Body Misperception and Volumes of Food on Plate in Nutrition and Food Disorders: a Treatment Proposal
Introduction
This article discusses the misperception of the body and of the food volume on the plate in Feeding and Eating Disorders (FED) and the research that a group of professionals has been doing in recent years.
The goal of this work is to help patients with FED to modify and improve their relationship with their body and with food. This work is carried out through specific experiments and cognitive restructuring, based on comparisons between the vision of body image and portioning of food that patients have developed through the illness, and new models acquired through cognitive and emotional restructuring.
The work on misperception uses Body Image Awareness Drawing (BIAD)18, which is based on the scientific square design, together with psychotherapeutic work of comparison and emotional processing to work on body image distortion. Practically, the patient is asked to draw some parts of their body, for example a forearm, on a graph sheet. Once the drawing is completed, the dimensions of what has been drawn are compared with the actual size of that part of the body. Simultaneously, psychotherapeutic course helps the patient in the processing of misperception.
In addition, an integrated psycho-nutritional treatment is proposed. It involves both manual and psychological work on the misperception of the volumes of food on the plate, as it has been observed that distortions of the perception of the volume of food on plate go hand-in-hand with the misperception of the body image.
The complexity of taking care of patients suffering from Anorexia Nervosa (AN) and their families is well known. The main guidelines (APA1, NICE2) indicate how difficult it is to identify clinically effective treatment methods (level of evidence A) in the treatment of such patients, while a level B recommendation indicates as an important factor the involvement of families in the treatment of teenagers with AN.
Among the manifestations of suffering that patients with AN show, there is the problem of dimorphism, that is the concern and the distress caused by persistent dissatisfaction with their appearance, supported by a wrong awareness of their own body image. This results in a constant sense of anguish and in the development of daily obsessions, that are all -encompassing to the control of one’s own body.
*Individual Psychotherapist rehabilitation therapeutic residence “In Volo” Parma, **Group-analyst and individual psychotherapist Centro DCA- Reggio Emilia AUSL IRCSS, *** Dietist rehabilitation therapeutic residence “In Volo”, ****Psychiatry resident doctor – Reggio Emilia AUSL IRCSS (Italy)
Body image and body misperception
The mental representation of our bodies changes with age and development. As theorized by Lacan3, starting from childhood the person learns to know him/herself through his/her own reflection in the mirror. The child progressively becomes aware of his/her own physicality, until they get to understand what could arouse a movement or an expression in the Other person, such as crying or smiling.
During puberty, the observation of the transformations that the body undergoes, the change in facial features and the development of secondary sexual organs can destabilize the teenager, making him/her more insecure especially when the result is unexpected. In other cases the person will experience satisfaction and pride if the changes respect the ideals of aesthetic ‘perfection’, especially in the case of the female sex4. In fact, puberty represents a critical moment in the development of the bodily experience5, because of this particular feature signed by evolutionary leap.
Reflections, tactile impressions and observations on parts of our body, both psychic and physical, create in us the perception of how the body appears seen from the outside and feed thoughts of acceptance or rejection, according to our level of tolerance or to the conflict of our bodies6.
The first person who introduced the distinction between body pattern and body image into the psychological debate was psychologist Paul Ferdinand Schilder, who — although with some ambiguity — defined the body pattern as the three-dimensional image that each one has of himself’7, while body image involves one’s own mental representation, that is a more strictly psychological/psychoanalityc concept.
In the same text Schilder reports a study by the French philosopher Georges-Henri Luquet8, a pioneer in the analysis of children’s drawings, who identified a parallel development between body pattern and sensory and motility systems. This Author, through graphic representation, highlighted the inability of the children to synthesize the knowledge and sensory experience of body image, connected with the degree of infantile cognitive maturity. The children expressed in the design of the human figure the body image they possessed at that stage of their growth, a mental image and a “broken” perception of their own body.
From the experiments of US psychologist George M. Stratton9,10it appears how the knowledge of one’s body is continually affected by the influence of previously and currently acquired visual impressions, and the tension that is determined between them as it is also integrated with information from other sensory systems. Using special lenses that can alter the image formed on the retina, Stratton inferred how the body image can undergo modifications and reconstructions to maintain its own unity.
At the beginning of the last century, the German neurologist Karl Scholl11introduced a further new element, declaring that the perception of our body is no different from the perception we ourselves have of external objects. In this perspective we could deduce that an altered vision of one’s body will result in an altered vision of the general proportions which also involves what we eat.
The body image is a unitary image, although not rigid but extremely dynamic5. Body image appears to be influenced by cultural patterns, changing according to fashions12, as well as by the constant comparison with other individuals, in particular for girls from the comparison with their peers13 both in person and through images seen on social media. This constant comparison with Other’s body is supported by evidence of neuroimaging, which points out an overactivation of the insula accompanied by a hypoactivation of the anterior rostral cingulate cortex14.
In addition to this, the sociocultural aspect also determines the manifestation of a possible disorder of the body image. It has been found that in the female sex there is a greater focus on weight loss through food restriction, while in the male sex excess physical activity15,16 appears to be predominant. “The body image is always to some extent the sum of the images of the community“, says Schilder, “in accordance with the various relationships in the community“: we speak therefore of a real social image of the body.
In eating disorders the unity of the parts is in continuous danger, there is in fact the possibility that some parts of the body are expelled as a defensive mechanism, as happens for example in Anorexia Nervosa. In Anorexia Nervosa there is an obsession on certain body districts considered disappointing and therefore to be modified, up to the limit of depersonalization. On the contrary, patients with other disorders of this category, such as Bulimia Nervosa, would instead show greater mental elasticity and therefore a greater ability to correct their body image17.
Starting from these bases, the study18is born from the collaboration between the Doctor and Designer Gal Peleg and the Psychotherapist Psychologist Ilaria Sterbizzi, who have observed how through the design of the parts of their body, patients with AN tend to report distorted images, deformed in an accretive sense when compared to the real size.
The drawing of the human figure has already been used as a specific diagnostic tool. We can mention, as an example, the projective personality test devised by psychologist K. Machoven19(1949) and the “Mi disegno” model proposed by the Philosopher and Psychologist Emanuela Confalonieri20, who has used it in several researches with teenagers in order to study the perception of body image.
By asking the patient to translate him/her self-image with a pencil on paper, the patient’s level of mentalization emerges through the application of these tools. In representing their own body experience, patients with AN tend to present stereotypical and childish human figures, often with evanescent and fragmentary traits, relegated to a small area of the working surface and without elements that refer to the uniqueness of the patient. Anatomical bodies often miss some elements or present numerous erasures, as to want to fragment a body that taken in its entirety would threaten the self-esteem of the person21; in particular, there is often a tendency among patients with AN to omit secondary sexual characteristics, which involve changes that highly threaten the ideal body image22. The result is the representation of a cold and bare inner world, empty when speaking of real relationships or concrete interests23,24,25.
Through the scientific design method created by Peleg and Sterbizzi18, patients have the opportunity to modify their distorted body images under expert guidance in order to become aware of their physical forms.
The work on the “correction” and mentalization of the body image appears essential and useful in the treatment of these patients who also show an alteration of the perception of the volume of food on the plate, especially in the case of phobic foods. The perceptual alteration in fact affects both the body and food, involving the size of the body shapes and the volumes of nutrients that should be taken to restore physical and mental health.
It happens that when the patients are with the dietist they manifest the adherence to the treatment that has been proposed and that consist of an agreed food plan. When they subsequently arrive home and have to consume the dish according to the agreed portioning they get into trouble, because the dish is in their eyes greater than they thought when they agreed. The food assumes magnified proportions due to the misperception of the proportions. Patients often feel ashamed to describe this phenomenon and tend to not report it to specialists or family members for fear of judgment. Other times patients are not aware of this alteration and avoid addressing the topic, as they do not think that their assessment is wrong. The method described is currently being validated with a view to its future application in the clinical field.
Evaluation and management of body image disturbance. Proposal for a clinical pathway
In our opinion, the treatment of body image disturbance can not be separated from the analysis of the factors which determine and maintain it: emotional, cognitive, perceptual and behavioral factors.
Emotional and cognitive factors refer to all those negative and dysfunctional emotions, feelings and thoughts towards the body that maintain a negative self image of the person. These aspects need to be treated with psychotherapy, but modifying them certainly takes time. From a perceptual level it is important to analyze and show the patient the alteration in the perception of volumes and give him proof of it. They often come out surprised and reassured. From a behavioural point of view, instead, it is necessary to make patients aware of all the behaviors which tend to overcontrol the body. These behaviors feed the anxiety and the alteration of the perceptive capacity, especially in the rehabilitation phase, where changes in weight and body must necessarily take place. Changes in the body are aspects that need to be analyzed at the beginning of treatment. The patient who is adhering to a treatment pathway sees the gradual changes in body shapes and tends to practice body checks. There are different types of checks: tactile cheks (e.g. measuring body circumferences with his hands, wearing clothing to see if they are still wide etc.), weight checks (continuous weight control on the scale), visual checks (keeping body changes under control in the mirror, comparing with idealized bodies through social media or with images of one’s body at different stages of the disease). These behaviours only lead to a hyper focused mode of observation that is a source of confusion, anguish, loss of sense of reality and altered perception of reality. This may consequently activate typical compensation behaviours such as hyperactivity, restriction, vomiting and other compensation behaviours. It becomes very useful, in order to work on the right perception of the body, to interrupt all these control mechanisms. The interruption of them decreases the anxiety associated with body experience and improves the examination of reality concerning body forms. Interrupting these patterns of behaviour means first of all making the patient aware of their existence and of the importance they have on the maintenance of body misperception, with the aim of finding strategies to eliminate them. Concerning the treatment of visual checks, as an example, the patient will be asked to recognize them, therefore working on awareness of the problem and the importance of avoiding exposing him/herself to the mirror or other reflective surfaces, without “good intentions” and at the wrong times (especially immediately after meals or when the patient has negative thoughts or emotions about the body). The goal is to re-educate the person to the functional use of the mirror to promote a healthy approach. Subsequently, mirror therapy can be undertaken, using guided body exposures as a non-focused observation experience associated with a non-judgmental self-description. It is a moment of knowledge, acceptance and enhancement of the body at a stage when the body itself has reached its healthy weight or at least normal weight. The use of the mirror in the phase when visual checks are still active only leads to increased anguish because the focus that results from the visual check could generate confusion, anxiety and likely perception of larger volumes. Therefore, experience has led us to observe that the use of the mirror, as a therapy to promote the acceptance of body change after weight recovery, leads to better results when the patient has managed to interrupt body checks and is more aware of the mechanism of body misperception. Otherwise, the mirror becomes the seat of visual checks and feeds concern that will probably be followed by compensation mechanisms.
On the basis of these reflections we hypothesized that work on the interruption of body checks is an essential prerequisite for treating misperception. Working on body distortion when body checks are still present could lead to the same result of nutritional rehabilitation in the presence of restrictions, binge eating or vomiting: the risk is an overall treatment invalidity.
From these considerations comes the proposal for a step-on treatment pathway for body misperception. The first step is certainly represented by the resolution of active body checks that are ‘hidden, intimate symptoms’: it is necessary to make patients aware of the importance of their interruption, empowering them in this regard. This process must necessarily take place through a path led by an experienced therapist. At the same time it is useful, already in a first phase of treatment, to work in psychotherapy on the emotional, cognitive and even perceptual components of body misperception. Concerning body image disturbance, a treatment proposal is the training of mentalization of the body and learning of the correct volumes of the body (BIAD – Peleg-Sterbizzi). The last step instead involves guided exposure to the mirror, but at a time when the healthy weight or at least the normal weight has been reached. It is a path of at least 10 sessions where the patient exposes himself to the mirror for the purposes of observation, knowledge and enhancement of the body. The goal is the gradual knowledge of all parts of the body. Initially the exposures will take place with the patient fully dressed. The attention should be paid to the type of clothing, which will have to be adjusted from the point of view of body size (many patients tend to participate in the session using loose clothing to cover or too tight to check). Gradually the exposures involve ‘discovering the body’ until it is observed wearing a swimsuit, this also to prevent any form of avoidance. However, mirror therapy must be preceded, as mentioned above, by a functional re-education to the use of the mirror itself. This step is essential since patients often continues, if not guided, to follow dysfunctional methods in looking at himself (for example in the way of observing himself focused instead of global, or speculating himself excessively or in
inappropriate situations). It is also possible to associate the “square pattern techique” after each exposure to facilitate the cognitive correction of any misperception (it often happens for the phobic parts for the patient). Compared to the latter modality, the first experiments of the model are underway. Future goals will be the study of the cognitive-perceptual component from a neuropsychological point of view and the study of the tactile component of body perception.
Introduction to psycho nutritional intervention applied to the misperception of food volumes on plate
The attention to the topic of body misperception and the application of the BIAD technique for its treatment, proposed for patients with FED in rehabilitation at the socio-rehabilitation community “In Volo” in Parma, has also led to hypothesize the presence of difficulties in the correct perception of the volumes of food on the plate. In fact, it has been hypothesized that
the difficulty in estimating volumes could extend not only to the body, but to all phobic ‘objects’ and probably also to the rest of the objects. Hence the idea of trying to investigate in more depth that concern about the quantities of food on the plate often verbalized by patients during a psychological and dietary interview.
It was then made a reflection on the need to find a way to analyze and correct the cognitive estimation ability of the volumes of food to be consumed. In the individual evaluation phase, the ability to estimate volumes through both visual and tactile modes was investigated. Initially, during the psychological and dietary interview, the patient was asked to draw the imagined size of some chosen foods, both phobic and non-phobic. Later it was asked to reproduce them using moldable paste. The obtained results have exceeded our expectations by far because on average the work of the users were characterized by the overestimation of the volumes. The next goal was to propose small group activities aimed at correcting cognitive errors applied precisely to the perception of food volumes. The therapeutic intervention techniques used were the same of the evaluative phase, drawing and reproduction using moldable pastes, to which was added the comparison between the estimated imaginary volumes and the actual ones.
The comparison aimed not only to help users to make an examination of reality, but also and above all to work further on the correction of the wrong model starting from visual observation, tactile exploration and reconstruction of the food in question. This has fostered the achievement of two closely related goals. The first is desensitization from the phobic object. Sometimes patients also have difficulty touching food because they are afraid of absorbing calories. Direct exposure has favored the decrease in associated anxiety levels and the faster introduction of a selcted food into the meal plan. On the other hand, the second goal concerns the improvement in the perception of the correct volume of food in the dish, which gradually becomes more correct following repeated “modelling” exercises throgh the reproduction of choosen food with moldable pastes at the correct size. The therapeutic work, through laboratories conducted in the presence of a psychologist and dietician, has also been extended to other objectives, such as the ability to make adequate bites, since in many cases distorted perception, both visual and tactile (perception of mouth too full) could explain some dysfunctional behaviours at mealtime.
Practical nutritional observations about the psycho nutritional intervention
During the psycho nutritional interventions of a tactile type, the difficulty of the patients in being able to manipulate fobic and/or excluded foods from their diet for a long time was immediately highlighted. They went so far as to ask for the help of gloves or cutlery in order not to touch the food itself. The most represented fear we have met was the passage of calories through the skin or the disgust felt toward the proposed food. In groups where it was asked to reproduce a certain food using moldable pastes, it was observed that patients with a lower BMI reproduced the actual food with greater alteration of the size. We highlight the case of a patient with a BMI of 14.3 kg/m2 who reproduced a cookie slice (real size 6 x 7.5 cm) in the dimensions of 8 x 9 cm and with doubled thickness. The patients with greater difficulties during psycho nutritional interventions have more dysfunctional behaviors at the table (shredding and long food consumption times).
A cross-sectional element that emerged in the various therapeutic session is the difficulty of the patients in recognizing the scent, size and volume of the foods in proportion to the time in which the food in question was excluded from the diet. Particularly during the olfactory groups, patients at the beginning of the nutritional rehabilitation path with diets mainly based on oral nutritional supplements and low BMI struggled to associate a smell/perfume with the corresponding food. The work through moldable pastes has allowed us to focus attention also on the methods of consumption of meals. The aim of the group was to become aware of the dysfunctional modalities adopted and subsequently to pratice the correct modalities. This exercise allowed many users to reduce anxiety while eating the dish and more easily change dysfunctional behaviors at the table.
The post-intervention observed results are: a desensitization about phobic food that has led to the reintegration into the diet of food eliminated for months/years from the diet, consequently managing to reduce food selectivity and improving dysfunctional behaviors at the table, specifically through the reduction of consumption times by making adequate bites.
After a first round of sessions focused on these issues we conducted group interviews (Focus Group). We have met the need for patients to continue working with these methods as it supports them positively in perceiving and correctly dealing with the avoided meals until that moment.
Below we list the observations collected by the focus groups:
- “This group helped me a lot to deal with apple, as I actually saw it bigger, whereas it was smaller than I thought.”
- “The psycho nutritional group has helped me to be more aware of my emotions compared to certain meals.”
- “It was a wet blanket. There are no way out. The three senses that are awakened seem to have fallen asleep a long time ago. Or rather they were as if under spell: whatever was placed near my nose, my eyes or that ended up in my hands always had the same value, it aroused me but fear. I couldn’t build a relationship with it, I couldn’t peacefully get closer to food: it was my enemy. Things have changed because of you. You have taught us to question our words, but not trivially as everyone tries (through dialogue), but by reactivating our senses. I do not deny that with every experiment memories do not emerge, but we have innate certainties that we can fight everything! You made me smell cookie slice, Nutella: both are the periodic object of my binges. You made me build with the moldable paste my most phobic element: pasta, just because it is associated with the figure of my mom. And now I find myself entering the dining room with the pride of peacefully, living the moment when I discover that I have on my plate, just those meals. Thanks to you, I have questioned all my unreasonable prejudices. And as you said, time is one of the most valuable keys to the resolution. I remember the first meeting I had theoretical session, ‘the healthy weight’. I started with: “utopian”. Utopian, my ***! Until this day it is anything but utopian: it is objective, it is perseverance, it is desire, it is a return to life, it is beauty. I feel it closer, really thanks to you and thank you.”
Body image and social networks
According to Thompson and colleagues, with the Tripartite Influence Model26,27, it shows the phenomenon of the idealization of body forms and the dissatisfaction that derive from it. They claim that there are three sources that influnce the development of body image alterations: parents, peers and media. As for females, the inputs that come from these sources tend to confirm introjection of the ideal of beauty related to thinness, while for males they pay attention to being muscular and to the physical performance, signs of virility. In this way, unrealistic body standards of beauty are spread, with which everyone must confront. In addition, the internalization of these ideals and the emotional dissatisfaction derived from the confrontation with them is favored. Especially in female teenagers, who spend a lot of time in contact with the body images on social networks, the dissatisfaction is strong28,29.
While boys are urged to develop sculpted abs on a statuesque body, as if physical strength corresponded to psychic strength, the body of girls must show accentuated breasts and narrow and infantile basins. The girl’s body must demonstrating the elasticity, the ductile and helpful capacity, the ability to adapt, which must extend to the emotional and psychological characteristics required of women. This may lead to the need of cosmetic surgery to obtain these physical forms30.
Nowadays social networks promotes interactivity, in this way the person becomes a user and at the same time creator of content. The person can observe , interact and behave active by including “likes” or “dislikes” and/or other comments, bringing their influence and thoughts. The person also promote his/her own image through several photos that show parts of him/her body or by highlighting him/her body.
In order to get better images, influencers use computerized filters and programs, as well as adopt poses that highlight or thin certain parts of the body or face. For example, an image that goes for the most is to be photographed or photographed from above, because in this position the features of the face are more “thin,” or they use filters or computer programs capable of changing the facial or body characteristics to emphasize the false beauty. Some influencers show their counterfeit appearance, but most of them mystify their true image, because they benefit from counterfeiting. Users, who follow the latter influencers, are thus confronted with altered images that produce frustration, not least because they are not aware of the changes implemented and with which they are measuring31.
Exposure to social media leads the person to internalize cultural ideals of stereotyped beauty and produces dissatisfaction with his/her physical appearance if this does not coincide with the internalization of the ideal32.
A study done by Engeln and collaborators33, highlighted how Instagram users tend to make more comparisons on physical appearance than Facebook users, and how they report a reduction in body satisfaction, precisely because images in Instagram can be manipulated. Instagram users are mostly teenagers and young adults, while Facebook users are adults and elders.
From another study carried out by Uchoa and collaborators34, it was found that the influence of the mass media is associated with a greater probability of developing body dissatisfaction especially in the teenager population, in particular in females, and that this dissatisfaction in turn risks triggering eating disorders in both genders, but specially in females.
Reaves35 pointed out that social networks are full of images of peers and celebrities, therefore teenagers are inclined to social comparisons, in which the value of thinness is highlighted compared to other physical characteristics. Digital manipulation of images on social networks is widespread and teenagers have difficulty identifying manipulated bodies in exposed images, because those images perfectly identify the idealization of beauty that they themselves would like to achieve.
Among the activities of teenagers , users of social networks , there is the activity of “lurking36”, a behavior that identifies checking one’s own profile, looking at that of others, reading posts/comments on the profiles of others, observing the photos of others, without ever leaving comments or interacting, for fear of receiving unpleasant comments. This behavior highlights the attitude of low self-esteem and the tendency to idealize others, which is perpetuated throughout the time of the use of social media.
Some research studied the most frequent content, which has appeared in recent years, on different social platforms, highlighting two contents in particular: thinspiration, which promotes the ideal of thinness and the importance of weight loss, and fitspiration, which propagates fitness at the expense of normal weight. Both emphasize the stigmatization of fat and weight. These content show either thin women who promote weight loss, food restriction and intensive exercise or men with sculpted and dry muscles37,38,39,40,41.
Diet culture is a system of indications on nutrition and body, which highlight thinness as a moral value to be followed at all costs, in this case the underweight person is a symbol of desirability, success and social importance. Lean body, light food, motor activity are emphasized in order to weight loss and calories consumption. Those who do not follow this lifestyle are considered with less value and success, not deserving of attention.
Longobardi42 argues that adolescents base their popularity on indicators depending on appearance, so they can meet their psychological needs for acceptance and fame by peers. Being considered beautiful indicates belonging to the group of popular peers and is a central factor linked to good self-esteem. During adolescence, liking or not pleasing other peers, makes you fragile, vulnerable and affects the sense of self-satisatisment. The complicated relationship with one’s own body image is connected to these experiences.
In the future it will be important to promote prevention and health promotion projects, that help girls/boys to develop a critical capacity about the vision of body models and identity models conveyed by media and social networks, in order to develop a vision that respects everyone’s diversity.
Conclusion
The Authors treat patients suffering from Feeding and Eating Disorders and highlight the importance of including, from the first phase of treatment, a work done on the misperception of the body image and on the alteration of the volumes of food on plate, to be able to help patients to mentalize the body and the food.
This article proposes a therapeutic method that is based on BIAD and works on the proportions of food, starting from the phobic one, for Anorexia Nervosa, or if differently interested, for Bulimie or Uncontrolled Feedings.
Observations on the effects of these modes of work underline the importance and the need to deconstruct dysfunctional sensoriality and perceptiveness through cognitive strategies capable of promoting new learning. The graphic experiences based on the design of one’s body, the sensory, perceptual, manipulative, olfactory experiences carried out with food, represent the right context for promoting new traces of oneself, in relation to one’s body and food, and for the organization of new and correct knowledge. The user observations, collected in the various focus groups, highlight their need to continue to use these modes of work, as they seem to promote better adherence to rehabilitation programs.
The authors have wondered what roots body and food misperception can have, and through this work interesting insights are offered.
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