Weight Phobia or Overvaluation of Shape and Weight?

The psychological conceptualization of anorexia nervosa has been dominated for many years by the avoidance paradigm, according to which the probability of behavior increases if it is followed by negative reinforcement (i.e., the removal of the aversive stimulus). If applied to anorexia nervosa, this model explains most of the distinctive behavioral expressions of the disorder (e.g., strict dieting, excessive exercising, self-induced vomiting and laxatives, and diuretics misuse), which are adopted for the purpose of avoiding specific aversive stimuli, i.e., weight gain and getting fat.

The avoidance model is also compatible with the conceptualization considering anorexia nervosa as an adaptive disorder in which "weight phobia" represents the avoidance of the feared circumstances associated with psychosexual maturity. According to this theory, weight loss becomes a means to avoid the challenges associated with psychosexual development, for which the person with anorexia nervosa feels unprepared. Although in most cases, the source of this phobia (the aversive stimulus) is not expressed by patients, some authors have reported that it is often associated with issues concerning sexuality, high-performance standards, separation from family, or family conflicts.

This avoidance model postulates that the avoidance, once acquired, is maintained by the persistence of the behaviors of eating disorders, which isolate the subject from the possibility of recognizing when the aversive contingencies are no longer operating. Cognitive variables seem to contribute in part to this process, as the avoidance prevents the development of inhibitory learning of fear by not allowing falsification of the occurrence of the feared consequences.

However, the conceptualization of anorexia nervosa as a simple phobic disorder is difficult to maintain, because the control of shape and weight seen in this disorder is often associated with a sense of triumph, mastery, self-control, and superiority in its sufferers. It is common to observe this characteristic in the accounts of patients who, especially in the early phases of their weight loss, report being "happy," "exultant," "satisfied," "powerful," and "proud." Indeed, weight loss is often experienced as a "goal," "an achievement," "a virtue," "a source of positive pleasure," and/or "a pleasure of the senses."

This condition is clearly distinct from simple "weight phobia." Indeed, persons with agoraphobia experience a severe state of anxiety when they are in open spaces, but they generally do not report a feeling of euphoria or a sense of power when they are indoors. Furthermore, individuals with agoraphobia tend to perceive their anxiety as excessive and uncontrollable, and they use the strategy of avoidance to eliminate this anxiety.

Those with anorexia nervosa, on the other hand, often perceive their preoccupation with shape, weight, and their control, and the associated negative mood states (e.g., anxiety) as useful means of keeping control over their shape and weight.

The egosyntonic characteristics of anorexia nervosa have led experts to consider the positive cognitive reinforcement associated with the control of shape and weight as the core psychopathology of the eating disorder. Indeed, according to the modern transdiagnostic cognitive-behavioral theory, a distinctive self-evaluation scheme, the overvaluation of shape, weight, and their control (i.e., judging oneself predominantly or exclusively in terms of shape, weight, and their control) are of central importance in maintaining anorexia nervosa, but also other eating disorders. According to this theory, most other clinical features of the disorder, including weight phobia, derive from this specific core psychopathology.

The identification of the core psychopathology of anorexia nervosa is important not only in academic speculation; above all, it has relevant implications for the psychological treatment of this disorder. Indeed, the evidence-based, "enhanced" cognitive-behavioral therapy (CBT-E), derived from the transdiagnostic theory, contrary to behavioral exposure-based programs, is not designed to primarily address weight phobia. On the contrary, CBT-E involves actively involving the patients in the implementation of strategies and procedures that make feel them in "control" in addressing the main expressions and maintaining factors of the disorder with the final goal to develop a more articulated and functional scheme of self-evaluation less dependent on shape, weight, and their control.