The assessment of body image distortion in female adolescents with anorexia nervosa: the development of a Test for Body Image Distortion in Children and Adolescents (BID-CA)

Influence of Identity Development on Weight Gain in Adolescent Anorexia Nervosa

BACKGROUND

Anorexia Nervosa (AN) typically begins during early adolescence, an important phase of personality development. A substantial proportion of adolescent AN patients shows impaired personality functioning, which might be a relevant but understudied aspect of illness severity. The developmental status of identity as key element of personality is suggested to influence inpatient treatment outcome in adolescents with AN.

METHODS

This study analyzed existing data of N = 60 adolescents with AN. Multilevel models assessed the influence of identity functioning, measured by the Assessment of Identity Development in Adolescence (AIDA) at admission, on weight gain [BMI (body mass index), BMI-SDS (BMI standard deviation score)] during 10 weeks of inpatient treatment. Moreover, the influence of other indicators of illness severity, i.e., eating disorders and comorbid psychopathologies, was explored.

RESULTS

As expected, higher AIDA scores negatively influenced the course of weight gain. A similar effect was observed for other psychopathology measures, especially body image distortion. In general, higher weight at admission was associated with less weight gain. Higher weight at admission was also predicted by higher other psychopathology measures, but not AIDA scores.

CONCLUSION

The course of weight gain during inpatient treatment was hampered in adolescent AN patients who have difficulties developing a stable identity. Unlike other aspects of psychopathology, this was independent of the initial weight. Thus, in addition to the level of underweight and other aspects of psychopathology, difficulties in identity development constitute a relevant aspect of illness severity in AN. This recommends consideration of identity development during treatment.

Essstörungen: Entwicklungspsychologische und entwicklungspsychopathologische Perspektive

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

Perceptual Distortions of 3-D Finger Size

Our body is a volumetric, three-dimensional (3-D) object in the world, and we experience it as such. Existing methods for measuring the perceptual body image, however, have been based on judgments of one-dimensional (1-D) length or two-dimensional images. We developed a new approach to the 3-D perceptual body image of the fingers by asking people to judge whether each finger would fit through rings of varying diameter. This task requires participants to conceptualize their finger as a volumetric object entering the ring. In two experiments, we used an adaptive staircase procedure to estimate the perceived size of each finger. There were systematic distortions of perceived 3-D finger size, with the size of index finger and (to a lesser extent) the middle finger underestimated. These distortions were unaffected by changes in hand posture. Notably, the pattern of distortions is qualitatively different from that found in previous research investigating 1-D finger length, suggesting that 3-D judgments of the body may differ in fundamental ways from 1-D judgments of individual body dimensions.

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

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

Clinical characteristics of early onset anorexia nervosa

The aim of the current paper is to evaluate clinical characteristics of 30 children with early onset anorexia nervosa (EO-AN; age = 12.2 ± 1.6 years) compared with 30 patients with adolescent onset AN (AO-AN; age = 15.9 ± 0.7 years) and 60 age-matched healthy controls. Statistical analyses included one-way analyses of variance with three planned comparisons and chi-square tests. Compared with AO-AN, EO-AN patients displayed more restrictive eating behaviour (p = 0.038), received more tube-feeding (p = 0.024), and had less problems with self-esteem (p < 0.001) and perfectionism (p = 0.001). EO-AN patients have similar eating disorder pathology (p = 0.183), body-image distortion (p = 0.060), and number of hospitalizations (p = 0.358) as AO-AN. Only a third of EO-AN patients suffer from low self-esteem. Overall, core AN pathology seems similar in EO-AN and AO-AN. However, EO-AN patients show differences in their pathological eating behaviour and the need for tube-feeding.

[Facets of Body Image Disorder: A Differential Analysis of the TEK-KJ (Test for the Detection of Body Disorder in Children and Adolescents) for the Direct Measurement of Haptic-Perceptual Parts]

There is presently a lack of instruments that measure the haptic-perceptive component of body-image distortion – a central criterion for the eating disorders anorexia nervosa and bulimia nervosa. We present a differential analysis for the Test for Body Image Distortion in Children and Adolescents (BID-CA, German: TEK-KJ) using a large child and adolescents sample, including for the first time male participants. We analyze convergent validity with the Contour Drawing Rating Scale (CDRS) as well as differences between children and adolescents from different type of schools and different BMI percentile groups. The sample size was N = 1,654 pupils (873 females and 781 males) with an average age of 13.35 years (SD = 0.76). We calculated a substantial convergent validity with the CDRS. Significant differences between children and adolescents from different type of schools and different BMI percentile groups were detected, with increased values for children and adolescents attending high school and underweight participants. The TEK-KJ seems to be an appropriate additional instrument for detecting the haptic-perceptive component of body-image distortion. The normative data presented improves the standardization of this instrument.

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

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

Body image is multifaceted and incorporates perceptual, affective, and cognitive components as well as behavioral features. Only few studies have examined the character of body-image disturbance in children/adolescents with eating disorders. It is unknown whether body-image disturbances in children/adolescent with eating disturbances are comparable to those of adult patients with eating disorders. Body-image disturbance might differ quantitatively and qualitatively according to the cognitive developmental status and the age of the individual. This paper provides an overview of the current evidence for body-image disturbance in children/adolescents with eating disorders, and how they compare with those adults with eating disorders. Current evidence indicates that older adolescent patients show similar deficits as adult patients with eating disorders, in particular for the attitudinal body-image component. However, evidence for a perceptual body-image disturbance in adolescent patients, in particular anorexia nervosa, is not conclusive. Reliable statements for childhood can hardly be made because clinical studies are not available. Investigations of body-image disturbance in children have focused on the predictive value for eating disorders. Limitations of the current evidence are discussed, and future directions for research and therapy are indicated.

The development and validation of the Body Image Dimensional Assessment (BIDA)

AIM

To validate a silhouette-based scale, the Body Image Dimensional Assessment (BIDA), an instrument for the screening of body dissatisfaction in large samples.

MATERIALS AND METHODS

Five-hundred ninety-two both gender non-clinical participants and 57 patients with eating disorders (ED) were administered the BIDA and the Body Dissatisfaction subscale of the Eating Disorder Inventory 2 (BD-EDI2). The BIDA consists of only 4 items to answer with reference to a series of four silhouettes not age- nor gender-related using a numeric scale that allows the quantification of the degree of Body Dissatisfaction, Sexual Body Dissatisfaction, Comparative Body Dissatisfaction and the calculation of the final Body Dissatisfaction Index (BDI).

RESULTS AND CONCLUSIONS

The study has shown that the BIDA has good reliability and validity as well as high predictive capability at a threshold BDI≥30 (sensitivity = 83.3% and specificity = 92.1%). By virtue of the rapid timing of administration, the BIDA can be a useful screening instrument of body dissatisfaction in non clinical populations to detect people at risk for ED and a follow-up instrument in clinical setting.

Neuropsychological psychopathology measures in women with eating disorders, their healthy sisters, and nonrelated healthy controls

OBJECTIVE

To assess the familial influence on neuropsychological dysfunction in eating disorders (ED) patients by comparing 16 patients with restricting type anorexia nervosa (AN-R), 18 patients with bingeing purging type anorexia nervosa, 20 patients with bulimia nervosa binge-purge type, 21 of the patients' nonaffected sisters, and 20 nonrelated healthy controls.

METHODS

Self-report questionnaires assessing psychopathology and 2 computerized cognitive tasks measuring hemispheric asymmetry for language and visuospatial abilities were administered to all participant groups.

RESULTS

On the self-report questionnaires, ED patients scored significantly more pathological than the healthy controls, whereas the healthy sisters were similar to the nonrelated healthy control group. For both of the computerized tasks, the behavior pattern of the sisters was similar to that of all, or most ED groups, and were significantly different from the nonrelated healthy controls. In addition, AN-R patients performed significantly worse on the visuospatial task than the other ED groups.

CONCLUSIONS

The dissociation between the performance on the cognitive tasks and psychopathology measures in healthy sisters, when compared to the ED and nonrelated healthy control groups, suggests that disturbances in neurocognitive functioning in ED patients are not necessarily the result of ED-related dysfunction. Rather, this may indicate general individual differences in cognitive processes that may run in families irrespective of the ED condition of the family member. The findings, with respect to the AN-R patients, support a neurocognitive continuum model of EDs in which AN-R represents the most severe form of the illness.

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.