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ATTITUDES TOWARDS EXTREME PATTERNS OF BEHAVIOR
A THESIS SUBMITTED TO THE GRADUATE DIVISION
OF THE UNIVERSITY OF HAWAI‘I AT MĀNOA
IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTERS OF ARTS
IN
PSYCHOLOGY
DECEMBER 2012
By
Yurie Julie Takishima
Thesis Committee:
Kelly M. Vitousek, Chairperson
Brad Nakamura
Scott Sinnett
ii
Acknowledgements
I would like to express my sincere thanks and appreciation to all the parties that
have contributed to this research project. My advisor, Dr. Kelly M. Vitousek, provided
me tremendous help and guidance throughout the project. My committee members, Dr.
Brad Nakamura and Dr. Scott Sinnett aided with methodological and statistical design.
My fellow graduate students, Anna Ciao, Daria Ebneter, Jaime Chang, Kelsie Okamura,
Krista Brown, Marcin Bury, and Trina Orimoto assisted with instrument development
and provided constant support along the way. In particular, Jamal Essayli was
instrumental in developing project materials and Yue Huang provided critical statistical
analysis consultation.
iii
Table of Contents
Acknowledgements ............................................................................................................. ii
List of Tables ...................................................................................................................... v
List of Figures .................................................................................................................... vi
General Background on Extreme Behaviors ....................................................................... 1
Anorexia Nervosa: A Clinical Extreme Behavior .............................................................. 4
Clinical Relevance of Studying Non-Clinical Extreme Behaviors ..................................... 8
Extreme Climbing: How High Is Too High? ................................................................... 9
Ultrarunning: How Far is Too Far? ............................................................................... 10
Competitive Birding: How Many is Enough? ............................................................... 12
Socially Situated Phenomena: Who Are Extreme Behavers? ........................................ 12
Extreme Consequences .................................................................................................. 16
Additional Themes Common to Anorexia Nervosa and Other Extreme Behaviors ...... 20
Public Views Towards Extreme Behaviors ...................................................................... 26
The Present Study ............................................................................................................. 30
Method .............................................................................................................................. 34
Participants ..................................................................................................................... 34
Materials ........................................................................................................................ 34
Procedure ....................................................................................................................... 44
Data Analysis ................................................................................................................. 46
Results ............................................................................................................................... 50
Representativeness of Sample........................................................................................ 51
Baseline Knowledge of Extreme Patterns of Behavior .................................................. 53
Attitudes Towards Intimate Partner Involvement .......................................................... 56
ATEP Extreme Patterns of Behavior Profiles ................................................................ 57
Reliability of the ATEP ................................................................................................. 72
Discussion ......................................................................................................................... 74
Behavior and Subscale Profiles ..................................................................................... 75
Findings in Relation to Hypotheses ............................................................................... 77
iv
Findings of the Experimental Component ..................................................................... 82
Limitations ..................................................................................................................... 85
Conclusions .................................................................................................................... 90
Appendix A: Attitudes Towards Extreme Patterns, Sports, and Disorders ...................... 92
Appendix B: Attitudes Towards Extreme Patterns, Sports, and Disorders – POSTTEST
version ............................................................................................................................. 115
Appendix C: Item Cluster Map ....................................................................................... 118
Appendix D: Item Cluster Survey................................................................................... 119
Appendix E: High-Altitude Mountaineering Script – Risks Version ............................. 123
Appendix F: High-Altitude Mountaineering Script – Vulnerability Version ................. 124
Appendix G: Recruitment Flyer...................................................................................... 125
Appendix H: Consent Form to Participate in Study ....................................................... 126
References ....................................................................................................................... 127
v
List of Tables
Table Page
1. Participants’ Background Information .......................................................................... 52
2. Participants’ Self-Reported Baseline Knowledge of Patterns ...................................... 53
3. Opinions Regarding Intimate Partner Involvement in an Extreme Behavior ............... 57
4. ATEP Pattern Profiles by Subscale............................................................................... 59
5. ATEP Subscale Mean Rank Comparisons by Pattern .................................................. 64
6. ATEP Subscale Mean Rank Comparisons For Anorexia Nervosa, High-Altitude
Mountaineering, and Competitive Birding ....................................................................... 68
7. ATEP High-Altitude Mountaineering Profiles and Mean Comparisons by Subscale .. 70
8. Internal Consistencies for Subscales for which Items were Expected to Correlate ...... 74
vi
List of Figures
Figure Page
1. Predicted ATEP profiles by subscale. ........................................................................... 33
2. Placement of Extreme Behaviors on the Dimensions of Interest. ................................ 38
3. ATEP Disorders Cluster Mean Profiles ........................................................................ 60
4. ATEP Physical Pursuits Cluster Mean Profiles ............................................................ 61
5. ATEP Other Pursuits Cluster Mean Profiles ................................................................ 61
6. ATEP Occupations Cluster Mean Profiles ................................................................... 62
7. Mean Rank Profiles for Seven ATEP Rational Subscales ............................................ 66
8. Mean Rank Profiles for Anorexia Nervosa, Competitive Birding, High-Altitude
Mountaineering, and Ultrarunning.................................................................................... 69
9. ATEP High-Altitude Mountaineering Script R Pre- and Posttest Mean Profiles ......... 71
10. ATEP High-Altitude Mountaineering Script V Pre- and Posttest Mean Profiles ....... 71
11. A Priori Predicted Profiles and Observed Pretest ATEP Mean Rank Profiles by
Subscale Categorized as Low, Moderate, or High ............................................................ 80
1
“Right now excellent is doing something other people think is crazy.”
- running shoe advertisement in Outside magazine featuring
champion ultrarunner Anton Krupicka
General Background on Extreme Behaviors
Many modern behaviors could be categorized as “extreme,” some of which are
considered distinctly psychopathological (e.g., heroin abuse) and some of which
generally are not. In fact, many extreme pursuits are widely regarded as admirable,
particularly in the growing arena of “alternative” sports. A multitude of extreme sports
have only been invented in the last 50 years. Many of those sports require developing
skills that allow participants to assume as much risk as is possible, such as high-altitude
mountaineering, which involves incurring significant risk of bodily harm and death to
summit the world’s highest and most challenging mountains. Some behaviors qualify as
extreme due to the difficulty of performing them even if they are not manifestly
dangerous. Two examples are ultrarunning, which involves running races of 50 to 100
miles (80.5 to 161 kilometers) or longer and competitive birding, in which people
compete to observe and record as many different species of wild birds as possible in a
fixed period of time. Some extreme activities remain relatively obscure, such as
competitive Scrabble®, which involves competing in game tournaments at high skill
levels. Others, through corporate media sponsorship and the explosive popularity of
reality/documentary television, have arguably entered the general public’s canon of bona
fide pursuits. Over 1.5 million people followed ultrarunner and media darling Dean
2
Karnazes online in 2010 as he completed a nearly 3000-mile “Run Across America” from
Los Angeles to New York, televised by LIVE! with Regis and Kelly® and sponsored by
major corporations (such as Walgreens®). The opening quote of this paper, in which
being extreme is equated with being viewed as crazy, exemplifies a common niche
marketing tactic. Companies peddle their wares by convincing the hobbyist or the
weekend warrior (in this case, the everyday runner) that buying a product will make him
or her more extreme, and therefore more “excellent” (just like elite ultrarunners).
There is no standard accepted definition of what qualifies as an extreme pursuit. It
has been observed that today the term “extreme” is loosely applied to many activities that
may or may not deserve this distinction, from celebrity behavior to sexual techniques.
The adjective is even affixed to products such as soft drinks or cosmetics as a marketing
strategy that takes advantage of the rising prestige of all things extreme (Rinehart &
Sydnor, 2003). While some aspects of specific extreme pursuits have been studied (e.g.,
the physiological consequences of high-altitude mountain climbing or the personality
traits of ultrarunners), there has been no systematic scientific examination of broader
phenomena that may link those patterns together as extreme behaviors. For example,
most pursuits that could be regarded as extreme in this context are very difficult in terms
of skill, endurance, and/or dangerousness. Therefore, engaging in these activities requires
significant commitment, investment, prioritization, and valuing on the part of the
participant. For the purposes of the current study, “extreme patterns of behavior” refers to
a recurrent set of behaviors which are highly valued by those who engage in the pursuit,
require an extraordinary degree of effort to maintain, and involve significant physical
3
risk and/or social or emotional cost. Not all patterns of behavior that are classified as
extreme by this definition are sports or games; some demanding, high-risk occupations
could also be subsumed under this heading (e.g., special operations forces). Furthermore,
this definition may also be applied to some patterns that are considered mental illnesses
(e.g., anorexia nervosa). The clearest way to describe or explain the overall construct of
extreme patterns of behavior, and differentiate them from “normal” behaviors, is through
a detailed discussion of specific examples, which will follow in the subsequent sections.
Little is known about general attitudes towards these patterns of behavior and
there are several central reasons why learning more about those attitudes is clinically
relevant. Each of these concepts will be reviewed in detail in the following discussion:
1. All of the patterns under inquiry in the present investigation are socially
influenced, specifically, public views impact the frequency and form of the
behaviors.
2. Understanding the variables that contribute to the differential categorization of
some extreme patterns as pathological and others as non-pathological may
provide insight into what is generally viewed as normal, abnormal, or
exceptional behavior.
3. The distinction between the clinical disorders under study (i.e., anorexia
nervosa and substance abuse) as disturbed and abnormal and other extreme
behaviors (e.g., high-altitude mountaineering or ultrarunning) as sane and
admirable is less clear than the general public often acknowledges. Whether or
not general opinion accurately categorizes these behaviors is important as all of
4
the patterns under investigation have substantial – and sometimes fatal –
consequences and are often acknowledged, even by practitioners, to be
psychologically questionable (e.g., terms ranging from “addiction” to
“alternative suicide” are often used to describe them).
4. Most specifically, an exploration of public views of extreme behaviors may
help illuminate a recognized form of psychopathology, anorexia nervosa,
which shares important similarities with the “non-diagnosable” extreme
behaviors under examination.
Anorexia Nervosa: A Clinical Extreme Behavior
Anorexia nervosa is an eating disorder characterized by the severe restriction of
one’s caloric intake, often in combination with compensatory behaviors such as over-
exercising, vomiting, or laxative or diet pill abuse, for the purpose of extreme weight loss
and the intentional maintenance of one’s weight below a natural body weight. The
prominence of denial and resistance to change in treatment has earned anorexia nervosa
the clinical reputation of being one of the most recalcitrant psychiatric disorders
(Vitousek, Watson, & Wilson, 1998). Research suggests that most anorexics never seek
or receive treatment (Striegel-Moore, Leslie, Petrill, Garvin, & Rosenheck, 2000) and
only approximately one-third of those who do recover fully (Herzog et al., 1999;
Steinhausen, 2002). Furthermore, one-third of those who achieve full weight recovery
subsequently relapse (Herzog et al., 1999). Anorexia nervosa commonly involves intense
fear of weight gain and distorted body image, which contribute to the egosyntonic nature
of the symptoms of anorexia nervosa. Specifically, symptomatic behaviors such as
5
extreme caloric restriction are directly aligned with the primary goal of weight
suppression and are therefore experienced as consonant with the anorexic patient’s self-
perception. The disorder is seen as mysterious and difficult to decode by many
professionals, and often elicits a strong negative reaction in clinical settings (Vitousek et
al., 1998).
Striking differences between anorexia nervosa and other psychiatric disorders
may contribute to the sense that it is “non-understandable” (Vitousek et al., 1998).
Clinicians are accustomed to working with irrational beliefs and resistance to change, but
many are perplexed by the more distinctive features of anorexia nervosa, such as the
valuing of the illness by anorexic patients and the resulting competitiveness between
patients. Substance abuse provides the closest analogy among psychopathological
disorders and the similarities between the two disorders has been noted in the eating
disorder literature (e.g., Crisp, 1980; Vitousek et al., 1998). Specifically, lack of
motivation, denial, deception, and rationalization are marked in both conditions. In
addition, some classic “addictive” patterns can also be observed in the typical progression
of anorexic symptoms. For example, anorexic patients often escalate behaviors used to
control weight when they encounter the decreasing effectiveness of their initial methods
due to slowing metabolism, and the growing realization that the weight loss they
originally believed would bring them emotional security is not providing the relief they
seek.
Nevertheless, while substance abusers are extraordinarily adept at denial when
relating to their own behaviors, they typically do not deny that being an alcoholic or an
6
addict is problematic in general. In contrast, anorexics often contend that the self-control
necessary to suppress weight is a virtue, and experience pride and a sense of superiority
in character and moral over those who do not control their weight (Bliss, 1982; Vitousek
& Ewald, 1993). These beliefs are strengthened by the extreme effort and constant
vigilance that are required to override one’s biological drive to eat (Garfinkel, 1974). The
sense of “specialness” individuals with anorexia derive from their capacity to maintain
this extremely difficult pursuit becomes a strategy for maintaining the behavior itself: the
more internal reinforcement the anorexic patient obtains, the more her motivation to
continue intensifies. This belief is sometimes further expressed as contempt and disdain
for those who are not able to effectively manage their weight, and translates into a
competitive attitude amongst anorexic patients who are vying for the distinction of being
the most special, virtuous, and extraordinary in the pursuit of thinness. The result is that
the disorder itself, and the beliefs and strategies that reinforce it, become highly valued
by the anorexic individual.
These beliefs are not entirely unsupported by the anorexic patient’s social
environment: contemporary culture has glamorized extreme thinness as the ideal,
virtuous female form (Polivy & Herman, 2002). Eating disorder experts who propose that
culture is a powerful influence on the rates and forms of eating disorders cite the higher
prevalence rates of anorexia nervosa and bulimia nervosa in Western culture (Garfinkel
& Garner, 1982; Hawthorne-Hoeppner, 2000), among Caucasians (Hsu, 1987), upper-
socioeconomic strata (Garfinkel & Garner, 1982), and particularly among women
(Gordon, 1990), as well as the disproportionate occurrence of these disorders in
7
occupational or professional fields that place a high value on slenderness (e.g., modeling,
gymnastics, ballet, long-distance running) (Garfinkel & Garner, 1982; le Grange, Tibbs,
& Noakes, 1994; Williamson et al., 1995). Epidemiological studies confirm that the
disorder is most commonly diagnosed in Caucasian adolescents or young women from
higher socioeconomic status families (Hoek, 2006). Through increased cultural
homogenization via widespread adoption of Western cultural ideals, however, the
equation of thinness and attractiveness has become more common (Steiner-Adair, 1986;
Striegel-Moore, 1993), resulting in the decreasingly discriminatory nature of eating
disorders across ethnicities and social status (Gard & Freeman, 1996; Striegel-Moore,
1997).
In spite of the increasing prevalence of weight concern and dieting, anorexia
nervosa remains a relatively low base rate disorder, with prevalence rate estimates
ranging from 0.3 to 0.9% (e.g., Hoek, 2006; Hudson, Hiripi, Harrison, & Kessler, 2007).
The disorder probably has the highest mortality rate of any form of psychopathology
(Agras et al., 2004), with estimates ranging from 4 to 10% (Hoek, 2006)1. This has
earned anorexia nervosa the distinction of the “deadliest” psychiatric disorder. Morbidity
is also high, including medical consequences such as malnutrition, dehydration,
dangerously low blood pressure, muscle atrophy, slowed reflexes, decreased stamina and
coordination, cold intolerance, osteopenia and osteoporosis, amenorrhea and infertility,
1 Mortality rates reported for anorexia nervosa widely vary between studies, in part because the immediate
(and therefore reported) cause of death is often a medical condition secondary to the eating disorder such as
organ failure, pneumonia, or suicide.
8
liver or kidney failure, pancreatitis, seizures, neurological deficits, and permanent brain
damage (Agras et al., 2004).
Clinical Relevance of Studying Non-Clinical Extreme Behaviors
As anorexia nervosa appears to be disparate from other forms of psychopathology
in several specific ways, it may be helpful to turn to patterns of behavior that may offer
closer parallels to the disorder on those dimensions. An examination of other highly
valued extreme patterns of behavior may be instructive, as many of those pursuits share
some of the characteristics that are seen as particularly baffling in anorexic behavior2.
Furthermore, systematically exploring distinctive features and examining parallels to
other extreme pursuits may help us view the disorder from a new and more sympathetic
perspective, as “patterns that appear mysterious and pathological in the context of
anorexia nervosa can be seen as sensible, even admirable, in the service of goals that
observers understand and endorse” (Vitousek, 2004, p. 277).
While the following discussion will explore several different extreme patterns of
behavior in comparison to anorexia nervosa, attention will be focused primarily on high-
altitude mountaineering. This pattern was selected as it shares many parallels with the
disorder while simultaneously highlighting two especially salient and important aspects
of anorexia nervosa: high-altitude mountaineering resembles (indeed, exceeds) anorexia
2 It is important to note that in making these comparisons, it could be inferred that the socially acceptable
extreme behaviors under discussion should be considered psychopathological (or vice versa, that eating
disorders should not be considered a mental illness). Clearly, anorexia nervosa constitutes a serious and
debilitating problem for those who suffer from it, and in making such comparisons here it is not being
suggested it should be reclassified as a normal behavior pattern. While it is probable that some of the
extreme behaviors being discussed have psychologically problematic implications for some participants,
those conclusions have not been drawn definitively; more importantly, the status of other extreme
behaviors does not have to be determined in order for the connections being established to be of potential
value to our understanding of anorexia nervosa (Vitousek, 2010 Fall).
9
nervosa in deadliness and both pursuits are highly influenced by the social contexts
within which they exist. Ultrarunning, and to a lesser extent competitive birding, will also
be given additional attention in the following discussion as these four extreme behaviors
(i.e., anorexia nervosa, competitive birding, high-altitude mountaineering, and
ultrarunning) were examined most closely in the present study.
Extreme Climbing: How High Is Too High?
High-altitude mountaineering is a relatively recent extreme behavior that involves
spending months at a time attempting to climb the tallest mountains on the planet. There
are 14 mountains over 8,000 meters (26, 240 feet), all found in the Himalayan and
Karakoram mountain ranges in Asia. High-altitude mountaineering is often aided by the
use of supplementary oxygen and an expedition-style approach that involves large teams
provided with substantial support over multiple camps, which can considerably increase
survival and success. This type of climbing is very expensive; for example, to attempt an
Everest summit as part of an organized commercial expedition can cost up to $100,000
(“What It Costs,” n.d.). Most elite high-altitude mountaineers prefer a more self-reliant,
and simultaneously more dangerous, approach to climbing, such as lightweight “alpine-
style” expeditions, making first ascents on increasingly difficult routes, climbing solo,
climbing during winter, and climbing without supplemental oxygen. To be considered the
best within elite extreme mountaineering, some climbers attempt to successfully summit
as many of the highest mountains as possible. The “All 8000ers Club” – which is not
technically a “club” but an exclusive roster of climbers who have summited all of the 14
10
peaks over 8,000 meters (26, 240 feet) – lists a total of 22 people who have completed
this feat undisputed (Jurgalski, 2011).
Ultrarunning: How Far is Too Far?
Technically, an ultramarathon is defined as any foot race longer than a standard,
Olympic marathon distance (i.e., 26.2 miles or 42.2 kilometers) (AUA, 2011). The most
common ultra events distances are 50 and 100 miles (80.5 to 161 kilometers), although
there are now many races that far exceed those distances (e.g., the Iditasport, one of the
most remote and longest winter ultra race in the world held on the Iditarod Trail in
Alaska in February, which offers racers 350 mile and 1000 mile options). The longest
certified ultra event is the 3100 Mile Self-Transcendence Race (“Self-Transcendence,”
n.d.). Ultramarathons utilize “do-as-you-please” rules, meaning that running, walking,
eating, drinking, and sleeping are allowed at the racer’s discretion, as long as one keeps
on pace for the cutoff time limit for the race. These cutoffs are highly variable depending
on race conditions such as altitude (including gain), terrain, and climate, but are generally
12 to 14 hours for 50 milers and 24 to 36 hours for 100 milers. The consensus is that the
world championship (but not necessarily the toughest) of ultramarathons is the 100-mile
Western States Endurance Run, which boasts 18,090 feet (5,514 meters) cumulative
elevation gain (“Western States,” n.d.). There is little agreement on “the” toughest
ultramarathon, mostly because so many factors influence this decision, such as altitude,
elevation gain, terrain, climate, and conditions (which can differ vastly from year to year
for the same race), but the Badwater Ultramarathon is definitely a top contender for that
title. Badwater stretches 135 miles (217 kilometers) through Death Valley and halfway
11
up Mount Whitney in July, when temperatures can reach upwards of 130 degrees
Fahrenreit, or 54 degrees Celsius (“Badwater Ultramarathon,” n.d.). A particularly mind-
numbing subtype of ultramarathon are timed runs, specifically 12-24-48 hour runs or
multi-day events (3-6-10 day runs), often held on a track, around a city block, or on a
short (e.g., 1 mile) loop, with the purpose of running as many loops as possible within the
allotted time. For example, the 3100 Mile Self-Transcendence Race is run around a half a
mile city block in New York City; competitors are allowed 51 days to complete the
distance and must therefore average approximately 61 miles (98 kilometers) per day to
finish (“Self-Transcendence,” n.d.). Journey running is another identified subcategory,
and typically involves solo attempts over long distances (e.g., the full length of the 2,175
mile Appalachian Trail that connects Maine to Georgia or the Pacific Coast Trail, which
runs from Canada to Mexico through the states of Washington, Oregon, and California)
at the runner’s own chosen daily pace (e.g., a prescribed number of miles per day).
“Trans” runs or races are related to journey running, but specifically involve crossing or
traversing a country or continent, either in solo attempts or in organized groups, such as
the Trans American Footrace which runs the 2,935 miles (4,723 kilometers) from Los
Angeles to New York in 64 consecutive days (runners must average of 45 miles, or 72
kilometers, a day to finish) (“Trans-American,” n.d.). Not satisfied with the challenge
offered by trans-runs, several runners have attempted a World Run, and Jesper Olsen
from Denmark completed the first fully documented run around the world (26,232
kilometers or 16,300 miles) on October 23, 2005 (“World Run,” n.d.).
12
Competitive Birding: How Many is Enough?
Competitive birders travel back and forth across specified areas, ranging from
counties to continents or even the globe, to chase down birds – ranging from the most
common to the rarest – to add to a list of species seen by the individual within a specified
period of time (e.g., The Big Year) or over a lifetime (i.e., Life List). Serious birders
invest exorbitant time and money into tracking as many species as they can, commonly at
the expense of their relationships and careers. These travels are also sometimes extremely
dangerous. These aspects of extreme birding are best exemplified by the birding exploits
of Phoebe Snetsinger (known in birding circles for her record-setting Life List). Her
relentless pursuit of birds was emotionally fueled by a cancer diagnosis and supported by
a sizable inheritance (Martin, 1999). Snetsinger (2003) described many treacherous
experiences, including contracting serious disease in remote places, being shipwrecked,
caught in the crossfires of violent civil unrest, and assaulted and raped in a third world
country. She eventually died in a van accident during a birding expedition in Madagascar
(Martin, 1999). Top birders can encounter dangerous or difficult events, such as natural
disasters, accidents, or plane crashes, in their relentless pursuit of birds that can results in
severe injury or death.
Socially Situated Phenomena: Who Are Extreme Behavers?
Virtually all of the extreme pursuits that were examined in the present study are
linked to characteristic demographics such as sex, age, culture, and ethnicity for differing
but socially-influenced reasons. For example, various climbing statistics strongly suggest
gender disparities in high-altitude mountaineering: a survey of 108 members of the 1976
13
Mountaineering Training Committee demonstrated that 88% were male (Mitchell, 1983);
94% of the fatalities recorded on Mount Rainier in Washington state from 1977 to 1997
were males (Christensen & Lacsina, 1999); 100% of the first ascents of all peaks over
8,000 meters (26, 240 feet) were completed by males, and all members of the “All
8000ers Club” as of July 2011 were male (Jurgalski, 2011)3. Other characteristic
demographics are evident in the survey of the 1976 Mountaineering Training Committee:
an overwhelming majority of the members worked in engineering or the physical
sciences, 100% were white, and the mean age was 38 years (Mitchell, 1983). Similar
examples of skewed demographics are found in competitive birding and ultrarunning. In
2007, only 2% of top North American birders and approximately 5% of the top birders in
the world were female, and various birder surveys indicate that they are overwhelmingly
white, well-educated, and middle-aged (Cooper & Smith, 2010). In a study of 400
ultrarunners, Mueller and Staudhammer (2009) reported that this population of extreme
athletes was mostly male (72%), middle-aged (median age 41.9), highly educated (87%
college educated and 48% holding graduate degrees), with a median household income of
$85,000.
Despite this stereotyped profile for many extreme behaviors, high-altitude
mountaineering also provides a particularly clear illustration of the impact of growing
social endorsement of a previously obscure pursuit. Just as cultural attitudes towards
issues that are central to eating disorders (e.g., thinness as the ideal female form) appear
3 Since the last published update of the “All 8000ers Club” list, two females have officially successfully
summited all 14 peaks over 8,000 meters (26, 240 feet) and a third woman’s claim to have done so is
currently in dispute.
14
to have impacted the rates and form of anorexia nervosa, both the number and profile of
mountain climbers appears to be changing, influenced in part by public attitudes towards
the behavior. It was not until late in the 19th century that anyone attempted to summit the
world’s highest mountains, and those few who did were viewed as eccentric or even
insane. As previously noted, the profile of a typical climber is highly typed (i.e., white,
educated, upper-class male), but as high-altitude mountaineering develops into a world-
wide phenomenon, the demographics of climbing are also becoming more heterogeneous
(Thompson, 2010). As the nonclimbing public encourages climbing by imbuing it with
heroic qualities and elevated social status across cultures, more people and a greater
diversity of participants are attracted to the endeavor (Mitchell, 1983). For example, in
recent years an increasing number of women climbers have entered the arena of elite
climbing, and as the popularity and prestige of high-altitude mountaineering spread in
parts of Asia, there have been more serious climbers emerging from countries like Korea
and China. In this way, the context of mountain climbing has been powerfully impacted
by public opinion. Understanding this influence is important because it not only affects
who participates in such an activity, but also provides insight into why they do (Mitchell,
1983).
A specific example of the impact of cultural depictions of an extreme behavior is
the “catching it from books” phenomenon (e.g., Roberts, 2000). Climbers often cite
classic mountain climbing adventure books such as Annapurna, written by Maurice
Herzog in 1951, as the starting point for their idealized relationship with high-altitude
mountaineering (Taylor, 2010). Similarly, a commonly cited mode of entry for anorexic
15
patients are books about the disorder, such as Steven Levenkron’s The Best Little Girl in
the World (Vitousek, 2010). For example, in her autobiography about her long struggle
with anorexia nervosa, Marya Hornbacher (1998) wrote that she wanted to be the best
little girl in the world after reading that novel, illustrating how the attraction to something
perceived as difficult, distinctive, and impressive can be powerfully compelling.
More recently, mountain climbing experienced a surge in public awareness and
popularity after the airing of a series of documentaries chronicling the experience of
climbers attempting to submit Everest. Such documentaries have aired on relatively
mainstream television channels such as PBS (NOVA: Everest – The Death Zone or Lost
on Everest) or the Discovery Channel (Everest: Beyond the Limit). In fact, in just the past
few decades there have been dozens of full-length movies released that document or
recreate attempts to scale Everest as well as other peaks around the world. First Ascent:
The Series, a particularly extreme climbing-related adventure documentary series, aired
on the National Geographic Channel. The program followed some of the world’s greatest
climbers as they attempted record-setting climbs, such as Alex Honnold’s free solo climb
of the 2,000-foot wall of Half Dome (Mortimer & Rosen, 2010). One particular theme
stands out in these depictions: high-altitude climbing is not only extreme, but extremely
“cool” and “epic.” It is not difficult to imagine impressionable viewers being
subsequently drawn to the adventure of conquering mountains, just like the fearless
heroes in these documentaries.
As the quote at the beginning of this paper suggests, however, there is a point at
which public admiration blurs with the perception of being “crazy.” The valuing of the
16
extreme in modern popular culture has not only been influenced by the increasing
presence of extreme pursuits in mainstream awareness, but the increasing popularity of
such patterns of behavior has no doubt been reciprocally influenced by public opinions of
them. For example, this social context contributes to an environment within extreme
sports communities in which participants continuously strive to outdo one another so as
to stay on top of the distinction of being extreme, which in turn continually pushes the
boundaries of what is considered extreme or even possible. As the quote likening
“excellence” to perceptions of “crazy” illustrates, to excel in these activities requires
crossing into territory that teeters on the edge of what the general public will accept. A
central question of the present investigation concerned the criteria people utilize when
categorizing extreme behaviors as “crazy” or as acceptable. One critical dimension may
be the degree of cost (i.e., physical risk and emotional consequences) that is associated
with that behavior.
Extreme Consequences
High-altitude mountaineering mortality rates far exceed those of anorexia
nervosa, with as many as 40 to 60% of career climbers dying of climbing-related causes
(e.g., Burhardt, 2008, April; O’Connell, 1993; Todhunter, 1999, November). One
prospective study of 49 serious climbers found that 8% had died in climbing accidents at
four year follow-up (Monasterio, 2005). When examined on a per-attempt basis, lethality
varies widely across the highest peaks, based on several factors such as difficulty,
remoteness, and popularity. For example, despite being the tallest mountain, Everest is
associated with one of the lowest fatality-to-summit ratios, reported as 7.5% in one 2005
17
study, which is contrasted to a ratio of 40.8% for Annapurna (the tenth highest peak)
cited in the same study (Stadum, 2007). This is in part because Everest is a relatively less
technical mountain to climb in comparison to Annapurna. Also, many amateur climbers
are now able to summit Everest by paying considerable fees to professional guides who
coordinate large expedition-style groups that increase chances of success and survival.
The deadliness of high-altitude mountaineering is due to the extremely dangerous
conditions that climbers face on the mountain, and include avalanches, falling into hidden
crevasses, high winds and storms, fallings rocks and ice, exhaustion, exposure, and
hypothermia. Furthermore, exposure to extreme altitude is linked to a number of
potentially fatal medical conditions, including acute mountain sickness (AMS), high
altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE).
As is the case with extreme caloric restriction in anorexia nervosa, high-altitude
mountaineers are depriving themselves of a biological necessity (i.e., oxygen) by
intentionally placing themselves in this reduced oxygen environment. This is particularly
true in the region above 25,000 feet (7,620 meters), which is referred to as “The Death
Zone.” When in “The Death Zone,” the body is quickly deteriorating from the lack of
oxygen (at these altitudes acclimatization does not attenuate the effects) and it is common
for climbers to experience severe cognitive impairments, painful headaches, insomnia,
nausea, diarrhea, visual disturbances, trouble breathing, hallucinations, loss of muscle
control, and coughing fits (Ashcroft, 2002; Hultgren, 1997; Kupper et al., 2011; West,
Schoene, & Milledge 2007). These mental and physical impairments result in confusion
and physical weakness, which increase the already high risks of injury and death.
18
Cumulative damage sustained over multiple exposures to “The Death Zone” results in
even further increased risk (Fayed, Modrego, & Morales, 2006).
Hypoxia, the medical term for lack of oxygen, can directly damage brain cells and
impacts reaction time, learning of new information, and accuracy judgments. Hypoxia is
also associated with a failure to shift set, which results in the inability to recognize that
one must abandon the climb when extremely ill, paralleling the difficulty that anorexic
patients have in making the decision to abandon weight control even when their bodies
are deteriorating (Vitousek, 2010). MRI brain scans performed on a group of professional
and amateur climbers returning from climbs of various altitude (ranging from Everest to
the 4,810 meter Mont Blanc in the Alps) demonstrated that almost all of those who
climbed mountains exceeding 20,000 feet (6,096 meters) suffered lasting brain damage
(Fayed, Modrego, & Morales, 2006). The damage was still evident at two year follow-up,
without any high-altitude climbing intervening (Fayed, Diaz, Davila, & Medrano, 2010).
Paola et al. (2008) reported significant deficits in executive functioning in a group of elite
climbers in comparison to a control group. Comparable findings have been reported
across several similar studies (e.g., Brugger, Regard, Landis, & Oswald, 1999; Garrido et
al., 1993; Regard, Oelz, Brugger, & Landis, 1989). Another study measured speech
motor control and syntax comprehension in five members of an American climbing team
on Everest at different altitudes and found significant deterioration at higher altitudes that
resembled deficits seen in Parkinson’s disease (Lieberman, Protopapas, & Kanki, 1995).
In combination with the effects of hypoxia, freezing temperatures often lead to
frostbite, which can result in the permanent loss of appendages such as toes, fingers,
19
noses, or even limbs. It is common for climbers to experience snow blindness (sunburn of
the cornea) or high-altitude retinal hemorrhages (HARH). Other morbidities include
severe sunburn from the glare of the sun reflecting off of the snow, dehydration due to
hyperventilation and the dry air found at high altitudes, and hypothermia (which impairs
both cognitive functioning and motor dexterity) (Kupper et al, 2011).
In an another interesting parallel to anorexia nervosa, one more side effect of
being at high altitudes for prolonged periods is “genuine” anorexia, in which climbers
simultaneously experience reduced appetite and decreased efficiency of nutrient
digestion, coupled with significantly increased need for calories due to greater energy
expenditure. The consequences of these factors result in dramatic weight loss (Boyer &
Blume, 1984; Westerterp, Kayser, Brouns, Herry, & Saris, 1992), accompanied by the
cognitive and emotional sequelae of the semi-starvation state. Furthermore, like
individuals with anorexia nervosa, climbers undergo changes in reproductive functioning
(e.g., sperm and menses abnormalities) as their bodies conserve resources (Okamura,
Fuse, Kawauchi, Mizuno, & Akashi, 2003).
High-altitude mountaineering is unusual among extreme behaviors in the severity
of the physical risks that the pursuit entails. Nevertheless, most extreme behaviors are
associated with significant physical and psychological consequences, some of which also
affect the ability to shift set and make rational decisions. For example, while deaths
reported due to ultrarunning are rare, some evidence for long-term effects of ultrarunning
is surfacing: new research with both animal and human subjects suggests that years of
endurance training can cause scarring of heart tissue that is not observed in comparison
20
groups of non-endurance elite athletes (Reynolds, 2011). Ultra-endurance athletes
commonly experience over-use injuries as a result of extreme training regimens and
racing schedules. During races, it is routine for ultrarunners to experience vomiting,
severe dehydration, hypoglycemia, hypothermia, and loss of consciousness as well as
major mood dysregulation, hallucinations, paranoid ideation, and errors in judgment
(Graubins, 2011). Illustrating some of these extreme consequences of ultrarunning, one
runner’s blog post after a particularly grueling ultra event read:
So, here I am at work with everyone asking: “Hey, what happened to your face?
How did your arm get all cut up? Why are you limping?” … So I give them the
explanation of downed trees, boulders, getting lost, briars, poison ivy, stinging
nettle, getting lost, snake hurdling, blisters on blisters, boulders, getting lost,
taking an hour to go the last 2 miles ... and their eyes just roll back. I'm working
on a new explanation - car crash. Seems more believable. (Anonymous, n.d.)
Additional Themes Common to Anorexia Nervosa and Other Extreme Behaviors
There are several other themes worth exploring briefly to illustrate striking and
potentially instructive similarities between anorexia nervosa and the other extreme
patterns of behavior that were examined in the present study. These key issues represent
dimensions that might influence public attitudes towards such pursuits and include the
extraordinary effort required to maintain most extreme pursuits, the perceived benefits of
engaging in such behaviors, and the compulsive and escalating nature of many extreme
behaviors.
21
Effortfulness. As previously discussed, it is extraordinarily difficult to maintain
the constant vigilance and willpower necessary to override the fierce and frantic hunger
experienced by individuals with anorexia. Ultrarunning provides an example of another
extremely effortful pursuit. The large majority of ultrarunners are not elite, but the
commitment required from the “average” ultramarathoner is still very demanding; aside
from the grueling nature of the races themselves, the time and energy that they must
devote to training, nutrition, and travel requires considerable sacrifices in other domains
of the person’s life (e.g., family, friendships, pleasurable activities, and work). Training
and racing require extraordinary mental and psychological toughness and determination,
captured by one ultrarunner’s summary: “Training to run 100 miles is like training to get
hit by a truck" (McDougall, 2009). Extreme pursuits that people do not generally
consider excessively difficult can also require sustained, intensive effort when taken to
extremes. For example, competitive Scrabble® involves competing, often at extremely
high skill levels, at regulated Scrabble® tournaments to win prizes and for ranked
standing in the official international Scrabble® rating system. Elite Scrabble®
competitors often adhere to strict and intensive word studying schedules. David Gibson, a
champion Scrabble® player, claimed he studied daily for twelve years, for an average of
four hours a day (Fatsis, 2001).
Pride (& Prejudice). The eating disorder field often fails to pay adequate
attention to the subjective benefits of anorexia nervosa, perhaps because of the severe
distress and impairment anorexia nervosa causes (Vitousek, Gray, & Grubbs, 2004).
Anorexic individuals commonly display pride in their ability to exert extreme willpower
22
over the control of their weight, and this can be unsettling in the context of
psychopathology. This is illustrated by the words of an anorexic patient who likened her
eating disorder to “winning the Nobel Prize” (patient cited in Way, 1993, p. 69). In
slightly different contexts, however, it is much easier for the observer to understand and
accept the pride that a climber experiences after having summited the highest mountain in
the world or the sense of accomplishment that an ultrarunner feels after running hundreds
of miles across harsh and remote terrain. In fact, high-altitude mountaineers often reframe
even some of their more severe climbing injuries, such losing appendages to frostbite, as
“badges of honor” and as markers of how serious and dedicated they are (e.g., Coffey,
2003; Leamer, 1982; Roberts, 2000), in the same manner that an ultrarunner will show
off lost toenails and blister-scarred feet (e.g., Jamison, Moslow-Benway, & Strover,
2005). Individuals with anorexia nervosa may also view protruding bones and being so
critically ill that they must be tube-fed as indicators of just how serious (and successful)
their eating disorder has become (e.g., Greenfield, 2006). Across these contexts, the sense
of “specialness” that extreme behavers derive from accomplishing the near-impossible
often manifests as disdain for the “weak” commoners who do not engage in such
pursuits. Many high-altitude mountaineers undoubtedly “relish the challenge of
overcoming difficulties that would crush ordinary men and women” as climber Mark
Twight (1999) wrote. Many extreme behavers justify their choices by contrasting
themselves with the “ordinary.” A favorite target for participants across extreme pursuits
are “overweight couch potatoes,” as if anyone who does not climb the world’s highest
mountains or engage in frenzied travel around the world chasing rare bird sightings
23
automatically fits that contemptuous profile. For example, one birder defended his
behavior by pointing out that at least birders are getting off their “arses” when they are
madly running down birds (McGrath, 2008).
Monomania. It has been theorized that one of the reasons that anorexia nervosa is
so recalcitrant is that the disorder functions to systemize and simplify the anorexic’s life
(Crisp, 1980; Vitousek & Hollon, 1990). The singular focus of the disorder is
experienced by many anorexic individuals as far preferable to the chaotic uncertainty of
normal life (Fairburn, Shafran, & Cooper, 1999). Counting and obsessing over every
calorie one eats requires constant focus and attention, and allows the anorexic patient to
avoid attending to the more difficult and painful realities of living. This preference for
simplification and “control” through a circumscribed focus, which perhaps could be best
described by the term “monomania,” can functions as motivation and reinforcement for
extreme behavior (Vitousek, 2010). In writing about his own competitive birding, Sean
Dooley (2005) describes competitive birders as “a bunch of obsessive freaks” (p. 26),
explaining that identifying and listing allows participants to find order in a confusing
universe and provides the illusion of control. Additionally, there is sometimes a
reciprocal relationship in which the extreme demands of the pursuit require singular focus
and attention. For example, in order to be successful at a nearly impossible task (i.e.,
overriding the body’s biological mechanisms for ensuring adequate nutrition), the
anorexic patient must organize most of her thinking and behavior around the pursuit.
Individuals with anorexia nervosa find it increasingly necessary to “retreat from the
world in order to pursue [the disorder]” (Vitousek et al., 2004), which often results in
24
social isolation. Similarly, the title of a popular ultrarunning website, “Run Junkie: For
Singletrack Minds,” hints at the restricted focus required to maintain 100 mile training
weeks and the dedication required to ensure proper nutrition while training and
competing at high endurance levels.
Monomania is a trait shared across extreme behaviors and may be one of the
primary psychological characteristics that distinguish behaviors under the present
definition from other, less extreme hobbies or sports participation. Discussing the
ramifications of competitive birding, naturalist Scott Weidensell (2007) described how
participants abandon career and family and empty bank accounts in order to travel for up
to a year at a time chasing bird sightings. As such, monomania inherently, and perhaps
reciprocally, engenders a considerable degree of selfishness. With the exception of those
extreme pursuits that are occupations (e.g., special operations forces or firefighting), the
self-centered nature of most extreme endeavors lacks obvious value to society and is
often costly for those close to the extreme behaver. Some climbers assert that selfishness
is in fact a requirement of high-altitude mountaineering, referring to the tens of thousands
of dollars climbers spend to leave their families for months at a time to risk their lives for
a climb (Medavoy & Geffen, 2010). In the foreword to Maria Coffey’s (2003) book that
focuses on the perspective of the loved ones of high-altitude mountaineers, climber Tom
Hornbein asked of himself and other climbers: “How does one reconcile the inevitable
tension between such selfish and risky mountain play and the realities of that other life
with its bonds and responsibilities?” (p. xiii). Coffey offered a possible answer to
Hornbein’s musings in her introduction: most do not attempt to reconcile this conflict, as
25
“it is a subject most mountaineers avoid” (Coffey, 2003, p. xvii). Dan Koeppel (2005), in
a book about his father’s birding, commented that those who are obsessed are unable to
see that they are obsessed; otherwise, they would not be able to continue.
Koeppel (2005) went on to discuss the escalating nature of his father’s obsession:
his father would promise to stop birding after seeing five thousand bird species, only to
push his goal further once he reached that goal, and again when he reached the next. This
parallels the anorexic patient’s moving weight target: the more weight she loses the more
severe her weight loss goals become. Climber Joe Simpson (1993) discussed the vicious
cycle that always followed a successful climb: “it’s not long before you’re conjuring up
another, slightly harder, a bit more dangerous” (p. 53). This obsession with climbing
regularly leads mountaineers to neglect their spouses and children. High-altitude
mountaineers are frequently away from their families for months at a time, and children
commonly become resentful that their climbing parent was missing for so much of their
lives (Coffey, 2003). While some climbers defend their time away from their children,
others feel guilty about the costs that their inability to stop climbing imposes on their
family. Many extreme behavers expressly describe this inability to stop climbing as an
“addiction.” Climber Matt Samet wrote, “[I] realized that no matter how many routes I
climbed, I’d never quite measure up . . . It’s the same yawning emptiness that drives all
addicts.” Similarly, in describing his devotion to adventure racing (a subtype of
ultrarunning), Roman Dial wrote, “I became addicted … I gave up relationships with my
family. I gave up money and academic advancement. I gave up everything but racing,
26
preparing for races, and thinking about races” (in Jamison, Moslow-Benway, & Stover,
2005).
In reviewing some of the similarities and differences between anorexia nervosa
and other socially accepted, extreme patterns of behavior that are not considered
psychopathological, a series of questions arise. Why do we categorize anorexia nervosa
separately from high-altitude mountain climbing, ultrarunning, competitive birding, or
any of the other extreme patterns of behavior? Such comparisons suggest that climbers,
ultrarunners, birders, and anorexics are similarly attempting to address real problems in
their lives in various active, valued, but highly consequential, ways (Vitousek, 2010). So,
then, why are patterns that are viewed as aberrant in the context of psychopathology
accepted as reasonable or even heroic when observed in other contexts? For example, is
an anorexic patient who disregards the potentially life-threatening nature of her behaviors
in order to achieve and maintain low weight status inherently more disturbed than the
high-altitude climber who is ignoring signs of impending catastrophe in order to summit
successfully? Why do many observers find it appalling when an anorexic patient
celebrates the extraordinary difficulty of her pursuit, but applaud the elite ultra-endurance
athlete who basks in the glory of his or her seemingly superhuman feat?
Public Views Towards Extreme Behaviors
There is a growing body of literature exploring psychological characteristics
exhibited by those who participate in extreme sports such as high-altitude mountaineering
and ultrarunning. For example, research has examined risk-taking as a common
vulnerability among mountain climbers (e.g., Breivik, 1996) or the personality profiles of
27
ultrarunners (e.g., Folkins & Wieselberg-Bell, 1981). Few systematic studies exploring
public views of these pursuits, however, have yet been undertaken. In a study conducted
by Richard Mitchell and published in an appendix of his 1983 book titled Mountain
Experience: The Psychology and Sociology of Adventure, a sample of 1,032 adults across
the United States were asked to provide the first word that came to their mind when they
thought of people who climb mountains. Responses were coded and categorized, and
resulted in 49.9% positive or existential descriptions of climbers (e.g., “brave,”
“beautiful,” or “Jesus”) and 23.9% unflattering or hazardous characterizations (e.g.,
“crazy,” “stupid,” or “death”). Mitchell (1983) reported that more older respondents
provided words indicative of negative attitudes than the younger participants in the study.
Another informal study examined public attitudes towards sports (loosely including
several extreme patterns of behavior) and was published online by Richard Wiseman and
Sam Murphy in an article entitled the “Sexiest Sports Experiment.” In a survey of a non-
random sample of more than 6000 people who visited a website (Quirkology) devoted to
the exploration of psychological oddities such as luck or the paranormal, investigators
found that female respondents considered climbing (57%) to be the most attractive sport
in the opposite sex, followed by extreme sports (56%; definition not provided), while
men rated aerobics (70%), yoga (65%), and going to the gym (64%) as the top three most
attractive sports in women (Wiseman & Murphy, n.d.). Results should be interpreted with
caution as methodological details about the research have not been published4.
4 The primary author responded that nothing could be provided in response to a written request for such
details.
28
More empirical studies exist regarding public views towards anorexia nervosa and
substance abuse (e.g., Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Crow & Peterson,
2003; Holliday, Wall, Treasure, & Weinman, 2005; Jorm et al., 1999; Link et al., 1997;
Mond, Robertson-Smith, & Vetere, 2006; Ries, 1977; Roski et al., 1997; Schmeck &
Poustka, 1998; Stewart, Schiavo, Herzog, & Franko, 2008). There is some evidence that,
consonant with many patients’ self-assessments, the public considers anorexic patients’
extreme self-control to be admirable; a corollary is that many raters also characterize the
disorder as self-inflicted and controllable (e.g., Crisp et al., 2000; Crisp, 2005; Stewart et
al., 2008). Smith, Pruitt, Mann, & Thelen (1986) demonstrated that a majority of high
school and college students reject people with anorexia as potential friends and dating
partners. Similar findings in the substance abuse literature suggest that the public also
views alcoholism and drub abuse as self-inflicted (Martin, Pescosolido, & Tuch, 2000;
Ries, 1977; Roski et al., 1997), but this pattern is not found in the public perception
literature for other mental illnesses such as schizophrenia (Roski et al., 1997). There is
some evidence of gender differences in public attitudes towards eating disorders:
Scheffield, Fiorenza, & Sofronoff (2004) found that females generally hold more
sympathetic attitudes than males. This may be related to findings that familiarity or
personal experience with the mental illness in question is associated with more
sympathetic attitudes towards various forms of psychopathology, including eating
disorders (Alexander & Link, 2003; Corrigan, Markowitz, Watson, Rowan, & Kubiak,
2003; Mond et al., 2006; Stewart et al., 2008). Few ethnic differences in attitudes towards
mental illnesses have been documented. A Chinese study suggested that some ethnic
29
differences in attitudes towards eating disorders exist, for example, that Chinese
respondents view eating pathology as very costly but do not view it as impressive relative
to their Western counterparts (Lee, 1997).
With the exception of the literature on public perceptions of anorexia nervosa and
substance abuse, very little is known about general attitudes towards extreme pursuits or
regarding the variables that may contribute to the differential categorization of some
extreme patterns as costly, admirable, or disturbed. It is not clear why people view
extremely high-risk physical activities (such as high-altitude mountaineering) as less
problematic than other extreme patterns unambiguously considered psychopathological
(such as the abuse of substances or the over-control of weight). Psychology and related
fields are just beginning to question why some physically risky and psychologically
problematic pursuits (such as sporting activities) are socially and morally accepted or
admired while others (such as drug abuse) are not (e.g., Nutt, 2009). Clearer insight into
those attitudes is important in part because general societal opinions about extreme
pursuits almost certainly influence the adoption of those patterns. Specifically, public
opinions about a pursuit may impact what kinds of people are attracted to those pursuits,
as well as why and how people engage in those behaviors. It has been clearly established
that public attitudes and behaviors towards persons with mental illness can impact the
course of the illness (Corrigan et al., 2003). Social variables, including public views
about the meaning of symptomatic behavior, are implicated in the rates and form of
disorders such as alcoholism (e.g., Ries, 1977; Roski et al., 1997) and anorexia nervosa
(Polivy & Herman, 2002; Striegel-Moore & Franko, 2003). For example, although the
30
effects of alcohol are widely considered to be biochemically hardwired in humans, it has
been found that drunken behavior and rates of problem drinking vary widely across
culture, depending on the social norms and standards surrounding that behavior (Social
Issues Research Centre, 1998). Findings suggest that the general public is ambivalent
about anorexia nervosa, acknowledging the severity of the disorder while also attributing
desirable properties to some of the symptoms (Mond et al., 2006; Vitousek et al., 1998).
As previously discussed, anorexia nervosa differs from other forms of psychopathology
in the difficulty and considerable effort required to maintain the associated behaviors, the
mortality and morbidity associated with the disorder, and the egosyntonic nature of the
symptoms. As these distinctive aspects of anorexia nervosa resemble patterns seen in
socially accepted extreme behaviors it is particularly fascinating that, despite these
similarities, the public does not generally consider extreme sports or occupations
psychopathological, even if those behaviors are inherently harmful. Some of the factors
that may be contributing to these discrepancies were the focus of the present study.
The Present Study
The current investigation was designed to examine the attitudes of a college
student sample toward a number of patterns of extreme behavior and toward two specific
forms of psychopathology. Specifically, public views of ten of the extreme patterns of
behavior described previously were examined with the Attitudes Towards Extreme
Patterns, Sports, and Disorders (ATEP; measure developed for the present study).
Pursuits selected for inclusion in the ATEP fit the proposed definition of an extreme
pattern of behavior and can be categorized into four logical groups: Physical Pursuits
31
(Caving/Deep Cave Exploration, High-Altitude Mountaineering, Ultra-Distance
Swimming, and Ultrarunning), Other Pursuits (Competitive Birding and Competitive
Scrabble), Occupations (Fire and Rescue Services and Special Operations Forces), and
Disorders (Anorexia Nervosa and Substance Abuse). The ATEP measures attitudes
across seven dimensions which tap into potentially important evaluative aspects of
extreme behaviors, including people’s perceptions of how volitional the behavior is
(Controllability subscales), the cost of engaging in the behavior (Cost subscale), the
difficulty of engaging in the behavior (Difficultness subscale), how admirable the pursuit
is (Impressiveness subscale), how personally rewarding the behavior is for participants
(Positive Gains subscale), whether the behavior is “crazy” or indicative of
psychopathology (Psychological Disturbance subscale), and whether the behavior has any
social value (Value subscale). Further description of the ATEP, including an explication
of these seven constructs, as well as the principles and rationale that guided the selection
process of the ten extreme behaviors and the relevant evaluative dimensions for study, are
detailed in the Procedures section below.
As previously noted, there is no precedent in the research literature concerning
public views of the majority of the patterns of behavior being explored in the proposed
study. There was therefore no empirical basis for making specific predictions about
public views on competitive birding, ultrarunning, or any of the other non-disorder
behaviors under study. Nevertheless, some tentative, logical predictions were hazarded.
For example, anecdotal sources provide convergent evidence that competitive birding and
competitive Scrabble are not typically characterized as “cool” sports (Obmascik, 2004;
32
Fatsis, 2002), and it was therefore predicted that participants would rate those patterns
low on the Impressiveness scale. On the other hand, patterns that represent extreme sports
or pursuits that are often revered as “heroic” in popular culture, such as high-altitude
mountaineering (Coffey, 2003), Special Operations Forces (Pfarrer, 2004; Tucker &
Lamb, 2007), and Fire and Rescue Services, were expected to yield relatively high mean
scores on the Impressiveness and Difficultness subscales. In the case of the high-risk
occupations included in the measure (i.e., Fire and Rescue Services and Special Ops
Forces), it was anticipated that public attitudes would be minimally negative (reflected,
for example, by high Value subscale scores and low Psychological Disturbance scores) as
a result of the high social value assigned to those activities (e.g., Pfarrer, 2004).
Endurance sports such as ultrarunning and ultra-distance swimming were anticipated to
yield high Difficultness mean scores. Figure 1 provides a summary of the tentatively
anticipated ATEP profiles for each extreme behavior subscale for which prediction was
attempted.
(Lack)
CON COS DIF IMP POS PSY VAL
Disorders
Anorexia Nervosa M H M M M H L
Substance Abuse M H L L M H L
Occupations
Fire & Rescue
Services L H H H H L H
Special Operations
Forces L H H H H L H
Physical Pursuits
Deep Cave
Exploration L ? ? ? ? ? L
33
High-Altitude
Mountaineering L H H H ? L L
Ultra-Distance
Swimming L ? H ? ? ? L
Ultrarunning L ? H M H ? M
Other Pursuits
Competitive Birding L ? ? L ? ? L
Competitive
Scrabble® L ? ? L ? ? L
Figure 1. Predicted ATEP profiles by subscale. Notes: (Lack) CON = ATEP (Lack of) Controllability; COS = ATEP Cost; DIF = ATEP
Difficultness; IMP = ATEP Impressiveness; POS = ATEP Positive Gains; PSY = ATEP
Psychological Disturbance; VAL = ATEP Value; H = high mean scores predicted; M =
moderately elevated mean scores predicted; L = low mean scores predicted; ? = no prediction
In addition, this research examined changes in those attitudes from pre to post
after the provision of one of two alternative sets of information about high-altitude
mountain climbing. Comparing how these information sets affect participants’ views of
high-altitude mountaineering provided the opportunity to explore whether lack of
knowledge could be implicated as one reason observers regard some extreme pursuits,
such as mountain climbing, as “normal” while simultaneously viewing other extreme
patterns, such as anorexia nervosa, with contempt or concern (versus knowing the risks
but still viewing mountaineering as impressive). In this way, findings of the current study
can contribute to a better understanding of how people construct differing views of these
socially influenced behaviors and of what dimensions may set anorexia and substance
abuse apart from other extreme behaviors. Furthermore, findings may inform our
understanding of some of the broader issues related to public views of mental illness,
34
providing some insight into what factors lead people to develop the disparaging attitudes
towards particular disorders that can lead to stigmatization and discrimination.
An important caveat to note is that, as there have been very few scientific studies
of public attitudes towards the non-disorder extreme behaviors being examined in this
study, the materials relevant to those behaviors were largely developed based on
anecdotal sources (e.g., autobiographies, magazine articles, internet resources, etc.). In
terms of the experimental component of the present study, this applies most significantly
to the High-Altitude Mountaineering Script – Vulnerability Version (described below)
because that version primarily features the psychological vulnerability factors of
mountaineering while the Risks Version (also described below) focuses heavily on
documented statistics, such as mortality and morbidity rates.
Method
Participants
Five hundred forty-two respondents were recruited from undergraduate
psychology courses at the University of Hawai‘i at Mānoa and given extra course credit
for their participation. Participants were not excluded on the basis of any type of
demographic or background information. For a detailed description of the recruitment
process, see the Procedures section below.
Materials
Attitudes Towards Extreme Patterns, Sports, and Disorders (ATEP;
unpublished measure). In view of the lack of any existing measures of public attitudes
towards most of the patterns of behavior examined in the present study, the ATEP
35
(Appendix A) was designed for this study. The ATEP is a 210-item, self-report
questionnaire. Respondents indicate degree of agreement on a Likert scale, ranging from
0 (Disagree) to 5 (Completely Agree) for 21 statements concerning different possible
views towards each of the 10 patterns included. Each pattern comprises a separate
module of the overall measure. As previously noted, all of the pursuits selected for
inclusion in the measure fit the proposed definition of an extreme pattern of behavior and
can be categorized into four logical groups: Physical Pursuits (Caving/Deep Cave
Exploration, High-Altitude Mountaineering, Ultra-Distance Swimming, and
Ultrarunning), Other Pursuits (Competitive Birding and Competitive Scrabble),
Occupations (Fire and Rescue Services and Special Operations Forces), and Disorders
(Anorexia Nervosa and Substance Abuse). Each module includes a brief description of
the extreme behavior referred to in that section (see Appendix A). Descriptions were
written to be concise but sufficiently detailed to provide respondents with a referent for
the behavior being rated. While it was necessary to provide some information about the
difficulty and riskiness of some of the behaviors in order to describe them accurately,
descriptions were carefully worded to avoid leading responses on the dimensions that are
measured by the ATEP (see below). Two different versions of the full questionnaire were
generated, Version A and Version B, differing only in the order in which the patterns are
presented to partially control for fatigue and order effects. Specifically, the presentation
of the patterns was semi-randomized in each version, exerting ordering influence only to
ensure that neither of the disorder sections (i.e., Anorexia Nervosa or Substance Abuse)
appeared in the first half of the instrument. This was done to avoid skewing respondents’
36
interpretations of other patterns in the direction of psychopathology before they have an
opportunity to better understand the context of the measure through the process of
completing some of the non-disorder subscales. Finally, an abbreviated, posttest version
of the questionnaire (Appendix B), which includes only the High-Altitude
Mountaineering section of the full measure, was also created to detect any changes in
attitudes after participants were administered informational scripts about that activity (see
below).
The 21 repeating items that ask for participants’ views about each of the ten
patterns are presented in a fixed order across subsections. The items were developed to
map into seven clusters (see Appendix C). Each cluster of three items comprises a
separate rational subscale and was intended to capture a different dimension of extreme
activities. These dimensional constructs were selected through a review of the limited
literature examining public attitudes towards anorexia nervosa and substance abuse (e.g.,
Crow & Peterson, 2003; Holliday et al., 2005; Mond et al., 2005; Ries, 1977; Roski et al.,
1997; Stewart et al., 2008), as well as the extensive but primarily anecdotal literature on
the other extreme patterns under study (e.g., autobiographies, blogs, descriptive accounts,
documentaries). This review guided the development of the seven rational subscales. The
subscales are labeled Difficultness, Cost, Positive Gains, Impressiveness, Value,
Psychological Disturbance, and Controllability. Definitions for each of the categories
were generated, and are summarized on the first page of the Item Cluster Survey
(described below). For example, items in the Difficultness subscale refer to the difficulty
of performing or pursuing an activity, that is, how hard or challenging it is to do the
37
activity, and include items 4, "[X] requires willpower to do," 12, "[X] requires substantial
effort," and 17, "[X] requires skill." The Psychological Disturbance subscale represents
items that relate to whether engaging in an activity is viewed as indicative of a deficit in
sound reasoning or emotional stability, and includes item numbers 5, "[X] is a sign of
psychopathology (i.e., an indication of serious emotional problems)," 11, "[X] is
irrational," and 19, "[X] is a 'crazy' thing for someone to do." The Controllability subscale
items reflect the perception of a lack of control over a particular behavior, specifically
whether an activity is not susceptible to personal control and decision-making. The latter
subscale includes items 6, "[X] is biologically-driven (i.e., some people are more
vulnerable to becoming X),” 13, "[X] is addictive,” and the reverse-scored item 20, "[X]
is a pattern people can control (i.e., people can decide to continue the activity or decide to
stop it).” The Item Cluster Map in Appendix B provides a list of all of the items by
corresponding subscale.
The ten extreme patterns of behavior under study were specifically selected to
represent a range of positions on the dimensions that were hypothesized to be central to
evaluating extreme pursuits. For example, some patterns involve substantial risk of death
(e.g., high-altitude mountaineering, anorexia nervosa, and special operations forces),
some are physically challenging but seldom fatal (e.g., ultrarunning or ultra-distance
swimming), and some are not associated with risks to physical safety (e.g., competitive
Scrabble). Figure 2 provides a map of the general placement of each of the ten extreme
behaviors selected for the current study on the dimensions of interest, which include
degree of risk of physical harm (i.e., injury or death), level of physical demand,
38
selfishness versus social value, and prestige. While any behavior practiced to an extreme
degree might fit the definition of an extreme behavior developed for the present study
(e.g., playing professional tennis or being a highly successful businessman), further
specification of the definition would have excluded some of the patterns of behavior that
were desirable to include.
AN BIRD SCRA CAV
E
FIR
E SWIM
MT
N OPS
SU
B RUN
Risk of
Physical
Harm
H M L H H M H H H M
Physical
Demands
H M L H H H H H L H
Social
Value
L L L L H L L H L L
Social
Status M L L M H M H H L M
Figure 2. Placement of Extreme Behaviors on the Dimensions of Interest.
Notes: AN = anorexia nervosa; BIRD = competitive birding; SCRA = competitive Scrabble;
CAVE = deep cave exploration; FIRE = fire and rescue services; SWIM = ultra-distance
swimming; MTN = high-altitude mountaineering; OPS = special operations forces; SUB =
substance abuse; RUN = ultrarunning; L = low on the dimension; M = moderate placement on the
dimension; H = high on the dimension
Additionally, it was considered potentially instructive to include several extreme
patterns of behavior that represent occupations versus recreational pursuits. This
prompted the addition of special operations forces and fire and rescue services, patterns
that were expected to be judged high in both costs/risks and social worth. The inclusion
of these occupations allowed for an exploration of how social value and recreational or
occupational status influence public perception.
39
Possible total scores for each rational subscale range from 0 to 15, with a higher
score indicating a greater degree of that attribute for that specific pattern. There are two
reverse-scored items: item 2, "[X] is selfish," in the Value cluster and item 20, "[X] is a
pattern people can control (i.e., people can decide to continue the activity or decide to
stop it)," in the Controllability cluster. Because the Controllability cluster was developed
to represent the lack of control attributed to a particular behavior, a higher score on that
subscale represents the perception of less control for a particular behavior and a low score
indicates the perception of greater control for that behavior.
Although the three items generated for each of the rational clusters were all
intended to represent the theme identified by the cluster label, it was anticipated that they
would be variably correlated across the extreme behavior patterns examined. For
example, for those patterns that most people are expected to view as “impressive” (e.g.,
high-altitude mountaineering), it was anticipated that the three items assigned to the
Impressiveness cluster (“[X] is impressive,” “[X] is prestigious,” and “[X] is ‘cool’”)
would be similarly highly rated, while consistently low ratings would be expected for
patterns such as competitive birding. For some extreme behaviors, however, it was
anticipated that item ratings would not be convergent within some rational clusters.
Specifically, the Cost subscale includes items regarding the physical, interpersonal, and
emotional cost of engaging in an activity. While some patterns would be perceived as
costly across all three domains, others such as competitive Scrabble could be rated as
interpersonally and emotionally costly without carrying any physical risk. Additionally,
some of the constructs upon which the subscales are built inherently overlap. For
40
example, it was expected that the Psychological Disturbance subscale would overlap with
the Controllability subscale for many of the patterns, best exemplified by substance abuse
for which lack of control can be considered an aspect of the psychological impairment of
the disorder. For these reasons, a factor analysis of the ATEP would not be appropriate or
instructive across all of the patterns examined.
Preliminary items were generated by a group of three researchers in the field of
eating disorders who had background in the study of extreme behaviors. Raters with
knowledge of the constructs measured in the ATEP were recruited to evaluate each item
of the instrument as recommended in Haynes, Richard, and Kubany (1995). The raters
were clinical psychology graduate students who participate in research, supervision, or
treatment of eating disorders; most had also taken a graduate-level course on extreme
behaviors. Eight panel participants were asked to scrutinize the items and instructions for
quality, clarity, appropriateness for the intended sample (i.e., undergraduate psychology
students), and wording. Individual written feedback, including suggestions for improving
items or instructions, was elicited from each panel participant. Their commentary
informed modifications of the measure. In addition, panel participants were asked to
assign each item to one of the seven rational clusters described previously using the Item
Cluster Survey (Appendix D) developed to evaluate this aspect of content validity of the
ATEP. The Item Cluster Survey provides brief, specific definitions for each of the seven
clusters and lists all of the ATEP items. Definitions were carefully worded to provide
adequate context for the participants to rate each item, but also to avoid leading or
obvious cuing (e.g., refraining from the use of the category label within the text of the
41
definition). Participants were asked to circle the construct that each statement best
represents. Results of the Item Cluster Survey for each original items are summarized in
Table 1.
Table 1
Percent Agreement for Original ATEP Items
Original ATEP Item
Intende
d
Cluster
%
Agreeme
nt
6. [X] is biologically-driven (i.e., some people are more vulnerable
to becoming X).
CON 100
13. [X] is addictive.
CON 60
20. [X] is a pattern people can control (i.e., people can decide to
continue the activity or decide to stop it). [reverse-scored]
CON 100
3. [X] is physically costly (e.g., causes physical injury or harm).
COS 80
9. [X] is interpersonally costly (e.g., causes strain in relationships,
time away from family).
COS 100
14. [X] is emotionally costly (e.g., causes people to feel more
depressed or compulsive).
COS 50
4. [X] requires willpower.
DIF 70
12. [X] is dangerous.
DIF 30
17. [X] requires skill. DIF 100
1. [X] is impressive.
IMP 100
7. [X] is appealing to me.
IMP 40
15. [X] is “cool.”
IMP 100
10. [X] has benefits for the individual.
POS 100
18. People gain personally from [X].
POS 80
21. [X] is rewarding.
POS 90
42
5. [X] is a sign of psychopathology (i.e., an indication of serious
emotional problems).
PSY 100
11. [X] is irrational.
PSY 70
19. [X] is a “crazy” thing for someone to do.
PSY 50
8. [X] has worth for society.
VAL 70
16. [X] is morally admirable. VAL 90
2. [X] is selfish. [reverse-scored] VAL 80 Note: CON = ATEP Controllability; COS = ATEP Cost; DIF = ATEP Difficultness; IMP =
ATEP Impressiveness; POS = ATEP Positive Gains; PSY = ATEP Psychological Disturbance;
VAL = ATEP Value
In most instances, items with less than 70% interrater agreement were excluded
from the final measure. Percent agreement is the most common and straightforward
method for calculating interrater agreement for categorical variables and carries the
added advantage that it can be calculated for any number of categories (Fleiss, 2003;
Szklo & Nieto, 2006). Five original ATEP items did not meet the criterion of 70%
agreement. On subsequent review of those items it was concluded items 7 and 12 had
been ambiguously worded; both were rewritten to represent the intended content more
clearly. Item 13 demonstrated moderately low agreement (60%); however, as previously
noted the rational clusters were not developed to be completely independent constructs,
and some overlapping meaning between categories was expected. Through discussion
with the raters, it was concluded that the low agreement on item 13 was due to that
overlap and that rewording was unlikely to eliminate the problem while retaining the
sense of the item. Accordingly, a decision was made to include the item as originally
phrased. Finally, although items 14 and 19 both demonstrated low percent agreement, it
43
was concluded that this was due to inadequate cluster definitions on the Item Cluster
Survey rather than ambiguities in the items themselves; those items were therefore left
intact.
Finally, panel participants (which included three non-native English speaking
students) were asked to time themselves while completing the ATEP and report how long
it took them to finish the measure. For the 8 of 10 panelists who reported timing,
completion time ranged from 12 to 20 minutes, averaging 14 minutes (after removing two
outlying non-native English speaking completers who reported 30 and 45 minutes from
the analysis). The majority (83%) of the respondents included in the analysis took 15
minutes or less to complete the measure.
The ATEP also includes two additional sections with items assessing
demographic variables (Section 1; eight items) and background information (Section 3;
two items). Items in these sections were based in part on factors that have been shown to
impact public perception of mental illness in previous studies (e.g., Alexander & Link,
2003; Lee, 1997; Sheffield et al., 2004) and include questions on gender, ethnicity, age,
educational background, and cultural context. In addition, as those studies have also
demonstrated that personal experience with or knowledge of mental illness influences
perceptions, items were written to assess personal participation in, and prior/baseline
knowledge of, athletic or extreme activities.
High-altitude mountaineering scripts. Two one-page informational scripts
providing alternative sets of information about high-altitude mountaineering were created
for this study. This manipulation was included to examine whether exposure to additional
44
materials about extreme climbing affects stated attitudes towards the pursuit. One of the
scripts highlights the physical risks involved in high-altitude mountaineering (High-
Altitude Mountaineering Script – Risks Version; Appendix E), while the other features
psychological vulnerability factors (High-Altitude Mountaineering Script – Vulnerability
Version; Appendix F). The Risks Version of the script contains information about the
morbidity and mortality associated with extreme climbing. The Vulnerability Version
discusses reasons why climbers engage in the activity, including some of the darker
aspects of motivation, such as depression and social discomfort. The scripts were worded
non-technically and were intended to be appropriate for the target reader (i.e.,
undergraduate psychology students). Efforts were made to include anecdotal examples
and provide imagery to engage readers and to facilitate the understanding of extreme
situations with which most readers are likely to be unfamiliar. Both scripts begin with the
same introductory paragraph providing some additional details regarding the extreme
difficulty of high-altitude mountaineering. Preliminary scripts were generated by a group
of three eating disorder researchers with relevant knowledge of high-altitude
mountaineering. Scripts were then piloted with a small sample of expert raters and
undergraduate students to assess clarity and appropriateness for target audience.
Individual written feedback, including suggestions for improving the scripts, was elicited
from each participant. Their commentary informed modifications of the scripts.
Procedure
Upon approval of the study by the Committee on Human Studies of the
University of Hawaii at Manoa (CHS #19591), all instructors teaching undergraduate
45
psychology courses were contacted by email and provided information summarizing the
study. The students of the first instructor to indicate approval and cooperation were used
as an informal pilot sample (Total N=8; Pilot Version A n=2 and Pilot Version B n=6),
utilizing identical recruitment procedures as for the full sample described below, except
that the investigator was invited to first present information relevant to study participation
to the class in person before distributing the electronic recruitment flyers. These pilot data
were scanned for anomalies or problematic patterns; none were detected. Pilot
participants were instructed during the investigator’s class presentation to provide
feedback regarding any technical problems; none were reported.
Subsequently, 11 additional classes were solicited for the full sample, and
recruitment flyers describing the study (Appendix G) were distributed to students by
email (either by the investigator, a teaching assistant, or the instructor himself or herself).
The flyers provided information that guided participants to the project webpage on
SurveyMonkey, a survey engine website that offers data encryption, for online
administration of the ATEP. Those students who elected to participate were first
prompted to read and electronically sign an online consent form (Appendix H) before
they were allowed access to the ATEP. Once participants indicated agreement to
participate, the website randomly directed them to one of the two versions of the full
questionnaire (i.e., Version A and Version B). Upon completion of the initial pretest
ATEP, participants were then randomly prompted to read one of the two versions of the
High-Altitude Mountaineering Scripts. Group R read the Risks Version, while Group V
read the Vulnerability Version. Simple randomization procedures were expected to
46
produce fairly equal sized treatment groups in relatively large (n > 200) samples (Kang,
Ragan, & Park, 2008). After reading the randomly assigned script, respondents were
asked to complete the abbreviated posttest version of the questionnaire. All but two
instructors offered extra credit to their students for participation, at a specific level that
was determined by each instructor. Upon completion of the full process, participants were
added to a list of participants for the course from which they were recruited and the
investigator provided the final version of each list for each course to the corresponding
course instructor for extra credit assignment.
Data Analysis
Data preparation. Data were directly downloaded from the online survey
website in Microsoft Excel spreadsheet and IBM SPSS data source file formats. Reverse-
scored items from the ATEP (i.e., items 2 and 20) were recoded and subscale means were
calculated for each of the seven subscales for each of the ten behavior sections. The two
versions of the survey, differing only in the semi-randomized ordering of the pattern
sections as previously described, were compared to detect any significant differences that
would indicate that the two datasets could not be combined. Specifically, independent t-
tests were conducted to compare Substance Abuse and Anorexia Nervosa subscale means
for version A (n = 324) and Version B (n = 145) of the ATEP, as those were the only two
sections that differed in the order of their appearance between the two versions. Results
of these tests revealed sequence effects for only the Substance Abuse Controllability
subscale, specifically, that respondents viewed Substance Abuse as being less
controllable (or biologically-driven) if they completed that section after the Anorexia
47
Nervosa section of the ATEP. Thus, the Substance Abuse Controllability subscale for
Version A and Version B was analyzed separately in the relevant inferential analyses. All
other data were combined to create the initial dataset.
Of the 542 cases in the initial combined dataset, 73 (13.5%) were repeated or
incomplete (i.e., the respondent discontinued the process before completing). Nineteen
(3.5%) repeated cases were identified using repeated case analysis and removed by using
a random numbers generator to select one of each of the pairs for deletion. Of the
remaining 54 non-completers, it was ascertained that 32 (5.9%) had later returned to
complete the full process, by comparing the university student identification number
provided by the respondents. Of the remaining 22 incomplete cases, 18 (3.3%) cases were
less than 80% complete, and were therefore removed for not meeting the 20% cutoff
criterion for fatigue effects (cf., Nakamura, Ebesutani, Bernstein, & Chorpita, 2009).
Finally, there was no way to ascertain whether or not the respondents associated with the
remaining four (0.7%) incomplete cases had returned to complete the at a later time
because student identification numbers were not reported for those cases. These cases
were also removed, resulting in the final N of 469 cases (Group R n = 239 and Group V n
= 230).
It was discovered that item 21 (“[Behavior X] is rewarding.”) from the Positive
Gains subscale of the ATEP was inadvertently omitted from almost all of the final sample
surveys (the item appeared in no discernable pattern across several different pattern
sections in only six cases), although it had been included in the pilot sample surveys. It
was therefore determined that this item had been excluded due to a technical problem
48
with the online survey engine and this item was subsequently deleted from all analyses.
Removal of this item is depicted by a strike-through of this item in the ATEP (Appendix
A), posttest ATEP (Appendix B), and the Item Cluster Map (Appendix C). Additionally,
item 4 (“[Behavior X] requires willpower to do.”) from the Difficultness subscale was
also inadvertently excluded from only the pre- and posttest High-Altitude
Mountaineering sections of all the final sample surveys. It was not determinable whether
this was again due to a technical glitch generated by the survey engine, or resulted from
an investigator error during the programming of the electronic survey. Regardless, this
item could not be included in the High-Altitude Mountaineering profile or the pre-post
analysis. Removal of this item is depicted by a strike-through of this item in the ATEP
(Appendix A), posttest ATEP (Appendix B), and noted with an asterisk in the Item
Cluster Map (Appendix C).
Missing data. As responses to all ATEP items were required in order to progress
through the electronic survey, all of the cases in the final dataset were 100% complete.
Therefore, Missing Completely At Random (MCAR) analysis was irrelevant.
Data screening. Distributional properties of the data (i.e., normality, skewness,
kurtosis) were analyzed, and results indicated that the data were not normally distributed.
The Kolmogorov-Smirnov Test (preferred over the Shapiro-Wilk Test for samples > 50)
was used to assess normality. Several data transformation strategies (e.g., logarithmic
transformation) were applied, but were unsuccessful in normalizing distribution.
Nonparametric tests are indicated for inferential analysis when the normality assumption
49
for the dependent variable is violated, even for continuous variables (Gravetter &
Wallnau, 2011).
Analytic Strategy. The Statistical Package for the Social Sciences (SPSS)
version 20.0 was used for all descriptive and inferential analyses. For descriptive
analyses, participant response rates were calculated and compiled into a characteristics
summary table to examine the representativeness of the sample with regard to age,
gender, ethnicity, cultural context, major and athletic status. Respondents’ self-reported
baseline familiarity with, and attitudes towards real or imagined intimate partner
involvement in, the set of extreme behaviors under study was also reported. Medians,
means, and standard deviations were computed for the seven rational subscales across the
ten extreme behavior patterns, and resulted in distinct profiles for each behavior and each
subscale, as well as for each of the posttest groups (Group R and Group V).
Inferential analyses were carried out to further examine observed differences in
the ATEP subscale profiles. First, Mann-Whitney U tests (nonparametric equivalent to
independent t-tests) and generalized linear model analysis were conducted in an attempt
to estimate the impact of baseline knowledge on pretest attitudes. Friedman chi-square
tests (nonparametric equivalent to repeated measures ANOVAs) and Wilcoxon sign-
ranked tests (nonparametric equivalent to related sample t-tests) were conducted on the
full sample to compare ATEP subscales across behaviors and to examine changes in pre-
to posttest attitudes for the ATEP High-Altitude Mountaineering module. A prototypic
subset of the ATEP patterns (i.e., Anorexia Nervosa, Competitive Birding, High-Altitude
Mountaineering, and Ultrarunning) was selected for more extensive interpretation of the
50
results. Additionally, interaction effects for Script R and Script V were examined using
Mann-Whitney U tests to compare subscale mean score differences. Significance levels
for post-hoc comparisons were adjusted using the Bonferroni correction whenever
running multiple post-hoc pairwise comparisons. All tests were conducted at the .05
significance level, given the exploratory nature of the study.
Finally, a psychometric examination of one measure of reliability of the ATEP
was conducted. Specifically, internal consistency for several of the seven rational
subscales was estimated by computing the Cronbach’s alpha and mean inter-item
correlation for the seven rational subscales and comparing them to conventional
standards, i.e., the former at or above .80 and the latter between .15 and .50 (Clark &
Watson, 1995).
Results
Sample demographics, including age, gender, ethnicity, cultural context, and
major as well as self-reported status as an athlete or non-athlete are reported in Table 2.
Means are reported for the continuous variable of age and frequencies are reported for
ordinal data (i.e., all other variables). Information regarding participants’ personal
experience (i.e., whether they themselves or someone close to them has been involved in
an extreme pursuit) was also collected, and qualitative questions specifying the nature of
the activity were included to ensure that responses were referencing the types of
experiences targeted by the item. Some participants indicated personal experience with an
extreme pattern of behavior (30.1%) and/or knowing someone to whom they were very
close who engaged in such behaviors (40.7%). An extensive review of those respondents’
51
narrative responses to the qualitative questions, however, revealed that most did not
appear to understand the context of the item. Specifically, many responses suggested that
people were endorsing behaviors that would not be considered extreme under the present
definition (e.g., “I was on the swim team in high school,” “…jumping down a large set of
stairs on a skateboard,” or “all sports you name it”). Additionally, some responses
indicated that the person had endorsed the item despite knowing that it was not relevant;
for example, one respondent wrote: “I dance hula and compete in some hula
competitions. But it's not to the extreme like these other activities.” Another response
read: “I smoked marijuana twice in high school.” Further, some responses appeared to be
incomplete or nonsensical: “ADMIRED,” “practicing,” “boto,” “improvements,” or
“effected relationships.” Therefore, responses to this item were considered uninstructive
and were not further analyzed.
Representativeness of Sample
Recruitment yielded a diverse sample reflective of the demographic make-up of
the University of Hawaii system (http://www.hawaii.edu/about/). In terms of the full
sample, participants ranged in age from 17 to 62 years, with a mean of 20.97 years (SD =
3.85). The sample was primarily female (71.4%). The majority of respondents reported
Asian ethnicity (41.8%), followed by multi-racial (22.6%), White (22.4%), and Native
Hawaiian or Other Pacific Islander (7.5%). Most respondents grew up in Hawaii, were
Social Science majors (primarily Psychology), and considered themselves former athletes
more often than current athletes or non-athletes (see Table 2).
52
Table 2
Participants’ Background Information
Background factors (N = 469)
Age in years
Mean
17-62
20.97 (SD = 3.85)
Gender
Female
Male
335 (71.4%)
134 (28.6%)
Ethnicity
Asian
Black or African American
Hispanic or Latino
Native Hawaiian
Other Pacific Islander
Portuguese
White or Caucasian
Multi-Ethnic/Racial
Unknown
196 (41.8%)
6 (1.3%)
17 (3.6%)
23 (4.9%)
12 (2.6%)
3 (0.6%)
105 (22.4%)
106 (22.6%)
1 (0.2%)
Cultural Context
Grew up in Hawaii
Grew up on the mainland U.S.
Grew up in a U.S. territory
Grew up in a foreign country
303 (64.6%)
133 (28.4%)
7 (1.5%)
26 (5.5%)
Major*
Arts
Biological Sciences
Business-Related Fields
Communication
Computer Science
Education
Architecture and Engineering
Health Fields
Languages and Literature
Mathematics and Physical Science
Social Sciences
Undeclared
11 (2.3%)
19 (4.1%)
16 (3.4%)
7 (1.5%)
7 (1.5%)
9 (1.9%)
9 (1.9%)
53 (11.3%)
12 (2.6%)
4 (0.9%)
237 (50.5%)
85 (18.1%)
53
Athletic Status
Not an athlete
Formerly an athlete
Presently an athlete
177 (37.7%)
216 (46.1%)
76 (16.2%)
Note: Unless otherwise indicated, frequencies are reported. *If multiple majors were specified, only the first listed was counted. Baseline Knowledge of Extreme Patterns of Behavior
Participants were asked to indicate their knowledge of the patterns of behavior
under study prior to completing the pretest ATEP. Overall sample baseline knowledge
scores are reported in Table 3. For anorexia nervosa and substance abuse, most
respondents reported “Some Knowledge” or “Considerable Knowledge” (35.0% and
39.7%, respectively, for anorexia nervosa and 33.0% and 45.6%, respectively, for
substance abuse). For fire and rescue services, “Minimal Knowledge” and “Some
Knowledge” were endorsed most often, with similar frequencies (34.1% and 31.1%,
respectively). The most frequently reported category for competitive Scrabble® was
closely split between “No Knowledge” and “Minimal Knowledge” (39.0% and 37.3%,
respectively). For all other patterns, a majority of respondents indicated “No Knowledge”
(see Table 3).
Table 3
Participants’ Self-Reported Baseline Knowledge of Patterns
Pattern (N = 469)
Anorexia Nervosa
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
34 (7.2%)
61 (13.0%)
164 (35.0%)
186 (39.7%)
24 (5.1%)
3
54
Caving/Deep Cave Exploration
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
Competitive Birding
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
Competitive Scrabble®
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
Fire & Rescue Services
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
Ultra-Distance Swimming
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
High-Altitude Mountaineering
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
249 (53.1%)
142 (30.3%)
65 (13.9%)
11 (2.3%)
2 (0.4%)
1
384 (81.9%)
55 (11.7%)
21 (4.5%)
7 (1.5%)
2 (0.4%)
1
183 (39.1%)
175 (37.3%)
86 (18.3%)
18 (3.8%)
7 (1.5%)
2
104 (22.2%)
160 (34.1%)
146 (31.1%)
52 (11.1%)
7 (1.5%)
2
205 (43.7%)
151 (32.2%)
74 (15.8%)
32 (6.8%)
7 (1.5%)
2
241 (51.4%)
146 (31.1%)
62 (13.2%)
16 (3.4%)
4 (0.9%)
1
55
Special Operations Forces
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
Substance Abuse
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
Ultrarunning
1 = No Knowledge
2 = Minimal Knowledge
3 = Some Knowledge
4 = Considerable Knowledge
5 = Highly Knowledgeable or Expert
Median
215 (45.8%)
140 (29.9%)
69 (14.7%)
40 (8.5%)
5 (1.1%)
2
17 (3.6%)
52 (11.1%)
155 (33.1%)
214 (45.6%)
31 (6.6%)
4
252 (53.7%)
125 (26.7%)
64 (13.6%)
23 (4.9%)
5 (1.1%)
1
To estimate the impact of baseline knowledge on pretest attitudes, two logical
categories were created for each of the behavior patterns. Specifically, responses
endorsing “No Knowledge,” “Minimal Knowledge,” and “Some Knowledge” were
recoded as “Not Knowledgeable”; responses of “Considerable Knowledge” and “Highly
Knowledgeable or Expert” were recoded as “Knowledgeable.” This resulted in groups
characterized as Not Knowledgeable and Knowledgeable for each extreme behavior.
Mann-Whitney U tests were conducted to detect differences between knowledge groups
for each extreme behavior subscale means. Significant differences were revealed for
many of the behavior pattern subscales, suggesting that prior knowledge has an effect on
attitudes. These findings, however, could be affected by the confounding influence of
other important variables such as age, gender, ethnicity, cultural context, or athletic
56
status. Nonparametric inferential analyses were conducted corresponding to the scale
level of the data to examine the possible impact of other available variables. Chi-square
analysis was carried out to detect any significant differences between the two knowledge
groups on the nominal variables (i.e., gender, ethnicity, cultural context, and athletic
status). Age was analyzed separately using a Mann-Whitney U test (normality test
revealed that this variable was not normally distributed). Significant differences were
demonstrated between knowledge groups on all tested background variables for two or
more behavior pattern module subscales, providing evidence that the detected differences
between knowledge groups might be confounded by all other five factors. A regression
analysis was therefore determined to be necessary to analyze how attitudes vary as a
function of baseline knowledge. A sample ordinal5 logistic regression was attempted, but
conditions for this analysis were not met. Specifically, even after collapsing each
predictor into as few categories as possible, ordinal logistic regression could not be
carried out because multiple cells contained zero frequencies.
Attitudes Towards Intimate Partner Involvement
As an additional evaluation of attitudes towards the extreme patterns of behavior under
study, after completing the pretest ATEP (but before reading the informational scripts
and completing the posttest ATEP), participants were asked to indicate how they would
feel if their intimate partner (real or imagined) engaged in one of those activities. A
significant majority (74.2%) reported ambivalence (see Table 4).
5 Although researchers often incorrectly treat Likert scale responses as continuous variables (there is
extensive disagreement in the literature on this topic), it is most accurate and stringent to treat them as
ordinal because one ultimately cannot assume that respondents perceive the differences between adjacent
levels as equidistant (Allen & Seaman, 2007, July; Jamieson, 2004; Vigderhous, 1977).
57
Table 4
Opinions Regarding Intimate Partner Involvement in an Extreme Behavior
Item n
I would be strongly opposed to or unhappy about it.
I would be ambivalent; that is, I would feel a mixture of
positive and negative feelings about it.
I would be in favor of it and feel positively about it.
Missing
69 (14.7%)
348 (74.2%)
51 (10.9%)
1 (0.2%)
ATEP Extreme Patterns of Behavior Profiles
The central analytic focus of the present study was to examine overall patterns of
how different extreme behaviors are viewed. Basic descriptive statistics (i.e., mean,
standard deviation, and median) for the entire sample were calculated for each subscale
within each extreme behavior module (reported in Table 5) and resulted in distinct
profiles of subscale central tendencies for each of the ten extreme behaviors. The ATEP
items were developed on an ordinal response scale (i.e., unequal intervals in response
scaling); however, means and standard deviations were also included as descriptive
indices of the profiles to aid in interpretation of the data as medians do not depict subtler
differences. Additionally, ATEP pattern profile histograms combining clusters of
behavior patterns were created for direct comparisons on each of the dimensions
measured by the ATEP (see Figures 3-6).
In general, most within-cluster behaviors of the ATEP appeared to follow similar
mean score profile patterns across the seven subscales, with the exception of Anorexia
58
Nervosa and Substance Abuse on the Difficultness subscale. Specifically, participants
seemed to rate Anorexia Nervosa (mean = 3.00) as higher on the Difficultness subscale
than Substance Abuse (mean = 1.89). Otherwise, the ATEP Disorder cluster patterns (i.e.,
Anorexia Nervosa and Substance Abuse) followed a similar trend across the other
subscales. Both patterns were rated high (descriptively defined as means between 3.50
and 5.00) on Psychological Disturbance, Cost, and lack of Controllability and low
(rationally defined as means between 0 and 1.50) on Impressiveness, Positive Gains, and
Value. The Physical Pursuits cluster patterns (i.e., Deep Cave Exploration, Ultra-Distance
Swimming, Ultrarunning, High-Altitude Mountain Climbing) were also rated very
similarly within the cluster. This set of extreme behaviors was rated moderate (defined
descriptively as means between 1.50 and 3.50) on all subscales, except for Difficultness,
which was rated high for all the behaviors in this cluster. The Other Pursuits cluster
patterns (i.e., Competitive Birding, Competitive Scrabble®) appeared to be viewed
relatively moderately across all subscales. Finally, the Occupations cluster patterns (i.e.,
Fire and Rescue Services, Special Operations Forces) were viewed as high on all
subscales except for lack of Controllability and Psychological Disturbance, which were
both rated in the moderate range.
59
Table 5
ATEP Pattern Profiles by Subscale
(Lack)
CON COS DIF IMP POS PSY VAL
Disorders
AN
Mean (SD)
Median
3.64
(0.82)
3.67
4.55
(0.76)
5.00
3.00
(1.06)
3.00
1.28
(0.64)
1.00
1.50
(0.80)
1.00
4.14
(0.94)
1.00
1.67
(0.65)
1.67
SUB
Mean (SD)
Median
3.86
(0.73)
4.00
4.57
(0.77)
5.00
1.89
(0.90)
1.67
1.24
(0.56)
1.00
1.50
(0.76)
1.00
3.89
(0.99)
4.00
1.46
(0.63)
1.33
Physical Pursuits
CAVE
Mean (SD)
Median
2.40
(.78)
2.33
2.91
(0.91)
3.00
4.08
(0.88)
4.33
3.48
(0.93)
3.67
3.34
(1.00)
3.50
2.21
(0.85)
2.33
3.33
(0.73)
3.33
SWIM
Mean (SD)
Median
2.52
(0.74)
2.67
2.89
(0.87)
3.00
4.41
(0.79)
4.67
3.68
(0.88)
4.00
3.78
(0.95)
4.00
2.25
(0.82)
2.33
3.35
(0.76)
3.33
RUN
Mean (SD)
Median
2.69
(0.76)
2.67
2.92
(0.88)
3.00
4.32
(0.81)
4.67
3.31
(0.94)
3.33
3.51
(1.02)
3.50
2.37
(0.90)
2.33
3.17
(0.77)
3.00
MC
Mean (SD)
Median
2.55
(0.81)
2.67
3.27
(0.86)
3.33
4.36
(0.87)
5.00
3.60
(0.94)
3.67
3.48
(1.02)
3.50
2.46
(0.90)
2.33
3.17
(0.81)
3.00
Other Pursuits
BIRD
Mean (SD)
Median
2.24
(0.77)
2.33
2.00
(0.85)
2.00
3.15
(1.07)
3.00
2.17
(0.93)
2.00
2.71
(1.09)
2.50
2.02
(0.93)
2.00
2.90
(0.71)
3.00
SCRAB
Mean (SD)
Median
2.34
(0.75)
2.33
1.63
(0.77)
1.33
3.39
(1.00)
3.33
2.65
(1.01)
2.67
3.07
(1.05)
3.00
1.67
(0.80)
1.33
2.92
(0.67)
3.00
60
Occupations
FIRE
Mean (SD)
Median
2.24
(0.76)
2.33
3.47
(0.91)
3.33
4.31
(0.80)
4.67
4.11
(0.83)
4.33
3.94
(0.91)
4.00
1.81
(0.78)
1.67
4.54
(0.68)
5.00
OPS
Mean (SD)
Median
2.48
(0.79)
2.67
3.76
(0.93)
4.00
4.34
(0.81)
4.67
3.98
(0.92)
4.33
3.80
(1.01)
4.00
2.14
(0.87)
2.00
4.20
(0.82)
4.33 Note: (Lack) CON = ATEP (Lack of) Controllability; COS = ATEP Cost; DIF = ATEP
Difficultness; IMP = ATEP Impressiveness; POS = ATEP Positive Gains; PSY = ATEP
Psychological Disturbance; VAL = ATEP Value. AN = Anorexia Nervosa; SUB = Substance
Abuse; CAVE = Deep Cave Exploration; SWIM = Ultra-Distance Swimming; RUN =
Ultrarunning; MC = High-Altitude Mountaineering; BIRD = Competitive Birding; SCRAB =
Competitive Scrabble®; FIRE = Fire and Rescue Services; OPS = Special Operations Forces.
Figure 3. ATEP Disorders Cluster Mean Profiles
00.5
11.5
22.5
33.5
44.5
5
Anorexia Nervosa
Substance Abuse
61
Figure 4. ATEP Physical Pursuits Cluster Mean Profiles
Figure 5. ATEP Other Pursuits Cluster Mean Profiles
00.5
11.5
22.5
33.5
44.5
5
Deep Cave Exploration
Ultra-DistanceSwimming
Ultrarunning
High-AltitudeMountaineering
00.5
11.5
22.5
33.5
44.5
5
Competitive Birding
Competitive Scrabble®
62
Figure 6. ATEP Occupations Cluster Mean Profiles
The statistical significance of these descriptive differences, both within and
between ATEP clusters, was examined using inferential tests. To examine the statistical
significance of differences across different behavior modules within each ATEP subscale,
mean ranks for each behavior were computed for each subscale, resulting in a distinct
profile for each ATEP subscale (see Table 6). Figure 7 depicts the graphic relation of
each of the subscales. When mean ranks were separated into three rational categories as
with the descriptive profiles – low (< 3), moderate (3-6), and high (> 6) – subtler within
behavior and subscale differences were revealed in the Physical Pursuits and Other
Pursuits clusters. Specifically, Competitive Birding and Competitive Scrabble® fell
within the low (versus moderate) range on the Cost subscale, and the Physical Pursuits
cluster moved up from moderate to high on the Impressiveness and Positive Gains
subscales.
00.5
11.5
22.5
33.5
44.5
5
Fire & Rescue Services
Special OperationsForces
63
Friedman tests were conducted to examine whether observed differences between
the extreme behaviors on each of the seven subscale domains were significant; results
indicated that at least two behaviors were significantly different from each other on each
of the seven subscales, warranting further analysis. In order to further explore these
findings, nonparametric post-hoc pairwise comparisons (i.e., Wilcoxon signed-rank tests)
were conducted. A separate analysis pairing each behavior pattern for each subscale (325
separate tests) was carried out. To account for the order effects between Dataset A and
Dataset B that were revealed for the Substance Abuse lack of Controllability subscale, the
data were analyzed and presented separately for this subscale. Results of these analyses
are reported in Table 6.
Table 6
ATEP Subscale Mean Rank Comparisons by Pattern
Disorders Physical Pursuits Other Pursuits Occupations
AN SUB* CAVE RUN SWIM MC BIRD SCRAB FIRE OPS
Controllability
Median
Mean rank
Comparisons
3.67
8.34(8.24) 1*/2*/3*/4*/
5*/6*/7*/8*/
9*/10*
DatasetA
4.00
9.07 7*/14*/20*/
26*/32*/
35*/39*/
43*/44*
DatasetB
3.67
(8.67) 8*/15*/21*/
27*/33*/
36*/40*/
45*/46*
2.33
4.48(4.85) 2*/11*/12*/
13*/14*/15*/
16*/17*
2.67
5.97(5.57) 5*/13*/19*/
25*/30*/34*/
35*/36*/37*/
38*
2.67
5.33(4.97) 9*/16*/22*/
28*/37*/41*/
43*/45*
2.67
5.19(5.20) 10*/17*/23*/
29*/38*/42*/
44*/46*
2.33
3.80(4.01) 1*/11*/12*/
13*/14*/15*/
16*/17*
2.33
4.29(4.52) 6*/31*/34*/
39*/40*/41*/
42*
2.33
3.76(3.98) 3*/18*/24*/
26*/27*/28*/
29*
2.67
4.77(4.99) 4*/12*/24*/
30*/31*/32*/
33*
Cost
Median
Mean rank
Comparisons
5.00
8.80 1*/2*/3*/4*/
5*/6*/7*/8*
5.00
8.80 14*/20*/25*/29*/33*/35*/
38*/39*
3.00
4.73 2*/9*/12*/
17*/18*/19*/
20*/21*
3.00
4.67 5*/12*/23*/
28*/32*/33*/
34*
3.00
4.66 7*/15*/26*/
30*/36*/38*/
40*
3.33
5.75 8*/16*/21*/
27*/31*/34*/
37*/39*/40*
2.00
2.42 1*/9*/10*/
11*/12*/13*/
14*/15*/16*
1.33
1.77 6*/13*/19*/
24*/28*/32*/
35*/36*/37*
3.33
6.33 3*/10*/17*/
22*/23*/24*/
25*/26*/27*
4.00
7.07 4*/11*/18*/
22*/28*/29*/
30*/31*
Difficultness
Median
Mean rank
Comparisons
3.00
3.48 1*/2*/3*/4*/
5*/6*/7*/8*/
37*
1.67
1.75 6*/14*/21*/25*/28*/30*/
32*/35*/36*/37*
4.33
6.09 1*/9*/12*/
17*/18*/19*/
20*/21*/22*/
23*
4.67
7.06 4*/12*/19*/
29*/30*/31*
4.67
7.47 7*/15*/22*/
26*/31*/33*/
35*
5.00
7.36 8*/16*/23*/
34*/36*
3.00
3.62 9*/10*/11*/
12*/13*/14*/
15*/16*
3.33
4.16 5*/13*/20*/
24*/27*/29*/
32*/33*/34*
4.67
6.93 2*/10*/17*/
24*/25*/26*
4.67
7.08 3*/11*/18*/
27*/28*
65
Impressiveness
Median
Mean rank
Comparisons
1.00
2.07 1*/2*/3*/4*/
5*/6*/7*/8*
1.00
1.94 15*/22*/27*/32*/36*/39*/
42*/43*
3.67
6.55 2*/9*/18*/
19*/20*/21*/
22*/23*/24*
3.33
6.00 5*/12*/13*/
20*/25*/30*/
35*/36*/37*/
38*
4.00
7.17 7*/16*/23*/
28*/33*/37*/
40*/42*
3.67
6.95 8*/17*/24*/
29*/34*/38*/
41*/43*
2.00
3.54 1*/9*/10*/
11*/12*/13*/
14*/15*/16*/
17*
2.67
4.55 6*/14*/21*/
26*/31*/35*/
39*/40*/41*
4.33
8.29 3*/10*/18*/
25*/26*/27*/
28*/29*
4.33
7.93 4*/11*/19*/
30*/31*/32*/
33*/34*
Positive Gains
Median
Mean rank
Comparisons
1.00
2.11 1*/2*/3*/4*/
5*/6*/7*/8*/
9*
1.00
2.13 15*/22*/28*/33*/36*/38*/
41*/42*
3.50
5.96 2*/10*/18*/
19*/20*/21*/
22*/23*/24*
3.50
6.46 6*/13*/20*/
26*/31*/35*/
36*/37*
4.00
7.30 8*/16*/23*/
29**/37*/
39*/41*/43*
3.50
6.46 9*/17*/24*/
30*/34*/40*/
42*/43*
2.50
4.40 1*/10*/11*/
12*/13*/14*/
15*/16*/17*
3.00
5.28 7*/14*/21*/
27*/32*/35*/
38*/29*/40*
4.00
7.64 3*/11*/18*/
25*/26*/27*/
28*/29**/
30*
4.00
7.27 4*/5*/12*/
19*/25*/31*/
32*/33*/34*
Psychological
Disturbance
Median
Mean rank
Comparisons
1.00
9.11 1*/2*/3*/4*/
5*/6*/7*/8*/
9*
4.00
8.61 7*/15*/21*/26*/31*/34*/
36*/39*/40*
2.33
5.03 2*/10*/18*/
19*/20*/21*/
22*
2.33
5.58 5*/13*/19*/
24*/29*/33*/
34*/35*
2.33
5.20 8*/16*/27*/
35*/37*/39*/
40*/41*
2.33
5.97 9*/17*/22*/
28*/32*/38*/
41*
2.00
4.24 1*/10*/11*/
12*/13*/14*/
15*/16*/17*
1.33
3.05 6*/14*/20*/
25*/30*/33*/
36*/37*/38*
1.67
3.50 3*/11*/18*/
23*/24*/25*/
26*/27*/28*
2.00
4.71 4*/12*/23*/
29*/30*/31*/
32*
Value
Median
Mean rank
Comparisons
1.67
2.20 1*/2*/3*/4*/
5*/6*/7*/8*/
9*
1.33
1.79 7*/14*/21*/26*/31*/35*/
37*/40*/41*
3.33
6.25 2*/10*/17*/
18*/19*/20*/
21*/22*
3.00
5.61 5*/13*/19*/
24*/29*/34*/
35*/36*
3.33
6.22 8*/15*/27*/
32*/36*/38*/
40*/42*
3.00
5.65 9*/16*/22*/
28*/33*/39*/
41*/42*
3.00
4.86 1*/10*/11*/
12*/13*/14*/
15*/16*
3.00
4.93 6*/20*/25*/
30*/34*/37*/
38*/39*
5.00
9.16 3*/11*/17*/
23*/24*/25*/
26*/27*/28*
4.33
8.33 4*/12*/18*/
23*/29*/30*/
31*/32*/33*
Note: Mean ranks from Friedman chi-square tests are shown in the table. *For the ATEP Controllability subscale, mean ranks were calculated separately
for DatasetA and DatasetB to account for order effects; mean ranks for Dataset B are reported in parentheses. The slash “/” separates the asterisks that
indicate the significance levels of the different post-hoc pairwise Wilcoxon signed-rank comparisons, numbered in order of comparison from left to
right. AN = Anorexia Nervosa; SubAb = SUB; CAVE = Deep Cave Exploration; SWIM = Ultra-Distance Swimming; RUN = Ultrarunning; MC =
High-Altitude Mountaineering; BIRD = Competitive Birding; SCRAB = Competitive Scrabble®; FIRE = Fire and Rescue Services; OPS = Special
Operations Forces.
** p < Bonferroni family-wise alpha of .05. * p < Bonferroni family-wise alpha of .01.
66
Figure 7. Mean Rank Profiles for Seven ATEP Rational Subscales
0
1
2
3
4
5
6
7
8
9
10
Anorexia Nervosa
Substance Abuse
Deep Cave Exploration
Ultraruning
Ultra-Distance Swimming
High-Altitude Mountaineering
Competitive Birding
Competitive Scrabble®
Fire & Rescue Services
Special Operations Forces
As most of these comparison tests revealed significant differences between pairs
of ATEP patterns on all subscales, four prototypic extreme patterns of behavior
illustrating a range of types of extreme activities (i.e., Anorexia Nervosa, Competitive
Birding, Ultrarunning, and High-Altitude Mountaineering) were selected for more
extensive interpretation of results. These patterns were selected for their varying
representativeness of the domains of interest. Additionally, the three non-disorder
patterns were chosen because they share specific similarities with anorexia nervosa, as
previously discussed in detail, that increase their instructive value in terms of the aims of
the present study. Table 7 and Figure 8 present the data for these four extreme behaviors.
Anorexia Nervosa was rated by respondents as significantly higher in comparison to the
other three patterns on the lack of Controllability, Cost, and Psychological Disturbance
subscales, and significantly lower on the Value, Positive Gains, and Impressiveness
subscales (p < Bonferroni family-wise alpha of .01). Both Competitive Birding and
Anorexia Nervosa were rated as similarly less difficult than High-Altitude
Mountaineering and Ultrarunning. The latter two patterns shared very similar profiles,
demonstrating statistically similar mean rank ratings on all but two subscales.
Specifically, Ultrarunning was rated as significantly less costly and impressive than
High-Altitude Mountaineering. These two patterns also scored similarly higher than
Competitive Birding on all the subscales.
68
Table 7
ATEP Subscale Mean Rank Comparisons For Anorexia Nervosa, High-Altitude
Mountaineering, and Competitive Birding
Anorexia
Nervosa
Competitive
Birding Ultrarunning
High-Altitude
Mountaineerin
g
Controllability
Median
Mean rank
Pairwise
comparisons
3.67
3.59
1*/2*/3*
2.33
1.70
1*/4*/5*
2.67
2.49
2*/4*/6*
2.67
2.21
3*/5*/6*
Cost
Median
Mean rank
Pairwise
comparisons
5.00
3.81
1*/2*/3*
2.00
1.27
1*/4*/5*
3.00
2.23
2*/4*/6*
3.33
2.69
3*/5*/6*
Difficultness
Median
Mean rank
Pairwise
comparisons
3.00
1.70
1*/2*
3.00
1.82
3*/4*
4.67
3.21
1*/3*
5.00
3.27
2*/4*
Impressiveness
Median
Mean rank
Pairwise
comparisons
1.00
1.28
1*/2*/3*
2.00
2.06
1*/4*/5*
3.33
3.15
2*/4*/6*
3.67
3.52
3*/5*/6*
Positive Gains
Median
Mean rank
Pairwise
comparisons
1.00
1.29
1*/2*/3*
2.50
2.34
1*/4*/5*
3.50
3.19
2*/4*
3.50
3.18
3*/5*
Psychological
Disturbance
Median
Mean rank
Pairwise
comparisons
1.00
3.78
1*/2*/3*
2.00
1.71
1*/4*/5*
2.33
2.18
2*/4*
2.33
2.33
3*/5*
69
Value
Median
Mean rank
Pairwise
comparisons
1.67
1.25
1*/2*/3*
3.00
2.68
1*/4*/5*
3.00
3.02
2*/4*
3.00
3.05
3*/5*
Note: Mean ranks from Friedman chi-square tests are shown in the table. The slash “/” separates
the asterisks that indicate the significance levels of the different post-hoc Wilcoxon signed-rank
test comparisons, numbered in order of comparison from left to right.
* p < Bonferroni family-wise alpha of .01.
Figure 8. Mean Rank Profiles for Anorexia Nervosa, Competitive Birding, High-Altitude
Mountaineering, and Ultrarunning
The second major aim of the present study was to examine whether opinions of
high-altitude mountaineering would change after the provision of the high-altitude
mountaineering scripts. To uncover and compare observable changes, the ATEP High-
Altitude Mountaineering pretest profile was compared to the posttest profiles for each of
the two high-altitude mountaineering script groups (Script R n=239 and Script V n=230).
Indices of subscale central tendencies for pre- and posttest are reported in Table 8. The
ATEP items were developed on an ordinal response scale (i.e., unequal intervals in
00.5
11.5
22.5
33.5
44.5
Anorexia Nervosa
Competitive Birding
High-AltitudeMountaineering
Ultraruning
70
response scaling) but means and standard deviations were also included as descriptive
indices of the profiles to aid in interpretation of the data. Figures 9 and 10 graph the
profiles for the pretest and both posttest groups. Results indicated that both script
versions were associated with significant change on all of the ATEP subscale dimensions
except for Difficultness. Furthermore, both scripts displayed the same trend in the
direction of influenced change. Specifically, regardless of which script was read,
respondents’ ratings of the lack of Controllability, Cost, and Psychological Disturbance
subscales increased significantly, and the Impressiveness, Positive Gains, and Value
subscales decreased significantly (p < Bonferroni family-wise alpha of .01).
Table 8
ATEP High-Altitude Mountaineering Profiles and Mean Comparisons by Subscale
Script R (n = 239)
Pretest Posttest
Script V (n = 230)
Pretest Posttest
Controllability
Mean (SD)
Median
2.45 (0.81)
2.33
2.64 (0.89)
2.67*
2.64 (0.80)
2.67
3.24 (0.74)
3.33*
Cost
Mean (SD)
Median
3.25 (0.87)
3.33
3.93 (0.93)
4.00*
3.30 (0.85)
3.33
3.98 (0.86)
4.00*
Difficultness
Mean (SD)
Median
4.39 (0.86)
5.00
4.51 (0.78)
5.00
4.33 (0.88)
4.75
4.30 (0.87)
4.50
Impressiveness
Mean (SD)
Median
3.58 (0.95)
3.67
3.28 (1.10)
3.33*
3.62 (0.93)
3.67
3.24 (1.05)
3.33*
Positive Gains
Mean (SD)
Median
3.45 (1.03)
3.50
2.98(1.13)
3.00*
3.51 (1.01)
3.50
3.13 (1.06)
3.00*
Psychological
Disturbance
Mean (SD)
Median
2.31 (0.83)
2.33
3.03 (0.99)
3.00*
2.62 (0.95)
2.67
3.22 (0.99)
3.33*
71
Value
Mean (SD)
Median
3.19 (0.82)
3.00
2.72 (0.95)
2.67*
3.15 (0.81)
3.00
2.62 (0.85)
2.67* Note: Comparisons were conducted using Wilcoxon signed-rank tests.
* p < .01.
Figure 9. ATEP High-Altitude Mountaineering Script R Pre- and Posttest Mean Profiles
Figure 10. ATEP High-Altitude Mountaineering Script V Pre- and Posttest Mean Profiles
00.5
11.5
22.5
33.5
44.5
5
Pretest Script R
Postest Script R
00.5
11.5
22.5
33.5
44.5
5
Pretest Script V
Postest Script V
72
Finally, to investigate for possible interaction between the Script R and Script V
groups, a Mann-Whitney U test was conducted for each pre- to posttest condition
subscale mean score difference value. Results revealed interaction effects for the ATEP
lack of Controllability and Difficultness subscales (p < .05). Specifically, Script V
resulted in a significantly larger increase in posttest scores for the lack of Controllability
and Difficultness subscales (although the change from pre- to posttest on the
Difficultness subscale was not statistically significant for either script version).
Reliability of the ATEP
Internal consistency. As previously described, steps were taken during the
development of the ATEP to examine and improve the content validity of the measure.
Additionally, some ATEP items were subjected to analysis of internal consistency. As the
literature to date provides little guidance as to which items could be expected to correlate
for extreme behaviors, this analysis was exploratory in nature. As previously explained,
items for some subscales could be anticipated to correlate together for some behavior
patterns but not for others. For some behavior subscales it was impossible to anticipate a
priori how items would hang together, in part because there was no way to predict the
accuracy of respondents’ baseline knowledge. Therefore, for the few behaviors for which
there is (often limited) scientific literature available upon which to base such predictions,
Cronbach’s alphas and inter-item correlations were calculated. For example, it was
anticipated that the three items in the ATEP Cost subscale, which were developed to
measure the physical, emotional, and relational cost of engaging in the identified
73
behavior pattern, would correlate for the ATEP Disorders cluster (i.e., Anorexia Nervosa
and Substance Abuse) as the literature suggests that public views of mental illness
include perceived costliness in all three domains measured by this subscale. Similarly, it
was anticipated that items regarding the psychopathological nature (as measured by the
ATEP Psychological Disturbance subscale) and the social or societal value (intended to
be reflected in the Value subscale of the ATEP) would also correlate highly for the
disorders. Due to the inherently societally beneficial nature of the patterns of behavior in
the ATEP Occupations cluster, it was anticipated that the items in the Value subscale
would correlate for Fire and Rescue Services and Special Operations Forces. Cronbach’s
alphas for the examined subscales are reported in Table 9. The Cronbach’s alphas for the
examined behavior patterns were .67 for the Psychological Disturbance subscale and
ranged from .78 to .81 for the Cost subscale and from .26 to .69 for the Value subscales.
The mean inter-item correlations ranged from .36 to .59. Only the alphas for Substance
Abuse of the Cost subscale met criteria recommended by Clark and Watson (1995), and
the mean inter-item correlations for all of the subscales did not fall within the
recommended range.
74
Table 9
Internal Consistencies for Subscales for which Items were Expected to Correlate
Disorders
AN – 0.78 – – – 0.67 0.26
SUB – 0.81 – – – 0.67 0.52
Other Pursuits
BIRD – – – – – – –
SCRAB – – – – – – –
Occupations
FIRE – – – – – – .69
OPS – – – – – – .66
Physical Pursuits
CAVE – – – – – – –
SWIM – – – – – – –
RUN – – – – – – –
PreMC – – – – – – –
Note: ª Cronbach’s Alpha; AN = Anorexia Nervosa; SUB = Substance Abuse; BIRD =
Competitive Birding; SCRAB = Competitive Scrabble®; FIRE = Fire and Rescue Services; OPS
= Special Operations Forces; CAVE = Deep Cave Exploration; SWIM = Ultra-Distance
Swimming; RUN = Ultrarunning; PreMC = Pretest High-Altitude Mountaineering; Posttest High-
Altitude Mountaineering; CON = ATEP Controllability; COS = ATEP Cost; DIF = ATEP
Difficultness; IMP = ATEP Impressiveness; POS = ATEP Positive Gains; PSY = ATEP
Psychological Disturbance; VAL = ATEP Value; – insufficient evidence to expect correlation or
items not expected to correlate
Discussion
Little is known about general opinions regarding extreme patterns of behavior,
although it is clear that public perceptions impact the frequency and form of these
behaviors (e.g., Mitchell, 1983; Polivy & Herman, 2002; Striegel-Moore & Franko, 2003;
75
Thompson, 2010). Understanding the variables that contribute to the differential
categorization of some extreme behaviors as pathological and others as non-pathological
or even admirable may provide insight into how the public constructs attitudes towards
some disorders, particularly anorexia nervosa. In the present study, attitudes of 469
undergraduate psychology students, representative of the demographic distribution of
University of Hawaii student population, were analyzed. The majority of participants
reported no baseline knowledge for most extreme behaviors included in the ATEP,
except for fire and rescue services, for which most respondents endorsed minimal
knowledge, and the disorders (i.e., anorexia nervosa and substance abuse), for which
respondents indicated considerable knowledge. The vast majority of the sample reported
ambivalence regarding real or imagined partner involvement in an extreme pursuit.
Behavior and Subscale Profiles
The primary analytic focus of the present study was to examine overall
descriptive patterns of how different extreme behaviors are viewed. In general, most
within-cluster behaviors of the ATEP appeared to follow similar mean score profile
patterns across the seven subscales. Specifically, the Disorder cluster patterns (i.e.,
Anorexia Nervosa and Substance Abuse) were rated high on Psychological Disturbance,
Cost, and lack of Controllability and low on Impressiveness, Positive Gains, and Value.
These two patterns differed only on the Difficultness subscale, for which Anorexia
Nervosa was viewed as significantly more difficult, probably because it is readily
understandable that it is challenging to deprive oneself of food, whereas people may not
attribute skill, willpower, or substantial effort to using drugs or alcohol. Generally, the
76
Physical Pursuits cluster patterns (i.e., Deep Cave Exploration, Ultra-Distance
Swimming, Ultrarunning, High-Altitude Mountain Climbing) were rated moderately on
all subscales, except for Difficultness, Impressiveness, and Positive Gains subscales,
which were rated high. The Other Pursuits cluster patterns (i.e., Competitive Birding,
Competitive Scrabble®) appeared to be viewed moderately across all subscales, except
for the Cost subscale, which was rated as low. Finally, the Occupations cluster patterns
(i.e., Fire and Rescue Services, Special Operations Forces) were viewed as high on all
subscales except for lack of Controllability and Psychological Disturbance, which were
both rated in the moderate range.
These analyses demonstrated that respondents viewed the profiles within ATEP
clusters (i.e., Disorders, Physical Pursuits, Other Pursuits, and Occupations) quite
similarly, but there were some striking differences across the clusters. This suggests these
categories may be relevant to how people generate attitudes towards them, although that
was not specifically examined in the present study. For example, findings of the present
study demonstrated that the Occupations cluster was rated low on lack of Controllability,
most likely because firefighting and special forces are jobs (i.e., activities people engage
in to support themselves and their families, and usually a result of the individual’s career
choices), and are therefore inherently considered as more controllable. These descriptive
observations also provided further evidence that these categories might dictate the
public’s disposition towards another previously identified key dimension that potentially
influences their attitudes: practitioners’ motivations for engaging in these pursuits.
Specifically, low ratings on the Positive Gains subscale for both of the patterns that
77
comprise the ATEP Disorders cluster demonstrate that the public does not understand, or
is not willing to concede, the personal benefits of engaging in such behaviors. As
previously noted, the eating disorder field often fails to pay adequate attention to the
subjective benefits of anorexia nervosa, perhaps because of the severe distress and
impairment caused by the disorder (Vitousek, Gray, & Grubbs, 2004). It is possible that
the public engages in a similar error of attention.
Findings in Relation to Hypotheses
Some of these observed similarities between the disorders under study were
consonant with previous findings regarding public attitudes toward anorexia nervosa and
substance abuse (e.g., Crisp, 2005; Crow & Peterson, 2003; Holliday et al., 2005; Jorm et
al., 1999; Link et al., 1997; Schmeck & Poustka, 1998). For example, as predicted, both
of the Disorder cluster behaviors were rated as highly psychopathological and costly.
Based on the literature, however, it was anticipated that greater ambivalence regarding
anorexia nervosa, indicated by moderately elevated mean scores on the Impressiveness,
Difficultness, and Positive Gains subscales, would be demonstrated. While anorexia
nervosa was perceived as more difficult than substance abuse, both disorders were
viewed equally as unimpressive and as not yielding benefit or gain. This provides some
evidence that people differentiate the difficulty of a pursuit from how impressive they
consider it to be. It is also possible that anorexia nervosa is perceived as “cooler” when
justaposed with other disorders (e.g., bipolar disorder or schizophrenia), as was the case
with previous research, and is seen as less impressive when considered in relation to
more “heroic” activities such as mountaineering. Finally, based on previous findings that
78
the public views both substance abuse and anorexia as self-inflicted or controllable (e.g.,
Crisp et al., 2000; Crisp, 2005; Stewart et al., 2008) a moderate mean score on the lack of
Controllability subscale was predicted for those patterns. Contrary to those previous
findings, data from the present study suggest that respondents viewed both behaviors as
highly uncontrollable, possibly because of their explicit classification as illnesses. An
additional or alternative possibility is that, this apparent change in attitudes may reflect
the success of recent public information campaigns casting these disorders as “diseases”
and “brain disorders.”
As previously noted, precedents were not found in the extant research literature
concerning public views of most of the patterns of behavior explored in the present study.
There was therefore no empirical basis for making specific predictions about public
views on competitive birding, ultrarunning, or the other non-disorder behaviors under
study. Nevertheless, some tentative predictions were hazarded. Figure 11 displays the a
priori predictions that were proposed for each of the ten extreme behaviors included in
the ATEP, side-by-side with the corresponding mean ranks obtained in the present
analysis. As previously described, the observed mean ranks were divided into low (< 3),
moderate (3-6), and high (> 6). The a priori predictions were not, however, subject to
these established cut-offs; rather, they were more generally categorized.
Anecdotal sources provide convergent evidence that competitive birding and
competitive Scrabble are not typically characterized as “cool” pursuits (e.g., Obmascik,
2004; Fatsis, 2002), but responses on the ATEP indicated moderate rather than the
anticipated low ratings of impressiveness. Out of all of the ten extreme behaviors
79
included, only the Disorders cluster patterns were rated by this sample as low on
impressiveness. As with mountaineering, other patterns under study that represent
extreme sports or pursuits often revered as “heroic” in popular culture, such as Special
Operations Forces (e.g., Pfarrer, 2004; Tucker & Lamb, 2007) and Fire and Rescue
Services, yielded the predicted high scores on the Impressiveness and Difficultness
subscales. As noted previously, in the case of the high-risk occupations included in the
measure (i.e., Fire and Rescue Services and Special Operations Forces), expectations that
public attitudes would be minimally negative as a result of the high social value assigned
to those activities (e.g., Pfarrer, 2004) were confirmed by high Value subscale scores.
Psychological Disturbance scores were moderate, however, rather than low as had been
predicted. Endurance sports such as ultrarunning and ultra-distance swimming were
anticipated to yield high Difficultness mean scores; along with mountaineering, these
pursuits were rated as the most difficult of all the extreme behaviors included in the
study.
(Lack)
CON
Pred/Obs
COS
Pred/Obs
DIF
Pred/Obs
IMP
Pred/Obs
POS
Pred/Obs
PSY
Pred/Obs
VAL
Pred/Obs
Disorders
Anorexia
Nervosa M / H H / H M / M M / L M / L H / H L / L
Substance
Abuse M / H H / H L / L L / L M / L H / H L / L
Occupations
Fire & Rescue
Services L / M H / H H / H H / H H / H L / M H / H
Special Ops
Forces L / M H / H H / H H / H H / H L / M H / H
Physical Pursuits
Deep Cave
Exploration L / M ? / M ? / H ? / H ? / M ? / M L / H
80
High-Altitude
Mountaineer L / M H / M H / H H / H ? / H L / M L / M
Ultra-Distance
Swimming L / M ? / M H / H ? / H ? / H ? / M L / H
Ultrarunning L / M ? / M H / H M / H H / H ? / M M / M
Other Pursuits
Competitive
Birding L / M ? / L ? / M L / M ? / M ? / M L / M
Competitive
Scrabble® L / M ? / L ? / M L / M ? / M ? / M L / M
Figure 11. A Priori Predicted Profiles and Observed Pretest ATEP Mean Rank Profiles by
Subscale Categorized as Low, Moderate, or High Notes: Observed mean ranks were divided into L (low, < 3), M (moderate, 3-6), and H (high, >
6); a priori predictions were not subject to these established cut-offs and were more generally
categorized. ? = no prediction. Pred = Predicted mean score category; Obs = Observed mean rank
category. (Lack) CON = ATEP (Lack of) Controllability; COS = ATEP Cost; DIF = ATEP
Difficultness; IMP = ATEP Impressiveness; POS = ATEP Positive Gains; PSY = ATEP
Psychological Disturbance; VAL = ATEP Value
Inferential analysis indicated the statistical significance of the observed
differences between four prototypic patterns (i.e., Anorexia Nervosa, Competitive
Birding, High-Altitude Mountaineering, and Ultrarunning). Specifically, Anorexia
Nervosa was rated by respondents as significantly higher in comparison to the other three
patterns on the lack of Controllability, Cost, and Psychological Disturbance subscales,
and significantly lower on the Value, Positive Gains, and Impressiveness subscales. Both
Competitive Birding and Anorexia Nervosa were rated as similarly less difficult than
High-Altitude Mountaineering and Ultrarunning, and the latter two physical pursuit
patterns shared very similar profiles, except that Ultrarunning was rated as significantly
less costly and impressive than High-Altitude Mountaineering.
Anorexia Nervosa Versus Other Extreme Behaviors
81
One central question of the present study was whether there are consistent
differences in how anorexia nervosa is rated in comparison to non-diagnosable extreme
patterns with which it shares some elements. For example, will high-altitude
mountaineering be rated as more impressive and less costly than anorexia nervosa despite
the fact that both involve high levels of persistence and self-control, and carry significant
risk of death? Findings of the present study support that hypothesis.
Perhaps mountaineering was rated as significantly more impressive than anorexia
nervosa because mountaineering was also rated as significantly more difficult. Arguably,
this differentiation does not reflect reality, in view of the substantial effort, willpower,
and skill required to successfully maintain long-term calorie restriction and underweight
status. Most respondents did not appear to understand how difficult the anorexia nervosa
is, despite the finding that the majority reported having “considerable” prior knowledge
of the disorder. Perhaps because these respondents do not construe anorexia nervosa as a
voluntary undertaking (evidenced by the high mean scores on the lack of Controllability
subscale), they do not characterize it as “difficult.” If difficulty is a key criterion people
use to judge impressiveness and if they do not appreciate that anorexia nervosa is an
effortful behavior pattern, it would follow that they would not consider anorexia nervosa
as impressive as mountain climbing either.
Yet, western society often reveres and glamorizes the ultra-thin female form,
regardless (or perhaps because) of the effort required for most women to achieve that
standard. So perhaps there is a hesitation to acknowledge the difficult/impressive aspects
of anorexia nervosa due to a perception that it is politically incorrect to view a
82
psychopathological disorder as prestigious. There would be no such barrier to labeling a
recreational pursuit, such as mountain climbing, as “cool.” Alternatively, the baseline
knowledge data collected in the present study could be interpreted to suggest that people
have a clearer awareness of the destructive nature of anorexia nervosa, and are reluctant
to endorse impressiveness for that reason. Furthermore, the majority of participants
indicated little to no prior knowledge of high-altitude mountaineering, presumably
including the risk of death that outweighs that associated with anorexia nervosa. This
ignorance, coupled with the heroic and epic depiction of mountain climbing in the
popular literature and media (Coffey, 2003), may explain why there is no hesitation to
endorse mountaineering’s “cool factor.” Despite claiming little prior knowledge of
mountain climbing, respondents appear to appreciate the difficulty of, and endorse the
impressiveness of, the pursuit; this finding provides some evidence that these are salient
aspects of the popular public image of climbing. Even those with no knowledge of high-
altitude mountaineering may have been exposed to a television show, documentary, or
magazine article depicting a bold, daring, and courageous summit of Everest.
Findings of the Experimental Component
The randomized informational scripts included in the present study provided an
opportunity to examine whether lack of specific knowledge may help to account for this
phenomenon. In particular, the impact of knowledge regarding the costs of (i.e., physical
risks) and some motivations for (i.e., psychological vulnerabilities) was tested. Pretest
findings provided preliminary evidence that cost may be an important criterion that
people utilize in differentially categorizing behaviors as disturbed or normal. Specifically,
83
pretest ratings on the Cost subscale generally corresponded with equivalent rating levels
on the Psychological Disturbance and lack of Controllability subscales across all of the
behaviors under study. It was expected that the pre- to posttest data would reveal a slight
overall change in attitudes in the direction of the script the participant is provided.
Specifically, it was anticipated that reading the Risks Version would result in rating
mountaineering as more costly, difficult, and psychologically disturbed at posttest, while
those who read the Vulnerability Version would endorse higher posttest scores on the
Psychological Disturbance, Cost, and lack of Controllability subscales as well as lower
scores on the Impressiveness subscale. Examination of pre- to posttest changes in attitude
did not support these expectations. Results indicated that the provision of detailed
information on either the physical risks or the psychological vulnerabilities associated
with the pursuit resulted in significant change across all dimensions examined by the
ATEP: an increase in the ratings of the physical, emotional, and relational costs and the
degree of psychopathology attributed to the pursuit, as well as a decreased willingness to
endorse the activity as beneficial, impressive, or societally valuable.
Opinions regarding the difficulty of mountain climbing were not significantly
impacted by either script version. This is most likely because, as noted, respondents had
already rated it as high on difficulty (second only to ultra-swimming) before the
introduction of the scripts. This suggests that after learning more about mountaineering,
people were able to acknowledge the problematic aspects of the activity and change
attitudes towards it in a more negative direction, while retaining the awareness of its
difficulty level.
84
Interaction effects analysis confirmed that, even without being given explicit
details on the psychological vulnerabilities demonstrated by many mountain climbers, a
better understanding of the mortality and morbidities of extreme climbing alone
influenced people to view climbers as more psychologically disturbed. Similarly, a better
understanding of either the psychological vulnerabilities or the physical risks of
mountaineering caused people to view the behavior as more costly and as less impressive,
socially valuable, and personally beneficial. The amount of change was not significantly
different between script versions. For the lack of Controllability subscale, however, the
Vulnerability Version of the script resulted in a greater increase in posttest scores. This
suggests that a clearer understanding the psychological struggles of many climbers
influences people to consider the pursuit as less controllable, and perhaps more
compulsive, addictive, and compensatory. The amount of change was also greater for
Script V on the Difficultness subscale, although the change from pre- to posttest on this
subscale was not statistically significant for either script version.
On the basis of these results, it appears that lack of familiarity with extreme
pursuits, such as high-altitude mountaineering, may play a significant role in public
opinion towards those activities. Furthermore, the physical risks of an activity and
motivations (particularly “heroic” versus psychopathological ones) for engaging in a
pursuit appear to influence how people construct these opinions. What the present study
did not examine, however, is whether these observed changes in attitude are resilient over
time. It is not known if these changes are due only to an immediate, transient reaction to
the graphic details provided in the informational scripts, or if the information results in a
85
lasting shift in their beliefs about mountaineering. Follow-up data would be necessary to
explore this question.
Limitations
Another limitation specific to the results of this experimental component of the
present study should be noted. Due to the minimal script-specific change between the
two conditions, it is impossible to rule out the interpretation that participants were simply
responding to the demand characteristic of the scripts themselves. Specifically, both
scripts implicitly suggest that people should view climbing more negatively, and
respondents may have been complying with this perceived mandate in their posttest
responses. Including a control group condition in future studies may help examine this
possibility.
Overall, respondents demonstrated mixed accuracy in terms of pretest
perspectives regarding costliness, difficultness, benefit, and controllability of the
different extreme behaviors on the seven dimensions included in the ATEP. What is not
known, however, is how much of this is due to prior knowledge about these extreme
behaviors, which represents a major limitation of the present investigation. Specifically,
because a regression analysis could not be carried out due to inadequate sample size it
was not possible to estimate the impact of baseline knowledge on pretest attitudes.
Findings of the present study that demonstrated that views of the lesser-known, more
obscure patterns (e.g., Competitive Birding) are less accurate regarding costliness and
difficultness suggest that baseline knowledge is an important predictor of accuracy of
opinion in these domains. Additionally, the significant impact of both versions of the
86
script on almost all of domains measured by the ATEP provides further evidence that
pretest attitudes may have been based on ignorance regarding the realities of
mountaineering. Future studies with larger samples would allow for an examination of
how attitudes differ as a function of this variable, as well as other important dimensions,
such as athletic status, gender, ethnicity, or cultural context. Factors that contribute to
differences in public opinion regarding these behaviors could thus be identified and
explored. Age may be a crucial variable to explore in studies of attitudes towards
extreme behaviors, given Mitchell’s (1983) survey findings demonstrating that attitudes
to climbing become less positive and more negative with increasing age. The present
sample was primarily university-aged, and interpretation of the results are thus limited to
that population. Another aspect to consider is sample location. For example, attitudes
towards high-altitude mountaineering may differ significantly between Honolulu and
Boulder, because the pursuit is much more salient in Colorado than in Hawaii. While the
aim of the present study was not necessarily to examine the attitudes of knowledgeable
people, this factor limits the generalizability of the present findings.
Also due to this restriction on regression analysis in the present study, personal
experience data could not be analyzed for impact on pretest attitudes. As previously
noted, the literature suggests that this factor may play an important role in shaping
individuals’ opinions towards behavior, particularly in terms of empathy. An important
caveat in the method of obtaining this information was discovered in the process of
administering the ATEP. Based on the questionable interpretability of responses due to
the lack of precision of the item, it is clear that careful thought must put into how to
87
phrase the question intended to elicit this information. Specifically, as was demonstrated
by the irrelevance of many responses to ATEP items about personal experience, the
prompt must be specific and sensitive enough to solicit the relevant endorsement. Clearer
and more detailed definition of the type of information being sought may help increase
the fidelity of responses (e.g., Have you been involved in extreme climbing?).
Additionally, alternative methods of data collection, such as individual interviews, might
be considered to allow the investigator the opportunity to clarify the intent of the
question.
A striking majority of respondents indicated ambivalence regarding their attitudes
towards intimate partner involvement in extreme behaviors after completing the ATEP.
Nevertheless, it is not clear which of the disparate behaviors participants were
referencing when responding. For example, people may feel quite differently about their
partner engaging in substance abuse compared to becoming a firefighter. It would have
been more instructive to ask about each extreme behavior under study separately, and
additionally ask about how interested participants themselves were in becoming involved
in each of the behaviors. Another interesting question to explore would be whether
respondents retain this ambivalence even after learning about the extremely dangerous
and emotionally problematic nature of mountaineering and after changing their responses
to reflect more negative attitudes towards that pursuit. If findings demonstrate that they
remain similarly ambivalent posttest, this could suggest that people do not entirely
relinquish the “cool factor” and heroic image of climbing, even immediately after rating
it as less impressive and more costly and psychologically disturbed.
88
Another limitation is that although self-reported knowledge was assessed prior to
the administration of the ATEP, the accuracy of that knowledge was not evaluated. For
example, it is not clear what participants knew about the variable level of risk or
difficulty associated with the different extreme behaviors prior to reading the pattern
descriptions provided on the ATEP, particularly with reference to pursuits that are
relatively obscure. For example, it seems plausible that few members of the general
public are aware of the dangerousness of deep cave exploration or the skill and
dedication required for competitive birding. Furthermore, because some of the patterns
included in the present study almost certainly were unknown to, or minimally understood
by, most of the participants, their responses may have been no more than a combination
of prevalent stereotypes and scraps of information (of questionable accuracy), coupled
with near-random guessing. Future studies could be designed to evaluate the accuracy of
knowledge and the effect of guessing by obtaining confidence ratings regarding baseline
knowledge and/or subscale-level responses.
A related issue concerns the investigator’s lack of control over the participants’
access to internet information during the administration of the ATEP. Since the study
was conducted online, it is impossible to know whether respondents sought information
regarding some, or all, of the extreme behaviors while completing the measure.
Furthermore, for those who engaged in concurrent internet research, the accuracy of the
information they read could not be ascertained.
Results of the reliability analysis of some of the ATEP subscales were mixed, and
did not provide strong support for the psychometric properties of the questionnaire. No
89
suitable existing measures are available for convergent or divergent comparisons.
Additionally, as previously discussed, it is inappropriate to cross-compare subscales
across most of the different extreme behaviors included in the ATEP. Findings may have
been influenced by the low number of items (two to three) per subscale, and may have
been inordinately skewed as it was not appropriate to calculate internal consistency
estimates on most of the subscales. Therefore, the reliability of the ATEP could not be
established. Furthermore, the removal of item 21 from the Positive Gains subscale, and
of item 4 from the Difficultness subscale of the pre- and posttest High-Altitude
Mountaineering modules, due to technical problems reduced the item count for those
corresponding subscales from three to two. Including additional items in each subscale in
the future may provide an opportunity to better explore the psychometric properties of
the measure.
As noted previously, the materials relevant to the non-disorder behaviors under
study were largely developed based on anecdotal sources. Future scientific examinations
measuring participants’ own experiences with the phenomena posited in the present
study, such as psychological disturbance, lack of control, or the cost of engaging in an
extreme behavior, would be highly instructive to this field of research.
Finally, because the data were not normally distributed, nonparametric analytic
methods were employed for all of the inferential investigations of the present study. The
primary shortcoming of nonparametric tests is that they are less powerful than parametric
tests; specifically, they are less likely to reject the null hypothesis when it is false. A
90
larger sample size may have increased the likelihood that the assumptions of parametric
tests were met in the present investigation.
Conclusions
Despite the noted limitations, the findings of the present study may provide some
tentative, preliminary answers to questions about similarities and differences in public
attitudes towards extreme behaviors. For example, why do we categorize anorexics
separately from climbers, ultrarunners, or birders since all are similarly attempting to
address real problems in their lives in various active, valued, but highly costly ways? And
why are characteristics or tendencies that are viewed as aberrant in the context of
psychopathology accepted as reasonable or even heroic when observed in other contexts?
For example, is an anorexic patient who disregards the potentially life-threatening nature
of her behaviors in order to achieve and maintain low weight status inherently more
disturbed than the high-altitude climber who ignores signs of impending catastrophe in
order to summit successfully? Why do many observers find it appalling when an anorexic
patient celebrates the extraordinary difficulty of her pursuit, but applaud the elite ultra-
endurance athlete who basks in the glory of his or her seemingly superhuman feat?
The findings of the present study suggest that lack of specific, accurate
knowledge regarding the physical and emotional costs of non-disorder extreme behaviors
and the oftentimes “darker” motivations of engaging in those pursuits contributes to the
public’s differential categorization of them, as attitudes about climbing do appear to shift
(at least immediately) to be less positive when participants are provided with more
91
information about that pursuit. This is presumably due in part to the relative obscurity of
many of the non-disorder behaviors under study in relation to anorexia nervosa and
substance abuse.
On the other hand, the present findings also provide preliminary evidence that the
public’s lack of familiarity with, or unwillingness to concede, the personal benefits of
anorexia nervosa may factor into these disparate attitudes towards similarly extreme
patterns of behavior. Further research is needed to examine the social mechanisms that
contribute to and maintain the general, collective assumptions that (1) anorexics do not
subjectively gain from their disorder, and (2) extreme sports, hobbies, or occupations are
not vulnerable to the problematic excesses that are readily acknowledged for anorexia
nervosa.
92
Appendix A: Attitudes Towards Extreme Patterns, Sports, and Disorders
Attitudes Towards Extreme Patterns, Sports, & Disorders
This scale measures the opinions that people hold about a variety of activities, sports, and
psychological disorders.
Section 1
Please provide the following information about yourself:
1. What is your gender? □ Female □ Male
2. What is your race/ethnicity? (please check ALL that apply):
□ Alaska Native
□ American Indian
□ Asian, please specify: ____________________
□ Black or African American
□ Hispanic or Latino
□ Native Hawaiian or Other Pacific Islander, please specify:
____________________
□ Portuguese
□ White or Caucasian
□ Other, please specify: ____________________
□ Unknown
3. If you are you multi-ethnic or multi-racial, and you primarily identify with one
race or ethnicity, please write in that race/ethnicity (please choose only one of the
above):
______________________________________________________________
OR, if you equally identify with more than one race or ethnicity, please check
here: □
4. What is your current age? _____ yrs.
5. What is your major? ____________________ OR, check here if undecided: □
93
6. Did you spend a majority of your time growing up… □in Hawaii □in
mainland U.S. or territory □in a foreign country
8. Please indicate how much you know about each of the following:
No
Knowledge
Minimal
Knowledge
Some
Knowledge
Considerable
Knowledge
Highly
Knowledgeable
or Expert
1. Anorexia
Nervosa 1 2 3 4 5
2. Caving/Deep
Cave
Exploration
1 2 3 4 5
3. Competitive
Birding 1 2 3 4 5
4. Competitive
Scrabble 1 2 3 4 5
5. Fire & Rescue
Services 1 2 3 4 5
6. Ultra-Distance
Swimming 1 2 3 4 5
7. High-Altitude
Mountaineering 1 2 3 4 5
8. Special
Operations
Forces
1 2 3 4 5
9. Substance
Abuse 1 2 3 4 5
10. Ultrarunning 1 2 3 4 5
94
Section 2
For each identified behavior, please read the description provided and rate the statements
that follow each description, circling the number that corresponds to your degree of
agreement with that statement. There are no right or wrong answers, so please try to be
completely honest in your answers. Thank you!
Ultrarunning
An ultramarathon is any sporting event that involves running longer than the traditional
marathon length of 26.2 miles (42.2 kilometers). Some utlramarathon events involve
running 50 to 100 miles or more, sometimes on highly demanding courses that require
significant elevation gain or in extreme conditions such as desert or snow; other events
involve running as far as one can in a fixed period of time, such as a day or a week.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
R1. Ultrarunning is
impressive. 1 2 3 4 5
R2. Ultrarunning is selfish. 1 2 3 4 5
R3. Ultrarunning is
physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
R4. Ultrarunning requires
willpower to do. 1 2 3 4 5
R5. Ultrarunning is a sign of
psychopathology (i.e., an
indication of serious
emotional problems).
1 2 3 4 5
R6. Ultrarunning is
biologically-driven (i.e.,
some people are more
vulnerable to becoming
ultrarunners).
1 2 3 4 5
R7. Ultrarunning is
prestigious. 1 2 3 4 5
R8. Ultrarunning has worth
for society. 1 2 3 4 5
R9. Ultrarunning is
interpersonally costly
(e.g., causes strain in
1 2 3 4 5
95
relationships, time away
from family).
R10. Ultrarunning has
benefits for the
individual.
1 2 3 4 5
R11. Ultrarunning is
irrational. 1 2 3 4 5
R12. Ultrarunning requires
substantial effort. 1 2 3 4 5
R13. Ultrarunning is
addictive. 1 2 3 4 5
R14. Ultrarunning is
emotionally costly (e.g.,
causes people to feel
more depressed or
compulsive).
1 2 3 4 5
R15. Ultrarunning is
“cool.” 1 2 3 4 5
R16. Ultrarunning is
morally admirable. 1 2 3 4 5
R17. Ultrarunning requires
skill. 1 2 3 4 5
R18. People gain
personally from
ultrarunning.
1 2 3 4 5
R19. Ultrarunning is a
“crazy” thing for
someone to do. 1 2 3 4 5
R20. Ultrarunning is a
pattern people can control
(i.e., people can decide to
continue the activity or
decide to stop it).
1 2 3 4 5
R21. Ultrarunning is
rewarding. 1 2 3 4 5
96
Competitive Birding
Competitive birding is an activity in which people try to see/count as many different
species of wild birds as possible. Some birders compete for the greatest number of bird
species observed in a fixed period of time and geographic location (e.g., counting all
species seen in North America within one calendar year). Other birders travel to some
of the most remote areas of the planet, competing for the longest list of bird species seen
anywhere in the world over a lifetime.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
B1. Competitive birding is
impressive. 1 2 3 4 5
B2. Competitive birding is
selfish. 1 2 3 4 5
B3. Competitive birding is
physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
B4. Competitive birding
requires willpower to do. 1 2 3 4 5
B5. Competitive birding is a
sign of psychopathology
(i.e., an indication of
serious emotional
problems).
1 2 3 4 5
B6. Competitive birding is
biologically-driven (i.e.,
some people are more
vulnerable to becoming
competitive birders).
1 2 3 4 5
B7. Competitive birding is
prestigious. 1 2 3 4 5
B8. Competitive birding has
worth for society. 1 2 3 4 5
B9. Competitive birding is
interpersonally costly
(e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
B10. Competitive birding 1 2 3 4 5
97
has benefits for the
individual.
B11. Competitive birding
is irrational. 1 2 3 4 5
B12. Competitive birding
requires substantial
effort.
1 2 3 4 5
B13. Competitive birding
is addictive. 1 2 3 4 5
B14. Competitive birding
is emotionally costly
(e.g., causes people to
feel more depressed or
compulsive).
1 2 3 4 5
B15. Competitive birding
is “cool.” 1 2 3 4 5
B16. Competitive birding
is morally admirable. 1 2 3 4 5
B17. Competitive birding
requires skill. 1 2 3 4 5
B18. People gain
personally from
competitive birding.
1 2 3 4 5
B19. Competitive birding
is a “crazy” thing for
someone to do. 1 2 3 4 5
B20. Competitive birding
is a pattern people can
control (i.e., people can
decide to continue the
activity or decide to stop
it).
1 2 3 4 5
B21. Competitive birding
is rewarding. 1 2 3 4 5
98
Caving/Deep Cave Exploration
Caving/Deep Cave Exploration is the activity of exploring the deepest caves on the
planet, often involving swimming through tunnels no wider than a steering wheel or
scaling slick underground rock walls. Within deep caves, diving with specialized
SCUBA equipment is often required to enable the exploration of caves which are at
least partially filled with water. Cavers vie to be the first to explore a new cave region
or to discover the deepest or longest cave.
Disagree
Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
C1. Deep cave exploration is
impressive. 1 2 3 4 5
C2. Deep cave exploration is
selfish. 1 2 3 4 5
C3. Deep cave exploration is
physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
C4. Deep cave exploration
requires willpower to do. 1 2 3 4 5
C5. Deep cave exploration is
a sign of
psychopathology (i.e., an
indication of serious
emotional problems).
1 2 3 4 5
C6. Deep cave exploration is
biologically-driven (i.e.,
some people are more
vulnerable to becoming
deep cave explorers).
1 2 3 4 5
C7. Deep cave exploration is
prestigious. 1 2 3 4 5
C8. Deep cave exploration
has worth for society. 1 2 3 4 5
C9. Deep cave exploration is
interpersonally costly
(e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
C10. Deep cave 1 2 3 4 5
99
exploration has benefits
for the individual.
C11. Deep cave
exploration is irrational. 1 2 3 4 5
C12. Deep cave
exploration requires
substantial effort.
1 2 3 4 5
C13. Deep cave
exploration is addictive. 1 2 3 4 5
C14. Deep cave
exploration is
emotionally costly (e.g.,
causes people to feel
more depressed or
compulsive).
1 2 3 4 5
C15. Deep cave
exploration is “cool.” 1 2 3 4 5
C16. Deep cave
exploration is morally
admirable.
1 2 3 4 5
C17. Deep cave
exploration requires skill. 1 2 3 4 5
C18. People gain
personally from deep
cave exploration.
1 2 3 4 5
C19. Deep cave
exploration is a “crazy”
thing for someone to do. 1 2 3 4 5
C20. Deep cave
exploration is a pattern
people can control (i.e.,
people can decide to
continue the activity or
decide to stop it).
1 2 3 4 5
C21. Deep cave
exploration is rewarding. 1 2 3 4 5
100
Ultra-Distance Swimming
Ultra-distance swimming, sometimes referred to as marathon swimming, involves
swimming long distances over open ocean or across big lakes, often through rough
water currents (e.g., swimming the channel between the islands of Molokai and Oahu or
the English Channel). Ultra-swimming can involve organized races with a group start
or be completed as a solo swim for record time or distance.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
D1. Ultra-distance swimming
is impressive. 1 2 3 4 5
D2. Ultra-distance swimming
is selfish. 1 2 3 4 5
D3. Ultra-distance swimming
is physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
D4. Ultra-distance swimming
requires willpower to do. 1 2 3 4 5
D5. Ultra-distance swimming
is a sign of
psychopathology (i.e., an
indication of serious
emotional problems).
1 2 3 4 5
D6. Ultra-distance swimming
is biologically-driven
(i.e., some people are
more vulnerable to
becoming ultra-distance
swimmers).
1 2 3 4 5
D7. Ultra-distance swimming
is prestigious. 1 2 3 4 5
D8. Ultra-distance swimming
has worth for society. 1 2 3 4 5
D9. Ultra-distance swimming
is interpersonally costly
(e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
D10. Ultra-distance 1 2 3 4 5
101
swimming has benefits
for the individual.
D11. Ultra-distance
swimming is irrational. 1 2 3 4 5
D12. Ultra-distance
swimming requires
substantial effort.
1 2 3 4 5
D13. Ultra-distance
swimming is addictive. 1 2 3 4 5
D14. Ultra-distance
swimming is emotionally
costly (e.g., causes
people to feel more
depressed or
compulsive).
1 2 3 4 5
D15. Ultra-distance
swimming is “cool.” 1 2 3 4 5
D16. Ultra-distance
swimming is morally
admirable.
1 2 3 4 5
D17. Ultra-distance
swimming requires skill. 1 2 3 4 5
D18. People gain
personally from ultra-
distance swimming.
1 2 3 4 5
D19. Ultra-distance
swimming is a “crazy”
thing for someone to do. 1 2 3 4 5
D20. Ultra-distance
swimming is a pattern
people can control (i.e.,
people can decide to
continue the activity or
decide to stop it).
1 2 3 4 5
D21. Ultra-distance
swimming is rewarding. 1 2 3 4 5
102
High-Altitude Mountaineering
High-altitude mountaineering involves efforts to scale the world’s highest mountains,
including the 14 peaks over 8000 meters (26,250 feet) such as Everest in Nepal/Tibet or
K2 in Pakistan/China. High-altitude climbers often focus on ascending mountains by
difficult new routes using minimal support and equipment (e.g., foregoing the use of
supplementary oxygen, even at extreme elevations).
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
M1. High-altitude
mountaineering is
impressive.
1 2 3 4 5
M2. High-altitude
mountaineering is selfish. 1 2 3 4 5
M3. High-altitude
mountaineering is
physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
M4. High-altitude
mountaineering requires
willpower to do.
1 2 3 4 5
M5. High-altitude
mountaineering is a sign
of psychopathology (i.e.,
an indication of serious
emotional problems).
1 2 3 4 5
M6. High-altitude
mountaineering is
biologically-driven (i.e.,
some people are more
vulnerable to becoming
high-altitude
mountaineers).
1 2 3 4 5
M7. High-altitude
mountaineering is
prestigious.
1 2 3 4 5
M8. High-altitude
mountaineering has
worth for society.
1 2 3 4 5
103
M9. High-altitude
mountaineering is
interpersonally costly
(e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
M10. High-altitude
mountaineering has
benefits for the
individual.
1 2 3 4 5
M11. High-altitude
mountaineering is
irrational.
1 2 3 4 5
M12. High-altitude
mountaineering requires
substantial effort.
1 2 3 4 5
M13. High-altitude
mountaineering is
addictive.
1 2 3 4 5
M14. High-altitude
mountaineering is
emotionally costly (e.g.,
causes people to feel
more depressed or
compulsive).
1 2 3 4 5
M15. High-altitude
mountaineering is “cool.” 1 2 3 4 5
M16. High-altitude
mountaineering is
morally admirable.
1 2 3 4 5
M17. High-altitude
mountaineering requires
skill.
1 2 3 4 5
M18. People gain
personally from high-
altitude mountaineering.
1 2 3 4 5
M19. High-altitude
mountaineering is a
“crazy” thing for
1 2 3 4 5
104
someone to do.
M20. High-altitude
mountaineering is a
pattern people can control
(i.e., people can decide to
continue the activity or
decide to stop it).
1 2 3 4 5
M21. High-altitude
mountaineering is
rewarding.
1 2 3 4 5
Competitive Scrabble
Competitive Scrabble involves playing the board game in a competitive context, often
at extremely high skill levels, at local, national, and international Scrabble tournaments. Players compete to win prizes and elevate their ranked standing in the
official Scrabble rating system.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
S1. Competitive Scrabble
is impressive. 1 2 3 4 5
S2. Competitive Scrabble is selfish.
1 2 3 4 5
S3. Competitive Scrabble is physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
S4. Competitive Scrabble
requires willpower to do. 1 2 3 4 5
S5. Competitive Scrabble
is a sign of
psychopathology (i.e., an
indication of serious
emotional problems).
1 2 3 4 5
S6. Competitive Scrabble is biologically-driven
(i.e., some people are
more vulnerable to
becoming Scrabble
1 2 3 4 5
105
competitors).
S7. Competitive Scrabble
is prestigious. 1 2 3 4 5
S8. Competitive Scrabble has worth for society.
1 2 3 4 5
S9. Competitive Scrabble
is interpersonally costly (e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
S10. Competitive
Scrabble has benefits
for the individual.
1 2 3 4 5
S11. Competitive
Scrabble is irrational. 1 2 3 4 5
S12. Competitive
Scrabble requires substantial effort.
1 2 3 4 5
S13. Competitive
Scrabble is addictive. 1 2 3 4 5
S14. Competitive
Scrabble is emotionally
costly (e.g., causes
people to feel more
depressed or
compulsive).
1 2 3 4 5
S15. Competitive
Scrabble is “cool.” 1 2 3 4 5
S16. Competitive
Scrabble is morally admirable.
1 2 3 4 5
S17. Competitive
Scrabble requires skill. 1 2 3 4 5
S18. People gain
personally from
competitive Scrabble.
1 2 3 4 5
106
S19. Competitive
Scrabble is a “crazy” thing for someone to do.
1 2 3 4 5
S20. Competitive
Scrabble is a pattern people can control (i.e.,
people can decide to
continue the activity or
decide to stop it).
1 2 3 4 5
S21. Competitive
Scrabble is rewarding. 1 2 3 4 5
Special Operations Forces
Special Operations Forces are elite military, police, or paramilitary tactical teams that
have been trained to perform highly technical, specialized missions, such as covert
operations or rescuing prisoners. The teams are usually small, elite units that can
operate deep behind enemy lines in unconventional warfare, foreign internal defense,
counter-terrorism, special reconnaissance, and direct action missions.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
O1. Being Special Ops is
impressive. 1 2 3 4 5
O2. Being Special Ops is
selfish. 1 2 3 4 5
O3. Being Special Ops is
physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
O4. Being Special Ops
requires willpower to do. 1 2 3 4 5
O5. Being Special Ops is a
sign of psychopathology
(i.e., an indication of
serious emotional
problems).
1 2 3 4 5
O6. Being Special Ops is
biologically-driven (i.e.,
some people are more
vulnerable to becoming
1 2 3 4 5
107
Special Ops soldiers).
O7. Being Special Ops is
prestigious. 1 2 3 4 5
O8. Being Special Ops has
worth for society. 1 2 3 4 5
O9. Being Special Ops is
interpersonally costly
(e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
O10. Being Special Ops
has benefits for the
individual.
1 2 3 4 5
O11. Being Special Ops is
irrational. 1 2 3 4 5
O12. Being Special Ops
requires substantial
effort.
1 2 3 4 5
O13. Being Special Ops is
addictive. 1 2 3 4 5
O14. Being Special Ops is
emotionally costly (e.g.,
causes people to feel
more depressed or
compulsive).
1 2 3 4 5
O15. Being Special Ops is
“cool.” 1 2 3 4 5
O16. Being Special Ops is
morally admirable. 1 2 3 4 5
O17. Being Special Ops
requires skill. 1 2 3 4 5
O18. People gain
personally from being
Special Ops.
1 2 3 4 5
O19. Being Special Ops is
a “crazy” thing for
someone to do. 1 2 3 4 5
108
O20. Being Special Ops is
a pattern people can
control (i.e., people can
decide to continue the
activity or decide to stop
it).
1 2 3 4 5
O21. Being Special Ops is
rewarding. 1 2 3 4 5
Anorexia Nervosa
Anorexia Nervosa involves severely restricting one’s food intake to lose and maintain
one’s weight below a natural/healthy body weight. In addition to restricting food intake,
anorexia nervosa often involves compensatory behaviors such as over-exercising,
vomiting, laxative use, or taking diet pills.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
A1. Anorexia is impressive. 1 2 3 4 5
A2. Anorexia is selfish. 1 2 3 4 5
A3. Anorexia is physically
costly (e.g., causes
physical injury or harm).
1 2 3 4 5
A4. Anorexia requires
willpower to do. 1 2 3 4 5
A5. Anorexia is a sign of
psychopathology (i.e., an
indication of serious
emotional problems).
1 2 3 4 5
A6. Anorexia is biologically-
driven (i.e., some people
are more vulnerable to
becoming anorexic).
1 2 3 4 5
A7. Anorexia is prestigious. 1 2 3 4 5
A8. Anorexia has worth for
society. 1 2 3 4 5
A9. Anorexia is
interpersonally costly
(e.g., causes strain in
relationships, time away
1 2 3 4 5
109
from family).
A10. Anorexia has benefits
for the individual. 1 2 3 4 5
A11. Anorexia is irrational. 1 2 3 4 5
A12. Anorexia requires
substantial effort. 1 2 3 4 5
A13. Anorexia is addictive. 1 2 3 4 5
A14. Anorexia is
emotionally costly (e.g.,
causes people to feel
more depressed or
compulsive).
1 2 3 4 5
A15. Anorexia is “cool.” 1 2 3 4 5
A16. Anorexia is morally
admirable. 1 2 3 4 5
A17. Anorexia requires
skill. 1 2 3 4 5
A18. People gain
personally from anorexia. 1 2 3 4 5
A19. Being anorexic is a
“crazy” thing for
someone to do. 1 2 3 4 5
A20. Anorexia is a pattern
people can control (i.e.,
people can decide to
continue the activity or
decide to stop it).
1 2 3 4 5
A21. Being anorexic is
rewarding. 1 2 3 4 5
110
Fire & Rescue Services
Firefighting involves working for the city, county, or federal government to fight or
manage destructive building, forest, or brush fires. Rescue Services provide emergency
response in accidents or disasters, locating and recovering endangered persons and
providing medical services.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
F1. Being in fire & rescue
services is impressive. 1 2 3 4 5
F2. Being in fire & rescue
services is selfish. 1 2 3 4 5
F3. Being in fire & rescue
services is physically
costly (e.g., causes
physical injury or harm).
1 2 3 4 5
F4. Being in fire & rescue
services requires
willpower to do.
1 2 3 4 5
F5. Being in fire & rescue
services is a sign of
psychopathology (i.e., an
indication of serious
emotional problems).
1 2 3 4 5
F6. Being in fire & rescue
services is biologically-
driven (i.e., some people
are more vulnerable to
becoming fire & rescue
workers).
1 2 3 4 5
F7. Being in fire & rescue
services is prestigious. 1 2 3 4 5
F8. Being in fire & rescue
services has worth for
society.
1 2 3 4 5
F9. Being in fire & rescue is
interpersonally costly
(e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
111
F10. Being in fire & rescue
has benefits for the
individual.
1 2 3 4 5
F11. Being in fire & rescue
is irrational. 1 2 3 4 5
F12. Being in fire & rescue
requires substantial
effort.
1 2 3 4 5
F13. Being in fire & rescue
is addictive. 1 2 3 4 5
F14. Being in fire & rescue
is emotionally costly
(e.g., causes people to
feel more depressed or
compulsive).
1 2 3 4 5
F15. Being in fire & rescue
is “cool.” 1 2 3 4 5
F16. Being in fire & rescue
is morally admirable. 1 2 3 4 5
F17. Being in fire & rescue
requires skill. 1 2 3 4 5
F18. People gain
personally from being in
Fire & Rescue Services.
1 2 3 4 5
F19. Being in fire & rescue
is a “crazy” thing for
someone to do. 1 2 3 4 5
F20. Being in fire & rescue
is a pattern people can
control (i.e., people can
decide to continue the
activity or decide to stop
it).
1 2 3 4 5
F21. Being in fire & rescue
is rewarding. 1 2 3 4 5
112
Substance Abuse
Substance Abuse is the overuse of and/or dependence on substances that alter mood and
behavior to a clinical level of severity. Substances that would fall under this category
include alcohol, marijuana, amphetamines, cocaine, hallucinogens, inhalants, opioids,
PCP, the misuse of prescription or over-the-counter medications, etc.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
U1. Substance abuse is
impressive. 1 2 3 4 5
U2. Substance abuse is
selfish. 1 2 3 4 5
U3. Substance abuse is
physically costly (e.g.,
causes physical injury or
harm).
1 2 3 4 5
U4. Substance abuse requires
willpower to do. 1 2 3 4 5
U5. Substance abuse is a sign
of psychopathology (i.e.,
an indication of serious
emotional problems).
1 2 3 4 5
U6. Substance abuse is
biologically-driven (i.e.,
some people are more
vulnerable to becoming
substance abusers).
1 2 3 4 5
U7. Substance abuse is
prestigious. 1 2 3 4 5
U8. Substance abuse has
worth for society. 1 2 3 4 5
U9. Substance abuse is
interpersonally costly
(e.g., causes strain in
relationships, time away
from family).
1 2 3 4 5
U10. Substance abuse has
benefits for the
individual.
1 2 3 4 5
113
U11. Substance abuse is
irrational. 1 2 3 4 5
U12. Substance abuse
requires substantial
effort.
1 2 3 4 5
U13. Substance abuse is
addictive. 1 2 3 4 5
U14. Substance abuse is
emotionally costly (e.g.,
causes people to feel
more depressed or
compulsive).
1 2 3 4 5
U15. Substance abuse is
“cool.” 1 2 3 4 5
U16. Substance abuse is
morally admirable. 1 2 3 4 5
U17. Substance abuse
requires skill. 1 2 3 4 5
U18. People gain
personally from
substance abuse.
1 2 3 4 5
U19. Substance abuse is a
“crazy” thing for
someone to do. 1 2 3 4 5
U20. Substance abuse is a
pattern people can control
(i.e., people can decide to
continue the activity or
decide to stop it).
1 2 3 4 5
U21. Substance abuse is
rewarding. 1 2 3 4 5
114
Section 3:
Please provide the following information about yourself:
1. You have answered questions about a variety of patterns, some of which are sports, some
are activities, and some are psychological disorders. Have YOU engaged in any of the
patterns described above or in any similar patterns (e.g., body building, base jumping,
bulimia, competitive chess)?
NO – skip to item 2 below
YES – please list these behaviors in the spaces below:
1.
2.
3.
If you listed any behaviors in the previous item, please circle the pattern or pursuit from
the list above in which you are/were most seriously involved and answer the following
question regarding that one behavior:
1A. During the 6-month period when you were most involved in that activity, how
much of your waking time from 0-100% did you spend engaged in that activity (i.e.,
thinking about it, reading about it, doing it)? __________%
1B. During that same 6-month period, on how many days per month from 0-30
would you estimate you were engaged in that activity (regardless of the proportion of time
spent each day)? __________days
2. Referring back to the full list you were asked about earlier in this questionnaire, has
ANYONE TO WHOM YOU WERE VERY CLOSE (i.e., partner, family member, close
friend) engaged in any of the patterns described above or in any similar patterns?
NO
YES – please list below:
Relationship to that person (i.e., brother, close friend): Pattern(s) that person engaged in:
1.
2.
3.
3. Referring again to the full list you were asked about earlier in this questionnaire, imagine
for a moment that your own partner were involved in one of these activities. How would you
feel about their participation in such a pursuit? (please check only one):
I would be strongly opposed to or unhappy about it.
I would be ambivalent; that is, I would feel a mixture of positive and negative feelings
about it.
I would be in favor of it and feel positively about it.
Appendix B: Attitudes Towards Extreme Patterns, Sports, and Disorders –
POSTTEST version
Attitudes Towards Extreme Patterns, Sports, & Disorders
Please take into consideration the information you just read on high-altitude
mountaineering when indicating your level of agreement with the statements below.
Disagree Slightly
Agree
Moderately
Agree
Mostly
Agree
Completely
Agree
M22. High-altitude
mountaineering is
impressive.
1 2 3 4 5
M23. High-altitude
mountaineering is
selfish.
1 2 3 4 5
M24. High-altitude
mountaineering is
physically costly (e.g.,
causes physical injury
or harm).
1 2 3 4 5
M25. High-altitude
mountaineering
requires willpower to
do.
1 2 3 4 5
M26. High-altitude
mountaineering is a
sign of
psychopathology (i.e.,
an indication of
serious emotional
problems).
1 2 3 4 5
M27. High-altitude
mountaineering is
biologically-driven
(i.e., some people are
more vulnerable to
becoming high-
altitude mountaineers).
1 2 3 4 5
116
M28. High-altitude
mountaineering is
prestigious.
1 2 3 4 5
M29. High-altitude
mountaineering has
worth for society.
1 2 3 4 5
M30. High-altitude
mountaineering is
interpersonally costly
(e.g., causes strain in
relationships, time
away from family).
1 2 3 4 5
M31. High-altitude
mountaineering has
benefits for the individual.
1 2 3 4 5
M32. High-altitude
mountaineering is
irrational.
1 2 3 4 5
M33. High-altitude
mountaineering
requires substantial
effort.
1 2 3 4 5
M34. High-altitude
mountaineering is
addictive.
1 2 3 4 5
M35. High-altitude
mountaineering is
emotionally costly
(e.g., causes people to
feel more depressed or
compulsive).
1 2 3 4 5
M36. High-altitude
mountaineering is
“cool.”
1 2 3 4 5
M37. High-altitude
mountaineering is
morally admirable.
1 2 3 4 5
M38. High-altitude
mountaineering 1 2 3 4 5
117
requires skill.
M39. People gain
personally from high-
altitude
mountaineering.
1 2 3 4 5
M40. High-altitude
mountaineering is a
“crazy” thing for
someone to do.
1 2 3 4 5
M41. High-altitude
mountaineering is a
pattern people can
control (i.e., people
can decide to continue
the activity or decide
to stop it).
1 2 3 4 5
M42. High-altitude
mountaineering is
rewarding.
1 2 3 4 5
Thank you for your participation!
Appendix C: Item Cluster Map
Attitudes Towards Anorexia Nervosa Competitive Birding Competitive Scrabble®
Deep Cave Exploration Fire & Rescue Services Ultra-Distance Swimming High-Altitude Mountaineering Special Ops Forces Substance Abuse Ultrarunning
VALUE 8. [X] has worth for society. 16. [X] is morally admirable. Reverse-scored 2. [X] is selfish.
PSYCHOLOGICAL DISTURBANCE 5. [X] is a sign of psychopathology (i.e., an
indication of serious emotional problems).
11. [X] is irrational. 19. [X] is a “crazy” thing for someone to do.
CONTROLLABILITY 6. [X] is biologically-driven (i.e., some
people are more vulnerable to becoming X).
13. [X] is addictive. Reverse-scored 20. [X] is a pattern people can control
(i.e., people can decide to continue the activity or decide to stop it).
IMPRESSIVENESS 1. [X] is impressive. 7. [X] is prestigious. 15. [X] is “cool.”
DIFFICULTNESS *4. [X] requires willpower to do. 12. [X] requires substantial effort. 17. [X] requires skill. *This item was inadvertently excluded from the High-Altitude Mountaineering sections.
POSITIVE GAINS 10. [X] has benefits for the individual. 18. People gain personally from [X].
21. [X] is rewarding.
COST 3. [X] is physically costly (e.g., causes physical
injury or harm). 9. [X] is interpersonally costly (e.g., causes strain
in relationships, time away from family). 14. [X] is emotionally costly (e.g., causes people to
feel more depressed or compulsive).
Attitudes Towards Extreme Patterns, Sports, & Disorders
Item Cluster Map
Appendix D: Item Cluster Survey
Item Cluster Survey
On the following page you will be asked to assign 21 questionnaire items to the one of seven
categories you believe the item best fits based on how you interpret the item. Please read the
following category descriptions carefully and use them to assign the items on the following page.
We will provide group feedback that includes interrater reliability estimates and will also ask
respondents to reconcile disagreements through discussion after this first round of ratings is
received.
Difficultness
This category is for items that relate to the difficulty of performing or pursuing an activity, that is,
how hard or challenging it is to do the activity.
Cost
This category is for items that relate to the potential drawbacks of engaging in an activity. NOTE:
The difficulty of performing an activity might also be considered one kind of cost associated with
that activity; nevertheless, items that reflect difficulty as defined in the first category above
should be assigned to that more specific category rather than to the broader category of “Cost.”
Positive Gains
This category is for items that relate to the positive gains people believe they obtain from
participating in an activity. NOTE: Others’ positive perception of the activity as impressive or of
value might also be considered to be benefits associated with that activity; nevertheless, items
that reflect the impressiveness or value (as separately defined below) should be assigned to those
more specific categories rather than to the broader category of “Positive Gains.” In other words,
“Positive Gains” is a residual category for those gains that don't better fit into another more
specific category.
Impressiveness
This category is for items that relate to whether an activity is viewed as interpersonally
impressive or "hip." NOTE: If an item principally refers to an activity’s moral or societal worth
or value, please assign them to the “Value” category below.
Value (or Lack of Value)
This category is for items that relate to the moral or societal worth of an activity, i.e., whether it is
a morally “good” or socially altruistic pursuit. Conversely, this category is also for items that
relate to whether an activity is self-serving or socially valueless.
Psychological Disturbance
This category is for items that relate to whether engaging in an activity is indicative of a deficit in
sound reasoning or emotional stability.
Controllability (or Uncontrollable)
This category is for items that reflect whether an activity is or is not susceptible to personal
control and decision-making (i.e., whether individuals retain the ability to choose whether and
how to continue participating in the pursuit).
Please place the following items into the category under which you interpret the question to belong by circling the label under
which it falls.
1. [Behavior X] is
impressive. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
2. [Behavior X] is selfish.
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
3. [Behavior X] is
physically costly (e.g.,
causes physical injury or
harm).
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
4. [Behavior X] requires
willpower to do. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
5. [Behavior X] is a sign of
psychopathology (i.e., an
indication of serious
emotional problems).
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
6. [Behavior X] is
biologically-driven (i.e.,
some people are more
vulnerable to becoming
ultrarunners).
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
7. [Behavior X] is appealing
to me. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
8. [Behavior X] has value to
society. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
9. [Behavior X] is
interpersonally costly Difficultness Cost
Positive
Gains Impressiveness Value (or
Lack of
Psychological
Disturbance
Controllability (or
Uncontrollableness)
121
(e.g., causes strain in
relationships, time away
from family).
Value)
10. [Behavior X] has benefits
for the individual. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
11. [Behavior X] is irrational.
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
12. [Behavior X] is
dangerous. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
13. [Behavior X] is addictive.
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
14. [Behavior X] is
emotionally costly (e.g.,
causes people to feel
more depressed or
compulsive).
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
15. [Behavior X] is “cool.”
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
16. [Behavior X] is morally
admirable. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
17. [Behavior X] requires
skill. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
18. People gain personally
from [Behavior X] . Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
19. [Behavior X] is a “crazy” Difficultness Cost Positive Impressiveness Value (or Psychological Controllability (or
122
thing for someone to do. Gains Lack of
Value)
Disturbance Uncontrollableness)
20. [Behavior X] is a pattern
people can control (i.e.,
people can decide to
continue the activity or
decide to stop it).
Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
21. [Behavior X] is
rewarding. Difficultness Cost Positive
Gains Impressiveness
Value (or
Lack of
Value)
Psychological
Disturbance
Controllability (or
Uncontrollableness)
Appendix E: High-Altitude Mountaineering Script – Risks Version
Please take some time to carefully read the following excerpt about High-Altitude
Mountaineering before completing the remainder of this questionnaire.
High-altitude mountaineering involves climbing the tallest and most challenging mountains in the
world, such as Mount Everest (29,035 feet or 8,850 meters) and K2 (28,250 feet or 8,611 meters).
Because of the impact of altitude near the top of the highest mountains, most climbers need
supplementary oxygen to make it to the summit. In order to make things more challenging,
however, some climbers refuse to use oxygen. Many climbers also find other ways of increasing
the difficulty of high-altitude mountaineering, such as trying more difficult routes, climbing solo,
climbing the greatest number of mountains, or climbing during winter.
The strong winds and intense storms that high-altitude mountaineers face when climbing are
treacherous, and climbers must constantly watch out for deadly avalanches and falling rocks and
ice if they want to stay alive. Any injury that prevents someone from climbing back down the
mountain will also likely lead to their death, since helicopters and rescue teams can’t reach most
areas high on the mountains. Even climbers that avoid death from avalanches or injury can be
killed by exhaustion and hypothermia. Moreover, the exposure to extreme altitudes can result in
climbers drowning from liquid that fills their lungs or dying from fluid that leaks into and swells
their brain. In fact, the conditions are so dangerous that about half of all high-altitude
mountaineers will die from climbing. Commenting on the high death rate, Hans Kammerlander, a
well-known climber, recently said: “There is no point glossing over the enormous risks [of
climbing]. Hardly any of my close friends are still alive.”
All of these deadly risks of high-altitude mountaineering are intensified by the lack of oxygen
near the summit. Climbers refer to altitudes of 25,000 feet (7,620 meters) or more as “The Death
Zone” because the lack of oxygen and severe conditions slowly begin to kill them. People
describe climbing in this zone as “running a marathon with a bag over your head” or “running on
a treadmill while breathing through a straw.” When in “The Death Zone”, it’s common for
climbers to get painful headaches, insomnia, nausea, diarrhea, and visual disturbances. Climbers
also become confused and weak, experience hallucinations, lose control of their muscles, have
trouble breathing, begin to cough severely, and have been described as having the awareness of
“a 3-year old child.” This mental and physical impairment increases the already high risks of
injury and death, as climbers make poor decisions that they would have avoided had they been
thinking clearly.
The high-altitude mountaineers that don’t die climbing will likely develop permanent physical
and mental injuries. The freezing cold weather on tall mountains commonly leads to frostbite,
where parts of the body blister and have to be removed. Most extreme climbers are missing parts
or all of their fingers and toes, and some have even lost their nose or other parts of their face.
Also, tests have shown that the brain actually changes from exposure to extreme altitude, leading
many climbers to have permanent problems with concentration, memory, and learning.
124
Appendix F: High-Altitude Mountaineering Script – Vulnerability Version
Please take some time to carefully read the following excerpt about High-Altitude Mountaineering before completing the remainder of this questionnaire.
High-altitude mountaineering involves climbing the tallest and most challenging mountains in the world, such as Mount Everest (29,035 feet or 8,850 meters) and K2 (28,250 feet or 8,611 meters).
Because of the impact of altitude near the top of the highest mountains, most climbers need supplementary oxygen to make it to the summit. In order to make things more challenging, however,
some climbers refuse to use oxygen. Many climbers also find other ways of increasing the difficulty of high-altitude mountaineering, such as trying more difficult routes, climbing solo, climbing the greatest number of mountains, or climbing during winter.
Although most climbers identify positive reasons for high-altitude mountaineering, they also describe themselves as being “loners” when they were growing up: they felt awkward, had trouble connecting
with other people, and struggled to find things in life that they excelled at. When they discovered climbing, however, most felt that they finally found the one thing that they were good at. For example,
mountain climber Alan Lester said, “In elite climbers, one finds an adolescent who is something of a loner, awkward with others, uninterested in the usual school sports, and most at home when alone. For such a person, exposure to mountains often brings an epiphany: the world has a place for me!” This
belief that mountain climbing provides a place of belonging is one of the main reasons that high-altitude mountaineers climb and have trouble quitting.
Many high-altitude mountaineers also climb in an attempt to improve their lives and pull themselves out of depression. The famous climber Beck Weathers said, “I fell into climbing [as] a willy-nilly response to a crushing bout of depression … [climbing] became a form of self-medication.”
Unfortunately, mountain climbing fails to heal this depression, which is why climbers usually experience disappointment, emptiness, and sadness when they reach the top of a mountain. For
example, climber Louis Lachena described the times he reached the top of the mountain as, “Those moments when one had expected a piercing happiness [but] brought only a painful sense of emptiness”, while Peter Habeler recalled that, “[Immediately after] the sense of redemption came the
emptiness and sadness, the disappointment.” Rather than trying to find other ways to alleviate depression and emptiness, mountaineers continue to climb and try to find new climbing challenges. Many mountaineers describe this inability to stop climbing as an “addiction.” Matt Samet said, “[I]
realized that no matter how many routes I climbed, I’d never quite measure up ... It’s the same yawning emptiness that drives all addicts”, while mountaineer Linda Givler claimed that, “We are far
worse off than any drug addict could ever imagine.” This obsession with climbing regularly leads mountaineers to neglect their spouses and children.
High-altitude mountaineers will often be away from their families for months at a time, and children commonly become resentful that their climbing parent was missing for so much of their lives. While some climbers defend their time away from their children, claiming that, “What I got from the
mountains, I gave to my kids”, others feel guilty about the costs that their inability to stop climbing has had on their family. Lene Gammelgaard sums up a self-awareness that many people have for their
motives and persistence for climbing: “...you’re fucked up somewhat or otherwise you wouldn’t be doing it.”
125
Appendix G: Recruitment Flyer
Extra Credit
Opportunity !
We are currently recruiting
participants to enroll in a
research project being
conducted to learn more
about public attitudes
towards extreme patterns of
behavior.
Attitudes Towards Extreme Patterns, Sports, &
Disorders Study
This study is being conducted online. To participate, all you will need to do is go
to: http://www.surveymonkey.com/[INSERT LINK]
Once at the study website, you will be given an opportunity to read a bit more
about the project and what will be required from you to participate. If you decide
to participate, the website will direct you to fill out an initial online questionnaire
regarding your opinions on a number of patterns of extreme behavior. You will
then be asked to read a brief passage that provides information about one of the
patterns of behavior. Finally, you will complete another short questionnaire
concerning your views of that activity. The whole process should take less than
an hour.
Along with the benefits of gaining some research experience, your instructor has
agreed to assign extra credit points for your participation at the completion of the
full process.
If you have any questions or concerns, please contact the principal investigator,
Julie Takishima, @ [email protected].
Appendix H: Consent Form to Participate in Study
Agreement to Participate in Attitudes Towards Extreme Behaviors Study
Julie Yurie Takishima, B.A.
Clinical Studies in Psychology
University of Hawaii at Manoa
2430 Campus Road
Honolulu, HI 96822
This research project is being conducted to learn more about public attitudes towards extreme patterns
of behavior. If you decide to participate in this study, you will be asked to fill out an initial online
questionnaire regarding your opinions on a number of patterns of extreme behavior, including sports,
recreational pursuits, high-risk occupations, and psychological disorders. You will then be asked to read
a brief passage that provides information about one of the patterns of behavior, then complete another
short questionnaire concerning your views of that activity. The whole process should take most
participants less than one hour.
Potential benefits of your participation include the general value of participating in a research study and
an opportunity to reflect on patterns of extreme behavior. If you have direct experience with any of the
behaviors discussed in this survey, there is a slight possibility of some discomfort in answering some of
the questions. At the completion of your participation your name will be included on a list of
participants that will be provided to your course instructor, who will assign extra credit points at his or
her discretion.
Research data will be confidential to the extent allowed by law. All electronic data is transported
in encrypted format and is stored in password protected format. To help protect your
confidentiality, the surveys will not contain information that will personally identify you and
originating IP addresses are masked. All research records will be stored in a locked file in the
primary investigator’s office for the duration of the research project. All other research records
will be destroyed upon completion of the project. Agencies with research oversight, such as the
UH Committee on Human Studies, have the authority to review research data.
As a volunteer participant you may withdraw your participation at any time and for any reason without
penalty or loss of benefit to which you would otherwise be entitled. If you have any questions
concerning your participation, please contact the researcher, Julie Takishima, at [email protected] or
the research project supervisor, Dr. Kelly Vitousek, at [email protected]. If you have questions
about your rights as a participant, you may contact the UH Committee on Human Studies, 1960 East-
West Road, Biomedical Building, Room B-104, Honolulu, HI 96822; Phone: 808.956.5007; Email:
Participant:
I have read and understand the above information, and agree to participate in this research project.
☐ I agree to participate in this research project. (Subject is directed to first page of electronic survey.)
☐ I DO NOT agree to participate in this research project. (Subject is not allowed access to survey.)
127
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