Curr Psychol (2010) 29:297–306 DOI 10.1007/s12144-010-9090-x
Associations Between Impulsivity and Body Dissatisfaction in Females at Risk for Developing Eating Disorders Jessica Scherr & F. Richard Ferraro & Jeffrey N. Weatherly
Published online: 23 November 2010 # Springer Science+Business Media, LLC 2010
Abstract Sixty-one women (40 at-risk for an eating disorder based on the Screening Instrument for Identifying Individuals at Risk for Developing Anorexia and Bulimia Nervosa, SCANS) completed a self-report packet of questionnaires concerning executive function, impulsive behavior, mood, anxiety, delayed discounting and measures of body image dissatisfaction. Results revealed that the at-risk group were more depressed, had lower motivation, displayed more empathy, were more anxious (state and trait) and had a greater impulse behavior of urgency. Keywords Body dissatisfaction . Impulsivity . Eating disorders Each year an increasing number of people are at risk for developing an eating disorder. In the United States, as many as 10 million females and 1 million males are fighting a life and death battle with an eating disorder such as anorexia or bulimia (Crowther et al. 1992; Fairburn et al. 1993; Gordon 1990; Hoek 1995; Shisslak et al. 1995). An eating disorder is defined by extremes. It is present when a person experiences severe disturbances in eating behavior, such as extreme reduction of food intake or extreme overeating, or feelings of extreme distress or concern about body weight or shape (National Institute of Mental Health 2009). Unfortunately, the chances for full recovery from an eating disorder are grim, since a large portion of people do not respond to treatment once the disorder exists. Therefore, it is important to identify those at risk for developing an eating disorder (Keel and Herzog 2004). By targeting other factors that are associated with people who are at risk for developing an eating disorder, clinicians can implement different prevention and treatment programs. This research concerned factors such as impulsivity, body dissatisfaction, Body Mass Index (BMI), state-trait anxiety, and mood. The results from this research may lead to more effective treatments for those that have eating J. Scherr : F. R. Ferraro (*) : J. N. Weatherly Department of Psychology, University of North Dakota, Corwin-Larimore Rm. 215, 319 Harvard Street Stop 8380, Grand Forks, ND 58202-8380, USA e-mail:
[email protected]
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disorders and create preventative measures for those at risk for developing an eating disorder by targeting other factors that may influence a person’s life other than the eating disorder itself. Being able to target a factor that may be associated with eating disorder could help save someone’s life and help stop this disorder before it starts. One of the factors this study addressed was whether there is an association between impulsivity and a risk for developing an eating disorder. The Setting Conditions for Anorexia Nervosa Scale (SCANS) was used to establish if female participants were at risk for developing an eating disorder (Slade and Dewey 1986). Impulsive behavior is often characterized by a lack of deliberation and a failure to consider risks and consequences before acting (Eisler and Fahy 1993). In addition to being included as a diagnostic criterion for many disorders in the Diagnostic and Statistical Manual of Mental Disorders, impulsivity has been implicated in risk models for a number of disorders including alcoholism, eating disorders, and pathological gambling (4th ed; DSM-IV; American Psychiatric Association 1994). Previous studies have identified impulsivity to be associated with eating disorders. One study explored the role of executive functioning, a popular measure of impulsive behavior, in individuals with anorexia nervosa. Usually people who are diagnosed with anorexia nervosa display reduced cognitive functioning across a number of domains, including executive functioning (Wade and Wilsdon 2005). These deficits in executive functioning have been found to be related to impulsivity or mental flexibility (Cooper and Fairburn 1992; Fassino et al. 2002; Green et al. 1996, Tchanturia et al., 2004a, b). People with anorexia nervosa are often less flexible when it comes to change. This lack of flexibility and resistance to change has been found to often effect the treatment and the recovery process of the patient (Tchanturia et al. 2004a). Past research has assessed the cognitive functioning of people with anorexia and bulimia, before and after treatment, to determine whether malnutrition is associated with the cognitive deficits. One study found little difference between the cognitive functioning of bulimic and anorexic patients before, during, and after treatment (Lauer et al. 1999). Results suggest that deficits in cognitive functions, specifically executive functioning, could be used to help target individuals who are at a greater risk for developing an eating disorder, since deficits in cognitive functioning were not a result directly caused by disordered eating. The present study used the Executive Function Index (Spinella 2005) as a measure of impulsivity. However, executive functioning is just one measure used to account for impulsivity. Impulsivity is thought to be a complex measure involving a wide array of different constructs. There is now wide agreement that impulsivity is not a single construct but probably consists of a number of related dimensions (Dawe and Loxton 2004). This study also addressed a few other constructs of impulsivity along with executive functioning. Delay discounting is a measure of the degree to which an individual is driven by immediate gratification compared to waiting a delayed period to receive a larger reward (Weller et al. 2008). By providing a variety in the number of delays, one can quantify the rate at which someone is willing to discount each reward. This measure provides an index of an overall discounting rate (Badger et al. 2010). Little research has been conducted on delay-discounting and eating disorders.
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One study that compared obese and non-obese women on a delay-discounting task found no group differences (Nederkoorn et al. 2006). Along with a delaydiscounting task, four other areas of impulsivity (premeditation, urgency, sensation seeking, and perseverance) were examined through the UPPS Impulsive Behavior Scale (Whiteside and Lynam 2001). This study looked to find similarities in different areas of impulsivity and eating disorders. The current study hypothesized that females who are at a risk for developing an eating disorder would score higher on impulsivity measures. The reasoning behind this hypothesis is that when an individual does something spontaneously or without much deliberation he/she may feel a lack of control over events, that individual may then develop a relationship with food intake in order to feel in control. If an individual is less impulsive, there will be a decreased need for control over events in his/her life, and a lower chance of developing an eating disorder. Along with impulsivity, this study aimed to show an association between eating disorders and body dissatisfaction. Researchers have found significant associations between body dissatisfaction and eating disorders. According to the National Eating Disorders Institution, body dissatisfaction, particularly regarding size and weight, is a common attribute found in people who are either at risk for, or have an eating disorder. Unfortunately body dissatisfaction is a widespread epidemic affecting young women today. Adolescent girls and college women are most affected by poor body image and most likely to diet (Grogan et al. 1996). The moderate degree of dissatisfaction that is now normative among women encourages many girls and women to diet to manipulate their size and shape (Gordon 2000). Dieting, coupled with certain personality and family dynamics, can induce all-consuming, dangerous eating disorders such as anorexia nervosa and bulimia nervosa (Polivy and Herman 1999). This study focused on the individual’s level of body dissatisfaction and the relationship to whether she is at risk for developing an eating disorder. To measure body dissatisfaction, the Silhouette Choosing Task (Fallon and Rozin 1985) was used. The results from the Silhouette Choosing Task were then compared to the results of the SCANS to see if there was an association between body dissatisfaction and females who were at risk for developing an eating disorder. It was expected that people who are at risk for developing an eating disorder will also have a higher level of body dissatisfaction compared to individuals that are not at risk for developing and eating disorder. Past research had shown that individuals that suffer from an eating disorder record higher levels of body dissatisfaction. This study aimed to confirm past results by showing a relationship between people at risk for developing an eating disorder and an increased level of body dissatisfaction. Also past research has shown that depression and anxiety are often comorbid with eating disorders (Grubb et al. 1993). Such comorbidity has been shown to increase the severity of the symptoms and to increase impairment of daily functioning and social disability (Lecrubier 1998). A mood scale (Mood Scale (short form), Ferraro and Chelminski 1996) and the State-Trait Anxiety Inventory (Spielberger 1983) was administered to the participants to determine if females who are at risk for developing an eating disorder show a greater tendency towards depression and anxiety when compared to females who are not at risk. Finally, to determine if there is an association between individuals with a lower BMI and individuals who are at a higher risk to develop an eating disorder, the height and
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weight of the individual was asked during the study. BMI is defined as the individual's body weight divided by the square of his or her height (Eknoyan 2008). However, BMI has become controversial because many people, including physicians, have come to rely on its apparent numerical authority for medical diagnosis. The BMI was designed for individuals who were not active and had an average body composition. For these individuals, the current value settings are as follows: a BMI of 18.5 to 25 may indicate optimal weight; a BMI lower than 18.5 suggests the person is underweight while a number above 25 may indicate the person is overweight; a BMI below 17.5 may indicate the person has anorexia nervosa or a related disorder; a number above 30 suggests the person is obese (over 40, morbidly obese) (Gadzik 2006). This study expected to find that individuals with a lower BMI would display an increased risk for developing an eating disorder. As eating disorders are becoming more prevalent in society, research has to be a main priority to distinguish certain risk factors and associations that occur with this deadly disease.
Method Participants The study was conducted at a large Midwestern university. Participants (all female) were recruited from the psychology department with the incentive of being offered one hour of extra credit from any professor that allowed his/her student to participate in research for extra credit, throughout the 2009 Fall and 2010 Spring semesters. Initially, 308 female participants completed the screening questionnaire packets, with an average completion time of 20–30 min. The ethnic composition of the sample had the majority of the participants being Caucasian/white. Based on the scores from the SCANS, the participants were separated into two groups. The experimental group (Group 1) consisted of 40 participants who scored high on perfectionism and dissatisfaction and were considered at risk for developing an eating disorder. The control group (Group 2) consisted of 21 participants who scored low on perfectionism and dissatisfaction, and were not considered at risk for developing an eating disorder. The other 247 participants were considered partially at risk for developing an eating disorder. The first partially at risk group (Group 3) consisted of 244 participants who scored high on perfectionism and low on dissatisfaction. The second partially at risk group (Group 4) consisted of 3 participants who scored low on perfectionism and high on dissatisfaction. The partially at-risk groups were not used in this study. Measures The following measures were given to all participants. Setting Conditions for Anorexia Nervosa Scale (SCANS) (Slade and Dewey 1986) The SCANS is composed of 40 questions to measure the risk of that individual developing an eating disorder. The individual chooses, for each of the 40 questions, which answer best applied to him/her. The SCANS has two measures of
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perfectionism and dissatisfaction to determine if an individual is at risk for developing an eating disorder. Both total dissatisfaction scores greater than 42 and perfectionism scores greater than 22, indicate that an individual is at risk for developing an eating disorder. Scores lower than both 43 on dissatisfaction and 23 on perfectionism indicate a non-risk individual for developing an eating disorder. An individual may partially be at-risk for developing an eating disorder if he/she scores high on one measure and not the other. Executive Function Index (EFI) (Spinella 2005) The EFI consists of 27 questions that assess an individual’s executive functions in daily life. The individual answers each of the 27 questions on a 4 point scale, with “NOT AT ALL” and “VERY MUCH” as the two extremes. The EFI measures five areas associated with frontal lobe function (motivational drive, strategic planning, organization, impulse control, empathy, plus a total score). Higher scores indicate better frontal lobe functioning. State-Trait Anxiety Inventory (STAI) (Spielberger et al. 1971) The STAI measures two types of anxiety: state anxiety and trait anxiety. Both of these measures of the State-Trait Anxiety Inventory ask 20 questions. The 20 questions are answered on a 4-point scale, with “NOT AT ALL” and “VERY MUCH” as the two extremes. Scores on the STAI have a direct relation to their scales, with high scores meaning more trait or state anxiety and low scores meaning less trait or state anxiety. UPPS Impulsive Behavior Scale (Whiteside and Lynam 2001) The UPPS has 45 items that represent four different measures of impulsivity, including Premeditation (11 items), Urgency (12 items), Sensation Seeking (12 items), and Perseverance (10 items). Each item is rated on a 0= “NOT AT ALL” to 4 =“VERY MUCH” point scale. Individuals who score high on impulsivity are characterized by having low premeditation and perseverance scores and high urgency and sensation seeking scores. Mood Scale (Short Form) (Ferraro and Chelminski 1996) The Mood Scale consists of 15 questions that assess the individual’s mood over the past week. The individuals will circle either a “YES” or a “NO” to answer each of the questions. Individuals who score higher on this scale report a more depressed mood than individuals who score lower. Body Mass Index (BMI) The participants will self-report their weight in pounds and height in inches. The BMI is then calculated using a mathematical formula using the individual’s weight and height. A person is considered underweight if his/her BMI is less than 18.5,
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normal weight if his/her BMI is 18.5–24.9, overweight if his/her BMI is 25.0–29.9, and obese if his/her BMI is 30.0 and above. Silhouette Choosing Task (Fallon and Rozin 1985) The Silhouette Choosing Task shows 9 females lined up in a horizontal row ranging from very thin to very overweight. The participants are then asked to choose the figure that represents them currently and the figure at which they would ideally like to be. The level of body dissatisfaction is the degree in which the two figures, the current body representation and the ideal body, differ. The greater the difference between the two figures indicates a higher degree of body dissatisfaction. Delay- Discounting Task The delay-discounting task gives individuals a scenario in which they won money. For each question, the participants determine the least amount of money they would like to obtain at various time periods instead of waiting for the full amount. It is considered impulsive to take the smaller immediate reward rather than waiting to receive a larger portion. The amount of money each participant discounts at various time periods will be examined. Procedure The participants signed up for this study in the University of North Dakota’s psychology building, Corwin Larimore, by filling out their names and email addresses in a folder by the entrance of the building. Once the participants signed up, they entered a room where they read and signed a consent form. Once all the participants that had signed up for that particular time were there or when five minutes past the initial study time had passed, the questionnaires were handed out as a packet. For privacy, the participants were asked to sit at least two desks away from the next person. The participants were informed that they could leave at any time, if they decided that they did not want to participate. After a participant had completed the pack of questionnaires and consent form, she was asked to hand in their questionnaire packet at the front of the room. The participants were offered a copy of the consent form once the questionnaire packet was handed to the researcher. The participants were then thanked for their time and given an hour of extra credit for their professor to sign.
Results A one-way analysis of variance (ANOVA), with Group (At-Risk, Not At-Risk) revealed significant differences on the mood scale, the motivation/drive and empathy subscales of the EFI, state and trait anxiety, and greater impulsive sense of urgency. No other effects were significant (Table 1).
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Table 1 Descriptive statistics between SCANS experimental and control groups and measures Measure Age BMI Mood Efmd Efic Efem Eforg Efsp Eftotal S-anxiety T-anxiety BD Premeditation Urgency Sen. Seeking Perseverance Discounting
Group
Mean
SD
1
20.45
2.90
2
18.86
5.28
1
24.31
5.39
2
23.33
7.17
1
5.05
3.33
2
1.29
1.27
1
14.40
2.36
2
16.05
2.50
1
16.50
3.24
2
17.29
3.36
1
26.23
3.09
2
24.14
3.02
1
20.68
2.88
2
20.09
3.46
1
19.88
2.51
2
20.24
2.88
1
97.68
8.61
2
97.52
8.84
1
45.08
10.51
2
32.67
8.68
1
50.05
7.51
2
34.52
8.03
1
2.10
1.02
2
1.71
1.07
1
24.00
6.67
2
24.33
5.63
1
33.43
6.45
2
24.00
7.06
1
33.70
8.96
2
36.10
6.85
1
20.65
5.01
2
21.48
4.77
1
.70
.232
2
.67
.253
F(1, 59)
p-value
2.32
.13
.36
.55
24.80
.00
6.44
.014
.79
.38
6.34
.015
.49
.49
.26
.61
.004
.955
21.50
.000
56.17
.000
1.89
.17
.04
.85
27.55
.000
1.15
.29
.39
.54
.20
.65
BMI indicates body mass index, Ef indicates executive function, md indicates motivational drive, sp indicates strategic planning, org indicates organization, ic indicates impulse control, em indicates empathy, BD indicates body dissatisfaction
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Discussion The purpose of this study was to determine if factors concerning higher measures of impulsivity and body dissatisfaction were associated with females who are at risk for developing an eating disorder when compared to females who were not considered to be at risk for developing an eating disorder. Results from the UPPS Impulsive Behavior Scale and Executive Function Index indicated that at-risk females scored higher on certain measures of impulsivity, such as having a high sense of urgency and empathy, and lower on motivational drive when compared to non-risk females. However, results failed to show a significant difference in the executive functioning measures of impulse control, organization, and strategic planning between at-risk and non-risk females. Also, results failed to show a significant difference between BMI, delay discounting, and impulsive behaviors relating to premeditation, sensation seeking, and persistence between the experimental and control groups of participants. There were a few limitations to this study. One possible limitation may be lack of honesty from the participants. Participants may be not completely honest when filling out the questionnaires, because of the fear of representing themselves poorly. Also, some participants may feel anxious about confidentiality and may alter their answers in fear that their responses will be associated to their name. Another limitation may be the small number of participants. The limited number of participants may not be enough to determine correct correlations between the factors being researched. This study included only a homogeneous sample of white females, which is not representative of the entire population. Non-college students are not included along with male students. There may be differences in the correlations of risk and other factors between males than in females or between college students and non-college students. These differences are limiting in that this study only looks at female college students. There was a risk for participants when filling out the questionnaires. Some of the questions may be upsetting to the participants, and that could raise some ethical issues. Questions about a participant’s weight and height may cause the participants to feel ashamed or anxious. Also, with the Body Image Silhouette Task, participants were asked to identify a drawing in which represents their body. This focus on a participant’s body could cause that individual distress as well. Even with limitations, this study can provide meaningful research on eating disorders. Experimenters may want to repeat this study to develop its reliability, while other experimenters may want to change a few factors and build upon what this study will test. After gathering data throughout the Fall semester of 2009 and Spring semester of 2010, this honors thesis was able to infer that certain measures of impulsivity were associated with being at risk for developing an eating disorder, as well as indicating greater body dissatisfaction with at risk females. Eating disorders are becoming more prevalent in society each day. Not only for those that develop eating disorders, but also for the friends and family that knows someone with an eating disorder. Unfortunately the chances for full recovery from an eating disorder are grim. Hopefully more research can be performed, to establish preventative measures, to stop this disease before it starts.
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