Self-Esteem and Eating Disorders as Related to Gender

Cassandra B. Fremder

  

 

 

Abstract

The objective of this experiment was to determine if gender or self-esteem contributed to the development of eating disorders. The study involved a total of 100 students who participated by completing a survey used to examine self-esteem, dietary habits, and experience with eating disorders. Results found that participants who reported higher self-esteem also reported less experience with eating disorders. Additionally, it was found that females rated themselves lower for self-esteem and were more likely to report experience with an eating disorder than did males. These results indicated a significant correlation between self-worth and eating disorders, as well as a significant correlation between gender and self-esteem, and gender and eating disorders. Therefore, it can be said that both hypotheses were supported within this sample, suggesting that students with high self-esteem are less likely to have an eating disorder, and that women are more likely than men to suffer from eating disorders.

 Keywords: self-esteem, eating disorders, gender

 

  

            Self-esteem is an important issue in eating disorders. It has been known that gender, self-esteem, body image, and perceived self-worth seems to be related to dietary habits and eating disorders; but researchers have wanted to understand the relationship more clearly, comprehending the degrees to which they interact with each other. Many research studies have presented the idea that those who suffer from an eating disorder are more likely to have lower self-esteem than those who do not have an eating disorder (e.g. de la Rie, Noordenbos, & Furth, 2005; Hesse-Biber, Marino, Watts-Roy, 1999). These studies and others have shown that eating disorders are associated with lower levels of self-esteem and perception of self-concept. Additionally, research regarding the impact of gender on self-esteem has continually supported the idea that women are more likely than men to report lower levels of self-esteem and endorse eating disorders (e.g. Green, Scott, Cross, Liao, Hallengren, Davids, & Jepson, 2009). Although much research has been conducted to show the degrees of relation between self-esteem, gender, and eating disorders among various populations, few studies have attempted to find these correlations among college students. The motivation that prompted this research study was to determine if students with higher self-esteem were less likely to develop eating disorders and to understand the impact of gender on self-esteem and eating pathology.

            For example, de la Rie, Noordenbos, and Furth (2005) sought to measure the quality of life of eating disorder patients and former eating disorder patients. The purpose of this study was to investigate whether the quality of life differs between four diagnostic groups: anorexia nervosa patients, bulimia nervosa patients, eating disorder not otherwise specified patients and former eating disorder patients, and to understand what factors influence the quality of life. To do this, the experimenters administered a generic health-related quality of life questionnaire, the Short Form-36, and the Eating Disorder Examination-Questionnaire to 156 eating disorder patients (44 anorexia nervosa patients, 43 bulimia nervosa patients, 69 eating disorder not otherwise specified patients) and 148 former eating disorder patients, all recruited from different parts of the Netherlands by various means. A limitation of this study was that participants were not asked to report on whether or not they had comorbid disorders. Another limitation was that the advertisements to participate in this study may have appealed especially to those who have received treatment for eating disorders.

            The results of the de la Rie, Noordenbos, and Furth (2005) study indicated that eating disorder patients had significantly poorer quality of life measures than the former eating disorder patients on the Short Form-36 subscales of Physical Role Functioning, Emotional Role Functioning, Vitality, General Health Perception, Social Functioning and Mental Health. Additionally, no significant differences were revealed between eating disorder diagnostic groups with regard to the quality of life, except on General Health Perception. Anorexia nervosa and eating disorder not otherwise specified patients reported poorer quality of life than former eating disorder patients on General Health Perception, but not bulimia nervosa patients. Higher self-esteem was associated with a higher score on General Health Perception and with a higher score on vitality. These findings presented that self-esteem showed the highest association with the quality of life of both eating disorder patients and former eating disorder patients.

            Previous studies have sought to observe to correlations of self-worth and eating disorders. On the contrary though, not many have researched these in regard to college students. Hesse-Biber, Marino and Watts-Roy (1999) conducted a longitudinal study to determine whether women in the college population who suffered from eating disorders during their college years would recover during their post-college years. The participants, who included 144 women in the original population, were asked to answer questionnaires during their sophomore and senior years of college. Later, the twenty-one participants that continued for the duration of the six-year study were engaged in in-depth interviews that covered a wide range of psychological, environmental, developmental, and sociocultural factors. A limitation of this study was that the researchers relied on qualitative data rather than hypothesis testing and replication of past studies.

After the interview, participants answered a short questionnaire, which dictated demographic information and used continuum scales to measure eating patterns. The Eating Habits Scale consists of five categories: normal eaters, normal dieters, presyndrome, at risk and problem eaters. Women in the study were placed in these categories during three different points in time: sophomore year, senior year, and two years post-graduation. The Changes in Eating Habits Scale measured changes in individual eating patterns from the sophomore year to the senior year and from the senior year to two years post-graduation. It was designed to capture the ways in which eating patterns could change. The researchers (Hesse-Biber, et al., 1999) found that eleven women “got better”: that their disrupted eating patterns in college returned to normal post-graduation, and that ten women “remain at risk”: that they continue to exhibit tendencies toward disordered eating and distorted body image. A pattern of healthy self-concept emerged for the eleven women in the “got better” group; themes of their interviews were confidence, autonomy, success in job and success in relationships. For those that remain at risk, their relationships are described as tense, dissatisfaction was reported in the autonomous realm, and the women expressed self-doubt and a diminished self-esteem.

            Another study (Green, Scott, Cross, Liao, Hallengren, Davids, Carter, Kugler, Read, & Jepson, 2009) examined whether a unique relationship exists between depression and eating disorder behaviors after controlling for maladaptive social comparison, body dissatisfaction, and low self-esteem. The participants were a volunteer sample with a total of 208 participants, with ages ranged from seventeen to thirty-two years and body weights ranged from ninety to 345 pounds. Participants included 127 undergraduate women and eighty-one undergraduate men who completed a demographic questionnaire, the Eating Disorder Examination-Questionnaire, the Rosenberg Self-Esteem Scale, the Body Shape Questionnaire – Shortened Version, the Social Comparison Rating Scale, and the Beck Depression Inventory-II. The results indicated that undergraduate women were more likely to endorse eating disorder pathology. Additionally, the hypothesis was supported, that minimal unique variance was found in eating disorder behaviors explained by depression after controlling for maladaptive social comparison, body satisfaction, and low self-esteem. A limitation of this study was its exclusive reliance on self-report measures and failure to incorporate biological and sociocultural predictors.

            There are many steps in recovery from an eating disorder, including biological, psychological, social, behavioral, and emotional aspects. Additionally, research by Bardone,-Cone, Schaefer, Maldonado, Fitzsimmons, Hamby, Lawson, Robinson, Tosh, and Smith (2010) provides support that an improved self-concept may be an integral part of full eating disorder recovery. In an experiment that focused on measures of self-esteem, self-efficacy and self-directedness, these researchers hypothesized that individuals fully recovered from an eating disorder would have higher self-esteem, self-efficacy and self-directedness than individuals partially recovered from an eating disorder or those currently meeting criteria for an eating disorder. Participants included ninety-six current and former female eating disorder patients from the University of Missouri Pediatric and Adolescent Specialty Clinic and sixty-seven healthy control participants who were aged sixteen and older with no current or past eating disorder symptoms.

Participants were told to fill out questionnaires and also participated in an interview, which operationalized eating disorders using the Structured Clinical Interview for DSM-IV, Patient Edition, the Eating Disorders Longitudinal Interval Follow-Up Evaluation Interview, the Eating Disorder Examination-Questionnaire, and the Body Mass Index. Self-concept was operationalized by using the Rosenberg Self-Esteem Scale, the General Self-Efficacy subscale of the Self-Efficacy Scale, and the Self-Directedness subscale of the Temperament and Character Inventory. Results indicated that the healthy controls and fully recovered group did not differ significantly in global self-esteem, self-efficacy, or self-directedness. Additionally, the partially recovered group was not significantly different from the active eating disorder group, although there was a marginally significant difference (p = .06) for intimate relationships. The nature of this study made the experimenters able to examine self-concept variables across various stages of an eating disorder: active, partially removed, and fully recovered.

            Ross and Wade (2004) presented a study in which they investigated mediational processes by which variables may work together to increase the likelihood of dietary restraint and uncontrolled eating, directed by the framework suggested by the cognitive model. The researchers’ sample consisted of 111 female college students aged between eighteen and twenty-five years, as this is likely when eating disorders develop. A self-image questionnaire was distributed to participants, who were asked to indicate the answer which was true for them at that particular moment in time. Their individual Body Mass Index was also calculated. Self-esteem was assessed using the State Self-Esteem Scale (SSES), where lower scores are indicative of lower self-esteem. Concerns about weight and shape, dietary restraint, and uncontrolled eating were measured using the Eating Disorders Examination-Questionnaire, where higher scores are indicative of higher degree of restrained eating behavior, and the Eating Disorders Inventory-2, where higher scores are indicative of a higher degree of uncontrolled eating behavior.

            Results of this study indicated that BMI, externalized self-perception and self-esteem together accounted for 54.9 per cent of the variance in overvalued ideas about body weight and shape, thus self-esteem partially mediated the relationship between externalized self-perception and a combined measure of weight and shape concern. Self-esteem and weight shape concern together accounted for 30.2 per cent of the variance in uncontrolled eating; therefore, weight and shape concern fully mediated the relationship between self-esteem and uncontrolled eating. Dietary restraint did not mediate the relationship between weight and shape concern and uncontrolled eating.

            In a study conducted by Tchanturia, Troop and Katzman (2002), 245 women from Georgia completed a number of questionnaires to determine whether weight and shape affect self-esteem and self-worth for women of non-Western countries as much as it affects those of Western countries. The participants were considered an “at-risk” sample for eating disorders, including participants engaging in psychotherapy, patients at a somatic clinic, or women in a diet/shaping club. The questionnaires, measuring eating pathology, anxiety and depression, as well as two measures concerning their evaluation of weight and shape in relation to self-esteem, were distributed to the participants. These standardized tests included the Eating Attitudes Test, Bing Investigatory Test, Edinburgh and the Hospital Anxiety and Depression Scale, a body dissatisfaction scale using line drawings, and the Shape- and Weight-Based Self-Esteem Scale. Both overvaluation of weight and shape and shape- and weight-based self-esteem were significantly correlated with measures of eating deviations. In addition, the 159 of the women desired a smaller body shape. However, despite these associations, the overall degree to which women based their self-esteem on weight and shape was less than that reported in Western-based studies.

            Katsounari (2009) conducted a cross-cultural study to examine two psychological variables – self-esteem and depression – and their relationship with eating disturbance in two different cultural contexts, Cyprus and Great Britain. Participants consisted of 140 randomly selected women, seventy from Great Britain and seventy from Cyprus, who ranged from nineteen to twenty-five in age and who were born and raised in Great Britain and Cyprus, respectively. Selection criteria required the Cyprus females to be able to read English. It was hypothesized that the women participants of Cyprus would have lower scores in the self-esteem scale and higher scores in the depression scale, suggesting higher disturbed eating attitudes than the British sample. Variables were operationalized using the EAT-40 (Eating Attitudes Test), wherein participants respond to forty questions on a six-point frequency scale (support to this measure of assessment is present in both Western and non-Western populations), the Beck Depression Inventory, which serves as the most prominent and frequently cited self-report of depression, and the Battle Culture-Free Self-Esteem Inventory for Adults, which measures perceived self-worth in three subscales: general self-esteem, personal self-esteem, and social self-esteem; the order of the questionnaires was counterbalanced to control for order effects.

            The analysis of the data gained found that the average self-esteem score for the British sample (M = 28.7) was higher than the average score reported for the Cypriot sample (M – 25.620) indicating higher self-esteem for the British participants. The average depression score for the British sample was lower (M = 5.3) than the Cypriot sample (M = 8.8) indicating that the Cyprus women had higher depressive tendencies. The average EAT score for the British sample (M = 9.9) was lower than the Cypriot sample (M = 17.1) indicating more disturbed eating behaviors than the British sample. For both samples, a positive relationship was found between depression and eating disordered attitudes, which was found to be significant.

            On a more specific note, not many studies have focused on male participation in studies measuring eating disorders and self-esteem. Even further, a rare amount has included transsexual subjects, as most of the studies seem to involve women only. One such study, (Vocks, Stahn, Loenser, & Legenbauer, 2009), attempted to discover whether people with Gender Identity Disorder (GID) differed from controls of both sexes and people with eating disorders in terms of the degree of eating and body image disturbance, self-esteem, and depression. Participants consisted of 356 participants in total, including eighty-eight self-identified male-to-female (MtF) transsexuals, forty-three female-to-male (FtM) transsexuals, sixty-two females with an eating disorder, fifty-six male controls, and 116 female controls. All of the participants completed the Eating Disorder Examination Questionnaire, Eating Disorder Inventory, Body Checking Questionnaire, Drive for Muscularity Scale, Rosenberg self-Esteem Scale, and Beck Depression Inventory.

            Results of the study conducted by Vocks (et al., 2009) indicated that MtF participants showed higher scores on restrained eating, body shape concerns, drive for thinness, bulimia, body dissatisfaction, and body checking compared to male controls and even with some variables compared to female controls. Additionally, FtM displayed a higher degree of restrained eating, weight concerns, body dissatisfaction and body checking compared to male controls. Even more, participants with GID showed higher depression scores than did the controls, though no differences concerning drive for muscularity and self-esteem were found. One implication of this study was that the participants were self-identified transsexuals, not diagnosed by the researchers, so therefore it cannot be known for certainty that each participant fully met the criteria for GID according to the DSM-IV-TR. This study is important because it speculates that people with GID might be at a higher risk of eating disorders, therefore prevention programs should be implemented to help people with GID to avoid developing an eating disorder.

            Another study, conducted by Roberto, Grilo, Masheb, and White (2010), aimed to compare bulimia nervosa, binge eating, and purging disorder on clinically significant variables and examine the utility of once versus twice-weekly diagnostic thresholds for disturbed eating behaviors. Participants in the study consisted of 234 female community volunteers chosen from a total of 930 respondents who discovered the study through various websites. Participants were asked to self-report on questionnaires including the Eating Disorder Examination Questionnaire, the Three Factor Eating Questionnaire, which looks at cognitive restraining, disinhibition of control over eating, and perceived hunger, the Questionnaire for Eating and Weight Pattern-Revised, the Beck Depression Inventory, The Rosenberg Self-Esteem Scale, and self-reported demographic information, height and current weight were also collected.

            The results of this study indicated that bulimia nervosa was a more severe disorder than binge eating disorder and purging disorder. Additionally, the three disorders differed significantly in self-reported restraint and disinhibition; the bulimia nervosa and binge eating disorder groups reported higher levels of depression than those of the purging disorder. Also, for bulimia nervosa, participants that engaged in behaviors twice-weekly rather than once-weekly were more symptomatic in their responses.

            In trying to examine the effects of anger, perfectionism, and exercise on eating pathology among college women, Aruguete, Edman, and Yates (2012) conducted a study involving 258 students of a California community college who varied in ethnicity and were unaware of the purpose of the study. The procedure involved a series of survey questions that measured trait anger and suppressed anger, eating pathology, exercise commitment, and perfectionism. Trait anger was measured using the State Trait Anger Expression Inventory and suppressed anger by the Anger Discomfort Scale. Eating pathology was measured using the Drive for Thinness Subscale of the Eating Disorder Inventory. Exercise commitment was evaluated using the Commitment to Exercise scale and the Self-Loathing Subscale of the Exercise Orientation Questionnaire. Lastly, perfectionism was assessed using two subscales from the Multidimensional Perfectionism scale: Concern over Mistakes Subscale and Parental Criticism Subscale.

            After performing bivariate correlations to test whether anger, perfectionism, and exercise commitment would be correlated with eating pathology, Aruguete (et al., 2012) performed a series of linear regressions to investigate the effects of anger on perfectionism, exercise commitment, and eating pathology. The results indicated that exercise and perfectionism (but not anger) showed significant associations with eating pathology. Additionally, they found that anger did not independently predict eating pathology, but that trait anger was negatively associated with exercise commitment and that anger would independently predict perfectionism. This study supports pervious research, although one limitation of this study was that it used a convenience sample that consisted of mostly Asian/Pacific Islanders.

            In an attempt to investigate the cross-cultural validity and reliability of the Chinese Eating Disorder Examination (CEDE) in China, Jun, Jing, Jian, Hong, Shu Fang, Xiao Yan, and Hsu (2011) conducted an experiment involving forty-one eating disorder participants and 43 non-eating disorder control participants of Mainland China. Each group included male and female participants, and the mean age was 19.86. Though the Eating Disorder Examination has been supported in prior research to be valid and reliable among Asian cultures, the researchers sought to examine its reliability in a specific population of central China after having it translated to Mandarin. The researchers distributed the CEDE to all participants to evaluate the reliability and validity in the study population. The reliability indicators were internal consistency, inter-examiner reliability and test-retest reliability. The validity indicators were content validity, criterion validity and discrimination validity. The researchers found the internal consistency, test-retest reliability, and inter-examiner reliability of the CEDE to be quite high, indicating that the CEDE has high validity and reliability for the study of eating disorders in Mainland China. Additionally, they found that the clinical features of eating disorders among this population are essentially similar to those of other cultures.  

            In another study, experimenters (Torres-McGehee, Monsma, Gay, Minton, & Mady-Foster, 2011) sought to examine the pressures to be thin on female athletes of appearance-based sports, particularly equestrian athletes. They wanted to analyze the riding style of the athlete and academic status, along with perceived body image disturbances. The study was cross-sectional and included 138 volunteer participants of seven universities throughout the United States. A questionnaire was used to acquire basic and demographic data, such as academic status and equestrian background, and participants also self-reported their height, current weight, lowest weight, and ideal weight. Following, the researchers administered two surveys via email to the participants. The first was the Eating Attitudes Test, which was used to screen for eating disorder characteristics and behaviors; the test includes three subscales: dieting, bulimia, and food preoccupation and oral control. The second, the Figural Stimuli Survey, was used to asses body disturbance based on perceived and desired body images; the survey is a scale involving sex-specific body mass index figural stimuli silhouettes associated with Likert-type ratings of oneself against nine silhouettes. Chi-square analyses and multivariate analyses of varies were run to examine the data. Based on the Eating Attitudes Test, estimated eating disorder prevalence among the participants was 42.0% in the total sample, 38.5% among English riders, and 48.9% among Western riders. The experimenters found that no body mass index or silhouette differences were found across academic status or riding style in eating disorder risk. Also, the participants perceived their body images as significantly larger than their actual sizes and wanted to be significantly smaller in everyday clothing and competitive uniforms.

            Recently, descriptive research was conducted by Mond, Peterson, and Hay (2010) to understand the prior occurrence of regular extreme weight-control behaviors among women with binge eating disorder. The study involved twenty-seven women who reported current regular binge eating episodes in the absence of current regular extreme weight-control behaviors. For each behavior assessed, participants were first asked whether they had ever engaged in that behavior, and a positive response to the initial question was followed by a series or related questions, including whether the behavior was regular. For this study, “regular” was defined as “on average at least weekly for a period of three months or more”, and “excessive” as “on average three or more times per week for a period of three months or more”.  Those who reported the behavior to be a regular occurrence were further asked questions about the age at which it first occurred and the actual frequency of the behavior.

Results of this study indicated that approximately two thirds of participants (65.4%) reported either one or more purging behaviors at least weekly or one or more non-purging behaviors at a frequency deemed “excessive” by definition; 38.5% of participants reported either purging behaviors at least twice weekly or non-purging behaviors five or more times per week for a period of three months or more. Additionally, five of the participants had met criteria for bulimia nervosa outlined in the Eating Disorder Examination, and three of these five participants met criteria for bulimia nervosa as outlined in the DSM-IV. As for confidence in their recollections, 38.7% reported to be very confident, 29.0% reported to be extremely confident, 25.8% reported to be moderately confident, and 6.5% reported to be a little confident. One implication of this study is that there may be a considerable overlap between bulimic eating disorders characterized by binge eating and those characterized by extreme weight-control behaviors.

Previous research has indicated that body awareness can have an effect on the symptoms of eating disorders. For instance, in a study conducted by Catalan-Matamoros, Helvik-Skjaerven, Labajos-Manzanares, Martínez-de-Salazar-Arboleas, and Sánchez-Guerrero (2011), twenty-eight outpatients with eating disorders for less than five years were treated with body awareness therapy for seven weeks to analyze the feasibility of improved body awareness in lessening the symptoms of eating disorders. The participants were randomly assigned into one of two groups: an experimental group (n=14) and a control group (n=14). The trial consisted of three phases: the pre-test in which participants from both groups were assessed, the intervention in which participants in the experimental group received basic body awareness therapy for seven weeks through twelve sessions, and the post-test in which participants from both groups were assed at the end. Assessments used in the pre- and post-tests included the Short Form-36 to assess quality of life, the  Eating Disorder Inventory to assess the psychological and behavioral common traits in anorexia nervosa and bulimia, and the Eating Attitude Test-40 to measure symptoms and concerns characteristic of eating disorders. Data was analyzed to understand the comparison between the effects produced in the dependent variables of the experimental and control groups. The results indicated that significant differences were found in Eating Disorder Inventory and its subscales (mean difference: 26.3; P=0.015), in Body Attitude Test (mean difference 33.0; P=0.012), Eating Attitude Test-40 (mean difference: 17.7; P=0.029), and in the Short Form-36 in the mental health section (mean difference: 13; P=0.002). This study found that there is some effectiveness of basic body awareness therapy in improving some symptoms in outpatients with eating disorders; also, that it heightens the ability to get well, especially in preventing relapses.

            In a qualitative research study conducted by Rance, Moller, and Douglas (2010), seven female counselors who had recovered from eating disorder pasts participated in semi-structured interviews to examine countertransference experiences in relation to their body image, weight, and food pathology, their perceptions about the impact of such experiences and their beliefs about the effects of their own eating disorder history. The data collection involved interviews that allowed for the unique, personal experiences of the counselor while ensuring the areas of interest in the research project were covered. Data was analyzed by guidelines that focused on themes and connecting features; the identified themes were ordered in a master table and were: “double-edged history,” which characterized a common problem faced by the participants, “emphasis on normality”, which describes a strategy of normalization to overcome this problem, and the theme of “selective attention”, which illustrates a number of cognitive and attention strategies employed to enact this solution. “Double-edged history” illustrated the participants’ awareness of both the benefits and dangers of their eating disorder past. Results of this study shed light upon an unexplored aspect of the personal and professional experiences of eating disorder counselors with an eating disorder past. The three themes illustrate a complex interwoven triad of problem, solution and strategy. The results suggested that counselors; experienced their eating disorder as a positive and negative that led them to engage in a number of self-presentational activities.

            Many standard instruments of measure for eating disorders exist, such as the Eating Disorder Inventory and the Eating Disorder Examination, although rarely are they examined for applicability among specific populations. In an attempt to analyze the dimensionality of three versions of the Eating Disorder Inventory (EDI) in adolescent girls, García-Grau, Fusté, Mas, Gómez, Bados, and Saldaña, C (2010) conducted a study involving 738 female adolescents aged between fourteen and nineteen; the mean age was 15.91 years. The Spanish adaptations of the Eating Disorder Inventory-1, 2 and 3 were used to assess psychological, behavioral and affective characteristics related to eating disorders, although conceptual and structural changes exist between the factors of the EDI-3 and EDI-2. Goodness of fit and chi-squared tests were employed in analysis of the data. The results of this study indicated that the dimensional structure of the three versions of the Eating Disorder Inventory was not clearly confirmed, at least in this particular sample. However, the shortened version of the EDI-2 used in this study may be more suitable for use with adolescent girls in the general population than the original questionnaire.

            Sallet, Alvarenga, Ferrão, de mathis, Torres, Marquess, and Fleitlich-Bilyk (2010) executed a study to evaluate the prevalence and associated clinical characteristics of eating disorders in patients with obsessive-compulsive disorder (OCD) by comparing 815 patients with OCD in a cross-sectional study. The researchers had three hypotheses: that OCD patients with comorbid eating disorders would be more frequently women with early onset of illness and severity of symptoms, have higher prevalence and severity of contamination obsessions and cleaning compulsions, and show higher rates of comorbid impulse control orders and body dysmorphic disorder. Assessment was conducted via structured interviews with mental health professionals with experience working with OCD and via standardized instruments, such as the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Dimensional Yale-Brown Obsessive Compulsive Scale (DY-BOCS), Yale Obsessive-Compulsive Disorder Natural history Questionnaire, Brown Assessment of Beliefs Scale (BABS), Beck Depression and Anxiety Inventories, and the Clinical Global Impressions Scale (CGI); there were no self-report assessments.

Results indicated that ninety two patients (11.3%) presented the following eating disorders: binge-eating disorders (59, 7.2%), bulimia nervosa (16, 2.0%), or anorexia nervosa (17, 2.1%). Compared to OCD patients without eating disorders, comorbid OCD-eating disorder patients were more likely to be women with previous mental health treatment. Additionally, assessment scores were similar within groups; however, comorbid OCD-eating disorder patients showed higher lifetime predominance of comorbid conditions, higher anxiety and depression scores, and higher frequency of suicide attempts than did the OCD group without eating disorders. OCD-eating disorder patients may be associated with “higher clinical severity.”

            Persons with Borderline Personality disorder often struggle with poor self-esteem. In a unique study conducted by Zanarini, Reichman, Frakenburg, Reich, and Fitzmaurice (2010), researchers attempt to describe the longitudinal course of eating disorders in patients with borderline personality disorder. The Structured Clinical Interview for DSM-III-R axis I Disorders (SCID-1), the Revised Diagnostic Interview for Borderlines (DIB-R) and the Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R) were administered to 290 borderline inpatients and seventy-two participants with other axis II disorders during their index admission and at five contiguous two-year follow-up periods.  Participants had a mean GAF score of 39.8, indicating major impairment in several areas. Results of the study indicated that the prevalence of anorexia, bulimia and eating disorder not otherwise specified declined significantly over time for those in both study groups; however, the prevalence of eating disorder not otherwise specified remained significantly higher among borderline patients. Over 90% of borderline patients meeting criteria for one of the eating disorders experienced a stable remission by the time of the ten-year follow-up, although diagnostic migration was common. Additionally, both recurrences and new onsets of eating disorder not otherwise specified were more common among borderline patients than recurrences and new onsets of anorexia nervosa and bulimia.

            In a study assessing the quality of life, course and predictors of outcomes in community women with eating disorders not otherwise specified and common eating disorders, researchers (Hays, Buttner, Mond, Paxton, Rodgers, Quirk, & Darby, 2010) sought to describe the functional and symptomatic outcome these women. The researchers investigated the two-year course and supposed predictors of outcome of eighty-seven young community women with common eating disorders following a health literacy (informational) intervention; the health literacy intervention was provided randomly to half participants at baseline and half at one year. The instruments of assessment included the Eating Disorder Examination, the Short Form-12 Health Status Questionnaire, Kessler-10 for general psychiatric symptoms, and the Defense Style Questionnaire. During the follow-up assessments, researchers measured alcohol and substance misuse and distributed the Life Events Checklist to indicate if the participant has experienced a variety of life events over the last twelve months. Results of multiple linear regression analyses indicated that eating disorder psychopathology remained high and mental health quality of life remained poor. For multivariate models, a higher baseline level of immature defense style significantly predicted higher levels of eating disorder symptoms as well as poorer mental health quality of life. Also, in line with the research conducted by de la Rie (et al., 2005), women with common eating disorders followed to two years continued to be highly symptomatic and have poor quality of life.

            A similar study, conducted by Muñoz, Quintana, Hayas, Aguirre, Padiema, and González-Torres (2009) aimed to evaluate and compare the quality of life in patients with eating disorders and general population, using the disease-specific Health-Related Quality of Life for Eating Disorders (HeRQoLED) questionnaire. Participants consisted of 358 patients with eating disorders who, upon inclusion into the study, were sent three measurement instruments: the HeRQoLED, the Eating Attitudes Test (EAT-26) and the Short Form-12. Each patient took part in psychopharmacologic and psychotherapeutic treatment programs, and after one year of treatment and follow-up, the three questionnaires were sent again to the participants. Univariate analysis was performed to determine which variables were predictive of change in each of the HeRQoLED domains after one year of treatment, and general linear models were performed to establish variables for the multivariate analysis. Results indicated that patients with anorexia nervosa had higher baseline scores (indicating worse perception of quality of life on the HeRQoLED questionnaire and experienced smaller improvements that patients with other eating disorder diagnoses after one year of treatment. Body-mass index and EAT-26 scores were associated with changes in quality of life. Short Form-12 scores showed significant improvement in the physical component but not in mental health. Additionally, quality of life in patients with eating disorders improved after one year of treatment, though it did not reach the values of the general population.

            In the current study, the researcher wanted to understand the relationship and interactions between self-esteem, gender, and eating disorders. The objective was to replicate similar studies to determine if having low levels of self-esteem or self-worth contributed to the development of eating disorders and whether or not gender impacted the prevalence of eating disorders. It was hypothesized that students with high self-esteem were less likely to suffer from eating disorders, including binge eating, bulimia nervosa, and anorexia nervosa. The independent variable is self-esteem, which was measured by asking the student participants questions regarding their self-worth and feelings towards themselves. The dependent variables are the eating disorders: bulimia nervosa, anorexia nervosa and binge eating. Another hypothesis was that women are more likely than men to suffer from eating disorders, where gender is the independent variable, and suffering from an eating disorder is the dependent variable. Eating disorders were evaluated by asking the student participants questions about their eating, exercising, dietary habits, and experience with eating disorders. Body type was also evaluated by asking the participants to select one of the given categories on the survey for themselves and for members of their immediate family; the categories consist of different body shapes such as underweight, average, or overweight. The survey consists of fifty-three questions in total, including demographic information, Likert scales, the categorical response of body type, and yes or no questions. It was hypothesized that students that have or have had an eating disorder are more likely to report low levels of self-esteem and that women are more likely than men to suffer from eating disorder.

 

Method

Participants

A sample of 100 college students was randomly selected from a small, private, liberal arts college in the midwest. There were 45 males, 52 females, and 3 participants that did not report a gender. Participants included 21 freshmen, 29 sophomores, 23 juniors, 17 seniors, 2 students in their fifth year or more, and 8 participants that did not report their year in school. Participation was a convenience sample and participants had the choice to withdraw at any point in time. The classes in which the surveys were distributed were: Introduction to Psychology, Victorian English Literature, Introduction to Ethics, and Introductory Biology.

 

Materials

The survey was designed by the researcher with questions adapted from the Index of Self-Esteem (ISE) and consisted of a questionnaire using 53 close-ended questions, presented using constancy. The survey included questions about eating habits, the participants’ body shape, how the participants feel about themselves, and other items relating to experience with eating disorders. Other questions included demographic information, such as gender, year in school, and body type. All 100 surveys that were distributed were returned, which may aid in the validity of this research.

Procedure

            The surveys were distributed in classrooms based on a convenience sample. Participants were asked to complete every question of the survey and were instructed to ask the researcher if there were any questions. The questions referring to self-esteem and dietary habits were designed to measure how the participants feel about themselves (their perceived self-esteem) and whether or not their eating pathology predisposed them to weight concern or an eating disorder. The eating disorder items served to determine outright whether or not the participants had prior exposure to eating disorders either through their friends or personal experience. Surveys were completely anonymous; participants signed their initials and dated the consent form, which they handed in separately from the survey (see appendix). The survey was field tested in a classroom of psychology majors studying experimental psychology, revised, and was submitted to McKendree University’s Institutional Review Board along with the purpose of research, hypotheses, and an agreement to abide by ethical principles of research with human participants. It received Institutional Review Board approval, valid for one year until March 8, 2013, exempt from IRB review for its anonymity and data from consenting adult college students. Ethical guidelines outlined by APA were followed. Statistical tests conducted to analyze data include one-way ANOVAs, independent samples t-tests, and correlation analyses to determine results.

 

Results

Figure 1

Figure 2

 

Figures 1 and 2 show the results in using a one-way ANOVA to test whether gender has an impact on dietary habits. Results indicated no significant difference in dietary habits based on gender, F (1, 95) = 1.368, p = 0.245. Statistically, females were no more likely than males to endorse healthier eating patterns.


Figure 3

Figure 4

 

Figures 3 and 4 show the results in using a one-way ANOVA to test whether gender influences meal skipping in an effort engage in weight management. Results indicated a significant difference in meal skipping to engage in weight management based on gender, F (1, 95) = 6.130, p = 0.015. It was found that more often than males, females reported that they skip meals to engage in weight management.

Figure 5

Figure 6

 

Figures 5 and 6 show the results in using a one-way ANOVA to test whether gender has an impact on a person’s self-esteem. Results indicated a significant difference in self-esteem based on gender, F (1, 91) = 8.098, p = 0.005. It was found that females reported lower levels of self-esteem than did males.

Figure 7


Figure 8

 

Figures 7 and 8 show the results in testing the hypothesis that gender impacts an individual’s experience with eating disorders by using a one-way ANOVA. Results indicated a significant difference in experience with eating disorders based on gender, F (1, 94) = 4.301, p = 0.041. Statistically, females were more likely than males to report experience with eating disorders, including bulimia nervosa, anorexia nervosa, or binge eating.


Figure 9

 

Figure 10

 

            Figures 9 and 10 show the results in again testing the hypothesis that gender impacts an individual’s experience with eating disorders by using an independent samples T-test. The independent samples T-test analysis comparing scores for males and females on eating disorders indicated that female scores (M = 59.9, SD = 4.62) differed significantly from male scores (M = 57.4, SD = 6.82), t(94) = 2.074, p = 0.0205.


Figure 11


Figure 12

            Figures 11 and 12 show the results in testing the hypothesis that self-esteem is directly related to the development of an eating disorder by using a correlation analysis. A Pearson’s Bivariate Correlation found a significant relationship between self-esteem and eating disorders, (r = 0.329, p = 0.001). It was found that participants who reported higher self-esteem also reported less experience with eating disorders.

 

Discussion

            The current research study can relate to a significant amount of other studies that have sought to examine the interactions between self-esteem, gender, and eating disorders. This study stands out from the others in that it sought to examine the correlation between gender and self-esteem, gender and eating disorders, and self-esteem and eating disorders. Though no solution was found through the current study to diminish the prevalence of eating disorders, awareness of the correlations between self-esteem, gender, and eating disorders may prompt further research in finding how to improve self-esteem and minimize eating disorders among college students, especially females.

While intriguing results, implications, and correlations were found, limitations were present as well. One limiting factor that may have affected the results was the small, convenience sample size of participants, which did not allow for a full representation of all college students. A larger sample size across a wider spread of campuses would provide higher validity than did the current study. Additionally, the survey should have included further demographic information, such as age, for descriptive statistical purposes, and questions about the standard of body image regarding gender.

            The first prediction was that students with high self-esteem are less likely to suffer from eating disorders, including binge eating, bulimia nervosa, and anorexia nervosa. The results showed that there was a statistically significant difference in that those who reported higher self-esteem also reported less experience with eating disorders. This could be because those with a higher sense of self-worth may not have as many body image issues and may endorse a healthier eating pathology. Results of previous research studies (e.g. Ross & Wade, 2004) indicated that self-esteem and weight shape concern together accounted for about one-third of the variance in uncontrolled eating.  

            Another hypothesis that was presented prior to research was that women are more likely than men to suffer from eating disorders. The results indicated a statistically significant relationship between gender and eating disorders, where females rated themselves lower for self-esteem and were more likely to report experience with an eating disorder than did males. This could be because society and the media instill a higher standard of body shape and image in females at a young age than in males, which becomes impressed in how they view themselves as adults. Many females struggle with body image expectations throughout their lifetime, which may lead to the development of specific eating and exercise pathologies.

            It is worth noting that although both hypotheses were supported, results indicated no significant difference in dietary habits based on gender. The significant results of the current study may lead to new directions for this research in the future. Perhaps further studies will begin to explore the impact of gender and body expectations on self-esteem and eating disorders in the college population. Subsequent research could lead to a greater understanding of the factors that influence gender-specific body expectations, self-esteem, and eating disorders; this could result in efforts to improve self-esteem and minimize eating disorders among college students, especially those that are female. There are many dangers related to eating disorders and low self-esteem, especially during college, when students seem to be more vulnerable and critical of themselves. The current study is intriguing and can most certainly add validity to previous research and also advance towards new findings in the future.

 

  

References

Aruguete, M. S., Edman, J. L., & Yates, A. (2012). The Relationship between Anger and other Correlates of Eating Disorders in Women. North American Journal Of Psychology, 14(1), 139-148.

Bardone-Cone, A. M., Schaefer, L. M., Maldonado, C. R., Fitzsimmons, E. E., Harnby, M. B., Lawson, M. A., & … Smith, R. (2010). Aspects of Self-Concept and Eating Disorder Recovery: What Does the Sense of Self Look Like When an Individual Recovers from an Eating Disorder?. Journal of Social & Clinical Psychology, 29(7), 821-846.

Catalan-Matamoros, D., Helvik-Skjaerven, L., Labajos-Manzanares, M., Martínez-de-Salazar-Arboleas, A., & Sánchez-Guerrero, E. (2011). A pilot study on the effect of Basic Body Awareness Therapy in patients with eating disorders: a randomized controlled trial. Clinical Rehabilitation, 25(7), 617-626.

De la Rie, S. M., Noordenbos, G., & van Furth, E. F. (2005). Quality of Life and Eating Disorders. Quality of Life Research, Vol. 14.

García-Grau, E., Fusté, A., Mas, N., Gómez, J., Bados, A., & Saldaña, C. (2010). Dimensionality of three versions of the eating disorder inventory in adolescent girls. European Eating Disorders Review, 18(4), 318-327.

Green, M. A., Scott, N. A., Cross, S. E., Liao, K., Hallengren, J. J., Davids, C. M., & ... Jepson, A. J. (2009). Eating disorder behaviors and depression: a minimal relationship beyond social comparison, self-esteem, and body dissatisfaction. Journal of Clinical Psychology, 65(9), 989-999.

Hay, P., Buttner, P., Mond, J., Paxton, S. J., Rodgers, B., Quirk, F., & Darby, A. (2010). Quality of life, course and predictors of outcomes in community women with EDNOS and common eating disorders. European Eating Disorders Review, 18(4), 281-295.

Hesse-Biber, S., Marino, M., & Watts-Roy, D. (1999). A Longitudinal Study of Eating Disorders among College Women: Factors That Influence Recovery. Gender and Society, Vol. 13.

Jun, T., Jing, S., Jian, W., Hong, Z., Shu Fang, Z., Xiao Yan, W., & Hsu, L. (2011). Validity and reliability of the Chinese language version of the eating disorder examination (CEDE) in mainland China: Implications for the identity and nosology of the eating disorders. International Journal Of Eating Disorders, 44(1), 76-80.

Katsounari, I. (2009). Self-esteem, depression and eating disordered attitudes: A cross-cultural comparison between Cypriot and British young women. European Eating Disorders Review, 17(6), 455-461.

Mond, J. M., Peterson, C. B., & Hay, P. J. (2010). Prior use of extreme weight-control behaviors in a community sample of women with binge eating disorder or subthreshold binge eating disorder: A descriptive study. International Journal Of Eating Disorders, 43(5), 440-446.

Muñoz, P. P., Quintana, J. M., Hayas, C., Aguirre, U. U., Padierna, A. A., & González-Torres, M. A. (2009). Assessment of the impact of eating disorders on quality of life using the disease-specific, Health-Related Quality of Life for Eating Disorders (HeRQoLED) questionnaire. Quality Of Life Research, 18(9), 1137-1146.

Rance, N. M., Moller, N. P., & Douglas, B. A. (2010). Eating Disorder Counsellors With Eating Disorder Histories: A Story of Being 'Normal'. Eating Disorders, 18(5), 377-392.

Roberto, C. A., Grilo, C. M., Masheb, R. M., & White, M. A. (2010). Binge eating, purging, or both: Eating disorder psychopathology findings from an internet community survey. International Journal Of Eating Disorders, 43(8), 724-731.

Ross, M., & Wade, T. D. (2004). Shape and weight concern and self-esteem as mediators of externalized self-perception, dietary restraint and uncontrolled eating. European Eating Disorders Review, 12(2), 129-136.

Sallet, P. C., de Alvarenga, P., Ferrão, Y., de Mathis, M., Torres, A. R., Marques, A., & ... Fleitlich-Bilyk, B. (2010). Eating disorders in patients with obsessive–compulsive disorder: Prevalence and clinical correlates. International Journal Of Eating Disorders, 43(4), 315-325.

Tchanturia, K., Troop, N. A., & Katzman, M. (2002). Same pie, different portions: shape and weight-based self-esteem and eating disorder symptoms in a Georgian sample. European Eating Disorders Review, 10(2), 110-119.

Torres-McGehee, T. M., Monsma, E. V., Gay, J. L., Minton, D. M., & Mady-Foster, A. N. (2011). Prevalence of Eating Disorder Risk and Body Image Distortion Among National Collegiate Athletic Association Division I Varsity Equestrian Athletes. Journal Of Athletic Training, 46(4), 431-437.

Vocks, S., Stahn, C., Loenser, K., & Legenbauer, T. (2009). Eating and Body Image Disturbances in Male-to-Female and Female-to-Male Transsexuals. Archives Of Sexual Behavior, 38(3), 364-377.

Zanarini, M. C., Reichman, C. A., Frankenburg, F. R., Reich, D., & Fitzmaurice, G. (2010). The course of eating disorders in patients with borderline personality disorder: A 10-year follow-up study. International Journal Of Eating Disorders, 43(3), 226-232.

 

 

  

APPENDIX A

Read this consent form.  If you have any questions ask the experimenter and

She will answer your questions.

 

“I have read the statement below and have been fully advised of the procedures to be used in this project.  I have been given sufficient opportunity to ask any questions I had concerning the procedures and possible risks involved.  I understand the potential risks involved and I assume them voluntarily.”

 

 

Please sign your initials, detach below the dotted line, and continue with the survey.

 

Sign your initials here_________________                                                      Date__________

 

 

  

----------------------------------------------------------------------------------------------------------------------------------------

 

  

The McKendree University Psychology Department supports the practice of protection for human participants participating in research and related activities.  The following information is provided so that you can decide whether you wish to participate in the present study.  Your participation in this study is completely voluntary.  You should be aware that even if you agree to participate, you are free to withdraw at any time, and that if you do withdraw from the study, your grade in this class will not be affected in any way.  This survey is being conducted to assist the researcher in fulfilling a partial requirement for PSY 496W.

 

 

You must be over 18 years of age to participate in the survey.  It should not take more than 10 minutes for you to complete and will be completely anonymous and confidential.  If you should have any other questions, don’t hesitate to contact me, Cassandra Fremder, 618-830-7052 or at cbfremder@mckendree.edu, or Dr. Bosse, 618-537-6882 or at mbosse@mckendree.edu.  Some of the questions in the survey may confront sensitive topics.  If answering any of these questions causes you problems or concerns, please contact one of our campus psychologists, Bob Clipper or Amy Champion-Stahlman, at 537-6503.

 

 

 

 

 

Rev. 3/31/09

APPENDIX B

 

STUDENT SURVEY

Gender: Male _____  or  Female ­­­_____

 

Year in School:  Freshman       Sophomore       Junior       Senior       5th Year or more

 

1. Please indicate your family’s body builds with an X. (Use additional X’s for multiple siblings.)

Underweight                  Average                Overweight

                Mother:                    _____                              _____                        _____   

                Father:                      _____                              _____                        _____   

                Sister(s):                   _____                              _____                        _____   

                Brother(s):               _____                              _____                        _____   

                Self:                            _____                              _____                        _____   

 

Please respond to numbers 2- 45 based on the following scale: 

1 - Never

2 - Almost Never

3 - Rarely

4 - Sometimes

5 - Frequently

6 - Almost Always

7 – Always

 

(Please circle only one.)

2. I snack with healthy food.

1                              2                              3                              4                              5                              6                              7

          Never                   Almost Never                Rarely                    Sometimes                Frequently              Almost Always                Always

 

3. I count calories.

1                              2                              3                              4                              5                              6                              7

 

4. I rely on other people to feel good about myself.

1                              2                              3                              4                              5                              6                              7

 

5. I exercise on a regular basis.

1                              2                              3                              4                              5                              6                              7

 

6. I am on a diet/dieting.

1                              2                              3                              4                              5                              6                              7

 

7. I feel good about myself.

1                              2                              3                              4                              5                              6                              7

 

8. I eat a lot of vegetables.

1                              2                              3                              4                              5                              6                              7

 

9. I depend on others for attention.

1                              2                              3                              4                              5                              6                              7

          Never                   Almost Never                Rarely                    Sometimes                Frequently              Almost Always                Always

 

10. I worry about my appearance.

1                              2                              3                              4                              5                              6                              7

 

11. I eat a lot of junk food.

1                              2                              3                              4                              5                              6                              7

 

12. I eat breakfast.

1                              2                              3                              4                              5                              6                              7

 

13. I eat at least three balanced meals a day.

                1                              2                              3                              4                              5                              6                              7

 

14. I worry about my weight.

                1                              2                              3                              4                              5                              6                              7

 

15. I feel as if I am in control of my decisions and actions.

                1                              2                              3                              4                              5                              6                              7

 

16. I feel healthy.

                1                              2                              3                              4                              5                              6                              7

 

17. I feel dependent on others.

                1                              2                              3                              4                              5                              6                              7

 

18. I think that I am a dull person.

                1                              2                              3                              4                              5                              6                              7

 

19. I like my body.

                1                              2                              3                              4                              5                              6                              7

 

20. I am concerned if other people like my body.

                1                              2                              3                              4                              5                              6                              7

 

21. I drink beer or alcohol.

                1                              2                              3                              4                              5                              6                              7

 

22. I eat a lot of fruit.

                1                              2                              3                              4                              5                              6                              7

 

23. I consume drinks high in sugar.

                1                              2                              3                              4                              5                              6                              7

 

24. I smoke.

                1                              2                              3                              4                              5                              6                              7

          Never                   Almost Never                Rarely                    Sometimes                Frequently              Almost Always                Always

 

25. I feel that people would not like me if they really knew me well.

                1                              2                              3                              4                              5                              6                              7

 

26. When I am with other people, I feel they are glad I am with them.

                1                              2                              3                              4                              5                              6                              7

 

27. I feel that I am a very competent person.

                1                              2                              3                              4                              5                              6                              7

 

28. I think I make a good impression on others.

                1                              2                              3                              4                              5                              6                              7

 

29. I feel that I need more self-confidence.

1                              2                              3                              4                              5                              6                              7

 

30. I stare into mirrors and windows to see what I look like.

                1                              2                              3                              4                              5                              6                              7

 

31. I believe that other people are staring at me when I walk into a room.

                1                              2                              3                              4                              5                              6                              7

 

32. I would say I am obsessed with what my body looks like.

                1                              2                              3                              4                              5                              6                              7

 

33. I have confidence in myself.

                1                              2                              3                              4                              5                              6                              7

 

34. I am confident about my body.

                1                              2                              3                              4                              5                              6                              7

 

35. I have high self-esteem.

                1                              2                              3                              4                              5                              6                              7

 

36. I like what I see when I am looking in a mirror.

                1                              2                              3                              4                              5                              6                              7

 

37. I have skipped meals before to engage in weight management.

                1                              2                              3                              4                              5                              6                              7

 

38. I feel that others have more fun than I do.

                1                              2                              3                              4                              5                              6                              7

 

39. I think I have a good sense of humor.

                1                              2                              3                              4                              5                              6                              7

          Never                   Almost Never                Rarely                    Sometimes                Frequently              Almost Always                Always

 

40. I feel very self-conscious when I am with strangers.

                1                              2                              3                              4                              5                              6                              7

 

41. I am afraid I will appear foolish to others.

                1                              2                              3                              4                              5                              6                              7

 

42. I think my friends find me interesting.

                1                              2                              3                              4                              5                              6                              7

 

43. I binge eat.

                1                              2                              3                              4                              5                              6                              7

 

44. If so, I feel guilty after binge eating.

                1                              2                              3                              4                              5                              6                              7

 

45. I engage in purging (throwing up) after meals to help with weight management.

                1                              2                              3                              4                              5                              6                              7

 

 

Please respond to numbers 46- 51 based on the following scale: 

1 - Strongly Disagree

2 - Disagree

3 - Slightly Disagree

4 - Neither Agree nor Disagree

5 - Slightly Agree

6 - Agree

7 - Strongly Agree

 

(Please circle only one.)

46. I think I may have a problem with binge eating.

1                              2                              3                              4                              5                              6                              7

   Strongly Disagree                                                                                                                                                                     Strongly Agree

 

47. I think I used to have a problem with binge eating.

1                              2                              3                              4                              5                              6                              7

 

48. I think I may have a problem with anorexia nervosa.

                1                              2                              3                              4                              5                              6                              7

 

49. I think I used to have a problem with anorexia nervosa.

                1                              2                              3                              4                              5                              6                              7

 

50. I think I may have a problem with bulimia nervosa.

                1                              2                              3                              4                              5                              6                              7

   Strongly Disagree                                                                                                                                                                     Strongly Agree

 

51. I think I used to have a problem with bulimia nervosa.

                1                              2                              3                              4                              5                              6                              7

 

 

Please circle one.

52. I have/had friends with bulimia nervosa.

                YES                         NO

 

53. I have/had friends with anorexia nervosa. 

                YES                         NO

 

 

 

 

 

 

THANK YOU FOR COMPLETING THIS SURVEY.

 

 

 

 

 

Survey questions adapted from the Index of Self-Esteem (ISE)