“Photo-Therapy:” A Promising Intervention in Anorexia Nervosa?

We now communicate in ways that are very different from those available just a decade ago. The iPhone, iPad, and similar devices also enable us to observe ourselves as we perform any number of activities. These and other new devices may have an application their designers never considered. I believe we can harness this technology to help us treat some of our patients.

Specifically, I propose that the ability of the iPhone and iPad to ”film” ourselves in real time could serve as an important therapeutic instrument in the treatment of patients with anorexia nervosa (AN). 

We know patients with AN have a delusional sense that they are overweight and have a distorted body self-perception, even when they are undernourished and near death. To address the distorted self-image, we use various medications and forms of individual, group, and family psychotherapy along with nutritional support administered with the help of dieticians.

These treatments aim to correct the patient’s delusional perception of body image and to establish life sustaining eating patterns that will maintain body weight. Correcting the patient’s delusional self-perception is seen as critical in the patient developing life-sustaining eating patterns. Over time, and for some patients, however, these treatment approaches have limited success. 

Mental health professionals typically employ verbal or written communications to address and alter an anorexic patient’s distorted self image. Patients may appear to accept our therapeutic pleadings and go along with varied elements of our treatments. Secretly, however, they often don’t believe what they tell us. Thus, even when we believe our treatment has been successful, seeds of relapse often exist.

If we focus on obtaining a better understanding of how patients with AN distort their body image, perhaps we can enhance our therapeutic approaches?

If a patient with AN sees her reflection in a mirror, she typically perceives herself as overweight. However, if she is shown an iPhone image of herself immediately after it is taken, I have found that she may see herself differently - in fact, as the undernourished person she really is.

When she sees herself in the mirror, the image she sees is instantaniously fused and distorted with her self-perception as overweight. When the same individual holds an iPhone with an image of herself immediately after it is taken, a different cognitive process is involved. First she observes in the iPhone a picture of a woman and that woman’s physical characteristics. She may be able to accurately describe the physicality of the woman in the picture as extremely thin. This may occur because the brain first registers the physicality of the person. Quickly the patient will realize that she is, in fact, the woman in the iPhone image. At this point, she may or may not continue to be able to report accurately what she now knows is her own picture.

The therapist who treats patients with AN can use the patient’s potential capacity to correctly describe the iPhone images to help her correct distortions of body image.  Let me describe an approach utilizing this knowledge that has successfully worked with some of my patients with AN.

First the patient is asked to observe and then describe her image as seen in a mirror with her therapist present. Then an iPhone image is taken. She is asked by her therapist to describe the iPhone image. If she can correctly describe her physicality in the iPhone image and distinguish it from her distorted view of the mirror image, her therapist can go on to address with the patient her distorted body image.
 
When a patient persistently describes the woman in the iPhone image in the same terms as she does when observing herself in the mirror, the therapist takes a picture with the patient. The therapist then asks the patient to describe separately their images. If she sees a distorted image of the therapist, the therapist and patient then work to develop a jointly shared description of the therapist. Once this is achieved, both re-examine the image of the other person in the phone image. . .  the patient. They now work together to develop a jointly shared view of the patient. 

The therapist does not correct the patient’s misinterpretation of the phone image. If she has correctly described the image of the the therapist but cannot accurately describe her own image, then the therapist may remind her that both agreed on the therapist’s image. At this point, they may again see if they can come to an agreement on a description of the woman in the image. If they now can not, the therapist can explore with the patient why she felt she could not.

The psychotherapeutic  techniques used in this process are described by Frieda Fromm-Reichmann in Principles of Intensive Psychotherapy.¹  “The psychiatrist should not argue . . . He should  state quite simply that he does not share the patient's . . . interpretation or evaluation of facts . . . He should try to interest the patient in the investigation of the following questions. . . why is there a difference in the patient’s interpretation or. . . perception from those of the psychiatrist.”

By reconciling the patient’s perception of herself in the phone image and in the mirror, the patient may actually be able to correct her errors of body image and would -- with additional therapeutic interventions to sustain this corrected vision and -- eventually be able to maintain her weight with little or no outside help.

The additional treatment would also utilize appropriate  principles and techniques of Cognitive Behavioral Therapy as well as nutritional counseling.

Because of the risk that body image distortion and weight loss will recur, the patient may benefit from learning how to use the selective phone images throughout her life to ensure a reliable body image, regardless of whether she is in therapy.

Conclusion
These therapeutic interactions may be a useful facet of a multifaceted therapeutic approach. They are intended to reduce the power of body distortion in perpetuating AN. CBT and nutritional counseling continue as important elements in the treatment of AN. The technique to address distortion of body image may also be of use in the treatment of patients with body dysmorphic disorder.

Reference
1. Fromm-Reichman F. Principles of Intensive Psychotherapy.  University of Chicago Press, Chicago;1950:175.