desirable possible selves and depression in adult women with eating disorders
TRANSCRIPT
ORIGINAL ARTICLE
Desirable possible selves and depression in adult womenwith eating disorders
Martin G. Erikson • Berit Hansson •
Suzanna Lundblad
Received: 8 November 2013 / Accepted: 28 March 2014 / Published online: 13 April 2014
� Springer International Publishing Switzerland 2014
Abstract
Purpose Possible selves are conceptions of our selves in
future states. Previous findings indicated that women with
anorexia nervosa tended to have more negative possible
selves than a control group, even when rating future situ-
ations normally regarded in our society as desirable. The
present study investigated whether this was a general pat-
tern in women with eating disorders, relating findings on
possible selves to depression. Possible selves concerning
treatment were also included.
Methods Patients with anorexia nervosa (n = 19), buli-
mia nervosa (n = 29) or an eating disorder not otherwise
specified (EDNOS) (n = 18) and a control group (n = 27)
rated the valence of five possible selves on Likert’s scales.
Levels of depression were measured among the patients
using the Beck Depression Inventory.
Results The patients rated the valence of the possible
selves significantly less positively and more negatively
than did the control group. A strong correlation between
valence and depression was found in patients with anorexia
nervosa and bulimia nervosa. No such correlation was
found in patients with EDNOS. Possible selves concerning
future treatment were rated even more negatively.
Conclusions The results indicate that, when compared to
a non-patient group, eating disorder patients make more
negative evaluations of possible selves usually seen as
desirable. Depression may be a mediating factor in these
evaluations for the anorexia and bulimia patients.
Keywords Anorexia nervosa � Bulimia nervosa � Eating
disorder not otherwise specified � Possible selves �Depression
Desirable possible selves and depression in adult women
with eating disorders
In the literature on anorexia nervosa and bulimia nervosa,
there is consensus on the importance of patients’ self-
concepts for understanding their disorders. The multitude
of theoretical approaches to the self in eating disorders
research calls for conceptual clarity, where Stein and Corte
[1] argued for the use of the social cognitive model [2, 3].
In relation to this model, it has been argued that possible
selves theory provides a viable approach to the study and
treatment of eating disorders [1, 4–6]. Possible selves are
part of the self-concept; they are the individual’s concrete,
idiosyncratic conceptions on his/her own future selves,
including conceptions of their value and their probability,
thus having a direct influence on meaning making and
behavior [7–10].
Patients with anorexia nervosa or bulimia nervosa have
been found to be more likely to formulate negative images
of the future [11], and patients with anorexia nervosa,
compared with a control group, tended to spontaneously
report a larger number of negative possible selves, with a
higher negative valence for these possible selves compared
with a control group [6]. Much less is known about
PsycINFO classification: 3260 Eating Disorders.
M. G. Erikson (&)
School of Education and Behavioural Sciences, University of
Boras, SE-501 90 Boras, Sweden
e-mail: [email protected]
B. Hansson � S. Lundblad
The Anorexia and Bulimia Clinic for Adults, Sahlgrenska
University Hospital, Olskroksgatan 30, SE-416 66 Goteborg,
Sweden
e-mail: [email protected]
123
Eat Weight Disord (2014) 19:145–151
DOI 10.1007/s40519-014-0122-7
self-deficits in patients with an eating disorder not other-
wise specified (EDNOS), although the research shows that
the condition can be as serious as anorexia nervosa or
bulimia nervosa [12–14]. The literature defines subgroups
of EDNOS, one being patients who have previously been
diagnosed with anorexia nervosa or bulimia nervosa and
who are given an EDNOS diagnosis based on sub-threshold
symptoms [12, 13, 15]. Patients with sub-threshold ED-
NOS have been shown to display levels of psychopathol-
ogy not different from the corresponding full criteria
patients [13, 14, 16].
One co-morbidity common in all eating disorders is
depression, and depressed patients have shown patterns of
negative expectations about the future similar to those
found in patients with eating disorders [16]. Previous
results suggest that no statistically significant differences in
levels of depression should be expected between patients
with anorexia nervosa, bulimia nervosa and EDNOS with
sub-threshold anorexia or bulimia symptoms [16]. In rela-
tion to possible selves, depression is known to reduce the
ability to anticipate future positive events by increasing
negative and decreasing positive thinking [17–20]. The
cognitive model of depression formulated by Beck [21, 22]
shares features with the theories of the self on which the
construct of possible selves is based, as it describes
depression as a function of both future and present selves.
One study of possible selves and depression found that
depressed subjects were characterized by having negative
beliefs about themselves rather than by an absence of
positive beliefs [23]. In this study, depression was strongly
connected with feelings of self-denigration, a phenomenon
also found in patients with anorexia nervosa [24, 25].
Further, participants who scored high on depression
reported more negative possible selves, which also corre-
lated with less effective coping strategies; this also accords
with previous findings [10, 26]. Studies have also shown
that possible selves are often complex, in that they have
both negative and positive valence [6, 11, 27].
Less is know about how depressed subjects rate the
positive and negative valence of possible selves that are
usually seen as desirable by subjects not suffering from
depression. Erikson, Hansson and Lundblad [6] found that
almost all patients with anorexia nervosa in their study saw
a range of negative or threatening futures in situations that
are normally regarded as positive by non-clinical groups.
About two-third of patients in this study reported strong
negative emotions and weak positive emotions in relation
to such ‘‘desirable’’ possible selves as meeting with friends.
The patients reporting negative expectations about ‘‘desir-
able’’ futures were asked to spontaneously report possible
selves, which makes it impossible to determine to what
degree fears of negatively rated ‘‘desirable’’ situations were
shared by the participants. Further, very few spontaneous
possible selves in this study [6] were related to treatment or
clinic visits.
The first question we addressed in the present study was
how widespread the tendency is for patients with anorexia
nervosa, as well as patients with bulimia nervosa and those
with EDNOS with sub-threshold anorexia or bulimia, to
regard normally ‘‘desirable’’ possible selves as negative.
This evaluation of ‘‘desirable’’ possible selves was made in
terms of both negative and positive valence. The second
question concerned how different levels of depression can
influence the valence of ‘‘desirable’’ possible selves in
these patient groups and the third how patients rate possible
selves related to treatment situations.
Method
Participants
The patient group consisted of 66 female patients diag-
nosed with eating disorders according to DSM-IV, all of
whom were outpatients at the Anorexia & Bulimia Clinic
for Adults, Sahlgrenska University Hospital, in Gothen-
burg, Sweden. In total, 72 patients were approached; one
declined participation and an additional five were discarded
due to incomplete data. Remaining were 19 patients with
anorexia nervosa in the age range 24–60 years
(Mage = 32.5, SD = 8.6), eight of whom had anorexia
nervosa of the purging type, 29 patients with bulimia in the
age range 25–49 years (Mage = 32.3, SD = 7.3) and 18
patients with EDNOS in the age range 25–52 years
(Mage = 31.1, SD = 7.5). The patients with EDNOS were
selected because they had all previously been diagnosed
with anorexia nervosa or bulimia nervosa, either upon
admittance to the Anorexia & Bulimia Clinic for Adults
Table 1 Background variables for the patient groups
Diagnosis
Anorexia Bulimia EDNOS
(n = 19) (n = 29) (n = 18)
Beck Depression Inventory score
(BDI)
18.3 27.1 25.7
Mean body mass index 17.0 22.3 20.8
Mean time in treatment at A and B
clinic (months)
30.5 11.2 29.5
Number of patients previously
treated at other clinics
13 16 11
Number of patients studying 4 6 1
Number of patients working 7 17 9
Number of patients on sick leave 7 6 8
Number of patients unemployed 1 0 0
146 Eat Weight Disord (2014) 19:145–151
123
(n = 7) or through previous diagnostics at other clinics
(n = 11), and had since undergone a change in symptoms
giving an EDNOS diagnosis––a diagnostic group that
previous research suggests is comparable with bulimia and
anorexia patients, as discussed above. At the time of the
study, 16 EDNOS patients reported that they starved
themselves and six reported that they purged occasionally.
Further, background data on the patients are presented in
Table 1.
The control group consisted of 27 Swedish female
psychology university students in the age range
20–51 years (Mage = 27.7, SD = 7.6). In total, 29 students
were approached and two declined participation. While the
health of the control group was not measured, the controls
can be assumed to be representative of a normally healthy
population of female students.
Material
The instrument, in Swedish, consisted of five predefined
possible selves describing ‘‘desirable’’ situations; an Eng-
lish translation is presented in Table 2. We selected the
situations based on the results reported in Erikson et al. [6]
and based on clinical experience. The common feature was
that the situations included opportunities for something that
would be considered desirable by most people. They were
not situations to be achieved, but situations that could
occur independent of any strivings or intentions. Beside
these five ‘‘desirable’’ possible selves, two more possible
selves related to treatment and clinic visits were included.
All possible selves were formulated so as to be general
enough to fit into anyone’s life, while at the same time
being specific enough to qualify as a possible self. The
situations selected did not involve or imply dealing with
food or eating.
The participants were asked to rate each possible self
in relation to positive and negative feelings associated
with the possible selves on 7-point Likert’s scales, with
values from 0 to 6, thus giving separate measures of
positive and negative valence for each possible self. The
control group was given the same instrument, with the
exception of the two possible selves describing visits to
the clinic. Further, the patients were scored on the Beck
Depression Inventory (BDI) [21, 22]. The control group
was not scored on the BDI, as they had recently studied
depression and measures of depression as part of their
psychology courses.
Procedure
All patients, already diagnosed and admitted as outpatients,
visiting at the clinic during four consecutive weeks were
approached by the clinic’s secretary and informed about
the study in person. Those interested were given further
information by the psychologist or psychiatrist responsible
for their treatment who also administrated the instrument.
Before volunteering, the patients were informed both ver-
bally and in writing that they were to imagine themselves
in the various situations and report how they spontaneously
believe they felt about them. They were also informed that
the test was not part of the treatment and that the results
would not be used to assess or compare individuals, only
groups. Finally, they were informed that the study was
completely voluntary, that their anonymity would be
ensured and that they could withdraw at any time. They
were also told that if they did withdraw, any data provided
by them would be deleted. The participants completed the
instruments at the clinic. Data from three patients with
anorexia nervosa and two patients with EDNOS were
discarded due to incomplete BDI data. No participants
withdrew from the study.
The control group was approached by their lecturer and
was given the same information as the patient group. For
those volunteering, the study was carried out in a classroom
setting. No student withdrew from the study.
The study was carried out in accordance with APA
ethical guidelines and approved by the section for medical
research of the Regional Ethical Review Board at the
University of Gothenburg, as required by Sahlgrenska
University Hospital (approval reference No. 040-07). Only
patients who had initially expressed an interest in the study
when approached in person by the secretary were asked to
participate by the clinical staff. The students in the control
group received no credit or other compensation for their
participation.
Table 2 Predefined possible selves presented to the participants in
random order, to be scored for negative and positive valence
‘‘Desirable’’ possible selves
I meet an old friend on the street who wants me to come
shopping.
I find the phone number of an old friend, with whom I have not
talked for a long time, who would be glad if I called.
A friend gives me a book about something that interests me a lot,
which my friend wants to discuss after I have read it.
A man who seems nice gives me a compliment about my hair.
Someone I care for wants to know my plans for the summer, so
we can do something together.
Possible selves described in relation to visiting the clinic
I am sitting in the waiting room here at the clinic, awaiting an
appointment with my therapist.
I participate in a group session with other patients here at the A
and B clinic.
Eat Weight Disord (2014) 19:145–151 147
123
Analysis
Means were compared using ANOVA, with Bonferroni’s
posthoc tests used for pairwise comparison when applica-
ble. Spearman correlations were two-tailed as there was no
directional hypothesis on which to base one-tailed corre-
lations. Linear regression analyses were used to assess the
influence of assumed multiple predictors. A posthoc power
analysis showed that on the basis of the means and effect
sizes (Cohen’s d) measured, some caution is called for
regarding the comparison between anorexia nervosa
patients and the control group (d = 1.1 for positive pos-
sible selves and d = 1.4 for negative possible selves), as a
sample size of n = 25 would have been required to achieve
statistical power at the 0.80 level. For the comparison
between the control group and the EDNOS patients
(d = 1.4 for positive possible selves and d = 2.0 for neg-
ative possible selves), as well as the bulimia nervosa
patients (d = 0.98 for positive possible selves and d = 2.4
for negative possible selves), statistical power at the rec-
ommended 0.80 level could be achieved with the present
sample size. An alpha level of 0.05 was used for all sta-
tistical tests.
Results
The total means of positive and negative valence for the
five ‘‘desirable’’ possible selves common to the patient
group and the control group are presented in Table 3. The
mean of the positive valence showed significant differ-
ences, F(3, 89) = 7.51, p \ 0.000, g2 = 0.202, where the
pairwise comparison showed that the control group differed
statistically significantly from all three patient groups, as
shown in Table 3. Similarly, the mean of the negative
valence showed significant differences, F(3, 89) = 11.20,
p \ 0.000, g2 = 0.274, where the control group differed
significantly from all three patient groups. There were no
significant differences between the patient groups for either
positive or negative valence.
For depression, as measured by BDI scores, the patient
groups differed significantly, F(3, 63) = 3.83, p = 0.027,
g2 = 0.108, where the pairwise comparisons showed that
patients with anorexia nervosa (MBDI = 18.3, SD = 11.7,
range 4–49) had significantly lower rates of depression
compared with patients with bulimia nervosa
(MBDI = 27.1, SD = 10.9, range 7–41), whereas patients
with EDNOS (MBDI = 25.4, SD = 10.6, range 4–47) did
not differ significantly from the other patient groups. The
correlations between the valence of ‘‘desirable possible
selves’’ and BDI score are presented in Table 4. For
patients with anorexia nervosa, there was a significant
negative correlation between depression and positive
valence, q(17) = -0.567, p = 0.011, and for negative
valence a strong trend toward positive correlation,
q(17) = 0.440, p = 0.059. Similarly, for patients with
bulimia nervosa, there was a significant negative correla-
tion between depression and positive valence, q(27) = -
0.475, p = 0.009, and for negative valence a significant
positive correlation, q(27) = 0.531, p = 0.003. For
patients in the EDNOS group, no significant correlations
were found, with negative correlations of both positive and
negative valence close to zero. Patients in the EDNOS
group who had previously been in treatment for anorexia
nervosa or bulimia nervosa at other clinics did not differ
significantly from those who had their first diagnosis at the
clinic where the study was conducted.
Due to the age distribution of the participants, a
regression analysis was carried out in order to control for
age as an independent variable. The results, presented in
Table 5, indicate that age had a negligible predictive value
on the valence of possible selves, and though the B-coef-
ficients in relation to age for the EDNOS patients were
higher, the results were not statistically significant.
The means of positive and negative valence for the
possible selves described in relation to visits to the clinic
were compared with the overall means for the five
‘‘desirable’’ possible selves. The positive valence of the
Table 3 Means, with standard deviation in parentheses, for the
valence of the ‘‘desirable’’ possible selves
Valence of
‘‘desirable’’
possible selves
Diagnosis
Anorexia Bulimia EDNOS Control
group
Positive 3.7 (1.3) 3.8 (1.3) 3.3 (1.4) 4.8 (0.6)**
Negative 2.5 (1.3) 2.3 (1.3) 2.8 (1.2) 1.1 (0.4)**
** Significant difference at the p \ 0.01 level (two-tailed) when
compared to the patient groups
Table 4 Spearman’s rho correlation between depression, measured
as BDI scores, and positive and negative valence of possible selves
Possible selves Diagnosis
Anorexia Bulimia EDNOS
‘‘Desirable’’ possible selves
Positive valence -0.567* -0.479** -0.032
Negative valence 0.440 0.531** -0.039
Visits to the clinic
Positive valence -0.077 -0.389* 0.279
Negative valence 0.313 0.343 -0.218
** Significant at the 0.01 level (two-tailed)
* Significant at the 0.05 level (two-tailed)
148 Eat Weight Disord (2014) 19:145–151
123
possible selves concerning visits to the clinic (M = 3.2,
SD = 1.5) was significantly lower, F(1, 65) = 6.67,
p = 0.012, g2 = 0.093, than the means of ‘‘desirable pos-
sible selves’’ (M = 3.7, SD = 1.2). There were no signif-
icant differences between the negative valence of the
possible selves concerning visits to the clinic (M = 2.7,
SD = 1.4) and the means for negative valence for ‘‘desir-
able possible selves’’ (M = 2.5, SD = 1.3). No significant
differences between patient groups were found in the dis-
tance between ‘‘desirable’’ possible selves and the possible
selves concerning clinic visits. The correlations between
valence for visits to the clinic and BDI score are presented
in Table 4. For patients with anorexia nervosa, the corre-
lations for both positive and negative valence of visits to
the clinic were not significant. For patients with bulimia
nervosa, there was both a significant negative correlation
between depression and positive valence, q(27) = -0.389,
p = 0.037, and a non-significant trend toward a positive
correlation between negative valence and depression,
q(27) = 0.343, p = 0.068. For patients in the EDNOS
group, no significant correlation was found.
In total, 72 % of the responses to the possible selves
were rated as having both positive and negative valence
(i.e., both negative and positive valence rated above zero).
For the control group, the proportion was 66 %, whereas it
was 75 % for patients with anorexia nervosa, 70 % for
patients with bulimia nervosa and 78 % for patients with
EDNOS.
Discussion
The purpose of the present study was to investigate the
valence of ‘‘desirable’’ possible selves and possible selves
concerning treatment in patients with eating disorders and
to relate these results to rates of depression. The main
finding was that, when compared to the control group, the
patient groups, regardless of diagnosis, were significantly
more negative in their negative ratings of ‘‘desirable’’
possible selves. Correspondingly, the patient groups were
significantly less positive in their positive ratings of these
possible selves. Thus, the present data support and expand
the findings of Erikson et al. [12], suggesting that this is a
general pattern, not only in patients with anorexia nervosa
but also in patients with bulimia nervosa and EDNOS.
While patients with anorexia nervosa had a statistically
significantly lower level of depression compared with
patients with bulimia nervosa, there were no significant
differences in ratings of positive or negative valence
between the patient groups. It has been suggested [28] that
tests of depression in patients with anorexia nervosa may
largely reflect symptoms of starvation rather than actual
depression, but it can at least be concluded that all three
patient groups showed some degree of depression as a co-
morbidity, which supports previous findings [13, 14, 16].
The correlations between depression and valence of
‘‘desirable’’ possible selves showed that patients with
anorexia nervosa and bulimia nervosa tended to regard the
possible selves as more negative and less positive with
increased rates of depression. Whereas a great deal of the
previous research on depression has focused on partici-
pants’ ability to formulate positive and negative futures,
the present results broaden the picture by including
‘‘desirable’’ possible selves, which accords well with the
general pattern as far as patients with anorexia nervosa and
bulimia nervosa are concerned [1, 11].
A more unexpected result was the total lack of corre-
lation between valence and depression for patients with
EDNOS. In other words, patients with EDNOS suffered
equally from depression and had equally negative ratings
of ‘‘desirable’’ futures as the other two patient groups did,
but without the relation between depression and valence
Table 5 Summary of
regression analysis for
independent variables
depression, measured as BDI
scores, and age as predictors for
positive and negative valence of
‘‘desirable’’ possible selves
** Significant at the 0.01 level
* Significant at the 0.05 level
Diagnosis
Anorexia Bulimia EDNOS
B Std.Error B Std.Error B Std.Error
Positive valence
BDI -0.060** 0.020 -0.053** 0.018 -0.003 0.026
Age 0.003 0.027 0.013 0.027 0.054 0.041
R2 0.371 0.249 0.104
F 4.71* 4.30* 0.87
Negative valence
BDI 0.055* 0.023 0.066** 0.020 0.000 0.025
Age -0.003 0.031 -0.004 0.030 -0.034 0.039
R2 0.276 0.298 0.39
F 3.05 5.52** 0.050
Eat Weight Disord (2014) 19:145–151 149
123
found in the other patient groups. One possible explanation
is that some of the patients with EDNOS, while recovering,
had also lost the mechanisms for dealing with anxiety and
life demands they once had in the form of anorexia and
bulimia symptoms. In future research, it may be fruitful to
include measures of anxiety as an additional variable in a
search for possible explanations of EDNOS symptoms. It
may also be worth investigating whether the self-punish-
ment found in patients with anorexia nervosa, as previously
reported [25], might find other outlets when patients with
EDNOS have lost some control over their eating behavior,
thus influencing their ratings of ‘‘desirable’’ possible selves
in this way.
All of the patient groups saw a future visit to the clinic, or
participation in treatment, as lower in positive valence than
their ‘‘desirable’’ possible selves and equally higher in
negative valence. The correlational patterns between
depression and valence were not as clear. For positive
valence, patients with anorexia nervosa showed no corre-
lation at all, whereas patients with bulimia nervosa showed
the same pattern as they did for the ‘‘desirable’’ possible
selves: the more depressed they felt, the less positive and
more negative the valence. Here, the EDNOS group differed
considerably: the more depressed subjects found visiting the
clinic more positive and less negative. This can be seen as a
healthier reaction: they feel ill and are motivated for treat-
ment. Whereas anorexia nervosa is typically connected with
resistance to change [29], less is known about these mech-
anisms in bulimia nervosa. Still, these patients show the
most negative reactions to visiting the clinic.
We believe that the present study underlines the rele-
vance of possible selves as a theoretical approach to our
understanding of eating disorders. One general conclusion
is that the results support the claim that possible selves
should not be regarded as either positive or negative. A
further general conclusion is that futures usually seen as
desirable by most of us can be regarded very differently by
an eating disorder patient. Our findings, combined with
patterns reported in previous research [13, 14, 16], also call
for caution in seeing a move from anorexia nervosa or
bulimia nervosa to EDNOS as a ‘‘recovery’’ in any sim-
plistic terms: while we cannot see whether the participating
patients with EDNOS are on their way to full recovery or
will relapse into anorexia nervosa or bulimia nervosa, the
change in diagnosis does not mean these patients must be
feeling better or find life easier than the average patient
suffering from anorexia nervosa or bulimia nervosa. If
patients were aware that leaving their original diagnosis
will not necessarily make them feel better, they could
develop strategies for dealing with their emotions that do
not involve harmful eating behavior. Such support could be
aimed at giving these patients new positive possible selves
to facilitate coping [10, 26].
Limitations
One weakness of the study is the small sample sizes, in
particular in the EDNOS and anorexia nervosa groups: the
effect sizes measured are not insubstantial but the results
need corroboration. Another limiting factor in the present
study is that many participants had long histories of illness
and younger patients might show quite different patterns.
Thus, similar research on younger patient groups with a
briefer history of illness is called for. Further, the lack of
health data on the control group adds some uncertainty, but
there is no reason to assume that the control group is not
representative of a normal population of female students of
a similar age as the patients. The instrument given to the
patient groups differed from that for the control group in
that two possible selves concerning treatment were inclu-
ded: this calls for caution, since the items about treatment
might affect the patients’ general views about the future by
triggering negative thoughts about their illness. Because
the patients were already in a treatment context when
filling out the instrument, we concluded that the risk was
small, but it must be considered.
I ought to be noted that there were different settings for
the questionnaires (clinical treatment vs. classroom). These
discrepancies may have influenced the outcome of our
observations. Nor did we employ the BDI score from the
control group. Nevertheless, it ought to be clear from the
study design that the control group employed was assigned
a specific role, i.e., that of estimating the valence of the
desirable possible selves.
Conflict of interest On behalf of all authors, the corresponding
author states that there is no conflict of interest.
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