Body image disturbance

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Not to be confused with Body Dysmorphic Disorder.

Body image disturbance
SpecialtyPsychiatry, psychology
SymptomsAltered body self-perception, body uneasiness, body dissatisfaction, body-checking behavior
ComplicationsEating disorders
Usual onsetEarly adolescence
Risk factorsBody dissatisfaction, childhood neglect, childhood abuse
Diagnostic methodEDI-3, body uneasiness test, clinical diagnosis
Differential diagnosisBody dysmorphic disorder, obsessive-compulsive disorder
PreventionPositive body image, good self-esteem, healthy eating behaviors
TreatmentPsychotherapy

Body image disturbance (BID) is a common symptom in patients with eating disorders.

The onset is mainly attributed to patients with anorexia nervosa who persistently tend to subjectively discern themselves as average or overweight despite adequate, clinical grounds for a classification of being severely underweight.[1] 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).[2]

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,[3][4] and is regarded as difficult to treat.[3][5] Thus, effective body image interventions could improve the prognosis of patients with ED, as experts have suggested.[6] Unfortunately, there is no hard evidence that current treatments for body image disturbance effectively reduce eating disorder symptoms.[7] Furthermore, pharmacotherapy is ineffective in reducing body misperception and it has been used to focus on correlated psychopathology (e.g., mood or anxiety disorders).[8] However, to date, research and clinicians are developing new therapies such as virtual reality experiences,[9][10] mirror exposure[11] or multisensory integration body techniques,[12][5] which have shown some extent of efficacy.

Characteristics

Hilde Bruch, 1960
Hilde Bruch, 1960

German-American psychiatrist Hilde Bruch first identified and described body image disturbance in anorexia nervosa. In her famous article "Perceptual and Conceptual Disturbances in Anorexia Nervosa" [6] she wrote:

What is pathognomic of anorexia is not the severity of the malnutrition per se—equally severe degrees are seen in other malnourished psychiatric patients—but rather the distortion of body image associated with it: the absence of concern about emaciation, even when advanced, and the vigor and stubbornness with which the often gruesome appearance is defended as normal and right, not too thin, and as the only possible security against the dreaded fate of becoming fat.[6]

— Hilde Bruch, Perceptual and Conceptual Disturbances in Anorexia Nervosa, Psychosomatic Medicine, 1962

However, body image disturbance is not specific to anorexia nervosa but is sometimes present in other eating disorders such as bulimia nervosa[13] and binge eating disorder.[14] Furthermore, recent studies have shown that it is possible to observe alterations in the perception of one's body, even in healthy subjects. Suggesting that 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).[15] Commonly, body image disturbance is confused with body dysmorphic disorder, an obsessive-compulsive disorder with whome it share 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 such as "I'm fat" or "my thighs are huge";
  • 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,[16] maintenance,[17][18] and relapse of anorexia nervosa,[19] as previously suggested by Hilde Bruch in 1962.[6] However, despite increasing evidence, a recent review 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".[20] As suggested by the authors, this lack of evidence is partly related to terminology problems used in the body image field.[21]

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",[22] "body image self-discrepancy",[23] "body image distortion",[1] "disturbed body image",[24] "disturbances in body estimations",[25] "body image disturbance",[26] and "negative body image".[27] Sometimes, the term "body dissatisfaction" is also used to refer to body image disturbance indiscriminately.[28] Moreover, the DSM-5 itself defines this symptom vaguely: "a disturbance in the way one's body weight or shape is experienced".[2] Thus, the lack of a clear definition is problematic from both a clinical and basic research point of view.[original research?][citation needed]

Multidimensional

Most recent[when?] studies define "body image disturbance" as a multidimensional symptom of various components associated with body image.[29][13][3][12][5][30] Specifically, we[who?] usually describe body image as a concept formed by the interaction of four body-related components: cognitive, affective, behavioral, and perceptual.

  • Cognitive: thoughts and beliefs about one's body and its shape; one's conscious mental representation of their body[31]
  • Affective: feelings and attitudes related to the body (e.g. bodily satisfaction/dissatisfaction).[21]
  • Behavioral: actions that people perform to check on, modify, or hide their body parts.
  • Perceptual: how one's body is perceived; it includes proprioceptive, interoceptive, tactile, and visual self-perception.[32]

All of these components are altered in body image disturbance.[5]

In 2021, Artoni et al proposed a clearer definition of body image disturbance, as part of a study in Eating and Weight Disorders.[5] 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 when an altered perception of the shape and weight of one's body is present and aggravates body dissatisfaction. The term is literally consistent with the DSM-5 description "a disturbance in the way weight and body shapes are experienced" [2] and it is therefore "preferable to others".[This quote needs a citation]

Components

Cognitive

Patients with body image disturbance exhibit an alteration in the conscious representation of their bodies—how the body's image is stored in the memory. This representation is a third-person perspective, more precisely an allocentric representation of the body.[33] This representation is evoked in self-image tasks, such as comparing one's body with others or drawing one's body shapes. However, in patients with anorexia nervosa and bulimia nervosa, this mental representation of the body is frequently overextended compared to the actual body shapes.[34] Also, patients with anorexia nervosa show negative thoughts about their body, such as "I'm too fat," "I'm horrible," and other negative body-related thoughts.[35] In some cases, however, the ideal internalized body has canons of pathological thinness (e.g., a body without female shapes or "that communicates suffering"). A "sick body" could be a critical maintenance factor, generating more attention from family members, reducing the requests and expectations of others,[36] and sexual attractiveness (especially in patients with sexual trauma).[37]

Affective

Affective alterations concern the feelings and emotions experienced towards one's body. Body dissatisfaction is frequently present,[1][38] sometimes related to anxiety[39] and shame[40] when the body is exposed or gazed at in a mirror. In some cases, anger and feelings of aggression towards one's body are reported.[41] Congruent with the self-objectification theory, one's body is frequently experienced only as an "object to be modified" rather than a "subject to take care of".[42] Fear is associated with the idea of getting fat.[41]

Behavioral

The behavioral component of body image disturbance contemplates different body-checking behaviors[43] such as repeatedly weighing during the day, spending much time in front of the mirror or avoiding it, frequently taking selfies, checking parts of the body with hands (e.g. measuring the circumference of the wrists, arms, thighs, belly or hips). Other behaviors are avoiding situations in which the body is exposed (for example, swimming pools or the sea), and wearing very loose and covering clothes.[44] More generally, avoidance of bodily sensations, particularly the interoceptive ones, is reported.[45]

Perceptual

In body image disturbance, several perceptual domains are altered. Visual perception is the most studied,[46][47][48] but research found misperceptions in other sensory domains such as haptic,[49] tactile,[50] and affective-touch.[51] Also, the body schema is overextended.[52] Some research suggested that this is related to a general enlarged mental representation of body size.[53] A recent study published in a companion journal to Nature[54] also highlighted how perceptual disturbance is present in subjects recovered from anorexia nervosa even without affective-cognitive body concerns. Finally, interoception, the "sense of the physiological condition of the body",[55] is problematic in those with eating disorders.[56]

Onset

The age of onset for body image disturbance is often early adolescence,[57] 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. Furthermore, puberty leads to rapid changes in body size and shape that need to be integrated into one's body image.[58] For this reason, adolescence is considered a critical age, with a greater vulnerability to internalizing ideals of thinness,[59] which may ultimately lead to the development of body dissatisfaction, body image disturbance,[57] or eating disorders.[60] In a recent review, eight on-topic studies were analyzed. 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.[57] Unfortunately, exactly how one passes from initial dissatisfaction with one's body to actual perceptual disorder is still unknown despite its clinical importance.[61]

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,[62] influencing the emergence of painful feelings towards one's body. In addition, social pressure is considered a risk factor 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;[63] 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.[64]

Dissatisfaction with one's body involves only three of the four components of the body image. Those suffering from 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[65][66]) . They may also have negative feelings of dissatisfaction with their body and be ashamed of showing it in public.[62] 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.[67]

Body dysmorphic disorder

Body image disturbance in anorexia and body dysmorphic disorder 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,[2] and alters the perception of weight and shapes of the whole body. Patients with anorexia believe that they are overweight, perceive their body as being "fat" and misperceive their bodys' shape.[68] 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[69]—patients with BDD are concerned about physical details, mainly the face, skin, and nose.[70] Thus, both anorexia nervosa and body dysmorphic disorder manifest significant disturbances in body image but are different and highly comorbid.[71] For example, Grant et al reported that 39% of AN patients in their sample had a comorbid diagnosis of body dysmorphic disorder, with concerns unrelated to weight.[72] Cereaet et al reported that 26% of their AN sample had a probable BDD diagnosis with non-weight-related body concerns.[73]

While a 2019 review by Phillipou et al in Psychiatry Research 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.[71]

Similarities

Previous studies found that both BDD and eating disorder groups were similar in body dissatisfaction, body checking, body concerns,[74] and levels of perfectionism.[75] Furthermore, both BDD and AN patients report higher intensities of negative emotions, lower intensities of positive emotions,[76] lower self-esteem,[75] and anxiety symptoms.[77] Moreover, we[who?] 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 holistically.[78] Indeed, neurophysiology and neuroimaging research suggests similarities between BDD and AN patients in terms of abnormalities in visuospatial processing.[79][80]

Differences

Despite many similarities, the two disorders also have significant differences.[81] The first is gender distribution. Body image disturbance is much more present in females,[82] unlike BDD, which has a much less unbalanced incidence.[83] Furthermore, those with dysmorphophobia tend to have more significant inhibitions and avoidance of social activities than those suffering from anorexia nervosa.[74] 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),[84] 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.[81] Thus, leading to an alteration of the entire explicit (body image)[1] and implicit (body schema)[85] mental representation of the body.[86] Furthermore, in anorexia nervosa, not only is visual perception of one's body altered, but both tactile[87] and interoceptive perception are as well.[88][89]

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 for body image disturbance. Numerous psychometric 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.

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 (always, usually, sometimes, rarely, never), with higher scores representing more severe symptoms. Precisely, the BD subscale of EDI-3 measures bodily dissatisfaction.[90]
  • 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.[91]
  • 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.[92]
  • 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.[93]
  • 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.[94]

Brain imaging

fMRI 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, precuneus, parietal cortex, insula, amygdala, ventral striatum, extrastriate body area, and fusiform gyrus.[95] However, as Janet Treasure commented, "the research [in the field] 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 [their] circuitry is not known yet."[1]

Prevention

The Body Project[96] 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.[97]

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.[98] CBT-E is a cognitive-behavioral therapy 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.[99] A recent 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.[100] A therapy of choice for eating disorders in adults has not yet been identified.[1]

Additionally, two other noteworthy body image treatments are Thomas F. Cash's "Body Image Workbook"[101] and BodyWise.[102] 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

New[as of?] treatments for body image disturbance have recently been developed, focusing on the disorder's perceptual component. One of the best known[weasel words] is Mirror Exposure. Mirror Exposure[11] is a 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, patients are invited to observe themselves in front of a large full-length mirror. There are different types of mirror exposure: guided exposure; unguided exposure; exposure with mindfulness exercises; and cognitive dissonance-based mirror exposure.[103][104] 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.[105] They found a significant improvement in body dissatisfaction only in the mirror exposure therapy group. Despite the positive evidence, a recent[as of?] review suggests that Mirror Exposure has a low-to-medium effect in reducing body image disturbance and further studies are needed to improve it.[106]

Common VR research setting

Another novelty[as of?] 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 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.[30][107] This treatment is promising[according to whom?] but provides, at the moment, only a short-term effect.[108]

hoop training
Hoop Training session

However, other treatments have also recently been developed to integrate tactile, proprioceptive, and interoceptive perception into one's overall body perception: Hoop Training. Hoop Training is a short-term 8-week intervention (10 minutes per session) designed to become aware of and reduce body misperception. Hoop Training is meant to work on the components cognitive, affective, and perceptive of body image disturbance.[12]

Another novelty[as of?] is the Body Perception Treatment (BPT). BPT is a specific group intervention for body image disturbance focused on tactile, proprioceptive, and interoceptive self-perceptions during a body-focused experience.[5] The treatment is consistent with the hypothesized role of interoception in developing body image disturbance by Badoud and Tsakiris in 2017.[45]

Both Hoop Training and Body Perception Treatment showed effective results in pilot studies and were designed to work within a multisensory integration framework.[12][5] However, they complement, not replace, current standard therapies for eating disorders. However, both are also novelty treatments, and the results have not yet[as of?] been replicated in independent studies. Thus, their actual effectiveness will be confirmed/disconfirmed by future research.[speculation?]

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