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Korean Journal of Clinical Psychology 2017. Vol. 36, No. 2, 192-205 Original Article 2017 Korean Clinical Psychology Association eissn 2466-197X The Influence of Maladaptive Perfectionism, Negative Affect, and Negative Urgency on Bulimic Symptoms among Female College Students Sujin Lee Hyein Chang Department of Psychology, Sungkyunkwan University, Seoul, Korea The purpose of this study was to examine the integrative effects of maladaptive perfectionism, negative affect, and negative urgency on bulimic symptoms in young women. Although negative affect and personality variables, such as maladaptive perfectionism and negative urgency have been studied as risk factors for bulimic symptoms, relatively little is known about underlying mechanisms by which these factors may conjointly lead to the development of bulimic symptoms. The current study therefore examined an integrative model of bulimic symptoms, including both personality and affect variables simultaneously. Specifically, maladaptive perfectionism was hypothesized as an antecedent of negative affect, and negative urgency was hypothesized as a mediator or a moderator between negative affect and bulimic symptoms. A total of 174 female college students completed a series of self-report inventories assessing maladaptive perfectionism, negative affect, negative urgency, and bulimic symptoms. The results indicated that negative affect and negative urgency sequentially mediated the effect of maladaptive perfectionism on bulimic symptoms. Additionally, negative urgency mediated the effect of maladaptive perfectionism on bulimic symptoms without its association with negative affect, and the direct effect of maladaptive perfectionism on bulimic symptoms was also significant. Based on these findings, the implications and limitations of this study were discussed. Keywords: maladaptive perfectionism, negative affect, negative urgency, bulimic symptoms 신경성폭식증 (Bulimia Nervosa) 은섭식장애의한종류로반복적 인폭식삽화와그후뒤따르는하제사용등의부적절한보상행동, 그리고몸무게와체형에대한심각한걱정으로특징지어진다 (American Psychiatric Association, 2013). 신경성폭식증은남성 환자에비해여성환자가열배이상많으며대부분이후기청소년 기에서초기성인기사이에발병하기때문에 (Oltmanns & Emery, 2014), 20 대초반의여자대학생은신경성폭식증발병에매우취약 한고위험집단으로볼수있다. 특히이시기에는사회가요구하는 이상적인미의기준을내면화하고자신의외모와체형을자존감의 Correspondence to Hyein Chang, Deparment of Psychology, Sungkyunkwan University, 25-2 Sungkyunkwan-ro, Jongno-gu, Seoul, Korea; E-mail: hichang@skku.edu Received Feb 8, 2017; Revised Apr 28, 2017; Accepted May 18, 2017 The present article is based on a master s thesis study conducted by the first author under the guidance of the second author. 원천으로삼는경향이두드러진다 (Stiegel-Moore, Silberstein & Rodin, 1986). 따라서여자대학생들은이상적신체상인마른체형에도달하고자노력하는데, 이러한노력은때때로건강하지못한섭식행동을불러온다. 일반적으로다이어트를시도하는여성들은음식섭취를엄격하게제한함으로써자신의체중을통제하려고한다. 그러나이러한억제는개인에게높은수준의스트레스를유발하며, 동시에음식단서에대한민감성을높이기때문에오히려폭식행동으로발전되기쉽다 (Lee, 2001). 뿐만아니라폭식이체중증가의공포를유발하면서구토나약물사용과같은부적절한보상행동으로이어지기도한다. 이러한증상이당장은임상적진단의기준을충족하지못한다할지라도이후섭식장애발병의위험요인이라는점에서 (Polivy & Herman, 1985), 젊은여성을대상으로신경성폭식증예방을위한적절한개입을실시하는것은매우중요하다. 또한섭식장애클리닉에오는환자중절반이진단기준중일부만만족시키는 www.kcp.or.kr 192

Risk Mechanisms for Bulimic Symptoms 준임상군으로알려져있는데 (Stice, 2001), 이처럼진단을충족하지못하는사람들또한증상으로인해상당한고통감을겪는다는점에서도환자집단뿐만아니라준임상, 고위험집단에까지개입할필요성이존재한다. 그러나이를위해서는우선증상을예측하는위험요인과그기제를검증하는작업이고위험집단에서선행되어야할것이다. 신경성폭식증을포함하여섭식장애의발달과유지에대한기존연구들은마른신체에대한미디어의이상화, 체중에대한비난등젊은여성이노출되는환경적위험요인에주로초점을맞추어왔다 (Hersen, Turner, & Beidel, 2011). 그러나동일한사회문화적환경에서도섭식증상을보이는사람이있는반면그렇지않고건강하게살아가는사람도있다는이질성에착안하여, 본연구에서는정서와성격특질을중심으로신경성폭식증증상에대한개인내적인취약성메커니즘을규명하고자한다. 부정정서는신경성폭식증증상의발생과유지를예측하는위험요인으로널리알려져있다 (Berg et al., 2013; Smyth et al., 2007). 여러이론들에서는폭식이나하제와같은신경성폭식증증상을부정정서를경감시키기위한부적응적대처방식의일환으로전제하였다. 예를들어정서조절이론에서는부정정서나정서적고통감을조절하기위한방법으로폭식과하제사용이나타나며, 이러한행동들이부적강화를통해유지된다고제안하였다 (Haedt-Matt & Keel, 2011). 한편 Heatherton과 Baumeister(1991) 의탈출이론 (escape theory) 에의하면, 개인은폭식행동을통해현재의순간적인음식섭취에만집중함으로써자신과세상에대한부정적인생각및정서로부터탈출할수있게된다. 또다른이론인기대이론에서는음식을섭취하면부정정서를감소시킬수있을것이라는기대가개인에게형성되고강화됨으로써신경성폭식증증상을증가시킨다고설명하고있다 (Hohlstein, Smith, & Atlas, 1998). 부정정서와신경성폭식증의관계는여러경험연구들을통해서도일관적으로확인되었다. 구체적으로, 여러자기보고연구와 (Agras & Telch, 1998; Fox & Froom, 2009) 실험연구들은 (Chua, Touyz, & Hill, 2004; Mauler, Hamm, Weike & Tuschen-Caffier, 2006) 높은수준의부정정서가폭식및하제에대해시간적으로선행하는위험요인임을검증해왔다. 최근에는일상생활속에서어떠한경험을한순간이나가까운시간내에자기보고를하게하는방법인생태학적순간평가법 (ecological momentary assessment, EMA) 을이용하여많은연구들이이루어지고있다. EMA를사용한연구들에서는폭식및하제행동직전에부정정서의유의미한증가가관찰되었으며, 또한높은부정정서를보이는날에신경성폭식증증상이더많이발생한다는결과가나타나 (Crosby et al., 2009; Goldschmidt et al., 2014; Lavender et al., 2015) 부정정서와신경성폭식증의전후관계에대한더욱구체적인정보가확인되었다. 이처럼다양한방법을사용한많은연구들에서높은부정정서가폭식및보상행동이전에발생한다는일관된증거가나타났으며, 이러한결과는부정정서가신경성폭식증증상에선행하는위험요인임을시사한다. 그러나같은상황에서도부정정서를경험하는정도는사람마다다르며, 또한같은정도의부정정서를경험하더라도이에대한반응으로모두가폭식이나하제를사용하는것은아니다. 이러한점들을고려하였을때, 신경성폭식증을유발하는개인내적취약성을더욱효과적으로설명하기위해서는부정정서뿐만아니라성격특질에대한고려가함께필요할것으로보인다. 신경성폭식증을예측하는것으로알려진성격특질중하나는부적응적완벽주의이다. 완벽주의는수행에대해비현실적으로높은기준을설정하는성격특질인데 (Frost, Marten, Lahart, & Rosenblate, 1990), 신경성폭식증을포함한섭식장애의중심특성이 완벽한 체중및체형에대한갈망이라는점에서 (Bardone- Cone et al., 2007) 이장애는본질적으로완벽주의적인성격을지니는것으로볼수있다. 완벽주의에대한여러요인분석연구들은완벽주의가다차원적인개념이며, 이러한다차원성기저에부적응적완벽주의와적응적완벽주의라는두가지하위요인이존재함을밝혔다 (Bardone-Cone et al., 2007; Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). 부적응적완벽주의는타인이자신에대해높은기대를가지고있다는대인관계적차원을반영하며, 그러한기대를충족시키지못할경우비난받을것이라는생각을표상한다. 반면적응적완벽주의는스스로에대해높은기준을설정하는것이특징이며, 주로타인에의해서보다는개인스스로가자신에게부과하는높은기준과압력을반영하는차원이다. 이중신경성폭식증과보다밀접한연관을보이는것은부적응적완벽주의로알려져있으며 (Hewitt, Flett, & Ediger, 1995), 여러선행연구들에서부적응적완벽주의가신경성폭식증의발병및유지를예측하는요인임을확인하였다. 구체적으로여러횡단및종단연구에서부적응적완벽주의가신경성폭식증증상과연관된다는결과가제시되었으며 (Gustafsson, Edlund, Kjellin, & Norring, 2009; Pearson & Gleaves, 2006), 여자대학생들을대상으로한연구에서또한부적응적완벽주의가스트레스와상호작용하여폭식조절의어려움을예측하는것으로나타났다 (Bardone-Cone et al., 2012). 한편몇몇연구에서적응적완벽주의또한이상섭식행동을설명한다는결과가제시된바있으나 (Bardone-Cone, 2007; Boone, Soenens, Braet, Goossens, 2010; Castro-Fornieles et al., 2007) 부적응적완벽주의에비해신경성폭식증에대한연관성및효과크기가떨어지며 193

Lee and Chang (Dunkley, Blankstein, Masheb, & Grilo, 2006; Steele, Corsini, & Wade, 2007), 폭식증보다는주로신경성식욕부진증과연관되는경향이있다 (Hewitt et al., 1995). 따라서본연구에서는완벽주의중에서도신경성폭식증증상들과높은관련성을지닌것으로알려진부적응적완벽주의에초점을맞추어신경성폭식증의발달기제를연구하고자한다. 완벽주의가다른위험요인들과함께작용하여신경성폭식증의발생및유지를이끌기도한다는주장에따라 (Stice, 2002) 완벽주의가어떠한기제를거쳐신경성폭식증증상을유발하는지에대해여러제안이이루어졌다 (Bardone-Cone, Abramson, Vohs, Heatherton, & Joiner, 2006; Fairburn, Cooper, & Shafran, 2003; Sherry et al., 2014). 그중몇몇학자들은완벽주의가부정정서를유발시킴으로써신경성폭식증증상을증가시킨다고제안하였다. 여러영역에서높은기준을가지고있는완벽주의자들은이러한기준이충족되지않는상황에서부정정서를느끼게되고, 일시적인폭식혹은하제를통해이러한상황에서탈출하고자할수있다는것이다 (Bardone-Cone et al., 2007). 뿐만아니라완벽주의자들은타인의지지적인조언조차도모두압력으로느끼기때문에 (Sherry & Hall, 2009), 이것이여러영역과연관된부정정서를증가시켜서신경성폭식증의행동적증상을유발할가능성이존재한다 (Bardone-Cone et al., 2012). 실제로부적응적완벽주의수준이높은사람들은일상생활에서높은수준의스트레스와부정정서를경험하며 (Dunkley, Zuroff, & Blackstein, 2003) 높은우울과불안증상을보였다 (Hewitt, Flett, & Ediger, 1996; Sherry & Hall, 2009; Song, 2015). 이러한연관성에도불구하고, 부적응적완벽주의가어떤심리적기제를통해신경성폭식증을예측하는지에대한연구는우울, 불안등의다른정신장애와비교했을때매우적은것으로알려져있다 (Bardone-Cone et al., 2007). 특히정서를매개요인으로설정한연구는소수에불과하며, 이또한대다수가우울에만초점을맞추어연구하였다는한계가존재한다 (Sherry & Hall, 2009; Son, 2013). 그러나신경성폭식증증상은우울뿐만아니라분노 (Waller et al., 2003) 나죄책감 (Berg et al., 2013; Corstorphine, Waller, Ohanian, & Baker, 2006) 등여러부정적인정서와연관되므로, 부적응적완벽주의가신경성폭식증으로향하는경로에서정서의역할을충분히설명하기위해서는부정정서의어느한단면에초점을맞추기보다는부정정서의여러측면을전반적으로고려할필요가있을것이다. 한편신경성폭식증환자들이부정정서상황에서충동적인방식으로부정정서를다룬다는점에서 (Jeon, 2011), 부정적긴급성또한폭식과부적절한보상행동등신경성폭식증증상을예측하는성 격특질로주목받아왔다. 부정적긴급성 (Negative Urgency) 은충동성의하위요인중하나로부정정서를경험할때성급하게행동하려는경향으로특징지어지며 (Cyders & Smith, 2008), 다양한연구들에서신경성폭식증증상들과연관이있는것으로나타났다. 특히부정적긴급성은충동성의여러하위요인및관련변인들을통제한후에도신경성폭식증증상을유의하게설명하였다 (Anestis, Smith, Fink, & Joiner, 2009; Miller, Flory, Lynam, & Leukefeld, 2003; Smith et al., 2007). 뿐만아니라여대생을대상으로한전향연구나 (Fischer, Peterson, & McCarthy, 2013) 생물학적영향과환경적영향을분리해서살펴보기위해쌍둥이표본을사용한연구 (Racine et al., 2013) 등에서도부정적긴급성은폭식및하제와같은조절되지못한식이행동을예측하였다. 이처럼다양한설계를사용한여러연구들에서부정적긴급성이부정정서상황에서증상에대한취약성을높이는성격적위험요인이라는것이일관적으로밝혀졌으나, 부정적긴급성과부정정서가어떤식으로관계를맺어폭식증증상을증가시키는지그구체적인메커니즘에대해서는여전히논의가계속되고있다. 구체적으로, 몇몇학자들은부정정서와이상섭식행동과같은위험행동사이의관계를조절하는변인으로부정적긴급성을개념화하였다 (Karyadi & King, 2011). 즉, 부정정서를처리하는방식에있어서개인차를유발하는성격특질이부정적긴급성이라는것이다. 이러한논의에서착안하여부정적긴급성의조절효과를검증하기위한연구들이수행되었으나, 그결과는혼재되어있다 (Byeon & Lee, 2016; Culbert et al., 2016; Cyders & Coskunpinar, 2011; Davis-Becker, Peterson, & Fischer, 2014; Jeon, 2011; Lim, 2014). 심지어유의한조절효과가관찰된연구들에서도효과의방향성이서로달랐으며 (Culbert et al., 2016; Cyders & Coskunpinar, 2011) 증상을설명하는조절효과의설명량이작은경향이있기때문에 (e.g., 약 1%; Jeon, 2011), 조절효과의유무및구체적인양상에대해서는아직까지논의가계속되고있다. 한편부정적긴급성을조절변인이아닌매개변인으로개념화하는흐름또한존재한다. 즉, 부정적긴급성은정서와독립적인개인차변인이아니며오히려부정정서를더많이느끼는사람일수록더높은수준의부정적긴급성을나타낸다는것이다 (Davis-Becker et al., 2014). Pang 등 (2014) 은높은수준의부정정서가정서적장해를축적시키며, 이러한정서적장해가부정정서상황에서개인의판단을방해하고성급하게행동하는경향을높임으로써위험행동을촉발시키는것으로부정적긴급성의매개효과를설명한바있다. 부정적긴급성을정서와위험행동사이의매개변인으로살펴보는경향은특히알코올중독분야에서두드러지며, 몇몇연구에서는부정적긴급성이 194

Risk Mechanisms for Bulimic Symptoms 우울증상과청소년및대학생의알코올문제사이를매개하는것으로나타나기도했다 (Gonzalez, Reynold, & Skewes, 2011; Pang, Farrahi, Glazier, Sussman & Leventhal, 2014). 그러나신경성폭식증과관련해서부정적긴급성을매개변인으로검증한연구는단하나에불과하다 (Lavender, Green, Anestis, Tull, & Gratz, 2015). 이연구에서는부정정서와폭식행동사이를부정적긴급성이완전매개한다는결과가나타났으나, 이러한결과는사고억제가낮은집단에게만유의했기때문에이를더넓은집단에까지일반화하여적용하는것이부적절할수있다. 뿐만아니라이연구가물질사용장애환자를대상으로이루어졌으며그중 30% 만이여성이었고, 또한평균연령이 30대중반이었다는점에서그결과를신경성폭식증고위험군및임상군에적용하기에는무리가있을것으로보인다. 섭식장애환자의 90% 이상은청소년에서초기성인기여성인만큼, 실질적인위험집단을대상으로한연구가필요할것이다. 종합하면, 앞서살펴본바와같이부정정서는신경성폭식증증상의발달과유지를예측하는주요위험변인이나, 증상으로향하는기제에있어서성격특질과어떠한관계를맺는지에대해서는알려진바가적다. 성격특질에관한연구들은특히과도한통제를반영하는완벽주의와통제의결여를상징하는부정적긴급성을강조하였는데, 이두성격특질모두가신경성폭식증과관련되어있다는것은얼핏생각하면반직관적일수있다. 그러나신경성폭식증은체중및체형에대해과도하게걱정하고이상적인신체상을추구하는등완벽주의적인속성이있는반면, 통제감의상실하에폭식및하제와같은충동적인행동을보이기도한다는점에서 (American Psychiatric Association, 2013) 두가지사고및행동패턴을모두보이는장애라고할수있다. 실제로신경성폭식증환자의성격특질을규명하기위한군집분석연구들에서완벽주의적인성격을지닌군집과충동적인성격을지닌군집, 그리고두성격특질을모두나타내는군집이나타난바있으나 (Boone, Claes, & Luyten, 2014; Wonderlich et al., 2005), 이러한결과에도불구하고대부분의선행연구들은두성격특질중하나로치우쳐신경성폭식증의기제를설명했다는점에서한계가존재한다. 따라서본연구에서는폭식증증상의발달을예측하는개인성격특질의여러측면을동시에고려하기위해과도한통제를나타내는부적응적완벽주의와통제의결여를표상하는부정적긴급성을모두모형에포함하고자하였다. 뿐만아니라이러한성격특질들이부정정서와신경성폭식증사이의관계에어떠한기제로작용하여증상발달에대한취약성을높이는지확인하고자하였다. 구체적으로, 높은수준의부적응적완벽주의는개인으로하여금일상생활에서부정정서를더욱많이경험하게함으로써신경성폭식증 증상을증가시킬것이다. 또한부정정서를경감시키고자폭식이나보상행동등의부적응적대처방식을사용하는경향은부정적긴급성에의해조절되거나매개될것이다. 부정적긴급성이조절변인일경우, 개인이가지고있는부정적긴급성수준에따라부정정서가신경성폭식증증상에미치는영향이달라질수있을것이다. 반면부정적긴급성이매개변인으로작용하는경우, 개인의높은부정정서가부정적긴급성을촉발시킴으로써더높은수준의신경성폭식증증상을유발하게될것이다. 이처럼본연구에서는기존에분리되어있던성격특질연구들, 그리고성격특질과정서에관련된연구들을통합함으로써신경성폭식증증상의발달과예방적개입에유용한정보를제공하고자하였다. 이를종합한본연구의가설은다음과같다. 가설 1. 부적응적완벽주의와신경성폭식증증상사이의관계에서부정정서의매개효과가유의할것이다. 가설 2. 부정적긴급성은부정정서와신경성폭식증증상사이의관계에영향을미칠것이다. 가설 2-1. 부정적긴급성은부정정서와신경성폭식증증상사이의관계를조절할것이다. 가설 2-2. 부정적긴급성은부정정서와신경성폭식증증상사이의관계를매개할것이다. 가설 3. 가설 2-1이지지될경우조절된매개효과가, 가설 2-2가지지될경우순차적매개효과가유의할것이다. 방법연구대상서울소재 4년제대학교에서심리학관련교양수업을수강하는여학생들을대상으로연구를실시하였다. 연구에참여한총참가자수는 174명이었으며, 이중불성실한참가자와지시를이해하지못했던외국인참가자를제외한 164명이분석에포함되었다. 분석에포함된참가자들의평균연령은 19.04 세 (SD = 0.99) 였다. 측정도구다차원적완벽주의척도 (Multidimensional Perfectionis, Scale, MPS). 부적응적완벽주의를측정하기위해 Frost 등 (1990) 의다차원적완벽주의척도 (FMS) 와 Hewitt과 Flett(1991) 의다차원적완벽주의척도 (HMPS) 를사용하였다. FMS는총 35문항의자기보고식질문지이며 5점척도로이루어져있다. 높은점수일수록완벽주의성향이높음을의미하며, 총여섯개차원으로이루어져있다. 본연구는 Hyun(1992) 이번안한 FMS를사용하였다. 한편 HMPS 195

Lee and Chang 는 7점척도로이루어져있으며총 45문항의자기보고질문지이다. HMPS 역시점수가높을수록완벽주의성향이높음을의미하며, 총세가지하위차원으로구성되어있다. 본연구에서는 Han (1993) 이번안한 HMPS를사용하되, 섭식장애에대한선행연구와유사하게 (Lee, 2004) 원척도에서구성된소척도문항으로소척도점수를사용하였다. 완벽주의와섭식장애에관한여러학자들의요인분석에의하면 (Bieling, Israeli, & Antony, 2004; Dunkley et al., 2006) FMPS에서의 실수에대한염려, 행동에대한의심 과 HMPS에서의 사회적으로부과된완벽주의 가부적응적완벽주의를표상하는것으로알려져있다. 이를바탕으로, 본연구에서도위의하위요인들을사용하여부적응적완벽주의를측정하였다. 서로다른두척도를사용하였기때문에, 두척도에서나타난참가자들의점수를각각표준점수화한뒤이를더하여나온부적응적완벽주의점수를분석에사용하였다. 본연구에서의내적합치도 (Cronbach s α) 계수는.89로나타났다. 한국판긍정정서및부정정서척도 (Positive and Negative Affect Schedule, PANAS) 부정정서를측정하기위해 Watson, Clark와 Tellegen(1988) 이개발하고 Lee, Kim과 Lee(2003) 가번안한한국판 PANAS를사용하였다. PANAS는총 20문항으로이루어져있으며, 긍정정서와부정정서를나타내는형용사가 10개씩포함되어있다. 또한일정기간동안해당정서를어느정도경험했는지에따라 전혀그렇지않다 (1 점 ) 부터 매우많이그렇다 (5점) 의 5점척도로평정하게되어있다. 본연구에서는지난 4주동안경험한부정정서를측정하였으며, 내적합치도 (Cronbach s α) 계수는.85로나타났다. 한국판다차원적충동성척도 (UPPS Impulsive Behavior Scale) 이척도는 Whiteside와 Lynam(2001) 이개발하고 Cyders 등 (2007) 이 1개요인을추가하여개정한총 59문항의자기보고형질문지이다. 부정적긴급성을포함하여총다섯가지하위요인으로이루어져있으며, 4점척도로평정하여점수가높을수록더충동적임을의미한다. 본연구에서는 Lim과 Lee(2014) 가국내대학생을대상으로타당화한한국판다차원적충동성척도를사용하여부정적긴급성 ( 총 12문항 ) 을측정하였으며, 내적합치도 (Cronbach s α) 계수는.90이었다. 신경성폭식증검사개정판 (Bulimia Test Revised, BULIT-R) 여대생의신경성폭식증증상을측정하기위해 Smith와 Thelen(1984) 이처음개발하고 Thelen, Farmer, Wonderlich 와 Smith (1991) 가개정하였으며 Yoon(1996) 이번안한 BULIT-R 을사용하였다. BULIT-R 은총 36문항의자기보고식질문지이며폭식을측정하는 28문항과체중조절행동을포함하는 8개문항으로이루어져있다. 문항에제시된폭식의정의로는타당한폭식행동을측정하기어렵다는 Jeon(2011) 의제안에따라, 폭식의정의는 DSM- 5(American Psychiatric Association, 2013) 를바탕으로수정하였다 ( 폭식 : 비슷한상황에서대부분의사람들이먹는양보다많이먹고, 먹는것을멈출수없다고느낌 ). 각문항은 5점척도로이루어져있으며, 점수가높을수록신경성폭식증증상이심각함을의미한다. 점수범위는최하 28점부터최고 140점까지나올수있고, 원척도에따르면여대생의경우 82점이상은폭식행동경향성을, 102 점이넘으면신경성폭식증진단을고려해야하는것으로알려져있다 (Thelen et al., 1991). 본연구에서의내적합치도 (Cronbach s α) 계수는.92로나타났다. 분석방법본연구에서는 SPSS 18.0을사용하여자료를분석하였다. 우선연구에서수집된모든응답에대해기술통계치를확인하였으며, 모든변인들에대한상관분석을실시하여변인간의관련성을파악하였다. 이후연구가설에따라각변인들의매개효과및조절효과를검증하고자하였다. 체질량지수 (BMI) 가종속변인인신경성폭식증증상에영향을미칠수있다는선행연구결과에따라 (Friedman, Wilfley, Pike, Striegel-Moore, & Rodin, 1995), 참가자들의키와몸무게를바탕으로 BMI를계산한후이를공변인으로설정함으로써독립변인들이종속변인에미치는고유한영향력을확인하고자하였다. 매개효과분석을위해서는 Preacher와 Hayes(2004, 2008) 의제안에따라중다회귀분석 (multiple regression analysis) 과부트스트래핑 (bootstrapping) 을사용하였으며, 이를통해직접효과와간접효과를산출하고그유의성을검증하였다. 조절효과를검증하기위해서는위계적중다회귀분석 (hierarchical multiple regression analysis) 을실시하였다. 먼저본연구에서통제변인으로가정한 BMI 지수를 1단계에투입하였으며, 이후독립변인과상호작용항을각각 2단계와 3단계에투입하였다. 상호작용항을생성하기위해해당독립변인들의점수를중앙화하였으며, 상호작용효과가유의할경우단순주효과를검증하고자하였다. 각가설들에대한매개및조절효과를확인한이후, 독립변인들이신경성폭식증에영향을미치는양상을종합적으로파악하기위해 Hayes(2013) 가개발한 SPSS 매크로프로그램인 PROCESS를사용하여분석을진행하였다. 가설 3에서부정적긴급성의조절효과가유의한경우에는조 196

Risk Mechanisms for Bulimic Symptoms 절된매개모형을, 부정적긴급성의매개효과가유의한경우에는부적응적완벽주의가신경성폭식증증상을예측하는경로에서부정정서와부정적긴급성을모두매개변인으로포함하는순차적매개모형을검증하였다. 결과주요변인의기술통계및상관먼저, 주요변인들의기술통계치및상관분석결과를 Table 1에제시하였다. 상관분석결과, 본연구에서공변인으로설정한 BMI가종속변인인신경성폭식증증상과유의한정적상관관계를가지는것을확인하였다, r =.46, p<.01. 종속변인인신경성폭식증증상은독립변인으로설정한세변인모두와유의한정적상관을나타내었다. 즉, 더높은수준의부적응적완벽주의, r =.30, p<.01, 부정정서, r =.24, p<.01, 부정적긴급성, r =.47, p<. 01은더높은수준의신경성폭식증수준과연관되어있었다. 독립변인들간의상관관계를살펴본결과, 세가지독립변인모두가서로유의한상관을나타내는것을확인할수있었다. 구체적으로부정정서는부적응적완벽주의, r =.38, p<.01, 및부정적긴급성, r =.36, p<. 01, 과모두정적인상관을나타내었고, 성격특질요인인부적응적완벽주의와부정적긴급성또한정적으로연관되었다, r =.39, p<.01. 한편신경성폭식증진단도구 (BULIT-R) 로측정한참가자들의신경성폭식증점수평균은 56.57 (SD =15.97) 이었으며 31점부터 97점까지의범위를나타내었다. 여대생의경우 82점이상의점수를받으면준임상수준의폭식증경향성을고려해야한다는제안에따라 (Thelen et al., 1991), 본연구에서는전체참가자중이에해당하는점수를받은 17명 ( 약 10.4%) 이준임상수준의폭식증증상을나타내는것으로보았다. 부적응적완벽주의, 부정정서, 부정적긴급성이신경성폭식증증상에영향을미치는경로분석우선, 본연구의첫번째가설을검증하기위해독립변인을부적응적완벽주의로, 매개변인을부정정서로, 종속변인을신경성폭식증증상으로하는매개분석을실시하였다. 먼저위계적회귀분석을실시하여 BMI를통제하고매개모형에서의직접효과와간접효과를계산하였다. 이때부적응적완벽주의가매개변인인부정정서에미치는영향, β=.38, p<.001, 과부정정서가신경성폭식증증상에미치는영향, β=.16, p=.021, 이모두유의하여간접효과가존재함을시사하였으며, 따라서이러한효과가통계적으로유의한지확인하기위해부트스트래핑을실시하였다. 그결과부정정서를매개변인으로설정한경로의신뢰구간이 0을포함하지않아, β=.5392, 95% CI[0.1401, 1.1217], 간접효과가유의함을확인하였다. 뿐만아니라부적응적완벽주의는매개변인인부정정서가모형에함께포함된이후에도신경성폭식증증상을유의하게예측하였는데, β=.26, p<.001, 이를통해신경성폭식증증상에대한부적응적완벽주의의직접효과또한유의함을확인할수있다. 이와같은매 Table 1. Descriptive Statistics and Bivariate Correlations of Study Variables M SD 1 2 3 4 5 6 1. Age 19.04 0.99 1 2. BMI 20.18 2.07.03 1 3. Maladaptive perfectionism 0.00 1.82 -.07 -.05 1 4. Negative affect 23.21 7.51 -.07 -.04.38** 1 5. Negative urgency 26.95 7.12.02.14.39**.36** 1 6. Bulimic symptoms 56.57 15.95.10.46**.30**.24**.47** 1 Note. **p <.01. Negative affect (M) β =.38*** β =.16* Maladaptive perfectionism (X) β =.26*** Bulimic symptoms (Y) Indirect effect (X M Y): β =.5392, 95% CI[0.1401, 1.1217] Figure 1. Negative affect as a mediator of the effects of maladaptive perfectionism on bulimic symptoms. Note. Solid lines represent significant paths. *p <.05, ***p <.001. 197

Lee and Chang 개분석결과를 Figure 1에제시하였다. 두번째로본연구의가설 2-1과 2-2를검증하기위해, 부정정서가신경성폭식증증상으로향하는경로에서부정적긴급성의역할을확인하는조절분석과매개분석을차례로실시하였다. 먼저, 부정적긴급성이부정정서와신경성폭식증증상사이의관계를조절하는지알아보기위해위계적회귀분석을실시하였으며그결과를 Table 2에제시하였다. Table 2에서 3단계에추가한부정정서와부정적긴급성의상호작용항이신경성폭식증증상을유의하게예측하지않았기때문에, β= -.01, p=.927, 부정적긴급성이부정정서와신경성폭식증증상사이의관계를조절하지않아가설 2-1이지지되지않음을확인할수있었다. 다음으로, 부정정서가신경성폭식증증상을예측하는경로에서부정적긴급성이매개변인으로기능하는지확인하기위해매개분석을실시하였으며, 그결과를 Figure 2에제시하였다. Figure 2를보면, 부정정서가부정적긴급성에미치는영향, β=.37, p<.001, 과부정적긴급성이신경성폭식증증상에미치는영향, β=.36, p<.001, 이모두유의하였으며, 이매개경로에대해부트스트래핑을실시한결과신뢰구간이 0을포함하지않아, β =.2806, 95% CI[0.1384, 0.4672], 유의한간접효과가존재함을확인하였다. 한편부정정서는신경성폭식증증상과유의한정적상관을가짐에도불구하고, r =.24, p<.01, 부정적긴급성을매개로하는간접효과가통제되었을때는신경성폭식증증상에유의한영향을미치지않았는데, β=.13, p=.056, 이를통해본매개모형에서신경성폭식증증상에대한부정정서의직접효과가 유의하지않음을확인할수있다. 앞서실시한분석에서부적응적완벽주의는매개변인인부정정서를거쳐신경성폭식증증상을부분적으로예측하며, 또한부정적긴급성은부정정서와신경성폭식증증상사이에서조절변인보다는매개변인으로기능한다는것이확인되었다. 본연구의최종적인목표는세독립변인들이신경성폭식증증상에미치는양상을종합적으로파악하는것이었으므로, 앞서실시한분석결과를바탕으로부적응적완벽주의가부정정서와부정적긴급성을차례로거쳐신경성폭식증을예측하는순차적매개모형이유의한지검증하고자하였다. 분석을위해 Hayes(2013) 가개발한 SPSS 매크로프로그램인 PROCESS의 model 6을사용하였으며, 앞선분석들과마찬가지로 BMI를통제변인으로설정하였다. 그결과 (Figure 3), 우선부적응적완벽주의가부정정서만을통해신경성폭식증증상을예측하는간접경로는앞선분석에서는유의한것으로확인되었으나, 부정적긴급성을포함해모든변인들을종합적으로고려하자그효과가사라졌다, β=.2794, 95% CI[-0.0999, 0.7847]. 반면부적응적완벽주의가두번째매개변인인부정적긴급성을거쳐증상을예측하는매개경로는신뢰구간이 0을포함하지않아통계적으로유의한것을확인할수있었다, β =.8231, 95% CI[0.2628, 1.6473]. 마지막으로, 부적응적완벽주의가부정정서와부정적긴급성을차례로거쳐신경성폭식증증상을예측하는경로또한통계적으로유의하였는데, β =.2598, 95% CI[0.1008, 0.5447], 이를통해순차적매개경로가지지되었음을확인할수있다. 한편독립변 Table 2. Results of Hierarchical Regression Examining Negative Urgency as a Moderator of the Effects of Negative Affect on Bulimic Symptoms Model Predictors Bulimic symptoms b β R 2 R 2 Step1 BMI 3.14***.41***.21*** - Step2 Negative affect.27.13.39***.18*** Negative urgency.81***.36*** Step3 Negative affect Negative urgency -.002 -.01.39***.00 Note. Estimates of the final model are presented. ***p <.001. Negative urgency (M) β =.37*** β =.36*** Negative affect (X) β =.13 Bulimic symptoms (Y) Indirect effect (X M Y): β =.2806, 95% CI[0.1384, 0.4672] Figure 2. Negative urgency as a mediator of the effects of maladaptive urgency on bulimic symptoms. Note. Solid lines represent significant paths. ***p <.001. 198

Risk Mechanisms for Bulimic Symptoms β =.38*** Negative affect (M1) β =.25** Negative urgency (M2) β =.30*** β =.09 β =.31*** Maladaptive perfectionism (X) Bulimic symptoms (Y) β =.17* Indirect effect (X M1 Y): β =.2794, 95% CI[-0.0999, 0.7847] Indirect effect (X M2 Y): β =.8231, 95% CI[0.2628, 1.6473] Indirect effect (X M1 M2 Y): β =.2598, 95% CI[0.1008, 0.5447] Figure 3. Effects of maladaptive perfectionism on bulimic symptoms: negative affect and negative urgency as sequential mediators. Note. Solid lines represent significant paths. *p <.05, **p <.01, ***p <.001. 인인부적응적완벽주의는두매개변인이함께포함되었을때도신경성폭식증증상을유의하게예측하였는데, β=.17, p=.019, 이를통해순차적매개효과를통제하고도신경성폭식증증상에대한부적응적완벽주의의직접효과가유의함을확인할수있었다. 논의본연구에서는섭식장애의고위험군인여자대학생을대상으로신경성폭식증증상의심리적기제를규명하고자하였으며, 이를위해그동안신경성폭식증의위험요인으로연구되어온부정정서와성격특질요인들을함께고려하였다. 본연구의주요결과를논의하면다음과같다. 첫째, 부적응적완벽주의는매개변인인부정정서를거쳐신경성폭식증증상을예측하였다. 즉높은수준의부적응적완벽주의가개인에게슬픔, 분노, 불안등의부정적인정서를유발시키고, 이러한부정정서가폭식이나하제사용등과같은신경성폭식증증상으로이어진다는것이다. 본연구의결과는완벽주의가부정정서를유발할수있다는선행연구 (Dunkley et al., 2003; Sherry & Hall, 2009) 및부정정서가신경성폭식증의위험요인이라는기존연구들 (Crosby et al., 2009; Kaye et al., 2000; Lavender et al., 2015) 의결과를통합하여, 완벽주의가부정정서를통해신경성폭식증증상을예측하는경로를검증했다는점에서의미를지닌다. 또한이는부적응적완벽주의가부정적인정서의수준을높이는선행성격요인으로작용함으로써신경성폭식증증상을예측할것이라는이론과일관되는결과이기도하다. 즉, 부적응적완벽주의자들이가지고있는높은기준과타인의평가에대한민감성은개인이완벽에미치지못한다고느낄때부정정서를유발하고, 이러한부정정서에서벗어나기위해여러부적응적인행동이유발된다는것이다 (Bardone-Cone et al., 2007). 특히완벽한신체상을설정하고그러한기준에도달하기위해끊임없이노력하는젊은여성의경우, 부적응적완벽주의는부정정서를거쳐폭식이나폭식이후보상행동과같은부적응적인식이행동으로나타날수있을것이다. 둘째, 부정적긴급성은부정정서가신경성폭식증증상을예측할때그관계를조절하지않고매개하였다. 즉, 부정적긴급성은부정정서와독립적인성격특질이라기보다는, 개인의부정정서수준에영향을받는요인이다. 부정정서와신경성폭식증사이를부정적긴급성이조절하는지에대한선행연구는혼재되어있는데, 본연구의결과는부정적긴급성의조절효과가존재하지않는다는연구결과들 (Byeon & Lee, 2016; Lim, 2014) 과동일한양상을나타내었다. 또한본결과는부정적긴급성이부정정서와여러위험행동사이의관계를매개한다는여러선행연구들과일치한다 (Gonzalez, Reynolds, & Skewes, 2011; Pang et al., 2014). 나아가본연구는신경성폭식증의발생과유지에대한여러이론들과도부합한다. 예를들어 Pang 등 (2014) 은높은수준의부정정서로인해축적된정서적장해가개인의판단을방해하고, 그에따라개인이성급하게행동하는경향성을증가시킨다고주장하였다. 따라서부정정서수준이높을수록개인은장기적으로유용하고적극적인대처방식을찾기보다는즉각적으로부정정서를해소하는방향을선호하게되고, 이러한행동경향성이결국폭식이나보상행동과같은부적응적인대처방식으로이어지는것이다. 또한 Cyders와 Smith (2008) 는부정적긴급성을정서장해와같은내재적증상과위험행동과같은외현적증상사이를효과적으로연결해줄수있는성격특질로개념화한바있는데, 이또한부정적긴급성이매개변인으로서기능한다는본연구의결과와일치하는맥락이다. 셋째, 부적응적완벽주의가신경성폭식증증상을예측하는경로에서부정정서와부정적긴급성의순차적매개효과가유의하였 199

Lee and Chang 다. 즉, 높은수준의부적응적완벽주의는부정정서를증가시키고, 이렇게증가된부정정서는개인의부정적긴급성수준을높임으로써신경성폭식증증상을증가시키는것이다. 이러한결과는신경성식욕부진증과신경성폭식증을아우르는섭식장애이론인범진단적이론 (Transdiagnostic theory) 과일치한다 (Fairburn et al., 2003). 이이론에의하면섭식장애환자들은완벽주의적인성향으로인해체중과체형에대해과도한기준을세우게되며, 이러한기준에부합하고자엄격한섭식절제를하다가섭식장애로발전한다. 이때신경성폭식증환자들은부정적정서상태를견디고적절하게대처하는능력으로정의되는기분감내력 (mood intolerance) 이부족해신경성식욕부진증환자들과달리폭식및하제와같은증상을보이게된다. 이이론을바탕으로본연구의결과를이해하자면완벽주의수준이높은개인이특히체중과체형에대해역기능적으로자기평가를하면서부정정서가증가하게되고, 이를성급히해소하고자하는부정적긴급성으로인해신경성폭식증증상이나타나는것으로볼수있을것이다. 이러한설명은신경성폭식증의위험메커니즘을살펴봄에있어서부정정서뿐만아니라성격특질을함께고려할필요가있음을시사한다. 특히본연구에서는과도한통제를상징하는부적응적완벽주의와통제의결여를상징하는부정적긴급성이서로정적인상관을보인다는결과가나타났다. 이러한결과는신경성폭식증환자를대상으로한군집분석연구에서두성격특질이모두높은군집이가장높은수준의신경성폭식증증상을보인것과도일치한다 (Boone et al., 2014). 본연구에서는신경성폭식증에취약한성격특질의조합을파악하는것을넘어서, 이들이이론적으로어떻게연결되어있으며또한정서변인과는어떤관계를지니는지구체적인기제를살펴보았다는점에서고유한의의를지닌다. 본연구에서의결과는부적응적완벽주의가부정정서를유발하는선행요인으로작용하는한편, 부정적긴급성은높아진부정정서가폭식이나하제등으로행동화되기직전에관여하는근접요인임을시사한다. 한편높은수준의부적응적완벽주의가부정정서를거치지않고도부정적긴급성을통해증상을예측한다는본연구의결과는설명이필요하다. 이는신경성폭식증증상이부정정서없이도유발될수있음을의미하는데, 신경성폭식증증상을부정정서에대한건강하지못한정서조절전략으로설명하는입장에서는선뜻이해하기어려운결과이다. 그러나이러한결과는신경성폭식증증상의발생과유지에있어서인지적인요인을강조한이론들로설명할수있다 (Fairburn et al., 2003; Penessi & Wade, 2016). 신경성폭식증환자들은대체로체중에대한높은기준을설정하고이를매우엄격히지키고자하는데, 이과정에서한번의실수라도발생하게 되면자신의노력이완전히실패한것으로간주하고충동적으로폭식행동을한다는것이다. 또한 Boone 등 (2014) 은완벽주의적인개인들이시간이지날수록인지적인자아고갈 (ego depletion) 을겪게되며, 그로인해폭식과같은충동적이고손상된자기통제행동이나타난다고설명한바있다. 과도한자기통제로인한자아고갈은 Baumeister 등 (1998) 에의해처음으로제기된개념으로, 자기통제가반복적사용의결과로고갈될수있는한정적인자원이라는것을전제하고있다. 지속적으로자기통제적행동을하게되면결국이러한능력이고갈되며, 이후자기통제를요하는행동에서의성취수준이제한될수있다는것이다. 최근에는신경성폭식증환자들이나타내는폭식행동에대해서도이러한자원고갈이직접적위험요인으로작용한다고보는자원고갈이론 (Resource Depletion Model) 이제안되었는데 (Loth et al., 2016), 본연구의결과는신경성폭식증증상이부정정서에의해서뿐만아니라완벽주의적인기준으로인한인지적고갈로인해충동적으로나타날수도있음확인했다는점에서이러한이론과잘부합한다. 마지막으로, 본연구에서는부정정서와부정적긴급성을매개로하는간접효과를제외한후에도신경성폭식증증상에대한부적응적완벽주의의직접효과가유의했다. 이러한결과는부정정서나부정적긴급성을거치지않고도부적응적완벽주의가신경성폭식증증상의발달과유지에관여할수있음을의미한다. 이는부적응적완벽주의의특징인높은기준과비판에대한압력그자체로도폭식증상의발달과유지에주요한위험요인임을의미한다. 이는섭식장애가본질적으로완벽한신체상에도달하고자하는욕구와노력임을고려하면, 지나치게높은기준을설정하거나이에완전히부합하려는성향을가진개인들은신경성폭식증에취약성을지니는것이라이해할수있다. 아울러부적응적완벽주의의직접경로는부적응적완벽주의가본연구에포함한부정정서나부정적긴급성이아닌다른경로를통해신경성폭식증증상을예측할가능성또한시사한다. 실제로기존몇몇선행연구들에서는완벽주의가부정정서나부정적긴급성이아닌여러다른요인들을매개요인으로하여신경성폭식증증상을예측할수있음을밝혔다. 예를들어 Boone 등 (2011) 의종단연구에서는 1년차의부적응적완벽주의가 2년차의마름에대한압력및신체불만족을거쳐 3년차의신경성폭식증증상을증가시킨다는결과가나타난바있다. 아직완벽주의가신경성폭식증증상을예측하는기제에관한이해가충분히이루어지지않았음을감안한다면 (Bardone-Cone et al., 2007), 완벽주의가사회문화적요인이나개인의기대수준등다양한위험요인을거쳐증상을예측할가능성이존재할수있을것이다. 본연구는표본, 측정도구, 변인및연구방법에관해몇가지한 200

Risk Mechanisms for Bulimic Symptoms 계를지닌다. 우선, 본연구는여자대학생을대상으로진행되었기때문에, 결과를임상집단에그대로적용하기에는적절하지않을수있다. 그러나여자대학생은신경성폭식증증상에매우취약한고위험집단이라는점에서본연구는신경성폭식증의발병기제를탐색한다는, 임상군을대상으로는살펴볼수없는고유한함의가존재한다. 또다른한계점은본연구에서주요변인들을측정하기위해사용한도구들이모두자기보고식질문지였으며모든보고는참가자들의회고에따라이루어졌다는것이다. 때문에특히부정정서와같은시간에민감한변인이망각이나왜곡으로인해타당하게측정되지않았을가능성또한존재한다. 그러므로상태적인부정정서와그에따른즉각적인신경성폭식증증상을측정하기위해생태학적순간평가법 (EMA) 과같이시간에따른상태적변화에보다민감한측정방식을사용할필요가있을것이다. 또한부정정서를측정할때사용한 PANAS 가단 10개문항만을포함한다는점에서부정정서의모든측면을살펴보았다고하기엔무리가있으므로, 추후연구에서는부정정서의보다다양한측면을고려하여여러갈래의부정정서가각각섭식문제에기여하는정도를확인할필요가있을것이다. 본연구의또다른한계는신경성폭식증증상을유발하는개인내적인위험요인만을살펴보았다는점이다. 물론동일한사회문화적환경속에서도신경성폭식증증상은일부집단에서만나타나기때문에개인내적인발병기제를살펴보는것은이론적, 임상적으로매우중요하다. 그러나신경성폭식증은 1950년대이후마른몸매를선호하는시대적변화와함께점점유병률이높아져온장애 (Oltmanns & Emery, 2014) 라는점에서, 이상적신체상의문화적차이나또래, 가족규범등의외부변인또한연구에서중요하게다루어질필요가있다. 마지막으로본연구의모든변인들은횡단적으로, 1회에한해서만측정되었다. 비록순차적매개모형에서모든변인들의전후및인과관계가선행연구와이론을바탕으로확립되긴하였지만, 연구설계상으로는이러한관계를규명하기어렵다는한계를지닌다. 특히본연구에서는부적응적완벽주의가부정적긴급성을거쳐신경성폭식증증상을예측하는매개경로가유의한것으로나타났다. 그러나이경로에서의독립변인과매개변인이어린시절형성되어대체로안정적인성격특질이라는점에서, 1회의측정만으로두변인사이에실제로전후관계가존재한다고볼수있는지에대한의문이여전히남아있다. 따라서이러한경로를보다명확하게파악하기위해서는장기적인종단연구를통해변인들간의전후발달순서를규명하고인과의실마리를찾고자시도해야할것이다. 이러한한계들에도불구하고, 본연구는신경성폭식증의발달과관련하여여러가지이론적의의를지닌다. 우선, 본연구에서는 부적응적완벽주의가부정정서와부정적긴급성을거쳐신경성폭식증증상을증가시킨다는순차적매개모형을검증하였다. 이는정서와성격요인이서로밀접하게관계를맺으며신경성폭식증증상을발달시킨다는것을의미한다. 기존에증상의발달과유지를예측할때정서와성격특질을함께살펴본이론들 (Engel et al., 2007; Sherry & Hall, 2009) 이있었음에도불구하고그기제를경험적으로검증하고자하는연구들은많지않았는데, 본연구는신경성폭식증의개인내적인발달기제를통합적으로살펴봄으로써이를보완하였다. 특히본연구는서로반대되는성격특질로알려져있지만신경성폭식증의위험요인으로각각연구되고있던부적응적완벽주의와부정적긴급성을함께살펴본첫번째연구이다. 연구결과부적응적완벽주의는부정적긴급성을거침으로써신경성폭식증을예측하였는데, 이는두가지성격특질요인이밀접하게연관되어있음을시사한다. 또한본연구의결과는신경성폭식증증상을발달시키는기제가다양할수있다는점을시사한다. 구체적으로신경성폭식증증상은부정정서에대처하기위한부적응적인정서조절방식일뿐만아니라인지적고갈에의한충동적인행동일수있으며, 심지어정서나충동성의영향과관계없이완벽주의적인성격차원이발현된결과일수도있다는것이다. 신경성폭식증을발달시키는다양한경로들의존재는최근제안및사용되고있는신경성폭식증에대한몇가지임상적개입들에도잘반영되어있다. 기존의많은개입방법들이폭식이나식이제한같은증상자체나단편적인위험요인에만초점을맞추어온반면 (Pennesi & Wade, 2016), 최근에는섭식장애발달의다양한경로를통합적으로고려하는소수의치료프로그램들이점점개발되고사용되기시작하였기때문이다. 대표적으로, 기존에가장널리사용되던신경성폭식증의심리치료인 CBT-BN (Cognitive behavioral treatment for Bulimia Nervosa; Fairburn, Marcus, & Wilson, 1993) 은신경성폭식증을포함하여섭식장애전반에개입하는 CBT-E (Enhanced cognitive behavioral therapy; Cooper & Fairburn, 2011) 로변화하였다. 이과정에서 CBT-E는기존치료에서주로초점을맞추던표면적증상뿐만아니라완벽주의와기분감내력 (mood intolerance) 을포함한섭식장애기저의다양한유지메커니즘까지도변화시키는것으로개입의범위를넓혔다. 이처럼개입의범위를보다다양한인지적, 정서적위험요인및그러한요인들이조합된경로로확장함으로써, CBT-E는기존의치료에서효과를얻지못했던환자들에게서까지도증상의경감을기대할수있는개입방법으로알려져있다. 최근치료프로그램의이러한양상은신경성폭식증증상의발생에있어서개인내적인기제의중요성과다양성을강조한본연구의결과와도맞닿아있는부분이며, 본연 201

Lee and Chang 구는이러한치료들의기제를간접적으로검증했다는임상적시사 점을지닌다. 뿐만아니라본연구는여자대학생집단을대상으로 신경성폭식증증상의발달을규명하였기때문에, 신경성폭식증 환자들에게주로사용되는여러개입방법을비임상군, 혹은증상 의심각도가임상적인수준에미치지않는준임상군에게도확장하 여적용할수있는가능성을시사하고있다. 구체적으로는, 여자대 학생들을대상으로개입프로그램을적용하여증상이더욱심각 한수준으로발전하는것을방지할수있을것이다. 또한아직임상 적으로문제가되는증상이관찰되지는않았으나완벽주의수준 이높고정서조절에취약한고위험여자대학생들을선별하여신경 성폭식증증상에대한사전교육이나예방적접근을실시하는방 법또한가능할것이다. 이처럼환자집단뿐만아니라준임상, 고위 험집단을대상으로개입의범위를넓힘으로써, 증상의발생과유 지로인한개인의고통을미연에방지하고장애로인한잠재적인 사회적비용을감소시킬수있을것이다. References Agras, W. S., & Telch, C. F. (1998). The effects of caloric deprivation and negative affect on binge eating in obese binge-eating disordered women. Behavior Therapy, 29, 491-503. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Publishing. Anestis, M. D., Smith, A. R., Fink, E. L., & Joiner, T. E. (2009). Dysregulated eating and distress: Examining the specific role of negative urgency in a clinical sample. Cognitive Therapy and Research, 33, 390-397. Bardone-Cone, A. M. (2007). Self-oriented and socially prescribed perfectionism dimensions and their associations with disordered eating. Behaviour Research and Therapy, 45, 1977-1986. Bardone-Cone, A. M., Abramson, L. Y., Vohs, K. D., Heatherton, T. F., & Joiner, T. E. (2006). Predicting bulimic symptoms: An interactive model of self-efficacy, perfectionism, and perceived weight status. Behaviour Research and Therapy, 44, 27-42. Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S., & Simonich, H. (2007). Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review, 27, 384-405. Bardone-Cone, A. M., Brownstone, L. M., Higgins, M. K., Harney, M. B., & Fitzsimmons-Craft, E. E. (2012). Predicting difficulties controlling overeating and drinking when experiencing negative affect in undergraduate women. Journal of Social and Clinical Psychology, 31, 1051-1073. Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S., & Simonich, H. (2007). Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review, 27, 384-405. Baumeister, R. F., Bratslavsky, E., Muraven, M., & Tice, D. M. (1998). Ego depletion: Is the active self a limited resource?. Journal of personality and social psychology, 74, 1252. Berg, K. C., Crosby, R. D., Cao, L., Peterson, C. B., Engel, S. G., Mitchell, J. E., & Wonderlich, S. A. (2013). Facets of negative affect prior to and following binge-only, purge-only, and binge/ purge events in women with bulimia nervosa. Journal of abnormal psychology, 122, 111-118. Bieling, P. J., Israeli, A. L., & Antony, M. M. (2004). Is perfectionism good, bad, or both? Examining models of the perfectionism construct. Personality and individual differences, 36, 1373-1385. Boone, L., Claes, L., & Luyten, P. (2014). Too strict or too loose? Perfectionism and impulsivity: The relation with eating disorder symptoms using a person-centered approach. Eating behaviors, 15, 17-23. Boone, L., Soenens, B., & Braet, C. (2011). Perfectionism, body dissatisfaction, and bulimic symptoms: The intervening role of perceived pressure to be thin and thin ideal internalization. Journal of Social and Clinical Psychology, 30, 1043-1068. Boone, L., Soenens, B., Braet, C., & Goossens, L. (2010). An empirical typology of perfectionism in early-to-mid adolescents and its relation with eating disorder symptoms. Behaviour Research and Therapy, 48, 686-691. Byeon, J., & Lee, J. (2016). The effects of positive and negative affect on binge eating behavior of high school students: Moderating effects of impulsivity based on UPPS-P model. Korean Journal of Clinical Psychology, 35, 784-796. Castro Fornieles, J., Gual, P., Lahortiga, F., Gila, A., Casulà, V., Fuhrmann, C.,... & Toro, J. (2007). Self oriented perfectionism in eating disorders. International Journal of Eating Disorders, 40, 562-568. Cooper, Z., & Fairburn, C. G. (2011). The evolution of enhanced cognitive behavior therapy for eating disorders: Learning from treatment nonresponse. Cognitive and Behavioral Practice, 18, 394-402. Corstorphine, E., Waller, G., Ohanian, V., & Baker, M. (2006). Changes in internal states across the binge-vomit cycle in bulimia nervosa. The Journal of Nervous and Mental Disease, 194, 446-449. Chua, J. L., Touyz, S., & Hill, A. J. (2004). Negative mood-induced overeating in obese binge eaters: An experimental study. International Journal of Obesity, 28, 606-610. Crosby, R. D., Wonderlich, S. A., Engel, S. G., Simonich, H., Smyth, J., & Mitchell, J. E. (2009). Daily mood patterns and bulimic behaviors in the natural environment. Behaviour Research and Therapy, 47, 181-188. 202

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