**4.3 Research methods**

152 New Insights into the Prevention and Treatment of Bulimia Nervosa

appearance [Cash, Pruzinsky, Thompson,Garner]. The major components of the variable

1. A body schema (a degree of an individual's knowledge of one's own body, and the

2. A sense of body boundaries (the feeling of separating one's own body from the external world, which facilitates the process of perceiving oneself as a bodily creature, definite

3. Interoceptive awareness, i.e. the feeling of perplexity accompanying the process of recognizing and responding to emotional states and body sensations; and also the fear

4. Experiences related to body functions (maturity fear experienced by an individual, that is, the person's approval of psychosexual development, which is related to the process of entering the stage of maturity, and to body image change as well as loss of the sense

5. Body image, i.e. a sensual image of sizes, shapes and forms of the body as well as the feelings regarding the body. The major aspects of body image include: adequate evaluation of body shape and size, as well as feelings regarding the body (satisfaction,

6. Self-evaluation and body satisfaction– the level of general satisfaction with one's own body, weight, body shape and physical appearance. Body self-evaluation includes assessment of an individual's current body shape (i.e. the "actual me"image) and evaluation of the ideal, most desired attributes which the person would like to have (i.e.

An additional control variable was body mass index BMI. It has been announced that individuals who fall into the BMI range of 19.5 to 24.5 have a healthy weight. A BMI of under 19.5 is usually referred to as underweight. A Body Mass Index reading over 24.5 is

102 Polish females participated in the research. The subjects were selected intentionally. Clinical population No. I consisted of 52 females clinically diagnosed with bulimia nervosa (the F.50.02 code, according to the ICD criteria of psychiatric classification). Whereas clinical population No. II was comprised of 50 women with no history of past or present eating disorders or other mental disturbances (e.g. bulimia or anorexia nervosa, psychogenic binge eating). The additional criteria which excluded participation in the research included: improper intellectual development, chronic somatic conditions (visible disability and body distortions), and organic changes in the CNS. The data mentioned above was gathered by means of clinical interviews conducted among the examined individuals. The aforementioned factors may affect the development of body image. Hence, the females exhibiting any of the dysfunctions mentioned above were excluded from the group of research subjects. During the research, all bulimic participants remained under medical care. The mean duration of treatment in the group of the examined bulimic females ranged from 2 to 12 months. A mean age in the research sample ranged from 21 to 25 years. The research was conducted anonymously with the personal consent obtained from each participant, and

which were empirically examined in the study included:

of high affection and the prospect of losing control over it)

the ideal body image - "what I would like to look like").

with the approval of a Human Research Ethics Committee.

person's awareness of specific body parts),

and different from others)

of childhood security),

considered overweight.

**4.2 Subjects** 

acceptance or disapproval).

The methods applied in the research included an inventory (i.e. the Eating Disorder Inventory (EDI) devised by Garner, and Thompson's Body Dissatisfaction Inventory) as well as projective techniques such as Thompson's Silhouette Test and a thematic drawing: "body image". The inventories and projective techniques applied in the research procedures, aimed at making a psychological diagnosis of the investigated variables, are fully described in the subject literature [Thompson, Hornowska, Paluchowski, Oster].

The Eating Disorder Inventory devised by Garner is one of the instruments most frequently used to measure the patterns of behaviour and attitudes dominating the clinical picture of anorexia and bulimia nervosa, including those related to the process of perceiving and experiencing body [Thompson]. The following 3 scales, considered the purposes they had been devised for, were applied in the research: the Body Dissatisfaction Scale, the Interoceptive Deficits Scale, and the Maturity Fear Scale.

The Body Dissatisfaction Scale was used to measure the indicators of the body self component called "body image". The scale allowed to evaluate the level of the overall body satisfaction, and ever increasing discreditation of one's own appearance, body shape and weight as well as the particular body parts. It consisted of ten items. Each research participant was rated on a 0 to 40 point scale. The score ranging from 40 to 36 was interpreted as a very high level of discreditation of one's own body shape and size as well as body dissatisfaction. The score ranging from 35 to 22 points to considerable dissatisfaction with body shape, size and weight, and to negative feelings regarding body parts. The score ranging between 21 and 0 denotes the norm [Higgins].

The "Interoceptive Deficits" Scale was applied to measure the level of interoceptive awareness in the group of examined females. It allowed to evaluate the level of perplexity, which occurs in the process of recognizing and responding to emotional states and body sensations, and helped to assess the level of fear of high affection and of losing control. The scale consisted of eight items. Each research participant was rated on a 0 to 32 scale. A high score (13-32 points) points to a high degree of perplexity and discreditation of the experienced emotions. It proves that instead of being experienced, emotions undergo intellectual evaluation aimed at checking whether they are well-grounded, desired and justified. It can be assumed that a high score on this scale is interpreted as a significant risk factor which contributes to development of an eating disorder. A low score (0-10 points) indicates a properly retained ability to deal with and accept positive and negative emotions regarding one's own body. It is also an indicator of mental health [Higgins].

The "Maturity Fear" scale served as an instrument for measuring the level of approval of psychosexual development. Maturity fear is related to the exhibited tendency, a desire to regain the pre-pubescent appearance [Higgins]. The examined subjects were rated on a 0 to 32 point scale. A high score (between 13 and 32) denotes a strong desire for being younger and regaining childhood security. It also proves the conviction that the requirements set during the period of maturity are too high. A low score (between 0 and 5) indicates a high level of psychosexual development acceptance, and mental transition to the stage of maturity [Higgins].

The second measurement instrument applied in the research was the Body Dissatisfaction Inventory devised by K. Thompson [Cash, Pruzinsky, Thompson]. It was used to measure the level of satisfaction and dissatisfaction with weight, body shape and appearance in the

A Psychological Profile of the Body Self Characteristics in Women Suffering from Bulimia Nervosa 155

indicators into the given categories was examined by five competent judges (clinical

The research comprised two stages. The first phase involved psychological measurement of the examined indictors of the body self in the population of 102 Polish females, using clinical and test methods, as well as projective techniques (e.g. observation, a clinical interview, or

The second stage of the research was aimed at conducting a statistical and clinical analysis




**5. A psychological profile of the body self characteristics in females suffering** 

Statistical cluster analysis conducted using the k-means allowed to distinguish three clusters in the whole research population of 102 females. Cluster No. I and Cluster No. II consisted of women diagnosed with bulimia nervosa. Whereas cluster No. III was comprised of

The research data analysis demonstrated certain significant differences between the examined females in the aforementioned three clusters in terms of the strength level and configuration of the body self characteristics. Hence, the three clusters were referred to as: "Bulimic Type I (a socio-cultural type)", "Bulimic Type II (a separation type)", and Type III (an adequate type). Each of them referred to certain distinctive characteristics of the body

Figure 1 displays a graphic illustration of significant differences regarding the emotional

Statistical analysis of the research data reveals certain significant differences between the examined 102 females in terms of such indicators of the body self structure as: the level of satisfaction with one's own body (the quality of emotions regarding the body); the overall body self-assessment (acceptance or disapproval of the current body image; perception of body image (both current and ideal body shape); recognizing body sensations (interoceptive awareness, i.e. a degree of perplexity arousing in the process of recognizing and responding to the emotional states and body sensations); experiencing bodily functions (i.e. the level of maturity fear – accepting the level of psychosexual development related to the process of

and cognitive characteristics of the body self in the examined 102 Polish females.

transition into adult life, body image transformation and loss of childhood security).

individuals in the control population) using the k-means method [Stanisz]

structure, using Student's t-test for two independent samples.

females revealing no mental disturbances or eating disorders.



psychologists), on the basis of the following scale:

of the research data, which involved the following steps:


**from bulimia nervosa** 

thematic drawing: "body image").

control population of females;

self structure in the examined women.

examined women. The research subjects rated themselves on a 10-point satisfactiondissatisfaction continuum, which resulted in the scores ranging from 0 (a high level of satisfaction) to 10 (a high level of dissatisfaction). It was assumed that the score of 5 should be interpreted as an average level of body satisfaction.

Another instrument used in the research to measure body image was a projective technique – the Silhouette Test by Thompson [Cash, Pruzinsky, Thompson]. It allowed to make a comparison between the actual body image (the actual self image), perceived by the subject, and its ideal image (the ideal self image). The instrument consists of a set of nine male and nine female silhouettes ranging from very thin to very fat. The subjects' task was to select the figure which most closely matched their current body shape, and one image which they considered ideal. Additionally, the subjects were supposed to provide details concerning their age, current weight and height. The figure ratings obtained in the test were used to calculate the current-ideal discrepancy (the individual's perceived current body shape versus the ideal body image), and thus to examine the respondents' body image acceptance The scores received in the research ranged from 0 (lack of discrepancy, which indicates a high level of body image acceptance) to 8 (very high discrepancy, which proves a low level of body image acceptance).

Thematic drawing ("body image") was used to examine the level of body schema complexity as well as a sense of body boundaries (the feeling of separating one's own body from the external world, which allows to perceive oneself as a bodily creature, definite and different from others). It is a projective technique, in which the study subject's task is to draw a picture of body. The test is based on an assumption that the drawing is projection of the examined person's self image, especially such components of the body self as the body schema and body boundaries [Hornowska, Paluchowski, Oster]. In order to investigate the aforementioned elements, the test analysis focused on such aspects of the drawing as evaluating the number of body details as well as investigating formal and structural elements of the drawing (the size of the figures, the pencil stroke and pressure). Referring to theoretical assumptions concerning the role of the human figure drawing in a psychological diagnosis, it was assumed that the greater number of details corresponds with a higher level of the body schema complexity [Hornowska, Paluchowski, Oster].

Formal and structural analysis of the drawings focused on the size adequacy of the depicted figures. Both too small and extremely large figures seem to point to inadequate perception of body size. Such aspects of drawings as the presence of the main body parts (e.g. head, hair, nose, lips, eyes, neck, trunk, arms, hands, legs, and feet) and the characteristics of the body portrayal (e.g. the pencil stroke, the kinds of lines, body proportions, scaling the figure up or down) were taken into consideration in psychological interpretation of the indicators of a body schema and body boundaries. The pencil stroke analysis, based on the Goodenough-Harris Draw-A-Person Test, involved examining the kinds of lines drawn by the research subjects (e.g. unbroken, dotted, thick, thin, or not sharp). An unconnected, thin and blurred stroke can be interpreted as difficulties in establishing precise body boundaries in the examined person.

It was also assumed that the number of body parts the subject considered significant and included in her drawing corresponded with the level of the person's body schema and image complexity. The subject scored 1 point for each detail depicted in the drawing. Lack of the particular body part meant 0 points. The accuracy of classifying the particular indicators into the given categories was examined by five competent judges (clinical psychologists), on the basis of the following scale:


154 New Insights into the Prevention and Treatment of Bulimia Nervosa

examined women. The research subjects rated themselves on a 10-point satisfactiondissatisfaction continuum, which resulted in the scores ranging from 0 (a high level of satisfaction) to 10 (a high level of dissatisfaction). It was assumed that the score of 5 should

Another instrument used in the research to measure body image was a projective technique – the Silhouette Test by Thompson [Cash, Pruzinsky, Thompson]. It allowed to make a comparison between the actual body image (the actual self image), perceived by the subject, and its ideal image (the ideal self image). The instrument consists of a set of nine male and nine female silhouettes ranging from very thin to very fat. The subjects' task was to select the figure which most closely matched their current body shape, and one image which they considered ideal. Additionally, the subjects were supposed to provide details concerning their age, current weight and height. The figure ratings obtained in the test were used to calculate the current-ideal discrepancy (the individual's perceived current body shape versus the ideal body image), and thus to examine the respondents' body image acceptance The scores received in the research ranged from 0 (lack of discrepancy, which indicates a high level of body image acceptance) to 8 (very high discrepancy, which proves a low level

Thematic drawing ("body image") was used to examine the level of body schema complexity as well as a sense of body boundaries (the feeling of separating one's own body from the external world, which allows to perceive oneself as a bodily creature, definite and different from others). It is a projective technique, in which the study subject's task is to draw a picture of body. The test is based on an assumption that the drawing is projection of the examined person's self image, especially such components of the body self as the body schema and body boundaries [Hornowska, Paluchowski, Oster]. In order to investigate the aforementioned elements, the test analysis focused on such aspects of the drawing as evaluating the number of body details as well as investigating formal and structural elements of the drawing (the size of the figures, the pencil stroke and pressure). Referring to theoretical assumptions concerning the role of the human figure drawing in a psychological diagnosis, it was assumed that the greater number of details corresponds with a higher level

Formal and structural analysis of the drawings focused on the size adequacy of the depicted figures. Both too small and extremely large figures seem to point to inadequate perception of body size. Such aspects of drawings as the presence of the main body parts (e.g. head, hair, nose, lips, eyes, neck, trunk, arms, hands, legs, and feet) and the characteristics of the body portrayal (e.g. the pencil stroke, the kinds of lines, body proportions, scaling the figure up or down) were taken into consideration in psychological interpretation of the indicators of a body schema and body boundaries. The pencil stroke analysis, based on the Goodenough-Harris Draw-A-Person Test, involved examining the kinds of lines drawn by the research subjects (e.g. unbroken, dotted, thick, thin, or not sharp). An unconnected, thin and blurred stroke can be interpreted as difficulties in establishing precise body boundaries

It was also assumed that the number of body parts the subject considered significant and included in her drawing corresponded with the level of the person's body schema and image complexity. The subject scored 1 point for each detail depicted in the drawing. Lack of the particular body part meant 0 points. The accuracy of classifying the particular

of the body schema complexity [Hornowska, Paluchowski, Oster].

be interpreted as an average level of body satisfaction.

of body image acceptance).

in the examined person.

The research comprised two stages. The first phase involved psychological measurement of the examined indictors of the body self in the population of 102 Polish females, using clinical and test methods, as well as projective techniques (e.g. observation, a clinical interview, or thematic drawing: "body image").

The second stage of the research was aimed at conducting a statistical and clinical analysis of the research data, which involved the following steps:

