REGULAR ARTICLE

Body Schema and Self-Representation in Patients with Bulimia Nervosa

Cosimo Urgesi, PhD1,2* Livia Fornasari, PsyD1,2 Sara De Faccio, MD3 Laura Perini, PsyD3 Elisa Mattiussi, MD3 Rossana Ciano, MD3 Matteo Balestrieri, MD3 Franco Fabbro, MD1,2 Paolo Brambilla, MD, PhD2,3*
ABSTRACT Objective: Neuroimaging evidences in eating disorder (ED) patients document dysfunctional neural activity of the posterior parietal cortex, which is engaged in the representation of body schema. Yet a full neuropsychological investigation of body schema representation in ED patients is lacking. We examined mental imagery and body schema representation in patients with bulimia nervosa (BN) and binge eating disorder (BED). Method: Consecutive samples of 15 BN patients and 15 BED patients were compared with two groups of 15 agematched controls in tasks requiring body or object mental transformation. Results: BN, but not BED patients, were selectively impaired in the mental transformation of their own body, although this decit was not correlated with measures of body dissatisfaction. In contrast, no patient group was impaired in the mental transformation of external objects. Discussion: Results showed altered selfbody representation in BN, but not BED patients, as the neuropsychological consequences of posterior parietal cortex dysC 2010 by Wiley Periodicals, functions. V Inc. Keywords: eating disorders; binge eating disorder; bulimia nervosa; body schema; self representation

(Int J Eat Disord 2011; 44:238248)

Introduction
Patients with eating disorders (ED) exhibit disturbances of body representation,14 but the neuropsychological bases of such alterations are still unclear. Understanding the specic levels of body representations that are altered in ED is crucial not only for diagnostic purposes but also for early detection, prevention, and treatment. Body representation is constructed and maintained through integrating information from multiple senses. Moreover, memories, thoughts, beliefs, social, and esthetic patterns also play a key role, collectively leading to the representation of personal anatomy5 and ultimately to the notion of self.6 NeuropsyAccepted 27 December 2009 Supported by Contract grant sponsor: IRCCS E. Medea (Ministry of Health) (to CU and PB); American Psychiatric Institute for Research and Education (APIRE) (to PB). *Correspondence to: Cosimo Urgesi, PhD, Dipartimento di Filosoa, di Udine, Via Margreth, 3, Udine I-33100, Italy. E-mail: Universita cosimo.urgesi@uniud.it or to Dr. Paolo Brambilla. E-mail: paolo. brambilla@uniud.it 1 Department of Philosophy, University of Udine, Udine, Italy 2 Scientic Institute E. Medea, Udine, Italy 3 Department of Pathology and Experimental and Clinical Medicine, Section of Psychiatry, Inter-University Centre for Behavioural Neurosciences (ICBN), University of Udine, Udine, Italy Published online 22 February 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.20816 C 2010 Wiley Periodicals, Inc. V

chological research has distinguished different forms of body representation referred to as body image, body structural description, and body schema.7 The body image includes the semantic representation of the body, such as knowledge of the names of body parts, their functions, and their relationships with objects. The body structural description is a topological map of body locations, dependent primarily on visual inputs, which denes body part boundaries and proximity relationships. On the other hand, body schema refers to the dynamic representation of the relative position of body parts, which depends on multiple sensorimotor inputs and their interaction with the planning and execution of actions. Although body image and body structural representations seem to engage the left temporoparietal cortex, body schema may involve right premotor and temporoparietal cortices.7 Several electrophysiological and neuroimaging studies in patients with eating disorder (ED) have documented alterations of neural activity in the right temporoparietal cortex,810 suggesting dysfunctions of the neural structures involved in the representation of body schema. Behavioral evidence for specic decits of body schema in ED patients, however, is still lacking. In the absence of such evidence, it cannot be established whether the alterations of right parietal activations have a clinical relevance in establishing the pattern of
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Demographic and clinical information of patients with bulimia nervosa (BN), binge eating disorder, and age-matched controls (CTR)

body representation disorders or are just epiphenomenal to primary dysfunctions in separate but connected brain areas. This study aimed at investigating body schema representation in bulimia nervosa (BN) and binge eating disorder (BED) patients by examining their ability to mentally transform the body in space, which relies on an internal representation of body position derived from sensorimotor information.7 We expected that, if BN and BED patients present a disorder of body schema representation, this ought to be reected in impaired mental body transformation abilities. Furthermore, the decits in the body schema task should be a reliable predictor of the clinical gravity of body perception symptoms.

Methods
Participants A total of 60 women were enrolled: 15 patients with a diagnosis of BN, 15 patients with a diagnosis of BED, and 30 healthy volunteers. BN and BED patients were recruited at the Psychiatric Outpatient Clinic of the University Hospital of Udine. Exclusion criteria for patients included: A history of a different type of ED, any personality or psychotic disorder, a history of traumatic brain injury or any other neurological illness, current major medical illness that may affect brain structures such as diabetes, cerebrovascular disease, etc., substance or alcohol abuse or dependence during the foregoing year. Following these exclusion criteria, no BN patient had a history of anorexia nervosa (AN) disorder and no BED patient had a history of BN or AN disorder. As the BN patients were younger than BED patients (Table 1), we compared the performance of the two patient groups with that of two different groups of 15 healthy volunteers matched 1:1 for age, sex, race, language, education, and IQ as evaluated by means of the Raven Standard Progressive Matrices test11 (Table 1). Healthy controls were recruited from the local community by word of mouth and through advertisements. Among those who volunteered to participate, we selected the individuals that were matched for age with patients. For each matched pair, we allowed a discrepancy of no more than 2 years between the ages of the patients and the controls. In keeping with the diagnosis, although the BN patients had a comparable body mass index (BMI) with respect to the controls, the BED patients had a greater BMI as compared with that of their age-matched controls and of BN patients (Table 1). The BN and BED patients had similar education level and IQ, whereas the age of BN patients at the onset of the illness was lower and the duration of illness longer as compared with that of BED patients (Table 1).
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Sample size Age (years) Education (years) IQ BMI (kg/m2) Age at onset (years) Duration of illness (months) BSQ (max 204) BAT Total (max 100) BAT 1 (max 35): Appreciation of body size BAT 2 (max 35) Lack of familiarity BAT 3 (max 20): General dissatisfaction HRSD (max 64) PAS (max 35)

Comparisons between the data of BN and BED patients and between the two patients groups with and the respective age-matched control groups were performed by means of independent sample t-test (twotailed). IQ, intelligence quotient; BMI, body mass index; PAS, perceptual aberration scale; BSQ, body shape questionnaire; BAT, body attitude test; HRSD, Hamilton rating scale for depression. The HRSD score was not available from one BN patient.

CTR Mean (SD) BED Mean (SD) CTR Mean (SD) BN Mean (SD) BN vs. CTR

TABLE 1.

15 30.9 (10.9) 13.7 (2.9) 121.8 (8.1) 21.6 (3.2) 23.4 (5.8) 60.5 (52.9) 144.1 (39.1) 66.2 (13.6) 24.1 (5.9) 21.2 (6.3) 12.4 (4.3) 5.1 (3.5) 12 (7.6)

15 30.3 (10.6) 15.6 (3.3) 125.2 (5.9) 21.1 (1.7) 65.5 (24.2) 23.3 (11.4) 8 (6.2) 5.6 (3.3) 4.3 (3) 1.7 (1.9) 2.1 (2.8)

t28 5 0.17, p 5 .866 t28 5 21.7, p 5 .1 t28 5 21.31, p 5 .201 t28 5 0.52, p 5 .607 t28 5 6.62, p\ .001 t28 5 9.4, p\ .001 t28 5 7.26, p\ .001 t28 5 8.53, p\ .001 t28 5 5.96, p\ .001 t27 5 3.31, p 5 .003 t28 5 4.74, p\ .001

15 46.1 (11.5) 12.7 (2.8) 122.9 (8.3) 38.6 (5.9) 43.7 (8.8) 21.8 (22.2) 115.9 (32.3) 58.2 (19.6) 24.7 (7.2) 17.1 (8.6) 9.5 (4) 4.7 (3.9) 5.9 (4.1)

15 45.7 (10.8) 14.3 (4.1) 123.2 (7.6) 21.6 (2.2) 63.3 (20) 22.9 (11.7) 7.3 (6) 5.9 (4.3) 5.2 (3.2) 1.7 (3) 3.1 (2.8)

t28 5 0.09, p 5 .925 t28 5 21.25, p 5 .22 t28 5 20.09, p 5 .927 t28 5 10.54, p\ .001 t28 5 5.36, p\ .001 t28 5 5.99, p\ .001 t28 5 7.25, p\ .001 t28 5 4.51, p\ .001 t28 5 3.23, p 5 .003 t28 5 1.72, p 5 .096 t28 5 2.17, p 5 .039

BED vs. CTR

t28 5 23.69, p 5 .001 t28 5 0.887, p 5 .382 t28 5 20.379, p 5 .708 t28 5 29.86, p\ .001 t28 5 27.45, p\ .001 t28 5 2.61, p 5 .014 t28 5 2.15, p 5 .04 t28 5 1.3, p 5 .204 t28 5 20.25, p 5 .804 t28 5 1.51, p 5 .142 t28 5 1.94, p 5 .063 t28 5 0.24, p 5 .809 t28 5 2.74, p 5 .01

BN vs. BED

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The patients were diagnosed using the Structured Clinical Interview for DSM-IV-TR12 criteria by an experienced investigator and clinical psychiatrist specialized in the psychotherapy of eating disorders. No BN or BED patient had a clinical history of a different ED. Two BN patients and eight BED patients received antidepressant therapy with selective serotonin reuptake inhibitors, whereas the remaining patients and all the controls were free of medication at the time of testing. Control individuals had no DSM-IV axis I disorders, as determined by the structured interview modied from the SCID-IV non-patient version (SCID-NP), no history of psychiatric disorders among rst-degree relatives, no history of alcohol or substance abuse or dependence, and no current major medical illness. All the participants were right-handed13 and had normal or corrected-to-normal visual acuity in both eyes. They were native Italian speakers of Caucasian race. Patients and controls provided written informed consent and the procedures were approved by the Ethics Committee of the Scientic Institute (IRCCS) Eugenio Medea. ve as to the purposes of the experiment They were na and were debriefed only at the end of the experimental session. The study was carried out in accordance with the guidelines of the Declaration of Helsinki. Clinical Evaluation Standard clinical scales were administered in order to characterize the patients disorder as compared with the controls (Table 1). Participants lled out the 34-item selfreport body shape questionnaire (BSQ)14 to measure shape and weight concerns. The body attitude test (BAT)15 was administered to measure subjective body experience and the attitude toward ones body. The Hamilton rating scale for depression (HRSD)16 was administered to all patients and controls, except one BN patient, to evaluate the eventual co-occurrence of depressive symptoms. The perceptual aberration scale (PAS)17 was used to measure aberrant bodily experiences associated with psychosis-proneness. Stimuli and Task We used a well-established body schema task, referred to as own-body transformation (OBT) task, requiring leftright judgments on a schematic human gure which may be facing toward (front-facing) or away from the observers (back-facing).1821 Stimuli were modied versions of those used in previous studies19,21 and depicted a schematic human gure whose left or right hand was marked to appear as wearing a gray glove. After imagining themselves to be in the gures body position and to have its visuospatial perspective, participants had to judge whether the left or the right hand of the human gure was marked. Although the back-facing orientation is compatible with the observers perspective, in the front-

facing orientation, the observers have to mentally transform their own bodies into the position of the front-facing human gure. The mental transformation of ones own body was compared with that of external objects, tapped by a letter transformation (LT) task19 requiring left-right judgments on a letter that was presented in the canonical position (unturned) or rotated by 1808 around its vertical axis (turned). The left or the right side of the letter was marked with a gray square. Participants had to judge which side of the letter, as viewed in its canonical position, was marked. In keeping with a previous study in healthy individuals,19 we used the LT task to provide a control condition matching the OBT task for the axis of the required mental transformation but dissociating the mental spatial transformations of external objects with that of the observers body. The stimuli in the OBT and LT task were black-and-white drawings and had identical vertical and horizontal dimensions (14.38 3 17.68 of visual angle).

Procedure Patients and controls were recruited and participated in a rst screening session in which the SCID-IV or the SCID-NP was administered to patients and controls, respectively. After the initial clinical screening, the experimental tasks were administered in a single experimental session lasting 30 min. The administration of the selfreport clinical scales was performed in a second session carried out within 1 week of the rst session. Before proceeding with the experimental blocks, the participants were presented with examples of the stimuli and were introduced to the task. They were instructed to imagine assuming the perspective of the stimulus body during the OBT task (motor imagery strategy) and to imagine rotating the letter without making any changes to their own position in the LT task (visual imagery strategy). For each experimental task, two 80-trial blocks were presented in a counterbalanced order. In one OBT and one LT block, the participants responded with their right hand, whereas they responded with their left hand in the other blocks. The order of the responding hand was counterbalanced across the participants. Forty front-facing/turned and 40 back-facing/unturned stimuli were randomly presented in each block. The left side of the stimuli was marked in half the trials; the right side was marked in the other half. A short rest was allowed before proceeding to a different block. The participants sat 57 cm away from a 19-inch monitor (resolution: 1,024 3 768 pixels; refresh frequency: 60 Hz), where stimuli appeared on a white background. Stimulus-presentation timing and randomization were controlled by using E-prime V1.2 software (Psychology Software Tools, Pittsburgh, PA) running on a PC.
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For each trial, the participants were presented with a body or letter stimulus that remained on the screen until a response was given. A maximum time of 10 sec was allowed to respond. They had to judge whether the left or the right side of the stimulus was marked by using their index or middle nger to press the left or the right button of the mouse. A 1-sec interval was allowed between trials. Reaction times (RTs) and accuracy were collected and stored for automated analysis. After the experimental blocks, printed versions of the experimental stimuli were presented on separate A4 pages in a counterbalanced order. For each image, the participants were asked to judge how frequently they used a motor or visual imagery strategy to respond. They marked a vertical, 10 cm visual analog scale (VAS) with 0 cm indicating minimal use and 10 cm maximal use. The VAS judgments could not be collected from one BED patient. Data Handling We calculated the proportion of correct responses and the mean RTs for correct responses for each individual and condition (80 trials per cell). Preliminary analysis showed similar patterns of results for responses provided with the left and right hand, and they were collapsed. The ratios between the individual mean RTs and the proportions of correct responses for each condition were considered as combined indexes of performance that enabled speed-accuracy trade-off effects to be taken into account. Because BN patients were on average 10 years younger than BED patients (Table 1), we expressed the patients RTs on accuracy ratios and the motor and visual imagery VAS judgments for the OBT and LT tasks as T-scores relative to the distribution of responses provided by the relative age-matched control group. This allowed us to compare the two ED groups as preventing that age differences may affect the observed effects. Two levels of analysis were performed, one for the raw healthy control data and the other for the patients T-score data. In the rst level of analysis, we entered the raw RTs on accuracy ratios scores and the motor and visual imagery VAS judgments provided by the two groups of healthy controls for the OBT and for the LT tasks into two separate two-way mixed model ANOVAs with age group (BNmatched vs. BED-matched controls) as between-subjects variable and orientation (back-facing/unturned vs. frontfacing/turned) as within-subjects variable. Furthermore, Pearson correlation coefcients were computed to investigate the relationship between age and the OBT and LT performance. In the second level of analysis, we entered the BN and BED patients T-scores for the OBT and LT task and the VAS judgments into separate two-way mixed model ANOVAs with patient group (BN vs. BED) as betweensubjects variable and orientation (back-facing/unturned vs. front-facing/turned) as within-subjects variable.
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Although we used T-scores for the analysis of the patients data, we further control for the residual effects of age differences between the BN and BED groups by testing the signicance of the interaction between patient group and orientation after controlling for the effect of the patients age. Thus, the patients T-scores were entered into a series of analyses of covariance (ANCOVAs) with patient group as between-subjects variable, orientation as within-subjects variable, and age as a covariate of interest. The clinical data of BN and BED patients were compared between each other and with that of the respective age-matched control group by means of an independent sample t-test (two-tailed). Furthermore, Pearson correlation analysis was used to correlate the performance of the BN and BED patients in the OBT and LT tasks with the individual BMI and IQ values and with scores on the BSQ, BAT, HRSD, and PAS scales. The T-scores of the differences between the RTs on accuracy ratios for the front-facing/turned and back-facing/unturned orientation was used as an estimate of the individuals ability to perform the mental rotation of his/her own body or of external objects. Signicance threshold was set at p \ .05 in all statistical tests. The source of all signicant ANOVA interactions was analyzed using the Newman-Keuls post-hoc test. All data are reported as Mean and Standard Deviation (SD).

Results
Clinical Scales

The BN patients had higher BSQ, BAT, HRSD, and PAS scores with respect to the age-matched controls, whereas the BED patients had higher BSQ, BAT, and PAS, but comparable HRSD scores than the age-matched controls ( Table 1). Nonsignicant difference was observed between the BAT and HRSD scores of the BN and BED patients, whereas BN patients had higher BSQ and PAS scores than BED patients ( Table 1).
OBT and LT Performance of Control Participants

The analysis of the raw RT on accuracy ratios for the response of the control groups in the OBT task ( Table 2) revealed a signicant main effect of orientation (F1,28 5 13.61, p 5 .001), showing that performance was lower in the front-facing (Mean 5 1,460.05 ms, SD 5 692.14) than in the back-facing body orientation (Mean 5 1,099.37 ms, SD 5 385.59). The lower performance in the front-facing as compared with the back-facing orientation 241

URGESI ET AL. TABLE 2. Performance of the patients and of controls at the experimental tasks OBT Back-Facing BN-matched controls BED-matched controls BN patients BED patients 978.67 (306.27) 1,220.07 (427.73) 1,072.36 (254.38) 1,311.73 (409.47) Front-Facing 1,145.35 (213.98) 1,774.76 (856.92) 1,439.02 (326.72) 1,666.39 (759.56) Unturned 809.18 (246.13) 1,012.3 (349.06) 1,073.74 (526.87) 1,100.87 (576.71) LT Turned 1,131.2 (324.26) 1,480.31 (565.2) 1,507.93 (817.32) 1,349.35 (534.14)

The mean (SD) raw reaction times (RTs) on accuracy ratios (ms) on the own body transformation (OBT) and letter transformation (LT) tasks are reported for the bulimia nervosa (BN) and binge eating disorder (BED) patients and for the two control groups (BN-matched controls and BED-matched controls).

reects the time required by the participants to mentally transform their own body in space and to imaginatively assume the perspective of the stimulus body. The main effect of age group was also signicant (F1,28 5 7.39, p 5 .011), because the BEDmatched controls had lower performance (Mean 5 1,497.341 ms) than the BN-matched controls (Mean 5 1,062.01 ms). On the other hand, the interaction between orientation and age group did not reach the signicance threshold (F1,28 5 3.94, p 5 .057), suggesting that, despite the reduced performance of the older BED-matched controls, both control groups engaged in the mental transformation of their own body to respond to the front-facing stimuli. The effect of age on the ability to perform the OBT task was also conrmed by a signicant correlation between the control participants age and their performance in the back-facing (r 5 .65; p \ .001; Fig. 1A) and front-facing (r 5 .364; p 5 .048) orientation conditions (Fig. 1A). Similar results were obtained from the ANOVA on the LT task ( Table 2), which revealed a signicant main effect of orientation (F1,28 5 64.59, p \ .001), showing that the participants found it more difcult to respond to the turned (Mean 5 1,305.75 ms, SD 5 486.31) as compared with the unturned (Mean 5 910.74 ms, SD 5 314.22) letter orientation. A signicant main effect of age group (F1,28 5 4.28, p 5 .048) and a nonsignicant interaction (F1,28 5 2.21, p 5 .149) were also obtained, revealing that the BED-matched controls had lower performance (Mean 5 1,246.3 ms) than the BN-matched controls (Mean 5 970.19 ms). The signicant correlations between the control participants age and their performance in the unturned (r 5 .446; p 5 .014) and turned (r 5 .481; p 5 .007) letter orientation conditions conrmed that increased age was associated to slower performance in the LT task (Fig. 1B). To investigate whether the effect of age on the OBT and LT performance was due to differences in the strategies adopted in the test, we compared the OBT- and LT-related VAS judgments provided by the control groups for the use of motor and visual 242

FIGURE 1 Pearson correlation between task performance and age of the control individuals. The correlation between the age and the performance on the own body transformation (OBT) (A) and letter transformation (LT) (B) tasks are displayed. Black and gray circles represent backfacing/unturned and front-facing/turned orientations, respectively.

imagery ( Table 3). The ANOVA on the OBT-related VAS judgments for the use of motor imagery revealed a signicant main effect of orientation (F1,28 5 42.9, p \ .001) but nonsignicant main effect of age group (F1,28\ 1) and interaction (F1,28 5 2.35, p 5 .136). This suggested that both BN- and
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BODY SCHEMA IN BULIMIA NERVOSA TABLE 3. Visual analog scale (VAS) judgments of the patients and controls OBT Back-Facing Motor imagery strategy BN-matched 1.03 (1.81) controls BED-matched 1.63 (2.56) controls BN patients 3.48 (3.74) BED patients 0.48 (1.45) Visual imagery strategy BN-matched 1.69 (2.95) controls BED-matched 0.56 (1.42) controls BN patients 1.59 (2.9) BED patients 1.44 (2.82) 6.46 (2.96) 4.99 (3.27) 4.05 (3.64) 3.49 (3.34) 1.56 (2.15) 1.44 (2.7) 4.69 (3.68) 3.36 (3.48) 0.75 (1.84) 0.21 (0.56) 2.44 (3.39) 0.13 (0.22) 1.69 (3) 1.67 (2.48) 2.94 (3.08) 1.27 (2.56) 1.38 (2.82) 0.58 (1.7) 2.41 (3.30) 0.14 (0.33) 7.48 (2.87) 6.22 (3.38) 5.73 (2.74) 7.26 (3.01) Front-Facing Unturned LT Turned

were expressed as T-scores relative to the data distribution of their respective age-matched control group.
BN Versus BED Patients

The mean (SD) raw VAS judgments on the use of motor imagery and visual imagery strategies during the performance of the own body transformation (OBT) and letter transformation (LT) tasks are reported for the bulimia nervosa (BN) and binge eating disorder (BED) patients and for the two control groups (BN-matched controls and BED-matched controls).

BED-matched control groups used motor imagery more frequently in the front- (Mean 5 5.73, SD 5 3.15) facing than in the back-facing body orientation (Mean 5 1.33, SD 5 2.2). Nonsignicant effects were obtained from the ANOVA on the VAS judgments for the use of motor imagery in the LT task (all Fs1,28 \ 1.6, p [ .22) as well as for the use of visual imagery in the OBT task (all Fs1,28 \ 1). Only a signicant main effect of orientation was obtained from the analysis of the VAS judgments of visual imagery use in the LT task (F1,28 5 45.62, p \ .001), but nonsignicant effect of group (F1,28 \ 1) and interaction (F1,28 \ 1), indicating that both control groups imagined to rotate the unturned letter to perform the LT task. Thus, the analysis of the VAS judgments revealed that both control groups predominantly used a motor imagery strategy to respond to the OBT task, and a visual imagery strategy to respond to the LT task. No difference was observed between the two groups, suggesting that their different performances could not be ascribed to the use of different response strategies. In sum, the analysis of the control groups performance revealed that the front-facing/turned conditions were more difcult than the back-facing/unturned conditions, indicating that the tasks were adept to disclose body and object mental transformation abilities. Furthermore, this analysis also showed that the absolute level of performance in the OBT and LT tasks was negatively affected by the age of the participants, suggesting that the performances of BN and BED patients needed to be compared to different baseline levels. Thus, the RTs on accuracy ratios of the BN and BED patients
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The analysis of the BN and BED patients T-scores for the OBT task (Fig. 2A) revealed signicant effects of patient group (F1,28 5 4.81, p 5 .037) and orientation (F1,28 5 5.1, p 5 .032). The patient group by orientation interaction was also signicant (F1,28 5 19.17, p \ .001), showing that the two patient groups performed differently in the two body orientations. Importantly, the main effect of patient group (F1,27 5 8.84, p 5 .006) and the interaction between patient group and orientation (F1,27 5 14.74, p 5 .001) were still signicant after controlling for the effect of age as a covariate, which yielded a non signicant effect (F1,27 5 3.62, p 5 .068). Thus, the differential performance of the BN and BED patients in the two body orientations was independent from their age differences. Pair-wise post hoc comparisons showed that the BN (Mean 5 53.06, SD 5 8.31) and the BED patients (Mean 5 52.14, SD 5 9.57) had a comparable performance in the back-facing body orientation (p [ .085). In contrast, the BN patients (Mean 5 63.72, SD 5 15.27) were impaired with respect to the BED patients (Mean 5 48.74, SD 5 8.86) in the front-facing body orientation (p 5 .033). Furthermore, as there was no signicant difference between the Tscores obtained by the BED patients in the two body orientations, the BN patients T-scores were higher in the front-facing than in the back-facing body orientation (p \ .001), suggesting that the BN patients performance was lower in the front-facing than in the back-facing orientation. Importantly, the T-scores of the BED patients were not signicantly different from the performance of the BEDmatched controls (Mean 5 50) in the back-facing (one-sample t-test: t14 5 0.867, p [ .4) and frontfacing orientations (t14 5 20.553, p [ .58). In contrast, the T-scores of the BN patients were signicantly different from the performance of the BNmatched controls (Mean 5 50) in the front-facing (t14 5 3.481, p 5 .004), but not in the back-facing orientation (t14 5 1.426, p [ .17). Thus, BN patients were impaired relative to the BED patients and age-matched controls in the mental body transformation ability required in the front-facing, but not in the back-facing orientation condition. Nonsignicant effects of patient group (F1,28 5 2.75, p [ .1), orientation (F1,28 5 1.02, p [ .32), or interaction (F1,28 5 2.1, p [ .15) were obtained from the ANOVA on the LT task (Fig. 2B) showing that BN and BED patients did not differ in their 243

URGESI ET AL. FIGURE 2 Performance of patients with bulimia nervosa (BN) and binge eating disorder (BED) at the experimental tasks. The BN and BED patients reaction times (RTs) on accuracy ratios are expressed as T-scores relative to the performance of their respective age-matched control groups. Mean (6SD) T-scores are shown for the (A) own body transformation (OBT) and (B) letter transformation (LT) tasks. The dashed reference lines at the 50 T-score value indicate the mean performance of the age-matched controls. Note that the BED patients T-scores were not signicantly different from the value of 50 for any condition, suggesting that their performance was comparable with that of controls, thus being lower in the front-facing/turned than in the back-facing/unturned condition. Error bars indicate standard deviations; *p \ .05.

ability to mentally rotate external objects. Nonsignicant main effect of patient group (F1,27 5 1.62, p [ .21) or interaction (F1,27 5 2.49, p [ .12) were also obtained after controlling for the effect of patients age as a covariate, which was in turn nonsignicant (F1,27 \ 1). Furthermore, the T-scores of BN and BED patients did not differ from the performance of their respective age-matched controls (Mean 5 50; for all one-sample t-tests: 20.94 \ t14 \ 1.95, p [ .07), suggesting that the absolute levels of performance of the two patients groups and the reduction of performance in the turned as compared with the unturned letter orientation were comparable with the ones observed in the controls. The difference between the BN patients performance on the front-facing/turned versus backfacing/unturned stimulus in the OBT and LT tasks was not signicantly correlated with the individual BAT, BSQ, HRSD, and PAS scores (20.46 \ all rs \ .3, p [ .09) nor with the BMI and IQ values (20.15 \ all rs \ .24, p [ .39). In a similar vein, nonsignicant correlations were found between the OBT and LT difference indexes of performance of the BED patients and their individual scores on the clinical scales and BMI values (20.07 \ all rs \ .11, p [ .7). On the other hand, the BED patients IQ values were signicantly correlated with their performance in the LT (r 5 .646, p 5 .009) but not OBT task 244

(r 5 .376, p [ .16). Furthermore, there was a marginally signicant correlation between the BED patients HRSD scores and the performance index in the OBT (r 5 .636, p 5 .011), but not in the LT task (r 5 .102, p [ .71), suggesting the possible existence of a link between depression scores and the ability to mentally transform the body. Because eight of 15 BED patients received antidepressant therapy, we investigated the effect of medication by entering the BED patients T-scores for the OBT and LT tasks into separate two-way mixed model ANOVAs with medication group (medicated vs. nonmedicated) as between-subjects variable and orientation (back-facing/unturned vs. front-facing/ turned) as within-subjects variable. The main effect of orientation was signicant for the OBT (F1,13 5 5.56, p \ .035), but not for the LT task (F1,13 \ 1). On the other hand, the main effect of medication group and the interaction between medication group and orientation were nonsignicant for both the OBT and LT tasks (all Fs1,13 \ 3.41, p [ .08). This suggests that the absence of any decit in the mental transformation of the body in BED patients cannot be ascribed to medication. The ANOVA on the OBT-related VAS judgments T-scores for the use of motor imagery in the BN and BED patients (Fig. 3A) revealed a signicant main effect of orientation (F1,27 5 15.06, p 5 .001)
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BODY SCHEMA IN BULIMIA NERVOSA FIGURE 3 Visual analog scale (VAS) judgments made by patients with bulimia nervosa (BN) and binge eating disorder (BED). The BN and BED patients VAS judgments on the use of (A,B) motor imagery and (C,D) visual imagery strategies are expressed as T-scores relative to the VAS judgments of their respective age-matched control groups. Mean (6SD) T-scores are shown for the (A,C) own body transformation (OBT) and (B,D) letter transformation (LT) tasks. The dashed reference lines at the 50 T-score value indicate the mean judgments of the age-matched controls. Error bars indicate standard deviations; *p \ .05.

but nonsignicant main effect of patient group (F1,27 5 3.01, p 5 .094). Crucially a signicant interaction between patient group and orientation was found (F1,27 5 14.72, p 5 .001). A nonsignicant main effect of patient group (F1,26 5 1.62, p [ .22) and a signicant interaction between patient group and orientation (F1,26 5 6.98, p 5 .014) were similarly obtained after controlling for the effect of patients age as a covariate, which yielded a nonsignicant effect (F1,26 \ 1). Pair-wise post hoc comparisons showed that the BN patients T-scores in the back-facing condition (Mean 5 63.53, SD 5 20.71) were signicantly higher with respect to their T-scores in the front-facing condition (Mean 5 41.87, SD 5 12.31; p \ .001) and to those of the BED patients in the back- (Mean 5 45.52, SD 5 5.67; p 5 .005) and front-facing conditions (Mean 5 45.39, SD 5 10.22; p 5 .002), which in turn did not differ from one another (all ps [ .55). Thus, the
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BN patients reported a more frequent use of the motor imagery strategy to respond to the back-facing body stimuli, whereas the BED patients and controls used a motor imagery strategy only to respond to the front-facing stimuli. The ANOVA on the VAS judgments for the use of motor imagery in the LT task (Fig. 3B) revealed signicant main effects of orientation (F1,27 5 5.77, p 5 .023), with higher T-scores in the unturned (Mean 5 54.08, SD 5 14.32) than turned letter orientation condition (Mean 5 50.62, SD 5 8.96), and patient group (F1,27 5 4.5, p 5 .043), with the BN patients (Mean 5 56.4) reporting more frequent use of the motor imagery strategy in the LT task with respect to the BED patients (Mean 5 48.01). The interaction between orientation and patient group was nonsignicant (F1,27 5 2.37, p [ .135). The main effect of patient group (F1,26 5 2.5, p [ .12) and the interaction between patient group and orientation (F1,26 245

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5 2.36, p [ .13) were similarly non signicant after controlling for the effect of patients age as a covariate, which yielded nonsignicant effect (F1,26 \ 1). Nonsignicant main effects or interactions were obtained from the analysis of visual imagery VAS judgments during the OBT task (Fig. 3C; all Fs1,27 \ 3.8, p [ .06), also when we controlled for the effect of patients age as a covariate (all Fs1,26 \ 1), which was in turn nonsignicant (F1,26 5 2.69, p [ .11). On the other hand, the analysis of the VAS judgments of visual imagery use in the LT task (Fig. 3D) revealed nonsignicant main effects of orientation (F1,27 5 1.39, p [ .249) and patient group (F1,27 \ 1) but a signicant interaction (F1,27 5 10.11, p 5 .004). A nonsignicant main effect of patient group (F1,26 5 1.21, p [ .28) and a signicant interaction between patient group and orientation (F1,26 5 5.58, p 5 .026) were also obtained after controlling for the effect of patients age as a covariate, which yielded nonsignicant effect (F1,26 5 1.06, p [ .31). Pair-wise post hoc comparisons showed that the BN patients T-scores in the unturned letter condition (Mean 5 54.15, SD 5 10.26) were signicantly higher with respect to their T-scores in the turned condition (Mean 5 43.9, SD 5 9.53; p 5 .023). This shows that the BN patients reported a more frequent use of the visual imagery strategy to respond to the unturned letter stimuli as compared to the reports of the age-matched controls. No other pair-wise comparison resulted signicant (all ps [ .16), suggesting that the reports of the BED patients in the two letter orientation conditions reected the pattern obtained in the age-matched controls. In conclusion, the analysis of the patients VAS judgments pointed out to the impairment of the BN patients, but not of the BED patients, in the appropriate use of the motor and visual imagery strategies to mentally transform their bodies or the external objects.

Discussion
This study investigated body schema representation in BN and BED patients by using tasks requiring the mental transformation of ones own body or external objects.1821 We found that the BN, but not the BED patients, were impaired in providing laterality judgments on the front-facing human gure, wherein patients had to perform a mental transformation of their own body to assume the perspective of the body stimulus. However, no decit was observed for the laterality judgments provided on the back-facing gures, in which no mental transformation of the body but similar left-right decisions were required. 246

The main nding of this study is that the BN patients, but not the BED patients, presented a signicant impairment in the mental transformation of the body. The selective impairment of the BN patients cannot be ascribed to the higher difculty of left-right judgments on the front-facing as compared with the back-facing human gure. Indeed, the decit was task-specic, as the BN patients were not impaired in the mental transformation of the external object. Furthermore, it was independent from age and the IQ levels, because both BN and BED patients were matched for age and IQ with the respective control group. In a similar vein, the BN and BED patients and the controls had comparable educational levels, thus ruling out that differences in education may have masked the decit of BED patients. The analysis of the subjective ratings on the strategies adopted by the patients during the task allowed us to ascertain that the BN patients were impaired in the correct use of the motor and visual imagery strategies to mentally transform their own body or the external objects. In particular, they appropriately used the motor imagery strategy in the OBT task and the visual imagery strategy in the LT task, but tended to use more frequently the motor imagery strategy also for the back-facing and not only for the front-facing body stimuli, and the visual imagery strategy also for the unturned, and not only for the turned letter. Thus, contrary to the control participants and to the BED patients, the BN patients did not differentiate between compatible and incompatible orientations of the stimuli with respect to their own body, revealing a difculty in the appropriate use of imagery strategies in mentally manipulating their body schema. Several studies have shown disorders of body processing in ED patients, which include an overestimation of ones own body parts1 at the perceptual level and body dissatisfaction at the emotional and attitudinal levels.4 Although the relationship between perceptual and emotional body disturbances of body representation is still unclear,1 it has been argued that the most signicant alteration may be at the emotional and attitudinal level, which may in turn affect body image representation.22 The BN patients impairment in the OBT task may hardly be ascribed to a decit in the visual processing of human body forms or a nonspecic emotional reaction to viewing human gures, which should have affected decisions on both back-facing and front-facing human gures. It seems unlikely that viewing front-facing schematic human gures may have evoked strong emotional reactions comparable with that evoked by viewing
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self images in the mirror. Indeed, body stimuli were very schematic and only a few details differentiated the back-facing and the front-facing gures. Furthermore, stimuli depicted a man, being semantically and perceptually distant from the patients body. It is also worthy noting that impaired leftright decisions on the front-facing gures were limited to the BN patients, whereas the BED patients were not impaired in the OBT task in spite of altered scores at the BAT15 that enables measurement of the degree of body dissatisfaction, including the negative appreciation of body size and the lack of familiarity with the body, which are the core symptoms of ED patients at emotional and attitudinal levels.4,22 Thus, although we cannot rule out that the front-facing human gures may have evoked different emotional reactions than the back-facing gures, it seems unlikely that the impaired mental transformation abilities of BN are due to the negative emotional reactions to viewing front-facing human gures. We suggest, instead, that the BN patients impaired performance in the OBT task reects a maladaptive mental representation of the bodily self.23 The OBT involves the manipulation of an egocentric frame of reference (perspective transformation), whereas the LT task involves manipulation of an object-relative frame of reference.19 Neuropsychological24,25 and neuroimaging19,21 evidences suggest that the perspective and object-based transformations engage partially distinct neural systems. In particular, the mental transformation of the body tapped by the OBT task has been linked to the activity of a network of temporoparietal areas which are involved in maintaining the spatial unity between the self and the body5,7,19,21 and play a crucial role in multisensory integration and body schema representation. Lesions of the right temporoparietal cortex induce body part disownership.26 Illusory localization of the self into the extrapersonal space has been reported in patients with left (heautoscopic phenomena)27,28 and right temporoparietal lesions (out-of-body experiences).27 Furthermore, stimulation of the temporoparietal junction may induce out-of-body experiences in epileptic patients29 and impair OBT performance in healthy individuals.19 Thus, the impaired mental body transformation abilities of BN patients may provide the neuropsychological counterpart of the neuroimaging evidence of altered functioning of the temporoparietal cortex in BN patients.9 The relative ability of BN and BED patients to perform the mental rotation of their own body was not correlated with the clinical measures of body dissatisInternational Journal of Eating Disorders 44:3 238248 2011

faction. Although the small sample sizes may have not allowed us to disclose possible relationships, the absence of correlations between the OBT and clinical measures is in keeping with the evidence that both the BN and BED patient groups presented body dissatisfaction as compared with control participants, but only the BN patients presented decits in the mental transformation of the body. Another novel result of this study is that the BN patients, with respect to the controls, and the BED patients had higher PAS scores and aberrant bodily experiences, which are typically associated with psychosis-proneness. Interestingly, the degree of aberrant bodily experiences, as measured with the PAS,17 is inversely correlated with mental body transformation abilities20 and with the latency of the electrophysiological responses originating from the temporoparietal junction during the OBT task.18 However, in this study, we found no correlation between mental body transformation abilities and individual PAS scores. This is in keeping with previous studies in healthy individuals showing signicant correlation in male but not in female healthy individuals.20 Alterations of motor imagery abilities have been previously reported in schizophrenia patients30,31 and may reect dysfunctional activity of the posterior parietal cortex.32 This study suggests that the ability to control the mental transformation of ones own body and body parts is impaired also in BN patients. This is in keeping with the notion of a maladaptive representation of self identity in ED patients determined by congenital dispositional traits33 or by cultural pressure emphasizing the reliance on a feminine ideal instead of on the search for an authentic self.34 Although the BED patients presented no alteration of body schema representation, they had higher BAT scores than their respective agematched control group. This is in keeping with studies showing that body dissatisfaction is an important clinical feature of BED.35,36 Furthermore, similar to the BN patients, the BED patients had higher PAS scores than that of the age-matched controls, suggesting the presence of aberrant bodily representation and self-processing disturbances, as well as higher depression ratings. However, the PAS scores of BED patients were lower than that of BN patients, suggesting that more severe aberrant bodily representations in BN are associated to impaired OBT performance. This shows that, in spite of comparable body dissatisfaction and depression aspects, BN and BED may be differentiated not only for BMI and eating behaviors but also for the different alterations of bodily self-representation. The results of this study ought to be corroborated by further studies including larger sample popula247

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tions. Indeed, the main limitation of our results is the restricted number of patients tested in each group, which imposes caution when generalizing results to the general population from which the patients were sampled. Furthermore, different tasks tapping body image, body schema, and body structural description should be used in combination with neurophysiologic and neuroimaging methods in order to identify the levels of body representations altered in the different ED subgroups and their neural correlates. Thus, future studies are needed to detail the specic features of body representation in BN, BED, and AN patients and determine whether the different ED subtypes are different behavioral manifestations of the same core disturbance, or whether they reect different levels of body representation disorder.
We thank all participants who took part in this study and Prof. Salvatore M. Aglioti for his insightful comments and suggestions.

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