Living in Our Bodies: Embodiment, Eating Disorders and the IDEA Scale

A good deal of my time is devoted to reading articles about eating disorders, feminism, qualitative research, and embodiment. I don’t know if this makes me a very interesting person or a very boring one, but it certainly makes me a very opinionated one, especially about these topics. Lately, I’ve been exploring the literature around eating disorders and embodiment in particular, trying to get a sense of how researchers attend to “embodiment” in the development, course, and outcomes of eating disorders and recovery. Predictably, I have my own opinions about this relationship, but am of course interested in how other researchers have explored embodiment in the context of eating disorders.

In my research spiral to find relevant articles, I came across an article by Stanghellini et al. (2012), in which the authors look at how individuals with eating disorders experience their bodies. In the article, the authors discuss a self-report questionnaire they have created to try to access bodily experiences, the IDEA (Identity and Eating Disorders) scale.

EMBODIMENT?

The authors define embodiment as “the way [people] experience their bodies” (p. 148). This is a rather broad definition of embodiment, a concept that has intrigued philosophers of the body for years (for example, Edmund Husserl, Maurice Merlau-Ponty, and Margrit Shildrick, among others). Nonetheless, this definition provides us with a little context for looking at what the authors conceptualize as “embodied experiences” of individuals with eating disorders.

To get a sense of where the authors are coming from, it helps to look at the philosophical roots of “embodiment,” as the authors conceptualize it. Stanghellini et al. are guided by the work of Jean-Paul Sartre, who wrote about “lived corporeality,” and distinguished the lived body (i.e. what you feel and experience about your body) from the physical body (i.e. what others notice about your body, both aesthetically and medically/anatomically).

Using this perspective, facts about the body are normally experienced in the first-person (e.g. “I am 5 foot 7”); when something happens to disrupt the facts one holds as true about their body, an understanding of the lived body can shift, making one more aware of the body’s materiality. Obviously, other people also observe our bodies, and we are usually aware of this; we can take note of the experience of others looking at us and integrate this into our experiences of our bodies (what Sartre called the “lived-body-for-others”).

Stanghellini et al. suggest that body weight and shape have a stronger impact on overall sense of self for those with eating disorders, and that embodiment disturbances are a major driver of eating disorders. The authors combine this approach to understanding eating disorder with Sartre’s “lived corporeality” to suggest that “anomalies of embodiment,” specifically the strong impact of “lived-body-for-others,” play a major role in driving and maintaining eating disorders.

THE STUDY

The authors hypothesized that individuals with eating disorders experience their bodies primarily from a sense of being observed by others, rather than from a first-person standpoint. They sought to test the notion that this Sartrean “lived-body-for-others” leads to feeling distanced from one’s body and emotions, provoking self-management of the body in the form of eating disorder symptoms. To do so, they developed and tested a questionnaire, the IDEA (Identity and Eating Disorders).

Participants were patients at an outpatient clinic in Florence, Italy. As a minor gripe, they do sometimes refer to their participants as “subjects,” which always bugs me; it’s 2014 (well the article is from 2012, but still)! Let’s call people participants! Digression aside, they administered their questionnaire to 147 individuals with eating disorders and 187 healthy controls. Criteria for inclusion in the eating disorder group included:

• 18-40 years old
• Female
• Currently diagnosed with AN, BN, or BED
• Literate
• No intellectual disability, comorbid schizophrenia or delusional disorders

Inclusion criteria for healthy controls were:

• BMI 18.5-25
• No Axis I mental disorder (major clinical mental illness as defined in the DSM)

THE MEASURE

Measuring embodiment is no easy task; how can you objectively conceptualize the “feeling” of being in the body? We only know the feeling of being in our own body; how can we presume this feels the same for diverse individuals? With the definition and philosophical roots the authors chose, this issue becomes a little easier: if we are to investigate embodiment under the understanding that disturbances of body perception hinge mostly on how we think others are seeing us, we can ask questions about the experience of being seen.

Still, does the measure really capture the experience of being in the body? I am always a bit skeptical about measuring things like “embodiment” and “body image” (see this post about body image I wrote last year) using self-report quantitative scales, but I do also see the potential usefulness of this kind of a measure (e.g. diagnostically and for inter-study comparison). So how did the authors develop a scale for embodiment?

The authors generated questions grounded in the notion of “lived corporeality” and  clinical concepts related to embodiment. They sought to create a list of items that fit into each of the following areas (verbatim from the article, p. 149):

1. Feeling oneself through the gaze of the other;
2. Defining oneself through the evaluation of the other;
3. Feeling oneself through objective measures;
4. Feeling extraneous from one’s own body;
5. Feeling oneself through starvation;
6. Defining one’s identity through one’s own body;
7. Feeling oneself through physical activity and fatigue

Stanghellini et al. went through a seemingly lengthy process of developing items in these domains and checking them against:

• Clinical experience
• Research literature
• Qualitative data on self-belief in eating disorders
• Transcripts from clinical interviews
• Diaries written by eating disorder patients
• Feedback on the items from psychiatrists and individuals with eating disorders

After this process was complete, the authors had arrived at a list of 61 items that participants rate on a Likert scale (0-4; from do not agree to strongly agree). They administered this scale to a test group of 221 individuals referred to an outpatient clinic and looked at how well the items on their scale were related to the domains they were seeking to measure and to each other (checking for redundancy, clarity, etc.) before arriving at a final version of the scale for the study.

Among items on the scale (from p. 152 of the article):

• “Knowing what the others think of me calms me down”
• “Having my weight under control makes me feel in control of my emotional states”
• “Eating according to my own rules is the only way to feel myself”

In addition to this measure, the researchers had participants complete the Eating Disorder Examination Questionnaire (EDE-Q), the Symptom Checklist (the SCL 90-R), the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI Form Y-1).

THE MAIN RESULTS

Strangellini et al. were investigating the psychometrics of their scale (the IDEA), as well as looking at the differences in scores between individuals with eating disorders and controls. They found that:

• The scale was reliable, with a high level of consistency between multiple tests (“test-retest reliability”) and a good score for internal consistency, meaning that the items on the scale work together to provide an overall measure of the construct they wanted to measure (embodiment)
• Scores on the IDEA were related to scores on the EDE-Q; that is, those who scored in clinically diagnosable ranges on the EDE-Q also had high scores on the IDEA
• High scores in the area of “feeling oneself through the gaze of the other and defining oneself through the evaluation of the over” were particularly strongly related to the EDE-Q domain of weight and shape concerns

Over all, the authors suggest that their scale provides evidence for the strength of disturbances in weight and shape as predictive of eating disorders. They argue that understanding lived corporeality helps us to understand the phenomenon of overvaluation of weight and shape among those with eating disorders.

IMPLICATIONS

I am unconvinced that this scale tells us that much more about the experience of eating disorders than the weight and shape subscales of the EDE-Q, and I think we can apply a similar critique to both. That is: which comes first, the eating disorder or the preoccupation with the body? Or does either have to come into play at all?

I see a lot of discussions around this issue cropping up these days. Can similar critiques to those that can be lodged at “body image” apply to the concept of lived corporeality as contributing to disordered eating? Again, we are trying to get at something that I would argue is not a static entity able to be captured in a list of items. These items in particular seem somewhat vague and would not, I imagine, cross the minds of the average individual on any given day. At the same time, looking at “the lived body for others” does incorporate more of an acknowledgment of how we can experience our bodies in relation to other people, which might be an improvement over the individualistic way in which body image has historically been conceptualized.

It is possible that the items seem a bit odd as they have been translated from Italian, and I would think that they might need tweaking if this scale were to be administered to a North American audience. Sometimes it is not very clear what an item actually means; for example: “I see myself out of focus, I don’t feel myself.”

Still, I am intrigued at the attempt to measure embodiment- I just think that embodiment goes beyond observing what others think about us/internalizing how others see us. While this might play a part in some people’s eating disorders, I don’t think this would be the case universally. There is also the risk, in suggesting that seeing oneself through the eyes of others and taking this to heart negatively impacts embodiment, that we are playing into the stereotype that individuals with eating disorders are somehow vain or simply people with bad body image, which we know is not the case.

Again, I lay the qualitative researcher in me bare when I suggest that it might be more effective to explore embodied experiences by allowing people to talk about their stories and experiences, rather than administering a quantitative scale. In some ways, I feel that this kind of measurement can’t really capture something as complex as embodiment; trying to pigeonhole people’s experiences of being in the body in a list of items loses some of the uniqueness of the way we experience embodiment in a way that is at odds with the philosophical roots of the concept. Particularly in the case of embodiment and eating disorders, I fear that our preconceived notions about the relationship between body image and eating disorders might too strongly colour the possible items we could generate for such a questionnaire.

I’d be very curious to hear what others think about this scale: do you think that it helps us to better understand the experience of having an eating disorders, or reifies ingrained stereotypes about individuals with eating disorders? Both? Neither? Let me know in the comments!

References

Stanghellini, G., Castellini, G., Brogna, P., Faravelli, C., & Ricca, V. (2012). Identity and Eating Disorders (IDEA): A Questionnaire Evaluating Identity and Embodiment in Eating Disorder Patients Psychopathology, 45 (3), 147-158 DOI: 10.1159/000330258