Specificity of Self-Concept Disturbances

in Eating Disorders

Corinna Jacobi,1* Thomas Paul,2 Martina de Zwaan,3 Detlef O. Nutzinger,2

and Bernhard Dahme1
1
Department of Psychology, Fachbereich I, University of Trier, Trier, Germany
2
Psychosomatic Hospital, Bad Bramstedt, Germany
3
Department of Psychosomatic Medicine and Psychotherapy, Friedrich Alexander
University Erlangen-Nuremberg, Erlangen, Germany
Accepted 27 December 2002

Abstract: Objectives: The current study examined self-concept deficits among three diag-
nostic groups of eating-disordered patients, evaluated the relationship between self-concept
deficits and depression, and addressed the specificity of self-concept deficits in eating-
disordered patients. Method: Three groups of eating-disordered patients (anorexia nervosa,
N ¼ 33; bulimia nervosa, N ¼ 38; binge eating disorder, N ¼ 28) were first compared to
three matched healthy control groups and then to two psychiatric comparison groups
(patients with anxiety disorders, N ¼ 37; patients with depressive disorders, N ¼ 37). Results:
All three groups of eating-disordered patients displayed lower self-esteem and higher
feelings of ineffectiveness compared with the healthy controls, even after controlling for
depression. Differences in self-esteem and ineffectiveness were also found between eating-
disordered patients and psychiatric controls. However, not all of the differences were
significant. In addition, the psychiatric controls also exhibited lower self-esteem than nor-
mative samples. Discussion: Findings suggest that self-concept deficits are more pronounced
in eating-disordered patients but cannot be regarded as highly specific. # 2004 by Wiley
Periodicals, Inc. Int J Eat Disord 35: 204–210, 2004.

Key words: self-concept disturbances; eating disorders; depression

INTRODUCTION

Low self-esteem or a negative self-concept has assumed a central role in many clini-
cally derived theories of eating disorders. Bruch (1962) first described disturbances in
self-concept in terms of a ‘‘paralyzing sense of ineffectiveness’’ (p. 191) as one of three
characteristic psychopathologic features of eating-disordered patients. More recent
psychodynamic models have described the self-concept deficits of patients with anorexia

*Correspondence to: Dr. Corinna Jacobi, Universität Trier, FB I, Universitätsring 15, 54286 Trier, Germany.
E-mail: jacobi@uni-trier.de
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.10240
# 2004 by Wiley Periodicals, Inc.
Self-Concept Disturbances 205

nervosa (AN) from a perspective of self-psychology (Goodsitt, 1985). In addition to

etiologic conceptualizations, self-concept deficits of patients with eating disorders are
also considered necessary core symptoms for the diagnosis according to the latest revi-
sion of the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV;
American Psychiatric Association [APA], 1994).
In the field of eating disorders, the concepts of self-esteem, ineffectiveness, and nega-
tive self-evaluation have been examined in a large number of cross-sectional studies
(Jacobi, 2000). Patients with AN and bulimia nervosa (BN) exhibit lower self-esteem or a
more negative self-concept than healthy control groups. Psychiatric control groups were
only included in a minority of studies with inconsistent findings. The only two studies
including patients with binge eating disorder (BED; de Zwaan et al., 1994; Telch & Agras,
1994) found self-concept deficits similar to those of anorexic and bulimic patients. Major
limitations of these studies concern sample selection and lack of stratification of healthy
control groups—mostly college students—as well as the lack of psychiatric control
groups. Furthermore, in not a single study was patients’ self-esteem or self-concept
controlled for depressive symptomatology, although depression and low self-esteem
are highly correlated (Bernet, Ingham, & Johnson, 1993; Haaga, Dyck, & Ernst, 1991)
and eating and depressive disorders are highly comorbid (Laessle, Kittl, Fichter,
Wittchen, & Pirke, 1987). Therefore, it is unclear whether self-concept deficits are con-
founded with patients’ possible depressive symptomatology.
A series of recently published studies have tried to overcome some of these limitations
using a community-based case-control design (Fairburn, Cooper, Doll, & Welch, 1999;
Fairburn et al., 1998; Fairburn, Welch, Doll, Davies, & O’Connor, 1997). Among both (pre-
viously) anorexic and (currently) bulimic subjects, but not among subjects with BED, nega-
tive self-evaluation (predating the onset of eating disorder, retrospectively assessed) was
more common than in healthy or psychiatric controls. However, rates of negative self-
evaluation also differed between psychiatric patients and healthy controls (30% vs. 13%).
Furthermore, self-esteem was not controlled for depressive symptomatology, which also was
reported frequently in anorexic and bulimic patients before the onset of the eating disorder.
The aims of the current study were (1) to assess self-concept deficits in three diagnostic
groups of eating-disordered patients (AN, BN, and BED) in comparison to matched
healthy control groups, (2) to examine the relationship between self-concept deficits
and depressive symptoms, and (3) to evaluate the specificity of self-concept deficits by
comparing eating-disordered patients with selected other psychiatric comparison groups.

METHOD

Subjects and Procedure

Patients in all clinical groups were consecutive admissions to the inpatient treatment
program of a hospital for psychiatric and psychosomatic disorders and were assessed the
week following admission. The mean ages of the AN, BN, and BED patients were 25.2
(SD ¼ 6.9; N ¼ 33), 26.1 (SD ¼ 7.8; N ¼ 38), and 32.8 (SD ¼ 9.6; N ¼ 28) years, respectively.
Patients with anxiety and depressive disorders had a mean age of 34.8 (SD ¼ 8.7; N ¼ 37)
and 40.8 (SD ¼ 10.0; N ¼ 37) years, respectively. All patients and controls were female.
Diagnoses based on criteria in the 3rd Rev. ed. of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-III-R; APA, 1987) were established using the computer version
of the Composite International Diagnostic Interview (CIDI-AUTO; Wittchen & Pfister,
206 Jacobi et al.

1991). Accordingly, 63.6% of anorexic patients were classified as the binge eating/pur-
ging subtype and 36.4% were classified as the restricting subtype. Of the bulimic patients
71.1% met criteria for the purging type and 28.9% met criteria for the nonpurging type.
The mean body mass index (BMI) was 15.0 (SD ¼ 1.1) for the anorexic group, 21.6
(SD ¼ 3.1) for the bulimic group, and 40.2 (SD ¼ 8.4) for the BED group.
Patients with anxiety disorders fulfilled criteria for panic disorder with agoraphobia
(78.4%), panic disorder without agoraphobia (2.7%), and agoraphobia without panic
attacks (18.9%). Depressive patients fulfilled diagnostic criteria for major depression,
singe episode (40.5%), major depression, multiple episodes (40.5%), and dysthymia
(19%). None of the patients with anxiety or depressive disorders fulfilled the criteria
for a comorbid (current or lifetime) eating disorder.
Healthy control subjects were recruited from the general population. One hundred and
fifty-three control subjects completed screening questions to rule out eating disorders or
severe symptoms of disordered eating. Consequently, 10 women were excluded. Three
independent control groups were matched according to age and level of education to the
three groups of eating-disordered patients.

Measures
Because none of the most widely used self-concept and self-esteem instruments (e.g., the
Rosenberg Self-Esteem Scale) have been validated for a German population, we chose a
well-validated German questionnaire, the Frankfurt Self-Concept Scales (FSKN; Deusinger,
1986). The FSKN covers four self-concept domains from different areas of life, comprising 10
subscales. Because the results of the individual subscales have been reported elsewhere
(Jacobi, 1999), we will limit the current study to the results of the ‘‘Global Self-Esteem’’
subscale of the FSKN. This subscale consists of 10 items, six of which are identical to items of
the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965). A number of validation studies
(Deusinger, 1986) have demonstrated good reliability (split-half coefficients between .84 and
.95) and satisfactory internal consistency (.77–.92) for the Global Self-Esteem subscale. In
addition, we explicitly examined the results of the German version of the Eating Disorder
Inventory (EDI) Ineffectiveness subscale (Thiel et al., 1997), which was conceived as an
operationalization of Bruch’s concept of ineffectiveness.
To assess the severity of depressive symptomatology, all study participants completed
the German version of the Beck Depression Inventory (BDI; Hautzinger, Bailer, Worall, &
Keller, 1993). All mean BDI scores of the clinical groups were in the clinical range (means:
16.9–23.5). Overall, the groups differed significantly on mean BDI scores, (F ¼ 2.7,
df(4,167), p
.03). However, no significant post-hoc differences between groups were
found using the Scheffe test.

RESULTS

Comparison of Eating-Disordered Patients and Healthy Control Groups

Differences in global self-esteem and ineffectiveness between each of the three eating-
disordered groups and the respective matched control groups were analyzed by uni-
variate analyses of covariance (ANCOVA) using BDI scores as the covariates. Even after
controlling for depression, all three groups of eating-disordered patients exhibited a
more negative global self-esteem than the respective matched control groups (Table 1).
Self-Concept Disturbances 207

Table 1. FSKN-Global Self-Esteem and EDI-Ineffectiveness of patients with eating disorders and
of healthy controls groups

FSKN Global Self-Esteema ANCOVA EDI-Ineffectivenessb ANCOVA

Group (N) M (SD) F (df), p M (SD) F (df), p

AN (33) 28.97 (9.8) 38.76 (8.9)

12.6 (1,61), .001 5.8 (1,62), .019
CG1 (33) 49.64 (6.5) 22.55 (5.6)
BN (38) 30.45 (11.2) 38.90 (9.2)
15.3 (1,73), .000 12.1 (1,73), .001
CG2 (38) 50.08 (5.3) 22.63 (5.3)
BED (28) 28.61 (8.6) 41.24 (7.5)
17.8 (1,53), .000 21.7 (1,53), .000
CG3 (28) 51.29 (6.2) 20.21 (5.5)

Note: FSKN ¼ Frankfurt Self-Concept Scales; ANCOVA ¼ analysis of covariance; EDI ¼ Eating Disorder
Inventory; AN ¼ anorexia nervosa; BN ¼ bulimia nervosa; BED ¼ binge eating disorder; CG1-3 ¼ control group 1–3.
a
Higher scores represent higher global self-esteem.
b
Higher scores represent more ineffectiveness.

Similarly, significant differences in ineffectiveness were found with the eating-disordered

groups displaying higher ineffectiveness scores than the control groups.1

Comparison of Eating-Disordered and Psychiatric Control Groups

After controlling for depression, all three eating-disordered groups differed signifi-
cantly from patients with anxiety disorders on the FSKN Global Self-Esteem subscale.
Differences in EDI Ineffectiveness were significant for the bulimics and binge eaters after
controlling for depression, but were not significant for anorexic patients (Table 2).
Compared with depressive patients, bulimics and binge eaters, but not anorexic patients,
differed significantly on the FSKN Global Self-Esteem subscale after controlling for
depression. However, none of the three groups of eating-disordered patients differed
significantly in EDI Ineffectiveness from depressive patients.
It is noteworthy that both FSKN Global Self-Esteem and EDI Ineffectiveness scores of
both psychiatric control groups were more pathologic than those of normative samples
and of our healthy control subjects (who were not matched to the two psychiatric control
groups).

DISCUSSION

This cross-sectional study confirms results of previous studies showing that patients
with eating disorders display self-concept deficits in comparison to matched healthy
control groups. The self-concept deficits could be confirmed for both global self-esteem
and ineffectiveness. Our aim was to overcome some of the limitations of previous studies
by carefully matching each group of eating-disordered patients by age and level of
education to respective control groups. This seemed to be especially important as we

1
Because patients with BED had a higher mean BMI than the respective control group, the analyses for binge
eaters were repeated using BMI as the covariate. These results did not differ from the previous ones, indicating
that self-concept deficits are independent of patients’ weight status.
 208

Table 2. FSKN-Global Self-Esteem and EDI-Ineffectiveness of patients with eating disorders and of psychiatric comparison groups

Anxiety Depressive
AN (N ¼ 33) BN (N ¼ 38) BED (N ¼ 28) Disorders (N ¼ 37) ANCOVA Post-hoca Disorders (N ¼ 37) ANCOVA Post-hoca

M (SD) M (SD) M (SD) M (SD) F (df), p M (SD) F (df), p

FSKN-Global 28.97 (9.8) 30.45 (11.2) 28.61 (8.6) 39.34 (10.9) 5.18 (3,127), .002 AN, BN, 36.96 (10.6) 4.25 (3,129), .007 BN, BED < D
Self-Esteem BED < A
EDI- 38.76 (8.9) 38.90 (9.2) 41.24 (7.5) 32.33 (9.4) 6.4 (3,141), .000 BN, 35.76 (9.0) 1.87 (3,130), .138 NS
Ineffectiveness BED < A

Note: FSKN ¼ Frankfurt Self-Concept Scales; EDI ¼ Eating Disorder Inventory; ANCOVA ¼ analysis of covariance; EDI ¼ Eating Disorder Inventory; A ¼ anxiety
disorders; AN ¼ anorexia nervosa; BN ¼ bulimia nervosa; BED ¼ binge eating disorder; D ¼ depressive disorders.
a
Planned comparisons.
Jacobi et al.
Self-Concept Disturbances 209

also included a group of patients with BED. Although these patients usually differ in age
and level of education from anorexic and bulimic patients, they displayed similar self-
concept deficits. Our findings also indicate that the self-concept deficits in eating-
disordered patients in comparison to healthy controls are independent of depressive
symptomatology. When compared with the other clinical groups, many, but not all,
differences remained after controlling for depression. Patients with AN did not differ
from depressed patients and differed from anxiety patients only on the FSKN Global Self-
Esteem subscale but not on the EDI Ineffectiveness subscale. In addition, all clinical
groups displayed a more negative self-concept and higher degrees of ineffectiveness
when compared with norm groups or to the scores of healthy controls. Consequently,
our findings do not suggest that self-concept deficits are highly specific for patients with
eating disorders. In the study by Cooper, Cooper, and Fairburn (1985), anorexic patients
differed significantly from psychiatric controls in terms of higher EDI Ineffectiveness
scores. The results in the current study support the finding of Cooper et al. (1985).
However, the psychiatric group also differed from healthy controls in terms of higher
ineffectiveness scores. Bers and Quinlan (1992) found no differences between anorexic
patients and mixed psychiatric controls on both the RSES and the EDI Ineffectiveness
subscale. Again, both clinical groups differed significantly from the nonclinical control
groups. Finally, Fairburn et al. (1997, 1998) found differences in retrospectively assessed
premorbid self-esteem of anorexic and bulimic patients compared with psychiatric con-
trols, with the latter group differing from healthy controls. Therefore, our results could
reflect ‘‘true’’ differences in the level of self-esteem in different diagnostic groups, with
patients with anxiety and depressive disorders representing an intermediate group
between patients with eating disorders and controls.
The overall nonspecificity of the results may also be related to the severity of the
disorders. Illness duration (Jacobi, 1999), the number of panic attacks, and the BDI scores
in patients with anxiety and depressive disorders were lower than the scores found in
treatment trials (Hautzinger & de Jong-Meyer, 1996). Finally, conceptual and/or psycho-
metric issues have to be considered in the interpretation of the results of the current study.
Whereas the FSKN is based on a trait-like notion, more recent conceptualizations of self-
concept and self-esteem have pointed out the importance of short-term fluctuations in self-
esteem along with the level of global self-esteem (Kernis, 1993; Roberts & Monroe, 1992).
The inclusion of a measure addressing the aspects of lability/stability may also have led to
more clear-cut results in the comparisons with the other clinical groups.
This study does not confirm that low self-esteem and ineffectiveness are specific
characteristics of patients with eating disorders. They seem to be nonspecific character-
istics of clinical groups in general, possibly to a different degree depending on the
diagnosis.

The authors thank W. Stewart Agras for helpful comments on an earlier version of this report.

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