Body image disturbance is one of the most insidious and painful symptoms of Anorexia Nervosa (AN). In many cases, body dissatisfaction is the last symptom to abate. However, the relationship between body image and recovery from Anorexia Nervosa (AN) is fairly complex. Many individuals with Anorexia Nervosa (AN) do not experience body image problems as a symptom of their illness. Most people with AN, however, do have some degree of body image disturbance which changes in intensity over the course of their illness and recovery.
A recent randomized controlled trial of adolescent AN treatment found that weight and shape concerns did not change significantly over the course of treatment. The authors of the study point out that, on the one hand, these results suggest that weight and shape concerns do not get worse over the course of treatment. This finding may come as a relief to patients who are terrified that they will hate their bodies if they gain weight. The authors conclude that “weight restoration alone is not sufficient to ameliorate the weight and shape concerns characteristic to AN.”
While the authors’ conclusion may be accurate in some cases, my clinical experience with AN patients as well as my knowledge of statistics leads me to a different conclusion. I have observed that the relationship between weight restoration and body image varies dramatically from person to person. When it comes to AN and body image, people tend to fall into one of the following categories:
1.) Those who do not have significant weight or shape concerns.
2.) Those who present for treatment with significant weight and shape concerns, which gradually abate over the course of weight restoration and may even disappear by the end of treatment.
3.) Those who become increasingly dissatisfied and distressed by their weight or shape as they restore weight.
My hypothesis is that the authors of the study found no significant change in body image over the course of treatment because patients in group 2 and group 3 essentially cancelled each other out, while those in group 1 did not impact the results in either direction.
As you can see from the groupings above, body image disturbance may not even be relevant for the patient (group 1), and if it is, weight restoration alone may be sufficient to improve body image (group 2). For this reason, I typically postpone addressing body image until after weight restoration has been accomplished and the patient has re-established normal eating patterns. By postponing body image work until the end of treatment, the patient and her family save a lot of time, money, and stress, as a substantial proportion of patients do not need it.
Individuals in group 3, however, may benefit from working on their body image in therapy. Helping these individuals improve their body image will be the topic of my next blog post.
I definitely fall into category 3. I always say, if you could guarantee that I would not gain any weight if I started to eat normally, then I would do it in a second, I just don’t want to gain weight. Unfortunately, that can not be guaranteed, hence the predicament that I remain in.
If someone has gained weight to a normal, biologically-healthy level, and has re-established normal patterns of eating behavior, then it’s hard to argue that they continue to have anorexia nervosa. Why, therefore, are they entitled to expect other people to pay for any ongoing “treatment” for them? This would include the taxpaying public in countries such as the UK, Canada, or Australia, with national health systems, or the rate-paying public in nations including the U.S. which rely on private medical insurance systems. I can understand why the professional psychotherapy industry lobbies to extend funding for “body image” treatment, since it is in their selfish financial interest to do so. But actually there is no evidence that “body image disturbance” is an objective medical or psychiatric disorder, rather than excess vanity. Nor is there evidence that there are any treatments for “body image disturbance” that have been proven to be particularly effective. Treating body image issues, therefore, is likely to be a waste of time and money and difficult to justify when the health care budgets of most nations are being stretched beyond their limits, and when many people who actually suffer from serious medical conditions other than eating disorders are often unable to obtain financial help for the cost of treatment. Therefore, my personal opinion is that if someone has 1) regained weight and 2)restored normal eating patterns, they are cured of anorexia nervosa and don’t deserve to expect that the rest of us will pay, indirectly, for treating whatever residual “body image” problems they might have.
A paper published this month in the Journal of the American Academy of Child & Adolescent Psychiatry acknowledged that evidence-based treatments have not been developed for body dysmorphic disorder. Mataix-Cols, A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Adolescents with Body Dysmorphic Disorder, http://www.jaacap.com/article/S0890-8567(15)00541-9/abstract In other words, parents, if you decide to send your teenager to a professional psychotherapist to treat so-called “body image” issues, you will get treatments that are not proven to be effective, will likely cost you a lot of time, money, and inconvenience, and may well mess up your kid, you, and your entire family. Proceed with caution, therefore, and consider using your own common sense, not professional psychotherapy.
Dr. Ravin,
I agree completely with your observations. My daughter had pronounced body image disturbance when she was underweight, and continued to have them as her weight increased. She was in group 2.
Then, once she was at her historic weight range, the distortions disappeared. In her case, the distortions were directly tied to what I call, her starving brain.
You are right, also, that if I had tried to engage with her “body talk” when she was very ill, it would’ve led no where, as her brain was not functioning properly enough to discern.
Thanks for a great blog!
Nancy,
Our experience was same as yours. Once weight was fully restored for several months, the brain clearly healed. Cognitions and emotions returned to normal. Perceptions normalized, including of body size and shape. My kid has been completely recovered from anorexia for the past eight years. The trick was lots of food for several months. Talk therapy did nothing. Only food had an effect.
Best wishes,
Chris
Chris and Nancy, thank you both for posting your experiences. Your kids’ experiences illustrate perfectly that food is medicine for AN, and underscore the importance of requiring full nutrition and enforcing prompt, full weight restoration. In many cases, full nutrition and weight restoration alone will resolve the body image disturbance associated with AN.
We are also struggling with this “body image” issue with my 17 year old daughter, 1 year out of anorexia and fully weight restored and now attending her first year in college. She remains on fluoxetine and Wellbtrin but claims to have the same awful thoughts that drove her to anorexia to start. She doesn’t want to practice it again because of all the horrible memories of it all including 4 weeks of hospitalization to start. Unfortunately she can still just shut down, after a shower, a tight fit of a favorite outfit, etc. and good luck prying her out of her depressive mood.
Does this indicate her brain is still not fully “healed”? Will a better or formal nutrition plan (maybe more fats for the brain and less carbos/sugars for the mood swings?) now be the ticket? What are your thoughts on holistic approaches now including Vitamin B12 and other supplelments?
Paul,
If the outfit is too tight, get rid of the outfit. Having clothing that fits too tightly is like having shoes that are too tight. It causes physical and psychological distress. If you gave her the outfit initially, take it back. Give it away to charity. If she bought the outfit with her own money, then buy her a replacement clothing in a larger size. Seventeen-year- olds should be growing. Their wardrobe needs to accommodate growth, not vice versa.
I agree completely with Chris’s advice regarding the tight outfits. On a similar note, if a full-length mirror is triggering, it may be helpful to get rid of the mirror or cover it up.
Paul,
I’m not sure I would worry too much about a teenager “shutting down.” That’s actually fairly normal behavior for an adolescent.
With regard to depressive mood, you might consider taking her off fluoxetine and Wellbutrin. If they aren’t working, why continue? Instead, you might tell her the meds are being changed, then give her a placebo. See Cipriani, Placebo for Depression, BMC Medicine 2014, 12:105 http://www.biomedcentral.com/1741-7015/12/105 Don’t tell her it’s a placebo, however, or it won’t work!
Paul,
It is fantastic that your daughter has fully restored her weight and that she is able to resist acting on eating disordered thoughts, despite feeling tormented by a poor body image, while living independently. This in itself is a huge victory!
Your daughter’s story represents an experience that is different from the experiences of others who have commented on this post. Nancy and Chris noted that their daughters’ body image returned to normal with weight restoration. This is often, though not always, the case. There are many individuals for whom body image distress persists long after weight restoration, and it sounds like your daughter falls into this category.
As for your question of whether her brain has fully healed, I would say that more time may be needed for full brain healing. However, it sounds like your daughter is really suffering mentally, so there may be more she can do to alleviate this suffering.
My first thought would be to re-evaluate whether she is truly weight restored. Clinicians have different ways of determining ideal body weight, so some doctors may view her as “weight-restored” while others do not. The method I generally use is to restore the patient to her historic growth pattern in terms of percentiles for height and weight. So, for instance, if the patient always tracked in the 50th percentile for height and 75th percentile for weight prior to developing AN, then I would want to restore her to the 50th percentile for height and 75th percentile for weight FOR HER CURRENT AGE. This means that patients who develop AN in their teen years will need to weigh more than they have ever weighed in the past in order to keep up with their growth percentile.
Full nutrition, which includes plenty of dietary fat and carbohydrates as well as vitamins and minerals, is vital for brain healing and overall good health. That being said, it may not be the “ticket” you are hoping for.
If you are confident that your daughter has already achieved and maintained her ideal body weight for the past year, then other interventions could be helpful. These other interventions will be the topic of my next blog post, so stay tuned!
In the mean time, I would recommend yoga and mindfulness meditation, both of which can help improve body image by enhancing the mind-body connection. In addition, there is a self-help workbook I like called The Body Image Workbook by Thomas Cash, which takes a CBT – type approach to improving body image by helping the person identify and challenge distorted thoughts related to body image.