Research

A pilot body image intervention programme for in-patients with eating disorders in an NHS setting

Patricia Caddy, Barbara Richardson

Background: Body image distortion, a distressing problem that precipitates eating disorders, remains a struggle for patients after other symptoms are controlled. Despite a strong physical aspect there is little recognition of physiotherapy intervention. This study aims to assess the effect of a tailored physiotherapy intervention programme for patients with eating disorders in an NHS in-patient unit. Methods: The intervention programme, targeted at known, potentially modifiable factors relevant to body image distortion in 7 patients, used touch, massage, drawing exercises and listening skills. Patients received 8 to 38 sessions determined by length of stay on the unit. Self-drawings were completed at each session and a body shape questionnaire (BSQ-34) and a self-assessment silhouette scale in the first and last sessions. Findings: Self-drawings showed improved comparative proportions of body areas. Initial silhouette scores of more than 5 out of 10 reduced to less than five. There was a reduction in BSQ-34 questionnaire scores for all patients, and to less than half for 3. Conclusions: This pilot study suggests that a tailored programme based on principles of physiotherapy can help to improve body image perception and satisfaction. It draws attention to the potential of physiotherapy intervention programmes in the UK.

Key words: n eating disorders n physiotherapy interventions n touch massage n body image Submitted 25 October 2011, sent back for revisions 14 December 2011; accepted for publication following double-blind peer review 20 February 2012

ody image distortion is a distressing argued that a narrow notion of body image should problem that precipitates eating dis- be replaced with the more complex construct of orders and remains a major issue for body experience, which encompasses cognitive Bthe patient after other symptoms are responses (what they think they really look like), controlled (Slade and Russell, 1973). A National affective responses (what they feel they look like) Institute of Clinical Excellence (NICE) Guideline and optative responses (what they want to look (NICE, 2004) proposes eating disorders comprise like) (Probst et al, 1995). Some studies combine a range of syndromes encompassing physical, reports of adolescent and adult case series without psychological, and social features. Anorexia ner- separate analysis (NICE, 2004, p. 34). vosa and bulimia nervosa are frequently chronic The NICE Guideline (NICE, 2004) includes Patricia Caddy conditions with substantial long-term physical physiotherapists in the list of health profession- was Physiotherapy and social sequelae, from which recovery is dif- als who can be involved with patients with eating Manager for the ficult. The NICE Guideline states that about 1 in disorders (ibid. p.12), but despite a strong physical Cambridge locality, Cambridgeshire and 250 females and 1 in 2000 males will experience aspect related to body image, no reference is made Peterborough Foundation anorexia nervosa, generally in adolescence or to physiotherapy intervention programmes. A spe- NHS Trust, UK (now young adulthood and about five times that number cifically adapted form of Cognitive Behavioural retired); and will suffer from bulimia nervosa. Males experi- Therapy (CBT) is recommended as the treat- Barbara Richardson ence many concerns about their bodies similar ment of choice for patients with bulimia nervosa is Reader Emeritus, Faculty of Medicine to females. The concept of body image, often (ibid. p.16) while therapies to be considered for and Health Sciences, termed body dissatisfaction, has two components: the psychological treatment of anorexia nervosa University of East first, body perception, the individual’s estimate also include cognitive analytical therapy (CAT), Anglia, Norwich, UK of their body size; and second, the individual’s interpersonal psycho-therapy (IPT), focal psy- attitude towards their body (Slade and Russell, chodynamic therapy, and family interventions Correspondence to: Patricia Caddy 1973; Rosen, 1996, Skrzypek et al, 2001). Not all focused explicitly on eating disorders (ibid. p.10). E-mail: p.caddy@ patients with eating disorders overestimate their A limited improvement from massage in anorexia ntlworld.com body size (Probst et al, 1998a; 1998b) and it is nervosa symptoms but not weight gain is noted

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(ibid. p. 103) and the lack of randomized control- condition, particularly body image disorder and led trials (RCTs) comparing exercise or massage inappropriate exercise behaviour. In a professional with psychological interventions for treatment of newsletter, Duckworth (2000) highlights the lack people with bulimia nervosa (ibid. p. 147). The of medical and public appreciation of physiothera- guidelines state that although physical therapies pists working in the recovery process of eating are used in some European countries e.g. Belgium disorders and points to less than 50 units available and Norway (ibid. p. 101), with a long tradition of for patient access in the NHS and the private sec- integrating physical therapies into psychological tor, many of which with long waiting lists being therapy, this is not the tradition in the UK. without physiotherapy. She calls for wider access The aim of this study was to assess the effect to outpatient departments to enable earlier inter- of a tailored physiotherapy programme. A lit- vention. Tonkin (2000) further argues that physi- erature search of relevant data bases: CINAHL, otherapists are well placed to help young people AMED, PsychINFO, EMBASE carried out for address body image and to play a key role in rein- physiotherapy studies reported in English, using forcing healthier lifestyle messages. combinations of key words: Body image, inter- Until a more substantial evidence base is estab- ventions, Anorexia Nervosa, Bulimia Nervosa, lished it is unlikely that physiotherapy can form Eating Disorder, and physiotherapy, substantiates part of the routine practice of eating disorder the paucity of evidence of physiotherapy inter- services in the UK. However, as suggested by the ventions in general and in UK health care in par- NICE Guideline (2004) the absence of empiri- ticular. Few relevant studies were identified. For cal evidence for the effectiveness of a particular example, in the United States the focus is on phys- intervention is not the same as evidence for inef- iotherapy responsibility in recognizing, treating fectiveness. Eating disorders present complex and preventing the female athlete triad, in rela- challenges and treatment tends to be long-term tion to eating disorders. In this syndrome the low with the possibility of frequent relapses. The set- energy availability that leads to menstrual dys- ting, finding the right person to work with who function and compromised bone health can result has expert knowledge and particular qualities, who from an insufficient calorific intake (Pantano, will accept and understand the person as ‘an indi- 2009). Reporting in the Swedish language Berg vidual with a unique experience’ rather than as et al, (2005) stress the role of communication ‘a case of pathology’, is thought to be critical to in the therapeutic process, and Mattsson (1998) treatment success (NICE, 2004 p. 39). theorises body awareness to be a key element of This paper is aimed at assessing the effect of physiotherapeutic practice in work with patients a tailored physiotherapy programme. It proposes with eating disorders. Thornberg and Mattsson physiotherapy can play a unique and explicit role (2010) used assessment scales to look at the in the treatment of eating disorders within the concordance of a physiotherapist’s observation multidisciplinary team, using physical strategies with 87 patients’ own reports of bodily expres- to help patients overcome their symptoms and to sion. Although the PT observations did not always accept their changing body shape. The concept of concur, the study prompts further examination a physiotherapy intervention programme was gen- of appropriate methodology and physiotherapy erated by the first author (PC), during many years research in this area of health. They suggest Basic of experience working with patients in this area. Body Awareness Therapy (BBAT) (Roxendal, Patients reported positively to not only benefit from 1985 cited in Thornberg and Mattsson, 2010), a massage for the relief of muscle tension and anxi- treatment modality within psychiatric and psy- ety, but also improvement in their body awareness. chosomatic physiotherapy, developed for patients with longstanding complex illnesses including Methods patients with eating disorder, is an established treatment in many countries, although this is not Following advice from the local ethics committee evidenced in this literature search. In the UK, in 2009 an opportunistic sample of seven patients Mandy and Broadbridge (1998) conducted a ques- with eating disorders post-discharge were invited tionnaire survey of 159 members of Chartered in writing to allow their personal data to be ana- Physiotherapists in Mental Health to ascertain lysed. They each signed a consent form. Six were their involvement in anorexia nervosa. Of the 115 female and one male. The intervention programme responses, just under half had treated patients with was targeted at known, potentially modifiable fac- anorexia nervosa. From the responses they con- tors relevant to body image distortion in each of clude that physiotherapists are adopting holistic the 7 patients and used touch, massage, drawing and individualistic approaches, using a range of exercises, and listening skills. Each programme techniques in the treatment of many aspects of the was individually tailored. Patients received a max-

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imum of 38 and a minimum of 8 treatment ses- (where 0 is anorexic and 10 is obese) in rela- sions determined by the patient’s length of stay in tion to a) how they felt about their body, b) how the Eating Disorder Unit. they thought they looked, c) how they would like to have looked and d) how they believed others Physiotherapy intervention saw them. Finally they completed a set of self- The aims of the programme were to provide the drawings, a technique devised by the author (PC) patients with relevant information on anatomy to gain a personalized picture of how they saw and the physiology of weight gain, to give them themselves. The self-drawings were intended to advice on healthy exercise levels (including facilitate a way for patients to communicate how types of exercise to help prevent loss of bone they perceived themselves and for the physiothera- density, particularly in the lumbar spine), to pist to be able to give feedback on comparison provide a tailored exercise programme appropri- between these images and her own observations. ate for the patient’s current Body Mass Index They also served as an on-going record of change (BMI), to encourage physical activity in a group in body perception which could be reassuring to setting and to teach relaxation techniques. An patients. Each session followed a set format of important focus, particularly with inpatients self-drawings, body awareness, touch, massage, with a very low BMI, was to help them gain a mirror work, and postural awareness. more realistic body image, to raise body aware- ness and to re-educate their posture using a 1. Self-drawings variety of techniques including shared discus- At the beginning of each session the patient sion, massage, self-drawings and use of a mir- was asked to draw a front view outline of them- ror. The interaction continued as the patients’ selves that represented how they felt about their BMI increased to help them accept a changing body. They were then asked to draw another body shape. one which represented how they thought they The work programme for each patient had six looked. They were asked to be as spontane- components and was provided on a one-to-one ous as possible while drawing and not to ago- basis by a physiotherapist (PC) in the in-patient nize over it. Some patients found it helpful to setting. Patients were referred by their primary also draw lateral (side) views of themselves. nurses, or ward doctors, who had, during the Following the whole body massage given later admission consultations, identified that they had in the session, they were asked to repeat this significant body image issues. The programme drawing exercise. A final set of two or more started as soon after admission as possible to drawings was then obtained during or after the ensure that a patient’s body image distortion did mirror work if the patient felt that the image not become entrenched and, therefore, more dif- they saw had changed further. The drawings ficult to change. In a series of weekly sessions were kept as a record of the changing percep- patients were introduced to basic, relevant infor- tion of the patient. mation on anatomy and physiology, self-drawings, massage, mirror work, Pilates for postural aware- 2. Body awareness ness and strengthening of core stability muscles. Body awareness work began with the patient It was also felt important to give patients time and lying on a mat on the floor as a firm surface. It psychological space to explore the feelings evoked was intended that the contact their body made by this work. with the surface would start to give them clues about their size and shape. With eyes closed, Assessment process working down from the back of the head, they At a first session, in order to establish baseline were asked to describe where the different parts measures, the patient completed a validated body of their body were making firm contact with the shape questionnaire BSQ-34 (Cooper et al, 1986) surface and to describe the shape of that con- which gave an indication of the degree of body tact. They were then asked to identify if there image distortion. This required them to respond were any concentrated areas of contact. This to 34 questions using a Likert-type scale rang- was followed by identifying the gaps where ing from 1(never) to 6 (always). They also com- there was no contact. The patient then compared pleted a self-assessment silhouette scale, an left and right contact and felt the position of adapted version of the BMI Silhouettes Survey arms and legs and whether their body was in a (Canadian Dietetic Association, 1988 cited in straight line. If they felt it was not, they were Abbott et al, 2007) to assess body size percep- asked to indicate what alterations in position tions. This asked them to score a series of body would achieve this and to compare the contact silhouettes of increasing size on a scale of 1–10 they felt with what they might have expected.

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3. Touch The third stage of the session involved using touch. The patient was asked to remain lying down with eyes closed. Using their hands, they were asked to estimate the width and depth of dif- ferent areas of their body, and then, for a moment, to open their eyes and look at where they had placed them. The physiotherapist (PC) then placed her own hands on the corresponding parts of the patient’s body, and asked them to describe what information they got from this contact.

4. Massage Having focused on different parts of their body through touching, it was important for each patient to get a sense of their body as a whole from a whole body massage. The massage was a par- ticularly important aspect of the treatment, dur- ing which the physiotherapist (PC) aimed to build a trusting relationship so that each patient could accept massage and the guidance and advice given Figure 1. Reversing the triangle to them. It was performed through light clothing, using firm, continuous strokes, so that the patient directly at themselves to help give more clues as was fully able to feel the contours of their body. to their real shape. Particular areas drawn to their In addition to giving information and a way of attention were their neck and the angle and width re-connecting with their body shape, touch and of their shoulders, and the elongated triangles massage used the therapeutic effect of helping formed by their arms resting at her sides with each patient to connect with another human being the apexes at either side their waist (typically, (Leder and Krucoff, 2008). Following the massage these patients often say that they do not have a they were immediately asked to do the second waist). This facilitates them to see the shapes self-drawing, representing what they actually felt around the outside of their legs that taper towards at that moment and not what they imagined they their feet and the colour of the wall between their might feel. This drawing was used for them to legs, which can further emphasise that their legs compare with the first drawing, completed at the are not ‘fat and round’. They were also asked beginning of the session. to compare the length of their upper and lower body, which is normally roughly half and half. 5. Mirror work Next they were encouraged to focus on looking In the mirror work part of the session, follow- directly at their body, to describe what they now ing the massage, it was first explained to the saw and to compare this with the drawings that patient that when they looked in the mirror they they did earlier in the session. This was followed would be asked to do so in a particular way. It by asking them to make a last drawing which is usual for many of these patients to see what reflected the changes they saw. they expect to see and to focus on the parts of their bodies they consistently overestimate in size 6. Postural awareness/re-education (Slade and Russell, 1973). Hence, the patient was The last part of the session was given over to pos- first positioned in front of a blank wall to make it tural awareness. Affective states, anxiety, in par- easier to see the body shape. Then, before look- ticular, have been shown to negatively influence ing in the mirror, they were asked to compare postural control (Galeazzi et al, 2006). Patients the width of their hips and shoulders. Typically, with eating disorders tend to be anxious and they will say that their hips are wider than their depressed and frequently display poor posture, the shoulders, so emphasis was put on asking them resulting image, when viewed in a mirror, adds to to check this in the mirror and to encourage them the distortion of how they perceive themselves. to see a reversed triangle, in which they noted Postural re-education, therefore, included use of that their shoulders were wider than their hips the mirror. Helping them to be more aware of and not vice versa (Figure 1). how they stand and move was an important aspect Each patient was then asked to focus on the of body image work. It was noted that most low shapes around their body rather than to look weight patients demonstrate poor core stability

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Figure 2. Patient 2 first treatment, BMI 15.8 End of treatment, BMI 22.8

from weakened postural muscles. The effect of Before any patient was discharged they were this is to increase the lumbar curve, which gives asked to complete a final self-assessment scale the appearance of having a protruding abdomen and a questionnaire which asked for their views on which can be interpreted by them as fat. A care- all of the techniques they had received. fully tailored exercise programme, including yoga and Pilates, was provided by the physiotherapist Process of analysis (PC) in collaboration with others in the physio- The self-assessment silhouette scores of each therapy team who were involved in these interven- patient were scrutinised for changes in body size, tions. Pilates was used as an exercise method to shape and proportions from before and after the elongate, strengthen, and restore the body to bal- intervention. Dissatisfaction with body shape was ance. It is considered to be one of the safest forms identified through responses to the BSQ-34 ques- of strengthening exercise (La Touche et al, 2008) tionnaire which focused on particular areas of the and therefore relevant to working with patients at body, most commonly, abdomen, hips and thighs. a low body weight. In addition to improving pos- Each set of patient self-drawings were compared ture, these techniques also aimed to improve mood for changes in body dimensions and whether and body perception through an increase in self- patients tended to represent themselves as hav- confidence and for patients to be able to observe ing a large body, with short, fat legs. Responses their dynamic as well as static posture. This part to the evaluative questionnaire at the end of the of the session was then sometimes finished with programme were examined to identify whether the completion of a third set of two self-drawings if programme was considered helpful, if there was they were now seeing a very different image. any pattern in preferred approaches at different Sessions lasted approximately 45 minutes and stages of the programme and for any commonali- were carried out on a weekly basis. The number ties in responses to open questions. of sessions depended on the patient’s willingness to engage, whether they could see evidence of Results improvement in their symptoms and their length of stay in the Eating Disorder Unit. Three patients The self-assessment silhouette scores at the were discharged and re-admitted during the study. beginning and end of the programme showed that

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Figure 3. Patient 6 First treatment, BMI 14.1 End of treatment, BMI 16.0

initial scores of more than 5 out of 10 moved to their drawings whilst similar numbers a focus on scores of less than five (Table 1). the massage, mirror work or postural strategies. Scrutiny of the patient self-drawings identified Positive comments on the programme and the changes in the comparative proportions of body personal guidance and interaction with the physi- areas to be more accurately represented (see for otherapist were typical (Box 1). example Figure 2). Body image tended to be more grossly distorted when their BMIs were at Table 1. Self- Assessment silhouette scores before and after (in bold) the their lowest (see for example Figure 3). programme The scores of the BSQ-34 questionnaire (Table 2) at the beginning and end of the programme Patient Question a Question b Question c Question d indicated an overall reduction in score for all PT1 9 4 9 2 2 2 9 2 patients, with 3 patients showing scores of less PT2 7 4 6 2 2 2 4 2 than half. PT3 8 3 6 3 3 3 2 3 Collation of responses to the discharge evalu- ation questionnaire indicated that all found the PT4 8 4 6 9 3 2 6 3 programme helpful. In the early to middle stages PT5 10 6 9 5 2 3 9 5 of intervention the seven participants valued the PT6 10 5 10 4 1 1 10 3 treatment strategies equally, but towards the end PT7 8 3 7 2 1 2 2 2 of the intervention some preferred a focus on

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Table 2. BSQ-34 scores before and after recognized that touch was a powerful experience programme that helped patients connect with their bodies and Patient Before After make a trusting relationship with another person. Participating patients accepted physical contact PT1  144 80 from the physiotherapist, seeing it as part of her PT2  159 74 professional role. Mirror work, considered an PT3  128 56 important component in bringing about changes PT4  159 97 in body image and results in reduction of body PT5  171 117 dissatisfaction (Key et al, 2002) was purposefully introduced to enable patients to make corrections PT6  161 95 to their postures while static, and also to main- PT7  150 67 tain the changes while moving. Posture can reflect how people feel about themselves (Delinsky and Discussion Wilson, 2006) and can add to a distorted percep- tion of body image, because it changes physical The findings of this pilot study endorsed the appearance. Pilates was an important aspect of observations made during work experience over body image work because the re-education of pos- several years with this patient group and with ture helped patients to see how this altered their findings of Slade and Russell (1973). The self- appearance and for them to become more aware drawing technique introduced by the author (PC) of how they stand and move. It is not yet under- showed that at a low body weight, patients’ body stood whether the patients who experience the image distortion is at its greatest, but by the end greatest distress about their bodies during weight of treatment/point of discharge, with higher body restoration also have the highest ratio of central weight, it was represented more accurately. This fat to extremity fat, however, assertions by some reflected the scores of those with a severe body patients that the weight is ‘all going to my stom- image distortion, who tended to choose only one ach’ may for them be a reality and not a body image from the silhouettes in the body silhouette image distortion (Mayer, 2001). Although it is not self-assessment to represent how their body felt known how long this persists, work on muscle and how they thought it looked. strengthening and posture to change appearance, During the body awareness and massage com- may help patients to tolerate this phenomenon. ponents of the programme, typically, the patient Analysis of the evaluative questionnaire high- expected to feel more contact with the mat than lighted the need to be flexible in the use and they actually experienced during the body aware- emphasis placed on the six component strategies ness and massage components of the programme. in an individual programme. The intervention pro- Others were able to distinguish between these gramme allowed a physiotherapist to establish a different perspectives, although feelings of being close rapport with patients who often have great big and fat predominated. Similarly, patients who difficulty trusting themselves or anyone who tries avoid making contact with their bodies and avoid to get physically close to them. Time was given being touched by others, were able to feel the true for patients to explore their feelings and encour- boundaries of their bodies in contrast to their mis- agement given to express them in the therapeutic perceptions about size and shape. From patient alliance which developed. The use of touch par- responses and physiotherapy observation it was ticularly helped patients express the feelings that the work evoked which was a crucial first step. Box 1. Typical comments from patient evaluation of the intervention Whole body massage can be a particularly power- “I have benefited greatly and this continues as I am now quite proud of my body, ful medium of communication with patients who which previously, I loathed.” avoid making physical contact and avoid looking “They were one of the most important and helpful meetings during my treatment. in mirrors. It is a very immediate way for patients I slowly started enjoying all the changes to get a woman’s body. Even though it to recognize that their body is not as they imagine was hard and painful sometimes, I could talk about everything to try to sort out it to be, although it may take further time for this my problems.” to be believed consistently. “I wish I could have seen her [sic the physiotherapist] every day. I could scarcely These findings suggest that as weight is slowly believe by how much I overestimated my size.” restored, cognitive ability improves and percep- “… has opened my eyes to a new perspective on the world and also myself. When tion of bodily dimensions becomes more accu- I look in the mirror I can see what is there. I have learnt how to see a realistic, rate. Rosen (1996) also proposes that as BMI rather than dysmorphic, picture of myself. My recovery is based upon this funda- increases, patients’ perception of their bodies mental change of view.” becomes more realistic, although notes that a focus on body size estimation alone is not suf-

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ficient to change body image. Key points In this unit the primary nurses, psychologists, occupational therapists, dieticians, doctors, and other Allied Health Professionals (AHPs), worked n Despite a strong physical aspect related to body image in eating disorders, individually and in groups simultaneously to chal- there is little acknowledgement of physiotherapy intervention programmes. lenge each patient’s eating disorder. The philoso- n Until a more substantial evidence base is established it is unlikely that phy of the unit was that perceptual and attitudinal physiotherapy can form part of the routine practice of eating disorder elements of body image could together reframe services in the UK. the patients’ beliefs during the work with the physiotherapist and key members of the multi- n A physiotherapy intervention programme to address body image distortion disciplinary team. It was therefore, important can be individually tailored to use touch, massage, drawing exercises, and for the physiotherapist (PC) to advise colleagues listening skills. on the physical dimensions of eating disorders n Self-assessment scales and body drawings can be used as an integral part of including information on associated problems of the intervention and to evaluate progress. osteoporosis and stress fractures, peripheral neu- ropathies, and physical activity levels appropriate n A physiotherapy intervention programme can make an important to BMI levels. There is a strongly held view by contribution to the work on body image in a physical way. some clinicians that confronting patients with their own distorted self-perception has little therapeutic There is no conflict of interest for either author. impact (Garner, 2002). The authors would like to thank all the patients who took While it cannot be claimed that this interven- part in this work; Librarians at the Chartered Society of tion programme alone achieved the successful Physiotherapy, London for their support in searching the literature. Elizabeth Chapman , Psychologist, Cambridgeshire outcomes, the findings suggest it does endorse a and Peterborough Foundation NHS Trust and Colleagues from holistic approach, where feelings as well as per- the Network of Physiotherapists working in Eating Disorders: Lynn Hammond, Judith Bentley, Lilian Mapeza, Maggie Ward, ceptions are addressed to improve body image Yvonne Hull, Jan Dunford, Christine Kemp, Kate Rogers. and psychological health. Body image is only This work was briefly outlined in a shared presentation with one symptom of an eating disorder but it is pro- other physiotherapy colleagues working with eating disorder posed that the more realistic the body image patients at the Chartered Society of Physiotherapy (CSP) Annual Congress 2003. is on discharge, the less likelihood there is of relapse (Slade and Russell, 1973; Slade, 1985). Patients with a chronic eating disorder are Abbott J, Morton AM, Musson H et al (2007) Nutritional sta- unlikely to restore much weight during hospital- tus, perceived body image and eating behaviours in adults with cystic fibrosis Clin Nutr 26(1): 91–9 ization, but, as these findings suggest, this type Berg AL, Boise F, Svensson K, Clinton D (2005) An intersub- jective approach to physiotherapy in patients with eating of physiotherapy intervention programme can disorders (English abstract) Nordisk Fysioterapi 9(2): 64–73 help patients become more satisfied with their Cooper PJ, Taylor MJ, Cooper Z, Fairburn CG (1986) The Development of the Body Shape Questionnaire Int J Eat body image which can lead to maintenance of Disord 6(4): 485–94 a slightly higher weight, which may allow them Canadian Dietetic Association (1988) The Body Test Canadian Dietetic Association Toronto Ontario Canada. to lead a fuller life than was previously pos- Delinsky SS, Wilson GT (2006) Mirror exposure for the treat- ment of body image disturbance Int J Eat Disord 39(2):108– sible. Future research needs to evaluate physi- 16 otherapy intervention programmes and further Duckworth N (2000) Tackling the twin faces of Anorexia nervosa and the physiotherapists role in helping sufferers work could look more closely at the use and to correct distorted body image. Physiotherapy Frontline value of self-drawings in personalized treatment 6(6):10–1 Galeazzi GM, Monzani D, Gherpelli C, Covezzi, Guaraldi programmes. GP (2006) Posturographic stabilization of healthy subjects exposed to a full-length mirror image is inversely related to body-image preoccupations. Neurosci Lett 410(1): 71–5 Conclusion Garner DM (2002) Body Image in Anorexia Nervosa. In: Cash TF, Pruzinsky T (eds) Body Image, A Handbook of Theory, Research, and Clinical Practice. 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COMMENTARies

ody image is a multidimensional con- This type of intervention has shown that struct that involves perceptual and “ Battitudinal (subjective/affective, cogni- perceptual and sensomotor learning may tive, and behavioural) factors whose altera- tion is considered a major diagnostic criteria contribute to the improvement of the attitudinal in eating disorders (ED). component of body image distortion in ED ” This study of body image distortion in ED. The role of physiotherapy has been gener- The AN patient thinks, ‘My mind is strong- American Psychiatric Association (2006) Practice ally limited to functional recovery of motor Guideline for the Treatment of Patients er than my body’, but he/she actually has a with Eating Disorders (3rd edn). American impairments and disabilities in the field of limited knowledge of his/her own body as Psychiatric Association, Washington DC. ED. In the present research, the authors well as a low interoceptive awareness. AN http://psychiatryonline.org/data/Books/prac/ EatingDisorders3ePG_04-28-06.pdf (accessed 15 pursue the reconstruction of a body image patients usually overestimate their weight March 2012) accepted by the patient with anorexia nervo- and shape when compared to other peo- Halmi KA (2009) Salient components of a com- sa (AN) through an adequate psychomotor ple. The proprioceptive experience of one’s prehensive service for eating disorders. World Psychiatry 8(3):150–5 experience that brings the patient to reality. body (touching, being touched, mirroring...) As it happens with innovative protocols, National Institute for Clinical Excellence (2004) seems to have improved the affective and Eating Disorders Core Interventions in the the study has a small sample size and some perceptual experience of the AN patients in treatment and management of anorexia ner- methodological flaws that do not allow a this study. vosa, bulimia nervosa and related eating dis- quantitative analysis but a qualitative evalu- orders. www.nice.org.uk/nicemedia/pdf/ CG9FullGuideline.pdf (accessed 15 March 2012) ation of the data. However, the intervention Conclusions used by the researchers involved many So it can be concluded that this work is a techniques to increase patients’ self image useful contribution and a promising field of and body awareness through a practical and research to expand the therapeutic strate- Dr. Cristina Segura-García MD, PhD direct method: self-drawing, body aware- gies for ED. New components to those that Assistant Professor, ness, touch, massage, mirror work, postural are currently advised (APA, 2006; Halmi, Dept. Health Sciences, awareness, and re-education. This type of 2009) or are marginally mentioned (NICE, University Magna Graecia of Catanzaro, intervention has shown that perceptual and 2004), like physiotherapists, could be prop- Catanzaro, Italy sensomotor learning may contribute to the erly involved in the multidisciplinary team of [email protected] improvement of the attitudinal component a comprehensive service for ED.

ody image distortion is a common plays a specific and complementary role. psychosocial wellbeing, individual body phenomenon among patients with Equally important is the clinical use of tools image, and physical fitness in patients with Beating disorders. The literature that that can identify eating disorders among eating disorders. addresses this issue is quite complex and healthy patients. The most involved profes- frequently questionnaires and other tools sionals on body image distortion cases are Applying the tools properly are used inappropriately with these patients. usually the dietitian, doctor, and psycholo- Because many of the tools used with body Therefore the multidisciplinary team must be gist. Physiotherapeutic intervention, on the image distortion are subjective measures, a mingling group where each professional other hand, has been shown to improve it would be interesting if the technique

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suggested by the authors in this study was period of treatment. ter treated and evaluated. Like many other applied to a larger sample, even in the case It might also be advantageous to cross ref- methods it needs some amendments but it of a pilot study. It would give more reliability erence information from the questionnaires is certainly an interesting, simple, and practi- for the technique which is very interesting. used by the physiotherapist with those used cal method. Moreover, the authors pointed Despite knowing that eating disorders affect by the others professionals involving dif- to the real need for a physiotherapist in the more women than men it would be interest- ferent yet complementary aspects such as multidisciplinary team, who would play a ing to have a larger group with male individ- Eating Disorder Inventory, Eating Attitude key role, taking the lead directly on body uals as this population has been increasingly Test, Body Attitude Test and Quality of Life issues contributing to the rehabilitation of involved with eating disorders. Scale SF-36. This is an important aspect, as these patients. Another possible development of this from this information, it could be elucidated study is that patients could do the drawing if the progression of body image is being test more than was proposed, for example, followed by the progression of the food Cristiane Moraes RD they would draw themselves at baseline, behaviour, for example. PhD Student at Cardiovascular Sciences after 2–3 weeks of treatment, and at the Graduate Program end of the treatment. This would help Conclusions Federal Fluminense University – UFF to identify which phase of treatment the It is crucial that methods such as those pro- Niterói- Rio de Janeiro- Brazil patient begins to progress in, which would posed by the authors are developed and val- [email protected] in turn help to define and set a minimum idated so body image distortion will be bet-

ody image disturbance has long tion. Moreover, the study highlights the been recognized as a key element This type of need to be flexible in the use of the several in eating disorders (ED). Previous “ components of the programme depending B intervention has shown studies provide evidence about the impor- on the specific needs of each patient. tant role that disturbances such as body that perceptual and shape and weight overestimation and body Conclusions image dissatisfaction, play in the develop- sensomotor learning Body oriented psychotherapy seems to have generally good effects on a wide range of ment, maintenance, and prognosis of ED. may contribute to the Actually, body image disturbances form mental disorders and is specially suitable for part of the criteria for the diagnosis of both improvement of the those pathologies that involves a disturbed anorexia and bulimia nervosa according to body image, such as ED. Practice-based clini- the DSM-IV-TR (APA, 2000). attitudinal component cal evidence provides support to this state- Despite this, body image has often been of body image ment but more empirical research is needed. neglected or ascribed a secondary role in This study by Caddy and Richardson is one ED treatment programmes. This is prob- distortion in ED more step in the right direction but there ably due to the fact that body image is a ” is still much work to do. More randomized sations and perceptions as well as their emo- clinical trial studies on the effectiveness of construct difficult to express and highly tions and behaviours. According to Röhricht resistant to reasoning-based interventions. different body oriented therapies are need- (2009), BOP offers promising additional ed. Likewise, future research should focus There are effective and well-established psychotherapeutic tools in psychopatholo- treatments for ED patients, such the cogni- on which individuals benefit from which gies such as ED, where traditional talking specific body oriented techniques. tive behavioural therapy. However, there therapies seem to fail. However, there is a is a percentage of patients who do not lack of systematic research evaluating the progress or suffer relapse. It is necessary effectiveness of these therapies. to explore possibilities of improvement of these treatments with the incorporation This study of components which specifically address The present study provides information American Psychiatric Association (2000). Diagnostic and statistical manual of mental Disorders. 4th body image disturbances. about a body image intervention pro- edn, text revision. Washington, DC Body oriented therapy and psychotherapy gramme for in-patients with ED, based Röhricht F (2009) Body oriented psychotherapy. (BOP) encompass a wide range of tech- on body oriented therapy. The programme The state of the art in empirical research and niques, including those involving touch, includes six components:  self-drawing, evidence-based practice: A clinical perspective. Body, Movement and Dance in Psychotherapy movement, and breathing, specifically body awareness, touch, massage, mirror 4(2): 135–56 addressed to the treatment of the disturbed work, and postural awareness/re-education. body. BOP is based on the premise that Data suggest that a programme based on reciprocal relationships within the body and principles of physiotherapy can contribute mind exist, and that both body and mind to help ED patients to improve their body Marta Ferrer-Garcia, PhD contribute equally to the organization and image. At the end of treatment, all partici- Lecturer at the Department of Personality, functioning of the whole person. The main pants showed a more accurate representa- Assessment and Psychological Treatments purpose of these interventions is helping tion of their own body and a reduction of Universitat de Barcelona, Spain people to be more aware of their bodily sen- both body distortion and body dissatisfac- [email protected]

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