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Working With Disorders of Body Image: A Guide for Mental Health Professionals
Introduction
Most of us are familiar with the classic picture of the beautiful but emaciated young
woman looking into a mirror. From the mirror’s reflection peers her obese counterpart. The
young woman viewing her reflection radiates a sense of profound despair and hopelessness,
yet the observer is often left with the feeling of confusion. How can this thin and attractive
young woman see herself so differently than reality? How can she perceive herself as
somehow deficient? Why is the mirror so distorted?
Although this severe a degree of body image distortion is seen in specific segments of
clinical practice, there is evidence to support the fact that body dissatisfaction is rampant in both
clinical and nonclinical populations, and these concerns span a range of ages and genders.
Petroski (2012) looked at body dissatisfaction among male and female adolescents,
finding that the prevalence of BI dissatisfaction was 60.4% (males = 54.5%, females = 65.7%).
Boys were more likely to wish to increase the size of their body silhouette (26.4%) while girls
wished to reduce theirs (52.4%). Monteath and McCabe (1997) found that 44% of women
verbalize negative feelings about their individual body parts as well as their body as a whole. A
similar survey by Psychology Today found that study respondents were concerned about their
mid and lower torsos, weight and overall appearance. In this study, 56% of female respondents
and 40% of male respondents were dissatisfied with their physical appearance (Cash, 1997).
The later statistics are surprising as body image concerns were once thought to be a “female
problem.” These trends have been conformed in a recent meta-analysis of body image among
college students (Cash et al., 2004).
Differences also exist across ethnic groups. African American women, as compared with
Caucasian women, typically report less body image dissatisfaction (Celio et al., 2002). Among
other ethnic groups, body image dissatisfaction appears to be related to the degree of
acculturation. As Asian and Hispanic American individuals acculturate to American customs,
body image dissatisfaction appears to increase and mirror that of the majority culture (Cash &
Pruzinsky, 2002).
With statistics such as this, it’s no wonder that most clinicians have seen clients who are
dissatisfied with their bodies, or whose sense of physical self is distorted. Body image plays a
role in many disorders including anorexia, bulimia and body dysmorphic disorder. Even the most
casual contact with a client with body image concerns demonstrates how painful this can be,
affecting a client’s sense of self, and feelings about their competence. The case below provides
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an overview of some of the factors related to body image.
Case Study
Paul is a 43-year-old married male. He is seeking the services of Dr. Pine. In the phone
call to set up the appointment, Paul seemed hesitant to provide many details of why he was
coming for treatment, sharing only that there were some issues in his marriage. On meeting
Paul, Dr. Pine immediately noted his physical condition. Although short in stature, it was clear
that Paul was very muscular, likely a weight lifter.
During the assessment, Paul spoke with Dr. Pine about his marital problems. Paul’s wife
of 17 years was considering separation due to Paul’s recent job loss and increasing distance.
Paul had lost the job due to sexual harassment. He stated that he had been talking to a female
co-worker about her body, but that he did not see the harm in it. In session, Paul also
discussed his weight lifting, sharing with Dr. Pine that he was spending about 4 hours per day
on a workout routine that consisted of aerobics and heavy lifting. To help build muscle, Paul
consumed about 150 grams of protein per day. Paul confided that he was not satisfied with his
current progress, stating that he felt “small” and “weak.” Paul was considering purchasing
steroids from a friend at gym. He was not certain how he would do so, however, because his
wife kept track of the budget and was already upset about the amount he was spending on
nutritional supplements. Despite the financial strain, Paul was not yet seeking a new job,
preferring to have the time to focus on his workouts.
During the psychosocial assessment, Paul disclosed that he was born with cerebral palsy.
Paul’s family was quite protective of him, and sought the best treatment they could afford, often
sacrificing their own needs to pay for it. Paul was happy to note that the only continued
evidence of his condition was a slight limp.
As this case illustrates, body image is a complex issue. There are behavioral and
interpersonal consequences of body image concerns. Many factors play a role in body image
distortions and dissatisfaction. This course will explore these issues and provide a framework for
treatment.
Objectives:
After finishing this course, the participant will be able to:
Define body image
Discuss the continuum of body image disturbance
Demonstrate familiarity with body image development
Discuss cognitive processing theory
List common tools for assessment
Discuss DSM-5 disorders related to body image
Describe research about BDD, and its treatment
Discuss pharmacological interventions
Describe approaches to the treatment of body image
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Defining Body Image
What is body image and why is it important? Body image was defined as early as the
1930’s. Schilder (1935) provides the following definition: “the perceptions of the self that are
centered on the individual’s sense of their own physical existence, both anatomical and
physiological.” Similarly Fisher and Cleveland (1968) define body image as “a term that refers to
the body as a psychological experience, and focuses on the individual’s feelings and attitudes
toward his own body.” Slade (1988) also focuses on the affective domain of body image — the
reactions people have to their bodies. He states that body image is “the picture people have in
their minds of the size, shape and form of their bodies and to people’s feelings concerning these
characteristics and our constituent body parts.”
It is easiest to appreciate the complexity of body image by looking at the components of
body image (Cash, Wood, Phelps, & Boyd, 1991). These factors apply to people with healthy
and unhealthy perceptions of their bodies and include:
•
•
•
•
•
•
•
Cognitive—thoughts and beliefs about the body
Perceptual—internal feelings and sensations related to one’s body. This includes
feelings of vulnerability and tiredness and sensations of hunger and fullness
Affective—feelings about the body
Evaluative—judgments about the body
Social—awareness of others' feelings and attitudes
Kinesthetic—sensed fluidity of movement (openness, heaviness, gracefulness)
Affective—feelings about the body
Although these components of body image are relevant for people with and without
clinical disorders, they are particularly helpful to consider when looking at dysfunctional
behaviors. For example, Hilde Bruch (1973), a pioneer in the field of eating disorders, was one
of the first to recognize that the perceptual aspect of body image is key in both anorexia and
obesity. We will look at this in more detail in our discussion of clinical disorders.
Body Image Disturbance
It is helpful to think of healthy versus unhealthy body image as a continuum with levels
of disturbance ranging from none to extreme, with most people falling near the middle of the
range. Clearly delineating where there is “normal” versus “disturbed” body image is sometimes
challenging. Often higher levels of body disturbance are associated with other clinical
conditions, such as eating disorders and depression.
Looking at the idea of a continuum, let’s begin with positive body image. People with
positive body image view their bodies in an affirmative way. They are not unduly influenced by
their weight and have a consistently accurate perception of internal body cues. These
individuals also engage in healthy body-related behaviors, such as moderate exercise, and
appropriate nutritional intake.
At the middle ranges of the continuum there may be some body dissatisfaction. Often
people at the middle ranges experience some affective experience related to their body, such as
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mild depression, and may engage in exercise or dieting in an effort to change their bodies. At
the middle ranges of the continuum, it is important to note that while there may be
dissatisfaction related to body image, there is generally an accurate overall perception.
At the more negative end of the body image continuum, there is more extreme
dissatisfaction with one or more aspects of one’s body (see below) or a more distorted sense
of body size, shape or sensitivity to body cues.
Ann Kearney-Cooke, Ph.D. (1989/2002), a psychologist who has used guided imagery
to explored the symbolic nature of body image disturbance, and has done research into dieting
frequency among college females and its association with disordered eating, body image, and
related psychological problems. Kearney-Cook has found that individuals with unhealthy
observations of their bodies generally experience one of the following:
•
Dissatisfaction with body size—those with body size dissatisfaction accurately
perceive their bodies but are disappointed by the way their bodies look. They may also engage
in unhealthy dieting practices.
•
Concern with body shape—this facet of body image concerns the belief that the body
shape is not acceptable. Those with body shape concerns may exercise compulsively to
achieve a lean or symmetrical look, or may focus on a discrete body part related to shape, such
as the hips for females.
•
Body size distortion—common in all eating disorders, the belief that one’s body is
larger or smaller than it actually is. Those with body size distortion will often lose weight to an
unhealthy level or will gain weight such as through increasing muscle mass.
•
Insensitivity to interoceptive cues—inability to recognize feelings of hunger or satiety.
This is common in people with compulsive eating and bulimia.
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The case study below illustrates many of these components of body image
disturbance.
Case Study
Lindsay is a 16-year-old high school junior, reluctantly seeking treatment with Karen
Chapin, LSW. Lindsay’s parents are concerned with her recent weight loss. She is eating one
small meal a day and has not had a period for the past three months. Lindsay denies that she is
hungry, and states that she forces herself to eat only because she knows her mother will be
angry if she doesn’t. Lindsay seems unconcerned by her weight, which is currently at 75% of
ideal body weight. Lindsay states that she still feels “too big” and that her hips are “huge.”
Lindsay does note that she has been more depressed and is having difficulty sleeping and
concentrating in school. When Karen suggests that Lindsay begin to increase her nutritional
intake, Lindsay becomes tearful and angry, accusing Karen of trying to make her “fat.” Lindsay
storms of session, vowing never to return.
As this case illustrates, perception of body image is often unrelated to weight. Changing
negative body image is critical in treating eating disorders and body dysmorphic disorder.
Negative body image can have wide ranging effects. Feminist object relations theorists such as
Susie Orbach (1982) have demonstrated a relationship between the development of boundaries
and body image. Thomas Cash (2008) also describes several reasons that positive body image
is important. He states that a poor body image can lower self-esteem and create interpersonal
anxiety. Body image is related to gender development and also impacts a person’s sexual
fulfillment. Cash maintains that depression and negative body image are often intertwined. He
calls this interconnection, where a negative body image leads to depression or depression leads
to a negative body image “a vicious cycle of despair” (p. 41).
Body Image Development
Case Study
Kendra is an adult client seeking counseling due to a variety of symptoms related to
body image. She reports that she has struggled with body dysmorphia since late
adolescence. Kendra presents with a notable limp and left side weakness, which she states
are the result of a stroke that she suffered at age 6. In her prior therapy Kendra had
overcome self-injurious behavior that had been quite extreme. She states that as an
adolescent she had such extreme body hatred that she attempted to cut off her limp arm
(impacted by the stroke) with a saw. Her current symptoms include continued body hatred, a
distorted sense of body image, and an overfocus on barely noticeable facial blemishes.
As demonstrated by the case study above, people with negative body image do not
form these impressions in a vacuum. Body image is influenced by biological, familial,
affective and cultural factors. At various developmental junctures different experiences
influence body image.
There is some debate as to when body image development begins. Some theorists (e.g.,
Fisher et al., 1980) believe that it actually begins prior to birth with the preconceived parental
image of what sex they want baby to be and what the baby will look like. Parents generally have
an ideal image of what they would like their child to look like. Upon the infant’s birth, if enough
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similarities exist between the ideal and the actual, parents welcome the infant and provide a
secure base from which body image develops. If parents are unable to reconcile the baby’s
actual physical characteristics with their idealized body image, they may view the infant
negatively, and a poor body image may develop.
Others think that body image first develops in infancy. In infancy, body image is
concerned with kinesthetic, visceral and motor sensation, and an adequate amount of sensory
stimulation is necessary. The infant begins to distinguish his or her body from that of others. In
infancy and early childhood, the parents are the primary influence on the child's conception of
his or her body. Key is how parents respond to normal developmental tasks such as toilet
training and increased attempts at autonomy (Mahler et al., 1975). In the toddler years children
become aware of their own gender through identification with a parent. They also learn about
societal norms, such as males being valued for competitiveness and athleticism (muscles,
strong legs, large arms), and females for beauty (glossy hair, unblemished skin) and smallness
(tiny waist, no hips) (Benninghoven et al., 2007). If a child’s body type or behavior does not
meet these norms, the child may formulate a negative representation. At school age and
continuing into adolescence, the role of the parents decreases, and peer responses become
more important (Erikson, 1963). Popularity is often based on attractiveness, and those
considered unattractive, such as overweight children, may be ostracized.
The teen years are a particularly difficult time with regard to body image. During puberty, the
adolescent female must cope with changes such as emerging curves, weight gain, developing
breasts and menarche. In girls with eating disorders, the lowering of body weight and body fat
levels from self-starvation can arrest the menstrual cycle and delay other body changes related
to puberty. Males experience similar changes in primary and secondary sex characteristics
(voice change, genital development, facial hair) as well as alterations in height, weight and
musculature. These physical changes occur at different rates within age-mates. Blos (1962)
notes that "a change in one's body image and reevaluation of the self in light of new physical
powers and sensations are two of the psychological consequences of the change in physical
status" (p. 7.) He further states that most adolescents are concerned at one time or another
with the normality of their physical status. Habitual negative body image is a psychological risk
factor in adolescents (Verplanken & Velsvik, 2008).
People with a negative a body image may experience difficulty at any of these
developmental junctures. In adolescence, for example, a critical event or series of events (i.e.,
peer rejection, teasing) may precede the perceived appearance defects. Grillo et al, (1994), for
example, examined the relationship of physical-appearance-related teasing history to body
image and self-esteem in a clinical sample of adult obese females. The researchers found that
frequency of being teased about weight and size while growing up was negatively correlated
with evaluation of one's appearance and positively correlated with body dissatisfaction during
adulthood. Similarly Kostanski and Gullone (2007) conducted a quantitative study of the
experience of being teased and body image satisfaction in a group of 431 primary aged
children. The researchers examined the prevalence, type and impact of teasing on children’s
perceived body image satisfaction. The results of the study indicated that many children,
especially those who are over or underweight experience being teased and that this
experience does have a negative impact on children’s body image
Extreme self-focused attention on negative body image leads the adolescent to assume
that others have the same view of their "defect." Cognitive psychologists also point to the
negative and distorted self-statements that individuals make regarding physical appearance;
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thoughts become automatic and deeply ingrained. It is sometimes difficult for individuals to
differentiate these negativistic thoughts from healthier ones as they become so deeply
ingrained.
Another experience commonly thought to influence body image is aging. Much of the
research into body image and aging has been done with women. These studies have supported
the idea that body image is a lifelong concern, and that older women often view a thinner body
as the ideal. Older women who are overweight are more concerned with weight than peers who
are either under-weight or at a healthy weight. Older women are also at more risk for health
problems that could lead to the development of eating disorders, such as obesity, diabetes,
muscle loss, loose skin, thinning hair and variations in bone density.
Research studies of body image and aging have yielded interesting results. Halliwell and
Dittmar (2003) conducted in-depth interviews were conducted with women and men (aged 22–
62 years) to explore their relationships with their bodies. The focus was age-related changes in
body image and attitudes toward the body aging. Analysis of themes revealed in the interviews
demonstrated distinctive gender differences. Men commonly conceptualized their bodies as a
holistic entity, whereas women commonly had compartmentalized their body conceptualizations.
They also construed the importance of their bodies differently: men tended to focus on
functionality, and women tended to focus on display. These findings may help to explain
gendered consequences of body dissatisfaction. Accounts about the aging of the body support
a “double standard of aging.” Women viewed aging most negatively in terms of its impact on
appearance, whereas men reported a neutral or even positive impact on appearance.
Other experiences that may result in negative body image include those that challenge a
sense of control over "ownership" of one's body, such as medical problems or surgeries. The
connection between body image and medical illness was studied as early as 1968 when
Schwab & Harmerling (1968) published a study comparing psychiatric patients with and without
medical illnesses with regard to their perception of body satisfaction. The individuals in the
medical illness group had various types of diseases, including cardiovascular, endocrine,
urogenital, eye and skin disorders. As expected, the researchers found that the medical patients
expressed the most dissatisfaction with those parts of the body affected by illness, but
additionally 20% had very low body-image scores because they were dissatisfied with many
bodily parts and functions. Schwab & Harmerling (1968) theorized that this was due to an
extension of negative feelings toward the body as a whole. Body-image differences were also
revealed between the sexes; the females were much more dissatisfied with their bodies and
their negative attitudes were closely tied to conditions of illness and psychological well-being. In
contrast, males' more negative body images correlated with advancing age and higher
socioeconomic status.
Illness and body image has also been the focus of more recent research studies,
including Bury (2006), Fife & Wright, (2000) and Seawell & Danoff-Burg (2005). These studies
confirm that the experience of a chronic illness may have a negative impact on people’s selfconcept. The social stigma that comes along with serious illnesses can deal affect self-esteem
and body image, as can the physical changes that occur with serious and chronic illnesses,
such as rapid weight loss or gain, hair loss, scarring or lost mobility. Both the physical
experience of illness and the social stigma attached to illness can have negative psychological
effects. These include feelings of fear (of rejection, of loss of control over body and emotions, of
exposure of formerly private things to public view), difficulties maintaining “normal” social
interactions and a loss of self-esteem, with a sense of being different, deficient, or unattractive.
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Seawell & Danoff-Burg (2005) conducted a study to investigate relationships among
sexual dissatisfaction, body image, and physical and psychological functioning in women with
systemic lupus erythematosus (SLE) and a demographically similar comparison sample of
healthy women. For women with SLE, sexual dissatisfaction was positively correlated with
fatigue, depressive symptoms, and feelings of physical attractiveness. No significant differences
existed between women with SLE and healthy women with respect to sexual dissatisfaction or
body image. The results of the study results suggested that the impact of disease on body
image and sexual dissatisfaction are greatest when levels of fatigue and depressive symptoms
are high.
Another type of experience that challenges an individual’s sense of ownership over his or
her body is the experience of having been abused physically or sexually. Individuals who have
been sexually abused often provide the most extreme example of body image disturbances.
Many studies have attempted to investigate the association between experiences of
abuse and body image concerns. Most have been with samples of women with eating
disorders. Miller et al. (1993) studied the relationships between childhood sexual abuse (CSA)
and adolescent onset of bulimia. The study found that adolescents diagnosed as bulimic
reported a higher incidence of CSA than nonbulimic adolescents. Another study by Wonderlich
et al. (1996) looked at female incest survivors who met diagnostic criteria for bulimia nervosa.
The study found that victims of CSA presented with higher levels of other tension-reducing
behaviors than control subjects. These behaviors could include eating disorder symptoms, as
well as focus and distraction on body image as a way of reducing tension.
For those that have been sexually abused, eating disorders may be a way of maintaining
identity and self-esteem, establishing psychological boundaries, or an attempt to create a large
or small body for protection (Schwartz & Cohn, 1996). Manifestations of body image difficulties
may include dissociation from one’s body (splitting off from the traumas inflicted on the body, but
may not be reintegrated, loss of awareness of the body’s cues), numbness (helps to repress the
trauma but may require symptoms to further numb, such as binging or purging), somatization
(holding memories of the abuse within the body), reenactment (e.g., starvation as a way of
keeping “dirty things” out of the body) and repetition (using the body to get needs met, use of
food as soothing).
Case Study
Marla, a 16-year-old high school junior is seeking treatment from Dr. Pinder. In her initial
assessment, Dr. Pinder notes that Marla is presenting with symptoms of depression. The
previously outgoing teen states that she the depression began about 3 months ago. At this time,
her close friend moved, and Marla felt very alone. She recognizes that she uses food to comfort
herself. Marla has gained 20 pounds since her friend left. She states that she feels very badly
about herself due to the weight gain. Marla uses adjectives such as “gross” and “ugly,” which do
not apply. She also shared that her mother has been critical of her and has made comments
such as “if you don’t lose this weight, no one will want you.” Marla would like to feel better, but is
just not certain where to begin.
As the case above illustrates, body image concerns arise from a number of factors and
play a peripheral role in many disorders. These include but are not limited to eating disorders.
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Assessment of Body Image
As may be evident from the definition of body image and cases discussed previously in
this text, body image has a number of components. In order to meet clinical criteria for disorders
of body image, a number of factors may be considered such as preoccupation with body image,
satisfaction/dissatisfaction with body image, distortion of body image and investment in
appearance. While these terms of fairly self-explanatory, the term investment is interesting, and
according to some researchers, such as Cash (2005), this may actually be the most important
measure. Loosely defined, investment is the component of body image that relates to how
important it is to a person’s overall functioning. For example, a woman with anorexia may spend
hours studying herself in the mirror, weighing herself, choosing clothing that makes her look
thinner, or refrain from social events due to the perception that she is “too fat” to go. Clearly this
is an example of an invested person.
While direct clinical questioning about body image is often sufficient to provide a view into
body image, there are also a number of more formal tools that can be used to assess body
image. Body image assessment instruments vary in type. These include self-report measures,
paper-and-pencil inventories, and use of figure drawings to indicate a person's level of body
image dissatisfaction.
Weight-Size Discrepancy
One of the simplest measures of overall weight satisfaction is to compare a person’s
ideal weight with their current weight, and use the difference as an indication of weight
dissatisfaction. This is known as affective-ideal discrepancy. For example, if assessing a
woman who is 5’10” tall, her ideal body weight would be about 150 lbs (plus or minus 10%). If
this woman is 110 lbs., and considers herself to be “overweight,” there is certainly an issue with
weight-size discrepancy. It is interesting to note that the DSM-5 criteria for anorexia no longer
uses the criteria of 85% of ideal body weight as the measure of anorexia, but instead uses the
verbiage “less than that minimally expected.” The DSM-5 does include a severity specifier
based on body mass index.
Another related approach involves using schematic figures of varying sizes from thin
(underweight) to heavy (overweight) and observing the discrepancy between the person’s
choice of their “ideal” figure versus their conception of the figure that matches their current size.
Formal Assessment Tools/Questionnaires
Body image measures also vary in their focus, as will be seen in the description of
several of the Cash (2005) instruments discussed below. Some of the most commonly used
general assessment measures for eating disorders include subscales that address body image
issues, including the Eating Disorder Examination (EDE, 16.0, 2008). A list of some of the most
commonly used measures of body image disturbance can be found in the resource Assessment
of Eating Disorders (Mitchell & Peterson, 2005).
The following is a brief description of some additional measures of body image:
The Eating Disorder Inventory (EDI-3) (Garner, 2004) can be used to assess body image
and related issues. Three subscales of the EDI-3 are particularly relevant for measuring body
image. The body dissatisfaction subscale measures dissatisfaction with overall shape and
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dissatisfaction with size of regions of the body that are of concern to the eating disorder
population, the drive for thinness subscale measures excessive concern for dieting,
preoccupation with weight and fear of weight gain, and the interoceptive awareness subscale is
an indicator of how attuned a person is to the emotional and physical sensations and feelings
including hunger and satiety.
Cash (2008), has developed several useful inventories for clinical work, The Body Areas
Satisfaction Test, The Wishing Well Test, The Distressing Situations Test, The Body Image
Thoughts Test, The Body/Self-Relationship Test. These self-help evaluation tools can be used
with clients to identify specific areas of body image, including areas of body dissatisfaction, how
closely the person resembles their “ideal,” situations that trigger negative feelings about
appearance, cognitive aspects of body image, and the connections between body and selfesteem.
Body Image Assessment (Williamson, 2011). There are several versions of this tool,
including the original, and adaptation for obesity, and one for children and adolescents. The
Body Image Assessment (BIA) was developed as a figural stimulus method for assessing body
image disturbances associated with eating disorders in women. It measures an individual’s
estimate of actual body size and an estimate of the individual’s ideal body size. The discrepancy
between current body size and ideal body size is a reliable and validated measure of
dissatisfaction of body size. The BIA uses silhouettes of nine female figures ranging from very
thin to overweight as test stimuli. Instructions for use are included.
DSM-5 and Body Image
DSM-5 entries that contain body image concerns include:
•
Body Dysmorphic Disorder (BDD) — Preoccupation with an imagined defect in
appearance, manifested by excessive concern about that defect. An individual with BDD has
perpetual negative thoughts about their appearance. In the majority of cases, an
individual suffering from BDD is obsessed with a minor or imagined flaw
•
Anorexia nervosa (AN) — Disturbance in the way one's body weight or shape is
experienced, undue influence of body weight or shape on self-evaluation, or denial or
seriousness of current low body weight.
•
Bulimia nervosa (BN) — Self-evaluation is unduly influenced by body shape and weight.
•
Binge eating disorder — Lack of perception of internal body cues of hunger, fullness
and satiety.
•
Other Specified Feeding or Eating Disorders/Unspecified feeding or eating
disorder (atypical anorexia nervosa, bulimia nervosa of low frequency/limited duration, binge
eating disorder of low frequency/limited duration, purging disorder, night eating syndrome) —
These disorders may or may not include body image concerns.
•
Compulsive eating or obesity —These disorders may or may not include body image
concerns.
Related Disorders
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•
•
•
•
•
Obsessive-compulsive disorder (OCD)
Major depressive disorder or other types of depressive disorders
Self-mutilation
Trichotillomania
Social phobia/agoraphobia
Body Dysmorphic Disorder
Case Study
Alan was a 32-year-old male was referred for therapy due to self-mutilative behavior
dating to high school. At this time he became obsessed with a perceived imperfection in his
teeth. Alan repeatedly scraped the teeth with a knife until he severely damaged the enamel.
Concern subsequently developed about facial blemishes and imperfections, which he admitted
others probably would not notice. Alan repeatedly examined his face and cut at blemishes with
a pin or tweezers, believing they would clear if he cut at them appropriately. He eventually
required cosmetic surgery of the face and neck for resultant scarring. Alan also described
multiple repeating, checking, counting, religious and contamination obsessions and compulsions
that began in early childhood. At age 25, Alan began to pull out scalp, beard, mustache and arm
hair. Depression, generalized anxiety, panic attacks and alcohol dependence further
complicated the picture.
The case illustrates many of the clinical features of BDD. BDD is characterized by a
preoccupation with an imagined deficit in appearance—such as "huge" thighs, "limp" hair or a
"bumpy" nose. Concerns often center on the face or head but may involve any body part. If a
slight physical abnormality is present, the person's concern is extreme, and the patient may go
to extraordinary lengths to hide the perceived defect. The preoccupation must cause notable
distress or impairment in function and must not be accounted for by another disorder (American
Psychiatric Association, 1994). Evidence suggests that BDD occurs with equal frequency in
males and females (Phillips, 1996).
People with BDD are generally secretive about their difficulties. Often it is only after some
time in treatment that patients feel comfortable discussing their body image concerns (Phillips,
1996). Most patients with BDD employ repetitious and time-consuming behaviors directed at
concealing, diminishing or reassuring themselves about the presumed defect. These include
checking behaviors, such as examining the defect in a mirror or reflective surface, camouflaging
the problem using clothing or sunglasses, ritualistic and complex grooming procedures,
comparing their appearance to others and asking for reassurance that the defect is not
noticeable (Phillips, 1996; Veale et al., 1996). Such behaviors resemble the compulsions seen
in obsessive-compulsive disorder (OCD) and may last for hours each day. These efforts are
seldom successful in diminishing appearance concerns. For comprehensive discussions of this
illness see Phillips (1996) and Phillips et al., (2008).
The DSM V has expanded the criteria for BDD is:
A.
B.
Preoccupation with one or more defects or flaws in physical appearance that are
not observable or appear slight to others
At some point during the course of the disorder, the individual has performed
repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking,
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C.
D.
reassurance seeking) or mental acts (e.g., comparing his or her appearance with
that of others) in response to appearance concerns
The preoccupation causes clinically significant distress or impairment in social,
occupational or other important areas of functioning.
The appearance preoccupation is not better explained by concerns with body fat
or weight in an individual whose symptoms meet diagnostic criteria for an eating
disorder.
The DSM-5 also adds a specifier for muscle dysmorphia, which is defined as a
preoccupation with the idea that body build is too small or insufficiently muscular. There is also
a specifier for degree of insight into the BDD. Options for this include good/fair insight, poor
insight, absent/delusional beliefs.
Body dysmorphic disorder (BDD) is associated with substantial suffering and
reduced quality of life. Surveys report widely varying prevalence estimates. Koran et al., (2008)
conducted a recent survey establish the prevalence of BDD. The survey was a random sample
national household telephone survey. The estimated point prevalence of DSM-IV BDD among
respondents was 2.4% (by gender: 2.5% for women, 2.2% for men), exceeding the prevalence
of schizophrenia and bipolar disorder type I and about that of generalized anxiety disorder. BDD
prevalence decreased after 44 years of age, and a larger proportion of BDD respondents were
never married.
There is some concern that the prevalence of BDD is even higher among certain
populations, particularly those individuals pursuing “appearance modifying behaviors” or
cosmetic surgery. Within the past decade, many of the studies on the psychological aspects of
cosmetic surgery have focused on body image. Body image dissatisfaction is believed to
motivate the pursuit of cosmetic surgery (Sarwer & Crerand, 2004). Among patients presenting
for cosmetic treatments, 7 to 15 percent may suffer from the condition. According to
retrospective outcome studies suggest that persons with body dysmorphic disorder typically do
not benefit from cosmetic procedures. Pharmacotherapy and cognitive-behavioral
psychotherapy, in contrast, appear to be effective treatments for body dysmorphic disorder
(Crerand, Phillips, Menard, & Fay, 2005.)
Multi-determined Nature of Body Image Disturbance
What causes this disturbance of body image? Although interest in BDD has increased
in the past decade, one area that remains largely conjectural is the question of what causes
BDD. Based on what we know about similar disorders and about the many factors that
influence body image development, it is likely that the causes of BDD are based on an
interaction between personal and environmental risk factors.
As suggested by the response that many BDD sufferers have to SSRIs, there appears
to be a neurochemical basis that creates a biologic vulnerability to BDD. In discussing potential
biological factors, Phillips (1996) points to known neurological conditions that produce body
image disturbance. Damage to the temporal lobes, for example, can result in anorexic-like
distortion of body size or in facial agnosia. Phillips also talks about the biological implications
of SSRI response, proposing that BDD may be due to an abnormality in the serotonin
neurotransmitter system. Another neurotransmitter, dopamine, which regulates mood, has
also been a target of study. Neurological explanations also include possible brain abnormalities
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that result in a "loop" causing obsessions and compulsions to repeatedly cycle through the
brain.
Biologic vulnerability most likely interacts with personal and environmental risk factors.
Veale et al. (1996) point to an innate perfectionism found in many with BDD. This perfectionism
is seen in many areas, including academics, intelligence and career success. Prior to BDD
onset, premorbid individuals may spend hours perfecting homework assignments, learning
new vocabulary words or setting career goals. Perfectionism becomes centered on
appearance concerns and affected individuals set impossible appearance standards.
Theorists (Phillips, 1996; Veale et al., 1996) also point to the role of self-esteem issues in
BDD and to the influence of early experiences on self-esteem. Related to this are fears of
rejection during adolescence; many individuals who develop BDD report comments and teasing
by peers during adolescence as a causal factor. Perfectionism, concerns about self worth and
fear of rejection may predispose those with BDD to become hypervigilant—overly focused on
appearance.
Therapeutic Interventions for BDD
Several prototypes have proven effective in the treatment of BDD. Evidence
indicates that SSRIs significantly lessen symptoms in the bulk of individuals with BDD;
many also respond well to cognitive-behavioral therapy.
Phillips (1996) discusses a pharmacological approach to BDD, focusing on the role of
selective serotonin reuptake inhibitors (SSRIs). SSRIs increase the amount of serotonin in the
brain by preventing its reuptake. Individuals responsive to SSRIs report abatement or
diminishment of obsessive thoughts. In cases where one type of SSRIs is ineffective, the patient
may try a different medication. If preoccupations diminish but do not disappear,
pharmacotherapy may be combined with cognitive therapy.
Cognitive-behavioral treatment of BDD includes a number of components (Rosen et al.,
1995; Veale et al, 1996). Patients are taught about the cognitive behavioral model and the role
of automatic thoughts on behavior. Individuals may be asked to identify the possible
antecedents of their body image disturbance (i.e., family pressures, sexual abuse and
sociocultural factors).
Exposure therapy, thought stopping and relaxation techniques are used to help
individuals gain control over distressing thoughts and feelings that occur during group exercises.
Automatic and critical thoughts are addressed through cognitive restructuring techniques and
the use of body image diaries. Veale et al. (1996) stress the importance of challenging the
meaning of distorted thoughts. For example, an individual's view that he is ugly is addressed by
discussing the assumption that he or she must be "perfect" to be loved (i.e., ugly people are
worthless). Patients are helped to see the irrationality of these beliefs and to substitute more
accurate thoughts.
The majority of controlled studies to date have focused on cognitive therapy. Further
work is needed to assess the efficacy of insight-oriented or psychodynamic approaches.
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Treatment results have been encouraging, and many with BDD are being helped through
pharmacotherapy, cognitive-behavioral therapy or a combination of these approaches.
A more comprehensive discussion of many of these techniques can be found later in this
course.
Case Study
Anna P., age 12, was referred for treatment due to weight loss and depressed mood. Due
to her low weight, Anna met DSM-IV criteria for anorexia nervosa, but was insistent that she did
not have a "food problem." Anna stated that her dieting was an effort to reduce her "huge
thighs," but that the weight loss "hadn't helped." Anna felt that when she was not dieting, she
ate a range of foods, including those high in fats. She had no difficulty recognizing that she was
overly thin, but continued to be discouraged at her lack of “symmetry.”
Anna continuously looked at magazine advertisements; she reported that she spent
several hours a day doing this. She would painstakingly focus on each part of every model's
body, lingering on long "glossy" hair and symmetrical "perfect" facial features. Anna was
hesitant to discuss her own perceived deficits in detail, but in comparing herself to peers she
described her appearance as "geeky." She was also often seen looking into mirrors or reflective
surfaces. In actuality, Anna was an attractive adolescent with long thick hair.
Anna was shy and had few peer relationships. She was a conscientious and gifted student,
however, her grades were beginning to fall, due to her preoccupation with her appearance.
Despite her excellent grades, Anna’s self-esteem was poor. Her mother and father set high
expectations for her and frequently compared family members' accomplishments. They
expressed few emotions regarding Anna's weight loss, except to say on admission that we'd find
Anna "quite well disposed" and amenable to treatment.
Anna was treated using a combination of factors including work on body image and selfesteem. She was also started on a trial of Fluoxetine. After several months of treatment Anna's
"checking" behaviors had reduced substantially and she was able to gain weight to within
normal ranges.
This case illustrates the complexity of behaviors associated with body dysmorphic
disorder, as well as the possible issues in differential diagnosis. In cases such as Anna’s it is
often difficult to determine whether eating disorders are an accurate diagnosis or whether body
dysmorphic disorder is more applicable. In Anna’s case the later was likely a better diagnosis.
Before continuing with a discussion of how to treat body image concerns, we will
discuss other disorders of body image, most notably the eating disorders.
Anorexia, Bulimia and Obesity
Body image distortion is a component in anorexia, bulimia, and obesity (Cash & Deagle,
1997). Although several similarities exist between BDD and disordered eating, such as faulty
body representation and compulsivity of the behaviors, there are a number of dissimilarities.
There is a marked gender difference in the prevalence of eating disorders with more females
diagnosed with eating disorders. Estimates of male-to-female ratio range from 1:6 to 1:10
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(Fosson & Knibbs, 1987) for anorexia and bulimia. In addition, men and women with eating
disorders have concerns about body image, as well as concerns about food and weight. Those
with eating disorders have obsessive thoughts of food or about fatness, but not obsessive
thoughts of a body part, and restricting or bingeing is a metaphoric expression of psychosocial
difficulties. In anorexia and bulimia, food is used as a "coping mechanism"; stress may cause
the bulimic to binge to soothe stressful feelings and the anorexic to restrict to be more in control.
Eating disorders have been reported in up to 4% of adolescents and young adults. The
most common age of onset for anorexia is the mid-teens although in 5% of the patients, the
onset of the disorder is in the early twenties. The onset of bulimia is usually in adolescence but
may be as late as early adulthood (American Psychiatric Association, 1994).
The DSM-5 criteria for anorexia includes restriction of food intake relative to requirements,
leading to a significantly low body weight in the context of age, sex, developmental trajectory,
and physical health. Significantly low weight is defined as a weight that is less than minimally
normal or, for children and adolescents, less than what is minimally expected. With anorexia,
there is also an intense fear of gaining weight or becoming fat, even though at a low weight, and
persistent behavior that interferes with weight gain. The DSM-5 diagnosis of anorexia also
includes specifiers for type (restricting type, binge-eating/purging type), remission status if
applicable (in partial remission, in full remission), and a severity specifier based on body mass
index (mild, moderate, severe or extreme). The level of severity is used to indicate functional
disability, to reflect clinical symptoms, and the need for supervision).
In terms of body image, in individuals with anorexia there is a disturbance in the way in
which one's body weight or shape is experienced, undue influence of body weight or shape on
self-evaluation, or denial of the seriousness of the current low body weight. The most notable
disturbance is anorexic client's defense of his or her emaciated body. The anorexic may profess
an overall denial of his or her thinness. Anorexics may be of the restricting type or the binge
eating/purging type.
Bulimia differs in some ways from anorexia but still contains features of body image
disturbance. People with bulimia engage in cycles of binge eating and purging. During a binge
episode, a person consumes a large amount of food usually in a rapid fashion. It is important to
note that while there are no specific guidelines on how much food constitutes a binge episode, it
is helpful to assess whether a self-reported binge may be more reflective of a period of
overeating, rather than binging. This can often be seen in whether the person feels a sense of
lack of control over eating. Another essential feature of bulimia is the use of compensatory
behavior to prevent weight gain after a binge. Compensatory behaviors may include vomiting,
laxative abuse, misuse of diuretics or other medication (including insulin) use or excessive
exercise. In order to meet clinical criteria for bulimia, the binge eating and inappropriate
compensatory behaviors occur, on average, at least once a week for three months. The DSM-5
includes a specifier for severity (mild = an average of 1-3 episodes of inappropriate
compensatory behaviors per week, moderate = 4-7 episodes, severe = 8-13 episodes, and
extreme = 14 or more episodes.
As with anorexia, a person’s self-evaluation is unduly influenced by body shape and
weight (American Psychiatric Association, 2013). People with bulimia often have very low selfesteem, and depression is a frequent co-morbid diagnosis.
The DSM-5 has added Binge Eating Disorder as a diagnosis. Binge eating disorder is
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similar to bulimia, but individuals with binge eating disorder do not engage in compensatory
behaviors. The criteria for binge eating disorder include episodes of binging behavior and a lack
of control over eating. Binge–eating episodes are associated with eating more rapidly than
normal, eating until feeling uncomfortably full, eating large amounts of food even when not
feeling physically hungry, eating alone because of feeling embarrassed by how much one is
eating and feeling disgusted with oneself, depressed or very guilty afterwards (three of these
criteria must be met).
While the formal criteria for binge eating disorder does not contain a descriptor specific to
body image, in clinical practice many individuals with binge eating disorder, have similar body
image concerns as the previously discussed eating disorders. Men and women with both binge
eating disorder and bulimia have a significant degree of insensitivity to interoceptive cues, that
is, an inability to recognize feelings of hunger or satiety. This is common in people with
compulsive eating and bulimia.
According to the DSM-5, binge eating disorder is often associated with overweight and
obesity but has several features that make it unique. Most pertinent to this text, however, is that
the levels of over evaluation of body weight and shape are higher in obese individuals with
binge eating disorder than those without the disorder.
As obesity is a medical condition, there is no formal DSM diagnosis specific to obesity.
Medically, a person is considered obese if they are 20 percent over their ideal weight. That ideal
weight must take into account the person's height, age, sex, and build. Obesity has been more
precisely defined by the National Institutes of Health (the NIH) as a BMI of 30 and above.
Depending on the behavioral manifestation of obesity, symptoms may merit a diagnosis of
“Unspecified Feeding or Eating Disorder.” Obese individuals vary in the way they perceive
themselves. People who became obese in adulthood generally have more realistic body image
than those with life-long obesity. Some may avoid looking in mirrors or seeing themselves.
There are many facets of body image disturbance connected with eating disorders. In
addition to a self-evaluation that is unduly influenced by body shape and weight, there is often a
misperception of bodily functions. Bruch (1973) was one of the first to discuss this problem,
which she labels as difficulty with “interoceptive awareness.” Those with eating disorders are
disconnected from body perceptions, such as feelings of tiredness or sensations of hunger or
fullness. Anorexics, for example, may complain about feeling full after one bite of food. There
may also be a magical quality to the impact of weight loss and the body in anorexia, such as the
belief that the body can continue to function on minimal amounts of food or that the person can
perform a workout or dance routine after having consumed minimal calories. Disconnection
from sensations of hunger or satiety may be found in anorexia, bulimia and compulsive eating.
Another aspect of body image disturbance that applies to many people with eating
disorders but cannot be generalized to all persons with eating concerns is misperception of
sexuality or the sexual role. The psychoanalytic view of women with anorexia is that they
express rejection of sex or pregnancy. Anorexic young women tend to exclude awareness of
curves and breasts from body image. Some anorexic patients report that they wanted to be the
opposite sex in childhood. Men who have been obese from childhood sometimes express
doubts about their masculinity. There is some evidence that this may also be a rejection of sex
role stereotype of "rough" boy. Men who become obese in later life may see obesity as sign of
status.
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Multi-Determined Nature of Eating Disorders
Eating disorders arise from a combination of long-standing psychological,
interpersonal, and social conditions. Those who have eating disorders may experience
feelings of inadequacy, or depression, or have troubled relationships.
Between one-third and one-half of patients report having struggling with depression or
anxiety prior to developing an eating disorder. These problems were severe enough that the
individuals felt out of control and unable to manage symptoms. Restrictive eating, excessive
exercise, and/or binge-purge behavior may be used as a way to contain or manage depression
and anxiety (Johnson, nd).
Johnson (nd) describes the following precipitants of eating disorders. While this list is not
exhaustive, it provides some guidelines.

Life transitions/Major life transitions — Many with eating disorders have
difficulty with change; these changes may be things that others of a similar age
or circumstance may be able to manage much more easily. Transitions such
as the onset of puberty, entering high school or college, a family separation or
divorce, or a major illness or death of someone close cause some to feel a loss
of control that they cope with by using eating disorder behaviors.

Family problems/boundary issues — Boundary issues are common in
families of those who develop eating disorders. Families of those who develop
anorexia are often enmeshed and/or controlling and in families of those with
bulimia there may be distance. Eating disorders can help a person to feel that
they can control something (i.e., their body shape and size or food), can be
used as a way to individuate or to rebel, or can be a way to distract from
feelings of disconnection. Anorexia or bulimia may also be ways that someone
connects with the family or distracts others from difficult family issues.

Low self-esteem — Self-esteem is defined by Silverstone as "the sense of
contentment and self-acceptance that stems from a person's appraisal of their
own worth, significance, attractiveness, competence and ability to satisfy their
aspirations" (Silverstone 1992) Many people who develop eating disorders
report having low self-esteem before the onset of their eating problems. They
may believe that this is due to being “fat” and that weight loss will help raise
self-esteem. Another author, Hanlon (nd) states that when women and girls are
insecure about their identity, they often shift the focus from their inner selves to
their physical bodies, allowing their physical appearance to become their sense
of self.

Perceived failure — There is often a perfectionistic and driven quality to those
with eating disorders; this is a personality trait they are born with. Perceived
“failures” (which are often distorted) can lead to feelings of shame, guilt or low
self-worth. Many times these failures involve not performing to a peak, such as
receiving a “B” in a class, or not accomplishing a goal that was set. Eating
disorder symptoms can provide a distraction from these feelings.

Trauma — As mentioned previously, there is evidence that between one- third
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and two-thirds those with eating disorders have histories of sexual or physical
abuse. Eating disorder symptoms may be an attempt to cope by consciously or
unconsciously avoiding further sexual attention by losing enough weight to lose
their secondary sexual characteristics (for instance, breasts). Weight gain or
severe weight loss may be a way to make oneself unattractive to potential
abusers.

Illness or injury — Illness or injury can result in an individual feeling
defenseless or out of control. Many people with eating disorders report a
history of childhood illness or develop eating disorder symptoms following the
onset of a chronic illness. Anorexia and bulimia can be attempts to control or
distract from such events.

Caroline is a 35-year-old single woman presenting for therapy with Dr. Milozi. In her initial
phone call with Dr. Milozi, Caroline stated that she would like to come to therapy to work on
long-standing issues with depression. She reported that she was having crying spells and
difficulty sleeping. In their first session, Dr. Miozzi noticed several things. Caroline presented
with depressed and flat affect; she had clearly been crying prior to the session. She was also
extremely obese, and had difficulty sustaining eye contact. In assessing for the presence of
eating disorders, Caroline stated that she had been overweight since her teens and that she
knew that her eating patterns were poor. She described a pattern of restricting food intake
during the day (no breakfast and a yogurt for lunch) then eating dinner. Her most difficult
times both for eating and depression were after dinner. Caroline described this time as a
period when she “ate constantly.” She felt that food had always been a comfort, and a way
of coping. Caroline was unable to identify any other coping skills that she had used. Social
contacts were minimal, and Caroline has never seriously dated anyone. In response to this
query she questioned “who would want someone who looks like me?”

As Caroline and Dr. Milozi continue to work together, Caroline became more disclosing. She
revealed that she had been molested by her grandfather from the ages of 6 to 13. The abuse
had occurred in the evenings when her mother was working. The abuse stopped after she
reached puberty and had begun to gain weight. Dr. Milozi pointed out that this defense had
served her well as a teen but that as an adult it was no longer needed. As Caroline and Dr.
Milozzi continued to work together on the abuse issues and on positive coping skills,
Caroline began to binge less and gradually reduced her weight. Her body image became
more positive and she began to express some interest in dating and socializing.
As the case above illustrates, trauma is a factor in the development of body image issues
and eating disorders. The factors described by Johnson (nd) are helpful in understanding
some of the reasons people develop eating disorders. Another interesting viewpoint is that
of feminist authors (e.g., Gutwill, 1994; Myers & Crowther, 2007; Orbach, 1982) who point to
our cultural idealization of thinness. Sociocultural theories focus on the messages contained
media advertisements. The message: that appearance is the key to happiness. Gutwill
(1994) describes this "beauty myth": "Targeting both the most primitive of people's needs
and their more adult aspirations, mass culture has aimed at nothing less than
institutionalization, the rationalization of fantasy life around sales that focus predominantly on
... beauty" (p. 11). These ideals, in themselves unrealistic due to the inhuman thinness of
models and the liberal use of airbrushing, results in impossible standards few can attain.
Often people who develop eating disorders strive for the same unrealistic standards of
appearance.
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A topic that has received increasing attention is that of eating disorders in men (see Halliwell
& Orsborn, 2007; Pope et al., 2000;). Although some men with eating disorders closely
resemble their female counterparts, eating issues may differ in this population. Pope et al.
(2000) describe phenomena that they call the “Adonis Complex.” They point to men that engage
in compulsive behaviors such as excessive workouts, steroid abuse and a have a distorted
perception that they are not muscular enough. They may eat limited quantities of foods, eschew
carbohydrates, and consume unhealthy amounts of protein. The case study above is an
example of the way that this “Adonis complex” may manifest. As with feminist theorists, Pope
and his colleagues state that the Adonis complex is related to societal norms that tell men that
they should be aggressive and competitive and have the body build to promote these ideals.
Most clinicians treating eating disorders emphasize importance of treating body image
distortion for recovery and relapse prevention (rectifying distortions and developing positive
attitude toward the body). Some research suggests that neglect of body image therapy may be
one reason for poor long-term treatment outcomes in eating disorders (Levine & Pinan, 2004).
Treatment of Body Image Disturbance
It is clearly important to address the role of body image distortion in both eating
disorders and body dysmorphia. Kearney-Cooke (1989) describes three critical steps to
addressing body image disturbance. These steps are:
(1) To reconstruct the individual's history of body image development and work
through key issues (family, trauma, etc.)
(2) To help clear up distortions of body image and assist clients in attaining
realistic expectations (e.g., goal weight)
(3) To help clients face the loss involved in developing a positive body image in
which the body is accepted as a positive source of feelings, physical needs, and
information about one's self
The first step in treating body image disturbance is a client assessment. The clinician
must try to determine the extent of body image concerns and distortions. For example, are body
concerns centered on a specific body part or parts? Do they involve the misperception that one
is “fat?” or that a certain area or part of the body needs to be changed in some way? Sources of
information include projective measures (such as drawings), guided imagery exercises (see
Hutchinson, 1985) and surveys (see Cash, 2005) or use of the formal assessment tools
discussed earlier in this material. The clinician may also begin with thought logs focused on
body image, and which can yield important information on the affective components of body
image, asking a client to keep track of negative body cognitions. A related issue and ongoing
component of body image treatment involves psychoeducation. In the initial stages of treatment
it is often helpful to normalize body image concerns by sharing universality of body
dissatisfaction, the idea that especially for women body image may be fluid and changing, but
that when body image dissatisfaction is pervasive or affects overall function, or when it is
distorted (belief that one is fat even when emaciated), it is then problematic.
After assessing the degree of body image distortion or dissatisfaction, it is beneficial
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to explore factors in the person’s body image history. One of the simplest approaches is
developmental. Cash (2008) for example, breaks down body image by stages (early
development, school age, puberty, etc.). Clients may be asked how they felt about their
bodies at each of these stages and whether there were any events that may have affected
their body image in a positive or negative manner. For example, early or late development,
teasing, or experiences that resulted in a lack of body efficacy may have played a role.
Often the feelings or associations related to these events continue to influence a person.
Jasper (1993) suggests an alternate approach to body image history in which the
participant is asked to respond to aspects of body image, such as “how parents, relatives
and siblings reacted to your body”; “your experience of sexuality”; “accidents illnesses and
surgeries” and other pivotal events. In instances where a person has experienced trauma,
working through traumatic events and making connections between trauma and body
image is key. Another helpful factor to explore at this stage are sources of body distress—
things a client may avoid due to negative body feelings.
One such exercise is a psychodramatic technique called the “Mirror Exercise” (Callahan,
1989). Group members face an area of the wall that is an imaginary mirror. They then visualize
themselves, describing what they "see." Each person assumes the role of someone significant
in his/her life that might think something similar. Following this, person asked to then assume
the voice of someone who supports him or her and appreciates his or her struggle.
Another experiential technique for correcting body image distortion is Image Marking or
Body Tracing. In this technique the person is asked to draw his or her body or disliked body
part as accurately as possible. A group member then traces the body [part] providing a look at
what is realistic. There is often a significant distortion between what the individual with the
body image distortion draws, and the actual body or body part. Some variations on the body
tracing exercise are to have the person write strengths of each part of the body on the tracing,
or to have the person speak to their body. When seeing a client in an individual treatment
setting, the therapist can assume the role of the group member.
In the early stages of body image work it is also important to promote self and body care
(Jasper, 1992). This involves helping the individual to see that there are many positive ways to
care for one’s self and one’s body. Positive self-care includes appropriate nutrition, rest,
exercise (if not contraindicated by the eating disorder), and activities such as massage or selfmassage. Yoga is particularly good for helping the client to establish the mind-body connection,
and many cities have yoga studios that offer classes that are specific to body image. For men
and women with trauma histories, many of these self-care activities are difficult, but are
important to healing body disparagement as well as trauma.
Relaxation training can provide important skills for clients to face distressing situations.
There are many types of relaxation training. These include meditation, counting breath
meditation, or may involve use of a positive affirmations a positive mantra (“I feel at peace”),
deep breathing, mindfulness, or body scanning. It is beneficial to teach these skills before
attempting things like desensitization or exposure (e.g., for treatment of body dysmorphia). In
terms of the later, the client should assess forms of avoidance, such as practices, (i.e., being
photographed, eating in front of others), places, (i.e., the beach), poses (i.e., sitting or standing
during interactions) and people. Recent studies have found that exposure can be helpful in
decreasing negative body emotions (Vocks et al., 2008). Exposure therapy helps clients to
begin to do those things that they have avoided. It is particularly helpful to encourage social
interaction.
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Response prevention refers to eliminating rituals and maladaptive behaviors associated
with disordered body image. Tasks that fall under this realm are those such as such as having
client weigh his or herself less frequently, inspecting his or herself in mirror less often, stopping
complex grooming rituals, or asking others for reassurance. Begin by restricting rituals (i.e.,
determining how long a ritual takes and limiting it to less time). For example, clients who must
check their appearance every 10 minutes may be asked to do it every 15, 20, 25, etc. You can
then establish specific times that rituals occur. Clients encouraged to developed positive body
experiences such as breathing exercises, exercise, movement, massage, etc.
The final stage of body image work involves helping clients face the loss involved in
developing a positive body image. For many people, body image concerns have been
longstanding and have at one time served an adaptive purpose. Giving up these behaviors may
involve a grieving process, but will enable people to live a healthier and fuller life.
After reconstructing body image history, therapeutic interventions can then focus on helping
to clear up distortions of body image and assisting people in attaining realistic expectations of
body image. Clients must learn to verbalize body dissatisfaction and correct distortions in body
image and self-statements. Thought logs and cognitive restructuring are useful tools. Many
theorists advocate the use of group work in correcting body image distortions (e.g., Jasper,
1992). In situations in which body image work can be done in this type of setting, clients may be
asked to explain as concretely the nature of distressing aspect of their appearance and be
provided with objective feedback from group members. There are also a number of experiential
exercises that may help to correct body image distortion. These include but are not limited to
techniques using guided imagery, art therapy, psychodrama, and poetry therapy.
Feminist Approaches to Body Image
Recent years have seen an uptrend in the feminist approaches to looking at body image.
One of the distinguishing features of the feminist approaches is that there is a definite trend
away from changing a woman’s appearance (such as through diet or exercise). Feminist
theorists instead focus on encouraging women to look critically at cultural demands for thinness
and to accept and celebrate the bodies that they have.
Perhaps the most often discussed trend is the “Health at Any Size” trend (Robison, 2005).
While this actually began in the 1960s, it is gaining increasing popularity in the eating disorder
communities. The major components of HAES are:

Self-Acceptance: Affirmation and reinforcement of human beauty and worth irrespective
of differences in weight, physical size and shape. This decreases emphasis on the need
to maintain an impossible ideal of thinness.

Physical Activity: Support for increasing social, pleasure-based movement for enjoyment
and enhanced quality of life, rather than physical activity for the sake of burning calories
or losing weight.

Normalized Eating: Support for discarding externally-imposed rules and regimens for
eating and attaining a more peaceful relationship with food by relearning to eat in
response to physiological hunger and fullness cues. This is also known as intuitive
eating.
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A table contrasting the HAES approach to traditional approaches to food and body image
is contained below (Robison, 2005).
Comparing The Underlying Assumptions
Traditional Weight Loss Paradigm
Everyone needs to be thin for good health
and happiness
Health At Every Size
Thin is not intrinsically healthy and beautiful, and
fat is not intrinsically unhealthy and unappealing
People who are not thin are “overweight”
because they have no willpower, eat too
much, and don’t move enough
Everyone can be thin, happy and healthy
by dieting
People naturally have different body shapes and
different preferences for physical activity
Dieting often ultimately leads to further weight
gain, decreased self-esteem, and increased risk
for disordered eating. Health and happiness
involve a dynamic interaction among the mental,
social, spiritual and physical considerations
Cognitive Remediation Therapy
One interesting approach to treating body image concerns is the use of cognitive
remediation therapy. Research into body image is beginning to look at the neuropsychological
aspects of how men and women with body image deficits cognitively process information. Of the
groups discussed in this training material, the population that has been widely included in
neuropsychological studies are men and women with anorexia nervosa. Many of these studies
have been conducted in European countries, but there are wide-scale efforts to replicate them in
the United States (see Tchanturia et al., 2008; Whitney, Easter, & Tchanturia, 2008). There is
robust evidence from neuropsychological laboratory research to suggest that patients with
anorexia exhibit the trait of cognitive inflexibility or poor ‘set-shifting’ (Roberts et al., 2007) . Setshifting entails changing one’s responses according to environmental contingencies. There is
also good evidence that people with anorexia and other disorders of body image exhibit an
excessively detailed information-processing style, with neglect of the gestalt. They, therefore,
overly focus on one aspect of appearance or body that they dislike (hips, nose, symmetry, etc.)
rather than focusing on overall appearance (Tokley & Kemps, 2007; Davies & Tchanturia.
2005).
Cognitive Remediation Therapy (or Cognitive Enhancement Therapy) is designed to
enhance an individual’s skills and improve neurocognitive abilities in areas such as cognitive
flexibility and planning, set-shifting and working memory (Hogarty, 2004; Davies & Tchanturia.
2005). Cognitive Remediation Therapy works to identify and target the cognitive impairments
specific to each patient, and to motivate the patient to engage in meta-cognitive processes.
What is unique about cognitive remediation therapy is that it does not specifically target
cognitions connected to the eating disorder (e.g., such as the thought that a person is fat) but
instead utilizes fun activities. A typical sequence of cognitive remediation therapy may be :

Explaining cognitive remediation therapy and its goals

Identification of cognitive style(s) by playing and by doing exercises, games and puzzles
(such as “Similarities and Differences,” “Up and Down” game).
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
Discussing current thinking styles, how these relate to real life, their pro’s and cons, and
explore new ways of thinking

Promoting thinking about thinking (i.e. meta-cognition)
Prevention Strategies
Prevention programs attempt to intervene with children and adolescents prior to the onset
of clinically severe body image disturbance, results have been mixed. Some of the goals for
early intervention are acceptance of diverse body shapes (including the common changes of
puberty), understanding of proper nutrition, discussion of the long-term negative effects of
dieting. And development of strategies to resist teasing, pressure to diet and misinformation
about the importance of thinness (Smolak & Levine, 1994).
Conclusion
Body image plays a role in many clinical disorders including anorexia and bulimia and
body dysmorphic disorder. Distortions in body image are painful and can influence self-esteem
and competence, and diminish social and occupational functioning. It is important to address
body image concerns when working with disorders including body dysmorphic disorder,
anorexia and bulimia. There are many techniques that can be useful in doing so. Helping clients
address these issues will enable them to lead more contented and productive lives.
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