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Bulimia and Object Relations: MMPI and Rorschach Variables John C. Parmer Published online: 10 Jun 2010.

To cite this article: John C. Parmer (1991) Bulimia and Object Relations: MMPI and Rorschach Variables, Journal of Personality Assessment, 56:2, 266-276, DOI: 10.1207/s15327752jpa5602_7 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5602_7

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JOURNAL OF PERSONALITY ASSESSMENT, 1991, 56(2), 266-276 Copyright 1991, Lawrence Erlbaum Associates, Inc.

Bulimia and Object Relations: MMPI and Rorschach Variables John C . Parmer

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Central Michigan University and The Bradley Center, Inc. Columbus, G A

Rorschach and Minnesota Multiphasic Personality Inventory (MMPI) responses from persons vomiting to manage body weight and fat phobia were compared to those from a matched control group to determine the levels of personality structure. These responses were also contrasted with those of representative groups from normal and personality disordered populations. Findings were that the bulimic group's test protocols differed significantly from those of the control group, displaying evidence of serious cognitive slippage and dramatic, emotional and erratic personality structures arrested at the differentiation subphase of ego development. The clinical importance of timely developmental diagnosis and interventions designed to promote object constancy was discussed in light of these findings.

T h e healthy ego maintains constant, stable, and realistic mental representations of one's self and the objects in one's environment from which affective responses arise while regulating tension and adaptively responding to environmental cues. Vomiting bulimics typically display cognitive distortions, tension regulation deficits, and self-destructive responses to environmental and internal demands t o manage body weight and anxiety; they also show evidence of impaired object relations (Aronson, 1986; Goodsitt, 1983; Lerner, 1983; Sugarman & Kurash, 1981; Swift & Letven, 1984). According t o Mahler, Pine, and Bergman's (1975) theory, during the first 2 months of neonatal experience the child is "unable to distinguish his own from his mother's tension-reducing operations" (Blanck & Blanck, 1974, p. 54). In normal development the symbiotic phase ensues next, during which time the infant is thought to have a delusional experience of blurred self-other boundaries. A n important ego function acquired during this phase is the ability to delay gratification, and developmental insults tend to produce generalized

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impulsiveness and predominantly need-gratifying interpersonal relationships. During the separation-individuation phase the child develops an awareness of psychological separateness and acquires the capacity for object constancy. Disillusionment in the face of the reality of separation becomes endurable because of an acquired capacity for self-soothing. The child suffering insult t~ during this phase will likely develop a borderline/narcissistic ~ e r s o n a l i organization, characterized by maladaptive compensatory behaviors such as drug and alcohol abuse, promiscuity, aggression, overeating, or other compulsive activities, and exploitative relationships in attempts to r~egainthe gratification which is lost forever and to defend against the resultant primitive rage and sense of emptiness (Kernberg, 1975).Josephson (1985)found that bulimics were prone to depression, substance abuse, promiscuity, and compulsive petty theft. Drawing from Winnicott's (1953) observations of infants' uses of controllable objects to assist in the transition from an illusion of oneness with the mother to an adaptive acceptance of self-other boundaries, Sugarman and Kurash (1981) conceptualized bulimics as maladaptively using their own bodies as transitional objects for self-soothing by way of binging on food followed by rejective vomiting to allay the perceived threat of symbiosis and loss of self. "Food is not the issue: rather it is the bodily action of eating which is essential in regaining a fleeting experience of mother. The dread of fusion . . . often lead(s) to vomiting, another bodily activity" (p. 61). Typical symptom onset during adolescence was attributed to the reemergence of analogous psychological issues during this second separation-individuation stage of development. Goodsitt (1983) regarded binging and purging as evidence of impaired tension-regulating ego functions and as dysfunctional methods to "drown out anguished feelings of deadness, emptiness, boredom, aimlessness, and the associated tensionsn(p. 54). Swift and Letven (1984) also conceptualized bulimia as evidence that the person is suffering a basic fault in ego structure that predisposes them to "intolerably high levels of internal tension that seriously enfeebles their sense of self"'(p. 489) when subjected to the stress of negotiating adolescence. IBinging and vomiting were seen as symbolic exaggerations of the two fundamental styles of defending against disillusionment in relating to others-ocnophilia and philsbatism, which are interpersonal patterns of clinging dependency and self-reliant distancing, respectively. The ocnophilic relationship serves as a defense against the threat of separation and emptiness, whereas the philobatic style is an attempt to alleviate fears of engulfment and loss of independence. Regarding personality tests, Norman and Herzog (1983) found mean MM131 elevations above 70 in a 4-2-7-8 profile of normal-weight vomiting bulimics. Wallach and Lowenkopf (1984) found a 4-2-8-7-6 mean profile with their sample, and Mitchell and Pyle (1985)reported a 2-4-7-8 mean profile for theirs. Dykens and Gerrard (1986) found MMPI profiles within the normal range for nonpatient bulimics but an elevated 9-4-8 code. Vincent et al. (1983)found that 50% of persons with high-point Scale 4 MMPI profiles were diagnosed "Dra-

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matic, Emotional, Erratic Personality Disorders" (p. 831), and those with 3-4, 4-8, 4-9, or 4-7-8 codes were given this diagnosis 80% of the time. Widiger, Sanderson, and Warner (1986) found that the 4-2-8 profile was most common for the borderline personality. Actuarial differences also exist between the Rorschach responses of patient and nonpatient populations (Exner, 1986a, 1986b), and analyses of human content responses have correlated with psychoscructural diagnoses (Coonerty, 1986; Kelly, 1986). Exner (1986b) found that a group of patients with diagnoses of borderline personality disorder gave an average of .45 seriously distorted perceptions of human movement (M -) and -63 unusual perceptions of human movement (Mu) per record, or 2.42% and 3.39%, respectively. Thus, his borderline group perceived unusual/minus form quality human movement on 5.81% of their responses. He published no average number of Mu responses for his standardized data from nonpatients, but reported that they averaged only .09 M- responses per record (.4%). It appears that an increase of M - (and probably Mu) responses is one characteristic of the borderline personality. Coonerty (1986) designed the Separation-Individuation Theme Scale as a measure of Rorschach content analysis and found evidence that borderline and schizophrenic patients' responses supported Mahler et al.'s (1975) theory of ego development. Coonerty's scale was divided into two major themes of preseparation-individuation and separation-individuation, with the latter further divided into the subthemes of differentiation, narcissism, and rapprochement. The differentiation subphase was the fulcrum of the ego developmental process at which the groups overlapped. Research using bulimics' Rorschach responses has been minimal and equivocal (Wallach & Lowenkopf, 1984). However, if bulimia is correlated with psychostructural faults, a sampling of bulimics' MMPI and Rorschach responses should resemble those of individuals diagnosed with dramatic, emotional, erratic personality disorders. Their responses should also statistically differentiate them from a control group and, apparently, from normal population data.

METHODS Design Actively vomiting bulimics were matched with control subjects in a quasiexperimental, posttest-only design with nonequivalent groups (Cook & Campbell, 1979). Between-group analyses were calculated for the 2, 4, 7, 8, Anxiety, and Ego Strength MMM T-scores, the number of Rorschach responses coded according to the Separation Individuation Theme Scale, and the number of Rorschach responses coded as human movement with poor form level (MU/-).

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Weight Parameters To control for the effects of malnutrition and body weight, only persons within the range from 80% to 120% of normal weight were examined. Normal weight was here defined as 100 pounds for a woman sixty inches tall, with increments of 5 pounds for each inch above or below this height 0. Hornak, personal communication, September 11, 1986). Data from 10 magazine models (Hefiler, 1986a, 198613, 1986c, 1987a, 198713, 1987c, 1987d, 1987e, 1987f, 1987g) revealed that these women (mean age = 22.4 years) averaged 85% of ideal weight according to this standard. In that they were presented as cultural ideals of the feminine form, yet also criticized as representing unrealistic weight standards (Garner, Rockert, Olmsted, Johnson, & Coscina, 1985), using their average weight as examples of the lower range of normalcy lends face validity to this scale. The 10 finalists from a local pageant were found to average 99% of ideal weight according to this criterion (Bohn, 1987).These young women (mean age = 20.4 years) were not professional models and thus may represent a more normal standard of weight for women their age.

Description of Subjects Thirteen bulimic, Caucasian, female, undergraduate students, ranging in age from 18 to 21 years and ranging from 81% to 101% of normal weight, were matched with 13 nonbulimic, same aged, Caucasion, female undergraduates from the same university who ranged from 84% to 120% of normal weight.

Statistical Procedures An analysis of variance (ANOVA) was used for each between-group comparison of MMPI T-scores, and a Mann-Whitney U Test was performed with the Rorschach data because of the probability that these data were derived from a population without normally distributed variances (Exner, 1986a).Determinant data were factored out of all statistical comparisons by changing each comparison to a percentage, thus controlling for the effects of differing record lengths.

Instruments The MMPI. Mean T-scores for each scale were plotted for both groups. It was expected that the bulimic group would obtain significantlyhigher elevations on Scales 2,4,7, and 8. Because the basic premise behind this research was .that bulimia is indicative of impaired ego functioning and that the symptoms are attempts to manage inordinate anxiety, the MMPI Ego Strength scale and Anxiety scale T-scores were also analyzed. The expectations were that the

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experimental group would obtain significantly lower scores on Ego Strength and higher scores on Anxiety when compared with the control group.

The Rorschach. The Rorschach plates were administered to each subject by second- and third-year clinical psychology graduate students. The content of subjects' test responses received scores according to the SeparationIndividuation Theme Scale. A n 84% interrater agreement was obtained, with the double-blind rater's codings used for the analyses. Human movement was also coded for each protocol. T o eliminate potential controversy over whether a response should be scored as either M - or Mu, Exner's (1986a) norms were used to determine form level. Unusual and minus human movement form level categories were combined (Mu/ -) because Exner listed every ordinary (0) response, but not every possible unusual (u), minus ( -), or plus (+) response. To mitigate the probability of responses not listed in Exner's tables being misjudged, interrater agreement was assessed by having another double-blind psychologist score those human movement responses requiring examiner judgment. Interrater agreement was 100%. RESULTS

MMPI Findings The control group had no scales elevated to 70 or above, whereas the bulimic group had elevations of 70 or above on Scales F, 4, 7, and 8, as displayed by Figure 1. Not only were these elevations significantly different than those of the standardized population (mean T = 50), but ANOVA revealed that the bulimic group's T-scores were statistically different from the nonbulimic group's on all of the MMPI scales examined except Scales L, 5, and 9. Table 1 displays the statistical results from between-group comparisons of the MMPI variables relevant to the research hypotheses.

Rorschach Findings Table 2 displays a summary of the differences between the bulimics' and nonbulimics' Rorschach responses, showing that the bulimic group gave significantly more seriously distorted or unusual perceptions of human movement (Mu/ -) than did their nonbulimic peers. Inspection of Table 2 also reveals that there were no significant between-group differences on the more developmentally advanced separation-individuation response variable, but that significance was obtained for the more primitive preseparation-individuation response. T o provide a closer analysis of the differences, the higher level theme was further

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(* =

Bulimic Mean T-Score, + = Nan-Bulimic Mean T-Srore)

FIGURE 1 Group mean MMPI profiles.

divided into three subthemes: differentiation, practicing narcissism, and rapprochement. Table 2 also displays a summary of the between-group differences on these three separation-individuation subthemes, revealing that the bulimics reported significantly more differentiation responses. No significance was obtained for the other two variables.

DISCUSSION -1

Profiles

The MMPI group profiles were quite dissimilar on almost every scale examined (see Figure 1). Whereas the nonbulimics' group profile was within normal limits,

TABLE 1 ANOVA Differences Between MMPI T-Scores

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Scales Depression (2) Bulimics Nonbulimics Psychopathic Deviance (4) Bulimics Nonbulimics Psychasthenia (7) Bulimics Nonbulimics Schizophrenia (8) Bulimics Nonbulimics Anxiety Bulimics Nonbulimics Ego Strength Bulimics Nonbulimics

M

SD

F

P

76.54 56.31

17.52 9.19

13.60

.0012

70.46 56.00

11.91 6.66

14.61

,0008

78.54 55.62

19.10 7.33

16.32

.0005

63.23 47.15

11.61 9.49

14.93

,0007

40.46 56.46

11.36 10.19

14.29

.0009

TABLE 2 Mann-Whitney U Differences Between Percentages of Rorschach Responses Responses Unusual/minus human movement Bulimics Nonbulimics Preseparation-individuation Bulimics Nonbulimics Separation-individuation Bulimics Nonbulimics Differentiation Bulimics Nonbulimics Practicing narcissism Bulimics Nonbulimics Rapprochement Bulimics Nonbulimics

Average Rank

U

P

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the bulimics obtained a 4-8 profile. Persons with similar configurations have been described as displaying marginal social functioning (Graham, 1987). Eighty percent of the time they were diagnosed as manifesting hysterical, antisocial, borderline, or narcissistic ~ersonalitydisorders (Vincent et al., 1983). Their high Scale 7 scores suggest obsessive-compulsive characteristics in perfectionistic individuals troubled by excessive doubts and unreasonable fears (Graham, 1987). Such ritualistic behaviors might serve as the psychological glue preventing an already fragile self-representation from crumbling into even more disarray. The bulimic group also obtained significance on the MMM Anxiety scale. This suggested that they were inordinately anxious, and their significantly lower Ego Strength scale score suggested that poor "ego resiliency" (Graham, 1987, p. 203) impaired their abilities to cope with even typical daily stressors. The bulimic group's Scale 2 scores were not significantly elevated, indicating that these women were not reporting depression. Examination of previous group samples revealed that those with elevations on this scale were from patients in treatment clinics (Mitchell & Pyle, 1985; Norman & Herzog, 1983; Wallach & Lowenkopf, 1984), whereas the group with no significant MMPI elevations was comprised of nonpatients (Dykens & Gerrard, 1986). It may be that the patient groups were more depressed than the others and thereby involved in treatment. Thus, significant elevations on this scale may be subjelct to more situational variables rather than being characteristic of bulimia. Still, a dramatic and unstable personality disorder correlating with bulimic vomiting seems highly probable from these MMPI results.

Rorschach Responses The bulimic group's Rorschach responses also evidenced personality disturbance. Whereas Exner's (198613) borderline group reported human movement with U/ - form quality in 5.81% of their responses, the bulimic group's Mu/ responses comprised an average of 16.7% of their protocols. Unexpectedly, even the nonbulimics gave more Mu/- responses than did Exner's borderlines, averaging 6.10%. Yet, the typical college student probably is not psychostructurally borderline. Without differentiating between M - and Mu responses, it cannot be determined whether these 18- to 2%-year-oldnonbulimics perceived grossly distorted images indicative of a thought disorder or whether their Mu/- elevations were attributable to a less disruptive resurfacing of identity issues at this age. Also, an elevated number of Mu/ - responses is E~ut one correla'te with borderline personality organization. Nevertheless, the bulimic group's excessive elevation of this variable clearly indicated serious cognitive slippage of the sort found with severe ego dysfunction (Exner, 1986a). The last area examined was the Rorschach content coded according to the Separation-Individuation Theme Scale. The groups were statistically indistin-

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guishable on the developmentally higher separation-individuation major theme, but the bulimics did give significantly more responses indicative of developmentally primitive ideations. These preseparation-individuation responses are thought to represent Mahler's autistic and symbiotic subphases, and they included percepts of viscera and fabulized combinations. Analyzing the subphases within the broader separation-individuation major theme provided further support for the theory that bulimia is correlated with a precarious boundary between self- and object-representations. Here the bulimics gave significantly more differentiation subphase responses involving merging, engulfment, and hatching themes. Whereas college-age persons may typically rework separation-individuation issues, these late-adolescent bulimics as a group were apparently preoccupied with some of the earliest of ego developmental phases, differentiating "self representations from the hitherto fused symbiotic self-plus-object representations" (Blanck & Blanck, 1974, p. 57). When these bulimic women were infants beginning to differentiate, they may have encountered ambivalence from their primary caregivers so that now they vacillate between seeking to regain positive introjects by binging on an oral representation of mother only to be frightened by potential psychological merger and the loss of their tenuously differentiated self. Their postexpulsive relief may be attributed to having escaped from the vacuum of psychological symbiosis only to reexperience this threat as they have insufficient self-soothing abilities.

Developmental Diagnosis and Treatment These results do not support diagnosing psychostructural impairment based on bulimic symptomatology alone; they do point to the viability of object relations conceptualizations. For example, bulimics may use their bodies as transitional objects to facilitate psychological differentiation (Sugarman & Kurash, 1981), and the binge-purge syndrome may exemplify ocnophilic and philobatic vacillations (Swift & Letven, 1984) in the defense of a fragile self-representation. Bulimia is not caused by a borderline personality organization, but such understructured ego development might predispose a person to bulimic symptoms which serve as metaphorical enactments of developmental conflicts. The difficulty treating these patients may be attributable to a tendency to view bulimia as either a specific behavioral disorder or as evidence of a more pervasive personality disorder. A more accurate conceptualization may be that bulimia represents both of these, and that treatment of the symptoms must be accompanied by ego building interventions to effect lasting recovery because the person on the road toward object constancy is less susceptible to this syndrome. Thompson and Sherman (1989) emphasized five potential therapist mistakes often made when working with the bulimic patient, the underlying thread of which is focusing attention on behavioral symptoms at the expense of

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the therapeutic process and alliance. Attention to the level of psychostructural development through timely personality assessments may militate against making this mistake.

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ACKNOWLEDGMENTS This article was derived from my doctoral dissertation and was presented at the annual convention of the Society for Personality Assessment as the 1990 Beck Graduate Research Award winner. I thank Robert Lovinger, Sophie Lovinger, James Carroll, and Michael Kent for serving as my dissertation committee. Jackie Kellogg, Sandra Ann-Marie, Will Volesky, Ed Schmitt, Tom Griffor, Art Horn, ancl Carlie Frederick also helped me as testers, coders, and friends.

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Hefkr, H. M. (1987g, August). Playmate data sheet. Playboy, p. 90. Josephson, A. M. (1985). Psychodynamics of anorexia nervosa and bulimia. In J. E. Mitchell (Ed.), Anorexia newosa and bulimia: Diagnosis and treatment (pp. 78-101). Minneapolis: University of Minnesota Press. Kelly, F. D. (1986). Assessment of the borderline adolescent: Psychological measures of defensive structure and object representation. Journal of Child and Adolescent Psychology, 3, 199-206. Kernberg, 0.P. (1975). Borderline conditions and pathological narcissism. New York: Aronson. Lerner, H. D. (1983). Contemporary psychoanalytic perspectives on gorge-vomiting. International Journal of Eating Disorders, 3,47-63. Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. New York: Basic Books. Mitchell, J. E., & Pyle, R. L. (1985). Characteristics of bulimia. In J. E. Mitchell (Ed.), Anorexia nervosa and bulimia: Diagnosis and treatment (pp. 29-47). Minneapolis: University of Minnesota Press. Norman, D. K., & Herzog, D. B. (1983). Bulimia, anorexia nervosa, and anorexia nervosa with bulimia: A comparative analysis of MMPI profiles. International Journal of Eating Disorders, 2, 43-52. Sugarman, A., & Kurash, C. (1981). The body as a transitional object in bulimia. International Journal of Eating Disorders, I, 57-67. Swift, W. J., & Letven, R. (1984). Bulimia and the basic fault: A psychoanalyticinterpretation of the bingeing-vomiting syndrome. Journal of the American Academy of Child Psychiatrists, 23,489-497. Thompson, R. A., & Sherman, R. T. (1989). Therapist errors in treating eating disorders: Relationship and process. Psychotherapy, 26, 62-68. Vincent, K. R., Iliana, C., Hauser, R. I., Stuart, H. J., Zapata, J. A., Cohn, C. K., & O'Shanick,-G. J. (1983). MMPI code types and DSM-111 diagnoses. Journal of Clinical Psychology, 39, 829-842. Wallach, J. D., & Lowenkopf, E. L. (1984). Five bulimic women: MMPI, Rorschach, and TAT characteristics. International Journal of Eating Disorders, 3, 53-66. Widiger, T. A,, Sanderson, C., & Warner, L. (1986). The MMPI, prototypal typology, and borderline personality disorder. Journal of Personality Assessment, 50, 540-553. Winnicott, D. W. (1953). Transitional objects and transitional phenomena. International Journal of Psycho-Analysis, 34(2), 89-97.

John C. Parmer Bradley Center 2000 Sixteenth Avenue Columbus, GA 3 1993 Received April 13, 1990 Revised May 14, 1990

Bulimia and object relations: MMPI and Rorschach variables.

Rorschach and Minnesota Multiphasic Personality Inventory (MMPI) responses from persons vomiting to manage body weight and fat phobia were compared to...
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