Personality and Behavioral Vulnerabilities Associated ...

Journal of Abnormal Psychology 1993, Vol. 102, No. 3,438-444

Copyright 1993 by the American Psychological Association, Inc. 0021-843X/93/S3.00

Personality and Behavioral Vulnerabilities Associated With Risk Status for Eating Disorders in Adolescent Girls

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Gloria R. Leon, Jayne A. Fulkerson, Cheryl L. Perry, and Robert Cudeck This article presents first-year cross-sectional findings from a study of the development of eating disorders. Adolescent female (N = 937) 7th through 1 Oth graders completed measures that included information on personality, self-concept, eating patterns, and attitudes. A risk status score was calculated on the basis of comprehensive information regarding DSM-HI-R eating disorders criteria and other weight and attitudinal data. All personality measures showed significant differences according to risk, based on subject classification into high, moderate, and mild risk status and comparison groups. Early puberty was not associated with increased risk. The strongest predictor variables for risk were body dissatisfaction, negative emotionality, and lack of interoceptive awareness. The possible diathesis of personality including temperamental factors in the later development of an eating disorder is discussed.

A risk factor paradigm for the study of eating disorders in adolescent populations (Striegei-Moore, Silberstein, & Rodin, 1986) seems important for gaining a better understanding of the etiology and developmental psychopathology of anorexia nervosa, bulimia nervosa, and subclinical forms of these disorders. Bruch (1978) cautioned researchers about making generalizations regarding the etiology of anorexia nervosa from data obtained during the acute episode when semistarvation is present and exerting its own influence on psychopathology and family relationships. The extended prospective assessment of high-risk normal populations should enable investigators to examine personality, behavioral, and family processes unconfounded by the disorder itself. On the other hand, cross-sectional assessment of risk status can provide important information on current interrelationships of mood and environmental factors and disordered eating. Eating disorders occur primarily in females, and adolescence is a major risk period for the development of these disorders (Halmi, Casper, Eckert, Goldberg, & Davis, 1979). However, in studying adolescents it is important to distinguish between normal, developmental concerns regarding independence, sexuality, and physical appearance, and preoccupations or attitudes that may be pathognomonic. Dieting behaviors, body dissatis-

faction, body weight ideals below current body weight, and unusual eating patterns are quite prevalent in adolescent girls and college women (Leon, Carroll, Chernyk, & Finn, 1985; Leon, Perry, Mangelsdorf, & Tell, 1989), as are weight concerns (Wadden, Brown, Foster, & Linowitz, 1991), and may not necessarily be associated with the presence of, or potential for, an eating disorder. The possible role of early pubertal development as a risk factor for the development of an eating disorder has received recent attention (Rodin, Striegel-Moore, & Silberstein, 1990). However, current findings are not consistent. Attie and BrooksGunn (1989) studied female adolescents (Grades 7-10) and found that early pubertal development, particularly as measured by body fat, was related to eating problems only in the initial testing and not at a 2-year follow-up. Personality and its temperamental underpinnings may be an important influence in current disordered eating patterns as well as in predisposing individuals to the later development of eating disorders. Patton (1988) found that neurotic and depressive symptoms and obsessional personality characteristics were associated with current risk factors for eating disorders. Bruch's (1969) formulations regarding poor awareness of the signals of bodily urges in persons with eating disorders suggest the possibility that chronic dysphoria or emotional lability coupled with difficulties in labeling one's feelings (lack of interoceptive awareness) may be associated with current disordered eating. If this association continues over an extended time, disordered eating patterns may then become a learned means of dealing with unpleasant arousal states. Related to this notion, Heatherton and Baumeister (1991) postulated that binge eating was motivated by an attempt to escape from aversive self-perceptions. A strong feeling of personal ineffectiveness and low selfesteem has also been identified in persons with eating disorders (Wagner, Halmi, & Maguire, 1987). Therefore, for individuals with particular personality vulnerabilities who live in a culture that promotes extreme body dissatisfaction in women, eating disorders may become a pathway for the expression of their psychopathologic potential.

Gloria R. Leon, Jayne A. Fulkerson, and,.Robert Cudeck, Department of Psychology, University of Minnesota; Cheryl L. Perry, Division of Epidemiology, School of Public Health, University of Minnesota. This research was supported by Grant IRQ 1-HD24700 from the National Institute of Child Health and Human Development. We thank Anita Dube, Mary Early, Joan Garrow, Amy Grengs, Steve Hughes, Patrick Jichaku, Lisa Lilenfeld, and Armando Loizaga for their enthusiastic help in carrying out the school testing, and we thank John Fleming for his statistical advice. The excellent support of Donald Sension and the staff of the Hopkins School District is most gratefully acknowledged. Correspondence concerning this article should be addressed to Gloria R. Leon, Department of Psychology, Elliott Hall, 75 East River Road, University of Minnesota, Minneapolis, Minnesota 55455. 438


EATING RISK FACTORS

This article presents the first-year cross-sectional data of a prospective investigation of the development of eating disorders in an adolescent population. The goal of the study was to identify particular combinations of personality and behavioral factors that are associated with current risk for an eating disorder. To our knowledge, this investigation is the first to sample a large adolescent population and the first in which both risk status and a wide range of theoretically and empirically relevant independent variables are comprehensively assessed. We also were able to examine the relative influence of an array of variables of interest in predicting eating-disorder risk. Furthermore, the assessment of both pubertal development and sexuality attitudes adds an important dimension to the study of the correlates of eating-disorder risk. A major hypothesis of this investigation was that negative mood and poor interoceptive awareness would differentiate those adolescents exhibiting high base-rate concerns about body image and frequent dieting behaviors from adolescents reporting clinically diagnosable signs of an eating disorder. Our prediction was that these personality factors would be predictive of risk status independent from the specific developmental or grade level of the adolescent. We also hypothesized that early pubertal development, negative attitudes about sexuality, and low autonomy within the family would be predictive of eating-disorder risk. Method Subjects AH 7th- through lOth-grade female students attending school in a particular suburban Minnesota school district were targeted for this study (N - 1,029). There were 977 students assessed. Only 4 students refused to cooperate. Forty-eight students were absent on the testing and makeup days (13.5% seventh graders, 28.8% eighth graders, 25% ninth graders, and 32.7% tenth graders). An additional 40 subjects were not included in the analyses because they missed more than 20% of the items needed to calculate risk score (17.5% seventh graders, 42.5% eighth graders, 25% ninth graders, and 15% tenth graders). This grade distribution does not demonstrate systematic increases or decreases in missing data with grade. Thus, the final sample was 937 female students (91% of the female students in the entire secondary level of the school district).1 The ages of the subjects, according to grade, were as follows: Grade 7, M= 12.1 years (SD = 0.3); Grade 8, M= 13.1 years (SD = 0.4); Grade 9,M=14.1 years (SD= 0.4); and GradelO,M= 15.1 years (SD = 0.4). The 9th- and 1 Oth-grade students were significantly more likely to be in the moderate- or high-risk groups, x2(9, N= 937) = 19.2, p < .05. The occupational category of executive, administrative, or professional occurred for 50.6% of the fathers and 32.7% of the mothers of the total sample. The category of clerical work, administrative support, sales, or technician was indicated for 21.9% of the fathers and 34.7% of the mothers. There were no significant differences in the father's occupation according to risk status; however, the mothers of the high-risk subjects were more likely than those in the other three groups to be in the executive, administrative, or professional category, x2(9, JV= 888)= 20.2, p < .05.

Procedure Research assistants administered the various assessment instruments, which were included in two questionnaires that students completed during their social studies classes over 3 testing days and a

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makeup day, if necessary. The experimenters conducted private height and weight measurements on a separate day; students also privately completed the Pubertal Development Scale at this time.

Measures Behaviors, attitudes, and lifestyle patterns. We created the Eating Disorders Checklist, a 24-item survey, to assess past and current history of diagnosed eating disorders, specific diagnostic criteria for anorexia nervosa, bulimia nervosa, and subthreshold forms of these disorders, weight fluctuations, weight gains and losses, dieting, and menstrual history. The mean 2- to 4-week test-retest concordance ratio was 96.8% (range = 86%-100%) for assessment of 317 girls and boys in Grades 8-12. Cronbach's alpha was .78 in this study. We also included the Eating Disorders Inventory (EDI; Garner, Olmstead, & Polivy, 1983), which is a 64-item measure of psychological and behavioral characteristics common to anorexia nervosa and bulimia nervosa. The eight subscales of this measure are Drive for Thinness, Bulimia, Body Dissatisfaction, Ineffectiveness, Perfectionism, Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears. Cronbach's alpha was above .80 for anorexic samples and .78 for female comparison groups (Garner et al., 1983). Normative data on adolescent populations have been collected (Leon et al., 1989; Rosen, Silberg, & Gross, 1988). The EDI Drive for Thinness and Bulimia subscales assess dieting and food-related behaviors; they were included in the current study in the group of 21 dependent variables that constituted the global measure of risk status. The other six EDI subscales were analyzed as independent variables because their items assess domains not specifically related to food intake. Finally, we used the Health Behavior Survey, a 27-item survey assessing food preferences, the frequency of food and alcohol consumption, and exercise patterns. Similar results across diverse populations have been obtained with an expanded form of this instrument (Perry, Griffin, & Murray, 1985). One-week test-retest correlations on the food patterns sections ranged from .59 to .74 (Perry, 1986; Perry et al., 1987). Physical measurement. Weight and height were assessed with an electronic scale and a tape measure and were the values used in computations of the body mass index (BMI), which was calculated as a girl's weight (in kilograms) divided by the square of her height (in meters). Pubertal development. To assess this variable, we used the Pubertal Development Scale (PDS; Petersen, Crockett, Richards, & Boxer, 1988), a 5-item scale in self-report or interview format that assesses growth spurt in height, body hair development, skin change, breast development, and menarche in girls and facial hair growth and voice change in boys. Petersen et al. reported that the median alpha for the PDS was .77; the median correlation between adolescent self-reports and interviewer ratings (based on self-report data plus visual information obtained by talking to the clothed adolescent) was .70. Personality characteristics. The Negative Emotionality (NE) and Constraint (CON) higher order factor scales of the Multidimensional Personality Questionnaire (MPQ; Tellegen, 1982) provide information on personality characteristics viewed as trait rather than state variables. The majority of NE items are from the Stress Reaction primary scale of the MPQ. NE was identified as a major dimension of mood

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All male students in the same grades were assessed as well. However, because only 8 boys in the total sample of 954 boys fell in the high-risk group, robust statistical comparisons across risk groups by grade and gender could not be carried out. Thus, only data for the girls were used in this article. The high-risk sample for boys should increase with the inclusion of additional cohorts, and subsequent reports will include data from boys.


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(Zevon & Tellegen, 1982). Convergent validity of the MPQ has been demonstrated (Tellegen, 1982). Thirty-item short forms of the NE and CON scales were developed by Waller (1990) and were used in this study. We also used the General Behavior Inventory (GBI; Depue et al., 1981), which was originally developed as an index of risk for bipolar disorder. The full 73-item measure showed an internal consistency alpha of .94 and a 15-week retest stability of .73. Separate scales for dysthymia (depression), hyperthymia (hypomania), and cyclothymia (biphasic) have been developed and validated (Depue, 1985). A 34item short form developed through factor analysis by Ellis (1989) was used in the present study. Self-concept and other attitudes. The Self-Perception Profile for Adolescents (SPPA; Harter, 1986) is a 45-item scale consisting of nine subscales: Scholastic Competence, Social Acceptance, Athletic Competence, Physical Appearance, Job Competence, Romantic Appeal, Behavioral Conduct, Close Friendship, and Global Self-Worth. Harter reported alpha levels ranging from .58 to .93 across the nine scales; items attenuating reliability in the scales with lower reliability were subsequently revised. Autonomy was measured with the Nowicki-Strickland Locus of Control Scale for Children (Nowicki & Strickland, 1973). More specifically, we used the Autonomy-Restriction factor, a four-item scale identified by Lindal and Venables (1983) through factor analysis of the scores of a large sample of adolescents. The Autonomy-Restriction items assess the adolescent's perceptions of autonomy in interactions with his or her parents and family. Cronbach's alpha on this scale was .70. Attitudes about sexuality were assessed through the My Sexual Feelings semantic differential scale, which consists of 12 bipolar adjectives (Leon, Lucas, Colligan, Ferdinande, & Kamp, 1985). Cronbach's alpha was .85 for the students evaluated in the current study.

in this study, except for several scales on the SPPA and the My Sexual Feelings scale. The MANOVA for the GBI scales found Depression, Hypomania, and Biphasic scores significant for risk (Wilks's X = 0.81), approximate multivariate F(9, 2188) = 22.59, p < .001. Subsequent univariate ANOVAs indicated that all three GBI scale scores systematically increased with risk. The MPQ MANOVA found NE and Constraint scales significant for risk (Wilks's X = 0.79), multivariate F(6,1812) = 36.49, p < .001. Univariate ANOVAs indicated that MPQ NE scores systematically increased with risk but that, contrary to expectations, the MPQ Constraint scores decreased with risk. The multivariate ANOVA for the six EDI scales showed significance for risk status (Wilks's X = 0.63), approximate multivariate F(l 8,2529) = 25.05, p < .001, and subsequent univariate ANOVAs indicated that all six EDI scales increased with risk status. The univariate analysis for autonomy found scores to systematically decrease with risk.2 Table 1 presents means and standard deviations for the variables hypothesized to be most strongly related to risk status. Grade also showed significant effects on several measures. The GBI Depression and Biphasic scores increased with grade, F(3, 949) = 3.20, p < .05, and F(3, 959) = 7.61, p < .001, respectively, as did Autonomy and My Sexual Feelings scores, F(3,962) = 3.43, p < .05, and F(3,926) = 5.38, p < .01, respectively. MPQ Constraint scores significantly decreased with grade, F(3,957) = 8.97, p < .001. The Interoceptive Awareness Grade X Risk interaction term was also significant, F(9,899) = 3.52, p