Body Image 11 (2014) 557–561
Contents lists available at ScienceDirect
Body Image journal homepage: www.elsevier.com/locate/bodyimage
Brief research report
Validation of an interpretation bias assessment for body dissatisfaction Mary K. Martinelli ∗ , Jayne B. Holzinger, Gregory S. Chasson Towson University, Towson, MD, United States
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 1 April 2014 Received in revised form 24 July 2014 Accepted 18 August 2014 Keywords: Body dissatisfaction Cognitive bias Interpretation bias Eating disorders
Currently, research on interpretation bias and body dissatisfaction is limited. The few experimental paradigms that have been used to explore this phenomenon utilized a method that may not accurately capture the nature of interpretation bias as explained by cognitive theory. The present study investigated the reliability and validity of a novel computerized assessment of interpretation bias (WSAP) for body dissatisfaction, which may more accurately reflect the cognitive processing involved in such bias by implementing the Word Sentence Association Paradigm (WSAP), a previously established method of measuring interpretation bias in other clinical populations. Undergraduate females (n = 214) completed the WSAP and other measures. Results indicate initial support for the WSAP as a valid, reliable measure of interpretation bias for body dissatisfaction. Although preliminary, this study contributes to the minimal research in this area and serves as the first psychometric investigation of the WSAP to measure such interpretation bias for body dissatisfaction. © 2014 Elsevier Ltd. All rights reserved.
Introduction Cognitive biases are thinking or perceptual tendencies that result in a propensity to process information from the environment in favor of disorder-relevancy over neutrality (Williamson, 1996) and are commonly accepted to be vital in the development and maintenance of many psychiatric disorders, including eating disorders (MacLeod, 2012). Research has demonstrated support for two types of cognitive biases in individuals who are body-dissatisfied: memory (e.g., Unterhalter, Farrell, & Mohr, 2007) and attention (e.g., Rieger et al., 1998) biases. Less work has been done to investigate a third type called interpretation bias, which occurs when individuals more readily endorse a negative weight/shape-related explanation for an ambiguous event (e.g., someone attributes an odd look from a stranger as a negative reaction to his/her weight). Cognitive biases may stem from disorder-relevant cognitive self-schemata. Markus (1977) defined self-schemata as, “cognitive generalizations about the self, derived from past experience, that organize and guide the processing of the self-related information contained in the individual’s social experiences” (p. 64). As such, individuals with appearance-schemata are more
∗ Corresponding author at: Towson University, 8000 York Road, Towson, MD 21254, United States. Tel.: +1 410 913 3413. E-mail address: [email protected] (M.K. Martinelli). http://dx.doi.org/10.1016/j.bodyim.2014.08.010 1740-1445/© 2014 Elsevier Ltd. All rights reserved.
invested in their appearance and therefore preferentially focus and place importance on appearance-related information when making determinations about the self (Cash & Grant, 1996). This can be problematic for individuals with negative body image because it can distort their perception of events in a way that confirms their body-image concerns (Cash & Grant, 1996). Cognitive biases—including memory, attention, and interpretation biases—are examples of these types of distortions. Jakatdar, Cash, and Engle (2006) found that individuals who were appearanceschematic (i.e., defined self-worth based on appearance) exhibited more negative cognitive distortions (e.g., biases) related to bodyimage. These distortions not only predicted negative body-image affect and quality of life, but also associated with eating pathology above and beyond what could be predicted by body dissatisfaction and appearance-schemata (Jakatdar et al., 2006). Although relatively understudied in body-dissatisfied populations, interpretation bias has received some attention. Most research has directly explored interpretation bias in bodydissatisfied individuals using an experimental paradigm in which participants are presented first with words/ambiguous scenarios and then asked second for their interpretations using either forced-choice and/or free-response formats. For instance, Jackman, Williamson, Netemeyer, and Anderson (1995) found that when presented with ambiguous scenarios (e.g., After exercising for 2 hours at a health club, you catch a glimpse of the shape of your hips as you pass by a mirror), women who were body-dissatisfied
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were more likely to select negative weight/shape-related interpretations (e.g., After exercising for 2 hours at a health club, you get a glimpse of your large hips as you pass by the mirror) than women who were not body-dissatisfied. According to evidence from studies using experimental approaches like this, women who are body-dissatisfied—either at the clinical (i.e., eating disordered; Cooper, 1997) or nonclinical level (Altabe, Wood, Herbozo, & Thompson, 2004; Jackman et al., 1995; Rosser, Moss, & Rumsey, 2010)—are more likely than non-body-dissatisfied peers to select negative weight/shape-related interpretations of ambiguous words/scenarios without recognizing alternative, more adaptive explanations. Although useful for fleshing out the cognitive processes of individuals with body dissatisfaction, the above experimental paradigm may not accurately reflect the nature of interpretation bias as explained by cognitive theory, which asserts that pre-existing schemata prime individuals for subsequent interpretations. This was the rationale behind the use of the Word Sentence Association Paradigm (WSAP) as a method to measure interpretation bias in anxiety (Beard & Amir, 2009), as the WSAP taps into disorder-relevant schemata before ambiguous stimuli are presented. In other words, the WSAP presents stimuli in a different order (i.e., prime comes before ambiguous scenario) compared to previously mentioned paradigms for interpretation bias in body dissatisfaction. The WSAP has been used to assess interpretation bias in populations with anxiety (e.g., Amir, Prouvost, & Kuckertz, 2012) and depression (e.g., Cowden Hindash & Amir, 2012), but no study to date has utilized the WSAP method to measure interpretation bias in individuals struggling with body dissatisfaction. Therefore, the objective of this study was to investigate the reliability and validity of a novel computerized assessment of interpretation bias for body dissatisfaction—the WSAP—in hopes of developing a task that more accurately reflects the cognitive processing involved in such bias. A more ecologically valid measure of interpretation bias would help to expand current cognitive and etiologic conceptualizations of body dissatisfaction, and the WSAP can also be easily adapted into an intervention vehicle.
Method Participants Participants included 214 female undergraduates who were recruited via the psychology participant pool at a large, midAtlantic university in the United States. Participants were primarily Caucasian (65%; 19% African American, 7% Asian, 3% Hispanic, 6% other) with a mean age of 20 (SD = 2.66; range = 18–33). The majority of participants chose “single” as their relationship status (59%; 40% in a relationship, 0.5% married; 0.5% divorced) and selected the highest bracket (>$100,000) for annual household income (24%; the university has a large proportion of commuters). Although eating disorder diagnoses were not the focus of the study, 4.7% of participants scored in the clinical range of eating pathology based on Eating Disorder Examination Questionnaire (EDE-Q) cut-scores (Carter, Stewart, & Fairburn, 2001). A subset of participants (n = 17) returned for a second session of testing to complete a retest of the WSAP. These participants were representative of the larger group on key demographic variables (i.e., primarily Caucasian [70%], mean age of 20), although this subset of participants was significantly higher than the larger group on measures of body dissatisfaction, eating disorder symptoms (excluding eating concern), depression, and anxiety.
Measures Word Sentence Association Paradigm Measure of Interpretation Bias (WSAP). An original assessment of interpretation bias for body dissatisfaction was modeled after Beard and Amir’s (2009) task for social anxiety. The WSAP more accurately reflects the nature of cognitive errors described by cognitive theory. For the WSAP, a fixation cross appears on the computer screen for 750 ms and alerts participants that a trial is beginning. Then, a word or brief phrase appears that represents either a negative interpretation (e.g., “Too Large”) or a benign interpretation (e.g., “Satisfied”). Half of the trials contained benign interpretation words/phrases and half contained negative interpretation words/phrases. The word/phrase remains on the screen for 750 ms before disappearing. Next, an ambiguous scenario related to body dissatisfaction (e.g., “While getting dressed, you examine your reflection in the mirror”) appears on the screen. Because cognitive theory asserts that pre-existing schemata about the importance of weight/shape may prime individuals’ subsequent interpretations, the WSAP introduces weight/shape (e.g., “fat”) or neutral (e.g., “fine”) primes prior to introducing scenarios. Participants were prompted to press either 1 if they thought the word and scenario were related or 3 if they thought the word and scenario were unrelated. Primes were considered negative/benign based on how they disambiguated the scenario that followed. For example, “proud” is not a negative word in isolation, but when endorsed as related to the situation, “You realize you have not eaten anything all day,” it disambiguates the scenario in a way that is consistent with negative weight/shape interpretations, and is therefore considered a negative target word. Similarly, while the scenarios are described as “ambiguous,” this is only within context to body dissatisfaction. For instance, although the scenario “Someone posts an unflattering picture of you on Facebook” has a negative context, it is ambiguous in that someone could easily interpret it as being related or unrelated to shape/weight concerns (e.g., it could be unflattering for reasons other than weight/shape—e.g., embarrassing facial expression). Participants completed five practice trials to ensure that they understood the procedure. Participants completed 45 scenarios total for the WSAP (see Appendix). An interpretation bias score (IB-score) was calculated by subtracting the number of neutral interpretations from the number of negative interpretations that individuals endorsed. Therefore, a higher IB-score indicates greater endorsement of negative associations between words/phrases and ambiguous scenarios. Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper, & Fairburn, 1987). The BSQ is a 34-item self-report measure of how often individuals experienced body- and shape/weight-related concerns in the past four weeks. The BSQ has good concurrent and discriminant validity, as well as good test–retest reliability (r = .88) and criterion-related validity (Rosen, Jones, Ramirez, & Waxman, 1996). Internal consistency for the BSQ in the current sample is strong (see Table 1). Depression Anxiety Stress Scales-Short Form (DASS; Lovibond & Lovibond, 1995). The DASS is a 21-item self-report inventory that was used to assess depression and anxiety levels. These scales have demonstrated good reliability (anxiety ˛ = .81, depression ˛ = .85) and validity for nonclinical samples (Osman et al., 2012). Internal consistencies for the DASS in the current sample are adequate (see Table 1). Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Bèglin, 1994). The EDE-Q is a 28-item self-report inventory that assesses four dimensions of eating disorder symptoms: Restraint (e.g., limiting food intake), Eating Concern, Shape Concern, and Weight Concern. The EDE-Q has good reliability (total
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Table 1 Summary of correlations and descriptive statistics. Measure
M
SD
1
2
3
4
5
6
7
8
9
1. BSQ 2. IB-score 3. DASS anxiety 4. DASS depression 5. EDEQ R 6. EDEQ EC 7. EDEQ SC 8. EDEQ WC 9. EDEQ total
89.09 10.96 3.78 3.19 1.65 0.90 2.52 2.14 1.80
29.67 4.86 3.38 3.28 1.35 1.00 1.52 1.46 1.17
(.96) .667** .438** .478** .596** .677** .846** .808** .843**
(.71) .295** .360** .464** .607** .664** .615** .670**
(.74) .515** .306** .379** .353** .341** .390**
(.83) .231** .376** .415** .411** .409**
(.79) .519** .598** .549** .764**
(.70) .768** .771** .852**
(.90) .919** .947**
(.83) .933**
(.89)
Note. n = 214; Cronbach’s ˛ values are presented in parentheses; BSQ = Body Shape Questionnaire; IB-score = Interpretation bias score; DASS = Depression Anxiety and Stress Scales; EDEQ = Eating Disorder Examination Questionnaire; EDEQ R = Restraint; EDEQ EC = Eating concerns; EDEQ SC = Shape concerns; EDEQ WC = Weight concerns. ** p < .01.
˛ = .95; restraint, ˛ = .85; eating concern, ˛ = .81; weight concern, ˛ = .83; shape concern, ˛ = .91) and is considered a psychometrically valid measure (Aardoom, Dingemans, Slof Op’t Landt, & Van Furth, 2012). Internal consistencies for the EDE-Q in the current sample are adequate (see Table 1). Procedure Participants enrolled for course credit, and the university’s Internal Review Board approved all research procedures. During the session, participants provided informed consent, filled out a basic demographic survey and self-report measures, and then completed the WSAP. Participants who returned for a second day of testing completed the WSAP again to evaluate test–test reliability. Results Reliability The coefficient alpha for IB-score was high (˛ = .71), indicating good internal consistency. For the subset of participants who returned to complete an additional WSAP (mean lapse between testing sessions was 12 days), first session IB-score was correlated with second session IB-score (r = .714, p < .01). See Table 1 for descriptive statistics, correlations, and Cronbach’s ˛ values. Validity As evidence of convergent validity, IB-score was correlated with BSQ score (r = .667, p < .01) and EDE-Q total score (r = .670, p < .01). IB-score was also correlated with subscales of the EDE-Q: Eating Concerns (r = .607, p < .01), Shape Concerns (r = .664, p < .01), and Weight Concerns (r = .615, p < .01). Although statistically significant, the Restraint subscale of the EDE-Q was significantly less correlated to IB-score (r = .464, p < .01) than other subscales according to a series of Fisher’s Z-tests: EC (z = −2.07, p = .04), SC (z = −3.06, p < .01), and WC (z = −2.20, p = .03). Suggesting discriminant validity, IB-score was correlated with DASS anxiety (r = .295, p < .01), however, according to a series of Fisher’s Z-tests, less robustly so than variables more closely aligned with the construct of body dissatisfaction or eating disorder symptoms: BSQ (z = −5.15, p < .01), EDE-Q total (z = −5.2, p < .01), EC (z = −4.11, p < .01), SC (z = −5.09, p < .01), and WC (z = −4.24, p < .01). The same was true for DASS depression (r = .360, p < .01) scores: BSQ (z = −4.4, p < .01), EDE-Q total (z = −4.46, p < .01), EC (z = −3.36, p < .01), SC (z = −4.35, p < .01), and WC (z = −3.49, p < .01). Discussion The present study evaluated the psychometric properties of a novel computerized assessment of interpretation bias for
body dissatisfaction—the first to use the WSAP method for this population—and found preliminary evidence for its reliability and validity. The results lend initial support for the use of this measure to study interpretation bias in individuals with body dissatisfaction in order to expand, more accurately, upon the limited research in this area and potentially adapt to tools designed to correct for such bias and reduce associated symptomology. Psychometric properties of the WSAP are promising. Test–retest correlations in a subsample of participants suggest good test–retest reliability. Additionally, the coefficient alpha (.71) for IB-scores indicated acceptable internal consistency. Evidence of construct validity for the WSAP was supported by overall patterns of convergent and discriminant validity. As expected, IB-score was highly, positively correlated with body dissatisfaction on the BSQ, suggesting good convergent validity. Also as expected based on findings of prior research that heightened body dissatisfaction is related to eating disorder symptoms (Makri-Botsari, 2009), IB-score was highly, positively correlated with eating disorder symptomology on the EDE-Q. Further, the restraint domain of the EDE-Q was less robustly correlated with IB-score than the other domains. One possible explanation for this is that the Restraint subscale measures behavioral aspects of eating disorders (e.g., avoiding food, following rules about eating), whereas the other subscales measure cognitive aspects of eating disorders. As the WSAP seeks to measure more cognitive components of body dissatisfaction, this nuanced correlation pattern provides evidence for convergent and discriminant validity. Also contributing to discriminant validity, IB-score was less positively correlated with depression and anxiety symptoms compared to measures more associated with body dissatisfaction and eating disorder symptoms. We expected depression and anxiety to be related to IB-score because body dissatisfaction is associated with depression and anxiety. However, as expected, depression and anxiety were less robustly correlated with IB-score than with body dissatisfaction and ED symptoms. Although the present study found promising evidence of reliability and validity for the WSAP, there are limitations to consider. Due to insufficient sample size, we used correlation patterns to assess construct validity rather than confirmatory factor analysis (CFA) from a structural equation modeling framework. Future research with a larger sample may provide a more sophisticated evaluation of construct validity. Body dissatisfaction is a central component of eating disorders, but the current findings only reflect on the reliability and validity of the WSAP for undergraduate females, as it was unclear how many participants met diagnostic criteria for an ED. Though, based on EDE-Q cut-scores (Carter et al., 2001), 4.7% of participants scored in the clinical range of eating pathology. Because we exclusively included undergraduate females for their increased risk of body dissatisfaction (Cook-Cottone & Phelps, 2003), research that directly addresses clinical samples with eating disorders, as well as body-dissatisfied men, is needed
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to further evaluate psychometric properties of the WSAP. Our sample was also primarily Caucasian women from high-income households, which may limit the generalizability of our findings, Subsequent investigations would benefit from including separate diagnostic groups (e.g., anorexia, bulimia) and a demographically diverse participant pool. Future research should also address the potential influence of personality and other related variables (e.g., negative affect) on body dissatisfaction and interpretation bias. The purpose of this study was to evaluate the psychometric properties of the WSAP for measuring interpretation bias associated with body dissatisfaction. The WSAP more closely mimics the automaticity and order of interpretation bias as explained by cognitive theory and, therefore, may serve as a more accurate measure of interpretation bias than previous self-report paradigms. The WSAP is also advantageous given its potential to be adapted to training models designed to correct for such bias, which have shown promising results in populations with anxiety (e.g., Beard & Amir, 2009) and depression (e.g., Bowler et al., 2012) for decreasing associated symptomology, but have yet to be used with individuals who are body-dissatisfied. Body dissatisfaction research should continue to use the WSAP to expand the limited knowledge of interpretation bias, which can be targeted in eating disorder prevention and treatment.
Appendix (Continued ) Scenario Satisfied Too busy Indifferent Fine Airbrush Fit Compliment Impartial Energy Opinion Fitting No problem Excessive Mistake Needless Thankful
Appendix. WSAP Interpretation Stimuli, Baseline Session
Need food Surprise
Scenario Negative words Fat Guilty Weight gain Distress Admire Excited Pudge Good No control Lazy Not enough Lie Admiration Flab Join in Judgment Look big Disappointed Proud Skinny Conflicted Understanding Embarrassed Neutral words Worried Concerned Not hungry
Satisfied You walk into class and you notice two girls look at you and laugh While eating dinner with your family, you go back for a second helping As you are getting dressed, the button of your jeans pops off While at the beach, your friend wants to take a picture of you Another girl in your dorm brags about how she restricts her calories A friend asks, ‘Have you lost weight?’ While joking around, your friend pinches your side It has been hours since you have eaten You eat a large dinner, dessert, and a late night snack You have not been to the gym in weeks You step on the scale and see that you have lost a few pounds Your friend tells you that you look really pretty today While sitting in class, you notice that the girl next to you is especially skinny The waist of your pants feels too tight Your friend tells you about a new diet that helped her lose weight fast Your friend makes a comment about your figure Someone posts an unflattering picture of you on Facebook In nutrition class you calculate your BMI and find that it is normal You realize you have not eaten anything all day Your friend introduces you to a new a friend who you consider very attractive While out to dinner with your friend, she wants to share a fattening appetizer A girl from your dorm who is thin tells you she wants to lose weight You are wearing a bikini while at the pool with your friends You notice that one of your friends has gotten extremely skinny lately While home for winter break, your Mom tells you that you look too thin You decide not to eat dinner
Your doctor tells you that you are at a healthy weight You are hungry in the morning, but you skip breakfast You try to borrow a friend’s top, but it is too tight You are looking at a photo of yourself You flip through a magazine full of extremely thin models While shopping, you try on a tight pair of pants and observe yourself in the mirror Your friend tells you that you look ‘curvy’ After finishing your dinner your friend says ‘You must have been hungry!’ While up late studying, you decide to have a snack Someone tells you that your shirt is too small While taking a fitness class, you notice that every other woman in class is very thin While you are changing clothes in the gym locker room, a group of girls walk in You notice your roommate weighs and measures herself each morning Your relative buys you a shirt for your birthday that is two sizes larger than what you wear A friend of yours recently tried a new diet and lost 10 pounds Someone comments that you have a ‘healthy’ figure You were sick last week and barely ate at all You notice your winter clothes from last year are loose on you now While getting dressed, you examine your reflection in the mirror
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Contents lists available at ScienceDirect
Body Image journal homepage: www.elsevier.com/locate/bodyimage
Brief research report
Validation of an interpretation bias assessment for body dissatisfaction Mary K. Martinelli ∗ , Jayne B. Holzinger, Gregory S. Chasson Towson University, Towson, MD, United States
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 1 April 2014 Received in revised form 24 July 2014 Accepted 18 August 2014 Keywords: Body dissatisfaction Cognitive bias Interpretation bias Eating disorders
Currently, research on interpretation bias and body dissatisfaction is limited. The few experimental paradigms that have been used to explore this phenomenon utilized a method that may not accurately capture the nature of interpretation bias as explained by cognitive theory. The present study investigated the reliability and validity of a novel computerized assessment of interpretation bias (WSAP) for body dissatisfaction, which may more accurately reflect the cognitive processing involved in such bias by implementing the Word Sentence Association Paradigm (WSAP), a previously established method of measuring interpretation bias in other clinical populations. Undergraduate females (n = 214) completed the WSAP and other measures. Results indicate initial support for the WSAP as a valid, reliable measure of interpretation bias for body dissatisfaction. Although preliminary, this study contributes to the minimal research in this area and serves as the first psychometric investigation of the WSAP to measure such interpretation bias for body dissatisfaction. © 2014 Elsevier Ltd. All rights reserved.
Introduction Cognitive biases are thinking or perceptual tendencies that result in a propensity to process information from the environment in favor of disorder-relevancy over neutrality (Williamson, 1996) and are commonly accepted to be vital in the development and maintenance of many psychiatric disorders, including eating disorders (MacLeod, 2012). Research has demonstrated support for two types of cognitive biases in individuals who are body-dissatisfied: memory (e.g., Unterhalter, Farrell, & Mohr, 2007) and attention (e.g., Rieger et al., 1998) biases. Less work has been done to investigate a third type called interpretation bias, which occurs when individuals more readily endorse a negative weight/shape-related explanation for an ambiguous event (e.g., someone attributes an odd look from a stranger as a negative reaction to his/her weight). Cognitive biases may stem from disorder-relevant cognitive self-schemata. Markus (1977) defined self-schemata as, “cognitive generalizations about the self, derived from past experience, that organize and guide the processing of the self-related information contained in the individual’s social experiences” (p. 64). As such, individuals with appearance-schemata are more
∗ Corresponding author at: Towson University, 8000 York Road, Towson, MD 21254, United States. Tel.: +1 410 913 3413. E-mail address: [email protected] (M.K. Martinelli). http://dx.doi.org/10.1016/j.bodyim.2014.08.010 1740-1445/© 2014 Elsevier Ltd. All rights reserved.
invested in their appearance and therefore preferentially focus and place importance on appearance-related information when making determinations about the self (Cash & Grant, 1996). This can be problematic for individuals with negative body image because it can distort their perception of events in a way that confirms their body-image concerns (Cash & Grant, 1996). Cognitive biases—including memory, attention, and interpretation biases—are examples of these types of distortions. Jakatdar, Cash, and Engle (2006) found that individuals who were appearanceschematic (i.e., defined self-worth based on appearance) exhibited more negative cognitive distortions (e.g., biases) related to bodyimage. These distortions not only predicted negative body-image affect and quality of life, but also associated with eating pathology above and beyond what could be predicted by body dissatisfaction and appearance-schemata (Jakatdar et al., 2006). Although relatively understudied in body-dissatisfied populations, interpretation bias has received some attention. Most research has directly explored interpretation bias in bodydissatisfied individuals using an experimental paradigm in which participants are presented first with words/ambiguous scenarios and then asked second for their interpretations using either forced-choice and/or free-response formats. For instance, Jackman, Williamson, Netemeyer, and Anderson (1995) found that when presented with ambiguous scenarios (e.g., After exercising for 2 hours at a health club, you catch a glimpse of the shape of your hips as you pass by a mirror), women who were body-dissatisfied
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were more likely to select negative weight/shape-related interpretations (e.g., After exercising for 2 hours at a health club, you get a glimpse of your large hips as you pass by the mirror) than women who were not body-dissatisfied. According to evidence from studies using experimental approaches like this, women who are body-dissatisfied—either at the clinical (i.e., eating disordered; Cooper, 1997) or nonclinical level (Altabe, Wood, Herbozo, & Thompson, 2004; Jackman et al., 1995; Rosser, Moss, & Rumsey, 2010)—are more likely than non-body-dissatisfied peers to select negative weight/shape-related interpretations of ambiguous words/scenarios without recognizing alternative, more adaptive explanations. Although useful for fleshing out the cognitive processes of individuals with body dissatisfaction, the above experimental paradigm may not accurately reflect the nature of interpretation bias as explained by cognitive theory, which asserts that pre-existing schemata prime individuals for subsequent interpretations. This was the rationale behind the use of the Word Sentence Association Paradigm (WSAP) as a method to measure interpretation bias in anxiety (Beard & Amir, 2009), as the WSAP taps into disorder-relevant schemata before ambiguous stimuli are presented. In other words, the WSAP presents stimuli in a different order (i.e., prime comes before ambiguous scenario) compared to previously mentioned paradigms for interpretation bias in body dissatisfaction. The WSAP has been used to assess interpretation bias in populations with anxiety (e.g., Amir, Prouvost, & Kuckertz, 2012) and depression (e.g., Cowden Hindash & Amir, 2012), but no study to date has utilized the WSAP method to measure interpretation bias in individuals struggling with body dissatisfaction. Therefore, the objective of this study was to investigate the reliability and validity of a novel computerized assessment of interpretation bias for body dissatisfaction—the WSAP—in hopes of developing a task that more accurately reflects the cognitive processing involved in such bias. A more ecologically valid measure of interpretation bias would help to expand current cognitive and etiologic conceptualizations of body dissatisfaction, and the WSAP can also be easily adapted into an intervention vehicle.
Method Participants Participants included 214 female undergraduates who were recruited via the psychology participant pool at a large, midAtlantic university in the United States. Participants were primarily Caucasian (65%; 19% African American, 7% Asian, 3% Hispanic, 6% other) with a mean age of 20 (SD = 2.66; range = 18–33). The majority of participants chose “single” as their relationship status (59%; 40% in a relationship, 0.5% married; 0.5% divorced) and selected the highest bracket (>$100,000) for annual household income (24%; the university has a large proportion of commuters). Although eating disorder diagnoses were not the focus of the study, 4.7% of participants scored in the clinical range of eating pathology based on Eating Disorder Examination Questionnaire (EDE-Q) cut-scores (Carter, Stewart, & Fairburn, 2001). A subset of participants (n = 17) returned for a second session of testing to complete a retest of the WSAP. These participants were representative of the larger group on key demographic variables (i.e., primarily Caucasian [70%], mean age of 20), although this subset of participants was significantly higher than the larger group on measures of body dissatisfaction, eating disorder symptoms (excluding eating concern), depression, and anxiety.
Measures Word Sentence Association Paradigm Measure of Interpretation Bias (WSAP). An original assessment of interpretation bias for body dissatisfaction was modeled after Beard and Amir’s (2009) task for social anxiety. The WSAP more accurately reflects the nature of cognitive errors described by cognitive theory. For the WSAP, a fixation cross appears on the computer screen for 750 ms and alerts participants that a trial is beginning. Then, a word or brief phrase appears that represents either a negative interpretation (e.g., “Too Large”) or a benign interpretation (e.g., “Satisfied”). Half of the trials contained benign interpretation words/phrases and half contained negative interpretation words/phrases. The word/phrase remains on the screen for 750 ms before disappearing. Next, an ambiguous scenario related to body dissatisfaction (e.g., “While getting dressed, you examine your reflection in the mirror”) appears on the screen. Because cognitive theory asserts that pre-existing schemata about the importance of weight/shape may prime individuals’ subsequent interpretations, the WSAP introduces weight/shape (e.g., “fat”) or neutral (e.g., “fine”) primes prior to introducing scenarios. Participants were prompted to press either 1 if they thought the word and scenario were related or 3 if they thought the word and scenario were unrelated. Primes were considered negative/benign based on how they disambiguated the scenario that followed. For example, “proud” is not a negative word in isolation, but when endorsed as related to the situation, “You realize you have not eaten anything all day,” it disambiguates the scenario in a way that is consistent with negative weight/shape interpretations, and is therefore considered a negative target word. Similarly, while the scenarios are described as “ambiguous,” this is only within context to body dissatisfaction. For instance, although the scenario “Someone posts an unflattering picture of you on Facebook” has a negative context, it is ambiguous in that someone could easily interpret it as being related or unrelated to shape/weight concerns (e.g., it could be unflattering for reasons other than weight/shape—e.g., embarrassing facial expression). Participants completed five practice trials to ensure that they understood the procedure. Participants completed 45 scenarios total for the WSAP (see Appendix). An interpretation bias score (IB-score) was calculated by subtracting the number of neutral interpretations from the number of negative interpretations that individuals endorsed. Therefore, a higher IB-score indicates greater endorsement of negative associations between words/phrases and ambiguous scenarios. Body Shape Questionnaire (BSQ; Cooper, Taylor, Cooper, & Fairburn, 1987). The BSQ is a 34-item self-report measure of how often individuals experienced body- and shape/weight-related concerns in the past four weeks. The BSQ has good concurrent and discriminant validity, as well as good test–retest reliability (r = .88) and criterion-related validity (Rosen, Jones, Ramirez, & Waxman, 1996). Internal consistency for the BSQ in the current sample is strong (see Table 1). Depression Anxiety Stress Scales-Short Form (DASS; Lovibond & Lovibond, 1995). The DASS is a 21-item self-report inventory that was used to assess depression and anxiety levels. These scales have demonstrated good reliability (anxiety ˛ = .81, depression ˛ = .85) and validity for nonclinical samples (Osman et al., 2012). Internal consistencies for the DASS in the current sample are adequate (see Table 1). Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Bèglin, 1994). The EDE-Q is a 28-item self-report inventory that assesses four dimensions of eating disorder symptoms: Restraint (e.g., limiting food intake), Eating Concern, Shape Concern, and Weight Concern. The EDE-Q has good reliability (total
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Table 1 Summary of correlations and descriptive statistics. Measure
M
SD
1
2
3
4
5
6
7
8
9
1. BSQ 2. IB-score 3. DASS anxiety 4. DASS depression 5. EDEQ R 6. EDEQ EC 7. EDEQ SC 8. EDEQ WC 9. EDEQ total
89.09 10.96 3.78 3.19 1.65 0.90 2.52 2.14 1.80
29.67 4.86 3.38 3.28 1.35 1.00 1.52 1.46 1.17
(.96) .667** .438** .478** .596** .677** .846** .808** .843**
(.71) .295** .360** .464** .607** .664** .615** .670**
(.74) .515** .306** .379** .353** .341** .390**
(.83) .231** .376** .415** .411** .409**
(.79) .519** .598** .549** .764**
(.70) .768** .771** .852**
(.90) .919** .947**
(.83) .933**
(.89)
Note. n = 214; Cronbach’s ˛ values are presented in parentheses; BSQ = Body Shape Questionnaire; IB-score = Interpretation bias score; DASS = Depression Anxiety and Stress Scales; EDEQ = Eating Disorder Examination Questionnaire; EDEQ R = Restraint; EDEQ EC = Eating concerns; EDEQ SC = Shape concerns; EDEQ WC = Weight concerns. ** p < .01.
˛ = .95; restraint, ˛ = .85; eating concern, ˛ = .81; weight concern, ˛ = .83; shape concern, ˛ = .91) and is considered a psychometrically valid measure (Aardoom, Dingemans, Slof Op’t Landt, & Van Furth, 2012). Internal consistencies for the EDE-Q in the current sample are adequate (see Table 1). Procedure Participants enrolled for course credit, and the university’s Internal Review Board approved all research procedures. During the session, participants provided informed consent, filled out a basic demographic survey and self-report measures, and then completed the WSAP. Participants who returned for a second day of testing completed the WSAP again to evaluate test–test reliability. Results Reliability The coefficient alpha for IB-score was high (˛ = .71), indicating good internal consistency. For the subset of participants who returned to complete an additional WSAP (mean lapse between testing sessions was 12 days), first session IB-score was correlated with second session IB-score (r = .714, p < .01). See Table 1 for descriptive statistics, correlations, and Cronbach’s ˛ values. Validity As evidence of convergent validity, IB-score was correlated with BSQ score (r = .667, p < .01) and EDE-Q total score (r = .670, p < .01). IB-score was also correlated with subscales of the EDE-Q: Eating Concerns (r = .607, p < .01), Shape Concerns (r = .664, p < .01), and Weight Concerns (r = .615, p < .01). Although statistically significant, the Restraint subscale of the EDE-Q was significantly less correlated to IB-score (r = .464, p < .01) than other subscales according to a series of Fisher’s Z-tests: EC (z = −2.07, p = .04), SC (z = −3.06, p < .01), and WC (z = −2.20, p = .03). Suggesting discriminant validity, IB-score was correlated with DASS anxiety (r = .295, p < .01), however, according to a series of Fisher’s Z-tests, less robustly so than variables more closely aligned with the construct of body dissatisfaction or eating disorder symptoms: BSQ (z = −5.15, p < .01), EDE-Q total (z = −5.2, p < .01), EC (z = −4.11, p < .01), SC (z = −5.09, p < .01), and WC (z = −4.24, p < .01). The same was true for DASS depression (r = .360, p < .01) scores: BSQ (z = −4.4, p < .01), EDE-Q total (z = −4.46, p < .01), EC (z = −3.36, p < .01), SC (z = −4.35, p < .01), and WC (z = −3.49, p < .01). Discussion The present study evaluated the psychometric properties of a novel computerized assessment of interpretation bias for
body dissatisfaction—the first to use the WSAP method for this population—and found preliminary evidence for its reliability and validity. The results lend initial support for the use of this measure to study interpretation bias in individuals with body dissatisfaction in order to expand, more accurately, upon the limited research in this area and potentially adapt to tools designed to correct for such bias and reduce associated symptomology. Psychometric properties of the WSAP are promising. Test–retest correlations in a subsample of participants suggest good test–retest reliability. Additionally, the coefficient alpha (.71) for IB-scores indicated acceptable internal consistency. Evidence of construct validity for the WSAP was supported by overall patterns of convergent and discriminant validity. As expected, IB-score was highly, positively correlated with body dissatisfaction on the BSQ, suggesting good convergent validity. Also as expected based on findings of prior research that heightened body dissatisfaction is related to eating disorder symptoms (Makri-Botsari, 2009), IB-score was highly, positively correlated with eating disorder symptomology on the EDE-Q. Further, the restraint domain of the EDE-Q was less robustly correlated with IB-score than the other domains. One possible explanation for this is that the Restraint subscale measures behavioral aspects of eating disorders (e.g., avoiding food, following rules about eating), whereas the other subscales measure cognitive aspects of eating disorders. As the WSAP seeks to measure more cognitive components of body dissatisfaction, this nuanced correlation pattern provides evidence for convergent and discriminant validity. Also contributing to discriminant validity, IB-score was less positively correlated with depression and anxiety symptoms compared to measures more associated with body dissatisfaction and eating disorder symptoms. We expected depression and anxiety to be related to IB-score because body dissatisfaction is associated with depression and anxiety. However, as expected, depression and anxiety were less robustly correlated with IB-score than with body dissatisfaction and ED symptoms. Although the present study found promising evidence of reliability and validity for the WSAP, there are limitations to consider. Due to insufficient sample size, we used correlation patterns to assess construct validity rather than confirmatory factor analysis (CFA) from a structural equation modeling framework. Future research with a larger sample may provide a more sophisticated evaluation of construct validity. Body dissatisfaction is a central component of eating disorders, but the current findings only reflect on the reliability and validity of the WSAP for undergraduate females, as it was unclear how many participants met diagnostic criteria for an ED. Though, based on EDE-Q cut-scores (Carter et al., 2001), 4.7% of participants scored in the clinical range of eating pathology. Because we exclusively included undergraduate females for their increased risk of body dissatisfaction (Cook-Cottone & Phelps, 2003), research that directly addresses clinical samples with eating disorders, as well as body-dissatisfied men, is needed
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to further evaluate psychometric properties of the WSAP. Our sample was also primarily Caucasian women from high-income households, which may limit the generalizability of our findings, Subsequent investigations would benefit from including separate diagnostic groups (e.g., anorexia, bulimia) and a demographically diverse participant pool. Future research should also address the potential influence of personality and other related variables (e.g., negative affect) on body dissatisfaction and interpretation bias. The purpose of this study was to evaluate the psychometric properties of the WSAP for measuring interpretation bias associated with body dissatisfaction. The WSAP more closely mimics the automaticity and order of interpretation bias as explained by cognitive theory and, therefore, may serve as a more accurate measure of interpretation bias than previous self-report paradigms. The WSAP is also advantageous given its potential to be adapted to training models designed to correct for such bias, which have shown promising results in populations with anxiety (e.g., Beard & Amir, 2009) and depression (e.g., Bowler et al., 2012) for decreasing associated symptomology, but have yet to be used with individuals who are body-dissatisfied. Body dissatisfaction research should continue to use the WSAP to expand the limited knowledge of interpretation bias, which can be targeted in eating disorder prevention and treatment.
Appendix (Continued ) Scenario Satisfied Too busy Indifferent Fine Airbrush Fit Compliment Impartial Energy Opinion Fitting No problem Excessive Mistake Needless Thankful
Appendix. WSAP Interpretation Stimuli, Baseline Session
Need food Surprise
Scenario Negative words Fat Guilty Weight gain Distress Admire Excited Pudge Good No control Lazy Not enough Lie Admiration Flab Join in Judgment Look big Disappointed Proud Skinny Conflicted Understanding Embarrassed Neutral words Worried Concerned Not hungry
Satisfied You walk into class and you notice two girls look at you and laugh While eating dinner with your family, you go back for a second helping As you are getting dressed, the button of your jeans pops off While at the beach, your friend wants to take a picture of you Another girl in your dorm brags about how she restricts her calories A friend asks, ‘Have you lost weight?’ While joking around, your friend pinches your side It has been hours since you have eaten You eat a large dinner, dessert, and a late night snack You have not been to the gym in weeks You step on the scale and see that you have lost a few pounds Your friend tells you that you look really pretty today While sitting in class, you notice that the girl next to you is especially skinny The waist of your pants feels too tight Your friend tells you about a new diet that helped her lose weight fast Your friend makes a comment about your figure Someone posts an unflattering picture of you on Facebook In nutrition class you calculate your BMI and find that it is normal You realize you have not eaten anything all day Your friend introduces you to a new a friend who you consider very attractive While out to dinner with your friend, she wants to share a fattening appetizer A girl from your dorm who is thin tells you she wants to lose weight You are wearing a bikini while at the pool with your friends You notice that one of your friends has gotten extremely skinny lately While home for winter break, your Mom tells you that you look too thin You decide not to eat dinner
Your doctor tells you that you are at a healthy weight You are hungry in the morning, but you skip breakfast You try to borrow a friend’s top, but it is too tight You are looking at a photo of yourself You flip through a magazine full of extremely thin models While shopping, you try on a tight pair of pants and observe yourself in the mirror Your friend tells you that you look ‘curvy’ After finishing your dinner your friend says ‘You must have been hungry!’ While up late studying, you decide to have a snack Someone tells you that your shirt is too small While taking a fitness class, you notice that every other woman in class is very thin While you are changing clothes in the gym locker room, a group of girls walk in You notice your roommate weighs and measures herself each morning Your relative buys you a shirt for your birthday that is two sizes larger than what you wear A friend of yours recently tried a new diet and lost 10 pounds Someone comments that you have a ‘healthy’ figure You were sick last week and barely ate at all You notice your winter clothes from last year are loose on you now While getting dressed, you examine your reflection in the mirror
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