Body image disturbance (BID) is a common symptom in patients with
eating disorders and is characterized by an altered
perception of one's own body.
The onset is mainly attributed to patients with
anorexia nervosa
Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. ''Anorexia'' is a term of Gr ...
who persistently tend to subjectively discern themselves as average or overweight despite adequate, clinical grounds for a classification of being considerably or severely underweight.
The symptom is an altered perception of one's body and a severe state of bodily dissatisfaction characterizing the body image disturbance. It is included among the diagnostic criteria for anorexia nervosa in DSM-5 (
criterion C).
The disturbance is associated with significant bodily dissatisfaction and is a source of severe distress, often persisting even after seeking treatment for an eating disorder,
and is regarded as difficult to treat.
Thus, effective body image interventions could improve the prognosis of patients with ED, as experts have suggested.
However, there is no hard evidence that current treatments for body image disturbance effectively reduce eating disorder symptoms. Furthermore, pharmacotherapy is ineffective in reducing body misperception and it has been used to focus on correlated psychopathology (e.g.,
mood or
anxiety disorders). However, to date, research and clinicians are developing new therapies such as
virtual reality
Virtual reality (VR) is a simulated experience that employs pose tracking and 3D near-eye displays to give the user an immersive feel of a virtual world. Applications of virtual reality include entertainment (particularly video games), educ ...
experiences,
mirror exposure,
or
multisensory integration
Multisensory integration, also known as multimodal integration, is the study of how information from the different sensory modalities (such as sight, sound, touch, smell, self-motion, and taste) may be integrated by the nervous system. A coherent r ...
body techniques,
which have shown some extent of efficacy.
History
The scientific study of bodily experiences began at the end of the 19th century. German physiologist
Hermann Munk
Hermann Munk (3 February 1839 – 1 October 1912) was a German physiologist. He was born at Posen, studied at Berlin and Göttingen, and in 1862 became docent in the former university. Seven years afterward he was promoted to assistant profess ...
was the first to suggest the existence of a cortical representation of the body, supported by his
vivisection
Vivisection () is surgery conducted for experimental purposes on a living organism, typically animals with a central nervous system, to view living internal structure. The word is, more broadly, used as a pejorative catch-all term for Animal testi ...
experiments on the parietal cortex of dogs. A few years later,
Carl Wernicke
Carl (or Karl) Wernicke (; ; 15 May 1848 – 15 June 1905) was a German physician, anatomist, psychiatrist and neuropathologist. He is known for his influential research into the pathological effects of specific forms of encephalopathy and also ...
hypothesized a
cortical map Cortical maps are collections (areas) of minicolumns in the brain cortex that have been identified as performing a specific information processing function (texture maps, color maps, contour maps, etc.).
Cortical maps
Cortical organization, espe ...
capable of collecting and processing sensory inputs from every point of the body. In 1905
Bonnier introduced the term ''body schema'', defining it as the mental representation of the body necessary for the brain to perceive objects near, far, or within the body itself.
Bonnier also described three different partial body pattern alterations, (
French; 'an overestimation of body size'), ('an underestimation of body size'), and ('a displacement of body parts including internal organs'). Head and Holmes in 1911 expanded the concept of a body schema, introducing the concepts of ''postural schema'' and ''surface schema''. They described a patient who could locate the stimuli applied to her body but could not locate her hand in space. They also defined the difference between schema and image. The ''schema'' defined as an unconscious representation necessary for movement and localization in space, and the "image" as a conscious body perception.
Therefore, in the history of medicine, distortions in the perception of one's body have mainly occurred in patients with
neurological damage or with amputated limbs and a consequence of
phantom limb syndrome
A phantom limb is the sensation that an amputation, amputated or missing limb (anatomy), limb is still attached. Approximately 80 to 100% of individuals with an amputation experience sensations in their amputated limb. However, only a small perc ...
. In the psychiatric field, the first systematic descriptions of bodily altered perception are already present in
Schneider's classification of symptoms of
schizophrenia
Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdra ...
in 1959. The German-American psychiatrist
Hilde Bruch
Hilde Bruch (March 11, 1904 December 15, 1984) was a German-born American psychiatrist and psychoanalyst, known foremost for her work on eating disorders and obesity.
Bruch emigrated to the United States in 1934. She worked and studied at v ...
was the first physician to describe body image disturbance in eating disorders accurately.
Characteristics
Hilde Bruch
Hilde Bruch (March 11, 1904 December 15, 1984) was a German-born American psychiatrist and psychoanalyst, known foremost for her work on eating disorders and obesity.
Bruch emigrated to the United States in 1934. She worked and studied at v ...
first identified and described body image disturbance in
anorexia nervosa
Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. ''Anorexia'' is a term of Gr ...
.
In her article "Perceptual and Conceptual Disturbances in Anorexia Nervosa"
she wrote:
Body image disturbance is not specific to anorexia nervosa, as it is sometimes present in other eating disorders such as
bulimia nervosa
Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
and
binge eating disorder
Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFE ...
.
Studies published in 2019 on ''Cortex'' have shown that it is possible to observe alterations in the perception of one's body in healthy subjects. A slightly altered perception of the body is a normal part of everyone's life and manifests itself more intensely in more vulnerable individuals (e.g., patients with eating disorders). Commonly, body image disturbance is confused with
body dysmorphic disorder
Body dysmorphic disorder (BDD), occasionally still called dysmorphophobia, is a mental disorder characterized by the obsessive idea that some aspect of one's own body part or appearance is severely flawed and therefore warrants exceptional meas ...
, an
obsessive-compulsive disorder with which it shares some features.
Body image disturbance is a multifaceted construct including both perceptual and attitudinal issues. Some of the more common signs are:
* altered body size estimation and altered perception of the body and its shapes;
* mental images of one's body appearing distorted or overweight;
* frequently third-person mental view of one's body;
* negative body-related thoughts;
* frequent
body-checking behaviors;
* frequent comparisons between one's own body and the bodies of others;
* emotions of anxiety, shame, and contempt for one's body.
Clinically speaking, a growing body of research suggests that body image disturbance plays a significant role in the onset, maintenance, and relapse of anorexia nervosa, as previously suggested by Bruch in 1962.
However, despite increasing evidence, a review by Glashouwer in 2019 stated that the available empirical data are still insufficient and "provide no basis to answer the question whether body image disturbance is a (causal) risk factor for anorexia nervosa". As suggested by the author, this lack of evidence is partly related to terminology problems used in the
body image field.
In binge eating disorder
Body image disorder is a characteristic symptom of anorexia nervosa and
bulimia nervosa
Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
. In both of these disorders, an excessive focus on body shapes and sizes made the body image disturbance easier to identify, to describe, and study.
Much less is known about the disorder in patients with binge eating disorder.
As early as 1993, Spitzer compared obese individuals with and without
binge eating disorder
Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFE ...
(BED) and found that those with BED were more frequently concerned about body shape and weight. Additionally, binge eating disorder patients show more significant concerns about weight and body shape, more intense body dissatisfaction, and more frequent avoidance and body checking behaviors.
On the other hand, few studies have investigated the altered body perception in patients with
binge eating disorder
Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFE ...
and the results are conflicting. Some patients tend to overestimate their body shapes, in others, they do not. In some cases the perceptual disturbance manifests itself in a paradoxical way, with an underestimation of the real body shapes and sizes. This difference suggests different
phenotype
In genetics, the phenotype () is the set of observable characteristics or traits of an organism. The term covers the organism's morphology or physical form and structure, its developmental processes, its biochemical and physiological proper ...
s in binge spectrum; hence, a perceptual disturbance can be considered an aggravation of the
binge eating disorder
Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFE ...
, as claimed by Lewer and colleagues in 2017.
Epidemiology
There are no reliable epidemiological data in the literature for body image disturbance.
There are numerous challenges with diagnosis, the most relevant of which is the unclear definition of body image disturbance within official diagnostic manuals such as the
DSM
DSM or dsm may refer to:
Science and technology
* Deep space maneuver
* Design structure matrix or dependency structure matrix, a representation of a system or project
* Diagnostic and Statistical Manual of Mental Disorders
** DSM-5, the fifth ed ...
and the
ICD, which prevents its identification in the population. Further, there are challenges with diagnostic tools, both for recognition and screening. The altered perception of the body can only be measured through behavioral tasks delivered individually (
See section below). It cannot be measured with questionnaires, or other tools typically used for broad-spectrum investigations.
As it is not always present in
eating disorders, its prevalence is not comparable to that of anorexia nervosa,
bulimia nervosa
Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
, and
binge eating disorder
Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFE ...
, and cannot be inferred from them. A negative
body image
Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in a number of disciplines, including neuroscience, psychology, medicine, psychiatry, ps ...
may also be present in other psychiatric conditions such as
PTSD
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
,
major depression
Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introdu ...
, and body dysmorphic disorder.
Taken together this data suggests the possible presence of perceptual disturbances in other pathological conditions not directly related to eating disorders. Therefore, the presence of a body image disturbance in other psychiatric diseases remains speculation, not yet supported by sufficient literature data, as suggested by Scheffers.
Definition
DSM-5
Different labels are used in research and clinical settings to describe body image disturbance, generating terminological confusion. Among the most used terms are ''body image discrepancy'', ''body image self-discrepancy'', ''body image distortion'',
''disturbed body image'', ''disturbances in body estimations'', ''body image disturbance'', and ''negative body image''. Sometimes, the term ''body dissatisfaction'' is also used to refer to body image disturbance indiscriminately. Moreover, the
DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
defines this symptom vaguely: "a disturbance in the way one's body weight or shape is experienced".
The lack of a clear definition is problematic from both a clinical and basic research point of view.
Multidimensional
Despite the terminological problems, during the early 2000s numerous scholars agree that body image disturbance is a multidimensional symptom of various components associated with
body image
Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in a number of disciplines, including neuroscience, psychology, medicine, psychiatry, ps ...
.
Body image is a concept formed by the interaction of four body-related components:
cognitive
Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought, ...
,
affective
Affect, in psychology, refers to the underlying experience of feeling, emotion or mood.
History
The modern conception of affect developed in the 19th century with Wilhelm Wundt. The word comes from the German ''Gefühl'', meaning "feeling. ...
,
behavior
Behavior (American English) or behaviour (British English) is the range of actions and mannerisms made by individuals, organisms, systems or artificial entities in some environment. These systems can include other systems or organisms as wel ...
al, and
perceptual
Perception () is the organization, identification, and interpretation of sensory information in order to represent and understand the presented information or environment. All perception involves signals that go through the nervous system ...
.
* Cognitive: thoughts and beliefs about one's body and its shape; a conscious mental representation of the body
* Affective: feelings and attitudes related to the body (e.g. bodily satisfaction/dissatisfaction).
* Behavioral: the actions that people perform to check on, modify, or hide their body parts.
* Perceptual: how the mind
sense
A sense is a biological system used by an organism for sensation, the process of gathering information about the world through the detection of Stimulus (physiology), stimuli. (For example, in the human body, the brain which is part of the cen ...
s and
perceives the body; it includes
proprioceptive
Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense".
Proprioception is mediated by proprioceptors, mechanosensory neurons ...
,
interoceptive,
tactile
Tactile may refer to:
* Tactile, related to the sense of touch
* Haptics (disambiguation)
* Tactile (device), a text-to-braille translation device
See also
* Tangibility, in law
* Somatosensory system, where sensations are processed
* CD96
CD ...
, and visual self-perception.
In people with body image disturbance all of these components are altered at the same time.
In 2021, Artoni ''et al'' proposed a clearer definition of body image disturbance as part of a study in ''
Eating and Weight Disorders''.
The authors suggested using the term ''bodily dissatisfaction'' when there are alterations in either the affective, cognitive, or behavioral components of body image and strictly reserving the term ''body image disturbance'' only when all four components are altered, including perception. In short, they define body image disturbance as the presence of an altered perception of the shape and weight of one's body, which aggravates body dissatisfaction. The term is consistent with the DSM-5 description "a disturbance in the way weight and body shapes are experienced"
and it is therefore "preferable to others".
Components
Cognitive
Patients with body image disturbance exhibit an alteration in how the body's image is stored in their memory—the conscious representation of their bodies. This representation is from a third-person, perspective, more precisely an
allocentric
Allocentrism is a collectivistic personality attribute whereby people center their attention and actions on other people rather than themselves. It is a psychological dimension which corresponds to the general cultural dimension of collectivism. ...
representation of the body. This representation is evoked in
self-image
Self-image is the mental picture, generally of a kind that is quite resistant to change, that depicts not only details that are potentially available to an objective investigation by others (height, weight, hair color, etc.), but also items that h ...
tasks, such as comparing one's body with others or drawing one's body shapes. However, patients with anorexia nervosa and
bulimia nervosa
Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
frequently perceive their body as larger than it is in reality.
Patients with anorexia nervosa have negative thoughts about their body, such as "I'm too fat," "I'm ugly," and other negative body-related thoughts. In some cases, however, the ideal internalized body is indicative of
unhealthy thinness (e.g., a body without female shapes or one that communicates suffering). An unhealthy body shape could be a critical maintenance factor, generating more attention from family members, reducing the requests and expectations of others, and minimizing sexual attractiveness (especially in patients with sexual trauma).
Affective
Affective components of body image are the feelings and emotions experienced towards one's body. Body dissatisfaction is frequently present in those with body image disturbance,
sometimes related to
anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
and
shame
Shame is an unpleasant self-conscious emotion often associated with negative self-evaluation; motivation to quit; and feelings of pain, exposure, distrust, powerlessness, and worthlessness.
Definition
Shame is a discrete, basic emotion, d ...
when the body is exposed or gazed at in a
mirror
A mirror or looking glass is an object that Reflection (physics), reflects an image. Light that bounces off a mirror will show an image of whatever is in front of it, when focused through the lens of the eye or a camera. Mirrors reverse the ...
. In some cases,
anger
Anger, also known as wrath or rage, is an intense emotional state involving a strong uncomfortable and non-cooperative response to a perceived provocation, hurt or threat.
A person experiencing anger will often experience physical effects, su ...
and feelings of
aggression towards one's body are reported.
Fear
Fear is an intensely unpleasant emotion in response to perceiving or recognizing a danger or threat. Fear causes physiological changes that may produce behavioral reactions such as mounting an aggressive response or fleeing the threat. Fear ...
is associated with thoughts of getting fat.
Congruent with the
self-objectification
Self-objectification is when people view themselves as objects for use instead of as human beings. Self-objectification is a result of objectification, and is commonly discussed in the topic of sex and gender. Both men and women struggle with self- ...
theory, people with body image disturbance frequently experience the body only as an object to be modified rather than as a subject to take care of.
Behavioral
The behavioral component of body image disturbance includes different body-checking behaviors such as repeatedly weighing during the day, spending significant time in front of the mirror or avoiding it, frequently taking
selfie
A selfie () is a self-portrait photograph, typically taken with a digital camera or smartphone, which may be held in the hand or supported by a selfie stick. Selfies are often shared on social media, via social networking services such as ...
s, checking parts of the body with hands (e.g. measuring the circumference of the wrists, arms, thighs, belly or hips). Other behaviors include avoiding situations in which the body is exposed (for example, when swimming), and wearing very loose and covering clothes. More generally, avoidance of bodily sensations, particularly the
interoceptive ones, is reported.
Perceptual
In body image disturbance, several perceptual domains are altered.
Visual perception
Visual perception is the ability to interpret the surrounding environment through photopic vision (daytime vision), color vision, scotopic vision (night vision), and mesopic vision (twilight vision), using light in the visible spectrum reflecte ...
is the most studied, but research has found misperceptions in other sensory domains such as
haptic,
tactile
Tactile may refer to:
* Tactile, related to the sense of touch
* Haptics (disambiguation)
* Tactile (device), a text-to-braille translation device
See also
* Tangibility, in law
* Somatosensory system, where sensations are processed
* CD96
CD ...
,
and affective-touch.
Also, the
body schema
Body schema is a concept used in several disciplines, including psychology, neuroscience, philosophy, sports medicine, and robotics. The neurologist Sir Henry Head originally defined it as a postural model of the body that actively organizes and m ...
is overextended. Some research suggested that this is related to a general enlarged
mental representation
A mental representation (or cognitive representation), in philosophy of mind, cognitive psychology, neuroscience, and cognitive science, is a hypothetical internal cognitive symbol that represents external reality, or else a mental process that ...
of body size. A 2017 study published in a companion journal to ''Nature''
highlighted how perceptual disturbance is present in those recovered from anorexia nervosa even without affective-cognitive body concerns. Finally,
interoception, the sense of the current state of the body,
is problematic in those with
eating disorders.
Onset
The age of onset for body image disturbance is often early
adolescence,
the age in which one's comparison to their peers becomes more significant and leads to a greater sensitivity towards criticism of, or teasing about, one's
physical appearance
Human physical appearance is the outward phenotype or look of human beings.
There are infinite variations in human phenotypes, though society reduces the variability to distinct categories. The physical appearance of humans, in particular those a ...
. Furthermore,
puberty
Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a boy. ...
leads to rapid changes in body size and shape that need to be integrated into one's body image. For this reason, adolescence is considered a critical age, with a greater vulnerability to
internalizing
Internalization ( or internalisation) is the process of making something internal, with more specific meanings in various fields. It is the opposite of externalization.
Psychology and sociology
In psychology, internalization is the outcome of ...
ideals of thinness, which may ultimately lead to the development of body dissatisfaction, body image disturbance,
or eating disorders. In a 2019 review, Sattler and colleagues analyzed eight on-topic studies. The authors found that most adolescents with anorexia nervosa and bulimia nervosa already had body-checking behaviors, negative body-related emotions and feelings, low body satisfaction, and an altered estimate of their body size compared to healthy controls.
Unfortunately, exactly how one passes from initial dissatisfaction with one's body to actual perceptual disorder is still unknown despite its clinical importance. The
etiopathogenesis is still unknown and the subject of hypotheses in the clinical and neuroscientific fields.
Relationship to other concepts
Body dissatisfaction
Body dissatisfaction and body image disturbance are closely related. Personal, interpersonal, cultural, social, and ethnic variables largely influence bodily dissatisfaction,
influencing the emergence of painful feelings towards one's body. In addition,
social pressure
Peer pressure is the direct or indirect influence on peers, i.e., members of social groups with similar interests, experiences, or social statuses. Members of a peer group are more likely to influence a person's beliefs, values, and behavior. A g ...
is considered a
risk factor
In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection.
Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often use ...
for body dissatisfaction. For example, the frequent presence on media of thin female bodies determines, especially in young girls, a daily comparison between their bodies and models and actresses favoring bodily dissatisfaction; comparing an "ideal" and "real" body feed an intense dissatisfaction with one's body and increases the feeling of shame, disgust, and anxiety towards the one's body and appearance.
Dissatisfaction with one's body involves only three of the four components of the body image. Those with bodily dissatisfaction can have negative thoughts about one's body (e.g., "I'm ugly" or "I'm too short"). In addition, they may have behaviors related to bodily dissatisfaction (e.g., going on a diet or resorting to cosmetic surgery) . They may also have negative feelings of dissatisfaction with their body and be ashamed of showing it in public.
However, all these aspects are not enough to define it as a body image disturbance. In fact, there is no perceptual alteration of one's body. Thus, "body image disturbance" cannot be used interchangeably with "body dissatisfaction", but they are closely related.
Body dysmorphic disorder
Body image disturbance in anorexia and body dysmorphic disorder (BDD) are similar
psychiatric conditions that both involve an
altered perception of the body or parts of it but are not the same disorder.
Body image disturbance is a symptom of anorexia nervosa (AN) and is present as criterion C in the DSM-5,
and alters the perception of weight and shapes of the whole body. Patients with anorexia nervosa believe that they are
overweight, perceive their body as being "fat" and misperceive their
body's shape.
Body dysmorphic disorder, meanwhile, is an
obsessive-compulsive disorder characterized by disproportionate concern for minimal or absent individual bodily flaws, which cause personal distress and social impairment
—patients with body dysmorphic disorder are concerned about physical details, mainly the
face
The face is the front of an animal's head that features the eyes, nose and mouth, and through which animals express many of their emotions. The face is crucial for human identity, and damage such as scarring or developmental deformities may aff ...
,
skin
Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation.
Other cuticle, animal coverings, such as the arthropod exoskeleton, have diffe ...
, and
nose
A nose is a protuberance in vertebrates that houses the nostrils, or nares, which receive and expel air for respiration alongside the mouth. Behind the nose are the olfactory mucosa and the sinuses. Behind the nasal cavity, air next passes th ...
.
Thus, both anorexia nervosa and body dysmorphic disorder manifest significant disturbances in body image but are different and highly comorbid.
For example, Grant ''et al'' reported that 39% of AN patients in their sample had a
comorbid
In medicine, comorbidity - from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together) - is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary ...
diagnosis of body dysmorphic disorder, with concerns unrelated to weight.
Cerea ''et al'' reported that 26% of their AN sample had a probable BDD diagnosis with non-weight-related body concerns.
While a 2019 review by Phillipou ''et al'' in ''
Psychiatry Research
''Psychiatry Research'' is a peer-reviewed medical journal covering psychiatry. It was established in 1979 and is published 21 times per year by Elsevier. A section of the journal, '' Psychiatry Research: Neuroimaging'', covers the discipline of ...
'' suggested that the two disorders could be taken together as "body image disturbances", plural, more in-depth studies are needed to confirm this new classification hypothesis.
Similarities
Previous studies found that both BDD and eating disorder groups were similar in body dissatisfaction, body checking, body concerns,
and levels of perfectionism.
Furthermore, both BDD and AN patients report higher intensities of negative emotions, lower intensities of positive emotions,
lower self-esteem, and anxiety symptoms.
Moreover, research find severe concerns about one's appearance, leading to a continuous confrontation with others' bodies in both diseases.
In addition, body image disturbances and body dysmorphic disorder generally onset during adolescence. Finally, alterations in visual processes seems to be present in both disorders, with greater attention to detail, but with greater difficulty in perceiving
stimuli
A stimulus is something that causes a physiological response. It may refer to:
* Stimulation
** Stimulus (physiology), something external that influences an activity
** Stimulus (psychology), a concept in behaviorism and perception
* Stimulus (eco ...
holistically. Indeed,
neurophysiology
Neurophysiology is a branch of physiology and neuroscience that studies nervous system function rather than nervous system architecture. This area aids in the diagnosis and monitoring of neurological diseases. Historically, it has been dominated b ...
and
neuroimaging
Neuroimaging is the use of quantitative (computational) techniques to study the structure and function of the central nervous system, developed as an objective way of scientifically studying the healthy human brain in a non-invasive manner. Incr ...
research suggests similarities between BDD and AN patients in terms of abnormalities in
visuospatial processing.
Differences
Despite many similarities, the two disorders also have significant differences.
The first is gender distribution. Body image disturbance is much more present in females,
unlike BDD, which has a much less unbalanced incidence.
Furthermore, those with
dysmorphophobia tend to have more significant
inhibitions and avoidance of social activities than those with anorexia nervosa.
Differences are self-evident when considering the focus of physical concerns and misperception in AN and BDD. Whereas BDD patients report concerns and misperception in specific body areas (mainly face, skin, and hair), in patients with AN the altered perception could involve the arms, shoulders, thighs, abdomen, hips, and breasts, and concerns are about overall body shape and weight.
Thus, leading to an alteration of the entire explicit (
body image
Body image is a person's thoughts, feelings and perception of the aesthetics or sexual attractiveness of their own body. The concept of body image is used in a number of disciplines, including neuroscience, psychology, medicine, psychiatry, ps ...
)
and implicit (
body schema
Body schema is a concept used in several disciplines, including psychology, neuroscience, philosophy, sports medicine, and robotics. The neurologist Sir Henry Head originally defined it as a postural model of the body that actively organizes and m ...
) mental representation of the body.
Furthermore, in anorexia nervosa, not only is visual perception of one's body altered, but both tactile
and interoceptive perception are as well.
Diagnosis
Body image disturbance is not yet clearly defined by official disease classifications. However, it appears in the DSM-5 under criterion C for anorexia nervosa and is vaguely described as "a disturbance in the way weight and body shapes are experienced". As a result, diagnosis is usually based on reported signs and symptoms; there are still no
biological markers
In biomedical contexts, a biomarker, or biological marker, is a measurable wikt:indicator, indicator of some biological state or condition. Biomarkers are often measured and evaluated using blood, urine, or soft tissues to examine normal biologic ...
for body image disturbance. Numerous
psychometric
Psychometrics is a field of study within psychology concerned with the theory and technique of measurement. Psychometrics generally refers to specialized fields within psychology and education devoted to testing, measurement, assessment, and ...
instruments to measure the cognitive, affective, and behavioral components of one's body image are used in clinical and research settings, helping in assessing the body image's attitudinal components. Recently, research developed other instruments to measure the perceptive component.
Attitudinal assessment tools
* The Eating Disorder Inventory 3 (EDI-3) represents an improvement of the earlier versions of the EDI, a self-report questionnaire widely used both in research and clinical settings. It consists of 91 questions, and items are rated on a six-point
Likert scale
A Likert scale ( , commonly mispronounced as ) is a psychometric scale commonly involved in research that employs questionnaires. It is the most widely used approach to scaling responses in survey research, such that the term (or more fully the ...
(always, usually, sometimes, rarely, never), with higher scores representing more severe symptoms. Precisely, the BD subscale of EDI-3 measures bodily dissatisfaction.
* The Body Uneasiness Test (BUT) is a self-administered questionnaire. It explores several areas in clinical and non-clinical populations: weight phobia, body image-related avoidance behavior, compulsive self-monitoring, detachment and estrangement feelings toward one's own body. Besides, explore specific worries about particular body parts, shapes, or functions. Higher scores indicate significant body uneasiness.
* The Body Image Disturbance Questionnaire investigates different areas related to body image disturbance. For example, it evaluates the parts of the body an individual finds most problematic, the psychological effects of their worries about their body, and effects on their social life and eating behavior.
* The Body Shape Questionnaire is a 34-item self-assessment questionnaire designed to measure the degree of dissatisfaction with the weight and shape of one's body. It includes questions about the fear of weight gain and about whether one has the urge or desire to lose weight.
* The Body Checking Questionnaire measures the frequency of body control behaviors, such as measuring specific body areas, using mirrors to check or avoid body shape, wearing loose-fitting, covering clothing, or checking for bony prominence with one's hands. Higher scores indicate a higher frequency of body checking behaviors.
Perceptual assessment tools
* BID-CA (Test for Body Image Distortion in Children and Adolescents): Patients with a 180 cm rope simulate the circumference of the different parts of the body, including the hips, thighs, shoulder width and other parts of the body considered phobic. This estimate is compared to the actual patient size. The procedure is validated for children and adolescents but can also be used in adults.
* Visual Size Estimation Task (VSE): patients are placed standing in front of a wall at a distance of about one meter. They place two stickers on the wall that reflect the perceived dimensions of different body parts, such as the width of the shoulders, hips, or waistline. These values are then taken and compared with those measured directly on the patient.
* Tactile Estimation Task (TET): a standard
gauge
Gauge ( or ) may refer to:
Measurement
* Gauge (instrument), any of a variety of measuring instruments
* Gauge (firearms)
* Wire gauge, a measure of the size of a wire
** American wire gauge, a common measure of nonferrous wire diameter, ...
is used for measurement. During the measurement, patients estimate the distance between the two points of the gauge while it is placed on different parts of the body. Several measurements are made and the gauge is oriented in different directions (for example, at the height of the hips, it is placed both horizontally and vertically)
* 3D Morphing: Numerous 3D modeling computer programs allow directly modifying a human body model by increasing or decreasing its size. Patients modify the 3D avatar so that it represents their body image as closely as possible. The model values are then compared with the actual measurements of the patients.
Multi-sensory perception
The perception of one's body is a multi-sensory process that integrates information deriving from different sensory cortices, including the
visual
The visual system comprises the sensory organ (the eye) and parts of the central nervous system (the retina containing photoreceptor cells, the optic nerve, the optic tract and the visual cortex) which gives organisms the sense of sight (th ...
,
proprioceptive
Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense".
Proprioception is mediated by proprioceptors, mechanosensory neurons ...
,
tactile
Tactile may refer to:
* Tactile, related to the sense of touch
* Haptics (disambiguation)
* Tactile (device), a text-to-braille translation device
See also
* Tangibility, in law
* Somatosensory system, where sensations are processed
* CD96
CD ...
,
interoceptive, and
auditory-vestibular areas. All of these areas are involved in the perception of one's body. An important component is the
premotor cortex
The premotor cortex is an area of the motor cortex lying within the frontal lobe of the brain just anterior to the primary motor cortex. It occupies part of Brodmann's area 6. It has been studied mainly in primates, including monkeys and humans ...
(PMC) and the
intraparietal sulcus
The intraparietal sulcus (IPS) is located on the lateral surface of the parietal lobe, and consists of an oblique and a horizontal portion. The IPS contains a series of functionally distinct subregions that have been intensively investigated usin ...
. These two areas are active during illusory hand perception tasks in both hemispheres.
The somatosensory areas are also involved, in particular the
primary somatosensory cortex
In neuroanatomy, the primary somatosensory cortex is located in the postcentral gyrus of the Human brain, brain's parietal lobe, and is part of the somatosensory system. It was initially defined from surface stimulation studies of Wilder Penfield ...
(S1). An important area is the
extrastriate body area The extrastriate body area (EBA) is a subpart of the extrastriate visual cortex involved in the visual perception of human body and body parts, akin in its respective domain to the fusiform face area, involved in the perception of human faces. The ...
located rostrocaudally in the
occipital lobe
The occipital lobe is one of the four major lobes of the cerebral cortex in the brain of mammals. The name derives from its position at the back of the head, from the Latin ''ob'', "behind", and ''caput'', "head".
The occipital lobe is the vi ...
and is specific to human bodies perception. Two other areas of considerable importance in the perception of the body are the
insula and the
anterior cingulate cortex
In the human brain, the anterior cingulate cortex (ACC) is the frontal part of the cingulate cortex that resembles a "collar" surrounding the frontal part of the corpus callosum. It consists of Brodmann areas 24, 32, and 33.
It is involved ...
.
The insular cortex is fundamental in the direct perception and integration of bodily signals from different cortical areas
and, despite being an area historically delegated to the sole function of perceiving the state of internal organs as proposed by Sherrington in 1911, research advances demonstrate the central role of the
insula in several domains, including the recognition that one's body belongs to us.
Namely the "body ownership".
Brain imaging
fMRI
Functional magnetic resonance imaging or functional MRI (fMRI) measures brain activity by detecting changes associated with blood flow. This technique relies on the fact that cerebral blood flow and neuronal activation are coupled. When an area ...
studies examining brain responses in anorexia nervosa patients to paradigms that include body image tasks have found altered activation across different brain areas, including the
prefrontal cortex
In mammalian brain anatomy, the prefrontal cortex (PFC) covers the front part of the frontal lobe of the cerebral cortex. The PFC contains the Brodmann areas BA8, BA9, BA10, BA11, BA12, BA13, BA14, BA24, BA25, BA32, BA44, BA45, BA46 ...
,
precuneus
In neuroanatomy, the precuneus is the portion of the superior parietal lobule on the medial surface of each brain hemisphere. It is located in front of the cuneus (the upper portion of the occipital lobe). The precuneus is bounded in front by th ...
,
parietal cortex
The parietal lobe is one of the four major lobes of the cerebral cortex in the brain of mammals. The parietal lobe is positioned above the temporal lobe and behind the frontal lobe and central sulcus.
The parietal lobe integrates sensory inform ...
,
insula,
amygdala
The amygdala (; plural: amygdalae or amygdalas; also '; Latin from Greek, , ', 'almond', 'tonsil') is one of two almond-shaped clusters of nuclei located deep and medially within the temporal lobes of the brain's cerebrum in complex verte ...
,
ventral striatum
The striatum, or corpus striatum (also called the striate nucleus), is a nucleus (a cluster of neurons) in the subcortical basal ganglia of the forebrain. The striatum is a critical component of the motor and reward systems; receives glutam ...
,
extrastriate body area The extrastriate body area (EBA) is a subpart of the extrastriate visual cortex involved in the visual perception of human body and body parts, akin in its respective domain to the fusiform face area, involved in the perception of human faces. The ...
, and
fusiform gyrus
The fusiform gyrus, also known as the ''lateral occipitotemporal gyrus'','' ''is part of the temporal lobe and occipital lobe in Brodmann area 37. The fusiform gyrus is located between the lingual gyrus and parahippocampal gyrus above, and th ...
.
However, as
Janet Treasure commented, "the research
n the field
N, or n, is the fourteenth letter in the Latin alphabet, used in the modern English alphabet, the alphabets of other western European languages and others worldwide. Its name in English is ''en'' (pronounced ), plural ''ens''.
History
...
is fragmented, and the mechanism of how these areas map onto the functional networks described above needs further study ... the mechanism by which the extremes of body distortion are driven and
heircircuitry is not known yet."
Prevention
The Body Project is an eating disorder
prevention program within a dissonant-cognitive framework. The program provides a forum for high school girls and college-age women to confront unrealistic-looking ideals and develop a healthy body image and self-esteem. It has been repeatedly shown to effectively reduce body dissatisfaction, negative mood, unhealthy diet, and disordered eating.
Treatments
Of cognition, affect, and behavior
Historically, research and clinicians have mainly focused on body image disturbance's cognitive, affective, and behavioral components. Consequently, treatments generally target symptoms such as body checking, dysfunctional beliefs, feelings, and emotions relating to the body. One of the best-known psychotherapies in the field is CBT-E. CBT-E is a
cognitive-behavioral therapy
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
that has been enhanced with particular strategies to address the psychopathology of eating disorders. These include reducing negative thoughts and worries about body weight and shape, reducing clinical
perfectionism, and body-checking behavior. In 2020 a review has shown that CBT-E effectively reduces core symptoms in eating disorders, including concerns about the body. Despite this, the results of CBT-E are no better than other forms of treatment. A therapy of choice for eating disorders in adults has not yet been identified.
Additionally, two other noteworthy body image treatments are Thomas F. Cash's "Body Image Workbook" and BodyWise. The former is an 8-step
group treatment within a classic cognitive-behavioral framework. The latter is a psychoeducational-based treatment improved with
cognitive remediation techniques to promote awareness of body image difficulties and to reduce cognitive inflexibility and body dissatisfaction.
Of perception
![Virtual-reality-woman](https://upload.wikimedia.org/wikipedia/commons/e/e1/Virtual-reality-woman.jpg)
Compared to the classic cognitive-behavioral therapeutic paradigms, since the early 2000s, new treatments for body image disturbance have been developed focusing on the disorder's perceptual component. Mirror Exposure
is a new cognitive-behavioral technique that aims to reduce experiential avoidance, reduce bodily dissatisfaction, and improve one's misperception of one's body. During the
exposure therapy
Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger (desensitization). Doing so is thou ...
, patients are invited to observe themselves in front of a large full-length
mirror
A mirror or looking glass is an object that Reflection (physics), reflects an image. Light that bounces off a mirror will show an image of whatever is in front of it, when focused through the lens of the eye or a camera. Mirrors reverse the ...
. There are different types of mirror exposure: guided exposure; unguided exposure; exposure with
mindfulness exercises; and cognitive dissonance-based mirror exposure. To date, few studies have investigated the effects of mirror exposure in patients with body image disturbance. In the ''
International Journal of Eating Disorders'', Key ''et al'' (2002) conducted a non-randomized trial in a clinical sample and compared a body image group therapy with or without mirror exposure. They found a significant improvement in body dissatisfaction only in the mirror exposure therapy group. Despite the positive evidence, in 2018, a review in ''Clinical Psychology Review'' suggests that Mirror Exposure has a low-to-medium effect in reducing body image disturbance and further studies are needed to improve it.
Another treatment for body image disturbance is Virtual Reality (VR) Body Swapping. VR-Body Swapping is a technique that allows generating a body illusion during a virtual reality experience. Specifically, after building a virtual
avatar
Avatar (, ; ), is a concept within Hinduism that in Sanskrit literally means "descent". It signifies the material appearance or incarnation of a powerful deity, goddess or spirit on Earth. The relative verb to "alight, to make one's appearanc ...
using
3D modeling software, it is possible to generate the illusion that the avatar's body is one's own body. The avatar is a 3D human body model that simulates the actual size of the patient and can be modified directly. Some studies have found that applying this technique to those with anorexia nervosa reduces their misperception of their bodies
but provides, at the moment, only a short-term effect.
![Hoop training](https://upload.wikimedia.org/wikipedia/commons/3/31/Hoop_training.png)
However, other treatments have also been developed to integrate tactile, proprioceptive, and interoceptive perception into one's overall body perception. Hoop Training is a short-term 8-week intervention (10 minutes per session) designed to become aware of and reduce body misperception. During the exercise, several flexible circles of different sizes are placed in front of the patient. First, the patients indicate which of the different circles best fits the circumference of their hips. Once indicated, patients are invited to enter the circle and, raising it, underestimating whether their estimate was accurate or not. The exercise takes place until the patient identifies the correct circumference for her hips. The circle chosen initially can be compared with the one that can coincide with the actual size of the patient. Hoop Training is meant to work on the components cognitive, affective, and perceptive of body image disturbance and the first efficacy data were published in 2019.
Another perceptive treatment is the Body Perception Treatment (BPT) whose first efficacy data were published in 2021. BPT is a specific group intervention for body image disturbance focused on tactile, proprioceptive, and interoceptive self-perceptions during a body-focused experience.
During the exercise, patients lie down on their backs in the supine position with closed eyes. Then the therapist guide patients to selectively focus attention on the different body parts in contact with the floor. In order: feet, calves, thighs, back, shoulders, hands, arms, head and the body in its entirety. In addition, patients are invited to pay attention to skin temperature, heart beat and flow of breath. The treatment is consistent with the hypothesized role of
interoception in developing body image disturbance by Badoud and Tsakiris in 2017.
Both Hoop Training and Body Perception Treatment showed effective results in pilot studies
and were designed to work within a
multisensory integration
Multisensory integration, also known as multimodal integration, is the study of how information from the different sensory modalities (such as sight, sound, touch, smell, self-motion, and taste) may be integrated by the nervous system. A coherent r ...
framework.
However, they complement, not replace, current standard therapies for eating disorders. However, both are also novelty treatments, and the results have not been replicated in independent studies. Thus, their actual effectiveness will have to be confirmed/disconfirmed by future research. As of the end of 2021 they have not yet been replicated.
References
{{Digital media use and mental health
Human appearance
Eating disorders