The Development and Validation
of the Body Shape Questionnaire
Peter 1. Cooper, Ph.D.
Melanie 1. Taylor, B.Sc.
Zafra Cooper, Ph.D.
Christopher G. Fairburn, M.D.
Concerns about body shape are common among young women in Western cultures, and, in an extreme form, they constitute a central feature of the eating disorders anorexia nervosa and bulimia nervosa. To date there has been no
satisfactory measure of such concerns. A self-report instrument, the Body Shape
Questionnaire (SSQ, has therefore been developed. The items that constitute this
measure were derived by conducting semistructured interviews with various groups
of women including patients with anorexia nervosa and bulimia nervosa. The SSQ
has been administered to three samples of young women in the community as well
as to a group of patients with bulimia nervosa. The concurrent and discriminant
validity of the measure have been shown to be good. The SSQ provides a means
of investigating the role of concerns about body shape in the development, maintenance, and treatment of anorexia nervosa and bulimia nervosa.
A number of community surveys have shown that dissatisfaction with body
shape is common among adolescent girls. In an early American study (Huenemann et al., 1966) it was found that most teenage girls were profoundly unhappy with their size and shape: although only a quarter were classified as
overweight, nearly three-quarters expressed a strong desire to lose weight.
Subsequent surveys of school girls in America (Dwyer et al., 1967), Sweden
(Nylander, 1971) and England (Wardle & Beales, 1986) have produced similar
findings. Equally high levels of dissatisfaction with shape have also been found
among older women: for example, among a sample of women attending a British family planning clinic, although more than three-quarters were within 15%
Peter J. Cooper, D.Phil., Dip. Psych. is Lecturer in Psychopathology, Department of Psychiatry, University of Cambridge; Melanie J. Taylor, B.Sc., is Research Student, Department of Experimental Psychology, University of Cambridge; Zafra Cooper, D.Phil., Dip. Psych., is Clinical Psychologist, Fulbourn
Hospital, Cambridge; and Christopher C. Fairburn, M.A., M.Phil., M.R.C. Psych., is Wellcome Trust
Senior Lecturer, Department of Psychiatry, University of Oxford. Send reprint requests to Peter Cooper,
Ph.D., University of Cambridge, Department of Psychiatry, Addenbrooke's Hospital, Hills Road, Cambridge C62 2QQ England).
international journal of fating Disorders, Vol. 6,No. 4,485-494 (1 987)
10804.00
CCC 0276-3478/87/0404850 1987 by John Wiley & Sons, Inc.
Cooper et al.
486
of average body weight, 39% reported that they thought themselves to be significantly overweight, and 60% reported persistently feeling fat (Cooper & Fairburn, 1983).
A disturbance of body image has long been recognized as a central feature
of anorexia nervosa (Bruch, 1962, 1973). Indeed such a disturbance is included
as a necessary feature of the disorder in the diagnostic criteria specified in the
third edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association (1980). However, the notion of body image disturbance is a complex one and may be considered to encompass two related but conceptually
distinct aspects, namely concern about body shape and body size overestimation (Garner & Garfinkel, 1981). The latter feature, which reflects an inability
to estimate body size accurately, has been extensively studied; but there has
been little systematic research into the former aspect. This is unfortunate since
concern about body shape is a well recognized feature of both anorexia nervosa
(Bruch, 1973) and bulimia nervosa (Fairburn & Cooper, 1984). It may vary in
intensity from mild dissatisfaction with particular regions of the body to extreme body shape disparagement in which patients find their body loathsome
and revolting.
A major reason for the dearth of systematic research into concerns about
body shape is the absence of an appropriate method for measuring this phenomenon. Although a number of assessment procedures have been developed
that deal with certain aspects of body image, none has provided a specific
assessment of the phenomenal experience of concerns about body shape together with their antecedents and consequences. Most measures simply assess
dissatisfaction with various body parts, such as the Body Cathexis Scale (Secord & Jourard, 1953), the Body Image Satisfaction Scale (Marsella et al., 1981),
the Body Image Questionnaire (Berscheid et al., 1972), and the Body Dissatisfaction subscale of the Eating Disorder Inventory (Garner et al., 1983). Other
measures, although containing some items concerned with bodily appearance,
do not specifically deal with body shape concerns. For example, the Body Distortion Questionnaire (Fisher, 1970) is largely concerned with unpleasant bodily sensations; the "Appearance" subscale of the Food, Fitness and Looks
Questionnaire (Hall et al., 1983) mainly covers cosmetic appearance; and the
"Appearance" subscale of the Body Self Relations Questionnaire (Winstead &
Cash, 1984) is principally concerned with physical attractiveness. One measure
that does address attitudes to body shape is the Eating Disorder Examination
(Cooper & Fairburn, 1987), but this is a research interview that was designed
to assess the full range of the specific psychopathology of anorexia nervosa
and bulimia nervosa and not concern with body shape per se. Thus, there is a
need for a specific measure of concerns about body shape. To meet this need,
a self-report measure was developed.
QUESTIONNAIRE DEVELOPMENT
The Derivation of Items
Subjects who would be expected to show various degrees of concern about
their shape were interviewed using an open-ended schedule. These subjects
were encouraged to elaborate upon the experience of "feeling fat," to describe
Body Shape Questionnaire
487
the specific circumstances that provoke such feelings, and to provide an account of the behavioral and emotional consequences of such feelings. This interview was administered to 28 young women: 6 patients with bulimia
nervosa, 4 patients with anorexia nervosa, 7 women on weight-reducing diets,
3 women attending an exercise class, and 8 female university students. Having
completed these 28 interviews it was apparent that no new information was
emerging. The interviews, which lasted approximately an hour each, were tape
recorded and transcribed. The transcribed material was organized into conceptual categories, and questions were formulated to reflect their content. There
were 51 separate questions thereby derived, and a self-report questionnaire
was constructed with a 6-point Likert scale (“never”, “rarely,” ”sometimes,”
“often,” “very often,” “always”). All questions referred to the subject’s state
over the previous 4 weeks.
Item Elimination and Questionnaire Validation
The Samples
The 51-item questionnaire was administered to four samples of women.
1. Patients with bulimia nervosa. The questionnaire was completed by a consecutive series of 19 female patients with bulimia nervosa attending a psychiatric outpatient clinic in Cambridge and a consecutive series of 19 female
patients with bulimia nervosa attending a similar clinic in Oxford. All these
patients fulfilled either Russell’s (1979) diagnostic criteria for bulimia nervosa
or the proposed DSM-111-R criteria for bulimic disorder (American Psychiatric
Association, 1985).
2. Family planning clinic attenders. A consecutive series of 371 women attending two family planning clinics in Cambridge over a 4-week period were
asked to complete the questionnaire: 13 refused, 276 (95.5%) completed the
questionnaire while waiting to see the doctor, and 82 were unable to complete
the questionnaire while waiting and were asked to return it by mail and 55
(67.1%)complied. Although the response rate was low among those returning
their questionnaire by mail, since their BSQ responses did not differ from the
remainder, the complete sample of 331 questionnaires was considered together.
3. Occupational therapy students. The questionnaire was administered to
132 female occupational therapy students, the total number in two training
classes, of whom 119 (90.27) returned it satisfactorily completed.
4. Female university undergraduate students. There were 85 female university undergraduate students who were approached and asked to complete the
questionnaire. All agreed.
In addition to completing the 51-item questionnaire, the 3 nonpatient samples also completed a background information sheet that included questions
about their demographic characteristics, weight and eating history, and the
importance the subject placed on being slim and on her attitude towards becoming fat. The patients with bulimia nervosa and the occupational therapy
students also completed the Eating Attitudes Test or EAT (Garner & Garfinkel,
1979). Considerable additional information was obtained on the patients, including their responses to the Eating Disorder Inventory.
The age and weight distributions of the four samples are shown in Table 1.
Cooper et al.
488
Table 1. Age and current weight (% matched population mean weight; Geigy
Pharmaceuticals, 1962) of the four samples of women.
Bulimia
Nervosa
Patients
(n = 38)
Age (years)
Weight (% mpmw)
Undergraduate
Students
(n = 85)
Occupational
Therapy
Students
(n = 119)
Family
Planning
Clinic
Attenders
(n = 331)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
22.2
102.8
4.1
13.9
20.0
99.8
1.1
10.8
21.3
98.9
3.2
8.9
23.8
97.7
6.3
11.6
Item Elimination
Since a brief questionnaire was considered desirable, a number of items were
eliminated. First, using a one to six scoring method (“never” = 1, ”always” =
6) all 51 items were intercorrelated (Pearson’s T ) separately for the 38 patients
and for the 535 other women. Items correlating at 0.60 or above for both samples were examined. In six cases, where the content of the questions was considered to be closely related, one of the items was eliminated. Second, the
patients and the nonpatients were compared on each item using Student’s ftest. There were six items eliminated because the difference between the two
groups failed to reach the 0.001 level of significance. Finally, a further five
items were eliminated because they fell below an arbitrary rarity threshold:
fewer than 25% of patients and fewer than 5% of nonpatients rated them as
occurring at least “often” in the past 4 weeks. The final set of 34 questions was
termed the Body Shape Questionnaire, or the BSQ (Appendix).
Questionnaire Validation
For each subject a total BSQ score was derived based on the one to six scoring system. Figure 1 shows the BSQ distributions for the patients and the nonpatients. It is apparent that the BSQ scores of the patients were significantly
higher than those of the nonpatients (t = 11.7, df = 571, p < .OOO).
Clearly, the fact that the BSQ scores of patients and nonpatients differ markedly does not in itself constitute validation since items were, in part, chosen
by their power to differentiate these two groups. To test for concurrent validity, the BSQ was correlated with the Body Dissatisfaction subscale of the ED1
and with the total EAT score among the patients with bulimia nervosa; and
with the EAT total score among the occupational therapy students. The results
are shown in Table 2. Among patients the BSQ correlated moderately highly
with the score on the EAT and very highly with the ED1 Body Dissatisfaction
score. Among the occupational therapy students, the BSQ correlated very
highly with the score on the EAT.
For a second assessment of validity, two groups were derived from the nonpatient sample. First, a group of women concerned about weight and shape
were identified as those who rated slimness as “moderately” or ”extremely”
important, and their fear of fatness as “moderate” or “marked,” and who were
currently dieting to lose weight; 95 women fulfilled these criteria. Second, a
group of women unconcerned about weight and shape were identified as those
Body Shape Questionnaire
489
Community
101 S a m p l e
Bulimia N e r v o s a
Patients
8%
6-
42-
36
BSQ Score
187
Figure 1. Distribution of BSQ scores for patients with bulimia nervosa (Mean = 136.9,
SD = 22.5) and women in the community (Mean = 81.5, SD = 28.4).
who rated slimness as "not at all" or only "slightly" important and their fear of
fatness as "not at all" or only "slight" and who were not currently dieting; 79
women fulfilled these criteria. The mean BSQ score of the "concerned" group
was 109.0 (SD = 21.2); and the mean for the unconcerned group was 55.9
(SD = 14.4). These scores are significantly different (t = 19.6, df = 172, p <
.000).
For the final assessment of validity, two further groups were derived from
the community samples. The first group comprised individuals who fulfilled
self-report diagnostic criteria for bulimia nervosa. These criteria were the current occurrence of bulimic episodes (defined as episodes of excessive uncontrolled overeating) at least once fortnightly; the current occurrence of
compensatory vomiting or laxative use; and a fear of becoming fat rated as
"marked," the most extreme point on the scale provided; 10 subjects fulfilled
these criteria and were classed as "probable cases" of bulimia nervosa. The
BSQ scores of these 10 subjects were compared with those of the 316 women
who were classified as "definite non-cases" (ie., they did not binge, vomit, or
Table 2. Correlations (Pearson's r) between the BSQ and
the EAT total score and the Body Dissatisfaction (BD)
subscale of the EDI.
Bulimia Nervosa
Patients (n = 38)
Occupational
Therapy Students (n
*p < .02.
"'p < .001.
=
119)
BSQ vs. EAT
BSQ vs. BD
0.35'
0.66''
0.61''
-
Cooper et al.
490
use purgatives). This comparison is shown in Table 3. It can be seen that the
two groups differed markedly on the BSQ. It can also be seen from the table
that the mean BSQ score for the 10 “probable cases” of bulimia nervosa was
not significantly different from that of the 38 patients with bulimia nervosa
mentioned earlier.
DISCUSSION
The Body Shape Questionnaire is a self-report measure of concerns about
body shape, in particular the phenomenal experience of “feeling fat.” Items
were empirically derived by interviewing both patients with eating disorders
and other women. It is simple to fill in and can be completed in about 10
minutes. Significant correlations between the BSQ and the total score on the
EAT and the Body Dissatisfaction subscale of the ED1 establishes its concurrent
validity. Its discriminant validity has also been shown to be satisfactory.
Among a community sample of women, those who independently declared
themselves as concerned about weight and shape had significantly higher BSQ
scores than those who were unconcerned about such matters. Similarly, community “cases” of bulimia nervosa were found to have significantly higher BSQ
scores than ”non-cases.”
There was a certain amount of overlap between the BSQ scores of patients
with bulimia nervosa and women in the community (as shown in Fig. 1).However, this is to be expected given that the BSQ measures a psychological dimension that is known to vary considerably in intensity both within patient
populations and within community samples. As such, the BSQ should be regarded as providing a measure of the extent of psychopathology rather than a
means of case detection.
The significance of concerns about body shape in the development and
maintainence of anorexia nervosa and bulimia nervosa is unclear. It is also
unclear how this aspect of these disorders relates to other features of their
specific psychopathology, such as body size overestimation; or how it relates
to aspects of their general psychopathology, such as depression. It is also not
known whether concerns about body shape relate to response to treatment.
The BSQ provides a means of investigating these issues.
Table 3. BSQ scores of ”probable cases” of bulimia nervosa compared with BSQ scores of
”probable non-cases” of bulimia nervosa.
Patients with
Bulimia
Nervosa
(n = 38)
”Probable
Cases“
of Bulimia
Nervosa
(n
=
10)
“Definite
Non-cases“
of Bulimia
Nervosa
(n = 316)
“Probable Cases”
vs.
”Definite Non-cases”
“Probable Cases”
vs .
Patients with
Bulimia Nervosa
Mean
SD
Mean
SD
Mean
SD
(t)
(4
136.9
22.5
129.3
17.0
71.9
23.6
7.62*
1.00
‘ p < ,000.
Body Shape Questionnaire
491
We are grateful to the Cambridge Family Planning Service and Dorset House School of
Occupational Therapy in Oxford for their help with this study. The Cambridge patient
sample was collected in the course of conducting a treatment study funded by the
East Anghan Regional Health Authority, and the Oxford patient sample was collected
in the course of a treatment study funded by the Wellcome Trust. Melanie Taylor was
supported by a Research Studentship from the Science and Engineering Research Council.
APPENDIX
BSQ
We should like to know how you have been feeling about your appearance over the
PAST FOUR WEEKS. Please read each question and circle the appropriate number to
the right. Please answer all the questions.
OVER THE PAST FOUR WEEKS:
Very
Never Rarely Sometimes Often Often Always
1. Has feeling bored made you
brood about your shape?. . . . . 1
3
4
5
2
6
2. Have you been so womed
about your shape that you have
been feeling that you ought to
2
diet? . . . . . . . . . . . . . . 1
3
4
5
6
3. Have you thought that youi
thighs, hips or bottom are too
large for the rest of you?. . . . . 1
2
3
4
5
6
4. Have you been afraid that you
might become fat (or fatter)? . . . 1
4
6
2
3
5
5. Have you womed about your
flesh not being firm enough? . . . 1
2
3
4
5
6
6. Has feeling full (e.g., after
eating a large meal) made you feel
fat? . . . . . . . . . . . . . . 1
2
4
5
3
6
7. Have you felt so bad about your
shape that you have cried?. . . . 1
2
3
5
6
4
8. Have you avoided running
because your flesh might
wobble? . . . . . . . . . . . . 1
2
4
5
3
6
9. Has being with thin women made
you feel self-conscious about your
4
2
5
shape? . . . . . . . . . . . . . 1
6
3
10. Have you worried about your
thighs spreading out when sitting
2
4
5
down? . . . . . . . . . . . . . 1
3
6
11. Has eating even a small amount
of food made you feel fat? . . . . 1
2
3
4
5
6
12. Have you noticed the shape of
other women and felt that your
own shape compared
2
3
4
5
6
unfavourably?. . . . . . . . . . 1
Cooper et al.
492
very
Never Rarely Sometimes Often Often Always
13. Has thinking about youz shape
interfered with your ability to
concentrate (e.g., while watching
television, reading, listening to
conversations)? . . . . . . . . .
14. Has being naked, such as when
taking a bath, made you feel
fat? . . . . . . . . . . . . . .
15. Have you avoided wearing clothes
which make you particularly
aware of the shape of your
body? . . . . . . . . . . . . . .
16. Have you imagined cutting off
fleshy areas of your body? . . . .
17. Has eating sweets, cakes, or other
high calorie food made you feel
fat? . . . . . . . . . . . . . .
18. Have you not gone out to social
occasions (e.g., parties) because
you have felt bad about your
shape? . . . . . . . . . . . . .
19. Have you felt excessively large
and rounded?. . . . . . . . . .
20. Have you felt ashamed of your
body? . . . . . . . . . . . . .
21. Has worry about your shape
made you diet? . . . . . . . . .
22. Have you felt happiest about your
shape when your stomach has
been empty (e.g., in the
morning)? . . . . . . . . . . .
23. Have you thought that you are
the shape you are because you
lack self-control? . . . . . . . .
24. Have you worried about other
people seeing rolls of flesh around
your waist or stomach? . . . . .
25. Have you felt that it is not fair
that other women are thinner
than you?. . . . . . . . . . . .
26. Have you vomited in order to feel
thinner? . . . . . . . . . . . .
27. When in company have you
worried about taking up too much
room (e.g., sitting on a sofa or a
bus seat)?. . . . . . . . . . . .
28. Have you womed about your
flesh being dimply? . . . . . . .
29. Has seeing your reflection (e.g.,
in a mirror or shop window)
made you feel bad about your
shape? . . . . . . . . . . . . .
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
Body Shape Questionnaire
493
Very
Never Rarely Sometimes Often Often Always
30. Have you pinched areas of your
body to see how much fat there
is?. . . . . . . . . . . . . . .
31. Have you avoided situations
where people could see your body
(e.g., communal changing rooms
or swimmingbaths)? . . . . . .
32. Have you taken laxatives in order
to feel thinner? . . . . . . . . .
33. Have you been particularly selfconscious about your shape
when in the company of other
people?. . . . . . . . . . . . .
34. Has worry about your shape
made you feel you ought to
exercise? . . . . . . . . . . . .
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
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