Anorexia nervosa: More than a body image disorder

Anorexia nervosa (AN) is currently listed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM 5) under the rubric of ‘Feeding and Eating Disorders’. As such and elaborating on the words of Hilde Bruch, it is seen as a relentless restriction of energy intake in the pursuit of achieving a sometimes dangerous level of thinness whether by self-starvation, excessive exercise, purging, chewing and spitting, alone or in various permutations and combinations of these. Significant medical, psychological and social impairments result which include a distorted body image with an intense fear of weight gain.

Phillipou et al. (2018) recently proposed that AN should be reconceptualised as a body image disorder as this is at the core of the disorder. This reclassification was seen to promote greater public understanding of this disorder and to change the research agenda. The authors propose directing the latter towards a focus on body image disturbance rather than the neuroendocrine vicious cycles of perverse reward, psychiatric comorbidity, the underlying psychological antecedents, maintaining factors and the social context of this supremely difficult-to-treat illness. We believe that this is a reductionist view.

The centrality of body image disturbance in AN emerged in Bruch’s work in 1960, and fear of weight gain was not incorporated as a diagnostic criterion until 1970. Cultural differences regarding weight concern and body image perception are well documented. In the absence of body image concerns, somatic complaints, in keeping with culturally acceptable expression of distress, are often seen. Clinically, this was initially reported by Sing Lee in some of his patients from Hong Kong without ‘fat phobia’ which can be seen to overlap with body image disturbance. The same can also can be observed among males and some females in Western cultures, although body image concerns may emerge later on. Interestingly, Sing Lee more recently reported that his patients have now become ‘fat phobic’ and body image disturbed as a result of media influences and globalisation (Lee et al., 2001). An undue focus on body image disorder could affect individuals from other cultures, male and female patients with longstanding chronicity and those who present atypically from being diagnosed correctly and receiving appropriate and prompt treatment.

The ‘rubber hand illusion’, to which AN patients are more readily susceptible, demonstrates the enhanced instability and suggestibility of body image in patients with all eating disorders (Keizer et al., 2014), although this is clinically less apparent in patients at normal weight, i.e., Bulimia Nervosa and Other Specified Feeding and Eating Disorders. Virtual reality techniques are being developed to address this important, but almost certainly, secondary phenomenon.

To suggest that body image is the driving force for AN, is not only erroneous but also vastly oversimplifies the multifactorial aetiology and nature of this disorder. Not only is there genetic predisposition (Kirk et al., 2017) but also personality factors, obsessive compulsive disorder, social deficits of the autistic spectrum, perfectionism, negative self-evaluation and extreme compliance appear to be specific risk factors for AN. These patients premorbidly have or as part of the illness develop significant emotional recognition and regulation deficits whereby disordered eating behaviours may temporarily reduce negative affect so as to be highly reinforcing (Harrison, 2009). A euphoric feeling attained by starvation is often described early on in AN. In the longer term, this feeling continues to be ‘chased’ but becomes increasingly elusive. Eating disordered behaviours thus become a maladaptive strategy for regulating negative affective experiences. During the process of refeeding and when engagement in eating disordered behaviours is less or prohibited, emotional distress increases and treatment must then be directed towards strategies for managing negative emotions and mood.

Experiences of significant trauma or attachment disruptions are frequent underpinnings and must be both understood and managed in their own right. Trauma informed care is still in its infancy in AN and treatment itself is often perceived as persecutory and traumatic. Cognitive rigidity is also an important issue in AN. This may be pre-existent but worsens significantly with weight loss and needs to be remediated in order to direct the patients towards change and recovery. It is therefore imperative that psychological treatments incorporate emotionally oriented techniques to educate patients about the acceptability of emotions, decrease experiential avoidance (Harrison et al., 2009), improve social and emotional skills and reduce cognitive rigidity. The Maudsley Treatment for Adults with Anorexia Nervosa (MANTRA) and Cognitive Behaviour Therapy - enhanced (CBTe) adapted for AN address these issues.

Reducing anorexia to a ‘body image disorder’ in the public opinion might not have the desired effect of increasing understanding, as it could be viewed pejoratively as a ‘vanity disorder’. It also distracts from the significant medical sequelae which can be life threatening. To achieve admission to hospital via an emergency department with the diagnosis of AN is already a challenge, having a ‘body image disorder’ might be considered even less worthy of serious medical and psychiatric attention.