Adult Separation Anxiety Disorder Symptomology as a Risk Factor for Thin-Ideal Internalization: The Role of Self-Concept Clarity

Abstract

The study of when and how individuals compare themselves against standards has been an enduring focus for clinical and social psychology researchers in efforts to facilitate well-being and health. Our study focused on internalization of the societal thin-ideal standard for feminine attractiveness, a construct that has proven to be very important in women’s psychological health. Although multiple adverse consequences of thin-ideal internalization have been documented, the understanding of variability in the extent of thin-ideal internalization across women (e.g., why do some women strongly internalize thin-ideal standards when others do not?) is much less well developed. This research was conducted to explore the role of adult separation anxiety disorder (ASAD) symptomology and conceptions of the self in young women’s propensity to internalize the thin-ideal attractiveness standard. Results show that elevated ASAD symptoms are associated with greater thin-ideal internalization. A structural equations model demonstrates the reason for this association; young women with higher ASAD symptomology exhibit lower self-concept clarity, which drives greater thin-ideal internalization. This research makes novel practical and conceptual contributions by (a) delineating a new risk factor for the development of thin-ideal internalization, (b) highlighting a previously undocumented vulnerability of women who experience ASAD symptoms, and (c) documenting the relationship between ASAD and lower self-concept clarity. Implications for mental health practitioners are discussed.

Keywords

Body image comorbidity gender health professionals risk factors self-concept separation anxiety

Introduction

The study of when and how individuals compare themselves against standards has been an enduring focus for clinical and social psychology researchers in efforts to facilitate well-being and health. Indeed, women’s propensity to internalize the thin societal standard of attractiveness for females is among the most important constructs in body image research. Body image, in turn, is a crucial focus for researchers and practitioners of psychology interested in understanding and promoting women’s health (Saules, Collings, Wiedemann, & Fowler, 2009; You & Shin, 2016). Thin-ideal internalization has been linked to numerous adverse consequences including eating disorders (Suisman et al., 2014), eating pathology (Schnitzler, von Ranson, & Wallace, 2012; Stice, Ng, & Shaw, 2010), body dissatisfaction (Fitzsimmons-Craft et al., 2014, 2016; Tiggemann, Brown, Zaccardo, & Thomas, 2017), and compulsive exercise (Homan, 2010; Stice & Whitenton, 2002). Moreover, to the extent that a woman has internalized the societal thin ideal, she is more likely to experience adverse effects when exposed to media images of attractiveness (Dittmar, Halliwell, & Stirling, 2009). One reason thin-ideal internalization is so toxic is that the extent of the discrepancy women perceive between their own attractiveness and the thin-ideal standard predicts body image disturbance (Posavac & Posavac, 2002; Shorter, Brown, Quinton, & Hinton, 2008).

Although our knowledge base regarding the measurement and consequences of thin-ideal internalization is strong, there is much less understanding of risk factors that may be related to its development (Suisman et al., 2014; Vartanian, Froreich, & Smyth, 2016; for exceptions see Boone, Soenens, & Braet, 2011; Vartanian, 2009). Learning more about such predictors is quite important given the significant adverse downstream consequences women experience if they develop high levels of thin-ideal internalization (see Thompson & Stice, 2001).

The purpose of this research was to explore the potential relationship between adult separation anxiety disorder (ASAD) symptomology and thin-ideal internalization. Although separation anxiety in children has long been a focus for clinicians and researchers, the adult manifestation of separation anxiety disorder has only recently been recognized as a unique condition (American Psychiatric Association, 2013). The defining characteristic of ASAD is excessive fear of separation from others with whom one is attached (American Psychiatric Association, 2013). Distress may occur when individuals are separated, or anticipate separation, from attachment figures or home, and when an event that would lead to losing or being separated from an attachment figure is contemplated.

Researchers have begun to explore the implications of, and phenomena associated with, the presence of ASAD. For example, Posavac and Posavac (2017) explored consequences of ASAD for attitude change and demonstrated that individuals higher in ASAD symptomology (versus those with lower or no symptoms) were particularly susceptible to persuasion by advertising that contained a narrative relevant to the concept of “home.” From a more practitioner-oriented perspective, Boelen, Reijntjes, and Carleton (2014) explored the role of intolerance of uncertainty in ASAD symptoms, and Silove and Marnane (2013) documented the pattern of comorbidity between ASAD and panic disorder with agoraphobia. Like our research, these investigations are important because as understanding is developed regarding the correlates, causes, and consequences of ASAD, clinicians will be better able to serve clients presenting with this condition.

Although this has not been previously established empirically, one of the tendencies clinicians may observe in clients with ASAD is the lack of a clear and stable self-concept. The self, of course, has a long history as a focus of social psychological research (Fiske & Taylor, 2017; Pozzebon, Visse, & Bogaert, 2012; Thompson, Robbins, Payne, & Castillo, 2011). Self-concept clarity has been explored as an individual difference variable and is an aspect of the structure of an individual’s self-concept that refers to “the extent to which self-beliefs are clearly and confidently defined, internally consistent, and stable” (Campbell et al., 1996, p. 141).

Given that self-knowledge often develops in the context of secure attachments, the lack of secure attachments for individuals with high ASAD symptomology may preclude the development of organized self-knowledge structures and accordingly may result in low self-concept clarity. This possibility drives our hypothesis that individuals high in ASAD symptomology may be particularly likely to be thin-ideal internalizers. Recent research by Vartanian (2009), Vartanian and Dey (2013), and Vartanian et al. (2016) has documented the link between having low self-concept clarity and the propensity to internalize the thin ideal. These authors argue that when self-concept clarity is low, individuals may be more likely to look to external standards for calibration, including the societal thin ideal. Thus, we hypothesized that women who experience higher levels of ASAD symptomology would be more likely to internalize the thin-ideal attractiveness standard because they would tend to be lower in self-concept clarity compared to women with either low or no ASAD symptoms. We conducted an experiment among young women to explore both the possibility that elevated ASAD symptomology would be associated with greater thin-ideal internalization and our hypothesis that ASAD symptomology would be a risk factor because of the possible negative relationship with self-concept clarity. Thus, our study was designed to test the following hypotheses

H1: As young women’s ASAD symptomology increases, so will their propensity to internalize the thin-ideal standard of attractiveness.

H2: Among young women, the positive relationship between ASAD symptomology and thin-ideal internalization is driven by the tendency for women high in ASAD symptomology to have lower self-concept clarity, which proximally drives greater thin-ideal internalization.

In sum, our research aims to contribute to two important literatures in the psychology of women’s health. First, we hope to add evidence of a previously undocumented cause to the currently underdeveloped state of knowledge regarding the etiology of thin-ideal internalization. A second goal of our research is to explore new associations with and consequences of ASAD, which is a particularly important focus for researchers given the recency of it being recognized as a unique disorder.

Method

Participants

We contracted with Qualtrics to administer the study with 200 of its female panelists aged 18 to 23 years serving as participants. Qualtrics returned 208 complete responses to us (Qualtrics typically contacts more individuals than the contracted sample size to ensure that study requirements are met); 60.6% of respondents identified as Caucasian or White, 13.9% as African American or Black, 11.5% as Hispanic, 7.2% as Asian, and 6.7% as Mixed Ethnicity or Other. The ethnic composition of our sample was thus quite similar to that of the U.S. population: 61% White, 18% Hispanic, 12% Black, 6% Asian, and 4% Mixed Ethnicity or Other (Kaiser Family Foundation, 2018).

Measures

We employed three measures in our study. ASAD symptomology was measured using the Severity Measure for Separation Anxiety Disorder – Adult (Craske, Wittchen, Stein, Andrews, & Lebeu, 2013), which has 10 self-report items regarding relevant recent experiences. The scale is specifically defined for use with adults 18 years of age and older, and its items assess the severity of ASAD symptoms described in the DSM-5 diagnostic criteria. The scale is not intended as a diagnostic tool. Instead, the purpose is to quantify the extent to which adults are experiencing the consequences of separation anxiety. The scale has been demonstrated to be both reliable and of clinical utility (Craske et al., 2013).

Participants were given the following instructions before completing the Severity Measure for Separation Anxiety Disorder – Adult scale items, “The following questions ask about thoughts, feelings, and behaviors that you may have had about being separated from home or from people who are important to you. Please rate how often the following statements are true for you.” They were then asked to indicate how often each of the 10 statements that comprise the scale have been true for them during the past week. Items are inspired by DSM-5 criteria for diagnosing ASAD and include, “I have felt moments of sudden terror, fear, or fright when separated,” “I have had thoughts of bad things happening to people important to me or bad things happening to me when separated from them (e.g., getting lost, accidents),” “I have felt a racing heart, sweaty, trouble breathing, faint, or shaky when separated,” and “I have avoided going to places where I would be separated.” Participants responded by indicating if each item was true for them in the past seven days “never,” “occasionally,” “half of the time,” “most of the time,” or “all of the time.” We coded responses so that higher numbers would reflect more separation anxiety symptomology.

Self-concept clarity was measured using Campbell et al.’s (1996) scale. This measure contains 12 items about which participants indicate their level of agreement or disagreement on a five-point response scale. For example, the Self-Concept Clarity scale asks respondents to reflect on items such as, “My beliefs about myself often conflict with each other,” and “In general, I have a clear sense of who I am and what I am.” The Self-Concept Clarity scale has been shown to have strong psychometric properties (Campbell et al., 1996). Responses were coded such that higher values would equate to higher self-concept clarity.

Thin-ideal internalization was measured using the four items of the thin/low body fat standard internalization subscale of the SATAQ-4R (Schaefer, Harriger, Heinberg, Soderberg, & Thompson, 2017). This scale asks respondents to consider items such as “I want my body to look very thin,” and “I think a lot about having very little body fat” and to indicate their level of agreement or disagreement with each on five-point response items. The subscales of the SATAQ-4R, including the thin/low body fat standard internalization subscale, have been proven to be both reliable as well as characterized by strong construct validity (Schaefer et al., 2017). The items were coded such that higher values indicated a greater extent of thin-ideal internalization.

Procedure

Qualtrics panelists were recruited to complete a study titled “Self-Perceptions and Experiences” and read that the study involved “opinions about your feelings about relationships and yourself.” After reading initial instructions, participants first completed the Severity Measure for Separation Anxiety Disorder – Adult items listed under the header “Experiences Questionnaire.” When done with this measure, participants read that they would be completing a “Self-Perception Questionnaire” next and responded to the Self-Concept Clarity scale items. When participants finished the Self-Concept Clarity scale, they were asked to complete a “Physical Attitudes Questionnaire” that contained the SATAQ-4R items.

The study concluded with measures of participants’ height and weight so that body mass index (BMI) could be calculated, and an open-ended suspicion check. After completion of the suspicion check, participants were thanked and debriefed, and the study concluded. Two participants came vaguely close to guessing the study’s hypotheses. All analyses were run with and without these participants, and because the results were identical, all of the analyses are based on the complete data set.

Analytic roadmap

Our analytic plan had three steps. First, we assessed the psychometric properties of our measures. Second, we explored if the data were consistent with our hypothesis that there would be a relationship between ASAD and thin-ideal internalization such that individuals with greater ASAD symptomology would exhibit more thin-ideal internalization. The third and final step in the plan was to elucidate the driver of the relationship between ASAD and thin-ideal internalization, should evidence for the hypothesized positive relationship between these variables be found. Specifically, structural equations modeling (SEM) would allow a simultaneous analysis of our hypothesis that ASAD symptomology would be related to thin-ideal internalization because it is negatively associated with self-concept clarity.

Results

The first set of analyses were conducted to confirm the psychometric properties of the measured constructs. Consistent with prior research, the items purporting to measure ASAD symptomology appeared to be measuring a unitary construct (Cronbach’s alpha = .94, p < .001). Similarly, the items comprising the Self-Concept Clarity scale hung together well (Cronbach’s alpha = .88, p < .001), as did the thin/low body fat standard internalization subscale items of the SATAQ-4R (Cronbach’s alpha = .87, p < .001). Accordingly, the items belonging to each of these scales were combined prior to subsequent analyses by adding the item scores then dividing by the total number of items. The mean aggregate ASAD score was 1.9 (SD = .93, range: 1–5). The mean aggregate self-concept clarity score was 2.81 (SD = .84, range: 1.08–5). The mean aggregate thin/low body fat standard internalization subscale score was 3.44 (SD = 1.08, range: 1–5). The zero-order correlations between the measures were as follows: ASAD—thin/low body fat standard internalization subscale: r = .293, ASAD—self-concept clarity: r = –.488, p < .01, and self-concept clarity—thin/low body fat standard internalization subscale: r = –435, p < .01.

To explore our core prediction stated in Hypothesis 1 (H1), we first regressed thin-ideal internalization on ASAD symptomology. Consistent with our hypotheses, greater ASAD symptomology was predictive of increased thin-ideal internalization, R² = .09, F(1, 206) = 19.31, p < .001. We expected that ASAD symptomology would be related to the likelihood of thin-ideal internalization because individuals with higher levels of ASAD symptoms would have less clarity regarding their self-concepts. Accordingly, we used structural equations modeling to provide more detailed insight into the association between ASAD symptoms and thin-ideal internalization.

Figure 1 shows the model we created to test our structural hypotheses specified in Hypothesis 2 (H2). The coefficients shown are standardized. We included BMI to demonstrate that ASAD symptoms were not related to BMI in an untoward way that might produce misleading results. Examination of fit statistics demonstrates that the model fits the data well (non-significant χ²(1) = 2.388, p > .12, adjusted goodness-of-fit index = .94, normed fit index= .98, comparative fit index = .99, root mean square error of approximation = .08). The path from ASAD symptoms to self-concept clarity was significant (p < .001), as was the path from self-concept clarity to thin-ideal internalization (p < .001). Most central to our hypotheses, a bootstrap analysis with 1000 samples using 95% confidence intervals demonstrated that the indirect path from ASAD symptomology to thin-ideal internalization through self-concept clarity was significant, p = .003 (the standardized indirect effect coefficient was .185, and the 95% confidence interval bounds were .106 and .259, which exclude zero). This result, taken in conjunction with the direct path from ASAD symptoms to thin-ideal internalization being not significant (p = .14) in the model, demonstrates that ASAD symptomology is predictive of the extent of thin-ideal internalization because individuals with higher levels of ASAD symptoms have less clarity regarding their self-concepts.

Figure 1.

Structural model of the relationship between adult separation anxiety disorder symptomology, body mass index, self-concept clarity, and thin-ideal internalization.

The path between BMI and ASAD symptomology was not significant, which demonstrates some degree of discriminant validity, and is consistent with the idea that considering ASAD symptomology provides unique value in the investigation of risk factors of thin-ideal internalization. The fact that BMI was not related to thin-ideal internalization is not surprising, as prior research exploring the potential of a relationship between these constructs has produced mixed results (Vartanian, 2009).

Discussion

Our research provides clear evidence that there is a tendency for ASAD symptomology to be positively associated with internalization of the thin-ideal standard and documents the psychological process that underlies this relationship. Specifically, our results show that females with higher levels of ASAD symptoms also exhibit greater internalization of the thin ideal, and that this relationship exists because of the tendency for women with elevated ASAD symptoms to have less clarity in their self-concepts. Thus, women with higher ASAD symptomology are at increased risk of internalizing thin-ideal beauty standards because they are more likely to rely on external standards as an input to self-knowledge.

Our results speak to two important but nascent literatures. First, although the adverse downstream effects of thin-ideal internalization have been documented in different contexts across multiple dependent measures, upstream risk factors that govern when and how thin-ideal internalization develops are much less well understood (Vartanian et al., 2016). It is important for researchers to ameliorate this deficiency because of the serious consequences for physical and psychological health that women who internalize the thin-ideal experience. Our research contributes by documenting elevated ASAD symptomology as a risk factor for thin-ideal internalization, and providing evidence that women with such symptoms may be more likely to internalize the thin ideal because their self-concept is characterized by low clarity.

The second literature to which we contribute regards ASAD itself. ASAD has only recently been recognized as a stand-alone disorder by the psychiatric and psychological communities, and research that sheds light on the condition as well as the phenomenological implications of having elevated ASAD symptomology is sorely needed. Our research contributes to this young literature both by providing evidence that individuals with higher levels of ASAD symptomology may have lower self-concept clarity, and by showing that ASAD is a risk factor for thin-ideal internalization. Accordingly, women with ASAD symptoms may also be at elevated risk for all of the adverse health consequences that thin-ideal internalizers often experience.

Although we do not have data that speak directly to this issue, some speculation may be warranted regarding the importance of ASAD in driving thin-ideal internalization. From our perspective, having elevated ASAD symptoms is likely neither necessary nor sufficient to drive thin-ideal internalization. Instead, we believe that ASAD is a risk factor, along with environmental and genetic factors (see Suisman et al., 2014; VanHuysse, Burt, O’Connor, Thompson, & Klump, 2016), that can contribute to a woman internalizing societal thin standards of attractiveness. We believe that our data are consistent with this perspective. Specifically, our results offer compelling support for our core hypotheses, but it is clear analytically, and intuitive conceptually, that there is variance explained by other constructs. Specifically, although the coefficient for the indirect effect of ASAD being associated with increased thin-ideal internalization because of the relationship to self-concept clarity was statistically reliable, the coefficient was not huge. This result is consistent with our position that although ASAD is an important and reliable contributor to the risk of thin-ideal internalization, there are certainly other important drivers of the likelihood of thin-ideal internalization that are yet to be documented.

The take-away from this study from a clinical perspective is that mental health practitioners working with women with elevated ASAD symptoms should be aware that their clients may have a proclivity to internalize the thin-ideal beauty standard, and be sensitive that this potential vulnerability for internalization may lead to toxic consequences for body image and behavior. Evaluating clients who are experiencing ASAD symptoms for potential body image disturbance comorbidity may be quite beneficial from the perspective of therapeutic outcomes.

Another potential implication of our findings is understanding the discordant results on the effects of experiential self-focus on individuals with social anxiety disorder (for a summary see Norton & Abbott, 2018). Norton and Abbott (2018) describe experiential self-focus as “direct, intuitive, concrete, and nonevaluative awareness of present experience of all aspects of the self” (p. 48). Although some research has shown positive benefits of inducing individuals with social anxiety to self-focus in this way (Vassilopoulos, 2008), other research has shown negative effects (Wong & Moulds, 2012), and Norton and Abbott’s (2018) results were equivocal in that experiential self-focus benefited control participants, but not participants with social anxiety disorder. When a literature is characterized by significant yet inconsistent findings, it is often the case that there is an important but not yet accounted variable lurking beneath the surface. Given comorbidity among anxiety disorders, it is likely that some individuals with social anxiety also experience ASAD. Such individuals would likely be less affected by an induction of experiential self-focus because they have lower self-concept clarity, and thus would not have sufficient self-knowledge structures to deeply experience multiple aspects of the self. Thus, across the literature, this differential insensitivity to experiential self-focus induction may be a crucial source of variance that drives the inconsistency observed in outcome measures. Interestingly, this possibility may explain Norton and Abbott’s (2018) unexpected finding that experiential versus analytic self-focus benefited control participants but not participants with social anxiety disorder. Specifically, participants with social anxiety disorder symptoms may have been higher in ASAD symptomology, which would mean that these participants would be lower in self-concept clarity, and less likely to benefit from an experiential self-focus induction compared to control participants. Of course, we are speculating here and leave definitive conclusions to future research.

Limitations

It is important to note that our study was conducted with a diverse non-clinical general population sample. There are advantages and disadvantages of such an approach. The advantage is that on one hand, confidence in the generality of our findings may be warranted because if the relationships we observed are present in a non-clinical sample, it might be expected that when ASAD symptomology is very high, as it would be among individuals diagnosed with the condition, that there is a particularly high risk of thin-ideal internalization because self-concept clarity may tend to be quite low. Thus, our results may underestimate the potency of ASAD at clinically diagnosable levels to drive thin-ideal internalization. However, given that our sample was based on a non-clinical population, this is a speculation that must be offered with some conservatism. Accordingly, although our data suggest that it may be important for mental health practitioners working with clients with an ASAD diagnosis to consider possible comorbidity with body image issues, we cannot make strong claims about individuals who have been formally diagnosed.

An additional limitation is the cross-sectional nature of our data. Although the data were supportive of our hypotheses, a stronger test would involve a longitudinal design in which young girls were assessed for separation anxiety, self-concept clarity, and thin-ideal internalization at multiple points over time. What we would expect is that females with an enduring tendency toward separation anxiety would be at increased risk to internalize the thin ideal because of lower self-concept clarity.

A final caveat is that it cannot be assumed that the structural model we presented can be generalized beyond the demographic parameters of our sample. Although the racial mix in our sample was quite similar to that of the United States, by design, our sample consisted of young women. Thus, how the relationships between the variables we measured evolve over the lifespan is something our data cannot address.

Footnotes

Acknowledgments

We thank Dr. Ryan Corser for his help in administering the data collection.

Article Notes

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