body image in eating disorders. virtual reality assessment and (PDF)

 BODY IMAGE IN EATING DISORDERS. VIRTUAL REALITY ASSESSMENT AND TREATMENT. . C. Perpiñá (Universidad de Valencia) C. Botella (Universidad Jaume I) R.M. Baños (Universidad de Valencia) .PROMOLIBRO VALENCIA 2000 MONOGRAPHS ON PSYCHOLOGY AND VIRTUAL REALITY ©Promolibro I.S.B.N: 84-7986-474-5  PRESENTATION ........................................................................................................................................................5 I. INTRODUCTION ....................................................................................................................................................7 1. "Reasonable neglect" of body image.....................................................7 2. VR as a clinical tool ..............................................................................8 3. VR in body image disturbances.............................................................9 II. BODY IMAGE DISTURBANCES IN EATING DISORDERS ..........................................................................11 1. Eating disorders...................................................................................11 2. The relevance of body image in eating disorders................................12 3. What is body image?...........................................................................12 4. Characteristics of body image disturbances in eating disorders..........13 III. ASSESSMENT OF BODY IMAGE DISTURBANCES IN EATING DISORDERS........................................16 1. Interviews............................................................................................16 2. Body image dissatisfaction and attitudes towards the body ................17 3. Behavioral aspects...............................................................................17 4. Aspects concerning the schematic processing of information relevant to body shape and weight 17 5. Body image in different contexts ........................................................18 6. Cultural aspects ...................................................................................18 7. Distortion of body size ........................................................................18 8. New technologies for the assessment of body image..........................18 9. Weekly control....................................................................................19 10. ANNEXES ........................................................................................20 ANNEX III.1: Behavioral Test Facing the Mirror and Weight20 ANNEX III.2: Weekly Assessment of Body Image ...................21 IV. COMPONENTS AND STRUCTURE OF BODY IMAGE DISTURBANCES TREATMENT IN EATING DISORDERS..............................................................................................................................................................23 1. Components.........................................................................................23 1.1. Psychoeducation..........................................................................23 1.2. Cognitive discussion....................................................................24 1.3. Exposure......................................................................................24 1.4. Self-esteem...................................................................................25 1.5. Learning how to enjoy one's body. Self-assertive techniques......25 1.6. Immersion in Virtual Reality .......................................................25 1.7. Relapse prevention ......................................................................26 2. Structure..............................................................................................26 V. METHODOLOGY AND AGENDA OF GROUP THERAPY..............................................................................28 1. General guidelines...............................................................................28 2. Contents and agenda of the group therapy sessions ............................28 2.1. Session 1......................................................................................28 2.2. Session 2......................................................................................29 2.3. Session 3......................................................................................30  2.4. Session 4...................................................................................... 30 2.5. Session 5...................................................................................... 31 2.6. Session 6...................................................................................... 31 2.7. Session 7...................................................................................... 31 2.8. Session 8...................................................................................... 32 2.9. Session 9...................................................................................... 32 2.10. Session 10.................................................................................. 33 2.11. Session 11.................................................................................. 33 2.12. Session 12.................................................................................. 34 2.13. Session 13.................................................................................. 34 2.14. Session 14.................................................................................. 35 2.15. Session 15.................................................................................. 35 VI. METHODOLOGY AND AGENDA OF VR THERAPY.................................................................................... 36 1. General guideline................................................................................ 36 2. Contents, agenda and records of the VR sessions............................... 36 2.1. Session 1...................................................................................... 36 2.2. Session 2...................................................................................... 42 2.3. Session 3...................................................................................... 47 2.4. Session 4...................................................................................... 50 2.6. Session 6...................................................................................... 57 2.7. Session 7...................................................................................... 58 2.8. Session 8...................................................................................... 64 2.9. Session 9...................................................................................... 66 2.10. Session 10 ................................................................................. 68 VII. THERAPIST’S MANUALS FOR DEVELOPING THE COMPONENTS ..................................................... 70 WHAT IS BODY IMAGE?.................................................................... 72 HOW IS BODY IMAGE FORMED?..................................................... 77 WHAT IS WEIGHT? ............................................................................. 83 WHAT IS BEAUTY?............................................................................. 93 THE IMPORTANCE OF THOUGHT (A-B-C)................................... 101 HOW TO OVERCOME NEGATIVE THOUGHTS............................ 106 COGNITIVE DISCUSSION (ABC-D) MANUAL.............................. 106 NEGATIVE BODY TALKING. WHAT ARE COGNITIVE ERRORS?111 SELF-ESTEEM MANUAL.................................................................. 116 EXPOSURE MANUAL ....................................................................... 123 WHAT ARE SAFETY AND CHECKING BEHAVIORS?................. 130 RELEARNING TO LIVE AND PAMPER YOUR OWN BODY ....... 135 PREVENTION RELAPSE ................................................................... 139 VIII. MATERIAL FOR THE PATIENT................................................................................................................ 144 VIII. REFERENCES .............................................................................................................................................. 164  Presentation 5 PRESENTATION This manual offers a guide for the evaluation and treatment of body image disturbances in eating disorders, with the support of Virtual Reality (VR) techniques. The application here presented has been validated in the clinical setting, and reflects increased efficacy of the therapeutic results obtained when the "traditional" measures are supplemented by this new technology (Perpiñá, Botella, Baños, Marco, Alcañiz and Quero, 1999; Marco, Perpiñá, Botella, Mahiques, Baños and Fabra, 1999; Marco, Fabra, Mahiques, Perpiñá and Botella, 1999). However, we wish to stress two aspects. In first place, VR does not constitute a novel therapeutic modality in itself, but is rather a tool involving characteristics (to be dealt with later on) that make it possible to secure a better grasp upon a concept as subjective as body image - a mental image - than that afforded by more "traditional" techniques. Moreover, when body image is dealt with in the context of disturbances as complex as eating disorders, VR is to be used as an important (but not the only) component in clinical patient intervention. This is a point that differentiates the use of VR in other problems such as specific phobias, for example, where much of the weight of intervention can be based on VR techniques. In the context of the problem dealt with in the present manual, coordination is on one hand required with the general treatment protocol of eating disorders, and on the other with other essential components of intervention in relation to body image such as psychoeducational measures, cognitive discussion, increased self- esteem, etc. A different question would be the application of such techniques to subclinical populations, where despite the existence of concern over personal body image and weight, the problem is not as serious as to merit the diagnosis of anorexia or bulimia nervosa. Obviously, in these cases, the VR and psychoeducational components would be fundamental. On the other hand, it should be stressed that the studies conducted to date in relation to the program here presented for the clinical population have always employed the treatment protocol described herein. After commenting these aspects of caution, it should be mentioned that VR offers a series of advantages for working with images and mental representations of people, for it is possible to "model", "objectivize" and "embody" them, place them in context and confront them. We therefore advise the reader to carefully follow each of the guidelines provided in this manual, for using the virtual scenarios of the program "Virtual & Body". The aim of this book is eminently practical. Accordingly, we have tried to avoid excessively technical language, and have often preferred to present information in the way  Presentation 6 we explain it to our patients in clinical practice. Furthermore, no exhaustive theoretical reviews of the subject are provided. This guide is divided into three main sections. The first analyses the characteristics of body image, with special emphasis on how it is addressed in eating disorders. Posteriorly, the aspects to be evaluated are commented, indicating the corresponding instruments that can be used. Finally, an account is provided of the methodology to be used in group therapy relating to body image, commenting on each of its components (psychoeducational, cognitive restructuring, etc.), and giving a step-by-step account of the methodology underlying application of the VR component - employing the scenarios included in "Virtual & Body".  Introduction 7 I. INTRODUCTION 1. "Reasonable neglect" of body image “I'm hungry, but I resist it. I like to eat; what I don't want is to become fat. Since I'm underweight, eating means getting fat, and that makes me scared; that's why I don't eat. I know I can't be fat… it's something you know, but you also see yourself. I'd rather die than become fat”. These words are an example of the dramatic and contradictory experience of many patients with eating disorders. Indeed, eating disorders have become a kind of epidemic at the close of the millennium, at least in western societies. The condition affects mainly pre- and post-pubertal adolescent females (hence the present work specifically addresses the female gender). The virulence and importance of these disorders has become so important in recent years that the fourth edition of the DSM (APA, 1994) classifies them separately and considers the problem an entity in its own right. Although eating disturbances and their manifestations have always existed (consider for example the anorexic "saints" in the excellent review by Toro, 1996), the problem intensified greatly in the sixties and seventies, coinciding with major cultural, aesthetic (and perhaps also ethical) changes that stressed passion for the body - especially a slim or thin body. This cultural setting stigmatizes obesity and encourages youth and a pleasant physical appearance; in women, this fundamentally drives concern over weight and body image, inducing and justifying restricted food intake, the application of impossible diets, and a struggle against personal body constitution. The over-dimensioned idea of losing weight, fear of becoming fat, and disturbances in body image form an essential part of the psychopathology of eating disorders, together with other characteristics of the problem: personality variables, altered eating behavior, physical complications, etc. Thus, while disturbances in body image are only one of the bases of the problem, they cannot be ignored or avoided. Considering that eating disorders can directly lead to death, it is no surprise that therapeutic efforts have mainly focus on the stabilization of body weight and on eating habits - relegating aspects relating to body image in a distant second place. However, disturbances in body image not only form part of the underlying psychopathology but also play a fundamental role in the initiation and maintenance of the eating disorder, and moreover constitute a factor in relapse and patient prognosis. The clinical "urgency" and social alarm generated by these problems may explain the reason why few studies to date provide an in-depth analysis of the subject of body image and its integration within the general therapeutic framework. As has been pointed out by a number of specialists in both eating disorders and disturbances in body image (Cash, 1996; Cash and Grant, 1996; Rosen, 1997), very few studies have  Introduction 8 addressed the use of a specific treatment component for body image or specific measures of this construct, in the context of the general management of eating disorders. Among the conclusions drawn from the review by Cash and Grant (1996) concerning the few studies conducted to date in clinical populations, emphasis may be placed on the following: a) even though one of the objectives of treatment is body image, it receives very little attention (only one or two sessions); b) patients are not assigned tasks focus on this component; c) the measures of change used are typically limited to a single body shape/weight dissatisfaction scale; d) no assessment is made of the clinical significance of the changes obtained with treatment; and e) normalization of the eating and weight patterns does not guarantee normalization of body image. Therefore, we agree with these authors that it is essential to specifically address body image in the general treatment of eating disorders, and that it is unlikely for body image to improve without direct and specifically designed intervention measures. 2. VR as a clinical tool The characteristics of the problem dealt with in the present work reflect the advantages afforded by a new technology such as VR in grasping or tackling body image - i.e., a complex mental representation. This computer-based technology offers an interface to a computer-generated scenario that proves so convincing that the user truly believes to be immersed in a three-dimensional world - even if it only exists in the memory of the computer, not in that of the user. In earlier studies (Perpiñá, Botella, and Baños, 1997; Botella et al., 1998a; Baños, Botella, Perpiñá, 1999), we addressed the nature and characteristics of VR, though it is nevertheless advisable to mention some of its advantages as a therapeutic tool. The patient is able to act without feeling threatened. In this context, the virtual situation constitutes a "safe environment" that therapy makes available to the patient, since nothing of what she really fears can "really" happen to her. From this "safety" the patient can freely explore, experiment, feel, live and re-live feelings and/or thoughts. In addition, VR makes it possible to grade the situation, progressing from simple to more difficult settings. Gradually, and based on the knowledge and domination afforded by the interactions with the virtual world, the patient becomes able to confront the real world. The fact that VR makes it possible to generate "protected" contexts also makes it more feasible to persuade the patient to take the step and enter action. VR thus becomes a very useful intermediate step between the consulting room and the real world. Moreover, it is not necessary to wait for events to take place in the real world, since any given situation can be modeled in a virtual environment - thereby greatly amplifying the possibilities for self-training. In addition to all these potentials of VR, the technique has some additional advantages over traditional techniques such as exposure "in vivo" or in the imagination (Botella et al., 1998a). In the context of "in vivo" exposure, the patient confronts, in a graded and guided manner, the subject of her fears. In comparison with this type of technique, VR offers increased confidentiality, in the sense that treatment takes place in the consulting room or office; as a result, the patient is not afraid of "making a spectacle" of herself were exposure to take place in public, and can moreover feel assured that others will not know about her problem. In the case of imagination-based exposure, the therapist trains the patient to confront her fears by means of imaginative techniques, i.e., by instructing the patient to try to imagine as genuinely as possible that what she fears is actually happening. Compared with this technique, VR is more immersing, for it stimulates several sensory modalities (auditory, visual and vestibular). This may be of great help for people who have difficulties imagining such scenes. Moreover, the therapist can at all times know what the patient is seeing - thus making it easier to identify what is causing her discomfort. Lastly, VR makes it possible to go beyond reality. On one hand, it allows the feared context to  Introduction 9 undergo change, modifying it to our convenience. In other words, VR is sufficiently flexible to allow the designing of different contexts in which the patient can (on a virtual basis) confront not only what she fears, but also other much more threatening aspects that can be generated by VR technology. The aim of VR need not be to merely "re-create reality". The essential consideration is to delimit contexts of therapeutic value, i.e., to "create" aspects and/or conditions of the environment (including information vital to the patient) to which the patient for the time being either does not have access or has lost access. 3. VR in body image disturbances A number of studies have been published supporting the ideality and efficacy of VR as a therapeutic tool for different psychological problems: acrophobia (North and North, 1996), agoraphobia (North, North and Coble, 1997), and phobia of spiders (Carlin, Hoffman and Weghorst, 1997). Our group has also contributed to this pioneering field, designing and validating VR applications for the treatment of claustrophobia (Botella et al., 1998 b,c) and phobia of flight (Baños et al., 2000; Botella et al., 2000) - with very good results among the clinical population suffering from such problems. In the field of disturbances in body image, a pioneering experience is represented by “The virtual body project” (Riva, Melis and Bolzoni, 1997) - the aim of which focused on the use of virtual environments for the study and treatment of body image disturbances in non-clinical populations. Posteriorly, the same team (Riva, Baccheta, Baruffi, Rinaldi and Molinari, 1998) applied these virtual environments to an anorexic patient; although this was not a controlled study, the results obtained were very promising. For our part, we have conducted a study with the aim of demonstrating the differential efficacy of a specific component of the evaluation and treatment of body image in eating disorders by means of VR techniques. This research satisfied the following requirements: it was a controlled study conducted in a clinical population, and afforded a comparison of the efficacy of the VR component versus the "traditional" body image techniques (Perpiñá et al., 1999). The results of this study showed that following treatment, all patients had improved significantly, though those who had been subjected to VR therapy exhibited significantly greater improvement in variables relating to general and eating psychopathology, and in parameters specific of body image. In sum, this study showed that VR treatment of body image appears to be useful in the field of eating disorders, for it addresses body image in a more direct manner than the traditional techniques. Moreover, these results were not only maintained after a six-month follow-up period, but improvement was seen to continue progressing for most of the variables assessed (Marco, 1999). What are the features that allow VR to more directly address the body image phenomenon? In first place, and as has been mentioned above, VR makes it possible to grasp or tackle a concept as subjective as body image. On one hand, it allows the patient to model, reflect and "embody" her body image, while on the other "communicating" it and making it known to the therapist. Finally, the patient is able to come face to face with her mental representation. In second place, VR facilitates concretion and the reflection of central aspects of body image such as its "perceptive", cognitive, emotional and behavioral features - furthermore offered in a significant context. In turn, however, we have identified additional advantages such as those commented below: A sensation of realism: despite the "virtual" nature of the situation, patients inform of a high degree of realism in the virtual settings. In fact, in the kitchen setting, when the patients "eat" virtually, they chew, swallow and become very nervous - even though they are eating something that does not really exist. The same applies when they weigh themselves, look at their own body image, compare themselves with others, etc. - despite the fact that all these events are "virtual". The important point is that the settings and scenarios are clinically significant for evoking the  Introduction 10 fears and thoughts that these patients have in real life. Acceptance: We have found that when patients are obliged to confront their distorted body image, they tend to accept the evidence sooner, since it is the computer system which indicates and shows it. The computer does not lie, it becomes an objective judge: Part of the previous characteristic is explained by the "impartial" role acquired by the computer. Of note is the observation that the typical distrust of these patients towards the comments of others (particularly if some type of relationship between them exists) regarding their personal appearance either disappears or becomes attenuated when it is the computer that shows the discrepancies. The system thus becomes a source of objective and reliable information, from which no secondary intentions are to be expected. Increased treatment motivation: One of the difficulties of therapy for eating disorders is the low patient motivation towards therapeutic procedures, and especially to change. In this new therapeutic scenario, however, these resistances decrease and the motivation for therapy increases. The patients "look forward" to coming to the consulting office to start or continue the adventure - apart from the fact that their subjective perception of time is usually considerably lower (30 minutes) than the true session duration (60 minutes). Paving the way to real life: The fact of grasping or tackling, confronting, practicing, commenting fears, etc., in this protected environment means that the patients dare to continue their adventure beyond the computer screen. Thus, we have had patients who for years had not eaten a piece of pizza or put on certain clothes until they did so virtually - followed shortly after by corresponding genuine practice and integration in their daily lives. Having commented the reasons why body image interventions have received comparatively lesser priority, and after defining what the novel VR techniques can afford, we will now move on to analyze the characteristics of the body image disturbances found in eating disorders, in order to facilitate their evaluation and adopt adequate interventional measures.  Body image disturbances in eating disorders 11 II. BODY IMAGE DISTURBANCES IN EATING DISORDERS 1. Eating disorders Eating disorders are clinical conditions involving severe disturbances in eating behavior -the maximum representative cases being anorexia and bulimia nervosa. Anorexia nervosa is characterized by the patient refusal to maintain a minimally normal body weight for her age and height, an intense fear of putting on weight or fattening (even when underweight), and disturbances in her body image. These features are, in turn, accompanied by a distorted perception of the propioceptive stimuli, and a general feeling of personal inefficacy - i.e., the psychopathology of these patients centers on the insuppressible desire to continue loosing weight, even if they have already suffered an important percentage weight loss (Perpiñá, 1999). This disturbance has serious physical consequences: hypothermia, hypotension, bradycardia, and a range of metabolic changes such as amenorrhoea. If anorexia develops before menarche, the interruption of pubertal development may lead to irreversible deterioration. Other likewise irreversible consequences of such emaciation are osteoporosis, fractures, kyphosis and other malformations, and mitral valve prolapse (Treasure & Szmukler, 1995). Moreover, the disorder exhibits high comorbidity with depressive and anxiety symptoms (basically obsessive ones). Bulimia nervosa is, in turn, characterized by recurrent binge eating that the patient is unable to control, followed by compensatory behaviors aimed to prevent weight gain (self-induced vomiting, use of laxatives, fasting, excessive exercise, etc.), and disturbances in the perception of their body image. Thus, the three essential characteristics of this condition may be defined as: subjective loss of control over eating, behaviors destined to control body weight, and extreme concern over body image and weight (Wilson, Fairburn, & Agras, 1997). Due to the continuous imbalance caused by these patients' eating patterns, vomiting, use of laxatives, etc., they suffer a broad range of physical complications, including potassium depletion, hypertrophy of the parotid gland secondary to the electrolytic imbalance, hypocalcaemia, urinary infections, peripheral paresthesias, cardiac arrhythmias, epileptic seizures, tetanus, and - over the long term - kidney damage and menstrual irregularities. Callosities on the back of the hand may also develop as a result of the continuous friction with the upper incisors when self-induced vomiting is frequent. Another repercussion of vomiting is the erosion of the dental enamel and the production of caries. Comorbidity in patients with bulimia nervosa is represented by anxiety, depression, suicidal ideation, and complications resulting from substance abuse. As regards the course of these disorders, in the case of anorexia some patients exhibit a fluctuating weight gain followed by relapses, while others suffer chronic deterioration over the years that may be complicated by bulimia. The long-term mortality associated with anorexia in  Body image disturbances in eating disorders 12 in-patients is about 10%. Death usually results from starvation, suicide, or electrolytic imbalance. In the case of bulimia, the course may be chronic or intermittent, with periods of remission that alternate with periods of binge eating (Treasure, 1991). These data reflect the severity and the tendency towards chronicity of these conditions (which causes prevalence to be high), and moreover highlight the fact that no totally effective treatment is yet available to deal with these problems in their full complexity (Fernández & Turón, 1998). Thus, eating disorders are characterized by an altered eating behavior so severe that it can cause serious physical complications or even death. However, such anomalous eating patterns are largely the consequence of attempts by these patients to control a weight and a body that they do not tolerate and which they despise. 2. The relevance of body image in eating disorders According to Habermas (1989), Charcot was the first to acknowledge the patients' concern over their body and body image, and the purposefulness of thinness, in the context of anorexia. On examining one of these patients, he described a pink ribbon around her waist, which the patient used to inform her of any weight gain. The patient moreover stated that she would rather die than become as fat as her mother. Other authors who are becoming classics, such as Crisp, Russell, or Bruch consolidated the notion that the essential characteristic of anorexia nervosa is to reach a status of thinness and maintain that status with utmost obstinacy. The DSM-IV acknowledges body image disturbances as the essential feature of both anorexia and bulimia. In the case of the former, and in addition to criteria A and B which relate to rejection and fear of weight gain, criterion C consists of: "Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self- evaluation, or denial of the seriousness of the current body weight". In the case of bulimia, criterion D states that: "self-evaluation is unduly influenced by body shape and weight". Disturbances in body image, thus, not only form part of the diagnostic criteria of eating disorders, but they are what essentially distinguishes these disorders from other conditions likewise involving an altered food intake and weight fluctuations (Rosen, 1990) - i.e., they are fundamental to the establishment of a differential diagnosis. Furthermore, body image disturbances play an important role as factors in both the development and prognosis of eating disorders. A number of studies have demonstrated the relation between the pressure to lose weight that characterizes our society and the increase in the prevalence of eating disorders; a correlation has likewise been shown between a distorted body image and altered eating attitudes and behaviors, and the role of body image disturbances in predicting the severity of the disorder and the occurrences of relapse (Cash & Deagle, 1997; Rosen, 1997; Thompson, 1992). After 30 years of research in the field of eating disorders, during which considerable advances have been made in the understanding of their psychopathology and treatment possibilities, we now have sufficient sensitivity and the theoretical and technical conditions required to seriously deal with an aspect raised by Bruch (one of the pioneers in eating disorders) in 1962, i.e.: the problem of such patients cannot be resolved without a correction in their body image. It therefore seems reasonable to pause a moment and consider this complex subject a little further. 3. What is body image? The concept of body image (BI) was defined by Schilder (1950) as "the picture of our own body which we formed in our mind, i.e., the way in which the body appears to ourselves " (p.11). It is therefore important to point out that BI and actual physical appearance need not coincide in the estimation made by the individual. Another more recent definition was provided by Slade (1988), in these terms: "Body image is the mental representation that we have of the size, shape,  Body image disturbances in eating disorders 13 and form of our body and of its component parts, i.e., the way in which we 'see' our body and the way we think that others see us". BI disturbances have traditionally been expressed in two ways: on one hand, as the accuracy with which body size is estimated and, on the other, as the feelings that our body elicits - not to mention the error that has sometimes been made in reducing body image disturbances to mere perceptual distortions (Hsu & Sobkiewicz, 1991). However, can the concept of body image be reduced only to an estimation of size and satisfaction? The human condition is inherently corporeal. We cannot imagine ourselves, appear to, or interact with others except through the body. It forms part of our identity. In fact, Sims (1988) assigns the body image psychopathology to the field of "disorders of the self". Pruzinsky and Cash (1990) summarized the keys to body image in terms of a series of characteristics: a) BI is composed of perceptions, thoughts, and feelings relating to the body and to the body experience. • Perceptions: In the course of development, and within a cultural setting, we construct images of the shape or size of various aspects of the body. •• Cognitions: Thoughts, beliefs, and self-statements concerning body and body experiences. •• Emotions: Experiences of comfort/discomfort, satisfaction or dissatisfaction associated to our appearance or to our body experience. b) BI experiences are in turn linked to feelings towards the "self". c) It has been determined socially: The development of body image takes place in parallel to the evolutive and cultural development of the individual. d) It is not a static construct: The aspects relating to our body experience are continuously changing. e) It influences the information processing: People who are schematic with respect to their physical appearance process the information in terms of competence in body attractiveness. f) BI influences behavior. To these characteristics we should add the following: g) It is a totally subjective and personalized experience; it need not be congruent with objective reality. h) Experiences related to the body take place at different levels of consciousness. According to Pruzinsky and Cash (1990), the body image construct is multifaceted. Body experience encompasses the perceptions and attitudes towards appearance, body size, body position, body limits, body competence, and aspects relating to physical condition, health, and disease, as well as one's gender. 4. Characteristics of body image disturbances in eating disorders As can be seen, we are dealing with a complex construct where in addition to addressing the issues of size and satisfaction, the scope of its characteristics should be broadened. A review of the most important is provided below. a) Disturbances in the estimation of size. • Overestimation of body size: Although the overestimation of body size is not a consistent phenomenon (a number of patients do not overestimate) and is not pathognomonic of eating disorders (many women do overestimate), it does represent one of the most common distortions in this type of patients. As commented by Cash and Deagle (1997), these discrepancies are possibly attributable to differences in the methodology employed, or even to an effect of the instructions given. On asking "What size do you think you have?", the answer obtained is different to that given in reply to "What size do you feel you have?", for as pointed out in the review by Thompson (1996), asking in affective terms induces greater overestimation than doing  Body image disturbances in eating disorders 14 so in intellectual terms. Another conclusion drawn from the meta-analysis by Cash and Deagle (1997) is the need to distinguish between the estimation of global body shape and the estimation of a particular body part, since when the estimation applies to a particular area, the latter becomes very conspicuous for the person in question - whether patient or otherwise. • Overestimation of body weight: Overestimation refers not only to the size of the body shape, but also to the "number" corresponding to the body weight that the patient thinks (feels) she has. • Distortion of size awareness: These patients do not acknowledge their state of emaciation, despite the evidence of their body form or their weight. • "Dissociative" aspects: We are often surprised by the firmness with which some patients appear to claim "That's not me" when examining themselves in the mirror - reflecting the discrepancy between the mental image they have of themselves and the objective image. On the other hand, some patients seem to have a fragmented body image and schemata - revealing their perplexity by not knowing which information to heed: their image reflected in a shop window, the number corresponding to their weight, their feelings of bloatedness, their belt holes, etc. • Distrust towards the information coming from others: Not only does the logic regarding their distortions fail to "sink in", but these patients moreover do not trust the other's opinion. They only trust their own judgment and clues. • Rigid and extravagant self-appraisal: The patient's body becomes measure of her global value, and impossible comparisons are made accordingly, e.g., comparing to (and wishing to have) the another person's body, or her own when the patient was thinner still, or even when she was younger. Another common practice is to evaluate progression via "markers" such as belts, trousers several sizes smaller than warranted, or the prominence of her knee bone or her ribs. b) Altered attitudes, beliefs, and feelings regarding the body. Although the range of attitudes and emotions of these patients regarding their own body tend to focus on the same subject (i.e., dissatisfaction and great concern over body shape and weight), it exhibits a series of particularities: • Dissatisfaction, disgust: Although anxiety may appear when the patients show or observe their own body, feelings of disgust and distress are far more frequent. • Negative automatic thoughts: These patients present a negative body language full of very generalizing (and particularly contemptuous) adjectives. • Morbid self-importance of an emaciated appearance: In some cases the patient may not overestimate and can acknowledge her emaciation, yet feel absolutely self-satisfied and even important in having been able to achieve such a skeletal appearance. "I like it when they study anatomy with my bones in the natural sciences class" was the proud comment of one of our patients. • Fundamental dimension in their value as persons: The aspect that most distinguishes dissatisfaction in these patients from that habitual in the rest of women is the value they attribute to physical appearance in terms of their concept, esteem, and value as persons. c) Behavioral disturbances. Eating disorders imply a series of eating behavioral disturbances, though important behavioral problems concerning the body are also observed. On one hand, avoidance behaviors can be observed, relating to some activity (walking, looking in the mirror, etc.), people (attractive people, men, etc.), places (swimming pools, gyms, etc.), or postures (sitting down in certain way, etc.). On the other hand, rituals can also be observed of a verifying (continuous weighing or self- checking) or grooming nature (covering up certain body parts, putting on makeup in a certain way).  Body image disturbances in eating disorders 15 As we see, rather than problems with the body, eating disordered patients and individuals who are concerned about their body shape actually have problems in the way they represent, value, feel, and live their body. The body has become the most important value that they have as persons - which illustrates one of the basic psychopathological characteristics of such disorders: the over-valued idea of losing weight, an emotional attachment, a "passion" that urges these people to achieve their main (and sometimes only) purpose.