CCC 0276-347818210203/49/8/2.00

A Comparison of Anorexics and Schizophrenics on

Psyc hod iag nost ic Measu res

Arnold Small’ Lorie Teagno2

James M a d e r ~ , ~ Howard Gross4 and Michael Eberts

ABSTRACT

Much controversy has existed concerning the nosological category to which primary anorexia nervosa belongs. In this study 27 hospitalized anorexic and schizophrenic females at NlMH were compared on two com- monly used psychodiagnostic measures, the Wechsler and Rorschach. Anorexics had higher IQ’s than schizophrenics. Specifically, with the excep- tion of similarities and vocabulary, anorexics showed a superiority on all sub- tests. On the other hand, anorexics, like schizophrenics, produced disturbed Rorshachs. The Delta Index means of the the two groups were not statistically significant and clearry reflected pathological thought organization. However, on specific Rorschach dimensions, anorexics produced more shading, achromatic color and whole responses which suggests greater organizing abilities and awareness of affectional needs and depression.

A unitary model of psychopathoiogy is criticized for insufficient descrip- tive and differentiating power, and a model is presented that allows for the measuring of levels of psychopathology. Based on general test considerations (e.g. differential response to degree of structure) and specific test findings (e.g. shading and achromatic responses, whole responses, Delta Index), it is proposed that anorexics have a number of features in common with border- line personalities. These similarities include proclivity toward disturbed thought processes, sensitivity to depression and affective needs but cognitive organization on structured tests.

‘George Mason University & Family and Child Development Services of Va Wniversity of Maryland 3-SNational Institute of Mental Health

‘Reprint requests to Arnold Small, Dept. of Psychology, George Mason University, 4400 University Dr., Farifax, VA 22030.

Vol. 1No. 3 49

A Comparison of Anorexics and Schizophrenics on Psychodiagnostic Measures

The nosological category to which anorexia nervosa belongs has been a con- troversial issue. It has been viewed as a syndrome associated with a wide vari- ety of psychopathology, including depression and schizophrenia (Bliss & Branch, 1960) while others feel that it is so distinct an entity that it should be considered separately from other psychiatric disorders (King, 1963; Feighner, 1972; APA, 1980). Specifically, anorexia nervosa has been postulated to be a psychotic process (Meyer & Weinroth, 1957; Escandes, et al, 1975), borderline constellation (Theilgaard, 1965) and neurotic disorder (traditionally consid- ered to be a variant of hysteria). Further confusion is reflected in Palazzoli’s hypothesis that anorexia represents a ”special defense structure midway be- tween schizo-paranoia and depression” (Palazzoli, 1974, p. 93).

The testing literature has not helped to clarify the issue as the contribution of psychodiagnostic testing to the diagnosis and treatment of anorexics has played a relatively unimportant role. Psychological testing with anorexics has been mainly preoccupied with a descriptive task of classifying anorexics ac- cording to personality dimensions such as hysteria (Wagner & Wagner, 1978), intellectual aloofness (Palmer, et al., 1952), obsessive-compulsive traits (Smart, et al., 1976) and depression (Sours, 1969). An exception to this is a study by Small, et al. (1981) which compared the MMPI profile configuration of a group of schizophrenics and anorexics. These authors found that the two groups were similar in that the same five clinical scales were either greater than or approached (for anorexics, the Pd score was 69.40) a T-score of 70 (although the order varied slightly). Because the variances were sometimes statistically significant, they indicated that despite the similarities amongst the groups, the samples may have been from different populations. An earlier study by Palazzoli (1971) found two types on the Rorschach: One group mani- fested disordered and pathological thinking while the other group did not. Roland (1970), also using projective tests, found strong depressive trends, body-image distortions, psychotic trends, poor ego-control, poor reality test- ing and strong feelings of isolation. In general, despite these findings, it is safe to conclude that psychodiagnostic tests have not provided nosological differ- entiation.

A resurgence of interest and research utilizing the Rorschach from an ego psychological model has stimulated innovative and evocative means of study- ing phenomena that may be differentiated on qualitative dimensions, such as object relations and representations, separation-individuation issues and levels of thought and affect organization (Kwawer, et al., 1980). This develop- ment has paralleled a shift in theoretical conceptualizations of anorexia from a model emphasizing psychosexual dimensions to ego weakness and interper- sonal disturbances (Bruch, 1973). This more recent model combined with-the few studies that demonstrate that anorexics perform poorly on some psychodiagnostic measures and show common features with psychotic in-

50 Int‘l Journal of Eating Disorders

dividuals, suggest that anorexia may be a borderline phenomena or, at the very least, share common developmental issues. Sugarman and Kurash (foot- note 1) propose that anorexics are arrested at the stage of transitional object development and that separation-individuation issues are at the core of anorexic pathology (Sugarman, et al., footnote 2). These same authors found that anorexics produced more contamination responses on the Rorschach than a normal control group reflecting fluidity in self-other boundaries. While Sugarman and his colleagues do not state that anorexia is a borderline phenomenon, deficiency in the use of transitional objects (Spiro and Spiro, 1980), core difficulties in separation-individuation and tenuousness of ego boundaries (Kernberg, 1967) are salient characteristics of the borderline personality.

This study compared hospitalized schizophrenics and anorexics on two commonly used psychodiagnostic measures. Since borderline personalities have been found to do well on structured tests but poorly on unstructured ones (cf. Weiner, 1966), anorexics were expected to show better cognitive organiza- tion on the Wechsler than schizophrenics, and were expected to exhibit defi- ciencies on the Rorschach, in areas such as in thinking processes. Because the literature provides no clues as to how anorexics and schizophrenics may com- pare on the Rorschach, either quantitatively or qualitatively, further specific hypotheses were not generated.

METHOD

Subjects and Procedure

Eighteen female schizophrenics (mean age 24.1) and 27 anorexic patients (mean age 20.6) participated. All were hospitalized at NIMH at the time of the study and were drug-free. Anorexics were diagnosed by the criteria of Feighner, Robins, Guze, Woodruff, Winokur and Munoz (1972). These in- clude: 1) age of onset prior to 30 years, 2) anorexia, i.e. accompanying weight loss of 25% of original body weight or 15% of ideal weight determined by Met- ropolitan Life Tables, 3) a distorted implacable attitude toward eating, food or weight that overrides hunger, admonition, reassurance and threats, 4) no known medical illness that could account for anorexia and weight loss, 5) no other primary psychiatric disorders with particular reference to primary affec- tive disorders and schizophrenia, 6) amenorrhea and 7) at least two of the fol- lowing manifestations: lanugo, bradycardia (persistent resting pulse of 60 or

'Sugarman, A. & Kurush, C. The body as a transitional object in anorexia nervosa. Paper presented at the an- nual meeting of thq American Psychological Association, Montreal September, 1980.

2Sugarman, A., Quinlan, D. & Devenes, L. Ego boundary and human representation disturbance in anorexia nervosa. Paper presented at the annual meeting of the Society for Personality Assessment, Scottsdale, Arizona, 1979.

less), periods of overactivity, episodes of bulimia and vomiting (may be self- induced). Schizophrenics were classified according to XDC criteria (Spitzer, 1975) after interviews with admitting psychiatrists. All subjects were adminis- tered the Rorshach and WAIS except 2 who took the WISC-R (object assembly was routinely not given). Administration was performed by the same psychol- ogist early in their hospitalization. Rorschach scoring was according to the method delineated by Klopfer, Ainsworth, Klopfer & Holt (1954). Standard tabulation according to Klopfer, et al. (1954) was violated because of the rela- tively infrequent appearance of certain shading and color responses (e.g. C' , C 'F, c, cF, k, kF, C). Therefore, the various shading and color responses were summed respectively. Movement responses were scored and tabulated accord- ing to standard procedure and were also summed into a composite score. Be- cause form was by far the most predominant aspect of shading or color re- sponses, combining the specific responses into composite shading and color scores did not seem to skew the data. Rorschach scoring (J.M. and L.T.) was 39 with subsequent agreement reached.

Because the phenomenon of anorexia nervosa is relatively rare in the population the small sample size precluded the use of a discriminant function analysis or multiple regression. The larger but ultimately important issue of prediction or classification must be held in abeyance at this time. With this in mind, the authors tried to determine whether difference in psychodiagnostic measures do indeed exist between these groups.

1

RESULTS

Analyses of variance of the Weschsler results indicated that anorexic pa- tients had significantly higher IQs (p C.05) (anorexics: FSIQ =108.9,

~ ~ ~~

TABLE 1. MEANS AND STANDARD DEVIATIONS ON THE WECHSLER

Information Comprehension Arithmetic Similarities Digit Span Vocabulary Digit Symbol Picture Completion Picture Arrangement Block Design Verbal Scale IQ Performance Scale IQ Full Scall IQ

ANOREXICS Mean __ S.D. 11.19 2.46 11.77 3.44 10.85 2.49 12.23 2.19 11.37 2.24 11.57 2.39 12.94 3.56 9.37 1.81

10.57 2.36 10.69 2.44

110.05 12.35 104.80 11.36 108.09 10.40

SCHIZOPHRENICS Mean S.D. -

9.35 2.98 9.31 3.52 7.37 3.21

11.31 1.97 9.56 3.58

11.05 3.77 9.05 2.74 7.33 2.40 8.36 3.00 8.16 3.25

98.88 14.92 90.01 14.09 94.81 14.71

F-Ratio 3.68* 5.46**

16.70- * 2.07 3.53* 2.52

15.04*** 9.28** 7.60'* 8.92** 6.81*'

13.65*** 11.25**

*p<:.O6 * * p c . o 5 ***p<.001

52 Int'l Journal of Eating Disorders

VIQ=llO.S, PIQ=104.80; schizophrenics: FSIQ=94.81, VIQ=98.88, PIQ =90.01). All subtests were significantly different except vocabulary and similarities and in every case, the anorexics had the higher mean (see Table 1 for means and standard deviations) indicating that they were brighter. Thus, anorexics can be differentiated from schizophrenics by higher 1.Q.s. Another possible explanation is that both groups have the same intellectual endow- ment, but that the schizophrenics show greater cognitive interferences. This is suggested by the vocabulary scores not being different. The vocabulary sub- test is the best estimate of general intelligence (g) and is most resistant to inter- fering effects (Matarazzo, 1972). At this time, though, it can safely be said that the intellectual abilities of anorexics are greater, whether it is a function of be- ing brighter or having fewer (if any) interfering factors than schizophrenics.

Rorschach Results

Because length of Rorschach protocol differed between the groups (anorex- ics, 25.4 responses; schizophrenics, 18.5 responses) length was covaried out on all the analyses involving Rorschach variables by all scores being converted to percentages. IQ was also covaried out. Raw scores and standard deviations can be found in Table 2. ANCOVAs were performed on location scores (W, D,

TABLE 2. MEANS AND STANDARD DEVIATIONS OF RIT DATA (BASED ON RAW SCORES)

W D S F M FM m Shading

*Fk= *k=

*kF= *FK= *KF = *Fc= *cF=

' C = Achromatic Color

* FC' *C'F

F+ % Color

Delta Index P

*frequencies t p 01

Schizophrenia Mean S.D.

5.93 3.22 9.70 4.40

.16 .38 11.88 5.71 2.20 1.91 1.91 1.97

.91 1.37

.33 .59 1 0 0 0 1 4 0 0 .26 .43

PAN Mean

9.51 11.72

.61 11.20

3.12 3.27 1.88 2.07 * 0. *O. *2. *9. *9.

*39. *5. *O.

.99

3 *21. 1 *5.

1.11 1.21 2.33 81.91 13.30 85.77 17.95 14,69 12.65 4.02 1.15 4.42

S.D. 5.73 8.67 1.10 5.63 2.89 2.94 2.40 2.18

1.15

3.09 18.38 11.29 1.64

F-Ratio 6.13t

.82 2.55

.24 1.54 2.91 2.32

10.54t

6.94t

2.54 .59

1.96 .61

Vol. 1 No. 3 53

d ) & determinants, F + 70 and Delta Index (scored according to the procedure of Watkins & Stauffacher, 1952). Shading, achromatic color and whole re- sponses were significantly different between the groups (p< .Ol), with anorex- ics having higher percentages. This indicates that the anorexic group shows greater awareness of affectional and emotional needs and dysphoric affect, as well as better integrating ability. Although the Delta Index, a research scale measuring pathological thinking, yielded no significant statistical differences, the means (anorexics 12.85; schizophrenics, 17.61) were consistent with those reported previously for schizophrenics (17.7, Kataguchi, 1959) and borderline schizophrenics (10.5, Powers and Hamlin, 1955).

DISCUSSION

The general hypothesis was supported as anorexic patients were differenti- ated from schizophrenics by their higher organizational, emotional and cogni- tive, capacities. On the Rorschach, anorexic patients produced more whole re- sponses which reflect greater integrating and organizing capacity. They also produced more shading and achromatic color responses. On the other hand, the Rorschach performance did not statistically differentiate the two groups on some critical variables, such as the Delta Index (which fell in the pathological range for both groups). The pattern of an intact and well-retained Weschler performance and poor Rorschach performance is considered to be the hall- mark of a borderline personality (Singer, 1977). While direct comparisons with Roland (1970) and Palazzoli (1971) are not possible, it is striking that all three studies point to a thinking disturbance and/or poor reality testing in the anorexics studied. Parallel clinical observations of anorexic patients exhibiting thinking disturbances in stress interviews, similar to that seen in individuals with a borderline personality organization as described by Kernberg (1967) are frequent.

While the test performances of anorexics point to an ego structure that is more organized and differentiated than schizophrenics (although still flawed) there are a number of factors in the data that perhaps were attenuated or masked due to the unitary dimension of many of the concepts. As a result, possibly important differences between the groups may have been diminished. For example, the Delta Index considers thought organization/disorganization in a unitary fashion which reduces the descriptive power of the measures (cf. Athey, Fleischer & Coyne, 1980). Furthermore, inspection of the means and comparisons with reference groups in the literature (see above) provide some support for the obscuring of levels of thought organization by the use of the Delta Index. Also the frequency of human movement responses indicates a su- periority in favor of the anorexics. In this study a statistical significance was not attained but an obscuring of a qualitative or levels dimension may have occurred. Human movement responses have been found to be powerful pre- dictors of a number of treatment outcomes (Frieswyk & Col~on,1980)~, predict

54 Int'l Journal of Eating Disorders

synthetic capacity, ego strength (cf. Lerner, 1975) and insight capacity. Thus, an analysis that affords a qualitative examination or considers the pro- duction of human movement responses on a continuum may prove more effi- cacious in delineating groups that share common symptomatology. An appli- cation of this model can be seen in Athey‘s (1974) work which stresses the need to examine different levels of regression in thought organization in predicting transference psychosis in schizophrenics.

Interestingly, the Rorschach determinants that significantly differentiated the groups in this study provide compelling reasons to further examine whether anorexics may be a borderline phenomena. It will be remembered that shading and achromatic color were two of the three determinants that were significantly different between the groups. This suggests that anorexics are more sensitive to affective needs and the experience of dysphoric affect. Borderline individuals show intense affects, especially depression (Kernberg, 1976), which influences perception and object relatedness. Empirically, Athey et al. (1980) found a positive correlation between poor form level blackness re- sponses and borderline pathology, suggesting a low tolerance for depression. Along these lines, anaclitic depression has been considered to be a central con- cept in anorexia (Sugarman, et al., 1979) and depression has been found to be prominent in their psychological tests (Sours, 1969; Roland, 1970; Small, et al., 1980).

Rorschach felt that the ultimate goal of his test was to differentiate between ”borderland states” (Kwawer et al., 1980). Until recently, an empirical model tied to a theory that allows for levels of concepts to be measured has been ab- sent. This study points to the inefficiency of unitary models of measuring psychopathology and demonstrates the potential utility of psychodiagnostic measures to differentiate between clinically overlapping syndromes.

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56 Int'l Journal of Eating Disorders