Body image disturbance in children and adolescents with eating disorders. Current evidence and future directions

Disordered Eating and Eating Disorders in Pediatric Obesity: Assessment and Next Steps

While the exact prevalence of disordered eating in youth who are overweight and have obesity has not been determined, studies show that the odds of a young adult (18-24 years) with obesity engaging in disordered eating behaviors is 2.45 times more likely to occur than in young adults with Body Mass Indexes (BMI) in the normative range. The purpose of this review is to highlight the role that disordered eating and eating disorders may play in pediatric obesity and the importance of screening for these conditions. The ability to identify and assess disordered eating alters the course of treatment. Without an understanding of the intersection of obesity and disordered eating, medical providers may continue treatment-as-usual. Doing so may inadvertently contribute to internalized weight bias in patients with obesity and exacerbate their disordered eating symptoms and behaviors. In addition, understanding the spectrum of disordered eating in pediatric patients with obesity allows providers to tailor treatments, discuss food and physical activity differently, and know when to refer patients to eating-disorder-specific providers for continued treatment.

Non-suicidal self-injuries and suicide risk in adolescent girls with eating disorders: associations with weight control, body mass index, and interpersonal sensitivity

BACKGROUND

Eating disorders (EDs) are associated with a risk of premature death, as well as suicidal and self-injurious behavior. A low or high body mass index (BMI) and weight control behavior can also have an impact on self-injurious and suicidal behavior. While some studies show that interpersonal sensitivity is a risk factor for EDs, affective disorders, and self-injurious behavior, in-depth studies of these issues have not been done.

AIM

The present study investigates how self-injurious and suicidal behavior relate to weight control behavior, BMI, and interpersonal sensitivity in adolescent girls from a clinical population with diagnosed EDs compared with adolescent girls from the general population.

METHODS

The main group was comprised of 31 girls with a diagnosis of ED (as the main diagnosis or co-occurring with affective disorders, M=151.13 years), being treated in in the Eating Disorder Clinic of the Scientific and Practical Center for Mental Health of Children and Adolescents named after G.E. Sukhareva. The comparison group consisted of 27 adolescent girls recruited from Proton Educational Center (M=15.511.09 years). The measures included a qualitative survey that yielded data on weight control behavior, and self-injurious behavior, a Blitz questionnaire probing the suicide risk (used only in the main group), and the Interpersonal Sensitivity Measure. Height and weight data were also recorded for BMI calculation.

RESULTS

The qualitative analysis of weight control behavior yielded the following results: purging behavior, restrictive behavior, and corrective behavior. Participants in the main group used purging and restrictive behavior more often, whereas participants in the comparison group used strategies associated with a healthy lifestyle. The main group and participants who practiced purging and restrictive weight control in the overall sample had the smallest BMI. Self-injurious behavior was approximately evenly distributed both amongst the main and comparison groups. Self-cutting was the most prevalent type of self-injury. In the main group, self-injury was associated with a smaller BMI, while in the comparison group it was associated with an increase in the fear of rejection and overall interpersonal sensitivity. Based on the assessment of the suicide risk, six participants in the main group were deemed high-risk; they also displayed increased fear of rejection, dependence on the assessments of others, and overall interpersonal sensitivity. All girls in the suicide risk subgroup had non-suicidal self-injuries.

CONCLUSION

The results of our study broaden our understanding of the risk factors of suicidal and self-injurious behavior in adolescent girls with EDs and reveal the characteristics of the type of weight control behavior used by this group in comparison with adolescent girls in the general population. Girls with EDs who were considered at the risk of committing suicide demonstrated high interpersonal sensitivity, which provides a rationale for further studying the general interpersonal mechanisms that underlie the pathogenesis of EDs, as well as that of self-injurious and suicidal behavior.

Two components of body-image disturbance are differentially associated with distinct eating disorder characteristics in healthy young women

Body-image disturbance comprises two components. The first is perceptual in nature, and is measured by a discrepancy between one’s actual body and perceived self-image (“perceived–actual discrepancy”). The other component is affective, and is measured by a discrepancy between one’s perceived self-image and ideal body image (“perceived–ideal discrepancy”). The present study evaluated the relationships between body-image disturbance and characteristics of eating disorders such as symptoms and related personality traits. In a psychophysiological experiment, female university students (mean ± SD age = 21.0 ± 1.38 years) were presented with silhouette images of their own bodies that were distorted in terms of width. The participants were asked whether each silhouette image was more overweight than their actual or ideal body images. Eating-disorder characteristics were assessed using six factors from the Japanese version of the Eating Disorder Inventory 2 (EDI2). We found that perceived–actual discrepancies correlated with negative self-evaluation (i.e., factor 3 of the EDI2), whereas perceived–ideal discrepancies correlated with dissatisfaction with one’s own body (i.e., factor 2 of EDI2). These results imply that distinct psychological mechanisms underlie the two components of body-image disturbance.

AN-VR-BE. A Randomized Controlled Trial for Reducing Fear of Gaining Weight and Other Eating Disorder Symptoms in Anorexia Nervosa through Virtual Reality-Based Body Exposure

In vivo body exposure therapy is considered an effective and suitable intervention to help patients with anorexia nervosa (AN) reduce their body image disturbances (BIDs). However, these interventions have notable limitations and cannot effectively reproduce certain fears usually found in AN, such as the fear of gaining weight (FGW). The latest developments in virtual reality (VR) technology and embodiment-based procedures could overcome these limitations and allow AN patients to confront their FGW and BIDs. This study aimed to provide further evidence of the efficacy of an enhanced (by means of embodiment) VR-based body exposure therapy for the treatment of AN. Thirty-five AN patients (16 in the experimental group, 19 in the control group) participated in the study. FGW, BIDs, and other body-related and ED measures were assessed before and after the intervention and three months later. The experimental group received treatment as usual (TAU) and five additional sessions of VR-based body exposure therapy, while the control group received only TAU. After the intervention, ED symptoms were clearly reduced in both groups, with most of the changes being more noticeable in the experimental group. Specifically, after the intervention and at follow-up, significant group differences were found in the FGW and BIDs, with the experimental group showing significantly lower values than the control group. The current study provides new insights and encouraging findings in the field of exposure-based therapies in AN. VR technology might improve research and clinical practice in AN by providing new tools to help patients confront their core fears (i.e., food- or weight-related cues) and improve their emotional, cognitive, and behavioral responses to their body image.

Computer Based Body Exposure in Adolescents With Anorexia Nervosa: A Study Protocol

Body dissatisfaction is a core feature of eating disorders (EDs) and plays an essential role in the development and maintenance of anorexia nervosa (AN). In the current study, a computer based body exposure intervention is conducted and evaluated regarding short-term effects on body dissatisfaction, psychopathology, viewing patterns, and stress reactivity. Within a randomized controlled trial (RCT) female adolescents and young women with AN are either receiving the intervention or treatment as usual (TAU). Furthermore, in a transdiagnostic approach, a highly body-dissatisfied group of clinical control participants obtaining the intervention will be surveyed to identify AN-specific processes. The standardized four-session body exposure intervention using photographs of the own body is adapted from a manualized body image treatment program for computer use. Psychopathology (body dissatisfaction, body image avoidance, body checking, depression, anxiety) is assessed via standardized questionnaires before and after the intervention. During each session, attentional biases regarding one's own body are measured via eye tracking, stress levels are measured via subjective ratings, heart rate variability, as well as salivary cortisol and alpha amylase. Between- and within-subject effects will be assessed. The pilot study aims to identify short-term effects of the intervention on body dissatisfaction and attentional bias, as well as to investigate the potential underlying mechanism of physiological habituation.

Body mass index and self-reported body image in German adolescents

BACKGROUND

Despite knowledge about eating disorder symptoms in children and adolescents in the general population, relatively little is known about self-reported and sex-specific eating-disorder-related psychopathology, as well as its specific correlates.

METHODS

880 German school-attending adolescents (15.4 ± 2.2 years) and 30 female patients with AN (16.2 ± 1.6 years) were studied. All participants completed the Eating Disorder Inventory-2 and a Body Image Questionnaire.

RESULTS

There were more overweight males than females (15.2% vs 10.1%, p < 0.001), but more females with underweight than males (6.2% vs. 2.5%, p < .001). Negative body evaluations (p < .001) and dissatisfaction (p < .001) were significantly more frequent in females. Compared to underweight female patients with AN, underweight school-attending females had less negative body evaluations (p < .001) and lower scores on 5 of the 11 EDI-2 subscales (p < .001; p < .05).

CONCLUSIONS

Males were more overweight than females, females more underweight. Body image was more important to female than to male youth, yet without reaching pathological values when compared to female patients with AN. Complex emotional and cognitive challenges seem to be a representative factor for eating pathology rather than simply being underweight. These aspects may be relevant for the shift from a thinness-related focus in girls in the general population to the development of an eating disorder.

Validity of Virtual Reality Body Exposure to Elicit Fear of Gaining Weight, Body Anxiety and Body-Related Attentional Bias in Patients with Anorexia Nervosa

Fear of gaining weight (FGW), body image disturbances, associated anxiety and body-related attentional bias are the core symptoms of anorexia nervosa (AN) and play critical roles in its development and maintenance. The aim of the current study is to evaluate the usefulness of virtual reality-based body exposure software for the assessment of important body-related cognitive and emotional responses in AN. Thirty female patients with AN, one of them subclinical, and 43 healthy college women, 25 with low body dissatisfaction (BD) and 18 with high BD, owned a virtual body that had their silhouette and body mass index. Full-body illusion (FBI) over the virtual body was induced using both visuo-motor and visuo-tactile stimulation. Once the FBI was induced, the FBI itself, FGW, body anxiety and body-related attentional bias toward weight-related and non-weight-related body areas were assessed. One-way analyses of covariance (ANCOVA), controlling for age, showed that AN patients reported higher FGW, body anxiety and body-related attentional bias than healthy controls. Unexpectedly, patients with AN reported significantly lower FBI levels than healthy participants. Finally, Pearson correlations showed significant relationships between visual analog scales and body-related attentional bias measures, compared to other eating disorder measures. These results provide evidence about the usefulness of virtual reality-based body exposure to elicit FGW and other body-related disturbances in AN patients. Thus, it may be a suitable intervention for reducing these emotional responses and for easing weight recovery.

Body image disturbance in children and adolescents with anorexia nervosa and bulimia nervosa: a systematic review

PURPOSE

While several meta-analyses and reviews revealed a worse body image disturbance (BID) in adults with anorexia nervosa (AN) or bulimia nervosa (BN) than in controls, no systematic evidence is available on BID in children and adolescents. Since the usual onset of AN and BN is before the age of 21 years, being aware of BID in children and adolescents is crucial for preventing and treating eating disorders. This systematic review aims to provide an initial overview of differences in the BID components perception, global subjective satisfaction, affect/cognition, and behavior between children and adolescents with AN and BN and healthy controls.

METHODS

We conducted a systematic data search in PubMed and PsycINFO based on a priori eligibility criteria (AN or BN group; gender-matched healthy control group; each group n ≥ 20; maximum age 19 years; BID outcome compared between groups; published in English or German).

RESULTS

We were able to include k = 8 records. Compared to healthy controls, children and adolescents with AN and BN scored higher in the BID components perception, global subjective satisfaction, affect/cognition, and behavior.

CONCLUSIONS

As previously found in adults, BID in children and adolescents is associated with AN and BN. Interventions and treatments are needed to alleviate BID in children and adolescents with BN and AN. We also noted that we need more investigations on BID differences in children and adolescents to improve the database.

LEVEL OF EVIDENCE

Level I, Systematic review.

Body Concept and Quality of Life in Patients with Idiopathic Dystonia

Patients with dystonia experience unusual postures and disfigurement. The aim of the study was to examine changes in the body concept in relation to quality of life and severity of dystonia. Our cohort consisted of 20 patients with idiopathic dystonia resistant to medical therapy who were planned for pallidal deep brain stimulation. The results were compared to 25 healthy controls. The patients were assessed with Frankfurt Body Concept Scale, Short Form 36 (SF-36) Health Survey, Hamilton Depression Scale, Beck Depression Inventory, Social Phobia Inventory and Social Interaction Anxiety Scale. The disease severity was evaluated with Burke-Fahn-Marsden Dystonia Rating Scale and Toronto Western Spasmodic Torticollis Rating Scale. Patients with dystonia had a significantly impaired body concept in eight out of nine subscales in comparison to healthy controls. The differences were most pronounced for the subscales general health, body care, physical efficacy, sexuality and physical appearance (p < 0.001). Furthermore, all eight subscales of SF-36 exhibited significantly lower values in patients with dystonia compared to controls. We also found significant positive correlations between SF-36 and body concept subscales. Impairment of body concept was not associated with disease severity or levels of social anxiety symptoms. However, there was a significant association between self-rated depression and disease severity. Our patients suffered from increased depression and social anxiety symptoms except social interaction anxiety. We conclude that patients with dystonia have significant body concept impairment that interferes with quality of life in both physical and emotional domains. Future studies should focus on assessing these symptoms after adequate therapeutic management of motor symptoms.

Comparison of body image evaluation by virtual reality and paper-based figure rating scales in adolescents with anorexia nervosa: retrospective study

PURPOSE

Assessment of the symptoms of body image disorder (BID) is crucial in anorexia nervosa (AN). Recent technological advancements such as virtual reality (VR) have improved the visual perception with 3D avatars and the feeling to be the avatar with the immersive conditions. This retrospective study examines the hypothesis that VR with standardized 3D avatars would improve body image perception and then body image evaluation by adolescents with AN, compared to the paper-based figure rating scales (FRS).

METHODS

Data of 31 female adolescents with AN were retrospectively studied. Paired data of perceived and desired body forms in addition to body perception index (BPI) (p = 0.2) and body dissatisfaction (p = 0.6), obtained by both VR and FRS were compared. Furthermore, correlation with validated psychometric questionnaires was also studied. Head-tracking technology allowed for the implicit measurement of explicit choices of patients.

RESULTS

Participants with AN overestimated own body size regardless of the assessment tool used. BPI and body dissatisfaction did not differ significantly between FRS and VR. VR-based evaluation was correlated with the psychometric parameters BID and body dissatisfaction. Head tracking revealed significantly longer participant engagement with avatars representing malnutrition and underweight states, while those least engaged corresponded to obesity.

CONCLUSIONS

Results of BID evaluation by VR standardized 3D avatars are comparable to those obtained by paper-based FRS. These findings suggest that comparable results obtained by both tools of evaluation reflect primarily the role of affective-cognitive perturbation in BID. The perceptive component could be better evaluated using biometric-enhanced assessment tools.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study (evaluation data retrospectively studied).

Body-related attentional bias as mediator of the relationship between body mass index and body dissatisfaction

Body image disturbance, consisting of an affective (body dissatisfaction) and perceptual (body distortion) component, is not only found in eating disorders, but is also present in healthy individuals, affecting their psychological well-being and everyday life. A higher body mass index is associated with higher body dissatisfaction, whereas results in relation to body distortion are mixed. Furthermore, body dissatisfaction is associated with a weight-related attentional bias. This study aimed to investigate the mediating role of a weight-related attentional bias in the relationship between body mass index and body image disturbance. Forty-one college women took part in a virtual reality and eye tracking procedure, in which the illusion of owning a virtual avatar with their body measurements was induced. During this procedure, body-related attentional bias was measured and afterwards body image disturbance was assessed. Mediation analysis revealed that weight-related attentional bias mediated the relationship between body mass index and body dissatisfaction (but not distortion). These findings suggest that modifying weight-related attentional bias would be a useful treatment target for improving body dissatisfaction. In addition, virtual reality technology could serve as an innovative method for modifying attentional bias in an ecologically valid way. HIGHLIGHTS: This Virtual Reality and Eye-Tracking study expands our knowledge about the relation between body mass index, body-related attention and body image disturbances. The results suggest that attentional bias towards weight-related body parts mediates the relation between BMI and body dissatisfaction. On the contrary, the relation between BMI and body distortion was not significant.

Neural mechanisms of perceptive and affective processing of body stimuli in anorexia nervosa - are there developmental effects?

Different components of body image processing seem to be reflected by different neural mechanisms. A core symptom of Anorexia nervosa (AN) is a disturbance of body image with correlates found on a neural level. The present study focuses on the neural processing of visual body stimuli of different weight categories in adolescent and adult AN patients. Thirty-three adolescents aged 12-18 years (15 AN patients, 18 control participants) and 36 adult women (19 AN patients, 17 control participants) underwent functional magnetic resonance imaging (fMRI) while performing a perceptive and an affective body image task involving photographic stimuli of women belonging to different BMI categories. Differential effects on activation, depending on the BMI of the women shown in the pictures, were found in frontal brain regions, the thalamus, the caudate and the fusiform gyrus. Group effects differentiating between AN patients and control participants were seen mainly in the caudate and insula. No significant developmental effect was seen. During a perceptive task, diminished activation of regions involved in perceptive and evaluative functions as well as emotional reasoning was seen in AN. During an affective task there was a tendency towards activation differences reflecting reduced ability of size estimation and impaired integration of visual and body perception with emotions.

The Body Image Approach Test (BIAT): A Potential Measure of the Behavioral Components of Body Image Disturbance in Anorexia and Bulimia Nervosa?

A disturbed body image with fluctuating behavioral patterns of body related avoidance (BA) and body checking (BC) characterizes individuals with eating disorders (EDs) such as anorexia (AN) or bulimia nervosa (BN). So far, these behavioral body image components are mostly assessed via self-report instruments thereby neglecting their behavioral and partially automatic characteristics. Therefore, behavioral measures of BA and BC are needed. The present study investigates a behavioral assessment task for BA and BC in a sample of patients with diagnosed EDs and healthy controls. The sample consisted of 40 women diagnosed with either BN (N = 19) or AN (N = 21; ED sample) and 24 non-eating disordered, healthy female controls (HC). Within the Body Image Approach Task (BIAT) participants viewed photos of their own body (self-image) and a matched control body (other-image) by zooming the photos closer toward them (image became more focused) on the screen. The BIAT yields zoom-levels recorded separately for self- relative to other-images. Further measures were attractiveness ratings of these body images as well as questionnaire measures of BA, BC, and general ED symptomatology. Results showed that despite strong body dissatisfaction and clearly negative ratings of self- relative to other-images in both EDs, no group differences were found in approach to self-images on zoom-level as measured with the BIAT. Correlational analysis in each group indicated that zoom-level was positively related to BA scores in the HC group only. Yet, stepwise regression analyses revealed that attractiveness ratings explained most of the variance accounted by BA in predicting zoom-level. In sum, the BIAT seems suitable to assess BA and self-rated body attractiveness, but only in healthy individuals with subclinical levels on these constructs. It does not seem to capture the body image satisfaction or the behavioral components of body image disturbances in AN or BN or it conflates the opposed influences of BA and BC. Further experimentation is needed to adapt measures of behavioral body image components to the processes evoked in patients with ED during confrontation with body images.

Body Image and Body Avoidance Nine Years After Bariatric Surgery and Conventional Weight Loss Treatment

Recently, there has been an increasing focus on body image dissatisfaction (BID), both as a motivational factor for seeking bariatric surgery and as a factor influencing weight loss outcome after surgery. Although associations have been reported between BID, emotional distress and successful weight loss, conclusions are limited due to methodological issues such as non-weight-specific assessment tools for body image and neglect of behavioral components (e.g. body avoidance, BA). The present study seeks to report on BID and BA 9 years after bariatric surgery using a cross-sectional data set from the 9-year follow-up assessment of the Essen-Bochum Obesity Treatment Study (EBOTS). In total, N = 291 participants of the original EBOTS sample were included in the present analyses (N = 78 bariatric surgery patients, SURG; N = 124 patients of a conventional treatment program, CONV; and N = 83 individuals with obesity not seeking treatment, OC). Current body image facets (BID and BA) were captured at the 9-year follow-up assessment via silhouette scales adapted for use in samples with obesity. Moreover, BID was assessed retrospectively to obtain baseline attitudes. Possible influences of eating disorder symptoms and depression/anxiety were controlled for and assessed via standardized self-report measures. The results imply an improvement in BID in the SURG group, but not in the CONV and OC groups. The level of BA in relation to clothing was significantly higher in the CONV group compared to both the SURG and OC group. Current BID as well as BA were positively associated with current body weight as well as depression, anxiety, and levels of disinhibited eating. A positive change from baseline to current levels of BID was associated with successful weight loss, independently of treatment. The findings emphasize the role of the different components of body image after surgery for mental health features, and suggest a robust relationship between BID and weight loss (success). Thus, it might be helpful to address BID in treatment. However, further research, particularly in the form of prospective studies, is necessary to determine the direction of influence.

Eating Disorders: An Evolutionary Psychoneuroimmunological Approach

Eating disorders are evolutionarily novel conditions. They lead to some of the highest mortality rates of all psychiatric disorders. Several evolutionary hypotheses have been proposed for eating disorders, but only the intrasexual competition hypothesis is extensively supported by evidence. We present the mismatch hypothesis as a necessary extension to the current theoretical framework of eating disorders. This hypothesis explains the evolutionarily novel adaptive metaproblem that has arisen when mating motives conflict with the large-scale and easy availability of hyper-rewarding but obesogenic foods. This situation is exacerbated particularly in those contemporary environments that are characterized by sedentary lifestyles, ever-present junk foods, caloric surplus and the ubiquity of social comparisons that take place via social media. Our psychoneuroimmunological model connects ultimate-level causation with proximate mechanisms by showing how the adaptive metaproblem between mating motives and food rewards leads to chronic stress and, further, to disordered eating. Chronic stress causes neuroinflammation, which increases susceptibility to OCD-like behaviors that typically co-occur with eating disorders. Chronic stress upregulates the serotonergic system and causes dysphoric mood in anorexia nervosa patients. Dieting, however, reduces serotonin levels and dysphoric mood, leading to a vicious serotonergic-homeostatic stress/starvation cycle whereby cortisol and neuroinflammation increase through stringent dieting. Our psychoneuroimmunological model indicates that between-individual and within-individual variation in eating disorders partially arises from (co)variation in gut microbiota and stress responsivity, which influence neuroinflammation and the serotonergic system. We review the advances that have been made in recent years in understanding how to best treat eating disorders, outlining directions for future clinical research. Current evidence indicates that eating disorder treatments should aim to reduce the chronic stress, neuroinflammation, stress responsivity and gut dysbiosis that fuel the disorders. Connecting ultimate causes with proximate mechanisms and treating biopsychosocial causes rather than manifest symptoms is expected to bring more effective and sophisticated long-term interventions for the millions of people who suffer from eating disorders.

Essstörungen: Entwicklungspsychologische und entwicklungspsychopathologische Perspektive

Zusammenfassung. Der vorliegende Beitrag betrachtet Essstörungen unter entwicklungspsychologischer und entwicklungspsychopathologischer Perspektive. Körperbildstörungen, gestörtes Essverhalten und der Einfluss beider Eltern werden in den Kontext der normalen Mädchenentwicklung gestellt und insbesondere der Einfluss der Freundinnen und der neuen Medien herausgearbeitet. Bereits bei nicht essgestörten Jugendlichen fallen extremes Diätieren und ängstliche Körperkontrolle, aber auch elterliche problematische Kommunikationsstile und die oft schädlichen Interaktionen mit Gleichaltrigen auf. Die Grenze zu pathologischen Phänomenen ist entsprechend schwer zu ziehen. Hinzukommen hohe Komorbiditäten zwischen verschiedenen Essstörungen und mit internalisierenden und externalisierenden psychischen Störungen. Zeitgeschichtliche Phänomene wie die „holy anorexia“ der vergangenen Jahrhunderte und die gegenwärtig beobachtbare Zunahme an Essstörungen bei Jungen und der Wunsch, das Geschlecht zu verändern (Transgender) werden ebenso betrachtet wie kulturelle Einflüsse („Is fat beautiful?“). In diesem Zusammenhang wird auch der Frage nachgegangen, ob Essstörungen zugenommen haben und welchen Beitrag die neuen Medien dabei möglicherweise haben.

The influence of gender and body dissatisfaction on body-related attentional bias: An eye-tracking and virtual reality study

OBJECTIVE

In the attentional bias (AB) phenomenon, eating disorder (ED) patients show a tendency to pay more attention to self-attributed unattractive body parts than to other body parts. However, little research has focused on gender differences in body-related attention, controlling for body dissatisfaction (BD). This study aimed to assess gender differences in AB toward specific weight- or nonweight-related body parts using a virtual reality (VR)-based embodiment technique and an eye-tracking AB assessment.

METHOD

Forty-five women (23 with high BD and 22 with low BD) and 40 men (20 with high BD and 20 with low BD) were subsequently embodied in three virtual avatars, the first based on the participant's actual measurements, the second being larger than the participant, and the third being the same as the first avatar. The number of fixations and complete fixation time on weight-related areas of interest (W-AOIs) and nonweight-related areas of interest (NW-AOIs) were recorded for the three assessment time/avatars.

RESULTS

The results showed a statistically significant interaction between gender and time for total fixation time and number of fixations (p < .05). BD levels did not significantly affect the results. Overall, women paid more attention to the W-AOIs than men, who in turn paid more attention to the NW-AOIs. Furthermore, preliminary evidence was found for an AB toward muscular-related AOIs among men.

CONCLUSIONS

This study provides new information about gender differences and BD in gaze pattern behaviors. Future psychological ED assessments and treatments could take advantage of the possibilities of VR while real-time AB is objectively measured.

Is This My Own Body? Changing the Perceptual and Affective Body Image Experience among College Students Using a New Virtual Reality Embodiment-Based Technique

Body image disturbances (BIDs) have been widely studied using virtual reality (VR) devices that induce a full body illusion (FBI) and allow manipulation of the individual’s perceptual and affective experiences of the body. This study aimed to assess whether the induction of the FBI over a virtual body would produce changes in body-related anxiety and BIDs using a new whole-body visuo-tactile stimulation procedure. Fifty non-clinical participants were randomly assigned to synchronous or asynchronous visuo-tactile groups. During the pre-assessment, all participants filled in BIDs and body-anxiety questionnaires. Then, they were embodied into two virtual bodies (VBs): firstly, with their real measurements, and secondly, with a larger-size body. Body image disturbances, body anxiety, fear of gaining weight, and FBI levels were assessed after exposure to each avatar. All participants in both conditions showed higher levels of BIDs and body anxiety after owning the larger-size VB than after owning the real-size VB (p < 0.05). The synchronous visuo-tactile group had higher scores, although the differences did not reach statistical significance. This study provides evidence of the usefulness of this new embodiment-based technique to induce changes in BIDs or body anxiety in a non-clinical sample, being suitable for use in future body image interventions.

Perceptive Body Image Distortion in Adolescent Anorexia Nervosa: Changes After Treatment

One key symptom of anorexia nervosa (AN) is body image distortion (BID). For example, AN patients who are asked to perform body size estimation tasks tend to overestimate their body size; this is thought to indicate a distortion of the perceptive component of body image. Although BID is an important treatment objective, only few treatment approaches explicitly target body image, and even fewer target the perceptive component. Moreover, very little is known about how patients' perceptive body image changes after treatment and related weight gain. Consequently, we investigated changes of the perceptive BID in adolescent AN patients at the beginning (T1) and the end (T2) of inpatient treatment using a body size estimation task. A total of 38 AN patients performed the test for Body Image Distortion in Children and Adolescents (BID-CA) within the first 2 weeks of inpatient treatment and at the end of treatment. The results were compared to 48 healthy control (HC) participants performing the same task once. At T1, AN patients overestimated their body size more than HC, i.e., a total overestimation of 33% in AN patients vs. 11% in HC. At T2, AN patients overestimated their arm size to the same degree that they did at TI, but overestimations for the thigh and waist were reduced, and their overestimations for the waist no longer differed from the HC group. Thus, after treatment, AN patients were partly able to more realistically estimate their body size. Several factors may have influenced the observed changes in body size estimation, including task repetition, deliberate adjustment, growing into their preexisting perceptive body image through weight gain, as well as targeted and non-specific psychotherapeutic treatments. In conclusion, the perceptive BID in adolescent AN patients is persistent but also modifiable. Although diverse factors presumably play a role in changing BID, these findings suggest that AN patients may benefit from targeted treatment of BID.

Holy anorexia: Eating disorders symptomatology and religiosity among Muslim women in the United Arab Emirates

There is a substantial body of literature reporting a negative association between religiosity and psychiatric symptoms. In the context of eating disorders, however, this relationship appears to be reversed. The few studies exploring the relationship between religiosity and eating disorders have mostly focused on the Judeo-Christian religious traditions in Western nations. The present study examines this relationship among Muslim college women from the United Arab Emirates (UAE). All participants (N = 1069) independently completed the religious commitment inventory (RCI-10) and the eating attitudes test (EAT-26). As hypothesised, there was a positive association between religiosity and eating disorders symptoms. Furthermore, those scoring above the EAT-26 cut-off reported significantly greater levels of religiosity. These findings suggest that heightened religiosity among young Emirati women may represent a vulnerability factor for eating disorders. Preventative initiatives in the UAE should consider focusing on religiosity.

Depictive and metric body size estimation in anorexia nervosa and bulimia nervosa: A systematic review and meta-analysis

A distorted representation of one's own body is a diagnostic criterion and core psychopathology of both anorexia nervosa (AN) and bulimia nervosa (BN). Despite recent technical advances in research, it is still unknown whether this body image disturbance is characterized by body dissatisfaction and a low ideal weight and/or includes a distorted perception or processing of body size. In this article, we provide an update and meta-analysis of 42 articles summarizing measures and results for body size estimation (BSE) from 926 individuals with AN, 536 individuals with BN and 1920 controls. We replicate findings that individuals with AN and BN overestimate their body size as compared to controls (ES=0.63). Our meta-regression shows that metric methods (BSE by direct or indirect spatial measures) yield larger effect sizes than depictive methods (BSE by evaluating distorted pictures), and that effect sizes are larger for patients with BN than for patients with AN. To interpret these results, we suggest a revised theoretical framework for BSE that accounts for differences between depictive and metric BSE methods regarding the underlying body representations (conceptual vs. perceptual, implicit vs. explicit). We also discuss clinical implications and argue for the importance of multimethod approaches to investigate body image disturbance.

Two sides of the same coin? A new instrument to assess body checking and avoidance behaviors in eating disorders

Body checking (BC) and avoidance behaviors (BA) are the dominant behavioral features of body image disturbances (BID) that characterize most individuals with eating disorders (EDs). Whereas BC can be reliably assessed, a valid assessment tool for BA is lacking, preventing an adequate assessment of BID differences across different EDs (anorexia nervosa, AN; bulimia nervosa, BN; binge eating disorder, BED). A total of 310 women with EDs and 112 nonclinical controls completed measures of BC-, BA- and ED-related symptoms. BA did not differentiate between EDs, whereas BC did: it was highest in AN and BN, and lowest in BED. Multivariate analyses also discriminated AN from BN based on BC. Given that results are of preliminary nature, evidence is promising that EDs can be discriminated from healthy controls and that differential BID profiles for the behavioral component among ED subgroups exist. However, replication of the factor structure remains open within ED subsamples.

Influence of Weight on Shared Core Symptoms in Eating Disorders

In terms of the transdiagnostic model of eating disorders, Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED) share the same distinctive psychopathology. However, empirical evidence showing similarities between these eating disorder diagnoses for core symptoms is scarce, and the role of weight status is unclear. Data from a total of 168 female participants were collected between April 2004 and April 2008, at an outpatient unit specialized in eating disorder treatment. Core symptoms of eating disorders were measured via self-report questionnaires. In particular, women with BED and BN showed similar patterns of core symptomatology compared with AN. However, when body mass index (BMI) was considered in the analyses, there were no differences between the three diagnostic groups in relation to body image. Differences in eating behavior are not solely triggered by weight differences, whereas body image disturbances are a transdiagnostic phenomenon among EDs and should also be considered in the treatment of BED.

Perception and evaluation of women's bodies in adolescents and adults with anorexia nervosa

Body image disturbance in anorexia nervosa (AN) has been widely studied with regard to the patient's own body, but little is known about perception of or attitude towards other women's bodies in AN. The aim of the present study was to investigate how 20 girls aged 12-18 years and 19 adult women suffering from AN compared to 37 healthy adolescent girls and women estimate weight and attractiveness of women's bodies belonging to different BMI categories (BMI 13.8-61.3 kg/m²). Weight and attractiveness ratings of the participant's own body and information on physical comparisons were obtained, and effects on others' weight and attractiveness ratings investigated. Differential evaluation processes were found: AN patients estimated other women's weight higher than control participants. Patients showed a bias towards assessing extremely underweight women as more attractive and normal weight and overweight women as less attractive than healthy girls and women. These effects were more pronounced in adult than in adolescent AN patients. The tendency to engage in physical comparison with others significantly correlated with weight as well as attractiveness ratings in patients. A logistic regression model encompassing own attractiveness ratings, attractiveness bias towards strongly underweight others' bodies and the interaction of this bias with age as predictors differentiated best between AN patients and controls. Our results indicate that females suffering from AN and healthy girls and women perceive other women's bodies differently. Assessment of others' weight and attractiveness may contribute to the maintenance of dysfunctional physical comparison processes.

[A pilot study on the specificity of body image disturbance in anorexia nervosa]

OBJECTIVE

Body image disturbance (BID) is a central feature of anorexia nervosa (AN), but evidence for bodily-related disorders also exists for patients with cystic fibrosis (CF), who are frequently underweight. A comparison of BID in patients with AN, CF and controls serves to clarify the specificity of BID for AN.

METHOD

22 patients with AN, 10 patients with CF, and 23 controls were tested with regard to perceptual and cognitive-affective components of BID. Further data concerning eating-disorder-related psychopathology were assessed.

RESULTS

BID occurred in all patients with AN. Patients with CF perceived themselves as thinner than the controls did, and three of them exhibited BID. Patients with AN and CF did not differ regarding body satisfaction, and only controls showed higher satisfaction than patients with CF. Patients with AN and CF differed on desire for thinness, dissatisfaction with their body, and interoceptive awareness, with higher scores occurring in patients with AN.

CONCLUSIONS

Our pilot study reveals no severe psychopathology concerning body image in patients with CF. However, we did observe a general body dissatisfaction among these patients, probably associated with their being underweight. BID still seems to be a central diagnostic criterion for AN and should be carefully considered during therapeutic interventions.

Adolescent eating disorders: update on definitions, symptomatology, epidemiology, and comorbidity

The prevalence of eating disorders among adolescents continues to increase. The starvation process itself is often associated with severe alterations of central and peripheral metabolism, affecting overall health during this vulnerable period. This article aims to convey basic knowledge on these frequent and disabling disorders, and to review new developments in classification issues resulting from the transition to DSM-5. A detailed description is given of the symptomatology of each eating disorder that typically manifests during adolescence. New data on epidemiology, and expanding knowledge on associated medical and psychiatric comorbidities and their often long-lasting sequelae in later life, are provided.

PreDictor Research in Obesity during Medical care - weight Loss in children and adolescents during an INpatient rehabilitation: rationale and design of the DROMLIN study

BACKGROUND

Obesity in adults and children is increasing worldwide at alarming rates. Obese children and adolescents are likely to become obese adults with increased risk of a number of comorbidities. In addition to preventing the development of obesity at young age, it is necessary to individualize the therapy of already obese children and adolescents in order to increase the likelihood of weight loss and maintenance. Therefore, the aim of this study is to identify predictors which play a significant role in successful weight loss and weight loss maintenance in children and adolescents.

METHODS/DESIGN

Over a one year period, 60 obese children and adolescents between 9 to 17 years of age shall be recruited at an inpatient children rehabilitation facility in Germany. They will be investigated twice within a few days following admission and prior to discharge. The study will be an integrated component of an established inpatient weight-loss and in part psychosomatic therapy. The collected data can be grouped into four clusters: 1) demographic, sociometric and psychometric data, 2) objective and subjective parameters of body condition, 3) autonomic nervous system regulated functions and 4) objective and subjective parameters for eating behavior. Primary outcome is the change of the body mass index standard deviation score (BMI-SDS). In order to evaluate the data appropriately, all examinations will be also conducted in a normal-weight reference group, matched for age and gender.

DISCUSSION

For some of the collected parameters the time span between measures may be too short. Therefore, a 6 months, 1 year and 2 year follow-up will be performed for evaluating the different predictors and their influence in regard to a successful intervention. Further middle- and long-term follow-up studies are planned.

TRIAL REGISTRATION

The study protocol was approved by the Ethics Committee of the University Hospital Tübingen, Germany. This study is registered at the German Clinical Trials Register (DRKS) with the clinical trial number DRKS00005122.