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The relationship between disordered eating behaviors and coping

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THE RELATIONSHIP BETWEEN
DISORDERED EATING BEHAVIORS AND COPING
by
Deborah Lee Southerland
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
University o f Southern California
In Partial Fulfillment o f the Requirement of the Degree
DOCTOR OF PHILOSOPHY
(Education—Counseling Psychology)
August 1999
© Copyright 1999 Deborah L. Southerland
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UM I Number 9955490
Copyright 1999 by
Southerland, Deborah Lee
All rights reserved.
___ ®
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UNIVERSITY OF SOUTHERN CALIFORNIA
TH E GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES. CALIFORNIA 90007
This dissertation, written by
.............................
under the direction of hex. Dissertation
Committee; and approved by all its members,
has been presented to and accepted by The
Graduate School, in partial fulfillment of re
quirements for the degree of
DOCTOR OF PHILOSOPHY
' D ate l U t f j m .
DISSERTATION COMMITTEE
------
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ii
ACKNOWLEDGEMENTS
I would like to express my deep felt appreciation for my advisor and
mentor. Dr. Joan Rosenberg, who has guided me with her wisdom and support for
many years as I have navigated this journey. Joan has inspired and challenged me.
and happily provided valuable consultation on this dissertation from a distance o f
3.000 miles.
I wish to thank Dr. Mitch Earleywine for maintaining an air o f calm in spite
o f my obsessive E-mail contact with him regarding statistical analysis. His
research knowledge and humorous encouragement were always welcome. Dr. Ruth
Chung was a grounding force in the initiation of this study. Her perspective and
helpful comments provided me with a useful structure from which to proceed.
I wish to thank the eating disorder experts who generously offered their
feedback on early versions o f the Coping and Disordered Eating Test: Dr. Cynthia
Whitehead-LaBoo, Dr. Laurie Mintz, Dr. Erika Schupak-Neuberg, Dr. Lisa
Lilenfeld, and Dr. Anna Tradd. I also thank Dr. Jill Welkley, Kim Newsome, Page
Love, and Karen Macke for aiding my quest to attain research participants, and for
being supportive o f my study.
My fellow interns have been wonderful friends who have kept me laughing
through some difficult times. I thank Maureen Deger and Rani Varghese for their
infectious spirit, Michelle Toma for being there, and Ashley Varner for her
interested and informed review o f m y work.
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I am grateful to my friends Rebekah Smart and Brenda Buttner for their
faith, patience, and love. Special thanks to my brother. Dr. Walter Baker, for
leading the way: to my mother Emilia for her confidence in me: to my father for his
own achievements and respect o f higher education; and to Dee for listening.
My husband Kevin has seen me through two advanced degrees from start to
finish. His love has been constant, his patience great, and his belief in me
unshakeable. 1 thank him for contributing to all aspects o f my life.
Finally, 1 would like to thank the anonymous reviewers who shared their
insight and experience with me. I appreciate all that they added to this dissertation,
and wish them well.
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tv
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS.................................................................................... ii
LIST OF TABLES..................................................................................................vi
LIST OF FIGURES................................................................................................vii
ABSTRACT...........................................................................................................viii
CHAPTER
1 INTRODUCTION.............................................................................. 1
Critique of the Research Literature....................................5
2 LITERATURE REVIEW................................................................ 11
Definitions......................................................................... 1 1
Functions of Disordered Eating Behaviors..................... 17
Affective and Cognitive Experience o f ..........................23
Disordered Eating
Coping Style......................................................................29
Summary of the Literature.............................................. 34
Purpose of Study.............................................................. 36
Research Hypotheses........................................................36
3 METHODOLOGY..........................................................................39
Participants........................................................................39
Procedure...........................................................................41
Measures............................................................................43
Pilot Study.........................................................................51
Statistical Analysis........................................................... 54
4 RESULTS........................................................................................ 55
Preliminary Analyses.......................................................55
Hypothesis 1......................................................................58
Hypothesis 2 ......................................................................58
Hypothesis 3 ......................................................................60
Hypothesis 4 ......................................................................62
Hypothesis 5 ......................................................................65
Hypothesis 6 ......................................................................65
Hypothesis 7 ......................................................................69
Exploratory Question A ...................................................76
Exploratory Question B....................................................78
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5 DISCUSSION..................................................................................82
Hypothesis 1...................................................................... 82
Hypothesis 2...................................................................... 83
Hypothesis 3...................................................................... 84
Hypothesis 4...................................................................... 84
Hypothesis 5...................................................................... 85
Hypothesis 6...................................................................... 85
Hypothesis 7...................................................................... 89
Exploratory Question A ................................................... 96
Exploratory Question B ...................................................99
Other Findings................................................................ 101
Implications for Prevention and Treatm ent.................106
Limitations o f the Study................................................. 108
Recommendations for Future Research....................... 110
Summary..........................................................................I l l
REFERENCES......................................................................................................113
APPENDICES
A INFORMED CONSENT............................................................. 119
B DEMOGRAPHIC QUESTIONNAIRE......................................121
C COPING INVENTORY FOR STRESSFUL............................. 123
SITUATIONS
D QUESTIONNAIRE FOR EATING DISORDER......................125
DIAGNOSES
E COPING AND DISORDERED EATING TEST...................... 129
F CORRELATION MATRIX BETWEEN THE C IS S .............. 136
AND THE CADET
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V I
LIST OF TABLES
Table Page
1 Sample Population...............................................................................40
2 Cronbach' s Alpha of the CADET........................................................ 52
3 DE Frequencies on the CADET Scales............................................... 56
4 Chi-Square of Male and Female DE.................................................... 59
5 Chi-Square of African-American and European-.................................61
American DE
6 Chi-Square of Asian-American and European-....................................61
American DE
7 Racial/Ethnic Group Frequency of DE.................................................63
8 Chi-Square of Female Athlete and Non-Athlete DE..............................64
9 Competitive and Body Conscious Athletes’ Rates of DE......................64
10 Chi-Square of Sorority and Non-Sorority DE....................................... 66
11 T-Test of DE and Asymptomatic on the CISS...................................... 66
12 ANOVA of ED and Symptomatic on the CISS ....................................68
13 T-Test of DE and Asymptomatic on the CADET................................. 71
14 DE and Asymptomatic Means on the CADET......................................72
15 ANOVA of ED, Symptomatic, and Asymptomatic on the....................74
CADET
16 T-Test of ED and Symptomatic on the CADET................................... 74
17 ED and Asymptomatic Means on the CADET..................................... 77
18 Anorexia, Bulimia, and Binge-Eating Disorder Means.........................79
on the CISS
19 Anorexia, Bulimia, and Binge-Eating Disorder Means........................ 81
on the CADET
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LIST OF FIGURES
Figure Page
1 DE and Asymptomatic on CISS Subscales..................................87
2 DE and Asymptomatic on Exercise Subscales of the CADET-90
3 DE and Asymptomatic on Restrict Subscales of the CADET ...91
4......... ED and Symptomatic on CADET Binge.....................................93
5 ED, Symptomatic, and Asymptomatic on CADET Restrict 95
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V III
ABSTRACT
This dissertation describes the development of a new measure o f disordered
eating called the Coping and Disordered Eating Test (CADET), and the subsequent
study in which it was used for the first time. The CADET is a self-assessment test
that identifies coping functions of six disordered eating behaviors: exercise,
dieting, use o f diet pills, use o f laxatives, binge eating, and vomiting. Participants
complete the sections that apply to their behavior, rating each item on a Likert
scale. Responses are classified into four types o f coping, or regulation: Affective,
Cognitive. Interpersonal, and Self. A z-score is then attained for each of these
subscales. The CADET demonstrated good internal reliability reported on the
majority of subscales.
The study sample (N = 307) included female and male participants, drawn
primarily from a university population. Clinical participants from eating disorder
therapy groups were also included. Survey measures included a demographic
questionnaire, a diagnostic measure of eating disorders (Q-EDD; Mintz,
O’Halloran, & Mulholland, 1997), a dispositional coping measure (CISS; Endler &
Parker, 1990), and the CADET.
High rates o f disordered eating were identified in this sample among both
women and men. There were higher than expected rates o f disordered eating in
some of the less represented racial and ethnic groups. Greater rates of disordered
eating were found in competitive and body conscious athletes. No differences in
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ix
disordered eating rates were found between sorority member participants and a
control group o f non-sorority college women.
Coping patterns differed between diagnostic groups. Compared to
participants with no symptoms o f disordered eating, participants with disordered
eating used more Emotion and Distraction coping, but less Social Diversion coping.
Participants with bulimia used more Distraction coping than those with anorexia.
Participants with disordered eating rated coping functions on the CADET higher
than participants with no symptoms of disordered eating. Differences were found
between participants with full versus subthreshold eating disorders, participants
with anorexia versus those with bulimia, and participants with anorexia versus
those with binge-eating disorder on several CADET subscales. Implications for
prevention and treatment and suggestions for future research were provided.
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I
CHAPTER 1: INTRODUCTION
During the past two decades, disordered eating has captured the interest o f
clinicians, researchers, and the lay public. There is serious concern about the
impact o f eating disorders on members o f our society, which is warranted given the
problematic emotional and physical consequences associated with eating disorders
(American Psychiatric Association, 1994). A vast amount of research has been
conducted recently, exploring various related aspects of eating disorders such as
epidemiology, etiology, co-morbidity, and treatment methods. Despite this trend,
there is still much to learn about the role disordered eating plays in peoples’ lives.
Eating disorders affect women at disproportionate rates compared to men;
90% of eating disorders occur among women (American Psychiatric Association,
1994). In the United States and other industrialized countries, adolescent girls and
young women are most likely to develop an eating disorder. Conservative
estimates from the Diagnostic and Statistical Manual o f Mental Disorders (DSM-
IV; American Psychiatric Association, 1994) report that .5% to 1% o f adolescent
and young adult women develop full-blown anorexia nervosa. It is further
estimated that between 1% and 3% of women meet the full criteria for bulimia
nervosa. However, research indicates that eating disorders are frequently
underreported (Martin & Wollitzer, 1988; Szmukler, 1985), so the accuracy o f the
rates reported in the DSM-IV are uncertain.
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Although eating disorders occur in all racial/ethnic groups, and all
socioeconomic classes (Stice, 1994). many studies report a greater incidence of
eating disorders among White European-American women. For example, in a
review of the literature, Dolan (1991) found the incidence of bulimia in European
American women to be 13% to 14%. In the same article. Dolan reported that
bulimia ranged from 6.7% to 13% in Latina and Hispanic women, from 3% to 4%
in African-American women and 2.7% in Asian-American women. When studies
broaden their criteria to examine disordered eating instead of diagnosable eating
disorders, there is evidence of significant eating disturbance among women of
color, including Native Americans (Rosen, Shafer, Dummer, Cross, Deuman, &
Malmberg, 1988; Smith & Krejci, 1991).
Eating disorders that meet full DSM-IV (1994) criteria only affect a small
percentage o f women and a smaller percentage o f men, but less severe eating
problems are more common. In Western society, most women and many men diet
at some point in their lives, a behavior that is often associated with the onset of
eating disorders (Boskind-White & White, 1983). Young college age women are
especially at risk o f developing eating problems. In a sample of undergraduate
college women, Mintz and Betz (1988) found that only 33% exhibited normal
eating patterns. Over 82% o f the sample reported using one or more dieting
behaviors daily, 38% had problems with binge eating, and 33% reported severe
forms of weight control, such as using laxatives or vomiting at least once a month.
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College women who are members o f sororities have been posited to be at greater
risk for eating disturbance than non-sorority college women (Alexander. 1998).
Research data supported this trend when sorority and non-sorority college women
were compared on eating disorder measures. Although the results were not
statistically significant, sorority women reported higher means on the measures
(Alexander, 1998; Schulken, Pinciaro, Sawyer, Jensen, & Hoban, 1997).
Some groups of people, namely those that tend to be body and weight
conscious, are at increased risk for eating problems. Certain athletes fall into this
category, such as gymnasts, figure skaters, runners, and wrestlers (Gamer. Rosen, &
Barry, 1998). A review of the literature indicates that recreational and competitive
bodybuilders have higher than average rates o f eating problems (Goldfield, Harper,
& Blouin, 1998).
Men may experience less disordered eating in general compared to women,
but some men are affected by eating problems to a significant degree. Besides
athletes, other groups of men may be at increased risk of disordered eating. A large
study of men in the Navy found that a significant proportion of them used laxatives,
diuretics, diet pills, vomiting, and fasting during body measurement and fitness
periods (McNulty, 1997). These behaviors were practiced year round by some
Navy men; 40.8% of the sample were diagnosed with eating disorder not otherwise
specified, 6.8% with bulimia, and 2.5% with anorexia. Another group o f men that
have higher than average eating problems is gay men, perhaps because o f the
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4
increased importance of appearance in the gay community (Williamson & Hartley.
1998).
Despite the wealth o f new research, little is actually known about how
eating disorders serve the individuals that engage in them. It is apparent that people
with eating disorders are loathe to give them up (Zerbe, 1993). Often, they have
tried to give them up but were unsuccessful (Abraham & Beumont, 1982), which
suggests that disordered eating behaviors carry certain reinforcing properties. It is
not clear what these reinforcing properties are or how they work. It seems unlikely
that eating disorders are maintained purely out o f a desire to achieve the thin ideal
perpetuated in our culture, although the behaviors involved may have originated as
an attempt to manage or change the body's appearance and weight. As the eating
disorder progresses, it is conceivable that disordered eating behavior may extend
beyond the initial function of achieving thinness; instead disordered eating behavior
may begin to serve more vital coping functions in the emotional and psychological
life o f an individual. Many clinicians and researchers concur. Thompson (1994)
calls eating problems "creative coping mechanisms," Rosenberg (1994) describes
them as "emotional management" disorders, and Zerbe (1993) calls them "coping
strategies." It has been hypothesized that eating disorders are used by the women
and men that suffer from them to deal with a variety o f issues, including painful
feelings (e.g., Hawkins & Clement, 1984; Rorty & Yager, 1996), intrusive thoughts
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(e.g.- Heatherton & Baumeister. 1991)- and the oppression o f racism, sexism,
classism, and homophobia (Thompson, 1994).
Coping strategies must be assessed in order to more fully understand the
context of disordered eating- Until we better understand these coping functions, we
will be limited in our ability to fully and effectively treat eating problems or offer
alternative coping strategies that will meet individuals' needs more adaptively-
identifying these functions is often empowering and helpful to those who suffer
from disordered eating, and is recommended as a primary treatment intervention
(Zerbe. 1993). The existing research makes it difficult to achieve this important
goal because only a limited number of studies have been conducted in this area;
furthermore, the research literature that is available is fraught with numerous
methodological limitations.
Critique of the Research Literature
First, only one published study was found which attempted to elucidate the
underlying coping functions o f disordered eating behavior. Although there are
studies which examine the relationship o f coping skills to disordered eating (e.g.,
Koff & Sangani, 1997; Troop, Holbrey, Trowler, & Treasure, 1994), only one
(Schupak-Neuberg & NemerofF, 1993) describes some ways in which disordered
eating behaviors themselves serve as coping strategies. Schupak-Neuberg and
Nemeroff (1993) constructed two self-report inventories for their study (The
Binging Inventory and The Purging Inventory), since no other appropriate measures
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6
existed. However, both inventories suffer from theoretical and methodological
limitations. The Binging Inventory is based upon the theory that binge eating is an
escape from the self, which as a theory is rather broadly defined and may limit the
potential for significant findings. Additionally, the theory is not comprehensive
enough to explain other potential functions of binge eating. Moreover. The Binging
Inventory has poor psychometric qualities. The second inventory, The Purging
Inventory, measures the emotional regulatory' function of purging, and is more
psvchometrically sound than The Binging Inventory. While The Purging Inventory
shows promise, it only tests one type o f disordered eating behavior.
Second, there are sampling problems. Most studies do not include men at
all. Samples are frequently quite small, so that results cannot be generalized (e.g..
Kaye et al., 1986; Johnson & Larson, 1982). Subjects are usually made up of
college students (e.g., Hansel & Wittrock, 1995) or clinical samples of eating
disordered clients (e.g., Abraham & Beumont, 1982); few actually combine these
different groups in order to gain a broader understanding of disordered eating.
Selecting only clinical samples may be problematic because a significant proportion
of those who suffer from eating disorders do not seek treatment (Pyle, Halvorson,
Neuman, & Mitchell, 1986), and they may be different from those people who do
seek treatment. A broad range of sample subjects representing the entire continuum
of disordered eating (from nondisordered to those with eating disorders) is needed
in order to understand the coping functions o f disordered eating.
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Third, there are methodological problems. While theoretical literature (e.g..
Rorty & Yager. 1996) and case studies (e.g.. Dellaverson. 1997: Zerbe. 1993) are
important, there is a strong need for well designed empirical studies. The research
design itself can be problematic in certain cases. For example, designs involving
naturalistic study have required participants to record their own disordered eating
behaviors, in their own environment, as it occurs. This is not a popular method
among people with disordered eating. Such studies often lose subjects who do not
want to participate in an intensive or detail oriented study, especially when it
centers around recording their food intake subjects (e.g.. Davis. Freeman. &
Solyom. 1985). Sometimes subjects adjust their typical eating patterns or they
simply omit shameful information when they are being recorded (Davis et al.,
1988). One study required subjects to record everything they ate or drank, rate their
moods, and report various other data every hour o f the day for six days (Davis et al.,
1988). This level o f recording requires subjects with an unusually high level o f
dedication and commitment to comply with the demands of this study.
Retrospective studies also have their limitations, given that only the most
salient aspects o f behaviors tend to be reported. Despite this limitation, some
researchers have been able to achieve acceptable reliability with a retrospective
method (e.g., Schupak & Nemeroff, 1993). One challenge researchers must face
regarding reliability is that disordered eating behaviors change over time, and as a
result, the functions o f eating behaviors will also change (Zerbe, 1993). If a
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s
person’ s eating behaviors change with average frequency, a study would not be
expected to demonstrate high reliability. No published literature was found by the
investigator that clarifies this process o f change or tracks the changing functions of
eating behaviors over time.
Fourth, diagnostic problems exist in the research literature. Diagnostic
criteria vary from study to study and are not always standardized to the DSM-IV
(1994); furthermore, the research literature cuts across several versions o f the DSM.
Additionally, research literature tends to define bulimia in such a way that it only
includes the purging type, ignoring the restricting type identified in the DSM-IV
(e.g.. Kaye, Gwirtsman, George, Weiss, & Jimerson, 1986). The purging type of
bulimia cited in the literature (e.g., Davis, Freeman, & Gamer, 1988) usually refers
to vomiting, not laxative abuse or other compensatory behaviors. This narrow
definition of bulimia interferes with our research knowledge about other purging
behaviors besides vomiting, and about restricting bulimia, which may be notably
different from purging bulimia.
Another limitation of the research literature is that it is frequently limited by
theoretical approach. For example, researchers might examine how disordered
eating may provide affective regulation, yet they may ignore how these same
disordered eating behaviors affect cognitive processes. The coping literature is
more likely to be discussed from a cognitive-behavioral perspective (e.g., Hansel &
Wittrock, 1995), while affective regulation is frequently written about from a
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9
psychodynamic viewpoint (e.g.. Dellaverson. 1997). However, both approaches are
necessary to understand the full experience o f disordered eating.
Finally, existing explorations have been too narrow in scope to adequately
explain the processes involved in disordered eating behavior. For example, the
measure o f affect in some studies is quite limited, falling along one vague
dimension o f "worst mood" to "best mood" (e.g., Davis et al.. 1985; Davis et al..
1988). Some studies do not separate out eating behaviors that are expected to have
different functions, like binge eating and purging (e.g., Johnson & Larson. 1982). It
is important that research illuminate the range o f functions that each type of
disordered eating behavior may have. It is unlikely that all people who binge, for
example, do so for the same underlying motive. Thus, research is needed that
identifies the most common coping functions served by restrictive eating, binge
eating, vomiting, excessive exercise, and abuse o f diet pills and laxatives.
In summary, the existing research literature fails to adequately address the
various coping functions that disordered eating behavior may provide. There is
scant, almost nonexistent research in this area. Related areas of research have been
limited by small sample populations, poor research design, and the use of
inconsistent diagnostic criteria. Additionally, studies have been hampered by
investigators who approach research from either a cognitive-behavioral or a
psychodynamic perspective, without considering other theories. Finally, existing
methods o f exploration have been narrow in scope. Thus, well designed research is
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needed, which avoids some o f the limitations that have plagued other studies. In
this way. important information about the functions o f disordered eating behaviors
will be learned about and better integrated into our understanding o f the etiology of
disordered eating.
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II
CHAPTER 2: REVIEW OF THE LITERATURE
Although there is an extremely limited amount of research that explores the
coping functions of disordered eating behaviors directly, related areas o f research
can help provide important background information on the area of study. This
chapter will review the literature, mostly theoretical in nature, winch suggests
possible coping functions o f disordered eating behaviors. Next, related research
literature detailing the affective and cognitive experience o f disordered eating will
be review ed, followed by a summary o f the research literature on situational and
dispositional styles of coping. Before delving into the literature, however,
definitions o f important terms relevant to this study will be provided so that they
are clear and understandable.
Definitions
Eating disorders are composed of specific clusters of symptoms that include
behavioral, cognitive, psychological, and physiological components. The most
commonly known eating disorders are anorexia nervosa and bulimia nervosa. The
DSM-IV (American Psychiatric Association, 1994) also includes the category o f
eating disorder not otherwise specified (EDNOS), which covers the preliminary
category o f binge-eating disorder. Binge-eating disorder has recently begun to
receive more attention from researchers, although little is known about this
disorder. These four eating disorder categories will be defined using the established
criteria from the DSM-IV.
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12
Anorexia nervosa is somewhat o f a misnomer, as it does not involve a loss
of appetite so much as intentional undereating; in anorexia, the appetite is willfully
ignored. According to the DSM-IV, the criteria used to diagnose anorexia nervosa
includes the following symptoms:
A. Refusal to maintain body weight at or above a minimally normal weight
for age and height (e.g., weight loss leading to maintenance o f body weight
less than 85% of that expected; o r failure to make expected weight gain
during period of growth, leading to body weight less than 85% o f that
expected).
B. Intense fear of gaining weight or becoming fat, even though thought to
be underweight.
C. Disturbance in the way in which one's body weight or shape is
experienced, undue influence o f body weight or shape on self-evaluation, or
denial o f the seriousness o f the current low body weight.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three
consecutive menstrual cycles. (A woman is considered to have amenorrhea
if her periods occur only following hormone, e.g., estrogen, administration.)
(p. 544-545)
Anorexia may be one o f two types. In restricting type anorexia, the person
does not engage in binge eating or compensatory behaviors, such as vomiting or
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1 3
using laxatives. In binge-eating/purging type anorexia, the person does engage in
binge eating and/or compensatory behaviors.
Bulimia nervosa is marked by binge eating and subsequent compensatory
behavior intended to counteract the effects o f the binge. The DSM-IV criteria for
bulimia nervosa includes:
A. Recurrent episodes o f binge eating. An episode o f binge eating is
characterized by both o f the following:
1. eating, in a discrete period of time (e.g., within any 2-3 hour
period), an amount o f food that is definitely larger than most people
would eat during a similar period of time and under similar
circumstances
2. a sense o f lack o f control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how much one
is eating)
B. Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives, diuretics,
enemas, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur,
on average, at least twice a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
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14
E. The disturbance does not occur exclusively during episodes o f Anorexia
Nerv osa, (p. 549-550)
Bulimia is specified as purging type or nonpurging type, both o f which are
conceptualized as compensatory behaviors. Purging type bulimia means the person
engages in vomiting or misuses laxatives, enemas, or diuretics. Nonpurging
bulimia excludes the use of vomiting. laxatives, enemas, or diuretics.
Compensatory behavior in nonpurging type bulimia includes fasting, extreme
dieting, or excessive exercise.
The DSM-IV category of eating disorder not otherwise specified (EDNOS)
includes those cases that do not meet the full criteria for either anorexia or bulimia,
but remain problematic and disturbing. The examples of EDNOS specified in the
DSM-IV include:
1. For females, all of the criteria for anorexia nervosa are met except that
the individual has regular menses.
2. All o f the criteria for anorexia nervosa are met except that, despite
significant weight loss, the individual's current weight is in the normal
range.
3. All of the criteria for bulimia nervosa are met except that the binge
eating and inappropriate compensatory mechanisms occur at a frequency of
less than twice a week or for a duration o f less than 3 months.
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15
4. The regular use o f inappropriate compensatory behavior by an individual
o f normal body weight after eating small amounts o f food (e.g.. self-induced
vomiting after the consumption o f two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts
o f food.
6. Binge-eating disorder (see full description below): recurrent episodes o f
binge eating in the absence of the regular use of inappropriate compensatory
behaviors characteristic o f bulimia nervosa, (p. 550)
Binge-eating disorder was included in the DSM-IV as a preliminary
category needing further study. It is similar to bulimia except that compensatory
behaviors are not practiced. The diagnostic criteria for this disorder includes the
definition o f binge eating previously described (see the criteria for bulimia
nervosa), and the following additional symptoms:
B. The binge eating episodes are associated with three (or more) o f the
following:
1. eating much more rapidly than normal
2. eating until feeling uncomfortably full
3. eating large amounts o f food when not feeling physically hungry
4. eating alone because o f being embarrassed by how much one is
eating
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5. feeling disgusted with oneself, depressed, or very guilty after
overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least 2 days a week for 6 months.
E. The binge eating is not associated with the regular use of inappropriate
compensatory behaviors (e.g., purging, fasting, excessive exercise) and does
not occur exclusively during the course o f Anorexia Nervosa or Bulimia
Nervosa- (p. 731)
In this study, eating problems that do not meet the full DSM-IV criteria for
anorexia, bulimia, or binge-eating disorder will be viewed as subthreshold eating
disorders. Subthreshold eating disorders are more broadly conceptualized than the
EDNOS category, as they may include singular diagnostic criteria or combinations
of behaviors. For example, a person of normal weight who has poor body image,
constantly diets, runs five miles daily, and receives bi-monthly colonics (an
intensive type o f enema which washes out the entire colon) is suffering from a
subthreshold eating disorder. This person does not meet the DSM-IV criteria for an
eating disorder, but is still exhibiting pathogenic types o f behaviors.
Subthreshold eating disorders are much more prevalent in our society than
eating disorders that meet full DSM-IV diagnostic criteria, since a large proportion
of cur population, particularly women, manifest varying degrees of eating problems
(Boskind-White & White, 1983). For the purpose o f this dissertation, the term
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17
disordered eating will be used to signify any eating disordered eating behavior,
ranging from subthreshold eating disorders to eating disorders meeting DSM-IV
criteria.
Eating disorders have been conceptualized by Mintz and Betz (1988) as
marking one end o f an eating disorder continuum, while the opposite end is
characterized by a total lack o f eating problems. In between are singular behaviors
used to control weight, such as chronic dieting and laxative abuse. Thus, people
with disordered eating may fall at any point on the continuum, except at the end in
which symptoms are not present at all.
Functions of Disordered Eating Behaviors
There is a widespread belief, evident in the theoretical and research
literature, that disordered eating behaviors serve various adaptive functions for the
individuals who engage in them. This literature will be reviewed here, starting with
the single empirical study previously mentioned. Next, the possible coping
functions of disordered eating behavior in general will be discussed. Finally,
behavior specific coping functions will be identified. A small pool o f relevant
literature will be referenced several times, since there is no other available literature
to draw from.
As mentioned earlier, one published study directly examined the coping
functions of two types o f disordered eating, purging and binge eating. Schupak-
Neuberg and Nemeroff (1993) measured the coping functions o f purging through
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IS
The Purging Inventory, a 23 item self-report instrument. Items are categorized into
four types o f coping functions: alleviation of negative affect, relaxation,
distraction, and expulsion. Alpha levels for the four sections ranged from .72 to
.90. Test-retest reliability for the sections ranged from .59 to .83. Thus, in this
study, the role of purging appears to be successfully described by the four
categories of coping. The second instrument. The Binging Inventory,
conceptualizes binge eating as an escape from the self. Unfortunately. The Binging
Inventory did not fare as well as The Purging Inventory in terms o f reliability; it
demonstrated low internal consistency (alpha = .48) and low test-retest reliability (r
= .53). although the authors were able to improve test-retest reliability by removing
the first item on the scale. This particular measure may be hindered by its narrow
theoretical approach; the lower levels o f reliability may reflect that binge eating is
serving other purposes besides providing an escape from the self.
Most o f the other literature which attempts to define functions of disordered
eating is either theoretical (e.g., Hawkins & Clement, 1984) or based on small case
studies (e.g., Thompson, 1994). The literature tends to categorize coping functions
of disordered eating as either affective regulation or cognitive management. Only a
small amount of literature exists that describes the affective regulation inherent in
disordered eating, and even less literature conceptualizes disordered eating as a
form of cognitive management.
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Many researchers have asserted that disordered eating serves as a
mechanism to regulate painful emotions (e.g.. Hawkins & Clement. 1984: Rorty &
Yager, 1996). Zerbe (1993) describes this as a distancing maneuver to keep
unwanted feelings away. It has been suggested that disordered eating facilitates the
process of denying or numbing one’s feelings (Heatherton & Baumeister. 1991:
Thompson, 1994). Disordered eating may also decrease stress, anger (Thompson,
1994), depression, and anxiety (Hawkins & Clement, 1984; Steinberg, Tobin, &
Johnson. 1990). In some cases, disordered eating may be used to deal with the pain
of loneliness, societal oppression (Thompson, 1994), and trauma (Rorty & Yager,
1996; Thompson, 1996). Depending how it is used, disordered eating can serve the
contradictory experiences o f self-soothing or self-punishm ent (Zerbe, 1993).
A second important function of disordered eating is its capacity to manage
cognition. This may involve mental distraction (Hawkins & Clement, 1984),
avoidance of certain thoughts (Heatherton & Baumeister, 1991), or an illusion of
control (Thompson, 1994). How cognitive processes are affected by disordered
eating is further confounded by the issue o f nutrition. A poor nutritional state,
common among eating disordered individuals, can actually interfere with thinking,
consciousness (Zerbe, 1993) and perception (Schupak-Neuberg & Nemeroff, 1993).
Some coping functions involve both affective and cognitive processes.
Several authors suggest that eating disorders provide an escape from self-awareness
(Heatherton & Baumeister, 1991; Rorty & Yager, 1996; Schupak & Nemeroff,
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20
1993). Heatherton and Baumeister (1991) describe the escape from self-awareness
as a motivated attempt to narrow the focus o f attention to present and immediate
stimuli. This in turn keeps self-awareness at a low level, which prevents focusing
on unpleasant or painful thoughts or feelings. The processes involved in
maintaining the disordered eating behavior, such as obsessional thinking, can
occupy the consciousness and keep unwanted affects or cognitions at bay.
Disordered eating is sometimes compared to self-inflicted injury; in both
types of behavior, there is a willingness to accept harm in exchange for temporary
relief, escape, or tension reduction. This process is believed to involve both
affective and cognitive operations. Attention is focused on immediate sensation,
similar to the cognitive narrowing that occurs during binge eating (Heatherton &
Baumeister, 1991), in an effort to escape or avoid negative affect. A significant
proportion o f people with eating disorders exhibit other self-destructive behaviors,
such as alcohol and other drug problems, self-mutilation, and suicide (Heatherton &
Baumeister, 1991).
A few other functions o f disordered eating behaviors deserve mention.
Rorty and Yager (1996) posit that eating disorders serve an organizing function for
someone prone to disintegration; in other words, eating disorders can provide a
means to focus one's identity and experience. Disordered eating behaviors can also
be used to distance oneself from others when more direct forms o f separation and
individuation are not possible (Thompson, 1994).
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Although similar coping functions may underlie disordered eating behaviors
in general, it is likely that there are unique coping functions operating between
specific types o f disordered eating. Several authors identify particular coping
functions for restrictive eating, binge eating, and compensatory behavior, which are
summarized below. Additional research is needed to clarify how each disordered
eating behavior may work alone or in concert with others to provide the various
desired emotional and/or cognitive effects.
Restrictive eating. There is very little known about the functions of
restrictive eating, dieting, or fasting. A basic function, of course, is to provide the
means to achieve thinness. In addition, it has been suggested that restrictive eating
provides a method o f achieving control, avoiding negative thoughts, and creating
heterosexual female bonding (Thompson, 1994). Zerbe (1993) posits that
restrictive eating makes a person feel more powerful when she or he becomes "the
thinnest" or achieves martyrdom through suffering and self-starvation.
Binge eating. The functions of binge eating identified in the literature are
almost all affective in nature. Binge eating is said to regulate mood and alleviate
emotional distress (Dellaverson, 1997; Heatherton & Beumeister, 1991; Johnson &
Larson, 1982), sedate (Thompson, 1994), deny feelings (Heatherton & Beumeister,
1991), numb feelings (Herman, 1992; Thompson, 1994), and decrease stress and
anxiety (Thompson, 1994). For some people, binge eating may be a way to comfort
the self (Dellaverson, 1997; Hawkins & Clement, 1982). In other cases, binge
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eating may be experienced as a pleasurable loss o f control (Heatherton &
Beumeister, 1991). Finally, binge eating may offer cognitive narrowing, as one’s
immediate experience is focused on the taste and sensation of food (Heatherton &
Beumeister. 1991); this can be an effective method o f managing anxiety or avoiding
uncomfortable thoughts.
Compensatory behaviors. The only compensatory behaviors mentioned in
the literature are excessive exercise and purging, which is confined to vomiting
behavior only. Compensatory behaviors are perceived to be the means to achieve
thinness (Johnson & Larson, 1982; Thompson, 1994). They function as a method
of self cleansing for some people (Thompson, 1994; Schupak-Neuberg &
Nemeroff. 1993). Vomiting is said to provide certain integrative functions
(Herman, 1992; Johnson & Larson, 1982; Steinberg et al., 1990), such as helping a
person return to reality after binge eating (Herman, 1992). Empirical research
shows that purging provides an escape from self-awareness for people with bulimia,
but not for people with binge-eating disorder (Schupak-Neuberg & Nemeroff,
1993), which may be why they do not choose this particular disordered eating
behavior- Affectively, vomiting appears to reduce anger, increase a sense of relief,
and provide an experience o f relaxation (Johnson & Larson, 1982). Exercise is also
believed to offer affective regulation, as it helps some people decrease their anger
and depression, and deal with loss (Zerbe, 1993).
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In summary, disordered eating behaviors are believed to serve a variety of
coping functions, mostly involving affective regulation and cognitive management.
The nature o f these coping functions sometimes varies between specific types o f
disordered eating. Although one empirical study successfully identified and
measured the coping functions o f purging behavior (Schupak-Neuberg & Nemeroff.
1993), little is known about the coping functions o f other types of disordered eating
behavior. Given the scarcity o f research studies available, this area merits more
investigation as there is a strong need to understand the psychological or coping
functions o f disordered eating.
Affective and Cognitive Experience of Disordered Eating
Disordered eating has been postulated to achieve affective and cognitive
regulation for those persons who engage in disordered eating behaviors. These
theories have appealing explanatory qualities, but empirical research has not studied
these directly, with the exception o f Schupak-Neuberg & Nemeroff s (1993)
exploration into the emotional coping functions o f purging. Indirectly, some
studies have attempted to understand the possible coping functions o f disordered
eating by examining the affective and cognitive experiences involved in these
behaviors. However, a review of the research literature offers confusing and
incomplete conclusions. Few studies consider cognitive processes and none
include the subjective experience o f restrictive eating. Most studies examine the
binge-purge cycle o f bulimia, with purging limited to vomiting behavior.
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Experiential data from these studies can be broken down into discrete periods:
before binge eating, during binge eating, after binge eating, during a purge, after a
purge, before non-binge eating (such as a meal or snack), and after non-binge
eating. The affective and cognitive experiences reported in the research literature
will be summarized for each o f these periods in the sections that follow.
Before a binge. Research subjects across studies showed evidence o f
negative affect and cognition before a binge. They also reported a lack of physical
hunger prior to binge eating (Davis, Freeman, & Gamer, 1988; Davis et ai., 1985;
Elmore & de Castro, 1990; Johnson & Larson, 1982; Kaye et ai.. 1986), indicating
that the binge eating that followed was influenced more by their emotional and
cognitive experience than calorie deprivation.
Affectively, subjects reported anxiety before binges (Abraham & Beumont,
1982; Elmore & de Castro, 1990; Kaye et al., 1986; Lingswiler. Crowther. &
Stephens, 1989a). Overall mood was lower (Davis et al., 1988; Davis, Freeman, &
Solyom, 1985; Lingswiler et al., 1989a; Schlundt, Johnson, & Jarrell, 1985;
Steinberg et al., 1990), and there was increased irritability, feelings o f inadequacy,
and weakness (Johnson & Larson, 1982). Cognitive changes were also reported by
subjects prior to binges. Subjects felt a decrease in control (Johnson & Larson,
1982) and reported increased thoughts about food (Lingswiler et al., 1989a).
During a binge. Emotional experience during binge eating episodes was
mixed, with some studies reporting an increase and some studies reporting a
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decrease in negative affect. However, categorizing experiences as negative or
positive is not always appropriate or definite. For example, some people might
experience a decrease in control as negative, but others might find a lack of
inhibition enjoyable.
Binge eating appeared to be relieving for some subjects, as they reported
decreased anxiety (Abraham & Beumont, 1982; Cooper, Morrison. Bigman.
Abramowitz. Levin. & Krener. 1988) and negative moods (Abraham & Beumont,
1982). However, subjects also reported increased feelings o f panic, helplessness
(Cooper et al., 1988), depression (Elmore & de Castro, 1990), guilt, shame, and
anger (Johnson & Larson, 1982). Some subjects felt excited and energized during a
binge (Cooper et ai., 1988), while others felt drowsy and tired (Johnson & Larson,
1982). Subjects with bulimia reported a decrease in self-awareness during binges,
but subjects with binge-eating disorder did not (Schupak-Neuberg & Nemeroff,
1993). Finally, some subjects felt inadequate and less in control during binges
(Johnson & Larson, 1982).
After a binge. Results across studies suggest that subjects experienced
significant negative moods after binges. In one study, 70% of subjects had thoughts
of suicide during this time (Abraham & Beumont, 1982). General mood decreased
(Abraham & Beumont, 1982; Cooper et al., 1988; Davis et al., 1985), and subjects
felt anger, guilt (Cooper et al., 1988; Lingswiler et al., 1989b), shame, stress
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(Lingswiler et al.. 1989b). disgust, decreased security, and decreased energy
(Cooper et al.. 1988).
During a puree. Only one study described how subjects felt during a purge,
although the actual reporting was done immediately after the purge. Johnson &
Larson (1982) found that subjects reported feelings o f guilt, shame, sadness, and
weakness during a purge. Subjects described their level o f anger as being near zero,
which was a significant reduction from the high levels o f anger they reported during
the binge period o f the study. This finding seems to indicate that purging had an
anger reducing effect for these subjects. Furthermore, subjects reported feeling
more alert during the purge, supporting the hypothesis that purging can be
grounding and integrative (e.g., Herman, 1992). If binge eating is a numbing,
almost dissociative experience for some people, then purging may possibly be the
antithesis o f that.
After a puree. The affective and cognitive states o f subjects after purges
were quite diverse in type and quality o f experience, ranging from overtly positive
to negative states. On the positive end o f the continuum, some subjects appeared
giddy and intoxicated after purging (Kaye et al., 1986). Others reported feeling
"better" (Abraham & Beumont, 1982), calmer (Cooper et al., 1988; Steinberg et al.,
1990), relieved (Steinberg et al., 1990), less anxious and depressed (Kaye et al.,
1986; Steinberg et al., 1990), and less panic, guilt, anger, and disgust (Cooper et al.,
1988).
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On the more negative end of the continuum, some subjects reported that
purging made them feel drowsy, weak, bored, inadequate, and less in control
(Johnson & Larson. 1982), while others were observed to be "spaced out" or
dissociated after purging (Kaye et al., 1986). Some subjects described a decrease in
their general mood (Davis et al., 1985), and an increase in depression (Elmore & de
Castro, 1990; Johnson & Larson, 1982: Steinberg et al.. 1990), guilt, shame
(Johnson & Larson, 1982; Lingswiler et al., 1989b), anger, and anxiety (Lingswiler
et al., 1989b). In contrast to these findings, some subjects reported no changes in
their level o f depression or anxiety after a purge (Kaye et al., 1986).
Before a meal or snack. In order to explore experiential differences between
binge eating and non-binge eating, some studies measured the affective and
cognitive states o f subjects before meals and snacks that were not part o f a binge.
Individuals with eating disorders reported significantly fewer negative thoughts and
feelings and more physical hunger at these times compared to binges (Davis et al.,
1985). Moods o f subjects with bulimia were not negative (Davis et al, 1988), and
in some cases, were even slightly positive before meals and snacks (Davis et al.,
1985). However, subjects with bulimia still reported more negative moods than
control subjects before eating (Lingswiler et al., 1989b), and they exhibited
evidence of dichotomous thinking ("all or nothing thinking") in regards to eating
(Lingswiler et al., 1989b).
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After a meal or snack. In general, control subjects reported better moods
after eating than did subjects with bulimia (Davis et al.. 1985: Lingswiler et al..
1989a; Lingswiler et al., 1989b). In contrast to control subjects and subjects with
bulimia, the moods of binge eaters did not change after eating meals or snacks
(Lingswiler et al., 1989b).
In summary, the current research shows that negative affect and cognition
are present before binges and after binges. However, during binges and after purges
there is a wide variety of feelings and thoughts reported among subjects, and this
often occurs within the same study (Abraham & Beumont. 1982; Cooper et al.,
1988; Kaye et al., 1986). For example, individual subjects who completed
measures that assessed a wide range o f experiences frequently reported both
positive and negative experiences as a result o f their disordered eating behavior. In
these instances, the individuals accepted certain emotional consequences in
exchange for other consequences considered more personally disturbing. For
example, if depression increases and anxiety decreases after purging, the overall
effect o f purging might be experienced as worthwhile to a person who has more
difficulty or discomfort dealing with anxiety than depression.
The mixed results in the research literature may be due to differences in the
subjects’ diagnostic categories, coping style, personality type, severity of disordered
eating, or type o f disordered eating behaviors practiced. For example, differences
were found between subjects diagnosed with bulimia and subjects diagnosed with
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29
both bulimia and borderline personality disorder (Steinberg et al.. 1990). and
between subjects with bulimia and subjects who binge eat (Schupak-Neuberg &
Nemeroff. 1993).
Coping Stvle
The ways in which people cope with stressful situations are important to
consider in the context o f disordered eating. In a causal model o f bulimia. Shatford
and Evans (1986) found coping behaviors to be a mediating factor. Thus, if
disordered eating is to be studied in terms o f affective and cognitive regulation,
coping style should also be assessed. While there is empirical literature on the
coping styles of people with eating disorders, no literature was found that also
examined affective and/or cognitive regulation. These areas do not seem to
intersect in the literature.
There are many different definitions of coping in the research literature. A
general definition o f coping describes it as the cognitive and behavioral efforts to
manage environmental and internal stressors impacting an individual (Coyne,
Aldwin, & Lazarus, 1981). Coping research has historically been approached from
two perspectives: the interindividual and the intraindividual. The interindividual
perspective views coping as a dispositional response, meaning that individuals
utilize habitual patterns o f coping strategies across situations. On the other hand,
the intraindividual perspective assumes that people will vary their coping response
according to the situation (Parker & Endler, 1996). This division has sparked much
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debate in the coping literature. Proponents of the intraindividual approach assert
that coping changes to fit the type o f problem or stress involved, so that a measure
of dispositional coping is not possible. There is, however, research that validates
the notion of dispositional coping. For example, at least one dispositional coping
measure has established moderate levels o f test-retest reliability after six weeks
(Endler & Parker. 1990). Furthermore, assessment o f situational coping has its own
problems. Many o f the intraindividual measures request subjects to identify a real
problem they have faced and describe the coping strategies they used to deal with it.
The researcher then assesses and labels the individual's coping style (e.g.. Rilling * ;
& Moos. 1984). Depending on the situational coping measure used, subjects may
be compared to each other on entirely different types o f problems. As a result, such
data may be even less reliable and less generalizable than data gathered from
dispositional coping measures.
Most coping assessment measures have been developed from only one of
these perspectives; dispositional and situational coping are rarely assessed together
in one measure. In actuality, both approaches are valid, and the nature and goals of
the study should determine which approach is used. For example, if a more general
understanding of coping is important, then the interindividual approach would be
used. If a researcher wants to assess how someone copes in response to a particular
event or problem, then the intraindividual approach would be more suitable.
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Another important area in the coping literature involves the kind of model
used to define coping. Various classifications have been suggested to characterize
coping responses. The approach/avoidance model suggests that coping is either an
active effort to deal with stress or an attempt to avoid the stress (Koff & Sangani.
1997). Avoidance o f the stress is sometimes achieved through distraction or social
diversion (Parker & Endler, 1996). The problem/emotion-focused model
differentiates between attempts to solve or manage the stress, and conscious
responses of affect regulation, such as the use o f fantasy (Parker & Endler. 1996).
Several studies have found that emotion-focused coping and avoidance coping
through distraction were positively related to psychological maladjustment, such as
psychiatric symptomatology and health problems (e. g., Endler & Parker, 1990).
However, problem-focused coping and avoidance coping through social diversion
were negatively related to or unrelated to psychological maladjustment (Endler &
Parker, 1990). In general, it has been found that women use more avoidance and
emotion-oriented coping than men (e.g., Endler & Parker, 1990; Shatford, 1986).
The reasons for this are uncertain. Women and men may be socialized to respond
to stress in different ways, or the coping theories and subsequent measures of
coping may be gender-biased.
Avoidance-focused coping. Upon examining the research literature, it is
clear that women with disordered eating (no studies included men) used more
avoidance coping than control subjects. Since many different measures of coping
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were used across studies, exact comparisons between the studies are not possible.
Nevertheless, results are consistent. Higher levels o f disordered eating were
positively related to avoidance coping in college samples (Koff & Sangani. 1997;
Mayhew & Edelmann, 1989). Compared to control groups, people with bulimia
used more avoidant styles o f coping (Neckowitz & Morrison. 1991: Soukup, Beiler.
& Terrell. 1990: Troop, Holbrey, Trowler. & Treasure, 1994). as did women with
anorexia (Soukup et al., 1990; Troop et al., 1994). Women with anorexia also
demonstrated more cognitive avoidance than control subjects (Troop & Treasure,
1997).
Emotion-focused coping. Given the relationship between emotion-focused
coping and psychological distress, it is expected that people with disordered eating
would show a greater proclivity toward this approach. One study clearly found that
higher levels of disordered eating were positively related to emotion-focused coping
(Koff & Sangani, 1997). Due to differences in coping measures, however, fewer
studies explicitly measured emotion-focused coping as opposed to avoidance
coping. For example, Troop et al. (1994) found that women with bulimia used
more wishful thinking, a construct they term avoidance, as compared to control
subjects. Other researchers label wishful thinking as emotion-focused coping
(Endler & Parker, 1990). Another study found that catastrophizing, a kind of
emotion-focused coping, was more prevalent in a sample of binge eaters than
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control subjects (Hansel & Wittrock. 1995). More research is needed to understand
the link between emotion-focused coping and disordered eating.
Problem-focused coping. The results are mixed in regards to the relation of
problem-focused coping, sometimes called task-focused coping, and disordered
eating symptomatology. On one hand, it seems that people with disordered eating
use less problem-focused coping than people without disordered eating. Yager,
Rorty, and Rossotto (1995) found that control subjects and people who had
recovered from bulimia used more kinds o f problem-focused coping (active coping,
planning, and social support) than people who were actively bulimic. Subjects who
had recovered from bulimia also vented emotions more than those who were
actively bulimic; the venting o f emotions appeared to serve an adaptive function,
perhaps substituting for purging. Troop et al. (1994) found that control subjects
used more social support than subjects with bulimia. On the other hand, Hansel
and Wittrock (1995) found that subjects who binged used both more
catastrophizing and "positive" coping, meaning active coping, than control subjects.
This suggests that people who binge eat are trying to cope, but some of their
methods are ineffective; it may also mean that they have more stressors in their
lives. Finally, Mayhew and Edelmann (1989) found that there was no relationship
between problem-focused coping and disordered eating.
Coping differences between disordered eating groups. There is limited
literature in this area, and existing research offers mixed results regarding
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differences between a specific type o f eating disorder and a pattern o f coping.
Troop and Treasure (1997) found that subjects with anorexia used more cognitive
avoidance than those with bulimia, who in turn used more cognitive rum ination
than the group with anorexia. As the authors point out, this is a compelling parallel
with each groups' relationship to food; people with anorexia avoid food while
people with bulimia take in large quantities. In contrast to this finding, Troop et ai.
(1994) found no differences between the coping patterns o f subjects with bulimia
and subjects with anorexia. Furthermore, in this study coping did not predict the
severity of the eating disorder, unlike other studies (Koff & Sangani, 1997;
Mayhew & Edelmann, 1989).
In summary, people with disordered eating appear to be trying to cope with
the stress they experience, but their coping methods are not always successful or
productive over time. They tend to use more avoidance-focused and emotion-
focused coping than people without disordered eating, but it is unclear if people
with disordered eating use less problem-focused coping than people without
disordered eating. It is also uncertain whether coping differences exist between the
diagnostically different types o f disordered eating. More information is needed to
clarify these areas.
Summary of the Literature
The theoretical literature suggests that disordered eating behaviors serve as
coping strategies for the people who use them. Most o f the coping functions of
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disordered eating behaviors in the literature are conceptualized as affective
regulation or cognitive management: some are also seen as a way to reduce tension
or organize the self. Research literature examining the stages o f the binge-purge
cycle has noted changes in mood and cognition during different periods o f the
cycle. Frequently, people felt negative kinds o f emotions (i.e.. anxiety or anger)
prior to binge eating or purging. Thus, perhaps people who engage in disordered
eating behaviors are attempting to reduce or change these negative feelings through
binge eating or purging.
The research literature on coping indicates that people with disordered
eating use more avoidant/distraction focused coping and emotion focused coping.
Disordered eating behaviors may be an extension of a person’s general coping style,
or the person’s coping style may have narrowed or changed once the eating problem
was established. However, there is an insufficient amount of literature that
explores how coping and disordered eating behaviors relate to each other.
In conclusion, the current literature on the coping functions of disordered
eating behaviors is not significantly clarified or strengthened by either the literature
on affective and cognitive regulation, or the literature on general coping style.
There appears to be a multitude of coping functions that each disordered eating
behavior serves. Most o f these coping functions are postulated; empirically, almost
nothing is actually known. Consequently, the effects o f affective and cognitive
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3 6
regulation are presumed to vary, and will not make sense until we first understand
the coping purposes disordered eating behaviors serve.
Purpose o f Studv
The purpose of this study was to explore the relationship between diagnostic
categories o f disordered eating, the coping functions served by disordered eating
behaviors, and general coping style. Given the characteristics o f the study sample,
rates of disordered eating were also compared between different groups (i.e., men
and women). Clinical and nonclinical populations were sampled in order to capture
a broad range o f disordered eating. Because there was not suitable existing
instrumentation to examine the coping functions o f disordered eating behaviors, a
new measure was created for this study, the Coping and Disordered Eating Test
(CADET).
Research Hypotheses
1. Male and Female Rates of Disordered Eating on the Q-EDD
a. Men will report lower frequency o f disordered eating than women.
b. Men will report lower frequency o f eating disorders than women.
2. African-American and European-American Rates o f Disordered Eating on the
Q-EDD
a. African-Americans will report less anorexia and bulimia than European-
Americans.
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b. African-Americans will report less anorexia and bulimia than European-
Americans.
3. Asian-American and European-American Rates o f Disordered Eating on the
Q-EDD
a. Asian-Americans will report less anorexia and bulimia than European-
Americans.
b. Asian-Americans will report similar levels o f subthreshold eating
disorders as European-Americans.
4. Female athletes will report greater frequency o f disordered eating behaviors
than female non-athletes on the Q-EDD.
5. College women in sororities will report greater frequency o f disordered eating
than non-sorority college women on the Q-EDD.
6. Emotion and Distraction Coping on the CISS Among Participants with
Disordered Eating
a. Participants with disordered eating will report greater levels of emotion-
oriented coping and distraction-oriented coping than participants
without symptoms of disordered eating.
b. Participants with eating disorders will report more emotion-oriented and
distraction-oriented coping than participants with subthreshold eating
disorders.
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7. Coping Functions on the CADET Among Participants with Disordered Eating
a. Participants with disordered eating will report more coping functions o f
disordered eating behaviors than participants without symptoms o f
disordered eating.
b. Participants with eating disorders would report higher scores than those
who have subthreshold eating disorders.
8. Exploratory Question A: Do coping functions on the CISS vary according to
eating disorder diagnosis on the Q-EDD?
9. Exploratory Question B: Does type o f coping function on the CADET (i.e..
Affective) vary with eating disorder diagnosis on the Q-EDD?
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CHAPTERS: METHODOLOGY
Participants
Sample. The study sample consisted o f 307 participants. College students
comprised the majority (96.4%) of the sample. Students were recruited from a
medium-sized private university and a large public university, which were both
located in the Southeastern part of the United States. Student participants from the
private university were recruited from sororities and fraternities, physical education
classes, and an eating disorder therapy group. Students from the public university
were psychology students. The students represented every undergraduate class
level: 24.1% were freshman, 28% were sophomores, 24.4% were juniors, and
20.2% were seniors. Other sample participants included members of a community
outpatient eating disorder therapy group called Anorexia Nervosa and Associated
Disorders (ANAD) and Overeaters Anonymous (O.A.), a peer based eating disorder
support group. Table 1 identifies the sources the sample were drawn from and the
number o f participants from each source.
Study participants ranged in age from 17 to 47 years, with an average age of
20.66 years. The majority o f the sample was female (79.5%, n = 244) and
European-American (77.2%, n = 237). African-Americans comprised 9.1% (n =
28) of the sample, 7.2% (n = 22) were Asian-American, 2.3% (n = 7) identified
themselves as Multiracial, 2% (n = 6) were Latino or Latina, 1.6% (n = 5) were
Middle Eastern, and .7% (n = 2) were American-Indian.
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Table 1
Sample Population
Source Frequency Percent
College sorority 189 61.6
College physical education class 62 20.2
College fraternity 32 10.4
College psychology' class 7 2.3
AN AD therapy group 7 2.3
O.A. support group 6 2.0
College eating disorder therapy group 4 1.3
Total 307 100.0
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College athletes from competitive sports and intramural sports comprised
15% of the sample. Athletes were categorized as competitive, meaning they played
on a college team that competed with other universities, or recreational, meaning
they played intramural or club sports. Additionally, athletes were classified as body
conscious (e.g., cheerleading and track and field) or non-body conscious (e.g.,
baseball and basketball), as described by Gamer. Rosen, and Barry (1998). Six of
the athletes (2%) participated in competitive body conscious sports. 15 (4.9%) were
in competitive non-body conscious sports, and 25 (8.1%) were in recreational non-
bodv conscious sports.
Twenty-nine participants comprising 9.4% of the sample had received
treatment for an eating disorder before. O f these, 4.9% (n = 15) reported they were
currently receiving outpatient treatment for an eating disorder. Separating out the
participants from the two therapy groups and the O.A. group, 5.5% o f the remaining
nonclinical group o f participants (n = 16) reported being in treatment before, and
1% (n = 3) were currently in outpatient therapy.
Procedure
Participants from the private university were gathered from four sources:
sororities, fraternities, physical education classes, and an eating disorder group
housed in the campus counseling center. First, permission to conduct the study was
granted by the university’s human investigations committee. The director of the
division o f Greek Life agreed to allow the investigator to gather data from sororities
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and fraternities. The investigator met with sorority and fraternity presidents during
an administrative meeting and explained the purpose of the study. Willing
sororities and fraternities allowed administration o f study questionnaires during
chapter meetings, which ranged in size from 30 to 60 students at a time. A few
sororities requested questionnaire packets with return envelopes so they could be
completed individually, rather than in a group meeting. The physical education
department granted approval o f the study, and questionnaires were administered to
students in several physical education classes during class time. Class sizes ranged
from 10-15 students. Questionnaires were also given to members o f an eating
disorder therapy group after permission was granted by the director of the
counseling center and the group co-facilitators. The investigator explained the
study to the 6 members o f the group, and interested participants (n = 4) completed
the questionnaires.
Participants from the public university were enrolled in introductory
psychology courses, and received credit for their participation. The university’s
human subjects research committee approved the study, and a faculty member of
this university agreed to sponsor the research. Questionnaires were completed in
groups of 3-6 participants at a time.
The leaders o f the ANAD therapy group were contacted about the study;
they polled the group members, who agreed to participate. At the end o f a group
meeting, the investigator administered the questionnaires to interested participants.
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Some completed the study immediately; others returned their packets in self
addressed stamped envelopes that had been provided.
A research assistant to the investigator contacted O.A. members after an
O.A. meeting, and gave them survey packets with self-addressed stamped return
envelopes. The research assistant explained the purpose of the study and expressed
that the anonymity of participants would be maintained.
When the questionnaires were administered to participants in person, certain
protocol was followed. Select information from the informed consent cover page
was read aloud, particularly those sections explaining that participation was
voluntary, anonymous, and could be stopped at any time. The purpose of the study
was stated to be an exploration o f coping style and eating and exercise behaviors.
Measures were given in order from the most general to the most specific, so that the
demographic questionnaire was first, followed by the CISS, then the Q-EDD, and
finally the CADET. Participants were told that the four questionnaires would take
between 10 and 30 minutes to complete. Participants were encouraged to contact
the researcher if they had questions about the study. Student participants were
provided with relevant disordered eating resource information and local referral
sources.
Measures
Demographic Questionnaire. A short demographic questionnaire was
included in the survey packet. Relevant questions were asked about the
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participant’ s age. gender, race/ethnicity. level of education, sorority or fraternity
status, and disordered eating treatment history. Additionally, athletes were asked to
identify their sport and level o f competition (i.e.. intramural or competitive team).
Coping Inventory for Stressful Situations (CISS). The CISS was developed
by Endler and Parker (1990) and measures a person’s typical style o f coping. This
is a 48-item self-report inventory, assessing dispositional coping using a 5 point
Liken scale. The CISS was developed in a rigorous way and has very good
psychometric properties (Schwarzer & Schwarzer, 1990). The authors o f the CISS
have described a 3 factor solution for it. consisting of these coping scales: Task-
oriented. Emotion-oriented, and Avoidance-oriented coping (Endler & Parker,
1990; 1994). Scoring the CISS as instructed in the scoring manual, however,
involves 5 subscales: the 3 factors previously mentioned, a Distraction subscale,
and a Social Diversion subscale, both of which use items culled from the
Avoidance subscale (Endler & Parker, 1990). There is a standardized T-score
calculated for each subscale. Cook and Heppner (1997) found that a 4 factor
solution worked best with their data set, using the Distraction, Social Diversion,
Task, and Emotion subscales.
Women tend to score higher than men on the Emotion, Avoidant,
Distraction, and Social Diversion scales of the CISS, a finding that is common on
other coping measures as well (Endler & Parker, 1990). One study found this
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expected result between male and female undergraduate students, but not between
nonstudent adult men and women (Endler & Parker. 1994).
The CISS has high internal consistency, as demonstrated by alpha
coefficients that range from .76 to .92 in samples o f college undergraduate students
and nonstudent adults (Endler & Parker. 1994). These were the best estimates of
internal consistency in a study which compared three measures o f coping, one of
which was the CISS (Cook & Heppner, 1997). The factor structure for men
compared to women, and undergraduate students compared to nonstudent adults
was almost identical (Endler & Parker, 1994). Concurrent validity was established
in this study by comparing CISS scores to a situational coping measure, in which
retrospective reports of coping responses were identified for particular problems.
Overall, this tactic demonstrated adequate concurrent validity (p = .40-.71). Test-
retest reliability was moderately reliable after a six week period (p = .51-.73).
The CISS has been used in several studies recently, including one
examining the relation o f coping to level of disordered eating and body image
disturbance (Koff &Sangani, 1997). The sample o f this study was a nonclinical
college sample, composed solely of women.
The Questionnaire for Eating Disorder Diagnoses (O-EDD). The Q-EDD is
a diagnostic measure o f disordered eating, developed by Mintz, O'Halloran,
Mulholland, and Schneider (1997). It was based on an earlier instrument called the
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Weight Management Questionnaire (Mintz & Betz. 1988). The Q-EDD was used
to assess and describe categories o f disordered eating among participants. The
Q-EDD is a self-report instrument, based upon the criteria o f the DSM-IV
(American Psychiatric Association, 1994). The Q-EDD differentiates between the
eating disordered diagnostic categories of anorexia nervosa (restricting type and
binge-eating/purging type), bulimia nervosa (purging type and nonpurging type),
and eating disorders not otherwise specified (EDNOS). Four EDNOS categories
are possible, taken from the six mentioned in the DSM-IV: menstruating anorexia,
subthreshold bulimia, non-binge eating bulimia, and binge-eating disorder. The
authors of the Q-EDD actually include menstruating anorexia as a subcategory of
anorexia, and subthreshold bulimia as a subcategory of bulimia in the scoring
manual. All non-eating disordered categories are further differentiated as
asymptomatic (non-eating disordered) or symptomatic (symptoms that do not meet
the full criteria of DSM-IV eating disorders).
The only published research using the Q-EDD is described in Mintz et al.
(1997). Mintz et al. tested the Q-EDD in three separate studies to examine validity
and reliability. Their results demonstrated that the Q-EDD has very good criterion
validity for differentiating between eating disordered and non-eating disordered
subjects, with an accuracy rate o f 98% compared to clinical interview and an
accuracy rate o f 78% compared to clinician judgment alone. The Q-EDD was able
to distinguish between the three main diagnostic categories o f eating disordered,
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symptomatic, and asymptomatic with 90% correspondence compared to clinical
interview and 78% correspondence compared to clinical judgment. Anorexia and
bulimia were differentiated 100% across the three studies.
Mintz et al. (1997) tested convergent validity of the Q-EDD by comparing it
to two established measures. The comparison yielded very high correspondence,
with significance levels ranging from p < .001 to p < .0001. Incremental validity
indicates that the Q-EDD is equal to or more accurate than other established
measures in determining diagnostic categories. Interscorer reliability was 100%
when differentiating between eating disordered and non-eating disordered groups,
and ranged from 98% to 100% when differentiating between eating disordered,
symptomatic, and asymptomatic groups. Test-retest reliabilities were within the
expected range, given that these diagnoses are known to change over time. They
were quite stable over a two week period, with a kappa value of .94 when two
diagnostic categories were used (eating disordered and non-eating disordered) and a
kappa value o f .85 when three diagnostic categories were used (eating disordered,
symptomatic, and asymptomatic).
In exploratory analyses, Mintz et al. (1997) determined that their six eating
disordered diagnostic categories (anorexia, bulimia, and the EDNOS categories of
menstruating anorexia, subthreshold bulimia, binge eating, and non-binge eating
bulimia) were differentiated in two studies with 88% accuracy and 69% accuracy.
In the last study, the 69% accuracy rate was increased to 85% when bulimia and
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subthreshold bulimia were combined, and further increased to 97% when anorexia
and menstruating anorexia were also combined. Overall, the Q-EDD demonstrates
very good psychometric properties, especially when used to distinguish between
eating disordered and non-eating disordered participants.
Coping and Disordered Eating Test (CADET). The CADET was designed
for this study in order to identify how disordered eating behaviors serve the
individuals who practice them. The main theory behind the measure is that
disordered eating functions as a coping strategy to deal with difficult,
uncomfortable, or painful thoughts or feelings.
The CADET is a self-report instrument made up o f 6 scales, each o f which
pertains to a particular kind of eating or exercise behavior. These are: Exercise,
Restrict, Diet Pill, Laxative, Binge, and Vomit. Individuals taking the CADET
complete the sections that relate to their behavior. Each of the 6 scales is divided
into 4 subscales that describe the type of coping involved. The subscale called
Affective Regulation includes items that concern affect or feeling states. For
example, an Affective Regulation item on the Binge scale is “Binge eating helps me
to block feelings.” This item, like many o f the items, appears on more than one
scale, with the wording adjusted to fit the different disordered eating behaviors.
Another subscale is Cognitive Regulation, containing items related to cognitive
processes. An example is “Binge eating helps m e focus my attention on food and
away from my problems.” The Interpersonal Regulation subscale pertains to the
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impact o f disordered eating behaviors on relationships with other people. For
example. “Restricting my food, dieting, and/or fasting helps me to get attention or
caretaking from others." The last subscale is Self Regulation, which is related to
self-esteem, self-perception, and self-states. An example o f a Self Regulation item
on the Exercise scale is “Exercise helps me to feel better about myself." CADET
items are rated on a 9 point Likert scale ranging from “completely untrue" to
“completely true.” When a person completes one of the CADET scales, the 4
individual subscales are scored and converted to z-scores. The CADET takes
between 2 and 10 minutes to complete, depending on the number o f disordered
eating behaviors endorsed by the test taker.
The CADET was developed in several stages. Initially a list of possible
coping functions for each of the behaviors (exercise, restrictive eating, use o f diet
pills, use o f laxatives, binge eating, and vomiting) was constructed based on
theoretical literature, research literature, and the author’s clinical experience with
clients who suffered from eating disorders. This initial list o f coping functions was
sorted into four groups according to the type o f coping, or regulation function, they
were thought to provide. The categories included Affective Regulation, Cognitive
Regulation, Interpersonal Regulation, and Self Regulation. The list was given to
experts in the field o f eating disorders, who provided feedback and suggestions.
The list was also given to a small clinical group o f people (n = 4) currently in
treatment for an eating disorder, who assessed if it fit their personal experience. An
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initial version of the CADET was then constructed utilizing this feedback. This
version was reviewed by people who had recovered from an eating disorder and a
few eating disorder experts for further evaluation, and some adjustments were made
based on this feedback. Content validity o f the CADET was thus established by the
agreement o f the eating disorder experts, people with eating disorders, and people
who had recovered from eating disorders.
A pilot study was then conducted to test the CADET on thirty subjects,
mostly undergraduate and graduate students, who represented a broad range of
eating behaviors. The pilot version o f the CADET included open-ended responses
so that participants could comment directly about the instrument. In this way,
information was gathered about the CADET, and additional adjustments were made
to improve the measure. Some items were altered to be more inclusive of male
participants; for example, questions about menstruation were marked for females
only. A few items were added at the suggestion of participants, such as “Exercise
helps me to test the limits of pain I can tolerate/endure.”
Statistical analysis was used to assess the internal reliability o f the CADET,
and to further refine the instrument. O f the original 125 items, 8 were eliminated in
order to improve the reliability o f the CADET subscales, reducing the test to a total
of 117 items. The items that were not used are marked by an asterisk on the copy
o f the CADET included in the appendix. The other items are labeled to indicate if
they are coded as Affective, Cognitive, Interpersonal, or Self Regulation.
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The CADET demonstrated very good internal reliability on the 6 scales,
with Cronbach's alpha levels ranging from .89 on the Vomit scale to .96 on the
Restrict scale (see Table 2). The 4 Regulation subscales of each scale were tested
together, and alpha levels ranged from .76 (Laxative) to .90 (Vomit). Individual
subscales ranged from .37 (Laxative Interpersonal) to .95 (Laxative Cognitive). Of
the 24 subscales, only 4 had alpha levels below .70; the mean o f the remaining 20
subscales was .82.
Pilot Study
The pilot study was conducted with several purposes in mind. First, the
pilot offered another chance to improve and refine the CADET. Open-ended
questions encouraged participants to comment on the wording and clarity of items,
as well as suggest different coping functions that were not already included on the
CADET. Second, the pilot provided an opportunity to determine the average time
needed to complete the survey packet as a whole, and the amount of time needed to
complete the CADET alone. Third, the internal reliability of the CADET was
explored with pilot data to make sure it was adequately reliable for the main study.
The pilot study consisted o f 30 participants ranging in age from 18 to 34
years, with a mean age o f 22.33. The majority o f the pilot participants were female
(n = 26). Most of the participants were undergraduate students (n = 25); 16 of these
were volunteers from a medium-sized private university in the Southeastern part of
the United States, and 9 o f the participants were volunteers from a large
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Table 2
Cronbach’s Aloha of the CADET
Exercise Restrict Diet Pill Laxative Binge Vomit
Scale Items
.94 .96 .95 .94 .93 .89
No. of items
24 27 14 13 20 19
Subscales (4)
.83 0 0
U \
.83 .76
0 0
oo
.90
Affective
.83 .82 .71 .92
o
0 0
.73
No. of items
6 4 2 2 8 3
Cognitive
.81 .74 .90 .95
0 0
.61
No. of items
■ - »
J 3 2 2 4 2
Self
.86 .92 .91 .88 .75 .74
No. of items
13 13 7 7 6 9
Interpersonal
.84 .78 .48 .37 .63 .72
No. o f items
2 7 3
2 2 5
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public university in the same geographical region. The pilot included 4 graduate
students from different universities across the United States, and 1 working
professional. Most of the participants were European-American (70%. n = 21);
16.67% (n = 5) were Asian-American, 10% (n = 3) were African-American, and
3% (n = 1) identified as Multiracial. Two o f the participants reported that they had
previously received treatment for an eating disorder.
The pilot was tested on participants individually and in small groups
ranging from 3 to 6 people. Information from the informed consent was
highlighted to participants, particularly the sections stating that participation was
voluntary, anonymous, and could be stopped at any time. Participants were
encouraged to contact the researcher if they had questions about the study. Student
participants were provided with disordered eating resource and referral information.
The measures were presented in the following order: demographic questionnaire,
CISS, Q-EDD, and CADET. Participants spent between 10 and 30 minutes
completing the measures. The CADET itself took between 2 and 10 minutes to
complete, depending on the number o f disordered eating behaviors endorsed by the
test taker.
Diagnostically, 30% (n = 9) o f the pilot participants had disordered eating
according to the Q-EDD (Mintz et al., 1997). Of these, 6.7% (n = 2) met the
criteria for an eating disorder (bulimia), while 23% (n = 7) o f the participants were
symptomatic (diagnosed with subthreshold eating disorder symptoms). All of the
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male participants were asymptomatic (no disordered eating symptoms). Both
participants with an eating disorder were European-American, but the symptomatic
group contained one African-American and one Asian-American.
In the pilot study, internal consistency o f the CADET was tested using
Cronbach's alpha and determined to be suitable for further testing in the main study.
The internal reliability o f all the items on the pilot version o f the CADET was high,
alpha >.90.
Statistical Analysis
In the study, intercorrelations of the CISS and the CADET were calculated
within a correlation matrix. Internal reliability o f the CADET was tested with
Cronbach’s alpha; alpha levels were calculated for the scales, related subscales, and
individual subscales. Chi-square tests were used to compare differences between
groups according to gender, race/ethnicity, athlete status, and sorority status on the
Q-EDD. T-tests compared asymptomatic participants to participants with
disordered eating on the CISS and the CADET. Analysis o f variance (ANOVA)
compared participants from different diagnostic groups on the CISS and the
CADET.
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CHAPTER 4: RESULTS
Preliminary Analyses
As measured by the Q-EDD (Mintz et al., 1997). the sample (N = 307)
represented a diverse group diagnostically, ranging from those who were
asymptomatic to those with eating disorders. O f the sample, 34.2% (n = 105)
reported symptoms o f disordered eating. Eating disorders that met the full criteria
of the DSM-IV (American Psychiatric Association, 1994) were found in 19 (6.2%)
participants. In this study, menstruating anorexia and subthreshold bulimia were
not included in the eating disordered group although the authors o f the Q-EDD had
organized them under the labels of anorexia and bulimia respectively; the full
DSM-IV criteria for eating disorders were used instead. Five participants (1.6%)
were diagnosed with anorexia, 7 (2.3%) with bulimia, and 7 (2.3%) with EDNOS, 6
(2%) of whom were identified with binge-eating disorder. The remaining 86 (28%)
of these participants were diagnosed as symptomatic. The majority of the sample
was asymptomatic (n = 202).
Given the structure o f the CADET, varying numbers o f participants
endorsed each scale. The Restrict scale had the highest number of participant
responders (n = 90), and the Laxative scale had the lowest number (n = 8). The
frequencies o f these scales according to disordered eating classification are listed in
Table 3. The frequency o f any disordered eating symptoms (DE; noted in
parentheses) is the sum o f the eating disorder (ED) frequencies and symptomatic
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Table 3
DE Frequencies on the CADET Scales
Scale Any DE ED Sympt. Asympt. Total
Exercise (33) 2 31 42 75
Restrict
(61) 11 50 29 90
Diet Pill
(9) 0 9 0 9
Laxative
(8)
1 7 0 8
Binge (54) 15 39 0 54
Vomit
(11)
3 8 0 11
Total (176) 32 144 71 247
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(Sympt.) frequencies. Asymptomatic (Asympt.) participants are those who have no
disordered eating symptoms.
A correlation matrix between the CISS subscales and the CADET subscales
(see Appendix F) revealed that many CADET subscales were significantly
correlated with the Emotion subscale o f the CISS. This finding relates to
Hypothesis 6, which predicts participants with disordered eating will report more
emotion-oriented coping than asymptomatic participants. The significant
correlations show' that disordered eating behaviors are correlated with emotion-
focused coping.
There were significant negative correlations between the Avoidant subscale
on the CISS and all of the Restrict and Diet Pill subscales on the CADET. Perhaps
people who restrict their food and/or use diet pills are practicing a more active form
of coping, as opposed to Avoidant coping.
Most o f the CADET subscales correlated with each other within each of the
6 scales. For example, Exercise Affective, Exercise Cognitive, Exercise
Interpersonal, and Exercise Self correlated significantly with each other. This
finding is expected, since the subscales are all related to the same behavior, i.e.,
exercise. Several o f the subscales were significantly correlated between different
behaviors. There was an especially high correlation between the Exercise and the
Restrict subscales, which makes sense since they are behaviors that often occur in
concert with each other. A moderately high correlation also exists between the
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Binge and Vomit subscales, which is not surprising since these behaviors may
occur together in the form o f bulimic type behavior.
Hypothesis 1
The first hypothesis, that men would report lower levels o f disordered eating
and eating disorders than women, was tested with a chi-square analysis using
diagnostic information from the Q-EDD. The frequency of men who had
disordered eating was compared to the frequency of women who had disordered
eating. As shown in Table 4, the chi-square (1, N = 307) = 3.804, p = .051 is very
close to significant, which lends mild support to the hypothesis.
Although the small number o f eating disorder diagnoses precluded
statistical significance testing of male and female differences, frequency data shows
that only 1 male participant met eating disorder diagnostic criteria on the Q-EDD,
compared to 17 female participants. The male eating disorder diagnosis was
exercise bulimia, which is subsumed under the bulimia category. Among the
female participants, 5 were diagnosed with anorexia, 6 with bulimia, and 6 with
binge-eating disorder, according to the Q-EDD.
Hypothesis 2
The second hypothesis predicted that African-Americans would report less
anorexia and bulimia than European-Americans, but similar levels of subthreshold
symptoms; it was partially supported, hi support of the first part of the hypothesis,
no cases o f anorexia or bulimia were reported by African-Americans. All but one
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Table 4
Chi-Square o f Male and Female DE
DE Asympt. Total
Male 15 48 63
Female 90 154 244
Total 105 202 307
Chi-Square = 3.804, £ = .051. Phi = .111.
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of the eating disorder diagnoses were found in the European-American sample:
there was one Middle Eastern identified participant with eating disorder.
To test the second part o f the hypothesis, chi-square tests were used to
compare the frequencies o f symptomatic responders. These results are displayed in
Table 5. The chi-square (1, N = 265) = 3.772, p = .052 comparing African-
American and European-American frequency o f disordered eating was very close to
significant, meaning that statistically, the frequency rates of disordered eating
among African-American and European-American participants were similar, but
just barely. Thus, this analysis only lends mild support for the second part o f
Hypothesis 2.
Hypothesis 3
As predicted, Asian-Americans had lower rates of eating disorders than
European-Americans; no eating disorders were actually reported among Asian-
Americans; thus supporting the first part o f Hypothesis 3. When Asian-Americans
and European-Americans were compared on disordered eating through a chi-square,
they showed similar rates o f disordered eating (1, N = 259) = .175, = .676), which
confirms the expected results o f the hypothesis. These results are shown in Table 6.
Thus, Asian-Americans and European-Americans in this sample have similar rates
o f disordered eating overall, but no Asian-Americans met the full criteria for an
eating disorder.
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61
Table 5
Chi-Square of African-American and European-American DE
DE Asympt. Total
African-Am 5 23 28
Euro-Am 86 151 237
Total 91 174 265
Chi-Square = 3.772, e = -052. Phi = -.119.
Table 6
Chi-Square of Asian-American and European-American DE
DE Asympt. Total
Asian-Am 7 15 22
Euro-Am 86 151 237
Total 93 166 259
Chi-Square = .175, e = .676. Phi = -.026.
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62
Unfortunately, there were not enough participants o f other racial/ethnic
groups to provide meaningful analyses o f frequency rates. The reported frequency
rates for all the racial/ethnic groups are included in Table 7. Some racial/ethnic
groups, although quite small in number, have disproportionately high disordered
eating rates, such as the Latino/a group; 50% (n = 3) of the Latino/a participants
were diagnosed with disordered eating. In contrast, 36% (n = 86) o f the European-
American group were diagnosed with disordered eating.
Hypothesis 4
It was predicted in the fourth hypothesis that female athletes would have
greater frequency of disordered eating than female non-athletes. Although a
significant result was found between female athletes and non-athletes on the
chi-square test (1, N = 244) = 4.688, < .05), it was in the opposite direction
predicted by the hypothesis. As seen in Table 8, female non-athletes had
significantly greater rates o f disordered eating compared to female athletes.
Among the female athletes with disordered eating symptoms, only one fit
the criteria for an eating disorder (bulimia) according to the Q-EDD. The athlete
given the eating disorder diagnosis was categorized as a competitive and body
conscious athlete, based on the criteria previously identified. This discovery
prompted a post hoc exploration o f how competitive (Comp) and body conscious
(BC) athletes compared to recreational and non-body conscious athletes. As shown
in Table 9, competitive, body conscious athletes had the highest rates o f disordered
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Table 7
Racial/Ethnic Group Frequency o f disordered eating
DE Asympt. Total
Afncan-Am 5 23 28
Am-Indian 0 2 2
Asian-Am 7 15 22
Euro-Am 86 151 237
Latino/a
- *
J J 6
Mid-Eastern 2 3 5
Multi-Racial
2
5 7
Total 105 202 307
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Table 8
Chi-Square o f Female Athlete and Non-Athlete DE
DE Asympt. Total
Athlete 6 25 31
Non-Athlete 84 129 213
Total 90 154 244
Chi-Square = 4.688. e = .030. Phi = -.139.
Table 9
Competitive and Bodv Conscious Athletes’ Rates of DE
Athlete Type DE Asympt. Total DE Ratio
Comp, BC 2 3 5 .40
Comp, Non-BC 2 9 11 .22
Non-Comp, Non-BC 2 13 15 .15
Total 6 25 31
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65
eating among the three groups. Non-competitive, non-bodv conscious athletes had
the lowest rates of disordered eating.
Hypothesis 5
Hypothesis 5 predicted that college women in sororities would report
greater frequency o f disordered eating than non-sorority college women. The
hypothesis was tested using a comparison group o f female college students in
physical education classes who were not members of sororities to contrast with the
sorority sample. A chi-square test established that the frequency o f sorority
disordered eating occurred at the approximate rate as non-sorority disordered eating
(1, N = 251) = 1.628, g = .202), invalidating the hypothesis. Results displayed in
Table 10.
Hypothesis 6
The sixth hypothesis has two parts. First, it was predicted that participants
with disordered eating would report higher levels of Emotion based coping and
Distraction based coping on the CISS (Endler & Parker, 1990) than asymptomatic
participants. A t-test was used to compare differences between these two groups,
and the significant results are shown in Table 11. The results validated the
hypothesis. Those with disordered eating reported significantly more (j) < .000)
Emotion coping (M = 56.57, SD = 9.25, SE = .90) than the asymptomatic group (M
= 49.54, SD = 10.16, SE = .71). Also as predicted, the disordered eating group
reported significantly more (p < .01) Distraction coping (M = 55.82, SD = 10.82,
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Table 10
Chi-Square o f Sororitv and Non-Sorority DE
DE Asympt. Total
Sorority 62 127 189
Non-Sororitv 15 47 62
Total 77 174 251
Chi-Square = 1.628, £ = .202. Phi = .081.
Table 11
T-Test o f DE and Asymptomatic on the CISS
Source df t
Emotion 305 5.923***
Distract 305 2.642**
Soc Div 305 -3.131**
* * _ £ < . 01. * * * £ < . 001.
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67
SE = 1.06) than the asymptomatic group (M = 52.63. SD = 9.61. SE = .68).
Additionally, an unexpected significant difference (p < -01) was found between the
disordered eating and asymptomatic groups on Social Diversion coping, with the
asymptomatic group showing greater amounts (M = 55.01, SD = 8.97, SE = .63) of
this coping style than the disordered eating group (M = 51.57, SD = 9.44, SE = .92).
The second part o f the sixth hypothesis predicted that participants with
eating disorders would report more Emotion and Distraction coping than
symptomatic participants. To test the hypothesis, an ANOVA was used to compare
the eating disordered, symptomatic, and asymptomatic groups on the CISS
subscales. Results were significant on two subscales. Emotion and Social
Distraction (see Table 12).
Tests o f homogeneity o f variance revealed that the Distraction subscale
suffered from heteroscedasticity, and thus a stricter criterion level (p < .025) was
used to establish significance for this test instead o f the standard cutoff value (p <
.05). As a result, Distraction was not significant, although it came close to being
statistically significant, F (2, 304) = 3.678, p = .026.
On Emotion coping, participants with eating disorders had greater means
(M = 60.39, SD = 8.80, SE = 2.07) than symptomatic participants (M = 55.78, SD =
9.20, SE = .99.), who in turn had greater means than the asymptomatic participants
(M = 49.54, SD = 10.16, SE = .71). These results appear to strengthen the
hypothesis. However, post hoc analyses using the Tukey Honestly Significant
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Table 12
ANOVA o f ED and Symptomatic on the CISS
Source d f F
Emotion
Between Grps 2 19.315***
Within Grps 304
Total 306
Soc Div
Between Grps 2 5.216**
Within Grps 304
Total 306
* * , £ < - 01. * * * £ < - 001.
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69
Difference (HSD) test revealed statistically significant differences between the
asymptomatic and eating disordered group (2 < .000). and between the
asymptomatic and symptomatic groups (2 < .000). but not between the eating
disordered and symptomatic groups.
Although the ANOVA did not reveal significant differences between
diagnostic groups on the Distraction subscale, descriptive statistics show a trend
that supports the hypothesis. The means o f Distraction coping on the CISS were
highest for those with eating disorders (M = 57.17, SD = 8.62, SE = 2.03), second
highest for symptomatics (M = 55.54. SD = 11.25, SE = 1.21), and lowest for
asymptomatics (M = 52.63, SD = 9.61, SE = .68).
Thus, while it was found that participants with eating disorders reported
more Emotion and Distraction coping than asymptomatic participants, these
differences were not statistically significant. An unexpected difference was found
on Social Diversion coping in post hoc analysis using the HSD between
asymptomatic participants and symptomatic participants (2 < -05). However, no
statistical differences were found between the asymptomatic and eating disordered
groups, or between the eating disordered and symptomatic groups on the Social
Diversion subscale.
Hypothesis 7
Hypothesis 7 has two parts. The first part predicted that participants with
disordered eating would report greater coping functions o f their disordered eating
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70
behaviors on the CADET subscales compared to asvmptomatics. Given the nature
of the CADET, only two scales were endorsed by asymptomatics. The Exercise
and Restrictive eating scales o f the CADET both include a normative group of
asymptomatics. which the Diet Pill, Laxative. Binge, and Vomit scales do not. As a
result, a t-test was conducted using the Exercise and Restrict subscales only,
consisting o f 4 subscales each. As Table 13 indicates, the significance level for
each of the 8 subscales was quite high, ranging from £ < .000 to £ < .05,
demonstrating significant differences between disordered eating and asymptomatic
participants.
Upon examination o f the means of the two groups on the subscales, it
becomes clear that the highest mean on each o f the eight subscales is represented by
the disordered eating group, thus strongly validating the hypothesis (see Table 14).
The CADET subscales are measured in z-scores; the mean o f the disordered eating
group is positive and the mean of the asymptomatic group is negative on each of the
subscales, which accentuates the clear difference between these two groups.
The second part o f the Hypothesis 7 predicted that participants with eating
disorders would report higher scores on the CADET than symptomatic
participants. The only CADET scale that did not include at least one person in both
the eating disorder and symptomatic categories was the Diet Pill scale; thus, it was
not used in any o f these analyses. Some o f the other scales were limited by small
group sizes. For example, o f the 8 participants who reported laxative use, only 1
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Table 13
T-Test o f DE and Asymptomatic on the CADET
Source df t
Exercise Affect 73 2.643*
Cog 54.94 4.540***
Inter 73 2.898**
Self 47.64 3.572**
Restrict Affect 78.894 5.828***
Cog 86.281 7.226***
Inter 87.734 6.802***
Self 87.975 7.111***
*_£ < .05. **,£<.01. ***£<.001.
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Table 14
DE and Asymptomatic Means on the CADET
Source M SD SE
Exercise Affect DE .331 1.106 .193
Asympt. -.260 .832 .128
Cog DE .543 1.043 .182
Asympt. -.427 .729 .113
Inter DE .356 1.029 .179
Asympt. -.283 .889 .137
Self DE .456 1.171 .204
Asympt. -.358 .660 .102
Restrict Affect DE .325 .979 .125
Asympt. -.683 .643 .119
Cog DE .367 .965 .124
Asympt. -.771 .525 .098
Inter DE .345 .996 .128
Asympt. -.726 .497 .092
Self DE .354 .991 .127
Asympt. -.745 .475 .083
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73
was diagnosed with an eating disorder. As a result of such small sample sizes,
analyses of the scales were approached with caution. The scales with adequate
numbers of participants for analysis were Restrict and Binge; the other scales will
be discussed in terms of their descriptive scores.
The eating disordered, symptomatic, and asymptomatic groups were
compared on the Restrict subscales with an ANOVA test. Tests o f homogeneity of
variance on the subscales revealed that all o f the Restrict subscales suffered from
heteroscedasticity, and thus a stricter criterion level (p < .025), was used to
establish significance for these tests instead o f the standard cutoff value (p < .05).
In these instances the Dunnett T3 post hoc was used in lieu of the HSD, because
Dunnett T3 does not assume homogeneity o f variance. The Dunnett T3 was
adjusted to the stricter criterion o f p < .025 as well.
Table 15 displays the Restrict subscales that demonstrated statistically
significant differences between the eating disordered, symptomatic, and
asymptomatic groups. All had very high significance (p < .000).
Only the eating disordered and symptomatic groups were compared on the
Binge subscales, because participants could not endorse binge eating without being
categorized as either symptomatic or eating disordered. A t - t e s t indicated that three
out of the four Binge subscales were significant: Affective (p < .05), Cognitive (p
< .000), and Self (p < .01). These results are displayed in Table 16.
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Table 15
ANOVA o f ED. Symptomatic, and Asymptomatic on the CADET
Source df F
Restrict Affect Between Grps 2 21.425***
Within Grps 87
Total 89
Cog Between Grps 2 26.412***
Within Grps 87
Total 89
Inter Between Grps 2 19.963***
Within Grps 87
Total 89
Self Between Grps 2 21.945***
Within Grps 87
Total 89
* * * £ < . 001.
Table 16
T-Test o f ED and Symptomatic on the CADET
Source df t
Binge Affect 52 2.451*
Cog 36.04 3.852***
Self 52 3.095**
*£<.05. **g<.01. ***£<.001.
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75
Post hoc analyses of the Restrict subscales show mixed support for the
hypothesis. H alf were able to successfully distinguish between eating disordered
and symptomatic groups. For instance, on Restrict Affective, significant
differences were found between eating disordered and symptomatic participants (p
< .01), asymptomatic and eating disordered participants (p < .000), and
asymptomatic and symptomatic participants (p < .000). On Restrict Cognitive, the
same differences emerged. Significance was noted between eating disordered and
symptomatic participants (p < .01), asymptomatic and eating disordered participants
(p < .000), and asymptomatic and symptomatic participants (p < .000).
On the other hand, post hoc analysis o f Restrict Interpersonal and Restrict
Self did not provide additional support for the hypothesis. On Restrict
Interpersonal, eating disordered and symptomatic groups were not significantly
different from each other, but asymptomatic and eating disordered groups were (p <
.000), as were asymptomatic and symptomatic groups (p < .000). Post hoc results
on Restrict Self showed no significant difference between eating disordered
participants and symptomatic participants, but statistical significance was found
between asymptomatic and eating disordered participants (p < .01), and between
asymptomatic and symptomatic participants (p < .000).
The descriptive statistics appear to offer support for the second part o f
Hypothesis 7. The means o f all Restrict and Binge subscales reveal that the eating
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76
disordered group had the highest mean, followed by the symptomatic group. The
descriptive statistics of the Restrict and Binge subscales are reported in Table 17.
In summary, participants with eating disorders tended to have higher means
on the CADET Restrict and Binge subscales compared to symptomatic participants,
with significant differences found on 5 of the 8 subscales. Thus, Hypothesis 7
received moderate support overall.
Exploratory Question A
The final research questions o f this study are exploratory in nature and
meant to identify patterns of coping among the different eating disorder diagnostic
categories. There is no published literature that addresses this subject. Exploratory
Question A is: Do coping styles on the CISS vary according to eating disorder
diagnosis on the Q-EDD?
An ANOVA was run comparing the scores o f three diagnostic groups:
anorexia, bulimia, and binge eating disorder. A significant difference, E(2, 15) =
4.364, p < .05 was found on the Distraction subscale. Post hoc results indicate that
there was a significant difference between the anorexic and bulimic groups on
Distraction (p < .05), but there were no statistical differences between the anorexic
and binge-eating disordered groups, or the bulimic and binge-eating disordered
groups. An examination of the score means on the Distraction scale reveal that
bulimic participants have the highest mean (M = 62.43, SD = 6.13, SE = 2.32),
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77
Table 17
ED and Asymptomatic Means on the CADET
Source M SD SE
Restrict Affect ED 1.161 .738 .223
Sympt. .141 .933 .132
Asympt. -.683 .643 .119
Cog ED 1.148 .707 .213
Sympt. .195 .933 .132
Asympt. -.771 .525 .098
Inter ED .983 1.001 .302
Sympt. .205 .948 .134
Asympt. -.726 .497 .092
Self ED 1.029 1.071 .323
Sympt. .206 .919 .130
Asympt. -.745 .475 .088
Binge Affect ED .514 .912 .236
Sympt. -.198 .971 .156
Cog ED .666 .696 .180
Sympt. -.256 .987 .158
Inter ED .490 1.195 .309
Sympt. -.188 .859 .138
Self ED .630 .941 .243
Sympt. -.242 .923 .148
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78
followed by participants with binge-eating disorder (M = 57.17. SD = 6.01. SE =
2.46). and lastly by participants with anorexia (M = 49.80, SD = 9.91. SE = 4.43).
Although there was not statistical significance on the other CISS subscales,
the descriptive scores provide information about how the eating disordered groups
cope in general. These are listed in Table 18. Like the pattern found on the
Distraction subscale, the bulimic group had the highest means on Emotion and
Avoidance, followed by the binge-eating disordered group and the anorexic group
respectively. On Social Diversion, the pattern was different; the binge-eating
disordered group had the highest mean, then bulimics, followed lastly by anorexics.
The Task subscale showed a different pattern entirely; here the anorexic group had
the highest mean, followed by the binge-eating disordered group, and finally the
bulimic group. It is noted that the Task mean of the anorexic group is even higher
the Task mean o f asymptomatic participants (M = 50.09, SD = 10.32, SE = .73).
Exploratory Question B
Exploratory Question B is: Does type o f coping function on the CADET
(i.e., Affective) vary with eating disorder diagnosis? Given that the number o f full
eating disorder diagnoses in this sample is small, although representative of the
prevalence rate o f eating disorders in the population, it is not possible to run
statistical analyses in all cases. Thus, frequency data will also be used to explore
this research question.
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79
Table 18
Anorexia. Bulimia, and Binge-Eating Disorder Means on the CISS
Source M SD SE
Task Anorexia 57.80 11.34 5.07
Bulimia 45.71 17.93 6.78
BED 46.83 15.57 6.36
Emotion Anorexia 56.60 12.82 5.73
Bulimia 63.14 7.49 2.83
BED 60.33 6.28 2.56
Avoid Anorexia 49.80 9.31 4.16
Bulimia 57.86 10.73 4.06
BED 55.67 6.71 2.74
Distract Anorexia 49.80 9.91 4.43
Bulimia 62.43 6.13 2.32
BED 57.17 6.01 2.46
Soc Div Anorexia 48.00 5.79 2.59
Bulimia 49.57 14.89 5.63
BED 52.17 6.79 2.77
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80
Eating disorder diagnoses were compared on CADET subscales using
ANOVA. Given the behaviors composing these disorders, only three are applicable
to explore that are inclusive o f the three different diagnostic groups. These are the
Exercise, Restrict, and Binge scales. However, since there were only two
participants with eating disorders who reported exercising five or more hours per
week, the Exercise scale was not used in this part of the analysis.
The ANOVA yielded only one subscale with significant differences
between diagnostic groups, Restrict Self F (2, 8) = 7.181, |) < .05. A post hoc test
showed significant differences between the anorexic and bulimic groups (g < .05),
and the anorexic and binge-eating disordered groups ft) = .05). No statistical
difference was found between the bulimic and binge-eating disordered groups. The
anorexic group had the highest mean on the Restrict Self subscale (M = 2.066, SD
= .591, SE = .296), followed by the bulimic group (M = .621, SD = .867, SE =
.388), and finally the binge-eating group (M = .028, SD = .221, SE = .157).
By examining the means o f the Restrict and Binge subscales, a clear pattern
emerges. In all cases, the anorexic group reported the highest mean, which was
greater than the mean of the bulimic group, which in turn was greater than the mean
of the binge-eating disordered group. These descriptive statistics are provided in
Table 19.
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81
Table 19
Anorexia. Bulimia, and Bince-Eating Disorder Means on the CADET
Source M SD SE
Restrict Affect Anorexia
Bulimia
BED
1.466
1.159
.557
.619
.885
.241
.310
.396
.171
Cog Anorexia
Bulimia
BED
1.663
1.070
.316
.516
.592
.571
.258
.265
.404
Inter Anorexia
Bulimia
BED
1.656
.873
-.096
.867
.933
.280
.433
.417
.198
Self Anorexia
Bulimia
BED
2.066
.621
-.028
.591
.867
.222
.296
.388
.157
Binge Affect Anorexia
Bulimia
BED
1.517
.477
.222
.323
.992
.789
.229
.375
.322
Cog Anorexia
Bulimia
BED
1.391
.564
.543
.282
.743
.661
.200
.281
.270
Inter Anorexia
Bulimia
BED
1.283
.502
.211
.152
.1.337
1.227
.107
.505
.501
Self Anorexia
Bulimia
BED
1.072
.646
.464
.314
1.1642
.848
.222
.440
.346
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82
CHAPTERS: DISCUSSION
In this chapter, the findings o f the study will be summarized, and the
meaning and significance of the study will be discussed, beginning with the
hypotheses. Next, other significant findings will be noted, followed by the
implications for prevention and treatment. The limitations o f the study will be
identified, and recommendations for future research will be suggested.
Hypothesis 1
The results mildly support Hypothesis 1, as the chi-square test comes very
close to showing a significant difference between male and female participants on
disordered eating. Only 1 o f the 18 participants with an eating disorder was male.
This result is expected, as epidemiological data confirms that women have much
greater frequency rates o f disordered eating and eating disorders than men
(American Psychiatric Association, 1994; Pyle et al., 1986). Perhaps if larger cell
sizes were available in this analysis, a greater significant difference between males
and females would have been found.
A surprising finding was that 24% of the men surveyed were diagnosed as
symptomatic on the Q-EDD (Mintz et al., 1997). This finding, coupled with the
recently identified high rates of disordered eating among certain subgroups of men
(e.g., McNulty, 1997), suggests that men may experiencing more pathogenic eating
than expected. More research is needed to establish accurate prevalence rates of
disordered eating among men. Furthermore, men may be utilizing different coping
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83
functions of their disordered eating behaviors compared to women; this is an area
that warrants further research.
Hypothesis 2
European-Americans were diagnosed with eating disorders with more
frequency than African-Americans, none of whom were actually diagnosed with an
eating disorder. These results strongly support the first part o f Hypothesis 2, in
which it was predicted that European-American participants would report more
anorexia and bulimia than African-American participants.
The second part o f Hypothesis 2 posited that African-Americans would
have similar levels o f disordered eating as European-Americans. However, the chi-
square test comparing African-Americans to European-Americans on disordered
eating also supports the hypothesis, but just barely. The statistical result was very
near the significant criterion level. It is possible that larger cell sizes might result in
more clearly significant differences between the two groups. This finding was not
expected.
Considering the research (Abrams, La Rue, & Gray, 1993) that correlates
Black racial identity with lowered rates o f disordered eating, it is possible that the
African-American participants in this study had developed strong Black racial
identities which mediated their risk of disordered eating. Most of the African-
American subjects in the study were recruited from two historically African-
American sororities, which may have drawn more Black-identified women to begin
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84
with, and then provided environments in which these women could further develop
or reinforce their Black racial identities. Moreover, the sororities provided a built-
in social support network, which may act as a buffer against disordered eating; as
noted earlier, higher rates o f Social Diversion coping were found in the
asymptomatic participants. Thus, social support may be an important mediating
factor o f disordered eating.
Hypothesis 3
The results offer strong support for the first part o f Hypothesis 3. in which it
was predicted that European-American participants would report more anorexia and
bulimia than Asian-American participants. No Asian-Americans in this sample
were diagnosed with an eating disorder.
The second part of this hypothesis predicted that Asian-Americans and
European-Americans would have similar rates of disordered eating. This was
clearly true, demonstrated by a chi-square test. The Asian-American women in this
sample came from predominantly European-American sororities and physical
education classes, so it makes sense that their subthreshold eating disorder rates
would match those o f their European-American peers.
Hypothesis 4
This hypothesis predicted greater frequency o f disordered eating among
female athletes as compared to female non-athletes. A chi-square test was
significant, but in the opposite direction than expected; non-athletes actually
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85
reported more disordered eating than athletes. One possible reason for this is that
the athletes were students at an institution known more for its rigorous academics
than its athletics. It is possible that athletes at more sports-oriented universities
might report higher levels o f disordered eating than those in this sample.
Hypothesis 5
Hypothesis 5 predicted greater disordered eating among college women who
are members o f sororities than non-sorority college women. The results o f a chi-
square test showed the two groups had similar frequency o f disordered eating, thus
giving no support to the hypothesis. Given the high frequency of disordered eating
among the college women in this sample, it seems as though the frequency of
disordered eating is just as problematic outside sororities as within them. One
possible reason the sorority participants did not have greater levels of disordered
eating than expected may be due to the social support provided by their
organizations. As previously mentioned, using social support as a form of coping
may protect a person from developing disordered eating, or from progressing to an
eating disorder if already symptomatic.
Hypothesis 6
Hypothesis 6 explores the relation of disordered eating to styles of coping
on the CISS. The first part o f Hypothesis 6 predicted that participants with
disordered eating would report more emotion-oriented coping and distraction-
oriented coping than asymptomatic participants. Results strongly support the first
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86
part of the hypothesis. A t-test found significant differences between the two
groups, as illustrated in Figure 1. The disordered eating group used more emotion
and distraction forms o f coping than the asymptomatic group, shown by higher
mean scores on the Emotion and Distraction subscales. This finding is consistent
with the research literature (e.g., Koff & Sangani, 1997). It is understandable that
people with disordered eating would use emotion and distraction coping; as
illustrated by the CADET, people with disordered eating may cope via Affective
Regulation, which shares qualities with emotion coping, and Cognitive Regulation,
which incorporates distraction kinds o f items. Since coping can be conceptualized
as the cognitive and behavioral efforts used to manage environmental and internal
stress (Coyne et al., 1981), then one way o f coping successfully may be to have a
variety o f coping strategies available to use. It is possible that people who have few
coping options may develop various kinds o f problems, such as disordered eating.
On the other hand, people who engage in disordered eating behaviors may become
over-reliant upon them as coping strategies, and may gradually utilize less o f other
kinds of coping. Future research is warranted to this area.
The second part o f Hypothesis 6 predicted that the same differences would
emerge on the CISS when participants with eating disorders were compared to
participants with subthreshold eating disorders; that is, that the eating disordered
participants would report greater emotion and distraction coping. An ANOVA
indicated significant differences on the Emotion subscale but not the Distraction
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Figure 1
DE and Asymptomatic on CISS Subscales
58
Emotion Coping
1 Distraction Coping
DE Asymptomatic
Disordered Eating Symptoms
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subscale. The means on the Emotion subscale support the direction o f the
hypothesis; the eating disordered group uses more emotion-oriented coping than the
symptomatic group, who in turn use more than the asymptomatic group.
Post hoc analysis revealed significant differences between the asymptomatic
group and eating disordered group, and between the asymptomatic group and the
symptomatic group, but not between the eating disordered group and symptomatic
group; thus, the analysis does not statistically support the second part o f Hypothesis
6. It appears that significant distinctions can be made between asymptomatic
participants and disordered eating participants, but the disordered eating group does
not separate out to show significant differences between eating disordered
participants and symptomatic participants. This result indicates that the eating
disordered group and symptomatic group are more alike than different on emotion-
oriented coping, which contrasts with Koff and Sangani’s (1997) finding that more
severe levels o f disordered eating were correlated with greater emotion-oriented
coping. In this case, the symptomatic group may be experiencing similar problems
in coping as the eating disordered group, despite clinical differences in severity.
Although there were not statistically significant differences between the
eating disordered, symptomatic, and asymptomatic groups on the Distraction
subscale o f the CISS, the means o f Distraction coping were highest for those with
eating disorders, second highest for the symptomatic group, and lowest for the
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89
asymptomatic group. This finding supports the direction predicted in the second
part o f Hypothesis 6.
In summary, results show that scores on both Emotion and Distraction
subscales follow the same pattern: the eating disordered group has the highest
mean, the symptomatic group has the second highest mean, and the asymptomatic
group has the lowest mean. This finding can be interpreted to mean that there is
incrementally greater use of emotion coping as a person progresses from
asymptomatic to symptomatic to eating disordered, causing a narrowing o f coping
responses.
Hypothesis 7
Hypothesis 7 explores the relation o f disordered eating to coping functions
on the CADET. The first part of Hypothesis 7 predicted that participants with
disordered eating would have higher means on the CADET subscales than
asymptomatic participants. A t-test found very high significance between the
disordered eating participants and the asymptomatic participants on the Exercise
subscales (see Figure 2) and Restrict subscales (see Figure 3), which were the only
CADET subscales that included asymptomatic responders and could therefore be
used to compare the two groups. Disordered eating participants had higher means
on all 8 subscales compared to the asymptomatic participants, which provides
strong support for the first part o f Hypothesis 7.
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Figure 2
DE and Asymptomatic on Exercise Subscales o f the CADET
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91
Figure 3
DE and Asymptomatic on Restrict Subscales of the CADET
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Consistent with the theory behind the CADET, people with disordered
eating are gaming something from their disordered eating behaviors. Data show
that they have higher, positive means on the CADET, while asymptomatic people
have lower, negative means on the CADET. Since some asymptomatic people
progress to disordered eating, this Ending indicates that a change in occurs once
disordered eating behaviors are practiced. If this is true, then comparing
asymptomatic, symptomatic, and eating disordered groups might show a
progressive increase in score means on the CADET. The second part of Hypothesis
7 provides the data to test this theory.
The second part o f Hypothesis 7 predicted that eating disordered
participants would use coping functions on the CADET to a greater degree than the
symptomatic participants. Only the Restrict and Binge subscales of the CADET
were used in these analyses because they were the only subscales with an adequate
number of responders for comparative analyses. An ANOVA showed significant
differences on all o f the Restrict subscales, and a t-test revealed significance on the
Binge Affective, Cognitive, and Self subscales. On ail of these subscales, the
eating disordered group had the highest mean, followed by the symptomatic group;
this appears to support the hypothesis. See Figure 4 for an illustration o f these
differences on the Binge subscales.
Post hoc analyses o f the Restrict subscales offered mixed support for the
second part of Hypothesis 7. Significant differences were found between the eating
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Figure 4
ED and Symptomatic on CADET Binge
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2
94
disorder group and symptomatic group on half o f the Restrict subscales. Restrict
Affective and Restrict Cognitive (see Figure 5). The Restrict Interpersonal and
Restrict Self subscales were not significant. This finding suggests that a real
difference in coping between eating disordered participants and participants with
subthreshold eating disorders Is related to Affective and Cognitive Regulation, as it
is measured by the CADET. It may be that these Restrict subscales capture relevant
items that differentially define the diagnostic groups.
In summary, 5 of the 8 possible subscales showed significance as predicted,
which lends moderate support to the hypothesis that the eating disordered group
would have higher means on the CADET compared to the symptomatic group.
Thus, this result further supports the expected incremental increases in coping
functions on the CADET as disordered eating symptoms increase in severity.
It is unclear why Restrict Interpersonal, Restrict Self, and Binge
Interpersonal did not follow the predicted pattern. The dividing issue does not
appear to be about the behavior represented (i.e., restrictive eating or binge eating),
as most of the subscales o f each behavior showed significant results. Furthermore,
it does not appear to be about the type of regulation involved, as the Binge Self
subscale was significant even though Restrict Self was not, and the Restrict
Interpersonal subscale was significant although Binge Interpersonal was not. It is
possible that the coping functions of disordered eating behaviors are more complex
than this hypothesis suggested, and warrant further investigation. An alternative
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95
Figure 5
ED. Symptomatic, and Asymptomatic on CADET Restrict
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theory is that the coping functions o f Restrict Interpersonal (e.g.. ''feel more
attractive to others”), Restrict Self (e.g., '‘feel better about myself’ ), and Binge
Interpersonal (e.g.. “distance myself from others”) serve eating disordered people
and symptomatic people in similar ways.
Exploratory Question A
Exploratory Question A was designed to explore the relation of eating
disorders and coping patterns on the CISS. The eating disorder categories used for
these exploratory analyses were anorexia, bulimia, and binge-eating disorder. An
ANOVA revealed that the only significant difference between these diagnostic
groups was on the Distraction subscale of the CISS. Post hoc analysis showed a
significant difference between those participants with anorexia and those with
bulimia. No differences were found between the anorexic group and the binge-
eating group, or between the binge-eating group and the bulimic group. Thus, only
anorexia and bulimia are different enough from each other to be distinguished on
the Distraction subscale.
The means o f the three eating disordered groups provide additional
information that may contribute to our understanding o f their differences. For
example, on three o f the CISS subscales (Distraction, Emotion, and Avoidance), the
bulimic group had the greatest mean, followed by the binge-eating group, and lastly
by the anorexic group. Thus, the bulimic group and the anorexic group are the most
different o f the three groups on Distraction, Emotion, and Avoidance, although the
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only statistical difference was on the Distraction subscale. These three styles of
coping tend to approach problems or stressors in a diffuse manner; in other words,
the coping response is not very focused on the problem at hand. The trend o f
bulimic participants to exhibit higher means on these coping subscales raises more
questions. Do participants with bulimia lack the skills to deal with problems more
directly? Or. are bulimic participants choosing to react in this way because it is
more tolerable to them? For example, focusing more directly on problems might
increase anxiety, which may be more unpleasant than experiencing the
consequences o f a diffuse coping style. Depending on the answer to these
questions, there may be a benefit for people with bulimia to learn a wider repertoire
of coping responses, or to learn alternate ways o f reducing anxiety. These are only
two possible explanations o f the findings. Other conclusions may be drawn from
more intensive study in this area.
In contrast to the diffuse coping style among the bulimic group, the anorexic
group has the highest mean on the Task subscale, followed by the binge-eating
group, then the bulimic group. This result fits w ith the finding that the participants
with anorexia had the lowest means on the Distraction, Emotion, and Avoidance
subscales. Participants with anorexia had even higher means on task-oriented
coping than asymptomatic participants. It is hypothesized that people with anorexia
may be overly focused on their problems, or lack the skills to distract themselves as
much as other people. Although distraction-oriented coping may not seem like an
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98
ideal response, it is likely that there are times when distraction is in fact helpful.
For example, distraction may provide relief when focusing on one's problems is too
overwhelming or threatening to self-esteem. In other instances, distraction may
keep obsessions and compulsions in check.
The finding that people with anorexia were high on Task coping relates to
the theory' previously mentioned that restrictive eating is an active form o f coping.
Restrictive eating requires focus on food choices; often, this behavior is associated
with an increase in thoughts about food or body size. In this way, restrictive eating
demands a certain amount of mental energy. Furthermore, restrictive eating and
using diet pills are both actions directly targeting the desired outcome of losing
weight or changing body size. In contrast, people who binge eat frequently want to
lose weight, but their behavior (binge eating) counteracts this goal.
On the Social Diversion subscale, the binge-eating group has the highest
mean, followed by the bulimic group, and finally the anorexic group. Perhaps the
binge-eating group manages to use social resources in a way that people with
anorexia and bulimia do not. The behavior involved in binge-eating disorder is
different from the behavior involved in anorexia or bulimia, which both attempt to
change the body directly through their representative disordered eating behaviors.
Instead, self-soothing may be a more primary coping function for people with
binge-eating disorder, who may also seek to have these needs met through Social
Diversion coping. The binge-eating group tends to be the more moderate of the
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99
three eating disorders; the mean o f the binge-eating group is in between the means
o f the anorexic and bulimic groups on the rest of the CISS subscales.
In summary, there appear to be distinguishable differences between people
with anorexia, bulimia, and binge-eating disorder on the CISS, as measured by their
mean scores on the CISS subscales. People with anorexia tend to have more task-
oriented coping responses, which relates to their over emphasis on food and weight.
People with bulimia tend to use more diffuse coping styles, such as emotion coping
and distraction coping. Clinically, it is recognized that people with bulimia
frequently engage in a variety of other coping strategies, such as substance abuse.
This further accentuates the diffuse approach that some people with bulimia
employ. Finally, people with binge-eating disorder use more social diversion forms
of coping compared to people with anorexia or bulimia, which fits with the nature
of their disordered eating behavior and their tendency to seek self-soothing from
sources outside of themselves.
Exploratory Question B
To explore how the eating disorders compare on the CADET, the Restrict
and Binge subscales were used in statistical analyses. These were the only CADET
subscales with sufficient numbers o f eating disordered responders. ANOVA results
show a significant difference on the Restrict Self subscale. Post hoc analysis
revealed significant differences on this subscale between the anorexic group and the
bulimic group, and the anorexic group and the binge-eating group, but not between
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100
the bulimic group and the binge-eating group. This is understandable because
people with bulimia and people with binge-eating disorder tend to restrict their food
in similar ways. Diagnostically, they do not differ in their eating habits per se: their
difference arises only in whether or not compensatory' behaviors are also used.
Therefore, the coping functions o f restrictive eating may not be that different for
people with bulimia or people with binge-eating disorder.
The anorexic group has the highest mean on the Restrict Self subscale,
followed by the bulimic group, and then the binge-eating group. In fact, upon
inspection, the same pattern o f means is found on every Restrict and Binge
subscale. This pattern makes sense on the Restrict subscales, since the anorexic
group restricts food by definition, and is probably deriving some coping benefits
from this behavior. It is unclear whether people with anorexia derive these benefits
from restricting because they do it more frequently and it is reinforcing, or if they
do it more frequently because they get more out of these coping functions in the
first place.
This pattern is more difficult to understand on the Binge subscales. One
would expect, if definitive behaviors are used, that people with bulimia and people
with binge-eating disorder would have higher means on the Binge subscales than
people with anorexia. One possibility is that participants with anorexia experience
a biological response to their calorie deprived state, which then makes binge eating
more powerful for them as compared to the bulimia or binge-eating groups, who
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101
tend to restrict their food intake less. Research indicates that people with anorexia
often transition to bulimia as a result o f their self-starvation and craving for
increased amounts o f food. Thus, the finding that people with anorexia have higher
means on the Binge subscales may be reflective of this fact. Another possibility is
that the anorexic group, who was shown to employ a smaller variety o f coping
styles on the CISS compared to the bulimic or binge-eating groups, rely more upon
the coping functions they derive from disordered eating behaviors.
In summary, exploratory analysis indicated that no single diagnostic group
seemed to prefer a specific kind o f coping over another on the CADET. For
example, there was not a trend for participants with anorexia to have higher means
on Affective Regulation, while binge-eating participants had higher means on
Cognitive Regulation. Instead, the differences between diagnostic groups on the
CADET appear to be driven more by behaviors, i.e., restricting or binge eating.
There may be a lack of differences between these three diagnostic groups because
of some similarity in behavior, as well as the fact that there is movement between
the diagnostic groups. It is possible that a larger sample o f participants who meet
the diagnostic criteria for anorexia, bulimia, and binge-eating disorder would show
stronger differences on the CADET in future research.
Other Findings
There are other findings in this study worth noting. Among them is the
surprising rate o f disordered eating among some o f the less represented racial and
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ethnic groups in this study. Although the small number o f participants belonging to
these racial and ethnic groups precludes meaningful analysis, the patterns of
disordered eating are striking. As noted earlier, 50% (n = 6) o f the small sample of
Latino/a participants were symptomatic. Additionally, 60% (n = 5) o f the Middle-
Eastern participants and 71% (n = 7) o f the Multiracial participants were
symptomatic. These rates substantially exceed the 36% o f European-American
participants with disordered eating. Given the representative small numbers of
these groups in the population from which the sample is drawn, one may wonder if
there is a correlation. Unlike the African-American participants in the sample, the
other racial and ethnic minority groups live in an area of the country in which they
are indeed a minority. There may be increased pressure on these groups to
assimilate to majority culture. These minority groups may be attempting to gain
acceptance by adopting the majority standard of beauty. The exception in this
sample are the American-Indian participants (n = 2); neither reported disordered
eating symptoms.
Another notable finding is the different rates of disordered eating
symptomatology among female athletes. Competitive, body conscious athletes (e.g.
runners) had the highest rates (40%) of disordered eating in this sample, as
compared to competitive, non-body conscious athletes (e.g. basketball players) who
had lower rates o f disordered eating (22%), or non-competitive, non-body
conscious athletes (e.g. intramural soccer), who had the lowest rates of disordered
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103
eating (15%). This finding is supported in the research literature (Gamer et al.,
1998). The pressure that competitive, body conscious athletes feel to maintain their
weight or body size for their sport is theorized to contribute to these higher rates of
disordered eating. The average rate of disordered eating for females in this study
was 37%; thus, being an athlete in a competitive, body conscious sport might
increase one’s risk o f developing disordered eating, but being an athlete in a non
competitive, non-body conscious sport might actually decrease the risk of
developing disordered eating. These findings have implications for prevention and
treatment and will be noted in that section.
Another unexpected finding is the significant difference between the
disordered eating group and the asymptomatic group on the Social Diversion
subscale o f the CISS; the disordered eating group was less likely to use Social
Diversion as a form o f coping. This finding has not been noted much in the
literature. However, clinically, we know that people who engage in disordered
eating, by its very nature, may begin to isolate themselves; as their behavior
progresses in severity, they become that much more isolated. The implications of
this issue on prevention and treatment will be discussed later.
A correlation matrix between the CISS and the CADET showed significant
negative correlations between Avoidant coping and the Restrict and Diet Pill
subscales o f the CADET. As previously argued, restrictive eating and using diet
pills may be active forms o f coping, and thus would not be described as avoidant.
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Restrictive eating and using diet pills may make a person focused on food intake (or
the lack thereof). Therefore, the negative correlation between Avoidant coping and
restrictive eating and diet pills would be expected. This theory might also explain
the negative correlation found between the Distraction subscale o f the CISS and 3
out of 4 of the Diet Pill subscales on the CADET. Carrying this theory a bit further,
if people who restrict and/or use diet pills are actively focused on their eating
behavior, then they may be less inclined to seek Social Diversion as a form of
coping. In support o f this theory, significant negative correlations were found
between the Restrict and Diet Pill subscales of the CADET and the Social
Diversion subscale o f the CISS.
One of the most striking findings in this study is just how prevalent
disordered eating is in our society. In this study, 37% (n = 90) o f the women
surveyed were classified as having disordered eating; o f these women, 30% (n = 72)
were classified as symptomatic. This is similar to the symptomatic prevalence rates
o f other studies, which range from 25-32% symptomatic (L. Mintz, personal
communication, July 8, 1999). Disordered eating, particularly subthreshold eating
disorders, is impacting a significantly larger group o f women than are full blown
eating disorders. Although the rates o f disordered eating are lower for men, in this
study 24% (n = 15) of the men surveyed reported disordered eating; o f these men,
22% were symptomatic. This rate is higher than what would be expected given the
much larger differential between rates o f eating disorders for women and men.
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Men are seldom targeted for prevention or treatment efforts: however, if almost a
quarter o f men are experiencing disordered eating, then this is a significant problem
that has not been addressed. Clearly, many women and men suffer from
subthreshold eating disorders. We have failed to respond to this population through
prevention and treatment.
The results o f this study indicate that there are not always strong differences
between the symptomatic group and the eating disorder group along dimensions o f
coping. This may be due to the similarity o f their behaviors. For example, a person
with anorexia, binge eating/purging type only differs from a person with bulimia,
purging type in weight, and if female, if the criteria o f amenorrhea has been met.
The lack of clear differences may mean that the symptomatic group is as limited as
the eating disorder group in their use of coping resources. In other words, the
symptomatic group may be experiencing as much emotional and psychological
distress as the eating disorder group. If so, then this is a problematic situation
because subthreshold eating disorders affect many more individuals than
diagnosable eating disorders. Additionally, people with subthreshold eating
disorders receive less attention and fewer resources devoted to helping them.
Interestingly, the rates o f anorexia and bulimia in this study match the rates
specified in the DSM-IV (1994), but are lower than those reported in some studies
(i.e., Dolan, 1991). This may be due to the criteria used to diagnose eating
disorders in other research studies. For example, cases o f anorexia or bulimia in
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previous studies may have included subthreshold cases that were misdiagnosed due
to clinician error, flaws in the diagnostic instrument, or loose definitions o f eating
disorders.
Implications for Prevention and Treatment
In terms o f allocating resources for prevention efforts, this study suggests
that more attention and resources should be apportioned to people with
subthreshold eating disorders. In particular, college age women and men can be
considered a primary audience for prevention outreach. Given their higher than
expected rate o f disordered eating, men should not be overlooked in these efforts.
However, outreach programs and other methods o f prevention that target men must
address the issues that are relevant to men, such as male body image, body
dysmorphic disorder, problems with weightlifting and overtraining, and steroid use,
especially since disordered eating outreach programs have been historically tailored
to women. Additionally, all racial and ethnic groups are at risk for disordered
eating, and prevention programs should be inclusive o f diverse ethnic groups.
If resources are limited, then competitive and body conscious athletes
warrant extra prevention efforts, because they are at greater risk o f developing
disordered eating than recreational or non-body conscious athletes. Thus,
swimmers, runners, gymnasts, dancers, and other body conscious athletes should be
a primary focus o f prevention. College counseling centers could offer prevention
programs to first year athletes in these sports. Coaches and/or trainers who may be
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intentionally or unwittingly contributing to or misinterpreting disordered eating
behavior are also appropriate targets o f prevention efforts. Furthermore, systemic
changes in athletics could be implemented which might decrease the risk o f
disordered eating among athletes. For example, changing weight standards to
reflect a weight range as opposed to a specific weight is one way that could
decrease the pressure to practice disordered eating behaviors.
Another important aspect o f prevention is social support. The results o f this
study clearly show that social support is a key part o f being asymptomatic.
Prevention efforts should be responsive to this finding and encourage expanded
social support systems to people at risk o f developing disordered eating.
Finally, the issue o f environmental or sociocultural factors that contribute to
disordered eating is important to address. Although sociocultural factors do not
cause disordered eating per se, they can reinforce its existence and make recovery
difficult. In this vein, broad based societal change would be helpful in reducing
rates o f disordered eating, and thus, psychoeducational programming to raise
awareness o f these issues and challenge commonly accepted standards o f beauty is
also a viable route o f prevention.
The results o f this study have several implications for the treatment o f
disordered eating. After assessing how a client copes with stressors in general,
treatment can focus on broadening the client’s coping methods, which offers her or
him increased options and flexibility. An important part o f treatment is to identify
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the coping functions o f a client's eating and exercise behaviors. This can be an
empowering experience for the client, especially when the behaviors are foamed as
attempts to cope. Over time, more adaptive coping strategies can be learned and
applied that suit the needs of the client, such as affective regulation, or more
specifically, anger management. The CADET can be a useful measure for
clinicians who wish to help clients identify their own pattern o f coping, and to
subsequently devise alternate behaviors that achieve a similar goal.
The treatment of choice for people with eating disorders is group therapy.
The results o f this study strongly support this mode o f treatment. Asymptomatic
participants used significantly more social diversion coping than participants with
eating disorders. Thus, increasing social diversion coping could help those with
eating disorders become asymptomatic. Group therapy decreases the isolation
associated with eating disorders, and offers peer support It would also be helpful
for people with eating disorders to develop social support with people who are
asymptomatic, so that more normative relationships with food can be observed and
perhaps incorporated by those with eating disorders.
Limitations o f the Study
This was the first study that used the CADET. As a new instrument, the
CADET performed well overall, but nevertheless needs improvement. In
particular, 4 o f the 24 subscales have low internal reliability, and thus, information
from these subscales should be used with caution if used at all. Also, since factor
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109
analysis was not used to test the subscales o f the CADET, it is possible that
different patterns o f coping functions would emerge within and between diagnostic
groups if the subscales are aligned differently after factor analysis.
The sample o f this study was limited in a number of ways. First, it was
composed o f mostly college undergraduates, which may limit the application o f the
findings to groups outside the college population. Second, only 5.6% of the sample
was gathered from clinical sources, which may limit the generalizability o f findings
to more eating disordered groups. The small clinical sample resulted in less
numbers o f eating disordered participants, which interfered in the analysis o f eating
disorder group differences. Although efforts were made to secure a sizable group
of eating disordered participants, this was a difficult task to achieve because o f the
rarity of full blown eating disorders and the unwillingness of inpatient treatment
centers to approve research with their patients. The racial and ethnic mix o f this
sample is also limited; in order to fully understand the similarities and differences
between groups, a larger sample of some ethnic groups (e.g., Latino/a) is needed.
Finally, it was expected that study participants would report accurate
information about their weight, eating patterns, and disordered eating behaviors.
Given the shame that sometimes surrounds these issues in our culture, it is possible
that some participants did not report their behaviors accurately on survey measures,
even though they knew the study was anonymous and confidential. If this actually
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no
occurred, then it is possible that the rates o f disordered eating in the study might
have been underreported.
Recommendations for Future Research
The structure o f the CADET should be explored through factor analysis to
determine if the content laden subscales described here (Affective, Cognitive,
Interpersonal, and Self Regulation) are actually the best fit o f each scale. If not, the
best fitting factors should be identified so that the structure o f the measure can be
strengthened. Afterwards, research can be conducted with the revised CADET
within and between diagnostic groups to better understand how these groups might
be similar or different. It is possible that the CADET could be altered to examine
the coping functions of other types of behaviors, such as alcohol and other drug
abuse and chronic gambling.
Future studies with the CADET would benefit from a larger sample of
eating disordered participants, to be able to examine between group differences
more extensively on measures of coping style, and on the CADET. Men should be
included in studies, in order to leam more about how they cope through disordered
eating behaviors. Larger groups of racial and ethnic minority participants would
also enhance our knowledge o f differences between and within groups.
The CADET can also be used to assess the progress o f treatment, by
employing a pre- and post-treatment study design. Reduced means on the CADET
might indicate treatment progress, in a reverse progression from eating disordered
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Ill
to asymptomatic. Additionally, if the CISS were used to assess general coping
changes, an increase in Social Diversion coping might also indicate progress and
movement to the more asymptomatic end o f the disordered eating continuum.
Finally, a longitudinal study design could test whether explore ineffective coping
styles existed prior to disordered eating symptoms and represented a potential risk
factor for disordered eating, or if disordered eating behavior itself gradually
changed or narrowed coping responses.
Summary
The CADET demonstrated itself to be a viable instrument for exploratory
research, with good internal reliability reported on the majority of subscales. High
rates of disordered eating were identified in this sample among both women and
men, while eating disorders were more rare. There were higher than expected rates
of disordered eating in some o f the less represented racial and ethnic groups.
Higher rates o f disordered eating were found in competitive and body conscious
athletes, when compared to recreational and non-body conscious athletes. Sorority
members had the same rates of disordered eating as compared to college women
who were not in sororities.
Regarding dispositional coping, people with disordered eating used more
emotion and distraction coping than asymptomatic people, and asymptomatic
people used more social diversion coping than people with disordered eating.
Being connected to others through social support was identified as a critical buffer
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112
against disordered eating. People with bulimia tended to use more diffuse coping
strategies on the CISS than people with anorexia, who tended to use more task
focused coping.
On the CADET, people with disordered eating used exercise and restrictive
eating as coping strategies more than asymptomatic people. Furthermore, people
with eating disorders used Affective and Cognitive Regulation more than
symptomatic people on the Restrict scale, and more Cognitive and Self Regulation
on the Binge scale. People with anorexia used the Restrict Self subscale as a
coping strategy more than people with bulimia or people with binge-eating
disorder. Overall, the study provides a needed initial exploration o f the coping
functions o f disordered eating behaviors, suggests ideas for prevention and
treatment, and identifies future paths o f research.
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113
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APPENDIX A
Informed Consent
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120
Informed Consent Regarding Participation in Research
My name is Deborah Southerland and I am a doctoral student in Counseling Psy chology.
School of Education, at the University of Southern California. You are being asked to
participate in a research project, which is being conducted in order to satisfy the
requirements of the Ph.D. degree that I am pursuing. Your participation is intended for
research purposes only.
The purpose of this study is to look at eating behaviors in relation to coping styles. This
study asks about personal issues including your attitude toward eating and general ways in
which you cope with situations. Please read the instructions for each questionnaire
carefully and answer the questions as honestly as you can. There are no right or wrong
answers. It is expected that most people will be able to answer these questions without
feeling uncomfortable. However, if you feel uncomfortable or upset because of answering
the questions, please speak to me, and I will assist you or help you to find someone with
whom you can talk. You can also call me at 404.727.1527.
This consent form will be separated from the completed questionnaires in order to protect
your privacy and keep your name separate from your responses. AH materials will be
stored away from the university and your responses will be destroyed after they have been
coded and entered into the computer. Your participation is completely voluntary and your
responses will be anonymous. No staff or faculty will ever know that you participated in
this study.
You may refuse participation at any time without negative consequences. Your
participation, if you decide to volunteer, will be greatly valued. Please feel free to ask me
any questions about the study or questionnaires.
I,_______________________________ , understand the explanation about this research
study and I consent to participate. My participation is completely voluntary. I have read
the entire informed consent, and I consent to complete written questionnaires. I
understand that all research information will be handled in the strictest confidence and that
my participation will not be individually identifiable in any reports. I understand that
participation or non-participation in this research project will not be known to faculty or
staff of this or any university.
Participant’s Signature Date
Deborah Southerland, M.A. Date
Joan Rosenberg, Ph.D., Faculty Advisor Date
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APPENDIX B
Demographic Questionnaire
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122
DEMOGRAPHIC QUESTIONNAIRE
Please answer the follow in g questions as honestly and accurately as you can.
AGE: ______
SEX: (please circle one) Female Male
Are you currently an athlete on an organized team? (please circle one) Yes No
If ves. please indicate the type o f team'. ______________________________ _
(i.e., collegiate swimming, intramural soccer, high school basketball, etc.)
Please check if you are a member of a sorority or fraternity___
EDUCATION
Are you currently a student? Yes No
If ves. please check your current year in school below, if no, please check the highest
level o f education you completed:
High School:
1 Freshman
2 Sophomore
3 Junior
4 Senior
RACE / ETHNICITY
(please check one)
1 African-American, Black
2 American Indian, Native American
3 Asian-American, Pacific Islander, South Asian, East Indian
4 Euro-American, White, Caucasian
5 Latino/a, Hispanic
6 Middle Eastern, North African
7 Multiracial (please specify): ______________________________________________
TREATMENT HISTORY
Have you ever been treated for an eating disorder? Yes No
If yes, what are/were you being treated for specifically? (i.e., anorexia, bulimia, binge
eating) Please specify: ______________________________________________________
Are you currently receiving outpatient treatment for an eating disorder? Yes No
(individual and/or group therapy)
Have you ever received inpatient treatment for an eating disorder? Yes No
Are you currently receiving inpatient treatment for an eating disorder? Yes No
College:
5 Freshman
6 Sophomore
7 Junior
8 Senior
9 Graduate school
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APPENDIX C
Coping Inventory for Stressful Situations (CISS)
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124
The Coping Inventory for Stressful Situations (CISS) for Adults by Drs. Norman S.
Endler and James D. A. Parker is copyrighted and licensed by Multi-Health
Systems Incorporated. Multi-Health Systems does not grant permission for the
CISS to be reproduced in its entirety. Questions about the CISS should be directed
to Multi-Health Systems Incorporated, 908 Niagara Falls Boulevard. North
Tonawanda. NY 1412-2080; 1-800-456-3003.
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APPENDIX D
Questionnaire for Eating Disorder Diagnoses (Q-EDD)
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Q-EDD
126
Please com plete the follow in g questions a s honestly as possible.
Present height: ____ fe e t inches
Present weight: ______ pounds
1. Do you experience recurrent episodes of binge eating, which means to eat in a discrete
period of time (e.g., within any 2 hour period) an amount of food that is definitely larger
than most people would eat during a similar time period?
Please circle one'. YES If YES: Continue to answer the following questions.
NO If NO: Skip to Question #4.
2. Do you feel out of control during the binge eating episodes (e.g., do you feel that you
cannot stop eating or control what or how much you are eating)? YES NO
3. Please fill in the blanks: On the average. I have had binge eating episodes a
week for at least months (specify if more than a year).
4. INSTRUCTIONS: Please circle the appropriate responses below concerning things
you may do to prevent weight gain. I f you circle yes to any question, please indicate how
often on average you do this and how long you have been doing this.
a) Do you make yourself vomit? YES NO
How often do you do this?
I) D aily 2) T w ice/w eek 3) Once/week 4) O nce/m onth
How long have yo u been doing this?
I) I m onth 2) 2 m onths 3) 3 months 4) 4 m onths 5 )5 -1 1 m onths 6) M ore than a year
b) Do you take laxatives? YES NO
How often do yo u do this?
I) D aily 2) T w ice/w eek 3) Once/week 4) O nce/m onth
How long have yo u been doing this?
I) l m onth 2) 2 m onths 3) 3 months 4) 4 m onths 5)5-11 m onths 6) M ore than a year
c) Do you take diuretics (water pills)? YES NO
How often do you do this?
1) D aily 2) T w ice/w eek 3) Once/week 4) O nce/m onth
How long have you been doing this?
1) 1 m onth 2) 2 m onths 3) 3 months 4) 4 m onths 5)5-11 m onths 6) M ore than a year
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127
d) Do you fast (skip food for 24 hours)? YES NO
How often do you do this?
1) Daily 2 ) Tw ice/w eek 3) O nce/w eek 4) O nce/m onth
How long have you been doing this?
I) I m onth 2) 2 m onths 3) 3 m onths 4) 4 m onths 5 )5 -1 1 months 6) M ore than a year
e) Do you chew food but spit it out? YES NO
How often do you do this?
I) Daily 2 ) T w ice/w eek 3) O nce/w eek 4) O nce/m onth
How long have you been doing this?
1) I m onth 2) 2 m onths 3) 3 m onths 4) 4 m onths 5)5-11 months 6) M ore than a year
f) Do you give yourself an enema? YES NO
How often do you do this?
1) D aily 2 ) T w ice/w eek 3) Once/w eek 4) O nce/m onth
How long have you been doing this?
I ) I m onth 2) 2 m onths 3) 3 m onths 4) 4 m onths 5)5 -1 1 months 6) M ore than a year
g) Do you take appetite control pills? YES NO
How often do you do this?
1) D aily 2) Tw ice/w eek 3) Once/week 4) O nce/m onth
How long have you been doing this?
1) 1 m onth 2) 2 m onths 3) 3 m onths 4) 4 m onths 5)5 -1 1 months 6) M ore than a year
h) Do you diet strictly? YES NO
How often do you do this?
1) D aily 2) Tw ice/w eek 3) Once/w eek 4) O nce/m onth
How long have you been doing this?
1) 1 m onth 2) 2 m onths 3) 3 months 4) 4 m onths 5)5-11 months 6) M ore than a year
i) Do you exercise? YES NO
How often do you do this?
I ) D aily 2) Tw ice/w eek 3) Once/w eek 4) O nce/m onth
How long have you been doing this?
1) 1 m onth 2) 2 m onths 3) 3 months 4) 4 m onths 5)5-11 months 6) M ore than a year
5. If you answered YES to "exercise" above, please answer questions a, b, and c below. If
y o u answered NO to "exercise," please skip to question #6.
a)_______________________________ I_______ (specify type of exercise, e.g., jog, swim)
fo r an average o f_____ hours at a time.
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128
b) My exercise sometimes significantly interferes with important activities. YES NO
c) I exercise despite injury and/or medical complications. YES NO
INSTRUCTIONS: For the following questions, circle the most accurate response:
6. Does your weight and/or body shape influence how you feel about yourself?
1 2 3 4 5
N ot at all A little A m oderate Very m uch E xtrem ely o r
am ount com pletely
7. How afraid are you of becoming fat?
1
N ot at all
afraid
2
A little
afraid
M oderately afraid V ery much
afraid
5
Intensely
afraid
8. How afraid are you of gaining weight?
1 2 3 4
N ot at all A little M oderately afraid Very much
afraid afraid afraid
Intensely
afraid
9. Do you consider yourself to be:
1 2 3 4 5
Grossly M oderately Overweight Normal Low
obese obese weight weight
6
Severely
underweight
10. Certain parts of my body (e.g., my abdomen, buttocks, thighs) are too fat. YES NO
11. I feel fat all over. YES NO
12. I believe that how little I weigh is a serious problem. YES NO
13. Females only (males leave blank): I have missed at least 3 consecutive YES NO
menstrual cycles (not including those missed during a pregnancy).
Note: The Q-EDD was developed by Mintz, O’Halloran, and Mulholland (1997).
Permission to use this instrument must be granted by the author. For more information,
please contact Dr. Laurie Mintz via E-mail at edcoibni@showme. M issouri.. edu or by
phone at 573- 882-4947.
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APPENDIX E
Coping and Disordered Eating Test (CADET)
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130
CADET C
Please answer the following questions as honestly and accurately as you can.
P lease fill in blanks: On average, I e x e rc ise days a week fo r hours at a time.
Do you exercise more than 5 hours a week? YES NO
If ves. please answer the following questions. If no. skin to the next page.
Please rate how accurate or true the following statements are for yourself. Circle the
corresponding number next to each item using the scale below.
I 2 .............. 3 ...............4 ..................5 .................. 6 ..................7 ................. £ ....................9
completely mostly somewhat somewhat mostly completely
untrue untrue untrue true true true
E x ercise helps m e to:
1. B lock feelings.A I 2 J 4 5 6 7 8 9
2. Punish m yself.s 1 2 4 5 6 7 8 9
3. Stay healthy.s 1 2 3 4 5 6 7 8 9
4. A void interacting with others.* I 2 3 4 5 6 7 8 9
5. "Start over" with a clean slate after o v ereatin g .c I 2 j 4 5 6 7 8 9
6 . Relieve feelings o f guilt about e a tin g .A I 2 3 4 5 6 7 8 9
7. Excel in fitness o r sp o rts.s 1 2 3 4 5 6 7 8 9
8. D istract m yself from unw anted th o u g h ts.c I 2 4 5 6 7 8 9
9. Feel better about m y self.s 1 2 J 4 5 6 7 8 9
10. Deal with stre ss.A 1 2 3 4 5 6 7 8 9
11. Feel like m yself a g a in .s I 2 j 4 5 6 7 8 9
12. Deal with an x iety .A I 2 3 4 5 6 7 8 9
13. G et rid o f m y sexual feelings and/or becom e 1 2 j 4 5 6 7 8 9
androgynous.
14. "Space out,” disconnect, o r dissociate. I 2 3 4 5 6 7 8 9
15. U ndo or reverse the effects o f e a tin g .s I 2 3 4 5 6 7 8 9
16. Feel a sense o f co n tro l.s I 2 3 4 5 6 7 8 9
17. R e la x .A
I 2 3 4 5 6 7 8 9
18. H ave an outlet for feelings o f self-h atred .s 1 2 3 4 5 6 7 8 9
19. Focus m y attention on m y body, an d aw ay from 1 2 3 4 5 6 7 8 9
m y problems.
20. Bond with m em bers o f m y sam e sex.* I 2 3 4 5 6 7 8 9
21. Feel m ore attractive to o th e rs.1 I 2 J 4 5 6 7 8 9
22. Feel better than other p e o p le .1 1 2 3 4 5 6 7 8 9
23. T est the limits o f pain I can to lerate/en d u re.s 1 2 3 4 5 6 7 8 9
24. C leanse or purify m yself.s 1 2 3 4 5 6 7 8 9
25. Fem ales only (m ales leave blank): G e t rid o f m y 1 2 3 4 5 6 7 8 9
m enstrual period.
26. D eal w ith anger. 1 2 3 4 5 6 7 8 9
27. D eal w ith sexism , racism, and/or hom ophobia.* 1 2 3 4 5 6 7 8 9
Please rank the two most important functions by placing a I and a 2 next to the relevant test
items.
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
131
Do you restrict your food intake, diet, and/or fast? YES NO
If please answ er the following questions. I f n o . skip to the next page.
Please rate how accurate or true the following statements are for yourself. Circle the
corresponding number next to each item using the scale below.
1 ...............2 ................ 3 ............. 4 ................. 5 .................. 6 .................. 7 ................. 8 ....................9
com pletely m ostly som ewhat som ewhat m ostly com pletely
untrue untrue untrue true true true
R estrictin g m v food, dieting, a n d /o r fasting h e lp s m e to :
28. Feel m ore attractive to others.1
1 2 3 4 5 6 7 8 9
29. Block fe e lin g s.A
1 2 j 4 5 6 7 8 9
30. D istract m y self from unwanted thoughts.c 1 2 4 5 6 7 8 9
31. Feel b etter about m y self.s
1 2 j 4 5 6 7 8 9
32. C leanse o r purify m y self.s
I 2 3 4 5 6 7 8 9
33. C ontain feelings o f an g er.A
I 2 3 4 5 6 7 8 9
34. Feel a sense o f c o n tro l.s
1 2 j 4 5 6 7 8 9
35. Undo o r reverse the effects o f eating.*
I 2 3 4 5 6 7 8 9
36. B ond w ith m em bers o f my same s e x .1 1 2 3 4 5 6 7 8 9
37. Relieve feelings o f g u ilt about eatin g .A 1 2 j 4 5 6 7 8 9
38. D eny m y n e e d s.s
I 2 3 4 5 6 7 8 9
39. Feel drugged o r "high." A 1 2 3 4 5 6 7 8 9
40. Deal w ith sexism , racism , and/or hom ophobia.1 1 2 3 4 5 6 7 8 9
4 1. Fem ales only (m ales leave blank): G et rid o f m y 1 2 3 4 5 6 7 8 9
m enstrual period.
42. Focus m y attention on m y body/food, and aw ay I 2
“ S
j 4 5 6 7 8 9
from m y problem s.
43. D istance m yself from others.
I 2 3 4 5 6 7 8 9
44. Increase m y sense o f order and structure.s 1 2 3 4 5 6 7 8 9
45. T est the lim its o f pain I can tolerate/endure.s 1 2 3 4 5 6 7 8 9
46. Have an o u tlet for feelings o f self-hatred.s I 2 3 4 5 6 7 8 9
47. G et attention or caretaking from o th e rs.1 I 2 3 4 5 6 7 8 9
48. "Start o v er” w ith a clean slate after o v ereatin g .c I 2 3 4 5 6 7 8 9
49. H urt o th e rs .1 1 2 3 4 5 6 7 8 9
50. Excel a t being th in .s I 2 3 4 5 6 7 8 9
51. Stay a ”little g irl.” s 1 2 3 4 5 6 7 8 9
52. "Space out," disconnect, or dissociate.s 1 2 3 4 5 6 7 8 9
53. Feel b etter than o th er p eople.1 1 2 3 4 5 6 7 8 9
54. Punish m y se lf.s 1 2 3 4 5 6 7 8 9
55. G et rid o f m y sexual feelings and/or becom e
__, ___ s
1 2 3 4 5 6 7 8 9
androgynous.
Please rank the two most important functions by placing a 1 and a 2 next to the relevant test
items.
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
132
Do you use diet pills? YES NO
If ves. please answ er the follow ing questions. If no. skip to the next page.
Please rate how accurate or true the following statements are fo r yourself Circle the
corresponding number next to each item using the scale below.
I 2 ...........3 ...........4 .............5 .............6 ..............7 .............8 .............. 9
completely m ostly som ew hat som ewhat m ostly completely
untrue untrue untrue true tru e true
D iet pills help m e to :
56. "Space out,” disconnect, o r d isso c ia te .s I 2 J 4 5 6 7 8 9
57. Feel high or en erg ized .A I 2 J 4 5 6 7 8 9
58. Distance m yself from o th e rs .1 1 2 J 4 5 6 7 8 9
59. Deny m y n e e d s.s 1 2 J 4 5 6 7 8 9
60. Deal with sexism, racism , a n d /o r ho m o p h o b ia.1 I 2 3 4 5 6 7 8 9
61. Distract m yself from unw anted th o u g h ts.c I 2 3 4 5 6 7 8 9
62. Punish m y self.s I 2 3 4 5 6 7 8 9
63. Focus m y attention o n my body/food, and aw ay
from my pro b lem s.c
I 2 J 4 5 6 7 8 9
64. Feel more attractive to o th e rs .1 I 2 J 4 5 6 7 8 9
65. Feel a sense o f co n tro l.s 1 2 3 4 5 6 7 8 9
66. Block feelings.A I 2 J 4 5 6 7 8 9
67. Excel at being th in .s 1 2 J 4 5 6 7 8 9
6 8 . Undo or reverse the effects o f e a tin g .s 1 2 3 4 5 6 7 8 9
69. Avoid withdrawal because Irm addicted to th e m .s I 2 j 4 5 6 7 8 9
Please rank the two most important functions by placing a 1 and a 2 next to the relevant test
items.
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
133
Do you use laxatives, enemas, or colonics? YES NO
If ves. please answ er the follow ing questions. I f no, skip to the next page.
Please rate how accurate or true thefollowing statements arefor yourself. Circle the
corresponding number next to each item using the scale below.
1 ............... 2 ............... 3 ...............4 .............5 ..................6 .................. 7 ................. 8 ....................9
com pletely mostly som ew hat somewhat m ostly com pletely
untrue untrue untrue true tru e true
L axatives, enem as, a n d /o r colonics h elp m e to :
70. D eal w ith anxiety.A I 2 3 4 5 6 7 8 9
71. Punish m y self.s 1 2 3 4 5 6 7 8 9
72. Stop thinking about what I a te .c I 2 3 4 5 6 7 8 9
73. D eal w ith a n g e r.A I 2 3 4 5 6 7 8 9
74. Undo o r reverse the effects o f e a tin g .s 1 2 3 4 5 6 7 8 9
75. C leanse o r purify m y self.s I 2 3 4 5 6 7 8 9
76. Feel like m yself ag ain .s 1 2 3 4 5 6 7 8 9
77. H ave an outlet for feelings o f self-h atred .s I 2 3 4 5 6 7 8 9
78. "Start over" with a clean slate after o v ereatin g .c I 2 j 4 5 6 7 8 9
79. D eal w ith sexism, racism, and/or h o m o p h o b ia.( I 2 3 4 5 6 7 8 9
80. Feel m ore attractive to o th e rs .1 1 2 3 4 5 6 7 8 9
81. Feel a sense o f con tro l.s I 2 3 4 5 6 7 8 9
82. G et rid o f w hat I ate when I can't v o m it.s I 2 3 4 5 6 7 8 9
Please rank the two most important functions by placing a I and a 2 next to the relevant test
items.
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
134
Do you b in g e e a t? (eat an am ount o f food th at is definitely larger
than w hat m ost people w ould e a t d u rin g th e sam e period o f tim e)
YES NO
If ves. please answ er the follow ing questions. I f no, skip to the next page.
Please rate how accurate or true thefollowing statements are fo r yourself Circle the
corresponding number next to each item using the scale below.
I
com pletely
untrue
m ostly
untrue
4 ...........
som ew hat
untrue
6 .........
somewhat
true
8
m ostly
tru e
completely
true
B inge ea tin g h elps m e to :
83. R elax .A
84. A void taking a risk o r fa ilin g .c
85. D eal w ith sexism , racism , an d /o r h o m o p h o b ia.1
86. Deal w ith b o red o m .A
87. B lock feelings. A
88. D istract m yself from unw anted th o u g h ts.c
89. Increase sensation. A
90. Reward m y self.s
91. Feel satiated .s
92. Procrastinate o r avoid so m eth in g .c
93. Feel h a p p y .A
94. Punish m y self.s
95. Deal with an x iety .A
96. G et rid o f m y sexual feelings a n d /o r becom e
androgynous.s
97. Bond with m em bers o f m y sam e sex.*
98. Contain feelings o f a n g e r.A
99. "Space out," disconnect, o r dissociate. 5
100. Focus m y attention on food, a n d aw ay from
m y p ro b lem s.c
101. D istance m yself from o th e rs .1
102. N urture o r soothe m y self.s
103. Feel free and uninhibited.A
2
o 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2
j 4 5 6 7 8 9
2
j 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2 j 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2
■ * *
j 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2
* *
4 5 6 7 8 9
2 J 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 j 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
Please rank the two most important functions by placing a / and a 2 next to the relevant test
items.
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
135
Do you purge by vomiting? YES NO
If ves. please answ er the follow ing questions. I f no. you are done w ith this test.
Please rate how accurate or true the following statements are fo r yourself Circle the
corresponding number next to each item using the scale below.
I .............2 ................ 3
completely m ostly
untrue untrue
V om iting helps m e to :
4 ..................5
som ew hat
untrue
6 .........
som ew hat
true
104.
105.
106.
107.
108.
109.
110.
1 1 1 .
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124.
125.
"Start over" with a clean slate after overeating.*
Relieve feelings o f g uilt ab o u t eating.*
Feel like m yself a g a in .s
Distance m yself from o th e rs .1
Deal with an g er.A
Feel a sense o f co n tro l.s
Focus m y attention on m y body, and away
from m y pro b lem s.c
Have an outlet for feelings o f self-h atred .s
Undo o r reverse the effects o f eating. s
Deal with stre ss.A
Feel m ore attractive to others.*
"Space out," disconnect, o r d isso ciate.s
Hurt o th e rs.1
Cleanse o r purify m yself. s
G et som eone to notice I am stru g g lin g .1
Deal with sexism , racism , and/or hom ophobia.1
Deal w ith an xiety.A
Punish m y self.s
Bond with members o f m y sam e s e x .1
Exhaust m y self.s
D istract m yself from unw anted th o u g h ts.c
Return to present space and tim e .s
m ostly
true
8
completely
true
2
3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2
J 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2
J 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2
j 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2
3 4 5 6 7 8 9
2 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
2 3 4 5 6 7 8 9
Please rank the two most important functions by placing a 1 and a 2 next to the relevant test
items.
N ote. Items w ere categorized as follow s:
A Affective Regulation
c Cognitive Regulation
1 Interpersonal Regulation
s S elf Regulation
* Items that w ere elim inated in o rd er to increase reliability.
© Copyright 1999 by D eborah L . Southerland. Permission to use m ust be granted by the author.
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
136
APPENDIX F
Correlation Matrix Between the CISS and the CADET
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
137
T A S K E M O T I O N A V O I D D I S T R A C T S O C D I V
T A S K 1.0 0 0 - .1 8 8 * * .0 2 6 - .1 3 9 * .1 8 7 * *
E M O T IO N - .1 8 8 * * 1 .0 0 0 .1 5 8 * * o i l * * - .0 4 2
A V O I D .0 2 6 .1 5 8 * * 1 .0 0 0 .8 2 5 * * .7 1 9 * *
D I S T R A C T - .1 3 9 * .3 1 1 * * .8 2 5 * * 1 .0 0 0 .2 8 0 * *
S O C D IV .1 8 7 * * - .0 4 2 .7 1 9 * * .2 8 0 * * 1.0 0 0
E X A F F E C T
.0 5 2 .4 6 1 * * - .1 5 7 - .1 4 2 - .1 2 9
E X C O G - .1 2 5 .6 4 2 * * - .0 4 2 .0 4 4 - .1 6 0
E X I N T E R .0 2 3 .3 3 6 * * .0 7 5 .1 0 0 .0 4 3
E X S E L F .1 1 3 .5 1 9 * * - .1 0 6 - .0 5 4 - .1 6 8
R E A F F E C T . 0 5 7 4 4 4 * * - .2 9 0 * * - .1 4 7 - .3 1 7 * *
R E C O G .0 6 2 .4 5 5 * * - .2 1 6 * - .0 6 7 - .2 9 1 * *
R E IN T E R .0 6 2 .4 5 1 * * - .2 1 7 * - .0 7 5 - .2 9 6 * *
R E S E L F .0 5 8 .4 4 3 * * - .3 5 1 * * -.1 9 1 - 3 5 5 * *
D P A F F E C T - .0 8 9 .8 0 9 * * - .8 3 9 * * - .7 5 6 * - .8 3 7 * *
D P C O G .0 4 2 .6 8 1 * - .6 7 5 * - .5 6 7 - .6 2 3
D P I N T E R - .1 4 7 .6 5 6 - .7 9 7 * - .7 0 2 * -.8 6 2 * *
D P S E L F .0 0 6 .7 3 1 * - .8 7 3 * * 00
o
•
«
- .7 8 0 *
L X A F F E C T -.6 6 1 .3 2 8 .5 7 6 .7 2 6 * - .1 0 0
L X C O G - .4 9 2 .6 7 1 .6 2 9 .4 3 9 .1 6 6
L X IN T E R - .8 0 5 * .5 0 7 .6 3 7 .6 4 9 - .0 1 3
L X S E L F - .5 0 8 .6 0 4 .8 0 1 * .5 8 4 .2 8 2
B G A F F E C T - .2 2 1 .3 2 3 * - .1 1 3 .0 1 2 - .1 5 7
B G C O G - .0 9 6 .4 5 5 * * - .1 6 2 - .0 6 0 - .1 5 4
B G I N T E R - .0 3 9 .3 6 7 * * - .1 1 0 .0 1 0 - .1 8 0
B G S E L F - .2 2 0 .3 4 5 * - .1 7 6 - .0 9 5 - .0 9 9
V M A F F E C T - .0 5 4 .2 1 8 - .3 8 3 - .1 5 5 - .5 2 5
V M C O G - .0 2 5 .1 0 3 0 6 6 - .2 6 5 - .3 7 0
V M I N T E R .0 5 5 .5 8 6 -.4 0 1 - .1 3 2 - .6 1 0 *
V M S E L F -.0 2 1 .3 3 6 - .3 1 3 - .2 4 1 - .3 3 8
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
E X A F F E C T E X C O G E X I N T E R E X S E L F
T A S K
.0 5 2 - .1 2 5 .0 2 3 .1 1 3
E M O T IO N .4 6 1 * * .6 4 2 * * 3 3 6 * * .5 1 9 * *
A V O I D - .1 5 7 - .0 4 2 .0 7 5 - .1 0 6
D I S T R A C T
- .1 4 2 .0 4 4 .1 0 0 - .0 5 4
S O C D I V - .1 2 9 - .1 6 0 .0 4 3 - .1 6 8
E X A F F E C T 1 .0 0 0 .7 5 1 * * .4 1 1 * * .8 4 1 * *
E X C O G .7 5 1 * * 1 .0 0 0 .5 1 4 * * .8 0 2 * *
E X I N T E R .4 1 1 * * .5 1 4 * * 1 .0 0 0 .5 2 9 * *
E X S E L F .8 4 1 * * .8 0 2 * * .5 2 9 * * 1 .0 0 0
R E A F F E C T .7 2 3 * * .7 0 3 * * .1 8 0 .8 0 8 * *
R E C O G .6 8 4 * * .6 8 7 * * .2 7 0 .7 6 0 * *
R E I N T E R
.5 6 9 * * .6 5 3 * * .3 1 6 .6 8 8 * *
R E S E L F .6 2 4 * * .5 9 8 * * .2 5 4 .6 9 9 * *
D P A F F E C T .8 2 2 .8 2 3 - .8 2 5 .8 4 7
D P C O G .6 3 7 .6 2 7 - .8 3 7 .7 9 0
D P I N T E R .6 1 8 .6 8 0 - .7 7 3 .4 5 7
D P S E L F .8 5 8 .8 2 7 - .8 8 1 * .8 5 7
L X A F F E C T
a a a a
L X C O G 1 .0 0 0 * .9 9 8 * .9 9 7 * .9 9 8 *
L X I N T E R .9 8 7 .9 9 7 * .9 9 8 * .9 8 1
L X S E L F .9 2 5 .8 8 9 .8 8 0 .9 3 8
B G A F F E C T
.7 5 3 * * .7 6 4 * * .0 1 7 .6 2 9 * *
B G C O G .7 1 6 * * .7 9 9 * * .1 0 9 .7 5 2 * *
B G I N T E R
.6 7 3 * * .8 3 4 * * - .0 0 9 .6 2 7 * *
B G S E L F
.4 5 6 .4 8 6 - .1 6 0 .4 0 0
V M A F F E C T .1 5 9 .5 7 1 - .9 5 4 .5 3 6
V M C O G .4 5 4 .7 9 5 - .8 1 7 .7 6 9
V M I N T E R
- .1 8 3 .2 6 1 - .9 9 9 * .2 2 0
V M S E L F .2 7 7 .6 6 6 -.9 1 1 .6 3 4
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
R E A F F E C T R E C O G R E IN T E R R E S E L F
T A S K .0 5 7 .0 6 2 .0 6 2 .0 5 8
E M O T I O N 4 4 4 * * .4 5 5 * * .4 5 1 * * .4 4 3 * *
A V O I D -.2 9 0 * * - .2 1 6 * - .2 1 7 * -.3 5 1 * *
D I S T R A C T - .1 4 7 - .0 6 7 - .0 7 5 -.1 9 1
S O C D I V -.3 1 7 * * -.2 9 1 * * - .2 9 6 * * -.3 5 5 * *
E X A F F E C T .7 2 3 * * .6 8 4 * * .5 6 9 * * .6 2 4 * *
E X C O G .7 0 3 * * .6 8 7 * * .6 5 3 * * .5 9 8 * *
E X I N T E R .1 8 0 .2 7 0 .3 1 6 .2 5 4
E X S E L F 00
o
00
•
#
.7 6 0 * * .6 8 8 * * .6 9 9 * *
R E A F F E C T 1 .0 0 0 .8 8 9 * * .8 2 9 * * .8 4 8 * *
R E C O G .8 8 9 * * 1 .0 0 0 .8 5 9 * * .8 8 8 * *
R E IN T E R
.8 2 9 * * .8 5 9 * * 1.0 0 0 .8 7 6 * *
R E S E L F .8 4 8 * * .8 8 8 * * .8 7 6 * * 1 .0 0 0
D P A F F E C T .6 5 9 .5 6 8 .7 7 5 * .8 0 5 *
D P C O G .7 1 4 * .6 6 7 .7 8 1 * .8 2 1 *
D P I N T E R .6 3 4 .5 3 5 .7 6 8 * .7 6 5 *
D P S E L F .6 7 3 .7 3 2 * .8 8 4 * * .8 6 0 * *
L X A F F E C T .9 2 6 .9 2 8 .4 4 9 .8 7 8
L X C O G - .7 6 2 - .8 2 4 - .4 7 2 -.9 2 8
L X I N T E R .9 3 8 .9 9 4 * * .6 2 6 .8 9 9
L X S E L F .7 6 4 .5 9 3 - .1 0 7 .5 3 5
B G A F F E C T .2 2 7 .5 1 1 * .3 1 1 .5 5 2 * *
B G C O G .4 7 4 * .5 5 9 * * .3 6 5 .4 9 4 *
B G I N T E R .5 3 3 * * .7 0 4 * * .5 9 8 * * .6 3 1 * *
B G S E L F .1 6 9 .3 5 1 .1 1 3 .4 4 0 *
V M A F F E C T .8 5 9 * * .9 4 0 * * .7 8 2 * .8 9 0 * *
V M C O G .9 0 1 * * .9 1 6 * * .7 1 0 * .8 0 9 *
V M I N T E R .7 5 8 * .7 5 5 * .8 1 1 * .8 6 1 * *
V M S E L F .7 2 3 * .8 0 9 * .8 2 9 * .8 2 8 *
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
D P A F F E C T D P C O G D P I N T E R D P S E L F
T A S K - .0 8 9 .0 4 2 - .1 4 7 .0 0 6
E M O T I O N .8 0 9 * * .6 8 1 * .6 5 6 .7 3 1 *
A V O I D - .8 3 9 * * - .6 7 5 * - .7 9 7 * -.8 7 3 * *
D I S T R A C T - .7 5 6 * - .5 6 7 - .7 0 2 * -.8 0 1 * *
S O C D I V - .8 3 7 * * -.6 2 3 - .8 6 2 * * - .7 8 0 *
E X A F F E C T .8 2 2 .6 3 7 .6 1 8 .8 5 8
E X C O G .8 2 3 .6 2 7 .6 8 0 .8 2 7
E X I N T E R - .8 2 5 - .8 3 7 - .7 7 3 - .8 8 1 *
E X S E L F .8 4 7 .7 9 0 .4 5 7 .8 5 7
R E A F F E C T .6 5 9 .7 1 4 * .6 3 4 .6 7 3
R E C O G .5 6 8 .6 6 7 .5 3 5 .7 3 2 *
R E I N T E R
.7 7 5 * .7 8 1 * .7 6 8 * .8 8 4 * *
R E S E L F .8 0 5 * .8 2 1 * .7 6 5 * .8 6 0 * *
D P A F F E C T 1.0 0 0 .8 8 9 * * .9 3 3 * * .9 0 1 * *
D P C O G .8 8 9 * * 1 .0 0 0 .7 7 1 * .8 2 1 * *
D P I N T E R .9 3 3 * * .7 7 1 * 1.0 0 0 .8 1 7 * *
D P S E L F .9 0 1 * * .8 2 1 * * .8 1 7 * * 1 .0 0 0
L X A F F E C T
a a a a
L X C O G
a a a a
L X I N T E R
a a a a
L X S E L F
a a a a
B G A F F E C T .9 6 9 * .9 2 4 .9 5 1 * .9 7 5 *
B G C O G .9 3 2 .9 6 9 * .7 3 8 .9 7 1 *
B G I N T E R
.9 1 2 .8 2 4 .9 5 8 * .8 5 3
B G S E L F .9 4 5 .9 2 4 .8 2 0 .8 9 0
V M A F F E C T .7 5 2 .9 7 0 - .3 0 2 .9 8 8
V M C O G .6 6 3 .9 9 3 - .4 1 9 .9 6 1
V M I N T E R .9 2 4 .2 1 2 .7 2 1 .5 7 7
V M S E L F .3 8 1 .9 7 7 - .6 9 3 .8 1 7
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
L X A F F E C T L X C O G L X I N T E R L X S E L F
T A S K
-.6 6 1 - . 4 9 2 - .8 0 5 * -.5 0 8
E M O T I O N .3 2 8 .6 7 1 .5 0 7 .6 0 4
A V O I D .5 7 6 .6 2 9 .6 3 7 .8 0 1 *
D I S T R A C T .7 2 6 * .4 3 9 .6 4 9 .5 8 4
S O C D I V -.1 0 0 .1 6 6 - .0 1 3 .2 8 2
E X A F F E C T
a
1 .0 0 0 * .9 8 7 .9 2 5
E X C O G
a
.9 9 8 * .9 9 7 * .8 8 9
E X I N T E R
a
.9 9 7 * .9 9 8 * .8 8 0
E X S E L F
a
.9 9 8 * .9 8 1 .938
R E A F F E C T .9 2 6 - .7 6 2 .9 3 8 .7 6 4
R E C O G .9 2 8 - .8 2 4 .9 9 4 * * .593
R E I N T E R
.4 4 9 - .4 7 2 .6 2 6 -.1 0 7
R E S E L F .8 7 8 - .9 2 8 .8 9 9 .535
D P A F F E C T
a a a a
D P C O G
a a a a
D P I N T E R
a a a a
D P S E L F
a a a a
L X A F F E C T 1 .0 0 0 .2 7 9 .7 5 3 * .578
L X C O G .2 7 9 1 .0 0 0 .7 5 9 * .9 0 5 * *
L X I N T E R .7 5 3 * .7 5 9 * 1 .0 0 0 .8 1 9 *
L X S E L F .5 7 8 .9 0 5 * * .8 1 9 * 1.000
B G A F F E C T
.9 7 7 .8 3 7 .9 4 5 .971
B G C O G .8 0 7 .9 8 7 .9 9 6 .9 8 4
B G I N T E R
.9 7 2 .5 1 7 .7 1 0 .773
B G S E L F .9 9 7 .6 4 0 .8 0 8 .860
V M A F F E C T
.9 8 7 - .8 9 1 .9 9 9 * .829
V M C O G .9 8 8 - .9 8 8 .9 3 3 .961
V M I N T E R .9 9 7 - .9 7 4 .9 5 7 .938
V M S E L F .6 7 2 - .8 6 6 .5 0 0 .921
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
B G A F F E C T B G C O G B G I N T E R B G S E L F
T A S K -.2 2 1 - .0 9 6 - .0 3 9 - .2 2 0
E M O T I O N
.3 2 3 * .4 55 * * .3 6 7 * * .3 4 5 *
A V O I D -.1 1 3 - . 1 6 2 - .1 1 0 - .1 7 6
D I S T R A C T
.0 1 2 - .0 6 0 .0 1 0 - .0 9 5
S O C D I V
- .1 5 7 - .1 5 4 - .1 8 0 - .0 9 9
E X A F F E C T
.7 5 3 * * .7 1 6 * * .6 7 3 * * .4 5 6
E X C O G .7 6 4 * * .7 9 9 * * .8 3 4 * * .4 8 6
E X I N T E R
.0 1 7 .1 0 9 - .0 0 9 - .1 6 0
E X S E L F
.6 2 9 * * .7 5 2 * * .6 2 7 * * .4 0 0
R E A F F E C T
.2 2 7 .4 7 4 * .5 3 3 * * .1 6 9
R E C O G .5 1 1 * .5 5 9 * * .7 0 4 * * .3 5 1
R E I N T E R
.3 1 1 .3 6 5 .5 9 8 * * .1 1 3
R E S E L F .5 5 2 * * .4 9 4 * .6 3 1 * * .4 4 0 *
D P A F F E C T
.9 6 9 * . 9 3 2 .9 1 2 .9 4 5
D P C O G .9 2 4 . 9 6 9 * .8 2 4 .9 2 4
D P I N T E R .9 5 1 * .7 3 8 .9 5 8 * .8 2 0
D P S E L F .9 7 5 * .9 7 1 * .8 5 3 .8 9 0
L X A F F E C T .9 7 7 .8 0 7 .9 7 2 .9 9 7
L X C O G .8 3 7 .9 8 7 .5 1 7 .6 4 0
L X I N T E R .9 4 5 .9 9 6 .7 1 0 .8 0 8
L X S E L F .9 7 1 .9 8 4 .7 7 3 .8 6 0
B G A F F E C T 1 .0 0 0 .8 1 7 * * .7 1 2 * * .7 9 5 * *
B G C O G .8 1 7 * * 1 .0 0 0 .7 4 1 * * .7 5 2 * *
B G I N T E R .7 1 2 * * .7 4 1 * * 1 .0 0 0 .6 5 0 * *
B G S E L F
.7 9 5 * * .7 5 2 * * .6 5 0 * * 1 .0 0 0
V M A F F E C T
.6 8 7 .7 3 6 * .8 4 5 * * .8 2 2 *
V M C O G .6 3 2 .8 2 6 * .6 8 2 .7 3 6 *
V M I N T E R
.4 7 3 .3 4 0 .8 3 6 * * .6 0 7
V M S E L F
.7 2 9 * .6 7 7 .8 1 8 * .8 7 8 * *
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.
VMAFFECT VMCOG VMINTER VMSELF
TASK
-.054 -.025 .055 -.021
EMOTION .218 .103 .586 336
AVOID
-383 -366 -.401 -313
DISTRACT
-.155 -.265 -.132 -.241
SOCDIV
-.525 -.370 -.610* -.338
EXAFFECT .159 .454 -.183 .277
EXCOG
.571 .795 .261 .666
EXINTER -.954 -.817 -.999* -.911
EXSELF
.536 .769 .220 .634
REAFFECT .859** .901** .758* .723*
RECOG .940** .916** .755* .809*
REINTER
.782* .710* .811* .829*
RESELF
.890** .809*
#
•
V O
O O
.828*
DPAFFECT
.752 .663 .924 .381
DPCOG
.970 .993 .212 .977
DPINTER
-.302 -.419 .721 -.693
DPSELF
.988 .961 .577 .817
LXAFFECT .987 .988 .997 .672
LXCOG -.891 -.988 -.974 -.866
LXINTER
.999* .933 .957 .500
LXSELF
.829 .961 .938 .921
BGAFFECT .687 .632 .473 .729*
BGCOG .736* .826* 340 .677
BGINTER
.845** .682 .836** .818*
BGSELF
.822* .736* .607 .878**
VMAFFECT 1 . 0 0 0 .917** .692* .799**
VMCOG .917** 1 . 0 0 0 .607* .799**
VMINTER
.692* .607* 1 . 0 0 0 .758**
VMSELF .799** .799** .758** 1 . 0 0 0
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).
a. Cannot be computed because at least one of the variables is constant.
R eproduced with perm ission of the copyright owner. Further reproduction prohibited without perm ission.

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Asset Metadata

Creator Southerland, Deborah Lee (author)

Core Title The relationship between disordered eating behaviors and coping

Degree Doctor of Philosophy

Degree Program Education--Counseling Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c17-563920

Unique identifier UC11351308

Identifier 9955490.pdf (filename),usctheses-c17-563920 (legacy record id)

Legacy Identifier 9955490.pdf

Dmrecord 563920

Document Type Dissertation

Rights Southerland, Deborah Lee

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA