Self-silencing and anger regulation as predictors of disordered eating among adolescent females

Eating Behaviors 12 (2011) 112–118

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Eating Behaviors

Self-silencing and anger regulation as predictors of disordered eating among adolescent females Sarah Jane Norwood a,⁎, Anne Bowker a, Annick Buchholz b, Katherine A. Henderson b, Gary Goldfield b, Martine F. Flament c a b c

Psychology Department, Carleton University, Ottawa, Ontario, Canada K1S 5B6 Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1 University of Ottawa Institute of Mental Health Research, 1145 Carling Avenue, Ottawa, Ontario, Canada K1Z 7K4

a r t i c l e

i n f o

Article history: Received 13 May 2010 Received in revised form 23 October 2010 Accepted 17 January 2011 Available online 26 January 2011 Keywords: Self-silencing Anger Disordered eating Dietary restraint Emotional eating

a b s t r a c t The main purpose of this study was to examine how self-silencing, emotional regulation, and body-esteem differentiated healthy eating from different patterns of disordered eating. A community sample of adolescent females was classified as either: 1) Restrained Eaters (n = 104, Mage = 14.48); 2) Emotional Eaters (n = 125, Mage = 14.52); or, 3) Healthy Eaters (n = 396, Mage = 13.71). A discriminant function analysis revealed two significant functions. The first function differentiated the two disordered eating groups (i.e., the restrained and emotional eaters) from the healthy group, with the disordered eating groups scoring significantly higher on levels of self-silencing and anger regulation, and lower on body-esteem. The second function differentiated between the restrained and emotional eaters, with the emotional eaters reporting higher levels of externalized self-perception and anger, and lower levels of body-esteem. The results suggest that bodyesteem and anger suppression were the most influential variables in differentiating between groups. The findings are discussed in terms of the implications for disordered eating prevention and treatment programs. © 2011 Elsevier Ltd. All rights reserved.

1. Introduction Given the severity and complexity of eating disorders, researchers have focused on identifying factors that may impact the risk that one will develop an eating disorder (see discussion in Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004). Common biological risk factors include genetic and developmental factors, while identified sociocultural risk factors include (among others): being female, having low body-esteem, and a perceived pressure to be thin (see discussion in Striegel-Moore & Bulik, 2007). Typically these pressures come from sociocultural influences, which include one's peers, the media, and/or family members (e.g., Keel & Gravener, 2008). A combination of these factors is believed to increase the likelihood that an adolescent will start dieting, and dieting can lead to more severe disordered eating behaviors, thus increasing the risk that the adolescent will develop a clinical eating disorder (McVey, Tweed, & Blackmore, 2004). In addition to these well-known risk factors, it has been theorized that disordered eating behaviors may result from a lack of a strong, positive sense of self (Stein, 2001). A poor sense of self has been a

⁎ Corresponding author at: Present address: Department of Psychology, York University, 4700 Keele Street, Toronto, Ontario, Canada M3J 1P3. Tel.: +1 647 984 7161; fax: +1 416 736 5814. E-mail address: [email protected] (S.J. Norwood). 1471-0153/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.eatbeh.2011.01.009

focus of interest among feminine theorists for many years (e.g., Gilligan, 1988; Pipher, 1994) and it has been proposed that this inadequate sense of self may develop as a result of women suppressing their true thoughts and emotions in attempt to become the ‘perfect’ woman (Gilligan, 1993; Jack & Dill, 1992). It is believed that this ‘perfect’ self, which involves placing others' needs before one's own, is synonymous with the ‘false’ self and presenting a ‘perfect’ (although false) self and suppressing negative emotions, such as anger, may lead to disordered eating as women learn to direct their anger inwards, and consequently displace their negative thoughts and feelings onto their body. The ‘false’ self has been associated with low self-esteem and poor body-esteem, which are both strong risk factors for the development of eating disorders (American Psychiatric Association, 1994). Thus, in keeping with past research and theories, this study examined how interpersonal orientation (i.e., whether one silences her true thoughts and feelings and presents a ‘false’ self), emotional regulation (i.e., how one expresses or suppresses one's feelings of anger), and body-esteem (i.e., feelings and beliefs one has about one's own body) increase the risk of dietary restraint and emotional eating. As restraint and emotional eating are characteristic of clinical eating disorders (American Psychiatric Association, 1994) it was hypothesized that when a female engaged in either or both of these behaviors she would be at a greater risk of developing an eating disorder, thus highlighting the importance of understanding these precipitating factors.

S.J. Norwood et al. / Eating Behaviors 12 (2011) 112–118

1.1. Restraint and emotional eating While early research on the Restraint Eating theory focused on a one-dimensional model of restraint (i.e., restraint leading to overeating), more recent research favours a two-dimensional model of restraint, assessing one's level of restraint eating and levels of disinhibition separately (Wardle, 1987). This research acknowledges that there may be more or less successful restrained eaters, depending on the likelihood that they will eat when disinhibited. In an attempt to validate the Dutch Eating Behavior Questionnaire (DEBQ), Wardle (1987) examined four groups of adult participants: a group of individuals who were overweight (OW), a group with Bulimia Nervosa (BN), a group with Anorexia Nervosa (AN), and controls. She found that all three of the experimental groups scored higher on the restraint subscale than the controls. Those who were suffering from BN had the highest scores on the emotional eating subscale, while the OW group scored higher than the control group on emotional eating, and those with AN scored significantly lower than the controls on the emotional eating subscale. However, scores on the restrained eating subscale were equally high for all three groups (OW, AN, and BN). The results of Wardle and colleagues' study support the idea that people who engage in disordered eating behaviors typically endorse items of restrained eating, but differ with respect to their levels of disinhibition. In the present study, an attempt was made to differentiate between those females who were more likely to engage in dietary restraint, as opposed to those females who were more likely to engage in emotional eating. 1.2. Self-silencing and anger The Silencing the Self theory maintains that females learn to suppress their true feelings and emotions, as assertion does not fit within the traditional female role, and as a result they learn to silence their selves (Jack, 1991). From the Self-Silencing theory, Jack and Dill (1992) created the Silencing the Self Scale (STSS) which measures four constructs, including the degree that one judges oneself based on the opinions of others (Externalized SelfPerception); the extent to which one puts the needs of others before one's own in an effort to secure one's relationships (Care as Self-Sacrifice); the degree to which one silences one's own true desires as a way of maintaining harmony with others (Silencing the Self); and finally, the effect of constantly portraying an outwardly compliant (fraudulent) self while one's concealed inner self grows angry and hostile (Divided Self). Research has also examined the same constructs among adolescents, using a revised version of the STSS that was adapted for use in adolescents by Sippola and Bukowski (1996). In a community sample of adolescent females, researchers found that a high level of externalized self-perception was predictive of lower body-esteem (Buchholz, 1998; Lieberman, Gauvin, Bukowski, & White, 2001). Similar results were reported in a clinical sample of adolescent females with eating disorders (Buchholz et al., 2007). These researchers found that self-silencing behaviors were positively correlated with eating disordered cognitions and behaviors, and that externalized self-perception was a unique predictor of eating disordered cognitions. Emotional eaters are those who eat in order to cope with changes in their emotional states (Schachter, Goldman, & Gordon, 1968). Negative emotions, such as anger, have been associated with eating disorders (Balfour, 1996; Geller, Cockell, Goldner, & Flett, 2000; Zaitsoff, Geller, & Srikameswaran, 2002). The way in which a female learns to express or suppress her anger may be related to the concept of presenting the ‘perfect’ self. From a young age, many females are socialized to present the ‘perfect’ self and not create or cause controversy with others (Brown, 1998; Brown, Tappan, Gilligan,

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Miller, & Argyris, 1989; Pipher, 1994). Outwardly expressing one's anger is not thought to fit within the feminine ideal; therefore girls are taught that it is more appropriate to suppress their true emotions. van Daalen-Smith (2008) argued that there is no seemingly right way for females to deal with their anger as there are social consequences imposed upon them when they express their anger, and mental and physical health consequences when they suppress their anger. Mental health issues that have been associated with loss of voice and anger suppression include poor self-esteem (van Daalen-Smith, 2008), depression (Munhall, 1994), and eating disorders (Buchholz et al., 2007; Geller et al., 2000; Zaitsoff et al., 2002). Research investigating the role of anger in eating disorders has focused primarily on the association between binge eating and anger expression and suppression among adult females (e.g., Fassino, Daga, Pierô, Leombruni, & Rovera, 2001; Fox & Harrison, 2008; Milligan & Waller, 2000; Peñas-Lledó, de Dios Fernández, & Waller, 2004). While there have been inconsistencies among the results of these studies, overall findings suggest that females with eating problems tend to report higher levels of anger than females without eating problems. However, there may be differential patterns of anger suppression, depending on the nature of the eating disorder. Studies have also examined both self-silencing and anger in relation to eating pathology. Geller et al. (2000) found that individuals with AN reported higher levels of anger suppression and self-silencing behaviors in comparison to psychiatric and healthy control groups. In a community sample of adolescent females, Zaitsoff et al. (2002) compared those with eating pathology to those without, finding that there were no differences in the way in which the two groups outwardly expressed their anger. However, when they examined eating disorder cognitions and behaviors separately, anger suppression accounted for a significant amount of variance in those with disturbed eating disorder cognitions (Zaitsoff et al., 2002). Findings from these studies elucidate the role of anger and selfsilencing in the development of disordered eating behaviors. While greater levels of self-silencing have been consistently found to relate to general eating pathology, research has yet to document how selfsilencing is related to specific disordered eating behaviors among adolescents. Additionally, previous research has not reported consistent findings regarding the ways that anger is expressed or suppressed in relation to disordered eating. Therefore, one of the goals of the current study was to expand on existing research by examining how anger suppression and expression were related to restrained and emotional eating, thereby increasing our understanding of the role of anger in disordered eating.

1.3. The present study The main objective of the current study was to examine how measures of self-silencing, anger expression and suppression, and body-esteem differentiated groups of adolescent females who differed on levels of restrained and emotional eating. Three groups of adolescent females were investigated: (1) healthy eaters; (2) emotional eaters; and, (3) restrained eaters. First, it was hypothesized that the healthy eating group would report higher levels of bodyesteem and lower levels of anger and self-silencing than the restrained and emotional eating groups. Second, it was expected that anger suppression would be more strongly associated with the restrained eating group, as compared to the emotional eating group, and that anger expression would be more strongly associated with the emotional eating group, as compared to the restrained eating group. Third, it was hypothesized that the constructs of self-silencing would be positively associated with disordered eating behavior (i.e., restraint and emotional eating), and it was expected that the relationship would be strongest between externalized self-perception and disordered eating (Buchholz et al., 2007; Lieberman et al., 2001).

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2. Methods 2.1. Participants and procedures Participants were part of a larger school-based study, the Ontario Research on Eating and Adolescent Lifestyles (REAL study, as described previously by Goldfield et al., 2010). For the purposes of this study only females were included, and the groups of interest were derived from a total of 1317 participants from grades 7 to 12 (Mage = 13.99 years, SDage = 1.45). After the participants filled out their questionnaires they were taken to a private area where they were weighed and measured by a research assistant. Body Mass Index (BMI) was calculated based on height and weight (BMI = weight [kg] / height2 [m2]). 2.2. Measures 2.2.1. Demographic information Demographic data, including grade, age, and gender, were collected from each participant. 2.2.2. Restrained and emotional eating The Dutch Eating Behavior Questionnaire (DEBQ; van Strien, Frijters, Bergers, & Defares, 1986) was used as a measure of restrained and emotional eating. The DEBQ is a 33-item self-report questionnaire with items rated on a 5-point Likert scale ranging from 1 (never) to 5 (very often). The measure is composed of three subscales measuring distinct types of disordered eating behaviors: restrained eating, that measures the extent to which one restricts their food intake (10 items); emotional eating, that measures the likelihood that a person will eat in order to seek comfort or to cope with an emotionally charged situation (13 items); and, external eating, that measures the frequency with which one eats when enticed by specific food cues (e.g., appearance and/or odour of food; 10 items). The DEBQ has been validated for use in adults (Wardle, 1987) and children (Halvarsson & Sjoeden, 1998) and has been shown to be a reliable measure in both populations. For the purpose of the current study only the restrained and emotional eating subscales were utilized. The restraint eating subscale has been demonstrated to be a reliable measure for use in adolescent females (Banasiak, Wertheim, Koerner, & Voudouris, 2001). In the current study, both the restraint and the emotional eating subscales of the DEBQ had strong internal consistency (α = .93 and .94, respectively). The DEBQ-restraint and emotional eating subscales were used to categorize the participants into the three groups of interest. In order to form groups that were representative of those who scored high on emotional eating and/or restraint, participants were classified as restrained eaters if they scored greater or equal to the 75th percentile on the restraint subscale and less than or equal to the 50th percentile on emotional eating subscale of the DEBQ (n = 104, Mage = 14.48, SDage = 1.67, MBMI = 23.77, SDBMI = 4.23). Similarly, participants were classified in the emotional eating group had they scored greater or equal to the 75th percentile on the emotional eating subscale and less than or equal to the 50th percentile on the restraint subscale of the DEBQ (n = 125, M a g e = 14.52, SD a g e = 1.56, M B M I = 19.54, SDBMI = 2.92). These classifications were based on the work of Zaitsoff et al. (2002), whose study involved a community sample of adolescent females who were grouped according to their scores on a measure of disordered eating behaviors, with those who scored above the 80th percentile placed into the disordered eating group. Lastly, a healthy control group was formed by selecting those participants who had scored less than or equal to the 50th percentile on both the restraint and emotional eating subscales of the DEBQ (n = 396, Mage = 13.71, SDage = 1.34, MBMI = 20.30, SDBMI = 3.60). Therefore, from the original sample of 1317 participants, 625 fell into one of the three groups, whereas 692 participants did not meet

criteria for any group and were not included in further analyses. Means and standard deviations on psychobehavioral variables were then calculated for each of the three groups (see Table 1). In order to verify that this method of categorization was statistically sound, the dataset was subjected to cluster analysis. K-means cluster analysis was utilized in order to identify homogeneous groups of participants based on their levels of restrained and emotional eating (Rapkin & Luke, 1993). The results of the cluster analysis supported three distinct groups that corresponded to the three groups of interest.

2.2.3. Body esteem The Body Esteem Scale for Adolescents and Adults (BESAA; Cecil & Stanley, 1997; Mendelson, Mendelson, & White, 2001) was used as a measure of body esteem. The BESAA is a 23-item measure that is rated on a 5 point Likert scale, from 0 (never) to 4 (always). The BESAA is composed of three subscales which each measure unique aspects of body-esteem: Appearance esteem, which measures how one feels about one's appearance, Weight esteem, how satisfied one is with one's weight, and Attribution, which examines others' evaluations about one's own physical appearance. Higher scores on all subscales reflect higher body-esteem. This measure has demonstrated convergent validity (with measures of self-esteem), test–retest reliability, and high internal consistency for each subscale (Mendelson et al., 2001). For the purposes of the current study, only the Appearance Esteem subscale was utilized as a measure of body-esteem (α = .75).

2.2.4. Self-silencing The Silencing the Self Scale for Adolescents (STSS-A; Jack & Dill, 1992; Norwood et al., 2007; Sippola & Bukowski, 1996) was used in this study to determine friendship intimacy and self-silencing behaviors. The STSS-A was originally adapted for use in adolescents by Sippola and Bukowski (1996) to capture the dynamics of friendships as opposed to romantic relationships, which the original 31item STSS (Jack & Dill, 1992) assessed. The STSS-A has since been validated in an adolescent sample. A principal components analysis of the revised STSS revealed a three factor structure that was identical for both males and females and suitable for use in adolescents (Norwood et al., 2007). The STSS-A has 15 items rated on a 5-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree). The STSS-A is composed of 3 subscales, Externalized Self-Perception, which is the extent to which one judges oneself based on the opinions of others, Silencing the Self, not expressing one's true thoughts to avoid confrontation with others, and Care as Self-Sacrifice, giving up one's own true wishes and desires by putting others before oneself. For the purposes of the current study, Externalized Self-Perception (α = .84), Silencing the Self (α = .71), and Care as Self-Sacrifice (α = .64) were utilized as individual predictors. Table 1 Means and standard deviations for restrained eating, emotional eating, self-silencing, externalized self-perception, care as self-sacrifice, anger-in, anger-out, and body-esteem for each eating behavior group.

Restrained eating Emotional eating Externalized self Self-silencing Care as self Anger-in Anger-out Body-esteem

Restrained eaters (n = 104)

Healthy eaters (n = 396)

Emotional eaters (n = 125)

M

SD

M

SD

M

SD

1.24a 1.25a 13.57a 8.74a 11.90a 12.92a 14.71a 3.83a

.19 .23 5.00 3.00 3.10 3.60 3.60 1.34

1.25a 3.20b 16.90b 9.91b 12.53b 16.70b 17.70b 3.35b

.20 .67 5.27 3.13 2.74 4.65 4.34 .72

2.98b 1.32a 16.52b 10.14b 13.00b 15.40c 16.75b 2.97c

.61 .23 5.22 2.42 2.90 4.52 4.24 .75

Note. Means in a row with different subscripts are significantly different (p b .05).

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2.2.5. Anger expression and suppression The State-Trait Anger Expression Inventory (S-TAXI; Forgays, Forgays, & Spielberger, 1997; Fuqua, Leonard, Masters, & Smith, 1991; Spielberger et al., 1985) was completed as a measure of anger expression and suppression. This measure includes three subscales, State Anger, Trait Anger and Anger Expression, but for the purpose of this study only the Anger-In and Anger-Out subsections of the Anger-Expression subscale were utilized. These subsections are composed of 8 items that rate anger expression on a 4-point Likert scale from 1 (almost never) to 4 (almost always). The possible range of total scores for both subsections is 8 to 32, with higher scores reflecting greater anger expression. The S-TAXI has been used with children and adolescents aged 7–17 (del Barrio, Aluja, & Spielberger, 2004). Both the Anger-In and Anger-Out subsections demonstrated adequate reliability in the present study (α = .79 and .78, respectively).

Correlations among the variables of interest were calculated in order to examine their interrelations (Table 2). A discriminant function analysis (DFA) was performed in order to determine whether restrained, emotional, and healthy eaters could be reliably classified from a set of predictors. DFA enabled us to determine the relative importance of the dependent variables (DVs) in discriminating among eating behavior groups. In this study, the DVs (i.e., silencing the self, externalized self-perception, care as self-sacrifice, anger-in, anger-out, and body-esteem) were treated as predictors in order to examine how they were able to predict group membership for the three eating behaviors groups (restrained, emotional, and healthy eaters). Univariate F tests were then calculated in order to determine the importance of each independent variable (IV) in forming the discriminant functions. Wilk's Λ was significant by the F tests for each of the predictors, supporting the inclusion of each of the variables in discriminating between groups, as well as classifying cases into their correct groups (see Table 3). Additionally, examining the Wilk's Λ values for each of the predictors revealed how important the IV was to the discriminant function, with smaller values representing greater importance. Thus, according to the results of the F tests, by order of importance the predictors in the model included: body-esteem, anger-in, anger-out, externalized self-perception, self-silencing, and care as self-sacrifice (see Table 3). 3. Results As shown in Table 2, most correlations between pairs of DVs were significant. The analysis revealed two discriminant functions with a combined χ2 (12) = 140.68, p b .001. Upon removal of the first function, a significant association was still found between the groups and predictors χ2 (5) = 34.33, p b .001. The two discriminant functions accounted for 84.3% and 15.7%, respectively, of the between group variance. The first discriminant function demonstrated the greatest Table 2 Correlations among the revised Silencing the Self Scale for Adolescents (STSS-A) subscales, the Anger-In and Anger-Out subscales of the State-Trait Anger Expression Inventory (S-TAXI), and body esteem.

Self silencing Externalized self Care as self Anger-in Anger-out Body esteem

Table 3 Results of the discriminant function analysis for the eating behavior groups. Predictor variable

Externalized-self Self-silencing Care as self Anger-in Anger-out Body-esteem Canonical R Eigenvalue

Standardized canonical discriminant function coefficients

Correlations of predictor variables with discriminant functions

1

2

1

2

.000 .128 .094 .297 .399 −.637 .504 .340

.413 −.145 −.158 .635 .323 .852 .244 .063

.537 .365 .250 .636 .535 −.828

.240 −.014 −.163 .552 .382 .469

Wilk's Λ

Univariate F(2, 620)

.908 .957 .978 .865 .904 .802

31.74⁎⁎ 14.04⁎⁎ 7.13⁎ 48.60⁎⁎ 32.95⁎⁎ 76.57⁎⁎

⁎⁎ p b .001. ⁎ p b .01.

2.3. Analytic plan

1 2 3 4 5 6

115

1

2

3

4

5

6

1 – – – – –

.64⁎ 1 – – – –

.41⁎ .20⁎ 1 – – –

.35⁎ .50⁎

−.02 .12⁎ .01 .29⁎

−.29⁎ −.46⁎ −.17⁎ −.41⁎ −.23⁎

.16* 1 – –

1 –

1

Note. 1, 2, and 3 are subscales of the revised STSS-A; 6, body esteem is measured by the Appearance Esteem subscale of the Body Esteem Scale for Adolescents and Adults (BESAA). ⁎ p b .01.

discrimination between the healthy eating group and the two unhealthy eating groups (i.e., restrained and emotional eaters), while the second discriminant function differentiated between the restrained and emotional eaters. An examination of the structure loadings of greater than .30 between predictors and discriminant function one (see Table 3) suggested that the best predictors for distinguishing between the two disordered eating groups and the healthy eaters (first function) were body-esteem, anger-in, anger-out, externalized self-perception, and self-silencing. The two disordered eating groups reported lower levels of body-esteem, higher levels of anger suppression, higher levels of anger expression, higher levels of externalized self-perception, and higher levels of self-silencing (see Table 1). Three predictors, anger-in, anger-out, and body-esteem had loadings in excess of .30 on the second discriminant function, which separated emotional eaters from restrained eaters. Emotional eaters reported greater levels of anger suppression and anger expression than restrained eaters, who reported lower levels of body-esteem than emotional eaters (see Table 1). Thus, the three groups of adolescent females differed most notably on their levels of anger regulation and body-esteem. Examination of the standardized canonical discriminant function coefficients in Table 3 indicates that the variables that contributed the most to discriminant function one, which differentiated between the healthy eating groups and two the unhealthy eating groups (after controlling for the presence of the other variables), were bodyesteem, anger-out, and anger-in. Additionally, the variables that contributed the most to discriminant function two, which differentiated between the restrained and emotional eaters (after controlling for the presence of the other variables), were body-esteem, anger-in, externalized self-perception, and anger-out. Body-esteem contributed negatively (i.e., lower levels of body-esteem discriminating between groups) and anger-in, anger-out and externalized self-perception contributed positively to the distinction between emotional eaters and restrained eaters. Upon examination of the classification procedure, 61.6% of the originally grouped cases were classified correctly. Results revealed that 49% of the restrained group, 46.4% of the emotional eating group, and 70% of the healthy eating group were correctly classified using participants' scores on factors of self-silencing, anger suppression and expression, and body-esteem.1

1 In order to cross-validate these results, a jackknifed quadratic classification procedure was conducted to check the predictive accuracy. The jackknifed procedure cross-validated the classification results by classifying a case into a group that was based on the discriminant function calculated by using all of the cases in the sample except that case that is being classified (Tabachnick & Fidell, 2007). Results indicated that 60.7% of the cross-validated group was correctly classified.

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4. Discussion The main goal of the study was to examine how measures of selfsilencing, anger suppression and expression, and body-esteem differentially predicted patterns of disordered eating behavior among adolescent females. It was expected that dietary restraint and emotional eating, both indicators of eating disorder symptomatology, would have differential patterns of predictor variables. The first objective of the study was to examine how the constructs of self-silencing (i.e., externalized self-perception, silencing the self, and care as self-sacrifice) differed between the three eating behavior groups. As hypothesized, healthy eaters scored significantly lower on overall levels of self-silencing than either the restrained or emotional eaters. As these behaviors are indicative of the ‘perfect’ self that females are socially reinforced to attain, the results indicate that females who engage in restrained or emotional eating are more likely to present an outwardly compliant self in an effort to be accepted by others. Furthermore, externalized self-perception was found to be the most important self-silencing construct in differentiating between healthy and disordered eating groups; that is, those who engaged in either restrained or emotional eating were more likely (than healthy eaters) to judge themselves based on the opinions of others. These results are in support of previous research that has found that eating pathology is positively related to self-silencing (Buchholz et al., 2007) and that externalized self-perception appears to be the most important predictor, compared to either silencing the self or care as self-sacrifice (Buchholz et al., 2007; Lieberman et al., 2001). As externalized self-perception is related to social anxiety in the way in which it encompasses the idea of being judged by others, this may help to explain why externalized self-perception is the strongest predictor of eating pathology (among the self-silencing subscales), as social anxiety has been found to be frequently comorbid with eating disorders (for a discussion see Swinbourne & Touyz, 2007). There were no differences between restrained and emotional eaters on any subscale of self-silencing, indicating that young women with either type of disordered eating put a high value in presenting an outwardly compliant self in an effort to be accepted by others. This is consistent with the overvalued importance of body weight and shape (i.e., what can be seen from the outside) that is part of the diagnostic criteria for both anorexia nervosa and bulimia nervosa (American Psychiatric Association, 1994). The second objective of the current study was to examine the role of anger in relation to disordered eating. Consistent with what was expected, restrained and emotional eaters reported higher levels of anger suppression and expression, in comparison to the healthy eating group. These findings are in support of previous research that has found anger to be related to eating pathology in both female adolescents (Zaitsoff et al., 2002) and adults (Fox & Harrison, 2008; Geller et al., 2000). As restrained eaters are thought to suppress their feelings of hunger, it was expected that this group would be more likely to suppress their true feelings of anger and therefore report higher levels of anger suppression than emotional eaters. In contrast to what was expected, emotional eaters reported higher levels of anger suppression than the restrained eating group. Although contrary to the hypothesis, this result is in line with some previous research, which has found anger suppression to be positively associated with bulimic attitudes and behaviors in late adolescents and adults (Fassino et al., 2001; Milligan & Waller, 2000). Additionally, it was expected that anger-out would be higher among those in the emotional eating group than those in the restrained eating group, as emotional eaters were expected to report greater levels of outward anger, which would correspond to their higher reports of emotional eating. Consistent with what was expected, emotional eaters reported higher levels of anger expression than normal controls; however, there was no significant difference

between the emotional and restrained eaters. Therefore, while these findings support the idea that anger is an important construct in relation to disordered eating, the results of the current study suggest that anger suppression may have a more central role than anger expression in the development and maintenance of disordered eating behaviors. In particular, anger suppression may be an important variable that is able to distinguish among specific types of disordered eating behaviors, with emotional eaters being most at risk. The results indicated that the emotional eaters were more likely to report greater levels of both anger suppression (anger-in) and anger expression (anger-out). Similar results were found in adults by Tan and Carfagnini (2008), who reported that women who were high in depressive symptoms also reported the highest levels of self-silencing behaviors, anger suppression and anger expression, compared to moderately and non-depressed women. It is possible that in an attempt to portray the ‘perfect’ self, females may try to suppress their feelings of anger, but be unable to, and this loss of control of anger may in turn lead to emotional eating. Furthermore, given that these results are crosssectional it is possible that emotional eating leads to greater levels of anger as these females were not able to control their eating the way that they wanted. Thus, anger may influence emotional eating, but emotional eating may also increase anger, creating a vicious cycle. The final objective of the current study was to examine the role of body-esteem in discriminating between the eating behaviors groups. Given that past research has shown that low body-esteem is a strong risk factor for the development of disordered eating behaviors (Attie & Brooks-Gunn, 1989; Leon, Fulkerson, Perry, & Cudek, 1993), it was expected that healthy eaters would report greater levels of bodyesteem than either the emotional or restrained eating groups. The results confirmed this hypothesis. Additionally, it was expected that the restrained eaters would report significantly lower levels of bodyesteem than the emotional eaters as it was hypothesized that females who pose restrictions on their dietary intake may be more likely to feel dissatisfied with their body, than those females who engage in emotional eating. Consistent with what was expected, the restrained eaters reported significantly lower levels of body-esteem than the emotional eaters. While it is interesting that the restrained eaters reported lower levels of self-silencing and anger suppression than the emotional eaters, it may be that this group of adolescent females is less in tune with their true thoughts and feelings. Restrained eaters may thus have lower interoceptive awareness (i.e., less ability to distinguish between internal cues, such as hunger, and emotional states). Interoceptive awareness has been found to be strongly associated with disordered eating in adolescent females (Leon, Fulkerson, Perry, & Early-Zald, 1995). 4.1. Implications and future research Self-silencing behaviors have been implicated in eating disorders, as it is theorized that females who constantly place others before themselves and aim to present an outwardly ‘perfect’ self, suppress their negative thoughts and feelings and in turn displace them onto their body. Therefore, self-silencing may lead to lower body-esteem and dietary restraint, as was seen with the participants in the restrained eaters group. Alternatively, females may learn to cope with their negative feelings through eating, as was seen with the participants in the emotional eaters group. The results of this study provide support for including a focus on interpersonal orientation and emotional regulation in programs designed for the prevention and treatment of eating disorders. It is important that females learn how to express their true thoughts and emotions; by helping girls develop these skills they may begin to feel more confident about themselves and their bodies and may thus engage in less disordered eating behavior. The findings of this study revealed that more than 60% of the cases were correctly classified into their respective subgroups using the selected psychobehavioral variables. While these results are

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consistent with previous studies that have examined individual predictors of disordered eating (Fairburn, Cooper, Doll, & Davies, 2005; Mack, Strong, Kowalski, & Crocker, 2007; Thurfjell, Eliasson, Swenne, von Knorring, & Engström, 2006), the results also indicate that there are other factors not considered in the present study that could have contributed to the correct classification of cases into their respective subgroups. Future research should investigate a broader scope of predictors, as well as other proximal factors of disordered eating, such as self-esteem and sociocultural influences, in order to better understand the differences between healthy, restrained, and emotional eaters. Interestingly, although the mean BMIs of the restrained, emotional, and healthy eating groups were all within the normal range of BMI according to the World Health Organization (WHO; World Health Organization, 2000), the mean BMI of the restrained eaters was significantly higher than the mean BMI of both the emotional eaters and the healthy eaters. The restrained eating group also reported lower levels of body esteem than both the other groups. Consequently, it could be postulated that the restrained eaters experienced greater body dissatisfaction, as they weighed more than their peers, and as a result they began to restrict their dietary intake. Alternatively, it may be that the restrained eating group is at a greater risk for attaining a higher BMI, as their higher levels of dietary restraint may result in overeating; however, they might not report emotional eating because they are less attuned to emotional cues. Given the crosssectional nature of this research causality cannot be assumed, and therefore future prospective longitudinal research should examine how these relations develop over time. 4.2. Conclusion To our knowledge, the present study is the first to attempt to identify how self-silencing, anger regulation, and body-esteem differentiates between healthy and disordered eating behavior groups in adolescents. The results suggested that restrained and emotional eaters are fairly similar, but both groups are significantly different from healthy eaters. More specifically, the findings indicate that females who engage in disordered eating behaviors are more likely to put others' feelings and needs in front of their own, report lower levels of body-esteem, and exhibit greater levels of anger suppression and expression. Additionally, some of these variables were able to differentiate between restrained and emotional eaters. Restrained eaters reported lower levels of body-esteem while emotional eaters reported greater levels of anger. The results of the present study may be applied to help identify females who are at a risk of engaging in disordered eating behaviors and subsequently at risk of developing an eating disorder. In addition, the findings of this study may be applied to help ascertain what type of disordered eating behavior adolescent females may be at risk for. Role of funding sources This study is part of the Ontario Research on Eating and Adolescents Lifestyles (REAL study), which has been funded by the Ontario Centre of Excellence for Child and Youth Mental Health at CHEO, and the University of Ottawa Medical Research Fund. These funding agencies had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Contributors Authors Buchholz, Henderson, Goldfield and Flament designed the study and are responsible for its implementation. Author Norwood conducted literature searches and provided summaries of previous research studies. Author Norwood and Bowker conducted the statistical analysis. Author Norwood wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.

Conflict of interest All authors declare that they have no conflicts of interest.

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Acknowledgements We wish to thank the Ottawa Carleton District School Board, the Ottawa Carleton Catholic School Board, the Upper Canada District School Board, and the many schools in the greater Ottawa area that generously contributed to the study. Special thanks go to each and all students who completed the survey.

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