Eating Behaviors 15 (2014) 125–131

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Eating Behaviors

Self-image and eating disorder symptoms in normal and clinical adolescents Emma Forsén Mantilla a,⁎, Katja Bergsten b, Andreas Birgegård a a b

Karolinska Institute, Dept. of Clinical Neuroscience, Resource Center for Eating Disorders, Norra Stationsgatan 69, Plan 7, 113 64 Stockholm, Sweden Uppsala University, Dept. of Psychology, S:t Olofsgatan 10B, 753 12 Uppsala, Sweden

a r t i c l e

i n f o

Article history: Received 13 August 2013 Received in revised form 28 October 2013 Accepted 20 November 2013 Available online 28 November 2013 Keywords: Adolescents Eating disorder SASB Self-image Gender differences

a b s t r a c t Eating disorders (ED) are psychiatric disorders of multifactorial origin, predominantly appearing in adolescence. Negative self-image is identified as risk factor, but the association between self-image and ED in adolescents or sex differences regarding such associations remains unclear. The study aimed to investigate the relationship between specific self-image aspects and ED symptoms in normal and clinical adolescents, including sex differences. Participants included 855 ED patients (girls = 813, boys = 42) and 482 normal adolescents (girls = 238, boys = 244), 13–15 years. Stepwise regression demonstrated strong associations between self-image and ED in normal adolescents (girls: R2 = .31, boys: R2 = .08), and stronger associations in patients (girls: R2 = .64, boys: R2 = .69). Qualitative sex differences were observed in patients. Connections between specific selfimage aspects and ED have implications for clinical management of ED. The strong link between self-image variables and ED symptoms in normal girls, but not boys, is discussed in terms of the continuity–discontinuity hypothesis. © 2013 Elsevier Ltd. All rights reserved.

1. Introduction Adolescence is a critical developmental period involving identity formation, physical, cognitive, social and sexual development, and increased self-awareness. Although the majority of adolescents make this transition without significant difficulties, some encounter psychological and behavioral problems with more lasting effects (Bongers, Koot, van der Ende, & Verhulst, 2003, Ybrandt, 2007). Eating disorders (ED) are one such problem area, predominantly found in females, usually appearing in adolescence and often with a chronic course. The female-to-male ratio of any ED changes from about 4:1 during adolescence to about 10:1 in adulthood (Reijonen, Pratt, Patel, & Greydanus, 2003; Striegel-Moore & Bulik, 2007), and a Norwegian study on 14 to 15 year-olds (Kjelsås, Børnstrøm, & Götestam, 2004) found total ED point prevalence rates of 7.6% among girls (counting anorexia nervosa, AN; bulimia nervosa, BN; and eating disorders not otherwise specified, EDNOS) and 2.2% among boys. Many more have sub-clinical symptoms, hence at risk for developing ED. Early detection and treatment of ED improve the chances for a better outcome (Berkman, Lohr, & Bulik, 2007), making research on risk factors and their relationship to normal-

⁎ Corresponding author at: Resource Center for Eating Disorders, Norra Stationsgatan 69, Plan 7, 113 64 Stockholm, Sweden. Tel.: +46 736 543 254. E-mail addresses: [email protected] (E. Forsén Mantilla), [email protected] (K. Bergsten), [email protected] (A. Birgegård). 1471-0153/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.eatbeh.2013.11.008

spectrum psychological variables important (Fichter, Quadflieg, & Hedlund, 2006). Besides being a young female and dieting, poor self-esteem has been identified as an important risk factor for ED (Fairburn, Cooper, Doll, & Welch, 1999; Fairburn, Cooper, & Shafran, 2003; Ghaderi & Scott, 2001). Cervera et al. (2003) found that high self-esteem protected from ED, while low self-esteem was related to subsequent development of ED in a sample of women aged 12–21. Patients with ED have in general lower self-esteem than normal controls (Ghaderi & Scott, 2001; Sassaroli, Gallucci, & Ruggiero, 2008). However, there is insufficient evidence for positive effects of prevention programs targeting self-esteem (Pratt & Woolfenden, 2008; Stice, Shaw, & Marti, 2007). One possible reason for this is that self-esteem as a concept is too global and undifferentiated, hence unable to capture all aspects of a person's self-image potentially important when developing ED. Rosenberg (1989) defines self-esteem as overall appraisal of self-worth; how much one values oneself. As a construct, the self might however be defined as a set of cognitions, knowledge, and opinions about the self, with a descriptive component of both internal and external attributes (self-concept), an evaluative component of both general personal worth (self-esteem), and own competencies and coping resources (self-confidence), as well as self-regulation strategies. Usually in research, one aspect is in focus at the time, most often self-esteem. One model that incorporates both self-image as a two-dimensional construct and theoretical implications for interpersonal behavior is the Structural Analysis of Social Behavior (SASB, Benjamin, 1974, 2000). It is based on interpersonal- and attachment theory and self-image

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is seen as a product of interpersonal interactions (Benjamin, 1993), continuously affecting social behavior (Henry, 1994). The SASB model is circumplex with two dimensions: Affiliation (Self-love to Self-hate) and Autonomy (Self-control to Self-freeing), and the theory describes how these relate to corresponding interpersonal behaviors. Fig. 1 shows the Introject surface of the model with the above-mentioned dimensions represented on two axes (Affiliation horizontally and Autonomy vertically). Points along the perimeter illustrate combinations of the underlying dimensions and divide into eight clusters. The affiliation dimension conceptually approximates self-esteem (Pincus, Gurtman, & Ruiz, 1998). SASB has been used previously in ED research (Birgegård, Björck, Norring, Sohlberg, & Clinton, 2009; Björck, Clinton, Sohlberg, Hällström, & Norring, 2003; Björck, Clinton, Sohlberg, & Norring, 2007; Björk, Björck, Clinton, Sohlberg, & Norring, 2009; Humphrey, 1989; Pincus et al., 1998; Ratti, Humphrey, & Lyons, 1996). More specifically, SASB self-image improves more in patients completing treatment compared to patients who drop out (Björk et al., 2009). Self-image successfully distinguishes between treatment dropouts and completers and predicts dropout (Björck et al., 2007). Furthermore, ED patients present with distinct interpersonal profiles significantly more negative than controls (Björck et al., 2003); high levels of self-hate increase the risk of poor outcome in ED (Björck et al., 2007), and different aspects of self-image predict outcome in BN and AN (Birgegård et al., 2009). In this research however, adult populations have been in focus. Little research has investigated whether the sex difference in ED prevalence is accompanied by psychological differences. Some gender differences in ED have been noted: Geist, Heinmaa, Katzman, and Stephens (1999) found that females scored higher than males on

drive for thinness and body dissatisfaction, Lewinsohn, Seeley, Moerk, and Striegel-Moore (2002) showed that women were more likely than men to seek treatment despite being at comparable levels of problematic eating behaviors; Støving, Andries, Brixen, Bilenberg, and Hørder (2011) found that illness duration among patients with AN was shorter for males (3 years) than for females (7 years). Their results also suggested better outcome for males. In normal samples, gender difference in self-esteem is a fairly robust finding (Feingold, 1994; Hall, 1984), with boys reporting higher self-esteem than girls during adolescence (Frost & McKelvie, 2004; Mäkinen, Puuko-Viertomies, Lindberg, Siimes, & Aalberg, 2012). With regard to gender differences in self-image as measured by SASB, little has been reported. In the only SASB study of gender differences, antisocial adolescent girls reported a more negative self-image than a corresponding subsample of boys. No such differences were found in a normal comparison group (ÖstgårdYbrandt & Armelius, 2004). Nothing has yet been reported about gender differences in the association between self-image and ED in normal or clinical groups. We aimed to identify associations between ED symptoms and distinct aspects of self-image in adolescents, and to compare these associations in a clinical sample versus a non-clinical sample, and in boys versus girls. While for example the importance of general selfesteem for ED has been investigated previously, we wanted to expand on this body of research using a more multi-faceted self-image operationalization. Higher precision regarding self-image factors related to ED detected before ED symptoms is fully established, may inform and improve both prevention programs and ED treatments. Contrasting normal and clinical samples may further our understanding of psychological variables in ED.

Fig. 1. The SASB Introject cluster model. The model displays the eight clusters and the two axes (Affiliation and Autonomy). From: Benjamin, L.S. (1996). Interpersonal diagnosis and treatment of personality disorders, 2nd Ed. N.Y.: The Guilford Press. © The Guilford Press.

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2. Methods 2.1. Participants 2.1.1. Normal sample From all schools in a Swedish community,1 675 adolescents aged 13–15 could have participated. For reasons not recorded 171 (25%) did not attend school the day data was collected, and 22 (3%) participants were excluded due to incomplete report-forms. That left n = 482 (71%, 238 girls and 244 boys) participants. Age ranged from 12 to 14 years (girls: m = 13.46, sd = .50; boys: m = 13.48, sd = .50). The reported mean age is an estimation based on which grade the participants were in. 2.1.2. Clinical sample Data came from the naturalistic quality assurance database, “Stepwise”, an Internet-based data collection system for specialized ED treatment in Sweden (Birgegård, Björck, & Clinton, 2010). Inclusion criteria are medical- or self-referral to one of the participating treatment units (N = 26), a DSM-IV ED diagnosis, and intention to treat the patient at the unit. There were 994 adolescents aged 13–15 registered in the database at time of data extraction. Of these, 12 participants were excluded due to incomplete registration; 57 were excluded due to lack of consent to research participation and 70 participants diagnosed with EDNOS Other were excluded due to the unspecific nature of the diagnosis. N = 855 (86%; 813 girls and 42 boys) remained to be analyzed. Age ranged between 13 and 15 years (girls: m = 14.26, sd = .76, boys: m = 14.07, sd = .87). 2.2. Instruments 2.2.1. Eating Disorder Examination Questionnaire (EDEQ) Eating Disorder Examination Questionnaire (EDEQ) (Fairburn & Beglin, 1994) adolescent version (Carter, Stewart, & Fairburn, 2001) was used to measure eating pathology. The Global score was calculated as the mean of the four subscales Restraint, Eating concern, Shape concern and Weight concern. Items are rated on a 0–6 scale. The adolescent version is structurally similar to the adult one, only semantically simplified and focusing on the past two, rather than four, weeks. The questionnaire is commonly used in international research and has good psychometric properties and reference data (Carter et al., 2001; Mond, Hay, Rodgers, Owen, & Beumont, 2004; Mond, Hay, Rodgers, & Owen, 2007; Welch, Birgegård, Parling, & Ghaderi, 2011). In this study each subscale had good internal consistency within both populations with Cronbach's alpha N.70 throughout (alphas ranging between .75 and .94). Mean alpha for the subscales in the normal sample was .85 for girls and .80 for boys. In the clinical sample alpha was .86 for girls and .85 for boys. 2.2.2. Structural Analysis of Social Behavior (SASB) The 36-item SASB self-image divides into eight cluster variables; 1) Self-emancipation, 2) Self-affirmation, 3) Self-love, 4) Selfprotection, 5) Self-control, 6) Self-blame, 7) Self-hate, and 8) Selfneglect. Participants rate items on a 0 to 100 scale indicating increasing levels of agreement. Benjamin (2000) reported an internal consistency of .76. Armelius (2001) reported an internal consistency of .87 for the Swedish translation of SASB Intrex. Factor analyses have yielded structures confirming the underlying SASB model (Benjamin, 1974, 2000). In clinical contexts, validity has been shown in SASB discriminating between psychiatric diagnoses (Benjamin, 2000; Henry,

1 Östhammar: www.osthammar.se/kommunfakta/0382%20osthammar%FAKTA.pdf; downloaded 2007-03-05.

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1994; including between ED, Björck et al., 2003). In the present study, clusters were excluded when Cronbach's alphas were b.70 for both girls and boys in either sample. Acceptable alphas were obtained for five (Self-affirmation, Self-love, Self-control, Self-blame, Self-hate) out of eight clusters in the normal sample, and for all clusters except Selfemancipation in the clinical sample. Of the remaining five clusters all displayed acceptable alphas (N.70) for both boys and girls in both samples, with two exceptions in the normal sample: cluster 5 and cluster 3 yielded acceptable alphas for girls (α = .72 and α = .83, respectively) but not for boys (α = .63 and α = .69, respectively). 2.2.3. Structured Eating Disorder Interview (SEDI) The semi-structured clinical interview SEDI was used to determine DSM-IV eating disorder diagnoses and their subtypes in the clinical sample (De Man Lapidoth & Birgegård, 2010). Between 20 and 30 questions are asked depending on which criteria are judged as being fulfilled. Preliminary validation against the EDE interview demonstrated concordance of 81% concerning ED diagnosis (including EDNOS and BED) and Kendall's Tau-b of 0.69 (p b .0001; De Man Lapidoth & Birgegård, 2010). 2.3. Procedure Regarding the normal sample, letters were sent to teachers and parents with information about the aim and procedure of the study. Parents were encouraged to contact the project supervisor if they had questions or if they did not want their child to participate. No parent objected. The student health care teams were also informed, in case filling out the forms should cause worry or concerns among the students. Final term students of the Psychology Program at Uppsala University collected the data. The collection was carried out during school hours in the classrooms, where attempts were made to physically separate the students and create privacy while filling out the forms. The research assistants followed a manual for instructions and procedure. Participants were informed that the study was about how they feel, with no specific mention of ED. They were also told that participation was voluntary and that their responses were confidential. Data collection was performed during a two-week period. The community Board of Education approved the study. ED professionals assessed the clinical group using Stepwise. Assessment was carried out prior to treatment and no later than the patients' third visit to the unit. The patients received information about Stepwise and about research participation being voluntary. After a brief introductory interview, the assessment starts with MINIKid DSM-IV Axis I screening interview (Sheehan et al., 1998) followed by the SEDI, clinical ratings of level of functioning and ED severity and finally self-report measures (EDEQ, SASB and the Strengths and Difficulties Questionnaire, not in consideration here). While completing the clinical interviews and ratings the clinician is seated at the computer recording the answers on the screen with the patient sitting opposite. The patient fills out the self-report forms while sitting at the computer. The entire assessment takes approximately 45 min for this age group. The Ethical Review board has approved the use of both samples in the present study (Dnr 2013/82-31/4). 2.4. Statistical analysis When describing the data we adopted the critical cut-off scores for ED risk on the EDEQ global scale demonstrated by Ekeroth and Birgegård (in preparation) as most accurate for the different groups: non-AN girls ≥ 2.17; AN girls ≥ 2.0; AN and non-AN boys ≥ 1.06. The results were analyzed using Stepwise regression. Prior to the Stepwise regression analysis with EDEQ as dependent variable and SASB variables as predictors, bivariate outliers were defined as observations with jackknife residuals beyond the critical t for p b .01. This resulted in elimination of between 4 and 22 participants in the different groups. The

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Table 1 Descriptive data on SASB clusters and EDEQ global scale. Subscales

Normal sample (N = 482)

Table 3 Stepwise regression results using SASB cluster subscales to predict eating disorder symptoms on the EDEQ: clinical sample.

Clinical sample (N = 855)

Girls (N = 238) Boys (N = 244) Girls (N = 813) Boys (N = 42)

SASB 2 SASB 3 SASB 5 SASB 6 SASB 7 EDEQ Global

m (sd)

m (sd)

m (sd)

m (sd)

63.6 (22.95) 58.9 (21.28) 53.2 (18.03) 28.8 (23.96) 21.0 (20.71) 1.4 (1.34)

71.4 (17.33) 61.6 (18.04) 56.5 (16.44) 20.3 (18.68) 16.4 (17.09) .6 (.81)

38.5 (25.94) 36.1 (23.37) 55.8 (19.28) 46.7 (26.55) 36.9 (26.37) 3.2 (1.65)

52.8 (27.77) 53.2 (25.94) 55.1 (23.71) 26.6 (22.58) 16.6 (18.74) 2.1 (1.57)

Models

r2

R2

t

p

β

Girls Step 1: Self-blame Step 2: Self-affirmation

.55 .09

.55 .64

15.39 −13.80

.000 .000

.46 −.41

Boys Step 1: Self-love Step 2: Self-blame

.62 .07

.62 .69

−5.66 2.83

.000 .000

−.62 .31

Note: SASB = Structural Analysis of Social Behavior; EDEQ = Eating Disorder Examination Questionnaire.

outliers were removed before the Stepwise regressions were computed. This outlier elimination procedure controls for different group sizes and number of predictors. Jack-knife residuals are studentized deleted residuals distributed as t with df = n − k − 2, where k is the number of predictors (Kleinbaum, Kupper, & Muller, 1988).

3. Results 3.1. Between-group comparisons on SASB and EDEQ To show how self-image and ED symptoms varied in the different groups (clinical vs. normal, boys vs. girls) descriptive data is presented in Table 1. Normal sample results indicate several sex differences. Risk-level ED symptoms were found in 24% girls and 18% boys. Most participants were found to have a positive self-image (82% of girls and 95% of boys), but while about half of the girls were controlled (48%) and half more spontaneous-impulsive (52%), among boys a greater proportion was spontaneous-impulsive (66%). In the clinical sample, 47% of the girls displayed a positive self-image, while the corresponding number for boys was 81%. The girls in the clinical sample were controlled to a great extent (80%), as were the majority of boys (66%).

3.2. Associations between ED symptoms and SASB clusters: normal sample Using Stepwise regression analysis with the SASB clusters as independent variables, Self-affirmation and Self-blame made significant contributions to the EDEQ Global score for both boys and girls (Table 2). For the girls, Self-blame contributed slightly more to the model than Self-affirmation (β = .36 and β = −.24 respectively). The same pattern was found for the boys (β = .19 and β = − .15 respectively). Notably, while Self-image was important for ED symptoms in both sexes, the relationship was more than three times stronger among girls (31% vs. 8% among boys, p for difference b.001).

Table 2 Stepwise regression results using SASB cluster subscales to predict eating disorder symptoms on the EDEQ: normal sample. Models

r2

R2

t

p

β

Girls Step 1: Self-blame Step 2: Self-affirmation

.27 .03

.27 .31

4.97 −3.29

.000 .001

.36 −.24

Boys Step 1: Self-blame Step 2: Self-affirmation

.06 .02

.06 .08

2.69 −2.13

.008 .034

.19 −.15

3.3. Associations between ED symptoms and SASB clusters: clinical sample The same analysis was carried out within the clinical sample. In this sample, there were sex differences with regards to which SASB clusters predicted ED symptoms (Table 3). For boys, Self-love and Self-blame were most strongly related to ED symptoms, with Self-love contributing more to the model (β = −.62) than Self-blame (β = .31). For girls, like in the normal sample, Self-affirmation and Self-blame made it into the model. The two variables contributed almost equally to the model: Self-affirmation β = − .41, and Self-blame β = .46. For the girls, two other predictor variables were significantly correlated with ED (Selflove and Self-control), although not contributing enough independent variance to be included. 4. Discussion We aimed to explore associations between specific self-image aspects and ED symptoms in normal adolescents and adolescents with ED. Our results suggested that out of the measured self-image aspects, love–acceptance and criticism seem to be the crucial ones in relation to ED symptoms in both samples of adolescents. The less loving and accepting and the more critical they were, the more ED symptoms they had. For both sexes in the normal sample, Self-blame and, negatively, Self-affirmation related to ED symptoms. The pattern of associations was qualitatively similar for boys and girls, but the relationship was more than three times stronger for girls. A potential problem with this is that the truncated range of scores in one group (boys had a smaller range and less shared variance) could attenuate correlations. We tested if equating ranges affected our results by excluding observations beyond two standard deviations from the mean of the group with the least variance in the variables where we found effects and running the regression analyses again. It did not; the quantitative gender difference remained despite restricting the range. Thus, there was no qualitative difference between the sexes, but a consistent quantitative one. One reason for this could be that there is a stronger cultural link between self-image and bodily appearance for girls; being fat equals being bad. In order for girls to achieve a sense of self-worth they (are expected to) manipulate their bodily appearance. For boys, the societal trend may also be in the direction of self-worth being associated with bodily appearance, but presently to a much lesser extent (Presnell, Bearman, & Stice, 2004). Another explanation for the weaker association between ED and self-image among boys could be that the EDEQ does not capture the particular issues of bodily appearance relevant to boys. Some items could be regarded as typically female in content, e. g. asking for concerns about being fat, rather than lacking muscles. An instrument specifically designed to capture boy-relevant issues might produce results more similar to the ones found among girls. In a validation study of an instrument with the aim of identifying ED risk in adolescents, Waaddegaard, Thoning, and Petersson (2003) failed to capture less severe risk

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behavior among boys. Interviews suggested that the items (similar in focus to EDEQ) were less relevant to boys. Bratland-Sanda and Sundgot-Borgen (2012) found instead that a measure of “drive for muscularity” correlated highly with the EDI in adolescent boys but not girls. And finally on a similar note, Griffiths, Murray, and Touyz (2013) suggest that pathological eating behaviors in males are driven by either a desire to become thin or a desire to become more muscular. In the clinical sample, associations between self-image aspects and ED were much stronger than in the normal sample. Thus for patients (both boys and girls) with ED, bodily appearance seems to be (almost) all that matters for their sense of self-worth; ED and self-image is extremely closely entwined. One could again argue that there might be a problem with restriction of range as the clinical sample had a greater spread of scores. It was not possible to equate the ranges of the clinical sample and the normal sample as more than two thirds of the clinical sample then would be excluded. We did however equate the ranges of the boys and girls within the clinical sample and the pattern still looked the same with equally strong associations for both boys and girls. Hence, the normal group (with a quantitative sex difference) and the clinical group (with no quantitative sex difference) appeared the same even when the ranges within the samples were equated. This suggests that the difference in magnitude between the samples is reliable. Our data does not allow conclusions about causality, but in search of a theoretical framework for the findings we may speculate that negative self-image precedes the development of ED. First, self-evaluation, selfdescriptive traits, and personality variables directly or indirectly related to self-image have been implicated as risk factors for ED. Thus, low selfesteem, self-criticism, and perfectionism, and the specific negative evaluative feature of body dissatisfaction, are found to relate to later development of ED (Ghaderi & Scott, 2001; Jacobi, Paul, de Zwaan, Nutzinger, & Dahme, 2004; Striegel-Moore & Bulik, 2007). Second, once symptoms appear, self-esteem suffers further due to for example social isolation, deteriorated relationships, and increased perfectionism with self-appraisal narrowly restricted to the body and appearance, resulting in extremely negative self-views, also compared to other psychiatric groups (Björck et al., 2003; Jacobi et al., 2004). Third, perfectionism and low self-esteem, in turn, may act as maintaining factors, resulting in self-perpetuating pathology (Fairburn et al., 2003). This reasoning is consistent with interpersonal theory, which would suggest that an individual is vulnerable to ED partly because that way of treating oneself is consistent with aspects of the person's self-image. The person's self-image in turn, mirrors the way the person has been treated by (significant) others, and people tend to repeat learned interactional styles working to maintain that self-image (Critchfield & Benjamin, 2008). As ED gradually increases its hold, with interpersonal isolation as a result, the “authority” of the ED becomes increasingly exclusive and pervasive, and the opinions and worries of significant others subordinate. As a result, the ED becomes the primary influence on self-image (which, again, is theoretically an introjection of others' treatment of one, in this case the ED). From this perspective then, the ED mimics a significant other in the sense that it shapes self-image, resulting in the strong associations we observed. There is empirical support for SASBdefined introjection, i.e. a link between treatment from others and self-image (Critchfield & Benjamin, 2008), but the idea above is speculative and needs further investigation. For male patients the associations also differed in quality compared to the normal sample and the female patients: besides Self-blame, Selflove rather than Self-affirmation was related to ED symptoms. This implies that for these boys, lack of love for oneself plays a more salient role in relation to ED than lack of acceptance for oneself. This is the first finding demonstrating a qualitative gender difference in a psychological mechanism connected to ED, and might suggest that ED in boys is governed by slightly different underlying variables than ED in girls. In the regression model for the male patients, shared variance was actually higher than for the female patients, indicating that in a patient

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population the EDEQ captures relevant symptoms well also in males. Maybe as boys and girls become ill, their bodily concerns become more similar. Alternatively, different populations are represented in our normal and clinical male samples; perhaps the boys who become ill represent a different group from the majority of boys, with different psychological mechanisms at play. This could be true for girls also, but previous research (Fitzgibbon, Sanchez-Johnsen, & Martinovich, 2003; Gleaves, Brown, & Warren, 2004; Holm-Denoma, Richey, & Joiner, 2010; Stice, Killen, Hayward, & Taylor, 1998) has failed to find a qualitative boundary in cognitive ED symptoms between normal and ED samples of females. The continuity–discontinuity issue has not yet been investigated in boys, but a recent study suggests a stronger genetic influence on ED in males (Klump et al., 2012), which could imply that males with ED are distinct from normal males. 4.1. Implications and significance Beyond replicating the finding that low self-esteem is associated with ED symptoms, our results have implications for treatment of ED and more tailored prevention efforts in adolescents; suggesting a lowering of control, i. e. relinquishing self-correcting criticism, and an increase of self-acceptance, self-love (especially with boys) and the ability to more freely explore ones needs and wants. The qualitative gender difference in our patients has not been observed previously and may be useful to consider when designing treatments. The finding that even for healthy adolescents, weight, figure and thoughts about food, was related to self-worth (and even more so for girls) has implications for prevention programs. A consistent finding is, as mentioned, that negative self-image on the one hand is a risk factor for ED, but on the other that prevention programs targeting general self-image or selfesteem are not reliably successful (Pratt & Woolfenden, 2009; Stice et al., 2007). This could be due to an undifferentiated approach to selfimage, whereas the SASB-model used in this study allows for more specificity. Our results, coupled with previous findings of interpersonal factors in ED (Arcelus, Haslam, Farrow, & Meyer, 2013) and research on genetic contributions to specific types of interpersonal sensitivity (Wade et al., 2008), are consistent with the idea that interactional processes and their self-image concomitants play a role in ED risk, pathogenesis, and maintenance. Our results predict that interactions characterized by friendly listening, empathic understanding and acceptance, rather than criticism, accusation and blame, are key in successful ED treatment and prevention efforts. To further illustrate the possibility of more precise implications for interventions using the SASB-model imagine a dysregulated profile characterized by the opposite diagonal: low Cluster 4 Self-protection and high Cluster 8 Self-neglect. Contrary to the ED group, interventions for this group should target an increase of control and a decrease of self-neglect. 4.2. Limitations We used self-report questionnaires for our main variables and possibly, due to gender socialization and greater maturity (Carskadon & Acebo, 1993), girls in our age group have better introspective abilities, which could underlie the quantitative gender difference in the associations between ED symptoms and self-image in the normal sample. Consistent with this idea, Cronbach alphas of the SASB clusters tended to be lower for normal boys compared to normal girls, although internal consistencies regarding the SASB variables that made it into the regression models were acceptable for both boys and girls. Also, in the clinical sample, the associations were stronger among boys than among girls, and SASB alphas were not generally lower for boys. Furthermore, the EDEQ perhaps is not the best measure for capturing problematic behaviors in normal boys, and inclusion of a muscularity measure in the future may be appropriate (Bratland-Sanda & Sundgot-Borgen, 2012).

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A final weakness is that a number of pupils in the normal sample were absent during the time of data collection and dropout analyses could not be performed, as we did not have access to any information about these adolescents. This decreases the generalizability of the results in the normal sample. 4.3. Summary and future research Specific self-image variables were related to ED symptoms among both boys and girls in two large samples, a clinical and a normal one. There was a quantitative gender difference in the normal sample and a qualitative gender difference in the clinical one. Future studies ought to attempt to determine causality in the negative interplay between self-image and ED. Our findings also need replicating, preferably including a slightly older age group. Finally, the strong association between self-image variables and ED is far from understood, and a theory is needed to further explore the strong associations between self-image and ED. Interpersonal theory may offer such a framework. Role of funding source This research was not supported by any funding. Contributors Emma Forsén Mantilla and Andreas Birgegård designed this study and wrote the manuscript collaboratively. Emma Forsén Mantilla conducted the statistical analysis, supervised by Andreas Birgegård. Katja Bergsten collected the normal sample data and participated in writing the first draft of the manuscript. All authors have approved the final manuscript. Conflict of interest All authors declare that they have no conflicts of interest.

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