- Email: [email protected]
The self-image of adolescents with acute anorexia nervosa
April 1981
656
The J o u r n a l o f P E D I A T R I C S
The self-image of adolescents with acute anorexia nervosa The Offer Self-Image Questionnaire for Adolescents was administered to 30female adolescents with a diagnosis o f acute anorexia nervosa. Patients were divided into an early group (12 to 15 years; N = 15) and a late group (16 to 19 years," N = 15). The mean percent weight loss calculated as deviation from norm weight for age and height was 32%, and the mean duration o f illness was 1.3 years, similar f o r both groups, whereas age of onset o f anorexia was significantly (P < 0.001) different. All patients differed significantly from normal adolescents by displaying disturbances in mood and self-esteem (P < 0.05), in social relationships (P < 0.05), and in attitude toward sex (P < 0.05); late adolescent patients additionally showed maladjustment in impulse control (P < 0.05), self-perception and body image (P < 0.01), and in general psychopathology (P < 0.05). Patients were f o u n d well adjusted with regard to moral values, family relationships, and educational goals. The lesser adjustment problems in the younger group agree well with reports finding a more favorable prognosis f o r patients with an early onset of anorexia nervosa.
Regina C. Casper, M.D.,* Daniel Offer, M.D., and Erie Ostrov, J.D., Ph.D., C h i c a g o , Ill.
ANOREXIA NERVOSA is a distinct clinical syndrome occurring predominantly in female adolescents and characterized by profound weight loss as a result of selfinflicted starvation. The syndrome also includes overactivity with denial of fatigue, and a distortion of the body image consisting of a failure to recognize the severity of the emaciation, linked with an overestimation in body size. From a psychologic point of view, one of the most intriguing phenomena in anorexia nervosa is the patient's total emotional and moral investment in a thin body. Slimness is pursued as the supreme goal, deserving any sacrifice. As long as patients can further the weight loss without too much outside interference, the pride and satisfaction derived from achieving slimness seems to enhance the self-esteem sufficiently to hold any other psychologic problem in abeyance. From the Illinois State Psychiatric Institute, Department o f Psychiatry, University of Hlinois, and Department o f Psychiatry, Michael Reese Hospital and Medical Center. *Reprint address: Research Department, Illinois State Psychiatric Institute, 1601 West Taylor St., Chicago, IL 60612.
Vol. 98, No. 4, pp. 656-661
Even when treatment becomes .mandatory, the clinical picture continues to be dominated by the tenaciously fought struggle over whether to eat or not to eat and by other behaviors typical of anorexia nervosa, and generally makes the emotional problems which have been noted by clinicians 1-3 difficult to discern. I
Abbreviation used OSIQ: Offer Self-Image Questionnaire
Apart from clinical accounts describing the psychologic aspects, few systematic studies examining the psychologic dimensions in acuteanorexia nervosa have been conducted. Smart et aP and Stonehill and Crisp ~ reported, on the basis of objective symptom and personality rating scales, that hospitalized patients with anorexia nervosa have significantly greater psychopathology on the anxiety, obsessional, somatic, and depression scales of the Middlesex Hospital Questionnaire. Patients ranked higher on the neuroticism and lower on the extroversion scale of the Eysenck Personality Inventory when compared to a normal female population. Eckert et al" reported moderate depressive symptoms in patients hospitalized in con-
0022-3476/81/040656+06500.60/0 9 1981 The C. V. Mosby Co.
Volume 98 Number 4
Self-image with anorexia nervosa
nection with a collaborative anorexia nervosa t r e a t m e n t study, z Overall, these reports suggest mixed neurotic symptoms in anorexia nervosa, but by virtue of the limitations i n h e r e n t in s y m p t o m - r a t i n g scales, these studies provide little i n f o r m a t i o n a b o u t the characteristics o f the psychologic p r o b l e m s e n c o u n t e r e d in a n o r e x i a nervosa. The present study was directed at filling this gap, a n d aimed at e x a m i n i n g the psychologic a d j u s t m e n t p r o b l e m s in patients w h o present with acute anorexia nervosa. T h e Offer Self-Image Q u e s t i o n n a i r e s was f o u n d well suited for s u c h an investigation for several reasons: (1) it was originally designed and validated for use in adolescence, (2) it has the a d v a n t a g e o f obviating observer bias by requiring self-ratings, and (3) it is constructed in such a way that it contains evaluative statements with reference to a full range o f the adolescent's life and psychologic experiences PATIENT POPULATION
AND M E T H O D S
The clinical sample comprised 30 female adolescent patients in the acute phase of anorexia nervosa, who were diagnosed according to reliable and established criteria~' as modified by Halmi et a12 The study was explained to the patients and their parents , who then gave their written consent for participation. Patients completed the Offer Self-Image Questionnaire either upon hospital admission or following a consultation for their condition. Two adolescent males who were seen and qualified for a diagnosis of anorexia nervosa were excluded from this study. Patients were divided into two groups, the so-called early adolescent group, from 12 to 15 years of age (N = 15), and the late adolescent group, from 16 to 19 years of age (N = 15). All patients had had severe weight loss as a result of intentionally reducing their food intake. Several patients periodically displayed bulimia (defined as uncontrollable rapid ingestion of large amounts of food over a short period of time, terminated by physical discomfort, interference by family oz friends, or sleep) followed by vomiting. With a few exceptions all patients who were evaluated eventually required hospitalization. The patients' responses were compared to those of a control group consisting of 200 age-matched normal, or mentally healthy, adolescent subjects, who were tested in suburban middle and high schools in the Chicago area. The samples thus tested were representative of students from the schools from which they wgre drawn.. The Offer Self-Image Questionnaire. The OSIQ was constructed to measure the self-concept of adolescents between the ages of 13 and 19. ~~The self-concept is considered a particularly crucial personality dimension for adolescents 11 and, empirically, has been directly correlated with their mental health and adjustment.l~. 13The self-concept also has been shown to be a relatively stable personality trait from adolescence onward. TM Because adolescents who can master one aspect of their environment may fail to adjust in other areas, the OSIQ was constructed with 130 items to evaluate functioning in 11 areas important in the
657
Table I. Clinical details of patients with a n o r e x i a nervosa (means, s t a n d a r d deviations, and range) Early adolescent group Number 15 Age (yr) 14.1 • Duration of illness (yr) 1.3 + Percent weight loss* 32.5 • Age at onset 12.7 • Bulimia 1/ 15
1 ( 1 2 - 15) 0.7 (0.5
3)
Late adolescent group 15 17.2 • 1.1 ( 1 6 - 19) 1.4 • 0.5 (0.9 -2)
5.8 ( 2 5 - 4 9 ) 30.4 • 6.5 (20 40) I (ll.l 14.5) 15.9 • 1.2 ( 1 4 - 17.5) 6/15
*Expressed as percentage of normal weight obtained from the Iowa Growth Charts?.' adolescent's psychologic world. Reliability and validity have been discussed elsewhere? Standard scoring. The OSIQ scores are presented in the form of average standard scores, and, in parentheses, standard deviations showing the amount by which individuals differ fiom a reference group average. Standard scores were derived by subtracting the mean of a normal reference group from that of the individual subject, divided by the normal reference group standard deviation, and multiplying the result by 15 and adding 50. All scale scores for the normal reference group are the same: 50 • 15, as an artifact of the standardization procedure. A score lower than 50 signifies a poorer reported self-image as compared to the reference group. The total OSIQ score, which excludes the sexual attitude scale (scale VI) for psychometric reasons, measures psychologic well-being and adjustment. Analysis. Differences in adjustment scores between the groups were examined with a 2-tailed t test for independent samples. RESULTS
Clinical characteristics. T h e clinical characteristics for the early a n d late adolescent anorexia nervosa groups were r e m a r k a b l y alike, with the exception o f age at onset (P < 0.001) (Table 1). The m e a n d u r a t i o n of illness was slightly over a year and the average weight loss calculated as percentage o f n o r m a l weight for age a n d height o b t a i n e d from the Iowa Growth Charts '~ was a b o u t 30%. The difference in the frequency of bulimia between the two groups was not f o u n d to be significant. Comparison of patients with anorexia nervosa and normal adolescents. T a b l e It shows that there were significant differences between b o t h groups o f patients with anorexia nervosa a n d the healthy control groups on the following scales: mood, social relationships, and attitudes toward sex. In addition, older patients showed significantly more disturbances in impulse control (P < 0.05), in self-perception a n d in b o d y image ( P < 0.01), and more general psychopathology (P < 0.05) as c o m p a r e d to older n o r m a l adolescent girls.
658
Casper, Offer, and Ostrov
7"he Journal of Pediatrics April 1981
Table II. Comparison of early and late adolescent patients with anorexia nervosa to normal
adolescent controls
Sample
Anorexia nervosa patients 12-15 yr Anorexia nervosa patients 16-19 yr
I Impulse control
11I II Body and Mood self-image
IV Social VI relationV Sexual ships Morals attitudes
IX x/ VII VIII Vocational X Superio Family Mastery and relation- of external educational Psychoadjust- Total pathology ment score ships world goa~
51 (17)
40* (19)
41 (15)
39* (19)
48 (18)
31' (30)
57 (14)
50 (24)
56 (21)
45 (20)
49 (19)
45 (20)
39* (21)
23t (15)
26t (17)
27* (26)
57 (14)
38* (19)
46 (12)
40 (19)
53 (12)
36* (18)
47 (16)
35* (18)
*P < tP < 0.05 0.01~ When this scoreis comparedto the standard scoreof 50 of the normal referencegroup of the same age and sex.
Features of the adjustment disturbance for both age groups. Mood. Loneliness, shame, and sadness were the pre-
dominant affects acknowledged by most patients; 67% of the younger and 73% of the older patients endorsed the statement "Sometimes I feel so ashamed of myself that 1 just want to hide in a corner," as compared to 30 and 26% of the younger and older normal subjects, respectively. About 70% of the patients admitted to "I feel so very lonely," and "1 frequently feel sad," in contrast to 18 and 32% of the normal adolescents. Nevertheless, for the young patient group these distressing feelings were counterbalanced by the ability to experience pleasurable affect, with 80% (compared to 87% of normal subjects) saying that they enjoyed life and 57% endorsing the statement "most of the time ! am happy." In contrast, the majority of older patients stated that they were no longer experiencing happiness or pleasure. Social relationships. The responses to items on the social relationship scale reflected great ambivalence in interpersonal relationships. About half of the patients thought it difficult to make friends, compared to 7% of normal adolescents; patients also stated that they felt out of place, unliked, and disapproved of by people. On the other hand, patients were desirous of being with people: 87% of the younger and 80% of the older group (compared to 95 and 100% of normal adolescents) endorsed the statement "Being together with other people gives me a good feeling." Sex. With regard to sexual feelings and experiences, patients saw themselves as inadequate, and denied and also felt frightened by sexual thoughts. Nevertheless , patients showed an interest in having a boyfriend; 40% of the younger and 73% of the older patient group, Corn-
pared to 70% of normal subjects, asserted that "having a boyfriend is important to me." Disturbances restricted to the patients with late adolescent anorexia nervosa. Impulse control. With regard to this scale the finding
that 40% of the late adolescent patient group admitted to bulimia is pertinent, because such gorging-vomiting episodes are generally experienced and described by patients as a loss of control. The impulse control scale therefore might be expected to reflect these difficulties. However, only one question, "Usually I control myself," could be considered to refer to this issue: 67% of older patients affirmed it as compared to 94% of the healthy controls. The remaining statements on this scale inquire into the ability to "remain calm" or "keep an even temper" and about experiencing resentment at criticism, indicating for patients insufficient control over resentment and frustration. Furthermore, 67% of patients, as compared to 27% of normal subjects, endorsed "I fear something constantly." Body and self-image. On the body and self-image scale, older patients expressed severe self-criticism; 87% of patients affirmed that "Very often I think that I am not at all the person 1 would like to be," compared to 35% of controls. Most patients stated that they frequently felt ugly and unattractive, more than half said that they worried about their health, yet 60% stated that they felt strong and healthy. This latter statement may reflect the invariably encountered overactivity, a primary, most likely biologically based symptom of anorexia nervosa, indicating preservation of strength and energy in spite of advanced emaciation. It was surprising that in view of the patients' preoccupation and investment in their body size, only one-third expressed pride in their body. The stan-
Volume 98 Number 4
dard scores on the older adolescent patients in the Mood and Body and Self-Image scales are the lowest we have ever obtained on any group, including physically ill adolescents,, psychiatrically hospitalized and psychiatrically disturbed adolescents treated on an out-patient basis, and juvenile delinquents. I~ On the psychopathology scale, harsh self-reproof, despair, and the feeling of being taken advantage of, stood out; 87% of patients compared to 37% of normal subjects affirmed "I often blame myself even if I am not at fault," and 53% of patients compared to 10% of normal adolescents endorsed "l often feel that I would rather die than go on living."
Areas of good adjustment. Morals. Honesty, truthfulness, helpfulness, and fairness were important moral values endorsed by the patients. They strongly disapproved of injustice and meanness. Family relationships. Responses to the individual items indicate that the trend for younger patients to score higher than normal adolescents with regard to family relationships related to their tendency to view their parents as more patient and understanding and less critical than did normal adolescents. Moreover, patients more often felt that they could count on their parents. Almost half of the younger and over half of the older patients, compared to 18% of normal subjects, nevertheless Considered themselves to be "a bother at home." Vocational and educational goals. The patients , desire for achievement, ambition, and their high regard for educational and vocational goals are well known?. ~ In this area patients assumed that they outranked their peers, and stated that they enjoyed learning, studying, and working; they appeared highly interested in aspiring to a profession.
Comparison of the late adolescent patients with early adolescent patients. When compared to the young patient group, older patients scored significantly lower on the Mood Scale (P < 0.01), the Body Image and Self-Image Scale (P < 0.02), and the family relationships scale (P < 0.05). This finding was unexpected and we therefore looked for other variables that could contribute to this difference. The only feature which distinguished the two groups was age of onset (P < 0.001). All patients in the late adolescent group developed the illness at or beyond age 14 and not earlier. By and large, then, our young patients constitute an early-onset group, whereas the older . group is comprised of patients with a later age at onset. DISCUSSION In the present investigation acutely ill patients with anorexia nervosa were found, in contrast to normal adolescents, to be characterized by a predominance of
Self-image with anorexia nervosa
6 59
distressing affects, a poor self-concept, insecurity in social relationships, and a sense Of inadequacy in approaching sexual issues. These observations have important implications for the understanding of the illness and for its treatment. Commonly the denial of illness in anorexia nervosa includes denial of emotional problems, yet the data suggest that the pursuit of slimness is associated with low self-regard in connection with feelings of shame and isolation. This lack of self-confidence and the expectation of disapproval and criticism probably carry over and may be in part responsible for the unease experienced by these adolescents in social relationships, and might also contribute to the sense of ineptitude experienced by them in relation to sexual issues. The fact that the data were derived f r o m a self-report means that patients are conscious of these difficulties. This awareness makes these disturbing feelings accessible to exploration in treatment, even if patients should continue to persist in disavowing the severity of their weight loss. Knowing about the patient's feelings will also aid the physician in reaching the patient, and wilt help build an emotional alliance with the patient, which is the prerequisite for arranging a consistent and successful weight gain program. Our findings are not easily compared to other studies because of differences in methods and the often older average age of the patients in these studies. The overall lower rating on the mood scale suggests the presence of depression in anorectic patients; this finding is in accord with the findings of several other investigations:'"~ ~'~ Stonehill and Crisp ~' also reported diff• in social relationships, which became more apparent when weight recovered patients returned to their every-day environment. For many the anxiety occasioned by social contacts was so incapacitating that Cris p coined the term "social phobia" for it. Strober's personality assessment of an adolescent anorexia nervosa group ~7 perhaps comes closest to our findings. In that study patients more often reported depressive symptoms and had a less outgoing social temperament, yet showed a greater degree of social integrity as compared to control subjects with a personality disorder. In comparison to adolescents with a diagnosis of depression, patients with anorexia nervosa showed less interpersortal confidence and spontaneity with more rigid impulse control, but a greater degree of intellectual efficiency. The two areas of intact functioning noted in Strober's study, 17 namely social integrity and intellectual efficiency, essentially correspond to the areas wherein we found patients with anorexia nervosa to match normal teenagers: moral values, educational achievement, and family relationships.
660
The Journal of Pediatrics April 1981
Casper, Offer, and Ostrov
The patient's psychosocial adjustment cannot be altogether separated from the state of the illness, although the areas of good functioning are probably less influenced by the illness. For instance, patients with anorexia nervosa believe in high moral standards and have a keen sense for what is right and wrong despite their manipulative and deceptive behavior in relation to food intake and weight records. Their conscientious and continued outstanding performance in school, often the result of great effort, often misleads parents into assuming that dieting and weight loss are merely a passing fad. The strength regarding educational aspirations is consonant with the patients' life-long quest for achievement, which has been noticed in many clinical reports 1,~ and seems to be an enduring personality trait. Follow-up studies provide supportive evidence that in comparison to all other areas, patients perform best in their jobs or professional roles.l~. 1, A finding that requires caution in interpretation is the marked difference in adjustment between the two patient groups, with late adolescent patients revealing a disparaging self- and body-concept and more severe and widespread adjustment problems. By contrast, normally developing adolescents become better adjusted as they grow older. 2~ Dally et a121 reported findings in the same direction: 11- to 14-year-old patients had significantly fewer psychiatric symptoms than 15- to 18-year-old patients; they suggested that this may reflect differences in psychopathology and personality development. In our study young patients had an early onset of anorexia nervosa and older patients had a later onset of the illness. In several investigations early age at onset of anorexia nervosa has been reported to predict a favorable outcome, '-'2-~~whereas a later age at onset was found to be associated with a poorer outcome. TM 2a, 26 Why young patients are emotionally less disturbed and have a better outcome than those who develop anorexia nervosa at a later age, given that the biologic factors are the same at both ages, we do not know. We believe, however, that certain differences in the prevailing developmental issues at each age, which then interact with psychologic and biologic factors to set the illness into motion, could provide a lead for further investigations. Clinicians such as Bruch 1 and Selvini2 have conceptualized anorexia nervosa as a struggle for autonomy, identity and sell'hood. In the young patients the wish for separateness and independence seems to be restrained primarily by anxiety arising out of conflicts over the implications of the maturational changes, including the gain in weight 2~ commonly associated with puberty. The increased concern over these bodily changes makes patients aware of their long-standing dissatisfaction with themselves. To
cope with this dissatisfaction, patients embark on selfstarvation, with the expectation that by being thinner, they will feel happier and more competent. For the Older group, who often pass through the physical changes of puberty without noticeable distress, unresolved individuation-separation issues seem to carry a greater weight in bringing about the illness. Late adolescence is fraught with demands involving self-assertion and separation. Those adolescents who have been unsuccessful in resolving conflicts regarding self-differentiation and disengagement from parental ties earlier, eventually become painfully aware of their deficiencies resulting from such a dependent passive participation in life3 and seize upon dieting, not only as a means to improve but also to differentiate themselves and to establish their identity. The psychologic regression induced by these differentiation issues seems to be more generalized than the one induced by the maturational changes. This hypothesis, of course, requires further testing in systematic Clinical and follow-up studies. Even though we have exclusively discussed the psychologic concomitants of anorexia nervosa, during the acute illness the emotional difficulties are largely incorporated into the anorectic symptoms. They are best addressed in connection with a treatment program designed to restore weight and to normalize the eating habiis. In principle, treatment aims at correcting and improving the selfconcept, which then allows patients to gradually relinquish their abnormal involvement with body size and food in favor of renewed meaningful relationships with people. REFERENCES
1. Bruch H: Eating disorders: Obesity, anorexia nervosa and the person within, London, 1974, Routledge & Kegan Paul. 2. Selvini Palazzoli M: Self-starvation,New York, 1978, Jason Aronson, inc. 3. Bruch H: Island in the river: The anorexic adolescent in treatment, Adolesc Psychiatry 7:26, 1979. 4. Smart DE, Beumont PJV, and George GCW: Some personality characteristics of patients with anorexia nervosa, Br J Psychiatry 128:57, 1976. 5. Stonehill E, and Crisp AH: Psychoneurotic characteristics of patients with anorexia nervosa before and after treatment and at follow-up 4-7 years later, J Psychosom Res 21:187, 1977. 6. Eckert E, Goldberg SC, Halmi KA, Casper RC, and Davis JM: Depression in anorexia nervosa, abstract No. 56D, American Psychiatric Association, Chicago, 1979. 7. Halmi KA, Goldberg SC, Casper RC, Eckert ED, and Davis JM: Pretreatment predictors of outcome in anorexia nervosa, Br J Psychiatry 134:71, 1979. 8. Offer D, Ostrov E, and Howard KI: The Offer Self-Image Questionnaire for Adolescents: A manual (revised), Chicago, 1977, Michael Reese Hospital and Medical Center.
Volume 98 Number 4
9. Feighner JP, Robins E, Guze S, et al: Diagnostic criteria for use in psychiatric research, Arch Gen Psychiatry 26:57, 1972. 10. Offer D, Ostrov E, and Howard KI: The adolescent in contemporary society, New York, Basic Books Inc, Publishers. (in press). t l. Blos P: On adolescence, New York, 1962, The Free Press. 12. Rosenberg M: Society arid the adolescent self-image, Princeton, N.J., 1965, Princeton University Press. 13. Offer D, and Offer JB: From teenage to young manhood: A psychological study. New York, 1975, Basic Books, Inc, Publishers. 14. Engel M: The stability of the self-concept in adolescence, J Abnorm Soc Psychol 58:74, 1959. 15. Jackson RL, and Kelby AG: Growth charts for use in pediatric practice, J P~DIATR 27:215, 1945. 16. Ben-Tovim DI, Marilov V, and Crisp AH: Personality and mental state (P.S.E.) within anorexia nervosa, J Psychosom Res 23:321, 1979. 17. Strober M: Personality and symptomatological features in young, non-chronic anorexia nervosa patients, J Psychosomat Res (in press). 18. Hsu LKG, Crisp AH, and Harding B: Outcome of anorexia nervosa, Lancet 1:61, 1979.
Self-image-with anorexia nervosa
66 1
19. Kay DWK, and Leigh D: The natural history of treatment and prognosis of anorexia nervosa, based on a study of 38 patients, J Merit Sci 100:411, 1954. 20. Offer D, and Howard KI: An empirical analysis of the Offer Self-Image Questionnaire for Adolescents, Arch Gen Psychiatry 27:529, 1972. 21. Dally P, Gomez J, and tsaacs AJ: Anorexia nervosa, London, 1979, W. Heinemann Medical Books Ltd. 22. Starkey TA, and Lee RA: Menstruation and fertility in anorexia nervosa, Am J Obstetr Gynecol 105:374, 1969. 23. Rowland CF: Anorexia nervosa-a survey of the literature and review of thirty cases, hal Psychiatr Clin 7:37, 1970. 24. Hahni KA, Brodland G, and Loney J: Prognosis in anorexia nervosa, Ann Intern Med 78:907, 1973. 25. Morgan HG, and Russell GFM: Value of family background and clinical features as predictors of long-term outcome in anorexia nervosa: Four-year follow-up study of 41 patients, Psychol Med 5:355, 1975. 26. Kalucy RS, Crisp AH, Lacey HH, and Harding B: Prevalence and prognosis in anorexia nervosa, Aust NZ J Psychiatry 11:251, 1977. 27. Frisch RE: A method of prediction of age ofmenarche from height and weight at ages 9 through 13 years, Pediatrics 53:384, 1974.
656
The J o u r n a l o f P E D I A T R I C S
The self-image of adolescents with acute anorexia nervosa The Offer Self-Image Questionnaire for Adolescents was administered to 30female adolescents with a diagnosis o f acute anorexia nervosa. Patients were divided into an early group (12 to 15 years; N = 15) and a late group (16 to 19 years," N = 15). The mean percent weight loss calculated as deviation from norm weight for age and height was 32%, and the mean duration o f illness was 1.3 years, similar f o r both groups, whereas age of onset o f anorexia was significantly (P < 0.001) different. All patients differed significantly from normal adolescents by displaying disturbances in mood and self-esteem (P < 0.05), in social relationships (P < 0.05), and in attitude toward sex (P < 0.05); late adolescent patients additionally showed maladjustment in impulse control (P < 0.05), self-perception and body image (P < 0.01), and in general psychopathology (P < 0.05). Patients were f o u n d well adjusted with regard to moral values, family relationships, and educational goals. The lesser adjustment problems in the younger group agree well with reports finding a more favorable prognosis f o r patients with an early onset of anorexia nervosa.
Regina C. Casper, M.D.,* Daniel Offer, M.D., and Erie Ostrov, J.D., Ph.D., C h i c a g o , Ill.
ANOREXIA NERVOSA is a distinct clinical syndrome occurring predominantly in female adolescents and characterized by profound weight loss as a result of selfinflicted starvation. The syndrome also includes overactivity with denial of fatigue, and a distortion of the body image consisting of a failure to recognize the severity of the emaciation, linked with an overestimation in body size. From a psychologic point of view, one of the most intriguing phenomena in anorexia nervosa is the patient's total emotional and moral investment in a thin body. Slimness is pursued as the supreme goal, deserving any sacrifice. As long as patients can further the weight loss without too much outside interference, the pride and satisfaction derived from achieving slimness seems to enhance the self-esteem sufficiently to hold any other psychologic problem in abeyance. From the Illinois State Psychiatric Institute, Department o f Psychiatry, University of Hlinois, and Department o f Psychiatry, Michael Reese Hospital and Medical Center. *Reprint address: Research Department, Illinois State Psychiatric Institute, 1601 West Taylor St., Chicago, IL 60612.
Vol. 98, No. 4, pp. 656-661
Even when treatment becomes .mandatory, the clinical picture continues to be dominated by the tenaciously fought struggle over whether to eat or not to eat and by other behaviors typical of anorexia nervosa, and generally makes the emotional problems which have been noted by clinicians 1-3 difficult to discern. I
Abbreviation used OSIQ: Offer Self-Image Questionnaire
Apart from clinical accounts describing the psychologic aspects, few systematic studies examining the psychologic dimensions in acuteanorexia nervosa have been conducted. Smart et aP and Stonehill and Crisp ~ reported, on the basis of objective symptom and personality rating scales, that hospitalized patients with anorexia nervosa have significantly greater psychopathology on the anxiety, obsessional, somatic, and depression scales of the Middlesex Hospital Questionnaire. Patients ranked higher on the neuroticism and lower on the extroversion scale of the Eysenck Personality Inventory when compared to a normal female population. Eckert et al" reported moderate depressive symptoms in patients hospitalized in con-
0022-3476/81/040656+06500.60/0 9 1981 The C. V. Mosby Co.
Volume 98 Number 4
Self-image with anorexia nervosa
nection with a collaborative anorexia nervosa t r e a t m e n t study, z Overall, these reports suggest mixed neurotic symptoms in anorexia nervosa, but by virtue of the limitations i n h e r e n t in s y m p t o m - r a t i n g scales, these studies provide little i n f o r m a t i o n a b o u t the characteristics o f the psychologic p r o b l e m s e n c o u n t e r e d in a n o r e x i a nervosa. The present study was directed at filling this gap, a n d aimed at e x a m i n i n g the psychologic a d j u s t m e n t p r o b l e m s in patients w h o present with acute anorexia nervosa. T h e Offer Self-Image Q u e s t i o n n a i r e s was f o u n d well suited for s u c h an investigation for several reasons: (1) it was originally designed and validated for use in adolescence, (2) it has the a d v a n t a g e o f obviating observer bias by requiring self-ratings, and (3) it is constructed in such a way that it contains evaluative statements with reference to a full range o f the adolescent's life and psychologic experiences PATIENT POPULATION
AND M E T H O D S
The clinical sample comprised 30 female adolescent patients in the acute phase of anorexia nervosa, who were diagnosed according to reliable and established criteria~' as modified by Halmi et a12 The study was explained to the patients and their parents , who then gave their written consent for participation. Patients completed the Offer Self-Image Questionnaire either upon hospital admission or following a consultation for their condition. Two adolescent males who were seen and qualified for a diagnosis of anorexia nervosa were excluded from this study. Patients were divided into two groups, the so-called early adolescent group, from 12 to 15 years of age (N = 15), and the late adolescent group, from 16 to 19 years of age (N = 15). All patients had had severe weight loss as a result of intentionally reducing their food intake. Several patients periodically displayed bulimia (defined as uncontrollable rapid ingestion of large amounts of food over a short period of time, terminated by physical discomfort, interference by family oz friends, or sleep) followed by vomiting. With a few exceptions all patients who were evaluated eventually required hospitalization. The patients' responses were compared to those of a control group consisting of 200 age-matched normal, or mentally healthy, adolescent subjects, who were tested in suburban middle and high schools in the Chicago area. The samples thus tested were representative of students from the schools from which they wgre drawn.. The Offer Self-Image Questionnaire. The OSIQ was constructed to measure the self-concept of adolescents between the ages of 13 and 19. ~~The self-concept is considered a particularly crucial personality dimension for adolescents 11 and, empirically, has been directly correlated with their mental health and adjustment.l~. 13The self-concept also has been shown to be a relatively stable personality trait from adolescence onward. TM Because adolescents who can master one aspect of their environment may fail to adjust in other areas, the OSIQ was constructed with 130 items to evaluate functioning in 11 areas important in the
657
Table I. Clinical details of patients with a n o r e x i a nervosa (means, s t a n d a r d deviations, and range) Early adolescent group Number 15 Age (yr) 14.1 • Duration of illness (yr) 1.3 + Percent weight loss* 32.5 • Age at onset 12.7 • Bulimia 1/ 15
1 ( 1 2 - 15) 0.7 (0.5
3)
Late adolescent group 15 17.2 • 1.1 ( 1 6 - 19) 1.4 • 0.5 (0.9 -2)
5.8 ( 2 5 - 4 9 ) 30.4 • 6.5 (20 40) I (ll.l 14.5) 15.9 • 1.2 ( 1 4 - 17.5) 6/15
*Expressed as percentage of normal weight obtained from the Iowa Growth Charts?.' adolescent's psychologic world. Reliability and validity have been discussed elsewhere? Standard scoring. The OSIQ scores are presented in the form of average standard scores, and, in parentheses, standard deviations showing the amount by which individuals differ fiom a reference group average. Standard scores were derived by subtracting the mean of a normal reference group from that of the individual subject, divided by the normal reference group standard deviation, and multiplying the result by 15 and adding 50. All scale scores for the normal reference group are the same: 50 • 15, as an artifact of the standardization procedure. A score lower than 50 signifies a poorer reported self-image as compared to the reference group. The total OSIQ score, which excludes the sexual attitude scale (scale VI) for psychometric reasons, measures psychologic well-being and adjustment. Analysis. Differences in adjustment scores between the groups were examined with a 2-tailed t test for independent samples. RESULTS
Clinical characteristics. T h e clinical characteristics for the early a n d late adolescent anorexia nervosa groups were r e m a r k a b l y alike, with the exception o f age at onset (P < 0.001) (Table 1). The m e a n d u r a t i o n of illness was slightly over a year and the average weight loss calculated as percentage o f n o r m a l weight for age a n d height o b t a i n e d from the Iowa Growth Charts '~ was a b o u t 30%. The difference in the frequency of bulimia between the two groups was not f o u n d to be significant. Comparison of patients with anorexia nervosa and normal adolescents. T a b l e It shows that there were significant differences between b o t h groups o f patients with anorexia nervosa a n d the healthy control groups on the following scales: mood, social relationships, and attitudes toward sex. In addition, older patients showed significantly more disturbances in impulse control (P < 0.05), in self-perception a n d in b o d y image ( P < 0.01), and more general psychopathology (P < 0.05) as c o m p a r e d to older n o r m a l adolescent girls.
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Casper, Offer, and Ostrov
7"he Journal of Pediatrics April 1981
Table II. Comparison of early and late adolescent patients with anorexia nervosa to normal
adolescent controls
Sample
Anorexia nervosa patients 12-15 yr Anorexia nervosa patients 16-19 yr
I Impulse control
11I II Body and Mood self-image
IV Social VI relationV Sexual ships Morals attitudes
IX x/ VII VIII Vocational X Superio Family Mastery and relation- of external educational Psychoadjust- Total pathology ment score ships world goa~
51 (17)
40* (19)
41 (15)
39* (19)
48 (18)
31' (30)
57 (14)
50 (24)
56 (21)
45 (20)
49 (19)
45 (20)
39* (21)
23t (15)
26t (17)
27* (26)
57 (14)
38* (19)
46 (12)
40 (19)
53 (12)
36* (18)
47 (16)
35* (18)
*P < tP < 0.05 0.01~ When this scoreis comparedto the standard scoreof 50 of the normal referencegroup of the same age and sex.
Features of the adjustment disturbance for both age groups. Mood. Loneliness, shame, and sadness were the pre-
dominant affects acknowledged by most patients; 67% of the younger and 73% of the older patients endorsed the statement "Sometimes I feel so ashamed of myself that 1 just want to hide in a corner," as compared to 30 and 26% of the younger and older normal subjects, respectively. About 70% of the patients admitted to "I feel so very lonely," and "1 frequently feel sad," in contrast to 18 and 32% of the normal adolescents. Nevertheless, for the young patient group these distressing feelings were counterbalanced by the ability to experience pleasurable affect, with 80% (compared to 87% of normal subjects) saying that they enjoyed life and 57% endorsing the statement "most of the time ! am happy." In contrast, the majority of older patients stated that they were no longer experiencing happiness or pleasure. Social relationships. The responses to items on the social relationship scale reflected great ambivalence in interpersonal relationships. About half of the patients thought it difficult to make friends, compared to 7% of normal adolescents; patients also stated that they felt out of place, unliked, and disapproved of by people. On the other hand, patients were desirous of being with people: 87% of the younger and 80% of the older group (compared to 95 and 100% of normal adolescents) endorsed the statement "Being together with other people gives me a good feeling." Sex. With regard to sexual feelings and experiences, patients saw themselves as inadequate, and denied and also felt frightened by sexual thoughts. Nevertheless , patients showed an interest in having a boyfriend; 40% of the younger and 73% of the older patient group, Corn-
pared to 70% of normal subjects, asserted that "having a boyfriend is important to me." Disturbances restricted to the patients with late adolescent anorexia nervosa. Impulse control. With regard to this scale the finding
that 40% of the late adolescent patient group admitted to bulimia is pertinent, because such gorging-vomiting episodes are generally experienced and described by patients as a loss of control. The impulse control scale therefore might be expected to reflect these difficulties. However, only one question, "Usually I control myself," could be considered to refer to this issue: 67% of older patients affirmed it as compared to 94% of the healthy controls. The remaining statements on this scale inquire into the ability to "remain calm" or "keep an even temper" and about experiencing resentment at criticism, indicating for patients insufficient control over resentment and frustration. Furthermore, 67% of patients, as compared to 27% of normal subjects, endorsed "I fear something constantly." Body and self-image. On the body and self-image scale, older patients expressed severe self-criticism; 87% of patients affirmed that "Very often I think that I am not at all the person 1 would like to be," compared to 35% of controls. Most patients stated that they frequently felt ugly and unattractive, more than half said that they worried about their health, yet 60% stated that they felt strong and healthy. This latter statement may reflect the invariably encountered overactivity, a primary, most likely biologically based symptom of anorexia nervosa, indicating preservation of strength and energy in spite of advanced emaciation. It was surprising that in view of the patients' preoccupation and investment in their body size, only one-third expressed pride in their body. The stan-
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dard scores on the older adolescent patients in the Mood and Body and Self-Image scales are the lowest we have ever obtained on any group, including physically ill adolescents,, psychiatrically hospitalized and psychiatrically disturbed adolescents treated on an out-patient basis, and juvenile delinquents. I~ On the psychopathology scale, harsh self-reproof, despair, and the feeling of being taken advantage of, stood out; 87% of patients compared to 37% of normal subjects affirmed "I often blame myself even if I am not at fault," and 53% of patients compared to 10% of normal adolescents endorsed "l often feel that I would rather die than go on living."
Areas of good adjustment. Morals. Honesty, truthfulness, helpfulness, and fairness were important moral values endorsed by the patients. They strongly disapproved of injustice and meanness. Family relationships. Responses to the individual items indicate that the trend for younger patients to score higher than normal adolescents with regard to family relationships related to their tendency to view their parents as more patient and understanding and less critical than did normal adolescents. Moreover, patients more often felt that they could count on their parents. Almost half of the younger and over half of the older patients, compared to 18% of normal subjects, nevertheless Considered themselves to be "a bother at home." Vocational and educational goals. The patients , desire for achievement, ambition, and their high regard for educational and vocational goals are well known?. ~ In this area patients assumed that they outranked their peers, and stated that they enjoyed learning, studying, and working; they appeared highly interested in aspiring to a profession.
Comparison of the late adolescent patients with early adolescent patients. When compared to the young patient group, older patients scored significantly lower on the Mood Scale (P < 0.01), the Body Image and Self-Image Scale (P < 0.02), and the family relationships scale (P < 0.05). This finding was unexpected and we therefore looked for other variables that could contribute to this difference. The only feature which distinguished the two groups was age of onset (P < 0.001). All patients in the late adolescent group developed the illness at or beyond age 14 and not earlier. By and large, then, our young patients constitute an early-onset group, whereas the older . group is comprised of patients with a later age at onset. DISCUSSION In the present investigation acutely ill patients with anorexia nervosa were found, in contrast to normal adolescents, to be characterized by a predominance of
Self-image with anorexia nervosa
6 59
distressing affects, a poor self-concept, insecurity in social relationships, and a sense Of inadequacy in approaching sexual issues. These observations have important implications for the understanding of the illness and for its treatment. Commonly the denial of illness in anorexia nervosa includes denial of emotional problems, yet the data suggest that the pursuit of slimness is associated with low self-regard in connection with feelings of shame and isolation. This lack of self-confidence and the expectation of disapproval and criticism probably carry over and may be in part responsible for the unease experienced by these adolescents in social relationships, and might also contribute to the sense of ineptitude experienced by them in relation to sexual issues. The fact that the data were derived f r o m a self-report means that patients are conscious of these difficulties. This awareness makes these disturbing feelings accessible to exploration in treatment, even if patients should continue to persist in disavowing the severity of their weight loss. Knowing about the patient's feelings will also aid the physician in reaching the patient, and wilt help build an emotional alliance with the patient, which is the prerequisite for arranging a consistent and successful weight gain program. Our findings are not easily compared to other studies because of differences in methods and the often older average age of the patients in these studies. The overall lower rating on the mood scale suggests the presence of depression in anorectic patients; this finding is in accord with the findings of several other investigations:'"~ ~'~ Stonehill and Crisp ~' also reported diff• in social relationships, which became more apparent when weight recovered patients returned to their every-day environment. For many the anxiety occasioned by social contacts was so incapacitating that Cris p coined the term "social phobia" for it. Strober's personality assessment of an adolescent anorexia nervosa group ~7 perhaps comes closest to our findings. In that study patients more often reported depressive symptoms and had a less outgoing social temperament, yet showed a greater degree of social integrity as compared to control subjects with a personality disorder. In comparison to adolescents with a diagnosis of depression, patients with anorexia nervosa showed less interpersortal confidence and spontaneity with more rigid impulse control, but a greater degree of intellectual efficiency. The two areas of intact functioning noted in Strober's study, 17 namely social integrity and intellectual efficiency, essentially correspond to the areas wherein we found patients with anorexia nervosa to match normal teenagers: moral values, educational achievement, and family relationships.
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The Journal of Pediatrics April 1981
Casper, Offer, and Ostrov
The patient's psychosocial adjustment cannot be altogether separated from the state of the illness, although the areas of good functioning are probably less influenced by the illness. For instance, patients with anorexia nervosa believe in high moral standards and have a keen sense for what is right and wrong despite their manipulative and deceptive behavior in relation to food intake and weight records. Their conscientious and continued outstanding performance in school, often the result of great effort, often misleads parents into assuming that dieting and weight loss are merely a passing fad. The strength regarding educational aspirations is consonant with the patients' life-long quest for achievement, which has been noticed in many clinical reports 1,~ and seems to be an enduring personality trait. Follow-up studies provide supportive evidence that in comparison to all other areas, patients perform best in their jobs or professional roles.l~. 1, A finding that requires caution in interpretation is the marked difference in adjustment between the two patient groups, with late adolescent patients revealing a disparaging self- and body-concept and more severe and widespread adjustment problems. By contrast, normally developing adolescents become better adjusted as they grow older. 2~ Dally et a121 reported findings in the same direction: 11- to 14-year-old patients had significantly fewer psychiatric symptoms than 15- to 18-year-old patients; they suggested that this may reflect differences in psychopathology and personality development. In our study young patients had an early onset of anorexia nervosa and older patients had a later onset of the illness. In several investigations early age at onset of anorexia nervosa has been reported to predict a favorable outcome, '-'2-~~whereas a later age at onset was found to be associated with a poorer outcome. TM 2a, 26 Why young patients are emotionally less disturbed and have a better outcome than those who develop anorexia nervosa at a later age, given that the biologic factors are the same at both ages, we do not know. We believe, however, that certain differences in the prevailing developmental issues at each age, which then interact with psychologic and biologic factors to set the illness into motion, could provide a lead for further investigations. Clinicians such as Bruch 1 and Selvini2 have conceptualized anorexia nervosa as a struggle for autonomy, identity and sell'hood. In the young patients the wish for separateness and independence seems to be restrained primarily by anxiety arising out of conflicts over the implications of the maturational changes, including the gain in weight 2~ commonly associated with puberty. The increased concern over these bodily changes makes patients aware of their long-standing dissatisfaction with themselves. To
cope with this dissatisfaction, patients embark on selfstarvation, with the expectation that by being thinner, they will feel happier and more competent. For the Older group, who often pass through the physical changes of puberty without noticeable distress, unresolved individuation-separation issues seem to carry a greater weight in bringing about the illness. Late adolescence is fraught with demands involving self-assertion and separation. Those adolescents who have been unsuccessful in resolving conflicts regarding self-differentiation and disengagement from parental ties earlier, eventually become painfully aware of their deficiencies resulting from such a dependent passive participation in life3 and seize upon dieting, not only as a means to improve but also to differentiate themselves and to establish their identity. The psychologic regression induced by these differentiation issues seems to be more generalized than the one induced by the maturational changes. This hypothesis, of course, requires further testing in systematic Clinical and follow-up studies. Even though we have exclusively discussed the psychologic concomitants of anorexia nervosa, during the acute illness the emotional difficulties are largely incorporated into the anorectic symptoms. They are best addressed in connection with a treatment program designed to restore weight and to normalize the eating habiis. In principle, treatment aims at correcting and improving the selfconcept, which then allows patients to gradually relinquish their abnormal involvement with body size and food in favor of renewed meaningful relationships with people. REFERENCES
1. Bruch H: Eating disorders: Obesity, anorexia nervosa and the person within, London, 1974, Routledge & Kegan Paul. 2. Selvini Palazzoli M: Self-starvation,New York, 1978, Jason Aronson, inc. 3. Bruch H: Island in the river: The anorexic adolescent in treatment, Adolesc Psychiatry 7:26, 1979. 4. Smart DE, Beumont PJV, and George GCW: Some personality characteristics of patients with anorexia nervosa, Br J Psychiatry 128:57, 1976. 5. Stonehill E, and Crisp AH: Psychoneurotic characteristics of patients with anorexia nervosa before and after treatment and at follow-up 4-7 years later, J Psychosom Res 21:187, 1977. 6. Eckert E, Goldberg SC, Halmi KA, Casper RC, and Davis JM: Depression in anorexia nervosa, abstract No. 56D, American Psychiatric Association, Chicago, 1979. 7. Halmi KA, Goldberg SC, Casper RC, Eckert ED, and Davis JM: Pretreatment predictors of outcome in anorexia nervosa, Br J Psychiatry 134:71, 1979. 8. Offer D, Ostrov E, and Howard KI: The Offer Self-Image Questionnaire for Adolescents: A manual (revised), Chicago, 1977, Michael Reese Hospital and Medical Center.
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9. Feighner JP, Robins E, Guze S, et al: Diagnostic criteria for use in psychiatric research, Arch Gen Psychiatry 26:57, 1972. 10. Offer D, Ostrov E, and Howard KI: The adolescent in contemporary society, New York, Basic Books Inc, Publishers. (in press). t l. Blos P: On adolescence, New York, 1962, The Free Press. 12. Rosenberg M: Society arid the adolescent self-image, Princeton, N.J., 1965, Princeton University Press. 13. Offer D, and Offer JB: From teenage to young manhood: A psychological study. New York, 1975, Basic Books, Inc, Publishers. 14. Engel M: The stability of the self-concept in adolescence, J Abnorm Soc Psychol 58:74, 1959. 15. Jackson RL, and Kelby AG: Growth charts for use in pediatric practice, J P~DIATR 27:215, 1945. 16. Ben-Tovim DI, Marilov V, and Crisp AH: Personality and mental state (P.S.E.) within anorexia nervosa, J Psychosom Res 23:321, 1979. 17. Strober M: Personality and symptomatological features in young, non-chronic anorexia nervosa patients, J Psychosomat Res (in press). 18. Hsu LKG, Crisp AH, and Harding B: Outcome of anorexia nervosa, Lancet 1:61, 1979.
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19. Kay DWK, and Leigh D: The natural history of treatment and prognosis of anorexia nervosa, based on a study of 38 patients, J Merit Sci 100:411, 1954. 20. Offer D, and Howard KI: An empirical analysis of the Offer Self-Image Questionnaire for Adolescents, Arch Gen Psychiatry 27:529, 1972. 21. Dally P, Gomez J, and tsaacs AJ: Anorexia nervosa, London, 1979, W. Heinemann Medical Books Ltd. 22. Starkey TA, and Lee RA: Menstruation and fertility in anorexia nervosa, Am J Obstetr Gynecol 105:374, 1969. 23. Rowland CF: Anorexia nervosa-a survey of the literature and review of thirty cases, hal Psychiatr Clin 7:37, 1970. 24. Hahni KA, Brodland G, and Loney J: Prognosis in anorexia nervosa, Ann Intern Med 78:907, 1973. 25. Morgan HG, and Russell GFM: Value of family background and clinical features as predictors of long-term outcome in anorexia nervosa: Four-year follow-up study of 41 patients, Psychol Med 5:355, 1975. 26. Kalucy RS, Crisp AH, Lacey HH, and Harding B: Prevalence and prognosis in anorexia nervosa, Aust NZ J Psychiatry 11:251, 1977. 27. Frisch RE: A method of prediction of age ofmenarche from height and weight at ages 9 through 13 years, Pediatrics 53:384, 1974.