Relationship of Dissociative Experiences to Body Shape Concerns in Eating Disorders

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1 European Eating Disorders Review Eur. Eat. Disorders Rev. 11, (2003) Published online in Wiley InterScience ( DOI: /erv.508 Paper Relationship of Dissociative Experiences to Body Shape Concerns in Eating Disorders Luis Beato*, Teresa Rodríguez Cano and Antonia Belmonte Eating Disorders Unit, Department of Psychiatry, Ciudad Real Hospital, Ciudad Real, Spain Objective: To examine the relationship of dissociative experiences to body shape concerns in a Spanish sample of eating disorders as compared to a general population. Method: 118 eating disordered outpatients and 64 controls completed the Body Shape Questionnaire (BSQ), the Rosenberg Self-esteem Scale (RSE) and the Dissociative Experiences Scale (DES). Scores were compared within different diagnostic categories. Regression analysis was used to assess the predictive power of the DES and RSES for the BSQ. Results: 36 (30.5 per cent) patients were found to be at high risk for dissociative disorders. In patients, DES together with RSES scores were predictors for BSQ. Discussion: These findings are consistent with the hypothesis that, in a subgroup of eating disorders, dissociation might be associated to the degree of dissatisfaction towards their own body and it might represent a way of coping with a negative self-image. Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords: eating disorders; dissociative disorders; anorexia nervosa; bulimia nervosa; body image; self-esteem INTRODUCTION The term Dissociation, defined as a disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment (DSM-IV; American Psychiatric Association, 1994), has been the subject of great interest in recent years. Researchers have *Correspondence to: Dr L. Beato, Carretera de Valdepeñas, 5, P-3, 4 -B, Ciudad Real, Spain. Tel: lbeato@terra.es European Eating Disorders Review Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 11(1), (2003)

2 Eur. Eat. Disorders Rev. 11, (2003) Dissociative Experiences focused on the assessment of dissociation (Bernstein, & Putnam, 1986) and the relationship between traumatic experiences, dissociative symptoms and psychopathology (Grave, Spitzer, & Freyberger, 1999; Vanderlinden, Vandereycken, Van-Dyck, & Vertommen, 1993). In eating disorders, high levels of dissociation have been linked with the frequency of binging, purging and eating psychopathology, such as ego dysfunction measured with the Eating Disorder Inventory (Everill, Waller, & Macdonald, 1995; McManus, 1995). However, the underlying process in this linkage remains unclear. A multifactorial model has been suggested (Vanderlinden & Vandereycken, 1997). In this model, there is a continuum between the constructive integration of the traumatic experience and a maladaptive dissociation. The outcome depends on a combination of some mediating factors. Vanderlinden, Vandereycken, and Probst (1995) reported that in eating disorders dissociative symptoms were strongly related to the way these patients perceived, experience and/or evaluate their own bodies. The body image alteration experienced by eating disorders patients has also been subject to frequent discussion. The core component of this psychopathological alteration is still unclear, even though the influence of Western cultural and aesthetic values has been generally agreed to be important. The present work was designed to study the relationship between dissociative experiences and the degree of dissatisfaction towards their own body in a Spanish sample of eating disordered patients. Self-esteem being an important factor in eating disorders aetiology, and shape-based self-esteem having been identified as a central cognitive substrate of eating disorders (Cooper & Fairburn, 1993), justify the inclusion of the self-esteem assessment in our analysis. The main purpose of the study was to investigate in patients with eating disorders, the predictive value of dissociative experiences (measured by the Dissociative Experience Scale (DES)) for the degree of dissatisfaction toward their own body (measured by the Body Shape Questionnaire (BSQ)), taking into account the effects of self-esteem (measured by the Rosenberg Self-esteem Scale (RSES)), in a percentage of patients with eating disorders and to compare them with subjects drawn from the general population. METHODS Participants The sample consisted of 118 outpatients (115 females and three males) who were consecutively assessed at the Ciudad Real Hospital Eating Disorders Programme, between 1998 and 2000, and 64 control subjects (58 Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 39

3 L. Beato et al. Eur. Eat. Disorders Rev. 11, (2003) females and six males) recruited through the Nursing School at the University College of Ciudad Real (Spain). Participants gave informed consent after receiving a full explanation of the study. Patients met the criteria for an eating disorder diagnosis, as defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994): anorexia nervosa restricting type (AR, n ¼ 22), anorexia nervosa purging type (AP, n ¼ 10), bulimia nervosa purging type (BP, n ¼ 42), bulimia nervosa non-purging type (BNP, n ¼ 6) and eating disorder not otherwise specified (EDNOS, n ¼ 38). The mean ages were (range 13 47, SD ¼ 6.94) and (range 21 30, SD ¼ 2.04) years, respectively for patients and controls. Patients did not differ from control subjects on demographic variables such as age (t-test, t ¼ 0.369, df ¼ 180, p ¼ 0.712), gender ( 2 ¼ 2.796, df ¼ 1, p ¼ 0.095), and marital status ( 2 ¼ 0.291, df ¼ 1, p ¼ 0.607), but significant differences were noted between both groups regarding educational level: all control subjects were studying at college (Nursing School), whereas only 34 patients, (28 per cent), were studying at college ( 2 ¼ 81.77, df ¼ 1, p < 0.001). PROCEDURE AND INSTRUMENTS The Ciudad Real Eating Disorders Unit is a regional facility for inpatient and outpatient treatment. It serves an area with a population of approximately 490,000. A psychiatrist experienced in the diagnosis and treatment of eating disorders assessed all patients. As a part of the assessment, a semi-structured interview, including demographic and clinical data, was administered. Patients who did not meet DSM-IV criteria for any eating disorder were excluded. As a measure of eating psychopathology, participants completed the Spanish versions of the Eating Attitudes Test (EAT-40; Castro, Toro, Salamero, & Guimerá, 1991), which assesses the most significant characteristic of anorexia nervosa, and the Bulimic Investigatory Test Edinburgh (BITE) (Cervera et al., 1995) which assesses bulimic symptoms. All subjects also completed the Spanish versions of the Dissociative Experience Scale (DES) (Icaran, Colom, & Orengo-Garciá, 1996), the Rosenberg Self- Esteem Scale (RSES) (Baños & Guillen, 2000) and the Body Shape Questionnaire (BSQ; Raich, Deus, Muñoz, Pérez, & Requena, 1996) at the time of the assessment process. Spanish norms were used. DES The Dissociative Experiences Scale (DES) has been developed to offer a reliable measure of dissociation in normal and clinical populations Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 40

4 Eur. Eat. Disorders Rev. 11, (2003) Dissociative Experiences (Bernstein & Putnam, 1986). The scale is a 28-item self-report questionnaire. Subjects are asked to make marks on a 100-mm line to indicate where they fell on a continuum for each question. The mean of all item scores ranges from 0 to 100 and is called the DES score. The internal consistency of the Spanish version (Cronbach alpha ¼ 0.91) is similar to those that in other studies (Icaran et al., 1996). RSES The Rosenberg Self-esteem Scale (Rosenberg, 1965) is a self-report questionnaire comprising 10 items, which assesses global attitudes toward the self. It correlates with other measures of self-esteem (Demo, 1985). Item total score correlations (0.69) and alpha reliabilities of the Spanish version (0.88; Baños & Guillen, 2000) supported the internal consistency of the scale. BSQ The Body Shape Questionnaire is a 34-item, six-point self-report questionnaire designed as a measure of concern about body shape. It has been shown to be a reliable and valid measure (Cooper, Taylor, Cooper, & Fairburn, 1987). Different studies have shown the internal consistency of the Spanish version (Cronbach alpha ¼ 0.96) and its validity (0.71 EAT correlations and 0.78 EDI correlations; Raich et al., 1996). Statistical analysis Differences between patients and control group regarding demographic data and scores on the different scales were assessed by means of t-test and chi-square test where indicated. The DES scores of all eating disorders and control groups were compared using an analysis of variance (one-way ANOVA) with a Scheffé test for post hoc comparisons. Forward stepwise multiple regression analysis was used to assess the importance of DES in the prediction of BSQ, controlling for the effect of RSES scores. Analysis was carried out using the SPSS 7.5 for Windows. RESULTS The mean scores on the EAT-40 were (SD ¼ 22.92) for patients and (SD ¼ 7.69) for controls (t ¼ 12.12, df ¼ 177, p < 0.001). The mean scores on the symptom subscale of the BITE were (SD ¼ 7.69) for patients and 4.73 (SD ¼ 4.71) for controls (t ¼ 11.37, df ¼ 176, p < 0.001). Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 41

5 L. Beato et al. Eur. Eat. Disorders Rev. 11, (2003) Table 1. Mean scores on the BSQ, RSES and DES of eating disorder patient and control group BSQ RSES DES Patients * * * Controls *Significant differences as compared to control group at p < (t-test). Table 1 summarizes the mean scores on the BSQ, RSES and DES of controls and eating disorder patients. For the DES, lower scores were found in controls than in patients with BP and EDNOS (F ¼ 4.248, df ¼ 5, p < 0.001). Based on the DES, 36 patients (30.5 per cent) and 4 (6.3 per cent) control subjects exceeded the cut-off point of 25 for the identification of high risk for dissociative disorders ( 2 ¼ 12.86, df ¼ 1, p < 0.001). Table 2 shows Pearson correlation coefficients between BSQ, DES and RSES scores for patients and controls. Linear regression analysis showed a statistically significant relationship between BSQ and DES only in the patient group (standardized regression coefficient beta ¼ 0.391, t ¼ 4.532, p < 0.001). The proportion of variance accounting for BSQ scores by the DES was 15.3 per cent. In patients, forward stepwise multiple regression analysis indicated that scores on the RSES (standardized regression coefficient beta ¼ 0.349, t ¼ 3.281, p < 0.001) and the DES (beta ¼ 0.227, t ¼ 2.734, p ¼ 0.007) combined to predict 24.2 per cent of BSQ scores (F ¼ , df ¼ 2, p < 0.001; Table 3). Independently of the self-esteem effect, the DES scores influenced Table 2. Correlations between BSQ, DES and RSES in patient and control group Patients Controls BSQ DES BSQ DES DES 0.373** DES 0.250* RSES 0.435** 0.352** RSES 0.512** 0.401** Pearson correlation coefficient; two-tailed significance, *p < 0.05, **p < Table 3. Results of stepwise regression predicting BSQ Step Variable Multiple R 2 Change in R 2 F ratio Significance 1 RSE DES Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 42

6 Eur. Eat. Disorders Rev. 11, (2003) Dissociative Experiences BSQ scores, explaining an additional 4.7 per cent of the variance, and this was statistically significant, although in the control group, DES scores did not show any significant predictive power. Only RSES (beta ¼ 0.512, t ¼ 4.696, p < 0.001) predicted 25.0 per cent of BSQ scores (F ¼ , df ¼ 1, p < 0.001). DISCUSSION In the present study of a Spanish population, 30.5 per cent of the eating disordered patients were identified at high risk for dissociative disorders using the DES. In agreement with previous reports (Everill et al., 1995; McManus, 1995; Vanderlinden et al., 1993; McManus, 1995), our results reveal that patients with a diagnosis of an eating disorder, predominantly bulimic purging type and eating disorders not otherwise specified, show higher levels of dissociation than the general population, indicating that our sample is typical for research samples studied elsewhere. Torem (1990) found that the eating disorder subgroup formed by bulimia and eating disorder no otherwise specified, disproportionately suffered from a multiple personality disorder or other dissociative symptoms. He concluded that, in some of these patients, dissociation might represent the underlying reason for the eating disorder. In addition, an association between traumatic childhood events and the development of both bulimic and dissociative symptoms has been noted. Schmidt, Tiller, and Treasure (1993), observed that bulimic patients reported significantly more severe difficulties in their childhood than patients with other eating disorders. Based on our previous work, we can say that patients with bulimia purging type reported a history of sexual abuse more frequently than patients with other eating disorders and the general population, and both variables showed a relationship with DES scores. In the present study, the DES scores did not show any influence on BSQ in the control group but they did so in the eating disorders group. The observation that, in our sample of eating disordered patients, dissociative experiences together with self-esteem, measured by the DES and RSES respectively, predicted 24.2 per cent of BSQ scores, a scale that evaluates the level of dissatisfaction towards one s own body, is in tune with the hypothesis that a subgroup of eating disorders might be explained as a way of coping with body experiences, probably related to a history of traumatic events (Vanderlinden & Vandereycken, 1997). In this subgroup, dissociation and low self-esteem might be associated in the way the patients experience their own bodies. Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 43

7 L. Beato et al. Eur. Eat. Disorders Rev. 11, (2003) The present results emphasize the need for a multidimensional approach in the assessment and treatment of eating disorders. For the subgroup of patients with high dissociation levels, it is recommended that consideration should be given not only to the cognitive aspects of dissatisfaction related to their body image, but also to the exploration of other subconscious aspects resulting from previous traumatic experiences, which may underlie the rejection of their body image. In our opinion it is essential to take an initial therapeutic approach, in which the relationship between the traumatic experience and the body is analysed. It is also vital to propagate the development of coping strategies, which are more adaptative than dissociative mechanisms. This could facilitate a better recognition and acceptance of the cognitive distortions of one s own body figure and, at the same time, make the modification of these perceptions easier. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baños, R. M., & Guillen, V. (2000). Psychometric characteristics in normal and social phobic samples for a Spanish version of the Rosenberg Self- Esteem Scale. Psychological Reports, 87, Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability and validity of a dissociation scale. Journal of Nervous & Mental Diseases, 174, Castro, J., Toro, J., Salamero, M., & Guimerá, E. (1991). The Eating Attitudes Test: validation of the Spanish version. Psychological Assessment, 7, Cervera, S., Gual, M. P., Lasa, L., Prat, O., Sandio, M., Hernández, C., Azpilicueta, M. J., Elizondo, M. P., Lacasa, C., Riestra, M., de la Fuente, M. C., Lahortiga, J., & de Quesada, L. (1995). Protocolo de atención a pacientes con trastornos de la conducta alimentaria. Navarra: Clínica Universitaria, Universidad de Navarra. Cooper, P. J., Taylor, M. J., Cooper, Z., & Fairburn, C. G. (1987). The development and validation of the body shape questionnaire. International Journal of Eating Disorders, 6, Cooper, P. J., & Fairburn, C. G. (1993). Confusion over the core psychopathology of bulimia nervosa. International Journal of Eating Disorders, 13, Demo, D. H. (1985). The measurement of self-esteem: refining our methods. Journal of Personality and Social Psychology, 48, Everill, J., Waller, G., & Macdonald, W. (1995). Dissociation in bulimic and noneating-disordered women. International Journal of Eating Disorders, 17, Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 44

8 Eur. Eat. Disorders Rev. 11, (2003) Dissociative Experiences Grave, H. H., Spitzer, C., & Freyberger, H. J. (1999). Relationship of dissociation to temperament and character in men and women. American Journal of Psychiatry, 156, Icaran, E., Colom, R., & Orengo-García, F. (1996). Estudio de validación de la escala de experiencias disociativas con muestra de población española. Actas Luso-Españolas de Neurología y Psiquiatría, 24(1), 7 9. McManus, F. (1995). Dissociation and the severity of bulimia psychopathology among eating-disordered and non-eating-disordered women. European Eating Disorders Review, 3, Raich, R. M., Deus, J., Muñoz, M. J., Pérez, O., & Requena, A. (1991). Estudio de actitudes alimentarias en una muestra de adolescentes. Revista Psiquiatría la Facultad de Medicina de Barcelona, 18, Rosenberg, M. (1965). Society and the adolescent self image. Princenton, NJ: Princenton University Press. Schmidt, U., Tiller, J., & Treasure, J. (1993). Psychosocial factors in the origins of bulimia nervosa. International Review of Psychiatry, 5, Torem, M. (1990). Covert multiple personality underlying eating disorders. American Journal of Psychotherapy, 44, Vanderlinden, J., Vandereycken, W., Van-Dyck, R., & Vertommen, H. (1993). Dissociative experiences and trauma in eating disorders. International Journal of Eating Disorders, 13, Vanderlinden, J., Vandereycken, W., & Probst, M. (1995). Dissociative symptoms in eating disorders: a follow-up study. European Eating Disorders Review, Vanderlinden, J., & Vandereycken, W. (1997). The link between trauma and dissociation. In J. Vanderlinden, & W. Vandereycken (Eds.), Trauma, dissociation and impulse dyscontrol in eating disorders, (pp ). Bristol, Pensylvania: Brunner/Mazel Eating Disorders Monograph Series No. 9. Copyright # 2003 John Wiley & Sons, Ltd and Eating Disorders Association. 45

Psychopathology of EDNOS patients: To whom do they compare?

Clinical Psychologist, Vol. 8, No. 2, November 2004, pp. 70 75. Psychopathology of EDNOS patients: To whom do they compare? SASHA MOOR 1, LENNY R. VARTANIAN 1,2, STEPHEN W. TOUYZ 1, & P. J. V. BEUMONT