Self-Focus Mediates the Relationship between Body Dissatisfaction, Depression and Disordered Eating Behaviors

Self-Focus Mediates the Relationship between Body Dissatisfaction, Depression and Disordered Eating Behaviors Wendy L. Wolfe and Kaitlyn Hewitt Armstrong State University Research suggests that depression may play a role in the relationship between body dissatisfaction and the development of disordered eating behaviors. Self-focus has been identified as playing a role in both depression and eating disorders. Using a self-report, cross-sectional methodology, we examined self-focused attention as a mediator between body dissatisfaction and depression and disordered eating in college females. Self-focused attention accounted for significant variance in disordered eating and depression, after accounting for body dissatisfaction. Both self-focused attention and depressive symptoms partially mediated the relationship between body dissatisfaction and disordered eating. The results suggest that a tendency to focus on the self is a risk factor in the development of disordered eating behaviors among those with body dissatisfaction. Longitudinal research is needed to further examine the role of self-focus in eating disorder development. However, preliminary prevention and treatment implications are discussed. Whereas the role of body dissatisfaction as a risk factor in the development of eating disorder behaviors has been well established, a recent longitudinal investigation illustrated that an additional role is played by depressive symptoms. Stice, Marti, and Durant (2011) followed a group of almost 500 middle school-aged females prospectively for eight years. They found that adolescent girls with higher levels of body dissatisfaction were four times more likely to develop eating disorders than those with lower levels of body dissatisfaction, and that within the high body dissatisfaction group, those with higher depressive symptoms were almost three times more likely to develop eating disorders than those with high body dissatisfaction and low levels of depression. Similarly, in a survey of 472 college women, Juarascio, Perone, and Timko (2011) found that depression, as well as anxiety and dieting, moderated the relationship between body dissatisfaction and disordered eating. Author info: Correspondence should be sent to: Wendy L. Wolfe, Department of Psychology, Armstrong State University, Savannah, GA 31419. North American Journal of Psychology, 2016, Vol. 18, No. 1, 85-94. NAJP

86 NORTH AMERICAN JOURNAL OF PSYCHOLOGY We believe that a variable that may further account for the pathway from body dissatisfaction to depression and disordered eating behaviors is self-focused attention. Self-focused attention has been defined as awareness of self-referent, internally generated information (Kiropoulos & Klimidis, 2006, p.297). Dispositional self-focus has been conceptualized as the tendency to be more aware of internal experiences, including bodily experiences, and more aware of oneself (and one s physical appearance) within a social context (Kiropoulos & Klimidis, 2006). Dispositional self-focus, especially rumination tendency, has been found to be associated with depressed mood (Watkins & Teasdale, 2004), and has been proposed as a risk factor for depression (Ingram, 1990). The degree of self-focus has also been found to differentiate between dieters and non-dieters (Heatherton, 1993). Indeed, restrained eating among those dissatisfied with their body size may result from a heightened degree of self-focus and concern about how one appears to others (Heatherton, 1993). It also has been proposed that other disordered eating behaviors, such as binge eating, may be used during times of stress in order to escape from an aversive state of heightened self-focus (Heatherton & Baumeister, 1991). In our study, we examined body dissatisfaction, depressive symptoms, dispositional self-focus, and disordered eating behaviors in college females using an online survey. We predicted that self-focused attention would mediate the relationship between body dissatisfaction and disordered eating (Hypothesis 1). We also predicted that self-focused attention would mediate the relationship between body dissatisfaction and depression (Hypothesis 2). Finally, we predicted that self-focused attention and depressive symptoms would mediate the relationship between body dissatisfaction and disordered eating (Hypothesis 3). METHOD Participants Participants were 281 undergraduate female students, who received course credit for their participation. As in the research by Stice et al. (2011) and Juarascio et al. (2011), females were surveyed due to higher rates of eating disordered symptoms in females and different sources of body dissatisfaction in females (Silberstein, Striegel-Moore, Timko, & Rodin, 1988). The mean age of participants was 21.81 (SD = 6.93), and 77% of our sample consisted of freshmen and sophomores. Sixty percent of our participants listed their race as Caucasian, 24% as African- American, and 6% each as Hispanic or Asian. The remainder declined to identify their race.

Wolfe & Hewitt SELF-FOCUS MEDIATES 87 Measures Body satisfaction/dissatisfaction. Body satisfaction/dissatisfaction was measured using the Body Shape Questionnaire (BSQ), the Body Esteem Scale (B-ES), and the Body Appreciation Scale (BAS). The BSQ is a 34-item self-report measure assessing degree of dissatisfaction and negative feelings about one s body shape (Cooper, Taylor, Cooper, & Fairburn, 1987). Items are rated on a 6-point scale ranging from 1 (Never) to 6 (Always), with higher total scores indicating greater body dissatisfaction. The B-ES is a 35-item measure with raters assessing how they feel about various body parts and functions (Franzoi & Shields, 1984). Items are rated on a 5-point Likert scale ranging from 1 (have strong negative feelings) to 5 (have strong positive feelings). This scale accurately measures body esteem, specifically in young adult populations (Franzoi & Shields, 1984). The B-ES consists of three subscales concerning women s body esteem: Sexual Attraction, Weight Concern, and Physical Condition. For the current study, only the Weight Concern subscale was scored. This subscale assesses feelings about body parts that can be physically changed through weight loss or gain. The BAS is a 13-item self-report measure, with items scaled from 1 (Never) to 5 (Always). It has been shown to be a useful measure in assessing positive body image, including body esteem, body surveillance, body shame, and psychological wellbeing (Avalos, Tylka, & Wood-Barcalow, 2005). High scores indicate positive feelings about one s body. In past research, each of these measures has shown good test-retest reliability and internal validity (Rosen, Jones, Remirez, & Waxman, 1996). In the current study, internal consistency was excellent for all body satisfaction/dissatisfaction measures (Cronbach s α =.97 for BSQ,.92 for B-ES Weight Concern,.94 for BAS). Disordered Eating. Eating behavior was measured using the Eating Attitudes Test (EAT) and the Binge Eating Scale (BES). The EAT is a standard measure of attitudes related to eating disorders and abnormal eating patterns, specifically anorexia nervosa (Garner & Garfinkel, 1979). This measure consists of 26 items ranked on a 4-point scale ranging from 0 (Sometimes, Rarely, Never) to 3 (Always), which form three subscales: Dieting, Bulimia and Food Preoccupation, and Oral Control. The total score is often used to identify individuals at risk for an eating disorder. The EAT has been found to be valid and consistent when measuring symptoms of anorexia nervosa (Garner & Garfinkel, 1979). The BES is a 16-item questionnaire that examines aspects of binge eating behavior (Freitas, Lopes, Applinario, & Coutinho, 2006). Each item consists of a group of statements for participants to choose from. For example, I have no difficulty eating slowly or Sometimes after I eat fast I feel too full. The statements are then recoded with a score of 0, 1,

88 NORTH AMERICAN JOURNAL OF PSYCHOLOGY 2, or 3. A score above 27 indicates severe binge eating (Celio, Wilfley, Crow, Mitchell, & Walsh, 2004). The BES has been found to be a valid and reliable measure (Freitas et al., 2006). We found both the EAT (Cronbach s α =.83) and BES (Cronbach s α =.88) to have good internal consistency in our study. Depression and Self-Focus. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess depressive symptoms. The CES-D consists of 20 items assessing degree of depressive symptoms experienced in the past week. Items are rated from 0 (rarely or not at all) to 3 (most or all of the time), with higher total scores indicating greater depressive symptoms. The CES-D has been used in many studies that have found consistent validity and reliability of the measure (Kim, DeCoster, Huang, & Chiriboga, 2011). Self-focus was measured through the Self-Focused Attention Scale (SFAS; Kiropoulos & Klimidis, 2006). This is a 17-item measure, with participants rating each from one (not true of me) to 4 (very true of me). The SFAS can be used to assess overall self-focus, or distinct dimensions of self-focus: Public Self- Consciousness, Private Self-Consciousness, Public Body Consciousness, and Private Body Consciousness. The SFAS subscales have been found to be internally consistent and the SFAS total score has been found to correlate with depression and anxiety (Kiropoulos & Klimidis, 2006). In our investigation, the SFAS total score (Cronbach s α =.84) and CES-D (Cronbach s α =.89) were found to have good internal consistency. Procedure After providing informed consent to participate in a Women s Health Study, participants completed the measures in Survey Monkey, with the body satisfaction/dissatisfaction and disordered eating measures staggered with the CES-D, SFAS, and other general health measures used in a larger-scale investigation. RESULTS Descriptive statistics and correlations for the variables are summarized in Tables 1 and 2. Comparison of participants scores with mean scores (and standard deviations) reported in the literature indicate that our sample was similar to other non-clinical female college samples in body dissatisfaction (on the BSQ; Rosen et al., 1996) and degree of disordered eating (on the EAT; Doninger, Enders, & Burnett, 2005). Following guidelines for testing mediation (Baron & Kenny, 1986), linear regression analyses were conducted to (1) test the effect of the predictor variable on the dependent variable, (2) test the effect of the predictor variable on the mediator, (3) test the effect of the mediator on the dependent variable, and (4) test the effect of the mediator on the

Wolfe & Hewitt SELF-FOCUS MEDIATES 89 dependent variable after controlling for the effect of the predictor variable on the dependent variable (hierarchical multiple regression). TABLE 1 Descriptive Statistics of Study Measures M SD Body Shape Questionnaire (BSQ) 94.37 37.98 Body-Esteem Scale, Weight Control Subscale (B-ES) 29.43 9.66 Body Appreciation Scale (BAS) 46.74 11.27 Eating Attitudes Test (EAT) 9.42 8.51 Binge Eating Scale (BES) 10.74 7.24 Center for Epidemiological Studies Depression Scale 17.68 10.95 (CES-D) Self-Focused Attention Scale (SFAS) 45.47 8.84 TABLE 2 Correlations of Study Measures BSQ B-ES (WC) BAS EAT BES CES- D SFAS BSQ 1 -.71** -.79**.67**.67**.49**.36** B-ES -.71** 1.75** -.45** -.61** -.29** -.07 (WC) BAS -.79**.75** 1 -.54** -.64** -.49** -.28** EAT.67** -.45** -.54** 1.49**.52**.42** BES.67** -.61** -.64**.49** 1.45**.28** CES-.49** -.29** -.49**.52**.45** 1.43** D SFAS.36** -.07 -.28**.42**.28**.43** 1 ** Pearson correlation significant at p <.01 (two-tailed) Test of Hypotheses 1 and 2 In Step 1, linear regression analyses were used to test the effect of the body satisfaction/dissatisfaction variables on the EAT, BES, and CES-D. In this step, all of the measures of body dissatisfaction/satisfaction were used. As expected, body satisfaction/dissatisfaction was found to be a significant predictor of disordered eating on the EAT [R 2 =.46, F(3, 280) = 77.41, p <.001] and the BES [R 2 =.50, F(3, 280) = 90.86, p <.001], and of depressive symptoms on the CES-D [R 2 =.29, F(3, 280) = 38.10, p <.001]. However, as can be seen in Table 3, most variance was

90 NORTH AMERICAN JOURNAL OF PSYCHOLOGY predicted by the BSQ. Due to concerns about multicollinearity (see correlations, Table 2), only the BSQ was retained for the remaining steps and for the test of hypothesis 3. TABLE 3 Prediction of Disordered Eating and Depression by Body Satisfaction/Dissatisfaction Measures EAT BES CES-D B SE B β B SE B β B SE B β BSQ.15.02.68.07.01.38.10.03.34 B-ES.08.06.09 -.14.05 -.18.30.09.26 (WC) BAS -.05.06 -.07 -.13.05 -.20 -.41.09 -.42 R 2.46.50.29 F 77.4*** 90.9*** 38.1*** *** p <.001 In Step 2, a linear regression analysis was used to test the effect of the BSQ on our mediator of interest, self-focused attention (SFAS total score). Body dissatisfaction, as assessed using the BSQ, was found to be a significant predictor of self-focused attention on the SFAS [R 2 =.13, F(1, 280) = 40.98, p <.001]. In Step 3, linear regression analyses were conducted to test the effect of the mediator, self-focused attention (SFAS total score), on the EAT, BES, and CES-D. Self-focused attention was found to be a significant predictor of disordered eating on the EAT [R 2 =.18, F(1, 280) = 59.83, p <.001] and the BES [R 2 =.08, F(1, 280) = 24.53, p <.001], and of depressive symptoms on the CES-D [R 2 =.18, F(1, 280) = 61.57, p <.001]. Finally, in Step 4, a hierarchical linear regression was conducted to test the effect of self-focused attention (SFAS) on disordered eating (EAT and BES) and depression (CES-D) after controlling for the effect of body dissatisfaction (BSQ). Model 1 tested the effect of body dissatisfaction on eating and depression variables and Model 2 tested the additional effect of self-focused attention on the eating and depression variables. As shown in Table 4, after accounting for the influence of body dissatisfaction (BSQ), self-focused attention (SFAS) significantly accounted for variance in disordered eating on the EAT and depressive symptoms on the CES-D but did not account for additional variance in disordered (binge) eating on the BES. Given that body dissatisfaction remained a significant predictor in these cases, after adding SFAS scores

Wolfe & Hewitt SELF-FOCUS MEDIATES 91 in Model 2, there is support for self-focused attention serving as a partial mediator of the relationship between body dissatisfaction and disordered eating on the EAT, and of the relationship between body dissatisfaction and depression on the CES-D (Baron & Kenny, 1986). TABLE 4 Regression Predicting Disordered Eating (EAT, BES) & Depression (CES-D) from Body Dissatisfaction (BSQ) & Self-Focus (SFAS) Model 1 Model 2 EAT BSQ SFAS B SEB β ΔR 2 / ΔF B SEB β ΔR 2 / ΔF.15.01.67***.45/230.78***.13.20.01.04.60***.21***.04/20.11*** BES BSQ SFAS.13.01.67***.45/228.44***.12.04.01.04.65***.05.00/1.14 CES- D.24/85.59***.07/29.19*** BSQ SFAS.14.02.49***.11.36.02.07.38***.29*** Note. Model 1 tests the effect of BSQ on the dependent variables and Model 2 tests the additional effect of SFAS on the dependent variables. *** p <.001 Test of Hypothesis 3 Because depressive symptoms have been found to relate to the development of eating disorder symptoms among those with body dissatisfaction (Stice et al., 2011), a hierarchical multiple regression analysis was conducted to determine if self-focused attention and depressive symptoms both predicted scores on the EAT, after accounting for the influence of body dissatisfaction. Model 1 tested the effect of body dissatisfaction (BSQ) on disordered eating (EAT) and Model 2 tested the additional effects of both self-focused attention (SFAS) and depression (CES-D) on EAT scores. As shown in Table 5, after accounting for the influence of body dissatisfaction (BSQ), both selffocused attention (SFAS) and depression (CES-D) significantly accounted for variance in disordered eating on the EAT. Because body dissatisfaction remained a significant predictor in Model 2, we can conclude that both self-focused attention and depression partially mediated the relationship between body dissatisfaction and disordered eating in our study.

92 NORTH AMERICAN JOURNAL OF PSYCHOLOGY TABLE 5 Regression Predicting Disordered Eating (EAT) from Body Dissatisfaction (BSQ), Self-Focus (SFAS), & Depression (CES-D) Model 1 Model 2 B SE B β B SE B β BSQ.15.01.67***.12.01.52*** SFAS.14.05.15** CES-D.16.04.21*** ΔR 2.45.07 ΔF 230.78*** 19.52*** Note. Model 1 tests the effect of BSQ on EAT scores and Model 2 tests the additional effect of SFAS and CES-D scores. ** p <.01, *** p <.001 DISCUSSION Our findings support a role for both self-focused attention and depressive symptoms in the relationship between body dissatisfaction and disordered eating. It seems likely that individuals who are dissatisfied with their body shape or size are most vulnerable to developing eating disorder symptoms if they are depressed. While this connection has been established in recent literature (e.g., Juarascio et al., 2011; Stice et al., 2011), in our study we found an additional role to be played by having a higher degree of self-focus. As this was a crosssectional study, it is unclear from our findings whether depression heightens self-focused attention, or if body dissatisfaction, combined with a high dispositional self-focus, increases risk for depression and eating disorder symptoms, as reported by study participants. Longitudinal research is needed to explore these connections. Other limitations of this study include the use of a female only sample, from a non-clinical population. While much research on body image, as it relates to eating disorder symptoms, is initially conducted with female samples, it is ultimately useful to extend such investigations to male participants in order to examine similarities and differences. However, given the dearth of research on self-focused attention as it relates to body dissatisfaction, depression, and disordered eating, we believe the use of a female sample was appropriate. Additionally, while college female populations have relatively high rates of eating disorders and subclinical eating disorder symptoms (Eisenberg, Nicklett, Roeder, & Kirz, 2011), it is possible that the relationship between the variables examined in this study would differ for a clinical sample. Despite these limitations, the identification of variables such as depression and self-focus that may mediate the pathway from body dissatisfaction to eating disorder development is important from prevention and treatment standpoints, particularly given how common body dissatisfaction is among adolescent and young adult females (Field et al., 1999). The identification of individuals at particularly high risk for

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