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The Social Appearance Anxiety Scale in Italian Adolescent Populations: Construct Validation and Group Discrimination in Community and Clinical Eating Disorders Samples

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Abstract

Anxiety in situations where one’s overall appearance (including body shape) may be negatively evaluated is hypothesized to play a central role in Eating Disorders (EDs) and in their co-occurrence with Social Anxiety Disorder (SAD). Three studies were conducted among community (N = 1995) and clinical (N = 703) ED samples of 11- to 18-year-old Italian girls and boys to (a) evaluate the psychometric qualities and measurement equivalence/invariance (ME/I) of the Social Appearance Anxiety (SAA) Scale (SAAS) and (b) determine to what extent SAA or other situational domains of social anxiety related to EDs distinguish adolescents with an ED only from those with SAD. Results upheld the one-factor structure and ME/I of the SAAS across samples, gender, age categories, and diagnostic status (i.e., ED participants with and without comorbid SAD). The SAAS demonstrated high internal consistency and 3-week test–retest reliability. The strength of the inter-relationships between SAAS and measures of body image, teasing about appearance, ED symptoms, depression, social anxiety, avoidance, and distress, as well as the ability of SAAS to discriminate community adolescents with high and low levels of ED symptoms and community participants from ED participants provided construct validity evidence. Only SAA strongly differentiated adolescents with any ED from those with comorbid SAD (23.2 %). Latent mean comparisons across all study groups were performed and discussed.

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Notes

  1. As the two cohorts respectively reflect students from Italian junior high and high schools [47], in line with prior Italian research [47] examining the psychometric proprieties and ME/I of self-reported measures of anxiety (social anxiety included), the younger (11–14 years) and older (15–18 years) adolescent groups were maintained in the analyses investigating age differences. Self-reported weight and height were used to calculate BMI (=kg/m2).

  2. Participants’ assent was also secured immediately before the assessment, which took place on the school campuses (after consent from school administrators was obtained) [36].

  3. Italian Census Bureau (ISTAT): www.istat.it; further detailed information is also available elsewhere [2, 11, 47].

  4. These criteria were used since the study was initiated before the official publication of the DSM-5.

  5. Inter-rater reliability for ED and SAD diagnoses was determined by having two randomly selected samples of 25 % of the EDEs-12.0D (κ = 1.0) and 25 % of the K–SADS–Ps (κ = 1.0) that were conducted at each participating site rated by a second blinded clinician (with almost 10-years experience in assessing and treating ED and comorbid disorders among adolescents) at the other site.

  6. As in prior research [26] a preliminary independent study was conducted to evaluate the content clarity of the Italian SAAS. Ninety adolescents (49 % boys; M years  = 11.22, SD = 0.35, range 11–12) recruited from two schools (from Northern and Southern Italy) completed the Italian SAAS with its original response format replaced by a 5-point Likert scale assessing the clarity of the items (1 = not at all clear, 5 = completely clear). Analyses of the clarity of the items were performed following Vallerand’s [52] suggestions, including the recommendation that an item clarity score <4 out of five should be considered unsatisfactory on a 5-point scale. We considered all items satisfactory, with observed scores ranging from a low of 4.34 (SD = 0.25) for Item 12 through a high of 4.77 (SD = 0.11) for Item 3. For interested readers the item-specific results are available from the corresponding author on request.

  7. ML estimator treats measured responses as continuous [41]. According to simulation studies, when variables/items are measured on an ordinal scale and contain five (or more) categories (such as SAAS items rated on a 5-point Likert-type scale), these could be safely treated as continuous, if they are not skewed or kurtotic [61]. The results of pre-analyses of data of all studies reported in the current manuscript indicated that skewness, kurtosis and Mardia’s normalized values for all SAAS items were well below critical limits, i.e., skewness <|2.0|; kurtosis <|7.0|; and Mardia’s normalized values <3 [41]. Hence, the use of ML estimator was deemed appropriate and it is also consistent with prior research, based on similar assumptions, and using the same estimator for examining the factor structure of a social anxiety measure matching the format response of I-SAAS [62].

  8. Given the dearth of research regarding domains of social anxiety as potential differentiators across EDs and specific ED diagnoses, the three ED diagnostic groups (AN, BN, EDNOS) were examined separately for comparative reasons.

  9. Given that in pre-analyses all variables examined separately (controlled for gender, BMI, age and depression) showed a significant difference between groups (p < .01), we entered all variables simultaneously into logistic regression models to determine the factor(s) that best distinguished individuals who reported an ED + SAD compared to those who only reported an ED [66]. The results of pre-analyses are available from the corresponding author on request.

  10. Except for data collected from adolescents recruited from the community (Model 0a) and adolescents with EDs (Model 0b) that have been independently analysed in the first two studies (see data analytic plan and results sections).

  11. Although the equality of the uniqueness matrix can be assessed as part of the ME/I [45], in line with prior research [44, 62] we did not analyse this characteristic, since the equivalence of error matrices is not necessary when the observed scores are used merely as indicators of latent variables [41], and as noted we focused on the latent variables.

  12. Modification indices provided by Mplus [60] were detected in this study as well as in the following studies reported, but in all cases their magnitude (<5.0) suggested that any not originally specified parameters did not impact the fit of model to the data [41].

  13. There were no differences between ED diagnostic groups in SAAS score [F(2700) = 0.22, ns]. Observed means for SAA by ED diagnostic groups were as follows: 55.48 (SD = 12.35) for AN; 56.11 (SD = 11.88) for BN, and; 55.33 (SD = 10.96) for EDNOS. The descriptive statistics of the SAAS for the entire ED sample and across diagnostic status (i.e., with or without comorbid SAD) are provided in the footnote (n. 14) of the present manuscript. For interested readers the descriptive statistics for the remaining study measures, and their associations with the SAAS stratified by ED diagnosis and diagnostic status are available from the corresponding author on request.

  14. Observed means for the SAA were: 39.87 (SD = 12.75) for boys (including clinical and non-clinical participants), 38.23 (SD = 15.88) for adolescents from community, 44.96 (SD = 10.62) for ED participants without SAD, 42.80 (SD = 14.48) for younger adolescents (including clinical and non-clinical participants), 48.65 (SD = 14.35) for girls (including clinical and non-clinical participants), 50.30 (SD = 11.51) for adolescents with EDs, 55.64 (SD = 12.02) for ED participants with comorbid SAD, and 45.72 (SD = 11.96) for older adolescents (including clinical and non-clinical participants).

  15. Our findings (Table 4) do not imply that the other domains of social anxiety considered (as measured by BFN, SPS, and SIAS) are not important for the co-occurrence of EDs with SAD. Rather, we believe that they are important given the results of univariate logistic regression models (footnote 10). However, the more specific form of fear of negative evaluation focusing on appearance (SAA) may be a unique construct of importance for the co-occurrence of EDs and SAD and what may drive the relationship between social anxiety and ED symptoms. This is consistent with what we found in the multivariate logistic regressions (Table 4), current vulnerability models for both EDs and SAD [9] (see also “introduction”), and other previous studies [22].

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Authors and Affiliations

  1. Department of Brain and Behavioral Sciences, University of Pavia, P.za Botta 11, 27100, Pavia, Italy

    Antonios Dakanalis & M. Assunta Zanetti

  2. Division of Psychiatry, Faculty of Brain Sciences, University College of London, London, UK

    Giuseppe Carrà

  3. School of Psychology, University of Kent, Canterbury, UK

    Rachel Calogero

  4. Department of Psychology, University of Milano-Bicocca, Milan, Italy

    Chiara Volpato

  5. Department of Psychology, Catholic University, Milan, Italy

    Giuseppe Riva

  6. Applied Technology for Neuro-Psychology Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy

    Giuseppe Riva & Pietro Cipresso

  7. Department of Surgery and Interdisciplinary Medicine, University of Milano-Bicocca, Milan, Italy

    Massimo Clerici

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Dakanalis, A., Carrà, G., Calogero, R. et al. The Social Appearance Anxiety Scale in Italian Adolescent Populations: Construct Validation and Group Discrimination in Community and Clinical Eating Disorders Samples. Child Psychiatry Hum Dev 47, 133–150 (2016). https://doi.org/10.1007/s10578-015-0551-1

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