Diagnostic Classification of Eating Disorders: The Role of Body Image

  • Umberto Volpe
  • Alessio Maria Monteleone
  • Palmiero Monteleone


A disordered body image is retained as a hallmark feature of all major eating disorders (ED). However, its role in psychopathology and classification of these complex mental illnesses has varied throughout the centuries. Indeed, while in the first descriptions of anorexia nervosa, body image disturbances were not included into its psychopathological core, the early European transcendental phenomenological tradition has attributed a central importance to disturbances of the “embodiment” processes for ED psychopathology. Since the second half of twentieth century ED have been intimately linked to perceptual and conceptual body image disorders and current nosological criteria for major ED retain those aspects of body distortion and denial of thinness as key diagnostic features. However, several issues concerning the inclusion and meaning of such diagnostic criteria for other mental disorders within the “eating-feeding” spectrum have been raised along the past decades and are reviewed here, also in the light of recent socio-cultural and neurobiological empirical evidence. Finally, issues concerning the boundaries with other mental illnesses in which a disordered body image is typically present are also critically considered. In conclusion, the role and relevance of body image disturbances in the diagnosis and classification of ED still remain to be fully clarified, although they might be of great relevance for designing more tailored psychological interventions for ED.


  1. 1.
    Gull WW. Anorexia nervosa (apepsia hysterica, anorexia hysterica). Trans Clin Soc Lond. 1874;VII:22–8.Google Scholar
  2. 2.
    Lasègue C. De l’anorexie hystérique. Arch Gén Méd. 1873;1:384–403.Google Scholar
  3. 3.
    Pearce JMS. Richard morton: origins of anorexia nervosa. Eur Neurol. 2004;52:191–2.CrossRefGoogle Scholar
  4. 4.
    Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med. 1979;9(3):429–48.CrossRefGoogle Scholar
  5. 5.
    Zahavi D. Husserl’s phenomenology of the body. Études Phénoménologiques. 1994;10(19):63–84.CrossRefGoogle Scholar
  6. 6.
    Husserl E. Ideen zu einer reinen phaenomenologie und phaenomenologischen philosophie I. In: Schumann K, editor. Husserliana III. Den Haag: Martinus Nijhoff; 1913/1976.Google Scholar
  7. 7.
    Merleau-Ponty M. The visible and the invisible. Evanston, IL: Northwestern University Press; 1964/1968.Google Scholar
  8. 8.
    Carman T. The body in husserl and merleau-ponty. Philos Top. 1999;27(2):205–26.CrossRefGoogle Scholar
  9. 9.
    Merleau-Ponty M. Sense and non-sense. Evanston, IL: Northwestern University Press; 1948/1964.Google Scholar
  10. 10.
    Merleau-Ponty M. Phenomenology of perception. London: Routledge; 1945/1962.Google Scholar
  11. 11.
    Bullington J. The expression of the psychosomatic body from a phenomenological perspective. Berlin: Springer; 2013. p. 19–37.Google Scholar
  12. 12.
    Sartre JP. Being and nothingness (L’etre et le neant). New York: Washington Square Press; 1943/1992.Google Scholar
  13. 13.
    Stanghellini G, Castellini G, Brogna P, Faravelli C, Ricca V. Identity and eating disorders (IDEA): a questionnaire evaluating identity and embodiment in eating disorder patients. Psychopathology. 2012;45(3):147–58.CrossRefGoogle Scholar
  14. 14.
    Monteleone AM, Castellini G, Ricca V, Volpe U, De Riso F, Nigro M, Zamponi F, Mancini M, Stanghellini G, Monteleone P, Treasure J, Maj M. Embodiment mediates the relationship between avoidant attachment and eating disorder psychopathology. Eur Eat Disord Rev. 2017;25(6):461–8.CrossRefGoogle Scholar
  15. 15.
    Bruch H. Perceptual and conceptual disturbances in anorexia nervosa. Psychosom Med. 1962;24:187–94.CrossRefGoogle Scholar
  16. 16.
    Skårderud F. Bruch revisited and revised. Eur Eat Disord Rev. 2009;17(2):83–8.CrossRefGoogle Scholar
  17. 17.
    Bruch H. Eating disorders. Obesity, anorexia nervosa, and the person within. New York: Basic Books; 1973.Google Scholar
  18. 18.
    Garfinkel PE, Moldofsky H, Garner DM, Stancer HC, Coscina DV. Body awareness in anorexia nervosa: disturbances in “body image” and “satiety”. Psychosom Med. 1978;40(6):487–98.CrossRefGoogle Scholar
  19. 19.
    Garfinkel PE, Garner DM. Anorexia nervosa: a multidimensional perspective. New York: Brunner/Mazel; 1982.Google Scholar
  20. 20.
    Slade PD, Russell GF. Experimental investigations of bodily perception in anorexia nervosa and obesity. Psychother Psychosom. 1973;22(2):359–63.CrossRefGoogle Scholar
  21. 21.
    Slade P. A review of body-image studies in anorexia nervosa and bulimia nervosa. J Psychiatr Res. 1985;19(2–3):255–65.CrossRefGoogle Scholar
  22. 22.
    World Health Organization (WHO). International classification of mental and behavioral disorder: clinical descriptions and diagnostic guidelines, tenth edition (ICD-10). Geneva, WHO, 1992.Google Scholar
  23. 23.
    Uher R, Rutter M. Classification of feeding and eating disorders: review of evidence and proposals for ICD-11. World Psychiatry. 2012;11(2):80–92.CrossRefGoogle Scholar
  24. 24.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.Google Scholar
  25. 25.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  26. 26.
    Grilo MC. Why no cognitive body image feature such as overvaluation of shape/weight in the binge eating disorder diagnosis? Int J Eat Disord. 2013;46:208–11.CrossRefGoogle Scholar
  27. 27.
    Masheb RM, Grilo CM. Binge eating disorder: a need for additional diagnostic criteria. Compr Psychiatry. 2000;41:159–62.CrossRefGoogle Scholar
  28. 28.
    Wilfley DE, Schwartz MB, Spurrell EB, Fairburn CG. Using the eating disorder examination to identify the specific psychopathology of binge eating disorder. Int J Eat Disord. 2000;27:259–69.CrossRefGoogle Scholar
  29. 29.
    Grilo CM, Hrabosky JI, Allison KC, Stunkard AJ, Masheb RM. Overvaluation of shape and weight in binge eating disorder and overweight controls: refinement of a diagnostic construct. J Abnorm Psychol. 2008;117:414–9.CrossRefGoogle Scholar
  30. 30.
    Grilo CM, Masheb RM, White MA. Significance of overvaluation of shape/weight in binge-eating disorder: comparative study with overweight and bulimia nervosa. Obesity. 2010;18:499–504.CrossRefGoogle Scholar
  31. 31.
    Goldschmidt AB, Hilbert A, Manwaring JL, Wilfley DE, Pike KM, Fairburn CG, et al. The significance of overvaluation of shape and weight in binge eating disorder. Behav Res Ther. 2010;48:187–93.CrossRefGoogle Scholar
  32. 32.
    Grilo CM, Crosby RD, Masheb RM, White MA, Peterson CB, Wonderlich SA, et al. Overvaluation of shape and weight in binge eating disorder, bulimia nervosa, and sub-threshold bulimia nervosa. Behav Res Ther. 2009;47:692–6.CrossRefGoogle Scholar
  33. 33.
    Ojserkis R, Sysko R, Goldfein JA, Devlin MJ. Does the overvaluation of shape and weight predict initial symptom severity or treatment outcome among patients with binge eating disorder? Int J Eat Disord. 2012;45:603–8.CrossRefGoogle Scholar
  34. 34.
    Hilbert A, Saelens B, Stein R, Mockus DS, Welch RR, Matt GE, et al. Pretreatment and process predictors of outcome in interpersonal and cognitive behavioral psychotherapy for binge eating disorder. J Consult Clin Psychol. 2007;75:645–51.CrossRefGoogle Scholar
  35. 35.
    Sysko R, Hildebrandt T, Wilson GT, Wilfley DE, Agras WS. Heterogeneity moderates treatment response among patients with binge eating disorder. J Consult Clin Psychol. 2010;78:681–90.CrossRefGoogle Scholar
  36. 36.
    Grilo CM, Masheb RM, Crosby RD. Predictors and moderators of response to cognitive behavioral therapy and medication for the treatment of binge eating disorder. J Consult Clin Psychol. 2012;80:186–95.CrossRefGoogle Scholar
  37. 37.
    Mond JM. Classification of bulimic-type eating disorders: from DSM-IV to DSM-5. J Eat Disord. 2013;1:33.CrossRefGoogle Scholar
  38. 38.
    Fisher MM, Rosen DS, Ornstein RM, Mammel KA, Katzman DK, Rome ES, Callahan ST, Malizio J, Kearney S, Walsh BT. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. J Adolesc Health. 2014;55(1):49–52.Google Scholar
  39. 39.
    Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U. Anorexia nervosa: aetiology, assessment, and treatment. Lancet Psychiatry. 2015;2(12):1099–111.CrossRefGoogle Scholar
  40. 40.
    Thompson JK, Heinberg LJ, Altabe M, Tantleff-Dunn S. Exacting beauty: theory, assessment, and treatment of body image disturbance. Washington, DC: American Psychological Association; 1999.CrossRefGoogle Scholar
  41. 41.
    Gaudio S, Wiemerslage L, Brooks SJ, Schiöth HB. A systematic review of resting-state functional-MRI studies in anorexia nervosa: evidence for functional connectivity impairment in cognitive control and visuospatial and body-signal integration. Neurosci Biobehav Rev. 2016;71:578–89.CrossRefGoogle Scholar
  42. 42.
    Gardner RM, Brown DL. Body size estimation in anorexia nervosa: a brief review of findings from 2003 through 2013. Psychiatry Res. 2014;219(3):407–10.CrossRefGoogle Scholar
  43. 43.
    Gutierrez E, Carrera O. Anorexia nervosa and body-image disturbance. Lancet Psychiatry. 2016;3:e9–10.CrossRefGoogle Scholar
  44. 44.
    Mitchison D, Hay P, Griffiths S, Murray SB, Bentley C, Gratwick-Sarll K, Harrison C, Mond J. Disentangling body image: the relative associations of overvaluation, dissatisfaction, and preoccupation with psychological distress and eating disorder behaviors in male and female adolescents. Int J Eat Disord. 2017;50(2):118–26.CrossRefGoogle Scholar
  45. 45.
    Calzo JP, Horton NJ, Sonneville KR, Swanson SA, Crosby RD, Micali N, Eddy KT, Field AE. Male eating disorder symptom patterns and health correlates from 13 to 26 years of age. J Am Acad Child Adolesc Psychiatry. 2016;55(8):693–700.e2.CrossRefGoogle Scholar
  46. 46.
    Mangweth-Matzek B, Kummer KK, Pope HG. Eating disorder symptoms in middle-aged and older men. Int J Eat Disord. 2016;49(10):953–7.CrossRefGoogle Scholar
  47. 47.
    Suffolk MT, Dovey TM, Goodwin H, et al. Muscle dysmorphia: methodological issues, implications for research. Eat Disord. 2013;21:437–57.CrossRefGoogle Scholar
  48. 48.
    Grant JE, Phillips KA. Is anorexia nervosa a subtype of body dysmorphic disorder? Harv Rev Psychiatry. 2004;12(2):123–6.CrossRefGoogle Scholar
  49. 49.
    Sandoval JRG, Caracuel JC, Cocca A, Cocca M, Gurrola OC. Relation between body mass index and body image in spanish and mexican adolescents. Behav Med. 2017;23:1–9.Google Scholar
  50. 50.
    Vocks S, Schulte D, Busch M, Grönemeyer D, Herpertz S, Suchan B. Changes in neuronal correlates of body image processing by means of cognitive-behavioural body image therapy for eating disorders: a randomized controlled fMRI study. Psychol Med. 2011;41(8):1651–63.CrossRefGoogle Scholar
  51. 51.
    Boehm I, Finke B, Tam FI, Fittig E, Scholz M, Gantchev K, Roessner V, Ehrlich S. Effects of perceptual body image distortion and early weight gain on long-term outcome of adolescent anorexia nervosa. Eur Child Adolesc Psychiatry. 2016;25(12):1319–26.CrossRefGoogle Scholar
  52. 52.
    Bardone-Cone AM, Harney MB, Maldonado CR, Lawson MA, Robinson DP, Smith R. Defining recovery from an eating disorder: conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behav Res Ther. 2010;48:194–202.CrossRefGoogle Scholar
  53. 53.
    Fairburn CG, Harrison PJ. Eating disorders. Lancet. 2003;361:407–16.CrossRefGoogle Scholar
  54. 54.
    Jacobi C, Paul T, de Zwaan M, Nutzinger DO, Dahme B. Specificity of self-concept disturbances in eating disorders. Int J Eat Disord. 2004;35:204–10.CrossRefGoogle Scholar
  55. 55.
    Keel PK, Dorer DJ, Franko DL, Jackson SC, Herzog DB. Postremission predictors of relapse in women with eating disorders. Am J Psychiatry. 2005;162:2263–8.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Umberto Volpe
    • 1
  • Alessio Maria Monteleone
    • 1
  • Palmiero Monteleone
    • 1
    • 2
  1. 1.Department of PsychiatryUniversity of Campania “L. Vanvitelli”NaplesItaly
  2. 2.Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”University of SalernoSalernoItaly

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