Looking Good—Family Focus on Appearanceand the Risk for Eating Disorders

Caroline Davis,1* Barbara Shuster,1 Elizabeth Blackmore,1 and John Fox2

1Department of Kinesiology and Health Sciences, York University,Toronto, Ontario, Canada

2Department of Sociology, McMaster University, Hamilton, Ontario, Canada

Accepted 17 July 2003

Abstract: Objective: Evidence suggests that eating-disordered families are overly concernedwith social appearance and physical attractiveness. However, some argue that parentalvalues are not sufficient to produce disordered eating in their offspring unless combinedwith certain third-factor effects of the child such as a psychological or biologic vulnerability.We tested this hypothesis by predicting that proneness to anxiety (neuroticism) and a familyappearance focus would relate interactively (after controlling for body size) to a measure ofweight preoccupation. Method: Data from 158 healthy young women were used in theanalyses. Results: Statistical analyses confirmed our hypothesis in a multiple regressionmodel that accounted for 42% of the variance in weight preoccupation. Discussion: Findingssupport the view that family risk factors have a more potent influence on young women whoare easily made anxious—perhaps because they are more sensitive to, or more likely tointernalize, pressures and expectations to conform to family values. # 2004 by WileyPeriodicals, Inc. Int J Eat Disord 35: 136–144, 2004.

Key words: physical attractiveness; appearance; eating disorders; young women

INTRODUCTION

The role of parents in the onset of their child’s eating disorder has been the subject ofstudy and speculation for as long as the clinical syndrome has been identified. In earlyresearch, the primary focus was on the [dys]functioning of the family system, withevidence indicating that the families of those with an eating disorder were more dis-turbed in some ways than those without such problems (see Humphrey, 1986; Kog &Vandereycken, 1989). However, the case-control comparison studies have not alwaysused patients from the same diagnostic categories and/or they used different methods toassess family variables (e.g., hospital records, personal interviews, self-report question-

*Correspondence to: Dr. Caroline Davis, York University, 343 Bethune College, 4700 Keele St., Toronto, Ontario,M3J 1P3, Canada. E-mail: cdavis@yorku.caPublished online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.10250

# 2004 by Wiley Periodicals, Inc.

naire, or direct observation), thereby obscuring possible differences between controls andspecific patient groups (see Kog & Vandereycken, 1985).

When eating-disordered subgroups were examined, some differences were observedbetween the families of anorexia nervosa (AN) patients and those with bulimia nervosa(BN); the former tending to display a more rigid family organization, a greater mutualinterdependence, and a greater avoidance of conflict, whereas the latter exhibited morehostility and disorganization (e.g., Bruch, 1971; Fornari et al., 1999; Minuchin, Rosman, &Baker, 1978; Steiger & Stotland, 1995; Strober & Humphrey, 1987). There is also a broadliterature suggesting poor or insecure attachment processes in families with eatingdisorders (see Ward, Ramsay, Turnbull, Benedettini, & Treasure, 2000). However, thescientific study of family functioning has always been constrained by the obvious diffi-culty of employing a longitudinal research design due to the low base rate prevalence ofeating disorders in the population and because the nature of family interactions isinherently dynamic and interactive. Consequently, it has not been easy to determinewhether family processes are causal in the development of an eating disorder or whetherthe presence of an ill family member creates the maladaptive characteristics we tend toobserve in these families (Polivy & Herman, 2002).

Some authorities have also suggested that a dysfunctional family environment maysimply create a vulnerable individual and, therefore, may not provide an adequate orsufficient explanation for the type of pathology that develops in specific families (e.g.,Head & Williamson, 1990; Ordman & Kirschenbaum, 1986; Stern et al., 1989). Rather, thecontent of what is expressed, valued, and modeled in the family may largely determinethe form of psychopathology and the symptoms that tend to emerge. Consistent with thishypothesis, Laliberte, Boland, and Leichner (1999) found that a family focus on appear-ance and achievement was a more powerful statistical predictor of disturbed eatingbehavior among university students than general family-process variables such as con-flict, cohesion, and constrained expressiveness. Even when they extended their researchto a clinical population, they found that eating-disordered patients could only be distin-guished from depressed patients and healthy controls by a specific family climate thatplaced value on the importance of appearance. This is especially interesting becauseresearch has shown a direct link between dieting and body dissatisfaction and those whoplace a high value on physical appearances (e.g., Ogden & Thomas, 1999).

In recent years, other evidence has reinforced the view that parents can contributedirectly to their children’s eating problems by the social values they espouse, in parti-cular, by fostering a home environment that places emphasis on physical attractiveness,admires thinness, and encourages behaviors like dieting and exercise in pursuit of anideal body shape. For example, in one study, the mothers of girls with disordered eatingwere more critical of their daughter’s appearance than the mothers of healthy girls (Hill& Franklin, 1998). In another study, mothers of eating-disordered patients reported moreconcerns about weight and shape than healthy control mothers (Woodside et al., 2002).Also, in a large sample of college-aged women, the strongest predictor of bulimicsymptomatology was negative comments from family members about the woman’sphysical appearance and her need to diet (Crowther, Kichler, Sherwood, & Kuhnert,2002). We are also learning that the impact of parental values can be seen at a relativelyearly age. In a study of elementary school children (Smolak, Levine, & Schermer, 1999),weight loss attempts and poor body esteem were related significantly to parental com-ments about the child’s weight and to parents’ complaints about their own weight. Thefindings in the Smolak et al. study support the hypothesis, and clinical research withan older cohort (Fairburn, Welch, Doll, Davies, & O’Connor, 1997), that both direct

Family Focus on Appearance 137

comments and parental modeling can influence the eating behaviors of children, espe-cially those who are female.

The studies described above also support clinical observation. On the basis of hisextensive experience as a therapist, Lieberman (1995) concluded that the families of ANpatients were much more than normally concerned with social and physical appearances.Marcus and Weiner (1989) also described a family interaction pattern deemed to be highrisk for an eating disorder. One focused on physical appearance and social acceptance,where discussions about clothing, body weight, fitness and exercise, and social connec-tions comprise much of the family’s verbal interactions.

There is convincing evidence that families can convey certain attitudes and values totheir children, which in turn heighten their risk for disordered eating. However, it seemsunlikely that parental attitudes and behaviors are sufficient, on their own, to produce achild’s eating disorder, unless they are combined with certain ‘‘third-factor’’ effects in theform of a biologic or psychological vulnerability (Steiger, Stotland, Trottier, & Ghadirian,1996). A high proneness to anxiety—a general term that subsumes overlapping person-ality traits variously known as neuroticism (Costa & McCrae, 1992; Eysenck & Eysenck,1985) and harm avoidance (Cloninger, 1987)—is one of the most consistently occurringpersonality characteristics in patients with eating disorders (e.g., Casper, Hedecker, &McClough, 1992; Davis & Claridge, 1998; Diaz-Marsa, Carrasco, & Saiz, 2000). In onesense, however, this trait lacks specificity to eating disorders because it is a potentgeneral indicator of almost all psychiatric disorders (see Claridge & Davis, 2001, for areview). But, we can also construe this trait in a more dynamic sense through itscontribution as a variable that modulates the influence of other factors on behavior.Examples of this effect in eating disorder research can be seen, for example, in Davis(1997) and Davis, Claridge, and Brewer (1996). They reported that perfectionism andnarcissism, respectively, were only related to disordered eating in individuals who werehighly prone to anxiety.

In the current study, we tested the two family-factor perspectives described above.First, we determined whether a family focus on physical attractiveness and appearance isrelated to eating-related disturbances; and second whether this relationship is exacer-bated in individuals who possess a vulnerable (or at-risk) personality for psychologicaldisturbances, as indicated by their relatively high scores on a measure of neurotics. Inother words, we predicted that neuroticism would interact with a family focus onappearance in predicting a high degree of weight preoccupation (WP). To avoid thedifficulties inherent in testing this hypothesis with a clinical population (e.g., the like-lihood of a restricted range on the outcome variable), we explored these relationships in asample of college-age women.

METHOD

Subjects

One hundred and fifty-eight woman between the ages of 17 and 30 years (mean age ¼21.04 years, SD ¼ 2.74) were recruited to take part in the study by means of advertise-ments posted on the campus of a large Canadian university. Female volunteers wereasked to take part in a ‘‘short psychology study.’’ To keep cultural influences as homo-geneous as possible, subjects were excluded if they had not resided in Canada since earlychildhood. The majority of participants were Caucasian of European background.

138 Davis et al.

Measures

Eating Disorder Inventory (EDI)WP was assessed by a composite score obtained by summing the 23 items from the

Drive for Thinness, Body Dissatisfaction, and Bulimia subscales of the EDI (Garner &Olmsted, 1984). Factor-analytic justification for combining these scales in nonclinicalsamples has been demonstrated (see Welch, Hall, & Walkey, 1988). The traditionalscoring of the subscales of the EDI employs a 0, 0, 0, 1, 2, 3 format assigned to theadverbs ‘‘always,’’ ‘‘usually,’’ ‘‘often,’’ ‘‘sometimes,’’ ‘‘rarely,’’ and ‘‘never.’’ Higherscores reflect a greater degree of the construct. However, this scoring procedure resultsin highly skewed data, which violate the assumptions of the multiple regression proce-dures used in the current study. Therefore, the data were also scored using a 1–6 format,which improved the distribution of the data. However, for a comparison with other data,the summary statistics for the traditional scoring method are reported in Table 1.

Family Focus on AppearanceFamily Focus on Appearance is a 17-item subscale of the Family Communication

Pattern Scale (Shuster, 1999). Items are scored on a 1–5 Likert scale and reflect the degreeto which the respondent’s parents are concerned with physical appearance and attrac-tiveness and with socially acceptable behavior. They also reflect the respondent’s feelingsof lack of independent thinking in the family. Good reliability has been demonstratedwith this scale (in this sample, Cronbach’s alpha ¼ .82). Table 2 shows a sample of theitems that comprise this scale.

Eysenck Personality Questionnaire-RevisedNeuroticism was assessed by the 24-item subscale of the Eysenck Personality Ques-

tionnaire-Revised (Eysenck & Eysenck, 1991), designed to measure emotional reactivityand anxiety proneness. This, and earlier versions of the scale, have demonstrated goodreliability and validity over several decades of research (Eysenck & Eysenck, 1991).

Body Mass Index (BMI)BMI (kg/m2) was calculated from height and weight measured with subjects standing

in stockinged feet.

Procedure

All subjects were assessed individually in a laboratory setting. The questionnairepackage was completed after written informed consent was obtained from the partci-pants. Following this, height and weight were measured, and the subject was paid asmall stipend for her participation.

Table 1. Means, standard deviations, and minimum and maximum values for all variables used inthe analyses

Variable M SD Minimum Maximum

Weight preoccupation 13.2 9.5 1.0 40.0Appearance focus 44.5 10.8 18.0 70.0Neuroticism 13.6 5.7 0 18.0Body mass index 22.2 3.6 15.8 35.5

Family Focus on Appearance 139

RESULTS

Descriptive Statistics

Means, standard deviations, and minimum and maximum values for all the variablesin the study are shown in Table 1. The summary statistics obtained for WP and neuroti-cism are very similar to normative data, and to values obtained in other studies samplinga similar population (e.g., Davis & Cerullo, 1996; Davis, Claridge, & Fox, 2000; Eysenck &Eysenck, 1991). In addition, the mean BMI value is well within the normal and healthyrange (i.e., 20–25).

Table 3 presents a matrix of the pairwise correlation coefficients among the studyvariables. The relationships among the independent variables were all low to moderate,and as expected, all were related to WP.

Regression Analyses

In the first stage of analysis, WP was regressed on the family appearance variable, withneuroticism and BMI entered as covariates in the model. Results indicated a strong maineffect for the two covariates, but no effect for the family appearance variable. To test themoderating effect of neuroticism, a second analysis included the Family Appearance �Neuroticism interaction in the model tested above, and it was found to have a highlystatistically significant influence on the dependent variable. Regression diagnostics iden-tified two observations that were significant multivariate outliers. Their removal made arelatively small increase in the coefficient of determination (R2) and a decrease in thep value associated with the interaction term in the model (0.4026 to 0.4198 and 0.0357 to0.0033, respectively). Table 4 presents the result summary of the trimmed model.

An analysis of variance (ANOVA) table for the regression model is shown in Table 5.Table 5 provides Type II sums of squares. Thus, for example, the sum of squares for theinteraction between neuroticism and family appearance is computed after the otherindependent variables, but the sum of squares for the main effect of neuroticism is

Table 2. A sample of items from the Family Focus on Appearance subscale

1. How I dressed was important to my mother.2. Appearance was important in my family.3. I was always expected to socialize with the ‘‘right people.’’4. My mother was very concerned with the latest fashion trends.5. My father often commented on my physical appearance.6. My father was always concerned about what other people thought of us.7. In my family I often felt that I must be careful how I acted.8. Having an attractive partner was important to my mother.

Table 3. A matrix of all pairwise correlation coefficients among variables used in the analyses

Variable Weight Preoccupation Appearance Focus Neuroticism Body Mass Index

Weight preoccupation 0.226* 0.494* .381*Appearance focus 0.259* .032Neuroticism .066Body mass index

*Correlation is statistically significant at the .01 level (two-tailed).

140 Davis et al.

computed after BMI and family appearance but ignoring the interaction. The ANOVAtable reveals that the interaction between neuroticism and family appearance adds .035 tothe squared multiple correlation of the model.

Figure 1 was created by fixing BMI to its average value while allowing family appear-ance and neuroticism to range over their values. For each combination of values of theseindependent variables, the fitted value of WP under the model was computed. The errorbars in Figure 1 indicate � 1 SE around the fit at selected points, which helps to judge thestability of the estimates. This method of displaying interactions in a linear or generalizedlinear model is explained in greater detail by Fox (1987). The plot of the interactionindicates that at low/moderate levels of neuroticism, there is no relationship betweenfamily focus on appearance and WP. However, as neuroticism increases, the slopedescribing this relationship becomes increasingly more positive. In other words, a familyfocus on appearance is only related to WP among women who are psychologicallyvulnerable as indicted by their relatively high scores on neuroticism.

DISCUSSION

In the current study, we sought support for two related theories linking familyenvironment and eating disorders. To test the hypothesis that family risk factors aremore salient in the presence of psychological vulnerability, we expected that neuroticismwould moderate the relationship between family appearance focus and WP in theregression model, after controlling for the variance accounted for by body size (BMI).Our prediction was supported by a significant Family Appearance Focus � Neuroticisminteraction term in the model. A plot of this effect indicated that family focus onappearance was only related to WP among young woman who had relatively high scoreson the neuroticism variable. This finding is in agreement with Steiger et al.’s (1996)conclusions that although parents may transmit weight, diet, and body shape concernsto their offspring (e.g., by expressing certain criticisms, or when children model the verbal

Table 4. Multiple regression analysis with weight preoccupation as the dependent variable

Parameter Estimate SE

Intercept 36.509 18.772Neuroticism �1.331 1.110Body mass index 1.790 0.390Family appearance �0.740 0.350Neuroticism � Family Appearance 0.072 0.024

Note: R2 ¼ 0.42.

Table 5. Analysis of variance of weight preoccupation (type II sums of squares)

Source df Sum of Squares F P

Body mass index 1 6,239 21.08 <.0001Neuroticism 1 15,820 53.45 <.0001Family appearance 1 822 2.78 .10Neuroticism � Family Appearance 1 2,634 8.90 .003Residuals 149 44,104Total 153 76,014

Family Focus on Appearance 141

expression of their parents’ values), this type of transmission will only have a deleteriousoutcome if some vulnerability factor is present in the child.

In our study, we chose to define vulnerability as proneness to anxiety, principally becauseof its ubiquity in psychological and behavioral disorders, including AN and BN (Casperet al., 1992), and because of compelling evidence that anxiety is causal in, rather than aconsequence of, their development. For example, in both AN and BN, social phobia is themost frequently reported anxiety disorder and is primary to the eating disorder in at least50% of cases (Brunello et al., 2000). There is also accumulating evidence that proneness toanxiety is a powerful and reliable moderator of other variables that relate to eating disordersymptomatology (see Claridge &Davis, 2001). The general effect seen in these studies is thathigh anxiety proneness can erode or diminish (in a statistical sense) adaptive relationshipsfound in individuals with lower levels of this characteristic. For instance, the positiverelationship between self-esteem and body satisfaction does not exist among subjects whoare highly anxious (see Davis et al., 1996). Alternatively, having low levels of anxiety seemsto buffer the impact of negative events and characteristics, as we have seen in the currentstudy. Family values emphasizing appearance and attractiveness were not related to heigh-tenedWP in womenwith normal or low scores on the measure of neuroticism. The relation-ship between these two variables was only substantially positive among subjects withneuroticism scores above the mean.

How do we explain the reliable role of proneness to anxiety as a moderator variable?One possibility is that this occurs because of the negative affect—the ‘‘bad mood’’—thatconstitutes high anxiety. This, in turn, potentiates negative elements in coexisting fea-

Figure 1. Fitted weight preccupation as a function of family appearance and neurotocism (N),fixing BMI at its mean value. The error bars indicate � 1 SE around the fit.

142 Davis et al.

tures of the individual or his/her life, transforming them from neutral, or even adaptive,features to unhealthy attitudes and behaviors. However, it is also possible to interpret theinteraction we found in another way. It may be that neuroticism is more likely to functionas a causal variable in the development of WP in families who place a high emphasis onmatters of appearance. Unfortunately, our ability to form strong conclusions from thefindings of the current study is constrained by the limitations inherent in all cross-sectional research, that is, that alternative explanations cannot be ruled out. For example,it is possible that the highly weight-preoccupied women in our study may be hypersen-sitive or overresponsive to family values that emphasize appearance and attractivenesssimply because they themselves are preoccupied with such concerns. However, arguingagainst that explanation are the results of a recent study that showed significant andindependent agreement between mothers and daughters in their perceptions of thefamily value system (Laliberte et al., 1999). This suggests quite strongly that the percep-tion of the family value system is, at least to some degree, a shared experience, not thebias of one person.

Other possible design limitations of this study should also be addressed. Given thereliance on self-report data, and taking into account the recognized negativity of those atthe relatively high end of the neuroticism continuum, it is possible that these individualstend to appraise environmental variables (in this case, the degree of family focus onappearance) in a more critical manner than their stable counterparts. Indeed, there is asignificant and positive correlation between neuroticism and the family appearancevariable. However, because this is a relatively weak association, accounting for slightlyless than 7% of the shared variance, we have confidence that self-report bias was not astrong confound in our results.

REFERENCES

Bruch, H. (1971). Family transactions in eating disorders. Comprehensive Psychiatry, 12, 238–248.Brunello, N., den Boer, J.A., Judd, L.L., Kasper, S., Kelsey, J.E., Lader, M., Lecrubier, Y., Lepine, J.P., Lydiard, R.B.,

Mendlewicz, J., Montgomery, S.A., Racagni, G., Stein, M.B., & Wittchen, H.-U. (2000). Social phobia: Diagnosisand epidemiology, neurobiology and pharmacology, comorbidity and treatment. Journal of Affective Disorders,60, 61–74.

Casper, R.C., Hedeker, D., & McClough, J.F. (1992). Personality dimensions in eating disorders and theirrelevance for subtyping. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 830–840.

Claridge, G., & Davis, C. (2001). What’s the use of N? Personality and Individual Differences, 31, 383–400.Cloninger, C.R. (1987). A systematic method for clinical description and classification of personality variants.

Archives of General Psychiatry, 44, 573–588.Costa, P.T., & McCrae, R.R. (1992). Revised NEO Personality Inventory (NEO PI-R) and NEO Five-Factor

Inventory (NEO-FFI) professional manual. Odessa, FL: Psychological Assessment Resources.Crowther, J.H., Kichler, J.C., Sherwood, N., & Kuhnert, M.E. (2002). The role of family factors in bulimia

nervosa. Eating Disorders, 10, 141–151.Davis, C. (1997). Normal and neurotic perfectionism in eating disorders: An interactive model. International

Journal of Eating Disorders, 22, 421–426.Davis, C., & Cerullo, D. (1996). Fat distribution in young women: Associations and interactions with beha-

vioural, physical and psychological factors. Psychology, Health and Medicine, 1, 159–167.Davis, C., & Claridge, G. (1998). The eating disorders as addiction: A psychobiological perspective. Addictive

Behaviors, 23, 463–475.Davis, C., Claridge, G., & Brewer, H. (1996). The two faces of narcissism: Personality dynamics of body esteem.

Journal of Social and Clinical Psychology, 15, 153–166.Davis, C., Claridge, G., & Fox, J. (2000). Not just a pretty face: Physical attractiveness and perfectionism in the

risk for eating disorders. International Journal of Eating Disorders, 27, 67–73.Diaz-Marsa, M., Carrasco, J.L., & Saiz, J. (2000). A study of temperament and personality in anorexia and

bulimia nervosa. Journal of Personality Disorders, 14, 352–359.Eysenck, H.J., & Eysenck, M.W. (1985). Personality and individual differences. A natural science approach. New

York: Plenum Press.

Family Focus on Appearance 143

Eysenck, H.J., & Eysenck, S.B.G. (1991). Manual of the Eysenck personality scales. London: Hodder &Stoughton.

Fairburn, C.G., Welch, S., Doll, H.A., Davies, B.A., & O’Conner, M.E. (1997). Risk factors for bulimia nervosa: Acommunity-based case-control study. Archives of General Psychiatry, 54, 509–517.

Fornari, V., Wlodarczyk-Bisaga, K., Matthews, M., Sandberg, D., Mandel, F.S., & Katz, J.L. (1999). Perception offamily functioning and depressive symptomatology in individuals with anorexia nervosa or bulimia ner-vosa. Comprehensive Psychiatry, 40, 434–441.

Fox, J. (1987). Effect displays for generalized linear models. Sociological Methodology, 17, 347–361.Garner, D.M., & Olmsted, M.P. (1984). Eating Disorder Inventory manual. Lutz, Fl: Psychological Assessment

Resources.Head, S.B., & Williamson, D.A. (1990). Association of family environment and personality disturbances in

bulimia nervosa. International Journal of Eating Disorders, 9, 667–674.Hill, A.J., & Franklin, J.A. (1998). Mothers, daughters and dieting: Investigating the transmission of weight

control. British Journal of Clinical Psychology, 37, 3–13.Humphrey, L.L. (1986). Family relations in bulimic-anorexic and nondistressed families. International Journal of

Eating Disorders, 5, 223–232.Kog, E., & Vandereycken, W. (1985). Family characteristics of anorexia nervosa and bulimia: A review of the

research literature. Clinical Psychology Review, 5, 159–180.Kog, E., & Vandereycken, W. (1989). Family interaction in eating disorder patients and normal controls.

International Journal of Eating Disorders, 8, 11–23.Laliberte, M., Boland, F.J., & Leichner, P. (1999). Family climates: Family factors specific to disturbed eating and

bulimia nervosa. Journal of Clinical Psychology, 55, 1021–1040.Lieberman, S. (1995). Anorexia nervosa: The tyranny of appearances. Journal of Family Therapy, 17, 133–138.Marcus, D., & Wiener, M. (1989). Anorexia nervosa reconceptualized from a psychosocial transactional per-

spective. American Journal of Orthopsychiatrics, 59(3), 346–354.Minuchin, S., Rosman, B.L., & Baker, L. (1978). Psychosomatic families—anorexia nervosa in context. Boston:

Harvard University Press.Ogden, J., & Thomas, D. (1999). The role of family values in understanding the impact of social class on weight

concerns. International Journal of Eating Disorders, 25, 273–279.Ordman, A.M., & Kirschenbaum, D.S. (1986). Bulimia: Assessment of eating, psychological adjustment, and

family characteristics. International Journal of Eating Disorders, 5, 865–878.Polivy, J., & Herman, P.C. (2002). Causes of eating disorders. Annual Review of Psychology, 53, 187–213.Shuster, B. (1999). Family interactional patterns in the risk for disordered eating. Unpublished master’s thesis,

York University, Toronto, Ontario.Smolak, L., Levine, M.P., & Schermer, F. (1999). Parental input and weight concerns among elementary school

children. International Journal of Eating Disorders, 25, 263–271.Steiger, H., & Stotland, S. (1995). Individual and family factors in adolescents with eating symptoms and

syndromes. In H.C. Steinhausen (Ed.), Eating disorders in adolescence (pp. 49–68). Berlin: Walter deGruyter.Steiger, H., Stotland, S., Trottier, J., & Ghadirian, A.M. (1996). Familial eating concerns and psychopathological

traits: Causal implications of transgenerational effects. International Journal of Eating Disorders, 19(2),147–157.

Stern, S.L., Dixon, K.N., Jones, D., Lake, M., Nemzer, E., & Sansone, R. (1989). Family environment in anorexianervosa and bulimia. International Journal of Eating Disorders, 8, 25–31.

Strober, M., & Humphrey, L.L. (1987). Familial contributions to the etiology and course of anorexia nervosa andbulimia. Journal of Consulting and Clinical Psychology, 55, 654–659.

Ward, A., Ramsay, R., Turnbull, S., Benedettini, M., & Treasure, J. (2000). Attachment patterns in eatingdisorders: Past and present. International Journal of Eating Disorders, 28, 370–376.

Welch, G., Hall, A., & Walkey, F. (1988). The factor structure of the Eating Disorders Inventory. Journal ofClinical Psychology, 44, 51–56.

Woodside, D.B., Bulik, C.M., Halmi, K.A., Fichter, M.M., Kaplan, A., Berrettini, W.H., Strober, M., Treasure, J.,Lilenfeld, L., Klump, K., & Kaye, W.H. (2002). Personality, perfectionism, and attitudes toward eating inparents of individuals with eating disorders. International Journal of Eating Disorders, 31, 290–299.

144 Davis et al.