on October 08, 2026
The real body and the perceived body
There is a biological body and a mental representation of it. There is not always a perfect correspondence between the two.
Body image does not coincide with the simple perception of physical dimensions. It is a complex construct in which visual, tactile, proprioceptive, and interoceptive information converge, along with emotions, memories, expectations, personal beliefs, and social meanings attributed to the body.
In eating and nutrition disorders, this representation can become profoundly altered. The person may focus disproportionate attention on weight and shape, interpret certain bodily sensations through negative lenses, or attribute excessive importance to their appearance in defining their self-worth.
It is therefore more accurate to speak of a body image disorder or alteration rather than reducing the phenomenon to the mere belief of being larger than one actually is.
Research, in fact, indicates that the cognitive-affective component of body image — dissatisfaction, preoccupation, fear of weight gain, and overvaluation of weight and shape — may be clinically more relevant than the simple perceptual overestimation of body dimensions.
When weight becomes a measure of self-worth
One of the most important psychological mechanisms in eating disorders is the overvaluation of weight and body shape.
In conditions of psychological well-being, weight represents only one of many characteristics of a person. In an eating disorder, however, it can become a dominant parameter through which one evaluates their self-worth, personal success, and social acceptability.
The reasoning can take different forms:
- “If I lose weight, I will finally be satisfied with myself.”
- “If I gain weight, it means I have failed.”
- “My body determines how much I am worth.”
- “I cannot afford to look this way.”
- “I must constantly check my body to make sure I haven't changed.”
It is therefore not only the body that is the object of concern: it is the meaning attributed to the body that becomes pathologically central.
This dynamic is particularly important in anorexia nervosa and bulimia nervosa, in which self-evaluation can be excessively influenced by weight and body shape. Contemporary diagnostic criteria consider the presence of a significant alteration in the way one's weight or shape is experienced and evaluated among the characteristic elements of anorexia nervosa.
Body checking and body avoidance: two seemingly opposite behaviors
One of the most interesting characteristics of body image alteration is that it can produce seemingly contradictory behaviors.
On one hand, body checking may emerge, which is the repeated and often ritualized checking of the body.
Continuously looking at oneself in the mirror, checking the circumference of a part of the body, comparing oneself with previous photographs, touching one's body to check for any changes, or repeatedly checking how clothes fit are some examples of this behavior.
On the other hand, body avoidance may emerge, which is the avoidance of the body.
The person may avoid mirrors, wear very loose clothing, avoid photographs, give up swimming or going to the gym, avoid social situations in which the body might be observed, or refuse to look at certain parts of their body.
These are different strategies, but they can serve a similar psychological function: temporarily reduce the distress caused by the body.
A systematic review with meta-analysis has highlighted significantly higher levels of body checking and body avoidance in people with eating disorders compared to controls; in non-clinical populations, both behaviors were also strongly associated with eating psychopathology.
A subsequent meta-analysis confirmed robust associations between body checking, body dissatisfaction, and eating symptomatology, as well as between body avoidance and these same psychopathological dimensions.
Continuous body checking can therefore become part of a maintenance cycle: the person experiences uncertainty or distress, checks their body to get reassurance, interprets what they see through negative cognitive lenses, and again experiences dissatisfaction and anxiety.
Body image distortion is not just “seeing yourself as fatter”
The popular representation of eating disorders often tends to simplify the problem: the person “sees themselves as fat” despite being very thin.
The clinical reality is more complex.
Body image includes at least three interconnected dimensions:
The perceptual component, relating to the way information about the body is processed.
The cognitive component, relating to thoughts, beliefs, and interpretations regarding weight and shape.
The affective component, relating to the emotions associated with one's body, such as shame, anxiety, disgust, fear, or dissatisfaction.
To these is added a behavioral component, represented by checking, avoidance, social comparison, and strategies aimed at modifying or protecting the body.
For this reason, two people with an eating disorder may present very different manifestations of bodily distress.
Research on the relationship between body image and anorexia nervosa suggests an important association with clinical course, but also highlights that it is not yet possible to consider every body image alteration as an independent and proven cause of the disorder. A systematic review of 46 studies, including almost 5,000 people with anorexia nervosa, found evidence of a relationship with the course of the illness, while emphasizing the need for more rigorous experimental studies to establish causal relationships.
This distinction is important: association, maintenance factor, and cause are not synonyms.
Why body image can hinder recovery
Recovery from an eating disorder does not exclusively consist in normalizing eating.
A person may stop bingeing and engaging in compensatory behaviors, improve their food intake, and achieve greater clinical stability while still experiencing their body through fear, judgment, and control.
This represents a major vulnerability.
The persistence of body dissatisfaction has, in fact, been associated with a higher risk of relapse and represents one of the areas that must be monitored during the therapeutic journey. A systematic review on body image alterations in anorexia nervosa highlighted precisely their relevance throughout the different phases of treatment and their association with the risk of relapse.
Treatment, therefore, should not be limited to eliminating pathological eating behavior, but should also address the cognitive and emotional mechanisms that continue to fuel it.
The signs that deserve attention
Body image distortion is not always immediately obvious.
Some signs may be subtle and appear before the eating disorder becomes clearly recognizable.
Among the elements that deserve clinical investigation are:
- persistent concern about weight, shape, or body dimensions;
- frequent mirror checking;
- avoidance of mirrors or photographs;
- the need to hide the body through very loose clothing;
- avoidance of swimming, the beach, the gym, or other situations in which the body may be exposed;
- continuous comparison with other people;
- strongly self-critical inner dialogue;
- intense fear of physiological changes in the body;
- strong dependence of self-esteem on weight or appearance;
- physical exercise used primarily to compensate for eating or modify the body;
- food restriction associated with the fear of gaining weight.
One fundamental element is to remember that outward appearance does not allow one to rule out an eating disorder. People with these disorders can have very different body types, and it is not possible to establish the presence or absence of the pathology simply by observing the body.
The role of the general practitioner
The general practitioner can represent a particularly important early point of detection.
However, the interview should avoid turning the visit into another occasion for judging weight.
Exclusively quantitative questions — “How much do you weigh?”, “How much do you want to lose?”, “How many calories do you eat?” — may be necessary in some clinical contexts, but are not sufficient to understand the problem.
It is equally important to explore the psychological meaning attributed to the body and eating.
Questions such as:
“How do you experience your body at this time?”
“How much space do thoughts about weight and shape occupy in your day?”
“Are there situations you avoid because you do not feel comfortable with your body?”
“How much does your mood depend on what you see in the mirror?”
can open up a much richer space for communication.
Contemporary clinical guidelines emphasize the importance of assessing not only eating behavior, but also the time spent thinking about food, weight, and body shape, psychosocial impairment, and weight control behaviors.
Validating the distress without reinforcing the disorder
Effective communication does not mean confirming the person's pathological belief.
Saying “You are right, you are really too fat” would clearly be inappropriate. But simply responding “You are not fat at all, you have no reason to worry” may also not be sufficient.
The problem is not only to establish whether the perception is correct.
The therapeutic point is to recognize the suffering that perception generates.
A more useful clinical communication can be:
“I understand that your body is causing you a lot of suffering.”
“These thoughts can become very intrusive.”
“We can work together on the relationship you have with your body.”
“The problem is not only weight: it is how much these thoughts condition your life.”
This approach allows validating the emotional experience without reinforcing dysfunctional beliefs.
Cognitive-behavioral therapy and body image treatment
Cognitive-behavioral therapy focused on eating disorders represents one of the most studied approaches.
In its CBT-E, Cognitive Behaviour Therapy-Enhanced form, the treatment does not consider eating behavior as an isolated phenomenon, but works on the processes that contribute to maintaining it.
Among these are:
- overvaluation of weight and shape;
- food restriction;
- body control;
- avoidance;
- compensatory behaviors;
- perfectionism;
- difficulty in emotional regulation;
- low self-esteem;
- rigid and dichotomous thoughts.
A systematic review comprising 20 studies, of which 10 were randomized, found evidence in favor of the efficacy and effectiveness of CBT-E in reducing pathological eating behaviors and the core psychopathology of eating disorders. However, the studies do not uniformly demonstrate the superiority of CBT-E over all other treatments, and long-term response remains an important area of research.
NICE guidelines include CBT focused on eating disorders among the main psychotherapeutic options for anorexia nervosa in adults and explicitly indicate intervention on concerns related to body image, self-esteem, and relapse prevention.
Mirror exposure: looking at yourself without judging
Among the strategies used in some psychotherapeutic pathways is mirror exposure.
It does not simply mean asking the person to look at themselves.
Therapeutic exposure is structured, progressive, and conducted within a clinical pathway. The goal is to reduce avoidance and gradually change the way the body is observed and interpreted.
Attention can be shifted from aesthetic judgment to a non-judgmental description of the body and the present emotional experience.
The evidence is promising, but must be interpreted with caution. A literature review found improvements in body image associated with mirror exposure, while a broader systematic review highlighted favorable results but also small samples, methodological heterogeneity, and difficulty in separating the effect of the single technique from that of the overall psychotherapeutic treatment.
Controlled studies have also shown improvements in body checking, avoidance, body dissatisfaction, and concerns related to weight and shape after structured mirror exposure interventions.
However, the technique should not be improvised independently by a person with an eating disorder: exposure can cause discomfort and must be adapted to individual characteristics and included in the appropriate treatment.
The role of the family and the care network
Eating disorders often require a multidisciplinary approach.
A doctor, psychologist or psychotherapist, nutritionist/dietitian, and, when necessary, psychiatrist can contribute to the assessment of the different dimensions of the disorder.
The involvement of the family takes on particular importance, especially in adolescents.
The family should not become a controller of food or weight, but a relational resource capable of supporting the therapeutic journey, recognizing signs of worsening, and promoting adherence to treatment.
Relapse prevention must also be considered an integral part of therapy. The person should learn to recognize early the return of rigid thoughts, body control, avoidance, restriction, or other pathological strategies.
A change of perspective: from the body to be corrected to the body to be inhabited
The recovery of body image does not necessarily mean reaching a point of loving every part of one's body.
This expectation can even be unrealistic.
A therapeutically more solid goal is to develop a more flexible, less judgmental, and less conditioning relationship with the body.
The body can gradually stop being a project to control.
A mirror can return to being a tool for recognizing oneself, not a verification device.
A physiological weight change can be accepted without automatically turning into a judgment on one's own value.
A meal can return to being a nutritional, social, and sensory experience, without becoming a moral test.
This transition is central because the goal of care is not simply to change an eating behavior: it is to restore to the person the possibility of living their body without being continuously judged by it.
A shared clinical responsibility
Eating and nutrition disorders represent complex, multifactorial, and potentially serious conditions. Available estimates indicate that over three million people in Italy are affected, with a particularly relevant involvement of the adolescent population.
Not all eating disorders present the same body image alteration, and not all people with strong body dissatisfaction develop an ED. This is precisely why the assessment must be clinical, individualized, and multidisciplinary.
Body image distortion, however, represents an area of great relevance: it can intertwine with food restriction, weight control, body checking, avoidance, shame, and self-evaluation, contributing to the persistence of suffering.
Recognizing these signs early means not stopping at the number indicated by the scale.
It means asking what relationship that person has with their body, how much this relationship conditions their life, and what suffering is hidden behind the desire to change it.
Care also begins here: from listening, from validating the suffering, and from the possibility of building, together with the person, a relationship with the body based less on control and more on awareness, flexibility, and well-being.
Bibliographic references
- Glashouwer KA, van der Veer RML, Adipatria F, de Jong PJ, Vocks S. The role of body image disturbance in the onset, maintenance, and relapse of anorexia nervosa: A systematic review. Clinical Psychology Review. 2019;74:101771. doi:10.1016/j.cpr.2019.101771.
- Nikodijevic A, Buck K, Fuller-Tyszkiewicz M, de Paoli T, Krug I. Body checking and body avoidance in eating disorders: Systematic review and meta-analysis. European Eating Disorders Review. 2018;26(3):159-185. doi:10.1002/erv.2585.
- Walker DC, White EK, Srinivasan VJ. A meta-analysis of the relationships between body checking, body image avoidance, body image dissatisfaction, mood, and disordered eating. International Journal of Eating Disorders. 2018;51(8):745-770. doi:10.1002/eat.22867.
- Ziser K, Mölbert SC, Stuber F, Giel KE, Zipfel S, Junne F. Effectiveness of body image directed interventions in patients with anorexia nervosa: A systematic review. International Journal of Eating Disorders. 2018;51(10):1121-1127. doi:10.1002/eat.22946.
- Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive Behavioral Therapy for Eating Disorders. Psychiatric Clinics of North America. 2010;33(3):611-627.
- Dalle Grave R, Calugi S, Sartirana M, Fairburn CG. Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight. Behaviour Research and Therapy. 2015;73:79-82.
- Butler M, Heimberg RG. Exposure therapy for eating disorders: A systematic review. Clinical Psychology Review. 2020;78:101851. doi:10.1016/j.cpr.2020.101851.
- Delinsky SS, Wilson GT. Mirror exposure for the treatment of body image disturbance. International Journal of Eating Disorders. 2006;39(2):108-116. doi:10.1002/eat.20207.
- Fairburn CG, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behaviour Research and Therapy. 2003;41(5):509-528.
- National Institute for Health and Care Excellence. Eating disorders: recognition and treatment. NICE guideline NG69.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). 2022.
