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The Use of Human Figure Drawings in the Evaluation of Eating Disorders
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The Use of Human Figure Drawings in the Evaluation of Eating Disorders
Anorexia nervosa and bulimia are two eating disorders that affect females in the United States and Europe every year, and both are recognized as major medical and psychiatric problems. Anorexia is a disorder that most commonly affects females in their teenage and young adult years. Leichner and Gertler (1988) estimate that as much as 20% of women on college campuses demonstrate anorectic behaviors. Despite improved therapeutic approaches, the mortality rate of this disorder is between 5% and 20% (Zerbe, 1993). Bulimia, the other eating disorder, also affects adolescent females, and the prognosis for individuals with bulimia is often worse than those with anorexia. Because of the prevalence and severity of eating disorders, psychological researchers desire to learn of the symptoms that precede such eating disorders, how those symptoms develop, and the additional problems that accompany such symptoms.
Clinicians, in an attempt to document symptoms that precede eating disorders, are often confounded by the fact that females are usually secretive in regard to their eating disorders. Adding further to the problem is the fact that many teenagers diet, and eating disorders can sometimes be confused with dieting. Thus, as noted by Zerbe (1993), early signs of eating disorders, such as weight loss, frequently go unnoticed by family members and are ignored by physicians. Since physical and other observable warning signs are often disregarded, and since eating disorders are related to, and perhaps caused by, underlying personality characteristics, emotions, and conflicts, it seems that a method of assessment that would project these underlying tendencies would be helpful in the early diagnosis of eating disorders.
Usually eating disorders are connected to emotional conflicts, personality characteristics, and other psychological problems. Researchers have long used human figure drawings (HFD) for the assessment similar psychological problems in children and adults (Dileo, 1983; Koppitz, 1968), and, according to Klepsch and Logie (1982), such drawings can capture symbolically on paper some of an individual's thoughts, feelings, and present state of mind or attitude. Note that such states or attitudes may be governed by developmental and social-emotional conditions at any given moment (Mortensen, 1984).
Since HFDs may capture various social-emotional conditions on paper, perhaps HFDs may be used as a diagnostic tool in an attempt to differentiate among individuals with and without eating disorders. Therefore, the purpose of this investigation will be to determine whether HFDs, viewed as a diagnostic tool, can adequately identify individuals with eating disorders. If HFD can be used successfully to diagnose individuals with eating disorders, then clinicians will have a tool to help identify young females who need assistance with overcoming these psychiatric problems.
Review of HFDs
Professionals in the field of psychology agree that HFDs are valuable in assessing important personality variables. Today, HFD tests are standard practice in clinical assessment. Robins, Blatt and Ford (1991) reported that HFDs used projectively are administered more often than any other psychological testing instrument besides the Rorschach.
Most research on HFDs focus on the validity of HFDs in differentiating well adjusted from maladjusted individuals. A common topic of investigation is the drawing content found in HFDs from emotionally disturbed individuals. Koppitz (1968) explored the clinical validity of 30 emotional indicators on HFDs. She found that emotionally disturbed children show a greater number of emotional indicators in their drawings. Similarly, Goodenough (1926), who has used drawings in the study of personality, observed bizarre features in HFDs of children with behavioral problems. Machover (1949) argued that HFDs relate to impulses, conflicts, anxieties, and compensations that are characteristics of an individual's personality.
Much criticism has been directed at earlier research on HFDs because evaluation of HFDs were based upon a clinician's holistic and intuitive judgments (Swenson, 1968). However, later studies that incorporated content analysis of drawings and inter-rater reliability methods indicated that HFDs are, in fact, valid diagnostic tools. For example, Hobbs (1966) and Fisher (1967) found that disturbed children place greater distance between human figures than do non-disturbed children, and Rabinowitz and Elden (1985) found greater distances between human figures for high-aggressive children than for low-aggressive children. In related studies, Delatte and Hendrickson (1982) showed that children's self-esteem and the height of a drawing were related, and Yama (1990) argued that the bizarreness of a drawing possibly reflects individual differences.
HFDs have been used extensively in research to detect differences among various psychological constructs, e.g., introverted tendency and psychosis (Martens, 1990; McNeish, 1991; Rabinowitz & Elden, 1985). Perhaps much of this research results from the controversial nature of the validity of HFDs to accurately differentiate individuals. Despite numerous attempts by researchers to validate HFDs as projective instruments in terms of thoughts and feelings, critics still abound. Martens, for example, states that if a figure drawing is weak psychometrically it can add little or nothing to findings derived from stronger measures. But McNeish claims that valid scoring of HFDs is possible; however, such scoring is almost never employed in routine psychological evaluations. As of yet, no research exists that examines the ability of HFDs to differentiate between individuals with and without eating disorders.
Eating disorders have been classified as a mental dysfunction, and are almost always preceded by sadness and anxiety. Moreover, eating disorders are often related to family conflicts, depression, poor self-concept, and many other mental disorders such as psychosis and depression (Bliss & Branch, 1960; Palazzoli, 1971; Roland, 1970), and neurosis and obsessive-compulsive disorders (Bemis, 1978; Dubois, 1949; Palmer & Jones, 1939; Smart, Beaumont, & George, 1976; Warren, 1968). Besides depression and crumbling self-esteem, despair leading to thoughts of suicide, a merciless conscience, and an inability to adjust to reality are also part of the clinical picture of an adolescent with an eating disorder (Palazzoli, 1971; Roland, 1970).
Because HFDs often serve as an accurate diagnostic tool for identifying various mental disorders that are associated with personality traits and emotional conflicts, it is reasonable to anticipate that HFDs may also provide adequate diagnosis for adolescent females with eating disorders since such disorders are typically linked to mental disorders, personality traits, and emotional conflicts. It is hypothesized that HFDs, scored according to Koppitz's (1968) 30-item emotional indicator checklist, will differentiate between adolescent females with and without eating disorders. This investigation differs from others on HFDs, anorexia, and bulimia in that it is the first to study whether HFDs can be used to diagnose individuals with eating disorders. Should HFDs prove to be predictive of individuals with eating disorders, then clinicians will have an important diagnostic tool when working with potential individuals suffering from anorexia and bulimia.
Thirty females between the ages of 14-19, who have all been previously diagnosed with anorexia or bulimia, and 30 females of normal weight, who will be screened to rule out any history of eating disorders, will participate in this study. A board certified psychologist will hold one screening session with each of the thirty control subjects. During each session the psychologist will collect a medical history and then rule out diagnosis of an eating disorder using established clinical criteria. A personal session with the psychologist, rather than the completion of a questionnaire, is used in order to establish rapport and gather more accurate information.
The 30 participants with eating disorders will be selected from inpatient eating disorders units of two major hospitals located in southeast Georgia. The second group will be selected from middle and high schools located near the hospitals. The second group of participants will be matched to the eating disorder participants on age, race, and socioeconomic status.
The "Koppitz Emotional Indicator Checklist-Revised" (Koppitz, 1968; Pate & Nichols, 1971) will be used because it is one of the better researched scoring systems, and because of its documented ability to differentiate adjusted from maladjusted groups of children and adolescents. In addition, developmental norms for this scoring system are available (Hall & Ladriere, 1970). Most reviewers, including those in The Twelfth Mental Measurements Yearbook (Conoley & Impara, 1995), have commended Koppitz on the extensive research she has done to validate her scoring system. See Koppitz and The Twelfth Mental Measurements Yearbook for more detailed information on the validity of Koppitz's scoring system for HFDs. Examples of Koppitz's emotional indicators used for evaluating drawings include: omission of major body parts, uncommon features, and signs of poor quality in the drawing. More detailed examples and illustrations can be found in Koppitz's book.
A single examiner will administer the HFD to each of the 60 subjects. Drawings will be obtained on an individual basis in order to eliminate suggestions or interference from other participants. All participants will be given a pencil and a 8.5" X 11" sheet of unruled, white paper. Participants will then be asked to draw a picture of a human male and female. When each participant completes her drawing she will be asked to identify ambiguous parts of the pictures. These will then be labeled by the examiner to aid in scoring.
All drawings will be evaluated by two clinicians. The first clinician will blindly rate the 60 drawings according to the absence or presence of indicators on the emotional indicator checklist. Since there are 30 items and two human figures, a maximum score of 60 is possible. Note that higher scores indicate more emotional disturbance. In order to establish inter-rater reliability, the HFD examiner will also rate the drawings using identical scoring methods.
Inter-rater reliability, using the kappa statistic (Cohen, 1960), will be reported in the final analysis. If a high level of inter-rater reliability exists, as indicated by kappa, the ratings from the two raters will be averaged to provide a single score for each participant on the HFD. If, however, a high level of reliability does not exist (kappa < .8), only scores from the first rater will be used in the final comparison of the two groups. Eliminating the examiner's scores will help control possible rating bias that may result from direct contact with the participants.
After obtaining scores for each of the 60 participants, means and standard deviations for both groups will be reported, and a two-group independent samples t-test will be used to determine whether the groups are statistically different. Additionally, a measure of effect size (Glass & Hopkins, 1996) will be reported to assist in determining whether HFDs actually provide strong discriminatory power in terms of differentiating between teenagers with and with eating disorders.
Limitations of Study
As with any causal comparative study, the main limitation is a lack of experimental control and thus the inability to ensure that the eating disorder, rather than some confounded variable, caused the indicated differences, if any, in the HFDs of the two groups. While HFDs may be capable of differentiating between adolescent females with eating disorders and those without, HFDs may not be able to differentiate among individuals with eating disorders and individuals with other mental illnesses. The lack of comparison of HFDs between adolescent females with eating disorders and those with other mental disorders poses another limitation of this study. To better assess these limitations, more research will be needed to determine the exact discriminatory power of HFDs in regard to eating disorder.
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Copyright © 2000, Bryan W. Griffin
Last revised on 05 January, 2005 01:56 PM