Body shape perception and its disturbance in anorexia nervosa

Behavioral, neuronal, and physiological facets of multidimensional body image in anorexia nervosa: a scoping review

Body image is a core identity facet in anorexia nervosa (AN). Current literature outlines body image as a multidimensional construct, characterized by perceptual, cognitive, and emotional components, which explain how individuals perceive, think, and behave in relation to their body. The purpose of this scoping review is to uncover neuropsychological disturbances in AN related to body image by focusing on its different behavioral and neuronal assessments, aiming to provide a broad overview of common findings and limitations. Additionally, we explore the role of somato-sensory/somato-motor components and physiological markers underlying body image disturbances, which have not been extensively examined in previous studies. Literature screening was performed across three databases (PubMed, PsycINFO, Scopus). We classified behavioral, physiological, and neuroimaging studies according to their degree of involvement with body image dimensions and discussed the primary findings for each component. A total of 4015 studies were identified, of which 107 were eligible (84 behavioral and 23 neuroimaging studies) based on eligibility criteria, covering research from 1973 to 2024. Notably, of those which specified the following factors: 16 studies focused on the restrictive subtype (AN-r), two on the binge-eating/purging subtype (AN-b/p), and 19 examined both AN-r and AN-b/p; finally four on the atypical subtype; 11 on the weight-recovered state (WR) and three included also male participants. The mean age across all studies was 20.1 years (SD = 3.79). Our findings reveal that body image disturbances in AN are not limited to the overestimation of body size but also encompass cognitive, emotional, and somato-sensory aspects. A strong drive for thinness emerged as a prominent cognitive factor in maintaining the disturbance, along with altered autobiographical recall, executive function, and attentional biases toward body-related stimuli. Emotional regulation difficulties, altered interoceptive awareness, and distorted somato-sensory aspects-reflected in tactile and motor processes-were highlighted. In addition, increased autonomic reactivity to body image stimuli, indicating a sympathetic/parasympathetic imbalance, is supported by specific cortical-subcortical functional alterations. Our review emphasizes that body image distortion in AN should not be viewed merely as a perceptual deficit but rather as a complex cognitive-emotional and somato-sensory process.

The flubbed body: Pathological body size representation in personal neglect

Personal Neglect (PN) is a disorder in which patients fail to attend or explore the contralateral side of their body. An increasing number of studies have considered PN as a form of body representation disorder frequently observed following damage to parietal areas. The extent and the direction of the body misrepresentation is still unclear with recent studies suggesting a general reduction of contralesional hand size. However, little is known about the specificity of this representation and whether the misrepresentation also generalises to other body parts. We explored the features of the representation of the hands and face in a group of 9 right brain damaged patients with (PN+) and without PN (PN-), when compared to a healthy control group. For this, we used a body size estimation task with pictures, in which patients were required to choose the one that most closely matched the perceived size of their body part. We found that PN + patients showed a labile body representation for both hands and face, having a larger distorted representational range. Interestingly, in comparison with PN + patients and healthy controls, PN- patients also showed misrepresentation of the left contralesional hand which could be related to impaired motor performance of their upper limb. Our findings are discussed within a theoretical framework suggesting a reliance on multisensory integration (body representation, ownership, and motor influences) for an ordered representation of the size of the body.

Restlessness and an Increased Urge to Move (Drive for Activity) in Anorexia Nervosa May Strengthen Personal Motivation to Maintain Caloric Restriction and May Augment Body Awareness and Proprioception: A Lesson From Leptin Administration in Anorexia Nervosa

Anorexia nervosa (AN), a disorder of voluntary food restriction leading to severe weight loss in female adolescents, remains an enigma. In particular, the appropriation of the starved thin body into the self-concept in AN is a process insufficiently researched and still poorly understood. Healthy humans undergoing starvation experience a slowing of movements and avoid voluntary exercise. By contrast, AN tends to be not infrequently associated with voluntary, sometimes excessive and/or compulsive exercise. Such deliberate exercise, not reported in starvation, seems to be facilitated by an increased urge for movement and physical restlessness, particular to AN. The increased urge to move would reflect spontaneous daily activity, the energy expended for everything that is not sleeping, eating, or voluntary exercise. Our hypothesis is that the starvation-induced increased urge to move and restlessness may promote the development of AN. Reversal of the fasting state, by either high caloric food or by leptin administration, would be expected to reduce restlessness and the increased urge to move along with improvement in other symptoms in AN. This review explores the idea that such restless activation in AN, in itself and through accelerating body weight loss, might foster the integration of the starving body into the self-concept by (1) enhancing the person’s sense of self-control and sense of achievement and (2) through invigorating proprioception and through intensifying the perception of the changing body shape. (3) Tentative evidence from studies piloting leptin administration in chronic AN patients which support this hypothesis is reviewed. The findings show that short term administration of high doses of leptin indeed mitigated depressive feelings, inner tension, intrusive thoughts of food, and the increased urge to be physically active, easing the way to recovery, yet had little influence on the patients’ personal commitment to remain at a low weight. Full recovery then requires resolution of the individuals’ personal unresolved psychological conflicts through psychotherapy and frequently needs specialized treatment approaches to address psychiatric co-morbidities. AN might be conceptualized as a hereditary form of starvation resistance, facilitated by the effects of starvation on fitness allowing for an exceptionally intense personal commitment to perpetuate food restriction.

Visual mapping of body image disturbance in anorexia nervosa reveals objective markers of illness severity

Body image disturbance (BID) is a core feature of eating disorders, for which there are few objective markers. We examined the feasibility of a novel digital tool, "Somatomap", to index BID related to anorexia nervosa (AN) severity. Fifty-five AN inpatients and 55 healthy comparisons (HC) outlined their body concerns on a 2-Dimensional avatar. Next, they indicated sizes/shapes of body parts for their current and ideal body using sliders on a 3-Dimensional avatar. Physical measurements of corresponding body parts, in cm, were collected for reference. We evaluated regional differences in BID using proportional z-scores to generate statistical body maps, and multivariate analysis of covariance to assess perceptual discrepancies for current body, ideal body, and body dissatisfaction. The AN group demonstrated greater regional perceptual inaccuracy for their current body than HC, greater discrepancies between their current and ideal body, and higher body dissatisfaction than HCs. AN body concerns localized disproportionately to the chest and lower abdomen. The number of body concerns and perceptual inaccuracy for individual body parts was strongly associated with Eating Disorder Examination Questionnaire (Global EDE-Q) scores across both groups. Somatomap demonstrated feasibility to capture multidimensional aspects of BID. Several implicit measures were significantly associated with illness severity, suggesting potential utility for identifying objective BID markers.

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.

Weight and perceptions of body image in women and men in a Sydney sample

Using a modification of the distorting camera technique, 50 obese women (body mass index (BMI; kg/m2 35.1 +/- 1.1), 40 obese men (BMI 38.2 +/- 1.5) and their respective normal weight controls estimated their body size. The obese women, control women and obese men overestimated their body size, whilst control weight men were accurate. The control men were satisfied with their body size, control women less so and the obese were unsatisfied. Whilst the control women considered themselves overweight (BMI 26.7 +/- 0.8 compared to actual BMI 23.1 +/- 0.5, P less than 0.001) their preferred and actual body sizes were identical. There were no differences between obese subjects and controls in the sizes they considered healthy and attractive. The accepted normal size range for a woman was lower than that accepted for men. Older men (both obese and normal weight) accepted larger sizes for women than younger men. These results show that the obese overestimated their body size and supports the notion that there is social pressure on women to strive towards a slimmer ideal, whilst overweight men are more accepted.

Body Image Assessment Software: psychometric data

The aim of the present study was to analyze the psychometric characteristics of the Body Image Assessment Software (BIAS), an innovative interactive computer program developed to assess body image disturbances. The program was tested on 252 psychology students at the University of Barcelona and 51 patients with an eating disorder (ED). The subjects filled in the Eating Attitudes Test-26, the Body Shape Questionnaire, the body dissatisfaction scale of the Eating Disorders Inventory-2, and the Body Image Assessment-Revised (a test of silhouettes). Results showed good validity and very high reliability. Furthermore, BIAS was able to discriminate between people who were at risk of an ED and those who were not, as well as between people with and without a history of an ED. Those at risk of having an ED and those with a current ED showed more body image distortion (overestimation of body size) and higher levels of body image dissatisfaction.

Implications of accuracy, sensitivity, and variability of body size estimations to disordered eating

The current study was conducted to investigate the relationships between body size estimations and disordered eating symptomatology. The method of constant stimuli was used to derive three measures of self-perceived body size in 93 women: (1) accuracy of body size estimations (body image distortion); (2) sensitivity in discriminating body size within blocks of trials (body image sensitivity); and (3) variability in making body size estimations between blocks of trials (body image variability). Participants also completed measures of disordered eating. Although body image distortion correlated with dietary restraint and eating concern, body image variability accounted for additional variance in these variables, as well as variance in binge eating. The relationships involving body image variability were found to be mediated by body dissatisfaction and internalization of the thin ideal. Together, these results are consistent with the proposition that body image variability is a significant factor in disordered eating.

Body image in eating disorders and analysis of its relevance: a preliminary study

The purpose of the present study was to assess body perception in eating disorders and its meaning in therapy. A total of 44 patients, 25 bulimia nervosa and 19 anorexia nervosa, admitted at a specialized in-patient treatment center participated in the present study. Body size estimation procedures (video-distortion and image-marking techniques) and self-report questionnaires were used for the assessment. No significant differences were found in actual body size estimation between the two eating disorder groups, either before or after therapy. It emerged after therapy that the outcome was not related to body size estimation. These findings suggest that there is no evidence for a serious impairment of body perception (size estimation) in eating-disordered patients, but rather for a disturbance in the emotional aspect of body image, as expressed in negative body attitudes. Body size perception does not appear to be a predictor of treatment outcome in eating disorders.

Body image in early-onset obese patients

In a group of early-onset-obesity obese patients eating behaviour, body image and psychological condition were assessed by the Eating Disorder Inventory, the Three Factor Eating Questionnaire, the Body Shape Questionnaire and the Body Attitude Questionnaire. These evaluations were carried out prior to and at long-term follow-up after biliopancreatic diversion when body weight had steadily fallen towards normal values. The aim was to establish the influence of actual body weight and shape over body image. A notable improvement in eating behaviour and overall psychological conditions was observed, while the parameters assessing body image remained substantially unchanged, indicating that early-onset-obesity postobese subjects, despite having obtained normal or nearly normal weight conditions, are still much more dissatisfied with their body weight and somatic morphology than never-obese subjects with very similar actual body weights.

Body-image distortion and mental imagery

This study explored whether body-image distortion is a function of difficulties with imagery or problems with judgment. 49 subjects were given the Modified Video Camera Technique to measure body-image distortion. Mental imagery was measured by a modified version of the Vividness of Visual Imagery Questionnaire and the Spatial Relations subtest of the Woodcock-Johnson Psycho-educational Battery. Visual recall was assessed on the Meier Art Judgment Test. Judgment bias was assessed by the Stunkard Silhouette Method and the shape and weight subscales of the Eating Disorder Examination. Subjects who distorted body-image scored significantly more poorly on mental imagery than those who did not distort. No differences were found between groups on visual memory recall or in judgment bias.

Body image assessment in anorexia nervosa patients and university students by means of video distortion: a reliability study

It is well known that anorexia nervosa is characterized by a disturbed body image. The video distortion method is one of the many methods to systematically study the perceptual aspect of this body image. Using a distorted image of her own appearance, the subject is asked to reconstruct the 'exact' measures of her body and to indicate her ideal image. The reliability of this method has been assessed in a study involving 67 anorexic patients and 105 female university students. Test--retest results within the same session and over a one-week interval were sufficiently constant. Nonetheless, for both anorexics and controls, significant differences were found between estimates with a narrowed (thin) image initially and those with a widened (fat) image initially. Both groups underestimate their body measures and only significantly differ on estimates of their ideal image, with anorexics clearly less underestimating their ideal image than students.

Disturbed body image in patients with eating disorders

OBJECTIVE

The authors attempt to answer the question of whether patients with eating disorders experience more distortions in body image than do individuals without eating disorders.

METHOD

The study group was composed of 214 women out of 230 patients consecutively admitted to an inpatient eating disorders program. Twelve men and four patients with atypical eating disorders were excluded from study. The 214 patients were divided into three groups: 87 with anorexia nervosa alone, 72 with anorexia and bulimia nervosa, and 55 with bulimia nervosa alone. The comparison group was composed of 61 women drawn from 125 consecutive participants in a survey of university students. Fifty-six men were dropped from the comparison group, along with eight women who fulfilled diagnostic criteria for eating disorders. Each subject used a three-dimensional measure to rate her body size and stated her desired body size at seven points: left biceps, left calf, left thigh, waist, abdomen, hips, and bust. The subjects' measurements at each of these points were taken. Distortion in body image was calculated as the subject's perceived body size divided by her actual body size. All subjects were also given a battery of tests of intelligence, skill, and memory.

RESULTS

All three patient groups differed significantly from the comparison group in distortions in body image. Most but not all patients with eating disorders had distortions in their body image.

CONCLUSIONS

If replicated, these findings would suggest that the diagnostic criteria regarding disturbance of body image for both anorexia and bulimia need to be revised.

Body image disturbance in anorexia nervosa: beyond body image

In this paper the literature on body image disturbance in anorexic patients is reviewed. After a decade of experimental investigation of body image in anorexia nervosa, where old and new techniques have been used and where a large number of correlations have been identified, what do we really know? The findings have been conflicting but some regularities exist. It is hypothesized that the conflicting results may be related to the presence of different subgroups among anorexics and different types of body image disturbance. Body size estimation is only one dimension of body image perception. Likewise, body size overestimation is only one aspect of body image perception. Likewise, body size overestimation is only one aspect of body image disturbance. Some, but not all anorexics, overestimate their body size, and those who do, seem to have poor prognosis. Body size overestimation is not confined to anorexics. It is not known whether it is a function of a general perceptual/cognitive disorder, but it does seem to be stable over time. The implications of the presence of other psychiatric conditions in anorexic patients are discussed and suggestions for future research and for practice are made.

Distorting patient or distorting instrument? Body shape disturbance in patients with anorexia nervosa and bulimia

Three current techniques for estimating body size (Image Marking, Visual Size Estimation, and Distorting Video techniques) were compared. Anorexia nervosa and bulimic patients and normal control subjects were required to make size judgments of the way they 'knew' they looked, the way they 'felt' they looked, and of the width of an inanimate control object. Results from the three techniques were not the same, thus implying that research findings can no longer be cross-compared. Moreover, while all subjects were similar in the accuracy of their estimation of a control object, anorexia nervosa and bulimic patients overestimated their own body size significantly more than normal controls. This difference was even more marked when affective instructions were compared.

Anorexia nervosa in a woman totally blind since birth

A 19-year-old woman, blind since birth, lost 26 kg over a 7-month period. This was achieved by restriction of food intake, excessive exercise, laxative abuse, and self-induced vomiting. Although the visual experience is often believed to be an integral component of body-shape perception and the overvaluation of thinness in contemporary society, it does not preclude the development of anorexia nervosa.

Distorted body image in bulimic women

Fifteen bulimic women (DSM III) and 15 women with no indication of an eating disorder, matched pairwise with respect to age, weight and height, were assessed via a distorting video image technique under four conditions. They were asked to: (1) estimate the width of a water bottle, (2) estimate the width of their own body, (3) repeat those estimates under a condition of reward for high accuracy, (4) focus attention on their bodily sensations and indicate how wide their body felt. While groups did not differ in their estimates under condition 1 (water bottle), significant differences were found between groups under conditions 2, 3 and 4 (own body), the percentage of overestimating being highest when subjects were to indicate how wide their body felt. Results suggest that modalities of perception other than visual are strongly involved in the body image distortion of bulimics.

Body image in anorexia nervosa and bulimia nervosa. A review of the literature

Disturbances in body image are often regarded as a cardinal feature of anorexia nervosa and bulimia nervosa. The various approaches to assessing body-image disturbances in anorexics and bulimics are detailed, including body-part size estimation techniques, distorting image methods, silhouettes, and attitudinal measures. The marked inconsistency of findings across studies comparing anorexics or bulimics with some "control" group on body-image variables is discussed in terms of variations in measurement techniques, subject characteristics, and experimental setting. The reliability and validity of existing measures are discussed. Finally, conclusions and recommendations for future research are provided, in addition to a brief presentation of therapeutic approaches to treating body-image disturbances.

Association of Body Cathexis and Morphological Variables on College-Aged Females in an Exercise Setting

The primary purpose of this study was to determine the association and predictability between body cathexis and morphology in college-aged females who were experiencing neither clinical obesity nor anorexia nervosa. The subjects were 41 female college-aged students who were beginning an aerobic dance course. Each subject completed a modified Body Cathexis Scale. The morphological evaluation included 6 skinfold measurements, 8 muscle circumferences, and 6 skeletal diameters. Body fatness and body density were estimated from the triceps, thigh, and suprailiac skinfolds. Somatotypes were determined from the Heath-Carter method. Body parts composing the midtorso were the area of greatest dissatisfaction. Independent t tests between subjects with positive versus negative body-cathexis scores indicated significant differences on 18 of the 32 body-cathexis items but there were no significant differences on any of the morphological variables between the two groups. Zero-order correlations between individual cathexis items, and the morphological variables were computed; 182 of the 924 correlates were significant. Stepwise multiple regression analyses utilized to estimate morphology from body cathexis and body cathexis from morphology resulted in adjusted Rs ranging from .33 to .10. In the present study morphological variables and body-cathexis score had little predictive value or association with each other.

Body size estimation in bulimia

Body size estimation was studied in 22 patients with bulimia and 20 normal controls. Two methods of body size estimation were used, a distorting television image method (DTIM) and the image marking method (IMM). The subjects estimated body size of a dummy as well as their own body on the DTIM. When estimating body size on the DTIM the bulimics overestimated and the controls underestimated, there being a significant difference between the two groups. There was no difference between the groups when estimating the size of the dummy. On the IMM a significant difference was found between the bulimic and control groups, the bulimics overestimating body size and the controls being more accurate. Marked directional effects were found with the DTIM. The two methods of body size estimation are compared.

'Demand characteristics' in body-size estimation in anorexia nervosa

We asked 24 patients with anorexia nervosa and 30 normal controls to estimate their body-size several times, each time using different instructions. The degree of over-estimation was found to vary predictably with the wording of the instructions. Informing the subject that she had made an error without specifying the direction of the error resulted in reduced over-estimation on a subsequent trial, for both anorexics and controls. 'Internally directed' instructions were associated with a greater degree of over-estimation than 'external' instructions in both groups, but particularly in anorexic subjects. Our results indicate the necessity of controlling the 'demand characteristics' of such experiments.

The measurement of body image disturbances in anorexia nervosa. Experimental comparison of different methods

Body image disturbances in anorexia nervosa patients have been assessed in an experimental study which dealt with the following issues: Three different procedures for the assessment of body image disturbances were compared in a discriminant function analysis: a Video Monitor Procedure, the Movable Caliper Procedure and the Image Marking Procedure. The Image Marking Procedure showed the best discrimination between groups. Anorexia nervosa patients showed a statistically significant overestimation as compared to the control group in the variables 'waist', 'upper thigh' and the compound measure 'soft body parts', while they did not overestimate control variables (Kruskal-Wallis-Rank-Analysis of Variance). A standard liquid meal of 240 Kal. had no statistically significant influence on the estimation of body width, irrespective of the amount of calories consumed and instruction given. Possibilities and limitations of various measurement procedures are discussed.