Object relations and the severity of behavioral and psychological indices of bulimia

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Object relations and the severity of behavioral and psychological indices of bulimia
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OBJECT RELATIONS AND THE SEVERITY OF
BEHAVIORAL AND PSYCHOLOGICAL INDICES OF BULIMIA











BY

STEPHANIE E. HAYMAKER


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1988















ACKNOWLEDGMENTS


I would like to express my gratitude to my chairman,

Dr. Hugh Davis, whose years of guidance, encouragement, and

mutative interpretations have greatly facilitated the

completion of this project and the evolution of my

professional identity; the members of my supervisory

committee, Dr. Russell Bauer, Dr. F. Joseph Kemker,

Dr. Eileen Fennell, and Dr. Nancy Norvell, who in their

research and clinical expertise model a standard of

excellence for their students; Karen Schlain and George

Sweting for their tireless efforts on the computer

analyses; Martin and Marcia Brody for their boundless

Interest, empathy, and optimism; and Douglas Haymaker, for

his steadfast enthusiasm and support.















TABLE OF CONTENTS


Page

ACKNOWLEDGMENTS........................................... ii1

LIST OF TABLES........................................... iv

ABSTRACT.................................................. v

INTRODUCTION ............. ........... .................... . 1

Object Representation. .. .. ......................... 3
Object Representation and Psychopathology.............5
Bulimia Within the Object Relations Framework........ 13
Research Hypotheses ..................... .. ... 19

METHOD .......................... ............... ... ...... 21

Subjects ..................... ........... 21
Measures..................................... ..... 24
Procedure................................ ..... ... 29
Data Analysis...................... ........... .. .. 31

RESULTS .................................................. 33

Interrater Reliability and Related Analyses.......... 34
Object Representation and Severity of Bulimia........34

DISCUSSION............ ..... .. ......... ............... 48

Additional Analyses.... ............ ...... ....... .54
Suggestions for Future Research......................56

APPENDIX SCORING OF CONCEPTUAL LEVEL................... 60

REFERENCES.............................................. 63

BIOGRAPHICAL SKETCH............................ ......... 68








iii














LIST OF TABLES


Table Page

1 One-Way ANOVA for Demographic and
Psychological Variables..........................23

2 Stepwise Regression Predicting Conceptual
Level .......................................... 36

3 Exploratory Stepwise Regressions Utilizing
Classic Indicators of Bulimia as Independent
Variables....................................... 39

4 Exploratory Stepwise Regressions Utilizing
Psychological Variables as Independent
Variables............. .......... ....... 41















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

OBJECT RELATIONS AND THE SEVERITY OF
BEHAVIORAL AND PSYCHOLOGICAL INDICES OF BULIMIA

BY

STEPHANIE E. HAYMAKER

August, 1988

Chair: Hugh Davis, Ph.D.
Major Department: Clinical and Health Psychology

The relationship between conceptual level of object

representation, and the behavioral and psychological

characteristics of bulimia was studied. Twelve treated

bulimics, 13 untreated bulimics, and 43 control subjects

completed a series of questionnaires including open-ended

parental descriptions which were rated for the qualitative

and structural dimensions of object representation. Other

behavioral and psychological indices assessed included

amount of bringing, vomiting, starving, and laxative abuse

per week; general psychological distress; depression; and

aspects of self-consciousness. Results suggested that the

relationship was not linear between conceptual level and

the indices targeted for study. However, psychological

variables related to the construct of conceptual level (for

example, father as nurturant factor) were demonstrated to










be predicted by these indices. Few differences were

observed between the treated and untreated clinical

groups. The implications of these findings were discussed

and recommendations for future research in the area were

offered.














INTRODUCTION


The term "bulimia" literally means "ox hunger" or

voracious appetite, but in recent years has come to mean

binge eating. The syndrome of bulimia is exhibited

primarily by women who alternatingly binge on food and then

purge via fasting, vomiting, or using laxatives. Bulimia

has been termed bulimarexia (Boskind, Lodahl, Sirlin, &

White, 1978), bulimia nervosa (Russell, 1979), compulsive

eating (Ondercin, 1979), and the dietary chaos syndrome

(Palmer, 1979).

There has recently been a dramatic increase in the

reported incidence of bulimia. Although the exact

incidence in the general population is still unknown,

Fairburn (1984) estimates its occurrence in adult women to

be approximately 1-2%. Recent studies suggest that 5-10%

or more college women in the United States may be gorging

and vomiting on a regular basis (Halmi, Falk, & Schwartz,

1981; Hart, 1984; Schwartz, Thompson, & Johnson, 1982).

Some indicate that these estimates are thought to be low,

speculating that some individuals are not willing to admit

to such eating behaviors. Complications from chronic

binging and vomiting include electrolyte disturbances,

cardiac irregularities, kidney dysfunction, swollen










salivary glands, neurological abnormalities,

gastrointestinal disturbances, and dental deterioration.

Hence, the seriousness and prevalence of this disorder make

it a compelling one for study.

There are many competing etiological theories of

bulimia (e.g., Fairburn, 1984; Rosen & Leitenberg, 1984;

Schwartz, 1982; Schwartz, et al., 1982; Sugarman & Kurash,

1982). Recent outcome research suggests that therapies

developed from these theories are equivocal in

effectiveness of treatment, although the number of

controlled studies in the literature is limited (Schleiser-

Stropp, 1984). One intriguing finding from several

treatment studies is that patients, who are recalcitrant to

"symptom-oriented" treatments such as exposure plus

response prevention and antidepressant drug therapy, often

present more severe symptoms and meet the criteria for

certain DSM-III personality disorders (Brotman, Herzog, &

Woods, 1984; Giles, Young, & Young, 1985). Hence, behavior

therapists and physicians are beginning to indirectly

acknowledge the importance of personality variables in the

assessment and treatment of bulimic patients. As Brotman

et al. comment:


Sixteen (73%) of our subjects also had a DSM-III
Axis II diagnosis. In our experience, the
personality disorders seen in this group
contribute to the chronicity of the syndrome.
Research into the personality characteristics of
bulimic patients is needed to aid clinicians in









designing more effective treatment strategies.
(1984, p. 9)


The following paragraphs will review literature relevant to

the conceptualization of bulimia within the framework of

object relations theory. This framework suggests

hypotheses regarding the bulimic's symptoms--why they are

manifest and how they are related to an underlying

personality organization. Specifically the topics of (a)

object representation, (b) the relationship between object

representation and psychopathology, and (c) object

representation in bulimic patients will be discussed, and a

research study examining the object relations theory of

bulimia will be outlined.


Object Representation

Object relations theory represents a recent advance in

modern psychoanalytic thinking that is a result of a

confluence of attachment theory (Mahler, 1968), cognitive

psychology (Piaget, 1954; Werner, 1948), and traditional

ego psychology (e.g., Hartmann, 1958; Rapaport, 1967), all

within a developmental framework. A central focus within

object relations theory is in the development of a

differentiated, cohesive, and integrated representational

world which develops within the context of a maternal or

primary matrix, termed by Winnicott (1965) "a holding

environment." The primary caretaking agent, in turn, is










seen as the mediator of psychological organization. The

concept of "objective representation" refers to the

conscious and unconscious mental schemata, including

cognitive, affective, and experiential components, of

objects encountered in reality (Blatt, 1974). These

schemata begin to develop within an interpersonal matrix as

vague, diffuse, variable sensorimotor experiences of

pleasure and displeasure, and gradually expand and progress

into differentiated, consistent, and relatively realistic

representations of the self and the object world. Earlier

forms of representation are the result of action sequences

associated with need gratification. The intermediate forms

are based on specific perceptual features of the object,

and higher forms of representation are more symbolic and

conceptual.

Blatt (1974) proposed four levels of object

representation: the sensorimotor, perceptual, iconic, and

conceptual. He states:


Representations at the sensorimotor-
preoperational level are based primarily on
particular action sequences in specific
context. Change in need satisfaction, in the
action pattern, or in the context can disrupt the
infant's experience of the object.
Representations at this level lack stability and
flexibility. At the concrete-perceptual level,
the object is recognized in a variety of contexts
and is experienced as a unique entity. But the
representations are literal and have little
differentiation within the perceptual totality.
Representations at the iconic level are more
differentiated, but they are based initially on










more manifest part properties and features, and
they often lack an integration of contradictory
elements. Representations at the conceptual
level are more symbolic; and they transcend the
manifest, the immediate condition, and the
momentary experience; they have greater
continuity and stability; and they integrate
diverse, separate, and apparently contradictory
images into a consolidated representation.
(p. 9)


The work of Blatt (1974) and his colleagues may be

distinguished from the work of Piaget (1954), although

certain similarities are apparent. While Piaget focuses on

cognitive development and primarily was concerned with the

child's processing of inanimate objects, Blatt (1974)

emphasizes the individual's development of interpersonal

perception. The conceptual levels he describes denote the

capacity the individual has to organize, experience, and

act upon the world of other objects. Despite these

different emphases, it is clear that object relations

theorists would agree that cognitive development and the

development of interpersonal perception are related. These

theorists utilize the concept of object representation to

explain the development and manifestation of

psychopathology.


Object Representation and Psychopathology

Early work in the area (Blatt & Ritzler, 1974; Blatt &

Wild, 1974) focuses on the differentiation of the severity

of psychosis by the degree of impairment in the









representation of boundaries between self and nonself, and

between inside and outside. Severity of psychosis was

found to be related to degree of impairment in these

earliest stages of object representation. Once basic

boundary differentiations have been established between

self and nonself and inside and outside, then the

developmental task is to establish self and object

representations, which become increasingly articulated,

diverse, integrated, symbolic, and constant. These later

stages of object representations are relevant to the

understanding of depression (Blatt, 1974).

Blatt (1974) distinguishes two types of depression in

adults: anaclitic and introjective. Anaclitic depression

is characterized by feelings of helplessness, weakness, and

depletion. There are intense fears of abandonment and

desperate struggles to maintain direct physical contact

with the need-gratifying object. Introjective depression,

in contrast, is characterized by feelings of worthlessness,

guilt, and a sense of having failed to live up to

expectation and standards. There are intense fears of a

loss of approval, recognition, and love from the object.

In both anaclitic and introjective depression, there

are impairments in object representation and struggles to

maintain contacts with objects. Yet the former is

characterized by feelings of being unloved--depression is

the result of abandonment and neglect. The latter is









characterized by feelings of being unlovable, where

depression develops as a function of early parent-child

interactions characterized by unrealistic demands,

ambivalence, depracatory experiences, and much hostility.

Recent studies have investigated the relationship

between conceptual level of object representations and the

existence of disorders such as schizophrenia and

depression. Blatt, Brenneis, Schimek, and Glick (1976)

used a comparable system to the one described in Blatt

et al. (1981) to assess the object representations

portrayed in the human figure responses on the Rorschachs

of normal and schizophrenic adolescents. They also traced

the progressive development of object representations in

normal individuals over time. In their comparison study,

patients' human responses were significantly more

inaccurately perceived, distorted, and partial, and were

seen as inert, or engaged in unmotivated, incongruent,

nonspecific, and malevolent activity. However, upon

further analysis, results indicated that patients

consistently gave a significantly greater number of human

responses at lower developmental levels (e.g., quasihuman,

distorted, incongruent, nonspecific, malevolent, and

passive) than did normals on accurately perceived

responses. However, on inaccurately perceived responses

they gave a significantly greater number of developmentally

more advanced human responses (e.g., full human,










functionally articulated, benevolent, and reactive) than

did the normal sample.

Blatt and his colleagues (1976) interpret these

findings to mean that these psychotic patients function at

a developmentally lower level and perceive the world as

distorted, malevolent, and destructive when they try to

maintain contact with the external environment. Psychotic

patients have a greater proclivity for experiencing the

world unrealistically, but within these unrealistic

experiences they are able to function at developmentally

higher levels and experience the world as less

threatening. Blatt et al. summarize their findings:


For psychotic patients, adequate interpretations
of reality seem to be a painful and disruptive
experience, and patients retreat and withdrew to
find comfort and peace. Psychotic patients
appear more disorganized when they are struggling
to deal with and integrate a painful reality and
less disorganized when absorbed in unrealistic
experiences. It is only for the most seriously
disturbed patients, those with severe boundary
disturbances, that both accurately and
inaccurately perceived responses seem to be at a
lower developmental level. (1976, p. 372)


Blatt, Wein, Chevron, and Quinlan (1979) studied

parental representation and depression in normal adults.

These researchers had college students describe both their

mothers and fathers in their standard procedure, and also

had them complete a version of the semantic differential

(Osgood, Suci, & Tannenbaum, 1957) for "my mother," "my










father," "myself as I am," and "myself as I would like to

be" on 17 bipolar adjective scales of the 3 basic factors

of Osgood et al.: evaluation, potency, and activity. The

descriptions were scored according to the system of Blatt

et al. These subjects also completed three measures of

depression: the Depressive Experiences Questionnaire (see

Method for a description of this instrument), the Zung

Self-Rating Depression Scale (Zung, 1965), and a depression

measure from the semantic differential.

Important results from this study included comparisons

of groups of subjects categorized according to dimensions

on the DEQ. Specifically, four groups were formed: those

subjects whose depression was primarily anaclitic (high

Dependency: DEQ Factor I, n = 13), a mix of anaclitic and

introjective depression (high Depression and Self-

Criticism: DEQ Factors I and II, n 13), primarily

introjective (high Self-Criticism: DEQ Factor II, n 20),

and a nondepressed group of subjects who were low on both

types of depression and high on Efficacy (DEQ Factor III,

n_ 16). Blatt et al. (1979) found a progressive increase

in the conceptual level ranging from low to high in the

four respective groups delineated above. There was a

significant planned comparison for the conceptual level of

both mother and father across the four groups.

Other findings included no significant differences

between the conceptual levels of males and females, or for










levels scored from description of mothers or fathers. The

sex-by-parent interaction was insignificant as well. In

females there were significant relationships, however,

between the conceptual level and independent measures of

depression. Higher levels of representation in females

were significantly and negatively correlated with

depression measured on the semantic differential and the

Zung Depression Scale. In addition, higher conceptual

levels were positively correlated with Efficacy (Factor III

on the DEQ). These findings were not found in analyses of

the male subjects' data.

The correlation between conceptual level and Factor II

(Self-Criticism) of the DEQ was not significant in either

females or males. Blatt (1974) indicates that the

conceptual level in introjective depression should be at a

moderate level, whereas in anaclitic depression the

conceptual level should be at the lowest level. He reasons

that the guilt characteristic of the introjective

depression involves the capacity to be self-reflective, to

accept responsibility, and to have some sense of self.

Blatt (1974) states that the relationship between Factor II

and conceptual level is not expected to be linear and is

better addressed by grouping subjects as demonstrated

above.

Blatt, Quinlan, Chevron, McDonald, and Zuroff (1982)

continued this program of research with clinical patients










as subjects. Two clinical populations (inpatients and

outpatients--90% with a primary or secondary diagnosis of

depression) were administered the DEQ, a version of the

semantic differential, the Zung, the Beck Depression

Inventory (Beck, 1967), and the Minnesota Multiphasic

Personality Inventory (MMPI). Relationships demonstrated

in the 1979 study between the DEQ and other measures of

depression were replicated in this clinical population with

a few minor differences.

Furthermore, utilizing median splits on each of the

DEQ factors, patients were again grouped to exemplify four

different types of depression: anaclitic, introjective,

mixed, and nondepressed. These four groups showed highly

significant differences on the Zung, the Beck Depression

Inventory, and the MMPI Depression Scale. There was a

particular tendency for the highest level of depression to

be reported by the mixed group, as well as to show

significant elevation on Feighner criteria (dysphoric mood,

neurovegetative signs, and duration of symptoms for at

least 1 month).

Four clinical judges without knowledge of the DEQ

scores reviewed independently prepared case records of

patients in each of the four groups. Judges attempted to

predict, in a consensus opinion, whether the patient was

high on Dependency, Self-Criticism, on both, or on neither

of these dimensions. The judges correctly predicted 56% of










the cases. Assessment of these predictions through the use

of the Kappa statistic indicates that judges were able to

predict type of depression at a level significantly greater

than chance. The most frequent error occurred with the

mixed group where the judges correctly identified an

elevation on one factor but failed to note the elevation on

the other factor.

These results suggest that dependency and self-

criticism are primary dimensions of depression that

differentiate types of depression within a clinical

context. Blatt et al. (1979) emphasize the need to study

these two dimensions further and to investigate their

relation to aspects of the clinical process, such as

precipitating life events, presenting symptoms, and

differential response to various treatment modalities.

They also point to the advantage in considering forms of

depression as deviations of normal developmental processes

and as the consequerne of exaggerations and distortions of

natural life experiences:


Many psychopathological phenomena may be impaired
or distorted modes of adaptation established
early in the life cycle, perpetuated by
subsequent untoward life experiences, and finally
expressed when the individual experiences severe
stress related to the issues involved in the
initial establishment of the maladaptive modes of
coping. Many forms of psychopathology may not be
disease entities but maladaptive coping styles
that have a continuity with normal developmental
processes. (p. 122)











Another form of psychopathology that has been

conceptualized as a manifestation of inadequate object

representation is, of course, bulimia. The following

paragraphs will describe this disorder as it has been

delineated within the framework of object relations theory.



Bulimia Within the Object Relations Framework

Selvini-Palazolli (1978) has written an accepted

formulation of the meaning of the body in the anorexic

syndrome. The theory states that the anorexic projects the

bad internalized mother into her body so the body becomes

identified with the maternal object and experienced as the

maternal object. Consequently, the body becomes a

persecutory object which must be controlled totally lest it

devour or smother the patient. Sugarman and Kurash (1982)

question the validity of this with bulimia, which they view

as a more developmentally primitive ego boundary

disturbance. These theorists utilize a developmental model

emphasizing both object relations and cognitive dimensions

of development:

Bulimia reflects an arrest at the earliest stage
of transitional object development. The failure
of adequately separate both physically and
cognitively from the maternal object during the
practicing subphase leads to a narcissistic
fixation on one's own body at the expense of
reaching out to other objects in a wide world,
through the use of external transitional
objects. This arrest in the area of transitional










objects has profound consequences as regard to
self-other boundary differentiation,
individuation and capacity for symbolization.
(p. 122)


Self and object representations associated with this

developmental period are sensorimotor in nature (Blatt,

1974). Thus, at this time objects are almost completely

embedded within the infant's interaction with them. Hence

Sugarman and Kurash (1982) indicate that self and object

representations form via action or motor sequences of the

self, with much emphasis given to the sensory quality of

the object represented. Thus, the practicing infant's own

body is its first transitional experience, later moving on

to external transitional objects which require more

cognitive complexity (because they symbolize a merged

maternal-infant representation as well as being external

objects in their own right). The transitional object

serves as an external cue to evoke symbolically the

illusion of reunion of the mother. During the later phase

of rapproachement in normal development, the child develops

to evoke a representation of the mother in her absence and

without the aid of external oje.

In the bulimic, this process is interrupted. Parental

influences that violate transactional boundaries via under-

or overinvolvement inhibit normal infant striving for

autonomy and activity associated with the practicing

subphase. The mother's symbiotic tie to the infant










precludes the symbolization of the reunion with her. The

position of Sugarman et al. (1982) can be summed up in

their comment:


The sensorimotor nature of the self and object
representations of this developmental period
contribute also to the bulimic's concreteness.
Consequently, these patients must engage in
concrete bodily action in order to again regain
the experience of the needed object. It is
likely that the acts of eating (in childhood) and
later gorging (in adolescence) become the need-
gratifying activities which allow the bulimic to
develop a sensorimotor representation of the
mother. Food is not the issue, rather it is the
bodily action of eating which is essential in
regaining a fleeting experience of the mother.
The dread of fusion and other psychodynamics
mobilized by the experience of the symbiotic
mother often lead to vomiting, another bodily
action. (p. 125)


This object relations approach to bulimia has been

formulated through several case studies in the literature

(e.g., Lerner, 1983; Masterson, 1977) but has rarely been

subject to empirical test. Clearly, such investigations

are warranted to support the use of these formulations in

the planning of interventions.

Object representation in bulimic individuals has not

been studied in depth. In fact, the research on

psychological test data (both personality and projective)

in this population is in its early stages. One study

compared the MMPI profiles of restricting anorectics,

binge/purge anorectics, and normal weight bulimics (Norman

& Herzog, 1983). Both anorectic groups demonstrated










significant elevations on the Depression (2) scale. Both

bulimic groups demonstrated elevations on the Psychopathic

Deviate (4) scale. The normal weight bulimic groups had a

4287 configuration, with minimal differences between 8 and

7. Thirty normal weight bulimics tested by Pyle, Mitchell,

and Eckert (1981) also demonstrated the 4287

configurations.

Allerdissen, Florin, and Rost (1981) gave the Picture

Frustration Test and several self-report inventories to 28

bulimics and 28 control subjects. Their bulimics tended

not to blame others for frustrating them, had greater

perception of external control, less sexual pleasure, and

more depression than the controls.

A recent in-depth study by Wallach and Lowenkopf

(1984) examined five bulimic women's responses on the

WAIS-R, Rorschach, TAT, figure drawings, and MMPI. Caution

must be taken in examining the results of such a limited

sample. Results included a mean MMPI profile similar to

the profile observed in the study of Norman and

Herzog--42876. Rorschach responses were scored according

to Exner's system. The only difference between the

subjects and a normative nonpatient sample was that

bulimics gave fewer responses with human content, implying

withdrawal from human contact and deficits in interpersonal

relationships. This may be due to a bias in the patient

sample, however. Other aspects of the patients' protocols










were entirely heterogeneous. The TAT stories were also

heterogeneous, although certain themes did emerge across

protocols upon analysis of the first two cards.

Specifically, the themes of complying to external (e.g.,

familial) demands and limited rebellion emerge from these

test data.

Joyce Aronson (1986) studied the relationship between

object relations and both demographic and behavioral

variables in a normal weight bulimic population. Forty-

nine female patients who met DSM-III criteria for bulimia

were given a self-administered questionnaire to elicit

demographic and behavioral information and the Blatt

Assessment of Qualitative and Structural Dimensions of

Object Representations to measure conceptual level. She

found that a combination of five variables could predict

level of object relations to a multiple R of .59 (R-square

- .35): (a) days per week laxative abuse, (b) use of

starvation, (c) days per week vomiting, (d) days per week

when drinking, and (e) residence status (living at home).

As Brotman et al. (1984) and others have noted, there

is still much to be understood about the relationship

between personality organization and bulimia. The

preceding paragraphs have reviewed the literature relevant

to the conceptualization of bulimia within the framework of

object relations theory. This framework suggests

hypotheses regarding the bulimic's symptoms--why they are










manifested and how they are related to underlying

personality organization. Recent studies have investigated

the relationship between conceptual level and the nature of

disorders such as schizophrenia and depression, but little

attention has been delegated to the empirical study of the

object relations theory of bulimia.

The formulations of Sugarman and Kurash (1982) are

often supported in the literature with case studies of

patients with borderline personality diagnosis, or who at

points have also met the criteria for anorexia nervosa.

However, limited emphasis has been given to elucidating

empirically the connections between personality function

and symptomatology. One question that emerges is "Where is

the pathology--in the behavior or in the personality

organization?" In the current study, object representation

will be studied in an effort to focus on aspects of

personality that may be related to presenting symptoms.

More specifically, the relationship between conceptual

level of object representation and severity of classic

indicators of bulimia will be studied. Given the function

of the symptoms of bulimia with object relations theory

(that singing and vomiting are efforts to evoke an early

sensorimotor experience of the illusion of union with the

mother, because bulimics do not have enduring mental

representations of their relationship with the mother), a

question that may be forwarded concerns the severity of










these symptoms. Do those bulimics at lower conceptual

levels demonstrate more severe symptoms than those at

higher levels due to their inability to rely on conceptual

evocation of enduring objects? The relationship between

conceptual level and the severity of bulimic and other

psychological symptoms will be examined in the present

study.



Research Hypotheses

Hypotheses for this study are:

1. Level of object representation will be predicted

by severity of bulimia as measured by number of binges per

week, episodes of vomiting per week, episodes of laxative

abuse per week, episodes of starving per week, level of

depression, and amount of alcohol consumed per week.

Specifically, those at lower conceptual levels will

demonstrate greater indices of symptom severity.

2. Differences between bulimics in treatment and

bulimics not in treatment will be observed on a number of

psychological variables. Hence, exploratory analyses will

focus on relationships between factors related to object

representation (e.g., conceptual level, mother as striving

factor, father as striving factor, mother as nurturant

factor, father as nurturant factor) and factors related to

bulimia and other psychological symptoms (e.g., social










anxiety, introjective and anaclitic depression) within and

between groups of treated, untreated, and control subjects.

3. Subjects will demonstrate a progressive increase

in conceptual level ranging from lower to higher when

grouped into four categories on the basis of their scores

on the Depressive Experiences Questionnaire. These groups

will include those subjects whose depression is primarily

anaclitic (high Dependency--DEQ Factor I), a mix of

anaclitic and introjective (high on both Factors I and II),

primarily introjective (high Self-Criticism--DEQ Factor

II), and those who are nondepressed (low on both Factors I

and II, and high on Efficacy--Factor III).














METHOD


Subjects

Clinical subjects were recruited from the Psychology

Clinic, the Counseling Center, and the Eating Disorders

Clinic at the University of Florida during a 1-year period

from January to December, 1986. Patients at these sites

meeting the DSM-III criteria for bulimia were invited by

their intake therapist to participate in a research study

of behaviors and interpersonal relationships. Bulimia was

not mentioned as the target for study. Clinical subjects

were also located via a screening of the undergraduate

Introductory Psychology classes at the University of

Florida. These students completed the Bulimia Test

included in a battery of 10 to 12 measures given at the

start of the semester as part of a class requirement.

Those testing above the cut-off score (using the screening

cut-off of 88) were called and invited to participate in a

study of "Behavior and Interpersonal Relationships" to

fulfill additional course requirements. No indication was

given to these individuals that they had been selected due

to their responses on the BULIT. Control subjects were

also Introductory Psychology students participating for

class credit and were recruited via posted sign-up sheets










at the Psychology Building. They, too, were invited to

participate in a study of behaviors and interpersonal

relationships. All control subjects achieving scores of 88

or higher on the BULIT were included in the untreated

clinical group if the questionnaire data indicated they met

the DSM-III criteria for bulimia. If they did not meet the

criteria, they remained in the control group. Twelve

bulimics currently in treatment, 13 bulimics not in

treatment, and 43 control subjects were included in the

study. All clinical subjects included in the study were

female. Thus only female students were recruited as

controls.

Clinical subjects ranged in age from 18 to 32. Mean

ages for the untreated and treated bulimic subjects were

19.7 and 21.4, respectively (n 13 and n 12). Table 1

summarizes results of analysis of variance (ANOVA)

performed on the three clinical groups for relevant

variables. Because few differences were observed between

the two clinical groups, they will be combined as one

clinical bulimic group for some of the data analyses.

Educational levels ranged from high school graduate to

college graduate. All but one clinical subject were

college students, though many had part-time jobs and one

student had a full-time job. Students majored in a

diversity of subjects ranging from education, social

sciences, humanities to sciences. Total family income of















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these individuals ranged from less than $10,000 to more

than $50,000 per year. Mean yearly family income was

$30,000 to $50,000. Weight of the subjects ranged from 102

to 227 pounds with a mean of 132 pounds. Height ranged

from 4'6" to 6' with a mean of 5'4". All clinical subjects

met the DSM-III criteria for bulimia at the time of their

participation in the study, as determined by clinical

interview or questionnaire data. Subjects were excluded

who also currently presented with anorexia nervosa. One

patient reported a past history of anorexia nervosa.



Measures

Measure of Object Representation

Object representation will be assessed according to

the rating system of Blatt et al. (1981) developed to judge

written descriptions of significant others. Subjects are

given a blank page with the instructions: "Describe your

mother" on one page, followed by a request on the next page

to "Describe your father." Five minutes are allotted for

each description. These descriptions are rated for

qualitative characteristics as well as conceptual level of

object representation.

Qualitative characteristics (attributed to the parents

by the subject) are measured by a series of 14 categories

scored on a 7-point scale by a trained rater. These

dimensions are Affectionate, Ambitious-Driving,









Malevolent-Benevolent, Cold-Warm, Degree of Constructive

Involvement, Intellectual, Judgemental, Negative-Positive

Ideal, Nurturant, Punitive, Successful, Weak-Strong, Degree

of Ambivalence, and Verbal Fluency. Blatt et al. (1981)

report interrater reliability (alpha coefficient) for three

raters to range from .68 for "affectionate" to .93 for

"successful."

In a factor analysis of their scoring system, Blatt

et al. (1981) found the first 13 characteristics (verbal

fluency is considered separately) loaded on two factors.

The first factor, parent as nurturant, was composed of

nurturance (factor loading .90), positive ideal (.90),

benevolence (.88), warmth (.87), constructive involvement

(.84), affectionate (.80), strength (.67), and successful

(.65). The second factor, parent as striving, was made up

of judgemental (.90), ambitious (.89), punitive (.88),

intellectual (.82), ambivalence (.60), successful (.48),

and strength (.48). The scale scores for parent as

nurturant and parent as striving were attained by adding

the scale scores of the characteristics which loaded on

that factor. Overall, the nurturant factor and striving
factor had a reliability of .95 and .93, respectively, for

all three judges rating the original sample of Blatt et al.

The 14th characteristic, verbal fluency, is measured

by coding the length of the typed description (e.g., 1-4

lines 1, 5-7 lines 2, 8-10 lines 3, more than










19 lines 7). When this factor was analyzed along with

the other 13 characteristics, verbal fluency formed a

third, single-variable factor.

Conceptual level is designated via a single-scale

score of 1-9 to denote one of the five possible levels of

development (see Appendix for descriptions from scoring

manual). Again, these levels are sensorimotor-

preoperational (scaled score = 1), concrete-perceptual (3),

external iconic (5), internal iconic (7), and conceptual

(9). Interrater reliability for scoring conceptual level

reported by Blatt (1981) ranged from .88 (between expert

and trained rater) to .70 (between expert rater and

untrained rater) to .85 (for all three raters).

Measures of Psychopathology

The Bulimia Test (BULIT). The BULIT (Smith & Thelen,

1984) is a 32-item, self-report, multiple-choice scale

designed to assess the symptoms of bulimia. The measure

may be used to assess severity of symptoms in clinical

populations and also to identify bulimia in a more general

population. Higher scores on the BULIT indicate greater

severity of symptoms. Test-retest reliability has been

demonstrated to be .87 over a 2-month period. Cross-

validation studies across two independent samples of normal

and bulimic subjects suggest that the scale has predictive

diagnostic ability. The BULIT was further validated on a

nonclinical college population. Scores were predictive of









diagnosis as judged on the basis of independent clinical

interviews. The scale was also shown to be correlated with

other measures of bulimic behaviors and attitudes, the

Binge Scale and the Eating Attitudes Test (.93 and .68,

respectively).

Depressive Experiences Questionnaire (DEQ). The DEQ

(Blatt, D'Affliti, & Quinlan, 1976) is a 66-item

questionnaire that assesses feelings about both the self

and general interpersonal relationships. These feelings

are thought to be relevant to depression but not in

themselves manifest symptoms of depression. Three highly
stable factors (Dependency, Self-Criticism, and Efficacy)

have been identified in several independent subject samples

(Blatt et al., 1976). Estimates of reliability (alpha

coefficients) for the three factors are .81, .80, and .72,

respectively. The construct validity of these factors was

demonstrated by differential correlations with adherence to

sex-role stereotypes (Chevron, Quinlan, & Blatt, 1978),

social class and social mobility (Steele, 1978), and

qualities and cognitive organization in the description of

parents (Blatt, Wein, Chevron, & Quinlan, 1979).

Self-Consciousness Inventory. The Self-Consciousness

Inventory (Fenigstein, Scheier, & Buss, 1975) is a 23-item

scale developed to assess self-awareness, or the tendency

to direct self-attention inward or outward. Each item is

rated on a scale of 0 (extremely uncharacteristic) to 4









(extremely characteristic). Factor analysis produces three

subscales: private self-consciousness, public self-

consciousness, and social anxiety. The first two scales

address processes of self-focused attention and the third

may be considered a reaction to these processes. The

private self-consciousness factor involves attending to

one's inner thoughts and feelings, e.g., "I reflect about

myself a lot." The public self-consciousness factor

addresses a general awareness of the self as a social

object that has an effect on others, e.g., "I'm very

concerned about the way I present myself." The third

factor, social anxiety, addresses discomfort in the

presence of others, e.g., "I feel anxious when I speak in

front of a group." Good test-retest reliability has been

demonstrated for the three subscales (.84, .79, .83,

respectively) and for the scale overall (.80). The authors

also present studies supporting the construct validity of

this measure.

Brief Symptom Inventory (BSI). The Brief Symptom

Inventory (Derogatis & Spencer, 1982) is a 53-item self-

report symptom inventory designed to assess the

psychological symptom patterns of psychiatric and medical

patients as well as nonpatient individuals. Each item is

rated on a 5-point scale of distress (0-4), ranging from

"not at all" (0) to "extremely" (4). The BSI may be scored

for three global indices and is comprised of nine primary










symptom dimensions. These dimensions are Somatization,

Obsessive-Compulsive, Interpersonal Sensitivity,

Depression, Anxiety, Hostility, Phobic Anxiety, Paranoic

Ideation, and Psychoticism. This measure is essentially

the brief form of the SCL-90-R (Derogatis, 1977).

Evaluation of that instrument suggested that five to six of

the items on each subscale were sufficiently saturated to

sustain an operational definition of each syndrome

construct, and the highest loading items of each dimension

were selected to form the BSI. Adequate test-retest

reliability is demonstrated over a 2-week period for the

global indices (e.g., .90 for the Global Symptoms Index)

and for the subsoale measures (which range from a low of

.68 for Somatization to a high of .91 for Phobic

Anxiety). Derogatis and Spencer (1982) summarize

considerable evidence of studies confirming the convergent,

discriminant, construct, and predictive validity of the

instrument, as well.



Procedure

Clinical subjects currently in treatment were invited

to participate in a research study on bulimia by their

therapist or intake interviewer. Those who agreed were

contacted by phone and scheduled for a session during which

they completed the research batteries. Clinical subjects

were tested individually with a researcher available in an









adjoining room to answer their questions about the study.

Clinical subjects not currently in treatment, as well as

control subjects, were recruited as described in the

Subjects section, above. They were also tested

individually. Normal control subjects' sessions were run

in groups of 3-4 students. All subjects completed the

questionnaires without discussion among group members.

Instructions were identical for clinical and nonclinical

subjects. They were instructed to complete each

questionnaire in succession and reminded to allot 5 minutes

for each parental description. They were permitted to ask

questions of the researcher, although very few utilized

this option. Most questions involved clarification of a

word, wherein a synonym was supplied. Several subjects

inquired about the alcohol amount question. They were told

to detail their answer in approximate ounces of alcohol per

drink. Subjects were asked to return the questionnaire

packet to the researcher upon finishing. Following the

sessions, all participants were debriefed via a short

written statement that explained the study. Appropriate

references were also included with this statement. These

references were Blatt's (1974) seminal article on object

representation and anaclitic versus introjective

depression, and the paper of Sugarman and Kurash (1982) on

the body as a transitional object in bulimia.









Data Analysis
For Hypothesis 1, a stepwise linear regression

analysis was performed to determine if level of object

representation was predicted by severity of bulimia as

measured by number of binges per week, episodes of vomiting

per week, episodes of laxative cause per week, episodes of

starving per week, level of depression, and amount of

alcohol consumed per week. Analyses were performed across

clinical subjects and also for each condition (controls,

untreated bulimics, and treated bulimics).

For Hypothesis 2, a series of stepwise linear

regression analyses were performed to determine differences

observed between bulimics in treatment and not in treatment

on a number of psychological variables. This investigation

focused on relationships between factors related to object

representation (e.g., conceptual level, mother as nurturant

and striving factors, father as nurturant and striving

factors) and factors related to bulimia and other

psychological symptoms (e.g., social anxiety, introjective

and anaclitic depression). Again, analyses were performed

across clinical subjects and separately for each condition.

For Hypothesis 3, a one-way analysis of variance was

performed on subjects' conceptual level scores when

subjects were grouped according to their responses on the

Depressive Experiences Questionnaire. Those who scored

high on the Dependency factor were placed in the first





32


group and those who scored high on the Self-Criticism

factor were placed in the second. Those who scored high on

both these factors were placed in the third group. Those

who scored low on both factors and high on the third

factor, Efficacy, comprised the fourth group.














RESULTS


In the first section, the reliability statistics for

the scoring of the written parental description are

presented, as well as other findings related to the scoring

of these instruments. The following sections will pertain

to the three hypotheses set forth. The results for

Hypothesis 1 address the relationship between the dependent

variable, conceptual level, and the classic indicators of

bulimia. This finding is summarized in Table 2, as are

summarized the results pertaining to the relationship

between the dependent variable, conceptual level, and the

more psychological indices targeted for study. Hypothesis

2 focuses on the exploration of additional psychological

variables as both independent and dependent variables and

addresses differences between subject groups as well.

Results for Hypothesis 2 are summarized in Tables 3 and

4. Table 3 delineates findings of analyses in which

various psychological indices are the dependent variables

and classic indicators of bulimia are the independent

variables. Table 4 delineates findings of exploratory

analyses in which various psychological indices are studied

as both dependent and independent variables. Finally, the









findings for Hypothesis 3 are summarized in the text and

are then followed by results of additional analyses.



Interrater Reliability and Related Analyses

Reliability of the parental description scoring was

assessed for the primary and independent raters' scores.

Twenty father and 20 mother descriptions were randomly

selected for this process. Cohen's statistic Kappa was

calculated to be .62 for the 40 descriptions rated.

Percentage agreement (within one scoring level) was .70 for

both mother and father descriptions. Discrepancies between

the two raters were clarified via discussion, with ratings

then changed accordingly.

Student's t-tests were performed between mean

conceptual level for mother and mean conceptual level for

father across all subjects and by condition. No

significant differences were found. Hence, the average of

the two scores was used for all analyses to represent

conceptual level. This practice was established by

Blatt et al. (1981) and is implemented in the majority of

his studies.


Object Representation and Severity of Bulimia

Hypotheses 1 and 2 address the relationship between

object representation and severity of bulimia. To recap,

Hypothesis 1 suggested that level of object representation









would be predicted, via stepwise linear regression, by

severity of bulimia as measured by number of binges per

week, episodes of vomiting per week, episodes of laxative

abuse per week, episodes of starving per week, level of

depression, and amount of alcohol consumed per week.

Specifically, those at lower conceptual levels would

demonstrate greater indices of symptom severity. As

indicated in Table 2, across clinical subjects, no classic

indicators of bulimia severity accounted for variance in

conceptual level, utilizing a stepwise regression

analysis. Independent variables utilized in that equation

were times per week vomiting (XVOM), binging (XBINGE),

exercising (XEXER), fasting (XFAST), and amount of alcohol

use (ALCAMT). In that population, however, significant

predictors were observed when the following independent

variables were entered into equations: psychological

distress (GSI), alcohol use (ALCAMT), general depression

(DEPBSI), introjective (DEQI) and anaclitic (DEQD)

depression, private (PRIVSC), public (PUBSC), and total

self-consciousness (TOTSC), social anxiety (SOCANX), mother

as nurturant (MOMFAC1) and striving (MOMFAC2) factor

scores, father as nurturant (DADFAC1) and striving

(DADFAC2) factor scores, and degree of perception of self

as overweight (PERC). Increasing father as nurturant

scores were predictive of higher conceptual level scores,












Table 2
Stepwise Regression Predicting Conceptual


Level


Independent
Group Variablea Model R2 F prob>F


1 + 2 DADFAC1 .1954 5.04 .036
(n = 25)

0 (-) GSI .0588 2.56 .117
(n 43)


(n 13)

2
(n 12)

0 + 1 + 2 (-) DEQI .0840 5.87 .018
(n 68) (-) SOCANX .1247 4.49 .015


aDADFAC1 father
distress, DEQI -
anxiety.


as nurturant, GSI psychological
introjective depression, SOCANX social









accounting for 20% of the variance. To review the factor

"father as nurturant" is a reflection of the following

dimensions: nurturance, positive ideal, benevolence,

warmth, constructive involvement, affectionate, strength,

and successful. For the control condition (0), a trend was

noted for lower GSI scores (an index of psychopathology or

psychological distress on the BSI) to be predictive of

higher conceptual levels. This trend was not found in the

untreated clinical (1) or treated clinical (2)

conditions. For conditions 1 and 2 analyzed separately, no

variables accounted for variance in conceptual level.

Across all conditions combined, lower levels of

introjective depression and social anxiety were predictive

of conceptual level, together accounting for 12% of the

variance.

Hypothesis 2 suggests that differences between

bulimics in treatment and not in treatment would be

observed on a number of psychological variables. Hence

exploratory stepwise regression analyses would focus on

relationships between factors related to object

representation (e.g., conceptual level, mother as striving

factor, father as striving factor, mother as nurturant

factor, father as nurturant factor) and factors related to

bulimia and other psychological symptoms (e.g., social

anxiety, introjective and anaclitic depression) within and

between groups of treated, untreated, and control subjects.











To address Hypothesis 2, two exploratory stepwise

regressions were performed. The first series are

summarized in Table 3 and utilized the following

independent variables: time per week vomiting, bringing,

exercising, fasting, use of alcohol, psychological

distress, introjective, and anaclitic depression scores.

Examination shows that higher father as nurturant factor

scores were predicted by lower introjective depression

scores, fewer times per week bringing, and higher

psychological distress scores across the two clinical

groups. No variables accounted for variance in DADFAC1 in

the control group, and lower introjective depression scores

were predictive of DADFAC1 for the treated and untreated

bulimic groups analyzed separately. Across clinical

groups, fewer times per week exercising and amount of

alcohol consumed were predictive of father as striving

factor scores. Again, to review, the father as striving

factor reflects the following dimensions: judgemental,

ambitious, punitive, intellectual, ambivalent, successful,

and strength. No variables were predictive of DADFAC2 for

the control subjects. Fewer episodes of exercising were

predictive of DADFAC2 in the untreated clinical group, and

psychological distress was predictive of that variable in

the treated group.









Table 3
Exploratory Stepwise Regressions Utilizing Classic
Indicators of Bulimia as Independent Variables


Dependent Independent
Variablea Group Variableb Model R2 F prob>F


DADFAC1 1 + 2 (-) DEQI .2055 5.43 .030
(-) XBINGE .3103 3.03 .097
GSI .3844 2.28 .147
0 NONE -
1 (-) DEQI .1985 2.47 .147
2 (-) DEQI .2878 3.63 .089

DADFAC2 1 + 2 (-) XEXER .2335 6.39 .020
ALCAMT .3531 3.69 .069
0 NONE -
1 (-) XEXER .2772 3.83 .079
2 GSI .4318 6.84 .028

MOMFAC1 1 + 2 (-) XVOM .2408 6.66 .017
0 ALCAMT -
1 NONE -
2 XEXER .3772 5.45 .044
(-) XVOM .6268 5.35 .049
GSI .9445 40.09 .001
MOMFAC2 1 + 2 NONE -
0 NONE -
1 (-) DEQI .1958 2.48 .1466
2 NONE -

DEQD 1 + 2 NONE -
0 GSI .1853 9.32 .004
1 GSI .2813 3.91 .076
2 NONE -

DEQI 1 + 2 ALCAMT .1650 4.18 .055
0 GSI .1985 10.15 .003
1 NONE -
2 ALCAMT .2549 3.52 .113

aDADFAC1 father as nurturant, DADFAC2 father as
striving, MOMFAC1 mother as nurturant, MOMFAC2 mother
as striving, DEQD anaclitic depression, DEQI -
introjective depression. bDEQI introjective depression,
XBINGE = times per week bringing, GSI = psychological
distress, XEXER times per week exercising, ALCAMT =
amount of alcohol use, XVOM times per week vomiting.









For the mother as nurturant factor scores, less

episodes of vomiting per week were predictive across the

clinical groups. Amount of alcohol consumed was predictive

of MOMFAC1 in the control group, and no variables were

predictive of that variable in the untreated clinical

group. For condition 2 analyzed separately, more

exercising, less vomiting episodes and higher psychological

distress scores were predictive of MOMFAC1. For mother as

striving factor scores, no variables were predictors for

either condition 0 or 2 analyzed separately, or for the

clinical groups combined. Lower introjective depression

scores were predictive of MOMFAC2 for condition 1

subjects. No variables were predictive of anaclitic

depression scores in the combined clinical group, and in

condition 2 analyzed separately. Psychological distress

scores were predictive of this variable for conditions 0

and 1 analyzed separately, however. Across both clinical

conditions and for condition 2 only, amount of alcohol

consumed was predictive of introjective depression. No

variables were predictive of that variable for condition

1. Psychological distress was predictive of introjective

depression in the control group.

The second series, summarized in Table 4, utilized the

following independent variables: conceptual level;

psychological distress (GSI); alcohol use; general










Table 4
Exploratory Stepwise Regressions Utilizing Psychological
Variables as Independent Variables

Dependent Independent
Variablea Group Variable Model R2 F prob>F

BULIT 1 + 2 (-) PUBSC .2458 6.84 .016
DEPBSI .4434 7.10 .015
DEQD .5831 6.36 .021
(-) DADFAC1 .6472 3.26 .087
0 (-) PERC .3936 26.61 <.0001
DEQI .4575 16.85 <.0001
1 NONE -
2 (-) PUBSC .4474 7.24 .024

DADFAC1 1 + 2 (-) DEQI .2055 5.43 .030
ALC .3828 5.74 .026
CONTOT .4947 4.20 .054
DEPBSI .5699 3.14 .093
SOCANX .6374 3.16 .093
0 CONTOT .1834 9.20 .004
1 TOTSC .4164 7.13 .024
SOCANX .7086 9.02 .015
DEQI .9044 16.39 .004
ALC .9530 7.23 .031
2 CONTOT .5307 10.17 .011
(-) SOCANX .7058 4.76 .061
DADFAC2 1 + 2 ALCAMT .2024 5.32 .031
0 CONTOT .1226 5.73 .021
1 (-) PUBSC .2604 3.52 .090
2 GSI .4318 6.84 .028
TOTSC .8282 18.46 .003
MOMFAC1 1 + 2 ALC .1666 4.19 .053
0 CONTOT .1765 8.78 .005
PERC .3062 7.47 .009
ALCAMT .4234 7.92 .007
1 NONE -
2 PUBSC .2617 3.19 .108
MOMFAC2 1 + 2 (-) PERC .1468 3.61 .071
CONTOT .2353 2.31 .144
0 (-) PERC .0640 2.80 .102
1 (-) PERC .3674 5.80 .037
CONTOT .7004 10.01 .012
(-) DEQI .7870 3.25 .105
(-) DEQD .8777 5.19 .057
2 (-) CONTOT .2395 2.83 .127
(-) SOCANX .4402 2.86 .129










Table 4--continued.


Dependent Independent
Variablea Group Variableb Model R2 F prob>F


DEQD 1 + 2 (-) PERC .1583 3.95 .060
GSI .2742 3.19 .089
0 GSI .1853 9.32 .004
1 NONE -
2 PERC .4069 6.14 .034

DEQI 1 + 2 (-) PERC .2145 5.73 .026
ALCAMT .4006 6.20 .022
(-) DADFAC1 .5542 6.54 .019
0 TOTSC .2827 16.15 <.0001
1 NONE -
2 (-) PERC .6720 18.44 .002

aBULIT Bulimia Test, DADFAC1 father as nurturant,
DADFAC2 father as striving, MOMFAC1 = mother as
nurturant, MOMFAC2 mother as striving, DEQD anaclitic
depression, DEQI introjective depression. bPUBSC -
public self-consciousness, DEPBSI general depression,
DEQD anaclitic depression, DADFAC1 father as nurturant,
PERC degree of perception of self as overweight, DEQI -
introjective depression, ALC days per week alcohol use,
CONTOT conceptual level, SOCANX social anxiety, TOTSC -
total self-consciousness, ALCAMT amount of alcohol use,
GSI psychological distress.









depression; introjective and anaclitic depression; private,

public, and total self-consciousness; social anxiety;

mother and father as nurturant factor scores; mother and

father as striving factor scores; and degree of perception

of self as overweight. Results of these analyses will be

reported according to dependent variable and will be

presented in relation to findings from Table 3 in order to

integrate the findings.

The Bulimia Tests (BULIT)

For scores on the Bulimia Test as the dependent

variable, across combined conditions 1 and 2, higher BULIT

scores were predicted by lower public self-consciousness

scores, higher general depression scores, lower anaclitic

depression scores, and lower father as nurturant factor

scores. For condition 0, BULIT scores were predicted by

less perception of the self as overweight and higher

introjective depression scores. Thus, as BULIT scores

approached the clinical range, individuals were less likely

to acknowledge considering themselves as overweight, but

more likely to experience symptoms of self-critical

depression. No variables were predictive of BULIT scores

for condition 1. For condition 2, the only variable

predictive was less public self-consciousness, perhaps

related to their ability to seek help for an often "secret"

problem.









Father as Nurturant Factor Score: DADFAC1

Across conditions 1 and 2, DADFAC1 was predicted by

lower introjective depression scores, fewer episodes per

week binging and higher GSI scores. Also across conditions

1 and 2, DADFAC1 could be predicted by lower introjective

depression scores, more frequent days of alcohol use,

higher conceptual levels, greater general depression, and

more social anxiety. No variables were predictors for

DADFAC1 in condition 0. DADFAC1 was predicted by lower

scores of introjective depression when both conditions 1

and 2 were analyzed separately.

Father as Striving: DADFAC2

Across conditions 1 and 2, DADFAC2 was predicted by

fewer days exercising and greater amounts of alcohol

consumption when drinking. No variables were predictive of

DADFAC2 when condition 0 was analyzed separately. For

subjects in condition 1, fewer episodes of exercising was

predictive of higher DADFAC2 scores. For those in

condition 2, higher GSI scores were predictive of higher

DADFAC2 scores.

Mother as Nurturant Factor Scores: MOMFAC1

Across conditions 1 and 2, higher MOMFAC1 scores were

predicted by fewer episodes of vomiting per week. Hence,

those clinical bulimics who viewed their mothers as more

nurturant were demonstrating less vomiting behaviors.

Higher MOMFAC1 scores were also predicted by more days upon









which alcohol was consumed. For condition 1, no variables

were predictors. For condition 2, higher MOMFAC1 scores

were predicted by more episodes of exercising, less

vomiting, and higher GSI scores.

Mother as Striving: MOMFAC2

Across conditions 1 and 2, no indications of bulimia

severity were predictive of MOMFAC2. MOMFAC2 was predicted

by less perception of the self as overweight and higher

conceptual level scores. No variables were predictors of

MOMFAC2 in condition 0. For condition 0, MOMFAC2 was

predicted by lower scores of introjective depression.

Anaclitic Depression Scores: DEQD

Across conditions 1 and 2, the classic symptoms of

bulimia were not predictive of DEQD. However, DEQD was

predicted by less perception of the self as overweight, and

higher GSI scores. For conditions 0 and 1 analyzed

separately, higher GSI scores were predictive of DEQD. No

variables were predictive in condition 2. Hence, it may be

the dynamics of anaclitic depression appear less

predominant in this bulimic sample.

Introjective Depression: DEQI

Across conditions 1 and 2, the classic symptoms of

bulimia were not predictive of DEQI. However, DEQI was

predicted by the greater amounts of alcohol consumed in

days drinking, both for conditions 1 and 2 combined and for

condition 2 alone. DEQI could also be predicted by less









perception of the self as overweight and lower father as

nurturant factor scores. For condition 0, DEQI was

predicted by higher GSI scores. No variables were useful

predictors in condition 1.

Replication of Blatt's Findings on Depression

Hypothesis 3 predicted that subjects would demonstrate

a progressive increase in conceptual level ranging from

lower to higher when grouped into four categories on the

basis of their scores on the Depressive Experiences

Questionnaire. These groups were to include those subjects

whose depression is anaclitic (high Dependency--DEQ Factor

1), a mix of anaclitic and Introjective (high on both

Factors 1 and 2), primarily introjective (high Self-

Criticism--DEQ Factor 2), and those who are nondepressed

(low on both Factors 1 and 2, and high on Efficacy--Factor

3).

Of the 68 clinical and control subjects, 32 were

categorized in Blatt's system. Blatt does not present data

indicating the percentage of his samples that fall into one

of his four categories. In the current sample, eight

subjects were categorized in the anaclitic group, seven

were placed in the introjective group, eight were in the

mixed group, and nine were in the nondepressed group

(scored low on anaclitic and introjective depression and

high on self-efficacy). A one-way analysis of variance

between mean conceptual levels of these groups was not









significant (p > .10). Significant differences between

groups was observed for both mother as nurturant factor

scores (F(3,29) = 3.58, 2 < .05) and on the Depression

scale of the Brief Symptom Inventory (jF(3,29) 3.02,

p < .05). Post hoc analyses reveal that the nondepressed

group mean mother as nurturant factor score is

significantly higher than the other three groups. Also,

post hoc analyses indicate that the mixed (anaclitic and

introjective) group mean depression score is significantly

higher than the other three groups.














DISCUSSION


Results indicate that the severity of bulimia, as

measured by classic indicators of the disorder, was not

predictive of level of object representation. There are

several avenues of explanation that may be addressed when

considering why this hypothesis was not confirmed. Both

methodological and theoretical issues will be examined in

this discussion.

One component often scrutinized in the object

representation literature is the operationalization of the

concept itself. Judgements by clinician raters, Rorschach

responses, and parental descriptions written by patients

have all been utilized in clinical research--they have all

been criticized for their limitations in construct validity

in those studies with weak or little findings. Given the

elusive nature of the aspects of personality these studies

attempt to investigate, and the still developing

methodology available to those who study these phenomena,

the measures used must be carefully evaluated. The

reliability figures for the present study are somewhat

lower than those presented by Blatt et al. (1979) for the

measure of object representation. However, adequate









reliability was demonstrated for this measure. Also, the

validity of the scoring system has been established (Blatt

et al., 1979). Hence, other methodological issues should

be considered.

Another variable that should be examined involves the

subjects studied. Both clinical groups were comprised of

individuals who met the DSM-III criteria for bulimia. The

ANOVAs to determine disparity between the two groups showed

little evidence of significant differences. However, more

complex analyses did demonstrate subtle differences between

the two groups, particularly in relation to such

psychological variables as introjective depression and

self-consciousness. Additionally, results indicate that

severity of bulimia was relatively comparable in the two

clinical groups. It would be important in future

investigations to include a sample of subjects whose

functioning was more disrupted by the disorder, for example

those who require inpatient treatment for bulimia. This

might provide more information about those individuals who

fall in the extreme upper end of the severity spectrum.

Additionally, the role of the variable laxative abuse

should be further addressed. In the one study (Aronson,

1986) examining conceptual level and indicators of bulimia,

laxative abuse was the variable most predictive of lower

conceptual levels. However, in that study all variables

examined were of limited predictive value. Incidence of









laxative abuse is not included as a scoreable item on the

Bulimia Test, because it shows relatively poor predictive

ability, presumably due to the infrequency of this

symptom. None of the subjects in the current study

reported laxative abuse, which, although an infrequent

behavior, may indicate that segment of the bulimic

population was not assessed. Further exploration of the

relationship of laxative abuse to other aspects of a

patient's presentation would prove useful in clarifying

remaining questions about its predictive utility.

Another difficulty with the study involves the

determination of conceptual level data as ratio. Again,

this is characteristic of the method of data analysis of

Blatt (1979), but it has not been established that someone

at conceptual level 4 is twice as "psychological developed"

as someone at level 2. The frequency distributions for the

clinical and control samples were normally distributed,

mitigating this problem somewhat. However, the conceptual

level data are interval data at best.

Also, the general issue of behavior-intrapsychic

relationships should be addressed; that is, that

correlations and related analyses of relationships between

these two categories of observation are often found to be

diminished. Thus the agreement for studying them

individually and examining the dissynchrony should be

considered. This may be considered analogous to a call









for studying behavioral, cognitive, and physiological

dimensions independently and observing variations as they

occur (Lang, 1968).

The other avenue of explanation for the

nonconfirmation of the central hypotheses is a theoretical

one. This argument suggests that the relationship between

level of object representation and severity of bulimia is

complex and not adequately addressed by such a linear model

as regression analysis. Thus, some patients who are at

lower conceptual levels demonstrate symptoms of bulimia

that function as sensorimotorr activities," evoking the

representation of the sensorimotor mother, compensating for

deficits in the ability to draw on constant and enduring

objects. However, for others at a higher conceptual level,

the same severity of binging/purging may serve another

purpose. For example, the behaviors may be a way to defend

against anger or the need to assert one's self.

Striegel-Moore, Silberstein, and Rodin (1986) review

literature pertaining to three questions: why are women

(rather than men) the primary sufferers of bulimia; which

women, in particular, are at risk; and why recently has

there been an apparent increase in the incidence of the

disorder. One point stressed throughout is that those at

greatest risk are individuals who have accepted and

internalized most deeply the sociocultural mores about

thinness and attractiveness. This point will be further









addressed in the section on additional analyses. The

authors also cite studies indicating that, when asked to

describe themselves, girls, moreso than boys, refer

frequently to the views of other people in their self-

descriptions. For girls, more than boys, they conclude,

self-concept is an interpersonal construct. They are

distinctly vulnerable to the pressures of their

sociocultural environment and they are also influenced by

earlier interpersonal experiences that provide the basis

for object representations. It is not surprising that

individuals at similar conceptual levels might respond

quite differently to sociocultural pressures. Hence one

person at the iconic stage might grasp onto the part-

properties aspect of popular trends and strongly adhere to

current ideals of attractiveness and weight. Another at

the same level might disregard these cultural norms because

they are uanble to integrate contradictory elements and

focus on family-based notions as the ideals for beauty and

attractiveness. The conceptual level may indeed be an

important factor in assessing the risk for developing

bulimia, but its role remains to be fully understood. A

multidimensional perspective may be more appropriate for

addressing the complexities intrinsic to the object

relations theory of bulimia, given the heterogeneity of the

population.









The last hypothesis to be examined predicted a

progressive increase in conceptual level ranging from low

to high when grouped into four categories on the basis of

scores on the Depressive Experiences Questionnaire:

anaclitic, mixture of anaclitic and introjective,

introjective, and nondepressed. This would replicate the

study of Blatt et al. (1982) with depressed inpatients and

outpatients. In the current study, there were no

significant differences between groups. Exploratory

analyses comparing the four groups on other variables

confirmed the finding of Blatt et al. (1982) that the mixed

group was significantly more depressed than the other three

groups. Also, significant differences were observed for

the mother as nurturant factor. That is, the nondepressed

group scored higher on this factor than did the other three

groups.

Therefore, it appears that the relationship

demonstrated between the two types of depression defined by

Blatt et al., (1982), and conceptual level in patients

whose primary or secondary diagnosis is depression may not

be observed in patients whose primary diagnosis is

bulimia. These results are additional data in the

controversy regarding bulimia's position (or nonposition)

in the affective disorders spectrum. The results do

support the distinction between the four groups and

severity of depression. Also, the mother as nurturant









factor finding demonstrates further empirical evidence that

this factor may be an ameliorative phenomenon and certainly

suggests a need for further investigation.



Additional Analyses

Several salient findings emerge from the additional

analyses. First, again, is the striking predictive power

of the father as nurturant (or nonnurturant as the case may

be) factor, relative to some of the other variables. For

example, in the clinical groups, although no indicators of

bulimia (e.g., bringing, vomiting, exercising) were

predictive of conceptual level, higher father as nurturant

scores were predictive of higher conceptual levels. In the

control group, lower psychological distress scores were

predictive of higher conceptual levels but this

relationship was not demonstrated in the clinical

conditions. Thus, in the face of documented

psychopathology, mediating factors may influence the

relationship between conceptual level and psychological

distress. Across all conditions combined, the father as

nurturant factor scores were predictive of conceptual

level.

Examining the father as nurturant factor score more

closely, it appears that higher scores on this variable may

be predicted in the combined clinical conditions by lower

introjective depression scores, less binging per week, and









higher psychological distress scores. This type of

positive relationship with father appears to be related to

less guilty and self-punitive dysphoria and less chaotic

eating habits, but is compensated for with other symptoms

of psychopathology. Conversely, those bulimics with less

or nonnurturant fathers may be more likely to suffer from

guilty depressive experience, chaotic eating, and less

likely to endorse other symptoms. Recent clinical findings

with bulimic patients suggest an increased incidence of

family histories of alcoholism and/or incest (Hatsukami,

Mitchell, Eckert, & Pyle, 1986). Krener, Abramowitz, and

Walker (1986) studied the treatment outcome of 25 bulimics

and found that family variables associated with maternal

warmth (therapists' ratings of "mother not critical," "not

controlling," "not busy") explained an appreciable portion

of the variance in outcome. Yet, father variables were not

studied in as much detail. Future studies should further

explore the nature of the "nonnurturance" that may occur in

the family environments of these patients.

Several interesting findings emerge from additional

analyses involving the Bulimia Test scores. Across the two

clinical conditions combined, higher BULIT scores were

predicted by lower public self-consciousness scores,

greater general depression scores, lower anaclitic scores,

and again, lower father as nurturant scores. In addition

to the impact again demonstrated by the nonnurturant










father, one sees the finding that decreased public self-

consciousness predicts increased BULIT scores. Analyzing

conditions 1 and 2 separately, it appears that the variable

is predictive in condition 2 (those in treatment) but not

in condition 1 (those bulimics not in treatment). It may

be that ability to defend against what others think that

has allowed these individuals to seek treatment. This

lesser degree of public awareness has not been sufficient

to shield these individuals from the sociocultural

pressures to attain current ideals of attractiveness,

however, if in fact these specific patients are vulnerable

to such forces.



Suggestions for Future Research

Given the findings of the current study, that the

relationship between level of object representation and

severity of symptoms in bulimia is not linear, several

suggestions for future research may be forwarded. First,

it would be helpful to assess in detail individuals at each

conceptual level to better determine the unique

constellation of factors contributing to their

presentation. Continued emphasis should be given to these

formative childhood experiences that contribute to the

mental schemata that guide an individual's integration of

later experiences. One's experience of parents as

nurturant or not, and striving or not, clearly impacts on









one's development of identity and characteristic modes of

functioning.

Nonlinear models might be the next step utilized in

further statistical analyses of related studies. Trend

analyses would be an appropriate set of statistical

techniques to further elucidate more complex relationships

between the object relations and behavioral data.

That bulimic patients are a heterogeneous group of

individuals is becoming increasingly empirically

validated. As Streigl-Moore et al. succinctly state,


we need diagnostic categories that allow
differentiation among subgroups, which would then
permit an investigation of the differential
relationships among these subgroups and the
various risk factors. Another question deserving
further attention is the place of bulimia in the
spectrum of psychiatric disorders in general and
the affective disorders in particular. (1986,
p. 258)


Certainly, a wide-ranging study of differences among

patients within and across subgroups according to

conceptual level would shed light on the relationship

between character structure and the various risk factors in

question. The bulimics in the current study could be

categorized according to Blatt's (1974) theoretical

framework for depression, although other relationships

demonstrated in primarily depressed populations were not

observed. Additional investigation should be focused on

the utility of these and other subtypes in the assessment










and treatment of bulimia. It may be that the loss of the

love object, or the loss of love by the object, may be more

important in the dynamics of a subgroup of bulimics than

previously noted. Another subgroup deserving of increased

attention is those bulimics with a concurrent presentation

of substance abuse. Recent studies (e.g., Hatsukami

et al., 1986) suggests that compared to patients with a

diagnosis of bulimia only, and patients with histories of

affective disorders, patients with diagnoses of bulimia and

substance abuse experienced a higher rate of diuretic use,

financial and work problems, stealing before and after the

onset of the eating disorder, previous psychiatric

inpatient treatment, and greater amount of alcohol use

after the onset of treatment.

Also in the initial stages of research are studies of

the families of these patients. Most recent formulations

conjecture that family characteristics heighten

sociocultural emphases on external appearances. Others

describe families with a bulimic member as sharing

similarities with "psychosomatic families" (Minuchin,

Rosman, & Baker, 1978), including enmeshment,

overprotectiveness, rigidity, and lack of conflict

resolution. However, little empirical work has been

completed to support clinical reports. Intrapsychic

formulations such as those reviewed in the introduction

focus primarily on the mother as the caretaker and central






59



interpersonal influence. Thus, more programmatic research

on the respective roles of the father and the mother as

individuals, and on the nature of systemic relationships

within the family would fill considerable gaps in the area

of family variables.















APPENDIX
SCORING OF CONCEPTUAL LEVEL


Based on developmental psychological concepts derived

from Piaget, Werner and developmental psychoanalytic

theory, five levels of object representation are defined.

Based on these theoretical formulations, the conceptual

levels of parental representations are scored as follows:

1. Sensorimotor-Preoperational (Score 1). The person

is described primarily by his/her activity in reference to

the gratification or frustration he/she provides. It is an

emphasis on the person as an agent who causes the subject

either pleasure or pain, making them feel good or bad. The

description has a personal, subjective focus and the person

is defined primarily in terms of his/her direct effect of

pleasure and pain for the subject. There is little sense

that the person exists, is experienced, or defined as a

separate and independent entity. The description centers

on the direct value of the person for the subject.

2. Concrete-Perceptual (Score 3). The person is

defined as a separate entity, but the definition is

primarily in concrete literal terms, often characterized in

terms of physical description. There is a literalness, a










globality, and a concreteness to the description. There is

little emphasis on part properties, attributes, or

features, but rather the person is experienced as a

literal, concrete totality. Emphasis is often on what the

person looks like in its external characteristics or

physical properties, in a literal, concrete sense.

3. Iconic (Score 5-7).

(a) External Iconic (Score 5). A focus on part

properties of the person in terms of his/her activities,

but the activities and functions (in contrast to Level 1,

Sensorimotor-Preoperational) are uniquely the person's and

have little or no direct and explicit reference to the

gratification or frustration of the subject. The

activities are not directly need gratifying for the

subject, but rather the focus is on the person as a

separate entity in terms of his/her functional activities

and attributes.

(b) Internal Iconic (Score 7). The person is

described in terms of his/her attributes and part

properties, but not in terms of what the object does but

rather what the person thinks, feels, and values. The

description is directed towards internal dimensions.

In both the external and internal iconic levels the

descriptions are predominantly one-sided and

unidimensional. They do not describe a complexity of

actions, feelings, or values, in which there are levels










(for example, manifest behavior versus more latent

feelings). There is no recognition of subtlety, apparent

contradiction, complexity, levels, or development over

time. The descriptions focus on either external or

internal attributes, values, principles, and feelings, and

are predominantly one-sided and not integrated.

4. Conceptual (Score 9). The person is described in

a way that integrates all of the prior levels. The total

description indicates that there are a wide range of levels

on which the person is understood and experienced. There

is an appreciation of internal dimensions in their own

right as well as in contrast to the external. Also, there

may be a time line in which there is an appreciation of

changes and variation. There are a variety of dimensions

which are integrated and in which apparent contradictions

are resolved. Thus, there is a sense of disjunctiveness in

which the manifest, literal, and concrete may appear in

contradiction to more internal dimensions. But the

apparent contradiction is resolved in an integrated,

complex synthesis. At this level there can be comments

about the need gratifying attributes, or physical and

functional characteristics of the parent, but the

description indicates that the person is experienced in

complex, integrated ways and that a number of different

attributes and functions are integrated in a cohensive

complex synthesis.














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BIOGRAPHICAL SKETCH


Stephanie Haymaker was born in Philadelphia,

Pennsylvania, and was raised primarily in southern

New Jersey. She graduated with honors in psychology from

New York University in 1982 and was elected to the Phi Beta

Kappa Honor Society. Her senior thesis examined

consistency in coping behaviors. In 1984, she received her

Master of Science degree from the University of Florida.

The focus of study for her master's thesis was the

psychomaintenance role of alexithymia in a chronic pain

population. Ms. Haymaker entered doctoral candidacy in the

fall of 1986 at the University of Florida. She is

currently working in a day-treatment program for

adolescents, providing individual, group, and family

psychotherapy. Her clinical and research interests include

psychodynamic psychotherapy with adolescents and adults,

psychotherapy outcome, and health psychology. She is

married and lives in Woodbridge, New Jersey.









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opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




HL'gh C. av is, Jr., Chair
Profess of Clinical and Health
Psychology


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




RBussell M. Bautr
Associate Professor of Clinical
and Health Psychology


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




Eileen B. Fennell
Professor of Clinical and Health
Psychology


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.


ciate Professor of Speech









I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.




Nancy K. Norvell
Assistant Professor of Clinical
and Health Psychology


This dissertation was submitted to the Graduate
Faculty of the College of Health Related Professions and to
the Graduate School and was accepted as partial fulfillment
of the requirements for the degree of Doctor of Philosophy.

/I

August, 1988 C). 3 f ...
Dean, College of Health Related
Professions


Dean, Graduate School












































UNIVERSITY OF FLORIDA
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