Eating Disorder Risk and Personality Factors in Adolescent Girls

1 Lecturer PhD, Ovidius University of Constanta, Constanta, Romania, claudiasalceanu@yahoo.com Abstract: There is a consistent research that shows that adolescents have frequent concerns and worries about their body and self-image. One important factor is the biological and physiological context of development in adolescence, a stage of significant transformation in overall human development. A sample of 185 adolescent girls, aged between 18 and 21 years old, all residing in Constanta County, has been assessed with 4 questionnaires: Garner’s Eating Disorder Inventory (2004), Zuckerman-Kuhlman Personality Questionnaire (2002), The Body Esteem Scale for Adolescents and Adults (Mendelson, Mendelson, & White, 2001), and the Sociocultural Attitudes toward Appearance Scale (Thompson, van den Berg, Roehring, Guarda, & Heinberg, 2004). The purpose of the study was to explore the relationship between the risk of eating disorders and various psychological traits and variables. We examined all variables the questionnaires measured and selected only the statistically confirmed hypotheses (for p<.05). We obtained significant correlations between the risk of eating disorders and ineffectiveness, interpersonal problems, affective problems, excessive control, neuroticism-anxiety, body esteem, the internalization of the perfect athletic body, the internalization of the perfect ideal body and the pressure of having a perfect appearance. Results are discussed with regard to the psychological implications of this study and the need for additional research.


Introduction
In western cultures, the transition from childhood to maturity requires a few years, which are known as adolescence, one of the most stressful and difficult stages of human development (Adams & Berzonsky, 2009;Crandell, Haines Crandell, & Vander Zanden, 2009;Muntean, 2009;Papalia, Wendkos Olds, & Duskin Feldman, 2010;Sion, 2007). Adolescence is definitely a stage of changes, and reviewing the multitude of papers that approach its problems shows that no other developmental stage has been characterized through so many attributes and metaphors. The word crisis has often been invoked and it is well deserved (Rayner, Joyce, Rose, Twyman, & Clulow, 2012).
Adolescence brings profound transformations at biological psychological and social level. Creating a new stable and mature identity, developing new social relations, developing the social role of man or woman, accepting the self-image, gaining independence in relationship with their parents, preparing for family life and a professional career, developing a personal value system, behaving in a socially responsible way, are few of the challenges an adolescent must find a solution for.

The effects of biological changes in adolescence
Adolescence is a top stage in physical growth. Corporal changes are acknowledged, moments of self-examining appear often and in different occasions, the desire to better know their own body are evidence of the profound interest in self-awareness (Creţu, 2009).
Preoccupation and worries for their body and body image are quite frequent in adolescence, and some studies (McCabe, Ricciardelli, Sitaram, & Mikhail, 2006;Wertheim & Paxton, 2011) show that many adolescent girls and boys are unhappy with their bodies and wish to change their looks. This prevalence of a negative body image, alongside predisposing and precipitator psychological factors, set up a framework for the development of eating disorders. Since the body image refers to emotional attitudes, beliefs and perceptions that an individual may have over his own body (Grogan, 2006), it is important to acknowledge the fact that it includes both aesthetic aspects of appearance and pressures reflected by the society (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999).
Depending of their personality, cultural environment and family beliefs, adolescents' experiences may vary. Some studies emphasize that not all individuals experience distress regarding their body image, as some of them only express dissatisfaction with only some particular features (Cash, 2008). Adolescents may feel enchanted, disgusted or terrified and if they lack the proper means to deal with these emotions, a crisis may be installed. Cash (2008) emphasizes that there are some teenagers that experience a range of emotional and behavioural problems, like depression, social anxiety or eating disorders, even if they are dissatisfied with only one physical attribute. Some girls may be worried about their attractiveness and they may have problems acknowledging themselves as women (Rayner et al., 2012). Recent studies show that body image dissatisfaction seems to increase as individuals feel an obligation to conform to standard ideals (Calzo et al., 2015).
In the latest years, the interest for the body image has grown exponential, due to the escalation and diversification of unhealthy behaviours of managing the body image, especially for adolescents and youth. And this is an important aspect for this study, as body image dissatisfaction has some unwanted effects: it leads to certain social and mental effects, among both youth and adults as well. People's distress about their own body image may be caused by a particular body part, or about their general shape, or they may feel uncomfortable with their whole body. In other words, individuals do not necessarily need to be overweight or underweight to think low about themselves (Curtis & Loomans, 2014).
As people constantly tend to compare themselves with others, the fact that modern western societies promote a thin ideal of body shape is an important factor of defective behaviours. Even at a young age, girls learn that they can be judged by their appearance and even valued in society in a certain way (Klein & Schiffman, 2005). And this is a fact of outmost importance, because the range of body projects that girls are taking on at the beginning of the 21 st century are well expanded beyond eating disorders. They include cosmetic surgery, body-piercing and tattooing, pubic waxing and shaving at more and more younger ages (Eckermann, 2009). Furthermore, we acknowledge the incredible development of the whole industry of make-up, which extended products even to preschool children. More and more preadolescent girls use make-up, in different social situations, trying to cover or to emphasize certain aspects of their physical appearance.
On top of all this, in less than two decades the acceptable female body size has been whittled down by one-third, making most girls and women unable to fit into it (Fallon, Katzman, & Wooley, 1994).
The development of the body image is situated at the crossing of social and individual (Cash & Pruzinsky, 2002;Grogan, 2008). Especially for adolescents, looks are considered a relevant image of their self (Harter, 1999) and a key-component for integration in a social group (Jones & Crawford, 2006).
Apart from the obvious biological functions, the body, by means of the appearance, sends messages about social status, group membership, individual preferences, and even personality and moral traits (Langlois et al., 2000;Rumsey & Harcourt, 2005). One of the imperious directives shown by the consumer culture is that of the ideal body, interceded by mass-media. Nevertheless, the dimensions of the ideal body popularized by the media are almost impossible to find in the population. This creates a major discrepancy that can only have negative effects on people in general, and on adolescents in particular.

Body image and eating disorders in adolescence
The concept of body image is multidimensional (Thompson et al., 1999). One dimension regards the perception and the mental representation of the body. The second dimension is the evaluation and it represents the attitude toward the body. The third dimension is the impact that the previous two dimensions have over the behaviour. The authors mention two categories of maladaptive behaviours regarding the body: avoidance and obsessive rituals of comparing one's own body with other people's bodies. We feel important to emphasize that body image has a dynamic character, due to physical changes that occur throughout our entire life (Thompson et al., 1999).
As we've said before, one maladaptive behaviour is represented by obsessive rituals, and in this context, we face the high risks of the emergence of eating disorders in adolescence. Eating disorders are the most common diseases in adolescence, from 12 to 25 years old. They can be influenced by several types of factors (Adams & Berzonsky, 2009):  biological factors (like genetics, neurotransmitters or hormones),  psychological factors (problems in puberty, body image, diets, involvement in activities that put an accent on looks and weight),  emotional and personality factors (dissatisfaction with the body, anxiety, depression, worries about the looks, self-criticism, lack of family cohesion, impulsivity, culpability, hostility, lack of self-control, vulnerability, perfectionism, etc.),  family factors (values passed from parents to children, lack of family support, negative response patterns, family interaction models, lack of independence, conflicts, etc.),  sociocultural factors (media, role models, ethnicity, race, social class, etc.).

Aim of the research and hypotheses
The main purpose of the study was to explore the relationship between the risk of eating disorders and certain psychological traits.
The objectives of the research are: Objective 1 -To identify the existence of correlations between the risk of eating disorders and the composite scales of the Eating Disorder Inventory (ineffectiveness, interpersonal problems, affective problems, excessive control).
For this objective we examined the following hypotheses:  Hypothesis 1 -We presume there is a significant correlation between the risk of eating disorders and ineffectiveness;  Hypothesis 2 -We presume there is a significant correlation between the risk of eating disorders and interpersonal problems;  Hypothesis 3 -We presume there is a significant correlation between the risk of eating disorders and affective problems;  Hypothesis 4 -We presume there is a significant correlation between the risk of eating disorders and excessive control.
Objective 2 -To identify the existence of correlations between the risk of eating disorders and neuroticism-anxiety.
For this objective we examined the following hypothesis:  Hypothesis 5 -We presume there is a significant correlation between the risk of eating disorders and neuroticism-anxiety.
Objective 3 -To identify the existence of correlations between the risk of eating disorders and scales of Body Esteem Scale for Adolescents and Adults (body esteem, internalization of the perfect athletic body, the pressure of having a perfect appearance, the internalization of the perfect ideal body).
For this objective we examined the following hypotheses:  Hypothesis 6 -We presume there is a significant correlation between the risk of eating disorders and body esteem;  Hypothesis 7 -We presume there is a significant correlation between the risk of eating disorders and the internalization of the perfect athletic body;  Hypothesis 8 -We presume there is a significant correlation between the risk of eating disorders and the pressure of having a perfect appearance;  Hypothesis 9 -We presume there is a significant correlation between the risk of eating disorders and the internalization of the perfect ideal body.

Sample and research instruments
The sample was made of 185 adolescent girls, aged between 18 and 21 years old, all residing in Constanta County. We used for this research a convenience sample (Sîntion & Călin, 2014), made up of the subjects who agreed to participate. We expressly selected subjects with these particular age limits in an attempt to control the fact that early adolescents are still going through the process of shaping their ideals and beliefs, their self-confidence and self-image.
The ethics of the research was ensured by obtaining an informed consent from all participants.
The sample has been assessed with four questionnaires, chosen based on the relevance we thought their scales have to the theme of the study. The questionnaires were applied to all participants, and the data was collected from February to May 2019. The four inventories we used were: (1) Eating Disorder Inventory -3 (Garner, 2004) provides a clinical evaluation of symptomatology associated with eating disorders; (2) Zuckerman-Kuhlman Personality Questionnaire (2002, available in Cognitrom Assessment System) is an alternative Five-factor model, developed to measure namely Neuroticism-Anxiety, Activity, Sociability, Impulsive Sensation-Seeking and Aggression-Hostility (Gomà-i-Ferixanet, Wismeijer, & Valero, 2005); (3) The Body Esteem Scale for Adolescents and Adults (Mendelson et al., 2001) with three subscales measuring body esteem -appearance, body esteem -weight and body esteem -attribution; and (4) The sociocultural attitudes toward appearance scale-3 (Thompson et al., 2004), developed to measure the societal influences on body image and eating disturbances.

Findings and results
The first objective was to identify the existence of correlations between the risk of eating disorders and the composite scales of the Eating Disorder Inventory (ineffectiveness, interpersonal problems, affective problems, excessive control). We obtained the following results: H1: We presume there is a significant correlation between the risk of eating disorders and ineffectiveness. We used Pearson correlation quotient and obtained a positive correlation (r=.870, p=.000). The hypothesis was confirmed. This means that the risk for an eating disorder increases as adolescent girls feel ineffective.
H2: We presume there is a significant correlation between the risk of eating disorders and interpersonal problems. We obtained a significant positive correlation (r=.297, p=.021). The hypothesis was confirmed, which means the risk for an eating disorder increases as interpersonal relationships are more difficult.
H3: We presume there is a significant correlation between the risk of eating disorders and affective problems. We obtained a significant positive correlation (r=.685, p=.000). The hypothesis was confirmed, which means that the risk for eating disorders grows as adolescents experience emotional problems.
H4: We presume there is a significant correlation between the risk of eating disorders and excessive control. We used Spearman rho quotient and obtained a significant positive correlation (rho=.657, p=.000). The hypothesis was confirmed. This means that the risk for an eating disorder increases as adolescents manifest a constant need to reach the highest standards of performance.
Based on these results, we can conclude that the objective has been achieved.
The second objective was to identify the existence of correlations between the risk of eating disorders and neuroticism-anxiety. We obtained the following results: H5: We presume there is a significant correlation between the risk of eating disorders and neuroticism-anxiety. We used the Pearson correlation quotient and obtained a significant positive correlation (r=.350, p=.006). The hypothesis was confirmed, meaning that the higher the anxiety and neuroticism are, the more increases the risk for eating disorders.
Based on these results, we can conclude that the objective has been achieved.
The third objective was to identify the existence of correlations between the risk of eating disorders and scales of Body Esteem Scale for Adolescents and Adults (body esteem, internalization of the perfect athletic body, the pressure of having a perfect appearance, the internalization of the perfect ideal body). We obtained the following results: H6: We presume there is a significant correlation between the risk of eating disorders and body esteem. We obtained an overall significant negative correlation (r=-.693, p=.000), meaning that the risk for eating disorders increases as the body esteem decreases. We conducted correlations between risk of eating disorders and all three subscales of the BESAA April, 2020 Openings Volume 11, Issue 1, Supl. 1 Questionnaire and obtained the following results: appearance (rho=.-575, p=.000); attribution (rho=-.566, p=.000); weight (r=-.557, p=.000). The hypothesis was confirmed. H7: We presume there is a significant correlation between the risk of eating disorders and the internalization of the perfect athletic body. We obtained a positive correlation (r=.352, p=.006), which means that the risk of eating disorders increases as the idea of a perfect athletic body is more internalized by adolescent girls. The hypothesis was confirmed.
H8: We presume there is a significant correlation between the risk of eating disorders and the pressure of having a perfect appearance. We obtained a positive correlation (rho=.273, p=.035), meaning that the higher the pressure for a perfect body is, the more the risk of eating disorder increases. The hypothesis was confirmed.
H9: We presume there is a significant correlation between the risk of eating disorders and the internalization of the perfect ideal body. We obtained a positive correlation (r=.293, p=.023), meaning that the higher the conviction of an ideal physical beauty is, the greater is the risk of eating disorders. The hypothesis was confirmed.
Based on these results, we can conclude that the objective has been achieved.
A summary of the bivariate correlations for all of the study variables are reported below, in Table 1.

Discussion
Detecting the psychological features that may predispose young adolescent girls to the risk of eating disorders is an important task, especially within both the parental guidance and the psychological counselling framework which should take into account the extensive role that external sources (like the media) have in promoting certain feminine beauty ideals. In order to compel to these standards, adolescent girls may sometimes choose extreme measures. Furthermore, the psychological wellbeing and mental health of our young people should be of the greatest importance.
The eating disorder risk we used in this research is a composite scale that includes Drive for Thinness, Bulimia and Body Dissatisfaction scales (Garner, 2004). The results of the first hypothesis reveal that ineffectiveness increases the risk of an eating disorder in adolescence. Bruch (1973) considers ineffectiveness as crucial to eating disordered behaviour. Adolescent girls that assess themselves as ineffective suffer from fear of weight gain, dissatisfaction with their body, a desire to be thinner and binge eating tendencies (Garner, 2004). First of all, intense fear of gaining weight is one of the diagnostic criteria for anorexia (DSM-V, 2013). Anorexic people consider that weight loss is a goal, an achievement or even a trait of character (Wilmshurst, 2007). Being afraid of not gaining weight and having a distorted perception regarding their appearance and proportions, anorexic adolescents initially lose weight by avoiding hyper-caloric foods, but over time, they can use more and more constraints. A wrong perception of the body image is often a cause of eating disorders, especially due to the unrealistic view of how someone sees their body. Comparison of the individual's own body shape and size with other people are frequent, envy on someone's appearance is quite common. Young adolescent girls may compare themselves with their peers or different celebrities in the media. Thus, self-critical evaluative concerns (Wade, Wilksch, Paxton, Byrne, & Bryn Austin, 2015), dieting or thinness expectations (Combs, Smith, Flory, Simmons, & Hill, 2010;Steiner et al., 2003), dissatisfaction with one's figure (Cooley & Toray, 2001), weight concerns (Killen et al., 1994) increase the risk of eating disorders. Furthermore, the binge eating behaviour can be predicted by negative affect and by the tendency to act rashly when the individual is distressed (Pearson, Combs, Zapolski, & Smith, 2012). A study conducted by Froreich, Vartanian, Grisham, and Touyz (2016) showed that among the dimensions related to disordered eating behaviours, ineffectiveness and fear of losing self-control are the strongest. April, 2020 Openings Volume 11, Issue 1, Supl. 1 We conclude that adolescence is a vulnerable stage, from the point of view of nutrition, due to the fast physical and psychological changes that occur. The risk of eating disorders is present and can be increased by the physiological stress that an adolescent experiences.
The results that we obtained in the second hypothesis reveal that the risk for an eating disorder increases as interpersonal relationships are more difficult. A possible explanation is served by the cognitive-interpersonal maintenance model (Treasure & Schmidt, 2013), that states the fact that both cognitive and socio-emotional factors predispose to eating disorders. The authors emphasize that anxious avoidance of emotions, especially those generated by social encounters and insecure attachments are present in eating disordered behaviour. Isolation (McKnight & Boughton, 2009), loneliness (Levine, 2011), having no close friends in childhood (Fairburn, Cooper, Doll, & Welch, 1999;Karwautz et al., 2001), a decreased number of social activities (Krug et al., 2012), having a reduced social support (Kim, Heo, Kang, Song, & Treasure, 2010), having high levels of attachment insecurity and disorganized mental states (Broberg, Hjalmers, & Nevonen, 2001;Tasca & Balfour, 2014), wrong interpretation of social signs, voice or body movement (Treasure & Schmidt, 2013) are predisposing and maintaining factors of eating disorders. Levine (2017) states that individuals with eating disorders interpret comments through a specific filter that can distort messages. Furthermore, they are anxious about other expectations communicated by the society through implied standards. Once again, media have a significant effect on individuals, by communicating these values.
These results are also supported by the next confirmed hypothesis, that show that the risk for eating disorders grows as adolescents experience emotional problems. A possible explanation is the fact that adolescent girls experiencing such problems don't acknowledge and don't respond in an adequate manner to different emotional states. They dodge real experiences, can be intolerant enough and have tendencies toward mood swings. They can also be characterized by impulsivity, anger, imprudence and even selfharming behaviours. Also, experiences of teasing, bullying and criticism, often regarding weight, shape or eating are found in these cases (Menzel et al., 2010).
Another explanation may be the attachment patterns that adolescent girls have. Since attachment regulates the conduct of closeness between children and parents, and it represents the very first social pattern that a child experiences since birth, its importance is overwhelming in the context of its protective function as an emotional security generator (Bowlby, 1982).
Thus, attachment forms are considered strategies designed to solve adaptive problems related to different types of environments in which the individuals grow up (Batista, Žigić Antić, Žaja, Jakovina, & Begovac, 2018). The mentioned authors state that preoccupied adolescents are high in attachment anxiety and dismissive adolescents are high in attachment avoidance.
The fourth hypothesis shows that the risk for an eating disorder increases as adolescents manifest a constant need to reach the highest standards of performance. When adolescents struggle to be the best at what they are doing, their strong will of chasing their ideals (like self-discipline, self-sacrifice, self-denial or body needs control) they may also experience suffering, insecurity and interpersonal retreat. Adolescents feel that they cannot disappoint others and, furthermore, they set up really high standards thinking that a worthwhile person must absolutely have these kinds of standards (Garner, 2004).
Individuals with eating disorders tend to be quite competitive and driven to success. The obsession for thinness often puts adolescent girls in competition with other people and this drives them to elaborate "strategies" of the pursuit of thinness (Nettersheim et al., 2018). Furthermore, the mentioned authors state that in thinness in females, especially in affluent societies, is consistently associated with youthfulness. Thus, female tend to constantly strategize in order to display signs of youth.
The next hypothesis emphasizes that the higher the anxiety and neuroticism are, the more increases the risk for eating disorders. Our results are also supported by other studies (Koren et al., 2014;Lee-Winn, Towsend, Reinblatt, & Mendelson, 2016) who state that neuroticism, low interpersonal esteem and depressive affect are risk and maintenance factors of eating disorders. High levels of neuroticism-anxiety in adolescence indicate emotional tensions, upsets, worries, lack of self-confidence, constant indecision (Pelta, 2018) or sensitivity to criticism. Our results in this hypothesis are sustained by all the other confirmed hypotheses. Studies show that disordered eating behaviour often occurs in response to negative emotions (Munsch, Meyer, Quartier, & Wilhelm, 2012). In this context, neuroticism and anxiety reflect the extent into which an individual may experience and express negative emotions (Carver, 2004;Davis-Beker, Peterson, & Fisher, 2014;Shiner & Caspi, 2003).
The sixth hypothesis shows that the risk for eating disorders increases as the body esteem decreases. The more adolescent girls are satisfied with their body, the lesser is the risk of eating disorders. A positive body esteem is manifested by positive feelings regarding one's appearance, positive beliefs about the way other perceive the individual and appreciate his/hers body, and positive feelings regarding one's own weight. Building a positive self-image is based on the positive feedback the adolescent receives from others. Adolescents tend to compare themselves with certain social groups, like family, friends, and mostly, to those similar to them from the point of view of the self-image. Parents have a great impact in building a positive self-image (Zaharia, 2012). If parents reflect a positive image, than the adolescent will describe him/her in positive terms, will appreciate and value himself/herself.
On the other hand, adolescent girls frequently analyse their body, test different clothes and accessories. They need to fit the rules imposed by their generation, by their friends, but in the same time, they need to develop a personal and unique style.
The next hypothesis shows that the risk of eating disorders increases as the idea of a perfect athletic body is more internalized by adolescent girls. This ideal is sustained by increased interest for the athletic shape, supported in a large extent by magazines and TV shows regarding fitness or fashion, and even different kinds of apps on the smartphones. People of all ages are practically bombarded with images, magazines, advertising, social media, recipes regarding what to eat, advices on how to stay fit, etc. Teenage girls are interested in their attractiveness; they use make-up, hairstyling, tattoos, trying to be cool. In order to look good they have diets, carry weights; they go to different physical programs in the gym in order to develop their muscles. The problem with these ideas is the fact they are unobtainable appearance ideals, many of which are fabricated by stylists, editors, art teams and cannot be naturally achieved in real life. Studies show that alongside negative affect, shape concern may affect the eating disordered behaviour (Stewart, Plasencia, Han, Jackson, & Becker, 2014).
The next hypothesis shows that the higher the pressure for a perfect body is, the more the risk of eating disorder increases. As said before, the entire society promotes a fit body as ideal. People need to work out, to eat healthy and to use diets in order to have a perfect body. Studies show that adolescents are preoccupied with body fat, overweight girls are dieting in order to lose weight and many high-school students reported an exaggerated concern with obesity, regardless of their body weight (Moses, Banilivy, & Lifshitz, 1989).
The last hypothesis shows that the higher the conviction of an ideal physical beauty is, the greater is the risk of eating disorders. Many young people are concerned about their body size and shape because of the social pressures to conform to a thin body ideal (Pajaujiene & Jankauskiene, 2012), as we also previously stated. Adolescents matching social expectations of body image were more likely to be dissatisfied with their appearance as well as have higher risk of eating disorders. Again, media plays an important part in shaping this belief.

Limits of the research
Although all objectives and hypotheses were achieved, this research has also its limitations. First of all, as previously said, the study is based on a convenience sample. Further research should be done by expanding the sample and by including already diagnosed adolescent girls, as well as public institutions responsible for the respective areas of intervention. Furthermore, the specific type of eating disorder should be considered.
Second, we expressly selected typical subjects within the particular age limits of 18 to 21 years old, in an attempt to control the fact that early adolescents are still going through the process of shaping their ideals and beliefs, their self-confidence and self-image. Further research should take into account the deprived areas and the disadvantaged communities in Constanta County, since there are gaps in the coverage of adolescents with basic social, educational, psychological or medical problems. Other variables with risk of supporting the development of eating disorders should be considered: the existence of medical conditions, such as type 1 diabetes (Mihai, 2016); the body height and body mass index (Chirilă, Hangan, Broască, Severin, & Mocanu, 2014); food choices and influencing factors, such as hunger, food cravings, appeal of food, etc. (Neumark-Sztainer, Story, Perry, & Casey, 1999); the genetic factors that predispose adolescents to eating disorders, etc.
We conclude that this study is an important step in the research of eating disorders, particularly in the South-Eastern Romania.

Conclusions
All three research objectives have been achieved. Our results are important mostly because of the lack of research in this field of interest, especially regarding Constanta County. The obtained results suggest the importance of several factors in the risk of eating disorders in adolescent girls. We identified a series of predisposing psychological factors we identified (such as anxiety, neuroticism, ineffectiveness, body esteem, affective problems and excessive control), but also a series of sociocultural factors (the internalization of the perfect athletic body, the internalization of the perfect ideal body and the pressure of having a perfect appearance). April, 2020 Openings Volume 11, Issue 1, Supl. 1 Furthermore, we feel it is important to emphasize the usefulness of interventions related to self-criticism, ineffectiveness, self-and body-esteem, dealing with criticism, bullying, in order to decrease the risk for developing an eating disorder in adolescent girls.