Body Image Disturbance
Body image disturbance is a family of related phenomena in which a person's internal sense of the size, shape, position, ownership, or existence of their own body becomes distorted, despite no actual change in the body itself. This general heading covers several more specifically named patterns, from a global sense that a limb has changed size to a much more specific failure to recognise ownership of one's own arm or leg.
The underlying idea, traditionally, is that the brain maintains a constantly updated internal map of the body, built from a running link between what the senses report from outside (exteroception) and what is felt from within the body itself (proprioception); disturbances in body image reflect a breakdown somewhere in that ongoing internal mapping process.
Recognition features
- A distorted sense of the size, shape, position, ownership, or existence of part or all of the body
- Occurs without any actual physical change to the body part in question
- Often, though not always, associated with a specific area of brain injury or disease
- Ranges from a subtle sense that a limb feels 'different' to a dramatic denial that a limb belongs to the person at all
Eliciting it at interview
- Ask in general terms first: "Does any part of your body feel like it belongs to you differently than before, or feel a different size or shape than it actually is?"
- Where a neurological cause is suspected, a careful physical and neurological examination is essential alongside the mental state assessment
- Note the person's emotional reaction to the distortion, since indifference to an obviously abnormal finding (such as paralysis) can itself be diagnostically significant
Distinguishing features
- Differs from a delusion about the body (such as a nihilistic delusion that a body part does not exist) in that body image disturbance is often, though not always, rooted in a demonstrable disturbance of sensory processing rather than a purely psychiatric belief system
- Different named patterns within this family are distinguished mainly by exactly what is distorted: size, ownership, awareness of illness, or spatial attention
Common misconceptions
- That body image disturbance is always psychiatric in origin; many of the specific patterns within this family are classically associated with focal brain injury, particularly affecting the right parietal lobe
- That all the phenomena in this family are the same thing under different names; they are distinct, separately named patterns with different underlying mechanisms
Related phenomena
Disturbance of the Boundaries of the Self · Borderline Personality Disorder
Diagnostically relevant to
Anorexia Nervosa (links open the DSM-5 Learning Lab)
Practice this
A patient reports that her left arm feels as though it has become enormous and grotesquely swollen, though there is no actual physical change and she does not deny that the arm belongs to her. What is this? · A severely depressed patient states, with complete conviction, that his legs no longer exist at all, insisting this is a literal fact despite clear visual evidence to the contrary, and that his body has effectively ceased to be. Before revealing the answer: is this body image disturbance? · A patient describes an abnormal experience involving part of their body. Before revealing the answer, decide what distinguishes body image disturbance from a nihilistic delusion. · You suspect a patient shows body image disturbance. Before revealing the answer, decide how you would assess for this. · Explain why body image disturbance is described as a family of related phenomena rather than a single, uniform experience.
Illustration
Following a stroke, a 68-year-old woman insists there is nothing wrong with her left arm, even though it is completely paralysed, and becomes mildly irritated when staff draw attention to it, changing the subject rather than engaging with the observation.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 3, 'Disorders of Perception'.