontal monitor; F, neutral backdrop; G, subject platform; H, profile monitor; I, high intensity lighting. Appendix E - The Body Image Aviodance Questionnaire (BIAQ)

106 107 BIAQ

Circle the number which best describes how often you engae in these behaviors at the present time.

Always Usually Often Sometimes Rarely Never 1 2 3 4 5 6 1. I wear baggy clothes. 1 2 3 4 5 6 2. I wear clothes I do not like. 1 2 3 4 5 6 3. I wear darker color clothing. 1 2 3 4 5 6 4. I wear a special set of clothing, e.g., my "fat clothes". 1 2 3 4 5 6 5. I restrict the amount of food I eat. 1 2 3 4 5 6 6. I only eat fruits, vegetables, and other low calorie foods. 1 2 3 4 5 6 7. I fast for a day or longer. 1 2 3 4 5 6 8. I do not go out socially if I will be "checked out". 1 2 3 4 5 6 9. I do not go out socially if the people I am with will discuss weight. 1 2 3 4 5 6 10. I do not go out socially if the people I am with are thinner than I am. 1 2 3 4 5 6 11. I do not go out socially if it involves eating 1 2 3 4 5 6 12. I weigh myself. 1 2 3 4 5 6

13. I am inactive. 1 2 3 4 5 6 14. I look at myself in the mirror. 1 2 3 4 5 6 15. I avoid physical intimacy. 1 2 3 4 5 6 16. I wear clothes that will divert attention from my weight. 1 2 3 4 5 6 17. I avoid going clothes shopping. 1 2 3 4 5 6 18. I don't wear "revealing" clothes (e.g. bathing suits, tank tops, or shorts). 1 2 3 4 5 6 19. I get dressed up or made up. 1 2 3 4 5 6 Appendix F - The Goldfarb Fear of Fat Scale (GFFS)

108 109 Goldfarb Fear of Fat Scale

Please read each of the following statements and select the number which best represents your feelings and beliefs.

1= very untrue 2= somewhat untrue 3= somewhat true 4= very true

1. My biggest fear is of becoming fat. 2. I am afraid to gain even a little weight. 3. I believe that there is a real risk that I will become overweight someday. 4. I don't understand how overweight people can live with themselves. 5. Becoming fat would be the worst thing that could happen to me. 6. If I stopped concentrating on controlling my weight, chances are that I would become very fat. 7. There is nothing that I can do to make the thought of gaining weight less painful and frightening. 8. 1 feel like all my energy goes into controlling my weight. 9. If I eat even a little, I may lose control and not stop eating. 10. Staying hungry is the only way I can guard against losing control and becoming fat. Appendix G Consent Form #2

110 An Investigation of Women's Self Image 111

Informed Consent

This research project is designed to compare several measures that assess concerns about body shape/image and weight among individuals who have varying levels of such concerns. I understand that the assessment in phase II will take approximately one hour and that I will be asked to wear a black leotard provided by the investigator during approximately 30 minutes of this period. Participation in this study will include a semi-structured interview which further assesses my eating behaviors, a video body size estimation task , and two videotapes of me. I understand that after the semi-structured interview, I will be asked to change into a freshly laundered black leotard and will be provided with a full length cover-up lab coat to be worn between the video camera procedures. I will then be asked to stand in front of a video camera and tell the investigator to adjust the picture on the video monitor until it corresponds to how I think I look, and how I want to look. Following the video body estimation task, the investigator will make two short videotapes of me. These tapes will be used later in phase III of the study. At the conclusion of the filming procedure, I will be allowed to change into my own clothes. The investigator will then pay me $5 and phase II will be complete. I understand that there are no physical risks to myself during the assessment, but that I may feel mild emotional discomfort due to the sensitive and possibly embarrassing nature of the questions during the interview and the video camera procedure I understand that my participation in this study is completely voluntary and that I may choose to discontinue my participation at any time without consequence. If I am in treatment, my treatment at the Humboldt State University Eating Disorders Clinic will not be affected by a decision to end participation. Should I decide not to participate in phase III, the videotapes will immediately be erased and all data including identifying information will be destroyed. Should I decide to complete participation in the study, I understand that phase III will involve measurements of my physiologic and subjective responses to the videotapes made during this phase, as well as completion of four questionnaires. I understand that the videotapes made of me will be used in phase III and will be erased in my presence at the conclusion of the study. I understand that a potential benefit of my participation in this study is knowing that I have contributed to a better understanding of body image concerns among women. Additionally upon request, I may receive a summary of the findings of this study. I also understand that I will receive $5 at the conclusion of phase II. I understand that if I have any questions regarding this study, I may contact the following individuals: 112 1) Dr. Alane Osborn, Department of Psychology, 826-5265 2) Elizabeth Brill, graduate student/Department of Psychology/Academic Research Program, 826-5265 3) Sandra Newes, graduate student/Department of Psychology/Academic Research Program, 826-5265

Subject's Signature Date

I would be interested in participating in Phase III.

NAME

CONTACT PHONE #

BEST TIME TO CALL Appendix H Real Body Image Instructions

113 Real Body Image Instructions 114

This is a special camera in which the picture can be adjusted. I will slowly change the pic-

ture on the monitor. Tell me when your body appearance looks accurate to you, as if you

were looking in a mirror. You'll need to watch the image carefully and tell me to stop when

you see an accurate image. I cannot readjust the image after you say *stop,* so pay close

attention, position your feet so you're facing the front monitor."

Front view Real Body Image:

Trial # 1 - Wide to Narrow - (Record meter value on data sheet)

Narrow to Wide - (Record meter value on data sheet)

(Instruct subject to close her eyes.)

Trial # 2 - Narrow to Wide - (Record meter value on data sheet)

Wide to Narrow - (Record meter value on data sheet)

"Now position your feet so you're facing the side monitor (point to side monitor) and your

toes are behind the horizontal bar. You need to watch the image carefully and tell me to

stopattention. when" you see the accurate image. I cannot readjust after you say "stop" so pay close

Side view Real Body Image:

Trial # 1 - Wide to Narrow - (Record meter value on data sheet)

Narrow to Wide - (Record meter value on data sheet)

(Instruct subject to close her eyes.)

Trial 1 2 - Narrow to Wide - (Record meter value on data sheet)

Wide to Narrow - (Record meter value on data sheet) Appendix I - Ideal Body Image Instructions

115 Ideal Body Image Instructions 116

"This time we're going to do something different. I'd like you me to stop when the picture looks as you'd like to look, that is, your ideal body appearance. Again, I cannot readjust the picture once you have told me to "stop." Now we'll do the front again, so position your feet so you're facing the front monitor."

Front view Ideal Body Image:

Trial # 1 - Wide to Narrow - (Record meter value on data sheet)

Narrow to Wide - (Record meter value on data sheet)

(Instruct subject to close her eyes.)

Trial # 2 - Narrow to Wide - (Record meter value on data sheet)

Wide to Narrow - (Record meter value on data sheet)

"Now the side again, so you're facing the side monitor (point to side monitor). Once again,

I cannot readjust after you've told mr to "stop".

Side view Ideal Body Image:

Trial # 1 - Wide to Narrow - (Record meter value on data sheet)

Narrow to Wide - (Record meter value on data sheet)

(Instruct subject to close her eyes.)

Trial # 2 - Narrow to Wide - (Record meter value on data sheet)

Wide to Narrow - (Record meter value on data sheet) Appendix J - Human Subjects: Letter of Approval

117 118

Office of the Dean Research and Graduate Studies MEMORANDUM

April 20, 1995

TO: Alane Osborn, Professor of Psychology

FROM: Susan H. Bicknell, Chair, committee for the Protection of Human Subjects in Research, and Dean for Research and Graduate Studies

RE: Your Proposal: Fear of Weight Gain in Females with and without an Eating Disorder: Operationalizing a Construct

As you know, the Committee for the Protection of Human Subjects met on Friday, April 7, 1995, to discuss your proposal, "Fear of Weight Gain in Females with and without an Eating Disorder: Operationalizing a Construct." Thank you for joining us for a portion of our meeting to address questions.

The committee was assured both by the proposal and by our discussion that you have carefully designed the research to obtain exceptional benefit in knowledge gained while protecting subject participants. You have responded to our one minor recommendation to modify your consent form to further protect subject identity by separating the subject identifiers from other subject responses associated with Phase I.

This memo constitutes formal approval for your research project. This approval is effective for one year, and will expire on April 20, 1996. If it is necessary to continue your research beyond this date, please apply for renewed approval sufficiently in advance of this date to avoid interruptions in your research. If it becomes necessary to modify the protocol, please submit application for modification according to the policies for human subject protection of Humboldt State University.

Thank you for your careful protection of the human subjects of your research.

C: Members of the Committee for the Protection of Human Subjects in Research: Chris Hopper, Health and Physical Education Susan Armstrong, Philosophy Beverly Nachem, Nursing R. W. Hicks, Student Affairs Leslie Foote, Arcata Family Medical Group Jean Perry, Office for Research and Graduate Studies Warren Carlson, Psychology Patrick Wenger, Anthropology

Arcata, California 95521-8299 • (707) 826-3949 • Fax (707) 826-5480

The California State University