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

In our recent work (Phillipou et al., 2018), we have proposed that anorexia nervosa (AN) should be considered a disorder of body image rather than a disorder of eating. This current paper is in response to the commentary by Larkin and Martin (2018) on this work. Larkin and Martin (2018) responded by first discussing the concept of whether AN is more accurately described as a body image disorder and also commented on the public’s perception of the illness.

In our work, we utilised examples from the restraint subscale of the Eating Disorders Examination Questionnaire (EDE-Q) to demonstrate that supposed measures of disordered eating are in actuality measuring disordered eating driven by body image distortion and dissatisfaction. Larkin and Martin (2018) accurately describe that three of the four EDE-Q subscales (restraint, shape concern and weight concern) support our proposal of reclassifying AN as a body image disorder given their focus on body image. However, the authors postulate that a diagnostic reclassification may not be necessary for this reason as body image concerns are already captured in this gold standard eating disorder measure, and reconsidering AN as a body image disorder may be a case of semantics. We disagree with this for a number of reasons.

First, a name for an illness which accurately describes it is a necessity. As with ‘multiple personality disorder’ which was re-classified and renamed to ‘dissociative identity disorder’ to more accurately represent the illness in which a multitude of personalities per se is not the problem, but that these patients switch between different identifies and behaviour patterns, a similar means is necessary for AN to emphasise the true nature of the disorder. Second, less emphasis on disordered eating in AN has a number of benefits for treatment focus; namely, for clinicians to focus on patients’ body image which is arguably the driving factor for their disordered eating behaviours and for less emphasis to be placed on weight-restoration as a form of remission when many patients will continue to show ongoing psychological symptoms (Pike, 1998). Third, a reclassification will inevitably lead to greater research into understanding the origins of the disorder. Finally, reclassifying AN as a body image disorder will enable a better understanding of the illness by the general public.

Larkin and Martin (2018) respond with scepticism to the notion that identifying AN as a body image disorder will result in fewer misconceptions by the lay person. They indicate that only few studies have empirically evaluated the public’s perception of AN. The stigma associated with AN has, however, been investigated in a number of significant publications. For instance, Stewart et al. (2006) described the perceptions of a community sample as those in which individuals with AN were to blame for their condition and that patients act this way for attention. Stigma and negative attitudes towards AN have also been described in other influential empirical investigations such as that by Mond et al. (2006), for example.

We conclude that the justification for reclassifying AN as a body image disorder is empirically justifiable.