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A multidimensional measure of core beliefs relevant to eating disorders: Preliminary development and validation
Eating Behaviors 11 (2010) 239–246
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Eating Behaviors
A multidimensional measure of core beliefs relevant to eating disorders: Preliminary development and validation Helen Fairchild, Myra Cooper ⁎ Isis Education Centre, Oxford University, UK
a r t i c l e
i n f o
Article history: Received 23 November 2009 Received in revised form 15 April 2010 Accepted 20 May 2010 Keywords: Eating disorders Core beliefs Negative self beliefs Schema
a b s t r a c t Core beliefs associated with eating disorders are likely to be multidimensional, and may not be adequately captured by existing measures. The current study aimed to develop such a measure and examine its relationship to eating disorder symptoms, anxiety, depression and putative diagnoses of their related disorders. Core belief items were rated by 500 female participants aged 18–65, who also completed selfreport measures of eating disorder symptomatology, depression, anxiety, and self esteem. Factor analysis revealed five subscales, with themes related to (a) self loathing, (b) unassertive/inhibited, (c) high standards for self, (d) demanding and needing help and support and (e) abandoned/deprived. Thirty two items were selected for a final scale, the Eating Disorder Core Beliefs Questionnaire (ED-CBQ). The ED-CBQ subscales showed adequate internal consistency and construct (convergent and discriminant) validity. Self loathing appeared to be particularly associated with putative eating disorder diagnosis, while abandoned/deprived was more characteristic of putative anxiety and depression diagnoses. The findings suggest that negative core self beliefs relevant to those with an eating disorder are a multidimensional construct and that self loathing as a core belief merits further research and clinical attention. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction A role has been suggested for underlying, negative core beliefs about the self, derived from early experiences, in the development and maintenance of eating disorders (EDs) (Cooper, 2005; Waller et al., 2007). Core beliefs have been defined as the content of schemas within the context of cognitive theory, where schemas are the cognitive structures that organize experience and behavior and determine the content of thinking, affect and behavior (Beck, Freeman, & Associates, 1990). Core refers to central to dysfunctional cognitions and behavior, and negative to their typical valence in clinical disorders. Negative core beliefs are typically absolute, inflexible and global, and thought to arise in early development. The terms schema and core belief are often used interchangeably, and while core beliefs may exist in a variety of domains, those relevant to self are often hypothesized to be crucial in determining psychopathology (Beck et al., 1990). In eating disorders, the term “negative self belief” has also been used to refer to these beliefs, and their content is known to be ostensibly unrelated to patients concerns with eating, food, weight and shape. Typical negative self beliefs in EDs include
⁎ Corresponding author. Isis Education Centre, University of Oxford, Warneford Hospital, Oxford, OX3 1JX, UK. Tel.: +44 1865 226432. E-mail address: [email protected] (M. Cooper). 1471-0153/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.eatbeh.2010.05.004
“I'm a failure”, “I'm worthless”, “I'm weak”, “I'm disgusting”, and “I'm all alone” (Cooper, Todd, & Wells, 1998). Beyond this, however, relatively little empirical research has investigated their specific content in relation to EDs. In particular, their potential relationship to comorbid ED psychopathology, including symptoms of depression and anxiety, as well as to ED diagnosis, remains unexamined. Two self-report questionnaire measures, namely the Young Schema Questionnaire (e.g. Leung, Waller, & Thomas, 1999; Waller, Ohanian, Meyer, & Osman, 2000) and the Eating Disorder Beliefs Questionnaire (e.g. Cooper, Cohen-Tovée, Todd, Wells, & Tovée, 1997; Cooper & Hunt, 1998) have been used to investigate these beliefs. The YSQ was developed as a generic measure of early maladaptive schemas. It has good levels of psychometric and clinical utility (Schmidt, Joiner, Young, & Telch, 1995) and measures 16 core beliefs or schemas. It has acceptable psychometric properties in women with AN and BN (Leung et al., 1999; Waller, Meyer, & Ohanian, 2001) but it was not developed specifically for patients with eating disorders. There is evidence that the YSQ lacks specificity in terms of its ability to distinguish eating disordered patients, compared to those with depression. For example, in a study comparing moderately–severely depressed bulimic patients with severely depressed patients and controls, Waller et al. (2001) found equivalent levels of core beliefs in both clinical groups. The EDBQ, conversely, is a measure of core beliefs and assumptions designed specifically for use among people with eating disorders. It contains four subscales; the negative self beliefs subscale being of most interest here. Like the YSQ, the negative self
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belief subscale may not distinguish depressed patients from those with EDs (Cooper & Hunt, 1998). Compared to the YSQ, however, where no distinction was found, an analogue study has shown that it does seem to distinguish those with ED related (but who do not also have depressive) symptoms from controls (Cooper, Rose, & Turner, 2005). Although designed with EDs in mind, the scale is relatively short (only 10 items). Clinical experience and research evidence (e.g. Woolrich, Cooper, & Turner, 2006) suggests that although helpful, it may not provide a comprehensive measure of all core or negative self beliefs relevant to eating disorders. Additional themes might be usefully included, and some items might usefully be elaborated into subscales; i.e. it is likely that the construct is likely to be multidimensional in relation to EDs. In support of this suggestion, clinically, the literature contains many examples of a range of themes which might be core beliefs of significance to those with EDs, and which might merit particular attention, and treatment as individual themes. Recent empirical studies have identified a number of additional and specific themes that are not captured on the EDBQ (e.g. Woolrich et al., 2006), while first person accounts (e.g. Liu, 1979) have described additional beliefs. These include a sense of defectiveness, powerlessness, worthlessness, and emptiness (Woolrich et al., 2006), as well as lack of self control, weakness and laziness (Somerville & Cooper, 2007), rejection, isolation, difference, abandonment, and setting of extremely high standards (Liu, 1979). One striking category is beliefs reflecting extreme self loathing, self hatred and self disgust which are not currently captured on the EDBQ, or indeed on the YSQ (Cooper & Cowen, 2009). An exploratory study with two diagnosed groups found that those with an ED and depressive symptoms could be distinguished from those with major depression in their negative core beliefs. The former group was characterised by high scores on scales reflecting repelled by self and lacking in warmth, and the latter by high scores on scales of isolation and self dislike (Cooper & Cowen, 2009). These beliefs also showed some specificity in their relation to either ED related or depressive symptoms. The exploratory study confirmed that core beliefs relevant to EDs are likely to be multidimensional (six themes emerged), and provided some evidence that those with an ED (plus depression), compared to those who are depressed may differ in their characteristic core beliefs. Importantly, some differentiation was also found in ED related vs depressive symptoms, suggesting that different symptoms as well as disorders may be associated with different types of belief. Development of a psychometrically sound multidimensional measure of core beliefs relevant to eating disorders would have theoretical and clinical utility. Theoretically, it might help identify those core beliefs most clearly related to key ED symptoms, as compared to those, for example, related to other aspects of psychopathology, and thus it might identify those which could be most usefully targeted in treatment. Clinically, a psychometrically sound measure of these beliefs could provide information useful for formulation, planning and evaluation of treatment designed to modify specific core beliefs. The first aim of the current study is to develop a multidimensional version of the EDBQ negative beliefs subscale. The revised scale will be termed the Eating Disorder Core Beliefs Questionnaire (ED-CBQ). The second aim of the study is to test the new measure's relationship to both depressive and anxious symptoms, as well as to putative ED and other diagnoses. This is particularly important given that depressive and anxious symptoms are relatively common in people with EDs, and it is currently unclear how the disorders and symptoms differ in their associated core beliefs. While the exploratory study (Cooper & Cowen, 2009) suggests that a certain amount of specificity can be identified in relation to EDs and depression, anxiety has not been investigated in this context, and the exploratory work undertaken by Cooper and
Cowen (2009) needs both replication and more rigorous investigation in a larger sample. 2. Method 2.1. Participants The inclusion criteria for participation in the study were being female and between the ages of 18 and 65. There were no other inclusion or exclusion criteria. Participants were recruited via posters and emails sent to acquaintances, colleagues, and university colleges and departments. Due to the nature of the recruitment methods, response rate for the study is not known. 2.2. Measures The questionnaire pack was available as both a paper version and an online website, which were identical in content. Most (92.8%) of the participants completed the questionnaires online. In the case of the paper versions, the packs were given to acquaintances and colleagues of the researchers. In the case of the online version, the website was included as a link in the email circulated to acquaintance and university colleges. 2.3. Eating Disorder Core Beliefs Questionnaire (ED-CBQ) This new self-report measure contained 147 items that had been selected as part of an examination of themes among self beliefs likely to be characteristic of either eating disorders or depression (Cooper & Cowen, 2009). A range of sources had been used to select these items, including clinical experience, statements identified in the literature as particularly associated with either eating disorders or depression, and qualitative data on self beliefs in eating disorders that had been routinely and systematically collected in the course of previous research in this area. Additionally, Anderson's personality word list (Anderson, 1968) had been reviewed and a broad range of negatively rated words judged likely (on the basis of clinical experience) to be associated with depression were included. Finally, the 10 items on the negative self beliefs subscale of the EDBQ were incorporated. Belief in each item was rated on a 7-point scale, with end points anchored at ‘feels very much untrue’ and ‘feels very much true’. Participants were asked to rate each word according to how they believe/feel most of the time. 2.4. Eating Attitudes Test — Short Form (EAT-26) The EAT-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982) is an abbreviated (26-item) version of the 40-item Eating Attitudes Test (EAT-40; Garner & Garfinkel, 1979), which is a self-report inventory that quantifies features commonly associated with eating disorders. Scores above 20 are indicative of potential eating disturbance. The EAT-26 is highly correlated with the EAT-40 (r = .98; Garner et al., 1982). Koslowsky et al. (1992) found the EAT-26 to be reliable among a non-clinical sample (Cronbach's alpha = .83). 2.5. Eating Disorder Diagnostic Scale (EDDS) The EDDS (Stice, Telch, & Rizvi, 2000) is a brief self-report scale for diagnosing eating disorders. It contains 22 self-report items, which specifically map onto DSM-IV criteria for AN, BN and Binge Eating Disorder (BED). The EDDS possesses good test–retest reliability (r = .87) and internal consistency (Cronbach's alpha = .89) (Stice et al., 2000).
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2.6. Hospital Anxiety and Depression Scale (HADS) The HADS (Zigmond & Snaith, 1983) is a commonly-used 14-item instrument that contains seven statements related to anxiety and seven related to depression. A score of 11 indicates the probable presence of a mood disorder. The anxiety and depression subscales have been found to be independent measures, and the HADS has good homogeneity and reliability (Spinhoven et al., 1997). 2.7. Rosenberg Self Esteem Scale (RSE) This is a 10-item self-report scale designed to elicit a global measure of self esteem. Lower scores indicate higher self esteem. The RSE has been found to have good reliability and validity (e.g. Blascovich & Tomaka, 1993). 2.8. Other information Self-reported height and weight were recorded for each participant in order to provide Body Mass Index [BMI = weight (kg) / height (m2)]. Demographic information (age, ethnic group, years in education and occupation of the main earner in the family of origin) was also recorded. 2.9. Procedure In the case of paper versions, participants were asked to send their questionnaires back to the researcher in a freepost envelope provided. In the case of the online questionnaires, data were stored automatically. The questionnaires generally took between 20 and 30 min to complete. 3. Results 3.1. Demographic characteristics Participants were 500 females. The mean age was 26.25 years (SD = 8.7), ranging from 18 to 60 years. The mean BMI was 22.85 (SD = 4.0), ranging from 12.7 to 43.4. The majority (90%) of participants were White and the ethnic distribution of the remainder of the sample was as follows: Asian 2.6%; Black .4%; Chinese 2.2; Mixed 2.8%; other 1.8%; not known/not reported 1.2%. Most participants had attained at least A-Level standard education (UK standardised tests usually taken at age 17– 18, i.e. after approximately 14 years in education). The most common socio-economic level was Level 2 (Professional; Office for National Statistics, 2000). 3.2. Questionnaire measures 3.2.1. EAT-26 The mean score on the EAT-26 was 12.95 (SD = 14.7), which is rather higher than the mean value of 9.9 for 140 female controls reported by Garner et al. (1982) in developing the EAT-26. 3.2.2. EDDS The mean score for the EDDS in this sample was 21.44 (SD = 16.1), which is slightly higher than that reported by Stice and Ragan (2002) of 18.0 (SD = 11.1). Eight participants (.2%) fulfilled diagnostic criteria for AN, 53 (10.6%) for BN, and 13 (2.6%) for BED. In addition 26 (5.2%) met subclinical diagnostic criteria for AN, and 20 (4.0%) met subclinical diagnostic criteria for BN. 3.2.3. HADS Participants scored a mean of 4.58 (SD = 4.0) for the HADSdepression (HADS-dep) and 9.41 (SD = 4.5) for the HADS-anxiety
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(HADS-anx). These mean scores are somewhat higher than those of 3.4 for depression (SD = 3.3) and 5.1 for anxiety (SD = 3.6) reported by Spinhoven et al. (1997) in a non-clinical population. 3.2.4. RSE On the RSE, the mean score for participants was 29.29 (SD = 6.6). This is lower than that of 34.73 (SD = 4.86) reported by Rosenberg (1989) in developing the RSE, indicating slightly higher self esteem among the current sample. 3.3. Development of the ED-CBQ 3.3.1. Factor analysis An exploratory factor analysis was conducted on the 147 core beliefs items in the ED-CBQ. A principal components method of factor extraction was used, the aim being to reduce the data to a smaller set of components. On the basis of the Scree test (Cattell, 1978), five factors (components) were extracted and subjected to oblique rotation using the Oblimin method. Following rotation, thirteen components were found to have eigenvalues over 1. The first five factors had eigenvalues as follows: 39.85, 4.27, 3.48, 2.89 and 2.36. Thereafter, the eigenvalues for the next three components were 1.79, 1.56 and 1.29. Items loading most highly on each factor were then selected to create a briefer questionnaire. Items were included if they loaded at least .45 on the relevant factor and below .45 on any other factor, with the added provision that there should be a difference of at least .20 between loadings on other factors and the relevant factor. On this basis, factors one and four contained 10 items, factors two and three contained eight items each and factor five contained four items. The rotated loadings for the five factors can be obtained from the corresponding author. The total amount of variance explained by the five factors was 52.84%, divided as follows: Factor 1 — 39.85; Factor 2 — 4.27%; Factor 3 — 3.48%; Factor 4 — 2.89% and Factor 5 — 2.36%. A copy of the final measure, together with the item numbers comprising each factor, can be seen in Appendix A. Each of the five factors was examined to determine themes that characterised the items contained within it, and labelled as follows: self loathing (Factor 1); unassertive/inhibited (Factor 2); high standards for self (Factor 3); demanding and needing help and support (Factor 4); abandoned/deprived (Factor 5). 3.4. Descriptive statistics Subscale scores were computed for each individual by dividing the total subscale score by number of items. Mean scores for each subscale are provided in Table 1. 3.5. Internal consistency Cronbach coefficient alphas were computed for each subscale. These ranged from .76 to .96, indicating high levels of internal
Table 1 ED-CBQ subscale scores for the sample.
Subscale Subscale Subscale Subscale Subscale
1 2 3 4 5
N
Mean
Range
487 477 484 489 495
.62 (1.13) 1.84 (1.18) 3.63 (.99) 2.25 (1.17) 1.60 (1.34)
0–6.00 0–.50 .5–5.88 0–5.70 0–6.00
Standard deviations in parentheses.
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consistency. There were no items that if deleted would increase the reliability of the individual subscales.
Table 2 Summary statistics for prediction of EAT-26 scores. Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
(Constant) HADS-anx RSE HADS-dep Subscale 1 Subscale 3
16.99 .79 −.45 −.48 3.01 1.53
6.44 .18 .14 .19 .68 .61
2.64 4.47 −3.30 −2.53 4.41 2.50
.009 .001 .001 .012 .001 .013
3.6. Subscale inter-correlations Pearson correlations indicated that all five subscales were significantly correlated with each other, and these correlations were all in a positive direction (range .42–.58) apart from those for subscale 3 (high standards for self), which correlated in a negative direction with all other subscales (range −.12 to .16). 3.7. Construct validity 3.7.1. Convergent validity Convergent validity was assessed by correlating ED-CBQ subscale scores with scores on the EAT-26, HADS-dep, HADS-anx and RSE. Subscales 1 (self loathing), 2 (unassertive/inhibited), 4 (demanding and needing help and support) and 5 (abandoned/deprived) correlated significantly and in a positive direction with scores on the EAT-26 (r = .26 to .38, all p-values b .001). Subscale 3 (high standards for self) was not correlated with EAT-26 score (r = −.04, p = −.37). All ED-CBQ subscales correlated significantly with HADS-dep (r = −.23 to .58) and with HADS-anx (r = −.12 to .53). All correlations were in a positive direction apart from those for subscale 3 (high standards for self), which were negative. All subscales also correlated significantly with RSE (r = −.31 to .60), with correlations in a positive direction for all scales apart from those with subscale 3 (high standards for self). Overall, the results suggested good convergent validity. 3.7.2. Divergent validity Divergent validity was assessed by correlating the subscales with participants' BMI and age. These correlations can also be seen in Table 3. None of the subscales correlated significantly with BMI, although all five subscales correlated significantly with age (range = −.23 to .20). However, the absolute values for these correlations are generally relatively small. Overall, the correlations suggest adequate divergent validity. 3.8. Ability of ED-CBQ to predict symptoms A series of stepwise linear regressions was performed in order to test the ability of the questionnaire subscales to predict (a) score on the EAT-26 when controlling for common variance associated with depression, anxiety and self esteem, (b) score on the HADS-dep when controlling for common variance associated with eating disorder symptoms, anxiety and self esteem, (c) score on the RSE when controlling for common variance associated with eating disorder symptoms, depression and anxiety. Demographics (age, socioeconomic status and level of educational achievement) and BMI were included as potential predictors in these analyses, with demographics and existing questionnaire scores entered on step 1 and the ED-CBQ subscales entered on step 2. Ability to predict RSE was included as an additional validity check for the ED-CBQ, with the expectation that most of its subscales should predict RSE score. 3.8.1. EAT-26 as dependent variable On step 1 R2 was .27 (F = 26.32, p b .001). ED-CBQ subscales 1 (self loathing) and 3 (high standards for self) added further to the model (R2 = −.318, F = 24.25, p b .001). Summary statistics for significant predictors in the final model are shown in Table 2. 3.8.2. HADS-dep as dependent variable In this analysis demographics, BMI, EAT-26, HADS-anx and RSE (entered on step 1) produced a significant model (R2 = .51, F = 72.1, p b .001). Subscale 1 (self loathing) was a further significant predictor
R2 = .32. HADS-anx = Hospital Anxiety and Depression Scale-anxiety subscale. RSE = Rosenberg Self Esteem Scale. HADS-dep = Hospital Anxiety and Depression Scaledepression subscale.
(r2 = 55, F = 74.3, p b .001). Summary statistics for significant predictors in the final model are shown in Table 3. 3.8.3. HADS-anx as dependent variable In this analysis demographics, BMI, EAT-26, HADS-dep and RSE (entered on step 1) produced a significant model (R2 = .49, F = 69.2, p b .001). Subscales 1 (self loathing) and 5 (abandoned/deprived) were further significant predictors (R2 = .51, F = 56.31, P b .001). Summary statistics for significant predictors in the final model are shown in Table 4. 3.8.4. RSE as dependent variable In this analysis demographics, BMI, EAT-26, HADS-anx and HADSdep (entered on step 1) produced a significant model (R2 = .57, F = 96.2, p b .001). Subscales 1 (self loathing), 2 (unassertive/inhibited), 3 (high standards for self) and 5 (abandoned/deprived) were further significant predictors (R2 = −.68, F = 87.17, p b .001). Summary statistics for significant predictors in the final model are shown in Table 5. 3.9. Ability of ED-CBQ to discriminate putative diagnostic groups 3.9.1. Eating disorders The high eating disorder symptoms group comprised those participants who scored above the cut-off score of 20 (signalling likely caseness) on the EAT-26, representing 24.2% of the sample (N = 121). These were matched with a low eating disorder group comprised those scoring 0–2 on the EAT-26, and representing 24.8% of the sample (N = 124). The two groups were similar in education level and BMI. The low symptoms group were slightly younger, less anxious, less depressed and higher in self esteem. Descriptive data for the two groups can be seen in Table 6. Three subscales entered the equation, 1 (self loathing), 4, (demanding and needing help and support) and 5 (abandoned/ deprived). The groups were discriminated by one function (Wilks's lambda = −.72, X2 = 69.3, df = 3, p b .001), and 74% of cases were
Table 3 Summary statistics for prediction of HADS-dep scores. Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
(Constant) Age HADS-anx RSE Subscale 1
7.64 .03 .24 −.21 1.00
1.41 .16 .39 .03 .15
5.40 2.20 6.17 −7.26 6.61
.001 .028 .001 .001 .001
R2 = .55. RSE = Rosenberg Self Esteem Scale. HADS-anx = Hospital Anxiety and Depression Scale-anxiety subscale.
H. Fairchild, M. Cooper / Eating Behaviors 11 (2010) 239–246 Table 4 Summary statistics for prediction of HADS-anx scores.
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Table 6 Descriptive data for high and low EAT-26 groups.
Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
Measure
Low EAT (N = 123) Mean SD
High EAT (N = 120) Mean SD
T
Significance (p)
(Constant) RSE EAT-26 HADS-dep Subscale 5 Subscale 1
12.11 −.22 .06 .31 .61 −.41
1.63 .03 .01 .06 .15 .19
7.43 −6.19 4.66 5.68 4.13 −2.15
.001 .001 .001 .001 .001 .032
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
27.66 22.85 1.11 3.16 7.62 31.33
24.32 (6.35) 22.54 (4.41) 34.85 (13.07) 6.99 (4.68) 12.52 (3.85) 24.65 (7.11)
3.23 .56 28.70 7.64 9.99 8.35
.001 .316 .001 .001 .001 .001
(9.43) (3.91) (.75) (3.00) (3.84) (5.29)
R2 = .52. RSE = Rosenberg Self Esteem Scale. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-depression subscale.
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
correctly classified. The function (eigenvalue = −.39) had moderately positive loadings on all 3 subscales. The low ED group had a negative loading on the function, while the high ED group had a positive loading.
Four subscales, 1 (self loathing), 2 (unassertive/inhibited), 3 (high standards for self) and 5 (abandoned/deprived) entered the equation. One function emerged (Wilks's lambda = −.48, X2 = 138.6, df = 4, p b .001), which correctly classified 84.2% of cases. Subscale 5 (abandoned/deprived) had the strongest loading on the function, while all other subscales had small loadings, all of which were positive except for subscale 3 (high standards for self), which loaded negatively.
3.9.2. Eating disorders — EDDS Participants were grouped into a no ED group (N = 354), an AN (N = 34) and a BN (N = 73) group, the latter two comprising both full and subclinical diagnoses. The AN group had a lower BMI than the other groups, and the BN group had a higher BMI compared to the controls. Both ED groups were more anxious and more depressed than the controls, and had higher ED symptom scores, and lower self esteem. Descriptive data can be seen in Table 7. Three subscales entered the equation, subscales 1 (self loathing), 3 (high standards for self) and 4 (demanding and needing help and support). The groups were discriminated by two functions (Function 1, Wilks's lambda = 86.5, df = 6, p b .001; Function 2, Wilks's lambda = 13.8, df = 2, p = .001), and 78.5% of the cases were correctly classified. Function 1 (eigenvalue = −.20, 85% of the variance) had a strong positive loading from subscale 1 (self loathing), and a moderate loading from subscale 4 (demanding and needing help and support). Function 2 had a strong loading from subscale 3 (high standards for self). The BN group had a strong loading on Function 1, the AN group had moderate loadings on both Functions, whereas the no ED group had small negative loadings on both Functions. 3.9.3. Depression The high depression group comprised those participants who scored in the mild or above range on the HADS-dep, i.e. with a score of 8 or above (Snaith & Zigmond, 1994). This included 103 participants (20.6%). The low depression group comprised those with a score between 0 and 2 (N = 122, 24.4%). The high depression group had higher scores on the measures of depression and anxiety, higher EAT26 scores and lower self esteem. Descriptive data can be seen in Table 8.
Table 5 Summary statistics for predictors of RSE scores. Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
(Constant) EAT-26 HADS-dep HADS-anx Subscale 2 Subscale 3 Subscale 5 Subscale 1
36.43 −.06 −.38 −.38 −1.25 .97 −.57 −.61
1.48 .02 .06 .06 .18 .20 .19 .24
24.69 −3.56 −5.63 −6.56 −6.88 4.90 −3.06 −2.56
.001 .001 .001 .001 .001 .001 .002 .011
R2 = .68. RSE = Rosenberg Self Esteem Scale.
3.9.4. Anxiety The high anxiety group comprised those who scored in the moderate or above range on the HADS-anx, i.e. with a score of 11 or above (Snaith & Zigmond, 1994). This included 98 participants (19.6%). The low anxiety group comprised those with a score between 0 and 3 (15.6%). The high anxiety group had higher scores on the measures of anxiety, depression and ED symptoms measured by the EAT-26, and lower self esteem. Descriptive data can be seen in Table 9. Three subscales entered the equation, 2 (unassertive/inhibited), 4 (demanding and needing help and support) and 5 (abandoned/ deprived). One function emerged (Wilks's lambda = −.41, X2 = 130.1, df = 3, p b .001), and 92% of cases were correctly classified. The function (eigenvalue = 1.4) had a moderate loading from subscale 5 (abandoned/deprived) and smaller loadings from the other subscales (with that for subscale 3 (high standards for self) being negative). The low anxious group had a negative loading on the function, and the high anxious group had a positive loading. 4. Discussion Five themes emerged from the factor analysis: self loathing (Factor 1); unassertive/inhibited (Factor 2); high standards for self (Factor 3); demanding and needing help and support (Factor 4); abandoned/ deprived (Factor 5). All subscales derived from the themes were internally consistent, and the majority (Subscales 1, 2, 4 and 5) had adequate levels of construct (divergent and convergent) validity.
Table 7 Descriptive data for eating disorder diagnostic groups. Measure
No ED (N = 352) Mean SD
AN (N = 34) Mean SD
BN (N = 73) Mean SD
Significance (p)
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
26.75 22.94 8.56 3.92 8.67 30.46
23.41 17.52 24.01 6.12 11.26 27.15
24.89 24.27 28.15 6.79 12.20 24.25
.001 .316 .001 .001 .001 .001
(9.13) (3.45) (10.59) (3.51) (4.25) (5.81)
(4.34) (.88) (21.03) (5.20) (4.91) (7.56)
(7.45) (4.74) (16.18) (4.52) (4.10) (7.18)
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
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Table 8 Descriptive data for high and low depression groups. Measure
Low depression (N = 121) Mean SD
High depression (N = 103) Mean SD
T
Significance (p)
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
27.06 22.74 7.47 .52 5.80 33.92
25.87 23.27 21.98 10.92 13.89 21.98
.98 .94 7.84 38.71 18.34 17.47
.327 .347 .001 .001 .001 .001
(9.80) (3.14) (9.07) (.50) (2.97) (4.56)
(6.35) (5.21) (17.91) (2.92) (3.65) (7.11)
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
Subscale 3 (high standards for self) did not correlate with EAT-26 score and correlated negatively with HADS-depression, HADSanxiety and self esteem, although it did emerge as a positive predictor in later regression analyses. In the regression analyses subscales 1 (self loathing) and 3 (high standards for self) were significant unique predictors of ED symptoms, subscale 1 (self loathing) was a unique predictor of depression and subscales 1 (self loathing) and 5 (abandoned/deprived) were unique predictors of anxiety. Subscales 1, 2, 3 and 5 were unique predictors of self esteem, thus providing validation for the ED-CBQ subscales. In the discriminant function analyses, high levels of ED symptoms were associated with subscales 1 (self loathing), 3 (high standards for self) and 4 (demanding and needing help and support), and high levels of depression and also anxiety were associated with subscale 5 (abandoned/deprived). When ED diagnoses were examined using discriminant function analysis, subscale 1 (self loathing) was particularly important in BN, and 1 (self loathing) and 3 (high standards for self) in AN. Self loathing (subscale 1) was a significant predictor of ED symptoms, anxious and depressive symptoms and self esteem when regression analyses were conducted. Given that other variance was controlled in these analyses, high levels of all these symptoms appear to be independently associated with self loathing. Self loathing thus appears important, not only in ED related symptoms but in depressive and anxious symptoms, and (as might be expected) in low self esteem. In predicting ED symptoms high standards for self (subscale 3) were also important, and in anxiety, abandoned/deprived (subscale 5) were also important. Self esteem (as might be expected) was associated with all subscales, except 4 (demanding and needing help and support). The findings suggest that self loathing in particular is important in a range of symptomatology including ED symptoms. However, when discriminant function analyses were conducted, using cut-off scores or putative ED diagnoses, subscale 1 (self loathing) was associated with EDs, both AN and BN, while depression and anxiety were associated with most strongly associated with subscale 5 (abandoned/ deprived). These findings are consistent with those of the exploratory study (Cooper & Cowen, 2009). The exploratory study identified six themes,
most of which were similar in content to the five identified here. While greater specificity was identified in regression analysis in relation to ED and depressive symptoms in Cooper and Cowen (2009) their sample, unlike the current unselected community sample, included two diagnosed groups. The findings of the cut-off and putative diagnostic groups identified here are consistent with those of the earlier study. In particular, self loathing is associated most clearly with a diagnosis of an ED, while depression (and here anxiety) are associated with abandoned/deprived core beliefs. Thus, as one moves from community samples and symptoms to putative diagnoses, it appears that EDs, depression and also anxiety are associated with specific core belief content. In the current study putative ED diagnoses, compared to depression and anxiety, were additionally associated with high standards for self and demanding and needing help and support. The latter two themes were particularly associated with AN rather than BN diagnoses. The content of both themes has been described as characteristic of those with AN by other researchers and clinicians. The diagnostic analyses, unlike the regression analyses, have not controlled for comorbid symptoms (or diagnoses), thus as well as differing on the core symptoms most groups also have different scores, compared to their control groups, on a range of other symptoms. While comorbidity might be expected to decrease differentiation in core beliefs, the findings presented here suggest that it increases it. This raises the possibility that features other than those identified or assessed here are at least partly responsible for producing differences between EDs and depression and anxiety in their characteristic core beliefs. The current study has identified a number of themes in core beliefs that are relevant to ED symptoms and diagnosis. Self loathing appears to be particularly important, and may differentiate EDs from depression and anxiety. Reassuringly, the results are consistent with those reported by Cooper and Cowen (2009), and draw attention to a category of belief, self loathing, that has been relatively neglected in the ED literature. Self loathing is often referred to as an extreme form of low self esteem which is particularly common in clinical samples, including those with depression and some personality disorders. The current findings are not inconsistent with this, particularly as depressive
Table 9 Descriptive data for high and low anxious groups. Measure
Low anxious (N = 77) Mean SD
High anxious (N = 98) Mean SD
T
Significance (p)
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
27.90 22.71 6.14 1.68 2.84 35.08
25.40 (7.65) 22.97 (4.70) 23.69 (19.02) 8.92 (4.14) 15.93 (1.71) 22.61 (5.87)
3.23 .56 7.77 7.64 9.99 8.35
.063 .684 .001 .001 .001 .001
(10.00) (3.43) (6.73) (1.94) (1.17) (3.78)
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
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symptoms were found to be related to self loathing, but further suggest that, as measured here, self loathing is particularly characteristic of those with EDs. This is consistent with the findings of Aruguete, Yates, and Edman (2007) who, using a brief 4 item scale, found that self loathing is typical of those with EDs, and may provide a screen for eating disorders in a vulnerable population. Inspection of the individual items comprising the self loathing subscale developed in the current study may help explain why the scale appears particularly relevant to EDs. It is noteworthy that the items depict extreme self loathing (beyond simple self dislike or simple negative evaluation), and moreover, that many of the items have a visceral quality to them. While self loathing may appear in other disorders, the scale used here may reflect the embodied nature of EDs particularly well. Such items may readily evoke different modalities of experience, beyond the purely verbal, and as such, fit well with the “embodied” experience of those with EDs. The study has a number of limitations. Internet based research is relatively new, and clearly excludes those who do not have on line access. On the other hand, the anonymity might be particularly attractive to those with concerns about eating and self esteem. A community sample enables constructs to be treated as dimensions and helps avoid ceiling and floor effects that can be associated with use of discrete categories, but by definition the sample consists mainly of participants who do not have a diagnosable disorder, making generalisability to EDs difficult. While putative diagnostic categories were created, these relied on self report, and the validity of the different diagnoses made was not independently verified. Overall, however, the measure reported here may be a useful clinical and research tool to explore the role of core beliefs in EDs in future studies. Investigation of patient groups, including those with EDs, depression and also a range of personality disorders, as well as dieters, who share some ED concerns, would be a useful next step, with carefully conducted diagnostic procedures, followed by study of the ability of the measure to predict ED symptoms and disorders longitudinally. The constructs identified in the subscales might also usefully form the basis for experimental studies designed to understand more about the specific content and the role of negative self beliefs in EDs; work which is already underway (Pringle, Harmer, & Cooper, 2010). Role of funding sources No specific funding was in place for this study. Contributors Both authors designed and planned the study. The first author collected the data. Both authors contributed to the data analysis and write up, and both approved the final paper. Conflict of interests There are no conflicts of interest to declare.
Appendix A. Eating Disorder Core Belief Questionnaire Instructions Listed below are a number of different words. People sometimes think these words describe how they feel about themselves as a person. Please read each word carefully and decide how much you feel each word describes how you feel about your own self. Base your answer on what you emotionally believe or feel to be true, not on what you rationally believe to be true. Choose the rating which best describes what you usually believe/feel or what you believe/feel most of the time, rather than how you feel right now. If you are unsure of the meaning of a word you may miss it out. Work as quickly as you can. Don't spend too long on each word — your first impression is the most important. Place a cross or tick in the box that best describes your response.
Scoring: Subscale 1: self loathing = items (7, 8, 9, 15, 20, 25, 27, 28, 29, 40)/10 Subscale 2: unassertive/inhibited = items (14, 17, 30, 33, 36, 37, 38, 39)/8 Subscale 3: high standards for self = items (4, 10, 11, 18, 22, 23, 24, 31)/8 Subscale 4: demanding/needing help and support = items (3, 5, 12, 13, 16, 21, 26, 32, 34, 35)/10 Subscale 5: abandoned/isolated = items (1, 2, 6, 19)/4.
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Leung, N., Waller, G., & Thomas, G. (1999). Core beliefs in anorexic and bulimic women. The Journal of Nervous and Mental Disease, 187, 736−741. Pringle, A., Harmer, C., & Cooper, M. J. (2010). Investigating vulnerability to eating disorders: Biases in emotional processing. Psychological Medicine, 40, 645−655. Rosenberg, M. (1989). Society and the adolescent self-image. Middletown, CT: Wesleyan University Press. Schmidt, N. B., Joiner, T. E., Young, J. E., & Telch, M. J. (1995). The Schema Questionnaire: Investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemas. Cognitive Therapy and Research, 19, 295−321. Snaith, R. P., & Zigmond, A. S. (1994). The Hospital Anxiety and Depression Scale manual. Windsor: Nelson. Somerville, K., & Cooper, M. J. (2007). Using imagery to identify and characterise core beliefs in women with bulimia nervosa, dieting and non-dieting women. Eating Behaviours, 8, 450−456. Spinhoven, P., Ormel, J., Sloekers, P. P., Kempen, G. I., Speckens, A. E., & Hemert, A. M. (1997). A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychological Medicine, 27, 363−370. Stice, E., & Ragan, J. (2002). A controlled evaluation of an eating disturbance psychoeducational intervention. International Journal of Eating Disorders, 31, 159−171. Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and validation of the Eating Disorder Diagnostic Scale: A brief self-report measure of anorexia, bulimia, and binge eating disorder. Psychological Assessment, 12, 123−131. Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive Behavioral Therapy for Eating Disorders: A Comprehensive Treatment Guide. Cambridge: Cambridge University Press. Waller, G., Ohanian, V., Meyer, C., & Osman, S. (2000). Cognitive content among bulimic women: The role of core beliefs. The International Journal of Eating Disorders, 28, 235−241. Waller, G., Meyer, C., & Ohanian, V. (2001). Psychometric properties of the long and short versions of the Young Schema Questionnaire: Core beliefs among bulimic and comparison women. Cognitive Therapy and Research, 24, 137−148. Woolrich, R. A., Cooper, M. J., & Turner, H. M. (2006). A preliminary study of negative self-beliefs in anorexia nervosa: A detailed exploration of their content, origins and functional links to “not eating enough” and other characteristic behaviours. Cognitive Therapy and Research, 30, 735−748. Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361−370.
Contents lists available at ScienceDirect
Eating Behaviors
A multidimensional measure of core beliefs relevant to eating disorders: Preliminary development and validation Helen Fairchild, Myra Cooper ⁎ Isis Education Centre, Oxford University, UK
a r t i c l e
i n f o
Article history: Received 23 November 2009 Received in revised form 15 April 2010 Accepted 20 May 2010 Keywords: Eating disorders Core beliefs Negative self beliefs Schema
a b s t r a c t Core beliefs associated with eating disorders are likely to be multidimensional, and may not be adequately captured by existing measures. The current study aimed to develop such a measure and examine its relationship to eating disorder symptoms, anxiety, depression and putative diagnoses of their related disorders. Core belief items were rated by 500 female participants aged 18–65, who also completed selfreport measures of eating disorder symptomatology, depression, anxiety, and self esteem. Factor analysis revealed five subscales, with themes related to (a) self loathing, (b) unassertive/inhibited, (c) high standards for self, (d) demanding and needing help and support and (e) abandoned/deprived. Thirty two items were selected for a final scale, the Eating Disorder Core Beliefs Questionnaire (ED-CBQ). The ED-CBQ subscales showed adequate internal consistency and construct (convergent and discriminant) validity. Self loathing appeared to be particularly associated with putative eating disorder diagnosis, while abandoned/deprived was more characteristic of putative anxiety and depression diagnoses. The findings suggest that negative core self beliefs relevant to those with an eating disorder are a multidimensional construct and that self loathing as a core belief merits further research and clinical attention. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction A role has been suggested for underlying, negative core beliefs about the self, derived from early experiences, in the development and maintenance of eating disorders (EDs) (Cooper, 2005; Waller et al., 2007). Core beliefs have been defined as the content of schemas within the context of cognitive theory, where schemas are the cognitive structures that organize experience and behavior and determine the content of thinking, affect and behavior (Beck, Freeman, & Associates, 1990). Core refers to central to dysfunctional cognitions and behavior, and negative to their typical valence in clinical disorders. Negative core beliefs are typically absolute, inflexible and global, and thought to arise in early development. The terms schema and core belief are often used interchangeably, and while core beliefs may exist in a variety of domains, those relevant to self are often hypothesized to be crucial in determining psychopathology (Beck et al., 1990). In eating disorders, the term “negative self belief” has also been used to refer to these beliefs, and their content is known to be ostensibly unrelated to patients concerns with eating, food, weight and shape. Typical negative self beliefs in EDs include
⁎ Corresponding author. Isis Education Centre, University of Oxford, Warneford Hospital, Oxford, OX3 1JX, UK. Tel.: +44 1865 226432. E-mail address: [email protected] (M. Cooper). 1471-0153/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.eatbeh.2010.05.004
“I'm a failure”, “I'm worthless”, “I'm weak”, “I'm disgusting”, and “I'm all alone” (Cooper, Todd, & Wells, 1998). Beyond this, however, relatively little empirical research has investigated their specific content in relation to EDs. In particular, their potential relationship to comorbid ED psychopathology, including symptoms of depression and anxiety, as well as to ED diagnosis, remains unexamined. Two self-report questionnaire measures, namely the Young Schema Questionnaire (e.g. Leung, Waller, & Thomas, 1999; Waller, Ohanian, Meyer, & Osman, 2000) and the Eating Disorder Beliefs Questionnaire (e.g. Cooper, Cohen-Tovée, Todd, Wells, & Tovée, 1997; Cooper & Hunt, 1998) have been used to investigate these beliefs. The YSQ was developed as a generic measure of early maladaptive schemas. It has good levels of psychometric and clinical utility (Schmidt, Joiner, Young, & Telch, 1995) and measures 16 core beliefs or schemas. It has acceptable psychometric properties in women with AN and BN (Leung et al., 1999; Waller, Meyer, & Ohanian, 2001) but it was not developed specifically for patients with eating disorders. There is evidence that the YSQ lacks specificity in terms of its ability to distinguish eating disordered patients, compared to those with depression. For example, in a study comparing moderately–severely depressed bulimic patients with severely depressed patients and controls, Waller et al. (2001) found equivalent levels of core beliefs in both clinical groups. The EDBQ, conversely, is a measure of core beliefs and assumptions designed specifically for use among people with eating disorders. It contains four subscales; the negative self beliefs subscale being of most interest here. Like the YSQ, the negative self
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belief subscale may not distinguish depressed patients from those with EDs (Cooper & Hunt, 1998). Compared to the YSQ, however, where no distinction was found, an analogue study has shown that it does seem to distinguish those with ED related (but who do not also have depressive) symptoms from controls (Cooper, Rose, & Turner, 2005). Although designed with EDs in mind, the scale is relatively short (only 10 items). Clinical experience and research evidence (e.g. Woolrich, Cooper, & Turner, 2006) suggests that although helpful, it may not provide a comprehensive measure of all core or negative self beliefs relevant to eating disorders. Additional themes might be usefully included, and some items might usefully be elaborated into subscales; i.e. it is likely that the construct is likely to be multidimensional in relation to EDs. In support of this suggestion, clinically, the literature contains many examples of a range of themes which might be core beliefs of significance to those with EDs, and which might merit particular attention, and treatment as individual themes. Recent empirical studies have identified a number of additional and specific themes that are not captured on the EDBQ (e.g. Woolrich et al., 2006), while first person accounts (e.g. Liu, 1979) have described additional beliefs. These include a sense of defectiveness, powerlessness, worthlessness, and emptiness (Woolrich et al., 2006), as well as lack of self control, weakness and laziness (Somerville & Cooper, 2007), rejection, isolation, difference, abandonment, and setting of extremely high standards (Liu, 1979). One striking category is beliefs reflecting extreme self loathing, self hatred and self disgust which are not currently captured on the EDBQ, or indeed on the YSQ (Cooper & Cowen, 2009). An exploratory study with two diagnosed groups found that those with an ED and depressive symptoms could be distinguished from those with major depression in their negative core beliefs. The former group was characterised by high scores on scales reflecting repelled by self and lacking in warmth, and the latter by high scores on scales of isolation and self dislike (Cooper & Cowen, 2009). These beliefs also showed some specificity in their relation to either ED related or depressive symptoms. The exploratory study confirmed that core beliefs relevant to EDs are likely to be multidimensional (six themes emerged), and provided some evidence that those with an ED (plus depression), compared to those who are depressed may differ in their characteristic core beliefs. Importantly, some differentiation was also found in ED related vs depressive symptoms, suggesting that different symptoms as well as disorders may be associated with different types of belief. Development of a psychometrically sound multidimensional measure of core beliefs relevant to eating disorders would have theoretical and clinical utility. Theoretically, it might help identify those core beliefs most clearly related to key ED symptoms, as compared to those, for example, related to other aspects of psychopathology, and thus it might identify those which could be most usefully targeted in treatment. Clinically, a psychometrically sound measure of these beliefs could provide information useful for formulation, planning and evaluation of treatment designed to modify specific core beliefs. The first aim of the current study is to develop a multidimensional version of the EDBQ negative beliefs subscale. The revised scale will be termed the Eating Disorder Core Beliefs Questionnaire (ED-CBQ). The second aim of the study is to test the new measure's relationship to both depressive and anxious symptoms, as well as to putative ED and other diagnoses. This is particularly important given that depressive and anxious symptoms are relatively common in people with EDs, and it is currently unclear how the disorders and symptoms differ in their associated core beliefs. While the exploratory study (Cooper & Cowen, 2009) suggests that a certain amount of specificity can be identified in relation to EDs and depression, anxiety has not been investigated in this context, and the exploratory work undertaken by Cooper and
Cowen (2009) needs both replication and more rigorous investigation in a larger sample. 2. Method 2.1. Participants The inclusion criteria for participation in the study were being female and between the ages of 18 and 65. There were no other inclusion or exclusion criteria. Participants were recruited via posters and emails sent to acquaintances, colleagues, and university colleges and departments. Due to the nature of the recruitment methods, response rate for the study is not known. 2.2. Measures The questionnaire pack was available as both a paper version and an online website, which were identical in content. Most (92.8%) of the participants completed the questionnaires online. In the case of the paper versions, the packs were given to acquaintances and colleagues of the researchers. In the case of the online version, the website was included as a link in the email circulated to acquaintance and university colleges. 2.3. Eating Disorder Core Beliefs Questionnaire (ED-CBQ) This new self-report measure contained 147 items that had been selected as part of an examination of themes among self beliefs likely to be characteristic of either eating disorders or depression (Cooper & Cowen, 2009). A range of sources had been used to select these items, including clinical experience, statements identified in the literature as particularly associated with either eating disorders or depression, and qualitative data on self beliefs in eating disorders that had been routinely and systematically collected in the course of previous research in this area. Additionally, Anderson's personality word list (Anderson, 1968) had been reviewed and a broad range of negatively rated words judged likely (on the basis of clinical experience) to be associated with depression were included. Finally, the 10 items on the negative self beliefs subscale of the EDBQ were incorporated. Belief in each item was rated on a 7-point scale, with end points anchored at ‘feels very much untrue’ and ‘feels very much true’. Participants were asked to rate each word according to how they believe/feel most of the time. 2.4. Eating Attitudes Test — Short Form (EAT-26) The EAT-26 (Garner, Olmsted, Bohr, & Garfinkel, 1982) is an abbreviated (26-item) version of the 40-item Eating Attitudes Test (EAT-40; Garner & Garfinkel, 1979), which is a self-report inventory that quantifies features commonly associated with eating disorders. Scores above 20 are indicative of potential eating disturbance. The EAT-26 is highly correlated with the EAT-40 (r = .98; Garner et al., 1982). Koslowsky et al. (1992) found the EAT-26 to be reliable among a non-clinical sample (Cronbach's alpha = .83). 2.5. Eating Disorder Diagnostic Scale (EDDS) The EDDS (Stice, Telch, & Rizvi, 2000) is a brief self-report scale for diagnosing eating disorders. It contains 22 self-report items, which specifically map onto DSM-IV criteria for AN, BN and Binge Eating Disorder (BED). The EDDS possesses good test–retest reliability (r = .87) and internal consistency (Cronbach's alpha = .89) (Stice et al., 2000).
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2.6. Hospital Anxiety and Depression Scale (HADS) The HADS (Zigmond & Snaith, 1983) is a commonly-used 14-item instrument that contains seven statements related to anxiety and seven related to depression. A score of 11 indicates the probable presence of a mood disorder. The anxiety and depression subscales have been found to be independent measures, and the HADS has good homogeneity and reliability (Spinhoven et al., 1997). 2.7. Rosenberg Self Esteem Scale (RSE) This is a 10-item self-report scale designed to elicit a global measure of self esteem. Lower scores indicate higher self esteem. The RSE has been found to have good reliability and validity (e.g. Blascovich & Tomaka, 1993). 2.8. Other information Self-reported height and weight were recorded for each participant in order to provide Body Mass Index [BMI = weight (kg) / height (m2)]. Demographic information (age, ethnic group, years in education and occupation of the main earner in the family of origin) was also recorded. 2.9. Procedure In the case of paper versions, participants were asked to send their questionnaires back to the researcher in a freepost envelope provided. In the case of the online questionnaires, data were stored automatically. The questionnaires generally took between 20 and 30 min to complete. 3. Results 3.1. Demographic characteristics Participants were 500 females. The mean age was 26.25 years (SD = 8.7), ranging from 18 to 60 years. The mean BMI was 22.85 (SD = 4.0), ranging from 12.7 to 43.4. The majority (90%) of participants were White and the ethnic distribution of the remainder of the sample was as follows: Asian 2.6%; Black .4%; Chinese 2.2; Mixed 2.8%; other 1.8%; not known/not reported 1.2%. Most participants had attained at least A-Level standard education (UK standardised tests usually taken at age 17– 18, i.e. after approximately 14 years in education). The most common socio-economic level was Level 2 (Professional; Office for National Statistics, 2000). 3.2. Questionnaire measures 3.2.1. EAT-26 The mean score on the EAT-26 was 12.95 (SD = 14.7), which is rather higher than the mean value of 9.9 for 140 female controls reported by Garner et al. (1982) in developing the EAT-26. 3.2.2. EDDS The mean score for the EDDS in this sample was 21.44 (SD = 16.1), which is slightly higher than that reported by Stice and Ragan (2002) of 18.0 (SD = 11.1). Eight participants (.2%) fulfilled diagnostic criteria for AN, 53 (10.6%) for BN, and 13 (2.6%) for BED. In addition 26 (5.2%) met subclinical diagnostic criteria for AN, and 20 (4.0%) met subclinical diagnostic criteria for BN. 3.2.3. HADS Participants scored a mean of 4.58 (SD = 4.0) for the HADSdepression (HADS-dep) and 9.41 (SD = 4.5) for the HADS-anxiety
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(HADS-anx). These mean scores are somewhat higher than those of 3.4 for depression (SD = 3.3) and 5.1 for anxiety (SD = 3.6) reported by Spinhoven et al. (1997) in a non-clinical population. 3.2.4. RSE On the RSE, the mean score for participants was 29.29 (SD = 6.6). This is lower than that of 34.73 (SD = 4.86) reported by Rosenberg (1989) in developing the RSE, indicating slightly higher self esteem among the current sample. 3.3. Development of the ED-CBQ 3.3.1. Factor analysis An exploratory factor analysis was conducted on the 147 core beliefs items in the ED-CBQ. A principal components method of factor extraction was used, the aim being to reduce the data to a smaller set of components. On the basis of the Scree test (Cattell, 1978), five factors (components) were extracted and subjected to oblique rotation using the Oblimin method. Following rotation, thirteen components were found to have eigenvalues over 1. The first five factors had eigenvalues as follows: 39.85, 4.27, 3.48, 2.89 and 2.36. Thereafter, the eigenvalues for the next three components were 1.79, 1.56 and 1.29. Items loading most highly on each factor were then selected to create a briefer questionnaire. Items were included if they loaded at least .45 on the relevant factor and below .45 on any other factor, with the added provision that there should be a difference of at least .20 between loadings on other factors and the relevant factor. On this basis, factors one and four contained 10 items, factors two and three contained eight items each and factor five contained four items. The rotated loadings for the five factors can be obtained from the corresponding author. The total amount of variance explained by the five factors was 52.84%, divided as follows: Factor 1 — 39.85; Factor 2 — 4.27%; Factor 3 — 3.48%; Factor 4 — 2.89% and Factor 5 — 2.36%. A copy of the final measure, together with the item numbers comprising each factor, can be seen in Appendix A. Each of the five factors was examined to determine themes that characterised the items contained within it, and labelled as follows: self loathing (Factor 1); unassertive/inhibited (Factor 2); high standards for self (Factor 3); demanding and needing help and support (Factor 4); abandoned/deprived (Factor 5). 3.4. Descriptive statistics Subscale scores were computed for each individual by dividing the total subscale score by number of items. Mean scores for each subscale are provided in Table 1. 3.5. Internal consistency Cronbach coefficient alphas were computed for each subscale. These ranged from .76 to .96, indicating high levels of internal
Table 1 ED-CBQ subscale scores for the sample.
Subscale Subscale Subscale Subscale Subscale
1 2 3 4 5
N
Mean
Range
487 477 484 489 495
.62 (1.13) 1.84 (1.18) 3.63 (.99) 2.25 (1.17) 1.60 (1.34)
0–6.00 0–.50 .5–5.88 0–5.70 0–6.00
Standard deviations in parentheses.
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consistency. There were no items that if deleted would increase the reliability of the individual subscales.
Table 2 Summary statistics for prediction of EAT-26 scores. Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
(Constant) HADS-anx RSE HADS-dep Subscale 1 Subscale 3
16.99 .79 −.45 −.48 3.01 1.53
6.44 .18 .14 .19 .68 .61
2.64 4.47 −3.30 −2.53 4.41 2.50
.009 .001 .001 .012 .001 .013
3.6. Subscale inter-correlations Pearson correlations indicated that all five subscales were significantly correlated with each other, and these correlations were all in a positive direction (range .42–.58) apart from those for subscale 3 (high standards for self), which correlated in a negative direction with all other subscales (range −.12 to .16). 3.7. Construct validity 3.7.1. Convergent validity Convergent validity was assessed by correlating ED-CBQ subscale scores with scores on the EAT-26, HADS-dep, HADS-anx and RSE. Subscales 1 (self loathing), 2 (unassertive/inhibited), 4 (demanding and needing help and support) and 5 (abandoned/deprived) correlated significantly and in a positive direction with scores on the EAT-26 (r = .26 to .38, all p-values b .001). Subscale 3 (high standards for self) was not correlated with EAT-26 score (r = −.04, p = −.37). All ED-CBQ subscales correlated significantly with HADS-dep (r = −.23 to .58) and with HADS-anx (r = −.12 to .53). All correlations were in a positive direction apart from those for subscale 3 (high standards for self), which were negative. All subscales also correlated significantly with RSE (r = −.31 to .60), with correlations in a positive direction for all scales apart from those with subscale 3 (high standards for self). Overall, the results suggested good convergent validity. 3.7.2. Divergent validity Divergent validity was assessed by correlating the subscales with participants' BMI and age. These correlations can also be seen in Table 3. None of the subscales correlated significantly with BMI, although all five subscales correlated significantly with age (range = −.23 to .20). However, the absolute values for these correlations are generally relatively small. Overall, the correlations suggest adequate divergent validity. 3.8. Ability of ED-CBQ to predict symptoms A series of stepwise linear regressions was performed in order to test the ability of the questionnaire subscales to predict (a) score on the EAT-26 when controlling for common variance associated with depression, anxiety and self esteem, (b) score on the HADS-dep when controlling for common variance associated with eating disorder symptoms, anxiety and self esteem, (c) score on the RSE when controlling for common variance associated with eating disorder symptoms, depression and anxiety. Demographics (age, socioeconomic status and level of educational achievement) and BMI were included as potential predictors in these analyses, with demographics and existing questionnaire scores entered on step 1 and the ED-CBQ subscales entered on step 2. Ability to predict RSE was included as an additional validity check for the ED-CBQ, with the expectation that most of its subscales should predict RSE score. 3.8.1. EAT-26 as dependent variable On step 1 R2 was .27 (F = 26.32, p b .001). ED-CBQ subscales 1 (self loathing) and 3 (high standards for self) added further to the model (R2 = −.318, F = 24.25, p b .001). Summary statistics for significant predictors in the final model are shown in Table 2. 3.8.2. HADS-dep as dependent variable In this analysis demographics, BMI, EAT-26, HADS-anx and RSE (entered on step 1) produced a significant model (R2 = .51, F = 72.1, p b .001). Subscale 1 (self loathing) was a further significant predictor
R2 = .32. HADS-anx = Hospital Anxiety and Depression Scale-anxiety subscale. RSE = Rosenberg Self Esteem Scale. HADS-dep = Hospital Anxiety and Depression Scaledepression subscale.
(r2 = 55, F = 74.3, p b .001). Summary statistics for significant predictors in the final model are shown in Table 3. 3.8.3. HADS-anx as dependent variable In this analysis demographics, BMI, EAT-26, HADS-dep and RSE (entered on step 1) produced a significant model (R2 = .49, F = 69.2, p b .001). Subscales 1 (self loathing) and 5 (abandoned/deprived) were further significant predictors (R2 = .51, F = 56.31, P b .001). Summary statistics for significant predictors in the final model are shown in Table 4. 3.8.4. RSE as dependent variable In this analysis demographics, BMI, EAT-26, HADS-anx and HADSdep (entered on step 1) produced a significant model (R2 = .57, F = 96.2, p b .001). Subscales 1 (self loathing), 2 (unassertive/inhibited), 3 (high standards for self) and 5 (abandoned/deprived) were further significant predictors (R2 = −.68, F = 87.17, p b .001). Summary statistics for significant predictors in the final model are shown in Table 5. 3.9. Ability of ED-CBQ to discriminate putative diagnostic groups 3.9.1. Eating disorders The high eating disorder symptoms group comprised those participants who scored above the cut-off score of 20 (signalling likely caseness) on the EAT-26, representing 24.2% of the sample (N = 121). These were matched with a low eating disorder group comprised those scoring 0–2 on the EAT-26, and representing 24.8% of the sample (N = 124). The two groups were similar in education level and BMI. The low symptoms group were slightly younger, less anxious, less depressed and higher in self esteem. Descriptive data for the two groups can be seen in Table 6. Three subscales entered the equation, 1 (self loathing), 4, (demanding and needing help and support) and 5 (abandoned/ deprived). The groups were discriminated by one function (Wilks's lambda = −.72, X2 = 69.3, df = 3, p b .001), and 74% of cases were
Table 3 Summary statistics for prediction of HADS-dep scores. Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
(Constant) Age HADS-anx RSE Subscale 1
7.64 .03 .24 −.21 1.00
1.41 .16 .39 .03 .15
5.40 2.20 6.17 −7.26 6.61
.001 .028 .001 .001 .001
R2 = .55. RSE = Rosenberg Self Esteem Scale. HADS-anx = Hospital Anxiety and Depression Scale-anxiety subscale.
H. Fairchild, M. Cooper / Eating Behaviors 11 (2010) 239–246 Table 4 Summary statistics for prediction of HADS-anx scores.
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Table 6 Descriptive data for high and low EAT-26 groups.
Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
Measure
Low EAT (N = 123) Mean SD
High EAT (N = 120) Mean SD
T
Significance (p)
(Constant) RSE EAT-26 HADS-dep Subscale 5 Subscale 1
12.11 −.22 .06 .31 .61 −.41
1.63 .03 .01 .06 .15 .19
7.43 −6.19 4.66 5.68 4.13 −2.15
.001 .001 .001 .001 .001 .032
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
27.66 22.85 1.11 3.16 7.62 31.33
24.32 (6.35) 22.54 (4.41) 34.85 (13.07) 6.99 (4.68) 12.52 (3.85) 24.65 (7.11)
3.23 .56 28.70 7.64 9.99 8.35
.001 .316 .001 .001 .001 .001
(9.43) (3.91) (.75) (3.00) (3.84) (5.29)
R2 = .52. RSE = Rosenberg Self Esteem Scale. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-depression subscale.
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
correctly classified. The function (eigenvalue = −.39) had moderately positive loadings on all 3 subscales. The low ED group had a negative loading on the function, while the high ED group had a positive loading.
Four subscales, 1 (self loathing), 2 (unassertive/inhibited), 3 (high standards for self) and 5 (abandoned/deprived) entered the equation. One function emerged (Wilks's lambda = −.48, X2 = 138.6, df = 4, p b .001), which correctly classified 84.2% of cases. Subscale 5 (abandoned/deprived) had the strongest loading on the function, while all other subscales had small loadings, all of which were positive except for subscale 3 (high standards for self), which loaded negatively.
3.9.2. Eating disorders — EDDS Participants were grouped into a no ED group (N = 354), an AN (N = 34) and a BN (N = 73) group, the latter two comprising both full and subclinical diagnoses. The AN group had a lower BMI than the other groups, and the BN group had a higher BMI compared to the controls. Both ED groups were more anxious and more depressed than the controls, and had higher ED symptom scores, and lower self esteem. Descriptive data can be seen in Table 7. Three subscales entered the equation, subscales 1 (self loathing), 3 (high standards for self) and 4 (demanding and needing help and support). The groups were discriminated by two functions (Function 1, Wilks's lambda = 86.5, df = 6, p b .001; Function 2, Wilks's lambda = 13.8, df = 2, p = .001), and 78.5% of the cases were correctly classified. Function 1 (eigenvalue = −.20, 85% of the variance) had a strong positive loading from subscale 1 (self loathing), and a moderate loading from subscale 4 (demanding and needing help and support). Function 2 had a strong loading from subscale 3 (high standards for self). The BN group had a strong loading on Function 1, the AN group had moderate loadings on both Functions, whereas the no ED group had small negative loadings on both Functions. 3.9.3. Depression The high depression group comprised those participants who scored in the mild or above range on the HADS-dep, i.e. with a score of 8 or above (Snaith & Zigmond, 1994). This included 103 participants (20.6%). The low depression group comprised those with a score between 0 and 2 (N = 122, 24.4%). The high depression group had higher scores on the measures of depression and anxiety, higher EAT26 scores and lower self esteem. Descriptive data can be seen in Table 8.
Table 5 Summary statistics for predictors of RSE scores. Predictors
β (unstandardised coefficients)
Standard error
T
Significance (p)
(Constant) EAT-26 HADS-dep HADS-anx Subscale 2 Subscale 3 Subscale 5 Subscale 1
36.43 −.06 −.38 −.38 −1.25 .97 −.57 −.61
1.48 .02 .06 .06 .18 .20 .19 .24
24.69 −3.56 −5.63 −6.56 −6.88 4.90 −3.06 −2.56
.001 .001 .001 .001 .001 .001 .002 .011
R2 = .68. RSE = Rosenberg Self Esteem Scale.
3.9.4. Anxiety The high anxiety group comprised those who scored in the moderate or above range on the HADS-anx, i.e. with a score of 11 or above (Snaith & Zigmond, 1994). This included 98 participants (19.6%). The low anxiety group comprised those with a score between 0 and 3 (15.6%). The high anxiety group had higher scores on the measures of anxiety, depression and ED symptoms measured by the EAT-26, and lower self esteem. Descriptive data can be seen in Table 9. Three subscales entered the equation, 2 (unassertive/inhibited), 4 (demanding and needing help and support) and 5 (abandoned/ deprived). One function emerged (Wilks's lambda = −.41, X2 = 130.1, df = 3, p b .001), and 92% of cases were correctly classified. The function (eigenvalue = 1.4) had a moderate loading from subscale 5 (abandoned/deprived) and smaller loadings from the other subscales (with that for subscale 3 (high standards for self) being negative). The low anxious group had a negative loading on the function, and the high anxious group had a positive loading. 4. Discussion Five themes emerged from the factor analysis: self loathing (Factor 1); unassertive/inhibited (Factor 2); high standards for self (Factor 3); demanding and needing help and support (Factor 4); abandoned/ deprived (Factor 5). All subscales derived from the themes were internally consistent, and the majority (Subscales 1, 2, 4 and 5) had adequate levels of construct (divergent and convergent) validity.
Table 7 Descriptive data for eating disorder diagnostic groups. Measure
No ED (N = 352) Mean SD
AN (N = 34) Mean SD
BN (N = 73) Mean SD
Significance (p)
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
26.75 22.94 8.56 3.92 8.67 30.46
23.41 17.52 24.01 6.12 11.26 27.15
24.89 24.27 28.15 6.79 12.20 24.25
.001 .316 .001 .001 .001 .001
(9.13) (3.45) (10.59) (3.51) (4.25) (5.81)
(4.34) (.88) (21.03) (5.20) (4.91) (7.56)
(7.45) (4.74) (16.18) (4.52) (4.10) (7.18)
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
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Table 8 Descriptive data for high and low depression groups. Measure
Low depression (N = 121) Mean SD
High depression (N = 103) Mean SD
T
Significance (p)
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
27.06 22.74 7.47 .52 5.80 33.92
25.87 23.27 21.98 10.92 13.89 21.98
.98 .94 7.84 38.71 18.34 17.47
.327 .347 .001 .001 .001 .001
(9.80) (3.14) (9.07) (.50) (2.97) (4.56)
(6.35) (5.21) (17.91) (2.92) (3.65) (7.11)
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
Subscale 3 (high standards for self) did not correlate with EAT-26 score and correlated negatively with HADS-depression, HADSanxiety and self esteem, although it did emerge as a positive predictor in later regression analyses. In the regression analyses subscales 1 (self loathing) and 3 (high standards for self) were significant unique predictors of ED symptoms, subscale 1 (self loathing) was a unique predictor of depression and subscales 1 (self loathing) and 5 (abandoned/deprived) were unique predictors of anxiety. Subscales 1, 2, 3 and 5 were unique predictors of self esteem, thus providing validation for the ED-CBQ subscales. In the discriminant function analyses, high levels of ED symptoms were associated with subscales 1 (self loathing), 3 (high standards for self) and 4 (demanding and needing help and support), and high levels of depression and also anxiety were associated with subscale 5 (abandoned/deprived). When ED diagnoses were examined using discriminant function analysis, subscale 1 (self loathing) was particularly important in BN, and 1 (self loathing) and 3 (high standards for self) in AN. Self loathing (subscale 1) was a significant predictor of ED symptoms, anxious and depressive symptoms and self esteem when regression analyses were conducted. Given that other variance was controlled in these analyses, high levels of all these symptoms appear to be independently associated with self loathing. Self loathing thus appears important, not only in ED related symptoms but in depressive and anxious symptoms, and (as might be expected) in low self esteem. In predicting ED symptoms high standards for self (subscale 3) were also important, and in anxiety, abandoned/deprived (subscale 5) were also important. Self esteem (as might be expected) was associated with all subscales, except 4 (demanding and needing help and support). The findings suggest that self loathing in particular is important in a range of symptomatology including ED symptoms. However, when discriminant function analyses were conducted, using cut-off scores or putative ED diagnoses, subscale 1 (self loathing) was associated with EDs, both AN and BN, while depression and anxiety were associated with most strongly associated with subscale 5 (abandoned/ deprived). These findings are consistent with those of the exploratory study (Cooper & Cowen, 2009). The exploratory study identified six themes,
most of which were similar in content to the five identified here. While greater specificity was identified in regression analysis in relation to ED and depressive symptoms in Cooper and Cowen (2009) their sample, unlike the current unselected community sample, included two diagnosed groups. The findings of the cut-off and putative diagnostic groups identified here are consistent with those of the earlier study. In particular, self loathing is associated most clearly with a diagnosis of an ED, while depression (and here anxiety) are associated with abandoned/deprived core beliefs. Thus, as one moves from community samples and symptoms to putative diagnoses, it appears that EDs, depression and also anxiety are associated with specific core belief content. In the current study putative ED diagnoses, compared to depression and anxiety, were additionally associated with high standards for self and demanding and needing help and support. The latter two themes were particularly associated with AN rather than BN diagnoses. The content of both themes has been described as characteristic of those with AN by other researchers and clinicians. The diagnostic analyses, unlike the regression analyses, have not controlled for comorbid symptoms (or diagnoses), thus as well as differing on the core symptoms most groups also have different scores, compared to their control groups, on a range of other symptoms. While comorbidity might be expected to decrease differentiation in core beliefs, the findings presented here suggest that it increases it. This raises the possibility that features other than those identified or assessed here are at least partly responsible for producing differences between EDs and depression and anxiety in their characteristic core beliefs. The current study has identified a number of themes in core beliefs that are relevant to ED symptoms and diagnosis. Self loathing appears to be particularly important, and may differentiate EDs from depression and anxiety. Reassuringly, the results are consistent with those reported by Cooper and Cowen (2009), and draw attention to a category of belief, self loathing, that has been relatively neglected in the ED literature. Self loathing is often referred to as an extreme form of low self esteem which is particularly common in clinical samples, including those with depression and some personality disorders. The current findings are not inconsistent with this, particularly as depressive
Table 9 Descriptive data for high and low anxious groups. Measure
Low anxious (N = 77) Mean SD
High anxious (N = 98) Mean SD
T
Significance (p)
Age (years) BMI EAT-26 HADS-dep HADS-anx RSE
27.90 22.71 6.14 1.68 2.84 35.08
25.40 (7.65) 22.97 (4.70) 23.69 (19.02) 8.92 (4.14) 15.93 (1.71) 22.61 (5.87)
3.23 .56 7.77 7.64 9.99 8.35
.063 .684 .001 .001 .001 .001
(10.00) (3.43) (6.73) (1.94) (1.17) (3.78)
BMI = Body Mass Index. EAT-26 = Eating Attitudes Test-26. HADS-dep = Hospital Anxiety and Depression Scale-anxiety subscale. HADS-anx = Hospital Anxiety and Depression Scale-depression subscale. RSE = Rosenberg Self Esteem Scale.
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symptoms were found to be related to self loathing, but further suggest that, as measured here, self loathing is particularly characteristic of those with EDs. This is consistent with the findings of Aruguete, Yates, and Edman (2007) who, using a brief 4 item scale, found that self loathing is typical of those with EDs, and may provide a screen for eating disorders in a vulnerable population. Inspection of the individual items comprising the self loathing subscale developed in the current study may help explain why the scale appears particularly relevant to EDs. It is noteworthy that the items depict extreme self loathing (beyond simple self dislike or simple negative evaluation), and moreover, that many of the items have a visceral quality to them. While self loathing may appear in other disorders, the scale used here may reflect the embodied nature of EDs particularly well. Such items may readily evoke different modalities of experience, beyond the purely verbal, and as such, fit well with the “embodied” experience of those with EDs. The study has a number of limitations. Internet based research is relatively new, and clearly excludes those who do not have on line access. On the other hand, the anonymity might be particularly attractive to those with concerns about eating and self esteem. A community sample enables constructs to be treated as dimensions and helps avoid ceiling and floor effects that can be associated with use of discrete categories, but by definition the sample consists mainly of participants who do not have a diagnosable disorder, making generalisability to EDs difficult. While putative diagnostic categories were created, these relied on self report, and the validity of the different diagnoses made was not independently verified. Overall, however, the measure reported here may be a useful clinical and research tool to explore the role of core beliefs in EDs in future studies. Investigation of patient groups, including those with EDs, depression and also a range of personality disorders, as well as dieters, who share some ED concerns, would be a useful next step, with carefully conducted diagnostic procedures, followed by study of the ability of the measure to predict ED symptoms and disorders longitudinally. The constructs identified in the subscales might also usefully form the basis for experimental studies designed to understand more about the specific content and the role of negative self beliefs in EDs; work which is already underway (Pringle, Harmer, & Cooper, 2010). Role of funding sources No specific funding was in place for this study. Contributors Both authors designed and planned the study. The first author collected the data. Both authors contributed to the data analysis and write up, and both approved the final paper. Conflict of interests There are no conflicts of interest to declare.
Appendix A. Eating Disorder Core Belief Questionnaire Instructions Listed below are a number of different words. People sometimes think these words describe how they feel about themselves as a person. Please read each word carefully and decide how much you feel each word describes how you feel about your own self. Base your answer on what you emotionally believe or feel to be true, not on what you rationally believe to be true. Choose the rating which best describes what you usually believe/feel or what you believe/feel most of the time, rather than how you feel right now. If you are unsure of the meaning of a word you may miss it out. Work as quickly as you can. Don't spend too long on each word — your first impression is the most important. Place a cross or tick in the box that best describes your response.
Scoring: Subscale 1: self loathing = items (7, 8, 9, 15, 20, 25, 27, 28, 29, 40)/10 Subscale 2: unassertive/inhibited = items (14, 17, 30, 33, 36, 37, 38, 39)/8 Subscale 3: high standards for self = items (4, 10, 11, 18, 22, 23, 24, 31)/8 Subscale 4: demanding/needing help and support = items (3, 5, 12, 13, 16, 21, 26, 32, 34, 35)/10 Subscale 5: abandoned/isolated = items (1, 2, 6, 19)/4.
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