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Anorexia nervosa: Eating disorder or body image disorder?

Article  in  Australian and New Zealand Journal of Psychiatry · August 2017

DOI: 10.1177/0004867417722640

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722640
research-article2017
ANP0010.1177/0004867417722640ANZJP DebatePhillipou et al.
Debate
Anorexia nervosa: Eating disorder
or body image disorder?
Andrea Phillipou1,2,3,4, David J Castle1,2 and Susan L Rossell1,3,5
Anorexia nervosa (AN) is a psychiatric
illness characterised by a restriction of
energy intake leading to dangerously
low body weight, an intense fear of
weight gain, body image disturbance
and impairments in perceiving the life-
threatening implications of the emaci-
ated state. In the current Diagnostic
and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), AN is
categorised under the classification of
‘feeding and eating disorders’, along
with other conditions such as pica,
rumination disorder, avoidant/restric-
tive food intake disorder, binge eating
disorder and bulimia nervosa (BN)
(American Psychiatric Association,
2013). With the exception of BN, the
remaining conditions falling under this
feeding and eating disorders classifica-
tion are just that: disorders of feeding
and eating. Pica is a condition charac-
terised by the consumption of non-
nutritive substances such as paper;
rumination disorder involves the
effortless regurgitation of food that is
sometimes re-consumed; avoidant/
restrictive food intake disorder, also
known as ‘selective eating’, involves
the consumption of food being limited
by certain features, such as its appear-
ance; whereas binge eating disorder is
characterised by recurrent episodes of
binge eating. BN, on the other hand, is
defined by recurrent episodes of binge
eating (disordered eating) associated
with inappropriate compensatory
behaviours to prevent weight gain, and
is influenced by self-evaluation related
to body weight and shape (disordered
body image). BN, and perhaps more
so AN which has a greater focus on
body image irrespective of inappropri-
ate feeding, differ significantly from
these disordered feeding and eating
conditions, in that although disordered
eating is experienced, a core feature of
these illnesses is a disturbance of body
image.
Distortions in the experience and/
or satisfaction with one’s own body,
and the anxiety associated with their
body image, is arguably the driving
force behind the restriction of eating
experienced in AN. Gold standard
measures such as the Eating Disorder
Examination Questionnaire (EDE-Q)
recognise this and include questions
related to restrained eating with the
provision that they are related to body
image, for example, ‘Have you been
deliberately trying to limit the amount
of food you eat to influence your
shape or weight?’ This begs the ques-
tion as to whether our conceptualisa-
tion of AN as an ‘eating disorder’ is
simplistic and misleading. Would it be
more appropriate to classify AN as a
‘body image disorder’? What benefits
would such a re-classification have?
Psychological treatments for AN
already incorporate strategies
addressing disturbances of body
image. Would a new classification
result in more emphasis placed on the
body image distortions that are driv-
ing other maladaptive behaviours in
the illness? Perhaps more importantly,
would it change the way the general
public think of AN? Thinking of AN as
a body image disorder may result in
fewer misperceptions and comments
directed to patients such as ‘why
won’t you just eat?’ or ‘I wish I had
anorexia so I could lose weight’ and
may help discourage ‘pro-ana’ web-
sites. It may also be a driving force in
changing the research agenda in AN.
Australian & New Zealand Journal of Psychiatry, 00(0)
Australian & New Zealand Journal of Psychiatry
1­–2
https://doi.org/10.1177/0004867417722640
DOI: 10.1177/0004867417722640
© The Royal Australian and
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Research in AN predominantly
focuses on understanding disordered
eating behaviours. For example, func-
tional brain activity in AN has often
been examined in response to food-
related stimuli (see Phillipou et al.,
2014, for a review). Does this
research, however, provide any
insight into the underlying mecha-
nisms involved in AN or simply iden-
tify changes in response to a perceived
aversive stimulus that is commonly
associated with weight gain? It is pre-
sumed that an individual will have a
different neural response to some-
thing they find aversive or threaten-
ing, relative to someone for whom
such stimuli are relatively neutral.
Would it be more beneficial for such
research to focus on disturbed body
image per se?
Relatedly, is the classification of
AN subtypes based on eating behav-
iour, restrictive or binge/purge, valu-
able? In terms of treatment, it is
important to understand the dis-
rupted eating behaviours that need to
be addressed. Yet, in relation to our
1Department of Psychiatry, St Vincent’s
Hospital, Melbourne, VIC, Australia
2Department of Psychiatry, The University of
Melbourne, Melbourne, VIC, Australia
3Centre for Mental Health, Swinburne
University of Technology, Melbourne, VIC,
Australia
4Department of Mental Health, Austin
Hospital, Melbourne, VIC, Australia
5Monash Alfred Psychiatry Research Centre,
Melbourne, VIC, Australia
Corresponding author:
Andrea Phillipou, Department of Psychiatry, St
Vincent’s Hospital Melbourne, PO Box 2900,
Fitzroy, VIC 3065, Australia.
Email: ap@unimelb.edu.au
2 ANZJP Debate
understanding of the disorder, this
classification is arguably less useful.
Both restrictive and binge/purge sub-
types of AN have the same ultimate
goal, namely, to reduce body weight.
Does the method used to try to
achieve weight loss enable a better
understanding of the illness or simply
demonstrate underlying personality
differences between different patients
resulting in different methods of
weight loss? Differences in personal-
ity characteristics are likely to influ-
ence the differences in weight loss
strategies, but arguably do not pro-
vide a greater level of insight into the
underlying mechanisms involved in
AN driving the disruptions in body
image.
In conclusion, we propose that the
classification of AN as a body image
disorder rather than an eating disor-
der may be a more valuable and accu-
rate description of the illness.
Distorted beliefs regarding the shape
and size of one’s own body often
Australian & New Zealand Journal of Psychiatry, 00(0)
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reach delusional intensity in AN,
emphasising the significance of disor-
dered body image in the illness
(Phillipou et al., 2017). We propose a
re-classification of AN under a new
category of body image disorders,
together with other mental illnesses
in which body image is the dominant
feature, such as BN, body dysmorphic
disorder (BDD) and muscle dysmor-
phia (MD). Although this increased
focus on body image may result in dif-
ficulties diagnosing the small number
of individuals with AN who present
with predominantly somatic concerns,
it may also enable more appropriate
diagnoses of somatic presentations,
including BDD and MD. The focus on
body image will also emphasise the
importance of concurrent psychologi-
cal support and therapy while under-
going re-feeding for dangerously low
body weight in AN. Finally, referring
to the illness as a disorder of body
image has clear benefits for increasing
the lay public’s understanding of AN
and could help destigmatise the
illness.
Declaration of Conflicting
Interests
The author(s) declared no potential con-
flicts of interest with respect to the
research, authorship and/or publication of
this article.
Funding
The author(s) received no financial sup-
port for the research, authorship and/or
publication of this article.
References
American Psychiatric Association (2013) Diagnostic
and Statistical Manual of Mental Disorders.
5th Edition. Washington, DC: American
Psychiatric Association.
Phillipou A, Mountjoy RL and Rossell SL (2017)
Overvalued ideas or delusions in anorexia
nervosa? Australian and New Zealand Journal of
Psychiatry 51: 563–564.
Phillipou A, Rossell SL and Castle DJ (2014) The
neurobiology of anorexia nervosa: A system-
atic review. Australian and New Zealand Journal
of Psychiatry 48: 128–152.