View source for Medicine:Body image disturbance

{{Short description|Altered perception of one's body image}}
{{Infobox medical condition (new)
| name          = Body image disturbance
| image         = 
| caption       = Drawing of a girl looking in the mirror with a body image disturbance
| field         = [[Biology:Psychiatry|Psychiatry]], [[Social:Psychology|psychology]]
| symptoms      = Altered body self-perception, body uneasiness, body dissatisfaction, body-checking behavior
| complications = Eating disorders
| onset         = Early adolescence
| duration      = 
| causes        = 
| risks         = Body dissatisfaction, childhood neglect, childhood abuse
| diagnosis     = EDI-3, body uneasiness test, clinical diagnosis
| differential  = [[Medicine:Body dysmorphic disorder|Body dysmorphic disorder]], obsessive-compulsive disorder
| prevention    = Positive body image, good self-esteem, healthy eating behaviors
| treatment     = [[Medicine:Psychotherapy|Psychotherapy]]
| medication    = 
| prognosis     = 
| frequency     = 
| deaths        = 
}}
'''Body image disturbance''' ('''BID''') is a common symptom in patients with [[Medicine:Eating disorder|eating disorder]]s. 

The onset is mainly attributed to patients with [[Medicine:Anorexia nervosa|anorexia nervosa]] who persistently tend to subjectively discern themselves as average or overweight despite adequate, clinical grounds for a classification of being severely underweight.<ref name="Treasure 1–21">{{Cite journal|last1=Treasure|first1=Janet|last2=Zipfel|first2=Stephan|last3=Micali|first3=Nadia|last4=Wade|first4=Tracey|last5=Stice|first5=Eric|last6=Claudino|first6=Angélica|last7=Schmidt|first7=Ulrike|last8=Frank|first8=Guido K.|last9=Bulik|first9=Cynthia M.|last10=Wentz|first10=Elisabet|date=2015-11-26|title=Anorexia nervosa|url=https://www.nature.com/articles/nrdp201574|journal=Nature Reviews Disease Primers|language=en|volume=1|issue=1|page=15074|doi=10.1038/nrdp.2015.74|pmid=27189821|s2cid=21580134|issn=2056-676X}}</ref> The symptom is an altered perception of one's body and a severe state of bodily dissatisfaction characterizing the body image disturbance. It is included among the diagnostic criteria for anorexia nervosa in DSM-5 (criterion C).<ref name=":3">{{Citation|title=Feeding and Eating Disorders|date=2013-05-22|url=https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm10|work=Diagnostic and Statistical Manual of Mental Disorders|publisher=American Psychiatric Association|doi=10.1176/appi.books.9780890425596.dsm10|isbn=978-0-89042-555-8|access-date=2021-08-01}}</ref> 

The disturbance is associated with significant bodily dissatisfaction and is a source of severe distress, often persisting even after seeking treatment for an eating disorder,<ref name="Eshkevari 2014 400–409">{{Cite journal|last1=Eshkevari|first1=Ertimiss|last2=Rieger|first2=Elizabeth|last3=Longo|first3=Matthew R.|last4=Haggard|first4=Patrick|last5=Treasure|first5=Janet|date=2014|title=Persistent body image disturbance following recovery from eating disorders|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22219|journal=International Journal of Eating Disorders|language=en|volume=47|issue=4|pages=400–409|doi=10.1002/eat.22219|pmid=24243423|issn=1098-108X}}</ref><ref>{{Cite journal|last1=Engel|first1=Manja M.|last2=Keizer|first2=Anouk|date=2017-11-23|title=Body representation disturbances in visual perception and affordance perception persist in eating disorder patients after completing treatment|journal=Scientific Reports|language=en|volume=7|issue=1|pages=16184|doi=10.1038/s41598-017-16362-w|pmid=29170439|pmc=5701063|bibcode=2017NatSR...716184E|issn=2045-2322}}</ref> and is regarded difficult to treat.<ref name="Eshkevari 2014 400–409"/><ref name=":2" /> Thus, effective body image interventions could improve the prognosis in patients with ED, as experts have suggested.<ref name=":0">{{Cite journal|last=Bruch|first=Hilde|date=1962|title=Perceptual and Conceptual Disturbances in Anorexia Nervosa|url=https://dx.doi.org/10.1097/00006842-196203000-00009|journal=Psychosomatic Medicine|language=en-US|volume=24|issue=2|pages=187–194|doi=10.1097/00006842-196203000-00009|pmid=13873828|issn=0033-3174}}</ref> Unfortunately, there is no hard evidence that current treatments for body image disturbance effectively reduce eating disorders' symptoms.<ref>{{Cite journal|last1=Alleva|first1=Jessica M.|last2=Sheeran|first2=Paschal|last3=Webb|first3=Thomas L.|last4=Martijn|first4=Carolien|last5=Miles|first5=Eleanor|date=2015-09-29|title=A Meta-Analytic Review of Stand-Alone Interventions to Improve Body Image|journal=PLOS ONE|language=en|volume=10|issue=9|pages=e0139177|doi=10.1371/journal.pone.0139177|issn=1932-6203|pmc=4587797|pmid=26418470|bibcode=2015PLoSO..1039177A}}</ref> Furthermore, pharmacotherapy is ineffective in reducing body misperception and it has been used to focus on correlated psychopathology (e.g., [[Medicine:Mood disorder|mood]] or [[Medicine:Anxiety disorder|anxiety disorders]]).<ref>{{Cite journal|last1=Ziser|first1=Katrin|last2=Mölbert|first2=Simone Claire|last3=Stuber|first3=Felicitas|last4=Giel|first4=Katrin Elisabeth|last5=Zipfel|first5=Stephan|last6=Junne|first6=Florian|date=2018|title=Effectiveness of body image directed interventions in patients with anorexia nervosa: A systematic review|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22946|journal=International Journal of Eating Disorders|language=en|volume=51|issue=10|pages=1121–1127|doi=10.1002/eat.22946|pmid=30189104|s2cid=52170683|issn=1098-108X}}</ref> However, to date, research and clinicians are developing new therapies as virtual reality experiences,<ref>{{Cite journal|last1=Clus|first1=Damien|last2=Larsen|first2=Mark Erik|last3=Lemey|first3=Christophe|last4=Berrouiguet|first4=Sofian|date=2018-04-27|title=The Use of Virtual Reality in Patients with Eating Disorders: Systematic Review|journal=Journal of Medical Internet Research|volume=20|issue=4|pages=e157|doi=10.2196/jmir.7898|issn=1438-8871|pmc=5948410|pmid=29703715}}</ref><ref>{{Cite journal|last1=Porras-Garcia|first1=Bruno|last2=Serrano-Troncoso|first2=Eduardo|last3=Carulla-Roig|first3=Marta|last4=Soto-Usera|first4=Pau|last5=Ferrer-Garcia|first5=Marta|last6=Figueras-Puigderrajols|first6=Natàlia|last7=Yilmaz|first7=Lena|last8=Onur Sen|first8=Yigit|last9=Shojaeian|first9=Nazila|last10=Gutiérrez-Maldonado|first10=José|date=2020-05-15|title=Virtual Reality Body Exposure Therapy for Anorexia Nervosa. A Case Report With Follow-Up Results|journal=Frontiers in Psychology|volume=11|page=956|doi=10.3389/fpsyg.2020.00956|pmid=32499742|pmc=7242758|issn=1664-1078|doi-access=free}}</ref> mirror exposure<ref name=":17" /> or [[Philosophy:Multisensory integration|multisensory integration]] body techniques,<ref name=":19">{{Cite journal|last1=Keizer|first1=Anouk|last2=Engel|first2=Manja M.|last3=Bonekamp|first3=José|last4=Van Elburg|first4=Annemarie|date=2019|title=Hoop training: a pilot study assessing the effectiveness of a multisensory approach to treatment of body image disturbance in anorexia nervosa|journal=Eating and Weight Disorders: EWD|volume=24|issue=5|pages=953–958|doi=10.1007/s40519-018-0585-z|issn=1590-1262|pmc=6751149|pmid=30288723}}</ref><ref name=":2">{{Cite journal|last1=Artoni|first1=Paolo|last2=Chierici|first2=M. L.|last3=Arnone|first3=F.|last4=Cigarini|first4=C.|last5=De Bernardis|first5=E.|last6=Galeazzi|first6=G. M.|last7=Minneci|first7=D. G.|last8=Scita|first8=F.|last9=Turrini|first9=G.|last10=De Bernardis|first10=M.|last11=Pingani|first11=L.|date=2021|title=Body perception treatment, a possible way to treat body image disturbance in eating disorders: a case-control efficacy study|url=https://pubmed.ncbi.nlm.nih.gov/32124409/|journal=Eating and Weight Disorders: EWD|volume=26|issue=2|pages=499–514|doi=10.1007/s40519-020-00875-x|issn=1590-1262|pmid=32124409|s2cid=211728899}}</ref> which have shown some extent of efficacy.

== Characteristics ==
[[File:Hilde Bruch, clinical professor of psychiatry.jpg|alt=Hilde Bruch, 1960|thumb|Hilde Bruch, 1960]]
German-American psychiatrist Hilde Bruch first identified and described body image disturbance in [[Medicine:Anorexia nervosa|anorexia nervosa]]. In her famous article "Perceptual and Conceptual Disturbances in Anorexia Nervosa" <ref name=":0" /> she wrote:

{{quote|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.<ref name=":0" />|author=Hilde Bruch|title=Perceptual and Conceptual Disturbances in Anorexia Nervosa|source=Psychosomatic Medicine, 1962}}

However, body image disturbance is not specific to [[Medicine:Anorexia nervosa|anorexia nervosa]] but is sometimes present in other eating disorders such as [[Medicine:Bulimia nervosa|bulimia nervosa]]<ref name=":1">{{Citation|last1=Hosseini|first1=Seyed Alireza|title=Body Image Distortion|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK546582/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=31536191|access-date=2021-07-31|last2=Padhy|first2=Ranjit K.}}</ref> and binge eating disorder.<ref>{{Cite journal|last1=Lewer|first1=Merle|last2=Bauer|first2=Anika|last3=Hartmann|first3=Andrea S.|last4=Vocks|first4=Silja|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|pmid=29182531|pmc=5748745|doi-access=free}}</ref> Furthermore, recent studies have shown that it is possible to observe alterations in the perception of one's body, even in healthy subjects. Suggesting that 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).<ref>{{Cite journal|date=2019-02-01|title=Distortions of perceived volume and length of body parts|url=https://www.sciencedirect.com/science/article/pii/S0010945218303496|journal=Cortex|language=en|volume=111|pages=74–86|doi=10.1016/j.cortex.2018.10.016|issn=0010-9452|last1=Sadibolova|first1=Renata|last2=Ferrè|first2=Elisa R.|last3=Linkenauger|first3=Sally A.|last4=Longo|first4=Matthew R.|pmid=30471452|s2cid=53153320}}</ref> Commonly, body image disturbance is confused with [[Medicine:Body dysmorphic disorder|body dysmorphic disorder]], an [[Medicine:Obsessive–compulsive disorder|obsessive-compulsive disorder]] with whome it share 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 distorted and overweight body.
* frequently third-person mental view of one's body.
* negative thoughts like "I'm fat" or "my thighs are huge."
* frequent body-checking behaviors.
* frequent comparisons between one's body and that of others
* emotions of anxiety, shame, and contempt for one's body

Clinically speaking, a growing body of research suggests that body image disturbance plays a significant role in the onset,<ref>{{Cite journal|last1=Stice|first1=Eric|last2=Desjardins|first2=Christopher D.|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}}</ref> maintenance,<ref>{{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}}</ref><ref>{{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}}</ref> and relapse of [[Medicine:Anorexia nervosa|anorexia nervosa]],<ref>{{Cite journal|last1=Keel|first1=Pamela K.|last2=Dorer|first2=David J.|last3=Franko|first3=Debra L.|last4=Jackson|first4=Safia C.|last5=Herzog|first5=David B.|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}}</ref> as previously suggested by Hilde Bruch in 1962.<ref name=":0" /> However, despite increasing evidence, a recent review 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".<ref>{{Cite journal|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://www.sciencedirect.com/science/article/abs/pii/S0272735819302831|journal=Clinical Psychology Review|language=en|volume=74|pages=101771|doi=10.1016/j.cpr.2019.101771|issn=0272-7358|last1=Glashouwer|first1=Klaske A.|last2=Van Der Veer|first2=Roosmarijn M.L.|last3=Adipatria|first3=Fayanadya|last4=De Jong|first4=Peter J.|last5=Vocks|first5=Silja|pmid=31751876}}</ref> As suggested by the authors, this lack of evidence is partly related to terminology problems used in the [[Medicine:Body image|body image field]].<ref name=":24">{{Cite journal|last1=Mitchison|first1=Deborah|last2=Hay|first2=Phillipa|last3=Griffiths|first3=Scott|last4=Murray|first4=Stuart B.|last5=Bentley|first5=Caroline|last6=Gratwick-Sarll|first6=Kassandra|last7=Harrison|first7=Carmel|last8=Mond|first8=Jonathan|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}}</ref>

== Definition of body image disturbance ==
Different labels are used in research and clinical setting to define the body image disturbance generating terminological confusion. Some of the most used terms are "body image discrepancy",<ref>{{Cite journal|last1=Pétré|first1=Benoit|last2=Scheen|first2=André J.|last3=Ziegler|first3=Olivier|last4=Donneau|first4=Anne-Françoise|last5=Dardenne|first5=Nadia|last6=Husson|first6=Eddy|last7=Albert|first7=Adelin|last8=Guillaume|first8=Michèle|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}}</ref> "body image self-discrepancy",<ref>{{Cite journal|last1=Solomon-Krakus|first1=Shauna|last2=Sabiston|first2=Catherine M.|last3=Brunet|first3=Jennifer|last4=Castonguay|first4=Andree L.|last5=Maximova|first5=Katerina|last6=Henderson|first6=Mélanie|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}}</ref> "body image distortion",<ref name="Treasure 1–21" /> "disturbed body image",<ref>{{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://pubmed.ncbi.nlm.nih.gov/1987820/|journal=The American Journal of Psychiatry|volume=148|issue=2|pages=211–215|doi=10.1176/ajp.148.2.211|doi-broken-date=6 August 2021|issn=0002-953X|pmid=1987820}}</ref> "disturbances in body estimations",<ref>{{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: The Journal of Mental Science|volume=134|pages=60–66|doi=10.1192/bjp.134.1.60|issn=0007-1250|pmid=570073}}</ref> "body image disturbance",<ref>{{Cite journal|last1=Feusner|first1=Jamie|last2=Deshpande|first2=Rangaprakash|last3=Strober|first3=Michael|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}}</ref> and "negative body image".<ref>{{Cite journal|last1=Spreckelsen|first1=Paula von|last2=Glashouwer|first2=Klaske A.|last3=Bennik|first3=Elise C.|last4=Wessel|first4=Ineke|last5=de Jong|first5=Peter J.|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|doi=10.1371/journal.pone.0198532|issn=1932-6203|pmc=5988313|pmid=29870558|bibcode=2018PLoSO..1398532S}}</ref> Sometimes, the term "body dissatisfaction" is also used to refer to body image disturbance indiscriminately.<ref>{{Cite journal|last1=McLean|first1=Siân A.|last2=Paxton|first2=Susan J.|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}}</ref> Moreover, the DSM-5 itself defines this symptom vaguely: "a disturbance in the way one's body weight or shape is experienced".<ref name=":3" /> Thus, the lack of a clear definition is problematic from both a clinical and basic research point of view.

However, most recent studies define "body image disturbance" as a multidimensional symptom of various components associated with [[Medicine:Body image|body image]].<ref>{{Citation|last1=Cash|first1=Thomas F.|title=Cognitive—Behavioral Treatment of Body-Image Disturbances|date=1996|url=http://dx.doi.org/10.1007/978-1-4899-1528-3_15|work=Sourcebook of Psychological Treatment Manuals for Adult Disorders|pages=567–614|place=Boston, MA|publisher=Springer US|isbn=978-1-4899-1530-6|access-date=2021-08-07|last2=Grant|first2=Jill R.|doi=10.1007/978-1-4899-1528-3_15}}</ref><ref name=":1" /><ref name="Eshkevari 2014 400–409" /><ref name=":19" /><ref name=":2" /><ref name=":22" /> Specifically, we usually describe [[Biology:Body image (neuroscience)|body image]] as 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; it also consists of a conscious mental representation of one's body<ref>{{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}}</ref>
* Affective: feelings and attitudes related to the body (e.g., bodily satisfaction/dissatisfaction).<ref name=":24" />
* Behavioral: actions that people perform to check on, modify, or hide their body parts.
* Perceptual: how one's body is perceived; it includes [[Biology:Proprioception|proprioceptive]], [[Medicine:Interoception|interoceptive]], [[Engineering:Tactile sensor|tactile]], and visual self-perception.<ref>{{Cite journal|date=2011-11-30|title=Tactile body image disturbance in anorexia nervosa|url=https://www.sciencedirect.com/science/article/pii/S0165178111003623|journal=Psychiatry Research|language=en|volume=190|issue=1|pages=115–120|doi=10.1016/j.psychres.2011.04.031|issn=0165-1781|last1=Keizer|first1=Anouk|last2=Smeets|first2=Monique Aldegonda Maria|last3=Dijkerman|first3=Hendrik Christiaan|last4=Van Den Hout|first4=Marcel|last5=Klugkist|first5=Irene|last6=Van Elburg|first6=Annemarie|last7=Postma|first7=Albert|pmid=21621275|s2cid=18451352}}</ref>

All of these components are altered in body image disturbance:<ref name=":2" /> 

=== Definition of body image disturbance ===
In 2021, Artoni and colleagues consistently proposed a more clarifying definition of body image disturbance, as part of research.<ref name=":2" /> The authors suggested using the term "bodily dissatisfaction" when there are alterations in the body image's affective, cognitive, and behavioral components and strictly using "body image disturbance" only when all four components are altered, including the perceptual one. In short, they define body image disturbance as when an altered perception of the shape and weight of one's body is present and aggravates body dissatisfaction. The term is literally consistent with DSM-5 description "a disturbance in the way weight and body shapes are experienced" <ref name=":3" /> and it is therefore "preferable to others".

== Altered components in body image disturbance ==

=== Cognitive ===
Patients with body image disturbance exhibit an altered conscious representation of their bodies. This representation is a third-person perspective, more precisely an allocentric representation of the body,<ref>{{Cite journal|last1=Ekstrom|first1=Arne D.|last2=Arnold|first2=Aiden E. G. F.|last3=Iaria|first3=Giuseppe|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|volume=8|page=803|language=English|doi=10.3389/fnhum.2014.00803|pmid=25346679|pmc=4193251|issn=1662-5161|doi-access=free}}</ref> which means how the body's image is stored in the memory. This representation is evoked in self-image tasks, such as comparing one's body with others or drawing one's body shapes. However, in patients with anorexia nervosa and bulimia nervosa, this mental representation of the body is frequently overextended compared to the actual body shapes.<ref>{{Cite journal|last1=Øverås|first1=Maria|last2=Kapstad|first2=Hilde|last3=Brunborg|first3=Cathrine|last4=Landrø|first4=Nils Inge|last5=Lask|first5=Bryan|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: The Journal of the Eating Disorders Association|volume=22|issue=2|pages=109–115|doi=10.1002/erv.2276|issn=1099-0968|pmid=24590562}}</ref> Also, patients with anorexia nervosa show negative thoughts about their body, such as "I'm too fat," "I'm horrible," and other negative body-related thoughts.<ref>{{Cite journal|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|last1=Cooper|first1=Myra J.|last2=Fairburn|first2=Christopher G.|pmid=1520236}}</ref> In some cases, however, the ideal internalized body has canons of pathological thinness (e.g., a body without female shapes or "that communicates suffering"). A "sick body" could be a critical maintenance factor, generating more attention from family members, reducing the requests and expectations of others,<ref>{{Cite journal|last1=Treasure|first1=Janet|last2=Schmidt|first2=Ulrike|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}}</ref> and  sexual attractiveness (especially in patients with sexual trauma).<ref>{{Cite journal|last1=Madowitz|first1=Jennifer|last2=Matheson|first2=Brittany E.|last3=Liang|first3=June|date=2015|title=The relationship between eating disorders and sexual trauma|url=https://pubmed.ncbi.nlm.nih.gov/25976911/|journal=Eating and Weight Disorders: EWD|volume=20|issue=3|pages=281–293|doi=10.1007/s40519-015-0195-y|issn=1590-1262|pmid=25976911|s2cid=22184762}}</ref>

=== Affective ===
Affective alterations concern the feelings and emotions experienced towards one's body. Body dissatisfaction is frequently present,<ref name="Treasure 1–21" /><ref>{{Citation|title=How Specific Are Body Image Disturbances in Patients With Anorexia Nervosa?|date=1995-12-31|url=http://dx.doi.org/10.1515/9783110808537-013|work=Eating Disorders in Adolescence|pages=145–160|publisher=De Gruyter|doi=10.1515/9783110808537-013|isbn=978-3-11-080853-7|access-date=2021-08-09}}</ref> sometimes related to anxiety<ref>{{Cite journal|last1=Levinson|first1=Cheri A.|last2=Rapp|first2=John|last3=Riley|first3=Elizabeth N.|date=2014-12-01|title=Addressing the fear of fat: extending imaginal exposure therapy for anxiety disorders to anorexia nervosa|url=https://doi.org/10.1007/s40519-014-0115-6|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}}</ref> and shame<ref>{{Cite journal|last1=Goss|first1=Kenneth|last2=Allan|first2=Steven|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}}</ref> 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.<ref name=":25">{{Cite journal|last1=Espeset|first1=Ester M. S.|last2=Gulliksen|first2=Kjersti S.|last3=Nordbø|first3=Ragnfrid H. S.|last4=Skårderud|first4=Finn|last5=Holte|first5=Arne|date=2012|title=The Link Between Negative Emotions and Eating Disorder Behaviour in Patients with Anorexia Nervosa|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/erv.2183|journal=European Eating Disorders Review|language=en|volume=20|issue=6|pages=451–460|doi=10.1002/erv.2183|pmid=22696277|issn=1099-0968}}</ref> Congruent with the self-objectification theory, one's body is frequently experienced only as an "object to be modified" and not as a "subject to take care of".<ref>{{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}}</ref> Fear is associated with the idea of getting fat.<ref name=":25" />

=== Behavioral ===
The behavioral component of body image disturbance contemplates different body-checking behaviors<ref>{{Cite journal|date=2014-01-01|title=Body checking and avoidance in low weight and weight restored individuals with anorexia nervosa and non-clinical females|url=https://www.sciencedirect.com/science/article/abs/pii/S1471015313001189|journal=Eating Behaviors|language=en|volume=15|issue=1|pages=5–8|doi=10.1016/j.eatbeh.2013.10.011|issn=1471-0153|last1=Bamford|first1=Bryony H.|last2=Attoe|first2=Chris|last3=Mountford|first3=Victoria A.|last4=Morgan|first4=John F.|last5=Sly|first5=Richard|pmid=24411741}}</ref> such as repeatedly weighing during the day, spending much time in front of the mirror or avoiding it, frequently taking [[Philosophy:Selfie|selfies]], checking parts of the body with hands (e.g. circumference of the wrists, arms, thighs, belly or hips). Other behaviors are avoiding situations in which the body is exposed (for example, the swimming pool or the sea), and wearing very loose and covering clothes.<ref>{{Cite journal|last1=Nikodijevic|first1=Alexandra|last2=Buck|first2=Kimberly|last3=Fuller-Tyszkiewicz|first3=Matthew|last4=de Paoli|first4=Tara|last5=Krug|first5=Isabel|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: The Journal of the Eating Disorders Association|volume=26|issue=3|pages=159–185|doi=10.1002/erv.2585|issn=1099-0968|pmid=29528168|s2cid=3874918}}</ref> More generally, avoidance of bodily sensations, particularly the interoceptive ones, is reported.<ref name=":26" />

=== Perceptual ===
In body image disturbance, several perceptual domains are altered. Visual perception is the most studied,<ref>{{Cite journal|last1=Engel|first1=Manja M.|last2=van Denderen|first2=Karlien|last3=Bakker|first3=Anne-Richtje|last4=Corcoran|first4=Andrew W.|last5=Keizer|first5=Anouk|last6=Dijkerman|first6=H. Chris|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|doi=10.1371/journal.pone.0237421|issn=1932-6203|pmc=7451544|pmid=32853272|bibcode=2020PLoSO..1537421E}}</ref><ref>{{Cite book|last=Wei.|first=Li|url=http://worldcat.org/oclc/1237663432|title=Visual processing abnormalities in anorexia nervosa and body dysmorphic disorder|oclc=1237663432}}</ref><ref>{{Cite journal|last1=Uher|first1=Rudolf|last2=Murphy|first2=Tara|last3=Friederich|first3=Hans-Christoph|last4=Dalgleish|first4=Tim|last5=Brammer|first5=Michael J.|last6=Giampietro|first6=Vincent|last7=Phillips|first7=Mary L.|last8=Andrew|first8=Christopher M.|last9=Ng|first9=Virginia W.|last10=Williams|first10=Steven C.R.|last11=Campbell|first11=Iain C.|date=2005|title=Functional Neuroanatomy of Body Shape Perception in Healthy and Eating-Disordered Women|url=http://dx.doi.org/10.1016/j.biopsych.2005.06.001|journal=Biological Psychiatry|volume=58|issue=12|pages=990–997|doi=10.1016/j.biopsych.2005.06.001|pmid=16084858|s2cid=15508818|issn=0006-3223}}</ref> but research found misperceptions in other sensory domains such as haptic,<ref>{{Cite journal|last1=Grunwald|first1=Martin|last2=Ettrich|first2=Christine|last3=Assmann|first3=Bianka|last4=Dähne|first4=Angelika|last5=Krause|first5=Werner|last6=Busse|first6=Frank|last7=Gertz|first7=Hermann-Joseph|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=http://dx.doi.org/10.1002/eat.1038|journal=International Journal of Eating Disorders|volume=29|issue=4|pages=417–428|doi=10.1002/eat.1038|pmid=11285579|issn=0276-3478}}</ref> tactile,<ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=Smeets|first2=Monique Aldegonda Maria|last3=Dijkerman|first3=Hendrik Christiaan|last4=van den Hout|first4=Marcel|last5=Klugkist|first5=Irene|last6=van Elburg|first6=Annemarie|last7=Postma|first7=Albert|date=2011-11-30|title=Tactile body image disturbance in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/21621275/|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}}</ref> affective-touch.<ref>{{Cite journal|last1=Crucianelli|first1=Laura|last2=Cardi|first2=Valentina|last3=Treasure|first3=Janet|last4=Jenkinson|first4=Paul M.|last5=Fotopoulou|first5=Aikaterini|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}}</ref> Also, the body schema is overextended.<ref>{{Cite journal|last1=Beckmann|first1=Nina|last2=Baumann|first2=Patricia|last3=Herpertz|first3=Stephan|last4=Trojan|first4=Jörg|last5=Diers|first5=Martin|date=2021|title=How the unconscious mind controls body movements: Body schema distortion in anorexia nervosa|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.23451|journal=International Journal of Eating Disorders|language=en|volume=54|issue=4|pages=578–586|doi=10.1002/eat.23451|pmid=33345338|issn=1098-108X}}</ref> Some research suggested that this is related to a general enlarged mental representation of body size.<ref>{{Cite journal|last1=Irvine|first1=Kamila R.|last2=McCarty|first2=Kristofor|last3=McKenzie|first3=Kirsten J.|last4=Pollet|first4=Thomas V.|last5=Cornelissen|first5=Katri K.|last6=Tovée|first6=Martin J.|last7=Cornelissen|first7=Piers L.|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}}</ref> A recent study published on Nature<ref>{{Cite journal|last1=Engel|first1=Manja M.|last2=Keizer|first2=Anouk|date=2017-11-23|title=Body representation disturbances in visual perception and affordance perception persist in eating disorder patients after completing treatment|journal=Scientific Reports|language=en|volume=7|issue=1|pages=16184|doi=10.1038/s41598-017-16362-w|pmid=29170439|pmc=5701063|bibcode=2017NatSR...716184E|issn=2045-2322}}</ref> also highlighted how a perceptual disturbance is present in subjects recovered from anorexia nervosa even without affective-cognitive body concerns. Finally, interoception, the "sense of the physiological condition of the body"<ref>{{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=http://dx.doi.org/10.1038/nrn894|journal=Nature Reviews Neuroscience|volume=3|issue=8|pages=655–666|doi=10.1038/nrn894|pmid=12154366|s2cid=17829407|issn=1471-003X}}</ref> is problematic in eating disorders.<ref>{{Cite journal|last1=Jacquemot|first1=Aimée Margarita Marisol Catherine|last2=Park|first2=Rebecca|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}}</ref>

== Onset ==
The age of onset for body image disturbance is often early adolescence,<ref name=":20">{{Cite journal|last1=Sattler|first1=Frank A.|last2=Eickmeyer|first2=Sarah|last3=Eisenkolb|first3=Julia|date=2019-06-08|title=Body image disturbance in children and adolescents with anorexia nervosa and bulimia nervosa: a systematic review|url=http://dx.doi.org/10.1007/s40519-019-00725-5|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|pmid=31177379|s2cid=182948695|issn=1590-1262}}</ref> age in which the comparison with peers becomes significant and leads to a greater sensitivity towards criticism and teasing about one's physical appearance. Furthermore, puberty leads to rapid changes in body size and shape that need to be integrated into the body image.<ref>{{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}}</ref> For this reason, adolescence is considered a critical age, with a greater vulnerability to internalizing ideals of thinness,<ref>{{Cite journal|last=Carlson Jones|first=Diane|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|pmid=15355169|issn=1939-0599}}</ref> to develop body dissatisfaction, body image disturbance <ref name=":20" /> and eating disorders.<ref>{{Cite journal|last1=Stice|first1=Eric|last2=Gau|first2=Jeff M.|last3=Rohde|first3=Paul|last4=Shaw|first4=Heather|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}}</ref> In a recent review, eight on-topic studies were analyzed. 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.<ref name=":20" />  Unfortunately, how one passes from an initial dissatisfaction with one's body to an actual perceptual disorder is still unknown despite its clinical relevance.<ref>{{Cite journal|last1=Ralph-Nearman|first1=Christina|last2=Arevian|first2=Armen C.|last3=Moseman|first3=Scott|last4=Sinik|first4=Megan|last5=Chappelle|first5=Sheridan|last6=Feusner|first6=Jamie D.|last7=Khalsa|first7=Sahib 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|doi=10.1038/s41598-021-90739-w|pmid=34112818|pmc=8192536|bibcode=2021NatSR..1112262R|issn=2045-2322}}</ref>

== Body image disturbance and body dissatisfaction ==
Body dissatisfaction and body image disturbance are closely related. Personal, interpersonal, cultural, social, and ethnic variables largely influence bodily dissatisfaction,<ref name="Michael 15–29">{{Cite journal|last1=Michael|first1=Shannon L.|last2=Wentzel|first2=Kathryn|last3=Elliott|first3=Marc N.|last4=Dittus|first4=Patricia J.|last5=Kanouse|first5=David E.|last6=Wallander|first6=Jan L.|last7=Pasch|first7=Keryn E.|last8=Franzini|first8=Luisa|last9=Taylor|first9=Wendell C.|last10=Qureshi|first10=Tariq|last11=Franklin|first11=Frank A.|date=2014-01-01|title=Parental and Peer Factors Associated with Body Image Discrepancy among Fifth-Grade Boys and Girls|url=https://doi.org/10.1007/s10964-012-9899-8|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}}</ref> 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;<ref>{{Cite journal|last1=Derenne|first1=Jennifer L.|last2=Beresin|first2=Eugene V.|date=2006-05-01|title=Body Image, Media, and Eating Disorders|url=https://doi.org/10.1176/appi.ap.30.3.257|journal=Academic Psychiatry|language=en|volume=30|issue=3|pages=257–261|doi=10.1176/appi.ap.30.3.257|pmid=16728774|s2cid=11131622|issn=1545-7230}}</ref> comparing an "ideal" and "real" body feed an intense dissatisfaction with one's body and increases the feeling of shame, disgust, and anxiety towards the one's body and appearance.<ref>{{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|url=https://doi.org/10.1186/1471-2458-9-313|journal=BMC Public Health|volume=9|issue=1|pages=313|doi=10.1186/1471-2458-9-313|issn=1471-2458|pmc=2740850|pmid=19712443}}</ref>

Dissatisfaction with one's body involves only three of the four components of the body image. Those suffering from 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<ref>{{Cite journal|last1=Rounsefell|first1=Kim|last2=Gibson|first2=Simone|last3=McLean|first3=Siân|last4=Blair|first4=Merran|last5=Molenaar|first5=Annika|last6=Brennan|first6=Linda|last7=Truby|first7=Helen|last8=McCaffrey|first8=Tracy A.|date=2020|title=Social media, body image and food choices in healthy young adults: A mixed methods systematic review|journal=Nutrition & Dietetics: The Journal of the Dietitians Association of Australia|volume=77|issue=1|pages=19–40|doi=10.1111/1747-0080.12581|issn=1747-0080|pmc=7384161|pmid=31583837}}</ref><ref>{{Cite journal|last1=Schaefer|first1=Lauren M.|last2=Harriger|first2=Jennifer A.|last3=Heinberg|first3=Leslie J.|last4=Soderberg|first4=Taylor|last5=Thompson|first5=J. Kevin|date=2017|title=Development and validation of the sociocultural attitudes towards appearance questionnaire-4-revised (SATAQ-4R)|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22590|journal=International Journal of Eating Disorders|language=en|volume=50|issue=2|pages=104–117|doi=10.1002/eat.22590|pmid=27539814|s2cid=30462042|issn=1098-108X}}</ref>) . They may also have negative feelings of dissatisfaction with their body and be ashamed of showing it in public.<ref name="Michael 15–29" /> 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 overlapped by body dissatisfaction, but they are closely related.<ref>{{Cite journal|date=2014-08-01|title=Body weight dissatisfaction: A comparison of women with and without eating disorders|url=https://www.sciencedirect.com/science/article/abs/pii/S1471015314000944|journal=Eating Behaviors|language=en|volume=15|issue=3|pages=453–459|doi=10.1016/j.eatbeh.2014.06.014|issn=1471-0153|last1=Coker|first1=Elise|last2=Abraham|first2=Suzanne|pmid=25064299}}</ref>

== Body image disturbance and body dysmorphic disorder ==
Body image disturbance in anorexia and [[Medicine:Body dysmorphic disorder|body dysmorphic disorder]] are similar psychiatric conditions that involve an altered perception of the body or parts of it but are not the same disorder. Body image disturbance is a symptom of [[Medicine:Anorexia nervosa|anorexia nervosa]] and is present as criterion C in the DSM-5,<ref name=":3" /> and alters the perception of weight and shapes of the whole body. Patients with anorexia believe that they are overweight, perceive their body as "fat" and misperceive their body shapes.<ref name=":5">{{Cite journal|last1=Marzola|first1=Enrica|last2=Panero|first2=Matteo|last3=Cavallo|first3=Fabio|last4=Delsedime|first4=Nadia|last5=Abbate-Daga|first5=Giovanni|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}}</ref> [[Medicine:Body dysmorphic disorder|Body dysmorphic disorder]] is an [[Medicine:Obsessive–compulsive disorder|obsessive-compulsive disorder]] characterized by disproportionate concern for minimal or absent individual bodily flaws, which cause personal distress and social impairment <ref name=":7">{{Citation|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}}</ref> Patients with BDD are concerned about physical details, mainly the face, skin, and nose.<ref name=":6">{{Cite journal|last1=Ahluwalia|first1=Rajiv|last2=Bhatia|first2=Navneet Kaur|last3=Kumar|first3=Priyanka Sethi|last4=Kaur|first4=Parvinder|date=2017|title=Body dysmorphic disorder: Diagnosis, clinical aspects and treatment strategies|url=https://pubmed.ncbi.nlm.nih.gov/28611331/|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}}</ref> Thus, both [[Medicine:Anorexia nervosa|anorexia nervosa]] and [[Medicine:Body dysmorphic disorder|body dysmorphic disorder]] manifest significant disturbances in body image but are different and highly comorbid.<ref name=":8">{{Cite journal|last1=Phillipou|first1=Andrea|last2=Castle|first2=David Jonathan|last3=Rossell|first3=Susan Lee|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}}</ref> For example, Grant and colleagues reported that 39% of AN patients in their sample had a comorbid diagnosis of body dysmorphic disorder, with concerns unrelated to weight.<ref name=":9">{{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}}</ref> Cereaet et al., reported that 26% of their AN sample had a probable BDD diagnosis with non-weight-related body concerns.<ref name=":10">{{Cite journal|last1=Cerea|first1=Silvia|last2=Bottesi|first2=Gioia|last3=Grisham|first3=Jessica R.|last4=Ghisi|first4=Marta|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}}</ref>

=== Similarities ===
Previous studies found that both BDD and eating disorder groups were similar in body dissatisfaction, body checking, body concerns,<ref name=":4">{{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}}</ref> and levels of perfectionism.<ref name=":11">{{Cite journal|last1=Hartmann|first1=Andrea S.|last2=Thomas|first2=Jennifer J.|last3=Greenberg|first3=Jennifer L.|last4=Matheny|first4=Natalie L.|last5=Wilhelm|first5=Sabine|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}}</ref> Furthermore, both BDD and AN patients report higher intensities of negative emotions, lower intensities of positive emotions,<ref name=":12">{{Cite journal|last1=Kollei|first1=Ines|last2=Brunhoeber|first2=Stefan|last3=Rauh|first3=Elisabeth|last4=de Zwaan|first4=Martina|last5=Martin|first5=Alexandra|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}}</ref> lower self-esteem,<ref name=":11" /> and anxiety symptoms.<ref>{{Cite journal|last1=Hartmann|first1=Andrea S.|last2=Thomas|first2=Jennifer J.|last3=Greenberg|first3=Jennifer L.|last4=Matheny|first4=Natalie L.|last5=Wilhelm|first5=Sabine|date=2015|title=Erratum. A Comparison of Self-Esteem and Perfectionism in Anorexia Nervosa and Body Dysmorphic Disorder.|url=http://dx.doi.org/10.1097/nmd.0000000000000307|journal=Journal of Nervous & Mental Disease|volume=203|issue=6|pages=484|doi=10.1097/nmd.0000000000000307|issn=0022-3018}}</ref> Moreover, we 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 and difficulty in perceiving stimuli holistically.<ref>{{Cite journal|last1=Harrison|first1=Amy|last2=Tchanturia|first2=Kate|last3=Treasure|first3=Janet|date=2011-05-09|title=Measuring state trait properties of detail processing and global integration ability in eating disorders|url=http://dx.doi.org/10.3109/15622975.2010.551666|journal=The World Journal of Biological Psychiatry|volume=12|issue=6|pages=462–472|doi=10.3109/15622975.2010.551666|pmid=21554026|s2cid=40046456|issn=1562-2975}}</ref> Indeed neurophysiology and neuroimaging research suggests similarities between BDD and AN patients in terms of abnormalities in visuospatial processing.<ref>{{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}}</ref><ref>{{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=http://dx.doi.org/10.1017/s0033291715000045|journal=Psychological Medicine|volume=45|issue=10|pages=2111–2122|doi=10.1017/s0033291715000045|pmid=25652023|pmc=4898970|issn=0033-2917}}</ref>

=== Differences ===
Despite many similarities, the two disorders also have significant differences.<ref name=":23">{{Cite journal|last1=Toh|first1=Wei Lin|last2=Grace|first2=Sally A|last3=Rossell|first3=Susan L|last4=Castle|first4=David J|last5=Phillipou|first5=Andrea|date=2019-04-01|title=Body parts of clinical concern in anorexia nervosa versus body dysmorphic disorder: a cross-diagnostic comparison|url=http://dx.doi.org/10.1177/1039856219839477|journal=Australasian Psychiatry|volume=28|issue=2|pages=134–139|doi=10.1177/1039856219839477|pmid=30931578|s2cid=89621217|issn=1039-8562}}</ref> The first is gender distribution. Body image disturbance is much more present in females,<ref name=":13">{{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}}</ref> unlike BDD, which has a much less unbalanced relationship between men and women.<ref name=":14">{{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}}</ref> Furthermore, those with dysmorphophobia tend to have more significant inhibitions and avoidance of social activities than those suffering from anorexia nervosa.<ref name=":4" /> Differences are self-evident when considering the focus of physical concerns and misperception in AN and BDD. Whereas BDD patients report concerns and misperception in specific body areas (mainly face, skin, and hair),<ref name=":15">{{Cite journal|date=2010|others=Andri S. Bjornsson, Elizabeth R. Didie, Katharine A. Phillips|title=Body dysmorphic disorder|journal=Obsessive-Compulsive Spectrum Disorders|language=en|volume=12|issue=2|pages=221–232|doi=10.31887/DCNS.2010.12.2/abjornsson|pmid=20623926|pmc=3181960|issn=2608-3477}}</ref> in patients with AN the altered perception could involve arms, shoulders, thighs, abdomen, hips, and breasts, and concerns are about the whole body shape and weight.<ref name=":23" /> Thus, leading to an alteration of the entire explicit ([[Biology:Body image (neuroscience)|body image]])<ref name="Treasure 1–21" /> and implicit ([[Body schema|body schema]])<ref>{{Cite journal|last1=Beckmann|first1=Nina|last2=Baumann|first2=Patricia|last3=Herpertz|first3=Stephan|last4=Trojan|first4=Jörg|last5=Diers|first5=Martin|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}}</ref> body's mental representations<ref name=":16">{{Cite journal|last=Gadsby|first=Stephen|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}}</ref> Furthermore, in anorexia nervosa, not only the visual perception of one's body is altered but also the tactile<ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=Smeets|first2=Monique Aldegonda Maria|last3=Dijkerman|first3=Hendrik Christiaan|last4=van den Hout|first4=Marcel|last5=Klugkist|first5=Irene|last6=van Elburg|first6=Annemarie|last7=Postma|first7=Albert|date=2011-11-30|title=Tactile body image disturbance in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/21621275/|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}}</ref> and interoceptive perception.<ref>{{Cite journal|last1=Crucianelli|first1=Laura|last2=Cardi|first2=Valentina|last3=Treasure|first3=Janet|last4=Jenkinson|first4=Paul M.|last5=Fotopoulou|first5=Aikaterini|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}}</ref><ref>{{Cite journal|last1=Jacquemot|first1=Aimée Margarita Marisol Catherine|last2=Park|first2=Rebecca|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}}</ref>

Finally, a recent review suggested that the two disorders could be classified as "body image disturbances" (plural) in light of similarities and differences. Although more in-depth studies are needed to confirm this new classification hypothesis.<ref name=":8" />

== Diagnosis ==
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 one's body image's cognitive, affective, and behavioral components 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.

=== Attitudinal Body Image assessment ===

* 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-type scale (always, usually, sometimes, rarely, never), with higher scores representing more severe symptoms. Precisely, the BD subscale of EDI-3 measures bodily dissatisfaction.<ref>{{Cite journal|last1=Clausen|first1=Loa|last2=Rosenvinge|first2=Jan H.|last3=Friborg|first3=Oddgeir|last4=Rokkedal|first4=Kristian|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}}</ref>

* 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.<ref>{{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: EWD|volume=11|issue=1|pages=1–13|doi=10.1007/BF03327738|issn=1590-1262|pmid=16801740|s2cid=10260135}}</ref>
* Body Image Disturbance Questionnaire investigates different areas related to body image disturbance. For example, evaluate the most problematic parts of the body, the psychological effects of worries on the body, and the effects on social life and eating behavior.<ref>{{Cite journal|date=2004-12-01|title=Measuring "negative body image": validation of the Body Image Disturbance Questionnaire in a nonclinical population|url=https://www.sciencedirect.com/science/article/abs/pii/S1740144504000683|journal=Body Image|language=en|volume=1|issue=4|pages=363–372|doi=10.1016/j.bodyim.2004.10.001|issn=1740-1445|last1=Cash|first1=Thomas F.|last2=Phillips|first2=Katharine A.|last3=Santos|first3=Melanie T.|last4=Hrabosky|first4=Joshua I.}}</ref>
* 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 the urge/desire to lose weight<ref name=":21">{{Cite journal|last1=Cooper|first1=Peter J.|last2=Taylor|first2=Melanie J.|last3=Cooper|first3=Zafra|last4=Fairbum|first4=Christopher G.|date=1987|title=The development and validation of the body shape questionnaire|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/1098-108X%28198707%296%3A4%3C485%3A%3AAID-EAT2260060405%3E3.0.CO%3B2-O|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}}</ref>
* 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 your hands. Higher scores indicate a higher frequency of body checking behaviors.<ref>{{Citation|last=Reas|first=Deborah Lynn|title=Body Checking Questionnaire (BCQ)|date=2015|url=https://doi.org/10.1007/978-981-287-087-2_10-1|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|access-date=2021-08-10}}</ref>

== Brain alterations ==
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 [[Biology:Prefrontal cortex|prefrontal cortex]], [[Biology:Precuneus|precuneus]], [[Biology:Parietal lobe|parietal cortex]], [[Biology:Insular cortex|insula]], [[Medicine:Amygdala|amygdala]], [[Biology:Striatum|ventral striatum]], extrastriate body area, and [[Biology:Fusiform gyrus|fusiform gyrus]].<ref name=":18">{{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|url=https://www.semanticscholar.org/paper/Neural-basis-of-a-multidimensional-model-of-body-in-Gaudio-Quattrocchi/343f251f0e8e97d34c58925b04a12c8cc191b4b2|journal=Neuroscience & Biobehavioral Reviews|volume=36|issue=8|pages=1839–1847|doi=10.1016/j.neubiorev.2012.05.003|pmid=22613629|s2cid=13475512}}</ref> 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 circuitry is not known yet."<ref name="Treasure 1–21" />

== Treatments ==

=== Treatments focused on cognitive, affective and behavioral components ===
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 psychotherapy in the field is CBT-E.<ref>{{Cite journal|last1=Murphy|first1=Rebecca|last2=Straebler|first2=Suzanne|last3=Cooper|first3=Zafra|last4=Fairburn|first4=Christopher G.|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}}</ref> 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.<ref>{{Cite journal|last1=Atwood|first1=Molly E.|last2=Friedman|first2=Aliza|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}}</ref> A recent 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.<ref>{{Cite journal|last1=Atwood|first1=Molly E.|last2=Friedman|first2=Aliza|date=2020|title=A systematic review of enhanced cognitive behavioral therapy (CBT-E) for eating disorders|url=https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.23206|journal=International Journal of Eating Disorders|language=en|volume=53|issue=3|pages=311–330|doi=10.1002/eat.23206|pmid=31840285|issn=1098-108X}}</ref> In fact, a therapy of choice for eating disorders in adults has not yet been identified.<ref name="Treasure 1–21" /> 

Additionally, two other noteworthy body image treatments are Cash's "Body Image Workbook"<ref>{{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}}</ref> and BodyWise.<ref>{{Cite journal|last1=Mountford|first1=Victoria A.|last2=Brown|first2=Amy|last3=Bamford|first3=Bryony|last4=Saeidi|first4=Saeideh|last5=Morgan|first5=John F.|last6=Lacey|first6=Hubert|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: The Journal of the Eating Disorders Association|volume=23|issue=1|pages=62–67|doi=10.1002/erv.2332|issn=1099-0968|pmid=25382845}}</ref> The former is an 8-step group treatment within a classic cognitive-behavioral framework. The latter is a psychoeducational-based treatment improved with [[Medicine:Cognitive remediation therapy|cognitive remediation techniques]] to promote awareness of body image difficulties, reduce cognitive inflexibility, and body dissatisfaction. Worthy of mention is The Body Projectt,<ref>{{Cite book|last1=Stice|first1=Eric|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=Paul|last3=Shaw|first3=Heather|year=2013|publisher=Oxford University Press|isbn=978-0-19-023065-4|language=en-US|doi=10.1093/med:psych/9780199859245.001.0001}}</ref> 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.<ref>{{Cite journal|last1=Stice|first1=Eric|last2=Marti|first2=C. Nathan|last3=Spoor|first3=Sonja|last4=Presnell|first4=Katherine|last5=Shaw|first5=Heather|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}}</ref> The Body Project is therefore not a treatment for eating disorders but a prevention program.

=== Treatments focused on perceptive component ===
New treatments for body image disturbance have recently been developed, focusing on the disorder's perceptual component. One of the best known is Mirror Exposure. Mirror Exposure<ref name=":17">{{Cite journal|last1=Delinsky|first1=Sherrie Selwyn|last2=Wilson|first2=G. Terence|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}}</ref> is a cognitive-behavioral technique that aims to reduce experiential avoidance, reduce bodily dissatisfaction, and improve one's misperception of one's body. During the exposure, 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, cognitive dissonance-based mirror exposure.<ref>{{Cite journal|last1=Moreno-Domínguez|first1=Silvia|last2=Rodríguez-Ruiz|first2=Sonia|last3=Fernández-Santaella|first3=M. Carmen|last4=Jansen|first4=Anita|last5=Tuschen-Caffier|first5=Brunna|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}}</ref><ref>{{Cite journal|last1=Luethcke|first1=Cynthia A.|last2=McDaniel|first2=Leda|last3=Becker|first3=Carolyn Black|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}}</ref> To date, few studies have investigated the effects of mirror exposure in patients with body image disturbance. Key et al.<ref>{{Cite journal|last1=Key|first1=Adrienne|last2=George|first2=C. Louise|last3=Beattie|first3=Desley|last4=Stammers|first4=Kate|last5=Lacey|first5=Hubert|last6=Waller|first6=Glenn|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}}</ref> conducted a non-randomized trial in a clinical sample and compared a body image group therapy with or without mirror exposure. They found a significant improvement in body dissatisfaction only in the mirror exposure therapy group. Despite the positive evidence, a recent review suggests that Mirror Exposure has a low-to-medium effect in reducing body image disturbance and further studies are needed to improve it.<ref>{{Cite journal|last1=Griffen|first1=Trevor C.|last2=Naumann|first2=Eva|last3=Hildebrandt|first3=Tom|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}}</ref>[[File:Virtual-reality-woman.jpg|thumb|Common VR research setting]]Another novelty treatment for body image disturbance is Virtual Reality - 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 (computing)|avatar]] using [[Software:List of 3D modeling software|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 modify directly. Some studies have found that applying this technique to anorexia nervosa reduces the misperception of one's body.<ref name=":22">{{Cite journal|last1=Serino|first1=Silvia|last2=Pedroli|first2=Elisa|last3=Keizer|first3=Anouk|last4=Triberti|first4=Stefano|last5=Dakanalis|first5=Antonios|last6=Pallavicini|first6=Federica|last7=Chirico|first7=Alice|last8=Riva|first8=Giuseppe|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}}</ref><ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=van Elburg|first2=Annemarie|last3=Helms|first3=Rossa|last4=Dijkerman|first4=H. Chris|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|doi=10.1371/journal.pone.0163921|issn=1932-6203|pmc=5053411|pmid=27711234|bibcode=2016PLoSO..1163921K}}</ref> This treatment is promising but provides, at the moment, only a short-term effect.<ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=Elburg|first2=Annemarie van|last3=Helms|first3=Rossa|last4=Dijkerman|first4=H. Chris|date=2016-10-06|title=A Virtual Reality Full Body Illusion Improves Body Image Disturbance in Anorexia Nervosa|journal=PLOS ONE|language=en|volume=11|issue=10|pages=e0163921|doi=10.1371/journal.pone.0163921|issn=1932-6203|pmc=5053411|pmid=27711234|bibcode=2016PLoSO..1163921K}}</ref>
[[File:Hoop training.png|alt=hoop training|thumb|Hoop Training session]]
However, other treatments have also recently been developed to integrate tactile, proprioceptive, and interoceptive one's body perception: the ''Hoop Training'' and the ''Body Perception Treatment''. Hoop Training is a short-term 8-week intervention (10 minutes per session) designed to become aware of and reduce body misperceptions. Hoop Training works on different components of body image disturbance: the cognitive, affective, and perceptive ones.<ref name=":19" />  

Another novelty is the Body Perception Treatment (BPT). BPT is a specific group intervention for body image disturbance focused on tactile, proprioceptive, and interoceptive self-perceptions during a body-focused experience.<ref name=":2" /> The treatment is consistent with the recent hypothesized role of [[Medicine:Interoception|interoception]] in developing body image disturbance by Badout & Tsakiris.<ref name=":26">{{Cite journal|last1=Badoud|first1=Deborah|last2=Tsakiris|first2=Manos|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}}</ref> 

Both Hoop Training and Body Perception Treatment showed effective results and were designed to work within a [[Philosophy:Multisensory integration|multisensory integration]] framework.<ref name=":19" /><ref name=":2" /> Indeed, they also complement and do not replace current standard therapies for eating disorders. However, both are also novelty treatments, and the results have not yet been replicated in independent studies. Thus, their actual effectiveness will be confirmed/disconfirmed by future research.

== References ==
{{Reflist}}

<!--- Categories --->
[[Category:Mental and behavioural disorders]]
[[Category:Psychiatric diagnosis]]

{{Sourceattribution|Body image disturbance|1}}