When do anorexic patients perceive their body as too fat? Aggravating and ameliorating factors

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

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

Are marked body shape concerns associated with poorer outcomes at the one-year follow-up in anorexia nervosa?

OBJECTIVE

Anorexia nervosa (AN) is a complex disease in which obsessive thoughts about body image, shape, or weight are expressed. The intensity of these concerns varies among individuals, and only a few studies have focused on their impact on patients' clinical course when patients are treated on an outpatient basis. Our study aimed to determine whether marked body concerns at inclusion were predictive of the one-year follow-up.

METHOD

Participants (N = 72) were women seeking treatment for AN in a specialized unit for eating disorder management. All participants were assessed at inclusion and at the 1-year follow-up. Clinical outcome was assessed using the Morgan & Russel Outcome Average Score (MROAS), and body concerns were assessed using the Body Shape Questionnaires (BSQ).

RESULTS

Marked body concerns (BSQ score >140) at inclusion were associated with a poorer outcome at the 12-month follow-up (lower MROAS "total score"). Other characteristics at inclusion that were predictive of a poorer outcome at 12 months were as follows: higher severity of ED at inclusion, longer hospitalization during follow-up, and experiencing a lower impact of the illness on school/work life.

DISCUSSION

The results confirmed the importance of a multifocal treatment that should address body concerns and motivation to change. Our results also highlighted the necessity of promoting the maintenance of school/work during the treatment course.

How the unconscious mind controls body movements: Body schema distortion in anorexia nervosa

OBJECTIVE

Besides all visible somatic manifestations, distorted body representation is a key symptom for anorexia nervosa (AN). Body representation can be divided into a conscious component, body image, and an unconscious action-related one, body schema. As behavioral studies already explored the impact of a distorted body image in AN, we aimed to explore whether distortion also extends into unconscious body schema. This study is the first with an unbiased measurement of the body schema in a homogeneous sample of AN patients.

METHOD

Twenty-three patients diagnosed with AN and 23 healthy controls (HC) walked through a door like aperture varying in width. Door width was based on participants shoulder width and ranged from an aperture-to-shoulder-ratio of (A/S) 0.9 to 1.45. Shoulder rotation was measured as indication of perceived body width. To measure the unconscious body schema, we used a cover story pretending to investigate the influence of change of position on retention memory.

RESULTS

We found a significantly higher critical A/S for AN than HC, which indicates that AN patients rotate their shoulders for relatively larger door widths than HC, thus unconsciously estimating their body size to be larger than in reality. Additionally, we found a correlation between negative body attribution and overestimation of bodily dimensions.

DISCUSSION

As stated by the "allocentric-lock"-hypothesis, AN patients might be locked to a stored representation of their body that cannot be updated and remains at pre-AN conditions. We suggest future AN-therapy to counter body schema alterations by combining cognitive behavioral therapy and virtual reality therapy.

A systematic and methodological review of attentional biases in eating disorders: Food, body, and perfectionism

OBJECTIVE

The current systematic and methodological review aimed to critically review existing literature utilizing implicit processing, or automatic approach- and/or avoidance-related attentional biases between eating disorder (ED) and nonclinical samples, which (a) highlights how psychophysiological methods advance knowledge of ED implicit bias; (b) explains how findings fit into transdiagnostic versus disorder-specific ED frameworks; and (c) suggests how research can address perfectionism-related ED biases.

METHOD

Three databases were systematically searched to identify studies: PubMed, Scopus, and PsychInfo electronic databases. Peer-reviewed studies of 18- to 39-year-olds with both clinical ED and healthy samples assessing visual attentional biases using pictorial and/or linguistic stimuli related to food, body, and/or perfectionism were included.

RESULTS

Forty-six studies were included. While behavioral results were often similar across ED diagnoses, studies incorporating psychophysiological measures often revealed disease-specific attentional biases. Specifically, women with bulimia nervosa (BN) tend to approach food and other body types, whereas women with anorexia nervosa (AN) tend to avoid food as well as overweight bodies.

CONCLUSIONS

Further integration of psychophysiological and behavioral methods may identify subtle processing variations in ED, which may guide prevention strategies and interventions, and provide important clinical implications. Few implicit bias studies include male participants, investigate binge-eating disorder, or evaluate perfectionism-relevant stimuli, despite the fact that perfectionism is implicated in models of ED.

Screening four broad categories of eating disorders: suitability of a clinical algorithm adapted from the SCOFF questionnaire

BACKGROUND

We evaluated the performance of a clinical algorithm (Expali™), combining two or more positive answers to SCOFF questionnaire with Body Mass Index (BMI), to identify four Broad Categories of eating disorders (ED) derived from DSM-5.

METHODS

The clinical algorithm (Expali™) was developed from 104 combinations of BMI levels and answers to five SCOFF questions with at least two positive answers. Two senior ED physicians allocated each combination to one of the four Broad Categories of ED derived from DSM-5: restrictive disorder, bulimic disorder, hyperphagic disorder and other unspecified ED diagnosed by ED clinicians. The performance of Expali™ was evaluated on data from 206 patients with ED. Sensitivity, specificity values and Youden index were calculated for each category.

RESULTS

The 206 patients were diagnosed as follows: 31.5% restrictive disorder, 18.9% bulimic disorder, 40.8% hyperphagic disorder and 8.8% other ED. The sensitivity of Expali™ for restrictive, bulimic, hyperphagic and other unspecified ED were respectively: 76.9, 69.2, 79.7 and 16.7%. The Youden index was respectively 0.73, 0.57, 0.67 and 0.07.

CONCLUSIONS

In a SCOFF-positive ED population (at least two positive answers), the clinical algorithm Expali™ demonstrated good suitability by correctly classifying three of the four Broad Categories of eating disorders (restrictive, bulimic and hyperphagic disorder). It could be useful both to healthcare professionals and the general population to enable earlier detection and treatment of ED and to improve patient outcomes.