Eating and Nutrition Disorders (ENDs) represent one of the major public health challenges, with rising data and a clinical complexity that reflect the cultural and social transformations of our era. The DSM-5-TR (2022) revision broadened the category, including not only anorexia nervosa, bulimia nervosa, and binge eating disorder (BED), but also newly emerging conditions.
In Italy, according to ISS, more than 3 million people are in treatment, and mortality remains among the highest rates for psychiatric disorders.
Body Image
Body image distortion is not merely a symptom but a core psychopathology of ENDs, recognized as a diagnostic criterion for anorexia nervosa and bulimia nervosa and present, albeit with different features, in BED as well.
Body image is a multisensory construct that integrates visual, tactile, proprioceptive, and interoceptive information. In ENDs, this integration is altered by cognitive biases (selective attention toward body parts perceived as defective, distorted memory of weight- and shape-related episodes, misinterpretation of bodily sensations).
Overestimating one’s body size, judging self-worth almost exclusively by weight and shape, avoiding the mirror or, conversely, engaging in obsessive self-monitoring: these behaviors are manifestations of distress that go far beyond mere body dissatisfaction.
Why it matters
Recent research emphasizes that body image distortion is one of the main factors maintaining an eating disorder and a negative predictor of treatment response. Not only that: even after remission of pathological eating behaviors, the persistence of concerns about the body increases the risk of relapse.
For this reason, the cognitive component—excessive evaluation of weight and shape—is today the main target of the most effective therapies, such as CBT-E (Enhanced Cognitive Behavioral Therapy) and the MindFoodNess approach.
The Role of the Doctor
The general practitioner is often the first to detect early signals of ENDs. It is essential that they recognize, beyond the physical and behavioral symptoms, also the signs of body image distortion:
- Excessive concern about weight and body shape
- Avoidance of situations that expose the body
- Wearing loose clothing to “hide”
- Obsessive mirror checking or mirror avoidance
- Highly self-critical inner dialogue (“I feel fat,” “I’m only worth it if I lose weight”)
The interview should be conducted with sensitivity, avoiding reinforcing the focus on weight or appearance. It is important to validate the suffering, offer a nonjudgmental space for listening, and explain that body image distortion is a recognized and treatable symptom.
Therapeutic Approach
Guidelines from NICE and the international literature agree: cognitive-behavioral therapy (CBT) is today the first-line treatment for adults with ENDs, as it specifically tackles the excessive evaluation of weight and shape and the cognitive mechanisms that sustain body image distortion.
Working on body image means helping the patient recognize and modify dysfunctional thoughts, reduce avoidance and body-checking behaviors, and develop a more flexible and less judgmental relationship with their body.
Experiential techniques (gradual mirror exposure, acceptance and mindfulness exercises) have proven useful in reducing distress and promoting change. An integrated approach, which also includes psychoeducation, work on personal values, and family involvement, is essential for preventing relapse.
Shared Responsibility
Body image distortion is at the heart of the suffering in nutrition and eating disorders. Recognizing, validating, and treating it in a targeted way is a shared responsibility among primary care physicians, specialists, and families. Only then is it possible to offer patients not only symptom remission but a real path to recovery and lasting well-being.
The Signals
These signals, if present, suggest body image distortion and should prompt the clinician to investigate further:
- Excessive concern about weight, shape, or body dimensions
- Mirror avoidance or obsessive mirror checking
- Wearing loose or “protective” clothing
- Avoidance of social situations that expose the body (e.g., swimming, gym)
- Self-critical and demeaning internal dialogue
- Difficulty accepting physiological body changes (puberty, pregnancy, aging)
Strategies for an Effective Interview
Dialogue with patients who struggle with an eating disorder requires particular attention to communication. Here are some practical strategies:
- Open-ended questions: Favor questions like “How would you describe your relationship with food?” rather than “How much do you weigh?” Open-ended questions encourage the patient to express their subjective experience.
- Emotional validation: Use phrases such as “I understand that this is hard to talk about, but we’re here to help.” Validation creates an accepting climate that facilitates the patient’s openness.
- Structured monitoring: Use validated scales to track the disorder’s progression in an objective way.
- Non-judgmental language: Avoid comments about weight or appearance that could reinforce body obsession. Focus instead on overall well-being and daily functioning.
- Active involvement: Make the patient a central participant in the care process, agreeing on realistic, gradual goals to achieve together.
References
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). APA Publishing, 2022.
- Mian E. Escape from the Mirror, Feltrinelli Editore, 2023.
- Riccardo Dalle Grave, AIDAP (2021). Body image in eating disorders: the central role of excessive weight and body shape evaluation.
- Nuova Rassegna di Studi Psichiatrici (2024). Body Image and Psychopathology of Eating Behavior.
- Straface E., Tarissi De Jacobis I., Capriati T., et al. Eating Disorders and the COVID-19 pandemic: effects on risk and symptoms. Not Ist Super Sanità 2024;37(5):3–6.
- Frontiers in Psychology. The role of therapeutic alliance in eating disorder treatment outcomes. 2024;15:211436.
- Mian E. MindFoodNess. Find peace with food, body and emotions. Feltrinelli Editore, 2025.
Abbonati a Karla Miller
