Abstract
Empiricist models explain delusional beliefs by identifying the abnormal experiences which ground them. Recently, this strategy has been adopted to explain the false body size beliefs of anorexia nervosa patients. As such, a number of abnormal experiences of body size which patients suffer from have been identified. These oversized experiences convey false information regarding the patients’ own bodies, indicating that they are larger than reality. However, in addition to these oversized experiences, patients are also exposed to significant evidence suggesting their bodies are in fact thin. This situation poses a conundrum: why do patients appear strongly influenced by the former kinds of evidence while the latter has little effect? To solve this conundrum, I suggest a two-factor account. First, I discuss research on the biases patients exhibit in how they gather, attend to and interpret evidence related to their own body size. Such biases in evidence treatment, I suggest, cause oversized experiences to be sought out, attended to and accepted, while veridical body size experiences are ignored or explained away. These biases constitute the second factor for this empiricist model, accounting for the unwarranted conviction with which these beliefs are held. Finally, in line with recent research into self-deception, I propose that, paradoxically, these biases in evidence treatment arise from patients’ own desires.
Similar content being viewed by others
Notes
Evidence of this comes from figural drawing scale experiments: participants are asked to select body size silhouettes that match both their current and ideal body sizes, with the difference in size taken to be an indication of “body dissatisfaction” (Moussally et al. 2017).
This isn't to say that the oversized experiences discussed are in no way related to the deficits in interoceptive processing that have been uncovered. A link between these two forms of dysfunction may emerge, though it’s not yet clear what this link might be.
Unlike with the other forms of oversized experiences, most of the research into spontaneous mental imagery in ED has been conducted on BN, rather than AN, patients (cf. Cooper et al. 1998). This lends further support to the possibility that the model discussed here might apply to a number of eating disorders (see Sect. 4).
It might be that patients also experience their body size accurately through direct visual perception, though this is a source of some contention. While some patients claim they (directly) see themselves as thin, others claim the opposite (Espeset et al. 2011). Based on evidence from mirror exposure research, it has recently been argued that AN patients’ direct perception of their bodies must be veridical (Gadsby 2017c, 27). Nevertheless, this is still an open question (cf. Mohr et al. 2016).
Within delusion literature, the maintenance problem just posed is sometimes distinguished from the adoption problem, which requires an explanation for why the abnormal content was adopted as belief in the first place (Davies and Egan 2013). That said, I won’t delve into the specifics of this distinction here as, although interesting, it’s orthogonal to my central thesis (cf. Gadsby 2017b, 501–503).
This example coheres with research into the confabulatory practices of delusional patients, who often arrive at patently implausible explanations for evidence which conflicts with their delusional beliefs (Langdon and Bayne 2010, 323).
See Holmes and Mathews (2010, 354–355) for a discussion of some different hypotheses for why clinical patients might come to interpret spontaneous mental imagery as veridical.
An interesting point arises here regarding whether the relationship between desires and biased hypothesis testing must be consciously mediated by a belief that this form of hypothesis testing will avoid the relevant costly error (Mele 2001, 31–32, 42–46). In some cases, such as the mentioned excerpt, patients clearly are aware that certain evidence treatment practices (i.e. body checking) will aid in avoiding undesirable situations. Yet this needn’t be the case with all instances of biased hypothesis testing. For example, it seems less likely that attentional and interpretational biases are consciously mediated and indeed the FTL model allows that much of this biasing is “automatic and inflexible … reflecting the operation of evolved cognitive adaptations to a range of biologically significant problems” (Friedrich 1993, p. 317).
It’s worth highlighting that this story would markedly differ from the discussed hypothesis regarding affordance salience in AN. While that hypothesis claims all size-determined affordances have increased salience (due to patients’ mental preoccupation with body size related themes), the proposed self-deception hypothesis suggests a particular subset of size-determined affordances (those likely to reinforce beliefs about being overweight) would exhibit increased salience. Such a bias would manifest in patients attending to affordances they believed their bodies were too large for.
References
Alleva, J., Jansen, A., Martijn, C., Schepers, J., & Nederkoorn, C. (2013). Get your own mirror. Investigating how strict eating disordered women are in judging the bodies of other eating disordered women. Appetite,68, 98–104.
Aspen, V., Darcy, A. M., & Lock, J. (2013). A review of attention biases in women with eating disorders. Cognition and Emotion,27(5), 820–838.
Baker, J. D., Williamson, D. A., & Sylve, C. (1995). Body image disturbance, memory bias, and body dysphoria: Effects of negative mood induction. Behavior Therapy,26(4), 747–759.
Bayne, T., & Fernández, J. (2009). Delusion and self-deception. Mapping the terrain in delusion and self-deception. New York: Psychology Press.
Bayne, T., & Pacherie, E. (2004). Experience, belief, and the interpretive fold. Philosophy Psychiatry & Psychology,11(1), 81–86.
Blechert, J., Nickert, T., Caffier, D., & Tuschen-Caffier, B. (2009). Social comparison and its relation to body dissatisfaction in bulimia nervosa: Evidence from eye movements. Psychosomatic Medicine,71(8), 907–912.
Bortolotti, L. (2010). Delusions and other irrational beliefs. Oxford: Oxford University Press.
Bortolotti, L., & Mameli, M. (2012). Self-deception, delusion and the boundaries of folk psychology. Humana. mente,20, 203.
Clutton, P. (2018). A new defence of doxasticism about delusions: The cognitive phenomenological defence. Mind and Language,33(2), 198–217.
Coltheart, M. (2007). The 33rd Sir Frederick Bartlett Lecture: Cognitive neuropsychiatry and delusional belief. The Quarterly Journal of Experimental Psychology,60(8), 1041–1062. https://doi.org/10.1080/17470210701338071.
Coltheart, M., Menzies, P., & Sutton, J. (2010). Abductive inference and delusional belief. Cognitive Neuropsychiatry,15(1–3), 261–287. https://doi.org/10.1080/13546800903439120.
Cooper, M. (1997). Bias in interpretation of ambiguous scenarios in eating disorders. Behaviour Research and Therapy,35(7), 619–626.
Cooper, M., Todd, G., & Wells, A. (1998). Content, origins, and consequences of dysfunctional beliefs in anorexia nervosa and bulimia nervosa. Journal of Cognitive Psychotherapy,12(3), 213–230.
Corning, A. F., Krumm, A. J., & Smitham, L. A. (2006). Differential social comparison processes in women with and without eating disorder symptoms. Journal of Counseling Psychology,53(3), 338.
Currie, G. (2000). Imagination, delusion and hallucinations. Mind and Language,15, 168–183.
Davies, M. (2009). Delusion and motivationally biased belief: Self deception in the two factor framework (pp. 71–86). Delusion and Self deception: Affective and Motivational Influences on Belief Formation.
Davies, M., Coltheart, M., Langdon, R., & Breen, N. (2001). Monothematic delusions: Towards a two-factor account. Philosophy, Psychiatry & Psychology,8(2), 133–158.
Davies, M., & Egan, A. (2013). Delusion: Cognitive approaches–Bayesian inference and compartmentalization. In The oxford handbook of philosophy and psychiatry (pp. 88–727).
de Vignemont, F. (2010). Body schema and body image—Pros and cons. Neuropsychologia,48(3), 669–680.
Deweese-Boyd, I. (2017). Self-deception. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy (fall 2017 edition).
Ellis, H. D., & Young, A. W. (1990). Accounting for delusional misidentifications. British Journal of Psychiatry. https://doi.org/10.1192/bjp.157.2.239.
Engel, M. M., & Keizer, A. (2017). Body representation disturbances in visual perception and affordance perception persist in eating disorder patients after completing treatment. Scientific Reports,7(1), 16184.
Espeset, E., Gulliksen, K. S., Nordbø, R. H., Skårderud, F., & Holte, A. (2012). Fluctuations of body images in anorexia nervosa: Patients’ perception of contextual triggers. Clinical Psychology & Psychotherapy,19(6), 518–530.
Espeset, E., Nordbø, R. H., Gulliksen, K. S., Skårderud, F., Geller, J., & Holte, A. (2011). The concept of body image disturbance in anorexia nervosa: An empirical inquiry utilizing patients’ subjective experiences. Eating Disorders,19(2), 175–193.
Fairburn, C. G., Shafran, R., & Cooper, Z. (1998). A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy,37(1), 1–13.
Freeman, R., Touyz, S., Sara, G., Rennie, C., Gordon, E., & Beumont, P. (1991). In the eye of the beholder: Processing body shape information in patients and bulimic patients. International Journal of Eating Disorders,10(6), 709–714.
Friedrich, J. (1993). Primary error detection and minimization (PEDMIN) strategies in social cognition: A reinterpretation of confirmation bias phenomena. Psychological Review,100(2), 298.
Gadsby, S. (2017a). Anorexia nervosa and oversized experiences. Philosophical Psychology, 30(5), 594–615.
Gadsby, S. (2017b). Explaining body size beliefs in anorexia. Cognitive Neuropsychiatry, 22(6), 495–507.
Gadsby, S. (2017c). Distorted body representations in anorexia nervosa. Consciousness and Cognition,51, 17–33.
Gadsby, S., & Williams, D. (2018). Action, affordances, and anorexia: Body representation and basic cognition. Synthese. https://doi.org/10.1007/s11229-018-1843-3.
Gardner, R. M., & Brown, D. L. (2010). Body image assessment: A review of figural drawing scales. Personality and Individual Differences,48(2), 107–111.
Gerrans, P. (2014). The measure of madness: Philosophy of mind, cognitive neuroscience, and delusional thought. Cambridge, MA: MIT Press.
Gibson, J. J. (1979). The ecological approach to visual perception. Boston: Houghton Mifflin.
Green, M. A., Scott, N. A., Cross, S. E., Liao, K. Y. H., Hallengren, J. J., Davids, C. M., et al. (2009). Eating disorder behaviors and depression: A minimal relationship beyond social comparison, self-esteem, and body dissatisfaction. Journal of Clinical Psychology,65(9), 989–999.
Guardia, D., Conversy, L., Jardri, R., Lafargue, G., Thomas, P., Dodin, V., et al. (2012). Imagining one’s own and someone else’s body actions: Dissociation in anorexia nervosa. PLoS ONE,7(8), e43241.
Guardia, D., Lafargue, G., Thomas, P., Dodin, V., Cottencin, O., & Luyat, M. (2010). Anticipation of body-scaled action is modified in anorexia nervosa. Neuropsychologia,48(13), 3961–3966.
Hackmann, A., Clark, D. M., & McManus, F. (2000). Recurrent images and early memories in social phobia. Behaviour Research and Therapy,38(6), 601–610.
Hackmann, A., Surawy, C., & Clark, D. M. (1998). Seeing yourself through others’ eyes: A study of spontaneously occuring images in social phobia. Behavioural and Cognitive Psychotherapy,26(1), 3–12.
Hamel, A. E., Zaitsoff, S. L., Taylor, A., Menna, R., & Grange, D. L. (2012). Body-related social comparison and disordered eating among adolescent females with an eating disorder, depressive disorder, and healthy controls. Nutrients,4(9), 1260–1272.
Hohwy, J., & Rajan, V. (2012). Delusions as forensically disturbing perceptual inferences. Neuroethics,5(1), 5–11. https://doi.org/10.1007/s12152-011-9124-6.
Holmes, E. A., & Mathews, A. (2010). Mental imagery in emotion and emotional disorders. Clinical Psychology Review,30(3), 349–362.
Jackman, L. P., Williamson, D. A., Netemeyer, R. G., & Anderson, D. A. (1995). Do weight-preoccupied women misinterpret ambiguous stimuli related to body size? Cognitive Therapy and Research,19(3), 341–355.
Jansen, A., Nederkoorn, C., & Mulkens, S. (2005). Selective visual attention for ugly and beautiful body parts in eating disorders. Behaviour Research and Therapy,43(2), 183–196.
Kaye, W. H., Fudge, J. L., & Paulus, M. (2009). New insights into symptoms and neurocircuit function of anorexia nervosa. Nature Reviews Neuroscience,10(8), 573.
Keizer, A., Smeets, M. A., Dijkerman, H. C., Uzunbajakau, S. A., van Elburg, A., & Postma, A. (2013). Too fat to fit through the door: First evidence for disturbed body-scaled action in anorexia nervosa during locomotion. PLoS ONE,8(5), e64602.
Konstantakopoulos, G., Varsou, E., Dikeos, D., Ioannidi, N., Gonidakis, F., Papadimitriou, G., et al. (2012). Delusionality of body image beliefs in eating disorders. Psychiatry Research,200(2), 482–488.
Langdon, R., & Bayne, T. (2010). Delusion and confabulation: Mistakes of perceiving, remembering and believing. Cognitive Neuropsychiatry,15(1–3), 319–345. https://doi.org/10.1080/13546800903000229.
Langdon, R., McKay, R., & Coltheart, M. (2008). The cognitive neuropsychological understanding of persecutory delusions. In D. Freeman, R. Bentall & P. Garety (Eds.), Persecutory delusions: Assessment, theory, and treatment (pp. 221–236).
Longo, M. R. (2015). Three-dimensional coherence of the conscious body image. The Quarterly Journal of Experimental Psychology,68(6), 1116–1123.
Longo, M. R., & Haggard, P. (2012). Implicit body representations and the conscious body image. Acta Psychologica,141(2), 164–168.
Maher, B. A. (1974). Delusional thinking and perceptual disorder. Journal of Individual Psychology,30(1), 98–113.
McKay, R., Langdon, R., & Coltheart, M. (2005). Sleights of mind: Delusions, defences, and self-deception. Cognitive Neuropsychiatry,10(4), 305–326. https://doi.org/10.1080/13546800444000074.
McKay, R., Langdon, R., & Coltheart, M. (2007). Models of misbelief: Integrating motivational and deficit theories of delusions. Consciousness and Cognition,16(4), 932–941.
McKenna, P. (1984). Disorders with overvalued ideas. The British Journal of Psychiatry: The Journal of Mental Science,145, 579.
McKenna, G., Fox, J. R., & Haddock, G. (2014). Investigating the ‘jumping to conclusions’ bias in people with anorexia nervosa. European Eating Disorders Review,22(5), 352–359.
Mele, A. (2001). Self-deception unmasked. Princeton: Princeton University Press.
Mele, A. (2006). Self-deception and delusions. European Journal of Analytic Philosophy,2(1), 109–124.
Metral, M., Guardia, D., Bauwens, I., Guerraz, M., Lafargue, G., Cottencin, O., et al. (2014). Painfully thin but locked inside a fatter body: Abnormalities in both anticipation and execution of action in anorexia nervosa. BMC research Notes,7(1), 707.
Mohr, H. M., Rickmeyer, C., Hummel, D., Ernst, M., & Grabhorn, R. (2016). Altered visual adaptation to body shape in eating disorders: Implications for body image distortion. Perception,45(7), 725–738.
Montibeller, G., & Winterfeldt, D. (2015). Cognitive and motivational biases in decision and risk analysis. Risk Analysis,35(7), 1230–1251.
Moscone, A.-L., Amorim, M.-A., Le Scanff, C., & Leconte, P. (2017). A model-driven approach to studying dissociations between body size mental representations in anorexia nervosa. (Report). Body Image,20, 40. https://doi.org/10.1016/j.bodyim.2016.11.003.
Mountjoy, R. L., Farhall, J. F., & Rossell, S. L. (2014). A phenomenological investigation of overvalued ideas and delusions in clinical and subclinical anorexia nervosa. Psychiatry Research,220(1), 507–512.
Moussally, J. M., Grynberg, D., Goffinet, S., Simon, Y., & Van der Linden, M. (2017). Novel assessment of own and ideal body perception among women: Validation of the computer-generated figure rating scale. Cognitive Therapy and Research,41(4), 632–644.
Norris, D. (1984). The effects of mirror confrontation on self-estimation of body dimensions in anorexia nervosa, bulimia and two control groups. Psychological Medicine,14(4), 835–842.
O’Connell, J. E., Bendall, S., Morley, E., Huang, C., & Krug, I. (2017). Delusion-like beliefs in anorexia nervosa: An interpretative phenomenological analysis. Clinical Psychologist. https://doi.org/10.1111/cp.12137.
Phillipou, A., Mountjoy, R. L., & Rossell, S. L. (2017). Overvalued ideas or delusions in anorexia nervosa? (Vol. 51, pp. 563–564).
Plies, K., & Florin, I. (1992). Effects of negative mood induction on the body image of restrained eaters. Psychology and Health,7(3), 235–242.
Pollatos, O., Kurz, A. L., Albrecht, J., Schreder, T., Kleemann, A. M., Schöpf, V., et al. (2008). Reduced perception of bodily signals in anorexia nervosa. Eating Behaviors,9(4), 381–388.
Schilder, P. (1935). The image and appearance of the human body: Studies in the constructive energies of the psyche. London: K. Paul, Trench, Trubner.
Shafran, R., Fairburn, C. G., Robinson, P., & Lask, B. (2004). Body checking and its avoidance in eating disorders. International Journal of Eating Disorders,35(1), 93–101.
Smeets, M. A. (1997). The rise and fall of body size estimation research in anorexia nervosa: A review and reconceptualization. European Eating Disorders Review,5(2), 75–95.
Somerville, K., & Cooper, M. (2007). Using imagery to identify and characterise core beliefs in women with bulimia nervosa, dieting and non-dieting women. Eating Behaviors,8(4), 450–456.
Somerville, K., Cooper, M., & Hackmann, A. (2007). Spontaneous imagery in women with bulimia nervosa: An investigation into content, characteristics and links to childhood memories. Journal of Behavior Therapy and Experimental Psychiatry,38(4), 435–446.
Sullivan-Bissett, E., Bortolotti, L., Broome, M., & Mameli, M. (2016). Moral and legal implications of the continuity between delusional and non-delusional beliefs. In G. Keil, L. Keuck & R. Hauswald (Eds.), Vagueness in psychiatry (chapt. 10). Oxford University Press.
Taylor, M. J., & Cooper, P. J. (1992). An experimental study of the effect of mood on body size perception. Behaviour Research and Therapy,30(1), 53–58.
Thompson, J. K., Coovert, M. D., & Stormer, S. M. (1999). Body image, social comparison, and eating disturbance: A covariance structure modeling investigation. International Journal of Eating Disorders,26(1), 43–51.
Tranel, D., Damasio, H., & Damasio, A. R. (1995). Double dissociation between overt and covert face recognition. Journal of Cognitive Neuroscience,7(4), 425–432. https://doi.org/10.1162/jocn.1995.7.4.425.
Trope, Y., & Liberman, A. (1996). Social hypothesis-testing: Cognitive and motivational mechanisms. In E. T. Higgins & A. W. Kruglanski (Eds.), Social psychology: Handbook of basic principles. New York: Guilford Press.
Tuschen-Caffier, B., Bender, C., Caffier, D., Klenner, K., Braks, K., & Svaldi, J. (2015). Selective visual attention during mirror exposure in anorexia and bulimia nervosa. PLoS ONE,10(12), e0145886.
Veale, D. (2002). Over-valued ideas: A conceptual analysis. Behaviour Research and Therapy,40(4), 383–400.
Vitousek, K., Watson, S., & Wilson, G. (1998). Enhancing motivation for change in treatment- resistant eating disorders. Clinical Psychology Review,18(4), 391–420.
Whitehouse, A., Freeman, C., & Annandale, A. (1986). Body size estimation in bulimia. The British Journal of Psychiatry: The Journal of Mental Science,149, 98–103.
Williamson, D. A., Perrin, L., Blouin, D., & Barbin, J. (2000). Cognitive bias in eating disorders: Interpretation of ambiguous body-related information. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity,5(3), 143–151.
Williamson, D. A., White, M. A., York-Crowe, E., & Stewart, T. M. (2004). Cognitive-behavioral theories of eating disorders. Behavior Modification,28(6), 711–738.
Young, G. (2011). On abductive inference and delusional belief: Why there is still a role for patient experience within explanations of Capgras delusion. Cognitive Neuropsychiatry,16(4), 303–325.
Acknowledgements
Thanks to Peter Clutton and Jakob Hohwy for feedback on earlier drafts. This research was supported by an Australian Government Research Training Program (RTP) Scholarship.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Gadsby, S. Self-Deception and the Second Factor: How Desire Causes Delusion in Anorexia Nervosa. Erkenn 85, 609–626 (2020). https://doi.org/10.1007/s10670-018-0039-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10670-018-0039-z