Wednesday 27/10/2021

PHOTO: ANTHONY SHKRABA

Text: Alejandra Misiolek

I will start this post by answering the question: Is body dysmorphic disorder a separate disorder or is it a symptom of eating disorders?

If we look at the definition of anorexia in the diagnostic manual, we see that it is characterised by “disturbance in the way one perceives one’s own weight or constitution”. On the other hand, body dysmorphic disorder is a diagnostic category under the category of obsessive-compulsive disorders, which is defined as “preoccupation with one or more perceived defects or imperfections in physical appearance that are not observable or appear unimportant to others”. In addition, the person with the disorder engages in behaviours such as excessive mirror-gazing or mental acts such as repeatedly comparing their appearance with that of others in response to appearance concerns. However, “preoccupation with appearance is not best explained by concern about fat tissue or body weight in a subject whose symptoms meet diagnostic criteria for an eating disorder.”

This means that dysmorphia is a symptom of eating disorders, but it can also be a separate diagnosis when the concern is not strictly related to weight.  

While it is true that dysmorphophobia is part of the ED picture, the severity of it can vary and studies seem to confirm that more pronounced body dysmorphia indicates a poorer prognosis for ED. In other words, recovery from the eating disorder is slower and more complicated. Furthermore, research supports the hypothesis that body dysmorphia often precedes the onset of the ED.

What does neuroscience explain about the relationship between body perception, body dysmorphia and eating disorders?

Body perception is one of our main tools for creating meaning about ourselves, organising our experience and shaping our social identity, and this perception evolves over time by integrating different experiences. We look at the world through our body, we perceive it through our body, and the response we get from the outside world about our body, both positive and negative, conditions our perception, which will always be subjective. Therefore this relationship is always bidirectional.

As a consequence, the formation of our perception of the body is a process that is strongly influenced by culture, and this is explained by two theories.

The theory of objectification holds that there is a social model of beauty that is transmitted in such a way that this ideal is internalised and therefore the level of one´s satisfaction in relation to their appearance will be a function of the degree to which they do or do not comply with this ideal. Self-objectification refers to the process by which we internalise the perspective of an observer and this causes us to reduce self-esteem to an assessment of physical appearance only, which in turn is linked to the social ideal. In addition, this looking at our own body from the outside and not from the inside generates experiences of disconnection from the more egocentric feeling of our body, a symptom that is very common in EDs and translates into a hypervigilance and hyper-awareness of the body as an object (seen from the outside) and a disconnection from the feeling of the body (lack of ability to know how one feels in one’s body, difficulty in relying on hunger and satiety signals, mismatch between the body’s needs and what is provided, e.g. responding to tiredness with sport rather than rest).

Therefore, the link between self-objectification and ED is very strong given this internalisation of sociocultural standards of beauty. Yet, only a small percentage of people are diagnosed with ED because of self-objectification. This means that there has to be more to it than just culture.

To answer this question, we can think of the allocentric lock hypothesis which understands that people create their body image through social interactions, and nowadays these are based more on observable body attributes that are supported by an accepted standard of beauty transmitted by society.  People who experience situations where they do not meet appearance standards and receive negative consequences, end up updating their perception accordingly to this objectification. This is closely related to eating behaviour; it is common to go on a diet to improve satisfaction with one’s own weight. And if this is achieved, there is a readjustment in the perception of the body. But from the theory of allocentric blocking, people with ED are locked into their negative objectified body and are unable to update their perception and move from body dissatisfaction to body shame. That is, as a consequence of measuring oneself against a cultural standard, they come to perceive themselves as judged and seen as inferior, defective or unattractive in the eyes of others. This shame can have two consequences; they would stop the control over food and overeat or start using radical methods to make the feeling go away. Finally in relation to this feeling, subjects suffer from a feeling of being outside their own body as it is seen from the perspective of the observer. 

And what does relational psychoanalysis bring to our understanding of dysmorphia? 

On the other hand, and linking it to the feeling of shame, we can look at the perspective of relational psychoanalysis and the understanding it brings to the concept of body dysmorphia in EDs. From this perspective we understand body dysmorphia as the shame of the body that develops in relationships. Lack of experiences of being seen by someone significant in childhood, or lack of the admiring gaze, generates a feeling of defectiveness and, therefore, shame of oneself. 

Rosa Velasco defines shame as “the central affect of the self, it concerns the feeling of self, that is, the image we have of ourselves. We construct our identity within meaningful relationships. The feeling of shame arises from the relational experience in which one feels exposed to the gaze of the other”.

This lack of emotional connection or non-existence in the mind of the other is a frequent feeling in relationships where there is no space for one to be as one is. One the other hand, there is space for expectations that one should be in a certain way in order to be liked or loved. This conditionality of love that one learns in these early stages can be understood as a condition that predisposes these people to live the culture of objectification in the way we described above and to be prone to develop an ED.

Sources:

1. American Psychiatric Association. (2014). Guía de consulta de los criterios diagnósticos del DSM-5®: Spanish Edition of the Desk Reference to the Diagnostic Criteria From DSM-5®. American Psychiatric Pub.
2. Dryer, R., Farr, M., Hiramatsu, I., & Quinton, S. (2016). The role of sociocultural influences on symptoms of muscle dysmorphia and eating disorders in men, and the mediating effects of perfectionism. Behavioral Medicine, 42(3), 174-182.
3. Riva, G. (2014). Out of my real body: cognitive neuroscience meets eating disorders. Frontiers in human neuroscience, 8, 236.
4. Velasco, R. (2010). Dismorfofobia o vergüenza del cuerpo. Revista Clínica e Investigación Relacional, 4(1), 208-220.