8 Jun 2021
The term “body dysmorphia” typically connotes anorexia nervosa in the lay public, though the nature of distorted body image in AN is greatly misunderstood.
The general picture in anorexia nervosa is not “skinny girl thinks she’s fat” (Sing Lee 1995) but rather “denial of severity of thinness” (Casper 1998).
By the description of Lasègue (1873), a French physician:
Ce qui domine dans l’état mental de l’hystérique, c’est avant tout une quiétude, je dirais presque un contentement vraiment pathologique. Non seulement elle ne soupire pas après la guérison, mais elle se complaît dans sa condition malgré toutes les contrariétés qu’elle lui suscite.
Ironically, it is not body dissatisfaction we see here but pathological contentedness in the context of low body weight.
One can recognize this attitude even in a 5th century Chinese hagiography (Eskildsen 1994, 249):
He was a man of Shanyin, Kuaiji. When his mother passed away he took up mourning and became renowned for his filial piety. From this time on he completely disengaged himself from merriment, drinking and culinary delicacies. He ate only porridge and vegetables and wore only plain clothing, vowing to do so for the rest of his life. His father was in the capital, and knew nothing about this. Later, when [Lingchan] went out to the capital to visit [his father], [his father] saw that [Lingchan] had become emaciated. His father felt sorry for him and ordered that fine foods be prepared in the kitchen for him and his son to eat together. Obeying the kindly instruction from his father [to eat], he reluctantly forced himself take [the food] to his mouth and eat it, and ultimately because of it became ill. His father [did what he did] because of his benevolence, but one’s nature endowed from Heaven cannot be changed. [Thus] he never forced [Lingchan to eat lavish food] again.
We see that Lingchan’s disturbing appearance did not motivate him though it worried his father.
So “denial of severity of thinness” is recognizable across disparate cultural contexts (S. Lee, Ho, and Hsu 1993); I posit that it is psychobiological in nature.
By contrast, wanting to be thinner despite not being overweight is common in young women in the US, and in the general population dissipates with age.
Even as young women may say they are fat without being overweight, they may not genuinely believe it in the way anorexics do. One of the seeming scar effects is distorted proprioception. This is eloquently demonstrated by door studies (Guardia et al. 2010; Beckmann et al. 2021): anorexics will tilt themselves more than controls when passing through a doorway (despite being thinner).
Thus, I do not believe the distorted body image present in anorexia nervosa has any continuity with the general population. One cannot have denial of thinness without thinness, and the proprioceptive aspects are simply not present.