A Psychological Profile of the Body Self Characteristics in Women Suffering from Bulimia Nervosa

Bulimia nervosa and eating disorders are common cause of distress and health related burden for young women and men. Despite major advances over the past three decades many patients come late to treatment and find that the therapy is incompletely addressed to the complex psychopathology and co-morbidities of the illness. The present book brings timely and contemporary understandings of bulimia nervosa to aid in current thinking regarding prevention and treatment. It will be read by therapists interested in enhancing their current approaches and those interested in earlier and more effective prevention and closing the gap between illness onset and accessing treatment. They will find practical guidance but also new ideas and ways of thinking about bulimia nervosa and the illness experience in this book.


The body self -a definition and specification of the body self dysfunctions in bulimia nervosa, based on selected elements of the psychoanalytic theory
In psychology, a variety of terms are used to refer to the phenomenon of experiencing one's own self. They include such notions as the ego, the self, a sense of self, a sense of personal identity, self-awareness, self-knowledge, self-representation, and others. According to the definitions provided in psychological literature, it is possible to distinguish the following domains of the structure of the self: the self-as-agent vs. the self-as-subject, the real self vs. the ideal self, and the body self vs. the mental self. All of them constitute the major components of the so called psychological Self [Pervin]. The correlation between the body self and the individual's mental development has been clearly demonstrated and described in the psychoanalytic and cognitive theories regarding human functioning [Fairburn, Lacey, Thompson, Cash, Pruzinsky, Garner, Józefik, Głebocka, Kulbat, Rabe-Jabłońska, Mikołajczyk, Samochowiec, Schier, Brytek, Pervin, Tyson, Sugarman]. A review of psychoanalytic literature reveals that body image has a considerable impact on the development of an individual's personality. The ego, as conceived by Freud, denotes mainly the "body ego" [Krueger, Tyson, Schier]. Taking into consideration the psychoanalytic approach, an eating disorder is regarded as a pathology that occurs as a result of unsatisfied drives and desires, or as pathological development of the self and a sense of personal identity. According to the fundamental assumptions of the object relations theory, the early childhood experiences significantly affect the separation-individuation process as well as the development of the self-as-subject and interpersonal relationships [Pervin]. As mentioned in Polish literature, the research results obtained in a group of bulimic females, using the Eating Disorder Inventory (EDI), prove that the women do not accept their psychosexual development, and exhibit incresed maturity fear as well as a tendency towards regression into childhood, which is a form of retreat, going back to a time when they felt safer than in adult life [Józefik]. Moreover, the findings reveal a low level of interoceptive awareness regarding body stimuli among the examined women. The level of difficulties related to psychosocial functioning turned out to be higher in this group, compared with the data received in the population of anorectic females [Józefik]. The findings of Sugarman's research on body image distortions in bulimia nervosa prove that the disturbances have their roots in the failure to carry out the process of separation of the object from the mother during the early practicing sub-phase of the separationindividuation process [Sugarman]. The author points out that women who suffer from bulimia nervosa find it difficult to differentiate and integrate the body self. Hence, they experience a number of neurotic conflicts and developmental deficits [Sugarman]. The clinical analysis conducted by Sugarman demonstrates that bulimic females tend to encounter problems in relationships with their mothers. The daughter's ambivalent identification with the mother and her body and femininity, determines the development of pathological behaviours that affect the body such as uncontrolled binge eating and purging. Sands, who represents the object relations perspective on the concept of the self, refers to Kohut's view and argues that bulimia nervosa "compensates" the deficits in the self-object functions that are initially provided by the mother [Sands]. She claims that a bulimic individual identifies him/herself by his or her symptoms with the false, perfectionist self, created under the influence of the person's narcissistic care-givers. Thus food becomes a substitute for the self-object. It is the bridge between the self and the self-object, and the significant transitional object whose role is to regulate the bulimic individual's affective states. The bulimic self (that is the body self) is expressed through body language and represents the primitive need for dependence and separation. Binge eating symbolically compensates for the need for care and dependence, and self-induced vomiting symbolizes the need for self-identity and for separation from the object [Sands]. Excessive preoccupation with body appearance, which is a natural consequence of developmental changes that occur during adolescence and emerging adulthood, may lead to body-size dissatisfaction among women with low self-esteem, who have experienced some developmental deficits. This in turn triggers the development of eating disorders such as bulimia nervosa. According to the psychoanalytic approach, body experiences correlate with the development of an individual's sense of identity. Lowen clings to the opinion that "in fact, a person has a double identity -one of them stems from identification with the ego, the other is related to identification with the body and the feeling regarding it" [Lowen]. Meissner established the basic terminology regarding the body and its image. He defined the body as an actual physical organism. He used the term "the body self' to refer to a psychic structure that forms an integral component of the person's self system. Body image is, according to Meissner's definition, a system of images organized into representations of the body [Krueger]. When dealing with the issue of body experience, Bielefeld distinguished between the body schema and body image [Schier]. The body schema comprises the following components: body orientation which refers to the orientation towards the internal structure of the body as well as its surface; body size estimation (i.e. estimation of the volume, mass, length, and surface area of the body); body knowledge (i.e. the knowledge of the body structure and body parts) [Schier]. Body image, as described by Bielefeld, comprises such components as body consciousness which refers to a psychic representation of the body or its specified part perceived at a conscious level; body boundaries (i.e. a sense of separation between the body and the external world); body attitude, that is a person's attitude towards his or her body, measured in terms of positive or negative body perception (body image satisfaction and dissatisfaction) [Schier]. Krueger defines the notion of body image, at its early stage of development, as a system of primary bodily sensations. He shares Mahler's view that a sense of touch is the factor behind the emergence of a primitive sense of self. Tactile sensations facilitate the development of the primitive "skin ego" which forms the foundation of a sense of body self [Krueger]. A sense of body boundaries allows to differentiate self from non-self. Empathic resonance between the mother and the child stimulates the process of internalization of reciprocity and affirmation, and consequently determines the development of self-efficacy [Krueger, Schier]. The body boundaries form the foundation for psychological boundaries.
The body appears to be a "container" for the psychological self which integrates internal and external experiences, thereby stimulating the emergence of a coherent identity [Krueger]. Bulimic episodes of uncontrolled binge eating and destructive compensatory behaviours (e.g. self-induced vomiting, fasting, abuse of laxatives, diuretics or slimming pills, etc.) allow a bulimia sufferer to maintain his or her positive self-portrait and self-assessment which in turn are affected by the person's body experiences as well as the cognitive evaluation of his/her own physical appearance. Engaging in compulsive, self-destructive behaviours, a bulimic individual applies a variety of specific symbols related to the person's sensomotoric experiences, which is aimed at bridging the body and mind [Krueger]. Bulimic symptoms appear to represent the individual's attempt to satisfy his or her needs and compensate for developmental emotional deficits by resorting to substances (e.g. food, alcohol or drugs) or to certain activities (e.g. self-induced vomiting, purging, compulsive spending, impulsive sex, etc.). This can also be regarded as a form of escape from "painful" emotions [Krueger].

A cognitive perspective on body image disturbances in bulimia nervosa
The most common terms that cognitive theories refer to in their attempts to define body perception include such notions as: self-image, body image, self-knowledge and selfassessment. Body image is frequently defined as a cognitive self-schema construct, that is, a system of conscious generalizations regarding the body [Pervin]. According to cognitive psychologists, body image is one of the fundamental components of the body self. It is commonly referred to as sensual image of sizes, shapes and forms of the body as well as feelings regarding the mentioned features of the whole body or one of its specified parts [Thompson, Cash, Pruzinsky]. Thompson and his co-researchers made an attempt at systematizing the notions related to body image [Thompson, Cash, Pruzinsky]. Defining the feelings regarding the body, they identified the following aspects: weight satisfaction which can be measured in terms of a discrepancy between the actual (current) and the ideal (most desired) weight; body satisfaction which most frequently refers to the specified body parts (e.g. breast, thighs or hips); appearance satisfaction, that is, satisfaction with general appearance or its specified elements such as certain parts of the face, or the body parts that carry connotations of weight (e.g. the lower part of the body). Thompson and his coresearchers identified the phenomenon of inadequate body mass perception, and linked it to the concept of appearance orientation measured in terms of a degree of cognitive and behavioral involvement in physical appearance. Appearance anxiety seems to reflect the feelings of dissatisfaction and discomfort which occur as a result of excessive focus on body image [Thompson]. Garner and Garfinkel distinguished the following two forms of body image disturbances: inadequate body percept and body dissatisfaction [Rabe-Jabłońska,Dunajska]. In their studies the psychologists put forward the view that the former refers to inadequate perception of the body size; whereas the latter is related to an emotional attitude towards the body [Rabe-Jabłońska, Dunajska]. Developed by E.T. Higgins, Self-Discrepancy Theory provides a platform for understanding the development of body image. Higgins's theory posits that the structure of the body self determines an individual's self-perception and self-evaluation of his or her own body features (the actual self), as well as the person's thoughts and aspirations regarding the ideal body image (the ideal self), and the mental evaluation of the body features and www.intechopen.com A Psychological Profile of the Body Self Characteristics in Women Suffering from Bulimia Nervosa 151 characteristics which the person believes she or he should display (the ought self) [Higgins]. According to Higgins's theory, an individual aims at minimizing the actual-ideal or actualought self discrepancies. Thompson refers to Higgins's theory of self-discrepancy in order to provide an explanation for body image disturbances. He claims that the constant comparison of an individual's actual body shape and the ideal body image has a negative effect on the development of a cognitive aspect of body image. The ideal-actual body image discrepancy underlies the state of body dissatisfaction, and determines development of an eating disorder [Cash, Pruzinsky, Thompson, Garner]. A cognitive model of eating disorders, developed by Fairburn, Cooper and Safran, points to a variety of interlinked factors which determine development of bulimia nervosa. The theory demonstrates that such factors as social pressure, dietary restriction, the feelings of hunger and inability to control it, trigger the onset of bulimia nervosa. Body image is considered to perform a significant regulatory role [Cash, Pruzinsky, Thompson]. A bulimic individual conducts subjective evaluation of his or her body attributes, which affects the person's cognitive functioning. A bulimia sufferer tends to be excessively concerned about body weight, shape and general physical appearance. This in turn leads to low self-esteem. The compensatory behaviours that a bulimic individual engages in (i.e. the bulimic symptoms) are aimed at improving hi or her self-assessment and reducing the consequent emotional tension and frustrations [Cash, Pruzinsky, Thompson].

A psychological profile of the body self characteristics in Polish women suffering from bulimia nervosa -an empirical analysis based on the author's own research results
An appropriate diagnosis of psychological mechanisms underlying eating disorders, including a diagnosis of the body self characteristics in adolescent girls and young females suffering from bulimia nervosa, proves to be a significant predictor of successful treatment. Hence, during many years of my scientific research, I focused on the above mentioned issues.

Research objectives and variables
The main aim of this research was to determine the strength level for the characteristics of the body self structure in a group of selected 30 young Polish females suffering from bulimia nervosa, and in the control population of females who were similar in age and social status, and were not revealing any eating disorders or mental disturbances. The main question addressed in this study was: "Do the examined women who suffer from bulimia nervosa significantly differ from the healthy females in terms of the strength level for the characteristics of their body self structure?" The main independent variable in the research was clinically diagnosed bulimia nervosa in the examined females. Its indicators included bulimic symptomatology as well as a medical diagnosis code (F.50.02, according to the ICD-10 classification).The main variable was the structure of the body self, defined, referring to the subject literature, as a complex construct constituting the following configuration: emotional experience related to body and its functions, as well as mental concept (perception and thoughts) regarding physical appearance [Cash, Pruzinsky, Thompson,Garner]. The major components of the variable which were empirically examined in the study included: 1. A body schema (a degree of an individual's knowledge of one's own body, and the person's awareness of specific body parts), 2. A sense of body boundaries (the feeling of separating one's own body from the external world, which facilitates the process of perceiving oneself as a bodily creature, definite and different from others) 3. Interoceptive awareness, i.e. the feeling of perplexity accompanying the process of recognizing and responding to emotional states and body sensations; and also the fear of high affection and the prospect of losing control over it) 4. Experiences related to body functions (maturity fear experienced by an individual, that is, the person's approval of psychosexual development, which is related to the process of entering the stage of maturity, and to body image change as well as loss of the sense of childhood security), 5. Body image, i.e. a sensual image of sizes, shapes and forms of the body as well as the feelings regarding the body. The major aspects of body image include: adequate evaluation of body shape and size, as well as feelings regarding the body (satisfaction, acceptance or disapproval). 6. Self-evaluation and body satisfaction-the level of general satisfaction with one's own body, weight, body shape and physical appearance. Body self-evaluation includes assessment of an individual's current body shape (i.e. the "actual me"image) and evaluation of the ideal, most desired attributes which the person would like to have (i.e. the ideal body image -"what I would like to look like"). An additional control variable was body mass index BMI. It has been announced that individuals who fall into the BMI range of 19.5 to 24.5 have a healthy weight. A BMI of under 19.5 is usually referred to as underweight. A Body Mass Index reading over 24.5 is considered overweight.

Subjects
102 Polish females participated in the research. The subjects were selected intentionally. Clinical population No. I consisted of 52 females clinically diagnosed with bulimia nervosa (the F.50.02 code, according to the ICD criteria of psychiatric classification). Whereas clinical population No. II was comprised of 50 women with no history of past or present eating disorders or other mental disturbances (e.g. bulimia or anorexia nervosa, psychogenic binge eating). The additional criteria which excluded participation in the research included: improper intellectual development, chronic somatic conditions (visible disability and body distortions), and organic changes in the CNS. The data mentioned above was gathered by means of clinical interviews conducted among the examined individuals. The aforementioned factors may affect the development of body image. Hence, the females exhibiting any of the dysfunctions mentioned above were excluded from the group of research subjects. During the research, all bulimic participants remained under medical care. The mean duration of treatment in the group of the examined bulimic females ranged from 2 to 12 months. A mean age in the research sample ranged from 21 to 25 years. The research was conducted anonymously with the personal consent obtained from each participant, and with the approval of a Human Research Ethics Committee.

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A Psychological Profile of the Body Self Characteristics in Women Suffering from Bulimia Nervosa 153

Research methods
The methods applied in the research included an inventory (i.e. the Eating Disorder Inventory (EDI) devised by Garner, and Thompson's Body Dissatisfaction Inventory) as well as projective techniques such as Thompson's Silhouette Test and a thematic drawing: "body image". The inventories and projective techniques applied in the research procedures, aimed at making a psychological diagnosis of the investigated variables, are fully described in the subject literature [Thompson, Hornowska, Paluchowski, Oster]. The Eating Disorder Inventory devised by Garner is one of the instruments most frequently used to measure the patterns of behaviour and attitudes dominating the clinical picture of anorexia and bulimia nervosa, including those related to the process of perceiving and experiencing body [Thompson]. The following 3 scales, considered the purposes they had been devised for, were applied in the research: the Body Dissatisfaction Scale, the Interoceptive Deficits Scale, and the Maturity Fear Scale. The Body Dissatisfaction Scale was used to measure the indicators of the body self component called "body image". The scale allowed to evaluate the level of the overall body satisfaction, and ever increasing discreditation of one's own appearance, body shape and weight as well as the particular body parts. It consisted of ten items. Each research participant was rated on a 0 to 40 point scale. The score ranging from 40 to 36 was interpreted as a very high level of discreditation of one's own body shape and size as well as body dissatisfaction. The score ranging from 35 to 22 points to considerable dissatisfaction with body shape, size and weight, and to negative feelings regarding body parts. The score ranging between 21 and 0 denotes the norm [Higgins]. The "Interoceptive Deficits" Scale was applied to measure the level of interoceptive awareness in the group of examined females. It allowed to evaluate the level of perplexity, which occurs in the process of recognizing and responding to emotional states and body sensations, and helped to assess the level of fear of high affection and of losing control. The scale consisted of eight items. Each research participant was rated on a 0 to 32 scale. A high score (13-32 points) points to a high degree of perplexity and discreditation of the experienced emotions. It proves that instead of being experienced, emotions undergo intellectual evaluation aimed at checking whether they are well-grounded, desired and justified. It can be assumed that a high score on this scale is interpreted as a significant risk factor which contributes to development of an eating disorder. A low score (0-10 points) indicates a properly retained ability to deal with and accept positive and negative emotions regarding one's own body. It is also an indicator of mental health [Higgins]. The "Maturity Fear" scale served as an instrument for measuring the level of approval of psychosexual development. Maturity fear is related to the exhibited tendency, a desire to regain the pre-pubescent appearance [Higgins]. The examined subjects were rated on a 0 to 32 point scale. A high score (between 13 and 32) denotes a strong desire for being younger and regaining childhood security. It also proves the conviction that the requirements set during the period of maturity are too high. A low score (between 0 and 5) indicates a high level of psychosexual development acceptance, and mental transition to the stage of maturity [Higgins]. The second measurement instrument applied in the research was the Body Dissatisfaction Inventory devised by K. Thompson [Cash, Pruzinsky, Thompson]. It was used to measure the level of satisfaction and dissatisfaction with weight, body shape and appearance in the examined women. The research subjects rated themselves on a 10-point satisfactiondissatisfaction continuum, which resulted in the scores ranging from 0 (a high level of satisfaction) to 10 (a high level of dissatisfaction). It was assumed that the score of 5 should be interpreted as an average level of body satisfaction. Another instrument used in the research to measure body image was a projective technique -the Silhouette Test by Thompson [Cash, Pruzinsky, Thompson]. It allowed to make a comparison between the actual body image (the actual self image), perceived by the subject, and its ideal image (the ideal self image). The instrument consists of a set of nine male and nine female silhouettes ranging from very thin to very fat. The subjects' task was to select the figure which most closely matched their current body shape, and one image which they considered ideal. Additionally, the subjects were supposed to provide details concerning their age, current weight and height. The figure ratings obtained in the test were used to calculate the current-ideal discrepancy (the individual's perceived current body shape versus the ideal body image), and thus to examine the respondents' body image acceptance The scores received in the research ranged from 0 (lack of discrepancy, which indicates a high level of body image acceptance) to 8 (very high discrepancy, which proves a low level of body image acceptance). Thematic drawing ("body image") was used to examine the level of body schema complexity as well as a sense of body boundaries (the feeling of separating one's own body from the external world, which allows to perceive oneself as a bodily creature, definite and different from others). It is a projective technique, in which the study subject's task is to draw a picture of body. The test is based on an assumption that the drawing is projection of the examined person's self image, especially such components of the body self as the body schema and body boundaries [Hornowska, Paluchowski, Oster]. In order to investigate the aforementioned elements, the test analysis focused on such aspects of the drawing as evaluating the number of body details as well as investigating formal and structural elements of the drawing (the size of the figures, the pencil stroke and pressure). Referring to theoretical assumptions concerning the role of the human figure drawing in a psychological diagnosis, it was assumed that the greater number of details corresponds with a higher level of the body schema complexity [Hornowska, Paluchowski, Oster]. Formal and structural analysis of the drawings focused on the size adequacy of the depicted figures. Both too small and extremely large figures seem to point to inadequate perception of body size. Such aspects of drawings as the presence of the main body parts (e.g. head, hair, nose, lips, eyes, neck, trunk, arms, hands, legs, and feet) and the characteristics of the body portrayal (e.g. the pencil stroke, the kinds of lines, body proportions, scaling the figure up or down) were taken into consideration in psychological interpretation of the indicators of a body schema and body boundaries. The pencil stroke analysis, based on the Goodenough-Harris Draw-A-Person Test, involved examining the kinds of lines drawn by the research subjects (e.g. unbroken, dotted, thick, thin, or not sharp). An unconnected, thin and blurred stroke can be interpreted as difficulties in establishing precise body boundaries in the examined person. It was also assumed that the number of body parts the subject considered significant and included in her drawing corresponded with the level of the person's body schema and image complexity. The subject scored 1 point for each detail depicted in the drawing. Lack of the particular body part meant 0 points. The accuracy of classifying the particular www.intechopen.com A Psychological Profile of the Body Self Characteristics in Women Suffering from Bulimia Nervosa 155 indicators into the given categories was examined by five competent judges (clinical psychologists), on the basis of the following scale: -0 -a low ( inadequate ) score (lack of the particular body part in the drawing); -1 -a high ( adequate) score (an element depicted in the drawing); -0.5 -an average score. The research comprised two stages. The first phase involved psychological measurement of the examined indictors of the body self in the population of 102 Polish females, using clinical and test methods, as well as projective techniques (e.g. observation, a clinical interview, or thematic drawing: "body image"). The second stage of the research was aimed at conducting a statistical and clinical analysis of the research data, which involved the following steps: -calculating the mean values for the strength level of the investigated body self indictors in the clinical population of women suffering from bulimia nervosa as well as in the control population of females; -assessing the intra-group similarities and differences regarding the strength and configuration of the investigated indicators of the body self structure in the whole population of the research subjects (i.e. females suffering from bulimia nervosa and the individuals in the control population) using the k-means method [Stanisz] assessing significant differences between the clinical population and the control group of females in terms of the strength level for the investigated indicators of the body self structure, using Student's t-test for two independent samples.

A psychological profile of the body self characteristics in females suffering from bulimia nervosa
Statistical cluster analysis conducted using the k-means allowed to distinguish three clusters in the whole research population of 102 females. Cluster No. I and Cluster No. II consisted of women diagnosed with bulimia nervosa. Whereas cluster No. III was comprised of females revealing no mental disturbances or eating disorders. The research data analysis demonstrated certain significant differences between the examined females in the aforementioned three clusters in terms of the strength level and configuration of the body self characteristics. Hence, the three clusters were referred to as: "Bulimic Type I (a socio-cultural type)", "Bulimic Type II (a separation type)", and Type III (an adequate type). Each of them referred to certain distinctive characteristics of the body self structure in the examined women.  Specification of significant differences regarding the strength level for the body self characteristics between the bulimic subjects (Type I and Type II) and the examined females revealing no mental disturbances or eating disorders (Type III).

Psychological assessment of the body schema and body boundaries dysfunctions in women suffering from bulimia nervosa and in females exhibiting no eating disorders or mental disturbances
The indicators of the body schema and body boundaries among the examined females were examined using a projective technique, i.e. thematic drawing: "body image". Formal and structural analysis of the drawings focused on the characteristics of the body portrayal which included such aspects as: the size adequacy of the depicted figures (the tendency towards scaling the figures up or down; maintaining or losing body proportions), the number of details included in the drawing, the pencil stroke, and the kinds of lines drawn by the research subjects. The aforementioned elements were examined by five competent judges (psychologists) on the basis of the following criteria: -1-0.7 -a high score (a highly detailed drawing which depicts an elaborate figure, and includes more than 11 major body parts all of which are proportional and clearly outlined), -0.6-0.4 -an average score (a norm) -(a drawing which includes 11 major body parts all of which are proportional and appropriately outlined),

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A Psychological Profile of the Body Self Characteristics in Women Suffering from Bulimia Nervosa 157 -0.3-0 -a low score (a drawing which is not very detailed, and includes fewer than 11 major body parts which are not proportional; the figure is vaguely sketched, the line is unconnected and blurred). The data gathered in the whole sample of 102 females (i.e. the women suffering from bulimia nervosa as well as the individuals exhibiting no eating disorders or mental disturbances) did not reveal any significant dysfunctions in terms of the body schema or body boundaries in any of the examined subjects. The mean values concerning the presence or absence of the major body parts in the participants' drawings turned out to be high or average in the majority of the examined females, which demonstrates the individuals' adequate (conforming to the norm) body schema complexity. Cluster analysis of the data collected in the whole population of 102 females discovered that the subjects not suffering from bulimia nervosa (who comprised Cluster No. III) maintained a proper body schema and body boundaries. The individuals in this cluster did not present any distorted figures in their body drawings (the mean value for scaling the figures up and down reached 0.7). The bodies sketched by the females did not miss any parts, all of which were properly attached to the depicted figures (head featuring eyes, mouth, nose, hair; sharply drawn arms and legs with thighs and feet, connected to the body trunk). The mean values for the body proportions shown in the participants' drawings prove that the women in cluster No. III, maintained body proportions in their drawings: the proportion of arms to trunk, legs to trunk, and head to trunk. A sharp pencil stroke dominating in the drawings (the mean value = 0.84) as well as the so called average unbroken line (the mean value = 0.53) demonstrate maintained body boundaries. Cluster No. III was predominated by the females whose mean age was 23, and their average body weight reached 55.7 kg, at which level their BMI was 20.16 (within the normal range). Analysis of the mean values for the level of the women's satisfaction with their own body, its weight, shape and general physical appearance, points to the subjects' average (adequate) level of body acceptance and appearance satisfaction. The mean values in the "Body dissatisfaction" scale as well as those obtained as a result of Thompson's Figure Test also denote a high level of satisfaction with body shape and appearance among the females in cluster No. III. The mean values for evaluation of the current self image ("what I look like") and the ideal one ("what I would like to look like"), reaching the value of 3.95 and 3.63 respectively, also indicate adequacy in perceiving and experiencing body in this group of examined females. This in turn points to adequate (positive) self-assessment, as well as to one's own body satisfaction. A low mean value of 2.74 in the "Interoceptive awareness" scale (the EDI inventory) points to the fact that the non-bulimic subjects maintain a highly adequate ability to recognize and respond to the occurring emotional states and body sensations. It can also indicate that the women are able to accept and experience the feelings regarding the body, and they do not make any discrediting intellectual evaluation. The mean value of 4.58 in the"Maturity fear" scale (the EDI inventory) indicates a low level of emotional discreditation of body among the examined females. It also proves that they fully accept their body sexuality and transition into adult life, which is accompanied by mental acceptance of "farewell to childhood and childlike body image". Summing up, the data obtained as a result of this research denote adequate self-perception and self-assessment as well as a high level of satisfaction with body shape and appearance in the group of non-bulimic females. Additionally, a certain tendency was detected: the females desired (ideal) body is thinner than their current body shape, which is proved by the mean BMI index value of 20.16 and the mean value of 3.63 for the ideal self in Thompson's Figure Test. It appears that although the women would like to have a slimmer body, and seem to be rather dissatisfied with their real body image, their body self is not pathologically distorted. It might suggest the influence of the socio-cultural cult of thinness. However, the level of the examined women's mental maturity, their biological age (they constitute the oldest sample, compared with the other two clusters), and lack of emotional deficits or traumatic experience (especially in relationships with care-givers) can prove that they do not exhibit any symptoms of increased separation anxiety which usually impedes the separation-individuation process. The observed finding can be underpinned by the object relations theory which suggests that the quality of the infant's early relationship with a primary caregiver (an object) affects the individual's further development. According to the approach represented by Bruch, Mahler, Clein or Kruger, the mother's empathic resonance with the infant's internal experience allows the formation of the infant's primary body self, that is, a system of early bodily sensations, which in turn is a prerequisite for the further emergence of a sense of self and body boundaries that allow to differentiate self from non-self [Krueger]. The interview data prove that the examined females in cluster No.III did not experience any emotional deficits or psychic traumas in relationships with their mothers. Moreover, the subjects did not report any facts in their lives which could determine development of traumas in their interpersonal relationships (e.g. physical, sexual or mental abuse). Their biological age points to the fact that the women have already completed the process of separation, they have managed to shape their personal, social identity and the ability to establish a partner relationship based on a strong (emotional, sexual) bond. The females tend to yield to social pressure related to the "cult of thinness" and comply with the standards of attractiveness, which seems to affect the evolution of their body image. However, the socio-cultural factors are not strong enough to impede development of their female identity and thereby lead to pathological distortions of body image in the examined women. Statistical analysis of the data obtained as a result of a Student's t-test demonstrates significant differences between the healthy females (Type III) and the bulimic subjects (Type I and Type II) in terms of body proportions in their figure drawings. Certain pathological tendencies were observed among the females suffering from bulimia nervosa. Significant disproportion of body parts (e.g. trunk-legs or trunk-head disproportion) was noticed in the figures drawn by the bulimic individuals. Additionally, certain body parts which they included in their drawings (e.g. stomach, hips, and breast) turned out to be excessively scaled up. The figure test was also applied by such researchers as Marike Tiggemann, Kevin Thompson, David Garner and Thomas Cash. The research results described in the subject literature prove that body image dissatisfaction refers to certain attributes of physical appearance, predominantly to body shape and weight, as well as face, hair, stomach or breast. The data provided in Polish professional literature [8,9,11] indicate that women suffering from eating disorders show excessive (pathological) concern with the aforementioned body parts, and they tend to overestimate the influence of the specified body parts on their global self-assessment, and consequently discredit their bodies, and lower their self-esteem Excessive focus on body, and its negative evaluation constitute the major factors determining development of eating disorders, as it was pointed out by Cash [Cash, Pruzinsky, Thompson, Garner]. Lack of significant differences between the examined females comprising the three clusters, in terms of major body schema indicators seems to be justifiable since the body schema and the ability to recognize body boundaries are considered to be the primary (developed in the first two years of the www.intechopen.com person's life) function of the body which is not disturbed in women. With age, the knowledge concerning the body, related to developmental mechanisms and social influence, becomes more profound, which is accompanied by adequate body size perception. During adolescence, a distinct emotional attitude towards the body is shaped, and appearance proves to have increasingly significant influence on the person's self-assessment and selfesteem. The research subjects were young females in late adolescence, the final stage of development. This may provide an explanation for the trunk-legs or trunk-head disproportion noticed in the figures drawn by the subjects suffering from bulimia nervosa. The characteristic feature of their figure portrayals was the tendency towards scaling up the trunk which did not stay in proportion with the legs and head that were reduced in size. It can be presumed that the disproportions of body parts result from distorted body perception, which an individual develops in the course of his or her psychological development, as well as from the person's emotional experience regarding the body and his or her emotional attitude towards physical appearance, which is shaped during adolescence. As a result of psychosexual development occurring during the period of adolescence, the level of concern regarding body image increases. This, when coupled with social pressure concerning the body, may either stimulate development of proper characteristics of body image, or trigger its pathological distortions in bulimia sufferers.

Cognitive and emotional characteristics of the body self (i.e. emotions regarding the body, interoceptive awareness, body perception and self-assessment)comparative analysis aimed at investigating the main differences between the bulimic subjects and the females exhibiting no mental disturbances or eating disorders
Statistical comparative analysis conducted using a student's t-test revealed significant differences between the examined women suffering from bulimia nervosa (N=52) and the nonbulimic subjects (N=50) in terms of such characteristics of the body self structure as the quality of emotions regarding the body, overall body self-assessment, perception of body image (both current and ideal appearance), recognizing bodily sensations (i.e. the deficits in interoceptive awareness), experiences related to bodily functions (i.e. the level of maturity fear and approval of psychosexual development which is related to the process of entering the stage of maturity, and to body image transformation as well as loss of the sense of childhood security). The mean values for the level of body self-satisfaction, its weight, shape and appearance, obtained in the group of females exhibiting no eating disorders, indicate that the individuals in this cluster express rather positive feelings towards their own body and are satisfied with it. The mean value of 5.33 for the level of body dissatisfaction, received in the EDI inventory, as well as the mean values for body shape satisfaction (1.59), weight satisfaction (0.95) and appearance satisfaction (1.04), obtained in Thompson's silhouette test proved to be low, which suggests that the examined females in this sample do not exhibit any disturbances regarding their emotional body experience or cognitive body image. The research results obtained in the group of females suffering from bulimia nervosa turned out to be significantly different. Analysis of the data collected in this sample revealed pathological (excessive) increase in the level of dissatisfaction with body, its shape and physical appearance. It is proved by the mean value of 23.06, obtained in the "Body dissatisfaction" scale (the EDI test), as well as by the mean values for body shape dissatisfaction (9.09), weight dissatisfaction (8.83) and appearance dissatisfaction (9.34), received in Thompson's silhouette test. The statistical significance of the differences between the bulimic and non-bulimic research subjects turned out to be considerably high (p=0.001).
The bulimia sufferers have been identified as having a decidedly higher, compared with the sample of healthy females, incidence of negative emotions regarding the body, and they reveal a higher level of body image dissatisfaction. The received finding seems to correlate positively with increased fear of gaining weight (the so called fat phobia) among the bulimic females. Low self-esteem and lack of body acceptance among bulimia sufferers, as well as their compensatory behaviours aimed at gaining the "perfect body" appear to have their roots in the fear of being fat, described in the subject literature [43], and regarded as a factor determining the onset of the eating disorder. Analysis of the mean values for the level of interoceptive deficits regarding one's own body demonstrated statistically significant differences between the two groups of examined women. The mean value obtained by the bulimic subjects in the EDI test proved to be high (=16.55), which points to the females' high degree of discreditation of emotions regarding their own body. It indicates that instead of being experienced, their emotions undergo intellectual evaluation aimed at checking whether they are well-grounded, desired and justified. The low mean value of 2.74, received in the control population, indicates a properly maintained ability to deal with and accept positive and negative emotions regarding one's own body. The mean values in the "Maturity fear" scale (the EDI inventory), obtained in the control population and in the clinical sample, as well as the data obtained as a result of statistical significance analysis conducted using a student's t-test reveal a considerable discrepancy between the two groups of examined females. The mean value of 12.45 for the level of maturity fear, obtained in the group of bulimic subjects, denotes the women's strong desire for being younger and regaining childhood security. It also proves the subjects' conviction that the requirements set during the period of maturity are too high. Whereas the low mean value of 4.58 in this scale, obtained in the sample of females exhibiting no eating disorders, can be interpreted as a low level of maturity fear among the individuals, and it indicates a high level of acceptance of psychosexual development and mental transition to the stage of maturity, that is, acceptance of feelings regarding the body and sexual functions of the body. Analysis of the data obtained as a result of Thompson's Figure Test, aimed at examining the current self image ("what I look like") and the ideal one ("what I would like to look like"), revealed statistically significant differences between the bulimic and non-bulimic subjects. It was found that when evaluating their actual body image, the examined females in the control group tended to select the figure which most resembled their own body shape and weight (the average body weight in this group reached 55.7 kg, at which level the females' BMI was 20.16). The image they frequently opted for in Thompson's Figure Test was the so called slim silhouette to which a mean value of 3.95 was assigned. This indicates adequacy in perceiving body image. Whereas analysis of the data gathered in the group of females suffering from bulimia nervosa, who were close in age to the non-bulimic subjects, discovered that they perceive their bodies as fatter than they really are. A considerable discrepancy was revealed between the bulimic females' mean value for the current self rating (5.75) and the women's average body weight (55.43 kg) and BMI index value (19.81). It is surprising that although the mean values concerning body weight and BMI index were similar in the two groups of the examined females, the bulimia sufferers tended to exhibit distortions in perception of their current body image. It can be concluded that although the bulimic individuals weighed less than the healthy subjects, they tended to perceive their bodies as much fatter than they really were. The image they most frequently chose in Thompson's Figure Test to evaluate their current body image was a silhouette much fatter than their actual body. This seems to point to www.intechopen.com distortions in cognitive body image, which is a distinguishing characteristic of body perception among individuals suffering from eating disorders, as was proved by the results of research conducted by Thompson and Cash [Cash, Pruzinsky, Thompson, Altabe]. Other significant differences between bulimic and non-bulimic females were discovered in terms of evaluation of the ideal body image ("what I would like to look like"). The data analysis revealed a tendency among the bulimic females which was dominated by a desire to have a much slimmer figure than their current body shape, which was proved by the mean value of 2.24 for the ideal self image, received in this group of women. This points to the individuals' "desire for slimness". An emaciated body shape turned out to be the image most frequently selected by the bulimic females in Thompson's Figure Test to represent their desired (ideal) body figure. A similar tendency is generally observed among anorectic individuals. The significant discrepancy between the current and ideal body image in the group of women suffering from anorexia nervosa may correlate with the fear of gaining weight, that is, fat phobia, which has been described in subject literature [Wilson].

Intra-group differences in terms of cognitive and emotional characteristics of the body self in the sample of females suffering from bulimia nervosa
Statistical analysis of the research data, conducted using a student's t-test (for two independent samples) revealed certain statistically significant differences between the examined females classified into the bulimic Type I and Type II. The following statistically different mean values were received in the EDI inventory, in Thompson's Body Dissatisfaction Inventory as well as in Thompson  Thompson and Gray's Figure Test -Type I: current self-image =5.54, ideal self-image = 2.29; Type II: current self-image = 6.00, ideal self-image = 2.17. The received data point to a considerably higher level of developmental dysfunctions and distortions in terms of body perception and emotions regarding the body in the subsample of bulimic females constituting Type II (the so called separation type). The subsample defined as Type I (socio-cultural) comprised 26 individuals who appeared to be slightly younger. A mean age in this group was 21 and 2 months. The females' average body weight was 54.5 kg, and a mean BMI in the investigated subsample reached the value of 19.38 (the lower limit of the norm). The real self-image score of 5.54, obtained in Thompson's silhouette test, proves that the bulimic females (Type I) have a realistic and adequate perception of their body. However, the man value of 2.29 for the ideal self rating, received in Thompson's figure test, points to the women's strong desire for an ideal body shape. This might mean that the need to yield to socio-cultural pressure related to the "cult of thinness" appears to be stronger among younger individuals who haven't completed the separation-individuation process yet. The subsample of bulimic females classified into Type II (the separation type) was constituted by 23 individuals whose mean age was 22.6, average body weight was 56 kg, and a mean BMI in the investigated group reached the value of 20.32. During the clinical interview, it was discovered that the women had experienced emotional deficits and psychic traumas in their lives. The majority of the subjects in the sample reported childhood psychic traumas and emotional deficits (e.g. physical or sexual abuse, some individuals were abandoned by significant objects -parents). As opposed to the females constituting the bulimic Type I, the individuals classified into Type II reported that their bulimic symptoms occurred in the early stages of the disease, and were preceded by several years of food restriction. According to the information gathered during the clinical interview, the earliest onset of bulimia nervosa among the examined females classified into the separation Type II occurred shortly before they undertook treatment, having been self-motivated and encouraged by their family members. Remaining under medical supervision, the bulimics were able to control the cycles of binge eating and purging, and to reduce the frequency of the compensatory behaviours. The present findings seem to be consistent with other research investigating the role of trauma symptoms (especially sexual trauma experienced during childhood) in the development of eating disorders , which has been described in the subject literature [Rorty, Yager, Rossotto, Kent, Waller, Dagnan, Hartt]. Although the conducted studies do not provide evidence for a high correlation between childhood sexual trauma and the development of bulimia nervosa, they demonstrate that such traumatic experience is likely to increase the incidence of eating disorders, especially bulimia nervosa. According to the assumptions of the object relations theory, the real mother-child relationships are internalized during childhood, and provide a foundation for the emergence of personality and the ego identity [Tyson]. The mean values received in the EDI inventory, in Thompson's Body Dissatisfaction Inventory as well as in Thompson and Gray's Figure Test, obtained in the subsample of females constituting the bulimic Type II, indicate that the individuals exhibit a strong tendency towards emotional and cognitive devaluation of the body. The socio-cultural pressure related to the "cult of thinness" , coupled with growing fear of maturity and adulthood (the mean value of 16.78 in the EDI inventory), as well as incresed separation anxiety, reinforces the examined women's tendency towards discrediting their own bodies, which is stronger than among the bulimic females classified into Type I. A high (pathological) mean value in the "Interoceptive Deficits" scale (the EDI inventory), obtained in this subsample, points to the individuals' inadequate level of interoceptive awareness. It denotes a high degree of perplexity and discreditation of bodily sensations and emotions regarding the body. The data prove that instead of experiencing the emotions regarding their body perception, the examined bulimic females classified into the separation type conduct intellectual evaluation aimed at checking whether the emotions are well-grounded, desired and justified. The psychic mechanism of rationalization which prevails in this group of subjects impedes the individuals' ability to go through direct emotional experience. This finding supports the research conducted by Józefik, which has been described in Polish literature [Józefik]. The so called "bulimic self", as referred to in the subject literature, is reflected in the body self, i.e. it is expressed through body language. The bulimic self represents the primitive need for dependence as well as the need for autonomy and separation, which is manifested through binge eating and self-induced vomiting. These compensatory bahaviours allow an individual to establish his or her own identity, and to separate from a significant object [Sands].

A psychological profile and different configurations of the body self components distinguished in the population of females suffering from bulimia nervosa (conclusions drawn from the author's own research)
The data obtained as a result of this research revealed diversity in terms of the body self characteristics in the examined individuals suffering from bulimia nervosa. The subjects' life www.intechopen.com experience appeared to be the factor determining this diversity. It was found that some of the examined females had experienced emotional traumas which affected their psychological development. As a consequence of inadequate separation and individuation process, the examined individuals appear to exhibit considerable dysfunctions of the body self, and they will probably need long-term and multi-dimensional (psychological and medical) treatment. This group of bulimic females was referred to as bulimic Type II, the so called separation type. It was comprised of 23 subjects diagnosed with bulimia nervosa, whose mean age was 22 and 6 months. A diagnosis of the body self characteristics in this sample revealed significant dysfunctions in terms of all components of the body self structure. The main features that characterize this group of women include: strong emotional and cognitive disapproval of the current body image (i.e. body dissatisfaction and critical body self-assessment); a low level of interoceptive awareness of the body; and a discrepancy between the real and ideal self-image, accompanied by a tendency towards gaining an ideal emaciated figure which does not conform to the developmental norms. The subsample is predominated by females who have been experiencing increased separation anxiety, and at the same time they tend to completely discredit their bodies. The mean values for the level of body acceptance and experiencing emotions regarding the body, obtained in this group of the examined females, denote the individuals' strong tendency towards cognitive and emotional devaluation of the body. The mean values for the current and the ideal self rating, received in Thompson's Figure Test, point to a significant discrepancy between the two aspects. It can be concluded that the females' distorted perception of the actual body image, as well as their increased (pathological) perplexity and difficulties in recognizing and responding to emotional states and body sensations prove that the women exhibit certain dysfunctions of one of the body self components, i.e. interoceptive awareness. It is worth mentioning that the mean age and BMI values obtained in the group of bulimics classified into Type II conform to the age-appropriate norms. The question arises as to whether it is possible to provide an explanation for the fact that the females who exhibit a high degree of the body self dysfunctions have a normal body weight. The received data indicate that at the time of the research, the examined individuals in question had been participating in long term treatment for at least 12 months, and remained under regular medical supervision (e.g. they had been undergoing medical tests and were provided with medical and psychotherapeutic consultations), which was an obligation imposed by their therapeutic contracts. Hence, it can be concluded that the females' normal (adequate) body weight acts as "camouflage" or a "cover" for the considerable body self dysfunctions which they exhibit. This points to the existence of certain destructive psychological mechanisms aimed at camouflaging negative emotions regarding the body as well as cognitive body distortions. It appears that the individuals who enter nto a therapeutic contract try to observe its stipulations by maintaining an adequate body weight, but they still exhibit disturbances in their emotional and cognitive attitude towards the body. It is likely that the women's subordination is feigned, and they only pretend that they participate in the process of treatment. This might suggest that a long term and intensive psychotherapy aimed at eliminating body image distortions is an indispensable element of effective (not superficial) treatment of eating disorders. The childhood and adolescent relational (sexual) traumas reported by the examined females point to the necessity of introducing the treatment methods which would focus on dealing with psychological separation and individuation, and the problems related to the process of experiencing the body. Another type of psychological profile distinguished among the examined females was defined as Type II -socio-cultural. It prevailed in the group of slightly older research subjects. It was discovered that evaluation of body image in this sample is determined by social-cultural factors and the cult of thinness. As a result of examination of the individuals' body self characteristics it was found that although the women do not exhibit any significant developmental dysfunctions (they display an average level of emotional and cognitive body acceptance, appropriate interoceptive awareness and adequate current body perception), they reveal a strong desire for a much slimmer (ideal) body. It is likely that the research data were affected by the fact that the examined females had been undergoing regular medical treatment and psychotherapy. The socio-cultural type is also characterized by an average sense of security related to the process of entering the stage of maturity and accepting "farewell to childhood". The research data demonstrate that the females are aware of their adequate feelings regarding the body, and they are generally satisfied with their actual appearance. However, a certain discrepancy was detected between the individuals' cognitive evaluation of their current body shape ("what I look like") and the so called ideal body image ("what I would like to look like"). This finding might point to slight distortions in the real body image observed in this group of research subjects.

Conclusions
Analysis of the data obtained as a result of this research revealed diversity in terms of the body self characteristics among bulimia sufferers experiencing a variety of destructive symptoms (e.g. episodes of binge eating and purging). Different configurations of the body self characteristics in bulimic individuals can be determined by a variety of major factors. They include socio-cultural determinants (e.g. the social pressure related to the commonly approved cult of thinness regarded as the key to success and positive self-assessment), which significantly contribute to development of bulimic tendencies. The major distortions in body perception and evaluation of physical appearance which develop in bulimia sufferers as a result of socio-cultural pressure, lead to developmental dysfunctions and disturbances of body experience. However, other components of the body self remain undisturbed (i.e. an appropriate body schema, an adequate level of interoceptive awareness and appropriate bodily functions, as well as lack of anxiety related to the process of transition into adult life and performing roles based on a female model of psychosexual maturity). The aforementioned dysfunctions are triggered by extrinsic (environmental) factors. A different configuration of the body self characteristics emerges as a result of an inadequate process of psychological separation and individuation, disturbed by emotional deficits and psychological traumas during childhood. It is characterized by a higher, compared to the socio-cultural type, degree of cognitive and emotional dysfunctions of all the investigated components of the body self. The disturbances are determined by intrinsic (personality-based) factors, and correlate with inadequate separation and individuation in bulimic individuals. A psychological differential diagnosis, aimed at distinguishing various types of the body self structure in the population of females suffering from bulimia nervosa, supports psychological diagnostic techniques, and thus improves the effectiveness of therapy in patients exhibiting this kind of disorder.