the sense of personal ineffectiveness in patients with eating disorders: one construct or several?

The Sense of Personal ineffectiveness in Patients

with Eating Disorders: One Construct or Several?

Susan Wagner, Ph.D. Katherine A. Halmi, M.D. Thomas V. Maguire, Ph.D.

The sense of personal ineffectiveness in eating disorders was investigated as a complex construct referring to various aspects of functioning rather than as the unidi- mensional trait assumed by prior studies. Eighteen patients and 78 controls were given a number of measures in order to test for ineffectiveness from several per- spectives. The results indicated that patients with eating disorders experience a sense of ineffectiveness in many areas of their lives. Their more general attitudes about personal control appear to be dominated by their lack of control over their eating behavior. However, these patients also exhibit distinct and specific difficul- ties in the areas of socjal effectiveness, personal independence, and self-esteem. These findings support the notion that ineffectiveness in eating disorders is not a single attitudinal style but a complex construct referring to a range of behaviors.

The psychological portrait of eating disorder patients has highlighted a pro- found sense of "personal ineffectiveness" as one of the important bases for the development of this disorder (Bruch, 1973). There have been some recent studies of anorexia nervosa and "bulimarexia" patients that have attempted to ex- amine systematically the notion that these patients feel or see themselves as ineffectual. Hood, Moore, and Gamer (1982) compared females with anorexia nervosa, ages 15 to 25, to normal high school and undergraduate females. They noted that Locus of Control externality (a tendency to regard life events as more influenced by factors outside one's control than by one's own efforts)

Susan Wagner, Ph.D., is on the Voluntary Faculty in Psychology, Department of Psychiatry, Cornell University Medical Center. Katherine A. Halmi, PCD., is Professor of Psychiatry, Department of Psy- chology, Cornell University Medical Center. Thomas V. Maguire, Ph.D., is Adjunct Associate Professor of Psychology and Director, Center for Psychological Services, Teachers College, Columbia University. Address all correspondence and requests for reprints to Katherine Halrni, New York Hospital- West- Chester Division, 2 1 Bloorningdale Road, White Plains, N Y 10605.

hternational journal of Eating Disorders, Vol. 6 , No. 4, 495-505 (1 987) 0 1987 by John Wiley & Sons, Inc. CCC 0276-3478/87l040495-11$04.00

496 Wagner, Halrni, and Maguire

increased with age in their anorexia nervosa sample and contrasted this with reports that externality decreases with age among normal persons. Hood et al. also found that among the anorectic "externals" were the following character- istics: greater premorbid obesity, greater age but not more time being ill, and greater bulimic and purging behaviors, alcohol and cigarette use, and hetero- sexual activity. Interestingly, they discovered that "internals" were more prone toward denial of weight loss (which could be seen as denial of illness). These authors conclude that Locus of Control, although a useful assessment tool for eating disorder patients, does not provide a global measure of ineffectiveness for this patient population.

Using adolescent female populations, Strober (1982) studied "ineffectiveness" via Locus of Control in anorexia nervosa, conduct disorder, and de- pressed patient groups. He found greater internality among the anorectic patients than either of the other groups, and he also noted that his anorectic patients were more "internal" than reported means of normal subjects of similar ages. Within his anorexia nervosa sample those with more "external" scores showed more psychopathology on the Psychiatric Rating Scale for An- orexia Nervosa (Goldberg, Halmi, Eckert, Casper, Davis, & Roper, 1980), specifically in the areas of denial of illness, fear of fat, fear of compulsive eating, desire for control, and use of purgatives. Externals were also more likely to overestimate their body size. In both the Hood et al. and Strober studies, a lower sense of effectiveness was associated with more severe symptoms. Rost, Neuhaus, and Florin (1982) investigated sex-role-related ineffectiveness in bulimic patients and found bulimics to feel more ineffective in this area. The results of these studies may suggest that ineffectiveness/effectiveness is a significant dimension associated with eating disorders.

However, the designation of scores on Locus of Control that approximate the norm as indicators of "ineffectiveness" raises interesting questions about the relationship of this measure to the construct. Yet Locus of Control Scales seem to have some popularity as a test of personal ineffectiveness (see also Chambliss & Murray, 1979, in a study of obesity). These scales measure beliefs about the causes of various life events, such as effort (internal control) versus luck or chance (external control). The assessment of ineffectiveness in this way-or, indeed, with any single measure of vague construct validity-is un- likely to produce solid advances in understanding either the varieties of ineffectiveness or the psychology of anorexics.

In the present preliminary report a sense of ineffectiveness was measured with several scales in order to clarify the specific meanings, if any, of "ineffectiveness" in eating disorders. Scales were chosen to operationalize "ineffectiveness" in diverse ways: attitudinal, perceptual, and behaviorally oriented. Relationships among these measures of ineffectiveness and other psychological states were studied as well.

METHOD

Subjects

There were 18 patients who had been admitted to an inpatient unit for the treatment of eating disorders and who gave informed written consent to par-

Sense of Personal Ineffectiveness 497

ticipate in this study: nine were restricting anorexics, four were normal weight bulimics, and five were anorexics who binged and purged. All patients were single, Caucasian women who met DSM-I11 criteria for anorexia nervosa or bulimia. The mean age of this group was 17.8 years, with a standard deviation of 2.8.

High school students (n = 18) who did not have eating disorders partici- pated in this study as control subjects. If subjects had pathological scores on one of the measures (Eating Disorders Inventory), they were interviewed ac- cording to DSM-I11 criteria for anorexia nervosa or bulimia. One subject met the criteria for bulimia and was replaced by another. The mean age of this group was 17.3, with a standard deviation of 2.6.

Signed parental consent was obtained for all subjects. Patients and control subjects were tested by a research assistant.

Procedure and Measures

All subjects completed the following instruments (patients did so during

1. The Nowicki-Strickland Locus of Control Scale (1973) is a 40-item questionnaire for children and adults in which subjects agree or disagree with statements about the causes of typical life events.

2. The Eating Disorders Self-Efficacy Scale-created by us, using as a model a scale developed by Bandura, Adams, and Beyer (1977)-asked subjects to rate the confidence with which they could perform certain tasks having to do with "Social Efficacy" (part l), "Eating" (part 2), "Eating without Purging" (part 3)' and "Independence" (part 4). These are four areas in which eating disorder patients are presumed to have difficulty. Following Bandura, behaviors were listed in increments from easier to more diffi- cult. An example of an easy Social Efficacy item is "Can you call out to someone you know and stop and chat?" The Independence scale had two forms, one for those under age 18 and one for those 18 and above. An example of a relatively easy item is "Can you spend a night sleeping over at a friend's?" The Eating scale asked subjects if they could eat specific amounts of food and stop. Items began with very small amounts of food and progressed to normal amounts. The Eating without Purging section consisted of the same questions, but subjects were asked if they could eat those amounts of food without purging. The actual items for those 18 and over are listed in Table 1.

3. Witkin's Embedded Figures Test (Witkin, Oltman, Raskin, & Karp, 1971) consists of 12 simple, geometric figures that the subject sees one at a time and must then find within another complex design. This test yields a measure of "field dependenceiindependence" and was chosen because it is perceptual rather than attitudinal and may relate to a global orientation reflective of ineffectiveness/effectiveness.

4. The Eating Disorder Inventory (Gamer, Olmsted, & Polivy, 1984) is a 64- item questionnaire with 8 separate subscales.

In addition, two measures were included in the analysis that had been created by one of us (K.A.H.) and colleagues and administered to the patient

their first 2 weeks in the hospital):


Table 1. Eating disorders self-efficacy scales.

Part I Social Efficacy

For the tasks you can do here, check ( ) them in the column Can Do, if you expect you could

For the tasks you check under Can Do, indicate in the column Confidence how confident you are do them now.

that you could do them. Rate your degree of confidence by recording a number from 10 to 100 using the scale given below:

10 20 30 40 50 60 70 80 90 100

quite uncertain

moderately certain

veTy certain

Can Do Confidence -% -%

- -%

% %

6. Go out on a date %

1. Call out to someone you know and stop and chat 2. Sit with a group of classmates at school who ask you to join

them

asked you to join them 3. Sit with a group of classmates at school who have not specifically

4. Go to a party with a girlfriend 5. Strike up a conversation with strangers at a party

Part I1 Eating

You have a plate consisting of one cup of spaghetti with sauce. There is more food available. Check ( ) items which you could do if you were asked to do them now.

For the tasks you check under Can Do, indicate in the column Confidence how confident you are that you could do them. Rate your degree of confidence by recording a number from 10 to 100 using the scale given below:

10 20 30 40 50 60 70 80 90 100

quite uncertain

moderately certain

1. Eat one forkful of spaghetti and stop 2. Eat one-half cup of spaghetti and stop 3. Eat one cup of spaghetti and stop 4. Eat one cup of spaghetti and one-half scoop of ice cream and

5. Eat one and one-half cups of spaghetti and one scoop of ice stop

cream and stop

v e y certain

Can Do Confidence % % % %

Part I11 Eating without Purging

You have a plate consisting of one cup of spaghetti with sauce. There is more food available. Check ( ) items which you could do WITHOUT PURGING (taking laxatives or vomiting) if you were asked to do them now.

confident you are than you could do them. Rate your degree of confidence by recording a number from 10 to 100 using the scale given below:

10 20 30 40 50 60 70 80 90 100

For the tasks you check under Can Do without Purging, indicate in the column Confidence how

quite uncertain

moderately certain

v e y certain


Cqn Do without Purging Confidence

% % % %

%

1. Eat one forkful of spaghetti and stop 2. Eat one-half cup of spaghetti and stop 3. Eat one cup of spaghetti and stop 4. Eat one cup of spaghetti and one-half scoop of ice cream and

5. Eat one and one-half cups of spaghetti and one scoop of ice stop

cream and stop

Part IV Independence

For the tasks you can do here, check ( ) them in the column Can Do if you expect you could do

For the tasks you check under Can Do, indicate in the column Confidence how confident you are them now.

that you could do them. Rate your degree of confidence by recording a number from 10 to 100 using the scale given below:

10 20 30 40 50 60 70 80 90 100

quite uncertain

moderately certain

1. Can you select-clothes to buy without consulting a friend,

2. Can you stay alone in your home for an evening? 3. Can you go away for a weekend without your family? 4. Can you take a 2 week vacation without your family? 5. Can you take a 2 week vacation without your family and

6. Can you live away from your parents but in the same town? 7. Can you live away from your parents at a distance greater than

50 miles? 8. Can you live away from your parents at a distance greater than

50 miles and have telephone contact only once each month? 9. Can you live away from your parents at a distance greater than

600 miles? 10. Can you live away from your parents at a distance greater than

600 miles and have telephone contact only once every 2 months?

spouse, or your mother?

telephone them only 1 time?

vefy certain

Can Do Confidence %

-% % % %

% %

%

%

%

group only (also in the first 2 weeks of hospitalization) as part of another on- going investigation. These measures are

5. The Attitude Questionnaire (Halmi, Eckert, LaDu, & Cohen, 1986) is a 63- item self-report questionnaire in which subjects rate the extent to which they concur with a variety of attitudes. Ratings go from 1 to 4, with 1 being “not at all” and 4 “extremely.” Factor analyses of this questionnaire yielded four factors.

6. The Self Description Questionnaire (Halmi et al., 1986) consists of 35 items, 17 of which are adjectives that refer to how ”my body is right now” on a scale from 1 to 7, e.g., from “flabby” = 1 to ”not flabby’’ = 7, and 18 items that are adjectives that indicate how “my personality is right now,” e.g., “unlovable” to “lovable,” again on a sclae from 1 to 7. Factor analysis of this instrument yielded three factors.

500

RESULTS

Wagner, Halmi, and Maguire

Since the Eating Disorders Self Efficacy Scales were newly developed for this study, the split-half method of obtaining reliability coefficients was employed. The obtained coefficients were as follows: Eating Efficacy, .95; Eating without Purging, .95; Social Efficacy, 31; Independence, 32.

A comparison of the various measures of ”ineffectiveness” for the patient and control groups is shown in Table 2. Note that the scores on the Eating Disorders Self-Efficacy Scales were reversed, so that high scores represent “ineffectiveness” (or pathology), to match the pattern of the rest of the measures used.

As can be seen in Table 2, the four subscales of the Eating Disorders Self Efficacy Scale (Eating, Eating without Purging, Social Efficacy, and Indepen- dence), the I/E Locus of Control Scale, and the Ineffectiveness Factor of the Eating Disorders Inventory all discriminate between patient and control groups. The Embedded Figures Test (EFT), however, failed to discriminate between groups.

In order to determine (1) the degree to which these measures of ineffectiveness are tapping similar phenomena and (2) the relationship of these measures to other typical anorectic attitudes and states, the intercorrelations among all of the variables were computed for each of the two subject groups. The intercorrelations of “ineffectiveness” variables for the patient group are shown in Table 3.

A principle finding here is that from among the various “ineffectiveness” measures, the Eating and Eating without Purging subscales of the Eating Dis- orders Self-Efficacy Scale correlate significantly with each other. The Social Ef-

Table 2. Comparisons of eating disorder patients and controls on measures of ineffectiveness.

Variable Group n M SD Statistic

EDSES Eating Efficacf Patients 18 33.7 32.0 t(34) = 2.54,

EDSES Eating wlo Purging” Patients 18 36.7 38.8 t(34) = 3.77, Controls 18 11.8 18.0 p < .01

Controls 18 1.7 7.1 p < .001

Controls 18 9.5 14.7 p < .001

Controls 18 10.8 10.5 p < .01

EDSES Social Efficacf Patients 18 33.7 19.8 t(34) = 4.15,

EDSES Independence’ Patients 18 32.0 25.8 t(34) = 3.22,

N-S Locus of Controlb Patients 18 13.8 6.1 t(34) = 1.96, Controls 18 10.1 5.2 p < .05

Controls 18 6.9 5.0 NS

Controls 17 50.3 32.8 NS

ED1 Ineffectiveness‘ Patients 18 8.2 6.3 t(34) = 0.68,

Embedded Figures Testd Patients 17 54.4 36.1 t(32) = 0.35,

aEating Disorders Self-Efficacy Scales: scores are “percent ineffectiveness,” derived by subtract-

‘Nowicfi-Shickland Locus of Control Scale: scores are totals of items endorsed on the “external”

‘Eating Disorders Inventory Ineffectiveness Scale: scores are totals of items endorsed indicating

dEmbedded Figures Test: scores are averages of times (in seconds) required to detect each of 12

in avera e confidence percentages from 100%.

direction, with a maximum possible score of 40.

lack of effectiveness.

figures, with an arbitrary maximum per figure of 180 seconds.


Table 3. Intercorrelations of ineffectiveness measures in the eating disorder patient group. a

EATEFF E WIOP SOCEFF INDEP N-SUE EDI-I EFT

EATEFF - .92* .04 .01 .39 .02 -.24 E wlo P - - .05 - .19 .34 -.a -.33 SOCEFF - .a' .39 .29 -.14 INDEP - .56* .40 -.11 N-S UE - .22 -.lo ED14 - .14 EFT -

Note: EATEFF = EDSES Eating Efficacy; E wlo P = EDSES Eating without Purging; SOCEFF = EDSES Social Efficacy; INDEP = EDSES Independence; N-S UE = Nowicki-Strickland Locus of Control; EDI-I = Eating Disorders Inventory Ineffectiveness; EFT. = Embedded Figures Test. 'n = 17 for EFT, n = 18 for all other variables. * p < .01.

ficacy and Independence subscales also show a strong significant correlation with each other but appear quite independent of the two scales dealing with food behaviors. Therefore, for these patients, a sense of being out of control of one's behavior with food appears somewhat distinct from a sense of ineffectiveness in other areas of life. The I/E Locus of Control scale also correlates significantly with the Independence subscale, suggesting that IIE is more sen- sitive to issues of effectiveness in non-food-related matters. The Embedded Figures Test and the Ineffectiveness factor of the ED1 yielded no significant correlations. The other scales appear to be measuring unrelated aspects of what has been seen as "ineffectiveness".

The intercorrelations of the same variables in the control group are shown in Table 4. In this group, the Eating Efficacy subscale of the Eating Disorders Self- Efficacy Scale correlates significantly with the Social Efficacy subscale as well as with the VE Scale. In addition, the Social Efficacy subscale also correlates significantly with I/E as well as with the Ineffectiveness scale of the EDI. In other words, a sharp demarcation of areas of ineffectiveness does not appear.

The ability of the Eating Disorders Self-Efficacy Scales to discriminate among the three diagnostic subgroups of patients was tested by one-way ANOVA,

Table 4. Intercorrelations of ineffectiveness measures in the control group.=

EATEFF E WIOP SOCEFF INDEP N-SUE EDI-I EFT

EATEFF - .03 .72* .01 .54* .39 - .14 E wlo P - .31 - .14 - .01 .30 - .06 SOCEFF - - .23 .6T .58* - .12 INDEP - - .15 .17 .19 N-S I/E - .18 - .21 EDI-I - .ll EFT -

Note: EATEFF = EDSES Eating Efficacy; E wlo P = EDSES Eating without Purging; SOCEFF = EDSES Social Efficacy; INDEP = EDSES Independence; N-S YE = Nowick-Strickland Locus of Control; EDI-I = Eating Disorders Inventory Ineffectiveness; EFT = Embedded Figures Test.

' n = 17 for EFT; n = 18 for other variables. * p < .01.


the results, together with results on two additional variables with significant F ratios, are presented in Table 5.

There was a significant difference by diagnosis on EDSES Eating Efficacy, principally accounted for by the especially poor scores of the anorectic bulimic (Mixed) group (t[15] = 2.62, p < .05). The differences among groups on Eating without Purging pointed to a better performance by the restricting anorexics (t[15] = 2.32, p < .05). Social Efficacy clearly separated the subgroups, indicating that the restricting anorexics and those with mixed symptomatology experienced much more difficulty in this area than the normal weight bulimics (t[15] = 3.51, p,.Ol), with the latter actually indistinguishable from controls. The Independence scale yielded only suggestive differences but with a contrast exactly parallel to Social Efficacy. The ED1 Bulimia Scale, as one might expect, yielded higher scores by the two groups that binge than by the restricters (t[15] = 2.89, p,.05). Finally, the Fear of Fat Scale from the Attitude Question- naire singles out the group with mixed symptoms from the other two (t[15] = 3.27, p,.Ol).

The relationship of the measures of ineffectiveness to other eating disorder variables for the patient group are shown in Table 6. Only those variables that yielded at least one correlation significant at the p < .01) level are displayed.

Of the ineffectiveness measures presented so far, only the Eating and Eating without Purging subscales of the EDSES were highly correlated with other scales, namely the following: Perfectionism and Drive for Thinness (both from the EDI), Fear of Fat (from the Attitude Questionnaire), and Anorectic Body Image (from the Self-Description Questionnaire). Furthermore, the latter fac-

Table 5. Disorder Self-Efficacy Scales, the Fear of Fat Scale, and the Bulimia Scale.

Comparisons of the three categories of eating disorder patients on the Eating

Variable Group n M SD Statistic

EDSES Eating Efficacy" Anorectic Bulimic Mixedb

Bulimic Mixed

Bulimic Mixed

Bulimic Mixed

Bulimic Mixed

Bulimic Mixed

EDSES Eating wlo Purging" Anorectic

EDSES Social Efficacy" Anorectic

EDSES Independence" Anorectic

ED1 Bulimia' Anorectic

ATQ Fear of Fatd Anorectic

9 19.1 29.6 4 30.0 33.8 5 63.0 12.9 9 17.3 32.4 4 47.5 49.9 5 62.8 24.8 9 41.3 17.9 4 9.3 14.0 5 39.4 10.6 9 40.3 26.5 4 8.0 7.7 5 36.2 25.0 9 2.6 4.5 4 12.3 6.2 5 9.0 7.8 9 29.2 5.8 4 30.5 6.5 5 39.2 2.6

F(2,15) = 4.23, p < .05

F(2,15) = 2.97, p < .10

p < .01

p < .10

F(2,15) = 6.43,

F(2,15) = 2.75,

F(2,15) = 4.34, p < .05

F(2,15) = 5.99, p < .05

"Eating Disorders Self-Efficacy Scales: scores are "percent ineffectiveness," derived by subtract-

h i x e d = anorectic bulimics. 'Eating Disorders Inventory Bulimia Scale; scores are totals of items endorsed. dAttitude Questiopnaire Fear of Fat Scale: scores are totals of items endorsed.

in average confidence percentages from 100%.


Table 6. Scales of the ED1 in the patient group (n = 18).

Intercorrelations of Eating, Eating without Purging, Fear of Fat, and Selected

EATEFF EwIoP ATQ-FF EDI-B EDI-DT EDI-IA EDI-P EDI-I

EATEFF - .92* E wlo P - ATQ-FF EDI-B EDI-DT EDI-IA EDI-I’ EDI-I

- .60* .58* .39 .28 .25 .02 .59* .56* .35 .30 .23 .06 - .4T* .53* .62* .31 .52**

- .54* .574 .72* .24 - ,76* .69* .59*

- .64* .63* - .51**

Note: EATEFF = EDSES Eating Efficacy; E wto P = EDSES Eating without Purging; ATQ-FF = Attitude Questionnaire Fear of Fat Scale; EDI-B = Eating Disorder Inventory Bulimia Scale; EDI- DT = Eating Disorder Inventory Drive for Thinness Scale; EDI-IA = Eating Disorder Inventory Interoceptive Awareness Scale; EDI-P = Eating Disorder Inventory Perfectionism Scale; EDI-I = Eating Disorders Inventory Ineffectiveness Scale.

* p < .01. **p < .05.

tors correlate highly with one another in the patient group and thus form a kind of “eating disorder cluster.” Data on the “cluster” variables were not available for the control group.

DI SCU SSI 0 N

These preliminary findings may shed some light on the phenomenon of ”ineffectiveness” in eating disorders. Eating disorder patients reported a sense of ineffectiveness in both attitudes and behavior (although they did not demon- strate it in perceptual style). Their attitudes about control over typical life events, their predictions of control over eating behaviors, and their confidence in their social skills and self-reliance all indicated lower levels of personal effectiveness than did those of controls.

However, for these patients, ineffectiveness in dealing with food appeared to be independent of ineffectiveness in the other areas, whereas social effectiveness and independence were moderately related to each other. In fact, the Eating and Eating without Purging scores of patients correlated most closely with Fear of Fat (Attitude Questionnaire) scores and Bulimia (EDI) scores than with any of the other ineffectiveness measures. Externality, a tendency to expect that one’s own efforts and skills will contribute little to life’s events, seems more closely related to lack of confidence in one’s capacity for self reliance than to any other construct. Looking into other areas of ineffectiveness gives little information about how ineffective eating disorder patients feel in relation to food.

On the other hand, for the control subjects, confidence about eating was related to confidence in social skills. (Note that control scores on Eating without Purging were so invariably low that low correlations with all other measures were inevitable.)

In general, the notion that a sense of ineffectiveness is a global experience appearing in many spheres of life may hold for those who do not have an


eating disorder but seems highly improbable for those who do. Even though eating disorder patients feel less effective in a number of ways than nonpa- tients (a statement that might hold for patients of many kinds), their sense of ineffectiveness in managing food remains a distinct issue that may trouble most those who fare best in other areas of life. In the present sample, this phenomenon is represented particularly by the four bulimic patients, who, although in moderate difficulty with eating control and more with purging, ex- hibited as much social confidence and sense of independence as the control subjects.

The Embedded Figures Test was used here as a cognitive/perceptual measure that tests the capacity to interpret stimulus situations from an autonomous perspective rather than passively responding to whatever structure the situations provide. Its failure to discriminate between eating disorder patients and controls suggests that “ineffectiveness” in eating disorders probably does not derive from a predisposing perceptual “style.”

Finally, the ability of the EDSES to discriminate among diagnostic groups should be addressed. The group of anorectic bulimics reported the greatest ineffectiveness with food, the restricting anorexics the least. It would seem that bingeing and purging behaviors produce more experienced loss of control than simple restricting behavior. Such a finding seems consistent with reports that restricting anorexics view their behavior not as symptomatic, but as evidence of will power, whereas bulimics tend to feel shame at repeating acts that they cannot control (Gamer & Garfinkel, 1984). On the other hand, both restricting anorexics and anorectic bulimics report the greatest deficits in the social and independence areas, whereas the normal weight bulimics compare well with controls.

These results suggest caution in conceptualizing “ineffectiveness” in eating disorders from a global perspective. “Ineffectiveness” can refer to such a broad range of attitudes and behaviors that its usefulness as a single researchable construct is doubtful. Clearly, the small size of the samples taken thus far in this study (especially in relation to the number of variables examined) also suggests caution. Nonetheless, the results highlight a theoretical issue that has been ignored: discriminating between a sense of ineffectiveness that is a general attitudinal style and one that is specific to the problems associated with eating disorders.

We gratefully acknowledge the assistance of Trish Gallegher in the data collection.

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the sense of personal ineffectiveness in patients with eating disorders: one construct or several?

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