European Eating Disorders Review

Eur. Eat. Disorders Rev. 14, 289–300 (2006)

Empirically Evaluated Treatments

for Body Image Disturbance:
A Review
Clare Farrell, Roz Shafran* and Michelle Lee
Oxford University, Department of Psychiatry, Warneford Hospital, Oxford, UK

Body image disturbance is both a risk factor for the development

of disturbed eating and a central feature of clinical eating
disorders. This review examines empirically tested interventions
for people with high levels of body image disturbance. The most
commonly used therapies with the most empirical support
are cognitive-behavioural. The specificity of the body image
interventions and the importance of individual components have
not yet been established. Prevention programmes to address body
image disturbance appear promising, although further research
evidence is required. It is concluded that treatments for addres-
sing body image disturbance are hindered by the lack of a clearly
specified theoretical model of the maintenance of body image
disturbance and that such an analysis is needed to increase the
effectiveness of current interventions. Copyright # 2006 John
Wiley & Sons, Ltd and Eating Disorders Association.

Keywords: body image; review; empirical; eating disorders; treatment; cognitive-behavioural

INTRODUCTION turbance. Such a review is warranted due to the

increasing number of empirically-evaluated inter-
Body image disturbance is among the diagnostic
ventions available (Cash, 1995; Rosen, 1997; Stice,
criteria for anorexia nervosa (AN) and bulimia ner-
Trost, & Chase, 2003). The paper reviews the reasons
vosa (BN) (American Psychiatric Association, 1994).
for the development of such interventions, and
The modern understanding of body image is of a
the nature of the interventions. The efficacy of
construct with several components, usually identi-
the interventions, and their individual components
fied as cognitive, affective, behavioural and percep-
is examined, and issues concerning format and
tual (Slade, 1994; Thompson, Heinberg, Altabe, &
delivery are presented. The paper ends by discuss-
Tantleff-Dunn, 1999). Body image disturbance can
ing how such an intervention may be integrated
be defined as a dysfunction in any one of these
in evidence-based treatments of eating disorders,
components. The aim of this review is to examine
and argues that an increase in the efficacy of these
empirically tested interventions for body image dis-
interventions is dependent on them being based on
a clear theoretical model of the maintenance of body
image disturbance.
* Correspondence to: Roz Shafran, Oxford University Depart-
ment of Psychiatry, Warneford Hospital, Oxford OX3 7JX,
UK. Tel: 01865 226 479. Fax: 01865 226 244.
E-mail: [email protected] BODY IMAGE DISTURBANCE IN
PEOPLE WITH EATING DISORDERS
Contract/grant sponsors: MRC Studentship; Wellcome
Research Career Development Fellowship; contract/grant A number of lines of research evidence support the
number: (063209) view that high levels of concern over shape and

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association.
Published online 7 September 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.693
290 C. Farrell et al.

weight (i.e. a disturbance in the cognitive and affec- fore may not warrant treatment. However, there is
tive components of body image) form the core reason to be concerned about high levels of body
psychopathology of eating disorders (Fairburn image disturbance. It has repeatedly been shown
& Harrison, 2003). Firstly, the residual level of shape that aspects of body image disturbance predict var-
and weight concerns at the end of successful treat- ious levels of eating disturbance. Body dissatisfac-
ment for BN have been found to predict relapse tion has been found to predict disturbed eating
(Fairburn, Peveler, Jones, Hope, & Doll, 1993). This (Cattarin & Thompson, 1994; Thompson, Coovert,
finding has been replicated in a separate study Richards, Johnson, & Cattarin, 1995), binge eating
(Freeman, Beach, Davis, & Solyom, 1985). Secondly, and compensatory behaviours (Stice & Agras,
full cognitive behavioural treatment (CBT) addres- 1998), and eating disorders (Garner, Garfinkel,
sing body image disturbance for BN was found to Rockert, & Olmsted, 1987). A comprehensive review
result in significantly more improvement of the eat- of the literature concluded that the relationship
ing disorder symptoms at the end of treatment and between body dissatisfaction and eating pathology
at follow up than a ‘dismantled’ behavioural version is mediated by increases in dieting and negative
which did not address body image disturbance affect (Stice & Shaw, 2002). A recent prospective
(Fairburn et al., 1991). Finally, in a prospective study study of 1177 adolescent girls found body dissatis-
of the natural course of bulimia nervosa, the baseline faction was associated with a range of specific eating
level of over-evaluation of shape and weight was and weight pathology, and also low self-esteem,
found to predict the persistence of binge eating stress, and depression (Johnson & Wardle, 2005).
(Fairburn et al., 1993). Further evidence of the impor- These findings led the authors to conclude that body
tance of body image disturbance in eating disorders dissatisfaction rather than dietary restraint is the key
has come from research using exploratory factor psychopathology in individuals who are trying to
analysis, which has identified body image distur- control their weight. The findings are consistent
bance as a main component of the psychopathology with earlier research indicating that body dissatis-
of AN (Gleaves, Williamson, & Barker, 1993) and faction is a risk factor for depressive symptoms
of BN (Gleaves & Eberenz, 1993; see Stice & Shaw, in adolescent girls (Stice & Bearman, 2001; Stice,
2002). Hayward, Cameron, Killen, & Taylor, 2000).
Taken together, these findings indicate that there
is a need to address body image disturbance itself,
both due to the distress associated with such distur-
BODY IMAGE DISTURBANCE
bance and also in order to help prevent the develop-
IN NON-CLINICAL SAMPLES
ment of eating (and other) psychopathology. Such
While body image disturbance is characteristic of treatments are incorporated in many eating disorder
patients with AN and BN, it is also experienced by treatment programmes including the leading
people without an eating disorder to different evidence-based CBT for bulimia nervosa (Fairburn,
degrees. For some, body image disturbance in the Marcus, & Wilson, 1993) and newer interventions
absence of an eating disorder can still be disabling, (Fairburn, Cooper, & Shafran, 2003). Specific thera-
and it has been found to be associated with depres- pies have also been developed to treat body image
sion in a community sample (Noles, Cash, & disturbance.
Winstead, 1985). The kind of preoccupations
reported by patients with eating disorders or severe
body image disturbance can be recognised at a less
extreme level by many women. The prevalence
SPECIFIC TREATMENTS FOR
BODY IMAGE DISTURBANCE
of some degree of dissatisfaction with one’s body
has been dubbed ‘normative discontent’ (Rodin, The present discussion will be limited to empirically
Silberstein, & Striegel-Moore, 1984) and data from tested treatments solely for body image disturbance
a large community study in the US reported that in the normal population rather than in patients with
one in four women engage in abnormal eating and eating disorders, or patients with obesity. Unfortu-
weight control practices (Forman-Hoffman, 2004). nately, there is a lack of data on the efficacy of the
Similar figures are reported for adolescents (McVey, individual components of treatment programmes
Tweed, & Blackmore, 2004) and middle-aged for eating disorders. With the exception of the ‘dis-
women (McLaren & Kuh, 2004). mantling’ study of Fairburn and colleagues men-
The normative nature of such a degree of distur- tioned above (Fairburn et al., 1991), studies have
bance implies that it is not pathological and there- not been designed to address whether specific

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
Body Image Disturbance 291

body-image-related components of the leading of the cognitive, behavioural or affective compo-

evidence-based approach to bulimia nervosa and nents of body image (Thompson et al., 1999). Var-
binge eating (National Institute for Clinical Excel- ious techniques are used to address these
lence; NICE, 2004) lead to improved body image or disturbances including cognitive restructuring
whether it is the reduction in binge eating that leads (questioning and challenging the veracity of proble-
to a decrease in concerns about shape. Without such matic thoughts), behavioural experiments (practical
studies, it is not possible to evaluate the efficacy of tasks to test predictions arising from problematic
the intervention for body image disturbance in the thoughts and beliefs), and size perception training
context of the treatment of the eating disorder (giving patients feedback on the accuracy of their
although a review of the nature of such interventions body size estimations to correct estimations). The
can be found elsewhere (Rosen, 1996). The same two most commonly used therapies with the most
argument applies to patients with obesity with the empirical support are those of Rosen (1997) and Cash
exception of one study (Ramirez & Rosen, 2001). (1995). These interventions are similar although
Specific interventions for body image disturbance they have never been directly compared, and they
have the potential to enhance evidence-based treat- address three key aspects of body image distur-
ments for eating disorders. At present, only between bance: size perception (overestimation of overall
30 and 50% of patients with BN who receive CBT cease size or size of a particular part, exaggeration of the
bingeing and purging (Wilson, 2005) and the need to extent of a perceived defect); cognitive and affective
enhance our interventions has been highlighted (Fair- (negative, unrealistic, and overvalued thoughts and
burn et al., 2003). Incorporation of an efficacious inter- emotions about the body, and the consequences of
vention for body image disturbance may be one way perceived defects); and behavioural (avoidance of
forward. In addition, such interventions are needed anxiety provoking situations, checking and groom-
for the high proportion of women whose body image ing behaviours, reassurance seeking). Specifically,
disturbance causes them distress, and for adolescents Cash’s programme includes a self assessment of
for whom body dissatisfaction presents a risk of the the development of body image disturbance, self
development of eating pathology and psychological monitoring; relaxation training; challenging dys-
distress. Table 1 summarises the body image therapies functional ‘appearance assumptions’, monitoring
that have been tested. and restructuring ‘cognitive body image errors’,
Studies needed to meet three criteria to be decreasing avoidant and compulsive body image
included in the table. First, the therapy was aimed behaviours, mastery and pleasure exercises, pro-
specifically at body image disturbance in normal blem solving and assertion training (Cash & Grant,
weight participants; second a control group was 1996). Rosen’s cognitive-behavioural programme
included to allow evaluation of whether beneficial includes the correction of size/weight overestima-
effects were specific to the intervention; third the tion by training, cognitive restructuring and expo-
sample size needed to be at least 20 to increase the sure including mirror exposure.
likelihood that the study had sufficient power.
In addition to the studies given in Table 1, a large
Efficacy of CBT
number of other therapies for body image distur-
bance have been reported (e.g. multiphasic treat- Rosen’s CBT for body image disturbance was initi-
ments, Brouwers, 1990; combined creative arts and ally tested in a sample of 23 female students with
verbal psychotherapy, Kaslow & Eicher, 1988). They high levels of body image disturbance but no eating
are not included in this review as they are usually disorder, and was shown to be more effective than a
based on single reports of the intervention and have condition that controlled for attention and informa-
not been empirically tested, making it impossible to tion (Rosen, Saltzberg, & Srebnik, 1989). Participants
draw sound conclusions about their efficacy. who received CBT significantly reduced their body
size overestimation by an average of 19%, and scored
less on the Body Shape Questionnaire (BSQ; Cooper,
Cognitive-Behaviour Therapy: Content
Taylor, Cooper, & Fairburn, 1987) by an average of
of Interventions
37%, and the body dissatisfaction scale of the Eating
The majority of established therapies aim to treat Disorders Inventory (EDI; Garner, Olmstead, &
body image disturbance using cognitive and beha- Polivy, 1983) by 60%. In addition, scores on a mea-
vioural techniques. These cognitive-behavioural sure of behavioural avoidance (the BIAQ; Rosen,
therapies are developed on the basis that body Srebnik, Saltzberg, & Wendt, 1991) decreased by
image disturbance consists of a disturbance in any 35%. Those in the minimal treatment condition also

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
 Table 1. Studies evaluating body image therapies
292

Authors Comparison Sample Outcome

Butters & Cash (1987) CBT vs. wait list 31 female students dissatisfied CBT group improved on most measures (evaluation of
followed by brief CBT with bodies appearance, discomfort looking in mirror, estimation of
body size, preoccupation). Maintained at 7-week follow
up. Wait list who received only three sessions achieved
comparable results.
Dworkin & Kerr (1987) 3 sessions CBT vs. 79 female students moderate/ All groups (including WL) improved. CT > CBT & RT
Cognitive therapy (CT), severe dissatisfaction based on on body image. CT ¼ CBT > RT on self concept.
Reflective therapy (RT), body cathexis scale.
Wait list control.
Rosen et al. (1989) Group CBT vs. minimal 23 female students CBT group improved on size estimation, body
treatment (controlled for Disturbed BI (>109 on BSQ) No dissatisfaction & behavioural avoidance. Comparison
information and attention). eating disorders group also improved, but to a lesser extent.
Rosen, Cado, Group CBT vs. Group CBT 24 female students Both groups improved on eating measures,
Silberg, Srebnik, & with size perception training Disturbed self esteem and psychological symptoms.
Wendt (1990) BI (>109 on BSQ) No difference between groups.
No eating disorders
Fernandez & Video confrontation vs. No 24 female patients with AN Significant changes seen on 2 of 13 ratings: body
Vandereycken (1994) intervention control group (12 in experimental group, 12 experienced as thinner and more active.
control) No changes in control group.
Fisher & Group CBT vs. Exercise 54 female students evaluating Treatments equally effective on body image anxiety,
Thompson (1994) therapy vs. no treatment appearance negatively overall body dissatisfaction & cognitive-behavioural
control aspects of body image, & more effective
than control. No follow up.

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association.
Grant & Cash (1995) Full group CBT vs. 23 women Extreme body Both treatments had beneficial effects on body image.
modest contact treatment. dissatisfaction Maintained at 2 month follow up. No difference in
efficacy between groups.
Cash & Lavallee (1997) Group body-image CBT vs. 13 female and 3 male students Three quarters of self-help participants functionally
individual self-directed CBT dissatisfied with physical recovered on Appearance Evaluation No significant
appearance causing distress/ effects of treatment condition on body image.
impairment
Rushford Video-confrontation in 18 women with AN 18 healthy Significant reductions in body image disturbance in
& Ostermeyer (1997) patients vs. controls women patients only
Winzelberg et al. (2000) Internet intervention based 60 female students reporting a No differences seen at post intervention.
on Cash’s material vs. no ‘desire to improve body Differences seen at follow up on BSQ &
treatment satisfaction’ drive for thinness.
Nicolino, Martz, 1 hour intervention vs. no 95 female college students Trend for reduced dieting. No change on body image
& Curtin (2001) intervention anxiety, body shape concern, or fear of fatness.

Stice et al. (2001) Cognitive dissonance 87 female college students, who Active treatment group improved on thin-ideal
vs. healthy weight responded to advertisements internalisation, body dissatisfaction, dieting, negative
management for a study to evaluate 2 affect, and bulimic symptoms. However, control group
interventions to help women also improved, and no significant differences in outcome

Eur. Eat. Disorders Rev. 14, 289–300 (2006)

C. Farrell et al.

improve their body image between the groups.

Body Image Disturbance 293

Mood decreased in patients, and appearance self-esteem showed statistically significant improvements on the
lowered in both groups, during exposure. Frequency of
negative cognitions decreased from the first to second

thin-ideal internalization, negative affect, and bulimic

effectiveness between the two conditions the result of

were observed for body dissatisfaction or dieting and

BSQ and the body dissatisfaction scale. However,

Compared to wait-list, both interventions decreased

symptoms at termination and follow-up. No effects

body dissatisfaction that caused significant improvements on body image with both
86 women and 3 men. Reported High (53%) dropout rate Clinically and statistically
whereas the improvements seen in the CBT group
brought participants’ scores into the normal range,

significant distress or impairment formats. Suggest unexpected lack of differential

low compliance with added cognitive-change

those in the minimal treatment group were not suffi-
cient to reduce the average score to below the clini-
cally severe range. These improvements were still
present at 2-month follow up for the CBT group
but not the minimal treatment group.
The treatment developed by Cash has been found

effects diminished over time.

to be more effective than no treatment on a number
of measures of body image, with improvements on
affective measures of body image disturbance of
between 30 and 65%, and cognitive measures of
exposure sessions.

between 10 and 40% (Butters & Cash, 1987). Unfor-

tunately, CBT was not compared to a non-specific
components.

therapy in this study so it is not possible to deter-

mine the specificity of the intervention.

Comparison of CBT with Non-Specific Therapies

While these studies of Rosen’s and Cash’s therapies
148 adolescent girls with body
30 patients with BED, 30 non

have shown them to be helpful in treating body

improving body image via
eating-disordered controls

image disturbance, the evidence from other studies

of self-esteem, interest in

does not provide unanimous support for the

efficacy of these treatments. For example, an inde-
pendent group compared Cash’s protocol to a non-
image concerns.

specific treatment condition of exercise therapy

and to a no-treatment control condition (Fisher &
Thompson, 1994). CBT was no more effective than
self-help

exercise therapy, but superior to no treatment. How-

ever, the effects of CBT found in this study were sig-
nificant for only two of six measures, and marginally
Compared 2 components of Cash’s
Disorder (BED) vs healthy controls

significant for two others, and therefore were smal-

Cognitive dissonance vs. healthy

ler than those reported by Butters and Cash (1987),

weight management vs waitlist
in Patients with Binge Eating

who reported highly significant changes for 14 out

of 15 of their measures.
Further support for the view that the effects of CBT
Body Image Exposure

on body image disturbance are non-specific was

reported by Dworkin and Kerr (1987) who compared
Reflective Therapy (RT, a non-specific technique) to
intervention.

CBT, cognitive therapy (CT), and a wait list condi-

tion in 79 female students. Using similar techniques
control

to those used by Rosen, they found that the body

image of all the groups in their study improved,
including those in the wait list condition. In addition,
Strachan & Cash, (2002)

they found the CT condition to be superior to the

other treatment conditions on their measure of body
Hilbert et al. (2002)

image, and equal to CBT (but better than Reflective

Stice et al. (2003)

Therapy) on the measure of self-concept.

Format and Delivery of CBT

Studies which have attempted to modify the for-
mat and delivery of CBT have provided further

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
294 C. Farrell et al.

evidence to suggest that current CBT for body image about the utility of the intervention for people at risk
disturbance needs improvement. The study by But- of developing an eating disorder or those with suffi-
ters and Cash (1987) reported comparable results in ciently high levels of body image disturbance to
a condensed three session treatment, given to parti- cause distress.
cipants in the wait list condition, as had been In summary, various forms of CBT for body image
achieved in the full course of therapy. The capacity disturbance have been reported to be more effective
of the reduced version to confer the therapeutic ben- than no treatment (Butters & Cash, 1987) and
efits in such a reduced amount of time suggests that more effective than a non-specific treatment (Rosen
the full therapy is unnecessarily lengthy and could et al., 1989). However, these studies have not been
be revised to be more time and cost effective. This reliably replicated, CBT has rarely been compared
view is confirmed by further studies of the effect of to an active treatment, and studies investigating
the format of Cash’s treatment. For example, the the format of the interventions indicate that the
treatment has been shown to be equally effective interventions may be over-inclusive.
when administered with modest therapist contact
(8 weekly individual sessions up to 20 minutes long)
INVESTIGATING TREATMENT
as when administered by therapist in 8 weekly
COMPONENTS TO IMPROVE OUTCOME
group sessions lasting 90 minutes each (Grant &
Cash, 1995). Both of these formats were subse- There is some support for the use of CBT for body
quently found to be equally as effective as a self-help image disturbance. However, as discussed the find-
format with minimal (5–10 min weekly telephone ings are mixed and they suggest that many of the
call) therapist contact (Cash & Lavallee, 1997). observed effects may be non-specific, and that exist-
A CBT programme for body image disturbance ing treatments could be made more efficient. CBT
based on Cash’s CBT programme was adapted to packages typically contain many different compo-
be disseminated over the internet (Winzelberg nents, and overall outcome data do not give any
et al., 2000). The intervention was a structured, information about the usefulness of the individual
8-week programme including optional and manda- components. One way to systematically improve
tory assignments, and a discussion group where the treatment of body image disturbance is to exam-
participants were required to post messages. How- ine these individual components and assess their
ever, this intervention yielded disappointing efficacy in reducing body image disturbance, in
results, with participants faring no better that the order to maximise the benefits of the useful ones.
no treatment comparison group (Winzelberg et al., In an attempt to investigate the relative effectiv-
2000). This should be treated as a preliminary find- eness of selected components of Cash’s CBT for
ing however, as participants were selected on the body image disturbance, Strachan and Cash (2002)
basis of a self-reported ‘desire to improve body satis- compared two self-help programmes. In the first,
faction’, and motivation to participate appeared low participants were given psychoeducation and self-
(indicated by a decline in compliance with weekly monitoring tasks, the second included these compo-
assignments from 70–40% over the course of the nents, but also included a component to identify and
study). This particular format of CBT therefore alter dysfunctional body image cognitions. Their
needs replication in a sample with higher levels of findings were compromised by an attrition rate of
body dissatisfaction before firm conclusions can be 53%, but nevertheless showed statistically and clini-
drawn about its efficacy. A similar problem faced cally significant effects of both programmes using
the study by Nicolino, Martz, and Curtin (2001) of intent-to-treat analyses. The finding that the second
a 1-hour intervention to reduce body image distur- programme which included techniques to alter dys-
bance. In this study, a 1-hour intervention included functional cognitions was not more effective was
a discussion of prevalence of negative body image, unexpected, and the authors suggest that this was
the developmental antecedents of body image, due to the observed poor compliance with latter
appearance-preoccupying rituals, dysfunctional assignments that included these components of the
thoughts feelings and behaviours and weight con- treatment.
trol behaviours. Their use of a non-eating-disor-
dered sample would have been appropriate if the
Mirror Exposure
sample of college students had been selected for
body image disturbance. However, an apparent The use of mirrors is frequently included as a com-
floor effect due to the non-dissatisfied sample does ponent of CBT for body image disturbance. Mirrors
not permit any valuable conclusions to be drawn are used for one of two purposes in body image

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
Body Image Disturbance 295

treatments; in exposure they’re used to reduce body Mirrors are not only used to treat body image dis-
image related anxiety and avoidance, and they are turbance by exposure therapy, but also as a tool to
also used in size perception training Rosen, Cado, correct size overestimation, by allowing participants
Silberg, Srebnik, and Wendt (1990). Rosen (1997) to look in the mirror before making, or while making
includes hierarchical mirror desensitisation in his body size estimations. Goldsmith and Thompson
body image treatment, as do others (Butters & Cash, (1989) increased the accuracy of participants’ body
1987; Thompson, 1990). The rationale for doing so is size estimations by confronting them with their
that anxiety is a component of body image distur- reflection before asking them to estimate their size
bance when looking in the mirror. Exposure therapy (although this change was not maintained at follow
has been shown to be effective for anxiety in many up). In one study, being able to look in a mirror
other areas, for example in the treatment of specific while making size estimations was found to increase
phobias (Barlow & Wolfe, 1981), and has therefore the accuracy of estimations (Gardner, Gallegos,
been included in treatment for anxiety about one’s Martinez, & Espinoza, 1989), but another study
body. Although this technique is widely used in failed to find any effect (Ben-Tovim & Walker,
CBT for body image disturbance, evidence for the 1990). The variability in findings from the different
usefulness of this procedure in this context is scarce. studies can be attributed to differences in methods
Recently, Hilbert, Tuschen-Caffier, and Voegle since a recent study found that estimations of body
(2002) investigated the effects of mirror exposure size differ according to whether estimations are
on the body image of patients with binge eating dis- made while looking at oneself in a mirror whilst
order. They report that this exposure resulted in a adjusting using a ‘mirror-size’ picture or whe-
deterioration of mood and appearance self-esteem ther estimations are made from memory using a
over the exposure session, although a reduction in ‘life-size’ picture (Farrell, Shafran, & Fairburn, 2003).
negative cognitions was seen after a second expo-
Video Feedback
sure session. A later study of patients with binge eat-
ing disorder reported that CBT with mirror Another component of two innovative programmes
exposure was equally (but not more) effective to of CBT for body image disturbance is video feed-
CBT with a cognitive restructuring component back. Watching a video of themselves is used to pro-
focused on body image (Hilbert & Tuschen-Caffier, vide participants with a novel way of looking at their
2004). Key, George, Beattie, Stammers, Lacey, and bodies, in the hope that they will be able to form a
Waller (2002) conducted a small study of inpatients more objective view of their appearance, and there-
with AN, and found that a body image programme fore reduce the disturbance in their body image.
including mirror exposure produced significant and There is still little evidence on the efficacy of video
sustained improvement in body dissatisfaction and feedback in the treatment of body image distur-
reduction in body anxiety and avoidance beha- bance, however what little that exists is encouraging.
viours, while a simple exposure treatment without Rushford and Ostermeyer (1997) found it reduce
mirror exposure had no beneficial effects. This was feelings of fatness in patients with anorexia nervosa
a pilot study, with a sample size of only 15, which by 85%, this change was statistically and clinically
requires replication. Taken together, the findings significant. Fernandez and Vandereycken (1994)
indicate that mirror exposure might yield positive observed an improvement on feelings of fatness.
outcomes, but that there may be alternative methods The reduction in participants’ ratings of the strength
to address body image concerns. It may also be the of such feelings was 15%, but post-test scores were
case that the duration of mirror exposure, and the within one standard deviation of initial scores, so
way it is conducted is critical as to whether it is help- this change cannot be considered to be clinically sig-
ful or not. Mirror exposure that aims to facilitate cog- nificant (Jacobson, Roberts, Berns, & McGlinchey,
nitive change and help patients distance themselves 1999). A recent innovative experimental study
from critical cognitions (Wilson, 1999) is likely to be (Tuschen-Caffier, Vogele, Bracht, & Hilbert, 2003)
more effective than mirror exposure that is simply exposed patients with bulimia nervosa to their
designed to encourage patients to habituate to their bodies via a video image and they were also asked
anxiety. The duration of mirror exposure is a to imagine and describe the appearance of their
critical variable that warrants further investigation body. The authors found that both the video expo-
since it is possible that such exposure may sensitise sure and the imagery/description task led to an
patients to their mirror reflection if the duration is increase in tension, anxiety, ‘insecurity’ and sad-
too short and therefore lead to an increase in negative ness. The same was found for healthy controls with
emotions. the patients reporting a steeper increase in negative

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
296 C. Farrell et al.

emotions from baseline to exposure than the con- follow-up study that included a wait-list control
trols for the video task. (Stice et al., 2003), 148 adolescent girls with body
The shortcoming of these studies of video feed- image concerns were randomized to either a healthy
back is that they have not used well known and rele- weight-management intervention, the dissonance
vant outcome measures. Rushford and Ostermeyer programme or a wait list control group. Participants
(1997) assessed participant body image characteris- in both active interventions reported decreased thin-
tics using the EDI yet their only outcome measures ideal internalization, negative affect, and bulimic
for body image were two bipolar visual analogue symptoms at termination and follow-up relative to
scales on which the participant was asked to rate the wait list control group. However, no effects were
(1) how fat she felt she was, and (2) to rate her found for body dissatisfaction or dieting and effects
size in comparison to other women. Fernandez and diminished over time. Stice et al. (2001) explained
Vandereycken (1994) also assessed participants well their findings as indicating that they had developed
before treatment, using the EDI, but as an outcome an effective placebo control, and that both the disso-
measure used a set of ‘Semantic Differential’ scales; nance intervention, and to a lesser extent the healthy
a group of 13 bipolar adjectives such as fat–thin, weight management intervention, could reduce
pretty–ugly, dirty–clean, on which participants bulimic pathology and risk factors for eating distur-
were asked to rate their body image. The more recent bances. However, the failure to reduce body dissa-
study of Tuschen-Caffier et al. (2003) used a series of tisfaction and dieting in the latter study is
7-point ratings (the psychometric properties of these disappointing and the relatively mild body image
ratings are not reported). The use of these unusual concerns of the sample raise the question of whether
outcome measures means that it is hard to draw con- such interventions would be equally effec-
clusions about the real usefulness of these studies. tive in samples with more significant body image
Video feedback appears to be a promising area, but disturbance.
more rigorously designed studies are needed to Other prevention programmes include giving
establish the merits of the video feedback technique. young women ‘life-skills’over a 6-week course as
In addition, evidence from its use in the treatment of part of the curriculum (McVey, Davis, Tweed, &
social anxiety suggests that techniques such as cog- Shaw, 2004). The programme includes a critical eva-
nitive preparation could be incorporated to existing luation of media influences, a discussion on lower-
video feedback protocols to enhance its therapeutic ing the importance of physical appearance on
effects (Harvey, Clark, Ehlers, & Rapee, 2000). self-worth, psychoeducation about the genetic con-
tribution of body size, the role of stress on body
image and the influence of positive relationships.
Prevention Interventions
Such skills are undoubtedly useful and are of most
A promising alternative to CBT for body image dis- relevance to those at high risk of developing an eat-
turbance is the cognitive-dissonance technique ing disorder due to dissatisfaction with body shape.
devised by Stice and colleagues (Stice, Chase, The broadness of the intervention, however, and
Stormer, & Appel, 2001). Developed as an eating dis- lack of emphasis on behavioural factors considered
order prevention programme (see Stice & Shaw, to contribute to the maintenance of eating psycho-
2004 for a review of prevention research), this inter- pathology (such as frequent ‘body checking’) are
vention requires participants to critique the current limitations. Furthermore, the utility of such an inter-
‘thin-ideal’ for beauty, and design information and vention for those high in shape concern has yet to be
strategies that could be used to dissuade others from established.
adopting the thin-ideal. It includes a body accep-
tance exercise (recording positive aspects of body
while looking in mirror).
DISCUSSION
In their original study, Stice et al. (2001) reported
that those who received the dissonance intervention Current body image treatments have been shown in
reported reductions in thin-ideal internalisation, some studies to reduce disturbance as assessed by
body dissatisfaction, dieting, negative affect, and various measures more effectively than no treat-
bulimic symptoms. However, improvements were ment (Butters & Cash, 1987) and more effectively
also seen for a placebo control group who were than a non-specific treatment (Rosen et al., 1989).
taught healthy weight-management, and on most These benefits were statistically and clinically signif-
measures these were not significantly different from icant, and encouraged optimism about the use of
those seen with the active intervention. In a larger CBT for body image disturbance. However, as has

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
Body Image Disturbance 297

been discussed, no published studies have indepen- sistence of such concerns in people with a range of
dently replicated these results and others have psychopathology (including binge eating, dietary
provided evidence to suggest that some effects of restriction, vomiting, low mood and globally low
body image therapy might be non-specific, and that self-esteem) and those whose concerns with their
some treatments for body image disturbance are shape appear to be circumscribed.
overly complex and could be delivered more effi- We suggest that the second change required to
ciently. High attrition rates are not uncommon, enable the development of efficacious and therapeu-
and present a problem both for researchers as they tic useful interventions for body image disturbance is
impact the validity of the findings, but also for the to enhance the clinical utility of the experimental ana-
individuals involved since they are potentially left lyses of the topic. Research into body size estimation
without treatment for a distressing condition. Any has been described as being plagued with methodo-
successful therapy will have to address this issue. logical and conceptual confusion (Smeets, 1997) and
These relatively high attrition rates, combined with has yielded little of therapeutic value (Hsu & Sobkie-
theoretical confusion that has hindered research into wicz, 1991). This should serve as a warning to those
body image disturbance (Smeets & Panhuysen, who hope that experiments can facilitate treatment.
1995), signify that a new approach is needed. Those who are dissatisfied with their body shape esti-
It is suggested that three changes are required to mate their size and scrutinise their shape using a mir-
enable the development of efficacious and clinically ror (Farrell, et al., 2003) yet until recently, mirrors
useful interventions for body image concerns. First, were almost never used in experiments to examine
a clearly specified, testable theory of the mainte- body size estimation with one or two exceptions
nance of concerns about body shape is needed. The (Gardner et al., 1989; Ben-Tovim et al., 1990; Shafran
psychological interventions that have yielded most & Fairburn, 2002). Making experiments clinically
of therapeutic value are those that are based on such meaningful is a challenge that needs to be met.
theories (panic disorder—Clark, 1986; BN— Finally, it is suggested that research on body image
Fairburn, 1997; NICE, 2004). The mutually beneficial concerns is most likely to be clinically useful if
interplay between theory, experiments and treat- the interventions can be incorporated into existing
ment advances has been demonstrated in these areas evidence-based interventions for psychological dis-
(Clark, 2004; Salkovskis, 2002) and it is likely that a orders. For example, one third to one-half of the
similar approach will yield fruit when addressing patients with BN make a full and lasting recovery
body image disturbance. The specific factors that from their eating disorder without any additional
maintain body image disturbance are likely to vary focus on their shape concerns except for that
among individuals, depending on the presence or described in the treatment manual (Fairburn et al.,
absence of other psychopathology. For example, 1993). This leaves a large proportion of patients
binge eating exacerbates shape concern in women who could potentially overcome their eating disor-
who are already dissatisfied with their bodies and der with enhanced methods of addressing their psy-
who over-evaluate the importance of shape and chopathology and/or broadening the focus to
weight. Reducing binge eating has the effect of sig- other factors that may be maintaining the problem
nificantly reducing shape concern. This makes sense (Fairburn et al., 2003). Being able to incorporate a
since eating large quantities of food will lead to specific piece of work on body image that has been
weight gain, and will also focus attention on shape shown to be efficacious could be of benefit. To this
and weight. In other individuals with eating disor- end, it is suggested that treatments for body image
ders, it may be that shape and weight concerns are disturbance are likely to be most useful if they are of
not dominant (e.g. those from other cultures or a structure, format and duration that can easily inte-
younger individuals (e.g. Lee, Ho, & Hsu, 1993; grated into existing evidence-based treatments for eat-
Tareen, Hodes, & Rangel, 2005). It is likely, therefore, ing disorders whether they are cognitive-behavioural
that a specific body image intervention will be of use or interpersonal in nature (NICE, 2004). A preliminary
to some patients with eating disorders but for others investigation of one possible intervention is under-
it will not be necessary. Furthermore, the large way (Farrell, Shafran, Lee, & Fairburn, 2005).
majority of women who are dissatisfied with their
shape will not be engaging in binge eating or
extreme dietary restriction, and these factors will
ACKNOWLEDGEMENTS
therefore not be relevant to the maintenance of their
dissatisfaction. A theory of the maintenance of shape Clare Farrell was supported by an MRC Student-
concerns needs to be able to take account of the per- ship. Roz Shafran is supported by a Wellcome

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
298 C. Farrell et al.

Research Career Development Fellowship (063209) ‘transdiagnostic’ theory and treatment. Behaviour
which also supports Michelle Lee. We are grateful Research and Therapy, 41, 509–528.
Fairburn, C. G., & Harrison, P. J. (2003). Eating disorders.
for the helpful comments of the reviewers on an ear-
Lancet, 361(9355): 407–416.
lier version of this manuscript. Fairburn, C. G., Jones, R., Peveler, R. C., Carr, S. J.,
Solomon, R. A., O’ Connor, M., Burton, J., & Hope,
R. A. (1991). Three psychological treatments for
REFERENCES bulimia nervosa: A comparative trial. Archives of
General Psychiatry, 48, 463–469.
American Psychiatric Association. (1994). Diagnostic Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993).
and statistical manual of mental disorders (4th ed.). Cognitive-behavioral therapy for binge eating and
Washington, DC: Author. bulimia nervosa: A comprehensive treatment manual.
Barlow, D. H., & Wolfe, B. E. (1981). Behavioral approaches In C. G. Fairburn, & G. T. Wilson (Eds.), Binge eating:
to anxiety disorders: A report on the NIMH-SUNY, Nature, assessment, and treatment. New York, NY, US:
Albany, research conference. Journal of Consulting and Guilford Press.
Clinical Psychology, 49, 448–454. Fairburn, C. G., Peveler, R. C., Jones, R., Hope, R. A., &
Ben-Tovim, D. I., & Walker, M. K. (1990). Effect of a Doll, H. A. (1993). Predictors of 12-month outcome in
mirror on body-size estimation. Perceptual and Motor bulimia nervosa and the influence of attitudes to shape
Skills, 71, 1151–1154. and weight. Journal of Consulting and Clinical Psychol-
Brouwers, M. (1990). Treatment of body image dissatis- ogy, 61, 696–698.
faction among women with bulimia nervosa. Journal of Farrell, C., Shafran, R., & Fairburn, C. G. (2003). Mirror
Counseling and Development, 69, 144–147. cognitions and behaviours in people concerned about
Butters, J. W., & Cash, T. F. (1987). Cognitive-behavioral their body shape. Behavioural and Cognitive Psychother-
treatment of women’s body-image dissatisfaction. apy, 32, 225–229.
Journal of Consulting and Clinical Psychology, 55, 889– Farrell, C., Shafran, R., Lee, M., & Fairburn, C. G. (2005).
897. Testing a brief Cognitive-behavioural intervention to
Cash, T. F. (1995). What do you see when you look in the improve extreme shape concern: A case series.
mirror? Helping yourself to a positive body image. New Behavioural and Cogntive Psychotherapy, 33, 189–200.
York: Bantam Books. Fernandez, F., & Vandereycken, W. (1994). Influence of
Cash, T. F., & Grant, J. R. (1996). Cognitive-behavioral video confrontation on the self-evaluation of anorexia
treatment of body-image disturbances. In M. Hersen, & nervosa patients: A controlled study. Eating Disorders:
V. Van Hesselt (Eds.), Sourcebook of psychological treat- The Journal of Treatment and Prevention, 2, 135–140.
ment manuals for adult disorders (pp. 567–614). New York, Fisher, E., & Thompson, J. K. (1994). A comparative
NY, US: Plenum Press. evaluation of cognitive-behavioral therapy (CBT)
Cash, T. F., & Lavallee, D. M. (1997). Cognitive-behavioral versus exercise therapy (ET) for the treatment of body
body-image therapy: Extended evidence of the effi- image disturbance: Preliminary findings. Behavior
cacy of a self-directed program. Journal of Rational Modification, 18, 171–185.
Emotive and Cognitive Behavior Therapy, 15, 281– Forman-Hoffman, V. L. (2004). High prevalence of
294. abnormal eating and weight control practices
Cattarin, J. A., & Thompson, J. K. (1994). A three-year among U.S. high-school students. Eating Behaviour, 5,
longitudinal study of body image, eating disturbance, 325–336.
and general psychological functioning in adolescent Freeman, R. J., Beach, B., Davis, R., & Solyom, L. (1985).
females. Eating Disorders: The Journal of Treatment and The prediction of relapse in bulimia nervosa. Journal of
Prevention, 2, 114–125. Psychiatric Research, 19, 349–353.
Clark, D. M. (1986). A cognitive approach to panic. Gardner, R. M., Gallegos, V., Martinez, R., & Espinoza, T.
Behaviour Research and Therapy, 24, 461–470. (1989). Mirror feedback and judgments of body size.
Clark, D. M. (2004). Developing new treatments: On the Journal of Psychosomatic Research, 33, 603–607.
interplay between theories, experimental science and Garner, D. M., Garfinkel, P. E., Rockert, W., & Olmsted,
clinical innovation. Behaviour Research and Therapy, 42, M. P. (1987). A prospective study of eating distur-
1089–1104. bances in the ballet. Psychotherapy and Psychosomatics,
Cooper, P. J., Taylor, M. J., Cooper, Z., & Fairburn, C. G. 48, 170–175.
(1987). The development and validation of the Body Garner, D. M., Olmstead, M. P., & Polivy, J. (1983).
Shape Questionnaire. International Journal of Eating Development and validation of a multidimensional
Disorders, 6, 485–494. eating disorder inventory for anorexia nervosa and
Dworkin, S. H., & Kerr, B. A. (1987). Comparison of bulimia. International Journal of Eating Disorders, 2, 15–
interventions for women experiencing body image 34.
problems. Journal of Counseling Psychology, 34, 136–140. Gleaves, D. H., & Eberenz, K. (1993). The psychopathol-
Fairburn, C. G. (1997). Towards evidence based and cost- ogy of anorexia nervosa: A factor analytic investiga-
effective treatment for bulimia nervosa. European tion. Journal of Psychopathology and Behavioral
Eating Disorders Review, 5, 145–148. Assessment, 15, 141–152.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Gleaves, D. H., Williamson, D. A., & Barker, S. E. (1993).
Cognitive behaviour therapy for eating disorders: A Confirmatory factor analysis of a multidimensional

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
Body Image Disturbance 299

model of bulimia nervosa. Journal of Abnormal Psychol- National Institute for Clinical Excellence. (2004). Eating
ogy, 102, 173–176. Disorders: Core interventions in the treatment and manage-
Goldsmith, D., & Thompson, J. K. (1989). The effect of ment of anorexia nervosa, bulimia nervosa and related
mirror confrontation and size estimation feedback on eating disorders. Nice Clinical Guideline No. 9. London:
perceptual inaccuracy in normal females who over- National Institute for Clinical Excellence. Available from
estimate body size. International Journal of Eating www.nice.org.uk.
Disorders, 8, 437–444. Nicolino, J. C., Martz, D. M., & Curtin, L. (2001).
Grant, J. R., & Cash, T. F. (1995). Cognitive-behavioral Evaluation of a cognitive-behavioral therapy interven-
body image therapy: Comparative efficacy of group tion to improve body image and decrease dieting in
and modest-contrast treatments. Behavior Therapy, 26, college women. Eating Behaviors, 2, 353–362.
69–84. Noles, S. W., Cash, T. F., & Winstead, B. A. (1985). Body
Harvey, A. G., Clark, D. M., Ehlers, A., & Rapee, R. M. image, physical attractiveness, and depression. Journal
(2000). Social anxiety and self-impression: Cognitive of Consulting and Clinical Psychology, 53, 88–94.
preparation enhances the beneficial effects of video Ramirez, E. M., & Rosen, J. C. (2001). A comparison of
feedback following a stressful social task. Behaviour weight control and weight control plus body image
Research and Therapy, 38, 1183–1192. therapy for obese men and women. Journal of Consult-
Hilbert, A., & Tuschen-Caffier, B. (2004). Body image ing and Clinical psychology, 69, 440–446.
interventions in cognitive-behavioural therapy of Rodin, J., Silberstein, L., & Striegel-Moore, R. (1984).
binge-eating disorder: A component analysis. Beha- Women and weight: A normative discontent. Nebraska
viour Research and Therapy, 42, 1325–1339. Symposium on Motivation, 32, 267–307.
Hilbert, A., Tuschen-Caffier, B., & Voegele, C. (2002). Rosen, J. C. (1996). Body image assessment and treatment
Effects of prolonged and repeated body image in controlled studies of eating disorders. International
exposure in binge-eating disorder. Journal of Psychoso- Journal of Eating Disorders, 20, 331–343.
matic Research, 52, 137–144. Rosen, J. C. (1997). Cognitive-behavioral body image
Hsu, L. G., & Sobkiewicz, T. A. (1991). Body image therapy. In D. M. Garner, & P. E. Garfinkel (Eds.),
disturbance: Time to abandon the concept for eating Handbook of treatment for eating disorders (2nd ed.). New
disorders? International Journal of Eating Disorders, 10, York: The Guilford Press.
15–30. Rosen, J. C., Cado, S., Silberg, N. T., Srebnik, D., & Wendt,
Jacobson, N. S., Roberts, L. J., Berns, S. B., & McGlinchey, S. (1990). Cognitive behavior therapy with and with-
J. B. (1999). Methods for defining and determining the out size perception training for women with body
clinical significance of treatment effects: Description, image disturbance. Behavior Therapy, 21, 481–498.
application, and alternatives. Journal of Consulting and Rosen, J. C., Saltzberg, E., & Srebnik, D. (1989). Cognitive
Clinical Psychology, 67, 300–307. behavior therapy for negative body image. Behavior
Johnson, F., & Wardle, J. (2005). Dietary restraint, body Therapy, 20, 393–404.
dissatisfaction, and psychological distress: A prospec- Rosen, J. C., Srebnik, D., Saltzberg, E., & Wendt, S. (1991).
tive analysis. Journal of Abnormal Psychology, 114, 119– Development of a body image avoidance question-
125. naire. Psychological Assessment, 3, 32–37.
Lee, S., Ho, T.P., & Hsu, L.K. (1993). Fat phobic and non- Rushford, N., & Ostermeyer, A. (1997). Body image
fat phobic anorexia nervosa: A comparative study of disturbances and their change with videofeedback in
70 Chinese patients in Hong Kong. Psychological anorexia nervosa. Behaviour Research and Therapy, 35,
Medicine, 23, 999–1017. 389–398.
Kaslow, N. J., & Eicher, V. W. (1988). Body image therapy: Salkovskis, P. (2002). Emprirically grounded clinical
A combined creative arts therapy and verbal psy- interventions: Cognitive behavioural therapy pro-
chotherapy approach. Arts in Psychotherapy, 15, 177– gresses through a multi-dimensional approach to
188. clinical science. Behavioural and Cognitive Psychother-
Key, A., George, C. L., Beattie, D., Stammers, K., Lacey, apy, 30, 3–9.
H., & Waller, G. (2002). Body image treatment within Shafran, R., & Fairburn, C. G. (2003). Body size estimation:
an inpatient programme for anorexia nervosa: The role Testing a new mirror-based assessment method.
of mirror exposure in the desensitization process. International Journal of Eating Disorders, 34, 162–171.
International Journal of Eating Disorders, 31, 185– Slade, P. D. (1994). What is body image? Behaviour
190. Research and Therapy, 32, 497–502.
McLaren, L., & Kuh, D. (2004). Body dissatisfaction in Smeets, M. A. M., & Panhuysen, G. E. M. (1995). What can
midlife women. Journal of Women and Aging, 16, 35–54. be learned from body size estimation? It all depends
McVey, G. L., Davis, R., Tweed, S., & Shaw, B. F. (2004). on your theory. Eating Disorders: The Journal of
Evaluation of a school-based programme designed to Treatment and Prevention, 3, 101–114.
improve body image satisfaction, global self-esteem, Smeets, M. A. M. (1997). The rise and fall of body size
and eating attitudes and behaviors: A replication estimation research in anorexia nervosa: A review and
study. International Journal of Eating Disorders, 36, 1–11. reconceptualization. European Eating Disorders Review,
McVey, G., Tweed, S., & Blackmore, E. (2004). Dieting 5, 75–95.
among preadolescent and young adolescent females. Strachan, M. D., & Cash, T. F. (2002). Self-help for a
Canadian Medical Association Journal, 170, 1559–1561. negative body image: A comparison of components of

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)
300 C. Farrell et al.

a cognitive-behavioral program. Behavior Therapy, 33, Tareen, A., Hodes, M., & Rangel, L. (2005). Non-
235–251. fat-phobic anorexia nervosa in British South Asian
Stice, E., & Agras, W. S. (1998). Predicting onset and adolescents. International Journal of Eating Disorders, 37,
cessation bulimic behaviors during adolescence: A 161–165.
longitudinal grouping analysis. Behavior Therapy, 29, Thompson, J. K. (1990). Body image disturbance: Assessment
257–276. and treatment. New York, USA: Pergamon Press.
Stice, E., & Bearman, S. K. (2001). Body-image and eating Thompson, J. K., Coovert, M. D., Richards, K. J., Johnson,
disturbances prospectively predict increases in S., & Cattarin, J. (1995). Development of body image,
depressive symptoms in adolescent girls: A growth eating disturbance, and general psychological func-
curve analysis. Developmental Psychology, 37, 597–607. tioning in female adolescents: Covariance structure
Stice, E., Chase, A., Stormer, S., & Appel, A. (2001). A modeling and longitudinal investigations. Interna-
randomized trial of a dissonance-based eating dis- tional Journal of Eating Disorders, 18, 221–236.
order prevention program. International Journal of Thompson, J. K., Heinberg, L. J., Altabe, M., & Tantleff-
Eating Disorders, 29, 247–262. Dunn, S. (1999). Exacting beauty. Washington, DC:
Stice, E., Hayward, C., Cameron, R. P., Killen, J. D., & American Psychological Association.
Taylor, C. B. (2000). Body-image and eating distur- Tuschen-Caffier, B., Vogele, C., Bracht, S., & Hilbert, A.
bances predict onset of depression among female (2003). Psychological responses to body shape expo-
adolescents: A longitudinal study. Journal of Abnormal sure in patients with bulimia nervosa. Behaviour
Psychology, 109, 438–444. Research and Therapy, 41, 573–586.
Stice, E., & Shaw, H. E. (2002). Role of Body Dissatisfac- Wilson, G. T. (1999). Cognitive behaviour therapy for
tion in the Onset and Maintenance of Eating Pathol- eating disorders: Progress and problems. Behaviour
ogy: A Synthesis of Research Findings. Journal of Research and Therapy, 37, S79–S95.
Psychosomatic Research, 53, 985–993. Wilson, G. T. (2005). Psychological treatment of eating
Stice, E., & Shaw, H. (2004). Eating disorder prevention disorders. Annual Review of Clinical Psychology, 1, 439–
programs: A meta-analytic review. Psychological Bulle- 465.
tin, 130, 206–227. Winzelberg, A. J., Eppstein, D., Eldredge, K. L., Wilfley,
Stice, E., Trost, A., & Chase, A. (2003). Healthy weight D., Dasmahapatra, R., Dev, P., & Taylor, C. B. (2000).
control and dissonance-based eating disorder preven- Effectiveness of an internet-based programme for
tion programs: Results from a controlled trial. Inter- reducing risk factors for eating disorders. Journal of
national Journal of Eating Disorders, 33, 10–21. Consulting and Clinical Psychology, 68, 346–350.

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 289–300 (2006)