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thesis entitled

The Psychodynamics of

Anorexia Nervosa and Bulima

presented by

Abby Loren Golomb

has been accepted towards fulfillment
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PhoDo degree in PsyCh0109y

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Tflf PSYCHUDYNAMYCS 0F
MUREXIA N£RVO$A AND BULIMIA

BY

Abby loren Golomb

A 01535374710”

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1984

ABSTRACT
Tflf PSYCHUDYNAMYCS 0F
ANDRfXIA N£RVO$A AND BULIMYA
BY

Abby [open Golomb

Anorexia nervosa and bulimia are severe eating disorders commonly
reported among college aged women. While their symptomatic behavioral
profiles have been well documented, less is known about the
psychodynamics of these syndromes. This study explored conscious and
unconscious dynamics associated with anorexia nervosa, bulimia, and more
normal eating patterns, as measured by a self-report questionnaire and
the Thematic Apperception Test (TAT). Subjects were 50 undergraduate'
women, selected from a larger subject pool on the basis of reported
eating patterns. Ten women reported histories of restrictive anorexia
nervosa, 20 binged and purged, ld dieted occasionally and lo were free
from such psychological involvement with food. Although TAT data did
not reveal differences in unconscious, internal conflicts as a function
of eating pathology, several important differences emerged in conscious
feelings about men in general and father in specific. Sulimics tendeg‘,

to perceive father as critical and controlling, although they respected
_.e,*-———

 

 

 

 

and admired him. In contrast to bulimics, anorexics expressed more
M“ L____

 

conflicted and ambivalent feelings towards father. Members of both

R

 

 

—.‘

eating disordered groups were afraid of adult heterosexual

 

 

H“ ’

relationships, fearing the destructive potential of closeness with men,

\
but expecting men to depart unscathed from their encounters with women.

 

 

 

 

 

 

 

~Comparing feelings of isolation, feelings about mother, and issues

 

 

 

 

'—- —-v-

around pleasing one's parents, no differences were found across groups.

——~ .-—---—-—.__.-_._r._ _ -fi__,‘

 

These results are discussed from a psychodynamic viewpoint, and
conclusions are drawn regarding normative patterns of eating, dieting
and purgation among young American women. While bizarre and
physiologically destructive eating patterns may be prevalent in this
population, the statistically normal preoccupation with food and weight
reduction should be carefully distinguished from the full clinical

syndromes of anorexia nervosa and bulimia.

To James

ii

ACKNOWLEDGE’MENTS

I would like to first thank Dr. Bertram P. Karon, the chair of my
dissertation committee. Throughout the course of this project, he has
lavishly offered me encouragement, support and good advice. My appreci-
ation of Dr. Karon transcends his expertise in research design and
statistics, his facility with the TAT, and even his delightfully con-
tagious enthusiasm for psychodynamic theory. He has contributed many
hours of careful thought, punctuated by hearty laughter and free coffee.
He has enabled me to pursue my own interests and ideas, but most
importantly he has guided me in the compassionate understanding of human
beings. I am most grateful.

I owe a great debt to Dr. Imogen C. Bowers, who served on my dis-
sertation committee and supervised me clinically. Our many conversa-
tions and supervisory hours devoted to the genesis and treatment of
eating disorders have enabled me to crystallize my own ideas in this
area; Dr. Bowers' solid understanding of her clients' experiences and
her careful attention to detail have significantly enhanced the final
form of this work. Dr. Bowers has helped and guided me as I cut. my
teeth on bulimic patients and professional audiences; I feel priveleged
to have worked so closely with her.

Drs. Jeanne Gullahorn and Robert Caldwell have beautifully rounded
out this dissertation committee, each offering their unique contribu-

tions constructively and with candor. Dr. Gullahorn encouraged and

enabled me to pursue my early interest in eating disorders, offering her
ideas without imposing her research questions upon me. Most importantly
she has provided a critical perspective: life and work both continue
after graduate school. Dr. Caldwell helped with his calm availability
and rational responsiveness in moments of crisis. ‘His incisive comments
regarding research design, statistics and conceptual issues have been
most useful, and his concerns about projective testing led to the only
statistically significant findings of this study.

Many other people contributed to the evolution and execution of
this dissertation. I thank Arthur Myers and Kathleen Long for the
tremendous energy they devoted to scoring data, and .Roxanne Hicks for
her thoroughness, dedication and availability to attend to the
uninspiring details of this project. I also appreciate the efforts of
Angela Holt, Kim Waples, Julie Attridge and Michele James, who helped to
collect and organize data. With all of my assistants I have enjoyed the
free-wheeling discussions about psychodynamics, the psychology of women,
and the roles of food and weight in modern culture, which I hepe placed
in perspective the tedium they, endured. I am grateful to M. Chet
Mirman for helping me to navigate the many snafus of research, from TAT
scoring to word processing. He made our office a much friendlier place
in the early morning hours.

To L.H., J.M., and S.R., I am forever indebted for what you have
taught me about the reality of suffering from eating disorders. I thank
my parents, Sylvia and Irving Golomb, for establishing the family
foundation that supported this research. Finally, I thank James Cole,
for love that proved the best motivator for the timely completion of my
dissertation.

iv

TABLE 0F CONTENTS

Page
LIST OF TABLES ..................................................... vi
INTRODUCTIUN ........................................................ I
The Bulimic Cycle .............................................. 3
The Anorexic Profile ........................................... 8
The Feeling of Isolation ...................................... IA
Pleasing One's Parents ........................................ l9
Relationship With Mother ...................................... 2l
Relationship With Father ...................................... 2b
Heterosexual Relationships .................................... 27
Projective Assessment of Eating Disorders ..................... 30
The Pilot Study ............................................... 32
Hypotheses .................................................... 3h
Unconscious Dynamics ....................................... 3h
Conscious Dynamics ......................................... 36
METHDD ............................................................. 38
Subjects ...................................................... 38
Measures ...................................................... 50
Procedure ..................................................... 5h
Consent Procedures ............................................ 57
RESULTS ............................................................ 58
Unconscious Processes ......................................... 58
Conscious Processes ........................................... 6h
DISCUSSION ......................................................... 79
APPENDICES ......................................................... 90
APPENDIX A - TAT Scoring Sheet ................................ 90
APPENDIX B - TAT Scoring Manual ............................... 9]
APPENDIX C - Conscious Themes Questionnaire .................. 10h
APPENDIX D - Eating Disorders Inventory ...................... lOS
APPENDIX E - Objective Test Materials ........................ ll3
APPENDIX F - Research Consent Form ........................... 125
R£F£R£NC£S ........................................................ 127

Table Page
l. DSM-III Criteria for Bulimia ................................... 5
2. Feighner et al. Diagnostic Criteria for Anorexia Nervosa ..... l0
3. DSM-III Criteria for Anorexia Nervosa ......................... ll
A. Demographic Features of Project Participants .................. 39
5. Demographic Features of Project Participants .................. LO
6. DSM-III Symptoms Reported by Bulimic Subjects ................. Al
7. Frequency of Reported Symptoms of Anorexia Nervosa ............ Ah
8. Percent Weight Loss Of Subjects By Group ...................... b5
9. Bulimic Symptoms Reported by Anorexic Subjects ................ A6
6?; Breakdown of History of Eating Patterns ....................... h8
ll. Scores on EDI Subscales as a Function of Group ................ 5i
l2. MANOVA on EDI Subscales by Group .............................. 52
I3. Frequencies of Unconscious Themes by Group .................... 59
IA. MANOVA on Unconscious Themes by Group ......................... 60
IS. Behavioral Correlates of Unconscious Themes ................... 6]
l6. Correlations Between Unconscious Themes and EDI Subscales ..... 63
I7. Frequencies of Conscious Themes by Group ........... .... ....... 65
l8. Manova on Conscious Themes by Group .. ......................... 66
6:) Current Dating Behavior of Pathological and Control Groups .... 70
20. Correlates of Significant Conscious Themes .................... 7l
2l. Correlations Between Conscious Themes and EDI Subscales ....... 73

LIST OF TABLES

vi

22. Correlations Between Conscious and Unconscious Themes ......... 76

vii

Food for Thought

viii

Introduction

As society changes over time, psychopathology seems to keep
current. Certain forms of psychological disturbance emerge, while
others decrease in prevalence. Few clinicians still treat the
conversion hysterias so common during Freud's time; the dynamics and
conflicts which he observed now seem to emerge through new
symptomatology, reflecting broad sociocultural changes. Two eating
disorders, anorexia nervosa and bulimia, seem to be modern neuroses in
this sense. Critical to both disorders is a relentless pursuit of
thinness and an abject fear of fat which seem to coincide with mounting
cultural pressure to be slim (Bruch, l973; Garner, Garfinkle 8 Dlmstead,
I983; Garner, Garfinkle, Schwartz 8 Thompson, I980). The incidence rate
of these disorders has reportedly risen exponentially over the last 25
years (Bemis, I978; Duddle, I973; Halmi, l97h, and others), spurring
popular interest and scientific research in this previously uncharted
region of psychopathology. Our knowledge and understanding of anorexia
nervosa has increased dramatically, but research on bulimia is still in
its incipient stages.

The diagnostic distinction between anorexia nervosa and bulimia is
a recent and not yet explicit one, reflecting overlapping symptomatology
and terminology. The self-induced starvation which is the cornerstone
of anorexia nervosa was first identified and labelled by Gull in l87h.
It was not until the seminal work of Boskind-Lodahl (I976) that such

restrictive dieting was distinguished from the cycle of bingeing and
l

purging found among normal weight women. Boskind-Lodahl termed the
latter disorder ”bulimarexia”, emphasizing both the uncontrolled
bingeing and the self-punitive laxative abuse, vomiting or restrictive
dieting which follows.

Palmer (l979) has addressed this diagnostic problem by coining the
term “dietary chaos syndrome". This syndrome is characterized by
I) grossly disturbed eating patterns, including vomiting, binge-eating
and abstinence, 2) a preoccupation with eating, food, and sometimes
weight, which overrides other thoughts, and 3) rapid fluctuations of
body weight in response to food intake and output. These features
roughly match the criteria for bulimia established in the Diagnostic and
Statistical Manual (DSM-lll, American Psychiatric Association, l980),
which will be discussed in greater detail below. Other researchers have
more casually referred to the binge-purge cycle as ”bulimia”, although
the DSM-III allows for the diagnosis of bulimia in the absence of any
attempts at purgation or dieting. For present purposes, the term
”bulimia” will be used only in the more narrow sense of the binge-purge
cycle.

Debate continues over whether anorexia nervosa and bulimia are
discrete disorders or extremes along a continuum. Many anorexics binge
and purge (Bruch, I973; Casper, Eckert, Halmi, Goldberg 8 Davis, I980;
Szyrynski, 1973; Thoma, I967), and either "true” or ”cryptic” episodes
of self-starvation may precede the development of bulimic symptomatology
(Russell, I979). Guiora (I967) argues that the psychological
similarities of anorexia nervosa and bulimia, and the alternation of
symptomatology within individuals indicate that these ”are not separate

dichotomous syndromes, but extreme ends of the same disorder” (p. 39I).

Other researchers have pointed to incisive distinctions between
anorexics who binge and purge and those who consistently restrict food
intake (Strober, I98I; Strober, in press). Examining a range of
demographic, clinical and psychometric variables, Garner, Garfinkle and
D'Shaughnessy (in press) conclude that ”as a group, the normal weight
bulimics closely resemble anorexic-bulimics. . . Not only do these
groups di5play many similarities, but also they both may be
distinguished from the anorexic-restricters on many dimensions.
Therefore, the presence or absence of bulimia, rather than the history
of weight loss may be of greater diagnostic and etiological
significance” (p. 8).

In sum, arguments can be made for both conjoint and separate con-
sideration of anorexia nervosa and bulimia. What is known about one
disorder may facilitate understanding of the other, but hasty equations
of the psychodynamics of these two entities should clearly be avoided.

They can only generate confusion and lead to inaccurate conclusions.

The Egliflic Cycle

In spite of this overlap in symptomatology, researchers have begun
to identify behavioral features and psychosocial correlates of bulimia.
Bulimia is characterized by recurrent episodes of binge-eating,
accompanied by the fear of not being able to voluntarily control food
intake. During the binge, large quantities of high-caloric food are
rapidly ingested in a discrete period of time, usually less than two
hours. Binges are usually private and inconspicuous, and are often
followed by feelings of guilt, depression and panic. Behaviorally, the

individual may induce vomiting, abuse laxatives, and/or initiate severe

diets after bingeing, in order to regain the feeling of being in control
and to insure against morbidly feared weight gains. As noted above, the
diagnosis of bulimia pivots upon difficulties with binge-eating; use of
purgation techniques and attempts at weight loss are not necessary
defining features of this disorder. See Table l for the DSM-lll
criteria for bulimia.

Bulimic individuals are usually women of normal weight, who are
single, Caucasian and upper class (Garner, Olmstead 8 Polivy, l983a;
Halmi, Falk 8 Schwartz, l98l; Johnson, Stuckey, Lewis 8 Schwartz, I982).
The eating disorder typically emerges in early adulthood, and recent
reports indicate that its incidence is dramatically high among college
women with no history of anorexia or obesity (Boskind-Lodahl, I976;
Halmi et al., I981; Pyle, Mitchell 8 Elke, I98l; Sinoway, I982).
Surveys at the State University of New York and at Pennsylvania State
University indicate that as many as I32 of all college women experience
the major symptoms of bulimia, as outlined in the DSM-lll (Halmi et al.,
l98l; Sinoway, I982). Other reports suggest a lower incidence rate,
ranging from 2.5 to 3.5% of college women (Button 8 Whitehouse, l98l;
Hawkins 8 Clement, I980).

0n the basis of her clinical observations, Boskind-Lodahl (I976)
has described the women caught in this cycle as accommodating, dependent
and passive. They uncritically embrace the traditional image of
femininity, and obsessively strive to achieve this ideal. Such
exaggerated esteem for the feminine role is at the expense of the
development of the individual, and hence these women have little sense

of personal identity or worth.

Table 1'

DSM-Ill Criteria for Bulimia

A. Recurrent episodes of binge eating (rapid consumption of a large
amount of food in a discrete period of time, usually less than two
hours). '

B. At least three of the following:

(I) consumption of high-caloric, easily ingested food during a binge

(2) inconspicuous eating during a binge

(3) termination of such eating episodes by abdominal pain, sleep, social
interruption, or self-induced vomiting

(h) repeated attempts to lose weight by severely restrictive diets,
self-induced vomiting, or use of cathartics or diuretics

(5) frequent weight fluctuations greater than ten pounds due to
alternating binges and fasts

C. Awareness that the eating pattern is abnormal and fear of not being
able to stop eating voluntarily.

D. Depressed mood and self-deprecating thoughts following eating
binges.

E. The bulimic episodes are not due to Anorexia Nervosa or any known
physical disorder.

Boskind-Lodahl traces these problems to childhood histories of
dependence and submissiveness. These children are valued for their
attractive appearance and praised for their compliance; they strive
perfectionistically to please their parents, both through academic
achievement and physical appearance. While many may consciously despise
their controlling and manipulative mothers, others have close and
intense mother-daughter relationships (Boskind-White 8 White, I983).
Generally they identify with mother and aspire to her role. Father is
likewise idolized; he is an ”object of hero worship, even though (he is)
preoccupied, distant, or emotionally rejecting“ (Boskind-Lodahl, I976,
p. 3A8). Often there is a secret yearning for greater intimacy with
father, especially as this relationship seems to become more distant
during adolescence (Boskind-White 8 White, I983).

Such women approach adulthood with low self-esteem. They seek ap-
proval from men, but are unprepared for close heterosexual relation-
ships. ”These women have already learned a passive and accommodating
approach to life from their parents and their culture. This accom-
modation is combined with two opposing tensions: the desperate desire
for self-validation. from a man and an inordinate fear of men and their
power to reject“ (Boskind-Lodahl, I976, p. 35h). Real or perceived re-
jections become critical events, generating intense concern about
appearance. Embracing the media's message that thin and beautiful women
are successful, happy, and most importantly, loved, they turn to dieting
as a panacea for their problems and unhappiness. It is when dieting
fails to deliver such bounties that these women enter the binge-purge

cycle (Boskind-Lodahl, I976; Sinoway, I982).

The binge provides a release of tension from social pressures and
the restrictions of dieting. All self-control is abdicated during the
binge. ”One gives one's self to the food, to the moment completely.
There is a complete loss of control (ego). It is an absolute here-and-
now experience, a kind of ecstacy" (Boskind-Lodahl, I976, p. 352).

The ego regains tight control during the purge, undoing the damage
of the binge-eating episode and the depression, shame and self-disgust
it generated. The anger which originally fueled the episode is again
submerged, until the next cycle begins.

Even when these women are not involved in the binge-purge cycle,
they experience dramatic and rapid mood swings, and their moods are
significantly more negative than those of normal women. Johnson and
Larson (I982) propose that these women may be at risk for addictive be-
haviors because of their vulnerability to dysphoric and fluctuating
moods. Their addiction is to food, which may modulate some of their
psychological problems, but which creates new concerns about being over-
weight. Discovery of purging, "The Perfect Solution”, leads to more
binges and more purges. ‘

The connection between bulimia, addictive behaviors and affective
disorder has also been posited by other researchers (Strober, in press;
Strober, Salken, Burroughs 8 Morrell, I982). Relatives of bulimics have
a high incidence rate for these disorders, suggesting that bulimics may
also be at risk. These researchers posit that the ground may well be
laid for such affective disorders among bulimics by childhood feelings

of isolation and distance from one or both parents.

The Aaecegie firefile

In contrast to the bulimic's chaotic eating habits, the anorexic
”plays it straight”. She consistently restricts her food intake,
obsessively striving for thinness at all costs. Although bingeing and
purging may accompany anorexia nervosa, the essential features of this
disorder are: l) a disturbance of body image and a body concept of
delusional proportions, 2) a disturbance of perception or cognitive
interpretation of stimuli arising from the body (e.g. bulimic behavior,
overactivity and denial of fatigue), and 3) a paralyzing sense of in-
effectiveness (Bruch, I965). These young women physically resemble con-
centration camp survivors, but they claim not to suffer hunger; rather,
they suffer ”from the panicky fear of gaining weight” (Bruch, I978,
p. h), and they report enjoyment of the feeling of emptiness. In spite
of their miniscule food intake and their exaggerated level of activity,
anorexics insist that there is nothing wrong with them; they take great
pride in their thinness. They are not troubled by their continuous
state of tension, nor by their hypersensitivity to light or sound.

According to Selvini Palazzoli (l97l, p. 208), anorexics' ”uncer-
tainty is complete. They do not have an inner spontaneous awareness of
needs, as the rest of us have. They never 'know' if and when they
should eat, if they have eaten enough, and when they should stop. Every
time they are overtaken by the fear, or terror, of not having controlled
themselves. The history often reveals that the feeling of uncertainty
first arose when departure for college or a vacation caused separation
from the family environment, where an automatic and other-directed
Feeding ritual held sway.” For many anorexics, controlling one's eating

leads to new but spurious feelings of competency, of being in touch with

feelings, and of having a core to one's personality.

The clinical picture of anorexia nervosa includes not only
restrictive eating patterns and their psychological correlates, but also
marked physiological changes that cannot be attributed to any known
medical illness, including loss of at least 252 of original body weight,
amenorrhea, lanugo (growth of fine, baby-like hair on the body), and
bradycardia (persistent resting pulse of 60 or less)(Feighner, Robbins,
Guze, Woodruff, Winokur 8 Munox, I972). These diagnostic criteria,
compiled in Table 2, have been widely used in research investigations,
although some modifications have been suggested. Rollins and Piazza
(I970) argue that the loss of 25% of one's body weight is an arbitrary
criterion dependent upon duration rather than severity of illness, which
may eliminate from research anorexics who have been promptly identified
and effectively treated. Investigators working with male anorexics have
likewise challenged the usefulness of amenorrhea in diagnosis, because
it has no clear analogue in the male (Beumont, Beardwood 8 Russell,
I972; Hogan, Huerta 8 Lucas, l97h). In the present study, anorexia
nervosa is defined by the diagnostic criteria set forth in the DSM-III
(See Table 3).

In the pre-anorexic's infancy, the essential food-related problem
is the ritual nature of feeding (Selvini Palazzoli, I97l). The mother
does not enjoy the relationship with her child, and ”control prevails
over signs of joy and tenderness” (p. 202). Feelings of personal inef-
fectiveness grow during childhood; ”an impervious presence constantly
interferes, criticizes, suggests, takes over the vital experiences and
prevents them from being felt as one‘s own" (p. 202). The child enters

adolescence with a close bond to her mother, and with poor peer

IO

Table 2
Feighner 2; al. (I972) Diagnostic Criteria for Anorexia Nervosa

 

l. Age at onset less than 25 years.
2. Anorexia with weight loss of at least 25% of original body weight.

3. A distorted, implacable attitude toward eating, food, or weight
overriding hunger, admonitions, reassurance, and threats, e.g. l)
denial of illness with a failure to recognize nutritional needs, 2)
apparent enjoyment in losing weight with overt manifestation that food
refusal is a pleasurable indulgence, 3) a desired body image of extreme
thinness with overt evidence that it is rewarding to the patient to
achieve and maintain this state, and h) unusual hoarding or handling of
food.

A. No known medical illness that could account for anorexia and weight
loss.

5. No other known psychiatric disorder with particular reference to
primary affective disorders, schizophrenia, obsessive-compulsive and
phobic neuroses.

6. At least two of the following manifestations:

l) Amenorrhea

2) Lanugo - growth of fine, baby hair on body

3) Bradycardia - persistent resting pulse of 60 or less
A) Periods of overactivity

5) Episodes of bulimia

6) Vomiting (may be self-induced)

II

Table 3

DSM-lll Criterias for Anorexia Nervosa

A. Intense fear of becoming obese, which does not diminish as weight
loss progresses.

B. Disturbance of body image, e.g. claiming to ”feel fat“ even when
emaciated.

C. Weight loss of at least 252 of original body weight or, if under I8
years of age, weight loss from original body weight plus projected
weight gain expected from growth charts may be combined to make the 252.

D. Refusal to maintain body weight over a minimal normal weight for age
and height.

E. No known physical illness that would account for the weight loss.

l2

relations. She experiences strong feelings of depression and hopeless-
ness, leading to an acute oral helplessness.

Bruch (I978) emphasizes some of the more positive features of the
pre-anorexic's family. These families often "look good“--they are
characterized by stable marriages, high achievement, and upper-middle to
upper class social positions. The parents tend to be older, the
families are small (2.8 children), and the probands rarely have
brothers. The fathers value their daughters for intellectual and ath-
letic achievements but are likely to criticize them if they become
plump. Often the mothers (and sometimes the fathers as well) are pre-
occupied with weight and dieting.

The child raised in such an environment typically feels an obliga-
tion because of family standards; much is expected of her and she
strives to enact her role of perfect child. She devotes great amounts
of time to predicting what her parents want to give and receive from
her. ”The distressing situation is to guess what the parents want to
give and to accept it with enthusiastic gratitude“ (Bruch, I978, p. A3).
Because their entire childhoods have been dedicated to outguessing
others, ”these youngsters appear to have no convictions of their own
inner substance and value, and are preoccupied with satisfying the image
others have of them" (p. #3).

Anorexics often excel in school, but their achievements are usually
the results of extraordinary efforts. Bruch believes that the need for
approval and recognition is so strong for these children that they
struggle willfully against their own conceptual abilities.

An understanding of the family background of the anorexic leaves

unanswered one essential question: why this disorder emerges so

l3

regularly in the pre-adolescent or adolescent phases of development.
Meyer (l97l, p. 5hl) suggests this is because the mother's situation
changes as her daughter approaches puberty. "She is searching for new
values in a home once again childless, while her husband is becoming
more and more absorbed in his professional commitments. Now the mother
has to introduce her child into adult life, a very different task from
what she has undertaken till then.‘|

Other theorists emphasize a more basic fear of being a teenager.
Galdston (l97h) stresses that the onset of anorexia nervosa reflects the
individual's efforts “to establish the dominance of her mind over her
matter in anticipation of the developmental work of adolescence. The
need for a mental confirmation of self-control is occasioned by an
experience in disappointment which the patient takes to be a sign of
intolerable personal fault, and which she seeks to remedy by regressing
to reform herself anew” (p. 2A6).

Often the ”sign of intolerable personal fault” is a remark that the
pre-anorexic is filling out or growing chubby. She begins to diet, in
much the same way as her peers diet. Bruch (I978, p. l9) claims that
"not one of the patients I have known had intended to pursue the
frightening road of life-threatening emaciation--and to sacrifice the
years of youth to this bizarre goal. They had expected that to be
slimmer would improve not only their appearance but their way of living.
It seems that the way hunger is experienced accounts for the decisive
difference."

In most cases the onset of anorexia nervosa is linked to early
pre-pubertal bodily changes. Particular significance is attached to the

development of breasts, which can be considered ”signals" of sexual

IA

maturity. According to Selvini Palazzoli (l97l, p. 20A), this is
because puberty in the girl is a sudden and traumatic experience in
which ”narcissistic libido cathexis has to be withdrawn from the
infantile body and directed toward the new body, the adult, curved body
that also has to be considered as belonging (belongingness of the
experience of one's body). This body, however, because of the permanent
incorporation of the object, does not succeed in emerging as one's own
and as distinct from the maternal object.” From this perspective
anorexia nervosa can be understood as a desperate attempt to distinguish
oneself from the maternal object.

Bruch notes that most cases of anorexia are precipitated by
external stresses, such as moving to a new neighborhood, leaving home
for vacation or college, separation or loss of friends or siblings, or
getting married. In such situations, the patient becomes “paralyzed
with the fear of being unable to meet others on equal terms" (I978,
p. 59). Casper and Davis (l977) suggest that in many other individuals,
these same events might lead to depression. Loss of weight may be an
active attempt to change one's .appearance rather than submit to the

depressive process.

Strober's (l98l) study of anorexic women and their families sheds
light upon the issue of feeling distant or isolated from one's family.
Subjects were classified according to whether they engaged in bulimic
behaviors or continually restricted food intake. In comparison to the
restricters, the premorbid functioning of the bulimics was characterized

by unhappiness, crying easily, and clinging to parents. As young women,

15

the bulimics reported feeling less close to both their mothers and their
fathers than did the restricters. Furthermore, scores on the Moos
Family Environment Scale (Moos, I97A), which was administered to
probands and their parents, indicated that bulimic families are
characterized by less organization, more conflict, and less cohesion
than families of restricters. Strober (in press) also reports that the
families of bulimic anorexics are characterized by disequilibrium,
turbulent interpersonal relations, affective lability and proneness to
addictive behaviors.

While the families of bulimic-type anorexics appear quite
disturbed, a number of researchers have found that the probands them-
selves are considerably more outgoing and socially integrated than are
restricters (Beumont, I977; Beumont, George 8 Smart, I976; Garfinkle,
Molodofsky 8 Garner, I980). The consistency of this finding leads one
to doubt the etiological significance of isolation in bulimia. However,
there is no easy translation of findings concerning subtypes of anorexia
nervosa to bulimic women of normal weight. Relative to anorexic
dieters, bulimics may appear socially adjusted, but in comparison to
normals they may have severe social handicaps. Brenner's (l98l)
comparison of the psychodynamics of obese, bulimic and normal women
lends support to this thesis. Using projective tests, tachistoscopic
procedures and a variety of self-report measures, she found that
bulimics tended more toward fear and avoidance of others, while obese
subjects tended more toward ”need“ toward others.

Aside from dynamic questions of predisposition, there is good
evidence to suggest that the splurge-purge cycle is often triggered by

social stress. As mentioned above, many young women report that their

l6

first binges followed what they felt to be rejections by men. Once this
pattern is established, it becomes the young woman's primary mechanism
of defense. When she cannot physically escape stressful social situa-
tions, the binger reduces her anxiety and keeps herself separate by
bingeing or contemplating bingeing. She takes refuge in her private
orgy, trying to eat her problems away rather than cope with them.

As much as she may yearn for intimacy, especially with men, the
fear of social integration propels the young woman into increasingly
profound isolation. Being alone is almost always a prerequisite to
bingeing and purging (Russell, I979). As this pattern becomes en-
trenched, the bulimic moves further away from the social world and her
problems seem only to worsen. Boskind-White and White (I983, p. A6)
write that “it is not surprising that bulimarexics have few friends - so
much of their time is spent in supporting their habit and in keeping
others from knowing about it.”

The clinical observations connecting bulimic behavior with the
experience of isolation have also received empirical support. In an
ingenious study, Johnson and Larson (I982) asked l5 bulimic women and 2A
normal women to report on their current feelings and situations at
various times of the day, when they were signaled by an electronic
beeper. Bulimic women reported spending significantly more time alone,
and their self-reports on a 7-point Likert scale indicated that they
subjectively felt more lonely as well. Additionally, Johnson and Larson
found that bulimics experience significantly more variability in mood,
that bingeing and purging almost always occur when the bulimic is alone,
and that more time in their daily lives is devoted to thoughts,

preparation and eating of food.

Johnson and Larson's study does not address the issue of causality,
but many of the women reported in post-trial interviews that ”as they
became increasingly involved with food they began to withdraw socially.
Several of the bulimics, angrily and with some despair, mentioned that
over the years food had become their closest companion, and that they
would often opt to stay home and binge rather than be with friends or
family” (p. 3A8). The powerful influence of eating difficulties has
been further documented by Johnson et al., (I982) in a survey of 3l6
bulimic women. More than 902 of their subjects reported that their
thoughts and feelings about themselves were ”totally” or “very much“ in-
fluenced by their eating behaviors. More than two-thirds of the
subjects reported a similar degree of influence over their interpersonal
relationships.

Among anorexic patients, social isolation also functions as an
etiological factor and as a secondary elaboration of symptoms. The per-
ception of social rejection often triggers anorexic dieting. In many
cases the pre-adolescent interprets a remark about filling-out or
growing chubby as an assasination of her character (Galdston, l97A); she
begins dieting to make herself more socially acceptable, and to enhance
her feelings of self-worth. Paradoxically, the outcome of her drive for
thinness is withdrawl and social isolation (Bruch, I973). One reason
for retreat is that social interaction often entails eating, an activity
that requires privacy for most anorexics (Levenkron, I982). The
anorexic may also withdraw because of starvation or low self-esteem, but
the consequences of her withdrawl are other symptoms, including loneli-
ness, isolation and poor social skills (Garfinkle 8 Garner, I982).

Furthermore, shyness and withdrawn behavior may persist after the

l8

restoration of lost weight (Pillay 8 Crisp, I977).

Taken together, these reports indicate that feelings of social
isolation or rejection can trigger restrictive dieting as well as
episodes of bingeing and purging; these behaviors, in turn, seem to
perpetuate and aggravate the isolation which they were originally
intended to combat. The connection between eating disorders and earlier
experiences of isolation is less clear, although it can be conjectured
that childhood feelings of isolation with regard to one's parents render
the young woman exquisitely sensitive to rejection by others. Her
consequent misperceptions may lead to a single-minded obsession with
weight reduction, or to a destructive behavioral cycle wherein the
immediate benefits of bingeing are offSet by the long-term costs of
increased depression and social isolation, as well as the medical
complications which inevitably follow.

In the present study, it was predicted that the unconscious
experience of isolation, as reflected in the TAT protocols of bulimics
and anorexics, would differ significantly from that of normals. This
difference at the unconscious level should reflect early experiences of
feeling cut-off from parents, which are presumed to be of etiological
significance in symptom formation. Differences between groups at the
conscious level were also predicted, but the self-report of loneliness
or isolation was expected to reflect the results of the eating disorder,
that is, current rather than past experiences of isolation. Presumably
the current and consciously felt isolation differs from buried and
inaccessible feelings psychological distance from one's parents. It is
because these dynamically critical feelings have not been allowed to

enter into conscious awareness that the young ~woman resorts to

l9

binge-eating and purgation to solve psychological problems. In ‘
contrast, the conscious report of loneliness should vary directly with
the duration of the disorder and the frequency of episodes, the young
woman feeling increasingly more isolated as her eating disorder
progresses. Differences were expected on unconscious indices and
conscious self-reports comparing young women with eating disorders to
normal controls, but no differences were expected in the comparison of

anorexics to bulimics.
P ' ’ r t

More specific hypotheses about early relationships with parents can
be formulated to address the process by which anorexics and bulimics
come to feel so isolated. Empirical exploration in this area has been
minimal, although several specific dynamic patterns have begun to
emerge.

Throughout the literature on anorexia nervosa and bulimia, there is
repeated mention of perfectionistic strivings and the drive to please
one's parents (Boskind-Lodahl, I976; Bruch, I973, and others). Women
suffering from these disorders often excel in academics, music, ath-
letics and art. They push themselves to achieve in these areas just as
they force themselves to attain what they consider the ideal body size.
However, ”in most cases the drive to achieve (has) as its goal pleasing
parents and marrying 'well'” (Boskind-Lodahl, I976, p. 3A8).

For the eating disordered patient, compliance has become a way of
life. Levenkron (I982, p. 7-8) sees this pathological drive to please
other people as the response to a “depleted” family; the parents feel

unable to cope with the problems of daily living, so they enlist the

20

daughter's help and support. ”Depletion of the parent(s) often results
in an implicit reversal of dependency between parent and child. The
parent's message to the child has been 'You have more strength than I.‘
The child reacts by becoming the parent within the relationship. She
assumes the role of assisting or supporting her parent(s) emotionally.
She may become a high achiever, a pleaser of others. Such behavior is
her contribution to raising family morale, or the morale of a depressed
parent.”

From a systems perspective, the anorexic family is enmeshed and un-
differentiated. “The parents are typically unable to exert appropriate
'executive' leadership in that they are too dependent on their
children's 'gOod' behavior as proof that they are good parents“ (Stern,
Whitaker, Hagemann, Anderson 8 Bargman, l98l). In such an environment
the child must strive to make others happy and to confirm their expect-
ations of her, for her failure would threaten her parents' self-esteem.

The anorexic's or bulimic's desire to pleease others may also be
accompanied by the wish to cause her parents pain, to make them unhappy.
She may resent the continual pressure for perfection, and the burden of
nurturing her parents. In retaliation she may wish to punish her
parents for their expectations.

On the TAT, the theme of displeasing one's parents was expected to
emerge in stories wherein an older couple receives bad news from their
child, which makes them both unhappy. This "bad news" may represent
either a wish, a fear, or both for the young woman. While the anorexic
or bulimic was expected to unconsciously feel that she makes her parents
unhappy, no differences were predicted on the conscious self-report of

such feelings comparing pathological and control subjects. As long as

2i

the bulimic successfully hides her problems with people and with food,
she is unlikely to be aware of deeper feelings of making others unhappy.
And the anorexic dramatically escapes her internal feelings of
interpersonal inadequacy through perfectionistic overkill. The young
woman who strives to please others through achievement and accommodation
may, in fact, be more likely to report that she makes her parents happy

than her counterpart who is not pathologically involved with food.

In traditional psychoanalytic theory, unconscious hatred for a dom-
ineering mother was posited as a major etiological factor in anorexia
nervosa (Boskind-Lodahl, I976; Boskind-Lodahl 8 Sirlin, l977: Szyrnyski,
I973). Guiora (I967, p. 392) emphasizes that eating disorders stem from
l'an early deprivation in the mother-child relation that finds its ex-
pression in food intake.” Hostility towards mother coupled with fix-
ation at the oral stage precludes proper identification with mother, and
hence blocks the emergence of womanhood and motherhood. While anger
towards an aggressive and controlling mother can be viewed in the
context of the anorexic's battle for independence, Wall (I959, p. 998)
describes ”a peculiar dependence upon the mother; a wish to hold her
responsible and at the same time to be independent of her, mingled with
resentment or strong feelings of envy and jealousy."

More recently psychodynamic theorists have shifted their emphasis
away from drive disturbances, focusing instead upon early object
relations. Selvini Palazzoli (I978), for example, suggests that the
maternal object is permanently incorporated into the body of the

anorexic. Although the young woman strives to separate from mother, the

22

maternal object remains incorporated because it is feared. This model
hinges upon the behavior of the mother, who has been conceptualized as
overprotective and unable to recognize the legitimate needs of her
child. She rewards compliance and cannot allow her daughter to separate
from her. ”For these girls attachment means passive submission to the
maternal object with a sense of dedifferentiation and fusion. Because
of the mother's need to impose her wishes and wants upon the child this
type of anorexia nervosa patient must withdraw and suppress all affect
in order to feel separate” (Sours, l97A, p. 570). Along the same line,
Bruch (I973) emphasizes the ”robot-like compliance“ that results from
the mother's continual subversion of the child's needs to her own sense
of propriety. Mother's omnipotence interferes with separation and
individuation throughout the daughter's childhood; this attachment
promotes fusion rather than nurturance, leading the daughter to suppress
all affect and to feel as though she has no will independent of her
mother (Sours, l97A). Kramer (l97A) cautions, though, that the
overemphasis on pathological and domineering mothering may obscure more
subtle contributions of the child to the disturbed mother-child
relationship.

Strober et al. (I982) have empirically addressed some of these
personality features in the mothers of anorexics, comparing women whose
daughters were restricters with the mothers of bulimic-type anorexics.
Although no comparisons were made to the mothers of healthy young women,
clear differences did emerge between eating disordered groups. The
mothers of anorexics who binged and purged exhibited more pronounced
depression, hostility ‘and emotional dissatisfaction while character

traits of mothers of restricters included submission, introversion, and

23

neurotic tension.

The mother-daughter relationship of bulimics of normal weight has
been described in some detail by Boskind-Lodahl (I976). Her clinical
impressions suggest that anger at mother is consciously felt; bulimics
tend to view their mothers as demanding, controlling and manipulative.
These mothers are bright and well educated, but they have devoted
themselves entirely to family, at the expense of their other
aspirations. As if to compensate for their lack of power outside the
home, they reign supreme over their children. The bulimic daughters are
well aware of their mothers' domineering qualities and feel duly angry
and resentful, but they simultaneously emulate their mother's role.

The view of the bulimic's mother as stubborn and manipulative has
received empirical support; Sinoway (I982) found these maternal
qualities to be significant discriminant functions when comparing
binger-purgers with women who binge-only and with nonbingers. However,
the most recent work of Boskind-White and White (I983) suggests that the
mother-daughter relationship may be best described as approach-
avoidance. Mother is at once felt as controlling and is deeply loved.
These authors caution that the view of mother as villain is myopic,
missing the subtleties of the young woman's relationships with each of
her parents.

' The maze of contradictions regarding the mother-daughter
relatio ship suggests that these findings may reflect conflicting
aspects of a complex reality. Mother may be described positively, but
still he may be felt negatively. If in fact the mothers of bulimics
and an rexics are controlling, then these young women have good reason

to f el angry and resentful. The expression of such negative feelings
I

2A

may be blocked, though, by mother's firm control and/or by the young
woman's caricatured endorsement of femininity. Angry expression is
branded as unladylike, and hence is unacceptable. In any event, the
young woman is unlikely to forget the benefits she gains from this
“smothering” relationship; its destructive aspects are certainly not
unmitigated.

If this hypothesized conflict exists between the experience and
expression of feelings towards mother, then the false front of this
ambivalent mother-daughter relationship sets the stage for feelings of
social isolation. The young woman not only misses the essential
experiences of honesty and freedom in closeness with her mother; she
will probably view her other relationships in'a similar manner. In the
present study, the anorexic's and bulimic's views of older women, as
projected in TAT stories, were hence expected to reflect control over
younger women; older women would be described positively but would be
felt negatively. The conscious description of mother was expected to be
decidedly positive, in contrast, reflecting the socially desirable side
of these ambivalent feelings. .Differences were expected contrasting
normal controls with these two pathological groups, although no

differences were predicted between anorexic and bulimic subjects.

As mentioned above, bulimics and anorexics are unusually sensitive
to the criticisms of men. Casual comments or requests may trigger
obsessive dieting or ritual purging. Clearly, men are vested with great
power by women with eating disorders. Both the corporal and

psychological parts of the self are forced to fit whatever form is

25

requested by a male

The dependence upon male approval is exemplified by the bulimic
cycle. The young woman strives to attain happiness by becoming what she
thinks will be pleasing to men. When she feels rejected, or finds that
her efforts fail to attract men and to improve her life, she feels
cheated and angry, so she binges. After the binge, she tries even
harder to solve her problems through beauty and thinness. Again and
again she fails, because of her basic deficit in self-esteem and her
overvaluation of male approval.

Certainly bulimics are not the only women who depend upon men for
their happiness and gratification. Sociocultural values for women
emphasize the joy derived from caring for husbands and children.
Historically, women's value has been set not by what they do, but by the
men with whom they keep company (deBeauvoir, I952). The psychology of
the bulimic seems an extreme caricature of such traditional femininity.
The substance of ego does not exist, except to be injected or drained by
men.

In dynamic terms, it is likely that the groundwork for this deifi-
cation of men was laid in the early father-daughter relationship.
Father was the first powerful man, because he could love and approve of
his daughter, or criticize and reject her. How father wielded this
power made him potentially dangerous and hurtful. Some of the women
studied by Boskind-Lodahl reported the perception of their fathers as
”more persistent in their demands for prettiness and feminine behavior”
(I976, p. 3A8) than were their mothers. Because father is held in such
high esteem, his criticisms cut sharply. Eventually the daughter learns

that she is unacceptable as she is; she must become something other than

26

she is to gain her lifeblood, the approval of men. In her determination
to succeed with other men where she has failed with father, the young
woman redoubles her efforts to conform to feminine stereotypes. She is
vigilant of men's criticisms and dissatisfactions, always feeling as if
she is on the brink of failure, but desperately hoping for personal
success.

In this regard, the anorexic experience seems quite different from
that of the bulimic. Few investigators have detailed the dynamics or
the father-daughter bond in anorexic families, and those who have
describe it as eminently uninteresting. Szyrynski (I973, p. A96) points
to a ”passive and ineffectual father in the background," and Bruch
(I973) suggests that the anorexic's father tends to feel inadequate,
despite his considerable personal successes. He values his daughter's
achievements, but his own weight-consciousness renders him likely to
criticize his daughter should she become plump. More emphasis is laid
upon the etiological role of the father by Levenkron (I982, p. 3), who
attributes the anorexic's disinterest in sexuality in part to ”the
failure of the father to romance (his) daughter healthily, to offer
affection and compliments."

Empirical validation of these clinically observed traits has been
presented by Strober et al. (I982). 0n the MMPI, fathers of restricters
tended towards greater reserve and passivity relative to their bulimic
counterparts. The latter group was characterized more by hostility,
immaturity, impulsiveness and dyscontrol.

As suggested in this review of the literature, the father-daughter
relationship may play a critical role in the etiology of eating

disorders, although its impact seems to differ across disorders. For

27

the bulimic, the idol status of father grants him, like the men who
follow him, the power to criticize, wound and reject. Hence in the TAT
stories of bulimics, it was predicted that father-figures would emerge
as both critical or disapproving, and elevated in stature or revered.
Again, the unconscious feelings about father were expected to be con-
flicted, but the consciously reported feelings were expected to be quite
positive. While the TAT stories of bulimic women were expected to
depict revered but feared father figures, self-reports were expected to
reflect only the positive aspects of the father-daughter relationship.
Anorexics, in contrast, were expected to describe father in more neutral
terms at both the conscious and unconscious levels. Like the father of
the bulimic, the anorexic's father was expected to emerge as critical on
the TAT, but it was predicted that he would not be more feared or

idolized than the fathers of healthy control subjects.
H i i

Closely tied to the view of father as critical is the more general
attitude towards men and heterosexuality. Although bulimics seem to
have more mature heterosexual relationships than restricter-type
anorectics (Beumont, I977; Beumont, Abraham 8 Simpson, l98l; Beumont et
al., I976; Garfinkle et al., I980), fear of closeness with men appears a
major issue for individuals with both anorexia nervosa and bulimia.
”Bulimic patients are sexually active, but usually feel misused and are
unable to enjoy sex. They often report that a feeling of being out of
control, sexually, exacerbates the bulimia“ (Garfinkle 8 Garner, I982,
p. 50). Hence their greater sexual experience may reflect more upon

their impulsive style than psychosexual maturity per se. This

28

hypothesis is supported by Crisp's (I967, p. l28) observation that
bulimics “rushed into one relationship after another . . . in the
mistaken belief that they would then feel secure and wanted.“

Comparisons of anorexic subtypes indicate that restricters are less
likely than bulimics to have engaged in sexual intercourse, to have
taken oral contraceptives or to have ever had a steady boyfriend
(Beumont, 1977; Beumont et al., I976; Garfinkle et al., I980). In a
parallel manner, bulimics “act out” more impulsively in sex and in
eating; the restricting anorexic shuns both bodily functions.

Anorexics seem to lose all interest in sex and to avoid interaction
with the opposite sex (Bruch, I973; Garfinkle 8 Garner, I982). Psycho-
dynamic theorists originally suggested that anorexics suffer from fears
and fantasies of oral impregnation (Lindner, I955; Szyrynski, I973); the
onset of anorexia nervosa was traced to alarming sexual experiences.
For instance, Crisp (I970, p. A9A) notes that the development of
anorexic symptomatology was frequently marked by a ”sexual misadventure
ranging from some largely phantasized experience to a first guilty
experience of sexual intimacy.”

More recently theorists have attributed the anorexic's disinterest
in sexuality to her general immaturity and fears of parental abandonment
(Levenkron, I982; Selvini Palazzoli, l97l, I978). New interpretations
of the bulimic pattern of heterosexual interaction have also been put
forth. Boskind-Lodahl (I976) posits an extreme fear of failure in
intercourse among bulimic women. Should they prove inferior as lovers,
they expect to be rejected. Their fear of closeness with men hence
stems from their reluctance to render themselves vulnerable to

rejection. It has been suggested that such fears have been exacerbated

29

by the sexual revolution of recent years, as dating and heterosexual-
relationships have seemingly become synonomous with intercourse
(Boskind-White 8 White, I983).

Both anorexics and bulimics hence suffer from fears of, adult
heterosexuality and relationships with men, although their fears arise
from different developmental conflicts and their behavioral manifest-
ations are quite different. The bulimic's fear of men's power to reject
in sex seems a likely result of the father-daughter relationship,
described above. With peers as with father, men are overvalued and
feared; they have the power to hurt. The woman risks criticism.
rejection, or personal injury, while the man leaves the encounter
unscathed. This theme was predicted to emerge on the TAT in several.
forms: men are viewed as dangerous and hurtful to women, men are seen as
”getting away with it“ when they harm others, and on card I3MF, sex is
equated with murder. The woman is killed or destroyed in sex, while the
murderer escapes without reprimand. In contrast, the bulimic's
consciously expressed image of heterosexual relationships was expected
to be quite positive. While the theme of ”sex equals murder“ reflects
unconscious fears about closeness and heterosexuality, the young woman
consciously craves the affection and approval of men. She views
relationships as the solution to her problems, unaware. of the
unconscious fears which bar her from succeeding in her attempts with
men.

It was predicted that the anorexic subjects would likewise display
considerable fear of men, but this was expected to emerge at both the
conscious and unconscious levels. This postulate is grounded in the

considerable evidence that anorexics actively avoid heterosexual

30

contact. (Little dynamic conflict surrounds their internal fears about
heterosexuality; the conflict, rather, is between the anorexic and those

others who expect her to be interested in dating.

mtfi'rdr'

To date, few researchers have utilized projective measures to
confirm their clinical observations about young women suffering from
eating disorders. Such exploration of the binge-purge cycle is
virtually nonexistent, although several researchers have reported on the
projective assessment of anorexia nervosa.

Wall (I959, p. I000) writes that anorexics ”reacted with shock and
disgust 'to male and female sexual symbols in the Rorschach. The
Rorschach responses were similar to those seen in alcoholics and
addicts: much oral preoccupation, simple responses and much reference to
sea life.” Their style of response was characterized by withdrawal and
flatness of affect, and the underlying personality emerged as infantile
and lacking in complex emotional responses.

Using the more specialized scoring technique developed by Singer
and Wynne (I966), Selvini Palazzoli (l97l) compared the cognitive styles
of restricting and bulimic anorexics. She found a greater prevalence of
disorganized thought among the anorexics who binged and purged, which
correlated with poorer prognosis. This finding was not confirmed,
though, in Bruch's (I973) replication of Selvini Palazzoli's study.

Although Blitzer, Rollins and Blackwell (l96l) do not present a
systematic analysis of their data, they noted several themes common to
the TAT stories and Sentence Completions of anorexics. Among these were

fears of relationships with men, and conflicts around the desire to grow

3l

up, the fear of leaving mother, and the restraints imposed upon them by
their mothers.

More empirical research is needed to clarify the unconscious
dynamics that propel young women into bizarre eating patterns like
anorexia nervosa and bulimia. While' the clinical observations of
psychotherapists may serve as guideposts in this endeavor, they are
notoriously biased and demand more scientific confirmation. The
objective test data available are also suggestive, as they indicate the
individual's perceptions of her problems. Such data cannot, however,
speak to the etiologically critical internal conflicts of which the
individual is unaware. The role of the projective test is hence to
systematically explore intrapsychic dynamic currents which by definition
cannot be assessed by objective self-report instruments.

In such investigation, two methodological caveats must be
remembered. First, claims about unconscious dynamic events must be
accompanied by clear evidence that these themes are not readily
accessible to conscious awareness. While conflicts circulating at both
the conscious and unconscious levels are certainly troublesome in the
psychological sense, more pathological states would be expected to
result from internal conflicts of which the individual has little or no
conscious awareness. Secondly, in order to substantiate claims that
certain dynamic constellations are etiologically linked to
psychopathological conditions, it must be demonstrated that these
dynamics are absent in healthy individuals. Hence in the present
investigation, assessments were made of psychological conflicts at the
conscious level in concert with projective assessment, which is assumed

to tap intrapsychic processes, comparing the psychological profiles of

32

identified anorexics and bulimics with young women who were free from

such disturbed eating patterns.

Mefllflitmll

Hypotheses and scoring criteria for the present investigation were
developed on the basis of prior research reports and an informal pilot
study. TAT protocols were collected from four female college students.
Two were bulimic women who had been administered the TAT by their
psychotherapists. The comparison subjects were undergraduates who had
taken the TAT for extra credit in their introductory psychology classes.

Protocols of the bulimic women were Carefully studied by two
psychologists trained in psychodynamic theory and projective assessment.
The aim here was to extract dynamic themes common to both bulimic
protocols, but absent in the protocols of comparison subjects.

This exploration led to the generation of IA hypotheses regarding
the intrapsychic and interpersonal experience of the bulimic. Five
dynamic -themes were selected for further investigation, as they
reflected broad psychological experiences that seemed relevant both to
current research and to clinical experience with bulimic women. These

five themes can be briefly outlined as follows:

I. The hero feels isolated, 95 cut-off from her parents. This feeling
of psychological isolation at the unconscious level was presumed to
reflect dynamic motivators of eating disorders. In contrast, conscious
self-reports of isolation were considered to reflect the results of an

ongoing, pathological involvement with food.

33

2. ad news lg received p1 3g older couple from their child/children.

 

The child 9; children make the couple unhappy. The symbolic I'bad news“
here is the young woman's fear of and/or desire to displease her
parents. This unconscious current may lead to her behavioral commitment
to pleasing others, as well as to her conscious image of herself as
successfully meeting her parents' standards and fulfilling their

expectations of a daughter.

3. Ag older woman controls 2 younger woman. The older woman 1;

 

described positively but felt negatively. Ambivalence towards mother,
who is loved but felt as controlling, seemed to emerge through the
contradiction between angry, negative feelings at the unconscious level

and loving, positive descriptions of mother at the conscious level.

A. A father-figure jg disapproving pf his daughter. He jg feared but

 

respected py his daughter. The positive aspects of this relationship
seemed to emerge through conscious self-reports of bulimics, but more
fearsome aspects of such hero worship were revealed through projective

testing.

5. Sex jg equated with murder, and the murderer lg 39; caught. This
unconscious theme was interpreted as reflecting fears of personal harm
as a result of closeness with men, either sexually or interpersonally.
While the bulimic may fear the consequences of such heterosexual
relationships, she expects the men involved to be unaffected emotionally
and unharmed physically by their involvements with women. This
unconscious fear was not openly expressed by bulimic women; rather, the
consciously reported feelings about men reflected their desire for

closeness with men and their hopes for greater happiness and self-esteem

3A

as a result of heterosexual involvement.

Most of these themes were evoked by a range of TAT stimulus cards,
although the psychological equation of sex with murder emerged only on
card I3MF. Because of the blatantly sexual hature of this stimulus,
this theme was interpreted in all sories told about card I3MF in which
the woman is murdered and/or raped. The assaulter leaves his victim and
escapes judiciary punishment as well as internal feelings of guilt or
regret.

For scoring ease, some of these themes were partitioned into their
less complex constitUent themes, which together comprised the constel-
lations of feelings noted in the pilot study. ”Comparison constel-
lations” were added to allow for complementary evaluations of
relationships with both parents, and for the sake of completeness.
means were developed to assess all psychological themes at both the

conscious and unconscious levels, in anorexics as well as in bulimics.

mum:

i mi
In the present investigation, the TAT was utilized to assess
unconscious psychological themes presumed to be relevant to the genesis
of eating disorders. These themes can be summarized as follows:

Isolation
l. The hero feels isolated. Words used in the story indicate separ-
ation from parents and feelings of abandonment.

Bad news
2. Bad news is received by an older couple from their child or
children. The child or children make the couple unhappy.

Mother Constellation

3. An older woman controls a younger woman.

A. An older woman is described positively, but felt negatively
(ambivalence to mother).

35

Father Constellation

5. A father—figure is disapproving of his daughter.

6. A father-figure is idolized by the hero.

7. A father-figure is feared by the hero.

Father Comparison Constellation

8. An older man controls a younger woman.

9. An older man is described positively but felt negatively
(ambivalence to father).

Mother Comparison Constellation

I0. A mother-figure is disapproving of her daughter.
II. A mother-figure is idolized by the hero.

l2. A mother-figure is feared by the hero.
Heterosexual Relations

l3. Men are viewed as dangerous and hurtful to women.
IA. Men are seen as 'getting away with' hurting women.

I5. Sex is equated with murder (I3MF).
l6. Sex is equated with death by means other than murder (I3MF).

TAT protocols were scored for the presence or absence of these
themes in each story. Each time a theme appeared, one point was scored;
hence each subject could earn a maximum of l2 points for each theme.
However, where designated, hypotheses were scored only on one particular
card. Scores here ranged from O to l.

A sample coding form is included in Appendix A, and the TAT scoring
manual can be found in Appendix 8.,

Significant differences between groups were predicted for all
hypotheses except 8 through l2 and I6; these 'comparison' items were
included to contrast the predicted behaviors of each parent. On these
themes, no differences were predicted across groups. For each of the
primary hypotheses (l-7, l3-l5), it was predicted that subjects in the
bulimic and anorexic groups would emerge as more distressed at the
unconscious level than control subjects. No differences were predicted
comparing anorexics and bulimics, except on themes 6 and A7. As

discussed above, the psychological absence of the anorexic's father was

36

expected to render him less fearsome and less admirable than his bulimic

counterpart .
Weenies

The differences predicted above for the unconscious dynamic
patterns of anorexics, bulimics and controls were not expected to be
maintained in comparisons of consciously reported feelings. In a number
of areas the eating disordered subjects were expected to deny or repress
their feelings, while their conscious expression of feelings in other
areas was expected to be more accurate. Responses to I5 Likert-type
scales were analyzed and correlations were computed between these
conscious self-report items and the unconscious themes that emerged on
the TAT. (See Appendix C for conscious self-report items). The follow-
ing predictions concern the conscious dynamics _of the bulimic or
anorexic young woman:

I. She does not report feeling isolated from her family as a child,
presumably because such memories are too painful. However, she reports.
current feelings of isolation, which stem from her eating disorder.

2. She reports that she makes her parents happy, in direct contrast to
her unconscious feeling that she makes them unhappy. The conscious
report reflects her efforts to compensate for unconscious feelings of
inadequacy through compliance and success. Here the self-report is
derived from the defense against distressing unconscious material.

3. (Mother Constellation) Mother is described positively. Although she
may unconsciously be felt as negative and controlling, only the positive
side of the anorexic's or bulimic's ambivalence is expressed
consciously.

A. (Father Constellation) Father is idolized by bulimics at both the
conscious and unconscious levels, but the feeling that he is critical or
disapproving is not consciously expressed. Again, the negative side of
the bulimic's ambivalence emerges only through examination of
unconscious dynamics. The anorexic was predicted to report only that

father is critical of her.

5. (Father ,Comparison Constellation) Father is described in positive

37

terms; there is no discrepancy between conscious and unconscious
dynamics with regard to father being felt negatively or seen as
controlling.

6. (Mother Comparison Constellation) Mother, like father, is idolized
by the bulimic or anorexic, but she is not felt to be disapproving.
Here there is no discrepancy between conscious and unconscious feelings.

7. 0n items regarding heterosexual relationships, it was predicted that
bulimics would deny their fears and anger towards men. While they may
unconsciously feel that men are dangerous and hurtful, their conscious
report was expected to reflect the desire for heterosexual relationships
and a highly positive estimation of the male sex. Anorexics, in
contrast, were expected to report conscious fears of men and closeness
in heterosexual relationships.

Met/10d

1mm:

Subjects were 50 undergraduate women selected from a larger subject
pool on the basis of their stated eating patterns. Using DSM-III
criteria, twenty subjects were classified as bulimics. Ten subjects,
the ”recovered anorexics”, reported having experienced the DSM-III
sumptoms of anorexia nervosa in the past, although none were presently
anorexic. Two comparison groups were matched to the pathological groups
on demographic variables; one group consisted of IO young women who
dieted occasionally, and the other was comprised of IO subjects with no
prior history of weight or eating difficulties. All project
participants were unmarried Caucasian women aged l7 to 20; most were
Catholic or Protestant, and most came from upper middle class families
(SES strata IV and V; Hollingshead, I975). See Tables A and 5 for
demographic variables as they relate to group membership. These
demographic characteristics closely resemble those reported in other
studies of eating disorders (Garfinkle 8 Garner, I982; Herzog, I982, and
others).

Descriptive information about the eating habits of the bulimic
sample is presented in Table 6. These young women binge on large quan-
tities of high caloric food and resort to a variety of methods of purga-
tion and weight reduction, including laxative abuse, self-induced

vomiting, dieting and fasting. These eating patterns, which are both

38

39

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2
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m
“a. 00.x. mm. om.m_ mm. m_.m_ Nm. o4.m_ 804
a. an a. 3% a Run a 8% 28::
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anacu

 

 

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Table 5

Demographic Features 9: Project

A0

Participants

Anorexics Bulimics

Variable _g _3 41 :3
Ethnicity

Caucasian l0 l00 20 l00
Year in School

Freshman 6 60 I7 85
Sophomore 3 3O 2 l0
Junior l ID I 5
Marital Status

Never married I0 l00 20 l00
Living Situation

Dormitory 8 80 I 5
With female

friends 3 30 I7 85
With parents I . I0 5 25
Birth Position

First born 2 20 6 30
Middle child 2 20 2 l0
Last child 6 60 IO 50
Only child - - l 5
Twin - - l 5
Religion

Protestant 3 30 A~ 20
Catholic 5 50 8 A0
Jewish I l0 2 l0
Other I IO A 20
None - - 2 l0
Note. There were no significant

variables

Group
Controls
.9. 3;
I0 loo
6 60
A A0
IO loo
9 90
3 30
3 30
2 20
S 50
5 50
3 30
2 20

Dieters
2.1
I0 I00
9 90
I I0
l0 l00
I l0
l0 IOO
3 30
5 50
I I0
I ID
I ID
A A0
2 20
2 20
I l0

differences across groups on these

AI

 

 

Table 6
DSM-lll Symptoms Reported py Bulimic Subjects (p = 20)
Yes, Now Used To No
Symptom _e .35. .2. i .n_ 26.
Binge-eating IA (70) 6 (30) -
Self-induced vomiting 7 (35) 8 (A0) 5 (25)
Laxative abuse 8 (A0) 6 (30) 6 (30)
Fasting after a binge IO (50) 2 (l0) 8 (A0)
Dieting for weight control I7 (85) 2 (ID) I (5)
Anorexia nervosa - 2 (l0) I8 (90)
Always Often Sometimes Rarely/Never

Symptom .n, 3. .D. X. .D. Z. .0. 3.
Rapid consumption 7 (35) 7 (35) 3 (IS) 3 (15)
Binge on large quantities

of food A (20) l2 (60) - A (20) -
lnconspicuous eating 5 (25) 9 (A5) A (20) 2 (l0)
Binges are terminated by:

Abdominal pain A (20) 5 (25) A (20) 7 (35)
Sleep I (5) A (20) 5 (25) 10 (50)
Social interruptions - 3 (l5) 9 (A5) 8 (A0)
Fear of not being able to stop

eating, out of control A (20) 7 (35) 7 (35) 2 (I0)

A2
Table 6 - Continuation

Symptom n 2

Frequency of Binges

More than once a day l (5)
Daily 3 (15)
At least once a week 7 (35)
A few times a month 3 (l5)
Once a month or less 5 (25)
Length of Binges

Less than one hour I2 (60)
l - 2 hours 7 (35)
More than 2 hours -
Weight Fluctuations

Not at all 2 (IO)

Sometimes ll (55)

Frequently 7 (35)
Depressed Mood After Binges

Yes l5 (75)

No 5 (25)
Symptom IEEEL 331
Calories per binge l585 ll30
Cost per binge $5.AA $A.59

Duration of binge-eating
pattern (years) 3.35 2.6A

“3

extreme and bizarre, were also considered to be problematic by subjects.
They reported fears of not being able to control their eating, and they
frequently experienced feelings of depression after episodes of
bingeing.

Women in the anorexic group reported the following symptoms of
anorexia nervosa: deliberate weight loss, loss of menstrual period,
overactivity or exercise without enjoyment, terror of fat, feeling fat
despite protests of others who say they are too thin, and obsession with
thoughts of food. Members of the anorexic group differed significantly
from those of the other groups ton all of these diagnostic criteria
(p < .0I)(See Table 7). Weight loss ranged from IA to 502 of original
body weight; the group mean was a 26.3% loss (Table 8). Roughly half of
these anorexics could be described as restricters; the others engaged in
bingeing and purging behaviors (see Table 9). All the women in this
group reported histories of anorexia nervosa, but none of them were
presently anorexic. For convenience they will be referred to as the
anorexic group, although a more accurate description would be “recovered
anorexics”.

The eating patterns of these pathological groups stand in direct
contrast to those of the control groups, as shown in Table l0.
'Dieters' had minimal experience with binge-eating, but were currently
involved with dieting behaviors for weight control. Members of the
'control' group were even less involved with food and eating. If ever
they had binged, their binges tended to be quite small (500-750
calories) and were not felt as problematic. While these individuals can

be considered normal control subjects in that they eat three square

meals a day, they are statistically a rare minority. The predominant

 

44

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“5

Table 8

Percent Weigh; Loss 9: Subjects gy Group

 

Group I; Mean fl 3: _F
Anorexic I0 26.32 9.9] 3, A6 2.30A
Bulimic 20 I8.I0 8.05

Control I0 I6.59 29.A5

Dieters l0 8.95 A.92

A6

Table 9

Bulimic Symptoms Repgrted py Subjects jg the Anorexic Group (g = ID)

Yes, now Used to Never

3

as
I:

or

Symptom n 2

Binge-eating 2 (20) 3 (3o) 5 (50)
Self-induced vomitting - 3 (30) 7 (70)
Laxative abuse 2 (20) 2 (20) 6 (60)

Always Often Sometimes Rarely/Never
Symptom _n_ 2 _Q_ 2 n 9: _n_ 2

Binge on large quantities

of food 2 (20) 3 (30) 2 (20) 2 (20)
Eat very rapidly l (l0) A (A0) 2 (20) 2 (20)
Fear of not being able to stop _

eating, out of control 2 (20) 2 (20) 3 (30) 2 (20)
lnconspicuous eating 3 (30) A (A0) 5 (50) I (I0)

Abdominal pain after binges - ' A (A0) 2 (20) A (A0)

A7

Table 9 - Continuation

Weight Fluctuation

Not at all. -

Sometimes 3 (30)
Frequently 7 (70)
Frequency of Binges

Daily 2 (20)
Weekly I (l0)
Monthly 3 (30)

Less than monthly 2 (20)
Symptom bean .éQ
Calories per binge I2l9 l2A7

Cost per binge $2.75 $3.Al

A8

Table IO

Breakdown pi History pi Eatipg Patterns py Group

Group
Anorexic Bulimic Control Dieters

Variable _n_ i e 35. _n_ 26. £1 39 2: LL
Last binged

Never 3 (30) - 7 (70) 6 (60) l2 3A.63**
Years ago - - - l (l0)

Months 39° 5 (50) 5 (25) l (l0) 3 (30)

Weeks ago I (ID) A (20) - -

Days ago I (I0) II (55) l (l0) -

Duration of bingeing problem

Not applicable 3 (30) 2 (l0) 9 (90) IO (lOO) 6 3A.80**
Years 6 (60) I8 (90) I (l0) -

Months I (l0) - - -

Last vomited

Never 7 (70) 6 (30) IO(IOO) 9 (90) 12 26.AA*
Years ago - - - I (l0)

Months ago 3 (30) IO (50) - -

Weeks ago - 2 (I0) - -

Days ago - 2 (l0) - -

Duration of vomiting problem

Not applicable 7 (70) 8 (A0) l0(l00) 10(100) 6 I7.25*
Years 2 (20) . 9 (AS) ‘ ‘

Months I (I0) 3 (l5) - -

Last laxative abuse

Never 7 (70) 7 (35) IO(IOO) 10(100) l2 26.72*
Years 2 (20) l (5) ' ‘

Months - 5 (25) - -

Weeks I (I0) A (20) ‘ '

Days - 3 (IS)

“9

Table I0 - Continuation

Control

Dieters

Anorexic Bulimic

Variable _n 5 _n i
Duration of laxative abuse problem

Not applicable 8: (80) IO (50)
Years 2 (20) 5 (25)
Months - A (20)
Weeks - l (l0)
Last fasted

Never 5 (50) 8 (A0)
Years I (l0) -
Months 2 (20) A (20)
Weeks - 6 (30)
Days 2 (20) 2 (l0)
Duration of fasting problem

Not applicable 7 (70) 8 (A0)
Years 3 (30) 9 (“5)
Months - 3 (l5)
Last Dieted

Never 2 (20) I (5)
Years I (I0) -
Months A (A0) A (20)
Weeks - 7 (35)
DaYS 3 (30) 8 (A0)
Duration of dieting problem ,

Not applicable I (I0) 2 (I0)
Years 9 (90) I6 (80)
Months - 2 (l0)

*2 < .0]. **p < .OOI.

ID

I I I I 0

l0

I—IIKO

-‘\D

(loo)

(I00)

(mo)

(90)

(IO)

(90)
(I0)

lO(IOO)

NUIJUT I I

NN—e

(50)
(30)
(20)

(lo)
(70)
(20)

26.AA*

l8.27*

A2.5A**

29.A3**

50

eating profile of the young women surveyed in this study featured both
binge-eating and dieting for weight control.

In order to check the validity of diagnosing DSM-III disorders in
this non-clinical population, scores on the Eating Disorders Inventory
(EDI, Garner, Olmstead 8 Polivy, l983b) were compared across groups.
Eight subscales were derived from EDI responses, using the procedure
outlined by Garner, Olmstead 8 Polivy, (l983a)(see Appendix D).
Multiple analysis of variance revealed significant differences between
the two pathological and the two control groups (F(8, 39) = 9.20A, p
< .000l), but no differences comparing anorexics with bulimics on the
psychological concomitants of disordered eating behaviors (See Tables II
and l2). The pattern of responses to EDI subscales suggests that the
recovered anorexics in this study are best classified as having
”subclinical anorexia nervosa” (Button 8 Whitehouse, l98l). Their
scores were significantly higher than those of the control subjects on
the Drive for Thinness, Bulimia, Body Dissatisfaction and Interoceptive
Awareness Subscales, but the typically anorexic feelings of
ineffectiveness and fears of maturity (Bruch, I973) were absent. The
patterns of EDI subscale scores for both pathological groups closely
resembled those of bulimics and bulimic anorexics studied by Garner,
Olmstead and Polivy (l983a).

All subjects received extra credit in their psychology courses for

their participation in this project.

Meatless

Several questionnaires and a projective test were used in this

study. A modified form of the Eating Problems Questionnaire (EPQ,

51

 

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oo.~ o~.m .~._ oa.o
m~.~ om.m No.~ om.m
em._ om._ mb._ o~.~
mm._ om.~ mm.~ om.o
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mm. can: qw .qmua
o. u.m. o. u a.
meouo_o «_OLuCOu

 

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~_.~ o~.m
:~.~ mm.a
_ ~o.~ mm.m
om.m oo.~_
mm.m o~.m
_o.m m~.m
mo.m mm.m
mm coo:
ON liq.
mu_E__:m
anceu
mooLu Hm

 

 

 

_m._ om.m unneum_a .chmLoaLouc_
m:._ om.: Em_co_uuoweoa
_m.~ oo.m memo; >u_c3umz
4:.m o~.m mmoco>_uuoeeoc_
_~.a oo... co_HUbem_aamm_o xuom
m~.m .o_.o u_mumn:m m_E__3m
om.m 04.0. mmucuem3< m>_uaouoLouc_
oo.: oo.m unocc_ch to; u>_co
mm. mama aa_aum .98
o. u.q
mo_xococ<
co_uuc:m m Ml mo_mumn:m .ou mm mocoom

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52

Table I2

MANOVA pp EDI Subscales and Group

Source df 13; F

EDI Subscales 2A,l23 .889 2.l6l**

A 8 B vs. C 8 D

Overall F-test 8,39 .65A 9,20bnene
Drive for Thinness l,A6 A66.253 A7.62A****
Interoceptive Awareness l,A6 80.083 8.375**
Bulimia Subscale l,A6 2A3.000 27.377****
Body Dissatisfaction l,A6 I36.0I3 l3.002***
Ineffectiveness l,A6 2A.083 A.A92*a
Maturity Fears l,A6 2Il.680 ' 3l.I5A****a
Perfectionism l,A6 7.053 2.ll8
Interpersonal Distrust l,A6 l.080 .l78
A vs. 8
Overall F-test 8,39 .067 .352
Drive for Thinness l,A6 . .8l7 .083
Interoceptive Awareness l,A6 8.8l7 .922
Bulimia Subscale l,A6 2.A00 .270
Body Dissatisfaction l,A6 6.667 .637
Ineffectiveness l,A6 2.8l7 .525
Maturity Fears l,A6 .l50 .022
Perfectionism l,A6 l.067 .320

Interpersonal Distrust l,A6 .600 .099

Table l2 - Continuation

Source

53

B vs. C and D

Overall F-test

Drive for Thinness
Interoceptive Awareness
Bulimia Subscale

Body Dissatisfaction
Ineffectiveness
Maturity Fears
Perfectionism

Interpersonal Distrust

9i. Jfli
8,39 .6l5
l,A6 A03.225
l,A6 A8.A00
l,A6 220.900
l,A6 136.900
l,A6 IA.A00
l,A6 180.625
l,A6 8.l00
l,A6 1.600

“Opposite predicted direction.

*2 < .05, **E < ,0], ***B

< .00l. ****p < .000l.

Al.

2A.

l3

26

,786****

187****

.062*

887****

a

.087***
.686
.583****
.A32

.26A

a

5A

Stuckey, Lewis, Jacobs, Johnson 8 Schwartz, I98l) provided descriptive
information regarding current bingeing, purging, fasting and dieting
behavior, and history of weight and eating disorders. The instrument
also surveys attitudes and medical difficulties associated with these
behaviors. It was used to generate DSM-lll diagnoses of anorexia
nervosa and bulimia. A second questionnaire examined conscious feelings
about parents and family using 7-point Likert-type scales. In addition,
a brief demographic questionnaire and the Eating Disorders Inventory
(EDI), which addresses psychological concomitants of eating disorders,
were administered to all subjects. Copies of objective test materials
are included in Appendices C, D, and E. The Thematic Apperception Test
(TAT) is a projective test, which is designed to tap into unconscious
processes through the stories subjects tell about a standard series of
pictures. TAT slides were used for group administration of this test,
as research indicates that administration technique has little overall
effect upon quality of stories (Stein, I978). While this method may
evoke stories that are somewhat shorter and less elaborate than those
told orally (Karon, I98l), it was assumed to be adequate for present

purposes.

Preeedgre

I

Students interested in participating in this study were admin-
istered questionnaires in groups of 20-30 people. Each subject was
given a packet containing the EPQ and a short demographic questionnaire.
All questionnaires were coded numerically, and participants submitted a
separate identification page with their names, telephone numbers and

subject numbers.

55

Fifty subjects were then selected from a pool of 283 young women
according to their responses on the EPQ. Twenty met the DSM-Ill
criteria for bulimia, and l0 reported recovery from the DSM-lll Symptoms
of anorexia nervosa. Two comparison groups of l0 subjects each were
then formed, each matched to the pathological groups on demographic
variables. 0f the 50 young women selected, eight refused to participate
in the second phase of the study. The refusal rate was roughly equal
across groups: one anorexic, three bulimics, three dieters and one
control subject. Replacement subjects were selected from the original
subject pool using the same diagnostic criteria described above.

In groups of four to eight people, subjects were shown TAT slides
by the investigator, who was blind to group membership. The cards used
were numbers l, 2, 38M, b, 5, 66F, 76F, l0, lZF, l3G, l3MF, and lb.

The following instructions (Karon, l98l) were given to subjects
taking the TAT:

I'm going to show you a set of l2 pictures, one at a

time. I want you to write a story, telling what‘s going

on, what the characters might be feeling and thinking,

what led up to it, and what the outcome might be. In other

words, write a good story. Use the pen and paper in

front of you. You can change anything that you have

written, but do NOT cross it out. Strike it out with

a single line and correct it.

Card 16 (the blank card) was introduced as follows:

Up to now I have asked you to tell stories. Now I

would like you to make up a picture. It can be a

picture you've seen or one that's entirely yours.

Write a description of the picture.

After the subjects had written their descriptions, the investigator

said:

Now take the picture you have described, and use
it like the other ones. Write a story about it.

56

Following the TAT administration, subjects were asked to complete
the Eating Disorders Inventory and the questionnaire on conscious
psychological themes.

All TAT protocols were independently rated by two psychologists
trained in the interpretation of projective techniques. Both raters
were blind to group membership of subjects. After extensive training on
pilot data, interrater reliability was established on 30 TAT stories
from the data pool. Using a binary code for each of l6 unconscious
themes, the concordance rate between raters was 9h.2%.

Conscious self-report data was analyzed in raw form, with the
exceptions of items addressing feelings of isolation and ambivalence
towards parents, and the items which comprise the EDI. Conscious
feelings of isolation were calculated by averaging the numerical
responses to the following two items:

When I was young, I often felt like I didn't have a family,
because I felt so disconnected from my parents (and siblings)

I feel separate, or cut-off from other people.

Feelings of ambivalence towards mother and towards father were
calculated using the following self-report items:

My mother/father often seemed kind and sweet.

I believe that inside, my mother/father was mean or dangerous.
Responses to the items on ambivalence towards parents were each summed
and recoded, since two mutually contradictory questionnaire items
comprised this topic. All sums less than or equal to eight were coded
”l”; sums from 9 to IA were reassigned consecutive values from 2 to 7.
Hence all computed scores still ranged from i to 7, where ”I” denoted

”Never or almost never true” and ”7” denoted "Always or almost always

57

true.“

Responses to the EDI were combined into eight subscales, using the
system set forth by Garner, Olmstead and Polivy (1983a). See Appendix D
for a listing of subscales and constituent items.

Each cluster of hypotheses regarding conscious and unconscious
dynamics was tested using multiple analysis of variance, followed by
three planned comparisons of groups. In each case these comparisons
were I) anorexics and bulimics versus controls and dieters, 2) anorexics

versus bulimics, and 3) bulimics versus controls and dieters.

Camel/lateness

Prior to participation in this study, all subjects were instructed
to read the consent agreement found in Appendix F. Their choice to
participate in this study implied an understanding and an acceptance of
the terms set forth in the consent form. Subjects were invited to leave
the testing room and to return their unanswered questionnaires if they
did not accept these terms. All subjects did, however, agree to
continue participation.

Separate from the consent letter and the numerically coded
questionnaire and answer sheet was a subject identification form. This
was used to compile a coded list of participants for the second phase of
the study (projective testing). Coded identification sheets were
separated immediately from completed questionnaires. They were stored
in a locked file, and destroyed within three months. Only the principal

investigator had access to this information.

Results

MW

Multivariate analysis of variance revealed few significant '
differences comparing groups on unconscious dynamic conflicts. As shown
in Tables l3 and IL, groups were not distinctive from each other on any
of the following themes: feelings of isolation, feeling that one makes
one‘s parents unhappy, relationship with father, and perceptions of het-
erosexual relationships. Groups also resembled each other on all
comparison themes.

Statistically significant differences were noted, however, on
themes subsumed under the Mother Constellation (mother is seen as
controlling; she is described positively but felt negatively)
(£(6, 92) = 2.752, p < .05). This difference was not maintained in
planned comparisons, as it reflected the dieters' perceptions of mother
as less controlling combined with their more strongly conflicted and
ambivalent feelings about her.

Two post hoc correlational analyses were performed on the TAT data,
comparing scores on unconscious themes with demographic/behavioral data
(Table l5) and with EDI subscales (Table 16). While these analyses
yielded some significant relationships between variables, no consistent

patterns emerged. Given the large number of correlations computed (736

correlations between unconscious themes and eating behaviors, 128

58

Table 13

Frequencies of Unconscious Themes by Group

59

 

Dieter

_Q_8 10

 

S

Anorexics
.fl_= 10
Unconscious Themes [Mega ‘SQ
Isolation 3.00 1.76
Bad News .90 .99
Mother Constellation
Controlling 1.70 1.3h
Ambivalence .20 .AZ
Father Constellation
Critical .60 .70
Respect, Admire .20 .AZ
Fearsome .20 .63
Relationships with Men
Hurtful 2.00 1.15
Men get away with
hurting women .70 .82
Sex=Murder .30 .h8

Mother Comparison Constellation

Critical .50 .53
Respect, Admire .10 .32
Fearsome .20 .63

Father Comparison Constellation

Controlling .50 .71
Ambivalence 0 0
Sex-Death, other causes .60 .8h

Group
Bulimics Controls
.fl.‘ 20 .fl_8 10
Mean SD Mean SD
2.80 1.A7 3.10 0.88
1.30 1.16 1.50 0.71
1.60 1.05 1.70 1.25
.20 .52 .10 .32
.A5 .60 .80 1.03
.05 .22 .10 .32
.15 -37 .20 .Az
1.95 1.53 1.80 1.13
.85 1.0L .60 .70
.30 .h7 .20 .AZ
.60 .60 .70 .67
.05 .22 0 0
.10 .AA 10 .32
.80 .91 1.20 1.1h
.05 .22 0 0
.30 .h7 .50 .53

.90

.30
.10

.20

.50

.50
.AO

.60

.10

.60

.20

.96
-57

.k8

.32
.52

.85

.71
.52

.52
.32

.52
.32
.h2

Table lb

MANOVA 22 Unconscious Themes by Group

Source _gfi
Isolation
Overall F-test 3,h6
A 8 B vs C 8 D 1.96
A vs 8 1,h6
B vs C 8 O l,A6
Bad News
Overall F-test 3,h6
A 8 B vs C 8 D I,h6
A vs 8 -1,h6
8 vs C 8 O l,A6
Mother Constellation
Overall F-test 6.92
A s 8 vs c s 0 2.1.5
A VS 8 201.5
B vs C 8 O 2.85
Father Constellation
Overall F-test 9,138
A 8 8 vs C 8 D 3,bh
A vs 8 3,kh
8 vs C 8 O 3.Ah
Relationships with Men
Overall F-test 9,138
A 8 B vs C 8 D 3.Ah
A vs 8 3.hh
8 vs C 8 O 3,Ah
Mother Comparison Constellation
Overall F-test 9,138
A 8 B vs C 8 O 3,Ah
A vs 8 3,AA
8 vs C 8 O 3,Ah
Father Comparison Constellation
Overall F-test 6.92
A 8 B vs C 8 O 2.85
A vs 3 2.85
8 vs C a O 2.55
Sex - Death, Other Causes
Overall F-test 3.96
A 8 B vs C 8 D l,A6
A vs 3 l,A6
B vs C 8 D l,A6

m< .05

.307
.653
.267
. 900

.650
-333
.817
.025

.30b
.096
.003
.079

.102
.002

.039
.010

.06h
.023
.010
.025

.053
.032
.019
.011.

.125
.019
.017
.007

.360
.030
.600
.025

.166
.35A
.lkh
.h87

.622
.319
.782
.021.

.752*
.380
.076
.9h0

.51.1
.028
.592
.151.

-337
.3h8
.1115
.380

.275

-h79
.282
.203

.019
.1131.
.396
.151,

.127
.091.
.878
.078

61

Table 15

Behavioral Correlates g: Unconscious Themes

Unconscious Themes

2 3 A

Bad Mom Ambiv.

8
Dad

13
Hurt- Men get Sex-

controls ful

lh

away

15

16
Other

Murder causes

 

Behaviors news controls Mom
Binge-eating .063 .0h6 -.253*
Eat large amounts .153 .0h8 -.l6l

Frequency of binges .073 -.026 .258*

Abdominal pain after
binges -.0h7 .261* -.066

Vomiting .231 .073 -.061

Frequency of vomiting -.235* -.167 -.093

Laxative abuse -.239* .131 -.135
Frequency of laxative

abuse .2A2* -.086 .052
Age at first laxative

abuse -.267* .060 -.093
Fasting -.113 .090 -.055
Age at first fast -.101 .170 -.088
Length of fasts -.O65 .193 -.O78
Dieting -.lh6 -.092 -.00h
Age at first diet -.099 .035 .212
Length of diets -.203 .026 .IZA
Amenorrhea -.186 .082 -.189

Exercise without
enjoyment -.275* .059 -.211

Terrified of fat -.10h .13h .121

.0k8

.115

-.003

-.0h8

-.IA8

-.210

.27h*

-.25h*
-.165
-.168
-.l32
-.275*
-.251*
-.271*

-.095

‘-275*

-.209

.0A7
.1u3

.171

.36h**
.130.
.2h6*

.251*

.201

~23}
.278*
.37lflk
.362**
.091
.028
.083

.112

~139

.022

.166
.189
.063

.325*
.100
-.306*

.2h5*

-.266*

.2h6*
-239*
.278*
.23h
-.O38
.036
-.225

.005

.068
.136

.08A
.062

.031

.OOh
.052
.150

~239*

.231

-259
~139
.069
.063
.181
.Ohl
.020

.19h

.218

.25u*

.072
.36b**
-.020

-.206

.300*

-.231
-.210
-.163
-.238*
-.055
--099
.006

.3hl*

.235

.161

62

Feel fat despite what

others say -.137 .229 -.003 -.31u* -.1A6 -.160 -.317*
Lowest weight -.237* .178 .199 -.289* -.099 -.126 -.356**
Have a boyfriend .083 .th -.073 .100 -.100 -.127 .238:
Regular Menses .160 .062 -.l70 .039 -.138 -.I32 .Zhst
Intentional

self-injury -.070 -.09A -.205 -.250t -.277* -.170 -.120
Frequency of exercise -.068 .316* .000 -.116 .028 -.002 -.298*
LL -.2u7* -.003 -.079 -.186 .279* .235* -.202
DL -.213 .091 -.090 -.120 .359** .308* -.269*
LF -.l3h .036 —.027 -.227 .213 .218 -.158
or —.122 .079 -.109 -.19A .379** .253* -.103
LD -.0u3 -.029 .236* -.226 -.101 -.106 -.039
00 -.22h .007 .12A -.258* —.129 -.072 -.02h
TSLW -.189 -.026 .009 -.153 -.ZAI* -.383**-.1&6

Note. Several behavioral measures and unconscious themes have been
deleted from this table beause their intercorrelatins were not
statistically significant with any other variables.

Note. LL - Last use of laxatives, DL - Duration of laxative abuse
problem, LF - Last fasted. OF I Duration of fasting problem, LD - Last
dieted. DD - Duration of dieting pattern. TSLW - Time elapsed since
lowest weight.

*2 < .05. **2 < .01.

 

.118
.082
-.009

.096

.030
-.o17
-.1u3
-.092
-.300*
-.111
-.101
‘-037

-.100

63

Table 16

Correlations Between Unconscious Themes and EDI Scales

 

EDI Subscales

Unconscious Themes Drithin Intawar Bulsub Bodydis Ineff Matfears Perfx Intdis

1. Isolation -.III -.203 .010 .153 -.088 -.l36 -.063 -.221
2. Bad News .017 °.061 -.155 .338** .102 -.017 -.085 .066
3. Mom Controls .128 .052 .125 .178 *.099 '.280* .232 ’.329**
h. Ambiv,Mom ‘ .065 .060 ‘.002 .129 .106 .019 -.003 °.095

5. Dad Dissaproves -.126 -.2ho* -.025 .107 -.Zh6* -.106 -.OAA -.00h
6

Idolize Dad -.106 .000 -.101 -.066 -.057 .208 -.lhO .110

7. Fear Dad ’.151 -.259* ‘.093 ‘.087 “.173 -.060 ‘.226 ’.1hb
8. Dad Controls -.O65 -.211 -.107 .221 -.065 '.021 -.029 -.Ohl
9. Ambiv. Dad .198 .113 .102 .095 .070 -.162 .08“ '.071

10.Mom Disapproves .069 .075 .225 .159 .271* -.201 .219 -.113

11.Idolize Mom .l7h .025 -.096 -.Oh6 .026 .089 -.029 .1h5
12.Fear Mom -.022 .006 -.osh -.202 -.103 -.136 .011 -.038
l3.Men, Hurtful .086 -.266* .208 .388** -.078 -.271 .126 -.296*
1h.Men get away .066 -.1h3 .172 .312k -.120 -.298* .187 -.155
15.Sex - Murder -.I7h -.120 -.267* - 010 -.20A .071 -.179 -.02&
16.0ther Causes .05A .299* .056 .136 -.027 -.077 -.0h8 .186

Note. Drithin - Drive for Thinness: Intawar - Interoceptive Awareness:
Bulsub - Bulimia Subscale: Bodydis - Body Dissatisfaction: Ineff -
Ineffectiveness: Matfears - Maturity Fears; Perfx - Perfectionsim:
Intdis - Interpersonal Distrust.

*2 < .05. **g < .01.

6A

correlations with EDI subscales), the number of statistically signif-
icant relationships that did emerge (59 and 7 respectively) would be
expected on the basis of chance alone. Therefore these results will not

be discussed in any further detail.

2 . 2 .

Analysis of conscious self-report data revealed differences across
groups in the areas of relationships with men and feelings towards
father. In contrast to predictions about conscious dynamics, those
differences which did emerge across groups were on negative affects: no
differences were noted on warm or positive feelings.

As shown in Tables 17 and 18, no differences were found comparing
groups on reported feelings of isolation. A nonsignificant trend
(2 < .20) was noted comparing subjects in the two pathological groups;
anorexics and bulimics tend to report feelings of isolation more often
than control subjects or dieters. No differences were found, though,
comparing current feelings of disconnection from others with childhood
feelings of psychological remoteness.

Direct questionning about feelings of displeasing one's parents
also failed to reveal differences across groups. Subjects in all groups
reported that they rarely made their parents unhappy.

In the feelings they reported about their mothers, anorexics and
bulimics closely resembled subjects in the comparison groups. They
tended to agree with the statement “I respected and admired my mother,”
but they were unlikely to describe mother as controlling, critical or
mean. Strong conscious feelings of ambivalence towards mother were not

reported by any of the subjects studied.

Table 17

Freguencies pi Conscious Themes pl Group

Conscious Themes

Isolation
Bad News

Mother Constellation
Controlling
Ambivalence

Father Constellation
Critical

Respect. Admire
Mean inside

Relationships with Men

Hurtful

Get away with hurting

Mother Comparison Constellation

Critical
Respect. Admire
Mean inside

Father Comparison Constellation

Controlling
Ambivalence

Anorexics
n_- 10
Mean fin
5.90 3.31
2.20 1.93
2.80 1.87
1.60 1.90
2.30 1.92
5.10 2.02
2.00 1.56
3.60 1.51
3.110 1.65
2.20 1.98
5.70 1.89
1.70 1.89
2.50 1.18

1.90

.97

_ouww

Bulimics
_n - 20
bean in
5.65 2.70
2.70 1.95
3-75 1-9“
1.10 .31
3.25 2.00
6.25 0.85
1.65 1.27
b.85 1.31
3.95 2.01
.30 1.78
.30 1.75
-70 .99
3.85 2.01
1.05 .22

Controls

Jl - 10

Mean an
11.60 2.81,
2.00 1.05
3.60 1.90
1.00 0

2.10 1.52
9.90 2.28
2.10 1.91
3.10 1.h5
2.90 1.35
3.00 1.70
5.10 1.99
1.50 .97
3.00 1.63
1.10 .32

Dieters

.n - 10

been $.11
A.90 3.20
2.50 1.93
2.80 1.118
1.10 0.32
1.70 1.16
5.90 1.20
1.90 0.97
3.90 1.66
3.00 1.33
2.80 1.69
5.60 1.58
1.70 1.16
2.30 1.6h
1.00 O

Table 18

MANOVA pp Conscious Themes and Group

Source

66

Isolation
Overall F-test
A 8 B vs. C 8 D
A vs. 8

B vs. C 8 D

Bad News

Overall F-test
A 8 B vs. C 8 D
A vs. 8

B vs. C 8 D

Mother Constellation
Overall F-test
A 8 B vs. C 8 D
A vs. 8
B vs. C 8 D

Father Constellation

Overall F-test

A 8 B vs. C 8 D

A vs. B

B vs. C 8 0
Critical
Respect, admire
Mean inside

3,96
1,96
1,96
1,96

3,96
1,96
1,96
1,96

6,92
2.95
2,95
2,95

9.138
3,99
3,99
3,99
1,96
1,96
1,96

6.290
18.253
.917

13.225

1.293

.963
1.667
2.025

.116
.021
.076
.020

~293

-135
.192

.213

.100

\NO‘WNN—d

.719
.087
.098
.512

.582
.933
.719
.911

.991
.972
.862
.962

.659
-299*
.939*
.958*
.609**
.009*
.099

Table 18 - Continuation

Source

67

Relationships with Men
Overall F-test
A 8 B vs. C 8 D

Hurtful

Get away
A vs. 8
Hurtful
Get away
8 vs. C 8 D
Hurtful
Get away

6,92
2.95
1,96
1,96
2,95
1,96
1,96
2,95
1,96
1,96

Mother Comparison Constellation

Overall F-test
A 8 B vs. C 8 D
A vs. 8

B vs. C 8 D

9.133

3,99
3,99
3.99

Father Comparison Constellation

Overall F-test
A 8 B vs. C 8 D
A vs. 8
Controlling
Ambivalence

B vs. C 8 D

*p< .10.

6,92
2,95
2,95
1,96
1,96
2,95

*92 < .05. ***p <.01.

.230
.115
.953

.653
.106

.917
.017
.169
.225
.625

.078
.003
.060
.013

~297
.051
.193
.150
.817
.103

t'NF'S'Nd

moo:-

Nwrmdw

.996*
.912*
.970**
.696**
.671*
.953*
.699
.923*
,665**

.379*

.909
.095
.990
.191

.262**
.197
,387***
.075**
.665*
.592*

68

Analysis of reported feelings towards father revealed more
complicated patterns. Subjects in all groups reported stronger feelings
of respect and admiration for father than dysphoric feelings, but
several important differences emerged in cross-group comparisons. While
the overall F-test of predicted feelings towards father .(father is
critical, mean, and admired) revealed no differences across groups,
planned comparisons pointed to significantly different patterns in this
constellation of feelings. Nonsignificant trends were noted comparing
anorexics and bulimics with the two control groups, and comparing the
pathological groups with each other, but statistically significant
differences emerged comparing the bulimic group with the two control
groups (£(3, 99) = 3.958, p < .05). This difference reflects the
bulimic's significantly stronger perception of father as critical
(£(1, 96) a 6.609, p < .05) and the trend for bulimics to feel greater
respect and admiration for father compared to subjects in the two
control groups ([(I, 96) = 3.009, py< .10).

Contrary to hypothesized predictions, statistically significant
differences also emerged on the conscious self-report items subsumed
under the Father Comparison Constellation (father is seen as control-
ling; he is described positively but felt negatively) (£(6, 92) =
2.262, p < .05). No differences were found contrasting the two pathol-
ogical groups with the control groups, but the bulimics differed signif-
icantly from the anorexics in this regard (£(2, 95) = 5.387, p < .01),
and a nonsignificant trend differentiated them from the two comparison
groups (£(2, 95) = 2.592, p < .10). These multivariate differences
reflect the bulimic's perception of father as controlling (£(1, 96) =

9.075, p < .05). and the anorexic's more ambivalent feelings towards

69

father (£(I, 96) a 3.665, p < .10).

Multivariate analysis of variance on items that addressed feelings
about men and heterosexual relationships did not yield significant
differences across groups (£(6, 92) a 1.996, p < .10), but a number of
significant trends emerged at the univariate level. Anorexics and bu-
limics agreed more strongly than control subjects or dieters with
statements that men are hurtful to women ([(1, 96) = 9.970, p < .05) and
that men get away with it when they create pain for women ([(1, 96) =
9.696, p < .05). Differences also emerged comparing anorexics and bu-
limics on attitudes towards men. The bulimics were considerably more
adamant about the dangers of heterosexual involvements than anorexics
(£(1, 96) = 9.953, p < .05). DifferenCes were also significant compar-
ing the bulimics with the control groups ([(2, 95) a 9.923, p < .05).
The bulimics again felt more strongly about the probability of getting
hurt in a close relationship with a man (5(1, 96) = 8.665, p < .01), and
they were more likely to believe that men 'get away with' hurting women
(£(I, 96) - 5.379. 2 < .05). 1

Turning to a more behavioral index of attitudes towards hetero-
sexual relationships, clear differences also emerged across groups on
current dating behavior. As shown in Table 19, anoreXIC‘ and bulimic
subjects were less likely to be involved in ongoing dating relationships
than control subjects or dieters ( (3, N - 96) = 10.05, p < .05).

Post hoc correlational analyses were performed on those variables
which distinguished pathological and control subjects (See Table 20). A
central core of bulimic behaviors seems related to the perceptions of
father as critical and controlling, and men as dangerous to women (they

hurt women and get away with it). Among these behavioral correlates are

70

Table 19

Current Datipg Behavior pf Patholpgjcal and Control Groups

Currently Not Currently

Group 11 Dating Dating .d: ‘jL;
Anorexic 10 3 7 3 10.05*
Bulimic 17 6 11
Control 9 8 1
Dieters 10 7 3

*p < .05.

Table 20

71

Correlates pi Significant Conscious Themes

Respect.Admire
Father

Behaviors

Father
Critical

Themes

Father
Controls

Men are
hurtful

Men get away
with it

Binge-eating

Large amounts of food
Eat rapidly

Eating out of control
Frequency of binges
Calories per binge

Abdominal pain after
binges

Sleep after binges

Social interruptions
end binges

Self-induced vomiting
Laxative abuse
Fasting

Obsessed by thoughts
of food

Currently dating
Suicidal thoughts

Exercise without
enjoyment

Total exercise per day

*2 < .05. **2 < .01.

.327
.127
.096
.182

.122

.157

.139

.016

.171
.086
.218

.090

.026
.090

.030

.032

.012

***p < .001.

.207
.252*
.298*

.390**

-.005

.029

.170

.999**

.139
.225
.617***

.507nea

.389*£
.318*

.292*

.235*
-237*

.290*
.322*
.382**
.163
.068
.268

.269*
.381**

.091
-255*
.290*

.186

-.199

-.008

-075

-.001

,tt3***
.962***
-297*
.292r
.309*

.388*

,953***

,953***

.155
.633***

.295*

.185

-.086
.2599

.250*

.212

-.039

.260*
.398**
.379**
.907**
.106

.169

,571***

.999***

.278*
.308*
.250*

.151

.128
.923**

.298*

.095

.193

72

various features of binge-eating, as well as laxative abuse and self-
induced vomiting. Women who consciously agreed with these themes and
engaged in those behaviors were also less likely to have steady boy-
friends. No clear pattern emerged connecting specific bulimic behaviors
with endorsement of particular conscious themes.

Table 21 shows the relationships between EDI subscales and
consciously reported themes. The magnitude and statistical significance
of these correlations points to the close relationship between these
themes and the psychological experience of eating pathology.

Feelings of isolation and being cut-off from others correlated with

the Drive for Thinness (L = .389, p < .01), and with the Bulimia (L =

.920, p < .001) subscales of the EDI. In this sample, Psychological
isolation was inversely related to Maturity Fears (£= -.503, p < .001)
and to Interpersonal Distrust (L = -.930, p < .001).

The perception of mother as controlling was significantly cor-
related with the Drive for Thinness (p = .303, p < .05), with Body Dis-
satisfaction (5 = .257, p < .05), with Perfectionism (L 8.329, p < .01),
and with Interpersonal Distrust. (p = -.296, p < .05). Likewise,
feelings that father was controlling correlated with two EDI subscales:
Bulimia (p = .250, p < .05), and Maturity Fears (p = -.289, p < .05).

Feeling disapproved of by one‘s parents related closely to the
psychological concomitants of anorexia nervosa and bulimia. Disapproval
by mother was significantly correlated with the Bulimia Subscale
(p 8 .251, p < .05), while disapproval from father was closely linked to
several EDI subscales: Drive for Thinness (L = .311, p < .01), Bulimia
(p I .389, p < .01) Maturity Fears (p = -.929, p < .001) and

Interpersonal Distrust (p = -.312, p < .05).

73

Table 21

Correlations Between Conscious Themes and EDI Subscales

EDI Subscales

Drithin Intawar Bulsub Bodydis
Conscious Themes
Isolation .389** .207 .920*** .157
Bad News .091 .081 .219 .179
Mom Controls .303* .133 .139 .2578
Ambivalence to Mom .178 .2588 .196 ' .070
Dad Disapproves .311* .051 .389** .168
Dad ldolized .022 .155 .053 -.137
Dad Feared .138 .101 .073 .039
Dad Controls .231 -.003 .2509 .127
Ambivalence to Dad .118 .133 -.037 .105
Mom Disapproves .177 .190 .2519 .115
Mom ldolized -.069 .092 .032 .005
Mom Feared .253 .2518 .088 -.067
Men are Hurtful .351** .216 .909** .308**

Men Get Away .927*** .223 .952*** .970***

Table 21 - Continuation

Conscious Themes

Isolation

Bad News

Mom Controls
Ambivalence to Mom
Dad Disapproves
Dad ldolized

Dad Feared

Dad Controls
Ambivalence to Dad
Mom Disapproves
Mom ldolized

Mom Feared

Men are Hurtful
Men Get Away

Note.

Bulsub = Bulimia

79

EDI Subscales

Matfears

Perfx

Intdist

.112
.139
-.022
-193
‘-157
.131
-.190

-.212

Drithin - Drive for Thinness:
Subscale;

Ineffectiveness: Matfears
Intdist = Interpersonal Distrust.

*2 < .05.

#92 < .01.

,5o3***
.2899
.203
.187
.929***
.003
~173
.2899
.219
-095
.066
.190
.935***

,592***

Bodydis
Maturity

*sb'cE < .001.

.023
.206
,32992
.152
.199
.092
.023
.207 i
.013
.232
.119
.097
.297*

.313*

Fears;

Intawar . Interoceptive
Body Dissatisfaction;
Perfx -

.930***
.123
.296*
-033
.3129
.063
.068
.190
.019
.165
.198

.192

.279*
.358**
Awareness;

Ineff 8
Perfectionism;

75

Finally, the beliefs that men are hurtful to women, and that men
leave heterosexual encounters emotionally unscathed, were both closely
related to six of the eight EDI scales. Theme-subscale correlations
were statistically significant for Drive for Thinness (p = .351, p
< .01: L c .927, p < .001), Bulimia (p = .909, p < .01; p = .952, p
< .001), Body Dissatisfaction (L = .380, p < .01; p = .970, p < .001),
Maturity Fears (p = -.935, p < .001; p = -.592, p < .001),
Perfectionism (p = .297, p < .05; L = .313, p < .05), and Inter-
personal Distrust (p = -.279, p < .05; L = -.358, p < .01)
respectively. Correlations with subscales were consistently higher for
the item "Men always seem to get away with it when they create pain for
women“ than for the item ”If you are in a close relationship with a man,
you always end up getting hurt.‘I

Table 22 shows the correlational relationships between TAT themes
and feelings accessible to consciousness. On only two items were the
corresponding correlations between conscious and unconscious themes
statistically significant: Mother is feared (p = .279, p < .05), and Men
get away with hurting women (1 = .271, p < .05). Interestingly, on two
other items, disapproval and control, the conscious perception of father
was significantly correlated with unconscious feelings about mother
(L - .339, p < .01; p a .257, p < .05). This pattern is repeated,
albeit less precisely, in many of the other statistically significant
correlations; rough equivalents of consciously expressed feelings
towards one parent are unconsciously felt towards the other parent. In
most cases, the negative affects admitted to consciousness were in
relation to father, while those not consciously expressed tended to

concern mother.

76

Table 22

Correlations Between Conscious and Unconscious Themes

Unconscious Themes

.027
.080
.092
.099
.008

.102

,333**
-135
-l73

.209

.257*

.172

.091
.091
.209
.069
.101
.109
.086
.131
.089

.109

-039
-039

Conscious Themes 1 2 3 9
1. Isolation .108 -.216 .101 -.036
2. Bad news .260* .066 -.052 .158
3. Mom controls -.159 .073 .152 .072
9. Ambivalence to Mom -.117 -.019 -.216 -.080
5. Dad disapproves .081 -.189 .063 .015
6. Dad idolized -.059 -.023 .095 -.093
7. Dad feared .192 .178 .078 -.009
8. Dad controls .095 0 .257* -.095
9. Ambivalence to Dad .109 .118 .179 .083
10.Mom disapproves -.l38 .057 .200 .028
11.Mom idolized .210 -.035 -.006 .076
12.Mom feared -.188 .007 -.109 .099
13.Men are hurtful .227 .031 .156 .260*

19.Men get away .138 -.079 .2959 .399**

.063

.101

.056

.192

77

~ Table 22 - Continuation

Unconscious Themes

Conscious Themes 7 8 9 10 11

1. Isolation .173 -.091 .129 .119 -.228
2. Bad news .139 .069 .151 .083 -.129
3. Mom controls .075 -.088 -.038 .093 -.151
9. Ambivalence to Mom -.087 -.189 -.093 .106 -.093
5. Dad disapproves -.099 -.200 -.062 .339** -.062
6. Dad idolized -.099 '.027 .169 -.031 .105
7. Dad feared -.099 .085 -.111 .987*** -.111
8. Dad controls -.023 .159 .218 .258* -.126
9. Ambivalence to Dad -.105 .070 -.052 .2538 -.052
10.Mom disapproves .269* -.091 _ .259* .009 -.112
ll.Mom idolized .011 .105 -.O97 .082 .130
12.Mom feared -.075 -.352** - .058 .006 -.113
l3.Men are hurtful .093 -091 .123 .187 -.205

19.Men get away -.108 .091 .259* .159 -.275*

78

Table 22 - Continuation

Unconscious Themes

Conscious Themes 12 13 19 15 16
1. Isolation .137 -.039 .037 -.129 .165
2. Bad news .111 .109 .296* -.069 .197
3. Mom controls -.027 -.082 .090 -.122 .167
9. Ambivalence to Mom -.058 -.029 -.l71 -.086 .197
5. Dad disapproves -.003 .190 .257* -.199 .081
6. Dad idolized .056 .196 .062 .219 .002
7. Dad feared -.085 .029 -.061 -.169 .168
8. Dad controls -.196 .152 .020 -.159 .102
9. Ambivalence to Dad -.070 .067 .089 -.165 .359**
10.Mom disapproves .152 -.122 .053 -.151 .011
11.Mom idolized -.091 .300* .203 .101 .008
12.Mom feared .2799 -.199 -.257* -.l79 .019
l3.Men are hurtful .019 i .239 .330** .087 .111
19.Men get away -.028 .276* .271* .023 .011
N235. Unconscious themes are labelled as follows: 1. Isolation; 2.

Bad News; 3. Mom Controls: 9. Ambivalence to Mom; 5. Dad Disapproves:
6. Dad ldolized: 7. Dad Feared; 8. Dad Controls; 9. Ambivalence to
Dad: 10. Mom Disapproves: 11. Mom ldolized; 12. Mom Feared; l3.Men
are Hurtful: 19. Men Get Away with Hurting; 15. Sex - Murder; 16.
Death, Other Causes.

*p < .05. **p < .01. ***p < .001.

 

'1

Discussion

In contrast to the psychodynamic conflicts hypothesized to underlie
anorexia nervosa and bulimia, the present investigation lends little
support to formulations linking ’these eating patterns with internal
psychological distress. Projective data, presumed to reflect dynam-
ically critical themes which may not be accessible to conscious aware-
ness, did not reveal clear anorexic or bulimic profiles. Psychological
and interpersonal variables relevant to eating disorders did emerge,
however, through examination of conscious conflicts and feelings. The
findings of this investigation lead both to methodological
considerations and clinical implications.

Turning first to the data regarding unconscious psychodynamics, the
failure of the present study to detect differences across groups
suggests two broad conclusions: either the hypothesized differences do
not exist, or the design of this investigation precluded their uncovery.
Acceptance of the first of these interpretations requires reconsider-
ation of the basic tenets of psychodynamic theory, namely that psycho-
logical disorders reflect unresolved conflicts at the unconscious level,
and it calls into question the degree to which anorexia nervosa and
bulimia are psychogenic syndromes.

More parsimonious interpretations focus upon the design of the
present investigation. Real differences may have been obscured by any

combination of the following factors. First, the TAT may not have

79

80

succeeded in tapping unconscious processes. Even if intrapsychic
conflicts were projected onto TAT stories, this study may have addressed
irrelevant dimensions of psychologically relevant variables. Use of the
group administration technique of the TAT, in which subjects write
rather than tell stories, may have also reduced the richness' of TAT
data. Furthermore, differences across groups would have had to be quite
dramatic to emerge in the present study, given the small number of
subjects in each group. Finally, the use of a nonclinical population in
the study of psychopathology leads to the question of whether project
participants were, in fact, bona fide anorexics and bulimics. Diagnoses
were not confirmed by personal interviews, as advocated by Nagelberg
(1983), and subjects in the anorexic group were recovered anorexics
suffering at most from a subclinical disorder. Many of the postulated
dynamics of anorexia nervosa and bulimia may, in fact, be operative in
the development of clinically critical symptomatology. Of course, such
relationships cannot be addressed satisfactorily through the study of
less severely disturbed individuals.

Consciously experienced feelings about father and fears of close,
personal relationships with men do, however, covary with eating habits.
The bulimic behavioral profile is closely associated with feelings of
respect and admiration for father, as well as perceptions of him as
critical and controlling. The prominence of this finding suggests that
the .role of the father in the development of bulimic symptomatology may
be far greater than previously assumed. His impact upon his daughter is
much stronger than would be expected from the passive and ineffective
father described in the clinical literature, and the valence of this

impact is clearly quite negative. Because he is so admired by his

81

daughter, his criticisms seem to carry more weight than those of a
parent who commands no respect. His daughter may hence become caught in
a spiraling pattern: she strives to please him and to respond to his
wishes, but her efforts are viewed as inadequate by her father. In
response she may redouble her efforts to meet her father's standards,
and/or seek refuge in bulimic behavior.

The bulimic's relationship with her father seems an exaggeration of
widely accepted sociocultural values. Modern changes in sex role
behavior have not yet altered the patriarchal structure of most
families; as a rule, father heads the household, implicitly or
explicitly controlling through economic and physical power. Rather than
confront his importance and power, and risk the loss of his love, family
members often organize themselves around father, catering to him and
thereby averting his, displeasure. To an extreme degree, the bulimic
seems to have internalized this traditional but unhealthy view of
father. Perhaps all members of bulimic families adhere more closely to
stereotyped roles than families of healthy young women. Alternatively,
the perception of father as admirable but critical and controlling may
be indelibly imprinted upon the bulimic young woman as a function of her
personal attributes, those of her father, and/or the specific nature of
their relationship.

This unhappy father-daughter relationship may be projected onto
later relationships, real or imagined, with male members of one's peer
group. In the same manner as she felt hurt by her father's demands and
criticisms, the bulimic anticipates personal destruction in heterosexual
relationships. As much as she hopes to gain self-esteem through her

relationships with men, she fears men's power to reject women. She

82

views men as potentially dangerous to women, while expecting that they
will in no way be hurt or affected by their closeness to women. In
spite of her fears, the bulimic strives to succeed with men, overvaluing
and admiring them as she does her father. She repeats the dynamically
established pattern described above, or else she shies away from dating
altogether. Either way, she is likely to feel that she has failed to
earn the highly coveted award of men's esteem: again, she may turn to
the splurge-purge cycle to comfort and to punish herself. This
conclusion is based not only upon the consciously reported attitudes of
bulimic young women, but also upon the finding that they are less likely
to successfully maintain ongoing dating relationships than other women
their same age. While the bulimics in this sample may impulsively enter
into sexual liasons, their involvements in ongoing interpersonal re-
lationships with men appear quite limited.

The relationship between eating pathology and feelings about men,
which is fairly straightforward for bulimics, is considerably less clear
for the anorexics who participated in this study. Their feelings
towards father tended to be more conflicted and ambivalent than those of
bulimics, and on the whole, reported feelings about father and
heterosexual relationships more closely resembled those of nonpatho-
logical eaters and dieters than those of bulimics. Like the bulimfcs,
the anorexics' dating experience was limited, but overall they emerged
as intermediate to the bulimics and control subjects on their attitudes
towards men.

This finding can be interpreted from several perspectives. First,
support is lent to the original hypothesis that the anorexic's father is

psychologically more distant than his counterpart in the bulimic family.

83

He is peripheral to the daughter's development, neither facilitating nor
hindering her growth in any direct way. His remoteness, though, renders
his adolescent daughter poorly prepared for heterosexual challenges.
She fears and avoids dating relationships not because she felt
frightened or criticized by her father, but because she never knew him.

Alternatively, it may be that anorexics are, in fact, less dis-
turbed psychologically than women who binge and purge. Such a conclu-
sion is supported by Strober's research (1981; in press) comparing
restricter and bulimic subtypes of anorexia nervosa. Restricters and
their parents consistently emerge as less disturbed than their
counterparts who binge and purge, and their prognosis is considerably
more favorable (Beumont et al., 1976; Garfinkle et al., 1980; Selvini
Palazzoli, 1971; Strober, in press).

However, the young women who participated in this study were not
hospitalized patients or clinic clients. They were recovered anorexics
who matched the description of "subclinical anorexia nervosa“ (Button 8
Whitehouse, 1981). On several critical psychological dimensions assoc-
iated with anorexia nervosa they seemed quite healthy, a finding which
suggests that the resolution of their issues with men may have
paralleled their recovery from anorexia nervosa. Such psychological
recovery is slow, though. 'As noted by Pillay and Crisp (I977), psycho-
sexual maturation among anorexics may lag behind the rate of maturity of
their healthy peers, even after weight restoration. This interpretation
may also help to explain the strong negative relationships noted between
the anorexic profile of project participants and EDI measurements of
maturity fears and feelings of ineffectiveness. Although development of

this disorder may be fueled by problems in each of these areas, the

.u

'11
O .i

‘ee

89

triumph over an obsession with dieting and body size may lead to new
feelings of self-efficacy and strong desires to accelerate the
maturational process.

Another possibility is that subjects in this group never suffered
from more than "subclinical anorexia nervosa“. The symptoms they
presented indicate that anorexia nervosa does occur on a continuum;
their internal psychodynamics may likewise deviate only slightly from
the norm. Such a conclusion is supported by Bruch's (I973) speculation
that “true“ anorexia nervosa, which entails specific ego deficits in
body image, interoception and feelings of personal effectiveness, must
be differentiated from ”anorexic-like“ behavior. Thompson and Schwartz
(1982) empirically illustrated this point. They compared clinically
identified anorexic patients to two groups of college women: those with
high scores on the Eating Attitudes Test (EAT, Garner 8 Garfinkle, 1979)
and those who scored low on this measure of eating pathology. While
behaviorally the high-EAT students resembled the anorexics, their
responses to a psychiatric symptom checklist and a social adjustment
inventory indicated that psychologically they were no more distressed
than their low-EAT counterparts. Given the media's glamorization of
anorexia nervosa, it would not be surprising for young women to self-
diagnose their dieting episodes as bouts of anorexia. Psychologically
sound young women may hence be eager to admit to any number of bizarre
anorexic symptoms, although their problems may actually be quite minor,
reflecting more broad sociocultural fashion as opposed to psychogenic
distress.

On the basis of the conscious self-report data regarding feelings

towards father and relationships with men, a clear psychological profile

85

emerges, even in the absence of conclusive projective data. The same is
not true, however, for hypotheses concerning the young woman's relation-
ship with her mother, her feelings about pleasing her parents or making
them unhappy, or her sense of psychological isolation. Conclusions
based upon data in these areas are tentative at best.

The nonsignificant trend noted on feelings of isolation suggests
that anorexics and bulimics may feel more cut-off or separate from other
people than do comparison subjects. Given the small sample size of the
present investigation and the consequently reduced power of the
findings, speculation here is warranted. This argument is bolstered by
the strong relationships noted between feelings of isolation,
pathologically bulimic attitudes, and personal requirements for
thinness. The data are inconclusive, however, regarding the question of
cause and effect. Because no differences were noted comparing present
and retrospective indices of isolation, it remains unclear whether
eating disorders emerge in response to loneliness, whether such
pathological involvement with food distances the individual from peers
and family, or, as clinical experience suggests, whether eating
pathologies and feelings of social isolation synergistically reinforce
each other.

Responses to questionnaire items regarding the anorexic's or
bulimic's relationship with her mother, and the feeling of making one's
parents unhappy, closely matched the original hypotheses of this study.
The data suggest that these young women do not experience conscious
conflict around the issue of pleasing or displeasing their parents.
Likewise, they do not consciously experience mother as controlling, nor

are they aware of having mixed or contradictory feelings about her.

86

Support for these hypotheses regarding conscious dynamics seems a
pynrhic victory, though, in the absence of conclusive evidence
concerning unconscious processes. Consistent with the original
hypotheses of this investigation, these findings hint at denial of
internal conflict. It remains unproven, though, whether such conflict
exists in anorexics or bulimics. Again, the use of a nonclinical sample
may have precluded uncovering real differences across groups.

On the whole, the anorexic and bulimic behaviors of these young
women appear to relate to personally problematic but culturally
normative relationships with father, and fears of heterosexual
involvements. These data do not, however, support the hypothesis that
such bizarre behaviors always stem from severe psychopathological
conflict. Rather, they point to the possibility that such anorexic- or
bulimic-like behaviors may be common among college-aged women who are
psychologically quite sound.

As suggested above, it is possible that the alarmingly high prev-
alence of anorexia nervosa and bulimia among young American women is a
pseudo-phenomenon. The trendy fascination with eating disorders, which
have captured such glamorous victims as Jane Fonda and Karen Carpenter,
may lead to the overreporting of behavioral symptoms associated with
these disorders.

If, in fact, the young women who participated in this study were as
pathologically involved with food as their self-disclosures indicated,
then an alternative interpretation should be considered. Perhaps binge-
ing, purgation and self-starvation are behavioral symptoms which can

accompany a range of psychological problems.

 

an

87

The prevalence of anorexic-like symptoms in non-anorexic women has
been well documented; the obsessive fear of fatness, the drive for
thinness, and the perpetual dissatisfaction with one's body shape, which
are the hallmarks of anorexia nervosa, are omnipresent in the psycho-
logically "healthy" population. Anorexia nervosa is more, however, than
just a condition of excessive dieting. Garfinkle and Garner (1982)
suggest that weight control may be used by non-anorexics “to deal with
issues similar to those of anorexics - the regulation and expression of
self, autonomy, and self-control” (p.33). The full anorexic syndrome
develops less often. Possible protective factors against the escalation
of life-threatening emaciation include healthier interpersonal and
familial relationships, social supports, ability to trust in others,
greater self-esteem, more autonomous ego functioning and a more abstract
level of conceptual development (Garfinkle 8 Garner, 1982).

Bingeing and purging behaviors may likewise be symptoms reflecting
varied degrees of psychic organization. Johnson (1983) suggests that
bulimia is a multidetermined disorder, which emerges along a continuum
of psychopathological disorganization. The most severely disturbed
group consists of anorexics who episodically binge and purge. They are
best described as borderline personalities; their poor premorbid history
and polysymptomatic presentation include clingy but transient relation-
ships, emotional lability, and substance abuse. A less disturbed group
of bulimics struggle with a pseudo-autonomous false self. These young
women experience themselves as having a dual identity. Their false self
hides a frightened and needy self, the discovery of which is both hoped
for and feared. The most healthy bulimics are those caught in a de-

velopmental conflict over desires, drives, and identity issues. Their

Pr“
‘9.
.

‘a

(I‘D

III

88

cognitive processes and interpersonal relationships reflect psycho-
logical integrity; their depression stems more from superego fears of
failure, rejection, or disapproval.

Most probably the bulimics identified by surveys of college
students fall into this third category of developmental conflict. For
them, bingeing and purging may be transitional objects, enlisted in the
struggle for separation from parents. While the aim of weight control
is probably consonant with parental values, self-indulgent binges and
Self-destructive purges may bespeak a silent rebellion. The secrecy and
shame which generally shroud bulimia may make this a less effective
means of joining one's peer group against the parental generation
compared with adolescent experimentation with sex, drugs or alcohol.
But there is solace in the knowledge that one suffers from an epidemic,
and the private nature of this syndrome may comfortably suit the young
woman who fears interactions with male peers. Again, heterosexual fears
and bulimic behaviors reciprocally intensify each other.

Recent research emphasizes the fact that seemingly pathological
involvement with food and weight may be statistically normal. Nylander
(1971), in an epidemiological study of 2370 normal 19- to 20-year-olds,
found that over half the girls thought that they were fat, and one-third
had dieted. Ten percent of the females in this survey reported three or
more symptoms of anorexia nervosa in connection with dieting. Along the
same lines, Wardle (1980) found a high frequency of binge-eating among
normal young women and men, accompaniedby food cravings and difficulty
stopping eating once begun. As confirmed by the screening phase of the
present investigation, these behaviors are not themselves abnormal.

Normal and clinical groups may differ on the frequency and content of

Pb

89

binges, but ”the possibility remains that it is the salience or meaning
of the dieting and bingeing which, as much as anything else, provokes
the distress” (Wardle 8 Beinart, 1981).

In conclusion it seems that anorexia nervosa and bulimia are
intricate syndromes which at once are both more common and less
consistently severe than has been presumed. Given the physiological
damage caused by these behaviors it behooves us to respond
prophylactically and therapeutically to their high prevalence among
young American women. This is a major undertaking, considering the
duration of time required for effective treatment and the documented
difficulty of such psychotherapeutic work. However, the recent wave of
publicity among lay and professional writers about this bizarre epidemic
may prove to be an overreaction. More microscopic analysis of the
psychological concomitants of eating disorders may clarify and distin-
guish the diverse causal agents of these disorders, leading to the
development of more specialized and effective psychotherapeutic

treatments .

Appendix A

TAT Scoring Sheet

APPENDIX A

CODING SHEET

No Code #

FORM B

 

H0
11 11

Yes Coder: AM KL

1. Isolation, abandoned

 

2. Child is bad news

 

Felteparental.behamfior

3. Mother controls

 

9. Mother disapproves

 

5. Father controls

 

6. Father disapproves

 

Child's feelings towards parents

7. Ambivalence to Mom

 

8. Idolizes Mom

 

9. Fears Mom

 

10.Ambivalence to Dad

 

11.Idolizes Dad

 

12.Fears Dad

 

Heterosexual Relations

13- Men areédangerous

 

14. Men get away (with it)

 

 

15. (13MF) Murder
16. (13MF) Death, other causes

 

9O

 

 

Appendix B

TAT Scoring Manual

APPENDIX B

TAT SCORING MANUAL

Coding Instructions

Copy the story code on a coding sheet.
Read protocol from beginning to end.
Rate themes 1 - 19.

0 = No

I = Yes

If the protocol is for card 13MF (code number ends in 11), rate
themes 15 and 16.
Circle your initials on the scoring sheet.

If you cannot decide how to rate a story, clip the incomplete
score card to the protocol and put it aside. Go through the
easiest ones first, then take a second run through your pile of
harder stories. Continue sorting through the pile until the
hard decisions become easier. For these harder ones, write
down the criterea you used on the score card, in case we need

to discuss it later. Do NOT write on the protocol.

91

92

Conversion of Protocol Code Numbers

In case you want to refer to the TAT card described in a protocol,
look at the last two digits in the code number. They correspond to

the card indicated below.

Code TAT Card

01 1 Boy with a violin

02 _ 2 Country scene

03 38M A figure huddled against a couch

09 9 A woman clutching the shoulders of a man
05 5 Woman in a doorway (Mother card)

06 60F Man standing behind a seated young woman
07 7GF Woman reading to a girl who holds a doll
08 10 Two people embracing

09 12F Young woman in front of a weird old woman
10 13G Girl climbing a flight of stairs

11 13MF Sex card

12 16 Blank card

93

Theme 1 - Isolation

The hero feels isolated. Words in the story indicate separation from
parents. Look for feelings of abandonment and loss in relation to
parents as well as friends and lovers. Score this even if there is

evidence that someone may try to ease the pain of isolation.

In some cases this theme may be alluded to in phrases like ”sitting in
her room” or “they Split up”, but this should only be scored if the

overall theme is one of isolation and abandonment.

Examples:

alone

by oneself

orphanage

boarding school

parents have left

(family members) don't match or go together
crying alone

getting lost

going to one's room alone

surrounded (separated) by a wall

doing something differently than the rest of the family
escaping from family

not paying attention to a parent

99

Theme 2 - Bad News

Bad news is received by an older couple from their child/children. The
child or children make the couple unhappy. The child may cause concern,
or may displease his/her parents. 'Bad News' is implied in parental
disapproval or criticism, although it is not limited to behaviors
evoking such reactions. Score this regardless of whether mother,

father, or both are made unhappy.

Theme 2 should not be scored if: I) it is not explicit that the bad

news was from a child 2) a parent is unhappy about a son- or

daughter-in-law, but still satisfied with their own child.
Examples:
Parents force the child to do something against his will (implying

that they are not happy with the previous failure to do it).
His parents are going to get angry.

The mother isn't going to be too happy.

They got bad news from their children.

The mother is sad because her daughter died.

95

Themes 3 and 5 - Control

3. A mother figure (older woman) controls her daughter (younger woman).

5. A father figure (older man) controls his daughter (younger woman).

This can be scored regardless of whether or not the attempt to control
succeds, as long as the hero experiences pressure from someone in a
position of authority. Often the implied feeling of the child/hero is

'Why don't you leave me alone?'.

N.B. If both parents jointly are described as controlling, score both

themes 3 and 5.

Examples:

Her mother doesn't want them to see each other, so one night they
ran off and got married in the city.

Her mother is trying to keep her attention.

The mother says 'I don't want to hear it' (records).

His mother is making him study the violin.

Threats from father.

He's scolding her, telling her what to do.

96

Themes 9 and 6 - Disapproval

9. A mother figure is disapproving of her daughter.

6. A father figure is disapproving of his daughter.

This can be scored even if the disapproving mother is dead. Do not
score if the parent disapproves of the daughter's husband, but still

approves of the daughter.

N.B.: If both parents jointly are described as disapproving, score both

themes 9 and 6.

N.B.: Any time that a parent disapproves of the child, the child can be

considered “Bad News“, so Theme 2 should also be scored.

Examples:

The mother isn't going to be too happy . . . child will be denied
privileges.

Mother criticizes what the girl does.

Mother confronts her daughter.

He is accusing her of something.

Her father's telling her “don't do that”.

Her mother gave her a look of disgust . . . She had wanted more out of
the farm. -

97

Themes 7 and 10 - Ambivalence

Mother (7) or father (10) is described positively but felt negatively.
The teller of the story has mixed feelings, but does not express anger,
hate, rage, etc. overtly. Often a parent may be doing something ”good“
but unappreciated by the child. The parent is described positively but
felt negatively. In stories where the mother is reading to the
daughter, the intention is definitely positive on the mother's behalf,

but the critical issue in scoring is whether the child views it as such.

Examples:

The mother is helping her . . . She's daydreaming, mother will be unhappy,
and the girl will be punished.

He's scolding her, but being real gentle about it.

The old woman has something up her sleeve . . . She makes the younger one
pose for a picture, which she resents.

She knew that mom was trying to help her with her homework, but she
couldn't bear to listen.

Do NOT score: Mom was reading to her and she didn't want to listen,

(Does not include child's perception of positive intent).

98

Themes 8 and 11 - Idolizing

Mother (8) and father (11) are admired, worshipped or idolized by the
hero/storyteller. Words used in the story indicate deep admiration or

respect.

Examples:

She always liked to go to Grandma's and Grandpa's house, becase they
were always so nice to her. She knew she would always want to spend
time with them, even though they feared that she wouldn't want to
visit when she got older.

His father is a very famous violinist, and he hopes that one day
he'll become famous too, just like his father.

N.B.: If both parents are-jointly described as admirable and respected,

score both themes 8 and 11.

99

Themes 9 and 12 - Fear

Mother (9) and father (12) are described as fearsome or dangerous. They
may threaten, intimidate, physically or emotionally hurt the child/hero.
Although the threat may be explicit, the fearful reaction to it may'

derive more from the tone of the story.

Examples:

Father never kissed her . . . dealing with men is too scary, she thought.
Her parents were in another fight. She always became so afraid when
they yelled at each other like that. She didn't know what to do.

N.B.: If both parents are described as fearsome, score both themes 9 and

12.

100

Theme 13 - Men are Dangerous

In heterosexual relationships, men are seen as dangerous or destructive
to women. The man can be described as controlling, manipulative,
bullheaded, macho, etc. He is hurtful either physically or emotionally

(He broke her heart).

Examples:

He's not listening to her, he's going to go do what he planned
anyway.

He used her.

He convinces her to go sky diving, even though she's really afraid
and doesn't want to. He lands safely, but her rip cord doesn't
work, so she dies as a result.

He talks his secretary into dinner at his house. His wife leaves
so they can ”work”, but to the surprise of the secretary, he just
wants her for sex.

The story teller voices criticism about a man who has a sexual affair
while still married.

101

Theme 19 - Menvget away with it

(Predicated upon theme 13) Men are described as hurtful to women, and
they get away with it. They are not reprimanded or caught, they leave
and do not feel appropriate guilt or regret. Score this unless the
story explicitly states that the man was caught or reprimanded, or that

he felt sad or guilty afterwards.

Examples:

He's going to leave before anyone catches him.
He left the scene before anyone suspected that he had killed her.
He used her for sex and now he's going to leave before she wakes up.

102

Theme 15 - Sex Equals Murder

(Predicated upon theme 13) (Card 13MF) Sex is equated with murder.

Score any story on 13MF in which the woman is killed or raped by a man.

Examples:

He killed her.
He became violent, raped her, and now she's dead.
He came in and found his wife had been murdered.

103

Theme 16 - Other Causes

(Card 13MF) Death from causes other than murder or rape.

Examples:

She wasn't feeling well in the morning. When he came home that

night she was dead.

She had been sick for a long time, but he still couldn't believe that

she had passed away.
She had an accident and died.

Appendix C

Conscious Themes Questionnaire

Appendix C

Conscious Themes Questionnaire

Directions: Consxder each of the following items seperately. Use the
scale provided to describe the degree to which each statement measures
feelings you have had. Mark your response in the space provided. Thank

you.

1 2 3 4 5 6 7

I I I 4

Never or Usually Sometimes but Occasionally Often Usually Always or

Almost Not Infrequently True True True Almost
Never True True True Always True
I. My mother often seemed kind and sweet.

2. If you are in a close relationship with a man, you always end

up getting hurt.

3. ___ I respected and admired my father.

4. ___ The things I did made my parents very unhappy.

5. ___ My father controlled most aspects of my life.

6. ___ I respected and admired my mother.

7. ___ When I was young, I often felt like I didn‘t have a family,
because I felt so disconnected from my parents (and siblings).

8. ___ My mother was very critical of me.

9. ___ I feel separate, or cut-off from other people.

IO.____ My mother controlled most aspects of my life.

11. ___ I believe that inside, my father was mean or dangerous.

12. Men always seem to get away with it when they create pain

f0r women.

13. My father was very critical of me.
14. My father often seemed kind and sweet.
15. I believe that inside, my mother was mean or dangerous.

109

 

 

Appendix 0

Eating Disorders Inventory

APPENDIX D

EATING DISORDERS INVENTORY

 

Date:___-___-_ -. __ . , --.

 

 

 

 

 

 

 

EDI

Name: _____ _ - _.. _ W, , - ___ __ t __ _n_-

Age:

Present Weight:___ (lbs) Height:

nghest Past Weight (excluding pregnancy): (lbs)
How Long Ago? (months)
How Long DId You Weigh Thls? (months)

Lowest Past Adult Weight: (lbs)
How Long Ago? (months)
How Long Did You Weigh This? (months)

What Do You Consider Y0ur Ideal Weight To Be? (lbs)

Age at Which Weight Problem Began (If any):

 

Father‘s Occupation:

INSTRUCTIONS

Sex:

 

Thls Is a scale which measures a variety of attltudes, feelings and behavlours. Some of the Items relate to
food and eating. Others ask you about your feellngs about yourself. THERE ARE NO RIGHT OR WRONG AN-
SWERS SO TRY VERY HARD TO BE COMPLETELY HONEST IN YOUR ANSWERS. RESULTS ARE COMPLETE-
LY CONFIDENTIAL Read each questlon and place an (X) under the column which applies best for you. Please

answer each question very carefully. Thank you.

0)
m > "2‘
2 3‘ 5 E E s
3 3 I: 3 § 6
< a O a c 2
Cl 13 13 Cl C] D 1 I eat sweets and carbohydrates without feeling nervous.
13 C1 C1 C1 Cl 13 2. I think that my stomach is too big.
D C1 [:1 Cl 13 Cl 3. I wish that 1 could return to the security of
childhood.
Cl 3 6 Cl C [1 4 I eat when I am upset.
C :3 D L;- 1’“. f7 5. I stuff myself with food.

EDI - 0 M, Garner.'M.P Olmsted and J P011vy.(1983) Toronto General Hospital. Toronto. Canada

 

105

0130131313130“st

DDDDDDDDDDDDDDU

F1

DUUDDDDDUSUALLY

DDUDDDDDDDDDDDD

C]

DDDDDDDDOFTEN

DDDDDDDDDDDDDDD

DDDDDUUDSOUHIMES

DDUDDDDDDDDUDDD

CI

DDDDDDDDDDDDiDDD

DDDDDDDDRARELY

[:1

CI

DDDDDDDDNEVER

CIDCJDCIUDCIDDCICICJUCJ

D

F]

10.
11.
12.

13.

14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.

28.

29.

30.

106

I wish that I c0uld be younger.

I think about dieting.

I get frightened when my feelings are too strong.
I thlnk that my thighs are too large.

I feel Ineffectlve as a person.

I feel extremely guilty after overeatlng.

I thlnk that my stomach Is Just the right size.

Only outstanding performance Is good enough In my
family.

The happiest time in Ilfe is when you are a chIId.
I am open about my feelings.

I am terrified of gaining weight.

I trust others.

I feel alone in the world.

I feel satisfied wlth the shape of my body.

I feel generally in control of thlngs In my life.

I get confused about what emotion I am feeling.
I would rather be an adult than a child.

I can communicate with others easily.

I wish I were someone else.

I exaggerate or magnify the Importance of weight.
I can clearly identify what emotion I am feellng.
I feel inadequate.

I have gone on eating binges where I have felt that 1
could not stop.

As a child. I tried very hard to avoid disappointing my
parents and teachers.

I have close relationships.

 

ALWAYS

I

‘—
ls

DDDDDDDDDDDDDDD

UDCJCJD

D

L] USUALLY

DDDDDDDDDDDDDDD

CIDCJDDD

D

DDDDDDDDDDDD'DDD

OFTEN

C3

DDCJCIC]

C]

c.

SOMETIMES

_.

DDDUDDDDDDDUDDD

[30000

C]

RARELY

DDDDDDDDDDDDDDD

00000

C]

NEVER

1— \

DDDDDDDDDDDDDDD

DDCJDC]

31.

32.

8

37.

39.

41.

42.

45.

47.

49.

51.

52.

54.

107

I like the shape of my buttocks.

I am preoccupied with the desire to be thinner.

I don’t know what’s going on inside me.

I have trouble expressing my emotions to others.
The demands of adulthood are too great.

I hate being less than best at things.

I feel secure about myself.

I think about bingeing (over-eating).

I feel happy that I am not a child anymore.

I get confused as to whether or not I am hungry.
I have a low opinion of myself.

I feel that I can achieve my standards.

My parents have expected excellence of me.

I worry that my feelings will get out of control.

I think that my hips are too big.

I eat moderately in front of others and stuff myself when
they're gone.

I feel bloated after eating a normal meal.

I feel that peOpIe are happiest when they are children.
If I gain a pound, I worry that I will keep gaining.

I feel that I am a worthwhile person.

When I am upset, I don’t know if I am sad, frightened
or angry.

I feel that I must do things perfectly, or not do them at all.

I have the thOught of trying to vomit in order to lose
weight.

I need to keep peOple at a certain distance (feel un-
comfortable if someone tries to get too close).

 

" ALWAYS

D

DDDDDDDD

. I USUALLY

C3

DDDDDDDD

OFTEN

(‘—

DDDDDDDDD

SOMETIMES

DDDDDDDDCI

RARELY

DDDDDDDCJC]

NEVER

[300000000

55.

57.

59.

61.

62.

108

I think that my thighs are just the right size.
I feel empty inside (emotionally).

I can talk ab0ut personal thoughts or feelings.

The best years of your life are when you become an adult. -

I think that my buttocks are too large.

I have feelings I can't quite Identify.

I eat or drink In secrecy.

I think that my hips are just the right size.
I have extremely high goals.

When I am upset, I worry that I will start eating.

 

109

EDI Subscales

Drive for Thinness

Item Number

I.*

II.
l6.
25.
32.
49.

Item on Subscale

I eat sweets and carbohydrates without feeling nervous.
I think about dieting.

I feel extremely guilty after overeating.

I am terrified of gaining weight.

I exaggerate or magnify the importance of weight.

I am preoccupied with the desire to be thinner.

If I gain a pound, I worry that I will keep gaining.

Interoceptive Awareness

Item Number

8.
21.
26.*
33-
1.0.
hh.
1.7.

SI.

60.
6h.

Item on Subscale

I get frightened when my feelings are too strong.
I get confused about what emotion I am feeling.

I can clearly identify what emotion I am feeling.
I don't know what's going on inside me.

I get confused as to whether or not I am hungry.
I worry that my feelings will get out of control.
I feel bloated after eating a small meal.

When I am upset, I don't know if I am sad, frightened or
angry.

I have feeelings I can't quite identify.

When I am upset, I worry that I will start eating.

Bulimia
Item Number

h.

5.
28.

38.
L6.

53.

61.

110

Item on Subscale
I eat when I am upset.
I stuff myself with food.

I have gone on eating binges where I have felt that I
could not stop.

I think about bingeing (overeating).

I eat moderately in front of others and stuff myself
when they're gone.

I have the thought of trying to vomit in order to lose
weight.

I eat or drink in secrecy.

Body Dissatisfaction

Item Number
2.

9.

I2.*

19,*

1.5.
55,*
59-

62.*

Item on Subscale

I think that my stomach is too big.

I think that my thighs are too large.

I think that my stomach is just the right size.
I feel satisfied with the shape of my body.

I like the shape of my buttocks.

I think my hips are too big.

I think my thighs are just the right size.

I think my buttocks are too large.

I think that my hips are just the right size.

Ineffectiveness

Item Number
l0.

I8.

20.*

2h.

27.

37-*

kl.

h2.*

50.*

56.

Item on Subscale

I feel ineffective as a person.

I feel alone in the world.

I feel generally in ccontrol of things in my live.
I wish I were someone else.

I feel inadequate.

I feel secure about myself.

I have a low opinion of myself.

I feel that I can achieve my standards.

I feel that I am a worthwhile person.

I feel empty inside (emotionally).

Maturity Fears

Item Number
3.

6.

lh.

22.9:

35.

39.*

#8.

58.*

Item on Subscale

I wish that I could return to the security of childhood.
I wish that I could be younger.

The happiest time in life is when you are a child.

I would rather be an adult than a child.

The demands of adulthood are too great.

I feel happy that I am not a child anymore.

I feel that people are happiest when they are children.

The best years of your life are when you become an adult.

112

Perfectionism

Item Number Item on Subscale
13. Only outstanding performance is good enough in my family.
29. As a child, I tried very hard to avoid disappointing my

parents and teachers.

36. I hate being less than best at things.

#3. My parens have expected excellence of me.

52. I feel that I must do things perfectly or not do them
at all.

63. I have extremely high goals.

Interpersonal Distrust

Item Number Item on Subscale

l5.* I am open about my feelings.

l7.* I trust others.

23.* I can communicate with others easily.

30.* I have close relationships.

3h. I have trouble expressing my emotions to others.
Eh. I need to keep people at a certain distance (feel

uncomfortable if someone tries to get too close).
57.* I can talk about personal thoughts or feelings.

* Indicates negaatively keyed item.

Appendix E

Objective Test Materials

APPENDIX E

OBJECTIVE TEST MATERIALS

Instructions

This questionnaire contains a number of questions dealing mostly with
how you see yourself. Please answer them to the best of your ability.

For the purposes of this questionnaire, "bingeing" is used to refer to
the rapid consumption of large amounts of food, which are usually high
in caloric content. Some peOple call this "pigging out". It can be
done in a variety of situations, as with friends, alone, when depressed,
when "high" etc. "Anorexia Nervosa" is defined as deliberate weight
loss and feeling terrified of fat, even though others say you are too
thin.

If you have questions about the meanings of any other terms on this
questionnaire, please feel free to ask for a definition.

‘113

114

QUESTIONNAIRE

Please mark your answers directly on this page. You will NOT need a
separate answer sheet for any of the following questions.

1. Age

2. Ethnicity:
Caucasian
Asian
Hispanic
Black
American Indian
Other

 

3. Current level in school:
___?reshman
‘__JSophomore
___;unior
.___Senior
_Other

 

4. Marital Status:
Never married
Married
Separated
Divorced

Widowed

5. Parents' Marital Status:
Never married
Married
Separated ‘ -
Divorced
Hid owed

6. How would you describe your present living situation? (Check
all that apply)
Live with parents
'__—Live with husband/male
Live alone
Live in a dormitory
.__;Live with a female friend

7. Which of the following describes your birth position in your
family? (Check all that apply)
First born
Middle child
Last child
Only child
Twin

IO.

11.

12.

13.
14.

15.

16.

170

18.

115

What is your religion?
Protestant
Catholic
Jewish
Other
None

 

What is your father's occupation?

 

What is the highest educational degree held by your father?

 

What is your mother's occupation?

 

What is the highest educational degree held by your mother?

 

What is your present weight? lbs

 

What is your height? ft in

 

 

What is the LOWEST YOU'VE WEIGHED since reaching your present
height?

 

What is the MOST YOU’VE WEIGHED since reaching your present
height?

 

In your opinion, you are now (check one)
very underweight
underweight
average
overweight

very overweight

 

 

Mew often does your weight fluctuate?
a. not at all

b. sometimes

c. frequently

1116

EATING PROBLEMS QUESTIONNAIRE

INSTRUCTIONS: This questionnaire covers several eating problems that
may or may not apply to you. You may find it difficult to answer some
questions if your eating pattern is irregular or has changed recently.
Please read each question carefully and choose the answer that BEST
describes your situation MOST OF THE TIME. Also, please feel free to
write remarks in the margins if this will clarify your answer. Thank
you.

1. Do you have a problem with binge eating?
Yes,now Used to ___ No

2. When was the last time you had a binge?
Specify number: - years, months, weeks, days ago

3. Please describe your binges:
Some— Rarely/

Always Often times Never
Eat a large amount of food ...... ..
Eat very rapidly ....... . ..........
Feel I can't stop/out of control..
Eat in private ..... ...............

 

 

 

#
#

 

 

If you answered "Rarely/Never" to two or more parts of Question 3,
please skip to Question 17.

4. How often do you binge?
More than once a day
Daily

At least once a week
A few times a month
Once a month or less

5. New long does the binge usually last?
Less than one hour

1-2 hours

___ More than 2 hours

I

6. What foods do you eat when you're bingeing? When you're not

bingeing? Check all'that apply:

Binge Foods Non-binge Foods
Bread/cereal/pasta..... ..... ........
Cheese/milk/yosurt..................
Fruit...............................
Meat/fish/poultry/eggs. .......... ...
Salty snack foods...................
Sweets..............................
Vegetables. ......... . ...............

 

 

IIIIII

10.

11.

12.

13.

14.

15.

16.

117

About how many calories do you consume in a typical binge?
calories

About how much would you estimate you spend on binge eating?
3 per binge

How old were you when you first started bingeing? years old

How long have you had a problem with binge eating?
Specify number: years, months, weeks

What event or feeling triggers a binge? (explain)

 

 

 

 

What best describes how you feel DURING a binge? Check all that
apply:

__Calm -__Excited ‘__Disgusted ._;Panicked
'__Melpless {__Angry __;Energized .__Relieved
Stimulated Spaced-out __Secure ‘__Cuilty

'__Depressed -__

How do you usually feel AFTER a binge (BEFORE purging)? Check all
that apply:

Calm Excited Disgusted Panicked
-—Melpless -—Angry '_—Energized '_ERelieved
:Stimulated :Spaced- out :Secure - :Guilty
__Depressed

Please describe how your binges end:
Some— Rarely/
Always. Often times- Never

Abdominal pain. . . . . . . .
Sleep.................
Social interruption...
Self induced vomiting.
Other

 

 

 

 

 

What time-of the day are you most likely to binge?
__ Mornings (7 am - 12 Noon)
____Afternoons (12 Noon - 4 pm)
Evenings (4 pm - 10 pm)
_ Night (after 10 pm)
: Varies

Why do you think you started binge eating in the first place?

 

 

 

118

17. Have you ever induced yourself to vomit, or have you ever thrown
up after a binge?
Yes, now Used to No

If you answered "No" to Question 17, skip to Question 26.

18. If yes, when was the last time you induced vomiting?
Specify number: months, weeks, days 880

19. How often do you induce vomiting?
More than once a day
Daily
At least once a week
A few times a month
___Once a month or less

20. How old were you when you induced vomiting fbr the first time?
years old.

21. How long have you been vomiting in this way?
Specify number: years, months, weeks

22. How do you usually get yourself to throw up?

 

 

 

23. Has it become harder or easier to vomit since you first began?
Harder Easier About the same

 

24. Do you remember why you did this originally? (explain)

 

 

25. What best describes how you feel AFTER you have purged by vomiting?
Check all that apply:

__Ca1m __Excited ‘__Disgusted ._;Panicked
__Nelpless ‘__Angry .__Energized __Relieved
_Stimulated _Spaced- out _Secure . _Guilty

‘__Depressed

26.

27.

28.

~ 29.

30.

31.

32.

33-

‘119

Have you ever used laxatives to control your weight or "get rid of
food"?
Yes, now Used to No

If you answered "No" to Question 26, please skip to Question 34.

If yes, when was the last time you took laxatives for weight
control?
Specify number: months, weeks, days ago

How often do you take laxatives for this purpose?
___ More than once a day
____Daily
At least once a week
___ A few times a month
___ Once a month or less

How old were you when you first took laxatives for weight control?
years old

How long have you been doing this?
Specify number: years ‘ months ' weeks

What dosage do you take? Brand Amount

 

Do you remember why you started using laxatives for weight control?

A

 

 

What best describes how you feel AFTER you have purged by using
laxatives? Check all that apply:

__Calm ‘__Excited __pisgusted .;_Panicked
_Helpl ess _Angry ‘ _Energized _Reliev ed
__§timulated ___Spaced-out '__Secure .__Cuilty

__Depressed

120

34. Have you ever fasted, or starved yourself AFTER A BINGE?
Yes, now Used to No

If you answered "no" to Question 34, please skip to Question 43.

35. If yes, when was the last time you fasted?
Specify number: months, weeks, days 880-

36; How often do you start fasting?
Mere than once a day
‘Daily
At least once a week
A few times a month
___pnce a month or less

37. How old were you when you fasted for the first time?
years old

38. How long have you been fasting in this way?
Specify number: years, months, weeks

39. How long is your average fast?
Less than a day
24 hours or less
A week or less
___fibre than a week

40. Has it become harder or easier to fast since you first began?
Harder Easier About the same

41. Do you remember why you did this originally? (Explain)

 

 

 

42. What best describes how you feel AFTER you have fasted? Check all
that apply:

_Calm _Ex ci ted _Di sgust ed Panicked
_Helpl ess _Ang ry _Energized _Relieved
Stimul at ed _Spaced- out _Se cure _Guil ty

Depressed

121

43. Have you ever dieted, or tried to diet to control your weight?
Yes, now Used to No

If you answered "no" to Question 43. Please skip to Question 51.

44. If yes, when was the last time you dieted fer weight control?
Specify number: months, weeks, days 86°

45. How often do you begin diets for this purpose?
_More than once a day
___paily
___At least once a week
___A few times a month
___pnce a month or less frequently

46. How old were you when you first dieted for weight control?
years old

47. How long have you been doing this?
Specify number: years, months, weeks

48. How long is your average diet?
Less than a day
24 hours or less
A week or less
More than a week
More than a month

49. Do you remember why you started dieting fer weight control?

 

 

 

50. What best describes how you feel AFTER you have dieted? Check all

that apply:
Calm Excited ‘__Disgusted ‘__Panicked
:Helpl ess :Angry _Energized _Relieved
Stimul at ed _Spaced- out _Se cure _Guil ty

Depressed

51.

52.

53.
54.

55-

S6.
57.

58.

59-

60.

1122

Do you consider yourself to have (or to have had) anorexia
nervosa?

_ Yes,now __ Used to __ No
Please indicate any of the following symptoms you have had:
Deliberate weight loss (not due to medical illness)
Loss of menstrual period
Overactivity/exercise without enjoyment
Feeling terrified of fat
Feeling fat despite others saying you are too thin
Being obsessed or totally preoccupied with thoughts
of food

Lowest weight reached? pounds

How long ago was this (lowest weight)?

Specify number: months, weeks,or days ago
Exercise: Less than
Type Daily Weekly Monthly Monthly Never

 

 

 

_

 

How much time do you spend exercising each day?
Specify time: hours or minutes

Are you presently involved with a man? Yes No

Have you noticed any changes in your physical health since your
eating problem began?

Yes No If yes, please describe: -

 

How often do you worry about possible ill effects of'bingeing and/or
pure ins?
Always Often Sometimes Rarely/Never

How often do you worry about possible ill effects of fasting and/or

dieting? -
Always Often Sometimes Rarely/Never

Have you ever taken any psychiatric medication? Yes No
Type:

Reason:

 

 

 

 

61.

62.

63.

64.

65.

66.

123

Are your menstrual periods regular? Yes No

If you do not menstruate regularly, please describe your pattern
over the past year:

 

 

 

When was your last menstrual period?
Specify number: months, weeks,or days ago

How often do you feel depressed?
Always/Very Often Often Sometimes Rarely/Never

Have you ever injured yourself intentionally? Yes No
Please describe what happened:

 

 

 

 

Have you ever felt so bad or hepeless that you thought of suicide?
No. '
Yes, considered it, but didn't act on the idea.
Yes, made a suicidal gesture or plea for help.
Yes, made a serious suicide attempt.
What brought this on?

 

 

 

 

12.4

Please feel free to use this space for canments about this study, your
reactions to it and/or your eating behaviors.
Thank you for your cooperation.

Appendix F

Research Consent Form

APPENDIX F
RESEARCH CONSENT FORM

Michigan State University
Department of Psychology
Research Consent Form

Eating Behavior Study

Investigator: Abby L. Golomb, M.A.
Supervisor: Bertram P. Karon, Ph.D.

The aim of this study is to learn about the eating patterns of young
women, and to investigate some of the personality features associated
with these eating behaviors.

In the first part of this study, you will be asked to complete a
questionnaire. It pertains to your eating habits, how you describe your
family and how you describe your personality. This should take approx—
imately one hour. You will be awarded two extra credit points for your
participation in this part of the study. Some questions are extremely
personal. You may skip any item which you do not wish to answer, and
you are free to discontinue your participation at any time without
penalty. .

Some of the people participating in this part of the study will be
asked to return fer a second one—hour testing session. During this
hour, subjects will be asked to tell a number of stories in an indivi-
dual interview. Participants in the second part of this study will re-
ceive an additional two points of extra credit. They will be selected
according to their eating behaviors, as described on the original ques-
tionnaire. We are looking for subjects with a variety of eating habits.
There is no right or wrong way to answer this questionnaire; we are
interested in a wide range of behavior. In giving your consent to par-
ticipate in this study, you are agreeing to fill out the following
questionnaire, and to be recontacted for the second part of this study.
If you change your mind later, you are free to discontinue participation
without any penalty. Bear in mind, though, that you may not be re-
contacted for the second part of this study.

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References

American Psychiatric Association. (1980). Diagnostic and statistical
manual 2: mental disorders (3rd ed.). Washington, D.C.: Author.

Bemis, K. M. (1978). Current approaches to the etiology and treatment of
anorexia nervosa. Psychological Bulletin, 85, 593-617.

Beumont, P. J. V. (1977). Further categorization of patients with
anorexia nervosa. Australian and New gealand Journal gi
Psychiatry, 11, 223-226.

 

Beumont, P. J. V., Abraham, S. F., 8 Simpson, K. G. (1981). The psycho-
sexual histories of adolescent girls and young women with
anorexia nervosa. Psychological Medicine, ll, l31-1h0.

Beumont, P. J. V., Beardwood, C. J., & Russell, G. F. M. (1972). The
occurence of the syndrome of anorexia nervosa in male subjects.
Psychological Medicine, 2, 216-231.

Beumont. P. J. V., George, G. C. W., 5 Smart, D. E. (1976). 'Dieters‘
and 'vomiters and purgers' in anorexia nervosa. Psychological
Medicine, 6, 617-622.

Blitzer, J. R., Rollins, N., 8 Blackwell, A. (1961). Children who starve
themselves: Anorexia nervosa. Psychosomatic Medicine, 13(4),

369-333-

Boskind-Lodahl, M. (1976). Cinderella's step-sisters: A feminist
perspective on anorexia nervosa and bulimia. §jgns: The Journal
2: Women jg Culture and Society, ;, 342-356.

Boskind-Lodahl, M., 8 Sirlin, J. (1977, March). The gorging-purging
syndrome. Psychology Today, 50-82.

I

Boskind-White, M., 5 White, W. C., Jr. (1983). Bulimarexia . NY:
Norton.

Brenner, D. P. (1981). The wish vs. the fear of merger: One element in
the specificity of symptom choice in eating disorders.
Dissertation Abstracts International, 41112), A653B.

Bruch, H. (1965). Anorexia nervosa and its differential diagnosis.
Journal 9: Nervous g Mental Diseases, 141, 555-566.

127

128

Bruch, H. (1973). Eating Disorders: Obesityi anorexia nervosa and the
person within . NY: Basic.

Bruch, H. (1978). The ggjden cage . New York: Basic Books.

Button, E. J., 8 Whitehouse, A. (1981). Subclinical anorexia nervosa.
Psyghological Medicine, 11, 509-516.

Casper, R. C., 8 Davis, J. M. (1977). On the course of anorexia
nervosa. American Journal 9: Psychiatry, 134, 974-978.

Casper, R. C., Eckert, E. D., Halmi, K. A., Goldberg, S. C., 8 Davis,
J. M. (1980). Bulimia. Archives 9: General Psychiatry, 31,
1030‘1035.

Crisp, A. H. (1967). The possible significance of some behavioral
correlates of weight and carbohydrate intake. Journal 9i
Psychosomatic Research, 11, 117-131.

Crisp, A. H. (1970). Anorexia nervosa: 'Feeding disorder', 'nervous
malnutrition' or 'weight phobia'? World Review 9: Nutriton and
Diet, 1;, 452-504.

de Beauvoir, S. (1952). The second sex. NY: Knopf.

Duddle, M. (1973). An increase of anorexia nervosa in a university
population. British Journal 91 Psychiatry, 123, 711-712.

Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G.,
8 Munoz, R. (1972). Diagnostic criterea for use in psychiatric
research. Archives gi General Psychiatry, 26, 57-63.

Galdston, R. (1974). Mind over matter: Observations on 50 patients
hospitalized with anorexia nervosa. Journal 9: Child
Psychiatry, l3, 246-263.

Garfinkle, P. E., 8 Garner, D. M. (1982). Anorexia nervosa: A
multidimensional perspective. New York: Brunner/Mazel.

Garfinkle, P. E., Molodofsky, H., 8 Garner, D. M. (1980). The hetero-
geneity of anorexia nervosa. Archives 91 General Psychiatry,

31, 1036-1040.

Garner, D. M., 8 Garfinkle, P. E. (1979). The eating attitudes test:
An index of the symptoms of anorexia nervosa. Psychological
Medicine, 9, 273-279.

Garner, D. M., Garfinkle, P. E., 8 Olmstead, M. P. (1983). An overview
of sociocultural factors in the development of anorexia
nervosa. In P. Darby, P. E. Garfinkle, D. M. Garner 8 D. V.
Coscina (Eds). Anorexia nervosa; Recent developments. NY: Liss.

129

Garner, D .M., Garfinkle, P. E., 8 D'Shaughnessy, M. (In press).
Validity of the distinction between bulimia with and without
anorexia nervosa. In New Directions jg Anorexia Nervosa, Report
of the Fourth Ross Conference on Medical Research.

Garner, D. M., Garfinkle, P. E., Schwartz, D., 8 Thompson, M. (1980).
Cultural expectations of thinness in women. Psychological

Reports, 31, 483-491.

Garner, D. M., Olmstead, M. P., 8 Polivy, J. (1983a). Development and
validation of a multidimensional eating disorder inventory for
anorexia nervosa and bulimia. International Journal 9: Eating
Disorders, 21;), 15-34.

Garner, D. M., Olmstead, M. P., 8 Polivy, J. (l983b). Eating Disorder
Inventory. Toronto General Hospital, Toronto, Canada.

Guiora, A. Z. (1967). Dysorexia: A psychopathological study of anorexia
nervosa and bulimia. American Journal 9: Psychiatry, 124,

391'393.

 

Gull, W. W. (1874). Apepsia hysterica: Anorexia nervosa. Clinical
Social Transactions, 1, 180-185.

Halmi, K. A. (1974). Comparison of demographic and clinical features in
patient groups with different age and weights at onset of anor-
exia nervosa. Journal 9: Nervous 9 Mental Diseases, l58,
222-225.

Halmi, K. A., Falk, J. R., 8 Schwartz, E. (1981). Binge-eating and
vomiting: A survey of a college population. Psychological
Medicine, 11, 697-706.

Hawkins, R. C., 8 Clement, P. F. (1980). Development and construct
validation of a self-report measure of binge eating tendancies.
Addictive Behaviors, 5, 219-226.

Herzog, D. B. (1982). Bulimia: The secretive syndrome. Psychosomatics,

23(5), 481-487.

Hogan, W. H., Huerta, E., 8 Lucas, A. R. (1974). Diagnosing anorexia
nervosa in boys. Psychosomatics, 15, 122-126.

Hollingshead, A. B. (1975). Four Factor Index 91 Social Status.
Available from author, 1965 Yale Station, New Haven, CT.

 

Johnson, C. L. (1983, Nov.). A psychoeducational approach. Paper
presented at the CSAB Conference on Psychotherapeutic Approaches
to Anorexia and Bulimia, New York, N.Y.

Johnson, C., 8 Larson, R. (1980). Bulimia: An analysis of moods and
behavior. Psychosomatic Medicine, 44(4), 341-351.

130

Johnson, C. L., Stuckey, M. K., Lewis, L. D., 8 Schwartz, D. M. (1982).
Bulimia: A descriptive survey of 316 cases. International
Journal 9: Eating Disorders, 2(1), 3-16.

 

Karon, B. P. (1981). The Thematic Apperception Test. In A. I. Rabin,
(Ed.), Assessment with projective techniqpes (Pp. 85-120). NY:
Springer.

Kramer, S. (1974). A discussion of the paper by John A. Sours on 'The
anorexia nervosa syndrome'. International Journal 9: Psycho-

analysis. 55. 577-579-

Levenkron, S. (1982). Treating and overcoming anorexia nervosa. NY:
Warner Books.

Lindner, R. (1955). The case of Laura. The fifty-minute hour. NY: Holt,
Rinehart 8 Winston.

Meyer, J. E. (1971). Anorexia nervosa of adolescence: The central
syndrome of the anorexia nervosa group. British Journal 91
Psychiatry, 118, 539-542.

Moos, R. (1974). Family Environment Scale. Palo Alto: Consutling
Psychologists Press. '

Nagelberg, D. B. (1983, Aug). Prevalence pi eating disorders jg college
women. Paper presented at the Annual Convention of the American
Psychological Association, Anaheim, CA.

Nylander, I. (1971). The feeling of being fat and dieting in a school
population. Acta Sociomedica Scandinavia, 3, 17-26.

Palmer, R. L. (1979). The dietary chaos syndrome: A useful new term?
British Journal 91 Medical Psychology, 5;, 187-190.

Pillay, M. 8 Crisp, A. H. (1977). Some psychological characteristics of
patients with anorexia nervosa whose weight has been newly
restored. British Journal 2: Medical Psychology, 59, 375-380.

Pyle, R. L., Mitchell, J. E., 8 Elke, D. E. (1981). Bulimia: A report of
34 cases. Journal 2: Clinical Psychiatry, 42(2), 60-64.

Rollins, N., 8 Piazza, E. (1978). Diagnosis of anorexia nervosa.
Journal 9: Child Psychiatry, 1 , 126-137.

Russell, G. (1979). Bulimia nervosa: An ominous variant of anorexia
nervosa. Psychological Medicine, 9, 429-448.

Selvini Palazzoli, M. D. (1971). Anorexia nervosa. In S. Arieti (Ed.),
World biennial g: psychiatry and psychotherapy, Vol. l(pp
197-218) . NY: Basic.

131

Selvini Palazzoli, M. (1978). Self-starvation: From individual to

 

 

 

family therapy jg the treatment 9: anorexia nervosa. NY: Jasgh
Aronson.

Singer, M. T., 8 Wynne, L. C. (1966). Principles for scoring commun-
ication defects and deviances in parents of schizophrenics:
Rorschach and TAT scoring manuals. Psychiatry, g3, 260-288.

Sinoway, C. G. (1982, August). The incidence and characteristics 9:
bulimarexia jg Penn State students . Paper presented at Annual
Convention of the American Psychological Association,
Washington, D.C.

Sours, J. A. (1974). The anorexia nervosa syndrome. International
Journal 9: Psychoanalysis, 55, 567-576.

Stein, M. I. (1978). Thematic Apperception Test and related methods. In
B. B. Wolman (Ed.), Clinical Diagnosis 2: Mental Disorders
(pp. 179-2351. NY: Plenum.

Stern, S., Whitaker, C., Hagemann, N., Anderson, R. 8 Bargman, G.
(1981). Anorexia nervosa: The hospital's role in family
treatment. Family Process, 20(4), 395-408.

Strober, M. (1981). The significance of bulimia in juvenile anorexia
nervosa: An exploration of possible etiologic factors.
International Journal 9: Eating Disorders, 1(1), 28-43.

Strober, M. (in press). An empirically derived typology of anorexia
nervosa. In P. Darby, P. E. Garfinkle, D. Garner 8 D. Coscina,
(Eds.), Anorexia nervosa: Recent developments. NY: Liss.

Strober, M., Salkin, B., Burroughs, J., 8 Morrell, W. (1982). Validity
of the bulimia-restricter distinction in anorexia nervosa.
Journal 9: Nervous 5 Mental Disease, 170(6), 345-351.

Stuckey, M. K., Lewis, L. D., Jacobs, B., Johnson, C. L., 8 Schwartz,
D. M. (1981). Eating Problems Questionnaire. Available from
senior author, c/o The Anorexia Nervosa Project, Psychosomatic
and Psychiatric Institute, Michael Reese Medical Center, 29th
and Ellis Ave, Chicago, IL, 60616.

Szyrynski, V. (1973). Anorexia nervosa and psychotherapy. American
Journal 2: Psychotherapy, legl, 492-505.

Thoma, H. (1967). Anorexia Nervosa. NY: International Universities
Press.

Thompson, M. G., 8 Schwartz, D. M. (1982). Life adjustment of women with
anorexia nervosa and anorexic-like behavior. International
Journal 9: Eating Disorders, 1, 47-60.

132
Wall, J. H. (1959). Diagnosis, treatment and results in anorexia
nervosa. American Journal 9: Psychiatry, 115, 997-1001.

Wardle, J. (1980). Dietary restraint and binge eating. Behavioural
Analysis and Modification, 5, 201-209.

Wardle, J. 8 Beinart, H. (1981). Binge eating: A theoretical review.
British Journal 9: Clinical Psychology, g9, 97-109.

 

     

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