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Different labels are used in research and clinical setting to define the body image disturbance generating terminological confusion. Some of the most used terms are "body image discrepancy",<ref>{{Cite journal|last1=Pétré|first1=Benoit|last2=Scheen|first2=André J.|last3=Ziegler|first3=Olivier|last4=Donneau|first4=Anne-Françoise|last5=Dardenne|first5=Nadia|last6=Husson|first6=Eddy|last7=Albert|first7=Adelin|last8=Guillaume|first8=Michèle|date=2016|title=Body image discrepancy and subjective norm as mediators and moderators of the relationship between body mass index and quality of life|journal=Patient Preference and Adherence|volume=10|pages=2261–2270|doi=10.2147/PPA.S112639|issn=1177-889X|pmc=5104290|pmid=27853356}}</ref> "body image self-discrepancy",<ref>{{Cite journal|last1=Solomon-Krakus|first1=Shauna|last2=Sabiston|first2=Catherine M.|last3=Brunet|first3=Jennifer|last4=Castonguay|first4=Andree L.|last5=Maximova|first5=Katerina|last6=Henderson|first6=Mélanie|date=2017-01-01|title=Body Image Self-Discrepancy and Depressive Symptoms Among Early Adolescents|url=https://www.jahonline.org/article/S1054-139X(16)30318-4/abstract|journal=Journal of Adolescent Health|language=English|volume=60|issue=1|pages=38–43|doi=10.1016/j.jadohealth.2016.08.024|issn=1054-139X|pmid=27793726}}</ref> "body image distortion",<ref name="Treasure 1–21" /> "disturbed body image",<ref>{{Cite journal|last1=Horne|first1=R. L.|last2=Van Vactor|first2=J. C.|last3=Emerson|first3=S.|date=1991|title=Disturbed body image in patients with eating disorders|url=https://pubmed.ncbi.nlm.nih.gov/1987820/|journal=The American Journal of Psychiatry|volume=148|issue=2|pages=211–215|doi=10.1176/ajp.148.2.211|doi-broken-date=6 August 2021|issn=0002-953X|pmid=1987820}}</ref> "disturbances in body estimations",<ref>{{Cite journal|last1=Casper|first1=R. C.|last2=Halmi|first2=K. A.|last3=Goldberg|first3=S. C.|last4=Eckert|first4=E. D.|last5=Davis|first5=J. M.|date=1979|title=Disturbances in body image estimation as related to other characteristics and outcome in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/570073/|journal=The British Journal of Psychiatry: The Journal of Mental Science|volume=134|pages=60–66|doi=10.1192/bjp.134.1.60|issn=0007-1250|pmid=570073}}</ref> "body image disturbance",<ref>{{Cite journal|last1=Feusner|first1=Jamie|last2=Deshpande|first2=Rangaprakash|last3=Strober|first3=Michael|date=2017|title=A translational neuroscience approach to body image disturbance and its remediation in anorexia nervosa|journal=International Journal of Eating Disorders|language=en|volume=50|issue=9|pages=1014–1017|doi=10.1002/eat.22742|issn=1098-108X|pmc=5752143|pmid=28755487}}</ref> and "negative body image".<ref>{{Cite journal|last1=Spreckelsen|first1=Paula von|last2=Glashouwer|first2=Klaske A.|last3=Bennik|first3=Elise C.|last4=Wessel|first4=Ineke|last5=de Jong|first5=Peter J.|date=2018|title=Negative body image: Relationships with heightened disgust propensity, disgust sensitivity, and self-directed disgust|journal=PLOS ONE|volume=13|issue=6|pages=e0198532|doi=10.1371/journal.pone.0198532|issn=1932-6203|pmc=5988313|pmid=29870558|bibcode=2018PLoSO..1398532S}}</ref> Sometimes, the term "[[body dissatisfaction]]" is also used to refer to body image disturbance indiscriminately.<ref>{{Cite journal|last1=McLean|first1=Siân A.|last2=Paxton|first2=Susan J.|date=2019|title=Body Image in the Context of Eating Disorders|url=https://pubmed.ncbi.nlm.nih.gov/30704635/|journal=The Psychiatric Clinics of North America|volume=42|issue=1|pages=145–156|doi=10.1016/j.psc.2018.10.006|issn=1558-3147|pmid=30704635}}</ref> Moreover, the DSM-5 itself defines this symptom vaguely: "a disturbance in the way one's body weight or shape is experienced".<ref name=":3" /> Thus, the lack of a clear definition is problematic from both a clinical and basic research point of view.
Different labels are used in research and clinical setting to define the body image disturbance generating terminological confusion. Some of the most used terms are "body image discrepancy",<ref>{{Cite journal|last1=Pétré|first1=Benoit|last2=Scheen|first2=André J.|last3=Ziegler|first3=Olivier|last4=Donneau|first4=Anne-Françoise|last5=Dardenne|first5=Nadia|last6=Husson|first6=Eddy|last7=Albert|first7=Adelin|last8=Guillaume|first8=Michèle|date=2016|title=Body image discrepancy and subjective norm as mediators and moderators of the relationship between body mass index and quality of life|journal=Patient Preference and Adherence|volume=10|pages=2261–2270|doi=10.2147/PPA.S112639|issn=1177-889X|pmc=5104290|pmid=27853356}}</ref> "body image self-discrepancy",<ref>{{Cite journal|last1=Solomon-Krakus|first1=Shauna|last2=Sabiston|first2=Catherine M.|last3=Brunet|first3=Jennifer|last4=Castonguay|first4=Andree L.|last5=Maximova|first5=Katerina|last6=Henderson|first6=Mélanie|date=2017-01-01|title=Body Image Self-Discrepancy and Depressive Symptoms Among Early Adolescents|url=https://www.jahonline.org/article/S1054-139X(16)30318-4/abstract|journal=Journal of Adolescent Health|language=English|volume=60|issue=1|pages=38–43|doi=10.1016/j.jadohealth.2016.08.024|issn=1054-139X|pmid=27793726}}</ref> "body image distortion",<ref name="Treasure 1–21" /> "disturbed body image",<ref>{{Cite journal|last1=Horne|first1=R. L.|last2=Van Vactor|first2=J. C.|last3=Emerson|first3=S.|date=1991|title=Disturbed body image in patients with eating disorders|url=https://pubmed.ncbi.nlm.nih.gov/1987820/|journal=The American Journal of Psychiatry|volume=148|issue=2|pages=211–215|doi=10.1176/ajp.148.2.211|doi-broken-date=6 August 2021|issn=0002-953X|pmid=1987820}}</ref> "disturbances in body estimations",<ref>{{Cite journal|last1=Casper|first1=R. C.|last2=Halmi|first2=K. A.|last3=Goldberg|first3=S. C.|last4=Eckert|first4=E. D.|last5=Davis|first5=J. M.|date=1979|title=Disturbances in body image estimation as related to other characteristics and outcome in anorexia nervosa|url=https://pubmed.ncbi.nlm.nih.gov/570073/|journal=The British Journal of Psychiatry: The Journal of Mental Science|volume=134|pages=60–66|doi=10.1192/bjp.134.1.60|issn=0007-1250|pmid=570073}}</ref> "body image disturbance",<ref>{{Cite journal|last1=Feusner|first1=Jamie|last2=Deshpande|first2=Rangaprakash|last3=Strober|first3=Michael|date=2017|title=A translational neuroscience approach to body image disturbance and its remediation in anorexia nervosa|journal=International Journal of Eating Disorders|language=en|volume=50|issue=9|pages=1014–1017|doi=10.1002/eat.22742|issn=1098-108X|pmc=5752143|pmid=28755487}}</ref> and "negative body image".<ref>{{Cite journal|last1=Spreckelsen|first1=Paula von|last2=Glashouwer|first2=Klaske A.|last3=Bennik|first3=Elise C.|last4=Wessel|first4=Ineke|last5=de Jong|first5=Peter J.|date=2018|title=Negative body image: Relationships with heightened disgust propensity, disgust sensitivity, and self-directed disgust|journal=PLOS ONE|volume=13|issue=6|pages=e0198532|doi=10.1371/journal.pone.0198532|issn=1932-6203|pmc=5988313|pmid=29870558|bibcode=2018PLoSO..1398532S}}</ref> Sometimes, the term "[[body dissatisfaction]]" is also used to refer to body image disturbance indiscriminately.<ref>{{Cite journal|last1=McLean|first1=Siân A.|last2=Paxton|first2=Susan J.|date=2019|title=Body Image in the Context of Eating Disorders|url=https://pubmed.ncbi.nlm.nih.gov/30704635/|journal=The Psychiatric Clinics of North America|volume=42|issue=1|pages=145–156|doi=10.1016/j.psc.2018.10.006|issn=1558-3147|pmid=30704635}}</ref> Moreover, the DSM-5 itself defines this symptom vaguely: "a disturbance in the way one's body weight or shape is experienced".<ref name=":3" /> Thus, the lack of a clear definition is problematic from both a clinical and basic research point of view.


However, most recent studies define "body image disturbance" as a multidimensional symptom comprising various components of [[Body image (medicine)|body image]].<ref name=":1" /> Specifically, we usually describe [[Body image (neuroscience)|body image]] as a multidimensional concept formed by the interaction of four body-related components: cognitive, affective, behavioral, and perceptual.
However, most recent studies define "body image disturbance" as a multidimensional symptom comprising various components of [[Body image (medicine)|body image]].<ref>{{Citation|last=Cash|first=Thomas F.|title=Cognitive—Behavioral Treatment of Body-Image Disturbances|date=1996|url=http://dx.doi.org/10.1007/978-1-4899-1528-3_15|work=Sourcebook of Psychological Treatment Manuals for Adult Disorders|pages=567–614|place=Boston, MA|publisher=Springer US|isbn=978-1-4899-1530-6|access-date=2021-08-07|last2=Grant|first2=Jill R.}}</ref><ref name=":1" /><ref name="Eshkevari 2014 400–409" /><ref name=":19" /><ref name=":2" /><ref name=":22" /> Specifically, we usually describe [[Body image (neuroscience)|body image]] as a multidimensional concept formed by the interaction of four body-related components: cognitive, affective, behavioral, and perceptual.


* Cognitive: thoughts and beliefs about one's body and its shape; it also consists of a conscious mental representation of one's body<ref>{{Cite journal|last1=Cash|first1=T. F.|last2=Deagle|first2=E. A.|date=1997|title=The nature and extent of body-image disturbances in anorexia nervosa and bulimia nervosa: a meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/9261648/|journal=The International Journal of Eating Disorders|volume=22|issue=2|pages=107–125|doi=10.1002/(SICI)1098-108X(199709)22:2<107::AID-EAT1>3.0.CO;2-J|issn=0276-3478|pmid=9261648}}</ref>
* Cognitive: thoughts and beliefs about one's body and its shape; it also consists of a conscious mental representation of one's body<ref>{{Cite journal|last1=Cash|first1=T. F.|last2=Deagle|first2=E. A.|date=1997|title=The nature and extent of body-image disturbances in anorexia nervosa and bulimia nervosa: a meta-analysis|url=https://pubmed.ncbi.nlm.nih.gov/9261648/|journal=The International Journal of Eating Disorders|volume=22|issue=2|pages=107–125|doi=10.1002/(SICI)1098-108X(199709)22:2<107::AID-EAT1>3.0.CO;2-J|issn=0276-3478|pmid=9261648}}</ref>
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New treatments for body image disturbance have recently been developed, also focusing on the perceptual component of the disorder. One of the best known is [[Mirror Exposure]]. Mirror Exposure<ref name=":17">{{Cite journal|last1=Delinsky|first1=Sherrie Selwyn|last2=Wilson|first2=G. Terence|date=2006|title=Mirror exposure for the treatment of body image disturbance|url=https://pubmed.ncbi.nlm.nih.gov/16231342/|journal=The International Journal of Eating Disorders|volume=39|issue=2|pages=108–116|doi=10.1002/eat.20207|issn=0276-3478|pmid=16231342}}</ref> is a cognitive-behavioral technique for treating BID. The treatment aims to reduce experiential avoidance, reduce bodily dissatisfaction, and improve one's misperception of the body. During the exposure, patients are invited to observe themselves in front of a large full-length mirror. There are different types of mirror exposure, guided exposure, unguided exposure, exposure with mindfulness exercises, cognitive dissonance-based mirror exposure.<ref>{{Cite journal|last1=Moreno-Domínguez|first1=Silvia|last2=Rodríguez-Ruiz|first2=Sonia|last3=Fernández-Santaella|first3=M. Carmen|last4=Jansen|first4=Anita|last5=Tuschen-Caffier|first5=Brunna|date=2012|title=Pure versus guided mirror exposure to reduce body dissatisfaction: a preliminary study with university women|url=https://pubmed.ncbi.nlm.nih.gov/22244836/|journal=Body Image|volume=9|issue=2|pages=285–288|doi=10.1016/j.bodyim.2011.12.001|issn=1873-6807|pmid=22244836}}</ref><ref>{{Cite journal|last1=Luethcke|first1=Cynthia A.|last2=McDaniel|first2=Leda|last3=Becker|first3=Carolyn Black|date=2011|title=A comparison of mindfulness, nonjudgmental, and cognitive dissonance-based approaches to mirror exposure|url=https://pubmed.ncbi.nlm.nih.gov/21561817/|journal=Body Image|volume=8|issue=3|pages=251–258|doi=10.1016/j.bodyim.2011.03.006|issn=1873-6807|pmid=21561817}}</ref> To date, few studies have investigated the effects of mirror exposure in patients with body image disturbance. Key et al.<ref>{{Cite journal|last1=Key|first1=Adrienne|last2=George|first2=C. Louise|last3=Beattie|first3=Desley|last4=Stammers|first4=Kate|last5=Lacey|first5=Hubert|last6=Waller|first6=Glenn|date=2002|title=Body image treatment within an inpatient program for anorexia nervosa: the role of mirror exposure in the desensitization process|url=https://pubmed.ncbi.nlm.nih.gov/11920979/|journal=The International Journal of Eating Disorders|volume=31|issue=2|pages=185–190|doi=10.1002/eat.10027|issn=0276-3478|pmid=11920979}}</ref> conducted a non-randomized trial in a clinical sample and compared a body image group therapy with or without mirror exposure. They found a significant improvement in body dissatisfaction only in the mirror exposure therapy group. Despite the positive evidence, a recent review suggests that further studies are needed to ensure the efficacy of mirror exposure in the treatment of body image disturbance.<ref>{{Cite journal|last1=Griffen|first1=Trevor C.|last2=Naumann|first2=Eva|last3=Hildebrandt|first3=Tom|date=2018|title=Mirror exposure therapy for body image disturbances and eating disorders: A review|url=https://pubmed.ncbi.nlm.nih.gov/30223161/|journal=Clinical Psychology Review|volume=65|pages=163–174|doi=10.1016/j.cpr.2018.08.006|issn=1873-7811|pmid=30223161}}</ref> Furthermore, the therapeutic mechanisms of Mirror Exposure that lead to a reduction in body dissatisfaction are still unknown.
New treatments for body image disturbance have recently been developed, also focusing on the perceptual component of the disorder. One of the best known is [[Mirror Exposure]]. Mirror Exposure<ref name=":17">{{Cite journal|last1=Delinsky|first1=Sherrie Selwyn|last2=Wilson|first2=G. Terence|date=2006|title=Mirror exposure for the treatment of body image disturbance|url=https://pubmed.ncbi.nlm.nih.gov/16231342/|journal=The International Journal of Eating Disorders|volume=39|issue=2|pages=108–116|doi=10.1002/eat.20207|issn=0276-3478|pmid=16231342}}</ref> is a cognitive-behavioral technique for treating BID. The treatment aims to reduce experiential avoidance, reduce bodily dissatisfaction, and improve one's misperception of the body. During the exposure, patients are invited to observe themselves in front of a large full-length mirror. There are different types of mirror exposure, guided exposure, unguided exposure, exposure with mindfulness exercises, cognitive dissonance-based mirror exposure.<ref>{{Cite journal|last1=Moreno-Domínguez|first1=Silvia|last2=Rodríguez-Ruiz|first2=Sonia|last3=Fernández-Santaella|first3=M. Carmen|last4=Jansen|first4=Anita|last5=Tuschen-Caffier|first5=Brunna|date=2012|title=Pure versus guided mirror exposure to reduce body dissatisfaction: a preliminary study with university women|url=https://pubmed.ncbi.nlm.nih.gov/22244836/|journal=Body Image|volume=9|issue=2|pages=285–288|doi=10.1016/j.bodyim.2011.12.001|issn=1873-6807|pmid=22244836}}</ref><ref>{{Cite journal|last1=Luethcke|first1=Cynthia A.|last2=McDaniel|first2=Leda|last3=Becker|first3=Carolyn Black|date=2011|title=A comparison of mindfulness, nonjudgmental, and cognitive dissonance-based approaches to mirror exposure|url=https://pubmed.ncbi.nlm.nih.gov/21561817/|journal=Body Image|volume=8|issue=3|pages=251–258|doi=10.1016/j.bodyim.2011.03.006|issn=1873-6807|pmid=21561817}}</ref> To date, few studies have investigated the effects of mirror exposure in patients with body image disturbance. Key et al.<ref>{{Cite journal|last1=Key|first1=Adrienne|last2=George|first2=C. Louise|last3=Beattie|first3=Desley|last4=Stammers|first4=Kate|last5=Lacey|first5=Hubert|last6=Waller|first6=Glenn|date=2002|title=Body image treatment within an inpatient program for anorexia nervosa: the role of mirror exposure in the desensitization process|url=https://pubmed.ncbi.nlm.nih.gov/11920979/|journal=The International Journal of Eating Disorders|volume=31|issue=2|pages=185–190|doi=10.1002/eat.10027|issn=0276-3478|pmid=11920979}}</ref> conducted a non-randomized trial in a clinical sample and compared a body image group therapy with or without mirror exposure. They found a significant improvement in body dissatisfaction only in the mirror exposure therapy group. Despite the positive evidence, a recent review suggests that further studies are needed to ensure the efficacy of mirror exposure in the treatment of body image disturbance.<ref>{{Cite journal|last1=Griffen|first1=Trevor C.|last2=Naumann|first2=Eva|last3=Hildebrandt|first3=Tom|date=2018|title=Mirror exposure therapy for body image disturbances and eating disorders: A review|url=https://pubmed.ncbi.nlm.nih.gov/30223161/|journal=Clinical Psychology Review|volume=65|pages=163–174|doi=10.1016/j.cpr.2018.08.006|issn=1873-7811|pmid=30223161}}</ref> Furthermore, the therapeutic mechanisms of Mirror Exposure that lead to a reduction in body dissatisfaction are still unknown.


Another novelty in the treatment of body image disorders is the [[Virtual Reality - Body Swapping]]. VR-Body Swapping is a technique that allows generating a body illusion during a virtual reality experience. Specifically, after building a virtual [[Avatar (computing)|avatar]] using [[List of 3D modeling software|3D modeling software]], it is possible to generate the illusion that the avatar's body is one's own body through a specific procedure. The avatar is a 3D human body model that simulates the actual size of the patient. Some studies have found that applying this technique to anorexia nervosa reduces the misperception of one's body.<ref>{{Cite journal|last1=Serino|first1=Silvia|last2=Pedroli|first2=Elisa|last3=Keizer|first3=Anouk|last4=Triberti|first4=Stefano|last5=Dakanalis|first5=Antonios|last6=Pallavicini|first6=Federica|last7=Chirico|first7=Alice|last8=Riva|first8=Giuseppe|date=2016|title=Virtual Reality Body Swapping: A Tool for Modifying the Allocentric Memory of the Body|url=https://pubmed.ncbi.nlm.nih.gov/26506136/|journal=Cyberpsychology, Behavior and Social Networking|volume=19|issue=2|pages=127–133|doi=10.1089/cyber.2015.0229|issn=2152-2723|pmid=26506136}}</ref><ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=van Elburg|first2=Annemarie|last3=Helms|first3=Rossa|last4=Dijkerman|first4=H. Chris|date=2016|title=A Virtual Reality Full Body Illusion Improves Body Image Disturbance in Anorexia Nervosa|journal=PLOS ONE|volume=11|issue=10|pages=e0163921|doi=10.1371/journal.pone.0163921|issn=1932-6203|pmc=5053411|pmid=27711234|bibcode=2016PLoSO..1163921K}}</ref> This treatment is promising but provides, at the moment, only a short-term effect <ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=Elburg|first2=Annemarie van|last3=Helms|first3=Rossa|last4=Dijkerman|first4=H. Chris|date=2016-10-06|title=A Virtual Reality Full Body Illusion Improves Body Image Disturbance in Anorexia Nervosa|journal=PLOS ONE|language=en|volume=11|issue=10|pages=e0163921|doi=10.1371/journal.pone.0163921|issn=1932-6203|pmc=5053411|pmid=27711234|bibcode=2016PLoSO..1163921K}}</ref>. However, other novelty treatments for body image disorder have also recently been developed to integrate tactile, proprioceptive, and interoceptive one's body perception.
Another novelty in the treatment of body image disorders is the [[Virtual Reality - Body Swapping]]. VR-Body Swapping is a technique that allows generating a body illusion during a virtual reality experience. Specifically, after building a virtual [[Avatar (computing)|avatar]] using [[List of 3D modeling software|3D modeling software]], it is possible to generate the illusion that the avatar's body is one's own body through a specific procedure. The avatar is a 3D human body model that simulates the actual size of the patient. Some studies have found that applying this technique to anorexia nervosa reduces the misperception of one's body.<ref name=":22">{{Cite journal|last1=Serino|first1=Silvia|last2=Pedroli|first2=Elisa|last3=Keizer|first3=Anouk|last4=Triberti|first4=Stefano|last5=Dakanalis|first5=Antonios|last6=Pallavicini|first6=Federica|last7=Chirico|first7=Alice|last8=Riva|first8=Giuseppe|date=2016|title=Virtual Reality Body Swapping: A Tool for Modifying the Allocentric Memory of the Body|url=https://pubmed.ncbi.nlm.nih.gov/26506136/|journal=Cyberpsychology, Behavior and Social Networking|volume=19|issue=2|pages=127–133|doi=10.1089/cyber.2015.0229|issn=2152-2723|pmid=26506136}}</ref><ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=van Elburg|first2=Annemarie|last3=Helms|first3=Rossa|last4=Dijkerman|first4=H. Chris|date=2016|title=A Virtual Reality Full Body Illusion Improves Body Image Disturbance in Anorexia Nervosa|journal=PLOS ONE|volume=11|issue=10|pages=e0163921|doi=10.1371/journal.pone.0163921|issn=1932-6203|pmc=5053411|pmid=27711234|bibcode=2016PLoSO..1163921K}}</ref> This treatment is promising but provides, at the moment, only a short-term effect <ref>{{Cite journal|last1=Keizer|first1=Anouk|last2=Elburg|first2=Annemarie van|last3=Helms|first3=Rossa|last4=Dijkerman|first4=H. Chris|date=2016-10-06|title=A Virtual Reality Full Body Illusion Improves Body Image Disturbance in Anorexia Nervosa|journal=PLOS ONE|language=en|volume=11|issue=10|pages=e0163921|doi=10.1371/journal.pone.0163921|issn=1932-6203|pmc=5053411|pmid=27711234|bibcode=2016PLoSO..1163921K}}</ref>. However, other novelty treatments for body image disorder have also recently been developed to integrate tactile, proprioceptive, and interoceptive one's body perception.


However, other novelty treatments have recently been developed, the ''[[Hoop Training]]'' and the ''[[Body Perception Treatment]]''. Hoop Training is a short-term 8-week intervention (10 minutes per session) designed to become aware of one's feelings and reduce body misperceptions. Hoop Training works on different components of body image disorder: the cognitive, affective, and perceptive ones<ref name=":19" />. Another novelty intervention is the Body Perception Treatment (BPT). BPT is a specific group intervention for body image disturbance that integrates different sensory, tactile, proprioceptive, and interoceptive perceptions during body perception exercises <ref name=":2" />. These interventions have shown effective results and are both built to complement and not replace current standard therapies. However, both are also new models, and the results have not yet been replicated in independent studies. Thus, their actual effectiveness will be confirmed/disconfirmed by future research.
However, other novelty treatments have recently been developed, the ''[[Hoop Training]]'' and the ''[[Body Perception Treatment]]''. Hoop Training is a short-term 8-week intervention (10 minutes per session) designed to become aware of one's feelings and reduce body misperceptions. Hoop Training works on different components of body image disorder: the cognitive, affective, and perceptive ones<ref name=":19" />. Another novelty intervention is the Body Perception Treatment (BPT). BPT is a specific group intervention for body image disturbance that integrates different sensory, tactile, proprioceptive, and interoceptive perceptions during body perception exercises <ref name=":2" />. These interventions have shown effective results and are both built to complement and not replace current standard therapies. However, both are also new models, and the results have not yet been replicated in independent studies. Thus, their actual effectiveness will be confirmed/disconfirmed by future research.

Revision as of 14:10, 7 August 2021

Not to be confused with Body Dysmorphic Disorder.

Body Image disturbance
Drawing of a girl looking in the mirror with a body image disturbance
SpecialtyPsychiatry, Psychology
SymptomsAltered body self-perception, body uneasiness, body dissatisfaction, body-checking behavior
ComplicationsEating disorders
Usual onsetEarly adolescence
Risk factorsBody Dissatisfaction
Diagnostic methodEDI-3, Body Uneasiness Test, Clinical diagnosis
Differential diagnosisBody dysmorphic disorder, Obsessive-compulsive disorder
PreventionPositive body image, Good selfesteem,Healthy eating behaviors
TreatmentPsychotherapy

Body image disturbance (BID) is a frequent symptom in patients with eating disorders. The symptom occurs mainly in patients with anorexia nervosa who, despite being severely underweight, continue to perceive themselves as average weight or even overweight.[1] An altered perception of one's body and a severe state of bodily dissatisfaction characterizing the body image disturbance. This symptom is included among the diagnostic criteria for anorexia nervosa in DSM-5 (criterion C).[2] The disturbance is associated with significant bodily dissatisfaction and is a source of severe distress, often persists in eating disorders after treatments [3][4], and is considered hard to treat.[3] Thus, effective body image interventions could improve the prognosis in patients with ED, as Hilde Bruch suggested.[5] Unfortunately, there is no hard evidence that current treatments for body image disturbance effectively reduce eating disorders' symptoms[6]. Furthermore, pharmacotherapy is ineffective in reducing body misperception and and it has been used to focus on correlated psychopathology (mood or anxiety disorders)[7]. However, to date, research and clinicians are developing new therapies as virtual reality experiences,[8][9] mirror exposure[10] or multisensory integration body techniques,[11][12] which are showing promising results.

Characteristics

Hilde Bruch, 1960
Hilde Bruch, 1960

Hilde Bruch first identified and described body image disturbance in anorexia nervosa. In her famous article "Perceptual and Conceptual Disturbances in Anorexia Nervosa" (Bruch, 1962) she wrote:

What is pathognomic of anorexia is not the severity of the malnutrition per se—equally severe degrees are seen in other malnourished psychiatric patients—but rather the distortion of body image associated with it: the absence of concern about emaciation, even when advanced, and the vigor and stubbornness with which the often gruesome appearance is defended as normal and right, not too thin, and as the only possible security against the dreaded fate of becoming fat.[5]

An altered perception of one's body is not specific to anorexia nervosa. and it has also been more recently observed in bulimia nervosa[13] and binge eating disorder.[14] Furthermore, recent studies have shown that it is possible to observe alterations in the perception of one's body, even in healthy subjects. Suggesting that a slightly altered perception of the body is a normal part of everyone's life and manifests itself more intensely in more vulnerable individuals (e.g., patients with anorexia nervosa).[15]

Body image disturbance is a multifaceted construct including both perceptual and attitudinal issues. Some of the more common signs are: :

  • altered body size estimation and altered perception of the body and its shapes.
  • mental images of one's distorted and overweight body.
  • frequently third-person mental view of one's body.
  • negative thoughts like "I'm fat" or "my thighs are huge."
  • frequent body-checking behaviors.
  • frequent comparisons between one's body and that of others
  • emotions of anxiety, shame, and contempt for one's body

Clinically speaking, a growing body of research suggests that body image disturbance plays a significant role in the onset,[16] maintenance,[17][18] and relapse of anorexia nervosa,[19] as previously suggested by Hilde Bruch in 1962.[5] However, despite increasing evidence, a recent review stated that the available empirical data are still insufficient and "provide no basis to answer the question whether body image disturbance is a (causal) risk factor for anorexia nervosa".[20] As suggested by the authors, this lack of evidence is partly related to terminology problems used in the body image field.[21]

Definition of body image disturbance

Different labels are used in research and clinical setting to define the body image disturbance generating terminological confusion. Some of the most used terms are "body image discrepancy",[22] "body image self-discrepancy",[23] "body image distortion",[1] "disturbed body image",[24] "disturbances in body estimations",[25] "body image disturbance",[26] and "negative body image".[27] Sometimes, the term "body dissatisfaction" is also used to refer to body image disturbance indiscriminately.[28] Moreover, the DSM-5 itself defines this symptom vaguely: "a disturbance in the way one's body weight or shape is experienced".[2] Thus, the lack of a clear definition is problematic from both a clinical and basic research point of view.

However, most recent studies define "body image disturbance" as a multidimensional symptom comprising various components of body image.[29][13][3][11][12][30] Specifically, we usually describe body image as a multidimensional concept formed by the interaction of four body-related components: cognitive, affective, behavioral, and perceptual.

  • Cognitive: thoughts and beliefs about one's body and its shape; it also consists of a conscious mental representation of one's body[31]
  • Affective: feelings and attitudes related to the body (e.g., bodily satisfaction/dissatisfaction).
  • Behavioral: actions that people perform to check on, modify, or hide their body parts.
  • Perceptual: how one's body is perceived; it includes proprioceptive, interoceptive, tactile, and visual self-perception.[32]

All these components are altered in body image disturbance and lead to altered body perception and severe body dissatisfaction.[12]

Definition of body image disturbance

Consistently, Artoni and colleagues proposed a more clarifying definition of body image disturbance in 2021.[12] The authors suggested using the term "bodily dissatisfaction" when there are alterations in the body image's affective, cognitive, and behavioral components and strictly using the term body image disturbance only when all four components are altered, including the perceptual one. In short, they define body image disturbance as when an altered perception of the shape and weight of one's body is present and aggravates body dissatisfaction.

Onset

The age of onset for body image disturbance is often early adolescence[33]. Age in which the comparison with peers becomes significant and leads to a greater sensitivity towards criticism and teasing about one's physical appearance. Furthermore, puberty leads to rapid changes in body size and shape that need to be integrated into the body image [34]. For this reason, adolescence is considered a critical age, with a greater vulnerability to internalize ideals of thinness[35], to develop body dissatisfaction, body image disturbance [33] and eating disorders [36]. In a recent review, 8 on-topic studies were analyzed. The authors found that most adolescents with anorexia nervosa and bulimia nervosa already had body-checking behaviors, negative body-related emotions and feelings, low body satisfaction, and an altered estimate of their body size compared to healthy controls [33]. Unfortunately, how one passes from an initial dissatisfaction with one's body to an actual perceptual disorder is still unknown despite its clinical relevance[37].

Brain alterations

fMRI studies examining brain responses in AN patients to paradigms that include body image tasks have found altered activation across different brain areas: prefrontal cortex, precuneus, parietal cortex, insula, amygdala, ventral striatum, extrastriate body area, and fusiform gyrus [38]. However, as Janet Treasure commented, "the research is fragmented, and the mechanism of how these areas map onto the functional networks described above needs further study [...] the mechanism by which the extremes of body distortion are driven and circuitry is not known yet."[1]

Body image disturbance and body dissatisfaction

Body dissatisfaction and body image disturbance are closely related. Personal, interpersonal, cultural, social, and ethnic variables largely influence bodily dissatisfaction,[39] influencing the emergence of painful feelings towards one's body. In addition, social pressure is considered a risk factor for body dissatisfaction. For example, the frequent presence on media of thin female bodies determines, especially in young girls, a daily comparison between their bodies and models and actresses favoring bodily dissatisfaction;[40] comparing an "ideal" and "real" body feed an intense dissatisfaction with one's body and increases the feeling of shame, disgust, and anxiety towards the one's body and appearance.[41]

Dissatisfaction with one's body involves only three of the four components of the body image. Those suffering from bodily dissatisfaction can have negative thoughts about one's body (e.g., "I'm ugly" or "I'm too short"). In addition, they may have behaviors related to bodily dissatisfaction (e.g., going on a diet or resorting to cosmetic surgery[42][43]) . They may also have negative feelings of dissatisfaction with their body and be ashamed of showing it in public.[39] However, all these aspects are not enough to define it as a body image disturbance. In fact, there is no perceptual alteration of one's body. Thus, body image disturbance cannot be overlapped by body dissatisfaction, but they are closely related.[44]

Body image disturbance and body dysmorphic disorder

Body image disturbance in anorexia and body dysmorphic disorder are similar psychiatric conditions that involve an altered perception of the body or parts of it but are not the same disorder. Body image disturbance is a symptom of anorexia nervosa and is present as criterion C in the DSM-5,[2] and alters the perception of weight and shapes of the whole body. Patients with anorexia believe that they are overweight, perceive their body as "fat" and misperceive their body shapes.[45] Body dysmorphic disorder is an obsessive-compulsive disorder characterized by disproportionate concern for minimal or absent individual bodily flaws, which cause personal distress and social impairment [46] Patients with BDD are concerned about physical details, mainly the face, skin, and nose.[47] Thus, both AN and BDD manifest significant disturbances in body image but are different and highly comorbid.[48] For example, Grant and colleagues reported that 39% of AN patients in their sample had a comorbid diagnosis of body dysmorphic disorder, with concerns unrelated to weight.[49] Cereaet et al., reported that 26% of their AN sample had a probable BDD diagnosis with non-weight-related body concerns.[50]

Similarities

Previous studies found that both BDD and eating disorder groups were similar in body dissatisfaction, body checking, body concerns,[51] and levels of perfectionism.[52] Furthermore, both BDD and AN patients report higher intensities of negative emotions, lower intensities of positive emotions[53], lower self-esteem[52], and anxiety symptoms[54]. Moreover, we find severe concerns about one's appearance, leading to a continuous confrontation with others' bodies in both diseases. In addition, body image disturbances and body dysmorphic disorder generally onset during adolescence. Finally, alterations in visual processes are present in both disorders, with greater attention to detail and difficulty in perceiving stimuli holistically[55]. Indeed neurophysiology and neuroimaging research suggests similarities between BDD and AN patients in terms of abnormalities in visuospatial processing [56][57].

Differences

Despite many similarities, the two disorders also have significant differences. The first is gender distribution. Body image disturbance is much more present in females,[58] unlike BDD, which has a much less unbalanced relationship between men and women.[59] Furthermore, those with dysmorphophobia tend to have more significant inhibitions and avoidance of social activities than those suffering from anorexia nervosa.[51] Differences are self-evident when considering the focus of physical concerns and misperception in AN and BDD. Whereas BDD patients report concerns and misperception in specific body areas (mainly face, skin, and hair),[60] in patients with AN the altered perception could involve arms, shoulders, thighs, abdomen, hips, and breasts, and concerns are about the whole body shape and weight. Thus, leading to an alteration of the entire explicit (body image) and implicit (body schema) body's mental representations[61] Furthermore, in anorexia nervosa, not only the visual perception of one's body is altered but also the tactile[62] and interoceptive perception[63].

Finally, a recent review suggested that the two disorders could be classified as "body image disturbances" (plural) in light of both similarities and differences. Although more in-depth studies are needed to confirm this hypothesis[48].

Diagnosis

Body image disturbance is not yet clearly defined by official disease classifications. However, it appears in the DSM-5 as criterion C for anorexia nervosa and vaguely described the symptom as "a disturbance in the way weight and body shapes are experienced" and "the persistent lack of recognition of the severity of the current significantly low body weight."[2] Numerous psychometric instruments measure body image disturbance and its cognitive, affective, and behavioral components. Among the most used in the clinical setting we mention:

Eating Disorder Inventory 3

The Eating Disorder Inventory 3 (EDI-3) represents an improvement of the earlier versions of the EDI, a self-report questionnaire widely used both in research and clinical settings. It consists of 91 questions, and items are rated on a six-point Likert-type scale (always, usually, sometimes, rarely, never), with higher scores representing more severe symptoms. Precisely, the BD subscale of EDI-3 measures bodily dissatisfaction.[64]

Body Uneasiness Test

The body uneasiness test (BUT) is a self-administered questionnaire. It explores several areas in clinical and non-clinical populations: weight phobia, body image-related avoidance behavior, compulsive self-monitoring, detachment and estrangement feelings toward one's own body. Besides, explore specific worries about particular body parts, shapes, or functions. Higher scores indicate significant body uneasiness.[65]

The Body Image Disturbance Questionnaire

The body Image Disturbance Questionnaire investigates different areas related to body image disturbance. For example, evaluate the most problematic parts of the body, the psychological effects of worries on the body, and the effects on social life and eating behavior.[66]

The Body Shape Questionnaire

The Body Shape Questionnaire is a 34-item self-assessment questionnaire designed to measure the degree of dissatisfaction with the weight and shape of one's body. It includes questions about the fear of weight gain and the urge/desire to lose weight[67]

The Body Checkin Questionnaire

The Body Shape Questionnaire is a 34-item self-assessment questionnaire designed to measure the degree of dissatisfaction with the weight and shape of one's body. It includes questions about the fear of weight gain and the urge/desire to lose weight[67]

Treatments

Treatments focused on cognitive, affective and behavioral components

Historically, research and clinicians have mainly focused on body image disturbance's cognitive, affective, and behavioral components. Consequently, treatments generally target symptoms such as body checking, dysfunctional beliefs, feelings, and emotions relating to the body. One of the best-known forms of psychotherapy in the field of eating disorders is CBT-E.[68] CBT-E is a form of cognitive-behavioral therapy that has been enhanced with particular strategies to address the psychopathology of eating disorders. These include reducing negative thoughts and worries about body weight and shape, reducing clinical perfectionism, and body-checking behavior.[69]

Additionally, two other noteworthy body image treatments are Cash's "Body Image Workbook"[70] and BodyWise.[71] The former is an 8-step group treatment within a classic cognitive-behavioral framework. The latter is a psychoeducational-based treatment improved with cognitive remediation techniques to promote awareness of body image difficulties, and reduce cognitive inflexibility and body dissatisfaction. Worthy of mention is The Body Project[72], an eating disorder prevention program within a dissonant-cognitive framework that provides a forum for high school girls and college-age women to confront unrealistic-looking ideals and develop a healthy body image and self-esteem. It has been repeatedly shown to effectively reduce body dissatisfaction, negative mood, unhealthy diet, and disordered eating[73]. The Body Project is therefore not a treatment for eating disorders but a prevention program.

Treatments focused on perceptive component

New treatments for body image disturbance have recently been developed, also focusing on the perceptual component of the disorder. One of the best known is Mirror Exposure. Mirror Exposure[10] is a cognitive-behavioral technique for treating BID. The treatment aims to reduce experiential avoidance, reduce bodily dissatisfaction, and improve one's misperception of the body. During the exposure, patients are invited to observe themselves in front of a large full-length mirror. There are different types of mirror exposure, guided exposure, unguided exposure, exposure with mindfulness exercises, cognitive dissonance-based mirror exposure.[74][75] To date, few studies have investigated the effects of mirror exposure in patients with body image disturbance. Key et al.[76] conducted a non-randomized trial in a clinical sample and compared a body image group therapy with or without mirror exposure. They found a significant improvement in body dissatisfaction only in the mirror exposure therapy group. Despite the positive evidence, a recent review suggests that further studies are needed to ensure the efficacy of mirror exposure in the treatment of body image disturbance.[77] Furthermore, the therapeutic mechanisms of Mirror Exposure that lead to a reduction in body dissatisfaction are still unknown.

Another novelty in the treatment of body image disorders is the Virtual Reality - Body Swapping. VR-Body Swapping is a technique that allows generating a body illusion during a virtual reality experience. Specifically, after building a virtual avatar using 3D modeling software, it is possible to generate the illusion that the avatar's body is one's own body through a specific procedure. The avatar is a 3D human body model that simulates the actual size of the patient. Some studies have found that applying this technique to anorexia nervosa reduces the misperception of one's body.[30][78] This treatment is promising but provides, at the moment, only a short-term effect [79]. However, other novelty treatments for body image disorder have also recently been developed to integrate tactile, proprioceptive, and interoceptive one's body perception.

However, other novelty treatments have recently been developed, the Hoop Training and the Body Perception Treatment. Hoop Training is a short-term 8-week intervention (10 minutes per session) designed to become aware of one's feelings and reduce body misperceptions. Hoop Training works on different components of body image disorder: the cognitive, affective, and perceptive ones[11]. Another novelty intervention is the Body Perception Treatment (BPT). BPT is a specific group intervention for body image disturbance that integrates different sensory, tactile, proprioceptive, and interoceptive perceptions during body perception exercises [12]. These interventions have shown effective results and are both built to complement and not replace current standard therapies. However, both are also new models, and the results have not yet been replicated in independent studies. Thus, their actual effectiveness will be confirmed/disconfirmed by future research.

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