Self-criticism, low self-esteem, depressive symptoms, and over-evaluation of shape and weight in binge eating disorder patients

Abstract

Despite the fact that negative self-evaluations are widely considered to be prominent in eating disorders, the role of self-criticism has received little empirical attention. The vast majority of research on the construct of self-criticism has focused on its role as a specific personality vulnerability factor in depression-related phenomena. In this study of 236 patients with binge eating disorder, confirmatory factor analysis supported self-criticism, self-esteem, depressive symptoms, and over-evaluation of shape and weight as distinct, albeit related, constructs. Structural equation modeling demonstrated that the relation between self-criticism and over-evaluation of shape and weight was partly mediated or explained by low self-esteem and depressive symptoms. Continued efforts to understand the role of self-criticism in eating disorders appear warranted.

Introduction

Despite the fact that negative self-evaluations are widely considered to be prominent in eating disorders (see Fairburn, Cooper, & Shafran, 2003; Cooper, 2005), the link between self-criticism and eating disorder symptomatology has received surprisingly little empirical attention. Blatt's self-criticism construct (Blatt, 1974; Blatt, D’Afflitti, & Quinlan, 1976) has generated an impressive amount of research activity over the past three decades, but the vast majority of this research has focused on its role as a specific personality vulnerability factor in depression-related phenomena (see Blatt, 2004; Coyne & Whiffen, 1995; Zuroff, Mongrain, & Santor, 2004 for reviews). Self-critical individuals are assumed to engage in constant and harsh self-scrutiny and evaluation, are unable to derive satisfaction from performance, and have a chronic fear of being disapproved and criticized (Blatt, 2004). Steiger, Goldstein, Mongrain, and Van der Feen (1990) suggested that self-criticism “would logically be present in disorders in which pathological fixations upon the self and the body stabilize a fragile self-image and compensate for the felt failure to obtain others’ recognition” (p. 137). Steiger et al. (1990) found elevated levels of self-criticism, assessed by the depressive experiences questionnaire (DEQ; Blatt et al., 1976), in all of their eating-disordered patient groups (anorexic, bulimic) compared to psychiatric and normal comparison groups. These elevations among the eating disordered patients remained significant when depression level was statistically controlled.

The present study aimed to examine the relation between self-criticism and over-evaluation of shape and weight in a sample of patients with binge eating disorder (BED). BED, a research category in the DSM-IV (American Psychiatric Association [APA], 1994), is characterized by recurrent binge eating without the compensatory weight-control methods that distinguish bulimia nervosa. BED is now recognized as a prevalent and important public health problem (Wilfley, Wilson, & Agras, 2003). While research has focused on the behavioural aspects of BED and associated psychiatric and medical co-morbidities (Wilfley et al., 2003), less is known about its cognitive psychopathology (Grilo, 2002) and few studies have examined the links between personality and BED (see Cassin & von Ranson, 2005).

The degree to which individuals evaluate their self-worth in terms of their shape and weight is widely recognized as the core cognitive feature of eating disorders (APA, 1994; Fairburn & Harrison, 2003). Although over-evaluation of shape and weight is not a required criterion for the research diagnosis of BED (APA, 1994), high levels of shape and weight over-concern are characteristics of persons with BED and are present at levels comparable to those found in bulimia nervosa (Masheb & Grilo, 2000; Wilfley, Schwartz, Spurell, & Fairburn, 1997). Fairburn et al. (2003) proposed a “transdiagnostic” theory that attempts to provide a single framework within which to conceptualize all eating disorders, including patients with atypical eating disorders that do not meet specific criteria for anorexia nervosa or bulimia nervosa. Fairburn et al. (Fairburn et al., 2003; Fairburn & Harrison, 2003) consider the over-evaluation of eating, shape, and weight and their control to be the “core psychopathology” of eating disorders, and this is reflected, to large degree, in the current classification system (APA, 1994).

Fairburn et al. (2003) noted that there is often an interaction between perfectionism and eating disorders “with the patient's perfectionist standards being applied to the attempts to control eating, shape and weight, as well as to other aspects of their life (e.g., their performance at work or sport)” (p. 516; see also Shafran, Cooper, & Fairburn, 2002). Further, Dunkley, Blankstein, Masheb, and Grilo (2006) suggested that self-criticism might be the most critical pathological component of perfectionism that underlies the determined pursuit of high standards despite adverse consequences (see also Dunkley, Zuroff, & Blankstein, 2006). In the context of eating disorders, the over-evaluation of shape and weight can be conceptualized, in part, as an attempt to compensate for self-criticism (see Steiger et al., 1990). Consistent with this perspective, Dunkley, Blankstein, Masheb, & Grilo (2006), Dunkley, Zuroff, & Blankstein (2006) found DEQ self-criticism to be related to both the over-evaluation of shape and over-evaluation of weight in a sample of BED patients. Moreover, after controlling for self-criticism, other perfectionism components were not uniquely related to the over-evaluation of shape and weight.

Low self-esteem is one of the most frequently considered psychological predisposing factors of people with eating disorders (see Fairburn et al., 2003; Fairburn & Harrison, 2003). Although self-criticism and low self-esteem are strongly related, they can be conceptually distinguished in that self-criticism involves negative self-judgments that pertain to feelings of failure to live up to one's own or others’ expectations (see Blatt, 2004). On the other hand, low self-esteem reflects a more global negative view of the self (see Fairburn et al., 2003). Past clinical accounts suggest that low self-esteem might arise from self-criticism (see Hamachek, 1978; Horney, 1950). Specifically, self-critics’ chronic and harsh self-evaluation perpetuates a gap between the ideal and actual self for these individuals that results in their having a more global negative view of the self. Low self-esteem, in turn, results in hopelessness and the determined pursuit of achievement in their valued domains (e.g., control over eating, shape, and weight) in an attempt to bolster their overall negative view of themselves (see Fairburn et al., 2003). Previous research with college students (Blankstein, Dunkley, & Wilson, 2005; Rice, Ashby, & Slaney, 1998) has used structural equation modeling (SEM) to support low self-esteem in an important mediational role that partly explains the relation between evaluative concerns perfectionism, of which self-criticism is a primary indicator (e.g., Dunkley, Zuroff, & Blankstein, 2003; Powers, Zuroff, & Topciu, 2004), and depressive symptoms. In a sample (N =137) of non-treatment-seeking obese women with BED, Pratt, Telch, Labouvie, Wilson, and Agras (2001) used path analysis to support low self-esteem as a mediator in the relation between evaluative concerns perfectionism and over-evaluation of shape and weight.

The aim of the present study was to gain a better understanding of the link between self-criticism and over-evaluation of shape and weight in patients with BED. In particular, we aimed to build on the literature by clarifying the relations among self-criticism, low self-esteem, depressive symptoms, and over-evaluation of shape and weight. It is important to consider the role of depressive symptoms and its relation to self-criticism, low self-esteem, and over-evaluation of shape and weight because of the frequent association found between depression and eating disorders (e.g., Brewerton et al., 1995; Grilo, Levy, Becker, Edell, & McGlashan, 1996; Herzog, Keller, Sacks, Yeh, & Lavori, 1992), including BED (Wilfley et al., 2000). We considered the possibility that (1) depressive symptoms mediate the relation between self-criticism and over-evaluation of shape and weight and (2) depressive symptoms mediate the relation between low self-esteem and over-evaluation of shape and weight. Moreover, we built on previous mediational studies (Pratt et al., 2001; Rice et al., 1998) by using SEM to perform complete and simultaneous tests of both low self-esteem and depressive symptoms as mediators in the relation between self-criticism and over-evaluation of shape and weight in BED patients. Fig. 1 presents the hypothesized mediational model of the relation between self-criticism and over-evaluation of shape and weight as follows: (1) self-criticism will be linked to each of low self-esteem, depressive symptoms, and over-evaluation of shape and weight, (2) low self-esteem will be linked to each of depressive symptoms and over-evaluation of shape and weight, and (3) depressive symptoms will be linked to over-evaluation of shape and weight.