Through a Glass, Darkly
By Christian Eggers and Verena Liebers
April 2007

A distorted body image is symptomatic of nearly all eating disorders. Correcting this mental reflection can help sufferers recover

They all look the same in front of the mirror--attractive and slim--but one after another, they get up in swimsuits and bemoan their physical faults: fat thighs, shapeless silhouettes, flat chests. These young women are participating in group sessions focused on body image, co-sponsored by the universities of Bochum and Mainz in Germany. Senior therapist Silja Vocks knows she will have a hard time getting through to these girls, who all suffer from eating disorders, but it is her job to help them learn to like themselves again.

Eating disorders are complex psychiatric conditions, instigated by a number of factors both inborn and circumstantial. For most patients, however, significant mental pain stems from having a faulty body image, a term psychologists use to describe an individual's internal picture of his or her exterior form. In truth, this image more accurately reflects self-esteem than physical appearance. It is based not so much on fact as on emotion, and the opinions of family and peers, as well as cultural ideals, can dramatically alter its dimensions

Most people have body images that roughly match their shape. For those with eating disorders, though, this mental picture becomes warped like a reflection in a fun-house mirror: severely distorted and often grossly obese. Ideally, treatment plans must be multifaceted, including nutritional, medical, psychiatric and psychotherapeutic interventions. But as programs such as Vocks's show, tackling body image head-on can offer some patients a first step toward escaping the vicious cycle of an eating disorder.

Starve, Binge, Purge
Finding new and more effective ways to treat eating disorders is vital. Their incidence continues to rise in the developed world; in the U.S. alone, recorded cases have doubled since the 1960s. Although the true prevalence of these disorders is hard to establish, an estimated 0.5 to 3.7 percent of women develop anorexia nervosa and some 1.1 to 4.2 percent experience bulimia nervosa in their lifetime, according to the National Institute of Mental Health. Within any given six-month period, another 2 to 5 percent of Americans succumb to a binge-eating disorder.

Of the three, anorexia nervosa is most deadly. Sufferers starve themselves, exercise excessively and still think they are too fat, even when their bones jut out from their skin. With each pound shed, they become increasingly out of touch with their bodies, only poorly registering hunger, cold, heat and even pain. Hormonal disturbances can set in: women often stop menstruating, and men experience impotence. Other physical consequences include low blood pressure, a variety of skin problems and fluid retention.
Even as their bodies begin to collapse, many anorexics remain obsessed with control and performance. They are often proud of their ascetic lifestyle and feel they gain strength from their ability to do without. Such stringent self-discipline can have fatal consequences. Statistically, only 30 percent of anorexic women make a full recovery. About 35 percent regain some weight but maintain a distorted body image. Another 25 percent are chronically anorexic, and 5.6 percent die from starvation or suicide over the course of a decade.

Whereas anorexia nervosa typically develops around puberty, bulimia nervosa more normally appears between the ages of 18 and 35. These patients fluctuate between two extremes--*starvation and binging. During binge phases, bulimics stuff themselves with calorie-rich food. Afterward, however, they feel shame and either regurgitate what they have just eaten or abuse diuretics or lax*atives as compensation. This purging is *extremely damaging: stomach acid in their vomit erodes their teeth and harms cells in the esophagus, which can lead to cancer. Electrolyte imbalances--a result of dehydration and potassium and sodium depletion--can cause organ damage and cardiovascular problems, including heart attacks.

Despite these life-threatening complications, bulimia nervosa often goes unnoticed, even by medical professionals. Victims usually sustain a normal weight and keep their binging and purging practices well hidden. Once exposed, bulimics who seek treatment have a 50 percent chance of making a full recovery. As for the half who remain unwell, they may adopt vomiting as a permanent habit, or they may fall into a kind of gray zone between recovery and illness. Some of these patients slide into binge eating, continuing to overeat while no longer purging.

For all their differences, anorexia, bulimia and binge eating exist along a continuum and usually emerge after a period of dieting. Those who succumb typically start out hoping to lose a few pounds but end up slashing fats, sugars and carbohydrates until all thoughts revolve around a single question: What am I permitted to eat? Almost half of all women have dieted at some point. But frequent and extreme dieting quickly scrambles the body's hunger-satiety system, paving the way to problem behaviors and faulty perceptions.

Mirror, Mirror
What lies behind a distorted body image? To answer this question, Vocks's team took photographs of 56 people suffering from eating disorders and 209 healthy subjects used as controls.The scientists then asked the test subjects to adjust their images on a computer screen until they "recognized" themselves. Additionally, they asked both groups to give their virtual "me" the figure that they wished they had. Whereas all the respondents had similar notions of an "ideal" figure, the bulimics and anorexics all significantly overestimated their real body mass. In contrast, the subjects who were not suffering from eating disorders believed that they were slimmer than they actually were.

Barbara Mangweth, a psychologist at the Innsbruck Medical University in Austria, reached similar conclusions in a study of men suffering from eating disorders conducted in 2004. In *collaboration with researchers at the Biological Laboratory of Psychiatry at McLean Hospital in Belmont, Mass., Mangweth compared 27 *anorexic and bulimic men with 21 male mountain climbers and 21 male controls. The subjects held similar ideas about the ideal male figure but proffered dramatically different assessments of their own bodies. Unlike the climbers and the controls, the bulimics and anorexics all believed that they had about twice as much body fat as they actually had. Mangweth concluded that a faulty body image--rather than an exaggerated notion of what is ideal--is crucial to the development of eating disorders.

We still do not have an adequate *understanding of why some people are subject to such distortions. Vocks and her colleagues suspect the problem involves information processing. According to their theory, the sensory organs of people with eating disorders correctly register their form, but negative thoughts filter the input. For example, memories of being teased about their looks as a child or teen may override how some bulimics and anorexics would otherwise see themselves. Because these individuals lack the emotional support to hold up a more flattering view, insecurity flourishes in them.

Self-Reflection
Clearly, insecurity helps to warp body image. Our view of ourselves often comes from how others see us or how we think they see us. If this reflection is not sufficiently positive, self-image will suffer, sometimes from the very start of *childhood. Optimally, parental nurturing leads to a sound relationship balanced between security and independence. Yet studies have confirmed that some 30 percent of all children lack such an attachment relationship. Without feeling safe and accepted, these children are at risk of falling into an addictive cycle involving food or other substances.

Other family dynamics contribute to poor self-image. Although eating disorders occur in all kinds of families, those affected often share certain traits. They are typically well situated and well educated and, to the outside world, appear to function harmoniously. Frequently, however, the children feel tremendous pressure to excel, the parents set high standards, and negative emotions such as anger or jealousy are suppressed. In keeping with these high standards, people with eating disorders strive to be model students or, as adults, to lead perfect lives. Even so, they usually feel that they never measure up.

Apart from a dearth of positive feedback, some individuals develop eating disorders in response to specific childhood traumas. According to the findings of Stephen Wonderlich's group at the Eating Disorders Institute in Fargo, N.D., sexual abuse in particular may increase the odds. Similarly, children whose parents are divorced or alcoholic are clearly at risk. Several teenagers seen at the Pediatric and Child Psychiatry Clinic in Essen, Germany, where one of us (Eggers) is director, reported that they felt overwhelmed when their parents divorced, unable to mediate or remain loyal to both sides. Self-hatred can easily arise from such perceived inadequacy--with terrible long-term consequences.

Certainly eating disorders are not exclusively the result of personal problems, but negative feedback from or neglect by family and friends can, at least in part, predispose an individual to anorexia, bulimia or binge eating. In these instances, many parents do not know how to help and feel guilty that they are unable to guide their child. As a result, family therapy can be an important component of an overall strategy in which problems are worked out together. Frequently, the eating disorder is merely the last link in a chain of unhappy events.

Unrealistic Ideals
The standards of beauty promoted by Hollywood films and the fashion industry today only magnify the problems behind most eating disorders. Until the end of the 19th century, curvaceous women were considered just as beautiful as their less voluptuous sisters. But aesthetics changed dramatically during the century that followed. Studies show that most people now prefer the look of bodies that weigh several percentage points below normal.
It is difficult to measure the direct effect that glossy magazines and other media images have on dieting behaviors, but Fiji offers an interesting case study. Anne E. Becker, director of the Adult Eating and Weight Disorders Program at Massachusetts General Hospital, documented eating habits in the Pacific nation throughout the 1990s. In 1995--almost immediately after the introduction of television on the island--she found that only 3 percent of schoolgirls, who were on average 17 years old, reported that they had vomited to control their weight. By 1998, though, that number had surged to 15 percent. And 74 percent of the girls described feeling "too big or fat" at least sometimes, even though Fijians traditionally associate robust body shapes with higher social rank.

For those in Vocks's program, finding the courage to bare their perceived faults in front of a group does often pay off. The 90-minute sessions are no substitute for long-term treatment, but Vocks's patients frequently change their eating habits for the better and often manage to raise their own battered sense of self-worth. Perhaps most important, many learn that the body they have long hated is beautiful in another's eye.