Body-image distortion and eating disorder: A reconceptualization based on the recent literature

An Overview of the Body Schema and Body Image: Theoretical Models, Methodological Settings and Pitfalls for Rehabilitation of Persons with Neurological Disorders

Given the widespread debate on the definition of the terms "Body Schema" and "Body Image", this article presents a broad overview of the studies that have investigated the nature of these types of body representations, especially focusing on the innovative information about these two representations that could be useful for the rehabilitation of patients with different neurological disorders with motor deficits (especially those affecting the upper limbs). In particular, we analyzed (i) the different definitions and explicative models proposed, (ii) the empirical settings used to test them and (iii) the clinical and rehabilitative implications derived from the application of interventions on specific case reports. The growing number of neurological diseases with motor impairment in the general population has required the development of new rehabilitation techniques and a new phenomenological paradigm placing body schema as fundamental and intrinsic parts for action in space. In this narrative review, the focus was placed on evidence from the application of innovative rehabilitation techniques and case reports involving the upper limbs, as body parts particularly involved in finalistic voluntary actions in everyday life, discussing body representations and their functional role.

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.

What influences judgments of physical attractiveness? A comprehensive perspective with implications for mental health

Judgments of physical attractiveness are based on appearance but are influenced by and influence more than just physical features of the face and body (e.g. clothing and personality traits). This is explored in a selective review of previous research, plus new analyses of data from three previously published studies: the Boston Couples Study, the Multiple Identities Questionnaire, and the Intimate Relationships Across Cultures Study, with implications for mental health. Self-ratings of attractiveness are inflated by self-esteem and confidence in self-halo effects. Partner-ratings are inflated by love and relationship satisfaction in partner-halo effects. Positive responses from others influence attractiveness-enhancing cycles, while negative responses influence attractiveness-deprecating cycles, with impacts on well-being. These influences are represented in a comprehensive Attractiveness Halo Model, which identifies Ten Components of Attractiveness that are inter-related, including physical, emotional, sexual, sensory, intellectual, behavioural, observer, situation, reciprocity, and time. Aspects of the model are supported by analyses of the three studies, generalising comprehensive attractiveness halo effects across time, identities, cultures, and relationship types.

Virtual Reality in the Assessment and Treatment of Weight-Related Disorders

Virtual Reality (VR) has, for the past two decades, proven to be a useful adjunctive tool for both assessment and treatment of patients with eating disorders and obesity. VR allows an individual to enter scenarios that simulate real-life situations and to encounter food cues known to trigger his/her disordered eating behavior. As well, VR enables three-dimensional figures of the patient's body to be presented, helping him/her to reach an awareness of body image distortion and then providing the opportunity to confront and correct distortions, resulting in a more realistic body image and a decrease in body image dissatisfaction. In this paper, we describe seminal studies in this research area.

Electrophysiological evidence for an attentional bias in processing body stimuli in bulimia nervosa

Empirical evidence suggests abnormalities in the processing of body stimuli in bulimia nervosa (BN). This study investigated central markers of processing body stimuli by means of event-related potentials in BN. EEG was recorded from 20 women with BN and 20 matched healthy controls while watching and evaluating underweight, normal and overweight female body pictures. Bulimics evaluated underweight bodies as less unpleasant and overweight bodies as bigger and more arousing. A higher P2 to overweight stimuli occurred in BN only. In contrast to controls, no N2 increase to underweight bodies was observed in BN. P3 was modulated by stimulus category only in healthy controls; late slow waves to underweight bodies were more pronounced in both groups. P2 amplitudes to overweight stimuli were correlated with drive for thinness and body dissatisfaction. We present novel support for altered perceptual and cognitive-affective processing of body images in BN on the subjective and electrophysiological level.

The use of virtual reality in the study, assessment, and treatment of body image in eating disorders and nonclinical samples: a review of the literature

This article reviews research into the use of virtual reality in the study, assessment, and treatment of body image disturbances in eating disorders and nonclinical samples. During the last decade, virtual reality has emerged as a technology that is especially suitable not only for the assessment of body image disturbances but also for its treatment. Indeed, several virtual environment-based software systems have been developed for this purpose. Furthermore, virtual reality seems to be a good alternative to guided imagery and in vivo exposure, and is therefore very useful for studies that require exposure to life-like situations but which are difficult to conduct in the real world. Nevertheless, review highlights the lack of published controlled studies and the presence of methodological drawbacks that should be considered in future studies. This article also discusses the implications of the results obtained and proposes directions for future research.

Body size estimation in early adolescence: factors associated with perceptual accuracy in a nonclinical sample

This study investigated body size estimation in Norwegian adolescents (aged 12-15; N=406) using a distorting photograph technique. The percentage of over- or underestimation was calculated for pictures of the subject, other persons and a neutral object. The Eating Disorders Inventory for Children (EDI-C) was also completed. Among adolescents at risk of eating problems, girls tended to overestimate their own body size while boys showed a pattern of underestimation, compared to a relatively accurate body perception for low-risk subjects. The groups did not differ in the perception of the neutral object. Important predictors of perceived body size included the size estimation of other children, preoccupation with weight and shape, self-esteem, and emotional instability. The results support the predictive value of body size estimation. Gender differences in judgement bias can be interpreted within present aesthetic ideals and their relation to self perception, body image, and eating problems in adolescence.

Weight perception, substance use, and disordered eating behaviors: comparing normal weight and overweight high-school students

Disordered eating behaviors and substance use are two risk factors for the development of serious psychopathology and health concerns in adulthood. Despite the negative outcomes associated with these risky behaviors, few studies have examined potential associations between these risk factors as they occur during adolescence. The importance of accurate or inaccurate weight perception among adolescents has received increased interest given documented associations with nutritional beliefs and weight management strategies. This study examined the associations among the perceptions of weight and substance use with disordered eating behaviors among a diverse sample of normal weight and overweight adolescent males and females. Data came from the 2007 National Youth Risk Behavior Survey (YRBS). The sample consisted of 11,103 adolescents (53.4% female; 44% Caucasian, 21% African American; 13% Hispanic; age responses ranged from 12 and under to 18 and over), with 31.5% meeting criteria for being either at-risk for obesity or already obese (i.e., overweight). As hypothesized, overestimation of weight among normal weight adolescents and accurate perceptions of weight among overweight adolescents were associated with higher rates of disordered eating behaviors. In normal weight adolescents, use of all three substances (tobacco, binge drinking, and cocaine) was associated with each disordered eating behavior. In contrast, findings revealed differences for overweight adolescents between the type of substance use and disordered eating behavior. Post hoc analyses revealed that gender moderated some of these relationships among overweight individuals. Implications for the development and implementation of secondary prevention programs aimed at reducing disordered eating behaviors, substance use, and obesity risk among normal and overweight adolescents are considered.

The validity of virtual environments for eliciting emotional responses in patients with eating disorders and in controls

This article explores the efficacy of virtual environments representing situations that are emotionally significant to patients with eating disorders (ED) to modify depression and anxiety levels both in these patients and in controls. Eighty-five ED patients and 108 students were randomly exposed to five experimental virtual environments (a kitchen with low-calorie food, a kitchen with high-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool) and to one neutral environment. In the interval between the presentation of each situation, anxiety and depressed mood were assessed. Results of several repeated measures analyses demonstrated that patients show higher levels of anxiety and a more depressed mood after eating, especially high-calorie food, and after visiting the swimming pool than in the neutral room. In contrast, controls only show higher levels of anxiety in the swimming pool. In the rest of the situations they presented a similar mood state as in the neutral room. We concluded that virtual reality is a useful vehicle for eliciting similar emotional reactions to those one would expect in real life situations. Thus, this technology seems well suited for use in experimental studies as well as in evaluative and therapeutic contexts.

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.

Assessment of emotional reactivity produced by exposure to virtual environments in patients with eating disorders

The aim of this study was to assess the usefulness of virtual environments representing situations that are emotionally significant to subjects with eating disorders (ED). These environments may be applied with both evaluative and therapeutic aims and in simulation procedures to carry out a range of experimental studies. This paper is part of a wider research project analyzing the influence of the situation to which subjects are exposed on their performance on body image estimation tasks. Thirty female patients with eating disorders were exposed to six virtual environments: a living-room (neutral situation), a kitchen with high-calorie food, a kitchen with low-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool. After exposure to each environment the STAI-S (a measurement of state anxiety) and the CDB (a measurement of depression) were administered to all subjects. The results show that virtual reality instruments are particularly useful for simulating everyday situations that may provoke emotional reactions such as anxiety and depression, in patients with ED. Virtual environments in which subjects are obliged to ingest high-calorie food provoke the highest levels of state anxiety and depression.

Static and dynamic body image in bulimia nervosa: mental representation of body dimensions and biological motion patterns

OBJECTIVE

The aim of the present study was to find out whether in bulimia nervosa the perceptual component of a disturbed body image is restricted to the overestimation of one's own body dimensions (static body image) or can be extended to a misperception of one's own motion patterns (dynamic body image).

METHOD

Participants with bulimia nervosa (n = 30) and normal controls (n = 55) estimated their body dimensions by means of a photo distortion technique and their walking patterns using a biological motion distortion device.

RESULTS

Not only did participants with bulimia nervosa overestimate their own body dimensions, but also they perceived their own motion patterns corresponding to a higher BMI than did controls. Static body image was correlated with shape/weight concerns and drive for thinness, whereas dynamic body image was associated with social insecurity and body image avoidance.

CONCLUSION

In bulimia nervosa, body image disturbances can be extended to a dynamic component.

Size of drawings influences body size estimates by women with and without eating concerns

Research has inconsistently shown that women, particularly those with eating concerns, inaccurately estimate their body size. In the present study, drawings of female bodies, ranging from emaciated to obese, were presented to women with and without eating concerns. Drawings approximated the women's actual height or were reduced (15.7cm). Women selected the drawing that represented how they thought they looked (cognitive rating), felt they looked (affective rating), and would like to look (desired rating). Women tended to select larger drawings when reduced-size drawings were used. Participants with eating concerns overestimated their body size and were more dissatisfied with their body size than participants without eating concerns. Size of drawings and the presence of eating concerns did not affect ratings of the size of a neutral object. Women did not demonstrate a generalized problem in estimating size. Overestimation of body size may be exaggerated in research that used reduced-size drawings.

Preconscious processing of body image cues. Impact on body percept and concept

OBJECTIVE

There is considerable evidence that body image is an elastic construct, which can be influenced by environmental and internal factors. The present study used a visual subliminal processing paradigm, with the aim of determining the impact of preconscious processing of verbal cues upon body image (percept and concept).

METHOD

Forty nonclinical women completed measures of body percept and concept before and after being exposed to very rapid presentations (4 ms) of fatness and thinness cues.

RESULTS

The women with relatively unhealthy eating attitudes were influenced by the fatness stimulus, with a worsening of their body percept and concept. In contrast, the women with healthier eating attitudes showed an improvement in their body percept in response to the thinness stimulus.

CONCLUSION

The findings support the centrality of body image schemata in eating psychopathology, although there is a need for replication and extension in other groups.

Neurocognitive evidence favors "top down" over "bottom up" mechanisms in the pathogenesis of body size distortions in anorexia nervosa

Perceptually-based disturbances in body image, or body size distortions, have been posited to occur in anorexia nervosa (AN). Perception does not result from a simple flow of sensory information from periphery to cortex ("bottom-up" processing), but involves the selection of inputs most likely to be relevant in light of an individual's experience and expectations ("top-down" processing). Most investigations of body size distortion in AN have used procedures likely to engage top-down processing, raising the possibility that attitudinal disturbances may play a role. To our knowledge, there have been no studies that assess the presence, in AN, of neurocognitive deficits associated with neurologically based disturbances in body schema. Such deficits, if found, could provide evidence of body image distortion unlikely to result from top-down processing. We tested 20 inpatients with AN on measures of proprioception, finger identification, right/left orientation, general cognition and eating disorders symptomatology, both before and after treatment. Matched normal controls were tested on the same measures over the same time intervals. Significant differences between the two groups occurred only prior to treatment, and only on those measures which involved executive, in addition to more body-schema-specific functions. This suggests that patients with AN do not have enduring deficits in the domain of body-schema, but may have subtle cognitive dysfunction, in the acute state, which is not specific to, but can interact with processing of body-schema-related information. This, in turn, suggests that their body image distortion may not be secondary to bottom-up perceptual disturbances.

Does the body image exist in three dimensions? The study of visual mental representation of a body and a nonbody object

Do the mental images of 3-dimensional objects recreate the depth characteristics of the original objects? This investigation of the characteristics of mental images utilized a novel boundary-detection task that required participants to relate a pair of crosses to the boundary of an image mentally projected onto a computer screen. 48 female participants with body attitudes within expected normal range were asked to image their own body and a familiar object from the front and the side. When the visual mental image was derived purely from long-term memory, accuracy was better than chance for the front (64%) and side (63%) of the body and also for the front (55%) and side (68%) of the familiar nonbody object. This suggests that mental images containing depth and spatial information may be generated from information held in long-term memory. Pictorial exposure to views of the front or side of the objects was used to investigate the representations from which this 3-dimensional shape and size information is derived. The results are discussed in terms of three possible representational formats and argue that a front-view 2 1/2-dimensional representation mediates the transfer of information from long-term memory when depth information about the body is required.

Eating disorders, dieting, and the accuracy of self-reported weight

OBJECTIVE

This study investigated the accuracy of self-reported weight and height in individuals with an eating disorder (i.e., anorexia nervosa [AN] and bulimia nervosa [BN]) and in individuals without an eating disorder (i.e., dieters and nondieters).

METHOD

Self-reported and measured weights and heights were obtained from the eating disorder sample (n = 81) and the college student sample (n = 163) and were compared within and between the groups.

RESULTS

Eating disorder patients were extremely accurate at self-reporting their weight. However, there was a significant difference in accuracy between AN and BN patients. AN patients slightly overreported their weight, whereas BN patients slightly underreported their weight. Both dieters and nondieters significantly underreported their weight. However, dieters significantly underreported their weight to a greater degree than did the nondieters.

DISCUSSION

The implications of these subgroup differences and their specificity to weight reporting are discussed with reference to the accuracy of self-reported height.

Self-discrepancy theory, standards for body evaluation, and eating disorder symptomatology among college women

Potential links between personal and sociocultural aspects of body-image concerns and sets of behavioral and emotional symptoms associated with eating disorders were explored within a self-discrepancy theory framework. It was predicted that actual:ideal body-image discrepancies from one's own standpoint would be related to symptoms reflecting feelings like dissatisfaction and actual:ought body-image discrepancies from a societal standpoint would be related to symptoms reflecting feelings like anxiety. The Bodies Questionnaire, Eating Disorder Inventory, and demographic information were completed by 196 undergraduate women volunteers. Results generally supported the predictions, although the effects were small. Perceived body-image discrepancies from sociocultural prescriptions for slimness and appearance are more closely associated with symptoms reflecting failures to achieve these standards than with symptoms reflecting efforts to attain them. In addition, the contribution of personal ideals to bulimic symptomatology and body dissatisfaction includes concerns about body attributes not associated with weight. Possible clinical applications are discussed.

Recall of the visual body image using a novel boundary detection task

A new task for eliciting a pictorial mental image of the body or other objects is described. The task involved relating a pair of crosses to the boundary of a mental image 'projected' onto a computer screen. Responses were assessed for accuracy defined as identifying a relationship between a cross and an image that would hold when a photograph (of the same object) was substituted for the mental image. A group of 30 female students achieved between 70 to 80% accuracy when using this task to assess mental images of their own faces, torsos, or a familiar nonbody object. Accuracy was similar for body and nonbody objects. The presence of some kind of quasipictorial representation of the body is confirmed. Its characteristics await further elucidation.