Body Shape Concerns

in Bulimia Nervosa

Colleen M. Hadigan, B.A.

B. Timothy Walsh, M.D.
(Accepted 26 March 1990)

Overconcern with shape and weight is considered a primary feature of the psycho-
pathology of bulimia nervosa and was included as a diagnostic criterion in DSM-
Ill-R. In order to test the significance of shape and weight concern in bulimia
nervosa, we administered the Body Shape Questionnaire (SSQi to 78 outpatients
with bulimia nervosa and three comparison groups: 7 4 women with seasonal affec-
tive disorder (SAD), 10 acquaintances of patients, and 32 normal controls. Women
with bulimia nervosa had significantly higher mean SSQ scores than did other sub-
ject groups. Other self-report measures of body shape concern, eating attitudes,
and depression were correlated with SSQ score. Furthermore, all patients had BSQ
scores greater than the average score of the normal control group. These data sup-
port the continued inclusion of body shape and weight overconcern as a diagnostic
criterion for bulimia nervosa but suggest that “overconcern” should be interpreted
as “above average” rather than “outside the normal range.”

Overconcern with body shape and weight has long been considered the core
psychological feature of bulimia nervosa (Fairburn, 1987; Russell, 1979). There-
fore, ”persistent overconcern with body shape and weight” was added as a di-
agnostic criterion for bulimia nervosa in the revision of DSM-I11 (APA, 1987).
One rationale for this addition was to limit the diagnosis of bulimia nervosa to
a more homogeneous population of patients; that is, to exclude those patients
who engage in binge eating and behaviors designed to control their weight but
who do not demonstrate the characteristic concerns with body shape and
weight. Fairburn & Garner (1986) suggested that eating and weight symptom-
atology evidenced in these patients is most likely related to another psychiatric

Colleen M. Hadigan, B.A. is a research assistant in the Department of Psychiatry, College of Physicians
and Surgeons, Columbia University. B. Timothy Walsh, M.D. is Professor of Clinical Psychiatry in the
Department of Psychiatry, College of Physicians and Surgeons, Columbia University, and Research Psy-
chiatrist at the New York State Psychiatric Institute. Address correspondence and reprint requests to the
first author at Department of Psychiatry, College of Physicians and Surgeons, Columbia University, 722
West 168th Street, New York, New York 10032, USA.

international journal of Eating Disorders, Vol. 10, No. 3, 323-331 (1991)

0 1991 by John Wiley & Sons, lnc. CCC 0276-3478/91/030323-09$04.00
324 Hadigan and Walsh

illness (e.g., affective disorder) and that such patients should receive a diagno-
sis of Atypical Eating Disorder.
A number of studies using a variety of assessment measures have docu-
mented the presence of body shape and weight concern in bulimia nervosa
(Cooper, Taylor, Cooper, & Fairburn, 1987; Cooper & Taylor, 1988; Fairburn &
Cooper, 1984). Cooper et al. (1987), for example, developed the Body Shape
Questionnaire (BSQ) which is a self-report instrument designed to measure
shape and weight concerns in patients with eating disorders. A sample of Brit-
ish women with bulimia nervosa ( n = 38) scored significantly higher than did a
group of normal controls ( n = 316) t136.9 vs. 71.9, respectively]. Similarly, the
Eating Disorder Examination (EDE) (Cooper & Fairburn, 1987), a structured
clinical interview, contains body shape and weight subscales on which patients
with bulimia nervosa evidence considerably more concern than do nonbulimic
women (Wilson & Smith, 1989).
Few empirical investigations, however, have examined the utility of this new
criterion since its inclusion in DSM-111-R. For example, it is not clear what
threshold should be used for identifying overconcern; does overconcern imply
above the average concern of normal women, or an excessive degree of con-
cern (i.e., outside the normal range)? It is also not clear whether individuals
who meet all criteria for bulimia nervosa except exhibiting overconcern with
shape and weight differ in important ways from those who meet all DSM-111-R
criteria. Finally, the frequency of overconcern about shape and weight among
individuals with possibly related conditions, such as mood disturbance, and
among patients’ peer groups, has not been clearly established. Elevated con-
cerns about shape and weight might conceivably be a non-specific symptom of
depression among women or might be particularly prevalent among the peers
of women with bulimia nervosa. The present study was conducted in an at-
tempt to begin to address these issues.

METHODS

Subjects
Self-report data regarding shape and weight concerns were obtained from
four different groups of women: 78 outpatients with bulimia nervosa, 10 ac-
quaintances of the patients with bulimia, 14 women with seasonal affective dis-
order (SAD) (Rosenthal et al., 1984), and 32 normal controls. Subjects in all
four groups were between the ages of 18 and 45 years and within 20% of their
ideal body weight for their height (Metropolitan Life Tables, 1959).
The patients with bulimia nervosa were being evaluated for participation in a
controlled trial of antidepressant medication for bulimia nervosa. Diagnosis of
bulimia nervosa according to DSM-111-R criteria was determined by a struc-
tured clinical interview (SCID) (Spitzer, Williams, & Gibbon, 1987). A liberal in-
terpretation of criterion ”E” was used in making the diagnosis of bulimia
nervosa, so that the expression of minimal concern regarding shape and
weight, in the presence of criteria “A” through “D”, was considered sufficient
to meet the diagnostic criteria for bulimia nervosa. No patient was excluded for
failure to meet criterion ”E”; that is, all patients reported at least minimal con-
Body Shape Concerns in Bulimia 325

cern regarding body shape and weight. In the patient sample, the mean binge
and vomit frequencies were 9.0 +- 6.6 and 13.7 2 16.8 per week and the mean
duration of bulimia nervosa was 6.9 2 4.2 years.
The SAD subjects were seeking outpatient treatment for depression and
were evaluated using the SCID. All met DSM-111-R criteria for major depression
and the criteria of Rosenthal et al. (1984) for Seasonal Affective Disorder. His-
tories of significant weight fluctuations and eating pathology were recorded for
SAD patients but subjects were not excluded on this basis.
The normal controls were women who responded to posted notices recruit-
ing healthy women of normal weight to take part in a survey. Respondents
were screened in an abbreviated SCID interview and were excluded if any past
or current depression, alcoholism, drug abuse, anxiety disorder or eating dis-
order was detected. In addition, controls were excluded if they had experi-
enced weight fluctuations of 220 lb or if they reported suffering from any
chronic medical conditions.
In order to obtain a group of women similar to the patients with bulimia ner-
vosa in age and background, we asked each of 43 patients to identify six female
acquaintances. Patients were told that one of the six women would be ran-
domly selected to participate in a survey of women’s attitudes about shape and
weight and were assured that their identities would not be disclosed to their
acquaintances. Twenty-two patients submitted the names of acquaintances
and, of these, 11 were successfully scheduled for evaluation. One subject was
excluded because her weight was above the established range. Acquaintances
were assessed in an abbreviated SCID interview but were not excluded on the
basis of current or past psychiatric diagnoses.

Procedure
Each subject was asked to complete the following self-report questionnaires:
the Body Shape Questionnaire (BSQ); Eating Attitudes Test (EAT) (Garner &
Garfinkel, 1979); Beck Depression Inventory (BDI) (Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961). In addition the following items, scored on a 5-point
scale (1 = Extremely to 5 = Not at All), were taken from an abbreviated and
revised version of the Diagnostic Survey for Eating Disorders (DSED)
(Johnson, 1984).
1. How important is your shape and weight in determining your self-es-
teem?
2. How much does a 2 lb weight-gain affect your feelings about yourself?
3 . How much does a 2 lb weight-loss affect your feelings about yourself?
4. How dissatisfied are you with the way your body is proportioned?
5. Are you currently afraid of becoming fat?
After completing the questionnaires each subject’s height and weight were
measured.

Data Analysis
Each subject’s total scores on the BSQ, BDI, and the EAT, as well as individ-
ual item scores from the DSED items, were calculated, and group means and
326 Hadigan and Walsh

standard deviations were computed. Age, body mass index (BMI), and the
greatest adult-weight fluctuation (highest adult weight minus lowest adult
weight) were similarly calculated. One-way analyses of variance were com-
puted on each of these measures between the patients with bulimia nervosa
and each of the remaining subject groups. In addition, correlation coefficients
were computed between BSQ scores and other self-report measures (e.g., BDI)
and clinical variables (e.g., binge and vomit frequency) in the bulimia nervosa
patients.

RESULTS

The bulimia nervosa patients had a significantly higher mean BSQ score
(141.6) than did the other subject groups (SAD = 82.9; acquaintances = 60.7;
normal controls = 64.6). (Table 1.)Bulimia nervosa patients also expressed sig-
nificantly more concern with shape and weight than did each of the compari-
son groups on all five items from the DSED ( p < 0.03) with one exception.
There was no significant difference between bulimia nervosa patients and SAD
patients in their response to the question on dissatisfaction with body propor-
tions (Item #4). In bulimia nervosa patients, there were significant negative
correlations between the BSQ score and responses to four items on the DSED
(higher scores on DSED items indicate a lesser degree of concern; p < 0.001, n
= 74, for each). There was a trend for a negative correlation in the remaining
question (Item #3: effect of 2-lb weight-loss on feelings about self; p = 0.10).
Therefore, an elevated score on the BSQ was associated with elevated concern
about shape and weight as measured by the DSED.
Mean EAT and BDI scores were also significantly higher in the bulimia ner-

Table 1. Mean scores ( 2 S.D.) of clinical measures.

Bulimia Nervosa Normal Control SAD Acquaintance

( n = 78) ( n = 32) ( n = 14) ( n = 10)

Ageb 25.4 i 5.1 25.4 i 7.4 36.2 i 7.6 27.6 t 8.1

BMI (kgim') 22.1 i 1.9 21.5 i 1.7 22.2 t 2.7 22.1 t 1.3
BSO"" 141.6 i 30.9 64.6 i 20.1 82.9 ? 33.0 60.7 t 23.5
EAT-+' 43.6 t 15.4 8.3 2 5.3 10.9 2 8.0 9.6 t 6.4
BDI"~' 16.6 t 9.5 2.0 i 2.5 22.3 rt 5.5 6.5 t 5.5
Adult-weight" 33.0 2 21.8 13.7 t 8.3 29.9 -+ 18.4 20.7 t 13.8
fluctuation (Ib)
DSED questionsd
Self-esteem"" 1.5 5 0.6 3.0 i 1.0 2.7 t 1.1 2.9 -+ 1.5
2-lb gainah' 2.2 F 1.0 3.9 2 1.2 3.3 t 0.8 3.9 t 1.4
2-lb lossabC 2.5 t 1.0 3.7 t 1.2 3.1 2 0.8 3.6 t 1.4
Dissatisfied
with body 3.0 2 1.1 4.2 i 0.8 3.4 2 1.3 4.2 i 0.8
proportion"'
Fear of fatabc 1.5 2 0.8 3.7 i 1.3 3.4 t 1.5 3.6 i 1.3

"Bulimia Nervosa vs. Normal Control-p < 0.001.

bBulimia Nervosa vs. SAD patients-p < 0.03.
'Bulimia Nervosa vs. Acquaintance-p < 0.001.
dSee Methods for complete description of questions
Body Shape Concerns in Bulimia 327

vosa group compared to the acquaintance group and the normal control group.
The bulimia nervosa patients had a significantly higher mean EAT score than
did the SAD group, but the SAD patients had a significantly higher mean BDI
score than did the patients with bulimia nervosa.
There was no significant difference between patients with bulimia nervosa
and the SAD and acquaintance groups in greatest adult-weight fluctuation. Al-
though the bulimia nervosa patients had significantly larger mean weight fluc-
tuations than did the normal control group, it should be noted that controls
were excluded for weight fluctuation of 220 pounds. There were no significant
differences in mean BMI between bulimia nervosa patients and any of the com-
parison groups.
The mean age of the SAD group was significantly greater than that of the
bulimia nervosa group. An analysis of covariance between the patients with
bulimia nervosa and the SAD patients, with age as the covariate, was com-
pleted to determine whether the differences in BSQ and EAT scores between
these two groups were attributable to their difference in mean age. The group
differences in,BSQ and EAT scores remained significant [F = 25.4, p < 0.001,
and F = 34.5, p < 0.001, respectively] despite the significant difference in age
between the two groups. No significant differences in BDI score, BMI or adult-
weight fluctuation were detected by ANCOVA between the SAD patients and
the bulimia nervosa patients. In the entire sample (all groups combined) there
was a significant correlation between age and BSQ score (Y = -0.19, p < 0.02).
We examined the relationship between body shape and weight concerns and
other measures of bulimic symptomatology. There was no significant correla-
tion between BSQ score and binge frequency, vomit frequency, or duration of
illness in the patients with bulimia nervosa ( p 2 0.06). There were significant
positive correlations, however, between the BSQ and the EAT and BDI scales
(EAT r = 0.67, p < 0.001, and BDI r = 0.49, p < 0.001).
Despite the significant elevation of mean BSQ score in the patients with
bulimia nervosa, there was a notable degree of overlap between the BSQ
scores of the patients with bulimia nervosa and those of the other subject
groups (Fig. 1). In order to determine if the patients who scored within the
range of the normal control group differed from patients with elevated BSQ
scores, the bulimia nervosa sample was divided into two groups: high BSQ
(scores >105) and low BSQ (1105) based on the normal control range (highest
score: 105). There were 69 patients in the high BSQ group and 9 in the low
BSQ group.
The two groups were compared on the following clinical measures: age,
BMI, binge frequency, vomit frequency, duration of illness, history of anorexia
nervosa, current affective disorder, BDI, and EAT scores. There were no signif-
icant differences in age, duration of illness, binge or vomit frequency, or great-
est adult-weight fluctuation (Table 2). In addition, there were no significant
differences in the frequencies of concurrent depression or past anorexia ner-
vosa (chi-squared = 0.007 and 0.46; p > 0.4 for both). However, patients with
high BSQ scores had significantly higher mean EAT scores and BDI scores than
did the patients with low BSQ scores ( p < 0.001 and p < 0.017, respectively). In
addition, there was a trend for patients with high BSQ scores to have a higher
mean BMI than patients who scored lower on the BSQ ( p = 0.07).
 Hadigan and Walsh

0 0
0 0
0

lo --+ 0

&
0 0

8 8 0 0
0
0
0
0
2!
0

80
8 0

BULIMIA NORMAL SAD ACOUAINTANCE

NERVOSA CONTROL (N=14) (N=10)
(N=78) (N=32)

Figure 1. BSQ scores in patients with bulimia nervosa, normal controls, SAD patients,
and acquaintances of bulimia nervosa patients.

Patients with low BSQ scores were also compared to the normal control
group. As was the case for the patient group as a whole, the low BSQ patients
had significantly higher mean BSQ, EAT, and BDI scores ( p < 0.001 for all).

DISCUSSION

Several limitations of the current study should be noted. One potential prob-
lem is the older mean age of the SAD patients. Although it was our hope that
the groups would be similar in age, the SAD patients were approximately 10
years older than the subjects in the bulimia nervosa and the control groups.

Table 2. Clinical characteristics of patients with bulimia nervosa: high BSQ score vs.
(Mean 2 S.D.) low BSQ score
Duration - Vomiting Weight
Age BMI* of Illness Binges Episodes Fluctuation
(yrs) (kg/mz) (yrs) Per Week Per Week BDI** EAT'" (Ib)

BSQ >lo5 25.6 22.2 7.1 8.9 14.0 17.5 46.5 33.9
( n = 69) ?5.3 C1.9 14.3 k6.5 C17.7 29.4 113.7 222.3

BSQ 5105 24.0 21.0 5.0 9.3 11.3 9.6 21.6 25.1
( n = 9) 23.0 21.3 12.5 27.2 27.4 27.0 27.2 215.2
~~

* p = 0.07.
**p < 0.02.
Body Shape Concerns in Bulimia 329

Because the BSQ score was proportional to age, this difference in age may have
contributed to the difference in mean BSQ scores between the bulimia nervosa
patients and the SAD patients. However, the difference in BSQ score between
SAD and bulimia nervosa patients remained significant in an analysis of cova-
riance that controlled for the effect of age. Further, it is interesting to note that,
although SAD patients had weight fluctuations similar to those of women with
bulimia nervosa, and 28% of the SAD sample reported binge eating during
their depressive episodes, their mean BSQ score was significantly lower than
that of the patients with bulimia nervosa. The two SAD patients who scored
outside the normal control range for the BSQ (119 and 162) had met subthresh-
old criteria for eating disorders: one woman had a previous subthreshold epi-
sode of anorexia nervosa, the other reported binge eating several times a
month as well as fasting and use of diet pills. This suggests that, even among a
group of depressed women, elevated concern with shape and weight is un-
usual, and, when it occurs, is often associated with the presence of a subclini-
cal eating disorder.
A second limitation is the relatively small number of acquaintances who par-
ticipated in the survey. This limits the statistical power of the comparisons in-
volving this group; specifically, only very large differences be tween the
patients’ acquaintances and the patient group would have been detectable by
the current study.
Finally, the BSQ, a self-report questionnaire, was the primary instrument
used in the current study to assess body shape and weight concerns. It has
been suggested that overconcern with shape and weight can best be assessed
via clinical interview, for example, the Eating Disorder Examination (Cooper &
Fairburn, 1987). Rosen, Vara, Wendt, & Leitenberg (1990) have recently com-
pared the ability of the EDE and the BSQ to distinguish non-bulimic-restrained
eaters from patients with bulimia nervosa. They found that ratings of concern
with shape and weight derived from the EDE were highly correlated with BSQ
scores. Although both the BSQ and the EDE distinguished patients from re-
strained controls, the EDE did not add significant discriminatory power to that
of the BSQ. Thus, even though it would have been useful to obtain interview
measures of body shape concern in the current study, it seems unlikely that
such data would have led to substantially different conclusions.
In the current study, the mean BSQ score of the patients with bulimia ner-
vosa was more than two times that of the control group. The other self-report
measures of body shape concern were highly correlated with the BSQ score
and were also substantially higher in the patient group. These results strongly
support previous reports that an abnormal degree of concern with shape and
weight is highly characteristic of patients with bulimia nervosa. In addition,
the mean BSQ score of our patient group was virtually identical to that of the
British sample described by Cooper et al. (1987) (141.6 vs. 136.9) indicating that
patients seen in different centers bear a strong resemblance to one another on
this feature of bulimia nervosa.
The mean BSQ score of the patient group was also higher than that of a
group of women with SAD and of acquaintances of patients. These results in-
dicate that an elevation of body shape concern is not simply a characteristic of
the patients’ peer groups or simply a manifestation of mood disturbance in
young women. Thus, overconcern with shape and weight appears to be rela-
330 Hadigan and Walsh

tively specific to the syndrome of bulimia nervosa. This conclusion is in agree-

ment with a recent report of Wilson & Smith (1989) who found that
overconcern with shape and weight, as assessed by the EDE, distinguished pa-
tients with bulimia nervosa from women who were restrained eaters.
In patients with bulimia nervosa, the BSQ score was highly correlated with
the other measures of body shape concern and with the EAT score which as-
sesses both attitudes and behaviors characteristic of patients with eating disor-
ders. As Cooper and Taylor (1988) have previously reported, there was a
significant correlation between the BSQ score and the degree of depression as
measured by the Beck Depression Inventory. On the other hand, there was no
relation between BSQ score and the duration of illness or the severity of behav-
ioral disturbance, as measured by the frequency of binge-eating or vomiting
episodes. This suggests that the degree of overconcern with shape and weight
characteristics of bulimia nervosa is more closely linked with the patient’s emo-
tional state and her self-esteem than with the severity of her behavioral prob-
lems.
Finally, it is important to note that in 12% of our sample of women with bu-
limia nervosa the degree of body shape concern, as measured by the BSQ, was
within the normal range. Though these women also had lower EAT and BDI
scores, they were similar to patients with higher BSQ scores on the following
characteristics: age, duration of bulimia nervosa, frequency of binge eating and
vomiting, history of anorexia nervosa, frequency of current depression, and
adult-weight fluctuation. Further, the patients with low BSQ scores differed
from normal controls in having higher BSQ, EAT, and BDI scores. Whether
these women should properly receive a diagnosis of bulimia nervosa according
to DSM-III-R criteria depends on what threshold is employed to define over-
concern. If overconcern is defined as an above average concern, as measured
by the BSQ, then our entire patient sample met criteria for bulimia nervosa.
However, in this case, all patients who met criteria A-D also met criterion E;
and from this perspective, criterion E might be viewed as redundant. On the
other hand, if the threshold is set as above the normal range, then 12% of our
patient sample would not receive the diagnosis of bulimia nervosa. It might be
argued that it would have been appropriate to exclude these patients, as they
not only had less body shape concern, but also lower EAT and BDI scores than
the remainder of the patient group. On the other hand, in the other character-
istics noted above, they were indistinguishable from the patients with higher
degrees of body shape concern.
It is currently unknown whether patients with relatively low degrees of body
shape concern differ from other patients on other parameters that might vali-
date a distinction, such as longitudinal course and response to treatment. In
the absence of such data, we suggest that it is appropriate to use as an opera-
tional threshold for overconcern with body shape and weight a degree of con-
cern greater than a normal average concern. The current study suggests that
the overwhelming majority of patients who meet criteria A-D for bulimia ner-
vosa will also satisfy such a definition of overconcern. Nonetheless, because
overconcern with shape and weight is relatively specific to bulimia nervosa, be-
cause treatment approaches focusing on altering this abnormal concern are
quite effective, and because of the potential importance of overconcern with
Body Shape Concerns in Bulimia 331

body shape in the development of this eating disorder, we believe that crite-
rion E should be retained.
We gratefully acknowledge the assistance of Madeline Gladis, Claire Holderness, and
Linda Wong. In addition, we would like to thank Drs. Michael and Juan Terman of the
Light Therapy Clinic of the New York State Psychiatric Institute for their cooperation in
the recruitment of Seasonal Affective Disorder patients. We also thank Dr. Michael Dev-
lin for his review of the manuscript. This work was supported in part by grant MH-
38355 from the National Institute of Mental Health, Bethesda, Maryland.

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