Body image disturbances and their change with videofeedback in anorexia nervosa

Pergamon

Behav. Res. Ther.Vol. 35, No. 5, pp. 389-398, 1997 © 1997ElsevierScienceLtd. All rightsreserved Printed in Great Britain PII: S0005-7967(96)00118-0 0005-7967/97 $17.00+ 0.00

BODY IMAGE DISTURBANCES AND THEIR CHANGE WITH VIDEOFEEDBACK IN ANOREXIA NERVOSA N O L A R U S H F O R D 1'2 and A N N E T T E O S T E R M E Y E R 1,2 ~Department of Psychology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Vic. 3052, Australia and 2The Royal Melbourne Hospital, Melbourne, Australia (Received 28 November 1996)

Summary--Disturbance in the way the body is experienced is a diagnostic criterion for anorexia nervosa, and impedes recovery. A method relatively free of external prompts, to reduce the potential for experimentally induced biases, evaluated body image distortions (BID) in 18 patients with anorexia nervosa soon after admission to an inpatient unit, and 18 normal controls, before and after a videofeedback session. The BID were assessed in the affectiveand self/socialdomains by visual analogue scales in which the instructional set oriented subjects to (a) the sensation of fatness (AffectiveResponse, AR), and (b) size compared with other young women (Comparative Size Response, CSR). The AR and CSR were significantly greater than normal in anorexia but decreased significantly with videofeedback, while values for controls were stable. The AR and CSR were only partially independent, indicating overlap of the domains. In anorexia only, the responses were related to two DSM-1V diagnostic criteria for anorexia, fear of gaining weight and health-weight concerns, as well as to drive for thinness and body dissatisfaction. Fear of gaining weight occupied a central position in determining the magnitudes of BID and the other measures, including anxiety and depression. © 1997 Elsevier Science Ltd

INTRODUCTION The seriousness of disturbances in the way the body is experienced in anorexia nervosa has been recognised by the continued inclusion of "Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight" as one of the four criteria for its diagnosis according to the Diagnostic and statistical manual f o r mental disorders--Edition I V (American Psychiatric Association: APA, 1994). The criterion was retained after evaluation by the Eating Disorder W o r k Group, established to identify the issues which should be examined more closely in relation to both anorexia and bulimia nervosa (Walsh, 1992). However, there is considerable uncertainty about operational definitions of body image disturbance or distortion (BID), the factors that contribute to its development (Slade, 1994), and the best therapeutic methods to reduce it (Probst, Van-Coppenolle & Vandereycken, 1995a). Reasons for the indeterminacy include the range of theoretical possibilities from which a definition of BID could be drawn (Smeets & Panhuysen, 1995), the variety of methods used to evaluate it (Hsu & Sobkiewicz, 1991; Rosen, 1992; Slade, 1994), and the type of instruction used to elicit a response (Slade, 1994). Definitions of BID have been drawn from the perceptual, attitudinal, cognitive, affective and behavioural domains within which appraisal of body image can occur (Altabe & Thompson, 1992, 1993; Carr-Nangle, Johnson, Bergeron & Nangle, 1994; Gardner & Moncrieff, 1988; Roth & Armstrong, 1993; Rosen, 1990; Rucker & Cash, 1992). It has become clear, however, that the distortion or disturbance is not the result of a failure of sensory processing or of a perceptual dysfunction but is mediated primarily by nonsensory, particularly affective, processes (Bowden, Touyz, Rodriguez, Hensley & Beumont, 1989; Gardner & Bokenkamp, 1996;Gardner & Moncrieff, 1988). Given this, perhaps it is time to reserve the term 'distortion' for primary perceptual processes and 'disturbance' for the possibly affective-laden processes. The methods used for assessing BID generally present to the S some objectified task. Tasks include visual body size estimations, image marking procedures, questionnaires, figure drawing, figural selection tasks and distorting television/video techniques (Ben-Tovim & Walker, 1992; Ben-Tovim, Walker, Murray & Chin, 1990; Bowden et al., 1989; Horne, Van Vactor & 389

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Emerson, 1991; Probst, Vandereycken, Van-Coppenolle & Pieters, 1995b; Rosen, Reiter & Orosan, 1995; Williamson, Barker, Bertman & Gleaves, 1995). Each task directs evaluation of BID to some degree: some filter responses through sets of assumptions about BID that can make results difficult to interpret, as with questionnaires, while others have methodological problems, as with figural selection tasks (Slade, 1994) or video distortion (Probst, Van Coppenolle, Vandereycken & Goris, 1992). The instruction sets also often reflect the theoretical perspective or domains being explored and the method used. For example, Ss can be asked how they think they look (cognitive instructions), how they feel they are (affective instructions), and how they wish they were (optative instructions) (Bowden et al., 1989). The distinction found between cognitive and affective instructions (Bowden et al., 1989; Slade, 1994) has been labelled the 'think-feel discrepancy' (Altabe & Thompson, 1993). Another domain of significance to BID is the psychosocial, specifically self/social comparisons (Thompson & Heinberg, 1993). The importance of sociocultural factors is seen in the perception of slimness as the embodiment of a cultural ideal of female attractiveness and success in Western societies (Gordon, 1990; Zraly & Swift, 1990). Young women with anorexia nervosa are particularly vulnerable to media representations of thin females (Beumont, Russell & Touyz, 1993). For the present study, to reduce the reliance on external prompts to a minimum, BID was assessed by simple, but clinically useful, visual analogue scales (McCormack, H o r n e & Sheather, 1988). The instructions reflected two domains, the affective and self/social, by asking the S to mark how fat she felt and how her size compared with other young women. The degree of independence of the two domains could then be determined. Another of the factors contributing to the debate on the role of BID in eating disorders (Slade, 1994) has been the belief that BID is fixed and delusional and thus not amenable to manipulation (Bruch, 1962). It is no longer an issue. Cognitive-behavioural methods have achieved reductions in BID (Rosen, Cado, Silberg, Srebnik & Wendt, 1990). The issue now is one of determining the most effective methods for its rapid reduction, since over-estimation of body size has been associated with poorer outcome and smaller weight gain during treatment (Slade, 1985; Sunday, Halmi, Werdann & Levey, 1992. The present study evaluated the effect of one session of videofeedback, during which the patient was guided to view her body more realistically, with assessment of BID before and after viewing the videotape. Normal control Ss were included, since a number of studies of young women have shown body image disturbances that predict dieting to achieve a slimmer and more 'attractive' shape (Abraham & Mira, 1988; Paxton et al., 1991). To determine whether the two measures of BID did reflect different aspects of clinical status, or whether they were from the same domain, their relationships to each other and to other variables were assessed. Changes with videofeedback were also observed. Variables relevant to anorexia nervosa included fear of gaining weight and denial of the seriousness of the current body weight, taken from the DSM-IV diagnostic criteria for anorexia nervosa (APA, 1994), measures of anxiety and depression, and two subscales of the Eating Disorders Inventory (Garner, Olmstead & Polivy, 1983), drive Jor thinness and dissatisJaction with the body. In summary, disturbances in evaluation of the body, derived from the affective and self/social domains in female inpatients with anorexia nervosa, were compared with each other and those in female normal control Ss of similar age. A videofeedback session was included to test whether disturbances in body image could be reduced in the short-term. Their relationships to each other and to psychological measures were investigated.

METHOD

Subjects Nineteen females satisfying DSM-IV criteria for anorexia nervosa (AN) (APA, 1994) and admitted for inpatient treatment in the Eating Disorders Unit at the Royal Melbourne Hospital, and 19 female normal controls (NC), entered the study after giving informed consent according to National Health and Medical Research Council of Australia (1983) guidelines and the ethical requirements of the Royal Melbourne Hospital. One inpatient withdrew before viewing the tape, being too afraid to look; three others had declined to participate in the videofeedback session, one

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saying that she knew she was skinny and each of the other two stating that she couldn't bear to see how fat she was. One normal control was omitted from data analysis because of a possible eating-related problem.

Questionnaires Baseline questionnaires. Inpatients completed a battery of assessment questionnaires at admission; NC Ss completed theirs in the week before the videofeedback session. They included the Trait scale of the State-Trait Anxiety Inventory (STAI: Spielberger, 1983), the Beck Depression Inventory (BDI: Beck & Steer, 1987) and the Eating Disorders Inventory (EDI: Garner et al., 1983) for its subscales drive for thinness and body dissatisfaction. Fear of gaining weight, a component of a DSM-IV diagnostic criterion for AN (APA, 1994) was assessed by a visual analogue scale 100 mm in length and ranging from 'Not at all Afraid' to 'Completely Afraid'. Videofeedback questionnaires. Body image distortions were calculated from bipolar visual analogue scales asking the S to first rate how fat she felt she was, between the extremes of 'Skinny' and 'Fat' with a central zero (Affective Response, AR) and, second, her size compared with other young women, between 'Skinnier' and 'Fatter' with a central zero (Comparative Size Response, CSR). The latter could not be interpreted as belonging in the cognitive domain, as no mention was made of the size they 'thought' they were. The responses were scored to give a range of - 1 to 1. Perception of the seriousness of current low body weight [part of the DSM-IV (APA, 1994) diagnostic criterion concerned with body image] was adapted to seriousness to health of low body weight to take into account the normal group. It was assessed by a 100 mm visual analogue scale, with ends anchored at 'Not at all serious' and 'Extremely serious'. To ensure that the techniques used were not causing undue distress, feelings associated with comfort during videotaping were recorded on a 100 mm visual analogue scale ranging from 'Not at all comfortable' to 'Very comfortable'. The State scale of the STAI (Spielberger, 1983) was included for the same reason. The videofeedback session Approximately 1 week after admission, each inpatient had the videofeedback session in a private room with a clinical psychologist or psychology student under supervision. Normal controls were tested privately outside the hospital. Height and weight were measured to calculate BMI. Areas of the body that caused particular distress were documented. Each S completed the videofeedback questionnaires. The S then stood in front of a plain background in underwear or swimwear and the video was made. The S was filmed from the front, both sides and the back, while being asked to turn slowly, in order to move away from a flat, two-dimensional representation of the body. Turning to the side allowed the AN S, in particular, to view her depth and to appreciate more fully how thin she was. The feeling of bloating in the early stages of recovery drove a number of inpatients to visualise their stomachs as 'huge' and this could generally be laid to rest by the side view. Videotaping took place, when possible, after lunch for this reason. Once the video was completed, the S got dressed. When the S was ready, the videotape was replayed. The researcher discussed with the S her perceptions of her body throughout the tape, pausing where necessary. Concerns and beliefs the S had about her body were compared with the reality of the videotape and with how a normal, mature female is meant to look. For example, if the patient had said she had fat thighs, the researcher would draw attention to the large gap between her inner thighs, commenting that normal women's thighs touch, or if she had been distressed by her 'flabby, fat stomach', not only was the evidence of the videotape discussed but also the effects of starvation and refeeding on muscle mass and tone and how the sensations of bloating arose (Szmukler, 1995). To strengthen objectivity during the viewing, the S was encouraged to view the figure on the screen as someone she might see standing on a beach, and to describe her. After viewing the videotape, the videofeedback questionnaires were completed again. Cue-cards summarising the changed cognitions about fatness and shape were prepared. The patient was escorted back to the ward where, to promote the continued challenging of dysfunctional body image thoughts, the session was discussed, with permission, with her primary nurse.

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Table I. Psychological measures, weight and equivalent BMI in 18 female inpatients with anorexia nervosa and their 18 normal controls at baseline Measure Age (yr) Anxiety--trait (STAI-T) Depression (BDI) Eating Disorder (EDI) Drive for thinness Body dissatisfaction BMI Weight at video (kg)

Normal controls Mean SD

Anorexia nervosa Mean SD

21 34 4 21 2 9 21,5 59.1

23 60 30 80 13 17 15.8 42.3

3 1I 5 12 2 7 1.8 6.4

5 15 13 47 7 8 1.5 4.0

Univafiate F~.30

P

0.4 50.5 82.1

0.561

30.6 12.5 86.3

0.000 0.00 I 0.000

0.000 0.000

Note: STAI-T--Trait scale of the State-Trait Anxiety Inventory (Spielberger, 1983); B D l - - B e c k Depression Inventory (Beck & Steer, 1987); E D I - - E a t i n g Disorders Inventory (Garner et al., 1983).

The videotape was kept by the S or in safe keeping with the researcher until the repeat session at discharge or at follow-up for the normal controls.

Data analysis Data were checked for satisfaction of criteria for use of parametric statistics. M A N O V A s were performed to test the hypotheses that: (a) the A N inpatients on admission to hospital for treatment would show greater body image disturbance than normal controls, using body mass index (BMI) as a covariate; and (b) the videofeedback session would result in a significant shift in the AR and CSR towards normal in the A N group while the NC group would not change. Relationships of psychological and eating disorder measures to the AR and CSR in the A N group were explored using second order Pearson product moment correlation coefficients, with BMI as covariate. RESULTS

Description of the groups At admission, a M A N O V A comparing the NC and A N groups showed that baseline measures were significantly different (F7.23 = 45.64, P = 0.000). Univariate post hoc comparisons (Table 1) showed that the inpatients were significantly more anxious and depressed, and had a greater drive for thinness and body dissatisfaction. Mean weight and BMI were significantly less than normal in the A N group, with the NC mean lying within the lower half of the normal range BMI of 20-25 kg/m 2 (National Heart Foundation of Australia, 1990); their ages were similar. In the A N group, fear of gaining weight had a mean (SD) of 76 (28) out of a possible 100, with a range of 0-100. The body image disturbance measures A single repeated measures M A N O V A of AR and CSR before and after videofeedback, with BMI as covariate, revealed a significant difference between groups (F2.32= 5.83, P = 0.007) and change with videofeedback (F2.33 = 13.4, P = 0.000) that showed an interaction (Group × Time) effect (F2.33 = 10.2, P = 0.000). Post hoc univariate A N O V explored where the differences lay (Table 2). Table 2. Body image disturbance responses in the affective (AR) and self/social comparative (CSR) domains in 18 female inpatients with anorexia nervosa and 18 normal controls, before and after videofeedback Disturbance index

Normal control Mean SD

AR

Pre-video Post-video

CSR

Pre-video Post-video

-0.01 0.01 FLt7 = 0.11 P = 0.741 0.03 - 0.05 Ft.~7 = 1.66 P = 0.215

Anorexia nervosa Mean SD

0.30 0.31

0.46 0.07

0.24 0.30

0.40 - 0.13

Univariate F~,3s

P

0.38 0.51

12.2 1.4

0.000 0.245

0.43 0.53

16.5 4.5

0.000 0.042

F L t r = 20.6 P = 0.000

Ft.17 = 25.2 P = 0.000

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Table 3. Perception of low body weight as a health concern, state anxiety and comfort on participating in a videofeedback session for body image disturbance, in 18 female inpatients with anorexia nervosa and their normal controls Measure

Normal controls Mean SD

Anorexia nervosa Mean SD

8 I0

41 58

7 6

56 53

P = 0.000 14 14

31 50

Perceived seriousness of low body weight

Pre Post

91 93

State anxiety (STAI-S)

Pre Post

30 27

Comfort in participating

Pre Post

75 83

NS

F, j7 = 8 . 7

F,.17 = 8 . 0

P = 0.011

22 26 F,.,7 = 8.0 P = 0.012 14 13

Univariate F,.~4 P 81.3 27. I

0.000 0.000

57.0 84.4

0.000 0.000

84.5 27.5

0.000 0.000

NS

20 25 El.t7 = 1 3 . 9 P = 0.002

Note: STAI-S---State scale of the State-Trait Anxiety Inventory (Spielberger. 1983).

Before videofeedback, body image was significantly more disturbed in the A N group than in the N C group. According to the AR, the A N inpatients' feelings of being fat were greater than for the much heavier normal females and, according to the CSR, they perceived themselves to be fatter than other women their age, while the N C group perceived themselves to be similar to others. The A R and CSR were strongly related in A N (r = 0.90, P = 0.000) but not in NC (r = 0.25, P = 0.337). After videofeedback, the A R and CSR in the A N group had shifted significantly towards normal (Table 2), while the N C means had not changed significantly. To gain a clearer idea of what the post-video measures signified, an adjustment to A R and CSR was made by taking into account the relative BMI of the A N and N C groups, still maintaining the range of - 1 to 1. It was then clear that the A N group still over-estimated their size. Comparing NC and AN, mean (SD) adjusted A R was 0.00 (0.14) and 0.38 (0.29), respectively ( F l a t = 30.6, P = 0.000) and adjusted CSR was - 0.02 (0.12) and 0.26 (0.20), respectively (Fl,17 = 26.6, P = 0.000). Relative stability of the BID measures was assessed by the strength of the Pearson product moment correlation coefficients between pre-video and post-video measures. In the N C group, the A R was stable across videofeedback (r = 0.82, P = 0.000), while the CSR showed greater variation (r --- 0.57, P = 0.012) as some N C Ss changed their perceptions of themselves to being slimmer compared with other females (Table 2). In the A N group, the significant shifts in A R with videofeedback tended to occur across the group as a whole (r = 0.71, P = 0.001) while the CSR change was less regular (r = 0.59, P = 0.010). The relationship between A R and CSR decreased for AN (r = 0.67, P = 0.002) and became significant for N C (r = 0.84, P -- 0.000).

The video session psychological measures Changes across the session in perceived seriousness of low body weight, state anxiety and comfort in participating in the videofeedback procedure were assessed by a repeated measures M A N O V A . There were significant group effects (6.32 = 37.6, P = 0.000), time effects (F3.3z = 10.4, P = 0.000) and interaction effects (F3.32= 3.41, P = 0.03). Post hoc univariate A N O V indicated the measures for which change was significant (Table 3). Pre-videofeedback, perception of the seriousness of low body weight was markedly less in the A N group than in the normal controls. After viewing the videotape the A N group were able to perceive low body weight as a more serious problem than before but still not as seriously as did the normal controls. The videotaping and viewing of the tape did not amplify distress. The significantly higher than normal state anxiety in A N (Table 3) remained stable over the session, while it decreased in the N C group. The A N group felt less comfortable in participating in the videofeedback session than the N C group, but both groups felt significantly more comfortable after videotaping than before.

Body image disturbance and its relationships to other measures Relationships were assessed by first order Pearson product moment correlation coefficients when relationships to BMI were examined, and second-order coefficients for the rest, with BMI as covariate. There were few significant relationships within the N C group involving A R or CSR.

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BMI. In the N C group, BMI was weakly related to pre-video CSR (r = 0.51, P = 0.032) and more strongly to post-video CSR (r = 0.61, P = 0.007). There were no significant relationships in the A N group, the strongest being between BMI and CSR (r = 0.45, P = 0.063). DSM-IV-related measures. Before videofeedback, in the A N group, the greater the A R and CSR the greater the fear of gaining weight (r = 0.80, P = 0.000; r = 0.75, P = 0.001, respectively) and the poorer the patients' perception of low weight as a health problem (r = - 0.52, P = 0.027; r = - 0 . 6 5 , P = 0.004). The greater the fear of gaining weight the less seriously they viewed low body weight (r = - 0.71, P = 0.001); neither measure was related to BMI. The EDI subscales. In the A N group, drive for thinness predicted how strong body image disturbance would be, for both AR and CSR (r = 0.70, P = 0.002; r = 0.74, P = 0.001, respectively), while body dissatisfaction set the scene for post-video disturbances (r = 0.55, P = 0.022; r = 0.73, P = 0.001, respectively). The other correlations of the set were not significant. Fear of gaining weight was strongly related to drive for thinness (r = 0.76, P = 0.000). In the N C group, body dissatisfaction was weakly related to pre-video CSD (r = 0.57, P = 0.016). There were no other significant relationships for NC. Mood. State anxiety, trait anxiety and depression did not interact significantly with the A N group's A R and CSR, the strongest link being between the BDI and A R and CSR (r = 0.48, P = 0.052; r = 0.49, P = 0.047, respectively). However, mood and other anorexia-related measures were related. Fear of gaining weight was related to the Trait scale of the STAI and BDI (r = 0.70, P = 0.002; r = 0.63, P = 0.007, respectively), as was drive for thinness (r = 0.56, P = 0.013; r = 0.62, P = 0.005, respectively). The only relationships approaching significance in the N C group were between drive for thinness and the State scale of the STAI before and after videofeedback (r = 0.64, P = 0.005; r = 0.57, P = 0.013, respectively). Fear of gaining weight. Because fear of gaining weight in the AN group appeared to occupy the most significant position in its relationships to the BID measures and the other variables, correlational analyses were repeated with it as a covariate. All the above significant correlations became non-significant, apart from the following. The pre-video relationship between A R and CSR remained significant, although diminished (r = 0.75, P = 0.001) and a weak relationship, similar to that seen in the N C group, between drive for thinness and the State scale of the STAI before videotaping was revealed (r = 0.54, P = 0.032). With drive for thinness replacing fear of gaining weight as covariate, the latter's statistically significant relationships to the other variables remained, even though reduced. Fear of gaining weight was thus of primary importance in explaining variance in the other variables. DISCUSSION Responses to two simple measures for assessing body image distortions in anorexia nervosa indicated abnormally heightened disturbance in the way a group of inpatients experienced their bodies. Reliance on external prompts in eliciting responses had been minimised by the use of bipolar visual analogue scales, reducing the probability of experimental bias, in contrast to other studies in which the prompts have included figures or questionnaires (Smeets & Panhuysen, 1995). The inpatients' ratings of feeling fat and their sense of being fatter than other young women were significantly more inflated than those of N C Ss, despite being almost six BMI units lighter. On scales ranging from - 1 to 1, mean responses of the normal-weight young females were close to zero, while for the inpatients they were near the mid-range possible for positively skewed responses. Viewing a videotape of themselves caused a significant reduction in the patients' responses only. There could be no doubt that the degree of disturbance bound up in feeling fat in the inpatients was of a different order to that experienced by the normal controls, and that their appraisal of themselves compared with other young women displayed a lack of objectivity about their bodies that was extreme. The possibility that there is little difference between anorexic and normal disturbances in body image (Casper, Halmi, Goldberg, Eckert & Davis, 1979; Fernandez, Probst, Meermann & Vandereycken, 1994; Probst et al., 1992; Strober, Goldenberg, Green & Saxon, 1979) was not supported in the present study. The conclusion drawn by the Eating Disorders Work Group, that disturbances in the way that the body is experienced should be retained in DSM-IV (APA, 1994) as a diagnostic criterion for anorexia nervosa (Walsh, 1992), was supported.

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The means by which the disturbances have more detrimental consequences for underweight eating disordered patients than for normal young women (Ryle & Evans, 1991; Ben-Tovim & Walker, 1992; Casper et al., 1979) was illustrated by the strength of their relationships to other variables. They illuminated, statistically, the firm grip seen clinically that anorexia nervosa has on the sufferer. In the inpatients only, responses were linked to a strong drive for thinness and body dissatisfaction, assessed by subscales of the Eating Disorders Inventory (Garner et al., 1983). The greater the disturbance, the less capable the patients were of perceiving low body weight as a health problem, to the point where disdain for the possibility that low body weight could have serious health consequences verged on insouciance. Fear of gaining weight, however, occupied a pre-eminent position in almost all aspects of psychological functioning examined for the study. It was the most strongly related of all to the body image responses, and its relationships to perception of the seriousness to health of low body weight, to drive for thinness, and to trait anxiety and depression absorbed much of their first order relationships to the responses. Thus, the fear of gaining weight appeared to drive the anorexic system, supporting its inclusion in the DSM-IV (APA, 1994) diagnostic criteria for anorexia nervosa. The pernicious combination of feeling fat while being emaciated, the drive to be thin, the fear of gaining weight and the lack of concern over being underweight indicates the means by which body image disturbance could be a predictor of poor outcome (Bruch, 1985). Denial of illness in anorexia has also been found to be related to poorer treatment outcome (Casper et al., 1979). Previously, body dissatisfaction has been inversely linked to ideal body image, but not to estimations of body size (Fernandez et al., 1994). Relationships in the NC group were weak but informative. Under conditions in which they knew they were going to view themselves, a stronger drive for thinness resulted in higher levels of state anxiety, as with the AN group. Presumably, the young women who were the most apprehensive about what they would see during the session were those who wished they were thinner, reflected in the drive for thinness. The drive to be thinner, however, was not related to actual size (BMI). Dissatisfaction with the body was related to their comparative responses and they, in turn, were weakly related to BMI, at least indicating some objectivity there. These weak interactions may be one end of a continuum that ends in the patients with anorexia nervosa, a reflection of the psychosocial forces equating feminine success and attractiveness to slimness (Gordon, 1990). The magnitude of body dissatisfaction was relatively high in the young women acting as controls, being over half the magnitude of the anorexic group, a common finding (Garner et al., 1983). It appears to reflect an extension of the concerns that young women have with their bodies, illustrated in a number of studies of high-school students in which body dissatisfaction was found to be a major concern of young women, impinging on their sense of self-worth (Martin, 1989; Moore, 1993; Paxton et al., 1991). Dissatisfaction with their bodies in young females may be related to deliberate weight loss (Moore, 1993) and would be magnified by size overestimation. The measures of mood in the anorexic inpatients at admission illustrated how their concerns with their bodies must keep them in a constantly anxious and depressed turmoil. Trait anxiety, as measured by the Trait scale of the STAI was very high, being well in excess of the mean quoted for psychiatric patients (Spielberger, 1983). Depression was high, the majority of Ss having scores within the ranges regarded as indicating depression that is severe (30-63) or moderate to severe (19-29) (Beck & Steer, 1987), with the mean for the group lying at the bound of the two ranges. Much of this anxiety and depression was fueled by the preoccupations and concerns assessed by the subscales of the Eating Disorders Inventory (Garner et al., 1983), a significant proportion of their variance being taken up by drive for thinness and body dissatisfaction, as well as by fear of gaining weight. The immediate effect of one session of videofeedback on the patients was considerable. A number of the inpatients were able to view themselves more realistically. Both the affective and the comparative responses changed significantly towards normal, even though continuing to be greater than normal when adjusted for the relative BMI of each group. The links with the admission measures of fear of gaining weight, drive for thinness and body dissatisfaction were weakened. The inpatients who were able to adjust their perception of being fatter than other young women to being thinner were also able to perceive that low body weight was more of a health problem than they

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had been able to admit beforehand, even if still not equated with normal concerns. The contribution of external reality to their responses was still minimal, however, only the comparative response showing a weak relationship to BMI. The patients still relied on cues unrelated to objective size estimation, the strongest one in the present study being internal, the fear of gaining weight. The improvement in body image disturbance with videofeedback may indicate why a number of studies have found that distorted body size estimation was not distinctive of eating disorder patients (Fernandez et al., 1994; Probst el al., 1995a). The video distortion technique used may be a de facto application of videofeedback. A number of young women in the NC group, on viewing themselves, reduced their comparative size estimations, strengthening the relationship to their affective responses and to BMI. Since the group BMI was towards the lower end of the normal range, this was reasonable. One conclusion is that one of the factors normal young women rely on when comparing themselves to others is their actual size. Videofeedback increases the accuracy of that perception. Another effect of the videofeedback session was the emergence of evidence of a statistical--as well as a conceptual--separation of the two domains, the affective and the self/social or comparative, from which the instructions were taken. They were not orthogonal, however. Before videofeedback it could have been assumed that they were measuring the same construct. They were of similar magnitudes, were strongly related to each other, sharing over 80% of their variance, and were similarly related to the other variables. With fear of gaining weight as a covariate, shared variance was reduced to 50%, indicating some separation. Videofeedback strengthened their separate qualities, having a greater effect upon comparative responses and loosening the similarity of their relationships to the other measures. Although the increase in their ability to perceive themselves more accurately may have been of immediate value to the inpatients there was no evidence to assume that it would have lasting effects. Anecdotally, a number of them reported later that they were able to eat more freely and were additionally helped by prompting from their primary nurse to remember what they had learnt from the videofeedback and to challenge their disturbed perceptions of their bodies. Two patients requested extra sessions to help allay a growing fear of fatness and loss of control as they put on weight. In summary, disturbance in the way the inpatients with anorexia nervosa experienced their bodies was greater than normal when compared with young women of normal weight but was reduced by a videofeedback session. Relationships to anorexia-related variables were also stronger in the A N group. The method used was relatively atheoretical and drew upon two domains for the instructions. They proved to be measuring similar constructs, obliquely related to each other. One assessed the affective domain through feelings of being fat and the other the self/social domain through comparing their size to other young women. Affect is apparently strong in both. We do not know whether the reductions in BID were long-term but the study is continuing to discharge, and has has been extended to evaluate a combination of videofeedback and group psycho-education. Acknowledgements--The authors would like to thank the staff of Ward 1 North at the Royal Melbourne Hospital for their

assistance with the project.

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