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What is Body Image Disturbance?

Body image disturbance is one of the most common clinical features attributed to eating disorders. Most contemporary theories consider body dissatisfaction to be the most immediate or proximal antecedent to the development of an eating disorder and empirical studies indeed confirm this association.

It is generally agreed that the body image construct is multidimensional, involving attitudinal as well as perceptual components. The perceptual deficit was best described by Hilde Bruch in her seminal publications based on years of clinical experience (1) and almost 40 years ago, one of us (DG) published one of the first empirical studies documenting size estimation in anorexia nervosa(2).

While size overestimation generated tremendous interest over the years, it has had limited impact in the understanding and the treatment of the disorder.

Nevertheless, recent research has linked body image disturbance to both psychopathology measured by the Eating Disorder Inventory(3) and temperamental characteristics confirming Bruch’s early observations regarding the relationship of body image disturbance to other core features such as poor interceptive awareness and feelings of ineffectiveness(4).

Eating Disorders Without Body Dissatisfaction

Although body dissatisfaction may be one of the most common modes of entry into an eating disorder, early case descriptions of anorexia nervosa and evidence from non-Western cultures indicate that some patients voluntarily reach an emaciated weight for a variety of psychological reasons body but do not show the characteristic body dissatisfaction.

Some of earliest 19th century clinical descriptions of anorexia nervosa do not even mention body dissatisfaction as a clinical feature of the disorder. Cases of apparent anorexia nervosa from China and India lack the “fear of becoming fat” or the body dissatisfaction so prominent in Western cases.

Some Patients Began Restricting Food Intake Because of “Spiritual” Concerns
Even in Western culture, research studies as well as clinical experience indicate that there is a small minority of patients who present with a very low weight but who deny body dissatisfaction at any point during the development of their disorder.

Some of these patients began restricting their food intake because of “spiritual” concerns, fears of choking, aversion to the texture of certain foods, food allergies, or a brief phase of physical illness. These cases have been traditionally classified as “atypical”; however, the diagnostic designations may be too restrictive as evidenced by the changes to the DSM-5.

Body Dissatisfaction is Still a Major Risk Factor

Nevertheless, to point out the exceptions is not to deny the overwhelming evidence that body dissatisfaction is one of the most important risk factors for restrictive dieting which, in turn, predicts the onset and the maintenance of serious eating disorders.

It is a major predictor of relapse in both anorexia and bulimia nervosa; patients who do recover report that body image is one of the major impediments to lasting change. The most challenging problem is how to affect lasting change in body dissatisfaction among those with eating disorders.

Methods to Correct Distorted Body Size

Various methods have been used to attempt to correct distorted body size estimation. One method has been to provide corrective feedback to anorexia nervosa patients with the aim of improving accuracy over time. This can be accomplished in several ways.

One strategy involves providing feedback on standardized measures of size estimation. Another involves directing patients to study their body in a mirror and try to develop a more objective or realistic view of their weight or shape.

Confronting patients With Their Own Distorted Self-perception has Little Therapeutic Effect
Some studies have shown that this exercise may have value in helping patients overcome denial of the severity of their disorder. However, most clinicians agree that directly changing body size perceptions has very limited role in the treatment of anorexia nervosa.

It is not surprising that confronting patients with their own distorted self-perception has little therapeutic effect since most patients have a long history of feedback by friends, family and therapists that they are too thin and must gain weight. This alone seems to have little impact.

A Cognitive Approach to Re-Interpreting Body Image

In our treatment setting, we prefer a cognitive approach aimed at re-interpreting the meaning of body size overestimation rather than trying to change it directly. Body size overestimation can be thought of as a perceptual anomaly that is often observed in eating disorders.

This is similar to other situations where people are encouraged to not rely on a particular perceptual state but rather defer to a higher-order judgment regarding the perception – for instance a person trying to decide whether or not to drive a car after drinking alcohol.

Accordingly, patients are encouraged to view their body-size misperception as an unfortunate perceptual disability (like being a color-blind person trying to coordinate his or her wardrobe). In this case, it is preferable to rely on objective data or a trustworthy person, rather than self-perception to determine actual body size.

Body image usually does not improve early in the process of recovery from anorexia nervosa, and in fact, it often becomes worse during weight gain. If it does improve, it is often in the later stages of recovery.

Treatment For Anorexia Nervosa

There has been remarkable advancement in recent years in the technology for treating body dissatisfaction in those at risk for eating disorders, and for obese individuals. The application of these approaches to anorexia nervosa has been less fully developed.

Treatment for anorexia nervosa requires increasing weight and weight gain is not uncommon in those with bulimia nervosa which predictably increases body dissatisfaction in the short-term.

Cognitive restructuring can be focused on identifying the idiosyncratic meaning that “being thin” and “weight control” has for the patient, and then finding more elegant personal and interpersonal solutions that do not require the life-long physical, psychological and interpersonal disadvantages of maintaining anorexia nervosa.

Within the context of a broader cognitive approach to anorexia nervosa (5), we have found group therapy focused on the “appearance assumptions” from Cash’s workbook particularly useful (6).

Avoiding Self-Defeating Practices

Developing a more positive body image often involves avoiding certain self-defeating practices (e.g. weighing, looking in the mirror, wearing revealing clothing and compulsive exercise) that provide short-term relief, but become rituals that only accentuate anxiety, discontentment and dysphoria.

These can be replaced by body image enhancement activities (yoga, movement, pleasure walks, listening to music,) that emphasize the body as a source of pleasure rather than a vehicle for control, mastery or self-definition. We emphasize the importance of viewing the functional aspects of the body rather than the ascetic features.

Finally, one of the most potent set of interventions derives from education about discrimination related to obesity (7) and the important advancements in advocating Health at Every Size as it’s health and civil rights implications (8).

Addressing Peer Relationships to Promote Change

It is also vital to understand the role of the interpersonal context in body dissatisfaction and to address peer relationships in promoting change. Recent evidence indicates that girls tend to select friends who are similar to themselves in terms of body dissatisfaction and bulimic symptoms but dissimilar in terms of dieting (9) and that body dissatisfaction is predicted by peer conversations about dieting, body consciousness and thin idealization (10).

These findings point to the importance of controlling for friendship selection when examining the role of peers in adolescent body image and eating problems. These findings can be extrapolated to group therapy in clinical settings by underscoring the importance of healthy and unhealthy group affiliations and their impact on recovery and relapse.

Changing Parental Attitudes Toward Weight

It has been our experience that promoting healthy group norms is one of the most important targets of intervention over the course of therapy.

Additionally, a major impediment to change can be parental attitudes toward weight and shape or parents’ overvaluation of thinness that can have a detrimental effect on the treatment of their children.

This issue must be approached with sensitivity to the historical factors influencing parental attitudes; however, treatment must focus on changing the family imperatives that interfere size acceptance as well as respect for individual differences of a wide array of attributes.

Psycho-Educationally Oriented Prevention Programs

Finally, the remarkable advancement in recent years in the technology for treating body dissatisfaction in those at risk for eating disorders, and for obese individuals can be applied in treatment of serious eating disorders. Psycho-educationally oriented prevention programs can reduce body dissatisfaction and reduce ameliorate disorder symptoms in college women that are sustained over a two-year follow-up (11).

Although the application of these approaches to those with clinical eating disorders has been less fully developed, we rely heavily upon psycho-education as well as cognitive approaches to challenging body image disturbance (12) and these have led to clinically and statistically significant changes in body dissatisfaction over the course of our Adult Partial Hospitalization and Adolescent Residential Programs.

Sources:

1. Bruch, H., Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine, 1962. 24(2): p. 187-&.

2. Garner, D.M., et al., Body image disturbances in anorexia nervosa and obesity. Psychosom Med, 1976. 38(5): p. 327-36.

3. Garner, D., Eating Disorder Inventory-3 Professional Manual. Psychological Assessment Resources, Inc, 2004.

4. Zanetti, T., et al., Clinical and Temperamental Correlates of Body Image Disturbance in Eating Disorders. European Eating Disorders Review, 2013. 21(1): p. 32-37.

5. Garner, D.M., K. Vitousek, and K.M. Pike, Cognitive Behavioral Therapy for Anorexia Nervosa, in Handbook of Treatment for Eating Disorders1997.

6. Cash, T.F., The body image workbook1997, Oakland, CA: New Harbinger.

7. Garner, D.M. and S.C. Wooley, Confronting the failure of behavioral and dietary treatments for obesity. Clinical Psychology Review, 1991. 11(6): p. 729-780.

8. Bacon, L., et al., Size acceptance and intuitive eating improve health for obese, female chronic dieters. Journal of the American Dietetic Association, 2005. 105(6): p. 929-936.

9. Rayner, K.E., et al., Adolescent Girls’ Friendship Networks, Body Dissatisfaction, and Disordered Eating: Examining Selection and Socialization Processes. Journal of Abnormal Psychology, 2013. 122(1): p. 93-104.

10. Lee, K., Engaging in peer conversation about slimming predicts body dissatisfaction in Chinese college women: A study in Hong Kong. Social Influence, 2013. 8(1): p. 1-17.

11. Stice, E., et al., Efficacy Trial of a Selective Prevention Program Targeting Both Eating Disorders and Obesity Among Female College Students: 1- and 2-Year Follow-Up Effects. Journal of Consulting and Clinical Psychology, 2013. 81(1): p. 183-189.

12. Garner, D.M. and C.D. Keiper, Anorexia and bulimia, in Handbook of clinical psychology competencies, J.C. Thomas and M. Hersen, Editors. 2010, Springer: New York. p. 1429-1459.

Contributed by the following River Centre Clinic Staff:

David M. Garner, Ph.D. is the Owner and Administrative Director

Julie J. Desai, M.A. is the Director of the Adult Partial Hospitalization Program

Meggan Desmond, LISW is the Director of the Adolescent Residential Program

The River Centre Clinic has almost two decades of experience providing innovative treatment to adults and adolescents suffering from eating disorders. It has developed a ground-breaking approach to treatment, based on extensive experience and research, designed to reduce costs without compromising high quality of care.

Childhood Eating Problems Program

The River Centre Clinic offers outpatient programming for children with eating difficulties. Childhood can be full of different phases and eating changes. Although this is fairly common behavior, it can leave parents feeling troubled. Disturbances in feeding become problematic when it causes the child to become upset or worry and when he or she is not eating enough to sustain proper nutrition and facilitate proper growth. Complications around eating can take many forms including but not limited to:

  • Trouble with food textures/sensory issues
  • Temper tantrums during meals
  • Refusing to eat
  • Limiting food groups
  • Choking, gagging, or vomiting after eating
  • Body image concerns
  • Anxiety/OCD

Although eating issues during childhood may seem to be just a frustration for parents and caregivers, there are real medical concerns including, nutritional deficiencies or a reliance on liquid supplements and vitamins. The staff at River Centre Clinic are carefully selected, not just for their experience in treating symptoms and underlying causes of eat problems, but also for their compassion and willingness to extend themselves on behalf of all clients. The staff is clinically trained in working with children suffering from:

  • Selective/restrictive eating (picky eating)
  • Food, choking, vomiting phobias (Functional Dysphagia)
  • Lacking interest in food/eating
  • Food avoidance due to sensory issues

River Centre Clinic’s outpatient therapists work with children and families to lessen the stress and anxiety surrounding mealtimes. They work closely with families to ensure that every member is part of the healing process. Many times, changes are necessary to the environment and  routine that will require the assistance of parents and caregivers.

The Clinic’s Childhood Eating Problems Program is based on well-established and evidence-based therapy models that integrate individual and family therapy. The treatment is based on applied behavioral principles, enhanced cognitive behavioral principles and directive play therapy techniques, which integrate individual and family therapy and is applied in an individualized manner for each patient. River Centre Clinic treats eating problems that may be coupled with co-occurring disorders and problems, including but not limited to:

  • ADHD
  • Anger Management
  • Anxiety
  • Autism Spectrum Disorders
  • Behavioral Problems
  • Conduct Disorders
  • Depression

For further information about this program, or to schedule an initial assessment, contact Anna Lippisch, MSW, LSW, Director of Childhood Eating Problems Program, at 419-885-8800.

Six Tips to Prevent Relapse

A residential treatment program can become a safe space for many patients. It may feel scary going back to your home, job, or school. While in treatment, you have invested time working on your recovery and hopefully whatever environment you are returning to can foster a pro-recovery environment. Despite the environment, many patients have a few slips during the recovery process post-treatment. River Centre Clinic’s hope is that you have learned strategies to prevent those slips from becoming relapse. These five tips are not all-inclusive, but they are some of the best strategies to ensure recovery.

Meal plan.

While in treatment you have learned how to meal plan and it most likely began to feel like a normal process towards the end of your stay. However, directly after treatment, meal planning may feel inflexible. It may be tempting to not follow your plan precisely or to completely stop planning. Rest assured that you will not have to meal plan forever to maintain your recovery. While the timeline differs for each individual as to when they can stop meal planning, patients who stick to their meal plan as ordered are less likely to relapse. Be open and honest with your outpatient therapist regarding your concerns with meal planning and create a strategy that works for both of you.

Connect with your outpatient treatment team regularly.

Before you leave residential treatment, you will have hopefully connected with an outpatient therapist and set up your first appointment post-treatment. Talk to your therapist to determine who else you should connect with to create a team of health professionals that advocate for your recovery. Often a team including a therapist, dietitian and primary care physician, all skilled in treating eating disorders, are highly beneficial for post-treatment care.

Utilize your team.

Connecting with a team of skilled health care professionals post-treatment is a vital part of recovery. Just as important, is connecting with a team of friends and family. Your tribe should include people that you feel comfortable talking to about your eating disorder, meal plan and urges. Take time to talk to these special individuals about the type of support you need. Ask your therapist if you can schedule a designated appointment for your tribe to help them understand your recovery
process and how they can help.

Define one self-care ritual and stick to it!

Stress is inevitable and it can make recovery more difficult. But you can combat stress by taking care of yourself and incorporating self-care into your daily routine. Self-care can look different depending on the individual. Do you enjoy reading, a nice hot bath, journaling, listening to music, meditation? These types of activities can be incorporated into your routine to help manage stress.

Know the difference between a slip and relapse.

A slip usually happens suddenly and may take you by surprise. Maybe you were having a particularly busy day and realized at 4:00 p.m. that you missed your afternoon snack. If you’re able to get right back to your planned meals and squeeze in the missed calories, consider that a slip. While a slip is still a setback, it’s much more minor than relapse. Relapse is when a slip turns into consistent eating disorder behaviors. To prevent this from happening, acknowledge a slip if it occurs. Call someone in your tribe or your therapist, if you are able to, so that they can help prevent guilt and shame that you may feel from your slip. These feelings will only exacerbate the problem. Focus on the progress you have made and brainstorm
solutions to prevent a future slip.

Make your own stoplight list.

How will you know when you are falling back into old eating disordered habits? By creating a personalized red, yellow and green flag list with the help of your therapist, you will have a written set of guidelines which will help you to recognize when you need to reach out for assistance. Look specifically at your own personal relapse cues and recovery behaviors and create a comprehensive list. Being sure to identify high-risk indicators that you are doing poorly (red flags), warning signs that you are slipping back into old habits (yellow flags), and signs that you are living a recovered lifestyle (green flags) is integral to keeping on track. Be sure to include both physical and emotional indicators of each.