INTELLECT, PERCEPTUAL CHARACTERISTICS, AND WEIGHT GAIN IN ANOREXIA NERVOSA

ARNOLD SMALL'

George Mason University Family and Child Development Services of Virginia

JAMES MADERO United States International University

LORIE TEAGNO University of Maryland

MICHAEL EBERT National Institure of Mental Health

Studied weight gain in a group of primary anorexics by examining two pop- ular psychodiagnostic measures, the Wechsler and Rorschach, for indices that may predict improvement. Twenty-seven successively admitted anorex- ics to a behavior modification weight gain program at NIMH were studied. Using weight gain as a continuous criterion, multiple regression analyses in- dicated that perceptual-personality variables did not have any predictive power. Cognitive focusing skills, as measured by the Arithmetic and Digit Span subtests of the Wechsler, were found to account for roughly half of the variance and to be good predictors of weight gain.

In the last decade, anorexia nervosa has undergone a conceptual reanalysis, with the emphasis shifting from psychosexual dimensions to a model that stresses ego weakness and interpersonal disturbances (e.g., Bruch, 1973). While understanding into the dynamics of anorexia is expanding, there is virtually no information available that is useful in predicting response to treatment. Hence, Bemis (1978) notes that prognostic factors have lacked validity. The search for prognostic variables, while important for psychopathology in general, takes on added importance for anorexics due to a 7 - 15% mortality rate.

A source of information that has not been tapped and that may provide crucial data for therapeutic and diagnostic purposes comes from psychodiagnostic testing. Psychological testing with anorexics has been limited primarily to a study of objective personality traits. The few investigations in the past decade that have examined the thinking and perceptual processes of anorexics have provided a fairly consistent picture in that they have found striking disturbances in both for a significant number (Palazzoli, 1971; Roland, 1970; Small, Teagno, Madero, Gross, & Ebert, 1982).

In addition to the fact the research literature does not provide reliable and valid prognostic signs, clinical observation also has failed to delineate the factors that would predict whether a particular anorexic does or does not gain weight. Too often, it is left to analytic speculation (e.g., resolution of unresolved issues) that, while possibly accurate, does not aid in specifying the signs that augur for weight gain or a continuance of a threatening situation. The few studies cited above, which have provided a new dimension to our understanding of anorexics, caused us to wonder whether psychodiagnostic data might provide some information concerning prognosis. For example, one relevant ques- tion, among many, is whether personality organization/disorganization influences weight gain? Thus, we studied the results of the age-appropriate Wechsler Scale (all but

'Address reprint requests to Arnold Small, Family Counseling Center, I1706 Bowman Green Drive, Reston. Virginia 22090.

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two took the WAIS) and the Rorschach of a group of anorexics in an attempt to deter- mine whether psychodiagnostic indices may be associated with weight gain.

METHOD Subjects and Procedure

Ss were 27 successively admitted anorexics to the behavior modification weight gain program at NIMH. All were drug free and diagnosed by the criteria of Feighner, Robins, Guze, Woodruff, Winokur, and Munoz, 1972. These included weight loss of 25% of original body weight or 15% of ideal weight determined by Metropolitan Life Tables, age of onset prior to 30, amenorrhea, a distorted implacable 'attitude toward eating that overrides hunger, admonition, reassurance and threats, no other medical illness or primary psychiatric disorder, and at least two of the following: lanugo, bradycardia (per- sistent resting pulse of 60 or less), episodes of bulimia and vomiting, and periods of overactivity. Average age was 20.9 years (SD = 5.34), initial weight averaged 72 pounds (SD = I1.65), and the mean percent weight gain was 24.3 (SD = 13.61). All took the aforementioned tests by the same psychologist early in their hospitalization (object assembly was routinely not given).

Rorschach administration and scoring were according to the method delineated by Klopfer, Ainsworth, Klopfer, and Holt ( 1954). Standard tabulation was violated because of the relatively infrequent appearance of certain shading and color responses (e.g., C', C'F, c, cF, k, kF, C). Therefore, the various shading, achromatic and color responses were summed respectively. Movement responses were scored and tabulated according to standard procedure. Because form was by far the most predominant aspect of shading or color responses, combining the specific responses into composite shading and color scores did not seem to skew the data. F + % and the Delta Index, a measure of pathological thinking, also was calculated. Reliability of Rorschach scoring (J.M. and L.T.) was .87 with subsequent agreement reached on all variables.

RESULTS AND DlScUSSlON Multiple regression analyses, using percent weight gain as a continuous criterion,

were conducted separately for Wechsler subtest scales and Rorschach determinants, location, F + % and Delta Index. The results of the Wechsler data show that when the variables are allowed to enter freely, two variables, Arithmetic & Digit Span, together explain nearly half of the explained variance (Rz = .45). Arithmetic is by far the best predictor (R' = .35), followed by Digit Span (Ra = .lo). Although Block Design does not contribute very much, it is interesting to note that it follows Digit Span and Arithmetic in the amount of contribution to the variance explained (R' = .07). While factor analyses of the WAIS consistently show Block Design as primarily loading on a Perceptual Organization factor, it periodically has a fairly significant loading on the Freedom from Distractibility factor, which Digit Span and Arithmetic primarily load on (e.g., Berger, Bernstein, Klein, Cohen, & Lucas, 1964). On the other hand, multiple regression analyses of Rorschach data yield disappointing results; no variable accounts for any sizeable contribution.

The results of the multiple regression analyses suggest that the Wechsler is more im- portant than perceptual-personality variables in predicting weight gain for anorexics in a behavior modification program. Surprising dimensions such as personality organization, reality testing, and thinking disturbances do not predict improvement in this type of program. I t also should be noted that as a group, thinking disturbances were present, at least as measured by the Delta Index. The group mean of 12.93 falls in the pathological range (cf. Weiner, 1966). although it is obvious that not every anorexic exhibited a thought disturbance on the Rorschach. Instead, it is the ability to attend and focus cognitively that appears to be a necessary condition for improvement in this type of

782 Journal of Clinical Psychology, September, 1983, Vol. 39, No. 5

program. In general, previous studies and reports consistently have found the cognitive functioning of anorexics to be free from interfering effects and relatively efficient (cf. Small et al., 1982). However, a clinical observation is that a vitiated state causes a dull- ing of cognitive processes and that no type of therapy is successful due to the patient’s lack of accessibility (Anderson, Note I). These data (plus previously reported informa- tion) suggest that the critical factor that may cause a lack of accessibility is not a general cognitive slowing, but instead the inability to sustain and organize a cognitive focus. This finding, if it can be replicated, may suggest treatment considerations; for example, psy- chopharmacological agents that have an effect on attentional processes and powers of concentration may increase the accessibility of the anorexic.

A final word of caution must be conveyed. This report deals only with weight gain and does not make any statements that concern adjustment. It long has been noted that the later adjustment of anorexics continues to be marginal (Bemis, 1978).

REFERENCE NOTE I . ANDERSON, A.

Current formulations and treatment. McLean, Va., 1981. Current treatment techniques. Paper presented at symposium entitled Anorexia Nervosa:

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