Body image disturbance

The scientific study of bodily experiences began at the end of the 19th century. German physiologist Hermann Munk was the first to suggest the existence of a cortical representation of the body, supported by his vivisection experiments on the parietal cortex of dogs.{{cite book|last=Munk|first=Hermann|url=http://worldcat.org/oclc/1068632617|title=Ueber die Functionen der Grosshirnrinde gesammelte Mitteilungen aus den Jahren 1877–80 ; mit Einleitung und Anmerkungen|date=1881|publisher=Hirschwald|oclc=1068632617}} A few years later, Carl Wernicke hypothesized a cortical map capable of collecting and processing sensory inputs from every point of the body.{{cite book|last=Wernicke|first=C|url=http://worldcat.org/oclc/909076000|title=Grundriss der Psychiatrie: In klinischen Vorlesungen|year=2007|publisher=VDM|isbn=978-3-8364-1337-4|oclc=909076000}} In 1905 Bonnier introduced the term body schema,{{cite journal|last=Bonnier|first=Pierre|title=L'aschématie|journal=Revue Neurologique|volume=54|pages=605–609}} defining it as the mental representation of the body necessary for the brain to perceive objects near, far, or within the body itself.

Bonnier also described three different partial body pattern alterations, {{lang|fr|hyperschématie}} (French; 'an overestimation of body size'), {{lang|fr|hyposchématie}} ('an underestimation of body size'), and {{lang|fr|paraschématie}} ('a displacement of body parts including internal organs'). Head and Holmes in 1911 expanded the concept of a body schema, introducing the concepts of postural schema and surface schema. They described a patient who could locate the stimuli applied to her body but could not locate her hand in space.{{cite journal|last1=Head|first1=H|last2=Holmes|first2=G|date=1911|title=Sensory Disturbances from Cerebral Lesions|url=https://academic.oup.com/brain/article-lookup/doi/10.1093/brain/34.2-3.102|journal=Brain|language=en|volume=34|issue=2–3|pages=102–254|doi=10.1093/brain/34.2-3.102|issn=0006-8950}} They also defined the difference between schema and image. The schema defined as an unconscious representation necessary for movement and localization in space, and the "image" as a conscious body perception.

Therefore, in the history of medicine, distortions in the perception of one's body have mainly occurred in patients with neurological damage or with amputated limbs and a consequence of phantom limb syndrome.{{cite journal|last1=Kaur|first1=A|last2=Guan|first2=Y|date=2018|title=Phantom limb pain: A literature review|url=|journal=Chinese Journal of Traumatology|volume=21|issue=6|pages=366–368|doi=10.1016/j.cjtee.2018.04.006|issn=1008-1275|pmc=6354174|pmid=30583983}} In the psychiatric field, the first systematic descriptions of bodily altered perception are already present in Schneider's classification of symptoms of schizophrenia{{cite book|last=Schneider|first=K|url=http://worldcat.org/oclc/500705737|title=Clinical psychopathology|date=1959|publisher=[publisher not identified]|oclc=500705737}} in 1959. The German-American psychiatrist Hilde Bruch was the first physician to describe body image disturbance in eating disorders accurately.

File:Hilde Bruch, clinical professor of psychiatry.jpg was the first to describe the body image disturbance in anorexia nervosa accurately. She has devoted a large part of her career to studying and treating eating disorders.]]

Hilde Bruch first identified and described body image disturbance in anorexia nervosa.{{cite journal|last=Skårderud|first=F|date=2009|title=Bruch revisited and revised|url=https://pubmed.ncbi.nlm.nih.gov/19241426/|journal=European Eating Disorders Review|volume=17|issue=2|pages=83–88|doi=10.1002/erv.923|issn=1099-0968|pmid=19241426}} In her article "Perceptual and Conceptual Disturbances in Anorexia Nervosa" she wrote:

{{blockquote|What is pathognomic of anorexia is not the severity of the malnutrition per se—equally severe degrees are seen in other malnourished psychiatric patients—but rather the distortion of body image associated with it: the absence of concern about emaciation, even when advanced, and the vigor and stubbornness with which the often gruesome appearance is defended as normal and right, not too thin, and as the only possible security against the dreaded fate of becoming fat.|author=Hilde Bruch|title=Perceptual and Conceptual Disturbances in Anorexia Nervosa|source=Psychosomatic Medicine, 1962}}

Body image disturbance is not specific to anorexia nervosa, as it is sometimes present in other eating disorders such as bulimia nervosa{{cite journal|last=Kaye|first=W|date=2008-04-22|title=Neurobiology of anorexia and bulimia nervosa|journal=Physiology & Behavior|volume=94|issue=1|pages=121–135|doi=10.1016/j.physbeh.2007.11.037|issn=0031-9384|pmc=2601682|pmid=18164737}} and binge eating disorder.{{cite journal|last1=Lewer|first1=M|last2=Bauer|first2=A|last3=Hartmann|first3=A|last4=Vocks|first4=S|date=2017|title=Different Facets of Body Image Disturbance in Binge Eating Disorder: A Review|journal=Nutrients|language=en|volume=9|issue=12|pages=1294|doi=10.3390/nu9121294|pmc=5748745|pmid=29182531|doi-access=free}} Studies published in 2019 on Cortex have shown that it is possible to observe alterations in the perception of one's body in healthy subjects. A slightly altered perception of the body is a normal part of everyone's life and manifests itself more intensely in more vulnerable individuals (e.g., patients with eating disorders).{{cite journal|last1=Sadibolova|first1=R|last2=Ferrè|first2=E|last3=Linkenauger|first3=S|last4=Longo|first4=M|date=2019-02-01|title=Distortions of perceived volume and length of body parts|journal=Cortex|language=en|volume=111|pages=74–86|doi=10.1016/j.cortex.2018.10.016|issn=0010-9452|pmid=30471452|s2cid=53153320|doi-access=free}} Commonly, body image disturbance is confused with body dysmorphic disorder, an obsessive-compulsive disorder with which it shares some features.

Body image disturbance is a multifaceted construct including both perceptual and attitudinal issues. Some of the more common signs are:

• altered body size estimation and altered perception of the body and its shapes;
• mental images of one's body appearing distorted or overweight;
• frequently third-person mental view of one's body;{{cite journal|last1=Dakanalis|first1=A|last2=Clerici|first2=M|last3=Carrà|first3=G|last4=Riva|first4=G|date=2016-12-01|title=Dysfunctional bodily experiences in anorexia nervosa: where are we?|url=|journal=Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity|language=en|volume=21|issue=4|pages=731–732|doi=10.1007/s40519-016-0299-z|pmid=27345845|s2cid=26819506|issn=1590-1262}}
• negative body-related thoughts;{{cite journal|last1=Hartmann|first1=A|last2=Thomas|first2=J|last3=Greenberg|first3=J|last4=Rosenfield|first4=E|last5=Wilhelm|first5=S|date=2015-02-28|title=Accept, distract, or reframe? An exploratory experimental comparison of strategies for coping with intrusive body image thoughts in anorexia nervosa and body dysmorphic disorder|url=https://pubmed.ncbi.nlm.nih.gov/25530419/|journal=Psychiatry Research|volume=225|issue=3|pages=643–650|doi=10.1016/j.psychres.2014.11.031|issn=1872-7123|pmid=25530419|s2cid=45568309}}
• frequent body-checking behaviors;{{cite journal|last1=Calugi|first1=S|last2=El Ghoch|first2=M|last3=Dalle Grave|first3=R|date=2017|title=Body checking behaviors in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/28117905/|journal=The International Journal of Eating Disorders|volume=50|issue=4|pages=437–441|doi=10.1002/eat.22677|issn=1098-108X|pmid=28117905|s2cid=23493247}}
• frequent comparisons between one's own body and the bodies of others;{{cite journal|last1=Blechert|first1=J|last2=Nickert|first2=T|last3=Caffier|first3=D|last4=Tuschen-Caffier|first4=B|date=2009|title=Social comparison and its relation to body dissatisfaction in bulimia nervosa: evidence from eye movements|url=https://pubmed.ncbi.nlm.nih.gov/19661192/|journal=Psychosomatic Medicine|volume=71|issue=8|pages=907–912|doi=10.1097/PSY.0b013e3181b4434d|issn=1534-7796|pmid=19661192|s2cid=31290938}}
• emotions of anxiety, shame, and contempt for one's body.{{cite journal|last1=Kollei|first1=I|last2=Brunhoeber|first2=S|last3=Rauh|first3=E|last4=de Zwaan|first4=M|last5=Martin|first5=A|date=2012|title=Body image, emotions and thought control strategies in body dysmorphic disorder compared to eating disorders and healthy controls|url=https://pubmed.ncbi.nlm.nih.gov/22405229/|journal=Journal of Psychosomatic Research|volume=72|issue=4|pages=321–327|doi=10.1016/j.jpsychores.2011.12.002|issn=1879-1360|pmid=22405229|s2cid=14370560}}

Clinically speaking, a growing body of research suggests that body image disturbance plays a significant role in the onset,{{cite journal|last1=Stice|first1=E|last2=Desjardins|first2=C|date=2018|title=Interactions between risk factors in the prediction of onset of eating disorders: Exploratory hypothesis generating analyses|journal=Behaviour Research and Therapy|volume=105|pages=52–62|doi=10.1016/j.brat.2018.03.005|issn=1873-622X|pmc=5929474|pmid=29653254}} maintenance,{{cite journal|last1=Tabri|first1=N.|last2=Murray|first2=H. B.|last3=Thomas|first3=J. J.|last4=Franko|first4=D. L.|last5=Herzog|first5=D. B.|last6=Eddy|first6=K. T.|date=2015|title=Overvaluation of body shape/weight and engagement in non-compensatory weight-control behaviors in eating disorders: is there a reciprocal relationship?|url=https://www.cambridge.org/core/journals/psychological-medicine/article/abs/overvaluation-of-body-shapeweight-and-engagement-in-noncompensatory-weightcontrol-behaviors-in-eating-disorders-is-there-a-reciprocal-relationship/35584739F620DD369CA34926021069DB|journal=Psychological Medicine|language=en|volume=45|issue=14|pages=2951–2958|doi=10.1017/S0033291715000896|pmid=25994276|s2cid=9759657|issn=0033-2917|url-access=subscription}}{{cite journal|last1=Amianto|first1=F.|last2=Spalatro|first2=A.|last3=Ottone|first3=L.|last4=Abbate Daga|first4=G.|last5=Fassino|first5=S.|date=2017|title=Naturalistic follow-up of subjects affected with anorexia nervosa 8 years after multimodal treatment: Personality and psychopathology changes and predictors of outcome|url=https://pubmed.ncbi.nlm.nih.gov/28957787/|journal=European Psychiatry |volume=45|pages=198–206|doi=10.1016/j.eurpsy.2017.07.012|issn=1778-3585|pmid=28957787|hdl=2318/1651769|s2cid=4921779|hdl-access=free}} and relapse of anorexia nervosa,{{cite journal|last1=Keel|first1=P|last2=Dorer|first2=D|last3=Franko|first3=D|last4=Jackson|first4=S|last5=Herzog|first5=D|date=2005|title=Postremission predictors of relapse in women with eating disorders|url=https://pubmed.ncbi.nlm.nih.gov/16330589/|journal=The American Journal of Psychiatry|volume=162|issue=12|pages=2263–2268|doi=10.1176/appi.ajp.162.12.2263|issn=0002-953X|pmid=16330589|s2cid=46209817}} as previously suggested by Bruch in 1962. However, despite increasing evidence, a review by Glashouwer in 2019 stated that the available empirical data are still insufficient and "provide no basis to answer the question whether body image disturbance is a (causal) risk factor for anorexia nervosa".{{cite journal|last1=Glashouwer|first1=K|last2=Van Der Veer|first2=R|last3=Adipatria|first3=F|last4=De Jong|first4=P|last5=Vocks|first5=S|date=2019-12-01|title=The role of body image disturbance in the onset, maintenance, and relapse of anorexia nervosa: A systematic review|url=https://pure.rug.nl/ws/files/107968419/1_s2.0_S0272735819302831_main.pdf|journal=Clinical Psychology Review|language=en|volume=74|pages=101771|doi=10.1016/j.cpr.2019.101771|issn=0272-7358|pmid=31751876|s2cid=208228110}} As suggested by the author, this lack of evidence is partly related to terminology problems used in the body image field.{{cite journal|last1=Mitchison|first1=D|last2=Hay|first2=P|last3=Griffiths|first3=S|last4=Murray|first4=S|last5=Bentley|first5=C|last6=Gratwick-Sarll|first6=K|last7=Harrison|first7=C|last8=Mond|first8=J|date=2017|title=Disentangling body image: The relative associations of overvaluation, dissatisfaction, and preoccupation with psychological distress and eating disorder behaviors in male and female adolescents|journal=International Journal of Eating Disorders|language=en|volume=50|issue=2|pages=118–126|doi=10.1002/eat.22592|issn=1098-108X|pmc=6585604|pmid=27539911}}

Body image disorder is a characteristic symptom of anorexia nervosa and bulimia nervosa. In both of these disorders, an excessive focus on body shapes and sizes made the body image disturbance easier to identify, to describe, and study. Much less is known about the disorder in patients with binge eating disorder.

As early as 1993, Spitzer compared obese individuals with and without binge eating disorder (BED) and found that those with BED were more frequently concerned about body shape and weight.{{cite journal|last1=Spitzer|first1=R. L.|last2=Yanovski|first2=S.|last3=Wadden|first3=T.|last4=Wing|first4=R.|last5=Marcus|first5=M. D.|last6=Stunkard|first6=A.|last7=Devlin|first7=M.|last8=Mitchell|first8=J.|last9=Hasin|first9=D.|last10=Horne|first10=R. L.|date=1993|title=Binge eating disorder: its further validation in a multisite study|url=https://pubmed.ncbi.nlm.nih.gov/8477283/|journal=The International Journal of Eating Disorders|volume=13|issue=2|pages=137–153|doi=10.1002/1098-108X(199303)13:2<137::AID-EAT2260130202>3.0.CO;2-#|issn=0276-3478|pmid=8477283|s2cid=35421508 }} Additionally, binge eating disorder patients show more significant concerns about weight and body shape,{{cite journal|last1=Allison|first1=K|last2=Grilo|first2=C|last3=Masheb|first3=R|last4=Stunkard|first4=A|date=2005|title=Binge Eating Disorder and Night Eating Syndrome: A Comparative Study of Disordered Eating.|url=|journal=Journal of Consulting and Clinical Psychology|volume=73|issue=6|pages=1107–1115|doi=10.1037/0022-006x.73.6.1107|issn=1939-2117|pmid=16392984}} more intense body dissatisfaction,{{cite journal|last1=De Zwaan|first1=M|last2=Mitchell|first2=J|last3=Seim|first3=H|last4=Specker|first4=S|last5=Pyle|first5=R|last6=Raymond|first6=N|last7=Crosby|first7=R|date=1994|title=Eating related and general psychopathology in obese females with binge eating disorder|journal=International Journal of Eating Disorders|volume=15|issue=1|pages=43–52|doi=10.1002/1098-108x(199401)15:1<43::aid-eat2260150106>3.0.co;2-6|pmid=8124326|issn=0276-3478}} and more frequent avoidance and body checking behaviors.{{cite journal|last1=Grilo|first1=C|last2=Reas|first2=D|last3=Brody|first3=M|last4=Burke-Martindale|first4=C|last5=Rothschild|first5=B|last6=Masheb|first6=R|date=2005|title=Body checking and avoidance and the core features of eating disorders among obese men and women seeking bariatric surgery|url=|journal=Behaviour Research and Therapy|volume=43|issue=5|pages=629–637|doi=10.1016/j.brat.2004.05.003|issn=0005-7967|pmid=15865917}} On the other hand, few studies have investigated the altered body perception in patients with binge eating disorder{{cite journal|last1=Lewer|first1=M|last2=Bauer|first2=A|last3=Hartmann|first3=A|last4=Vocks|first4=S|date=2017-11-28|title=Different Facets of Body Image Disturbance in Binge Eating Disorder: A Review|journal=Nutrients|volume=9|issue=12|page=1294|doi=10.3390/nu9121294|issn=2072-6643|pmc=5748745|pmid=29182531|doi-access=free}} and the results are conflicting. Some patients tend to overestimate their body shapes, in others, they do not.{{cite journal|last1=Mond|first1=J|last2=Hay|first2=P|last3=Rodgers|first3=B|last4=Owen|first4=C|date=2007|title=Recurrent binge eating with and without the "undue influence of weight or shape on self-evaluation": Implications for the diagnosis of binge eating disorder|url=|journal=Behaviour Research and Therapy|volume=45|issue=5|pages=929–938|doi=10.1016/j.brat.2006.08.011|issn=0005-7967|pmid=17010307}} In some cases the perceptual disturbance manifests itself in a paradoxical way, with an underestimation of the real body shapes and sizes. This difference suggests different phenotypes in binge spectrum; hence, a perceptual disturbance can be considered an aggravation of the binge eating disorder, as claimed by Lewer and colleagues in 2017.

There are no reliable epidemiological data in the literature for body image disturbance.

There are numerous challenges with diagnosis, the most relevant of which is the unclear definition of body image disturbance within official diagnostic manuals such as the DSM and the ICD,{{cite web|title=2021 ICD-10-CM Diagnosis Code F45.22: Body dysmorphic disorder|url=https://www.icd10data.com/ICD10CM/Codes/F01-F99/F40-F48/F45-/F45.22|access-date=2021-09-20|website=www.icd10data.com}}{{Cite book|chapter=Feeding and Eating Disorders|date=2013-05-22|chapter-url=https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm10|title=Diagnostic and Statistical Manual of Mental Disorders|series=DSM Library|publisher=American Psychiatric Association|doi=10.1176/appi.books.9780890425596.dsm10|isbn=978-0-89042-555-8|access-date=2021-09-20|archive-date=15 August 2021|archive-url=https://web.archive.org/web/20210815125054/https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm10|url-status=dead}} which prevents its identification in the population. Further, there are challenges with diagnostic tools, both for recognition and screening. The altered perception of the body can only be measured through behavioral tasks delivered individually (See section below). It cannot be measured with questionnaires, or other tools typically used for broad-spectrum investigations.

As it is not always present in eating disorders, its prevalence is not comparable to that of anorexia nervosa, bulimia nervosa, and binge eating disorder, and cannot be inferred from them. A negative body image may also be present in other psychiatric conditions such as PTSD, major depression, and body dysmorphic disorder.{{cite journal|last1=Scheffers|first1=M|last2=van Busschbach|first2=J|last3=Bosscher|first3=R|last4=Aerts|first4=L|last5=Wiersma|first5=D|last6=Schoevers|first6=R|date=2017|title=Body image in patients with mental disorders: Characteristics, associations with diagnosis and treatment outcome|url=https://pubmed.ncbi.nlm.nih.gov/28095340/|journal=Comprehensive Psychiatry|volume=74|pages=53–60|doi=10.1016/j.comppsych.2017.01.004|issn=1532-8384|pmid=28095340}} Taken together this data suggests the possible presence of perceptual disturbances in other pathological conditions not directly related to eating disorders. Therefore, the presence of a body image disturbance in other psychiatric diseases remains speculation, not yet supported by sufficient literature data, as suggested by Scheffers.

Different labels are used in research and clinical settings to describe body image disturbance, generating terminological confusion. Among the most used terms are body image discrepancy,{{cite journal|last1=Pétré|first1=B|last2=Scheen|first2=A|last3=Ziegler|first3=O|last4=Donneau|first4=A|last5=Dardenne|first5=N|last6=Husson|first6=E|last7=Albert|first7=A|last8=Guillaume|first8=M|date=2016|title=Body image discrepancy and subjective norm as mediators and moderators of the relationship between body mass index and quality of life|journal=Patient Preference and Adherence|volume=10|pages=2261–2270|doi=10.2147/PPA.S112639|issn=1177-889X|pmc=5104290|pmid=27853356|doi-access=free}} body image self-discrepancy,{{cite journal|last1=Solomon-Krakus|first1=S|last2=Sabiston|first2=C|last3=Brunet|first3=J|last4=Castonguay|first4=A|last5=Maximova|first5=K|last6=Henderson|first6=M|date=2017-01-01|title=Body Image Self-Discrepancy and Depressive Symptoms Among Early Adolescents|url=https://www.jahonline.org/article/S1054-139X(16)30318-4/abstract|journal=Journal of Adolescent Health|language=English|volume=60|issue=1|pages=38–43|doi=10.1016/j.jadohealth.2016.08.024|issn=1054-139X|pmid=27793726|url-access=subscription}} body image distortion, disturbed body image,{{cite journal|last1=Horne|first1=R. L.|last2=Van Vactor|first2=J. C.|last3=Emerson|first3=S.|date=1991|title=Disturbed body image in patients with eating disorders|url=https://ajp.psychiatryonline.org/doi/10.1176/ajp.148.2.211|journal=The American Journal of Psychiatry|volume=148|issue=2|pages=211–215|doi=10.1176/ajp.148.2.211|issn=0002-953X|pmid=1987820|s2cid=25361678 |url-access=subscription}} disturbances in body estimations,{{cite journal|last1=Casper|first1=R. C.|last2=Halmi|first2=K. A.|last3=Goldberg|first3=S. C.|last4=Eckert|first4=E. D.|last5=Davis|first5=J. M.|date=1979|title=Disturbances in body image estimation as related to other characteristics and outcome in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/570073/|journal=The British Journal of Psychiatry|volume=134|pages=60–66|doi=10.1192/bjp.134.1.60|issn=0007-1250|pmid=570073|s2cid=43247202}} body image disturbance,{{cite journal|last1=Feusner|first1=J|last2=Deshpande|first2=R|last3=Strober|first3=M|date=2017|title=A translational neuroscience approach to body image disturbance and its remediation in anorexia nervosa|journal=International Journal of Eating Disorders|language=en|volume=50|issue=9|pages=1014–1017|doi=10.1002/eat.22742|issn=1098-108X|pmc=5752143|pmid=28755487}} and negative body image.{{cite journal|last1=Spreckelsen|first1=P|last2=Glashouwer|first2=K|last3=Bennik|first3=E|last4=Wessel|first4=I|last5=de Jong|first5=P|date=2018|title=Negative body image: Relationships with heightened disgust propensity, disgust sensitivity, and self-directed disgust|journal=PLOS ONE|volume=13|issue=6|pages=e0198532|bibcode=2018PLoSO..1398532S|doi=10.1371/journal.pone.0198532|issn=1932-6203|pmc=5988313|pmid=29870558|doi-access=free}} Sometimes, the term body dissatisfaction is also used to refer to body image disturbance indiscriminately.{{cite journal|last1=McLean|first1=S|last2=Paxton|first2=S|date=2019|title=Body Image in the Context of Eating Disorders|url=https://pubmed.ncbi.nlm.nih.gov/30704635/|journal=The Psychiatric Clinics of North America|volume=42|issue=1|pages=145–156|doi=10.1016/j.psc.2018.10.006|issn=1558-3147|pmid=30704635|s2cid=73414441}} Moreover, the DSM-5 defines this symptom vaguely: "a disturbance in the way one's body weight or shape is experienced". The lack of a clear definition is problematic from both a clinical and basic research point of view.{{cite journal|last=de Vignemont|first=Frederique|date=2010|title=Body schema and body image--pros and cons|url=https://pubmed.ncbi.nlm.nih.gov/19786038/|journal=Neuropsychologia|volume=48|issue=3|pages=669–680|doi=10.1016/j.neuropsychologia.2009.09.022|issn=1873-3514|pmid=19786038|s2cid=16746475}}

Despite the terminological problems, during the early 2000s numerous scholars agree that body image disturbance is a multidimensional symptom of various components associated with body image.{{cite book|last1=Cash|first1=T|title=Cognitive—Behavioral Treatment of Body-Image Disturbances|date=1996|url=|work=Sourcebook of Psychological Treatment Manuals for Adult Disorders|pages=567–614|editor-last=Van Hasselt|editor-first=Vincent B.|place=Boston, MA|publisher=Springer US|language=en|doi=10.1007/978-1-4899-1528-3_15|isbn=978-1-4899-1530-6|last2=Grant|first2=Jill R.|editor2-last=Hersen|editor2-first=Michel}} Body image is a concept formed by the interaction of four body-related components: cognitive, affective, behavioral, and perceptual.

• Cognitive: thoughts and beliefs about one's body and its shape; a conscious mental representation of the body{{cite journal|last1=Cash|first1=T. F.|last2=Deagle|first2=E. A.|date=1997|title=The nature and extent of body-image disturbances in anorexia nervosa and bulimia nervosa: a meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/9261648/|journal=The International Journal of Eating Disorders|volume=22|issue=2|pages=107–125|doi=10.1002/(SICI)1098-108X(199709)22:2<107::AID-EAT1>3.0.CO;2-J|issn=0276-3478|pmid=9261648}}
• Affective: feelings and attitudes related to the body (e.g. bodily satisfaction/dissatisfaction).
• Behavioral: the actions that people perform to check on, modify, or hide their body parts.
• Perceptual: how the mind senses and perceives the body; it includes proprioceptive, interoceptive, tactile, and visual self-perception.{{cite journal|last1=Keizer|first1=A|last2=Smeets|first2=M|last3=Dijkerman|first3=H|last4=Van Den Hout|first4=M|last5=Klugkist|first5=I|last6=Van Elburg|first6=A|last7=Postma|first7=A|date=2011-11-30|title=Tactile body image disturbance in anorexia nervosa|journal=Psychiatry Research|language=en|volume=190|issue=1|pages=115–120|doi=10.1016/j.psychres.2011.04.031|issn=0165-1781|pmid=21621275|s2cid=18451352|doi-access=free}}

In people with body image disturbance all of these components are altered at the same time.

In 2021, Artoni et al proposed a clearer definition of body image disturbance as part of a study in Eating and Weight Disorders. The authors suggested using the term bodily dissatisfaction when there are alterations in either the affective, cognitive, or behavioral components of body image and strictly reserving the term body image disturbance only when all four components are altered, including perception. In short, they define body image disturbance as the presence of an altered perception of the shape and weight of one's body, which aggravates body dissatisfaction. The term is consistent with the DSM-5 description "a disturbance in the way weight and body shapes are experienced" and it is therefore "preferable to others".

Patients with body image disturbance exhibit an alteration in how the body's image is stored in their memory—the conscious representation of their bodies. This representation is from a third-person, perspective, more precisely an allocentric representation of the body.{{cite journal|last1=Ekstrom|first1=A|last2=Arnold|first2=A|last3=Iaria|first3=G|date=2014|title=A critical review of the allocentric spatial representation and its neural underpinnings: toward a network-based perspective|journal=Frontiers in Human Neuroscience|language=English|volume=8|page=803|doi=10.3389/fnhum.2014.00803|issn=1662-5161|pmc=4193251|pmid=25346679|doi-access=free}} This representation is evoked in self-image tasks, such as comparing one's body with others or drawing one's body shapes. However, patients with anorexia nervosa and bulimia nervosa frequently perceive their body as larger than it is in reality.{{cite journal|last1=Øverås|first1=M|last2=Kapstad|first2=H|last3=Brunborg|first3=C|last4=Landrø|first4=N|last5=Lask|first5=B|date=2014|title=Memory versus perception of body size in patients with anorexia nervosa and healthy controls|url=https://pubmed.ncbi.nlm.nih.gov/24590562/|journal=European Eating Disorders Review|volume=22|issue=2|pages=109–115|doi=10.1002/erv.2276|issn=1099-0968|pmid=24590562}}

Patients with anorexia nervosa have negative thoughts about their body, such as "I'm too fat," "I'm ugly," and other negative body-related thoughts.{{cite journal|last1=Cooper|first1=M|last2=Fairburn|first2=C|date=1992-09-01|title=Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa|url=https://www.sciencedirect.com/science/article/abs/pii/000579679290034E|journal=Behaviour Research and Therapy|language=en|volume=30|issue=5|pages=501–511|doi=10.1016/0005-7967(92)90034-E|issn=0005-7967|pmid=1520236|url-access=subscription}} In some cases, however, the ideal internalized body is indicative of unhealthy thinness (e.g., a body without female shapes or one that communicates suffering). An unhealthy body shape could be a critical maintenance factor, generating more attention from family members, reducing the requests and expectations of others,{{cite journal|last1=Treasure|first1=J|last2=Schmidt|first2=U|date=2013-04-15|title=The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors|journal=Journal of Eating Disorders|volume=1|pages=13|doi=10.1186/2050-2974-1-13|issn=2050-2974|pmc=4081714|pmid=24999394|doi-access=free}} and minimizing sexual attractiveness (especially in patients with sexual trauma).{{cite journal|last1=Madowitz|first1=J|last2=Matheson|first2=B|last3=Liang|first3=J|date=2015|title=The relationship between eating disorders and sexual trauma|url=https://pubmed.ncbi.nlm.nih.gov/25976911/|journal=Eating and Weight Disorders|volume=20|issue=3|pages=281–293|doi=10.1007/s40519-015-0195-y|issn=1590-1262|pmid=25976911|s2cid=22184762}}

Affective components of body image are the feelings and emotions experienced towards one's body. Body dissatisfaction is frequently present in those with body image disturbance, sometimes related to anxiety{{cite journal|last1=Levinson|first1=C|last2=Rapp|first2=J|last3=Riley|first3=E|date=2014-12-01|title=Addressing the fear of fat: extending imaginal exposure therapy for anxiety disorders to anorexia nervosa|url=|journal=Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity|language=en|volume=19|issue=4|pages=521–524|doi=10.1007/s40519-014-0115-6|issn=1590-1262|pmc=4183728|pmid=24691784}} and shame{{cite journal|last1=Goss|first1=K|last2=Allan|first2=S|date=2009|title=Shame, pride and eating disorders|url=https://pubmed.ncbi.nlm.nih.gov/19639646/|journal=Clinical Psychology & Psychotherapy|volume=16|issue=4|pages=303–316|doi=10.1002/cpp.627|issn=1099-0879|pmid=19639646}} when the body is exposed or gazed at in a mirror. In some cases, anger and feelings of aggression towards one's body are reported.{{cite journal|last1=Espeset|first1=E|last2=Gulliksen|first2=K|last3=Nordbø|first3=R|last4=Skårderud|first4=F|last5=Holte|first5=A|date=2012|title=The Link Between Negative Emotions and Eating Disorder Behaviour in Patients with Anorexia Nervosa|url=|journal=European Eating Disorders Review|language=en|volume=20|issue=6|pages=451–460|doi=10.1002/erv.2183|issn=1099-0968|pmid=22696277}} Fear is associated with thoughts of getting fat.

Congruent with the self-objectification theory, people with body image disturbance frequently experience the body only as an object to be modified rather than as a subject to take care of.{{cite journal|last1=Daniels|first1=Elizabeth A.|last2=Zurbriggen|first2=Eileen L.|last3=Monique Ward|first3=L.|date=2020|title=Becoming an object: A review of self-objectification in girls|url=https://pubmed.ncbi.nlm.nih.gov/32470822/|journal=Body Image|volume=33|pages=278–299|doi=10.1016/j.bodyim.2020.02.016|issn=1873-6807|pmid=32470822|s2cid=219106220}}

The behavioral component of body image disturbance includes different body-checking behaviors{{cite journal|last1=Bamford|first1=B|last2=Attoe|first2=C|last3=Mountford|first3=V|last4=Morgan|first4=J|last5=Sly|first5=R|date=2014-01-01|title=Body checking and avoidance in low weight and weight restored individuals with anorexia nervosa and non-clinical females|url=|journal=Eating Behaviors|language=en|volume=15|issue=1|pages=5–8|doi=10.1016/j.eatbeh.2013.10.011|issn=1471-0153|pmid=24411741}} such as repeatedly weighing during the day, spending significant time in front of the mirror or avoiding it, frequently taking selfies, checking parts of the body with hands (e.g. measuring the circumference of the wrists, arms, thighs, belly or hips). Other behaviors include avoiding situations in which the body is exposed (for example, when swimming), and wearing very loose and covering clothes.{{cite journal|last1=Nikodijevic|first1=A|last2=Buck|first2=K|last3=Fuller-Tyszkiewicz|first3=M|last4=de Paoli|first4=T|last5=Krug|first5=I|date=2018|title=Body checking and body avoidance in eating disorders: Systematic review and meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/29528168/|journal=European Eating Disorders Review|volume=26|issue=3|pages=159–185|doi=10.1002/erv.2585|issn=1099-0968|pmid=29528168|hdl=11343/283691|s2cid=3874918|hdl-access=free}} More generally, avoidance of bodily sensations, particularly the interoceptive ones, is reported.

In body image disturbance, several perceptual domains are altered. Visual perception is the most studied,{{cite journal|last1=Engel|first1=M|last2=van Denderen|first2=K|last3=Bakker|first3=A|last4=Corcoran|first4=A|last5=Keizer|first5=A|last6=Dijkerman|first6=H|date=2020|title=Anorexia nervosa and the size-weight illusion: No evidence of impaired visual-haptic object integration|journal=PLOS ONE|volume=15|issue=8|pages=e0237421|bibcode=2020PLoSO..1537421E|doi=10.1371/journal.pone.0237421|issn=1932-6203|pmc=7451544|pmid=32853272|doi-access=free}}{{cite book|last=Wei|first=L|url=http://worldcat.org/oclc/1237663432|title=Visual processing abnormalities in anorexia nervosa and body dysmorphic disorder|oclc=1237663432}}{{cite journal|last1=Uher|first1=R|last2=Murphy|first2=T|last3=Friederich|first3=H|last4=Dalgleish|first4=T|last5=Brammer|first5=M|last6=Giampietro|first6=V|last7=Phillips|first7=M|last8=Andrew|first8=C|last9=Ng|first9=V|last10=Williams|first10=S|last11=Campbell|first11=I|date=2005|title=Functional Neuroanatomy of Body Shape Perception in Healthy and Eating-Disordered Women|url=|journal=Biological Psychiatry|volume=58|issue=12|pages=990–997|doi=10.1016/j.biopsych.2005.06.001|issn=0006-3223|pmid=16084858|s2cid=15508818}} but research has found misperceptions in other sensory domains such as haptic,{{cite journal|last1=Grunwald|first1=M|last2=Ettrich|first2=C|last3=Assmann|first3=B|last4=Dähne|first4=A|last5=Krause|first5=W|last6=Busse|first6=F|last7=Gertz|first7=H|date=2001-03-28|title=Deficits in haptic perception and right parietal theta power changes in patients with anorexia nervosa before and after weight gain|url=|journal=International Journal of Eating Disorders|volume=29|issue=4|pages=417–428|doi=10.1002/eat.1038|issn=0276-3478|pmid=11285579}} tactile,{{cite journal|last1=Keizer|first1=A|last2=Smeets|first2=M|last3=Dijkerman|first3=H|last4=van den Hout|first4=M|last5=Klugkist|first5=I|last6=van Elburg|first6=A|last7=Postma|first7=A|date=2011-11-30|title=Tactile body image disturbance in anorexia nervosa|journal=Psychiatry Research|volume=190|issue=1|pages=115–120|doi=10.1016/j.psychres.2011.04.031|issn=0165-1781|pmid=21621275|s2cid=18451352|doi-access=free}} and affective-touch.{{cite journal|last1=Crucianelli|first1=L|last2=Cardi|first2=V|last3=Treasure|first3=J|last4=Jenkinson|first4=P|last5=Fotopoulou|first5=A|date=2016-05-30|title=The perception of affective touch in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/27137964/|journal=Psychiatry Research|volume=239|pages=72–78|doi=10.1016/j.psychres.2016.01.078|issn=1872-7123|pmid=27137964|hdl=2299/17368|s2cid=18426175|hdl-access=free}} Also, the body schema is overextended.{{cite journal|last1=Beckmann|first1=N|last2=Baumann|first2=P|last3=Herpertz|first3=S|last4=Trojan|first4=J|last5=Diers|first5=M|date=2021|title=How the unconscious mind controls body movements: Body schema distortion in anorexia nervosa|url=|journal=International Journal of Eating Disorders|language=en|volume=54|issue=4|pages=578–586|doi=10.1002/eat.23451|issn=1098-108X|pmid=33345338|s2cid=229341829}}{{Clarify|reason=What does overextended mean?|date=October 2021}} Some research suggested that this is related to a general enlarged mental representation of body size.{{cite journal|last1=Irvine|first1=K|last2=McCarty|first2=K|last3=McKenzie|first3=K|last4=Pollet|first4=T|last5=Cornelissen|first5=K|last6=Tovée|first6=M|last7=Cornelissen|first7=P|date=2019|title=Distorted body image influences body schema in individuals with negative bodily attitudes|url=https://pubmed.ncbi.nlm.nih.gov/30500663/|journal=Neuropsychologia|volume=122|pages=38–50|doi=10.1016/j.neuropsychologia.2018.11.015|issn=1873-3514|pmid=30500663|s2cid=53734054}} A 2017 study published in a companion journal to Nature highlighted how perceptual disturbance is present in those recovered from anorexia nervosa even without affective-cognitive body concerns. Finally, interoception, the sense of the current state of the body,{{cite journal|last=Craig|first=A. D.|date=2002|title=How do you feel? Interoception: the sense of the physiological condition of the body|url=|journal=Nature Reviews Neuroscience|volume=3|issue=8|pages=655–666|doi=10.1038/nrn894|pmid=12154366|s2cid=17829407|issn=1471-003X}} is problematic in those with eating disorders.{{cite journal|last1=Jacquemot|first1=A|last2=Park|first2=R|date=2020|title=The Role of Interoception in the Pathogenesis and Treatment of Anorexia Nervosa: A Narrative Review|journal=Frontiers in Psychiatry|volume=11|pages=281|doi=10.3389/fpsyt.2020.00281|issn=1664-0640|pmc=7181672|pmid=32362843|doi-access=free}}{{Clarify|reason=Problematic in what way?|date=October 2021}}

The age of onset for body image disturbance is often early adolescence,{{cite journal|last1=Sattler|first1=F|last2=Eickmeyer|first2=S|last3=Eisenkolb|first3=J|date=2019-06-08|title=Body image disturbance in children and adolescents with anorexia nervosa and bulimia nervosa: a systematic review|url=|journal=Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity|volume=25|issue=4|pages=857–865|doi=10.1007/s40519-019-00725-5|issn=1590-1262|pmid=31177379|s2cid=182948695}} the age in which one's comparison to their peers becomes more significant and leads to a greater sensitivity towards criticism of, or teasing about, one's physical appearance. Furthermore, puberty leads to rapid changes in body size and shape that need to be integrated into one's body image.{{cite journal|last1=Rierdan|first1=J.|last2=Koff|first2=E.|date=1980|title=Representation of the female body by early and late adolescent girls|url=https://pubmed.ncbi.nlm.nih.gov/24318155/|journal=Journal of Youth and Adolescence|volume=9|issue=4|pages=339–346|doi=10.1007/BF02087985|issn=0047-2891|pmid=24318155|s2cid=23399514}} For this reason, adolescence is considered a critical age, with a greater vulnerability to internalizing ideals of thinness,{{cite journal|last=Carlson Jones|first=D|date=2004|title=Body Image Among Adolescent Girls and Boys: A Longitudinal Study.|url=http://doi.apa.org/getdoi.cfm?doi=10.1037/0012-1649.40.5.823|journal=Developmental Psychology|language=en|volume=40|issue=5|pages=823–835|doi=10.1037/0012-1649.40.5.823|issn=1939-0599|pmid=15355169|url-access=subscription}} which may ultimately lead to the development of body dissatisfaction, body image disturbance, or eating disorders.{{cite journal|last1=Stice|first1=E|last2=Gau|first2=J|last3=Rohde|first3=P|last4=Shaw|first4=H|date=2017|title=Risk factors that predict future onset of each DSM-5 eating disorder: Predictive specificity in high-risk adolescent females|journal=Journal of Abnormal Psychology|volume=126|issue=1|pages=38–51|doi=10.1037/abn0000219|issn=1939-1846|pmc=5215960|pmid=27709979}} In a 2019 review, Sattler and colleagues analyzed eight on-topic studies. The authors found that most adolescents with anorexia nervosa and bulimia nervosa already had body-checking behaviors, negative body-related emotions and feelings, low body satisfaction, and an altered estimate of their body size compared to healthy controls. Unfortunately, exactly how one passes from initial dissatisfaction with one's body to actual perceptual disorder is still unknown despite its clinical importance.{{cite journal|last1=Ralph-Nearman|first1=C|last2=Arevian|first2=A|last3=Moseman|first3=S|last4=Sinik|first4=M|last5=Chappelle|first5=S|last6=Feusner|first6=J|last7=Khalsa|first7=S|date=2021-06-10|title=Visual mapping of body image disturbance in anorexia nervosa reveals objective markers of illness severity|journal=Scientific Reports|language=en|volume=11|issue=1|pages=12262|bibcode=2021NatSR..1112262R|doi=10.1038/s41598-021-90739-w|issn=2045-2322|pmc=8192536|pmid=34112818}} The etiopathogenesis is still unknown and the subject of hypotheses in the clinical and neuroscientific fields.{{cite journal|last1=Riva|first1=G|last2=Gaudio|first2=S|date=2012|title=Allocentric lock in anorexia nervosa: new evidences from neuroimaging studies|url=https://pubmed.ncbi.nlm.nih.gov/22546757/|journal=Medical Hypotheses|volume=79|issue=1|pages=113–117|doi=10.1016/j.mehy.2012.03.036|issn=1532-2777|pmid=22546757}}

Body dissatisfaction and body image disturbance are closely related. Personal, interpersonal, cultural, social, and ethnic variables largely influence bodily dissatisfaction,{{cite journal|last1=Michael|first1=S|last2=Wentzel|first2=K|last3=Elliott|first3=M|last4=Dittus|first4=P|last5=Kanouse|first5=D|last6=Wallander|first6=J|last7=Pasch|first7=K|last8=Franzini|first8=L|last9=Taylor|first9=W|last10=Qureshi|first10=T|last11=Franklin|first11=F|date=2014-01-01|title=Parental and Peer Factors Associated with Body Image Discrepancy among Fifth-Grade Boys and Girls|url=|journal=Journal of Youth and Adolescence|language=en|volume=43|issue=1|pages=15–29|doi=10.1007/s10964-012-9899-8|issn=1573-6601|pmc=4835178|pmid=23334988}} influencing the emergence of painful feelings towards one's body. In addition, social pressure is considered a risk factor for body dissatisfaction. For example, the frequent presence on media of thin female bodies determines, especially in young girls, a daily comparison between their bodies and models and actresses favoring bodily dissatisfaction;{{cite journal|last1=Derenne|first1=J|last2=Beresin|first2=E|date=2006-05-01|title=Body Image, Media, and Eating Disorders|url=|journal=Academic Psychiatry|language=en|volume=30|issue=3|pages=257–261|doi=10.1176/appi.ap.30.3.257|issn=1545-7230|pmid=16728774|s2cid=11131622}} comparing an "ideal" and "real" body feed an intense dissatisfaction with one's body and increases the feeling of shame, disgust, and anxiety towards one's body and appearance.{{cite journal|last1=Austin|first1=S. Bryn|last2=Haines|first2=Jess|last3=Veugelers|first3=Paul J.|date=2009-08-27|title=Body satisfaction and body weight: gender differences and sociodemographic determinants|journal=BMC Public Health|volume=9|issue=1|pages=313|doi=10.1186/1471-2458-9-313|issn=1471-2458|pmc=2740850|pmid=19712443 |doi-access=free }}

Dissatisfaction with one's body involves only three of the four components of the body image. Those with bodily dissatisfaction can have negative thoughts about one's body (e.g., "I'm ugly" or "I'm too short"). In addition, they may have behaviors related to bodily dissatisfaction (e.g., going on a diet or resorting to cosmetic surgery{{cite journal|last1=Rounsefell|first1=K|last2=Gibson|first2=S|last3=McLean|first3=S|last4=Blair|first4=M|last5=Molenaar|first5=A|last6=Brennan|first6=L|last7=Truby|first7=H|last8=McCaffrey|first8=T|date=2020|title=Social media, body image and food choices in healthy young adults: A mixed methods systematic review|journal=Nutrition & Dietetics|volume=77|issue=1|pages=19–40|doi=10.1111/1747-0080.12581|issn=1747-0080|pmc=7384161|pmid=31583837}}{{cite journal|last1=Schaefer|first1=L|last2=Harriger|first2=J|last3=Heinberg|first3=L|last4=Soderberg|first4=T|last5=Thompson|first5=J|date=2017|title=Development and validation of the sociocultural attitudes towards appearance questionnaire-4-revised (SATAQ-4R)|url=|journal=International Journal of Eating Disorders|language=en|volume=50|issue=2|pages=104–117|doi=10.1002/eat.22590|issn=1098-108X|pmid=27539814|s2cid=30462042}}) . They may also have negative feelings of dissatisfaction with their body and be ashamed of showing it in public. However, all these aspects are not enough to define it as a body image disturbance. In fact, there is no perceptual alteration of one's body. Thus, "body image disturbance" cannot be used interchangeably with "body dissatisfaction", but they are closely related.{{cite journal|last1=Coker|first1=E|last2=Abraham|first2=S|date=2014-08-01|title=Body weight dissatisfaction: A comparison of women with and without eating disorders|url=|journal=Eating Behaviors|language=en|volume=15|issue=3|pages=453–459|doi=10.1016/j.eatbeh.2014.06.014|issn=1471-0153|pmid=25064299}}

Body image disturbance in anorexia and body dysmorphic disorder (BDD) are similar psychiatric conditions that both involve an altered perception of the body or parts of it but are not the same disorder. Body image disturbance is a symptom of anorexia nervosa (AN) and is present as criterion C in the DSM-5, and alters the perception of weight and shapes of the whole body. Patients with anorexia nervosa believe that they are overweight, perceive their body as being "fat" and misperceive their body's shape.{{cite journal|last1=Marzola|first1=E|last2=Panero|first2=M|last3=Cavallo|first3=F|last4=Delsedime|first4=N|last5=Abbate-Daga|first5=G|date=2020-01-31|title=Body shape in inpatients with severe anorexia nervosa|journal=European Psychiatry|volume=63|issue=1|pages=e2|doi=10.1192/j.eurpsy.2019.5|issn=1778-3585|pmc=7315881|pmid=32093789}} Body dysmorphic disorder, meanwhile, is an obsessive-compulsive disorder characterized by disproportionate concern for minimal or absent individual bodily flaws, which cause personal distress and social impairment{{Cite book|title=Obsessive-Compulsive and Related Disorders|date=2013-05-22|url=https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm06|work=Diagnostic and Statistical Manual of Mental Disorders|series=DSM Library|publisher=American Psychiatric Association|doi=10.1176/appi.books.9780890425596.dsm06|isbn=978-0-89042-555-8|access-date=2021-08-03|archive-date=3 August 2021|archive-url=https://web.archive.org/web/20210803121503/https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm06|url-status=dead}}—patients with body dysmorphic disorder are concerned about physical details, mainly the face, skin, and nose.{{cite journal|last1=Ahluwalia|first1=R|last2=Bhatia|first2=N|last3=Kumar|first3=P|last4=Kaur|first4=P|date=2017|title=Body dysmorphic disorder: Diagnosis, clinical aspects and treatment strategies|journal=Indian Journal of Dental Research|volume=28|issue=2|pages=193–197|doi=10.4103/ijdr.IJDR_669_15|issn=1998-3603|pmid=28611331|s2cid=37272729|doi-access=free}} Thus, both anorexia nervosa and body dysmorphic disorder manifest significant disturbances in body image but are different and highly comorbid.{{cite journal|last1=Phillipou|first1=A|last2=Castle|first2=D|last3=Rossell|first3=S|date=2019|title=Direct comparisons of anorexia nervosa and body dysmorphic disorder: A systematic review|url=https://pubmed.ncbi.nlm.nih.gov/30784781/|journal=Psychiatry Research|volume=274|pages=129–137|doi=10.1016/j.psychres.2019.01.106|issn=1872-7123|pmid=30784781|s2cid=73457945}} For example, Grant et al reported that 39% of AN patients in their sample had a comorbid diagnosis of body dysmorphic disorder, with concerns unrelated to weight.{{cite journal|last1=Grant|first1=Jon E.|last2=Kim|first2=Suck Won|last3=Eckert|first3=Elke D.|date=2002|title=Body dysmorphic disorder in patients with anorexia nervosa: prevalence, clinical features, and delusionality of body image|url=https://pubmed.ncbi.nlm.nih.gov/12210643/|journal=The International Journal of Eating Disorders|volume=32|issue=3|pages=291–300|doi=10.1002/eat.10091|issn=0276-3478|pmid=12210643}} Cerea et al reported that 26% of their AN sample had a probable BDD diagnosis with non-weight-related body concerns.{{cite journal|last1=Cerea|first1=S|last2=Bottesi|first2=G|last3=Grisham|first3=J|last4=Ghisi|first4=M|date=2018|title=Non-weight-related body image concerns and Body Dysmorphic Disorder prevalence in patients with Anorexia Nervosa|url=https://pubmed.ncbi.nlm.nih.gov/29886274/|journal=Psychiatry Research|volume=267|pages=120–125|doi=10.1016/j.psychres.2018.05.068|issn=1872-7123|pmid=29886274|s2cid=47012587}}

While a 2019 review by Phillipou et al in Psychiatry Research suggested that the two disorders could be taken together as "body image disturbances", plural, more in-depth studies are needed to confirm this new classification hypothesis.

Previous studies found that both BDD and eating disorder groups were similar in body dissatisfaction, body checking, body concerns,{{cite journal|last1=Rosen|first1=J. C.|last2=Ramirez|first2=E.|date=1998|title=A comparison of eating disorders and body dysmorphic disorder on body image and psychological adjustment|url=https://pubmed.ncbi.nlm.nih.gov/9587886/|journal=Journal of Psychosomatic Research|volume=44|issue=3–4|pages=441–449|doi=10.1016/s0022-3999(97)00269-9|issn=0022-3999|pmid=9587886}} and levels of perfectionism.{{cite journal|last1=Hartmann|first1=A|last2=Thomas|first2=J|last3=Greenberg|first3=J|last4=Matheny|first4=N|last5=Wilhelm|first5=S|date=2014|title=A comparison of self-esteem and perfectionism in anorexia nervosa and body dysmorphic disorder|url=https://pubmed.ncbi.nlm.nih.gov/25390930/|journal=The Journal of Nervous and Mental Disease|volume=202|issue=12|pages=883–888|doi=10.1097/NMD.0000000000000215|issn=1539-736X|pmid=25390930|s2cid=43880482}} Furthermore, both BDD and AN patients report higher intensities of negative emotions, lower intensities of positive emotions, lower self-esteem, and anxiety symptoms. Moreover, research find severe concerns about one's appearance, leading to a continuous confrontation with others' bodies in both diseases. In addition, body image disturbances and body dysmorphic disorder generally onset during adolescence. Finally, alterations in visual processes seems to be present in both disorders, with greater attention to detail, but with greater difficulty in perceiving stimuli holistically.{{cite journal|last1=Harrison|first1=A|last2=Tchanturia|first2=K|last3=Treasure|first3=J|date=2011-05-09|title=Measuring state trait properties of detail processing and global integration ability in eating disorders|url=|journal=The World Journal of Biological Psychiatry|volume=12|issue=6|pages=462–472|doi=10.3109/15622975.2010.551666|issn=1562-2975|pmid=21554026|s2cid=40046456}} Indeed, neurophysiology and neuroimaging research suggests similarities between BDD and AN patients in terms of abnormalities in visuospatial processing.{{cite journal|last=D|first=Rangaprakash|url=http://worldcat.org/oclc/1163669037|title=Aberrant Dynamic Connectivity for Fear Processing in Anorexia Nervosa and Body Dysmorphic Disorder.|journal=Frontiers in Psychiatry|date=2018-01-01|volume=9|page=273|publisher=eScholarship, University of California|doi=10.3389/fpsyt.2018.00273|pmid=29997532|pmc=6028703|oclc=1163669037|doi-access=free}}{{cite journal|last1=Li|first1=W.|last2=Lai|first2=T. M.|last3=Bohon|first3=C.|last4=Loo|first4=S. K.|last5=McCurdy|first5=D.|last6=Strober|first6=M.|last7=Bookheimer|first7=S.|last8=Feusner|first8=J.|date=2015-02-05|title=Anorexia nervosa and body dysmorphic disorder are associated with abnormalities in processing visual information|url=|journal=Psychological Medicine|volume=45|issue=10|pages=2111–2122|doi=10.1017/s0033291715000045|pmid=25652023|pmc=4898970|issn=0033-2917}}

Despite many similarities, the two disorders also have significant differences.{{cite journal|last1=Toh|first1=W|last2=Grace|first2=S|last3=Rossell|first3=S|last4=Castle|first4=D|last5=Phillipou|first5=A|date=2019-04-01|title=Body parts of clinical concern in anorexia nervosa versus body dysmorphic disorder: a cross-diagnostic comparison|url=|journal=Australasian Psychiatry|volume=28|issue=2|pages=134–139|doi=10.1177/1039856219839477|issn=1039-8562|pmid=30931578|s2cid=89621217}} The first is gender distribution. Body image disturbance is much more present in females,{{cite journal|last1=Smink|first1=Frédérique R. E.|last2=van Hoeken|first2=Daphne|last3=Hoek|first3=Hans W.|date=2012|title=Epidemiology of eating disorders: incidence, prevalence and mortality rates|journal=Current Psychiatry Reports|volume=14|issue=4|pages=406–414|doi=10.1007/s11920-012-0282-y|issn=1535-1645|pmc=3409365|pmid=22644309}} unlike BDD, which has a much less unbalanced incidence.{{cite journal|last1=Bjornsson|first1=Andri S.|last2=Didie|first2=Elizabeth R.|last3=Phillips|first3=Katharine A.|date=2010|title=Body dysmorphic disorder|journal=Dialogues in Clinical Neuroscience|volume=12|issue=2|pages=221–232|doi=10.31887/DCNS.2010.12.2/abjornsson|issn=1294-8322|pmc=3181960|pmid=20623926}} Furthermore, those with dysmorphophobia tend to have more significant inhibitions and avoidance of social activities than those with anorexia nervosa. Differences are self-evident when considering the focus of physical concerns and misperception in AN and BDD. BDD patients report concerns and misperception in specific body areas (mainly face, skin, and hair).{{cite journal|last1=Bjornsson|first1=A|last2=Didie|first2=E|last3=Phillips|first3=K|date=2010|title=Body dysmorphic disorder|journal=Dialogues in Clinical Neuroscience|volume=12|issue=2|pages=221–232|doi=10.31887/DCNS.2010.12.2/abjornsson|issn=1294-8322|pmc=3181960|pmid=20623926}} In patients with AN, the altered perception could involve the arms, shoulders, thighs, abdomen, hips, and breasts, and concerns are about overall body shape and weight; thus leading to an alteration of the entire explicit (body image) and implicit (body schema){{cite journal|last1=Beckmann|first1=N|last2=Baumann|first2=P|last3=Herpertz|first3=S|last4=Trojan|first4=J|last5=Diers|first5=M|date=2021|title=How the unconscious mind controls body movements: Body schema distortion in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/33345338/|journal=The International Journal of Eating Disorders|volume=54|issue=4|pages=578–586|doi=10.1002/eat.23451|issn=1098-108X|pmid=33345338|s2cid=229341829}} mental representation of the body.{{cite journal|last=Gadsby|first=S|date=2017|title=Distorted body representations in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/28284109/|journal=Consciousness and Cognition|volume=51|pages=17–33|doi=10.1016/j.concog.2017.02.015|issn=1090-2376|pmid=28284109|s2cid=3827318}} Furthermore, in anorexia nervosa, not only is visual perception of one's body altered, but both tactile and interoceptive perception are as well.

Body image disturbance is not yet clearly defined by official disease classifications. However, it appears in the DSM-5 under criterion C for anorexia nervosa and is vaguely described as "a disturbance in the way weight and body shapes are experienced". As a result, diagnosis is usually based on reported signs and symptoms; there are still no biological markers for body image disturbance. Numerous psychometric instruments to measure the cognitive, affective, and behavioral components of one's body image are used in clinical and research settings, helping in assessing the body image's attitudinal components. Recently, research developed other instruments to measure the perceptive component.

• The Eating Disorder Inventory 3 (EDI-3) represents an improvement of the earlier versions of the EDI, a self-report questionnaire widely used both in research and clinical settings. It consists of 91 questions, and items are rated on a six-point Likert scale (always, usually, sometimes, rarely, never), with higher scores representing more severe symptoms. Precisely, the BD subscale of EDI-3 measures bodily dissatisfaction.{{cite journal|last1=Clausen|first1=L|last2=Rosenvinge|first2=J|last3=Friborg|first3=O|last4=Rokkedal|first4=K|date=2011|title=Validating the Eating Disorder Inventory-3 (EDI-3): A Comparison Between 561 Female Eating Disorders Patients and 878 Females from the General Population|journal=Journal of Psychopathology and Behavioral Assessment|volume=33|issue=1|pages=101–110|doi=10.1007/s10862-010-9207-4|issn=0882-2689|pmc=3044826|pmid=21472023}}
• The Body Uneasiness Test (BUT) is a self-administered questionnaire. It explores several areas in clinical and non-clinical populations: weight phobia, body image-related avoidance behavior, compulsive self-monitoring, detachment and estrangement feelings toward one's own body. Besides, explore specific worries about particular body parts, shapes, or functions. Higher scores indicate significant body uneasiness.{{cite journal|last1=Cuzzolaro|first1=M.|last2=Vetrone|first2=G.|last3=Marano|first3=G.|last4=Garfinkel|first4=P. E.|date=2006|title=The Body Uneasiness Test (BUT): development and validation of a new body image assessment scale|url=https://pubmed.ncbi.nlm.nih.gov/16801740/|journal=Eating and Weight Disorders|volume=11|issue=1|pages=1–13|doi=10.1007/BF03327738|issn=1590-1262|pmid=16801740|s2cid=10260135}}
• The Body Image Disturbance Questionnaire investigates different areas related to body image disturbance. For example, it evaluates the parts of the body an individual finds most problematic, the psychological effects of their worries about their body, and effects on their social life and eating behavior.{{cite journal|last1=Cash|first1=T|last2=Phillips|first2=K|last3=Santos|first3=M|last4=Hrabosky|first4=J|date=2004-12-01|title=Measuring "negative body image": validation of the Body Image Disturbance Questionnaire in a nonclinical population|url=|journal=Body Image|language=en|volume=1|issue=4|pages=363–372|doi=10.1016/j.bodyim.2004.10.001|issn=1740-1445}}
• The Body Shape Questionnaire is a 34-item self-assessment questionnaire designed to measure the degree of dissatisfaction with the weight and shape of one's body. It includes questions about the fear of weight gain and about whether one has the urge or desire to lose weight.{{cite journal|last1=Cooper|first1=P|last2=Taylor|first2=M|last3=Cooper|first3=Z|last4=Fairbum|first4=C|date=1987|title=The development and validation of the body shape questionnaire|url=|journal=International Journal of Eating Disorders|language=en|volume=6|issue=4|pages=485–494|doi=10.1002/1098-108X(198707)6:4<485::AID-EAT2260060405>3.0.CO;2-O|issn=1098-108X}}
• The Body Checking Questionnaire measures the frequency of body control behaviors, such as measuring specific body areas, using mirrors to check or avoid body shape, wearing loose-fitting, covering clothing, or checking for bony prominence with one's hands. Higher scores indicate a higher frequency of body checking behaviors.{{Cite encyclopedia|last=Reas|first=D|title=Body Checking Questionnaire (BCQ)|date=2015|url=|encyclopedia=Encyclopedia of Feeding and Eating Disorders|pages=1–5|editor-last=Wade|editor-first=Tracey|place=Singapore|publisher=Springer|language=en|doi=10.1007/978-981-287-087-2_10-1|isbn=978-981-287-087-2}}

• BID-CA (Test for Body Image Distortion in Children and Adolescents): Patients with a 180 cm rope simulate the circumference of the different parts of the body, including the hips, thighs, shoulder width and other parts of the body considered phobic. This estimate is compared to the actual patient size. The procedure is validated for children and adolescents but can also be used in adults.{{cite journal|last1=Schneider|first1=N.|last2=Martus|first2=P.|last3=Ehrlich|first3=S.|last4=Pfeiffer|first4=E.|last5=Lehmkuhl|first5=U.|last6=Salbach-Andrae|first6=H.|date=2009-06-01|title=The assessment of body image distortion in female adolescents with anorexia nervosa: The development of a Test for Body Image Distortion in Children and Adolescents (BID-CA)|url=|journal=Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity|language=en|volume=14|issue=2|pages=e128–e136|doi=10.1007/BF03327810|pmid=19934626|s2cid=29281266|issn=1590-1262}}
• Visual Size Estimation Task (VSE): patients are placed standing in front of a wall at a distance of about one meter. They place two stickers on the wall that reflect the perceived dimensions of different body parts, such as the width of the shoulders, hips, or waistline. These values are then taken and compared with those measured directly on the patient.
• Tactile Estimation Task (TET): a standard gauge is used for measurement. During the measurement, patients estimate the distance between the two points of the gauge while it is placed on different parts of the body. Several measurements are made and the gauge is oriented in different directions (for example, at the height of the hips, it is placed both horizontally and vertically)
• 3D Morphing: Numerous 3D modeling computer programs allow directly modifying a human body model by increasing or decreasing its size. Patients modify the 3D avatar so that it represents their body image as closely as possible. The model values are then compared with the actual measurements of the patients.{{cite journal|last1=Cornelissen|first1=K|last2=McCarty|first2=K|last3=Cornelissen|first3=P|last4=Tovée|first4=M|date=2017-11-17|title=Body size estimation in women with anorexia nervosa and healthy controls using 3D avatars|journal=Scientific Reports|language=en|volume=7|issue=1|pages=15773|bibcode=2017NatSR...715773C|doi=10.1038/s41598-017-15339-z|issn=2045-2322|pmc=5693901|pmid=29150646}}

The perception of one's body is a multi-sensory process that integrates information deriving from different sensory cortices, including the visual, proprioceptive, tactile, interoceptive, and auditory-vestibular areas.{{cite journal|last1=Tsakiris|first1=M|last2=Schütz-Bosbach|first2=S|last3=Gallagher|first3=S|date=2007-09-01|title=On agency and body-ownership: Phenomenological and neurocognitive reflections|url=|journal=Consciousness and Cognition|series=Subjectivity and the Body|language=en|volume=16|issue=3|pages=645–660|doi=10.1016/j.concog.2007.05.012|pmid=17616469|s2cid=11049449|issn=1053-8100}} All of these areas are involved in the perception of one's body. An important component is the premotor cortex (PMC) and the intraparietal sulcus. These two areas are active during illusory hand perception tasks in both hemispheres.{{cite journal|last=Tsakiris|first=M|date=2017-04-01|title=The multisensory basis of the self: From body to identity to others|url=|journal=Quarterly Journal of Experimental Psychology|language=en|volume=70|issue=4|pages=597–609|doi=10.1080/17470218.2016.1181768|issn=1747-0218|pmc=5214748|pmid=27100132}}

The somatosensory areas are also involved, in particular the primary somatosensory cortex (S1). An important area is the extrastriate body area located rostrocaudally in the occipital lobe and is specific to human bodies perception. Two other areas of considerable importance in the perception of the body are the insula and the anterior cingulate cortex.{{cite journal|last1=Ishida|first1=H|last2=Suzuki|first2=K|last3=Grandi|first3=L.|date=2015|title=Predictive coding accounts of shared representations in parieto-insular networks|url=https://pubmed.ncbi.nlm.nih.gov/25447372/|journal=Neuropsychologia|volume=70|pages=442–454|doi=10.1016/j.neuropsychologia.2014.10.020|issn=1873-3514|pmid=25447372|s2cid=22932245}} The insular cortex is fundamental in the direct perception and integration of bodily signals from different cortical areas and, despite being an area historically delegated to the sole function of perceiving the state of internal organs as proposed by Sherrington in 1911,{{cite book | last=Sherrington | first=Charles S. | title=The integrative action of the nervous system | publisher=Yale University Press | publication-place=New Haven | year=1911 | doi=10.1037/13798-000 | page=| hdl=2027/mdp.39015010040445 | url=http://archive.org/details/integrativeactio00sheruoft }} research advances demonstrate the central role of the insula in several domains, including the recognition that one's body belongs to us. Namely the "body ownership".{{cite journal|last1=Lopez|first1=C.|last2=Halje|first2=P.|last3=Blanke|first3=O.|date=2008|title=Body ownership and embodiment: vestibular and multisensory mechanisms|url=https://pubmed.ncbi.nlm.nih.gov/18539248/|journal=Neurophysiologie Clinique = Clinical Neurophysiology|volume=38|issue=3|pages=149–161|doi=10.1016/j.neucli.2007.12.006|issn=0987-7053|pmid=18539248|s2cid=6024776}}{{cite journal|last=Tsakiris|first=M|date=2010|title=My body in the brain: a neurocognitive model of body-ownership|url=https://pubmed.ncbi.nlm.nih.gov/19819247/|journal=Neuropsychologia|volume=48|issue=3|pages=703–712|doi=10.1016/j.neuropsychologia.2009.09.034|issn=1873-3514|pmid=19819247|s2cid=1926912}}

fMRI studies examining brain responses in anorexia nervosa patients to paradigms that include body image tasks have found altered activation across different brain areas, including the prefrontal cortex, precuneus, parietal cortex, insula, amygdala, ventral striatum, extrastriate body area, and fusiform gyrus.{{cite journal|last1=Gaudio|first1=S.|last2=Quattrocchi|first2=C.|date=2012|title=Neural basis of a multidimensional model of body image distortion in anorexia nervosa|journal=Neuroscience & Biobehavioral Reviews|volume=36|issue=8|pages=1839–1847|doi=10.1016/j.neubiorev.2012.05.003|pmid=22613629|s2cid=13475512}} However, as Janet Treasure commented, "the research [in the field] is fragmented, and the mechanism of how these areas map onto the functional networks described above needs further study ... the mechanism by which the extremes of body distortion are driven and [their] circuitry is not known yet."

The Body Project{{cite book|last1=Stice|first1=E|url=https://www.oxfordclinicalpsych.com/view/10.1093/med:psych/9780199859245.001.0001/med-9780199859245|title=The Body Project: A Dissonance-Based Eating Disorder Prevention Intervention|last2=Rohde|first2=P|last3=Shaw|first3=H|publisher=Oxford University Press|year=2013|isbn=978-0-19-023065-4|language=en-US|doi=10.1093/med:psych/9780199859245.001.0001}} is an eating disorder prevention program within a dissonant-cognitive framework. The program provides a forum for high school girls and college-age women to confront unrealistic-looking ideals and develop a healthy body image and self-esteem. It has been repeatedly shown to effectively reduce body dissatisfaction, negative mood, unhealthy diet, and disordered eating.{{cite journal|last1=Stice|first1=E|last2=Marti|first2=C|last3=Spoor|first3=S|last4=Presnell|first4=K|last5=Shaw|first5=H|date=2008|title=Dissonance and Healthy Weight Eating Disorder Prevention Programs: Long-Term Effects from a Randomized Efficacy Trial|journal=Journal of Consulting and Clinical Psychology|volume=76|issue=2|pages=329–340|doi=10.1037/0022-006X.76.2.329|issn=0022-006X|pmc=2677629|pmid=18377128}}

Historically, research and clinicians have mainly focused on body image disturbance's cognitive, affective, and behavioral components. Consequently, treatments generally target symptoms such as body checking, dysfunctional beliefs, feelings, and emotions relating to the body. One of the best-known psychotherapies in the field is CBT-E.{{cite journal|last1=Murphy|first1=R|last2=Straebler|first2=S|last3=Cooper|first3=Z|last4=Fairburn|first4=C|date=2010|title=Cognitive behavioral therapy for eating disorders|journal=The Psychiatric Clinics of North America|volume=33|issue=3|pages=611–627|doi=10.1016/j.psc.2010.04.004|issn=1558-3147|pmc=2928448|pmid=20599136}} CBT-E is a cognitive-behavioral therapy that has been enhanced with particular strategies to address the psychopathology of eating disorders. These include reducing negative thoughts and worries about body weight and shape, reducing clinical perfectionism, and body-checking behavior.{{cite journal|last1=Atwood|first1=M|last2=Friedman|first2=A|date=2020|title=A systematic review of enhanced cognitive behavioral therapy (CBT-E) for eating disorders|url=https://pubmed.ncbi.nlm.nih.gov/31840285/|journal=The International Journal of Eating Disorders|volume=53|issue=3|pages=311–330|doi=10.1002/eat.23206|issn=1098-108X|pmid=31840285|s2cid=209384429}} In 2020 a review has shown that CBT-E effectively reduces core symptoms in eating disorders, including concerns about the body. Despite this, the results of CBT-E are no better than other forms of treatment.{{cite journal|last1=Atwood|first1=M|last2=Friedman|first2=A|date=2020|title=A systematic review of enhanced cognitive behavioral therapy (CBT-E) for eating disorders|url=|journal=International Journal of Eating Disorders|language=en|volume=53|issue=3|pages=311–330|doi=10.1002/eat.23206|issn=1098-108X|pmid=31840285|s2cid=209384429}} A therapy of choice for eating disorders in adults has not yet been identified.

Additionally, two other noteworthy body image treatments are Thomas F. Cash's "Body Image Workbook"{{cite web|title=APA PsycNet|url=https://psycnet.apa.org/record/2009-02757-000|access-date=2021-08-03|website=psycnet.apa.org|language=en}} and BodyWise.{{cite journal|last1=Mountford|first1=V|last2=Brown|first2=A|last3=Bamford|first3=B|last4=Saeidi|first4=S|last5=Morgan|first5=J|last6=Lacey|first6=H|date=2015|title=BodyWise: evaluating a pilot body image group for patients with anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/25382845/|journal=European Eating Disorders Review|volume=23|issue=1|pages=62–67|doi=10.1002/erv.2332|issn=1099-0968|pmid=25382845}} The former is an 8-step group treatment within a classic cognitive-behavioral framework. The latter is a psychoeducational-based treatment improved with cognitive remediation techniques to promote awareness of body image difficulties and to reduce cognitive inflexibility and body dissatisfaction.

File:Virtual-reality-woman.jpg

Compared to the classic cognitive-behavioral therapeutic paradigms, since the early 2000s, new treatments for body image disturbance have been developed focusing on the disorder's perceptual component. Mirror Exposure{{cite journal|last1=Delinsky|first1=S|last2=Wilson|first2=G|date=2006|title=Mirror exposure for the treatment of body image disturbance|url=https://pubmed.ncbi.nlm.nih.gov/16231342/|journal=The International Journal of Eating Disorders|volume=39|issue=2|pages=108–116|doi=10.1002/eat.20207|issn=0276-3478|pmid=16231342}} is a new cognitive-behavioral technique that aims to reduce experiential avoidance, reduce bodily dissatisfaction, and improve one's misperception of one's body. During the exposure therapy, patients are invited to observe themselves in front of a large full-length mirror. There are different types of mirror exposure: guided exposure; unguided exposure; exposure with mindfulness exercises; and cognitive dissonance-based mirror exposure.{{cite journal|last1=Moreno-Domínguez|first1=S|last2=Rodríguez-Ruiz|first2=S|last3=Fernández-Santaella|first3=M|last4=Jansen|first4=A|last5=Tuschen-Caffier|first5=B|date=2012|title=Pure versus guided mirror exposure to reduce body dissatisfaction: a preliminary study with university women|url=https://pubmed.ncbi.nlm.nih.gov/22244836/|journal=Body Image|volume=9|issue=2|pages=285–288|doi=10.1016/j.bodyim.2011.12.001|issn=1873-6807|pmid=22244836|s2cid=22467171}}{{cite journal|last1=Luethcke|first1=C|last2=McDaniel|first2=L|last3=Becker|first3=C|date=2011|title=A comparison of mindfulness, nonjudgmental, and cognitive dissonance-based approaches to mirror exposure|url=https://pubmed.ncbi.nlm.nih.gov/21561817/|journal=Body Image|volume=8|issue=3|pages=251–258|doi=10.1016/j.bodyim.2011.03.006|issn=1873-6807|pmid=21561817}} To date, few studies have investigated the effects of mirror exposure in patients with body image disturbance. In the International Journal of Eating Disorders, Key et al (2002) conducted a non-randomized trial in a clinical sample and compared a body image group therapy with or without mirror exposure.{{cite journal|last1=Key|first1=A|last2=George|first2=C|last3=Beattie|first3=D|last4=Stammers|first4=K|last5=Lacey|first5=H|last6=Waller|first6=G|date=2002|title=Body image treatment within an inpatient program for anorexia nervosa: the role of mirror exposure in the desensitization process|url=https://pubmed.ncbi.nlm.nih.gov/11920979/|journal=The International Journal of Eating Disorders|volume=31|issue=2|pages=185–190|doi=10.1002/eat.10027|issn=0276-3478|pmid=11920979}} They found a significant improvement in body dissatisfaction only in the mirror exposure therapy group. Despite the positive evidence, in 2018, a review in Clinical Psychology Review suggests that Mirror Exposure has a low-to-medium effect in reducing body image disturbance and further studies are needed to improve it.{{cite journal|last1=Griffen|first1=T|last2=Naumann|first2=E|last3=Hildebrandt|first3=T|date=2018|title=Mirror exposure therapy for body image disturbances and eating disorders: A review|url=https://pubmed.ncbi.nlm.nih.gov/30223161/|journal=Clinical Psychology Review|volume=65|pages=163–174|doi=10.1016/j.cpr.2018.08.006|issn=1873-7811|pmid=30223161|s2cid=52294554}}

Another treatment for body image disturbance is Virtual Reality (VR) Body Swapping. VR-Body Swapping is a technique that allows generating a body illusion during a virtual reality experience. Specifically, after building a virtual avatar using 3D modeling software, it is possible to generate the illusion that the avatar's body is one's own body. The avatar is a 3D human body model that simulates the actual size of the patient and can be modified directly. Some studies have found that applying this technique to those with anorexia nervosa reduces their misperception of their bodies{{cite journal|last1=Serino|first1=S|last2=Pedroli|first2=E|last3=Keizer|first3=A|last4=Triberti|first4=S|last5=Dakanalis|first5=A|last6=Pallavicini|first6=F|last7=Chirico|first7=A|last8=Riva|first8=G|date=2016|title=Virtual Reality Body Swapping: A Tool for Modifying the Allocentric Memory of the Body|url=https://pubmed.ncbi.nlm.nih.gov/26506136/|journal=Cyberpsychology, Behavior and Social Networking|volume=19|issue=2|pages=127–133|doi=10.1089/cyber.2015.0229|issn=2152-2723|pmid=26506136|s2cid=5428082}}{{cite journal|last1=Keizer|first1=A|last2=van Elburg|first2=A|last3=Helms|first3=R|last4=Dijkerman|first4=H|date=2016|title=A Virtual Reality Full Body Illusion Improves Body Image Disturbance in Anorexia Nervosa|journal=PLOS ONE|volume=11|issue=10|pages=e0163921|bibcode=2016PLoSO..1163921K|doi=10.1371/journal.pone.0163921|issn=1932-6203|pmc=5053411|pmid=27711234|doi-access=free}} but provides, at the moment, only a short-term effect.

File:Hoop training.png

However, other treatments have also been developed to integrate tactile, proprioceptive, and interoceptive perception into one's overall body perception. Hoop Training is a short-term 8-week intervention (10 minutes per session) designed to become aware of and reduce body misperception. During the exercise, several flexible circles of different sizes are placed in front of the patient. First, the patients indicate which of the different circles best fits the circumference of their hips. Once indicated, patients are invited to enter the circle and, raising it, underestimating whether their estimate was accurate or not. The exercise takes place until the patient identifies the correct circumference for her hips. The circle chosen initially can be compared with the one that can coincide with the actual size of the patient. Hoop Training is meant to work on the components cognitive, affective, and perceptive of body image disturbance and the first efficacy data were published in 2019.

Another perceptive treatment is the Body Perception Treatment (BPT) whose first efficacy data were published in 2021. BPT is a specific group intervention for body image disturbance focused on tactile, proprioceptive, and interoceptive self-perceptions during a body-focused experience. During the exercise, patients lie down on their backs in the supine position with closed eyes. Then the therapist guide patients to selectively focus attention on the different body parts in contact with the floor. In order: feet, calves, thighs, back, shoulders, hands, arms, head and the body in its entirety. In addition, patients are invited to pay attention to skin temperature, heart beat and flow of breath. The treatment is consistent with the hypothesized role of interoception in developing body image disturbance by Badoud and Tsakiris in 2017.{{cite journal|last1=Badoud|first1=D|last2=Tsakiris|first2=M|date=2017|title=From the body's viscera to the body's image: Is there a link between interoception and body image concerns?|url=https://pubmed.ncbi.nlm.nih.gov/28377099/|journal=Neuroscience and Biobehavioral Reviews|volume=77|pages=237–246|doi=10.1016/j.neubiorev.2017.03.017|issn=1873-7528|pmid=28377099|s2cid=768206}}

Both Hoop Training and Body Perception Treatment showed effective results in pilot studies and were designed to work within a multisensory integration framework. However, they complement, not replace, current standard therapies for eating disorders. However, both are also novelty treatments, and the results have not been replicated in independent studies. Thus, their actual effectiveness will have to be confirmed/disconfirmed by future research. As of the end of 2021 they have not yet been replicated.

{{clear}}

{{Reflist}}

{{Medical resources

| ICD11 =

| ICD10 =

| ICD10CM =

| ICD9 =

| OMIM =

| MeshID = D000079182

| DiseasesDB =

| SNOMED CT =

| Curlie =

| MedlinePlus =

| eMedicineSubj =

| eMedicineTopic =

| PatientUK =

| NCI =

| GeneReviewsNBK =

| GeneReviewsName =

| NORD =

| GARDNum =

| GARDName =

| RP =

| AO =

| WO =

| OrthoInfo =

| Orphanet =

| Scholia =

| OB =

}}

{{Digital media use and mental health}}

Category:Human appearance

Category:Eating disorders