Self-image in females with eating disorders

A research article in the BMC journal maps a 12 month outcome in females with Eating Disorders, extending previous findings. May 2019.


The interpersonal Structural Analysis of Social Behavior (SASB) model of self-image has repeatedly proven valuable in relation to eating disorder (ED) symptoms and in predicting ED outcome.


We studied the association between initial self-image according to the SASB and 12-month outcome, in five diagnostic groups of female ED patients. Based on previous findings, we expected autonomy related variables (self-control/autonomy) would strongly predict outcome in anorexia nervosa (AN) groups, whereas variables related to affiliation (self-attack/love) would moderately predict outcome in bulimia nervosa (BN).


Participants were adult female patients, of whom 457 had AN restrictive type, 228 AN binge/purge subtype, 861 BN, 505 other specified ED and 170 binge eating disorder. Data came from the Stepwise clinical database in Sweden. Outcomes were presence/absence of ED diagnosis and self-rated ED symptoms, and we controlled for baseline ED pathology, BMI, age and general psychiatric symptoms.


Regression analyses showed that although the pattern differed somewhat between diagnostic groups, high initial self-love and low self-attack/self-blame predicted a more positive 12-month outcome. In some groups (AN/R in particular), these variables remained important even when baseline pathology and age were included in the analyses.


Self-image aspects once again display substantial power in predicting outcome in EDs. In AN/R patients, self-love plays an almost as crucial a role as baseline ED pathology in relation to 12-month outcome.

Plain English summary

In eating disorders, research has found that self-image, or the way a person treats him- or herself, is important for becoming, remaining, or ceasing to be ill. This study looked at whether eating disorder patients’ self-image at the start of treatment could inform about how successful treatment was likely to be at a second measurement after 12 months. A large sample of 2221 patients from a clinical database participated, with various types of eating disorder diagnosis. We found that most important for a good outcome were high self-love and low self-attack and self-blame. There were some differences between diagnoses but the basic pattern was fairly consistent. We conclude that self-image is important and informative for the outcome of eating disorders, and that for some patients in particular (who have anorexia nervosa, especially of the restrictive subtype), self-image may be of central importance even compared to eating disorder symptoms themselves.


In order to tailor treatment efforts, predictors of treatment outcome in the different eating disorders (ED) need to be studied. In recent years, psychological and interpersonal functioning have attracted increasing attention as potential risk- and/or maintaining factors in ED [1,2,3]. Self-esteem is commonly researched in relation to ED, and findings suggest that high and low self-esteem decreases vs. increases risk of ED, respectively [4,5,6]. The idea that interpersonal difficulties may influence the development and/or maintenance of ED via an adverse effect on self-esteem [5] has gained partial support [7]. However, global self-esteem concerns only the evaluative component of self-worth, and higher specificity may be attained using more multifaceted conceptualizations of self-image. The interpersonal Structural Analysis of Social Behavior (SASB) self-image or introject captures both the evaluative component of self-esteem and self-directed actions [8], i.e. how one treats oneself as a result of interpersonal learning. It also has theoretical (and empirically supported) implications for interpersonal functioning: the self-image forms in early interactions with attachment figures and provides a template for subsequent interpersonal behavior as people tend to behave in ways to confirm their self-image, regardless of its quality [8,9,10]. SASB maps self-directed behavior around two dimensions in a circumplex, where Affiliation (love vs. attack) constitutes the horizontal dimension and Autonomy (control vs. autonomy) the vertical. The dimensional end points and their combinations form eight behavior “clusters” (see Fig. 1); e.g. self-love combined with autonomy-giving form behaviors such as being spontaneous and free to explore and accept one’s feelings, needs and wishes, whereas control combined with attack form excessive adherence to both internal and external rules, and harsh self-criticism.

Fig. 1

Previous research has shown that patients’ SASB self-image profiles are diagnostically distinct and significantly more negative than controls [11], and that negative self-image predicts poor outcome [12], treatment dropout [13] and suicidal behavior [14]. Also, we found strong associations between self-blame and inversely self-love/affirmation and ED symptoms, in several groups of female adolescent and adult ED patients, normal controls and non-treatment seeking but symptomatic women (anorexia nervosa [AN], bulimia nervosa [BN] and ED not otherwise specified [EDNOS]; [1516]. In adult BN patients, self-attack was also positively associated with ED symptoms.

In a study on outcome prediction of self-image among adult women with AN and BN, degree of self-love/self-attack moderately predicted outcome after three years in BN, whereas self-control powerfully predicted three year outcome in AN [17]. Adding baseline clinical characteristics in a second set of analyses, SASB overall had substantial impact on outcome over and above these. Predicting outcome from SASB alone tests whether initial self-image can be used as a prognostic tool and may suggest treatment implications connected to the SASB interpersonal model. It does not, however, exclude an influence of for example initial symptoms that affects theoretical interpretations. Adding clinically relevant baseline characteristics evaluates if the predictive power of SASB may be better explained statistically by such variables, but keeping in mind that they provide less clear indications for treatment course and for how to interact with patients in therapy than SASB variables do.

In summary, the SASB affiliation dimension seems important in BN for both initial symptom levels and outcome. For AN, self-blame and self-love/acceptance seem important for initial symptom levels, but for long-term outcome self-control was a stronger predictor. These associations need to be investigated using a shorter time-span to follow-up, and more importantly extended to include the ED diagnostic spectrum relevant to DSM-5 [18]. Examining a shorter time-span to follow up may give indications about which self-image aspects to focus for short-term treatment gains, thus complementing the long-term focus of the previous study. Including the entire ED diagnostic spectrum, as well as AN subgroups, is essential as previous research suggests that the pattern of associations may differ depending on symptom presentation [11, 16; 17]. This could have importance for future research regarding diagnostic classification, treatment interventions and outcome prediction.

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