Assessing Guilt in Adolescents with Anorexia Nervosa
Berghold, Karena M., Lock, James, American Journal of Psychotherapy
Objective: This study explores the role of guilt in adolescents with anorexia nervosa. Numerous clinical observations have suggested guilt in adolescents or parents contributes to the development of anorexia nervosa, though systematic assessment of this phenomenon has not been undertaken.
Methods: The Interpersonal Guilt Questionnaire was used to assess types and levels of guilt in adolescents with anorexia nervosa and their parents.
Results: We found significantly elevated levels of self-hate guilt in adolescents with anorexia nervosa compared to adolescent norms. However, parents had lower levels of guilt compared to adult norms.
Conclusion: Self-hate guilt is elevated in adolescents with anorexia nervosa. Treatment strategies should take this phenomenon into consideration when developing clinical approaches.
Anorexia nervosa affects approximately 0.48% of females between the ages of 15 and 19 (1). It also has the highest mortality rate of any other mental illness (2). There are a myriad of approaches and theories that purport to account for the illness, but most of them remain untested. One of the more compelling theories suggests that guilt is a central theme in patients and families with anorexia nervosa.
In 1978 Minuchin, Rosman, and Baker described the "anorectic system" as a system in which loyalty and protection take precedence over autonomy and self-realization (3). Children in anorectic systems are particularly loyal to, and protective of, their parents at the expense of their autonomy and self-development. Guilt is seen as the motivator behind this self-sacrifice. Friedman theorized that the relief of guilt is instrumental in treating patients with anorexia nervosa in order for them to return to normal developmental tasks of adolescence and young adulthood (4). Similarly, Dare and Eisler suggested that decreasing parental guilt is essential to successful family treatment (5). In addition, according to others, mothers feel guilty and experience intense feelings of failure when their child develops anorexia nervosa (6, 7). Maine (6) argued that this is in part because they bear the responsibility for the family's emotional life (6). She also believed that for many women this is rooted in their search for approval and praise for being the perfect "super-mom." Fathers, she explained, feel guilty when they sense that they are unable to make an impact, which can often be the case with anorexia nervosa.
Systematic study of guilt and psychopathology has been limited. However, Joseph Weiss and the San Francisco Psychotherapy Research Group developed and tested a measure to assess guilt in the context of control-- mastery theory. Control-mastery theory emphasizes the role of interpersonal guilt in a wide range of psychopathology. According to the theory, certain kinds of interpersonal guilt impede normal, healthy development. Control-mastery theory, though founded on the principles of classical analytic theory, is unique in that it contends that the repetition of pathogenic behavior is an adaptive attempt to master one's problems rather than an unconscious drive. Similarly, the theory supports the idea that certain forms of guilt have adaptive underpinnings.
In 1997, O'Connor, Berry, and Weiss (8) reported on the development of a new measure (Interpersonal Guilt Questionnaire [IGQ]) designed to operationalize and assess several kinds of interpersonal guilt related to the fear of harming others (8). In 1999, O'Connor, Berry, and Weiss reported on their most recent studies utilizing the IGQ-67 (9). These studies included a subject pool of 223 college students from a large university and a pool of 61 college students from another large State University. The results support the hypothesis that interpersonal guilt, as measured by the four subscales of the IGQ-67, is correlated with a wide range of psychological problems and symptoms.
If guilt does play a critical role in the etiology of anorexia nervosa, as Friedman suggested, then the IGQ may be able to elucidate specific forms of interpersonal guilt that are present in both the adolescent with anorexia nervosa and his or her family. …