Body image distortion in bulimia nervosa. S A Birtchnell, J H Lacey and A Harte BJP 1985, 147:408-412. Access the most recent version at DOI: 10.1192/bjp.147.4.408
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British Journal of Psychiatry (1985), 147, 408—412
Body Image Distortion in Bulimia Nervosa SANDRA A. BIRTCHNELL, J. HUBERT LACEY and ANNE HARTE
Body image perception was measuredin 50 women with bulima nervosaand 19age and weight matched female controls, using a visual size estimation apparatus. Both groups overestimated body widths, but not the width of a neutral object, and whilst there was a trend for bulimics to overestimate more than controls this did not reach
significance. The part of the body most overestimated correspondedto the part most disliked in only a third of both groups. The bulimics without a previous history of anorexia nervosaoverestimated body width more than those with such a history; this may be related to the fact that the former had a significantly greater weight index. Bulimics who were within 5% of mean-matched population weight overestimated body width less than the others, this difference reaching significance when compared with the heaviergroups; a similar, but non-significant, trend was demon strated in controls. This may be linked to a greater dissatisfaction with body size. Duration of illness, frequency of bingeing and self-induced vomiting were not shown
significantly to alter body size estimation. The bulimics who completed a 10-session outpatient treatment programme subsequently demonstrated a significant decrease in overestimation of waist and hip width. Body image is described by Schilder (1935) as “¿the with a third type of eating disorder, bulimia picture of our own body which we form in our mind, nervosa, which, since Russell's (1979) seminal that is to say, the way in which our body appears to paper, has been of considerable interest and ourselves―.As a concept it was developed from the concern. The aims of the study were: work of neurologists such as Head (1920) who delineated the brain's ability to detect weight! 1. To determine whether patients suffering from shape/size and form, and incorporate these into bulimia nervosa overestimate body size. schemata, and Gerstmann (1958) who described the 2. To determine whether the following clinical syndrome associated with right-sided parietal variables influence body size estimation in lesions. The work on patients reporting phantom bulimics: limb phenomena supports the idea that body image —¿previous history of anorexia nervosa is not necessarily consistent with actual physical —¿currentweight appearance. Writers such as Kolb (1959) have —¿durationof illness (bingeing) stressed the inclusion in the concept of body image —¿frequency of bingeing of attitudes and feelings of the individual towards —¿thepractice of self-induced vomiting. his body. As well as misperception of size according 3. To determine whether the body part most to objective or clinical assessment, disturbance of disliked is correspondingly most distorted per body image may also be expressed independently as ceptually. extreme loathing for all or part of the body, or 4. To determine whether body size estimation alters alternatively as an exaggerated pleasure in extreme with the treatment of the bulimia. emaciation.
Fuelled by clinical observations, many studies
In recent years there has been considerable interest in the issue of body image in relationship to eating disorders. Bruch (1962) was the first to claim that body image disturbance was an essential characteristic of anorexia nervosa, and considered its correction
a ‘¿preconditionto recovery'
have attempted to objectify disturbance of body image, and a wide range of techniques has been developed to measure different aspects of body
image, including projective instruments, figure drawings, questionnaires, clinical interviews and the estimation of size from visual and tactile cues. These have been reviewed by Schontz (1974). Investiga tions of body size estimation have used two
(Bruch,
1973). Disturbances of body image have also been described in obese populations (Stunkard & Mendelson, 1967). The present paper is concerned 408
BODY
IMAGE
DISTORTION
approaches, assessment of total body size percep tion (Glucksman & Hirsch, 1969) and estimation of the width of specific body regions
(Reitman
&
IN BULIMIA vomiting
409
NERVOSA
daily
or more
often,
less often
than
daily,
or
notatall. The control group consisted of 19 volunteers from the
Cleveland, 1969; Slade & Russell, 1973; Askevold,
non-permanent
1975). In support of the latter approach it has been noted that females tend to judge their bodies on a
students, nursing students, psychology students, OT students) who, in a confidential questionnaire, declared no current or previous history of eating disorder and who were not currently dieting.
part-by-part basis, whereas men tend to make whole body judgements (Crisp & Kalucy, 1974), and that females have a much clearer view of what they like
female
staff
in the hospital
(medical
Body image perception was measured using a visual size estimation apparatus adapted from Slade & Russell. This
and dislike about their bodies (Heunemann et al, apparatus consisted of two lights mounted on a horizontal 1966). The studies using these techniques have been bar at eye level, which could be moved towards or away extensively reviewedby Garfinkel & Garner(1982). fromeachotherby thesubject depressing buttons on a Using the moveable lights technique, Slade & hand-held control to represent perceived widths, with a
Russell (1973) demonstrated that anorectics over perceived their width in comparison to controls and that overperception decreased as normal weight was restored. Fries (1977) and Pierloot & Houben (1979) similarly reported
overestimation
by anorectics
in
comparison to controls. However, Crisp & Kalucy (1974) showed that non-anorectic controls also over estimated and have suggested that overestimation is
read-out of the distance between the lights which was visible to the experimentor but not to the subject. Each subject stood approximately two metres from the apparatus in the same room, in natural subdued lighting, and was asked to estimate the width of her body across the chest (axilla to axilla), her waist (at the narrowest point) and her hips (at the widest point)
and the width of a neutral
age-related, the controls in the earlier studies being
object (a rectangular box) placed to once side of the apparatus whereitcouldnotbeviewedconcurrently with the apparatus. Four estimations were made for each
older than the anorexic groups. A study by Button et
region,
a! (1977) repeating Slade & Russell's study with carefully age-matched controls found no difference between the two groups, although overestimation in the anorectic group was related to vomiting and early relapse. Garner et a! (1976) also found over estimation as marked in controls as in anorectic and
twomovingthemout,andthese wereaveraged. Theactual widthsof thesubject's chest, waistand hipswerethen measured using an anthropometer. For each region of each subject a Body Image Perception Index was calculated by expressing the perceived width as a per centage of the actual width.
obese subjects.
10 week outpatient
Method
During
the course
the lights into the perceived
of the study 29 patients
treatment
programme
width and
completed
a
similar to that
described elsewhere (Lacey,1983)and theBody lmage Perception was re-measured, at the end of the 10th session, in the same room using the same apparatus. Overestimation of body size in anorectics has been shown to increase after ingestion of a high carbohydrate
Subjects
Theexperimentalgroup consistedof 50womenreferredto the out-patient eating disorders clinic, who at assessment met the criteria for diagnosis of bulimia nervosa (Russell,
1979)and the syndrome ‘¿Bulimia' (DSM III, American Psychiatric Association, 1980).
The group was subdividedinto: —¿Iwogroups on the basis of (a) no previous history of anorexia nervosa, or (b) previously, but not currently, meeting the research diagnostic criteria for anorexia nervosa (Feighner eta!,
two moving
1972).
—¿four groups on the basis of weight index, this being calculated for each subject as a percentage of the mean
matchedpopulation weightwithreferenceto a standard table(Kemsley, 1953/54) of averageweightsin the population of females at different ages and heights. —¿twogroups on the basis of a history of binge eating for
(a) more than fiveyears, (b) fiveyearsor less. —¿two groups on the basis of current bingeeating (a) less than once daily, (b) once or more often daily.
—¿threegroups on the basis of current self-induced
meal (Crisp & Kalucy, 1974). The subjects had not been asked to fast, but on all occasions measurement of Body Image Perception was carried out when they had been in the department between two and three hours and unable to eat.Notewas made of weight, height, ageand desired body
weight.
Bulimics
were asked
at interview,
and
controls by questionnaire, whether they disliked one body partinparticular and,ifso,whichpart.
Results As shown in Table 1, there were no significant differences between
the bulimics
and controls
in age, height,
weight or
weight index.
The bulimicshad a history of binge-eatingfor a mean duration of 5.8 years (SD 4.39) and 80°lo of the sample practised self-induced vomiting. The frequency of these behaviours is summarised in Table II. Laxatives were used by 38°lo of the sample. Bulimics without a previous history of anorexia nervosa(66'lo of the
sample) had a mean minimum weight of 91.5°lo and a mean maximum of 123.5°lo ofmean matchedpopulation
410
SANDRAA. BIRTCHNELL,J. HUBERTLACEY,ANNEHARTE TABLE
TABLE
I
Comparison of age, height, weight and weight index of bulimics and controls
III
Body imageperception indices(%) of controls and bulimics
(n=l9) (n=50) S.D.Age24.54.7924.8 Mean MeanBulimicsS.D.Controls
(n=l9)
(n=50)
MeanControls S.D.MeanBulimics S.D.Chest119.710.80122.124.44NSWaist121.018.62129.924.70NSHips112.215.98119.123.12NSNeutra
4.75NSHeight64.5―2.2264.2'
2.59NSWeightl35lbs18.24126.2lbs 11.81NSWeight index(‘1.)106.812.04100.7
object98.45.6297.512.06NS 7.36NS
body widths, most markedly at waist and least at hip level. Although
TABLE
II
Frequencyof bingeingand self-inducedvomiting in the bulimics Bingeing Vomiting (n=50) (n=40) More than daily32'!.47.5%Daily34%22.5°!.Weekly daily30°!.25¾Less or more, but lessthan weekly401o2.5°!.Less than than fortnightly0¾2.5%
weight at the same age and weight (MMPW). Those with a
previoushistory of anorexia nervosa(34% of the sample) had a mean minimum weight of 74.8% and a mean maximum of 123.2% of MMPW.
the trend was for bulimics to distort more, this
did not reach significance. Bulimics with a previous history of anorexia nervosa overestimated every body width parameter less than those without, though this reached significance only for the chest. However, although the groups did not differ by age, those bulimics who had not previously been anorectic had a significantly greater weight index (P
