Body Image: Disturbances of

   These are of interest in psychiatry because the image that the mind gives a person of his or her body is of importance in one’s perception of trouble.

   Reil’s theory of cenesthesia (body feeling) (1803). Leipzig psychiatrist Johann C. Reil saw psychiatric illness as a disorder of sensations arising in the mind, as well as of sensations that the mind created in the body (Gemeingefühl). As he wrote in his Rhapsodies on the Application of the Psychic Method of Cure in Mental Disorders (Rhapsodien über die Anwendung der psychischen Curmethode auf Geisteszerrüttungen) in 1803, "When unpleasant feelings arise in the wake of mental sensations, do these feelings exist because of excitable mind images [erregte Vorstellungen] or because of abnormal activity in the brain fibers? At least it is this brain route that gives unpleasant feelings their painful consequences for the body’s cenesthesia (Gemeingefühl)" (p. 159). Reil pointed out that the power of suggestion lent to the mind the ability to cause all kinds of physical symptoms of illness. (See German "Romantic" Psychiatry: Reil.)

   Phantom-limb (1871). Silas Weir Mitchell, the Philadelphia neurologist who had been a surgeon in the Union army during the U.S. Civil War, noted that many patients with severed limbs continued to "feel" the amputated part as though it were still present. "When a limb has been cut off the sufferer does not lose the consciousness of its existence. . . . [Amputees] retain a sense of its existence so vivid as to be more definite and intrusive than is that of its truly living fellow-member. A person in this condition is haunted, as it were, by a . . . phantom of so much of himself as has been lopped away—an unseen ghost of the lost part. . . . There is something almost tragical, something ghastly, in the notion of these thousands of spirit limbs haunting as many good soldiers, and every now and then tormenting them with the disappointments which arise when, the memory being off guard for a moment, the keen sense of the limb’s presence betrays the man into some effort, the failure of which of a sudden reminds him of his loss" (pp. 565–566). Mitchell said that, "Sometimes the ghostly members are in a perpetual state of automatic activity, and the fingers open and shut or twist across one another, especially when there is about to be a change of weather" (p. 568). His 1871 article in Lippincott’s Magazine of Popular Literature and Science is an early example of understanding breakdowns between actual somatic states and the mind’s appreciation of them.

   Anorexia nervosa (later understood as a disorder of body image) (1873). Although reports of young women refusing food for psychogenic reasons were long familiar, only in 1873 did Ernest-Charles Lasègue coin the diagnostic term "hysterical anorexia" (l’anorexie hystérique) in a paper in the Archives générales de médecine. Laségue described the onset: "[The female patient] experiences at first some malaise following her meals: vague sensations of fullness, of pain, gastralgia post prandum or else occurring at the beginning of the meal." The refusing of food continues under various pretexts of pain and such. "After several weeks, it is no longer a supposedly transitory dislike of eating; it is a refusal of food that continues indefinitely. The illness has begun" (p. 388). Later that year, in a lecture, William Gull (1816–1890), a consulting physician to Guy’s Hospital in London, called this kind of food refusal "Anorexia hysterica (Apepsia Hysterica)." As the paper was published in 1874 in the Transactions of the Clinical Society of London, it bore the title "Anorexia nervosa." Neither clinician considered that a disorder of body image was involved, but the diagnosis itself had entered the medical marketplace.

   See Dysmorphophobia (1891). A belief in the ugliness of one’s looks.

   Henry Head’s study of the body image in the brain (1918). Head (1861–1940), a neurologist at London Hospital, had learned a good deal about the representation of the body in the brain from the head trauma of the First World War. In the journal Brain (1918), he explained that some aspects of the body, such as the axis of a limb, were not represented topographically in the brain but functionally: "It is the functions, rather than the anatomical relationships, of any one part of the body that are represented [in the cortex]" (quotation from his collected articles, Studies in Neurology [1920], p. 736).

   Schilder: body image as a social and biological phenomenon (1935). Shortly after Paul Schilder arrived in the United States in 1928—first at Johns Hopkins University then moving to Bellevue Hospital in New York—he developed an interest in body image and its determinants. After a series of articles, especially one published in the psychoanalytic journal Imago in 1933 on "Body Image and Social Psychology" ("Das Körperbild und die Sozialpsychologie"), in 1935 he wrote a book on The Image and Appearance of the Human Body in which he determined that body image changed throughout the life cycle in accordance with the body’s underlying physiology and with people’s emotional lives and relations with others, that it represented an expression of the total personality, and that all life experiences influenced it. Individuals internalize the sensations of organic disease, which in turn influences their images of their bodies.

   Anorexia nervosa as a disorder of body image (1966). From the beginning of her academic career in the United States, Hilde Bruch (1904–1984), who had fled Nazi Germany in 1933, was interested in disorders of body image. In her days as a pediatrician, she had studied overweight children (see her 1940 article on "Obesity in Childhood" in Psychosomatic Medicine). Then, after her formal shift to psychiatry, which she taught at Columbia University beginning in 1943, she focused on body image in the overweight (The Importance of Overweight; 1957); in a landmark article published in 1962 in Psychosomatic Medicine, she said: "The first symptom [in anorexia nervosa] is a disturbance in body image of delusional proportions" (p. 188). After the appearance in 1973 of her influential work, Eating Disorders: Obesity, Anorexia Nervosa and the Person Within, the standard interpretation in the eating disorders field came to see anorexia as a problem not of appetite but of body image.

   DSM-III highlights disturbances of body image in anorexia nervosa (1980). The third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association emphasized that, among the essential features of the disorder, were "intense fear of becoming obese" and "disturbance of body image, e.g. claiming to ‘feel fat’ even when emaciated."