British Journal ofClinical Psychology (1999), 38, 167±179 Printed in GreatBritain 167 # 1999The British Psychological Society

Acognitivedistortion associated with eating disorders:Thought-shapefusion

RozShafran*, Bethany A. Teachman, SeanKerry and S. Rachman Psychology Department, University of British Columbia, Canada

Objectives. Theprimary objectiveof this study was to describeand investigate a cognitivedistortion associatedwith eatingpsychopathology. This distortion, termed` thought-shapefusion ’, is said to occurwhen merely thinking about eating aforbiddenfood increases the person’s estimate oftheir shapeor weight, elicits a perceptionof moral wrongdoingand makes the person feel fat.

Design. Two studies wereconducted. The ® rst was apsychometricstudy andthe secondutilized awithin-participants experimentaldesign.

Methods. In Study1, thought-shapefusion was assessed in asampleof 119 undergraduatestudents using aquestionnaire.In Study2, 30students with high thought-shapefusion scores participatedin anexperiment designed to elicit the distortion.

Results. Thought-shapefusion was foundto besigni® cantly associated with measures ofeatingdisorder .The questionnaire used to measure thought-shapefusion hadhigh internal consistency,a goodfactor structure accountingfor 46 .2%of thevariance and predictive validity. Theresults from Study2 indicatedthat thedistortion canbe elicited underexperimental conditions, producesnegative emotional reactions and prompts theurge to engagein corrective behaviour(e.g. neutralizing } checking).This correctivebehaviour promptly reduces thenegative reactions.

Conclusion. Theresults ofthetwo studies indicatethat theconcept of thought- shapefusion is coherent,unifactorial andmeasurable. It is associatedwith eating disturbanceand elicits negativeemotional and behavioural responses.

Cognitivedistortions have been identi® ed in a rangeof psychopathology, including ,(Beck, 1976),panic (Clark, 1986), hypochondr iasis(Warwick, Clark, Cobb& Salkovskis,1996), eating disorders (Garner & Bemis, 1982)and obsessive- compulsivedisorder (Freeston, Rhe ! aume& Ladouceur,1996 ; Salkovskis,1985 ; Shafran,Thordarson & Rachman,1996). Cognitive distortions are saidto occur if thethinking is consistent, non-veridical and skewed (Rachman & Shafran,1998) ;

*Requestsfor reprints should be addressed toRoz Shafran, Oxford University, Department ofPsychiatry, WarnefordHospital, OxfordOX3 7JX, UK. Partsof thispaper were presentedat the 3rd London Conference onEatingDisorders (1996)and the 31st Annual AABT Convention(1997). 168 Roz Shafran et al. theyoften serve to maintain dysfunctional behaviour. For example, thereis good evidencethat episodes of panicare maintainedby thepatient engaging in the skewed misinterpretationof bodilysensations (Clark et al.,1997).Ultimately, eliminating the cognitivedistortion should lead toa reductionin the psychopatholog y;however,it is® rstnecessary to identifythe speci® c cognitivedistortions that are playinga part inthe maintenance of psychopathology.Acognitivedistortion is assumed to play a rolein a disorderif :(1)it isassociated with thepsychopatholog yofthedisorder ;(2) experimentalmanipulation of the distortion results in the predicted eå ects on psychopathology;and(3) the reduction } elimination ofthedistortion is followed by a reduction} elimination oftheabnormal behaviour or experience. Workon cognitivedistortions in obsessive-compulsiv edisorder(OCD) haslead tothe identi® cation of adistortiontermed ` thought-actionfusion ’(TAF ;Rachman, 1993;Rachman,Shafran, Mitchell, Trant& Teachman, 1996; Shafran et al., 1996). Thisdistortion comprises two components :(1)the belief thathaving a negative thoughtincreases the likelihood that the feared event will occur(likelihood TAF) ; and(2) the belief thathaving a negativethought is the moral equivalent to carrying outthe negative action (moral TAF). Inaseriesof studies,it hasbeen shown that TAF is(a) related toobsessive-compuls ive psychopathology(Shafran et al., 1996), and(b) that eliciting TAF experimentally leadsto the predicted eå ects on psychopathology(Rachman et al., 1996). Thereis clinical andpsychometric evidence that people with eating disorders have avarietyof cognitive distortions (Cooper, Cohen-Tove ! e, Todd,Wells &Tove ! e, 1997;Garner& Bemis, 1982; Mizes, 1992).Based on this, we hypothesizedthat a comparable(but not identical) typeof cognitivedistortion to TAF may beimplicated ineating disorder psychopatholog y. We assumedthat thought-shape fusion (TSF) hasat least threecomponents. First, the belief thatjust thinking about eating a forbiddenfood makes it likely thatthe person has gained weight } changedshape (likelihoodTSF). Second,the belief thatthinking about eating a forbiddenfood is almostas morally wrong as actually eatinga forbiddenfood (moral TSF) and third, thebelief thatthinking about eating a forbiddenfood makes the person feel fat (feeling TSF). Like itscounterpart (i.e. TAF), we hypothesizedthat people with this distortionknow rationally that thinking about eating a forbiddenfood cannot actually create weightgain or shapechange, but thatthey nevertheless feel thisto be thecase onanemotional level. Moreover,we consideredthat TSF was likely tobe associatedwith a rangeof other cognitive distortions (e.g. thebelief thatmoral unacceptability ofeatingforbidden food is greater if theperson voluntarily chooses toeat it, asopposed to eating the forbidden food when there is little choice) and associatedbehaviour (e.g. thatthinking about gaining weight can elicit theurge to checkthat clothes are not® ttingmore tightly). Apreliminarystudy of 70undergraduatestudents indicated that such distortions dooccur and are positivelycorrelated with eating disorder psychopatholog y. Encouragedby the results of thispreliminary study we developeda moredetailed questionnaireto assess TSF, andpredicted that : (1)TSF isassociated with the psychopathologyofeatingdisorders ;and(2) that eliciting TSFinan experimental situationwould lead topredicted psychological eå ects. Thesehypotheses were examinedin two separate studies. Thought-shape fusion distortion 169

STUDY 1 Method Thepurpose of Study1 was to investigatethe construct andmeasurement of TSFand to determineits association with eatingdisorder psychopathology,obsessional compulsiveproblems anddepression.

Sample Participants were119 undergraduate students whotook part in exchangefor coursecredit. Themean ageof thesample was 20 .7 years (SD 5 4.3)and77 % werefemale.

Measures TSFquestionnaire .This questionnairecontained 33 items that coveredthe three domains (likelihood, moral andfeeling components) which we assumed to comprise TSF. Participants wereasked to rate their agreementwith eachstatement onascaleof 0`notat all ’to 4`totally ’.Examplesof items include `Just picturing myself gainingweight can really makeme gain weight ’,`For me, just thinkingabout notexercisingfor amonthis almost as wrongas actuallynot exercising ’ and` Ifeelfatter if Ijust think about`` piggingout ’’’.Wealso includedsome items to assess associatedcognitions (e.g. `If Ichoose to eatcake it is moreunacceptable than if it is servedto meat afriend’s house’;`If Ieatfried food, Iwill gainfar moreweight than if afriend eats fried food’)andassociated behaviour (e.g. `Just thinking aboutnot exercising for amonthmakes me want to cutdown on whatI eat’). Theeating disorders examinationÐquestionnaire version (Fairburn &Beglin, 1994).This questionnaireis basedon theEating Disorders Examination(Cooper & Fairburn, 1987)and comprises four subscales: restraint, eatingconcerns, weight concerns and shape concerns. It rates beliefs andbehaviour for the previous4 weeks,and most questions requireeither aseverity orfrequencyrating. TAF scale (Shafran et al., 1996).This 19-item scalecomprises asubscaleof likelihoodTAF (e.g. `If I thinkof arelative } friend falling ill this increasesthe risk that he } shewill fall ill’)andmoral TAF (e.g. `WhenI thinkunkindly about a friend, it is almost as disloyal as doingan unkindact ’). Items arerated ona5-point scaleranging from 0`disagreestrongly ’to 4`Agreestrongly ’.Within theTAF likelihood scalesome items relate to TAF for oneself, andothers relate to TAF for otherpeople. Maudsley Obsessional Compulsive Inventory (MOCI;Hodgson& Rachman,1977 ; Sternberger& Burns, 1990).This 30-item scalerequires atrue } false responseand assesses obsessive-compulsive checking, cleaning,doubting and slowness. Beck Depression Inventory (BDI;Beck,Rush, Shaw& Emery, 1979).This 21-item scaleassesses symptoms ofdepressionand each item is ratedon a scalefrom 0to 3. All participants completedthe questionnaires andreturned them in exchangefor coursecredit.

Results Descriptives Themeans and standard deviations for the scale are shownin Table 1. Theresponses are typical ofastudentpopulation indicating non-clinical scoreson all themeasures. The precise N variesas some students omitted items.

Factorstructure Aprincipalcomponents analysis with varimax rotation to extract thethree putative factorswas conductedon the 33-items of the TSF questionnaire,but the analysis 170 Roz Shafran et al.

Table 1. Descriptivestatistics for the measures used in Studies 1 and2

Study 1 Study 2

Measure N Mean (SD) N Mean (SD)

Thought-shapefusion total 115 16.4 (18.74) 28 52.57 (21.02) EDEQ-4 Restraint: 118 1.08 (1.32) 29 3.13 (1.47) Eatingconcerns 109 .84 (1.05) 30 2.49 (1.52) Weightconcerns 116 1.69 (1.42) 30 3.65 (1.24) Shapeconcerns 116 2.23 (1.62) 30 4.19 (1.04) Thought-actionfusion total 114 24.56 (13.66) 23 43.13 (11.09) TAF moral 119 18.88 (10.4) 23 30.39 (8.13) TAFlikelihood (others) 118 2.86 (3.14) 22 6.36 (4.20) MaudsleyObsessional 118 8.95 (5.52) 30 12.33 (6.24) CompulsiveInventory BeckDepression Inventory 118 10.5 (9.16) 27 15.96 (8.68) revealedthat the best solution was aone-factorsolution accounting for 46 %ofthe variance. Thethree subscales (likelihood, moral, feeling) didnot separate into separatefactors. (As the analysis yielded onemain factor, subsequent analyses were completedby using the total TSF score).The scale hadhigh internal consistency (a 5 .96)indicating a largedegree of overlapamongst the items on thescale.

Correlationalanalyses Spearman’scorrelations were conductedto investigatethe relationships among the diåerent measures. A signi®cant association was foundbetween TSF andall subscales ontheEDE-Q ( r 5 .51withthe restraint subscale, r 5 .58with theeating concerns subscale, r 5 .57with the weight concerns subscale and r 5 .54with the shape concernssubscale ; r 5 .61between total on TSF andEDE-Q total ;all p ! .001). TSFwas alsosigni® cantly associatedwith total TAF ( r 5 .323, p ! .01) and BDI (r 5 .252, p ! .01)but not with theMOCI ( r 5 .189, p " .01). Thecorrelations amongstTSF andEDE-Q subscalesremained signi® cant when partialling out the eåects of depressionand obsessionality (all r " .47, p ! .001).

Discussion ofStudy1 Thisstudy ful® lled the® rstcriterionin investigating the roleof cognitivedistortions inpsychopatholog y,namely thatTSF isa coherentand measurable construct ; moreoverthere is an association between the TSF distortionand eating disturbance. Thestrength of the association was remarkablystrong ( r 5 .61, p ! .001) and it was notmediated by depression or obsessionality. There are severalexplanations forthis association. It is possible that the distortion increases eating disorder Thought-shape fusion distortion 171 psychopathology, e.g. byincreasing preoccupation with food, shape and weight. Alternatively, peoplewith high levels ofshapeand weight concerns may bemore likely toexperience thisdistortion. Thenext study was designedto answer three speci® c questions.First, can the distortionbe made explicit inan experimental laboratory setting ? Second,what behaviouris associated with the distortion ?Third,does the questionnaire have predictivevalidity ?

STUDY2 :ANEXPERIMENTAL INVESTIGATIONOF TSF Theaim ofthis study was toelucidate therole of TSF ineating disorder psychopathologyandto answer the questions described above. Based on our previouswork on TAF (Rachman et al.,1996),it was hypothesizedthat the distortion can bemade explicit ina laboratorysetting by asking people who report this distortionin the questionnaire to write asentenceabout eating a forbiddenfood and thento imagine themselveseating the forbidden food to the point that it isaversive.

Predictions Thefollowing predictions were made: 1. Theexperimental procedure will elicit thedistortion and hence lead to: (a) participantsestimating that it islikely thatthey had gained weight or changedshape solely from thinking about eating the forbidden food ; (b)participants reporting a feeling ofmoral wrongdoing after thinking about eatingthe forbidden food ; (c) participantsreporting feeling fatterafter thinking about eating the forbidden food. 2. Theexperimental procedure will elicit (a) , (b) and (c) theurge to performsome corrective behaviour (e.g. checkingin the mirror or having a `correctiveimage ’suchas imagining themselves to be eating celery orwriting a sentencethat they are eatingcarrots). 3. Followingperformance of correctivebehaviour, the eå ects of the experimental procedurewill diminish(i.e. participants’estimates of the likelihood that they had gainedweight from thinking about eating fattening food } writingthe sentence will decrease, aswill feelingsof moralwrongdoing and feelings of fatness). Inaddition,we predictedthat questionnaire responses to TSF wouldpredict the eåect ofthe experimental procedure. We alsoexpected that people with TSF will showthe same pattern of associationswithin their questionnaire responses as in the previousstudy. Method Participants Thirty undergraduatestudents whoendorsed signi® cant levels ofat least oneof thethree components ofTSFon abrief screeningquestionnaire completed this study in exchangefor coursecredit. Noneof this sampleparticipated in theprevious study. Themean age of thesample was 21 .3 years (SD 5 5.3) and87 %werefemale. 172 Roz Shafran et al.

Measures Themeasures usedwere the same as in Study1.

Procedure Participants completedthe battery of questionnaires andwerealso askedto report their current weight, howfat theycurrently felt, andthe type of foodthey consider to beextremelyfattening to eat.After completingthe questionnaires, theparticipants weregiven some relaxation training until their anxiety was 30points or less ona verbalanalogue scale (where ` 0’correspondsto `notat all’and` 100’ correspondsto extremelyhigh). Their baselinerating ofcurrent feelings guilt werealso assessed. The participants wereasked to thinkof afoodthat theyconsidered to beextremelyfattening, andthat would belikely to makethem gain weight if theyate it. After theyhad thought of sucha food(or combination offoods), theywere asked to completethe following sentence: `Iameating j j j j j j ’, ®lling in thename ofthefattening food(s) in theblank. The purpose of this was to helpthe participant conjure up animage ofthemselves eatingthe forbidden food. They were asked to thinkabout eating the food and to think abouteating large quantities of it so that it was unpleasantfor them. Theywere asked to keepon thinkingabout this imageuntil their feelings of anxietywere at least 20points higherthan baseline. Threeparticipants whoseanxiety did not increaseby 20points wereexcluded as wereseven participants whodid not experiencethe TSF distortion (despite highscores ontheTSF questionnaires) becausetheir datacould not beusedto test theexperimental predictions. Fourparticipants hadelevated scores onthe BDIandwere excluded from thestudy for ethicalreasons. Using verbalanalogue scales, ratings werethen taken of current anxiety,guilt, feelings offatness and estimates of actualweight. Theywere asked to estimate thelikelihood that theyhad gained weight} changedshape solely from theexperimental procedure (i.e. thinkingabout eating the forbidden foodand writing thesentence), and how much fatter theyfelt solely from theexperimental procedure. Theywere also askedhow much control theythought they had over whether they ate their forbidden foodin thenext 24 hours, howmorally unacceptablethey thought it was to haveengaged in the experimentalprocedure, the strength oftheurge to reduceor cancelthe eå ects ofwriting thesentence, andthe strength oftheurge to checkthat theyhadn’t actually gained weight. Theratings wereprefaced with thestatement that `Iwantto understandwhat you think about these questions, eventhough your thoughtsmay seem senseless to you.In otherwords, Iwantto knowwhat you think on anemotional level, so pleaselisten to theirrational voicein theback of yourhead, and not just therational voice’. Theparticipants couldthen choose whether to engagein 2minutes ofeither `correctivebehaviour ’ (akinto neutralizing) orcheckingwhether they had gained weight. Theexperimenter left theroom if participants choseto checkin order to allow privacy; theprecise nature of thechecking was then determinedwhen the experimenter re-entered. All theTSF ratings ofanxietyetc. were again taken after thechecking } neutralizingbehaviour. At theend of theexperiment, participants weregiven relaxation training until their anxietywas less than30 } 100on averbalanalogue scale and they were then debriefed.

Results Thissample was selected forhigh scores on the TSF. Comparedto the unselected sampleof studentsin Study 1, theTSF grouprecorded elevated levels ofobsessive compulsiveproblems and depression, which were bothin the clinically signi®cant range.The means and standard deviations of thequestionnaire scores are shownin Table 1.Manyof thespeci® c predictionsfor the experiment were con®rmed.

Prediction1 . (a) Participants will reportthat it is likelythat theyhad gained weight orchanged shape solelyfrom thinking about eating the forbidden food ; (b) theywill reporta feeling ofmoral wrongdoingand (c) reportfeeling fatterafter thinking about eating the forbidden food . Twenty- Thought-shape fusion distortion 173 sixof the30 participants (87 %)reportedthat they believed theprocedure had caused someweight gain or shape change ;themean estimate ofthe likelihood that the experimentalprocedure had caused weight gain or shapechange was 27 .83% (SD 5 19.8). Ofthe 30 participants, 24 (80 %) reportedfeeling thatit was morally unacceptableto havethought about eating the forbidden food or tohave written the sentence;themean estimate ofthe moral unacceptability ofthe experimental procedurewas 34 .2% (SD 5 28.04). Inresponseto the question ` howmuch fatter do you feel ’" ,all participantsreported feeling fatter, andthe mean score was 51 .04% (SD 5 21.82; N 5 24" )indicatingthat the participantsfelt approximately50 %fatter thanbefore they had thought about eating the forbidden food } writtenthe sentence. Insummary, predictions 1(a), 1(b)and 1(c) were ful®lled.

Prediction2 . Theexperimental procedurewill elicit (a) anxiety, (b) guilt and (c) the urge to performsome corrective behaviour .Anxiety increasedsigni® cantly from17 .00 (SD 5 10.39) to 60.00 (SD 5 20.68)following the experimental procedure (paired t-test: t(29) 5 11.13, p ! .001).Feelings of guilt increased signi® cantly from17 .67 (SD 5 22.77) to 57.33 (SD 5 24.06) (t(29) 5 7.25, p ! .001).The experimental procedureelicited anurge to check weight and shape of 24 %(SD 5 23.4) and an urgeto perform a correctivebehaviour of 41 .67% (SD 5 32.12).

Prediction3 . Followingthe performanceof correctivebehaviour , the eåects of the experimental procedurewill diminish .Two-thirdsof theparticipants chose to `neutralize ’theeå ects oftheexperiment by engagingin a `corrective’behaviour.Such behaviour included crossingout the sentence, imagining themselves exercising, having an image of eatingcelery etc. Theother third chose to check in the mirror. All participantswere givena maximumof 2minutesto performtheir corrective behaviour. The corrective behavioursigni® cantly reducedall theexperimental variables ( p ! .01)except forthe feeling ofmoral wrongdoing ( t 5 2.28, p 5 .03). Therewere nosigni® cant diåerences in the eå ects of neutralizingcompared to checking,except thatperforming theneutralizing behaviour was (unsurprisingly)signi®cantly moreeå ective in reducingthe urge to neutralize thanchecking ( t(28) 5 2.4, p ! .05). Therewas a trendfor neutralizing to be better than checking at reducinganxiety, guiltand feelingsof fatnessbut these diå erences did not reachsigni® cance ( p " .05)(Table 2). Inorder to rule out the eå ects of a spontaneousdecline inthese feelings, future experimentsshould include a placeboattention control. Inaddition,we predictedthat questionnaire responses to TSFwouldbe associated withestimates of thelikelihood of weightgain } shapechange from thinking about eatingforbidden food } writingthe sentence, and also with thefeelings of moral unacceptability andfatness elicited bytheprocedure. We alsoexpected that people withTSF wouldshow the same pattern of associations within their questionnaire responsesas in Study 1. Signi®cant positive Spearman’s correlations were foundbetweenthe total score on theTSF scale and(a) estimatesof likelihoodthat the experimental task had caused weight gain} shapechange ( r 5 .44, p ! .05)and (b) the urge toneutralize ( r 5 .375,

" Data fromthe ® rstsix participants were excluded afterthe wording of thisitem changed. 174 Roz Shafran et al.

Table 2. Percentage changeafter neutralization or checking

Post-experiment Immediately (before after neutralization } neutralization } checking) checking t (d.f.)*

Likelihoodof weightgain } shape 27.83 18.17 3.24 (29) change Moralwrongdoing 34.17 26.17 2.28 (29)a Reportedincrease in feelings of 51.04 26.88 3.98 (23) fatness Anxiety 60.00 25.67 8.57 (29) Guilt 57.33 24.67 6.15 (29) Urgeto neutralize 41.67 16.83 4.40 (29) Urgeto check 24.00 13.20 2.92 (29)

*All p ! .01unless otherwise stated. a p 5 .031. p ! .05). Scoreson the TSF scale were notsigni® cantly associatedwith the other variablesassessed in the experimental task (all p " .05). Spearman’scorrelations were calculated toinvestigatethe relationshipsamong the diåerent measures, as in Study 1. The® ndingswith respect to the relationship withsubscales of the EDE-Q were replicated. Asigni®cant association was found betweenTSF andall subscaleson theEDE-Q ( r 5 .46, p ! .05with the restraint subscale; r 5 .45, p ! .05with theeating concerns subscale ; r 5 .37, p 5 .05 with theweight concerns subscale and r 5 .42, p ! .05withthe shape concerns subscale). AlthoughTSF was signi®cantly associatedneither with total TAF ( r 5 .20, p " .05) nor BDI (r 5 .185, p " .05), themean scores of theBDI andTAF were elevated in thissample compared to Study 1 andthere was anon-signi®cant association between TSFandMOCI ( r 5 .302, p " .05). Thecorrelations among TSF andEDE-Q of restraint,eating concerns and shape concerns remained signi® cant when partialling outthe eå ects of depression and obsessionality (all r " .41, p ! .05), but the correlationbetween the TSF andweight concerns subscale of theEDE-Q failed to meet signi®cance ( r 5 .33, p " .05).

Discussion ofStudy2 Insummary,the main results showed that TSF can bemadeexplicit ina laboratory setting.After writing a sentenceabout eating forbidden food and imagining themselveseating it, peoplewho reported the TSF distortionon a screening questionnaireperceived that it was likely thatthey had gained weight } changed shapeand they had feelings of moral wrongdoing and feelings of fatness ; their anxiety andtheir feelings of guiltalso increased. The procedure elicited theurge to checkand to neutralize, andperformance of such behaviour reduced anxiety. The questionnairehad limited predictivevalidity inthat there was asigni®cant associ- Thought-shape fusion distortion 175 ationbetween questionnaire scores and the likelihood of weight gain } shape change,but not between questionnaire scores and feelings of moral wrongdoing orfeelings of fatness. As in Study 1, theTSF responseswere associatedwith eatingdisorder psychopatholog yandthis relationship was notmediated by depressionand obsessionality.

GENERAL DISCUSSION Themain purpose ofthisresearch was toexplore the TSFhypotheses,and the results ofthe specially constructedquestionnaire lend support to the occurrence of the phenomenon.The TSF scale didnot con® rm the existence ofthethree postulated factors,and the TSF totalscore was foundto have some concurrent and predictive validity, plusthe power to identify people who are proneto the TSF distortion. Moreoverthe TSF scale was, aspredicted, signi® cantly associatedwith eating disorderpsychopatholog ywhichis consistent with the proposal that the cognitive distortionof TSFmay play arolein eating disorders. Theevidence of concurrentvalidity isseen in the signi® cant correlation with the associatedcognitive known as TAF inthe large initial sample. Moreover,the 30 participantsin Study 2 selected forthe TSF distortionhad a totalTAF scoreof 43 .13 whichis signi® cantly largerthan the TAF meanof 24 .6inthe unselectedparticipants inStudy 1. Theevidence for predictive validity isseen in the successful selection of TSFrespondersin the experiment of Study2 andspeci® cally, thesuccesses in using TSFtopredict behavioural and subjective experimental changes. Theconcepts of TSFandTAF are related butseparable.TSF includesa perceptual distortionwhereas TAF isa conceptualbias but thereis overlap between them ;their exact relationshipremains to be determined. In Study 1 theywere signi®cantly correlatedand in Study 2 thequestionnairedesigned to identifyTSF participantsalso pickedup a highlyelevated TAF. BothTSF andTAF are readily evokedin experimentalconditions, give rise to comparable negative emotional reactions, and tosimilar correctiveurges and neutralization. However, there are at least two importantdiå erences between the TAF andTSF. The® rstdiå erence isthat TAF consistsof two components, whereas the new conceptof TSF hasa coherent, unifactorialstructure. On re¯ection it isnot surprising that TSF isunifactorial. Itis tobe expectedthat someone who fears weight gain and who considers her thoughts aboutfood to have some eå ect inthe real world,is also likely tofeel fatterafter experiencingthoughts about eating forbidden foods and to ® ndsuch thoughts unacceptable. Similarly, thefeeling offatnessand thoughts about weight gain } shape changeare closely aligned. All threeputative factors are psychologicallyinter- connectedand it ispossible that the questionnaire is also picking up the broader conceptsof shapeconcern and fear of fatness.The second diå erence betweenTAF andTSF istheir real worldeå ects. Thereis no realistic connectionbetween the thoughtand the action in the TAF bias.In TSF, theconnection between the thought andits eå ects on perceivedshape, feelings of fatnessand wrongdoing are realistically connectedif theperson responds to their thoughts by actually eatingthe forbidden food.Eating the food will evokefeelings of fatnessand concerns about weight gain, shapeand change. If thinkingabout the forbidden food and eating the forbidden foodregularly co-occur, then just thinking about eating a forbiddenfood will be 176 Roz Shafran et al. associatedwith the feelings of fatness. Indeed, one participant stated that the sensationsshe experienced when thinking about eating the forbidden food were similar tothoseshe had when actually eatingit ;shefelt thatthinking about eating theforbidden food and actually eatingthe forbidden food had similar consequences andrequired similar compensatorybehaviour (i.e. prolongingher workout). TSFmaybe onlyone example ofageneraltendency to interpretthoughts (about eating)as carrying excessive personal signi® cance (Rachman,1997 ; Salkovskis, 1985).For example, peoplewho overvalue the importance of shapeand weight may interpretthinking about eating forbidden foods as meaning ` I’mnot perfect } I’m out of control} Ilack self-discipline } I’ma pig’. Suchinterpretations may lowermood andcontribute to the breaking of dietaryrestraint with itsassociated behaviour (e.g. checkingthe body for signs of weightgain). Some participants reported an urge to exercise afterthe study. Therole of checking behaviour } neutralizingin the maintenance of TSF is interesting.The sample size was toosmall todetermine diå erences between these methodsbut it isnot surprising that the majority of thesample (two-thirds) chose acognitivemethod (neutralizing) to deal witha cognitivedistortion (TSF) as opposedto a behaviouralmethod (checking). Examples of neutralizing behaviour includecrossing out the original sentence and writing : `Iam eatinga well-balanced diet ’, `Iam noteatingchocolate ;Iam drinkingwater ’,`Iam eatingveggies ’, `Iam eatingmy normal lunch ’,`Iam eatinglow-fat pizza withlow-fat cheese andno meat ’.Oneparticipant chose to imagine herselfexercising and another chose to imagine thatshe was vomiting.Thepotential implications of neutralizingremain to be investigated.It couldbe arguedthat engaging in neutralizing serves to maintain the distortionbecause participants never learn that their thoughts are meaningless; they continueto noticethem and therefore feel fatteretc., whenthey occur. Alternatively, if participantsfeel lessanxious after engaging in such mental neutralizing,perhaps it couldbe utilized ina therapeuticcapacity. Forexample, imaginingoneself exercisingcould be used as an interim measure to enable patientsto reduce their actual exercise. Forpatients who are at low weight, thismay enable weight restorationto advance and reduce the eå ects of starvationwhich are suggestedto maintaindysfunctional beliefs andbehaviour (Vitousek & Ewald, 1993). Ithasbeen hypothesized that checking behaviour serves to maintain body image distortionsand may beimportantin the maintenance of anorexianervosa (Fairburn, Shafran& Cooper,1999 ;Rosen,1996) and identifying a cognitivedistortion that elicits thechecking behaviour is of clinical utility. Challengingthe distortion using traditionalcognitive methods may reducethe checking behaviour, which in turn will decreasethe distortion in body image. Itremains open to empirical investigation whetherneutralizing behaviour serves the same (dys)function as checking behaviour. Inadditionto maladaptive checkingbehaviour, we suggestthat the distortion of TSFwill lead tocertain maladaptive cognitivestrategies. In particular, the person whobelieves thatthoughts have an in¯ uence on weight } shapeis likely toengage in avoidanceof suchthoughts. It ispossible that such thought-supp ressionleads to a reboundof suchthoughts, based on thework of Wegner,Schneider, Carter & White (1987),although a recentstudy using dieters failed toshow this predicted eå ect (Harnden,McNally &Jimerson,1997). Thought-shape fusion distortion 177 IdentifyingTSF inclients witheating disorders has clinical implications. First, TSFmayadd to distress and to negative self-evaluations. Second, it mayelicit checkingbehaviour which maintains body image distortion,and hence challenging TSFmay serveto reduce checking behaviour. Third, if peoplewith TSF are engagingin thought suppression, thenstrategies such as exposure to thoughtswould needto be introduced.Fourth, if it ishypothesized that TSF isa cue associatedwith thebreaking of dietaryrestraint, then there are likely tobe otherinternally generated cuesto breaking of dietaryrestraint such as ` feeling fat ’related tomenstrual stage, feelingsof fullnessassociated with delayed gastricemptying, etc. Thesestudies have a numberof limitations. First,participants were selected onthe basisthat they believed inat least oneof thethree postulated components of TSF. Itremainspossible that participants who do notreportthe distortion would respond similarly inthe experiment. Some evidence against this is students ( N 5 10) who endorsedTSF onthe screening form but actually hadlow scoreson the TSF questionnaire.These participants did not respond to the experimental procedure withanxiety oran urge to perform corrective or checking behaviour ;theywere thereforeexcluded from continuing because the experimental predictions do not applyto peoplewho are free ofthedistortion. Second, we didnot assessbody image distortionspeci® cally. Theinclusion for such a measurewould address the question ofthe association between TSF andbody image distortion.Third, we are unsure whichpart of theexperimental procedure is primarily responsible for activating the TSFdistortionÐit couldbe that writing the sentence is critical, thinkingabout image isthe key element orelse thinkingabout bingeing } losingcontrol is fundamentalto eliciting thedistortion ;re®nement of the methodology is needed. Fourth,we didnot include a placeboattention control when testing the validity of Prediction3, pertainingto the eå ects of corrective behaviour. Such a controlis neededto rule out the eå ects of a spontaneousdecline inthese feelings and experimentsmay bealong the lines of previous studies of neutralization of TAF (Rachman et al.,1996).Fifth, we were notable todiagnose participants with an eating disorderbecause we were assessingeating disorder psychopatholog yusinga questionnaire.Inclusion of a standardizedassessment measure such as the Eating DisordersExamination (interview version ;Fairburn& Cooper,1993) would facilitate acomparisonbetween women with aclinical eatingdisorder vs. subclinical population. We are notsuggesting that everyone with weight and shape concerns will experience thiscognitive distortion and our data indicate thatthere are farmore peoplewith weight } shapeconcerns than with TSF :noteveryone with an eating disorderwill showthis distortion. However, the prevalence of this distortion in a studentpopulation and the strength of its association with eating disorder psychopathologyintwo separate studies indicates that it isworthy of further investigationin a clinical populationand that awareness of thiscognitive distortion may havetherapeutic implications. Itispossible that patients with bulimia nervosa bingein response to the triggering of thiscognitive distortion whereas patients with anorexianervosa increase dietary restraint in response to the eå ects of TSF. Insummary, we believe thatwe haveidenti® ed a cognitivedistortion that may play somepart in the maintenance of eatingdisorder psychopatholog y. Theprecise 178 Roz Shafran et al. natureof that role and the clinical implicationsof the distortion warrant further investigation. Acknowledgements Theauthors aregrateful to DaveHammond for his helpin preparingthe manuscript for publication.

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Received 22June 1998 ; revised version received 12January 1999