Original Paper

Psychopathology 2012;45:147–158 Received: January 18, 2011

Accepted after revision: June 17, 2011
DOI: 10.1159/000330258
Published online: March 2, 2012

Identity and Eating Disorders (IDEA):

A Questionnaire Evaluating Identity and
Embodiment in Eating Disorder Patients
Giovanni Stanghellini a Giovanni Castellini b Patrizia Brogna c Carlo Faravelli d
Valdo Ricca b
a
Department of Biomedical Sciences, University ‘G. d’Annunzio’, Chieti, b Psychiatric Unit, Department of
Neuropsychiatric Science, Florence University School of Medicine, Florence, c Institute of Psychology, University
‘Cattolica del Sacro Cuore’, Rome, and d Department of Psychology, University of Florence, Florence, Italy

Key Words
Eating disorders ⴢ Embodiment ⴢ Identity ⴢ
Psychopathology ⴢ Questionnaire
Abstract
Background: In this paper we tested the hypothesis that
persons with eating disorders (EDs) are affected by distur-
bances of the way they experience their own body (embodi-
ment) and shape their personal identity, assuming that the
various kinds of anomalies of eating behavior are conse-
quences thereof. Sampling and Methods: We developed
and validated a new self-reported questionnaire named
IDEA (IDentity and EAting disorders), which was adminis-
tered to 147 ED patients and 187 healthy controls. Test-retest
reliability, internal consistency, psychopathological corre-
lates, and concurrent validity were evaluated. A factor analy-
sis was performed to verify the distribution of items into sub-
scales. Results: The questionnaire showed good test-retest
reliability, and internal consistency. IDEA scores were spe-
cifically associated with ED psychopathology, and they did
not show any correlation with sociodemographic and gen-
eral clinical variables. Four factors were extracted, which
were related to the following phenomena: ‘feeling oneself
only through the gaze of the other and defining oneself only
through the evaluation of the other’, ‘feeling oneself only
through objective measures’, ‘feeling extraneous from one’s
own body’, and ‘feeling oneself through starvation’. Conclu-
sions: IDEA represents a multidimensional, brief, versatile,
easy-to-perform instrument for clinical evaluation, assessing
abnormalities in lived corporeality, and of personal identity,
which appeared to be specifically associated with the core
features of ED psychopathology. The main limitations of the
study are the cross-sectional design. Also, it is impossible to
ascertain whether the domains we assessed are specific
traits of patients with EDs, or state-related features. To an-
swer this question, a longitudinal study is needed.
Copyright © 2012 S. Karger AG, Basel
Introduction
Eating disorders (EDs) are severe psychiatric syn-
dromes that most likely result from, and are sustained by,
sociocultural, psychological and biological factors [1, 2].
DSM IV-TR [3] divides EDs into three diagnostic catego-
ries: anorexia nervosa, bulimia nervosa and eating disor-
ders not otherwise specified, a heterogeneous category
considering those EDs that fail to meet the diagnostic cri-
teria for either anorexia nervosa or bulimia nervosa and

© 2012 S. Karger AG, Basel Giovanni Stanghellini MD, DHC

0254–4962/12/0453–0147$38.00/0 Department of Biomedical Sciences, University ‘G. d’Annunzio’
Fax +41 61 306 12 34 Via dei Vestini, 31
E-Mail karger@karger.ch Accessible online at: IT–66013 Chieti (Italy)
www.karger.com www.karger.com/psp Tel. +39 0871 355 4040, E-Mail giostan @ libero.it
that includes binge eating disorder [4]. These disorders
are characterized by abnormal patterns of eating behav-
ior, and pathological concerns about body shape and
weight. In particular, Fairburn and Harrison [5] hold that
patients with EDs typically overvalue their body shape
and weight. By that they mean that whereas most people
evaluate and define themselves on the basis of the way
they perceive their performance in various domains (e.g.
relationships, work, parenting, sporting prowess, etc.),
‘patients with anorexia nervosa or bulimia nervosa judge
their self-worth largely, or even exclusively, in terms of
their shape and weight and their ability to control them’
(p. 407). They also suggest that most of the other features
of these disorders (including behavioral anomalies such
as starvation) could be secondary epiphenomena to this
more profound pathological core, i.e. an overestimation
of the importance of bodily appearance instead of other
aspects of existence and personal identity. According to
this theory, different studies found that severe concerns
about body shape and weight can play a significant role
in the persistence of EDs [6–11]. Furthermore, shape and
weight concerns have been associated with different re-
sponses to psychological treatment in several reports [12–
15].
In this paper, we build on and extend Fairburn and
Harrison’s idea, as well as other reports [16–22], and es-
pecially we develop the hypothesis that persons with EDs
are affected by a more profound disturbance consisting
in disorders of the way they experience their own body
(embodiment) and shape their personal identity, assum-
ing that the various kinds of anomalies of eating behavior
are a consequence thereof. Patients with EDs are charac-
terized by an excessive concern for their own appearance
[3, 23]. In order to better understand their disproportion-
ate worry for their own exteriority, we draw on philoso-
pher Jean Paul Sartre’s [24] analyses of lived corporeality.
Since the beginning of the 20th Century, phenomenology
has developed a distinction between lived body (Leib) and
physical body (Koerper), or body-subject and body-ob-
ject. The first is the body experienced from within, my
own direct experience of my body in the first-person per-
spective, myself as a spatiotemporal embodied agent in
the world; the second is the body thematically investi-
gated from without, as for example by natural sciences as
anatomy and physiology, a third-person perspective [25,
26]. One’s own body can be apprehended by a person in
the first-person perspective as the body-I-am. This is the
cenesthetic apprehension of one’s own body, the primi-
tive experience of oneself, the basic form of self-aware-
ness, or the direct, unmediated experience of one’s own
148 Psychopathology 2012;45:147–158
‘facticity’, including oneself as ‘this’ body, its form, height,
weight, color, as well as one’s past and what is actually
happening. First and foremost, we have an implicit ac-
quaintance with our own body from the first-person per-
spective. The lived body turns into a physical, objective
body whenever we become aware of it in a disturbing way.
Whenever our movement is somehow impeded or dis-
rupted, then the lived body is thrown back on itself, ma-
terialized or ’corporealized’. It becomes an object for me.
Having been a living bodily being before, I now realize
that I have a material (impeding, clumsy, vulnerable, fi-
nite, etc.) body [27]. In addition to these two dimensions
of corporeality, Sartre emphasized that one can appre-
hend one’s own body also from another vantage point, as
one’s own body when it is looked at by another person.
When I become aware that I, or better that my own body
is looked at by another person, I realize that my body can
be an object for that person. Sartre calls this the ‘lived-
body-for-others’. ‘With the appearance of the Other’s
look’, writes Sartre, ‘I experience the revelation of my be-
ing-as-object.’ The upshot of this is a feeling of ‘having
my being outside (…) [the feeling] of being an object’.
Thus, one’s identity becomes reified by the gaze of the
other, and reduced to the external appearance of one’s
own body.
We propose that the reason why persons with EDs
overvalue their body shape and weight can be better un-
derstood as a specific disorder of lived corporeality, and
more specifically as the predominance of one dimension
of embodiment, namely the ‘lived-body-for-others’. The
idea that anomalies of embodiment can play a key-role in
conceptualizing mental disorders is not new. It has been
applied in various domains, including schizophrenia [28,
29], manic-depressive disorders [30] and body dysmor-
phic disorder [31]. Our hypothesis is that persons with
EDs experience their own body first and foremost as an
object being looked at by another, rather than cenesthet-
ically or from a first-person perspective. Alienation from
one’s own body and from one’s own emotions, disgust for
it, shame, and an exaggerated concern to take responsi-
bility for the way one appears to the others, as well as the
possibility to feel oneself only through the gaze of the oth-
ers, through objective measures and through self-starva-
tion, i.e. many of the features of persons with EDs, can be
illuminated by looking at it in the light of the Sartrean
concept of feeling a ‘lived-body-for-others’.
In order to test this hypothesis, we developed and val-
idated a new self-reported questionnaire named IDEA
(IDentity and EAting disorders), which was administered
to a large sample of patients with EDs, as well as controls.
Stanghellini /Castellini /Brogna /Faravelli /
Ricca 
 Materials and Methods
Data were collected at the Outpatient Clinic for Eating Disor-
ders of the Psychiatric Unit of the University of Florence, Italy.
Development of the Questionnaire
The Italian version of the questionnaire was developed with
the contributions of several psychiatrists and psychologists, tak-
ing in consideration the patients’ attitudes toward their lived cor-
poreality, and the definition of their own identity.
The steps for the development of the questionnaire were as fol-
lows:
– The generation of a first list of questions was conducted in dif-
ferent phases, including domain generation, and item genera-
tion. To develop domains, experts in ED research and treat-
ment, together with researchers with a phenomenological
background, identified areas that were most important and
impacted ED patients. The theoretical background of the
questionnaire was an attempt of integrating the phenomeno-
logical approach of lived corporeality described in the Intro-
duction with the clinical one, based on the cognitive behav-
ioral model.
The experts were specifically asked to think about the concept
of lived corporeality, and more specifically the ‘lived-body-for-
others’, as it applies across a broad range of ED patients. They were
also asked to make use of their familiarity with ED research as
well as their clinical experience.
The items were conceptually related to different areas:
(1) feeling oneself through the gaze of the other;
(2) defining oneself through the evaluation of the other;
(3) feeling oneself through objective measures;
(4) feeling extraneous from one’s own body;
(5) feeling oneself through starvation;
(6) defining one’s identity through one’s own body;
(7) feeling oneself through physical activity and fatigue.
– Then, items meant to tap each of these content areas were gen-
erated. The most commonly voiced identity concerns and be-
liefs were considered on the basis of the clinical experience,
statements identified in the literature as particularly associated
with EDs, and qualitative data on self-beliefs in EDs that had
been routinely and systematically collected in the course of pre-
vious research in this area. Moreover, this material was inte-
grated with transcripts from clinical interviews, and with ED
patients’ diaries. Diaries are tools commonly used in the context
of the cognitive-behavioral treatment provided at our clinic. Pa-
tients provided their written informed consent to the use of
their diaries for the present research. All the sentences selected
by the researchers were reviewed, collected and redistributed to
add additional items to each domain of the questionnaire.
– Afterwards, junior psychiatrists read the items and provided
feedback regarding which of them were confusing or easily
misinterpreted. Next, patients with a diagnosis of EDs pro-
vided feedback about the content of the items and directions
for the instrument. Patients explained, in their own words,
what they believed each item and the directions for the instru-
ment meant. Items or directions associated with common mis-
interpretations were revised. After this initial field testing, the
sentences were modified considering the feedback from pa-
tients and other physicians. Experienced clinicians examined
each item for clarity, redundancy, and content validity.
IDentity and EAting Disorders
– This iterative process resulted in a developed set of 61 sentenc-
es, in such a way that they could be applied to a wide popula-
tion of ED patients including all the principal diagnoses (an-
orexia nervosa, bulimia nervosa, and binge eating disorder),
regardless of age, sex, familial status, occupation, or education
level. For each question, the patient is asked to score on a
5-point Likert scale (0: do not agree, 4: strongly agree with the
sentence).
– Considering that the areas mentioned above were only based
on our theoretical model, we effectively verified the structure
of the questionnaire by a an exploratory factor analysis.
– The first version of the questionnaire was administered to a se-
ries of 221 ED patients being referred for the first time to the
Outpatient Clinic for Eating Disorders. Prior to factorization,
we explored the frequency distribution of each item, and an
item analysis was performed, including difficulty index, and
discrimination index. An exploratory factor analysis (with Pro-
max rotation) was applied, showing that 4 main factors should
be retained. Items that showed a weak unrotated correlation
(r ! 0.30) with all the four factors were excluded. On the basis
of these initial analyses, the number of items was reduced, and
a shorter version of the questionnaire was developed (23 items).
The complete final version of the questionnaire, together with
the scoring system, is reported in the Appendix. The total IDEA
score is obtained as the mean of all item scores.
Subjects
The final version of the questionnaire was evaluated in a series
of ED patients attending the Outpatient Clinic for Eating Disor-
ders of the Psychiatric Unit of the University of Florence between
October 1, 2009, and June 30, 2010, and in a group of healthy con-
trol subjects. Patients involved in the development of the IDEA
questionnaire did not participate in the present study. Patients
were enrolled according to the following inclusion criteria: female
gender, age 18–40 years, current DSM-IV diagnosis of anorexia
nervosa, bulimia nervosa or binge eating disorder. The diagnoses
were based on the current symptomatology at referral.
Exclusion criteria were as follows: illiteracy, intellectual dis-
ability, comorbid schizophrenia and delusional disorders.
Of the 162 Caucasian cases with an ED consecutively referred,
6 patients refused to participate in the study, and 9 subjects were
excluded from the study because of the following reasons: illit-
eracy (1), intellectual disability (1), comorbid schizophrenia (1),
and delusional disorder (6). The final sample was composed by
147 ED subjects.
Healthy controls (matched with the clinical sample for age,
gender and education) were recruited among female students of
the University of Florence, provided they met the following inclu-
sion criteria: absence of Axis I mental disorders, evaluated by
means of a structured interview [32], and body mass index (BMI)
between 18.5 and 25. Of the 190 consecutive healthy controls re-
cruited, 3 subjects refused to give their informed consent, so that
the final sample group consisted of 187 subjects.
Assessment
The IDEA questionnaire was administered together with the
clinical assessment at the first day of admission. Sociodemo-
graphic, psychopathological and clinical data were collected
through a face-to-face interview by two expert psychiatrists (V.R.,
G.C.). The diagnosis of Axis I mental disorders was performed by
Psychopathology 2012;45:147–158 149
means of the Structured Clinical Interview for DSM-IV [32]. In-
ter-rater reliability (␬ coefficient) for diagnoses was 0.94. During
the visits, anthropometric measurements were made using stan-
dard calibrated instruments. Height (meters) was measured using
a wall-mounted stadiometer, weight (kilograms) using electronic
scales. BMI was calculated and the psychopathological evaluation
was performed. BMI was calculated as weight in kilograms di-
vided by the square of height in meters.
Eating attitudes and behaviors were specifically investigated
by means of the Italian version of the Eating Disorder Examina-
tion Questionnaire (EDE-Q) [33]. It consists of 38 items, assessing
the core psychopathological features of EDs, and contains 4 sub-
scales: dietary restraint, eating concern, weight concern and
shape concern. The dietary restraint subscale is an admixture of
cognitions and behaviors pertaining to dietary restriction. The
three other subscales evaluate the dysfunctional attitudes regard-
ing eating and overvalued thoughts regarding weight and shape.
The global score represents the mean of the four subscale scores.
Furthermore, patients were evaluated by means of the follow-
ing questionnaires:
– Symptom Checklist (SCL 90-R), a psychometric instrument
for the identification of psychopathological distress [34];
– the Beck Depression Inventory (BDI), a widely used and well-
established measure of current depression level and symptoms
[35];
– the State-Trait Anxiety Inventory (STAI Form Y-1), to measure
levels of trait anxiety [36].
All the diagnostic procedures and the psychometric tests pre-
viously described (with the exception of the IDEA questionnaire)
are part of the routine clinical assessment for ED patients, per-
formed at our clinic. Before the collection of data, during the first
routine visit, the procedures of the study were fully explained; af-
ter that, the patients were asked to provide their written informed
consent. The study protocol was approved by the ethics commit-
tee of the institution.
Validation of the Questionnaire
Test-Retest Reliability
All patients and controls were asked to complete the question-
naire twice, within 7 days. The time between the first clinical
visit and the beginning of a clinical intervention generally lasts
more than two weeks; therefore no specific treatment for EDs was
administered between the two tests.
Intraclass correlation coefficients were then calculated. Four
patients failed to complete the questionnaire for the second time;
therefore, test-retest reliability was evaluated on a sample of 143
patients.
Internal Consistency
Internal consistency was evaluated using Cronbach’s ␣
method.
Clinical Correlates
To evaluate the relationship between IDEA scores and clinical
parameters, Pearson’s correlations were calculated; for correla-
tion of IDEA scores with parameters that did not show a normal
distribution, Spearman’s method was used.
150 Psychopathology 2012;45:147–158
Convergent validity represents the association between con-
structs that theoretically should be related: to assess the conver-
gent validity of IDEA, we examined the association with EDE-Q
scores, and depression measured by BDI. Discriminant validity
reflects the association between constructs that theoretically
should be unrelated: to assess discriminant validity of IDEA, we
examined its association with age, and general symptomatology
measured by SCL-90, and STAI.
Incremental Validity
According to Haynes and Lench [37], incremental validity can
be defined as ‘the degree to which a measure explains or predicts
some phenomena of interest, relative to other measures’. In this
study, we specifically evaluated the degree to which IDEA accu-
rately identifies persons placed into groups of EDs according to
DSM-IV diagnoses. We performed a stepwise logistic regression
analysis in order to evaluate to what degree the addition of IDEA
to other measure of ED psychopathology (EDE-Q) increased the
predictive efficacy of ED assessment [37]. The dependent variable
was the ED diagnosis according to DSM-IV (coded as dummy
variable: healthy controls = 0; patients with EDs = 1). In the first
step, age, gender, BMI and EDE-Q total score were entered as pre-
dictive variables. In the second step, the IDEA total score was
added to the model. To test whether the overall fit of the model
was improved by entering the IDEA scores, we used the ␹2 likeli-
hood ratio test.
Factor Analysis
To verify the distribution of items into subscales, factor analy-
sis was performed. Factor loading was calculated using the prin-
cipal component analysis with Promax rotation and Kaiser nor-
malization, based on the assumption that the retained factors
would be correlated to some degree, rather than orthogonal; the
cut-off of coefficient was set at 0.4. Only components with an ei-
genvalue higher than 1 were retained, and the Cattell’s scree test
for the number of factors was applied [38]. Cronbach’s ␣ evalu-
ated the internal consistency reliability of the resulting scales.
After selecting the best factor models, scale scores for each di-
mension were obtained, calculated through the average of the cor-
respondent items. Next, two-tailed Student’s unpaired t test, and
univariate analysis of variance (ANOVA) were applied for com-
parison of means between patients with EDs and healthy controls,
and among ED diagnoses, respectively. Clinical correlates of sub-
scales derived from factor analysis were evaluated following the
procedures just described. To test the effect of IDEA domains on
ED symptoms, multiple linear regressions were performed,
adopting EDE-Q subscales as dependent variables and age and
IDEA factor scores as possible determinants.
All analyses were performed using SPSS for windows 15.0
(SPSS Inc., Chicago, Ill., USA).
Results
General characteristics of the sample are reported in
table  1. As expected, patients with EDs showed higher
ED-specific and general symptomatology compared with
healthy controls, while no significant difference was ob-
Stanghellini /Castellini /Brogna /Faravelli /
Ricca  
Table 1. General characteristics of the sample

AN BN BED F All patients Healthy t

(n = 50) (n = 48) (n = 49) with EDs controls
(n = 147) (n = 187)

Age 24.387.7 27.889.0 34.9816.7 13.33** 29.0810.8 27.386.1 1.77

BMI 16.181.3 23.486.0 38.088.4 119.0** 23.9810.1 22.183.0 2.16*
SCL-90 GSI 1.8180.56 1.9080.51 1.8080.61 0.18 1.8380.56 0.6580.44 11.99**
BDI 21.8086.08 23.05811.97 21.3487.68 0.77 21.9488.07 5.3985.52 14.69**
STAI 56.85813.52 67.6087.16 57.82811.05 3.13 59.90811.82 38.6589.04 11.24**
EDE-Q total score 3.3380.79 3.7881.28 3.3681.00 1.35 3.4881.05 1.0280.99 16.86**
EDE-Q restraint 3.0981.50 3.2781.58 2.7681.54 0.67 3.0381.53 1.1881.37 8.99**
EDE-Q eating concern 2.9581.18 3.5881.54 2.7281.38 2.56 3.0781.40 0.4480.69 18.66**
EDE-Q weight concern 3.1880.99 4.0681.45 3.5981.32 2.86 3.6181.30 1.1181.09 14.91**
EDE-Q shape concern 4.1681.19 4.3981.40 4.4181.22 0.27 4.3381.26 1.3481.23 16.95**

Values are reported as mean 8 standard deviation. ANOVA (F) for comparison of means among patients’ diagnoses, and two-
tailed Student’s unpaired t test (t) for comparison of means between patients and healthy controls; * p < 0.05; ** p < 0.01.
EDs = Eating disorders; AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating disorder; BMI = body mass index; SCL-
90 GSI = symptom checklist (SCL 90-R) global severity index; BDI = Beck depression inventory; STAI = state-trait anxiety inventory;
EDE-Q = eating disorder examination questionnaire.

served among ED diagnoses in terms of clinical variables Table 2. Scores of individual items
(with the exception of BMI). BMI, age, and STAI scores
did not show a normal distribution. Scores of individual Item Eating disorder Healthy controls
patients (n = 147) (n = 187)
items are summarized in table  2. Patients with EDs
showed higher scores for all IDEA items compared with 1 2.0981.46** 0.8581.01
healthy controls, as well as for IDEA total score (mean 8 2 1.6881.34** 1.0181.23
standard deviation: 1.59 8 0.95 vs 0.45 8 0.47; p ! 0.001). 3 1.3381.42** 0.8481.02
4 1.7782.20** 0.3280.61
5 1.9181.51** 0.5080.86
Test-Retest Reliability 6 1.4781.43** 0.1180.38
Intraclass correlation coefficients, 95% confidence in- 7 1.8181.39** 0.6280.85
terval (CI) of IDEA total score were 0.94, 0.90–0.96 for 8 1.6681.43** 0.2980.66
patients with EDs, and 0.91, 0.84–0.95 for healthy con- 9 2.0681.47** 0.5080.89
trols. 10 1.8381.53** 0.4680.80
11 1.5981.48** 0.3980.71
12 0.9381.34** 0.0580.28
Internal Consistency 13 1.8681.56** 0.5580.86
Cronbach’s ␣ value was 0.92 for IDEA total score. A 14 1.3181.39** 0.0580.28
value of 0.80 is considered satisfactory for internal con- 15 1.7281.40** 0.8480.89
sistency [39]. 16 1.5381.45** 0.5280.82
17 0.9081.23** 0.0880.31
18 1.3181.40** 0.3980.72
Clinical Correlates 19 1.7881.49** 0.3680.67
Table  3 reports correlations for IDEA subscales ob- 20 1.4181.40** 0.3480.64
tained from the retained factors. Considering convergent 21 1.8281.40** 0.3480.64
validity, IDEA total score was significantly associated 22 1.8481.55** 0.3080.62
with EDE-Q total score, and with all EDE-Q subscales, 23 1.0981.36** 0.3880.70
and with BDI scores (r = 0.30; p ! 0.05). Considering dis- Values are reported as mean 8 standard deviation.
criminant validity, IDEA total score did not show signif- Two-tailed Student’s unpaired t test (t) for comparison of
icant correlation with sociodemographic and general means between patients and healthy controls; ** p < 0.01.
clinical variables.

IDentity and EAting Disorders Psychopathology 2012;45:147–158 151

Table 3. Correlations between IDEA scores and other psychometric measures for eating disorder patients (n = 147)

SCL-90 BDI STAI EDE-Q

GSI total score restraint eating concern weight concern shape concern

IDEA total score 0.24 0.30* 0.17 0.40** 0.34** 0.25* 0.30** 0.36**
GEO 0.12 0.16 0.07 0.33** 0.32** 0.15 0.20 0.31**
OM 0.26 0.30* 0.16 0.32** 0.19 0.30* 0.32** 0.28*
EB 0.29* 0.28* 0.26 0.37** 0.20 0.19 0.36** 0.36**
S 0.15 0.22 0.05 0.32** 0.39** 0.19 0.14 0.22*

Correlation coefficients: * p < 0.05; ** p < 0.01.

SCL-90 GSI = Symptom checklist (SCL 90-R) global severity index; BDI = Beck depression inventory; STAI = state-trait anxiety
inventory; EDE-Q = eating disorder examination questionnaire; GEO (factor 1) = ‘feeling oneself only through the gaze of the other
and defining oneself only through the evaluation of the other’; OM (factor 2) = ‘feeling oneself only through objective measures’; EB
(factor 3) = ‘feeling extraneous from one’s own body’; S (factor 4) = ‘feeling oneself only through starvation’.

Table 4. Summary of exploratory factor analysis

Item (n = 23) Rotated factor loadings

factor factor factor factor
1 2 3 4

Knowing what the others think of me calms me down (15) 0.79

I can’t stand not to know what the others think of me (18) 0.89
For me it’s very important to see myself through the eyes of the others (1) 0.80
When I meet someone I can’t stay without knowing what he thinks of me (23) 0.78
I am dependent on the evaluation of the others (13) 0.91
Even if I think that the way the others evaluate me is wrong, I can’t do without it (16) 0.86
The way I feel depends on the way I feel looked at by the others (11) 0.82
Sometimes I focalize myself through the gaze of the others (7) 0.70
Seeing myself from their point of view makes me feel very anxious (8) 0.72
Having control of my weight means having control of the possible changes that happen in my body (21) 0.89
Only if I have my weight under control does being looked at by the others make me feel alright (10) 0.85
Having my weight under control makes me feel in control of my emotional states (22) 0.91
In all this confusion knowing that my weight is under control reassures me a little bit (9) 0.77
If my measures remain the same over time I feel that I am myself, if not I feel I am getting lost (5) 0.77
Sometimes, the emotions I feel are extraneous to me and scare me (4) 0.80
I see myself out of focus, I don’t feel myself (14) 0.86
I see myself fuzzy/hazy, as if I had no boundaries (6) 0.79
The fear of change is an emotion that I can’t tolerate (20) 0.80
The flesh is unimportant; it doesn’t let me feel my bones (12) 0.71
Eating according to my own rules is the only way to feel myself (2) 0.84
If I could not eat the way I want I would not be myself anymore (3) 0.86
If I follow your dietary prescriptions I cannot recognize myself when I look at myself in the mirror; 0.73
this does not happen if I do things in my own way (17)
Changing my own eating habits scares me to death, as does any other change in my life (19) 0.71
Eigenvalues 10.80 2.45 1.51 1.35
% of variance 46.96 10.54 6.56 5.87
␣ 0.93 0.89 0.88 0.82

152 Psychopathology 2012;45:147–158 Stanghellini /Castellini /Brogna /Faravelli /

       

Ricca 
 Incremental Validity
According to stepwise logistic regression analysis, at 12

step 1, EDE-Q total score (with age, gender, and BMI ad- 10
justment) predicted ED diagnosis with odds ratio (OR),
95% CI of 7.49, 4.87–11.52 (–2 log-likelihood = 226.27); at 8

Eigenvalue
step 2, with IDEA total score added to the model, EDE-Q
6
total score and IDEA total score predicted ED diagnosis,
respectively, with OR 95% CI of 4.91, 3.12–7.73 and 4.99, 4
2.77–9.00. The difference between the –2 log-likelihood
of the first and the second step (–2 log-likelihood = 2

184.29) revealed that adding IDEA scores improved the 0

model with a highly significant effect.
Factor Analysis
A principal component analysis (PCA) was conducted
on the 23 items with oblique rotation (Promax) for pa-
tients with EDs. The Kaiser-Meyer-Olkin measure veri-
fied the sampling adequacy for the analysis (KMO = 0.90).
Bartlett’s test of sphericity (␹2 (253) = 1,980.88, p ! 0.001)
indicated that correlations between items were sufficient-
ly large for PCA. An initial analysis was run to obtain ei-
genvalues for each component in the data. Four factors
had eigenvalues over Kaiser’s criterion of 1, and in combi-
nation explained 69.95% of the variance, according to the
factor analysis performed for the development of the
questionnaire. The scree plot (fig. 1) was slightly ambigu-
ous and showed inflexions that would justify retaining
both factors 2 and 4. Given the convergence of the scree
plot and Kaiser’s criterion on four factors, and the neces-
sity of an accurate description of different dimensions
considered on the basis of the clinical observation, this is
the number of factors that was retained in the final analy-
sis. Table 4 shows the factor loadings after rotation. The
items that cluster on the same factor suggest that factor 1
represents ‘feeling oneself only through the gaze of the
other and defining oneself only through the evaluation of
the other’ (GEO), factor 2 represents ‘feeling oneself only
through objective measures’ (OM), factor 3 represents
‘feeling extraneous from one’s own body’ (EB), and factor
4 represents ‘feeling oneself through starvation’ (S).
Retained Factor Characteristics
Significant correlations were found among the re-
tained factors (table 5). The ␣ coefficients obtained for the
retained factors (table 4) showed high internal consisten-
cy among the items of each factor.
For each factor, an average score of the related items
was calculated and reported (table 6). A significant dif-
ference was found between patients with EDs and healthy
controls groups, while no significant difference was ob-
1 3 5 7 9 11 13 15 17 19 21 23
2 4 6 8 10 12 14 16 18 20 22
Component No.
Fig. 1. Cattell’s scree plot for the number of retained factors.
Table 5. Correlations among the 4 factors of IDEA
OM EB S
GEO 0.54** 0.53** 0.42**
OM 0.51** 0.50**
EB 0.51**
** Pearson correlation is significant at the 0.01 level (2-tailed).
GEO (factor 1) = ‘Feeling oneself only through the gaze of the
other and defining oneself only through the evaluation of the oth-
er’; OM (factor 2) = ‘feeling oneself only through objective mea-
sures’; EB (factor 3) = ‘feeling extraneous from one’s own body’; S
(factor 4) = ‘feeling oneself only through starvation’.
served among ED diagnostic groups in terms of all the
considered factors.
Stepwise multiple linear regressions (age adjusted)
showed that EDE-Q restraint was associated with factor
4 ([S] ␤ = 0.30, p = 0.015), EDE-Q eating concern was as-
sociated with factor 2 ([OM] ␤ = 0.30, p = 0.01), EDE-Q
weight concern was associated with factor 3 ([EB] ␤ =
0.27, p = 0.034), and factor 2 ([OM] ␤ = 0.30, p = 0.01),
EDE-Q shape concern was associated with factor 1
([GEO] ␤ = 0.34, p = 0.004), and factor 3 ([EB] ␤ = 0.36,
p = 0.002). The performed analyses could be biased by
multi-collinearity, which results in a lack of statistical sig-
nificance of individual independent variables, although
the overall model may be strongly significant. To test for
multi-collinearity, we measured the variance inflation

IDentity and EAting Disorders Psychopathology 2012;45:147–158 153

Table 6. IDEA scores

AN BN BED F All patients with Healthy controls t

(n = 50) (n = 48) (n = 49) EDs (n = 147) (n = 187)

IDEA total score 1.5680.88 1.6681.04 1.5680.94 0.18 1.5980.95 0.4580.47 15.19**
GEO 1.7981.15 1.5681.16 1.5481.16 0.66 1.6381.15 0.5380.64 10.90**
OM 1.7181.20 2.0581.28 1.9081.27 0.86 1.8981.25 0.4280.63 13.78**
EB 1.1580.88 1.5481.09 1.4481.12 1.82 1.3881.04 0.1780.29 15.01**
S 1.3580.91 1.5481.22 1.3681.19 0.42 1.4181.11 0.6580.60 7.98**

Values are reported as mean 8 standard deviation. ANOVA (F) for comparison of means among patients’ diagnoses, and two-
tailed Student’s unpaired t test (t) for comparison of means between patients and healthy controls; ** p < 0.01.
EDs = Eating disorders AN = anorexia nervosa; BN = bulimia nervosa; BED = binge eating disorder; GEO (factor 1) = ‘feeling one-
self only through the gaze of the other and defining oneself only through the evaluation of the other’; OM (factor 2) = ‘feeling oneself
only through objective measures’; EB (factor 3) = ‘feeling extraneous from one’s own body’; S (factor 4) = ‘feeling oneself only through
starvation’.

factor (VIF). For our current models, the VIF values were
all below 2, showing that collinearity should not be cause
for concern [40].
Discussion
The IDEA questionnaire, administered to a sample of
female patients with EDs referred to an ED clinic and to
a control group, showed a satisfactory test-retest reliabil-
ity and internal consistency, and IDEA total score was
significantly higher in patients than in controls. As far as
convergent validity is concerned, IDEA total scores
showed a significant association with EDE-Q total and
subscale scores, suggesting that this new questionnaire is
able to identify some important psychopathological phe-
nomena which are closely related to the specific anoma-
lies of patients with EDs. The BDI scores were found to
be statistically correlated with IDEA scores, which could
depend on the frequent mood depression affecting pa-
tients with EDs [41].
The factor analysis allowed for the identification of
four distinct subscales: ‘feeling oneself through the gaze
of the other and defining oneself through the evaluation
of the other’ (GEO), which contains 9 items, ‘feeling one-
self through objective measures’ (OM) with 5 items, ‘feel-
ing extraneous from one’s own body’ (EB) with 5 items,
and ‘feeling oneself through starvation’ (S) with four
items (factors 1, 2, 3, 4, respectively). These subscales sig-
nificantly correlated with each other, as with the items of
each factor, suggesting the coherent nature of the ques-
tionnaire and of the different factors that compose it.
In the present study, we decided to administer and test
the questionnaire to subjects suffering from anorexia
nervosa, bulimia nervosa and binge eating disorder. This
choice to include different subtypes of ED is based on the
assumption that patients with EDs share some common
as well as distinctive psychopathological core dimen-
sions. In particular, it has been pointed out that what is
most striking about the variety of EDs is not what distin-
guishes them, but how much they have in common [42],
so that different clinical configurations may not be de-
pendent on differences in core psychopathology.
Moreover, longitudinal studies indicate that most pa-
tients migrate among diagnoses over time [42, 43] with-
out a substantial change in basic psychopathological fea-
tures [44–46]. Finally, The Eating Disorders Work Group
of the American Psychiatric Association has recently pro-
posed some diagnostic revisions and recommendations
in order to improve the actual ED classification [47], and
binge eating disorder has been formally recognized as a
full-blown ED.
According to our findings, IDEA is a specific tool able
to clearly identify some peculiar phenomena in patients
with EDs. In particular, IDEA total scores are significant-
ly higher in patients with EDs than in controls, whereas
no significant difference was observed between the three
diagnostic groups. Furthermore, the incremental validity
analysis, according to Haynes and Lench [37], showed
that adding IDEA questionnaire to the assessment would
improve the identification of patients with EDs. In order
to improve the clinical utility of this instrument in terms
of incremental validity, further longitudinal studies
should provide information about the degree to which

154 Psychopathology 2012;45:147–158 Stanghellini /Castellini /Brogna /Faravelli /

       

Ricca 
this new measure leads to the design of more effective
treatments.
Furthermore, the same profile was obtained when the
four different factors were taken into account. It is of note
that these results were obtained considering the simple
categorical diagnostic criteria for the three disorders,
which are based on both behavioral and cognitive crite-
ria.
As far as the correlations between IDEA scores and the
specific ED psychopathological dimensions are con-
cerned, we found a significant association between the
IDEA total score and the EDE-Q total and subscale scores.
Also, the severity of embodiment and identity disorders,
measured by IDEA total score, is positively correlated
with the degree of the ED psychopathology. Moreover, the
lack of a significant association between IDEA total score
and the SCL-90 global severity score indicates that the
IDEA items are able to identify some nuclear feature spe-
cific for patients with EDs, and are not a generic measure
of psychological or psychiatric suffering. These results
suggest that the disorders of embodiment and identity as-
sessed by IDEA could represent a core dimension in the
onset and maintenance of ED psychopathology.
According to the cognitive model of the maintenance
of EDs [48], the ‘core psychopathology’ of EDs is basi-
cally an overconcern about body shape and weight, such
that self-worth is judged largely or even exclusively in
terms of satisfaction with weight and shape. Our results
showed that this core psychopathology is related to the
dimension of embodiment named ‘lived-body-for-oth-
ers’, confirming that persons with ED experience their
own body first and foremost as an object being looked at
by another, rather than cenesthetically or from a first-
person perspective.
As far as the subscale scores are concerned, it is to note
that even if the four factors showed a high correlation
with each other, they had a different pattern of associa-
tion with EDE-Q domains. The correlations of each sub-
scale’s scores with abnormalities in eating behavior were
those expected, on the basis of the different dimensions
explored by the questionnaire. In particular the GEO
subscale (‘feeling oneself through the gaze of the other
and defining oneself through the evaluation of the other’)
was associated with overvalued thoughts regarding body
shape. Weight and shape concerns are also associated
with EB subscale (‘feeling extraneous from one’s own
body’), which represents a measure of the alienation of
patients with EDs from their own body and emotions.
OM subscale (‘feeling oneself through objective mea-
sures’) and S subscale (‘feeling oneself through starva-
IDentity and EAting Disorders
tion’) were associated with overvalued thoughts regard-
ing weight and eating concern, and with dietary restric-
tion, respectively. According to these patterns of
association, some characteristic ED behaviors, such as
starvation and the fixated checking of objective mea-
sures, might be interpreted as an alternative coping strat-
egy aimed to feel oneself for those patients who are unable
to feel themselves cenesthetically.
Finally, some of the constructs which were explored by
the present questionnaire could conceptually resemble
dimensions assessed by different scales or by previous
qualitative research. For example, the GEO subscale
(‘feeling oneself through the gaze of the other and defin-
ing oneself through the evaluation of the other’) shows
some similarities with the social-psychological construct
‘public self-consciousness’. Public self-consciousness, as
opposed to private self-consciousness, includes all those
qualities of the self that are formed in other people’s eyes.
In fact, persons with ED have the tendency to think of
those aspects of their own self that are matters of public
display rather than to attend to the more covert, hidden
aspects of the self, e.g. one’s privately held beliefs and feel-
ings [49]. More in general, previous research has shown
important relationships between abnormal eating behav-
ior and these persons’ self-construct or identity. Nordbø
et al. [50] documented that anorectic persons may ex-
plain their behavior as a tool for achieving a new identity.
Skarderud [51, 52] showed that to some persons with ED,
changing one’s body is a tool to become another. They
want to change, and changing one’s body serves as both
a concrete and a symbolic tool for such ambitions. Thus,
shaping oneself is a ‘concretized metaphor’, establishing
an equivalence between a psychic reality (identity) and a
physical one (one’s body shape). As suggested by Surgenor
et al. [53], looking into the different ways persons with ED
construe their own self, especially in relation to their dis-
order and therapy, has strategic implications for the ther-
apeutic endeavor. Compared with other measures which
are referred to constructs related to general beliefs, our
questionnaire was specifically designed for patients with
EDs, and our results showed its association with the spe-
cific psychological dimensions of these disorders.
It is important to note that, given the cross-sectional
design of our study, we have not been able to establish any
supposed causal relationships between IDEA scores and
ED behavior. A second limitation of this study is that it is
impossible to ascertain whether the domains we assessed
by means of our questionnaire are specific traits of pa-
tients with EDs, or state-related features. To answer these
questions, a longitudinal study is needed.
Psychopathology 2012;45:147–158 155
 Conclusion
IDEA represents a new, multidimensional, brief, ver-
satile, easy-to-perform instrument for the evaluation be-
fore, during and after a psychological treatment, assess-
ing these patients’ abnormal experiences and attitudes.
The anomalous phenomena explored and measured by
IDEA are mainly two: abnormal attitudes toward one’s
own corporeality, and difficulties in the definition of
one’s own identity. We suggest that specific abnormalities
in lived corporeality, namely experiencing one’s own
body first and foremost as an object being looked at by
another (rather than cenesthetically and from a first-per-
son perspective), and of personal identity, namely defin-
ing one’s own self largely in terms of the way one feels
looked at by the others and through one’s ability to con-
trol one’s shape and weight (rather than through other
kinds of performance), are supposedly core features of
ED psychopathology.
From a clinical point of view, we already demonstrated
the importance of concerns related to the body (e.g. shape,
weight) in determining a different course of patients with
EDs, in terms of response to treatment and long-term
outcome [15, 54]. This study suggests that a specific dis-
order of lived corporeality might help to explain why per-
sons with EDs overvalue their body shape and weight. If
further cross-sectional and prospective studies would
confirm our preliminary findings, the evaluation of the
‘lived-body-for-others’ dimension could be considered a
relevant feature for clinical assessment and treatment
protocols.

Appendix

IDentity and EAting Disorders (IDEA) Questionnaire

Instructions: In the following list you find a series of statements which are often reported by people who have eating behavior prob-
lems. Please indicate how much you agree with the following claims.

Not Just a Enough Much Very

at all little (2) (3) much
(0) (1) (4)

1. For me it’s very important to see myself through the eyes of the others 0 1 2 3 4
2. Eating according to my own rules is the only way to feel myself 0 1 2 3 4
3. If I could not eat the way I want I would not be myself anymore 0 1 2 3 4
4. Sometimes, the emotions I feel are extraneous to me and scare me 0 1 2 3 4
5. If my measures remain the same over time I feel that I am myself, if not I feel I am getting lost 0 1 2 3 4
6. I see myself fuzzy/hazy, as if I had no boundaries 0 1 2 3 4
7. Sometimes I focalize myself through the gaze of the others 0 1 2 3 4
8. Seeing myself from their point of view makes me feel very anxious 0 1 2 3 4
9. In all this confusion, knowing that my weight is under control reassures me a little bit 0 1 2 3 4
10. Only if I have my weight under control does being looked at by the others make me feel alright 0 1 2 3 4
11. The way I feel depends on the way I feel looked at by the others 0 1 2 3 4
12. The flesh is unimportant; it doesn’t let me feel my bones 0 1 2 3 4
13. I am dependent on the evaluation of the others 0 1 2 3 4
14. I see myself out of focus, I don’t feel myself 0 1 2 3 4
15. Knowing what the others think of me calms me down 0 1 2 3 4
16. Even if I think that the way the others evaluate me is wrong, I can’t do without it 0 1 2 3 4
17. If I follow your dietary prescriptions I cannot recognize myself when I look at myself in the 0 1 2 3 4
mirror; this does not happen if I do things in my own way
18. I can’t stand not to know what the others think of me 0 1 2 3 4
19. Changing my own eating habits scares me to death, as does any other change in my life 0 1 2 3 4
20. The fear of change is an emotion that I can’t tolerate 0 1 2 3 4
21. Having control of my weight means having control of the possible changes that happen in 0 1 2 3 4
my body
22. Having my weight under control makes me feel in control of my emotional states 0 1 2 3 4
23. When I meet someone I can’t stay without knowing what he thinks of me 0 1 2 3 4

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Ricca  
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