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Eating Disorders, 19:175193, 2011Copyright Taylor & Francis Group, LLCISSN: 1064-0266 print/1532-530X onlineDOI: 10.1080/10640266.2011.551635

The Concept of Body Image Disturbancein Anorexia Nervosa: An Empirical InquiryUtilizing Patients Subjective Experiences

ESTER M. S. ESPESET, RAGNFRID H. S. NORDB,and KJERSTI S. GULLIKSEN

Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway

FINN SKRDERUDDepartment of Health and Social Sciences, Lillehammer University College, Lillehammer; and

Regional Centre for Eating Disorders, Oslo University Hospital, Oslo, Norway

JOSIE GELLEREating Disorders Program, St. Pauls Hospital; and Institute of Psychiatry, University of

British Columbia, Vancouver, Canada

ARNE HOLTEDivision of Mental Health, Norwegian Institute of Public Health, Oslo; Department

of Behavioral Sciences in Medicine, University of Oslo, Oslo; and Modum

Bad Research Institute, Vikersund, Norway

We explored the concept body image disturbance (BID) by utilizingthe subjective experience of 32 women (aged 2039 years) diag-nosed with AN (DSM-V). Using methods from Grounded Theorywe identified four phenotypes of BIDIntegration, Denial,Dissociation, and Delusionwhich differed according towhether the patients overestimated their own body size (Subjectivereality), and whether they acknowledged the objective truth that

they were underweight (Objective reality). The results suggest

This research is in collaboration with the Modum Bad Research Institute, to whom theauthors are indebted for their contribution in preparing the project and practical arrangementsfor data collection. The authors want in particular to thank Dr. yvind R and Professor AsleHoffart and for their valuable help in developing this article. We also want to thank Professor

Walter Vandereycken for comments on an earlier draft of this paper. The project is supportedby grants awarded by the Research Council of Norway and by the Norwegian Foundation forHealth and Rehabilitation through The Norwegian Council for Mental Health.

Address correspondence to Ester M. S. Espeset, Division of Mental Health, NorwegianInstitute of Public Health, P. O. Box 4404, Nydalen, Oslo No-0403, Norway. E-mail: [email protected]


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176 E. M. S. Espeset et al.

that BID should be conceptualized as a dynamic failure to inte-grate subjective experiences of ones own body appearance with anobjective appraisal of the body. Conceptual, diagnostic and clinicalimplications are discussed.

Body image disturbance (BID), defined as a disturbance in the way inwhich ones body weight or shape is experienced (American PsychiatricAssociation, 2000), is an essential diagnostic feature of anorexia nervosa(AN). The nature of such disturbances is, however, poorly understood (Cash& Deagle, 1997; Farrell, Lee, & Shafran, 2005; Hennighausen, Enkelmann,

Wewetzer, & Remschmidt, 1999; Skrzypek, Wehmeier, & Remschmidt, 2001;Smeets, Klugkist, Rooden, Anema, & Postma, 2009). In this study we haveexplored the concept of BID as it appears in the daily life of patients who

suffer from AN. Unlike most previous studies, we interviewed AN-patientsabout their perception of their body in different contexts of daily life andinvited them to reflect upon and discuss these perceptions.

BID is regarded as a complex and multidimensional construct withperceptual, affective, cognitive-evaluative, and behavioral components(Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). The perceptual com-ponent has received the most comprehensive attention. In research on bodysize estimation experimental methods were used to measure the degree to

which patients overestimate the size of their bodies (Cash & Deagle, 1997;Farrell et al., 2005; Hennighausen et al., 1999; Skrzypek et al., 2001). Resultsfrom these studies have shown that AN patients overestimate their bodysize as compared to healthy controls (Cash & Deagle, 1997; Farrell et al.,2005; Smeets, 1997). Such findings are consistent with the clinical experi-ence that many AN patients describe perceiving their body as fat and bigeven though they are extremely thin. It is, however, still unclear how thesefindings should be interpreted.

While the traditional assumption underlying body size estimationtasks is that they assess the patients visual image of their body (e.g.,perceptual disturbance), inconsistent results using these methodologies,

as well as conceptual and methodological problems have led to alter-native explanations (Cash & Deagle, 1997; Farrell et al., 2005; Smeets,1997; Smeets, Smit, Panhuysen, & Ingleby, 1997; Stewart & Williamson,2004). For instance, cognitive behavior theories (Cash, 2002a; Cash, 2004;

Williamson, Stewart, White, & York-Crowe, 2002) suggest that the bodysize estimation tasks assess patients feelings or evaluations of their bodysappearance. Accordingly, the overestimation is defined as a cognitive-emotional phenomenon, and not as a sign of an underlying perceptualdisturbance.

Body size estimation studies have also been criticized because they have

yielded few therapeutic or clinical applications (Farrell et al., 2005; Farrell,


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Body Image Disturbance in Anorexia Nervosa 177

Shafran, & Lee, 2006; Hsu & Sobkiewicz, 1991). Recently, more ecologi-cally valid methods have been developed to address these concerns (Farrell,Shafron, & Fairburn, 2003; Probst, Vandereycken, & Van Coppenolle, 1997;Shafran & Fairburn, 2002). Despite these improvements, body size estima-

tion studies are still typically carried out as single-assessments in laboratories.That is, BID is considered as a stable trait that can be studied outside thecontext in which it occurs. There is, however, growing evidence that inreal-life situations body experiences fluctuate with varying contexts (Cash,2002b; Cash, Fleming, Alindogan, Steadman, & Whitehead, 2002; Melnyk,Cash, & Janda, 2004; Rudiger, Cash, Roehrig, & Thompson, 2007).

In sum, a challenge to the scientific study of BID is to develop anempirically grounded concept of BID that is both clinically and ecologically

valid. In order to do this, we explored the concept of BID contextualized,in patients daily lives (Melnyk et al., 2004; Rudiger et al., 2007) by analyz-

ing interviews with women who suffer from AN about their perceptions oftheir body in different contexts of daily life. The reported body perceptions

were categorized into the least possible number of phenotypes needed toconceptualize individual differences in BID while capturing the full range ofperceptual, affective and cognitive-evaluative components.

METHODS

Design

The principles of Grounded Theory (Corbin & Strauss, 2008; i.e., theoreticalsampling, open coding, focused coding, axial coding) were used in thecollection and analysis of data. Consistent with Grounded Theory we aimedat constructing a theoretical understanding of the nature of body imagedisturbance (BID) that was grounded in empirical data about the everydayexperiences of the participants in the study. The design was also foundedon a Patient as Expert Perspective, i.e., the patient was regarded as an experton her own experience. This type of study requires the researcher to helpthe patient explore, reflect on, and precisely verbalize her experiences.

The study was part of a larger research project on how patients expe-rience living with AN (Nordbo et al., 2008; Nordbo, Espeset, Gulliksen,Skarderud, & Holte, 2006). To maximize study validity, we used a two-phasestudy design. First, a wide-angled and exploratory study on a sample of 18

AN patients was conducted. The purpose of this phase was to describe awide range of experiences associated with living with AN, of which bodyimage experiences were one. In the second phase, we conducted a focusedstudy on a sample of 14 other women in which the interviews specificallyaddressed patients body image experiences. The aim of this phase wasto further explore and validate findings from step 1, and the interviews

were structured directly upon the experiences from the first phase of the


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study. The interview guide was provided with more detailed prompts andprobes to stimulate reflections specifically and exclusively about body imageexperiences. In this way, the first phase of the study guided the theoreticalsampling (Corbin & Strauss, 2008) of the second phase. The aim of the sec-

ond phase was to get rich, in depth descriptions of different aspects of bodyimage experiences.

Participants

The total sample consisted of 32 ethnically Norwegian women aged2035 years (mean: 27.3 years) recruited from four clinical institutions inSouthern Norway, which included both specialized services for eating dis-orders and general psychiatric services. At the time of the interview, twentyparticipants were outpatients and twelve were inpatients. All participants had

been diagnosed with AN (American Psychiatric Association, 2000) within thepast 2 years. Duration of AN ranged from 125 years (mean 11) and dura-tion of treatment ranged from 0.516 years (mean 5.8). Participants lowestbody mass index1 (BMI) during their history with AN ranged from 817(mean 13.8). At the time of the interview, their BMI ranged from 10.723.1(mean 16.3)2. Six participants were weight-recovered (BMI > 20) follow-ing in-patient treatment. One participant was pregnant in her third semester(BMI 19.1). Eight participants had a partner, one was separated, and fourhad children. Four participants were in paid employment, fourteen werestudents and fourteen participants were on sick leave.

Setting and Procedure

Participants were provided with written information about the study, includ-ing a description of the purpose and procedure by their therapist or by oneof the first three authors. Participating women gave their informed consent.

All procedures were conducted in accordance with the Helsinki declara-tion and the study was approved by the Norwegian Regional Committeefor Medical Research Ethics. The Step 1 interviews were conducted by the

first and second author (EMSE and RHSN); the Step 2 interviews by the firstauthor (EMSE). The interviews were audio taped and lasted between 75 and120 minutes.

The data were collected by means of semi-structured, informant centredinterviews. In the first phase we used an open interview strategy. Bodyimage experiences were spontaneously mentioned by some participants;others were invited to do so through open instruction such as, Now, please

1 Body mass index (BMI) is calculated as weight in kilograms/height in meters22 BMI information was not available for one participants and lowest BMI information wasunavailable for five participants.


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tell me, how your body appears to you . . .. In the second phase we applieda more focused interview strategy, aimed at verifying and further exploringthe participants body image experiences. All participants were asked keyquestions about their body image experiences, such as: Now, please tell me

about the appearance of your own body . . ., What do you see when youlook at yourself in the mirror? or Tell me now, please, how do you thinkother people see your body? To encourage the participants to be specific,in all interviews they were asked to describe their perceptions, emotions,and thoughts about their own bodies in concrete situations such as lookingat oneself in the mirror, being naked, and being touched. After 32 interviews

we considered the data gathering as saturated. Such theoretical saturation(Corbin & Strauss, 2008) has occurred when the researcher has exploredeach category in some depth, and has identified its various properties anddimensions under different conditions.

Data Analysis

The data consisted of verbatim transcripts of audiotapes and post interviewnotes. The analyses were conducted in several steps using NVivo 7 (QSRInternational). In the first step, we conducted an open, exploratory thematiccoding (Corbin & Strauss, 2008) according to the bottom-up principle. Inthis process all text excerpts that included statements about body appear-ance were condensed into their essence of meaning, labelled, and codedinto the database. For example, a longer text excerpt could be condensedinto an essence of meaning such as: When I look at myself in the mir-ror I think that I look fat and labelled, e.g., subjective reality as fat. Allinterpretations were based on contextual analysis which means that state-ments like I am fat, I see a fat body, I feel that I look fat, and I thinkIm fat were interpreted as different qualities of body image (including per-ceptions, cognitions, emotions) and coded as Subjective reality as fat. Eachsuccessive code was given a tentative definition with reference to its essenceof meaning and the definitions were continuously adjusted. All the codedmaterial was categorized into higher order constructs. We endeavoured to

find a solution where as few relatively independent higher order constructs(dimensions) were needed to conceptualize the coded essences of meaning.The solution that gave the best fit to the data consisted of two higher orderconstructs, namely Subjective reality and Objective reality.

Second, in order to detect relations among the higher order constructs,we conducted axial coding (Corbin & Strauss, 2008). In this process wecombined experiences from the higher order constructs Subjective realityand Objective reality into four conceptual categories using a 2 x 2 table(see Table 1). The four phenotypes that emergedIntegration, Denial,Dissociation, and Delusionspecified different types of relations

integrationdisintegrationbetween the higher order constructs. Based on


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TABLE 1 Four Phenotypes of Body Image Disturbance

Subjective reality as thin Subjective reality as fat

Acceptance of objective reality I. Integration (n = 20) III. Dissociation (n = 20)Rejection of objective reality II. Denial (n =16) IV. Delusion (n = 9)

these categories we induced the central theoretical concept (Corbin &Strauss, 2008) of the analysis; the definition of BID as a disintegrationbetween Subjective reality and Objective reality.

In the final step, all the 32 interviews were analyzed again accordingto the top-down-principle. In this process, all constructs that had been gen-erated through the open and axial coding (e.g., Delusion) were validatedagainst the original text using confirmatory and selective coding (Corbin &Strauss, 2008). The purpose of this backward translation was to ensure thatthe generated constructs fit with the original text, to detect possible overlapbetween constructs, and to identify whether there was need for adjustments,supplements, or refinements. For example the applicability of the constructDelusion, referring to subjective reality as fat combined with rejectionof objective reality, was checked by semantically reanalyzing and recodingall text excerpts that fit with these descriptions.

The analysis was conducted by the first author (EMSE). To add credibil-ity to the study and to ensure that the concepts were well represented in the

data and grounded within, the developing analysis was regularly discussedwithin the research team and continuously monitored by the last author(AH). This allowed for an external check of the research process wherebyconcepts and interpretations were challenged, discussed, and reassessed. Atthe end of the analysis the results were also presented to different groups ofexperienced professionals with competence on eating disorders in order toensure that the findings were meaningful from their clinical experience andthis was confirmed.

RESULTS

Participants described in detail the way their body appeared to them. Theyeither referred to what they saw when they looked at themselves in a mir-ror or how they experienced their body in different situations. There werelarge differences in how participants experienced their bodies. While somedescribed themselves as thin (e.g., severely underweight, meagre, orwithout female curves), others described themselves as fat (e.g., hav-ing fat, flabby thighs, rolls of flesh, and big buttocks). All participants

were prompted to reflect upon what their body looked like from an external


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observers point of view, e.g., how their body appeared according to objec-tive criteria such as body mass index (BMI) or the size of their own clothes.Independent of their own perceptions, some participants acknowledged thatthey were underweight or very thin, while others refused to acknowledge

that they were underweight.

But I really cant see any anorexia on myself. Ive never had any such

experiences as maybe Im a bit thin. Never! I always see that Im fat.

(Frida, BMI 14)

Ive always seen that Im thin. And thats quite unusual. I have always

realized that I have a problem. (Louisa, BMI 16)

Participants were also asked if their body image changed or variedin the course of the day. Some reported to have a relatively stable bodyimage experience across time and contexts. Others reported their bodyimage changed depending on the context. The way they perceived theirown body could vary from perceiving their body as thin to perceiving itas fat. They could also fluctuate between accepting and rejecting that they

were underweight.

One day I see myself as too thin, and the next day too fat, and it can also

vary from hour to hour. (Irene, BMI 16.5)

Sometimes I actually see that Im underweight, but then other times, I

cant see it at all. (Susan, BMI 13.2)

By condensing all of the reported body perceptions, we were able todifferentiate between two relatively independent constructs of body imageexperiences; namely subjective reality and objective reality. Subjectivereality refers to participants perceptions, feelings and thoughts about theirbody irrespective of their objective body appearance and ranged from per-

ceiving their body as thin to fat. Objective reality refers to how participantsresponded to the fact that they were severely underweight according toobjective criteria such as BMI and ranges from acceptance to rejection. Next,by combining experiences from Subjective reality and Objective reality,four phenotypesIntegration, Denial, Dissociation, and Delusion

were derived that describe variation between and within participants alongthe two underlying dimensions (Table 1). The first category describes suc-cessful integration of the subjective and the objective reality. Denial,Dissociation, and Delusion describe three qualitatively different failuresto integrate subjective and objective realities. While stable body image expe-

riences are categorized into one of these phenotypes, more fluctuating body


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image experiences are best described as a fluctuation or borderline betweentwo or more phenotypes. Hence, across time the phenotypes should not be

viewed as mutually exclusive.In the next sections, the four phenotypes and their empirical basis are

described in more detail and illustrated with interview extracts, includingparticipants body mass index (BMI) at the time of the interview. LowestBMI was used for six participants who were weight-recovered (BMI > 20) atthe time of the research. For transparency reasons, we report in parenthesesthe number of informants whose interviews led to the inference of a givenconstruct. Because each interview was tailored to the individual participant,the numbers should not be used to indicate distribution of the constructsin the sample or population. The numbers also should not be consideredto reflect upon the validity of the construct. Due to space constraints theinterview extracts were edited, though not in a way that interferes with the

individual style of phrasing or emotional colouring. Information that couldreveal the participants identities were removed.

Integration of Subjective and Objective Reality (n= 20)

Integration is present when the patient integrates the experience of her ownbody as thin with acceptance of the objective reality that she is severelyunderweight.

A stable integration was reported by a few participants who consistentlyaccepted that they were underweight over time and in different situations.Two participants reported that they had been aware that they were under-

weight throughout their entire history with AN, Other participants had along history of AN and treatment experiences, which they said helped themrealize that they were underweight and to accept their diagnosis of AN:

Ive never thought that I was too fat. Actually, Ive always seen that; gosh,

Im getting too thin now, Im sure people will notice it. (Aase, BMI 14.9)

It depends on your age and how long youve been sick because when I was

younger I think I saw myself bigger in the mirror than I actually was inreality. But now I feel that Im quite realistic, that I actually see my body

as a childish body. Im not big and fat; I realize that Im thin. (Cindy,BMI 14.9)

For most participants, however, the integration was unstable, and therecognition of being underweight was sporadic. They reported havingepisodes where they experienced glimpses of the objective reality of theirbody. In these brief moments of insight the patients were able to see whattheir body looked like from an external observers point of view; they saw

that they were extremely thin. Frequently described were contexts where


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they tried on clothes in a fitting-room or when they unexpectedly saw thereflection of their own body in a mirror. Such moments of insight could befrightening. The women saw that they were skinny, skeletally thin, and thatthey lacked shape or womanly forms:

I remember one occasion, I was passing an open door and saw myself in

the mirror, but actually, I didnt know that I saw myself. I just saw the

image of a person in the mirror and thought; Oh gosh, she is thin! But

then, when I understood that it was actually me, I didnt see me as thin

anymore. But then I actually saw a glimpse of it. (Sarah, BMI 16.6)

Some times Ive experienced that I think Im too thin. Then I think its

not normal to look like that when Im as old as I am (laughing). Its not

normal. It doesnt look healthy. (Zynthia, BMI 15.9)

Denial of Objective Reality (n= 16)

Denial is present when although the participant is able to perceive herbody as thin, she rejects the objective reality that there is somethingunhealthy about her current weight status (i.e., that she is underweight or toothin.)

Participants could reject objective facts (e.g., their low weight) or denythe impact their low body weight had on their health. Being confronted

with the objective reality that they looked terribly thin or that other people

reacted to how they looked, participants became irritated and rejected thefact that they were too thin:

Although everybody said I looked terrible, I didnt think so. I remember

a good friend of mine said I was so thin that I couldnt wear a t-shirt,

cause he didnt want to see my arms. Then I got irritated that he could

say something like that! I thought my arms maybe were a little thin, but it

was an exaggeration. So I got very annoyed and thought it was nonsense.

(Ninni, BMI 15.8)

Participants also described different thoughts, actions, and behaviourswhich bolstered their confidence that their low body weight was within thenormal range, and that they did not have to gain weight. Some partici-pants rejected the objective truth by attributing their low weight to obviousmisconceptions such as an unusually light bone structure or that their scales

were manipulated:

Jane (BMI 16.6): I think I weigh more than 48 kilos. Actually, I believethat Im 55 kilos, that my weight is what its supposed to be. But perhapsthat sounds silly.

Interviewer: So you believe that you weigh more than you really do?


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Jane: Yeah, the way I look. Maybe my bones are lighter than others orsomething like that. Something has to be lighter with me than with other

people.

Dissociation Between Subjective and Objective Reality (n= 20)Dissociation is present when the patient experiences her body as fat, butsimultaneously accepts the objective reality of being severely underweight,e.g., there is a dissociation between the subjective experience of being fatand the accepted fact that she is severely underweight.

Seemingly living in two worlds at the same time, these participantsreported two separate and incompatible realities about their body, theirsubjective experienced reality, and the objective referenced reality. Theydescribed a lack of coherence between their perceptions and emotions and

their cognitions and inferences. They perceived themselves as fat, while atthe same time accepted that they were severely underweight. They referredto the objective reality by reference to reason or intellect:

With my eyes I actually saw myself as big, but my intellect told me that it

couldnt be true. (Ylva, Lowest BMI 16.4)

I actually understand that it cant be quite so, because I do know the size

of my clothes, so it cant actually be true. And its rather confusing and

sometimes frustrating because I actually know that its impossible that I

could be that fat, because then these clothes wouldnt fit me. But at thesame time it doesnt make sense with how I see myself. (Johanna, BMI 16)

Although these participants acknowledged the objective truth that theywere too thin and thereby gave the impression that they were aware of theirillness, it was as if they distanced or dissociated themselves from this objec-tive reality. Accordingly, the fact that they were thin was not experienced asreal and was not integrated into their own experience of themselves:

Im very good at talking about eating disorders and stuff like that, butthen its like I distance myself from it. I can sit and talk about it and

smile and laugh, and its really as if I talk about a third person. Although

everyone knows that its about me, its not like it anyway. (Eva, BMI 15.2)

Delusion (n= 9)

Delusion is present when the patient experiences her body as fat and rejectsthe objective reality that she is underweight.

Although these participants were severely underweight, they could not

recognize that their body was thin and found it difficult to believe that they


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objectively were underweight. They were convinced that their subjectivereality about their own body was accurate and undistorted:

Ive had big problems accepting that Ive been diagnosed with anorexia.

Cause people with anorexia are very thin, and Im not. So then it doesntfit me. And when I look at myself in the mirror I really cant understand

where I have anorexia. Its nowhere! (Frida, BMI 14)

When confronted with the discrepancy between their subjective expe-rience and the objective reality of their body, these participants questionedtheir grip on reality or whether they were insane; Ive gone crazy and Ivelost my mind were frequently used expressions:

I really cant understand when the doctor tells me; Anne, now you are so

thin, I will soon have to hospitalize you. And then I just sit there. But, my

goodness! I cant see it myself. Hello! What has happened here? I hear what

the doctor tells me, but I really cant understand it because I cant see it

myself. So then I start wondering if Ive gone crazy. (Anne, BMI 15.6)

I know another girl with anorexia, we are exactly the same height and

weight. But we both feel three times as big as the other. We have even taken

pictures of ourselves. In fact, I feel three or four times as big as she is. So

in a way it becomes schizophrenic. You dont see reality. (Leah, BMI 15)

DISCUSSION

The aim of this study was to provide an empirically grounded and clin-ically valid concept of body image disturbances (BID) in patients withanorexia nervosa (AN). Our approach differs from previous studies in that

we explored the concept of BID by utilizing the subjective experience ofwomen with AN. We uncovered four phenotypes of BIDIntegration,Denial, Dissociation, and Delusionaccording to whether the patients

overestimate their body size (Subjective reality) and whether they acknowl-edge the objective fact that they are underweight (Objective reality). Ourfindings contribute to the literature in several ways.

First, this study suggests that BID can be conceptualized as a dynamicfailure to integrate the subjective experience of ones body appearance

with a more objective appraisal. This definition challenges the concept ofBID that has been presented and investigated in many previous studiesin which BID is considered a single and stable dispositional trait (Cash &Deagle, 1997; Farrell et al., 2005; Hennighausen et al., 1999; Skrzypek et al.,2001). In contrast, our results suggest that BID may be described as a set of

dynamic failures of integration. Accordingly, BID may fluctuate and change


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in character across time and situations depending upon how the patient isable to relate her subjective experience to the objective reality that she isunderweight. The dynamic nature of BID was illustrated in the unstableintegration phenomenon, in which participants unexpectedly saw that their

body was extremely thin. Common to these situations was the patients beingable to see their thin body, but unable to integrate this impression into theirsubjective experience of themselves.

Second, this study provides an empirically grounded dimensional modelin which individual differences in BID are conceptualized as varying alongtwo underlying dimensions, thereby suggesting that severity of BID mayrange across a continuum from integration to delusion. The dimensionalapproach is in accordance with the existent literature on body image whichsuggests a continuum model with levels of disturbance ranging from noneto extreme (Thompson et al., 1999). Possibly the current DSM-IV criteria

reflect an implicit, albeit not fully articulated, continuum of body imagedysfunction (Cash & Pruzinsky, 2002). This is, however, the first study toempirically explore and conceptualize the underlying dimensions of BIDin patients with AN, and suggests a new way of thinking about individualdifferences in BID.

Third, this study reconceptualizes BID into four empirically based phe-notypes corresponding to different psychological processes patients mayuse to cope with their body image experiences. Integration is the clinicallyleast severe phenotype occurring in patients with an undistorted and ade-quate experience of their own bodys appearance. Some participants related

this integration to treatment experiences which they felt had helped themrealize that they were underweight and to accept their AN diagnosis. Thiscould indicate that stable integration is associated with insight into ones ill-ness and readiness for behavior change. However, our findings also suggestthat some patients had always realized that they were too thin. Althoughthese patients did not exhibit a disturbance in their body perception, theynevertheless suffered from severe AN.

Denial refers to the process in which patients cope with their bodyimage experiences by rejecting objective facts about their own weight and

shape, and is a well acknowledged mechanism of AN in the literatureon eating disorders (American Psychiatric Association, 2000; Vandereycken,2006a; Vandereycken, 2006b; Vandereycken & Van Humbeeck, 2008).

Vandereycken (2006b) suggests that denial in AN can be categorized aseither an unintentional denial, including distorted information processing,or as a deliberate refusal of self-disclosure (e.g., concealment of symptoms).Some participants in our study rejected the objective truth by attributing theirlow weight to an unusually light bone structure or to the fact that theirscales were manipulated. Such deficits in information processing are oftenexplained in terms of cognitive schemata (Cash, 2002a; Williamson et al.,

2002). Adding to this, denial may also function as a psychological protection


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(Nordbo et al., 2006; Serpell & Treasure, 2002; Serpell, Treasure, Teasdale,& Sullivan, 1999) against the unpleasant reality of being underweight. Forsome patients denial may simply represent an unwillingness to accept ordeal with objective facts because the patients do not want to interrupt their

self-starvation-project.The dissociative phenotype suggests that AN-patients cope with theirbody image experiences by psychologically dissociating themselves fromobjective facts about their own bodys appearance (Yes I know that Im thin,but I see that Im fat). Hence, the term dissociation is used to describethe psychological process in which an individual copes with incompati-ble experiences by splitting thought processes into separate compartments(e.g., through derealization or depersonalization). The dissociation pheno-type may shed light on the clinical experience that many patients, despitethe fact that they acknowledge that they are severely underweight, are

ambivalent to behaviour change and weight gain. An association betweenBID and dissociative phenomena has previously been described in patients

with bulimic behaviour (Beato, Cano, & Belmonte, 2003; Vanderlinden &Vandereycken, 1997; Vanderlinden, Vandereycken, & Probst, 1995), but thesestudies address dissociation in terms of psychiatric disorders, i.e., dissocia-tive disorders (American Psychiatric Association, 2000). Further research mayshow whether the discovery of dissociative phenotype may link certainsymptoms of AN to symptoms of dissociative disorders such as amne-sia, depersonalization, identity confusion, and identity change (Dale, Berg,Elden, degrd, & Holte, 2009).

Finally, the delusion phenotype refers to being convinced that onessubjective body image is undistorted and shared by others. Althoughdelusions are frequently associated with psychotic experiences as in halluci-nations, we found no indications that delusional BID had psychotic qualities.

We therefore tentatively suggest that delusional phenotype refers to a wayof coping with body experiences in circumstances that incite attention tothe bodys appearance, while thought processes outside such situationsremain non-delusional (Rosen, 1997). In DSM-IV AN-patients perceptionsand beliefs are defined as intense beliefs or overvalued ideas, and not as

delusional. The DSM reflects the commonly held opinion that AN-patientsacknowledge that their perceptions are not shared by others, e.g., that theirreality testing is intact. The present study tentatively challenges this view andsuggests that some AN-patients are so convinced that their body image expe-riences are undistorted and shared by others that it would be appropriate toclassify them as having a delusional disorder or with the diagnostic signi-fier low insight (Steinglass, Eisen, Attia, Mayer, & Walsh, 2007). This findingis in accordance with the classification of the related diagnostic category ofBody Dysmorphic Disorder (BDD; American Psychiatric Association, 2000)in which patients can receive an additional diagnosis of delusional disor-

der if their preoccupation with an imagined defect in appearance is held


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with a delusional intensity (p. 510). Although delusion appears to be theclinically most severe phenotype, further research is needed to determine

whether patients with delusional BID have more severe pathology, longerduration of illness, or lower level of functioning than other patients with AN

(Grant, Kim, & Eckert, 2002).This study has a number of interesting clinical applications. First, ourconceptualization of BID as a dynamic disintegration of subjective and objec-tive reality suggests that one goal of therapy might be to achieve a stableand dynamic integration of ones feelings, thoughts, and perceptions of bodyappearance. Thus, therapy might focus on helping patients increase aware-ness of subjective experiences while connecting these to the objective realityof their actual weight status. In this process, the four BID constructs mayserve as a guide to recognize nuances or qualities of such experiences.

Second, it also may be helpful to track changes in patients BID phe-

notype over time. For instance, perhaps patients who oscillate between twoBID phenotypes have a different recovery path from those who have arelatively stable phenotype. Clinicians could also explore whether changesin BID phenotype correspond to meaningful shifts in other aspects ofrecovery (e.g., eating disorder symptom severity or comorbid psychologicalconditions).

Third, the four BID phenotypes may be associated with differentprognoses and optimal treatment strategies. For instance, the integrationphenotype may be the most prognostically positive because these patientsare able to see and acknowledge that they are sick. Possibly, such patients

will be most likely to benefit from action oriented therapy that directly tar-gets behaviour change (e.g. cognitive behaviour therapy; Fairburn, Cooper,& Shafran, 2003). On the other hand, patients with the remaining three phe-notypes (denial, dissociation, and delusion) are less likely to benefit fromaction-oriented therapy, as these patients reject that their underweight statusis a problem. Consequently, these individuals are more likely to respondto interventions focusing primarily on alliance building and developing ashared understanding of the patients situations (e.g., Geller, Williams, &Srikameswaran, 2001). Possibly, of these three groups, individuals with the

denial phenotype may feel that they benefit the most from their AN symp-toms (Nordbo et al., 2006; Nordbo et al., 2008) and thus may benefit fromtherapy focusing on the functional role of their eating disorder (Cockell,Geller, & Linden, 2003). The dissociation phenotype refers to a disconnec-tion between emotional states and reason or intellect (e.g., the fact that oneis underweight). We would hypothesize that this group of patients wouldbenefit from efforts to integrate their internal subjective experiences withthe objective reality. Mentalization-based therapy for eating disorders wouldbe an example of such an approach (Skarderud & Fonagy, in press). Finally,the delusion phenotype refers to patients who are completely convinced

that their subjective experiences are undistorted and shared by others; e.g.,


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seemingly being stuck in their own experience of themselves as fat. As indi-cated earlier, these patients would likely benefit from therapy that proceedscautiously and prioritizes alliance building and increasing trust, as describedin Motivational Enhancement Therapy (Geller et al., 2001; Miller & Rollnick,

2002) and Mentalization-based Therapy for eating disorders (Skarderud &Fonagy, in press).This study has limitations. Our sample is restricted to young, ethnically

Norwegian women. As a result, we do not know whether a more homoge-nous sample with regard to sub-diagnosis, duration of illness, or comorbidity

with other psychiatric disorders would have influenced the results. Moreresearch is needed to determine the existence and prevalence of the pheno-types among individuals with eating disorder. Although the total sample sizeof this study may be considered small, it is considerably larger than usual forthis type of phenomenological design (Smith, Flowers, & Larkin, 2009). In

addition, in order to ensure that the patients had sufficient experience to beable to reflect upon the study questions we over-sampled patients with rel-atively long careers of AN. Although we were careful to include in the totalsample a variety of duration of illness, treatment, and types of treatment,this may limit generalizability to early phases of the illness. Another possi-ble limitation is that patients were recruited from different institutions andhad experienced therapists with various clinical traditions. Such treatmentexperiences may have influenced their use of language and descriptions ofbody image experiences. There was, however, nothing in our results to sug-gest that these experiences influenced their attributions about BID. A further

possible limitation is that some of the participants did not fulfil criteria forAN at the time of the interview. As such, their distance to the reported expe-riences might have influenced the results. However, these participants wererepeatedly told that the interview should address their subjective experienceof their body at the time they were underweight, and we only includeddescriptions of such experiences in the analysis. On the other hand, beingseverely underweight may also have influenced patients insight and abilityto reflect upon their own experiences. For instance, we cannot exclude thepossibility that participants body image experiences were coloured by their

present situation, e.g., reinterpretation of their experiences in light of presentinsight into their symptoms, current weight status, general knowledge aboutAN, or recent treatment experiences. For these reasons, having patients atdifferent stages of recovery was considered optimal. Finally, it is possiblethat some participants experiences and verbal responses were shaped bythe interview protocol and/or the interviewer. However, a strong argumentin favour of such interviews is the potential for the researcher to explore andchallenge the authenticity of and reflections about the reported experiences.

In summary, this study describes four phenotypes of BID, namely inte-gration, denial, dissociation and delusion. These phenotypes provide


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a conceptual framework for understanding individual differences in sever-ity and stability of BID. In contrast to body size estimation studies whichfocus on whether patients are able to correctly perceive their body size ina laboratory setting, this study highlights the degree to which they are able

to integrate subjective and objective realities in daily life contexts. The pro-cesses involved in such integration-disintegration may be highly dependenton factors other than the perceptual stimuli of a thin body. Our study repre-sents a step towards an empirically based understanding of the dynamicnature of BID in patients with AN, which has theoretical, methodologi-cal, and clinical implications. To further develop these implications, moreknowledge is needed, particularly about factors associated with changein BID.

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