Disturbed
Body
R. Lynn
Home,
Objective:
consecutively with
divided nervosa,
C. Van
attempt
to answer
more distortions The study group
admitted
to
atypical
eating
an
drawn
were
agnostic her body waist, taken.
from
the
from
inpatient
eating were
abdomen, Distortion
by her actual
memory.
hips, and bust. in body image body
size.
Results:
in distortions
in body
in their
image.
body criteria
The subjects’ was calculated were
patient
image.
Most
Conclusions:
regarding
program. from
The
72 with group of university
along
eight
with
also
measurements as the subject’s given
differed
but
all patients
not
If replicated,
disturbance
a battery
groups
ofbody
these image
for
with findings both
men
students.
women
oftests
would anorexia
bulimia of 61
fulfilled
di-
measure to rate left calf, left thigh, points were size divided skill,
the comparison
disorders
had
suggest and
four were
Fifty-six
who
ofintelligence,
from eating
and
2 1 4 patients
at each of these perceived body
significantly
eating eating patients
anorexia and was composed
in a survey
Ph.D.
with
without of 230
Twelve
study.
nervosa alone, The comparison
group,
patients
Each subject used a three-dimensional body size at seven points: left biceps,
All subjects
All three
of whether
Disorders
Emerson,
than do individuals of 214 women out
disorders excluded
Eating
and Shirley
question
participants
the comparison
criteria for eating disorders. size and stated her desired
Ph.D.,
in body image was composed
disorders
I 25 consecutive
dropped
With
Vactor,
into three groups: 87 with anorexia and 55 with bulimia nervosa alone.
women
nostic
in Patients
John
authors
experience Method:
patients
men
M.D.,
The
disorders disorders.
Image
bulimia
that
and
group distortions the need
diagto be
revised. (Am
T age,
J
Psychiatry
1991;
148:211-215)
he second criterion for the diagnosis nervosa in DSM-III is “disturbance e.g., claiming to ‘feel fat’ even when
of anorexia body imemaciated”
of
(p. 69). DSM-III-R places as the third criterion for this diagnosis an expanded description: “Disturbance in the way in which one’s body weight, size, or shape is experienced, e.g., the person claims to ‘feel fat’ even when emaciated, believes that one area of the body is ‘too fat’ even when obviously underweight” (p. 67). In the eating disorders literature, there is continuing controversy over whether disturbance in perception of body image is a necessary and always present attribute
Presented
at the 1 4 1 st annual
meeting
of the American
Psychiatric
Association, Montreal, May 7-12, 1988. Received May 2, 1989; revisions received Sept. 28, 1989, and July 25, 1990; accepted Aug. 27, 1990. From Montevista Hospital, the University of Nevada School of Medicine, and the University of Nevada, Las Vegas. Ad-
dress reprint requests Vegas, NV 89121.
to Dr.
Emerson,
4240
Woodcrest
Rd.,
Las
Detailed tables and figures for the data given here are available on request from Dr. Emerson. Supported in part by HCA Montevista Center and by a Barrick Faculty Research Grant from the University of Nevada, Las Vegas.
The Brown
authors thank Kim Parsons for help in data collection,
data analysis. Copyright
Am
J
© 1991
Psychiatry
American
148:2,
for the scaled silhouettes, Sharon and Judy Jaeger for assistance in Psychiatric
February
Association.
1991
of anorexia nervosa. Crisp (1) did not deny some distortion in the anorexic patient’s perception of her body size but stated that the anorexic patient does not differ greatly from the majority of adolescent girls who are not obese in a medical sense, but who report that they consider themselves fat and overestimate the degree of their overweight in terms of their shape and size. Crisp suggested that the gross overestimates which charactenize many patients with anorexia probably owe this extra distortion to factors such as their wish to be thought of as physically normal and their terror that they could become truly obese if they cannot continue to curb their eating. Garner and Garfinkel (2) stated that the distorted perceptions of body image among patients with eating disorders range from mild to severely delusional. This would seem to leave little question that the patient with an eating disorder has a distorted body image. Garner and Ganfinkel suggested that assessing the degree of distortion in body image is most important because outcome research indicates that those anonexic individuals who persistently maintain the cognitive distortion that they are terribly fat, despite their emaciated condition, show the poorest improvement with treatment. The tendency for patients with anorexia to overes-
211
DISTURBED
BODY
IMAGE
timate their body size was first reported by Bruch (3). Many studies (4-12) have substantiated this finding. Hsu (13) questioned the validity of the evidence for distortion in body image. Garner and Garfinkel, however, cited their finding that self-overestimation is highly predictive of poor prognosis at 1-year follow-up (2, p. 22) as reinforcing the presence and usefulness of the concept. There is confusion surrounding the overlap between anorexia nervosa and bulimia. DSM-III treated them as separate disorders and stated specifically that “the bulimic episodes are not due to Anorexia Nervosa or any known physical disorder” (p. 69). DSM-III-R changed “bulimia” to “bulimia nervosa.” Some clinicians, however, refer to “bulimarexia,” a term that Hilde Bruch, according to Garner and Garfinkel (2, p. 12), called a semantic atrocity because it indicates that the two conditions are nearly identical, which they are not. Bnuch expressed doubts that bulimia is a clinical entity. Compulsive overeating may occur, but in varying conditions and with different severity. Following this philosophy would suggest that DSM manuals should not list the condition at all. In an earlier book, Garfinkel and Garner (14) used elaborate clinical findings as a basis for their conclusion that patients with restricting anorexia and those who later develop bulimia are different. DSM-III (pp. 70-71) listed five major criteria for the diagnosis of bulimia but did not mention body image. DSM-III-R (pp. 68-69) amplified the criteria with “persistent overconcern with body shape and weight” but did not mention distorted image of body size. In an attempt to determine whether patients with eating disorders have distorted body images, this study focuses on similarities and differences in perceived, desired, and actual body image, measured in three and two dimensions.
Each subject’s ideal body weight was identified by using the Metropolitan Life Tables (16). Tests were conducted during the first few days of hospitalization. All patients and comparison subjects were asked to look at their bodies and then adjust a tape measure marked in centimeters so that the circumference of the tape was equal to the circumference of their bodies at seven points: left biceps, left calf, left thigh, waist, abdomen (defined as the “largest point between nib cage and hips-what most people call the stomach”), hips, and bust. Subjects estimated each point twice, one time opening the tape to the selected circumference and the other time closing the tape. The mean of the two was used as the subject’s perceived body size. Subjects were then asked to select their desired body size at the same seven points by again adjusting the tape in the same way. Actual body size was then measured. Distortion was calculated as perceived body size divided by actual body size. In addition to perceived, desired, and actual body size (which required three-dimensional measurements), all subjects indicated their perceived body size with a two-dimensional pen and paper test. They were given five scaled silhouettes designed to represent too thin, thin, average, overweight, and obese. They were asked to select the silhouette that best represented their present overall shape and then to indicate modifications, if needed, at seven points: biceps, bust, waist, abdomen, hips, thigh, and calf. They then selected the silhouette that best represented their desired body size and again indicated needed modifications. The subject’s actual body size was rated by the clinician by choosing which of the five silhouettes best represented the subject’s shape. This rating, however, was not used in the analysis reported here. All patients were also given a battery of tests that included the WISC-R (17) on WAIS-R (18) and the Tactile Performance Test (19), the Trail-Making Test the Halstead Finger-Tapping Test (19), and the Wechsler Memory Test (19). Comparisons within the clinical groups in perceived, desired, and actual body size were obtained by Pearson product-moment correlation, and comparisons between groups (clinical or clinical and comparison) were obtained by one-way analysis of variance (ANOVA). The incidence of distortion in the clinical groups was determined by chi-square with correction for percentages. Differences between the various dinical and comparison groups on neuropsychological and intellectual variables were analyzed by one-way ANOVA, as were comparisons between those with and without distortions of body image. The scores on distortion and body image by body point of the three eating disorders groups and the comparison group were factor-analyzed. Finally, the intellectual variables (WISC-R on WAIS-R scones) of the subjects were cornpared with those of the standardization sample by means of a multiple analysis of variance (MANOVA), and the overall effect of eating disorders was tested by linear models procedures (Wilks’s criterion, Pillai’s 1959
(19),
METHOD The original study group was composed of 230 consecutive admissions to an inpatient eating disorders program. Four patients with atypical eating disorders and 12 men were dropped from the study. The remaining 214 patients were divided into three groups according to DSM-III-R criteria: patients with anorexia nervosa only (N=87), patients with anorexia and bulimia nervosa (N=72), and patients with bulimia nervosa only (N=S5). The comparison group was drawn from 125 consecutive participants in a survey of university students in freshman English classes. The return rate of the questionnaires was 71% (125 returned out of 175 distnibuted). Eight women were excluded from the comparison group because their Eating Attitudes Test scores (iS) were higher than 35 and they fulfilled diagnostic criteria for an eating disorder. Fifty-six men were also dropped from study, leaving a comparison group of 61 women.
212
Am
J
Psychiatry
148:2,
February
1991
HORNE,
TABLE
1. Distortions
in Body Image of Women
With and Without
Patients With Anorexia
Patients Anorexia
Nervosa (N=87)
Body
Point
VAN
VACTOR,
AND
EMERSON
Eating Disordersa
With and
Paitents With Bulimia
Bulimia (N=72)
Comparison
Nervosa (N=SS)
Subjects
(N=61)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Biceps
1.34
0.22
1.33
0.27
1.25
0.17
1.15
0.14
11.66
F1’
Calf
1.15
0.18
1.19
0.26
1.12
0.14
0.98
0.11
14.73
Thigh Waist
1.22 1.25
0.23 0.20
1.24 1.33
0.24 0.21
1.56 1.26
0.14 0.16
1.05 1.08
0.12 0.11
12.72 23.04
Abdomen
1.16
0.19
1.23
0.20
1.15
0.16
0.95
0.12
29.70
Hips
1.12
0.17
1.19
0.19
1.13
0.13
0.94
0.10
30.26
Bust Total aCalculated 134%
1.10 0.14 1.20 0.16 as perceived size divided by actual as large
as they
pO.0001
1.17 0.18 1.24 0.19 size. For example, on average,
171;
trace, study,
and Hotalling-Hawley p
Body
R. Lynn
Home,
Objective:
consecutively with
divided nervosa,
C. Van
attempt
to answer
more distortions The study group
admitted
to
atypical
eating
an
drawn
were
agnostic her body waist, taken.
from
the
from
inpatient
eating were
abdomen, Distortion
by her actual
memory.
hips, and bust. in body image body
size.
Results:
in distortions
in body
in their
image.
body criteria
The subjects’ was calculated were
patient
image.
Most
Conclusions:
regarding
program. from
The
72 with group of university
along
eight
with
also
measurements as the subject’s given
differed
but
all patients
not
If replicated,
disturbance
a battery
groups
ofbody
these image
for
with findings both
men
students.
women
oftests
would anorexia
bulimia of 61
fulfilled
di-
measure to rate left calf, left thigh, points were size divided skill,
the comparison
disorders
had
suggest and
four were
Fifty-six
who
ofintelligence,
from eating
and
2 1 4 patients
at each of these perceived body
significantly
eating eating patients
anorexia and was composed
in a survey
Ph.D.
with
without of 230
Twelve
study.
nervosa alone, The comparison
group,
patients
Each subject used a three-dimensional body size at seven points: left biceps,
All subjects
All three
of whether
Disorders
Emerson,
than do individuals of 214 women out
disorders excluded
Eating
and Shirley
question
participants
the comparison
criteria for eating disorders. size and stated her desired
Ph.D.,
in body image was composed
disorders
I 25 consecutive
dropped
With
Vactor,
into three groups: 87 with anorexia and 55 with bulimia nervosa alone.
women
nostic
in Patients
John
authors
experience Method:
patients
men
M.D.,
The
disorders disorders.
Image
bulimia
that
and
group distortions the need
diagto be
revised. (Am
T age,
J
Psychiatry
1991;
148:211-215)
he second criterion for the diagnosis nervosa in DSM-III is “disturbance e.g., claiming to ‘feel fat’ even when
of anorexia body imemaciated”
of
(p. 69). DSM-III-R places as the third criterion for this diagnosis an expanded description: “Disturbance in the way in which one’s body weight, size, or shape is experienced, e.g., the person claims to ‘feel fat’ even when emaciated, believes that one area of the body is ‘too fat’ even when obviously underweight” (p. 67). In the eating disorders literature, there is continuing controversy over whether disturbance in perception of body image is a necessary and always present attribute
Presented
at the 1 4 1 st annual
meeting
of the American
Psychiatric
Association, Montreal, May 7-12, 1988. Received May 2, 1989; revisions received Sept. 28, 1989, and July 25, 1990; accepted Aug. 27, 1990. From Montevista Hospital, the University of Nevada School of Medicine, and the University of Nevada, Las Vegas. Ad-
dress reprint requests Vegas, NV 89121.
to Dr.
Emerson,
4240
Woodcrest
Rd.,
Las
Detailed tables and figures for the data given here are available on request from Dr. Emerson. Supported in part by HCA Montevista Center and by a Barrick Faculty Research Grant from the University of Nevada, Las Vegas.
The Brown
authors thank Kim Parsons for help in data collection,
data analysis. Copyright
Am
J
© 1991
Psychiatry
American
148:2,
for the scaled silhouettes, Sharon and Judy Jaeger for assistance in Psychiatric
February
Association.
1991
of anorexia nervosa. Crisp (1) did not deny some distortion in the anorexic patient’s perception of her body size but stated that the anorexic patient does not differ greatly from the majority of adolescent girls who are not obese in a medical sense, but who report that they consider themselves fat and overestimate the degree of their overweight in terms of their shape and size. Crisp suggested that the gross overestimates which charactenize many patients with anorexia probably owe this extra distortion to factors such as their wish to be thought of as physically normal and their terror that they could become truly obese if they cannot continue to curb their eating. Garner and Garfinkel (2) stated that the distorted perceptions of body image among patients with eating disorders range from mild to severely delusional. This would seem to leave little question that the patient with an eating disorder has a distorted body image. Garner and Ganfinkel suggested that assessing the degree of distortion in body image is most important because outcome research indicates that those anonexic individuals who persistently maintain the cognitive distortion that they are terribly fat, despite their emaciated condition, show the poorest improvement with treatment. The tendency for patients with anorexia to overes-
211
DISTURBED
BODY
IMAGE
timate their body size was first reported by Bruch (3). Many studies (4-12) have substantiated this finding. Hsu (13) questioned the validity of the evidence for distortion in body image. Garner and Garfinkel, however, cited their finding that self-overestimation is highly predictive of poor prognosis at 1-year follow-up (2, p. 22) as reinforcing the presence and usefulness of the concept. There is confusion surrounding the overlap between anorexia nervosa and bulimia. DSM-III treated them as separate disorders and stated specifically that “the bulimic episodes are not due to Anorexia Nervosa or any known physical disorder” (p. 69). DSM-III-R changed “bulimia” to “bulimia nervosa.” Some clinicians, however, refer to “bulimarexia,” a term that Hilde Bruch, according to Garner and Garfinkel (2, p. 12), called a semantic atrocity because it indicates that the two conditions are nearly identical, which they are not. Bnuch expressed doubts that bulimia is a clinical entity. Compulsive overeating may occur, but in varying conditions and with different severity. Following this philosophy would suggest that DSM manuals should not list the condition at all. In an earlier book, Garfinkel and Garner (14) used elaborate clinical findings as a basis for their conclusion that patients with restricting anorexia and those who later develop bulimia are different. DSM-III (pp. 70-71) listed five major criteria for the diagnosis of bulimia but did not mention body image. DSM-III-R (pp. 68-69) amplified the criteria with “persistent overconcern with body shape and weight” but did not mention distorted image of body size. In an attempt to determine whether patients with eating disorders have distorted body images, this study focuses on similarities and differences in perceived, desired, and actual body image, measured in three and two dimensions.
Each subject’s ideal body weight was identified by using the Metropolitan Life Tables (16). Tests were conducted during the first few days of hospitalization. All patients and comparison subjects were asked to look at their bodies and then adjust a tape measure marked in centimeters so that the circumference of the tape was equal to the circumference of their bodies at seven points: left biceps, left calf, left thigh, waist, abdomen (defined as the “largest point between nib cage and hips-what most people call the stomach”), hips, and bust. Subjects estimated each point twice, one time opening the tape to the selected circumference and the other time closing the tape. The mean of the two was used as the subject’s perceived body size. Subjects were then asked to select their desired body size at the same seven points by again adjusting the tape in the same way. Actual body size was then measured. Distortion was calculated as perceived body size divided by actual body size. In addition to perceived, desired, and actual body size (which required three-dimensional measurements), all subjects indicated their perceived body size with a two-dimensional pen and paper test. They were given five scaled silhouettes designed to represent too thin, thin, average, overweight, and obese. They were asked to select the silhouette that best represented their present overall shape and then to indicate modifications, if needed, at seven points: biceps, bust, waist, abdomen, hips, thigh, and calf. They then selected the silhouette that best represented their desired body size and again indicated needed modifications. The subject’s actual body size was rated by the clinician by choosing which of the five silhouettes best represented the subject’s shape. This rating, however, was not used in the analysis reported here. All patients were also given a battery of tests that included the WISC-R (17) on WAIS-R (18) and the Tactile Performance Test (19), the Trail-Making Test the Halstead Finger-Tapping Test (19), and the Wechsler Memory Test (19). Comparisons within the clinical groups in perceived, desired, and actual body size were obtained by Pearson product-moment correlation, and comparisons between groups (clinical or clinical and comparison) were obtained by one-way analysis of variance (ANOVA). The incidence of distortion in the clinical groups was determined by chi-square with correction for percentages. Differences between the various dinical and comparison groups on neuropsychological and intellectual variables were analyzed by one-way ANOVA, as were comparisons between those with and without distortions of body image. The scores on distortion and body image by body point of the three eating disorders groups and the comparison group were factor-analyzed. Finally, the intellectual variables (WISC-R on WAIS-R scones) of the subjects were cornpared with those of the standardization sample by means of a multiple analysis of variance (MANOVA), and the overall effect of eating disorders was tested by linear models procedures (Wilks’s criterion, Pillai’s 1959
(19),
METHOD The original study group was composed of 230 consecutive admissions to an inpatient eating disorders program. Four patients with atypical eating disorders and 12 men were dropped from the study. The remaining 214 patients were divided into three groups according to DSM-III-R criteria: patients with anorexia nervosa only (N=87), patients with anorexia and bulimia nervosa (N=72), and patients with bulimia nervosa only (N=S5). The comparison group was drawn from 125 consecutive participants in a survey of university students in freshman English classes. The return rate of the questionnaires was 71% (125 returned out of 175 distnibuted). Eight women were excluded from the comparison group because their Eating Attitudes Test scores (iS) were higher than 35 and they fulfilled diagnostic criteria for an eating disorder. Fifty-six men were also dropped from study, leaving a comparison group of 61 women.
212
Am
J
Psychiatry
148:2,
February
1991
HORNE,
TABLE
1. Distortions
in Body Image of Women
With and Without
Patients With Anorexia
Patients Anorexia
Nervosa (N=87)
Body
Point
VAN
VACTOR,
AND
EMERSON
Eating Disordersa
With and
Paitents With Bulimia
Bulimia (N=72)
Comparison
Nervosa (N=SS)
Subjects
(N=61)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Biceps
1.34
0.22
1.33
0.27
1.25
0.17
1.15
0.14
11.66
F1’
Calf
1.15
0.18
1.19
0.26
1.12
0.14
0.98
0.11
14.73
Thigh Waist
1.22 1.25
0.23 0.20
1.24 1.33
0.24 0.21
1.56 1.26
0.14 0.16
1.05 1.08
0.12 0.11
12.72 23.04
Abdomen
1.16
0.19
1.23
0.20
1.15
0.16
0.95
0.12
29.70
Hips
1.12
0.17
1.19
0.19
1.13
0.13
0.94
0.10
30.26
Bust Total aCalculated 134%
1.10 0.14 1.20 0.16 as perceived size divided by actual as large
as they
pO.0001
1.17 0.18 1.24 0.19 size. For example, on average,
171;
trace, study,
and Hotalling-Hawley p
