Journal of Consulting and Clinical Psychology1982, Vol. 50, No. 1, 3-13

Copyright 1982 by the American Psychological Association, Inc.0022-006X/82/5001-0003S00.75

Locus of Control as a Measure of Ineffectivenessin Anorexia Nervosa

Jane Hood and Timothy E. MooreGlendon College, York University, Toronto,

Ontario, Canada

David M. GarnerClarke Institute of Psychiatry, Toronto,

Ontario, Canada

Using Reid and Ware's (1974) multidimensional Internal-External Locus ofControl Scale (I-E scale), scores of female anorexia nervosa patients (n = 54)were compared to norms. Younger anorexic patients (M age = 16,3) demon-strated higher internal control compared to norms on items related to fatalismand social-system control, I-E scores for older patients (M age = 21.2) couldnot be differentiated from the norms. Comparison of high (external) with low(internal) scorers within the patient sample revealed significant differences onclinical variables related to weight history, eating habits, and psychosocial be-havior. In addition, externality was associated with symptomatic scores on theBeck Depression Scale, the Eysenck Personality Questionnaire, the RestraintScale, and the Sixteen Personality Factor Questionnaire. It is concluded that theI-E scale may provide a useful prognostic index for the subgroup of anorexicpatients who demonstrate external I-E orientation.

Anorexia nervosa is classified as a psy-chosomatic disorder on the basis of its char-acteristic psychological symptoms, whichoften precede the onset of dieting. Bruch(1973) has outlined three central areas ofpsychological dysfunction in anorexia ner-vosa. These are (a) a distorted body image,(b) inaccurate perception of internal states,and (c) a paralyzing sense of ineffectiveness.Body-size overestimation and lack of aver-sion to sucrose have been demonstrated ex-perimentally (Garfinkel,- Moldofsky, Gar-ner, Stancer, & Coscina, 1978; Garner,Garfinkel, Stancer, & Moldofsky, 1976).The dimension of ineffectiveness, in contrast,has received limited empirical attention.Clinically, it has been described in devel-opmental terms.

Minuchin, Rosman, and Baker (1978)describe the anorexic child as growing up ina highly "enmeshed" family, one in whichintrusive concern and overprotection by theparents curtail the development of auton-omy. Similar descriptions, with specific ref-erence to the power and control exerted bythe mother, are common in the clinical lit-

Requests for reprints should be sent to Timothy E.Moore, Department of Psychology, Glendon College,York University, 2275 Bayview Avenue, Toronto, On-tario, Canada M4N 3M6.

erature. The mother is described as "pro-gramming" the child (Bruch, 1973), as un-able to see her daughter as separate (Selvini,1974), and as subverting fulfillment of thechild's needs by emphasizing her own senseof what is appropriate (Bemis, 1978). Thesepatterns of interaction inhibit the develop-ment of self-directed behavior and result ina child of "robot-like" obedience (Bemis,1978). Underlying this obedience to parentalexpectations, however, are feelings of self-doubt and an inability for self-assertion. Theanorexic feels that she has no will of her ownand cannot initiate or influence things in anysignificant way (Selvini, 1974).

It is not surprising, then, that anorexianervosa has its onset during adolescence, aperiod of accommodation to new social ex-periences and to the biological changes ofmaturation (Crisp, 1977a). In the healthyadolescent, this stage of development rep-resents a time of psychological growth.Through extrafamilial experience, the child'sperception of her parents and family is ul-timately changed, and she begins to developa sense of identity and independence (Min-uchin et al., 1978). The anorexic has beeninadequately prepared for such a challengeand finds these new ways of acting strangeand frightening (Bruch, 1977). The onset ofanorexia can be viewed as a maladaptive

J. HOOD, T. MOORE, AND D. GARNER

defense against feelings of ineffectivenessand as a struggle for control (Bruch, 1973).

Various interpretations of the adolescent'schoice to starve herself have been made(Bruch, 1977, 1978; Crisp, 1977b; Selvini,1974; Sours, 1969). All interpretations im-ply that feelings of ineffectiveness are a cen-tral dimension of the anorexic personality.Yet, individual case histories and clinicalintuition are not satisfactory bases for es-tablishing theories. Several authors havecommented on the lack of research in thisarea and have stressed the need for objectivepersonality measurement (Kay, Shapira, &Brundan, 1967; Smart, Beaumont, &George, 1976). Garner, Garfinkel, and Mol-dofsky (1978) referred specifically to theneed for an adequate measure of the inef-fectiveness dimension. An earlier study byGarner, Garfinkel, Stancer, and Moldofsky(1976), which found a positive correlationbetween body-image disturbance and exter-nal locus of control, suggests that the inter-nal-external (I-E) construct may be relatedto feelings of ineffectiveness in anorexia ner-vosa.

Gilmor (1978) found that parental be-havior, particularly that of the mother, is animportant antecedent of locus of controlorientation. Several studies have reportedthat adolescent females who perceive theirmothers as providing low control and littleprotectiveness score more internally on I-Emeasures than do females who perceive theirmothers as exerting high control (Levensen,1973; Scheck, 1978). Levensen (1973) sug-gests that warm, accepting families raisetheir daughters to believe that they should ^be dependent and that a more rejecting homeenvironment may encourage independence.Maternal attitudes that appear to influencelater internality include early independenceexpectancies, less intrusiveness, and sugges-tive, rather than directive, interaction. Theseattitudes are in direct contrast to those de-scribed for anorexics' mothers and suggestthat external I-E orientation may be char-acteristic of patients with anorexia nervosa.

A closer examination of clinical differ-ences within the anorexic population, how-ever, suggests that the externality hypothesismay not be generalizable to all patients.

There are several means by which anorexicsbring about weight loss. Some emaciatethemselves solely by food abstention and ex-cessive exercise. These patients are referredto as dieters or restricters. Another groupof anorexics, known as bulimics, continue toconsume large quantities of food but are ableto control their weight through self-inducedvomiting and purgation. The importance ofthis distinction, which may be related to dif-ferences in psychopathology, also centers onissues of control. Whereas the dieter dem-onstrates considerable self-discipline and de-nial, the bulimic is often described as fluc-tuating between an intense sense of self-control and loss of control (Garfinkel, Brown,& Darby, 1981). It seems reasonable to con-clude that the bulimic continues to experi-ence feelings of ineffectiveness and that therestricter has been successful in her searchfor self-control. Whether or not externalcontrol is characteristic of the entire anor-exic population or tends to be confined to aspecific clinical subgroup (i.e., bulimics) isan empirical question that demands furtherattention.

The primary purpose of our investigationwas to determine the usefulness of the I-Econstruct in measuring feelings of ineffec-tiveness in anorexia nervosa. Using a mul-tidimensional I-E scale, scores of anorexianervosa patients were compared to norms.A further goal of the study was to elucidatemeaningful psychometric and clinical cor-relates of the ineffectiveness dimension, bycomparing internal and external scorerswithin the patient sample. The literature in-dicates that other personality dimensions,such as depression and neuroticism, are re-lated to feelings of ineffectiveness and pat-terns of dieting in anorexia nervosa.

MethodSubjects

Female anorexia nervosa (AN) patients referred tothe Clarke Institute of Psychiatry from 1976 to 1979served as subjects in this study. Diagnostic criteria werethose specified by Feighner et al. (1972). All clinicaland psychometric data were obtained during each pa-tient's initial assessment.

Because normative I-E data were gathered separatelyfor high school and university students, the AN samplewas divided into two groups matched for age and ed-

LOCUS OF CONTROL IN ANOREXIA NERVOSA

ucational status. Percentage of average weight was cal-culated using Canadian female average weights for ageand height. Patient demographic data are shown in Ta-ble 1.

All female AN patients between the ages of 15 and25 were included in the comparison of internal and ex-ternal scorers within the patient sample. A median cut-off procedure for total I-E scores was used to delineatethe two groups. High scorers (externals) represented thetop 50% of the distribution, and low scorers (internals),the bottom 50%. Additional comparison data for thesetwo groups are presented in the Results section.

NormsI-E norms for high school students were obtained

through the Health Sciences Department at the Uni-versity of Waterloo. The norms represent a random sam-ple of females in Grades 9 through 12 (n = 425; Mage = 16.34).

I-E scores for female undergraduates were obtainedfrom the Psychology Department at York University(« = 44). Age of subjects was not available.

The I-E ScaleThe I-E Scale is a 45-item forced-choice question-

naire. Thirty-two of the items offer the subject an al-ternative between internal or external interpretations ofvarious events. The remaining 13 items serve as buffers.External responses are scored as 1 and internal responsesasO.

The I-E scale is a modified version of Rotter's (1966)scale and has been cross-validated and factor analyzedby Reid and Ware (1973, 1974). It yields three factorsin addition to the total score: the Fatalism factor (12items), which measures the degree to, which the subjectperceives luck or fate as controlling life events; SocialSystem Control (12 items), which measures perceivedpersonal versus sociopolitical control over the environ-ment; and Self-control (8 items), which .indicates howmuch control the individual feels over his or her im-pulses, desires, and emotions. The three factor scoresare summed to give the total score.

In the present investigation, a factor analysis of I-Eitems was not possible because individual item, scoreswere not coded in the AN sample. However, in order

Table 1Patient Demographic Data

to determine the relative independence of the three fac-tors, Pearson product-moment correlation coefficientsbetween factors were calculated. The r values were com-parable to those obtained by Reid and Ware (1974),which indicates that the factors were reasonably inde-pendent for the present sample. Reid and Ware (1974)reported a test-retest reliability of .76 for the I-E scale,with similar reliability across factors.

Comparison MeasuresHigh (external) and low (internal) scorers within the

patient sample were compared on clinical variables re-lated to weight, eating habits, and psychosocial behav-ior. In addition, correlational tests (Pearson /•) weremade between the I-E scale and the following psycho-metric indexes.

1. Beck Depression'Scale. Several of the symptomcategories measured by this scale relate to attitudes ob-served in AN (e.g., sense of failure, body image, guilt).

2. Body Image. This measure assesses body-sizeperception using a distorting lens technique. The subjectviews a self-photograph projected through a variableanamorphic lens and is asked to adjust the image to herperceived, body size and to her "ideal" body size.Amount of distortion is scored in percentage units rang-ing from -20 (constricted image) to +20 (expandedimage). Body-image distortion is characteristic of mostAN patients and has been found to correlate with otherobjective measures of psychopathology (Garner et al.,1978).

3. Eating Attitudes Test (EAT). The EAT is a 40-item self-report scale that measures a broad range ofbehaviors and attitudes observed in AN. The EAT hasbeen found to successfully differentiate AN patientsfrom normal and obese subjects (Garner & Garfinkel,1979).

4. Eysenck Personality Questionnaire (EPQ). TheEPQ is a 90-item self-report inventory that measurespersonality on dimensions of neuroticism and extraver-sion. Garner et al. (1978) reported a correlation betweenbody-size overestimation and both introversion and neu-roticism on the EPQ. Similarly, Smart et al. (1976)found anorexics to be significantly more neurotic andintroverted compared to Eysenck Personality Inventorynorms.

5.- Sixteen Personality-Factor Questionnaire (16PF).

Group 1 (« = 31)High school students

Group 2 (n = 23)Undergraduates

Patient data M SD M SD

Age (years) 16.3Weight (kilograms) 39,8% of average weight 69.3Duration of illness (months) 17.2

1.586.709.76

15.73

21.244.676.431.7

1.799.86

14.9825,48

Note. 1 kg = 2.2 Ibs.

J. HOOD, T. MOORE, AND D. GARNER

Several factors on the 16PF may be useful in measuringsymptomatic personality traits in AN. Of particular in-terest with regard to I-E differentiation are factors re-lating to emotional lability, self-confidence, interper-sonal dependency, and self-control.

6. The Restraint Scale. The Restraint Scale is a 10-item questionnaire designed to measure dieting behaviorand eating habits. High scorers, or restrained eaters,are individuals who experience weight fluctuation, goon eating binges in solitude, and feel guilty after over-eating. Unrestrained eaters (low scorers) have a stableweight and give little thought to food or dieting. Polivy,Herman, and Warsh (1978) reported that the scale suc-cessfully differentiates obese subjects and normal-weightdieters from nondieters.

Results

I-E Comparison to Norms

Results of the /-test comparisons of ANI-E scores with norms are presented in Table2. In the younger group (Group 1), total,Social System Control and Fatalism scoreswere significantly lower than the norms,which indicates greater internal controlamong anorexic subjects. No difference wasobtained between groups for scores on theSelf-control factor.

In the older group (Group 2), total, SocialSystem Control and Fatalism score differ-ences were in the expected direction (i.e.,higher than the norms), but none of thesedifferences reached statistical significance.Means for the Social System Control factorwere identical in the two groups.

Examination of I-E scores obtained for thetwo anorexic age groups revealed that I-Escores were higher in the older group. Thisincrease in externality with age was observedacross the entire anorexic sample, r(\09) =.31, /x.OOl,1 and did not correlate withduration of illness. The implication of thisfinding is that age of onset and (presumably)duration of premorbid conflict are meaning-fully related to external I-E orientation inAN. In view of the facts that the normativescores did not show a similar relationshipand that the literature reports an increasein internality with age among normals (Gil-mor, 1978), the age distribution of I-E scoreswithin the anorexic sample is noteworthy.

Internal and External AN ComparisonThe median of the total I-E scores ob-

tained for AN subjects was 15.5. All subjects

scoring above 15 were designated as high(external) scorers, and those with a score of15 or less were classified as low (internal)scorers.

Clinical Features

Demographic and weight-history compar-isons of internal and external anorexics arepresented in Table 3. External subjects were,on the average, a year older than internalsubjects, t(ll) = 2.20, p < .03, but did notdemonstrate a significantly longer durationof illness. Weight histories revealed that in-ternal subjects had achieved a significantlylower minimum body weight, based on per-cent of average weight, compared with ex-ternals, f (77) = 2.12, /><.04. Althoughexternal subjects had higher maximumpremorbid weights and weighed more thaninternals at presentation, these differenceswere not significant.

Premorbid obesity in adolescence, definedas S: 120% of average weight, was more prev-alent among externals (16.4% vs. 6.5%), anda history of obesity in childhood significantlydifferentiated the two groups, x2U) = 5.88,p < .01. In addition, early menarche, whichhas been reported to correlate with amountof body fat (Crisp, 1977a), was about threetimes more common in externally controlledsubjects.

Significant findings for food-related andpsychosocial behaviors are presented in Ta-bles 4 and 5. Variables described on an or-dinal scale of frequent, regular, or occasionalrefer to engagement in a given behavior ona daily, weekly, or monthly basis, respec-tively.

The incidence of self-initiated dieting wassignificantly higher among internal subjects(92% vs. 70%), x2(0 - 6.8,p < .02. Externalsubjects more often reported that onset ofdieting was encouraged by parents or peers.Externals were more inclined than internalsto eat snacks regularly, x2(0 = 4.40, p <.05, although meal patterns were similar inthe two groups. Over twice as many exter-nals as internals induced vomiting on a fre-

1 This r was calculated on all anorexics for whom ageand I-E scores were available, hence df = 109.

LOCUS OF CONTROL IN ANOREXIA NERVOSA

Table 2Comparison of Patient I-E Scores to Norms

I-E scalecomponent

Anorexia nervosagroup Norms

M SD M SD

SelfsscFate

Total

4.555.843.13

13.52

High school students

2.312,602.164.37

5.006.984.95

16.93

1.982.251.934.18

-1.39-2.78*-5.20**-4.55**

University undergraduates

SelfSSCFate

Total

5.527.265.48

18.26

2.152.823.556.68

5.526.844.47

16.83

1.912.752.886.54

1.00.61

1.31.87

Note. Self = Self-control; SSC = Social System Control; Fate = Fatalism. Homogeneity of variance was obtainedfor all comparisons. For the high school students (Group 1), n = 31 for the anorexia nervosa group; n = 425 forthe norms. For the university undergraduates (Group 2), « = 23 for the anorexia nervosa group; n = 44 for thenorms;' df = 454 for Group 1, and df = 65 for Group 2.* p < .05, two-tailed. ** p < .001, two-tailed.

quent or regular basis, x2( 1) = 7.60, p < .01,and bulimia and laxative abuse were about20% higher in the external group. Moderateto marked denial of weight loss, which isassociated clinically with lack of insight, wasmore characteristic of internal subjects,X2(l) = 4.20,><.01.

Table 5 presents significant findings re-lated to psychosocial behavior. Differencesbetween the two, groups may, in part, reflect

the difference noted earlier for age. How-ever, in view of the facts that the mean agedifferential was only 1.4 years and that allsubjects included in this comparison were atleast 15 years old, the psychosocial findingsmerit some attention.

External subjects were found to use al-cohol on a frequent or regular basis signif-icantly more often than internal subjects,X2(l) = 5.17, p < .05, and a higher percent-

Table 3Demographic Data and Weight History

Internal(n = 43)

External(n = 36)

Patient data M SD M SD P<

Age (years)Duration of illness

(months)Maximum weight (%

of average)Minimum weight (% of

average)Weight on presentation

(% of average)

19.0

30.1

103.0

63.8

70.8

3.2

26.2

18.0

11.0

15.0

20.4

37.1

108.6

69.1

76.3

2.6

30.8

16.1

11.3

14.1

2.20

1.07

1.48

2.12

1.64

.03

ns

ns

.04

ns

Note. 77.

8 J. HOOD, T. MOORE, AND D. GARNER

Table 4Significant Clinical Features of Internal Versus External Anorexics: Food-Related Behavior

Food-related behavior

Reason for dietingSelf motivatedOthers (e.g., parents, peers)

Eat snacksFrequent-regularNever-occasional

Bulimic episodesFrequent-regularNever-occasional

Self-induced vomitingFrequent-regularNever-occasional

Laxative useYesNo

Denial of weight lossModerate-markedAbsent-slight

% ofinternal(« = 43)

91.98.1

8.391.7

35.164.9

24.375.7

24.375.7

77.222.8

%ofexternal(« = 36) X

2

69.8 6.0830.2

26.8 4.4073.2

54.0 2.7046.0

54.6 7.6045.4

41.9 2.7458.1

45.2 4.2064.8

.02

.05

.10

.01

.10

.01

Note. df=\.

age of external subjects (60% vs. 33%) weresmokers, x2U) = 5.87; p < .02.

Level of education indicated that the ma-

jority of external subjects had either grad-uated from or were enrolled in a university,whereas two thirds of the internal subjects

Table 5 'Significant Clinical Features of Internal Versus External Anorexics: Psychosocial Behavior

Psychosocial behavior

Alcohol useFrequent-regularNever-occasional

Cigarette useYesNo

Grade levelUniversityHigh school

Level of achievementExcellent/above averageAverage/failing

Heterosexual involvementIsolationSteady relationships

% ofinternaln = 43

5.694.4

33.366.7

33.366.7

85.314.7

69.530.5

% ofexternaln = 36 x

2

24.4 5.1775.6

61.0 5.8739.0

60.4 5.7839.6

60.1 2.7430.9

41.1 2.7258.9

P<

.05

.02

.02

.10

.10

Note. < / /= ! .

LOCUS OF CONTROL IN ANOREXIA NERVOSA

had not yet finished high school, x2( 1) =5.78, p < .02. In addition, internal subjectswere described as excellent or above averagestudents more often than externals. Al-though heterosexual involvement was moreprevalent among externals, over 60% of thesubjects in both groups reported that theydid not engage in sexual intercourse.

Psychometric Data

Results of psychometric correlations arelisted in Table 6. Also shown are mean testscores for internals and externals, respec-tively. The value given in parentheses besideeach test name represents a symptomaticcut-off score for that specific test. The group«s vary for different measures because notall subjects received all tests. The reportedrs represent correlations between I-E scores

and the various psychometric test scores, Alow r would indicate a weak relationshipbetween I-E orientation and the dimensionin question. Pearson r values of .40 orgreater, obtained at a minimum probabilityof .005, were considered to be clinicallymeaningful. Although many of the correla-tions between I-E scores and comparisonmeasures were significant, in some casesmean scores for both internal and externalanorexics were within normal limits.

I-E orientation correlated signficantly withscores on the Beck Depression Scale, r(45) =.64, p < .001, and the mean score for exter-nal subjects was well above the cut-off. In-ternal subjects' scores, on the other hand,did not indicate a symptomatic level ofdepression.

Both groups of subjects tended to over-estimate their body size on the body-image

Table 6Psychometric Test Score Differences Between Internal and External Anorexics

Internal External

Psychometric test M SD M SD df P<

Beck Depression Scale(>15) 16.6 12.4 16 29.4 13.7 29 .64 45 .001

Body image (% deviation)(>±10) 3.1 10.5 35 3.7 11.1 44 .11 79 ns

Ideal body image 50 15.3 35 -2.5 13.5 45 , .31 80 .003

EAT(>30) 48.4 26.1 ' 18 59.5 22.7 24 .33 42 .02

EPQExtraversion(<13) 14.5 2.9 20 12.1 5.3 31 -.57 51 .001Neuroticism(>ll) 15.5 6.0 18.5 4.5 .53 .001Lie (>5) 8.6 4.4 7.2 4.4 -.21 ns

Restraint Scale (> 17) 20.2 6.1 30 23.8 5.2 39 .44 69 .001

16 PF bipolar scales (<5 or >6)(Low score description)

C—Affected byfeelings 5.4 2,1 17 3.9 2.5 27 -.62 44 .001

H—Shy 5.8 1.9 4.7 2.7 -.52 .001L—Trusting 5.3 2.0 7.0 2.3 , .41 .003O—Self-assured 6.5 2.6 8.;1 2.6 .55 .001Q3—Undisciplined self-

conduct 5.8 1.8 3.9 2.0 -.52 .001Q4—Relaxed 5.5 2.4 7.9 2.2 .56 .001

Note. Values in parentheses are symptomatic cut-off scores for specific tests, EAT = Eating Attitudes Test; EPQ =Eysehck Personality Questionnaire; 16 PF = Sixteen Personality-Factor Questionnaire. Letters preceding the 16PF bipolar scales are the factor labels used by the authors of the 16 PF.

10 J. HOOD, T. MOORE, AND D. GARNER

test, although the degree of deviation fromzero was minimal. In estimating ideal bodysize, however, internal subjects tended toexpand their image, whereas external sub-jects showed a negative deviation from ac-tual body size, r(80) = .31, p < .003.

On the EPQ, both introversion and neu-roticism increased with externality, r(51) =.57 and -.53, respectively, p < .001. In bothgroups, neuroticism scores were above thecut-off. Scores for extraversion were symp-tomatic for the externals only—indicatinggreater introversion for this group. The EPQlie scale did not correlate significantly withI-E, but lie scores for internal and externalswere above the norm, indicating some degreeof dissimulation in both groups.

Restraint Scale scores correlated with I-E, K69) = .44, p < .001, indicating that ex-ternal subjects are more restrained in theireating habits compared with internals. EATscores did not correlate highly with I-E, al-though both groups of subjects had meanscores well above the cut-off.

Only those correlations between I-E andthe 16PF that reached significance are listedin Table 6. Externality was associated withhigher levels of emotional lability, r(44) =-.62, p < .001, suspiciousness, r(44) = .41,p < .003, insecurity, r(44) = .55, p < .001,undisciplined self-conflict, r(44) = -.52, p <.001, and tenseness, K44) = .56, p < .001.Although I-E also correlated'with the "shy-ness" factor (-.52), the mean score for ex-ternals was only slightly below the cut-offand therefore was not considered symptom-atic. For all factors, internals' scores werewithin normal limits.

To summarize the results of the psycho-metric correlations: Externality was gener-ally associated with more symptomatic testscores. External subjects were found to bemore depressed on the Beck DepressionScale and more neurotic and introverted onthe EPQ. External subjects also obtainedsomewhat higher scores on the RestraintScale. Scores for the 16PF test that wereassociated with externality included emo-tional lability, suspiciousness, insecurity, un-disciplined self-conflict, and tension. In ad-dition, scores for external subjects on all ofthe above measures were beyond recom-mended cut-off scores.

Discussion

The results of our study indicate that ex-ternal I-E orientation is not a global char-acteristic of patients with anorexia nervosa.Rather, externality was found to increasewith age, and high scores were associatedwith specific clinical symptomatology andpersonality measures. The significantly lowerI-E scores compared to norms noted in theyounger age group were unexpected, al-though Strober (in press) recently made asimilar observation.

Schlegel and Crawford (1976) suggestedthat differences between university and highschool students' cognitions of internality-ex-ternality are related to differences in sociallearning experiences. It is possible that thelack of opportunity for high school studentsto test out control expectancies would beparticularly acute for anorexia nervosa pa-tients. Clinical descriptions have suggestedthat the anorexic is unable to separate herown learning experiences from the mother'ssignals and actions (Selvini, 1974). Perhapsin younger patients, individual control hasnot yet been differentiated from control ex-erted by the mother. This line of reasoningwould also account for the increase in ex-ternality noted for older anorexic patients.When the environment encourages the ad-olescent to define personal control expectan-cies, as would be the case upon separationfrom the family, the anorexic's lack of in-ternal resources is severely tested.

Internal control expectancies have alsobeen found to correlate with higher levels ofachievement, social influence, and socialclass (Gilmor, 1978; Lefcourt, 1966). Thefact that these variables could not be con-trolled for in matching the anorexic patientsto norms may have confounded the study'sfindings. Indeed, over 60% of the presentsample were from Social Classes I and II(Hollingshead's Index), which consist largelyof professionals, executives, and large busi-ness proprietors. The greater discrepancybetween anorexics' I-E scores and norms inthe high school group than among universitystudents may reflect a better matching ofsocial class and achievement expectations inthe latter group.

Internal and external comparisons within

LOCUS OF CONTROL IN ANOREXIA NERVOSA 11

the patient sample yielded a variety of sig-nificant findings suggesting that the I-E scalemay provide a useful diagnostic and prog-nostic tool in the assessment of patients withanorexia nervosa. Although there is an in-herent danger in delineating groups of sub-jects on the basis of psychometric scores,since any error attributable to test-takingstrategy will presumably affect the resultson comparison measures as well, the numberand magnitude of clinical variables that alsodiff6rentiated the two groups suggest thatthe distinction between internal and externalanorexics is valid.

Some of the clinical variables that differ-entiated the anorexics have also been foundto differentiate internal and external sub-jects in normal samples. For example,internal control was found to mediateachievement behavior (Gilmor, 1978). A re-lationship between externality and substanceabuse in adolescents was also reported(Schlegel & Crawford, 1978). Finally,Hersch and Schiebe (1967) found that in-ternals obtained higher scores than externalson measures of defensiveness and "achieve-ment via conformance," and that generally,externality related to measures of malad-justment.

The within-patient comparison, however,yielded other findings clearly related to dif-ferences in eating behavior. Many of thedifferences between internal and externalanorexics correspond to those obtained byBeaumont, George, and Smart (1976), whocompared dieters with bulimics.

Bemis (1978) reported that severe depres-sion is often associated with the binge-eatingpattern in anorexia nervosa. This, observa-tion is confirmed by the symptomatic scoresobtained by externals on the Beck Depres-sion Scale. The relationship between depres-sion and bulimia is no doubt a product ofthe eating pattern itself. Whereas the bu-limic may derive intense pleasure from gorg-ing on "forbidden" foods, once the binge hasended there are often feelings of shame andself-disgust (Boskind-Lodahl, 1976).

With regard to body image, the twogroups demonstrated an equivalent degreeof body-size overestimation. Garner et a).(1976) reported a significant correlation be-tween externality and body-image distur-

bance, although this finding was restrictedto scores on the Self-Control factor. Idealbody image in the present study indicatedthat internal subjects preferred to see them-selves as larger, whereas external subjectstended to constrict their images. Given thatthe degree of emaciation in the two groupswas equivalent at the time of testing, exter-nals demonstrated a more disturbed percep-tion of ideal body size.

Of the few studies that have objectivelymeasured the anorexic personality, the mostfrequently employed psychometric measurehas been the Eysenck Personality Inventory,or the more recent EPQ. In the presentstudy, both groups of subjects obtainedsymptomatic neuroticism scores, but neu-roticism increased with externality. Beau-mont (1977) found both dieters and vomitersand purgers to be more neurotic on the EPIcompared to normal controls, but no differ-ence between groups was obtained.

The failure to find a correlation betweenI*E and EAT scores was not surprising. Anequal number of items on the EAT apply tothe characteristic eating patterns noted forboth internal and external anorexics. Thequestions are generally directed toward mea-suring preoccupation with food and weightgain, symptoms that are pathognomic for allanorexics. The significant correlation ob-tained between I-E orientation and scores onthe Restraint Scale, however, demonstratesobjectively that, compared to internals, ex-ternal subjects suffer from greater weightfluctuation, loss of control, and feelings ofguilt.

The results obtained for the 16PF ques-tionnaire indicate a greater degree of emo-tional instability among external anorexics.Most of the 16PF factors that correlatedwith I-E relate to issues of control and lossof control. To use Gattell's terminology, ex-ternal anorexics were less stable and moreguilt prone, self-reproaching, and careless ofsocial rules. They followed their own urgesand were tense, frustrated, and overwroughtin comparison to internals.

The results of the psychometric correla-tions suggest that internally controlled an-orexics, although slightly neurotic, representa healthier group of patients. Indeed, thevomiting and purging pattern that was found

12 J. HOOD, T. MOORE, AND D. GARNER

to be most characteristic of external subjectshas been associated with poor prognosis inanorexia nervosa (Beaumont, 1977; Kalucy,Crisp, Lacey, & Harding, 1977).

The results of our study indicate that I-Eorientation may be influenced by the successwith which the anorexic is able to controlher weight. The greater psychological mor-bidity noted for external subjects on com-parison measures may as well reflect the con-flict experienced by patients who are inconstant fear of losing control. Anorexicswho resort to vomiting and purging havebeen described as less consistent than an-orexics who control their weight solely bydieting in regard to personality profile(Beaumont, George, & Smart, 1976), ashave external I-E scorers in general (Hersch& Scheibe, 1967).

In conclusion, the I-E scale does not pro-vide an adequate measure of ineffectivenessas a primary disturbance in patients withanorexia nervosa. Nevertheless, the value ofthe I-E scale as an assessment measureshould not be overlooked. It can provide auseful prognostic index for the subgroup ofpatients who demonstrate external controlorientation. Bruch (1973, 1977) criticizedthe use of both behavior modification andpsychoanalytic therapy in the treatment ofanorexia nervosa. Her objections are derivedfrom an etiological model that considers thedisorder as a desperate struggle for self-de-termination (Bemis, 1978). Thus, operanttherapy is seen as a form of "brutalcoercion," whereas interpretative methodsthreaten to reinforce the patient's experienceof being told what she feels and thinks. Bothstrategies, according to Bruch, only serve toconfirm the anorexic's sense of inadequacy.However, given recent evidence concerningthe relationship between locus of control andweight loss in obese subjects, Bruch's ar-gument may only be applicable to those pa-tients who already possess internal controlexpectancies with regard to their dieting.Chambliss and Murray (1979) obtainedgreater therapeutic success with obese pa-tients when there was a congruence betweenpersonal control expectations and the char-acteristics of the treatment situation. It ap-pears that therapeutic efficacy in anorexia

nervosa might improve with an alignment oftreatment modality with control orientation.

References

Beaumont, P. J. V. Further categorization of patientswith anorexia nervosa. Australia and New ZealandJournal of Psychiatry, 1977, //, 223-226.

Beaumont, P. J. V., George, C. C. W., & Smart, D. E."Dieters" and "vomiters and purgers" in anorexianervosa. Psychological Medicine, 1976, 6, 617-622.

Bemis, K. M. Current approaches to the etiology andtreatment of anorexia nervosa. Psychological Bulle-tin, 1978, 85, 593-617.

Boskind-Lodahl, M. Cinderella's stepsisters: A feministperspective on anorexia nervosa and bulimia. Signs,1976, 2, 343-356.

Bruch, H, Eating disorders. New York: Basic Books,1973.

Bruch, H. Psychological antecedents of anorexia ner-vosa. In R. A. Vigersky (Ed.), Anorexia nervosa. NewYork: Raven Press, 1977.

Bruch, H. The golden cage. Cambridge: Harvard Uni- 'versity Press, 1978.

Chambliss, C. A., & Murray, E. J. Efficacy attribution,locus of control and weight loss. Cognitive Therapyand Research, 1979, 3, 349-353.

Crisp, A. H. Some psychobiological aspects of adoles-cent growth and their relevance for the fat/thin syn-drome (anorexia nervosa). International Journal ofObesity, 1977, 1, 231-238. (a)

Crisp, A. H. The prevalence of anorexia nervosa andsome of its associations in the general population.Advances in Psychosomatic Medicine, 1977, 9, 38-47. (b)

Feighner, J. P., Robins, E., Guze, S. B., Woodruff,R. A., Winokur, G., & Munoz, R. Diagnostic criteriafor use in psychiatric research. Archives of GeneralPsychiatry, 1972, 26, 57-63.

Garfinkel, P. E., Brown, C. M., & Darby, P. L. Thepsychoendocrinology of anorexia nervosa. Interna-tional Journal of Mental Health, 1981.P, 162-193.

Garfinkel, P. E., Moldofsky, H., Garner, D. M., Stancer,H. C., & Coscina, D. Body awareness in anorexianervosa: Disturbances in "body image" and "satiety".Psychosomatic Medicine, 1978, 40, 487-498.

Garner, D, M., & Garfinkel, P. E. The Eating AttitudeTest: An index of the symptoms of anorexia nervosa.Psychological Medicine, 1979,9, 1-7.

Garner, D. M., Garfinkel, P. E., & Moldofsky, H. Per-ceptual experiences in anorexia nervosa and obesity.Canadian Psychiatric Association Journal, 1978, 23,249-263.

Garner, D. M., Garfinkel, P. E., Stancer, H. C., &Moldofsky, H. Body image disturbances in anorexianervosa and obesity. Psychosomatic Medicine, 1976,38, 327-336.

Gilmor, T. M. Locus of control as a mediator of adaptivebehavior in children and adolescents. Canadian Psy-chological Review, 1978, 19, 1-26.

Hersch, P. D. & Scheibe, K. E. Reliability and validityof internal-external control as a personality dimen-

LOCUS OF CONTROL IN ANOREXIA NERVOSA 13

sion. Journal of Consulting Psychology, 1967, 31,609-613.

Kalucy, R. S., Crisp, A. H., Lacey, J. H., ,& Harding,B. Prevalence and prognosis in anorexia nervosa. Aus-tralia and New Zealand Journal of-Psychiatry, 1977,11, 251-257.

Kay, D. W. K., Shapira, K., & Brundan, S. Early factorsin anorexia nervosa compared with control groups.Journal of Psychosomatic Research, 1961,11, 133-139.

Lefcourt, H. M. Internal versus external control of re-inforcement. Psychological Bulletin, 1966,65, 206-220.

Levensen, H. Perceived parental antecedents of internal,powerful others, and chance locus of control orien-tations. Developmental Psychology, 1973, 9, 260-265.

Minuchin, S., Rosman, B. L., & Baker, L. Psychoso-matic families, anorexia nervosa in context, Cam-bridge: Harvard University Press, 1978.

Polivy, J., Herman, C. P., & Warsh, S. Internal andexternal components of emotionality in restrained andunrestrained eaters. Journal of Abnormal Psychol-ogy, 1978/S7, 497-504.

Reid, D. W., & Ware, E. E. Multidimensionality ofinternal-external control: Implications for past andfuture research. Canadian Journal of BehavioralScience, 1973, 5, 264-271.

Reid, D. W., & Ware, E, E. Multidimensionality ofinternal versus external control: Addition of a thirddimension and non-distinction of self versus others.Canadian Journal of Behavioral Science, 1974, 6,131-142.

Rotter, J. B. Generalized expectancies for internal ver-sus external control of reinforcement. PsychologicalMonographs. 1966, 80 (1, Whole No. 609).

Scheck, D. C. An exploratory investigation of the in-teraction effects of three child rearing dimensionsupon the development of I-E orientation in adolescentfemales. Psychology, 1978, 15, 8-13.

Schlegel, R. P., & Crawford, C. A. Multidimensionalityof internal-external locus of control: Some additionaldata bearing on the validity of self-control as a thirddimension. Canadian Journal of Behavioral Science,1976,'S, 375-387.

Schlegel, R. P., & Crawford, C. A, Multidimensionallocus of control and drug use among high school stu-dents. Canadian Journal of Behavioral Science,1978, 10, 141-151.

Selvini, M. P. Self-starvation. London: Human ContextBooks, 1974.

Smart, D, E., Beaumont, P. J. V., & George, G. C. W.Some personality characteristics of patients with an-orexia nervosa. British Journal of Psychiatry, 1976,128, 57-60.

Sours, J. A. Anorexia nervosa: Nosology, diagnosis, de-velopmental patterns and power-control dynamics. InC. Caplan (Ed.), Adolescence: Psychological per-spectives. New York: Basic Books, 1969.

Strober, M. Locus of Control, psychopathology, andweight gain in juvenile anorexia nervosa. Journal ofAbnormal Child Psychology, in press.

Received February 23, 1981