Eating disorders across two cultures: does the

expression of psychological control vary?

Nerissa Soh, Lois J. Surgenor, Stephen Touyz, Garry Walter

Objective: Because both the expression of eating disorder (ED) symptoms and preferred
psychological control styles may be affected by culture, the purpose of the present study
was to examine whether the expression of psychological control in women with EDs varies
across two cultures.
Method: North European Australian and Chinese Singaporean women (n
117) with
anorexia nervosa (n
36), bulimia nervosa (n
13) and eating disorders not otherwise
specified (n
3), and without an ED (n
65) recruited in Australia and Singapore
completed a multidimensional inventory assessing sense of control, domains of control,
preferred means by which to gain control, and motivation for control.
Results: Although the normative control profile for each culture differed slightly, control
profiles among those with an ED were very similar across both cultures. However, the
directionality and extent of specific aspects of control pathology associated with the
presence of an ED differed across cultures. North European Australians with an ED were
much more deviant from the cultural norm than their Chinese Singaporean ED
counterparts in relation to overall sense of control, methods of gaining control, and
control in the domain of body. Chinese Singaporean woman with an ED were much more
deviant from the cultural norm than their North European Australian ED counterparts in the
domain of control over impulses.
Conclusions: Having an ED powerfully distorts psychological control irrespective of
culture. However the degree, directionality, and form of the displacement from normal
control styles is also culture dependent. This has implications for treatments that attempt to
redress or correct control issues in people with an ED in other cultures.
Key words: cultural differences, eating disorders, psychological control.

Australian and New Zealand Journal of Psychiatry 2007; 41:351 358 

Lois Surgenor, Senior Lecturer (Correspondence)
Department of Psychological Medicine, Christchurch School of Medicine
and Health Sciences, University of Otago, PO Box 4345, Christchurch
8140, New Zealand. Email lois.surgenor@chmeds.ac.nz
Nerissa Soh, Research Officer
Child and Adolescent Mental Health Services, Northern Sydney Central
Coast Area Health Services, Sydney, New South Wales, Australia
Stephen Touyz, Professor of Clinical Psychology
Psychology Department, University of Sydney, Sydney, New South
Wales, Australia
Garry Walter
Professor of Child and Adolescent Psychiatry, Discipline of Psychological
Medicine, University of Sydney, and Area Clinical Director, Child and
Adolescent Mental Health Services, Northern Sydney Central Coast
Area Health Services, Sydney, New South Wales, Australia
Received 28 September 2006; accepted 29 November 2006
Historically, eating disorders (EDs) were considered
rare in non-Western societies. Consequently research
interest about EDs in these societies and information
about potential cross-cultural differences has emerged
only relatively recently [1]. Being a member of a non-
Western ethnic group was thought to confer some
degree of protection [2,3], although other hypotheses
for the reported lower prevalence have included
referral bias [4 6], social stigma in some non-Western
societies [7] and a reluctance to consult Western-based
physicians over traditionally based practitioners [8,9].
The heightened interest in the cultural context of
EDs has included speculation about different risk

# 2007 The Royal Australian and New Zealand College of Psychiatrists

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352 EATING DISORDERS ACROSS TWO CULTURES
factors in non-Western cultures [10,11], cultural
variation in the expression of symptoms [12,13], and
whether outcomes differ in Western and non-Western
societies [14]. Generally there has been little evidence
for major differences in psychopathology, with stu-
dies showing no [4,12,13] or few differences
[10,15,16]. Lee et al. considered fear of fatness to be
a relatively recent reason for food refusal offered by
people with anorexia nervosa (AN) in the Western
world, and used this to explain why non-Western
patients may be less likely to present with this core
symptom [14]. More recently, a typography for
atypical cases in Chinese patients has been proposed
[17]. But with increasing exposure to Western dietary
and beauty values, fear of fatness could become more
common. That is, any differences may dissipate.
Nevertheless at this stage body image dissatisfaction
among Hong Kong women, for example, may not be
as critical a risk factor for EDs [18].
Whatever the differences, if they do indeed exist, it
is nonetheless plausible that classic features of EDs
may have a different meaning in different cultural
contexts and, in turn, different strengths of associa-
tions with ED psychopathology. That is, what is
deemed as pathology directly associated with an ED
in Western settings may in fact be due to reasons
unrelated to the ED in non-Western settings [19,20].
Psychological control, culture and eating and body
image disturbances
It has been proposed that when ED patients in non-
Western countries present without shape and weight
concerns, issues of self-control may be the primary
motivator instead [21]. A core construct associated
with EDs is that of psychological control, and there is
considerable clinical and empirical evidence to sup-
port this association in general (see [22] for a
conceptual review). Control has been argued to be
important in the aetiology [23,24], maintenance [21],
and treatment approaches [25] of EDs. The empirical
evidence consistently supports a profile among those
with an ED that includes overreliance on particular
means by which to gain control, and reduced overall
control [26,27].
Importantly, there is reason to believe that what is
a normal ‘control profile’ may differ between cultural
settings. Marks noted that what has previously been
considered normal (and thus leading to a treatment
bias towards attaining specific control goals) may be
influenced by the Western cultural value of personal
autonomy [28]. In short, norms for psychological
control may be culture dependent. For example,
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Japanese culture emphasizes external control, while
European Americans reported greater internal con-
trol, as do those in Hispanic cultures [28]. Along the
same lines, people from East Asian cultures are
perhaps less likely to see matters in isolation;
accordingly, a sense of personal control is less
important. Ji et al. explained the difference in control
preferences between East Asian and European socie-
ties in terms of the agricultural heritage of China
lending itself to a collective society while the hunting
and herding heritage of Europe favours autonomy
and a looser social structure [29]. Chan provides
additional empirical evidence of the East Asian
culture valuing and endorsing external control [30].
Further, in terms of forming self-identity, Hong
Kong adolescents seem concerned with ability and
competence rather than other personal control as-
pects of identity [31]. Instead, in that culture there is
an emphasis on external control, implying that an
individual should work hard on their immediate task
and fate would take care of the rest. Levels of
acculturation also affect expression of control, and
this provides a powerful argument for studying
control issues in the primary cultural setting of that
group rather than one in which they have relocated
into. For example, first-generation Japanese students
in the USA scored more highly on external control
while their third- or later generation peer group
scored more highly on internal control [28].
Compounding the Western bias [26] in understand-
ing healthy psychological control styles has been the
traditional reliance on constructs such as locus of
control [32]. Invariably, the accompanying assump-
tion is that a lack of active or internal control
orientation in an individual is undesirable.
Bringing these tracts of research together, there is
good reason to speculate that any reportedly strong
association between EDs and particular issues of
psychological control may be influenced by culture.
This has been only partially tested in non-Western
groups and to date has not yet been tested in clinical
groups in two different countries alongside their non-
ED peer group. Kempa and Thomas suggested that
ethnic minority individuals may draw a sense of
control from eating attitudes and behaviours when
facing racism and oppression and the consequential
sense of powerlessness [6]. In Hong Kong, Lee et al.
investigated the relationship between psychological
control and outcome in women with AN [33].
Participants classified as having a good outcome
had significantly higher overall sense of control,
positive sense of control and specific sense of control
compared to patients categorized as having a poor
 N. SOH, L. J. SURGENOR, S. TOUYZ, G. WALTER
outcome. In general, the control profile of Hong
Kong women with AN was consistent with other
research in that greater eating pathology is associated
with a greater desire for control and greater use of
more negative forms of gaining control. Lee et al.
acknowledged that the study could not ascertain if
these control issues were peculiar to EDs because the
study design did not include a non-ED sample [33],
and thus it is not clear what the psychological control
norms would be in the Hong Kong population.
Nevertheless, the authors hypothesized that while
fear of fatness may not be present in some women
with AN in Hong Kong, the general similarity of
control profiles between typical and atypical (non-fat
phobic) patients may mean that psychological control
is a more useful culturally impervious diagnostic
criterion. Because information regarding this is
almost absent, an equally plausible hypothesis is
that a typography using phenomenon of psychologi-
cal control (rather than fat phobia as proposed by
[17]) may be equally worthwhile exploring. That is,
can variability between cultures, or typical and
atypical cases within a culture, be captured by a
typography based on psychological control profiles?
In summary, a particular control profile in itself
may not be pathological; instead, the degree to which
it deviates from the relevant population norm may be
of greater clinical importance in understanding its
association with EDs. To the best of our knowledge,
this hypothesis has not been previously investigated
despite the existing implication that control issues
may be the psychopathology that permeates all
cultures. This leaves the intriguing and entirely
underresearched question as to whether any pre-
sumed pathological control styles, expressions and
ambitions in EDs are culturally-bound.
The aim of the present study was to investigate
psychological control profiles in North European
Australian and Singaporean Chinese women with
and without an ED in their own cultural setting.
Based on the limited studies to date, it is hypothesized
that (i) certain expression of psychological control
may be culture dependent and, in particular, Singa-
porean Chinese participants will prefer less assertive
and more passive means by which to experience
control, and have less motivation for control overall
than their North European Australian counterparts;
(ii) the previously observed strong association be-
tween psychological control and EDs will permeate
both cultures; and (iii) the specific psychological
control pathology associated with an ED may be
culture dependent.
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353
Method
Participant and recruitment method
Participants (n
117) were women aged 14  38 years recruited in
the 2 years ending June 2004 across two countries (Australia and
Singapore) as part of a larger study investigating cross-cultural
differences in body composition, body image, and EDs. The study
was approved by the relevant Ethics Committee and Authority at
each recruitment site in each country (Human Research Ethics
Committee, University of Sydney; Ethics Review Committee,
Central Sydney Area Health Board; Human Research Ethics
Committee, Western Sydney Areas Health Board; Ethics Commit-
tee, Singapore General Hospital). When participants were deemed
minors (under 16 years of age in Australia; under 21 years of age in
Singapore), written informed consent was obtained from the
participant’s parents.
The ED participants were recruited from four teaching hospitals
affiliated with University of Sydney and from two teaching
hospitals in Singapore. All were undergoing treatment for an ED
(AN, bulimia nervosa (BN), or eating disorder not otherwise
specified (EDNOS)) as classified by DSM-IV criteria [34].
Healthy Australian participants (of North European ethnicity)
who had never been diagnosed with an ED (as per clinical interview
self-report) were recruited via advertising flyers at University of
Sydney campus and website, and by word of mouth. Participants
needed to have been born in Australia, or migrated there from
North European settings before the age of 12 years. Healthy
Singaporean participants (Chinese ethnicity) were recruited
through the nursing department at Singapore General Hospital.
In this instance, potential participants were made aware of the
study by verbal announcements through the nursing management
structure and each staff shift handover. Exclusion criteria were
non-fluency in spoken or written English, self-report of current or
past ED, and current pregnancy or lactating.
Data collection and measures
In all cases, face-to-face appointments were made to obtain
written consent, undertake the physical assessments (weight, height
etc.), and complete demographics sheets recording ethnicity/
cultural group and age. For the ED participants, formal diagnosis
was made by the treating psychiatrists using DSM-IV criteria, and
collected from their current clinical medical records in the clinic
setting where they were receiving treatment. All participants then
completed the Shapiro Control Inventory (SCI) [35] in their own
time as part of a larger questionnaire booklet examining cultural
differences in ED psychopathology and sociocultural factors. This
was returned immediately or shortly thereafter.
Shapiro Control Inventory
The SCI is a 187-item Likert-style questionnaire assessing an
individual’s multi-dimensional psychological control profile. The
duration for completion is 20  30 min. The SCI has been used to
investigate issues across a wide range of psychiatric and medical
354 EATING DISORDERS ACROSS TWO CULTURES

populations, including in ED populations in New Zealand [27] and
Hong Kong [33]. It uses language comprehensible to individuals
with equivalence of 8 years formal education, and has demon-
strated good internal consistency across clinical populations,
including Hong Kong Chinese women [33,35  37]. Nine scales
examine three different facets of control, which can be summarized
as follows.
(1) As the first and most general component, Sense of Control
‘‘measures a person’s view that s/he has control, as well as the belief
that s/he can gain control if desired’’ (p. 7, [35]) The Overall Sense
of Control score (scale 1) gives the broadest view of the
respondent’s sense of control, and is further analysed with respect
to its constituent parts: Positive Sense of Control (scale 2), which
assesses belief in the ability to attain future control, ability to utilize
positive modes of control, and current level of self-control; and
Negative Sense of Control (scale 3), which assesses the sense of loss
of control in areas previously experienced as controlled, aspects of
inadequate of self-control or environmental control, and feelings of
helplessness and passivity. Sense of Control is also examined with
respect to domains in which such control is experienced, either as
an overall Domain Sense of Control score (scale 4) or by each of
seven specific domain scores (body, mind, relationships, self,
career, environment, or impulse control) imbedded in the scale.
In this way, to what extent loss of control in one domain is also
experienced in another can be examined.
(2) Mode of Control assesses the means by which an individual
attempts to attain and maintain a sense of control. Distinctions are
made across the two dimensions of assertive  yielding and positive 
negative, thus yielding four scales. Positive  assertive (scale 5)
measures the perceived ability to use an active, altering mode of
control, and includes descriptors such as ‘decisive’, ‘leading’
and ‘communicating needs’. Positive-yielding (scale 6) measures
sense of control through means of letting go of active control.
Descriptors include ‘patient’ and ‘accepting’. Negative-assertive
(scale 7) measures too much active control (‘manipulating’,
‘dogmatic’) while Negative-yielding (scale 8) measures aspects
of too little control, with descriptors such as ‘indecisive’ and
‘manipulated’.
(3) Motivation (Desire) for Control (scale 9) measures the desire
for psychological control, over oneself, others, and the environ-
ment. Components of desire include the perceived importance of
being in control, efforts to achieve control, and fear of losing
control.
Statistical analyses
All analyses were conducted with SPSS Version 13.0 for
Windows (SPSS Inc., Chicago, IL, USA). Each SCI scale and the
seven domain-specific subscales of scale 4 were analysed using the
general linear model (GLM) with cultural group (North European
Australian and Chinese  Singaporean) and caseness (ED or no ED)
as independent variables. Because body mass index (BMI) was
associated with cultural group (t(115)
1.9, p
0.056) and caseness
(t(115)
6.7, p
0.000), and both BMI and age were significantly
associated with aspects of the dependent measure (SCI scales), BMI
and age were included as covariables in all linear regression
analyses.
Results
Characteristics of the sample
Participants from both cultures included young women in the age
range typical of those who present with EDs both in Western and
Asian settings (Table 1) [33,38]. Among the ED participants, 69%
had a primary diagnosis of AN, 25% a primary diagnosis of BN,
and the remaining 3% were diagnosed with EDNOS.
Relationship between sense of control, culture and
caseness
Culture was significantly associated with three aspects of
psychological control (Table 2), all of which related to the means
by which people prefer to gain control. North European Australian
participants preferred to gain control through positive assertive
methods (SCI scale 5; F(1,110)
17.4, p B0.001) and positive
yielding methods (SCI scale 6; F(1,110)
6.4, p B0.05), and were
significantly less likely to use negative yielding methods (SCI scale

Table 1. Demographic characteristics of sample (mean 9 SD)

North European Australians Chinese Singaporeans

No ED ED No ED ED Total
n 32 34$ 33 18 117
Height (m) 1.68 9 0.59 1.65 9 0.50 1.59 9 0.47 1.59 9 0.54 1.63 9 6.4
Weight (kg) 60.4 9 7.6 47.4 9 8.5 57.4 9 13.0 44.9 9 11.8 53.4 9 11.9
BMI (kg m  2) 21.4 9 2.5 17.4 9 2.7 22.6 9 4.6 17.7 9 4.6 20.0 9 4.2
Age (years) 21.5 9 2.9 20.8 9 3.8 22.2 9 3.0 22.5 9 5.2 21.6 9 3.6

ED, eating disorder.; $One participant was excluded from this anthropometric analysis due to a history of weight-altering in situ silicone
implants, but was included in all other subsequent analyses.

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 N. SOH, L. J. SURGENOR, S. TOUYZ, G. WALTER 355

Table 2. Psychological control (SCI) scores by culture and caseness (mean 9 SD)

North European Chinese Caseness

Australians Singaporean Culture Caseness  Culture
SCI scale No ED ED No ED ED (p) (p) (p value)
Scale 1: Overall 5.2 9 0.65 3.8 9 0.98 4.8 9 0.72 4.0 9 0.81 0.306 0.000 .046
Sense of Control
Scale 2: Positive 5.3 9 0.69 3.9 9 1.0 4.6 9 0.88 4.2 9 0.83 0.316 0.000 .004
Sense of Control
Scale 3: Negative 2.9 9 0.84 4.4 9 1.1 2.9 9 0.98 4.6 9 1.2 0.489 0.000 .573
Sense of Control
Scale 4: Overall Domain 4.8 9 0.54 4.0 9 0.54 4.8 9 0.55 3.9 9 0.77 0.873 0.000 .785
Sense of Control
Body 4.7 9 0.82 3.4 9 0.92 4.1 9 0.87 3.6 9 1.2 0.372 0.000 .043
Mind 4.5 9 0.84 2.9 9 1.2 4.7 9 0.84 2.9 9 1.2 0.703 0.000 .665
Relationships 4.7 9 0.55 4.0 9 1.2 5.0 9 0.72 4.0 9 0.92 0.564 0.000 .500
Self 4.9 9 1.2 2.3 9 1.5 4.8 9 1.1 3.2 9 1.8 0.096 0.000 .063
Career 4.5 9 0.90 4.1 9 1.1 4.6 9 0.64 3.8 9 1.2 0.628 0.002 .354
Environment 4.6 9 1.2 4.5 9 1.6 4.9 9 0.72 3.9 9 2.0 0.690 0.053 .124
Impulse 5.4 9 0.58 5.5 9 0.52 5.6 9 0.31 5.3 9 0.66 0.527 0.006 .005
Scale 5: Positive 2.8 9 0.44 2.3 9 0.51 2.2 9 0.35 2.2 9 0.41 0.000 0.042 .005
Assertive Mode
Scale 6: Positive 2.7 9 0.46 2.2 9 0.49 2.3 9 0.37 2.1 9 0.42 0.013 0.005 .188
Yielding Mode
Scale 7: Negative 1.8 9 0.48 2.1 9 0.56 1.8 9 0.45 2.4 9 0.67 0.166 0.000 .094
Assertive Mode
Scale 8: Negative 1.7 9 0.43 2.1 9 0.66 2.0 9 0.49 2.2 9 0.68 0.047 0.004 .640
Yielding Mode
Scale 9: Motivation 4.3 9 0.85 5.3 9 0.82 4.3 9 0.76 5.2 9 1.1 0.841 0.000 .843
for Control

ED, eating disorder; SCI, Shapiro Control Inventory.

8; F(1,110)
4.0, p B0.05) to attain control than their Chinese
Singaporean counterparts.
Caseness was significantly associated with all major SCI scales.
That is, ED participants reported a reduced overall sense of control
(SCI scale 1; F(1,111)
35.2, p B0.001) including the positive and
negative components of this (SCI scales 2,3; F(1,111)
18.3,
pB0.001 and F(1,111)
48.3, p B0.001 respectively), along with
reduced control in all domains (SCI scale 4; F(1,103)
51.8,
pB0.001) of functioning (excepting control over environment),
reduced use of positive means of gaining control (SCI scales 5,6;
F(1,110)
4.2, pB0.05 and F(1,110)
8.1, pB0.01, respectively),
increased use of negative means (SCI scales 7,8; F(1,106)
17.4,
pB0.001 and F(1,110)
8.4, p B0.01, respectively), and signifi-
cantly elevated desire for control (SCI scale 9; F(1,111)
23.4,
pB0.001).
A significant interaction for culture and caseness was found for
specific aspects of psychological control. In this respect, compared
with their Chinese Singaporean ED counterparts, eating disordered
North European Australians deviated significantly more from their
cultural norm on aspects of overall sense of control (SCI scale 1;
F(1,111)
4.1, pB0.05), positive sense of control (SCI scale 2;
F(1,111)
8.9, p B0.01), positive assertive methods of attaining
control (SCI scale 5; F(1,110)
8.3, pB0.01) and control in
the domain of body (SCI 4 subscale Body; F(1,108)
4.2, p B
0.05). Compared with their North European Australian ED
counterparts, Chinese Singaporeans with an ED deviated signifi-
cantly more from their cultural norm on aspects control in the
domain of impulsivity (SCI subscale 4 Impulsivity; F(1,109)
8.1,
pB0.01).
Discussion
Psychological control is a construct of sustained
interest in the area of EDs, but one that requires
further explication to reconcile the contradictory
literature within cultures and add to the limited
knowledge base across cultures. Theories and some
empirical evidence suggest that expressions of control
may be, in part, affected by culture. Existing argu-
ments are also made that the expression of ED
symptoms may be influenced by culture. This is the
first study to examine multidimensional aspects of
psychological control in ED subjects and their non-
ED peer group concurrently in two cultures.
The study does suffer from a number of limitations,
many of which are associated with obtaining cross-
cultural samples, and a larger sample overall would
have enabled more subtle and detailed results beyond

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356 EATING DISORDERS ACROSS TWO CULTURES
those obtained, including analysis by ED subtype.
A further limitation is that the sample was recruited
under different circumstances and with different
strategies  in part due to the cultural and
infrastructural difference between Australia and Sin-
gapore. Although care was taken to minimize such
differences, they may have, nevertheless, impacted on
the findings. Also, the ED participants recruited in
the treatment centres may not be representative of the
wider ED population in each setting, especially given
the referral bias that may be operating in non-
Western clinic settings.
The overall pattern revealed in this series of
analyses was that women with EDs in these two
cultures exhibit control profiles that cannot be
differentiated by culture. That is, ED women, irre-
spective of culture, can be marked out from their
non-ED peer group by their reduced overall sense of
control, greater negative sense of control, reduced
control in the domains of mind, relationships, self
and career, and marginally lower levels of control in
the domain of environment. ED women across both
cultures also reported significant differences in the
methods by which they attain psychological control.
Having an ED seems to mute use of active assertive
methods. It means that these people are less likely to
experience control through trusting others, and more
likely to resort to dogmatic methods at the same time
as feeling manipulated by others. Clearly, this occurs
while experiencing elevated motivation for control.
The ED control profile across these two cultures is
very similar in these respects, and it is a profile that
concurs with existing recent studies within cultures
[27,33,39]. In particular, Lee et al. observed that AN
patients in Hong Kong used less assertive means of
achieving control and were more likely to view
themselves as being controlled by others when
compared to normal or recovered individuals [33].
Although the aforementioned similarities initially
suggest that control psychopathology may be imper-
vious to culture, this is not the case for all aspects of
control, and some important differences exist. In
terms of cultural norms, in the present study the
means by which individuals prefer to attain and
maintain control is significantly associated with
culture, with Chinese Singaporean women being less
likely to use methods involving assertiveness and self-
initiation, whereas North European Australians were
less likely to use strategies that risk a sense of
manipulation or indecision. Put another way,
although no more motivated to achieve control than
Chinese Singaporean women, the Australian norm is
one of less timidity and more assertiveness in the
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choice of methods by which day-to-day control is
achieved. Longstanding cultural traditions in both
settings could account for this. East Asian societies
have been described as highly conforming and
supportive of a social norm that promotes a sense
of fatalism [29,31]. Likewise, a western cultural
conditioning to value self-responsibility and decisive-
ness is likely to colour which methods of gaining
control are selected. This style is one that also
permeates psychological interventions [39]. Although
we hypothesized that Singaporean Chinese women
would have less motivation for control overall, the
present study did not find this. A potential reason is
that level of acculturation was not taken into
account; and westernization in Singapore in view of
its prominent use of the English language, and access
to English language media, may have served to
distort (increase) desire for control in this more recent
sample.
By far the most intriguing findings, especially in
terms of understanding the directionality and extend
of control psychopathology, relate to the interactions
between cultural group and caseness. In many
respects, there was some evidence of convergence at
the stage of a clinical ED, yet on specific aspects of
psychological control North European women with
an ED deviated much more from their cultural peers
than their Chinese Singaporean ED counterparts.
That is, the extent of specific aspects of control
pathology in those with an ED is culture dependent,
with North European Australian women more likely
to exhibit much more severe deviations from their
non ED peers in the direction of reduced overall
control, reduced control in the domain of body, and
more aberration in their ability to utilize positive
assertive methods by which to gain control. Whereas
having an ED in Singapore may lead to greater
deviancy from one’s Chinese Singaporean peer group
in the domain of impulse control than one’s Western
ED counterparts. It is not clear why this latter finding
emerged but it may reflect the higher proportion of
BN patients in the Singaporean Chinese ED sample
compared to the North European Australian clinical
sample.
The study of the role of psychological control in
EDs in non-Western groups has only recently com-
menced and further studies are clearly necessary
before more conclusions can be drawn. Fear of
fatness has been previously proposed to be a
culture-bound feature of EDs [40], and in many
respects the present study suggests that, in general,
psychological control issues may be the more uni-
versal and less culture-bound feature of EDs. That is,
 N. SOH, L. J. SURGENOR, S. TOUYZ, G. WALTER
an ED powerfully distorts sense of control irrespec-
tive of culture. That said, the present study provides 5.
preliminary evidence that it is western culture that
may experience the more pathological shifts once an
ED takes hold. Although these findings cannot 6.
evaluate the hypothesis that issues of self-control 7.
are the more primary motivator in non-Western EDs
[21], they nonetheless suggest that the ambition to
8.
achieve self-control is no more intense than that seen
in Western ED cases. 9.
Clearly, cultural differences with respect to aspects
of a normal control profile need to be taken into
10.
account when understanding the meaning or signifi-
cance of any assumed control psychopathology
associated with an ED. In short, deviation from a
11.
cultural norm may be just as important in under-
standing control psychopathology in each culture,
and universal conclusions cannot be drawn simply 12.
about absolute levels of control. In specific areas,
deviation from a cultural norm on issues of psycho- 13.
logical does not occur to the same degree in
Singaporean ED patients. It could be that future
14.
shifts towards westernization (and thus more wester-
nized control norms) could see ED women in Asian
settings become more deviant in their control profile, 15.
and for this reason future research should consider
the effect of adherence to Western or traditional 16.
cultures. If deviance from a cultural norm is some-
thing that matters, then this may not be static. These
17.
are all important hypotheses requiring further exam-
ination before control-based approaches to treatment
[e.g. 21] can be confidently applied. 18.
19.
Acknowledgement
This study was partly supported by the Edith Mary 20.
Rose Travelling Scholarship awarded to the first
author. 21.
22.
References
23.
1. Soh N, Touyz S, Surgenor LJ. Eating and body image
disturbances across cultures. Eur Eat Disord Rev 2006; 14:54 
24.
65.
2. Wildes JE, Emery RE, Simons AD. The roles of ethnicity and
culture in the development of eating disturbance and body 25.
dissatisfaction: a meta-analytic review. Clin Psychol Rev 2001;
21:521  551.
3. Nasser M. The emergence of eating disorders in other
cultures/societies. In: Nasser M, ed. Culture and weight 26.
consciousness , London: Routledge, 1997:24  60.
4. Streigel-Moore RH, Smolak L. The influence of ethnicity on
eating disorders in women. In: Eisler RM, Hersen M, eds.
Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on February 20, 2016
357
Handbook of gender, culture and health , Mahwah, NJ:
Lawrence Erlbaum Associates, 2000:227  253.
Tchanturia K, Katzman M, Troop NA, Treasure J. An
exploration of eating disorders in a Georgian sample. Int J
Soc Psychiatry 2002; 48:220  230.
Kempa ML, Thomas AJ. Culturally sensitive assessment and
treatment of eating disorders. Eat Disord 2000; 8:17  30.
Nakamura K, Yamamoto M, Yamazaki O et al . Prevalence
of anorexia nervosa and bulimia nervosa in a geographically
defined area in Japan. Int J Eat Disord 2000; 28:173  180.
Tsai G. Eating disorders in the Far East. Eat Weight Disord
2000; 5:183  197.
Pate JE, Pumariega AJ, Hester C, Garner DM. Cross-cultural
patterns in eating disorders: a review. J Am Acad Child
Adolesc Psychiatry 1992; 31:802  809.
Shaw H, Ramirez L, Trost A, Randall P, Stice E. Body image
and eating disturbances across ethnic groups: more
similarities than differences. Psychol Addict Behav 2004;
18:12  18.
Humphry TA, Ricciardelli LA. The development of eating
pathology in Chinese-Australian women: acculturation versus
culture clash. Int J Eat Disord 2004; 35:579  588.
le Grange D, Stone AA, Brownell KD. Eating disturbances in
white and minority female dieters. Int J Eat Disord 1998;
24:395  403.
le Grange D, Telch CF, Agras WS. Eating and general
psychopathology in a sample of Caucasian and ethnic
minority subjects. Int J Eat Disord 1997; 21:285  293.
Lee S, Ho TP, Hsu LK. Fat phobic and non-fat phobic
anorexia nervosa: a comparative study of 70 Chinese patients
in Hong Kong. Psychol Med 1993; 23:999  1017.
Ryu HR, Lyle RM, McCabe GP. Factors associated with
weight concerns and unhealthy eating patterns among young
Korean females. Eat Disord 2003; 11:129  141.
Lee HY, Lee EL, Pathy P, Chan YH. Anorexia nervosa in
Singapore: an eight-year retrospective study. Singapore Med J
2005; 46:275  281.
Ngai ES, Lee S, Lee AM. The variability of phenomenology
in anorexia nervosa. Acta Psychiatr Scand 2000; 102:314 
317.
Lake AJ, Staiger PK, Glowinski H. Effect of Western culture
on women’s attitudes to eating and perceptions of body
shape. Int J Eat Disord 2000; 27:83  89.
Jennings PS, Forbes D, McDermott B, Juniper S, Hulse G.
Acculturation and eating disorders in Asian and Caucasian
Australian adolescent girls. Psychiatry Clin Neurosci 2005;
59:56  61.
le Grange D, Louw J, Breen A, Katzman MA. The meaning
of ‘self-starvation’ in impoverished black adolescents in South
Africa. Cult Med Psychiatry 2004; 28:439  461.
Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural
theory of anorexia nervosa. Behav Res Ther 1998; 37:1  13.
Surgenor LJ, Horn J, Plumridge EW, Hudson SM. Anorexia
nervosa and psychological control: a reexamination of
selected theoretical accounts. Eur Eat Disord Rev 2002;
10:85  101.
Bruch H. Eating disorders: obesity, anorexia nervosa, and the
person within , New York: Basic Books, 1973.
Polivy J, Herman CP. Causes of eating disorders. Annu Rev
Psychol 2002; 53:187  213.
Jarman M, Smith JA, Walsh S. The psychological battle for
control: a qualitative study of health professionals’
understandings of the treatment of anorexia nervosa. J
Community Appl Soc Psychol 1997; 7:137  152.
Shapiro DH, Blinder BJ, Hagman J, Pituck S. A
psychological ‘‘sense-of-control’’ profile of patients with
anorexia nervosa and bulimia nervosa. Psychol Rep 1993;
73:531  541.
358 EATING DISORDERS ACROSS TWO CULTURES
27. Surgenor LJ, Horn J, Hudson SM. Empirical scrutiny of a
familiar narrative: sense of control in anorexia nervosa. Eur
Eat Disord Rev 2003; 11:291  305.
28. Marks LI. Deconstructing locus of control: implications for
practitioners. J Counsel Dev 1998; 76:251  260.
29. Ji LJ, Peng K, Nisbett RE. Culture, control, and perception of
relationships in the environment. J Pers Soc Psychol 2000;
78:943  955.
30. Chan DW. Dimensionality and adjustment correlates of locus
of control among Hong Kong Chinese. J Pers Assess 1989;
53:145  160.
31. Leung PWL, Salili F, Baber FM. Common adolescent
problems in Hong Kong: their relationship with self-esteem,
locus of control, intelligence and family environment.
Psychologia Int J Psychol Orient 1986; 29:91  101.
32. Rotter J. Generalised expectancies for internal versus external
locus of control of reinforcement. Psychol Monogr 1966;
80:489  493.
33. Lee S, Chan YY, Kwok K, Hsu LK. Relationship between
control and the intermediate term outcome of anorexia
nervosa in Hong Kong. Aust N Z J Psychiatry 2005; 39:
141  145.
Downloaded from anp.sagepub.com at PENNSYLVANIA STATE UNIV on February 20, 2016
34. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders , 4th ed. Washington, DC:
American Psychiatric Association, 1994.
35. Shapiro DH. Manual for the Shapiro Control Inventory , Palo
Alto, CA: Behaviordata, 1994.
36. Surgenor LJ, Horn J, Hudson SM, Lunt H, Tennent J.
Metabolic control and psychological sense of control in
women with diabetes mellitus: alternative considerations of
the relationship. J Psychosom Res 2000; 49:267  273.
37. Surgenor LJ, Horn J, Hudson SM, Adamson SJ, Robertson
P. Alcohol dependence and psychological sense of control:
refining the links. N Z J Psychol 2007; 35:146  152.
38. Makino M, Tsuboi K, Dennerstein L. Prevalence of eating
disorders: a comparison of Western and non-Western
countries. Medscape Gen Med 2004; 6:49.
39. Shapiro DH, Astin JA. Control therapy: an integrated
approach to psychotherapy, health and healing , New York:
John Wiley and Sons, 1998.
40. Keel PK, Klump KL. Are eating disorders culture-bound
syndromes? Implications for conceptualizing their etiology.
Psychol Bull 2003; 129:747  769.