Body Image in Eating Disorders

Clinical Diagnosis and Integrative Approach to Psychological Treatment

Bernadetta Izydorczyk

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000528503
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología anormal

Body Image in Eating Disorders explores issues relating to the prevention, clinical diagnosis, and psychological treatment of distortions of body image in eating disorders. It presents a multifactorial model of indicators for diagnosis and treatment, considering psychological, sociocultural, and family indicators.

Based on original empirical research with women and girls suffering from eating disorders, the book draws attention to limitations and dilemmas related to psychological diagnosis and treatment of people with eating disorders including anorexia readiness syndrome, bulimia, and bigorexia. The book proposes an integrative psychodynamic approach to the diagnosis and treatment of body image disorders and presents case studies illustrating examples of application of integration of psychodynamic therapy and psychodrama in psychological treatment of young people suffering from eating disorders. It considers risk factors including abnormal body image for the development of eating disorders and argues that psychological diagnosis of the body image is an important factor in determining the right direction of psychological treatment for people with eating disorders.

Drawing on theoretical foundations and evidence-based clinical practice, the book will be of great interest to researchers, academics, and students in the fields of clinical and applied psychology, mental health, and specialists in eating disorders.

The Open Access version of this book, available at www.taylorfrancis.com, has been made available under a Creative Commons Attribution-Non Commercial-No Derivatives 4.0 license.

1 The phenomenon of body image: a psychological perspective

DOI: 10.4324/9781003251088-1

Chapter 1 presents the theoretical and empirical arguments for the importance of taking a multidimensional perspective on defining the phenomenon of body image in the process of psychological diagnosis of body image distortions as well as the process of psychotherapy of eating disorders. The multi-factor model of psychosocial risk factors for body image distortions and anti-health eating behaviors (restrictive, compulsive, and bulimic) presented in Chapter 1 is in line with the principles of evidence-based practice, which is necessary for its use in treatment of eating disorders.

Body image: a predictor of anti-health behaviors toward eating

During literature reviews and analyses of clinical experiences of psychologists and other specialists cooperating in the process of treating eating disorders, it should be assumed that regardless of the adopted theoretical paradigm (psychoanalytical, cognitive-behavioral, and sociocultural), specific and nonspecific eating disorders in adolescents and adults are disorders characterized by ambiguity, complex determinants and mechanisms of development, and diverse self-destructive (restrictive, bulimic, and compulsive) behaviors toward eating and one’s own body (Cash & Pruzinsky, 2004; Izydorczyk, 2015; Józefik, 2008, 2014). The body image in eating disorders is also complex and multifaceted. Most of its definitions, both in cognitive, psychoanalytical, and sociocultural theories, highlight its emotional (satisfaction/dissatisfaction with appearance and weight), cognitive (perception, estimation of its dimensions, schema regarding one’s own body and appearance), and behavioral (the behaviors toward the body) aspects (Cash, 2004, 2012; Schier, 2010; Thompson & Smolak, 2001). Body image is a mental structure describing the experience of the individual’s internal world in relation to the external (social, i.e., shared with other people) environment, simultaneously taking into account its emotional background which develops across the lifespan through relations with others.

Body image is an element of the personality structure of the body Self, and thus a component of the personality structure of the Self (Higgins, 1987). According to Higgins’ self-discrepancy theory, people strive to reduce the differences (discrepancies) between how they perceive themselves (actual Self) and what they would like to be (ideal Self) or should be (ought Self, Higgins 1987). The discrepancy between the actual Self and another specific type of Self-standard (e.g., the ideal Self) is reflected in the content of cognitive schemas indicating an unfavorable (negative) psychological situation for the person which has emotional and motivational consequences for behaviors toward the body and eating (Cash & Pruzinsky, 2004; Izydorczyk, 2015a; Thompson & Smolak, 2001).

In cognitive theories, an important factor explaining the formation of body image is the sociocultural influence and body image standards promoted in the culture of westernization (Izydorczyk & Sitnik-Warchulska, 2018; Izydorczyk et al., 2020). The nature and strength of the attitudes adopted by a person toward the assimilation of sociocultural standards of an ideal body influence his undertaking of pro- or anti-health behaviors in relation to his body and eating.

In the theory of body objectification, Fredrickson and Roberts (1997) emphasize the importance of self-sexualization, in which girls and young women treat their bodies – themselves – as sexual objects. From the perspective of the psychoanalytical–psychodynamic paradigm, body image is an element of the personality structure of the Self, called the body Self (Krueger, 2002a, 2002b; Sakson-Obada, 2008). The structure of the body Self and the psychological quality of experiencing the body (in perception, thoughts, and emotions) are influenced by autobiographical experiences (especially during childhood). Trauma theories prove that trauma, sexual violence, and violations of personal boundaries, especially in childhood, cause developmental distortions in experiencing one’s body and in building close, emotional relationships with others in the future (Izydorczyk, 2017a; Krystal, 2000; Madowitz et al., 2015; McDougall, 2014; Sakson-Obada, 2008, 2009a, 2009b).

The psychodynamic approach and attachment theory not only focus on the cognitive and emotional assessment of the external body (body image), but also on learning about oneself through the body, that is, the experience of body functions, control of incoming stimuli and emotions as well as acceptance of one’s psychosexual identity (Krueger, 2002a, 2002b; Sakson-Obada, 2009b; Skrzypska & Suchańska, 2011). Summarizing the above-mentioned review of the basic claims of psychological theories concerning body image, it is worth pointing to the validity of the statement that it is impossible to treat patients with eating disorders without targeting the psychological mechanisms of body image distortions.

Anorexia and bulimia nervosa or binge eating disorder are disorders in which both the body and the mental Self are simultaneously affected (Józefik, 2008; Józefik et al., 2010; Krueger, 2002a, 2002b; McDougall, 2014). At each stage of treatment of various types of eating disorders, addressing both the patients’ somatic health and mental well-being is necessary to re-establish their biopsychosocial balance (Domaradzki, 2013; World Health Organization, 2018). Patients with eating disorders can exhibit various levels of personality structure pathology: from the neurotic to the borderline and psychotic (Gabbard, 2015). The level of dysfunction in the personality structure also determines the direction and form of (medical and psychotherapeutic) interventions in the course of the entire treatment process (Clarkin et al., 2013; Gabbard, 2015). In order to provide comprehensive treatment, apart from examining the personality structure, which may present various levels of destabilization, it is also worth to conduct a psychological diagnosis of various body image distortions.

Depending on the destabilization of the personality structure and individual life history (especially the history of psychological traumas) patients may present with various cognitive deficits (or even defects) concerning the perception of the body and its individual parts, negative thoughts and emotions about body image, as well as interoceptive deficits related to the differentiation of various stimuli from the body (Garner, 2004; Izydorczyk, 2011; 2013a, 2013b, 2015). Psychosomatic theories and their application in clinical practice indicate that people who are unaware of the frustration of their important emotional needs, internal conflicts, and emotional deficits often experience somatic symptoms – their bodies suffer (McDougall, 2014; Sakson-Obada, 2008, 2009a, 2009b; Schier, 2010). The somatic symptom is a specific symbol of unconscious and highly diversified internal conflict (Krueger, 2002a, 2002b; McDougall, 2014; Schier, 2010).

When making a psychological diagnosis of the mechanisms underlying the symptoms of anorexia and bulimia, it is worth reflecting on the symbolic functions of restrictive and/or compulsive (bulimic) eating behaviors. Such destructive behaviors as restrictive, debilitating attempts to lose weight, fasting, provoking vomiting, and other forms of purging are often puzzling in their purpose. Why does the patient dislike their body and devalue it in such unfavorable, unhealthy ways? There are many questions, and they all center around the body. The body is subject to restrictive or impulsive actions that harm life and health, and it must be taken into account both in the process of diagnosis and treatment.

A comprehensive (medical, psychotherapeutic, and dietary) treatment process of patients with eating disorders always takes into account multidirectional interactions, which, depending on the adopted therapeutic paradigm, include interventions focused on restoring health. This also means compensating for disturbances in the cognitive and emotional experience of body image. In the process of treatment of body image distortions, patients with anorexia, bulimia, or binge eating disorder often require support in recognizing and eliminating/reducing these distortions and in shaping healthy eating behaviors (Cash & Pruzinsky, 2004; Izydorczyk, 2015; Vartanian et al., 2018; Wertheim et al., 2004). Psychotherapeutic treatment of emotional and cognitive body image distortions is one of the most important aspects of treating patients with various types of eating disorders. It utilizes specific, professional diagnostic measures in order to completely remove or reduce the symptoms of eating disorders.

Psychotherapy of eating disorders, including body image distortions, should be multidirectional and dependent on the patient’s current health condition and needs (in a situation of physical exhaustion, it will be much more limited than when the patients’ psychophysical well-being is better and their condition is no longer life-threatening). The psychological diagnosis of the perception and thoughts and negative emotions about body image is a significant complement to the diagnosis of a specific personality structure and a psychological profile (especially intense emotional dysregulation, fear, excessive perfectionism, impulsivity, low self-esteem, lack of self-confidence, distrust and uncertainty in emotional relationships; Izydorczyk, 2011, 2013a, 2013b, 2015; Mikołajczyk & Samochowiec, 2004a, 2004b). Such a comprehensive psychological diagnosis is needed to determine the appropriate psychotherapeutic treatment for patients with eating disorders presenting a diverse spectrum of destructive behaviors toward the body and eating.

The dominant influence of sociocultural factors and psychosocial determinants on the relationship between unfinished separation and individuation in adolescents, the formation of body image, and the escalation of destructive behavior toward the body (based on the drive for thinness and emotional dissatisfaction) indicates a different direction of psychotherapy (often with the use of family therapy) than situations where adult patients experience body image distortions and simultaneously present a destabilization of the personality structure at the borderline or psychotic level (Gabbard, 2015; Izydorczyk, 2010; 2015, 2017b). The dominance of perfectionism or impulsivity together with low self-esteem and distrust in interpersonal relationships (i.e., difficulties in building an emotional bond) may significantly hinder the course of the entire therapeutic process, but also determine the specificity of therapeutic interventions aimed at the body. A review of definitions of body image in psychology shows their ambiguity and varied etiology as well as the differences of diagnosing specific and nonspecific eating disorders in the ICD-10 (World Health Organization, 1993) and DSM-V (American Psychiatric Association, 2013) medical classifications (Garner, 2004). Psychiatric diagnosis is not a sufficient criterion for diagnosing the pathogenesis of eating disorders. It requires a multifactorial approach to neurobiological and psychosocial causes showing the relationship between mental disorders and eating disorders, for example, the occurrence of symptoms of psychological anorexia (Södersten et al., 2019). For this reason, a clinical psychological diagnosis including the multifactorial determinants of eating behaviors becomes necessary to determine the direction of treatment and psychotherapy (Södersten et al., 2019).

The psychological profiles of patients with eating disorders and the diagnostic criteria for anorexia and bulimia nervosa present in the ICD-10 (World Health Organization, 1993), ICD-11 (World Health Organization, 2018), and DSM-V (American Psychiatric Association, 2013) emphasize the etiological importance of the relationship between cognitive body image distortions, fear of gaining weight (fat phobia), restrictive eating behaviors (diets), excessive physical activity, and impulsive (bulimic) behaviors consisting in purging the body without existing health indications (e.g., inducing vomiting; Vartanian et al., 2018; Wertheim et al., 2004). Both theorists and researchers have confirmed the multifactorial model of the determinants of restrictive and impulsive (bulimic)...