واکنشهای روانی برای مواجهه با شکل بدن در بیماران مبتلا به بولیمیا

One of the unresolved issues regarding research on bulimia nervosa concerns the question as to how patients diagnosed with bulimia nervosa respond to body image exposure. In addition, it remains unclear whether there are differential responses associated with different exposure techniques (e.g. in vivo exposure vs. exposure by visualization). The aim of the present study was to investigate psychological responses to body image exposure. Twenty participants diagnosed with bulimia nervosa (DSM IV) and twenty non-eating disordered individuals were exposed to their body image using a video recording (video confrontation). In addition, they were asked to imagine and describe the appearance of their body (imagery task). Results indicate that self-reported negative emotions increased in response to both, video confrontation and imagery task, in the clinical as well as in the control group. Furthermore, video confrontation led to more pronounced group differences than exposure by visualization (imagery task). Participants diagnosed with bulimia nervosa took less time to describe their waist, hips and bottom compared to non-eating disturbed controls. This last result could be interpreted in terms of avoidance behavior and other mechanisms during body image exposure.

Frequently patients with bulimia nervosa are excessively concerned with body weight and shape, and these factors are assumed to be important for self-evaluation (American Psychiatric Association, 1994) and the maintenance of bulimia nervosa. The majority of studies investigating psychological responses of eating disordered patients to their body has been done on body perception operationalized as the accuracy of body size estimation ( Gleghorn, Penner, Powers and Schulman, 1987, Kulbartz-Klatt, Florin and Pook, 1999, Lindholm and Wilson, 1988, Probst, Vandereycken and van Coppenolle 1997 and Cash and Deagle, 1997). In some studies, patients with bulimia nervosa estimated their body size to be larger compared to controls ( Kulbartz-Klatt, Florin and Pook, 1999 and Lindholm and Wilson, 1988), but their estimates also tended to be more accurate. In other studies no group differences were found ( Probst et al., 1997). Such contradictory results led researchers to question the validity and clinical significance of the body image concept ( Hsu & Sobkiewicz, 1991) as operationalized by the accuracy of body size estimation ( Probst, Vandereycken, Vanderlinden, & van Coppenolle, 1998). Most researchers distinguish at least between perceptual body size distortion and cognitive-evaluative dissatisfaction (Cash and Brown, 1987, Lautenbacher, Roscher, Strian, Pirke and Krieg, 1993, Polivy, Herman and Pliner, 1990, Probst, Vandereycken, Vanderlinden and van Coppenolle, 1998 and Thompson, 1990). Studies on cognitive-evaluative aspects of body size found that bulimic patients often are dissatisfied with their body and would like to be thinner (Cash and Deagle, 1997 and Hsu and Sobkiewicz, 1991). However, there is also some evidence that body dissatisfaction does not discriminate between non-eating disordered persons and individuals diagnosed with bulimia nervosa (Goldfein, Walsh, & Midlarsky, 2000). Concerns about body shape and weight are widespread in women ranging in age between 18 and 70 years (Cash and Herny, 1995, Ricciardelli, Tate and Williams, 1997 and Wood, Becker and Thompson, 1996). It has been suggested that body dissatisfaction may be a risk factor for the development of bulimia nervosa only if it occurs in combination with dietary restraint, the latter being viewed as one of the main etiologic risk factors for binge eating or bulimic eating (Stice, 1994). In contrast to etiologic processes, concerns about shape and weight are thought to be of primary importance for the maintenance of eating disorders, as they can lead to food restriction and dieting behavior (Wilson, Fairburn, & Agras, 1997). Cognitive-behavioral therapies, therefore, use a variety of procedures (e.g. cognitive restructuring, exposure) for overcoming extreme concern with body weight and shape (Fairburn, Marcus and Wilson, 1993 and Tuschen and Bents, 1995). Recently, video feedback and mirror exposure have been used to change body disparagement in eating disorders (Fernández and Vandereycken, 1994, Geissner, Bauer and Fichter, 1997, Norris, 1984 and Rushford and Ostermeyer, 1997). These techniques mainly focus on body size perception. However, results on improvements in body size perception are inconsistent. Interestingly, three studies (Fernández and Vandereycken, 1994, Geissner, Bauer and Fichter, 1997 and Rushford and Ostermeyer, 1997) report a decrease in subjective feelings of fatness after visual body image exposure. The authors conclude that visual feedback may improve the cognitive-emotional component of body image disparagement without explicitly focusing on it. Since bulimia nervosa is more affected by a body image disturbance in terms of cognitive-emotional distortions than by a perceptual body image disparagement, a more direct or explicit focus on cognitive-affective aspects of body image may be useful. Reports on studies using exposure techniques which focus more on cognitive-emotional aspects of body image disturbance, are rare (Rosen, Orason and Reiter, 1995 and Tuschen-Caffier and Florin, 2002). Using a mirror or video technique, patients are encouraged to describe their physical appearance in detail. In order to facilitate habituation to negative feelings about body shape, sessions can be prolonged to 1 h and are performed repeatedly (Tuschen-Caffier & Florin, 2002). In cognitive interventions, body image exposure is used as a priming stimulus (Segal & Ingram, 1994), which may activate negative body-related schemata and may make negative cognitions and emotions salient. Cognitive-behavioral approaches, which include exposure techniques, have been requested to improve the efficacy of treatment for eating disordered patients (Wilson, 1999). However, reports on systematic investigations of such exposure techniques in eating disordered individuals are scarce. One of the unresolved issues concerns the question as to how patients diagnosed with bulimia nervosa respond to body image exposure and whether these reactions differ from those exhibited by non-eating disordered individuals. In addition, it remains unclear whether there are differential responses associated with different exposure techniques (e.g. in vivo exposure vs. exposure by visualization). Generally, it is assumed that in vivo exposure produces more rapid changes than exposure by visualization. However, to our knowledge, no reports on direct comparisons of these exposure techniques in eating disordered patients have yet been published. The aim of the following study was to investigate psychological responses of individuals diagnosed with bulimia nervosa to exposure with their body image using two different exposure methods: participants were exposed to their body image using a video recording (video confrontation); additionally, they were asked to imagine and describe the appearance of their body (imagery task). Because of the more detailed pictorial image of a video recording compared to an imagery task, we hypothesized group differences should especially be pronounced during video confrontation. Given that body dissatisfaction as measured by self-report may not discriminate between non-eating disordered individuals and bulimia nervosa patients (Goldfein et al., 2000), and also bearing in mind that concerns about body shape and weight are widespread in the female population (Cash and Herny, 1995, Ricciardelli, Tate and Williams, 1997 and Wood, Becker and Thompson, 1996), we assumed that differences in body dissatisfaction between eating disordered patients and non-eating disordered participants may be more apparent in behavioral rather than self-report measures. Thus, the length of time taken by study participants to describe individual body areas was monitored. Using these exposure techniques we found patients suffering from bulimia nervosa to frequently exhibit avoidance behavior, especially when asked to describe body areas like waist, hips or bottom. Thus, we assumed that bulimia nervosa patients take less time to describe certain body areas (waist, hips, bottom) than non-eating disordered individuals.