Anorexia and body-image

It is commonly understood that people with anorexia have an intense fear of appearing overweight even when they are normal or underweight.

Here is the diagnostic criteria (according to the Mayo Clinic website – pulled directly from the DSM) for anorexia (emphasis mine):

  • Refusal to maintain a body weight that is at or above the minimum normal weight for your age and height
  • Intense fear of gaining weight or becoming fat, even though you’re underweight
  • Denying the seriousness of having a low body weight, or having a distorted image of your appearance or shape
  • In women who’ve started having periods, the absence of a period for at least three consecutive menstrual cycles

There you have it: people with anorexia suffer from both a phobia (an irrationally intense fear) and a serious perceptual disorder. It is in the diagnostic criteria.

So, what do we make of the folllowing? In studies where anorexia patients were asked to assess their body size, their answers were compared to a control group of women who did not have anorexia. And there were two surprises. Some anorexia patients overestimated their physical size, but others did not…and the women in the normal (non-anorexic) control groups also tended to overestimate their physical size, especially the petites: 

…subjects with eating disorders sometimes tend to overestimate their body shape but not always, and normal female control groups also overestimate their bodies quite often, in particular when they are small-sized…

Another way to state this is that “small women – whether anorexia patients or controls (small women with no history of eating disorders) – tend to overestimate their body size.”

Others wonder why body image distortions are in the diagnostic criteria at all, and conclude that anorexia nervosa may be conceptualized in several different ways without including the phenomenon of weight phobia or body image disturbance.

A Canadian review article concludes: “After a decade of experimental investigation of body image in anorexia nervosa, where old and new techniques have been used and where a large number of correlations have been identified, what do we really know? The findings have been conflicting…Some, but not all anorexics, overestimate their body size, and those who do, seem to have poor prognosis. Body size overestimation is not confined to anorexics.”

It is interesting that anorexics with a distorted body image have a worse prognosis than anorexics as a whole. This raises the possibility that the anorexia patients with body image distortions actually are suffering from two diseases – anorexia and body dysmorphic disorder (BDD), a very severe form of obsessive-compulsive disorder. “It is important to recognize BDD in patients with anorexia because, based on the available evidence, women with both disorders are more severely ill than those with anorexia but not BDD.”

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