Commentary on Phillipou et al. (2018),Anorexia nervosa: Eating disorder or body image disorder?

Phillipou et al. (2018) assert that anorexia nervosa (AN) should be thought of as a body image disorder (BID), and not as it is currently categorized as an eating disorder (ED; American Psychiatric Association, 2013). They propose that the change in description may serve as a more valuable and accurate portrayal of the illness, and suggest that conceptualizing AN as an ED is too simplistic and thus misleading. Phillipou et al. (2018) examine the view that AN is somehow different from other EDs such as pica, rumination disorder, avoidance/restricted food intake disorder, binge ED and bulimia nervosa, because at its core AN is fundamentally an illness of ‘body image’. A parallel objective of Phillipou et al. (2018) is to alter the general public’s perception of AN, from one in which the public believe the AN patient is principally driven by disordered eating behaviour in order to reduce body fat, to one in which the patients’ overriding stimulus is actually body image.

We will deconstruct the idea that AN is better thought of as a BID, before examining the public perception of AN. Phillipou et al. (2018) use the eating disorder examination questionnaire (EDE-Q; Fairburn and Beglin, 1994) as the foundation for their argument which is critical. The EDE-Q is the self-report version of the eating disorder examination (EDE), a semi-structured EDs interview. The EDE-Q allows for assessment of the specific ED psychopathology on four subscales of restraint, eating concern, weight concern and shape concern. The restraint subscale includes questions related to restriction, abstinence, desire for an empty stomach, avoidance and rules to eating that are followed by the AN patient to influence shape, weight or body composition, the questions therefore are specifically related to body image. They use this as evidence to support their contention that AN should be reclassified as a BID. However, Phillipou et al. (2018) appear to share only a partial story of the EDE-Q, two further subscales, shape and weight concerns could have also been referenced adding an extra dimension not currently apparent in Phillipou et al.’s proposition. Both subscales of shape and weight concerns have at their core body image components. The shape concern subscale has questions related to ‘dissatisfaction with shape’, or ‘discomfort seeing one’s own body’ for example, whereas the weight concern subscale has questions related to ‘preoccupation and dissatisfaction with shape or weight’. If it is accepted that the EDE-Q has three of its four subscales related to body image, then Phillipou et al.’s proposition to reclassify AN to a BID should be strongly considered. However, if the ‘Gold-standard questionnaire’ (Phillipou et al., 2018) already acknowledges that AN is strongly influenced by BID, is there any need to reclassify the condition, or is it simply a case of semantics, and not of diagnostic necessity. However, Phillipou et al. (2018) argue that distorted beliefs regarding the shape and size of one’s own body often reach delusional intensity in AN, therefore emphasizing the important role that body image has in this condition. However, they also acknowledge that there may be a small number of individuals with AN who present with predominantly somatic concerns. They also make the perceptive observation regarding psychological support and therapy, in which a significant minority of individuals with AN may not receive the appropriate treatment if the BID component of AN is not acknowledged or endorsed in treatment sessions.

Phillipou et al. (2018) suggest that the reclassification of AN is urgently required so the general public can be better informed, which will lead to a change in language and the public perception of AN. They argue that the general public perceive AN inaccurately, and have many misconceptions, leading to statements such as ‘why won’t they just eat?’ or ‘I wish I had anorexia so I could lose weight’. Unfortunately, these statements were not referenced, therefore unverifiable, and could simply be anecdotal. The reality is very few empirical studies have been conducted specifically aimed at the public perception of AN.

Therefore, it could be argued that without verifiable evidence that the public have a misconception of AN, the change in AN to a BID is unwarranted, and maybe unnecessary. Further compelling evidence on public perceptions is thus required.

In conclusion, Phillipou et al. (2018) present a proposal for the reclassification of AN as a BID rather than an ED, which they argue may be a more valuable and accurate description of the illness. They argue that distorted beliefs regarding shape and size of one’s own body often reach delusional intensity with AN; therefore, the emphasis should be placed on the dominant feature of body image. Their argument is convincing but whether such a radical reclassification is diagnostically essential is not entirely empirically supported.