Anorexia Nervosa is a Body-Image Disorder

Our conceptualisation of anorexia nervosa (AN) as an ‘eating disorder’ is not only simplistic and misleading (Phillipou et al., 2018) but also leads to extraordinary focus on weight and re-feeding, both in treatment and research efforts. This consequently results in the revolving door syndrome, a recurring theme in mental health, where patients are admitted, re-fed, offered limited psychological therapies and discharged, only to return again, and yet, again. Ultimately a proportion of these patients, labelled resistant, are as a matter of necessity, admitted involuntarily and with mixed results.

That AN is primarily a body-image disturbance and is better classified along with body dysmorphic disorder (BDD) is a step in the right direction, as it shares with BDD overvalued ideas about one’s body, which reaches delusional proportions and often cannot be shifted, irrespective of treatment. That AN closely resembles mono-symptomatic psychosis was previously raised by this author (Haliburn, 2005). BDD is a debilitating disorder characterised by excessive preoccupation with an imagined or very slight defect in one’s physical appearance. It usually begins in adolescence, and without treatment often becomes chronic as a result of insight which can range from good, poor, to frankly delusional (Phillips et al., 2008). AN has more in common with these disorders, and with certain obsessive-compulsive disorders, particularly those associated with perfectionism (Halmi et al., 2000) present in anorexic individuals from a young age. Perfectionism is a robust, discriminating characteristic of AN and is likely to be one of a cluster of phenotypic trait variables associated with a genetic diathesis for AN. Greater severity of eating disorder symptoms was found to be associated with greater perfectionism (Halmi et al., 2000). Exploration in psychotherapy of the pursuit of perfectionism in such individuals reveals that it is a chronic attempt to obtain praise from a significant other/s and of seeing oneself beyond reproach – sweet, pleasant, compliant females who fail to adjust their body image even when they become progressively emaciated (Bruch, 1962) and who can yet, accurately perceive the emaciation of other patients with AN. Why don’t we spell out that the disturbed body image in AN is in fact a delusion? Is it a misperception on the part of Psychiatry to continue to refer to AN and bulimia nervosa (BN) as eating disorders and often to lump them together in research and literature as such, when in fact the dynamics of both disorders are strikingly different? The psychological must be strenuously addressed alongside the physical, and AN recognised as a body-image disorder, in an effort to re-focus treatment efforts and thus change the way it is portrayed in digital and print media with questionable effects on impressionable young lives.

I disagree with the statement that personality differences in AN and BN do not provide a greater level of insight into the underlying mechanisms contributing to body-image disturbance in both disorders. The borderline personality characteristics of BN and the narcissistic personality characteristics of AN including the incidence of dissociation in both disorders when processed in psychotherapy help not only in the understanding of each of these disorders but also the need for different treatment perspectives.

The focus must change from seeing AN as an eating disorder to a serious body-image disorder that requires investigation, psychological understanding, medication and re-feeding when necessary.